Beyond Buzzwords: Evidence-Based Practices

By Vera Bernard-Opitz, Ph.D.
(reprinted with permission)

The term "Evidence-Based Practices" has become a buzzword in conferences, articles and educational settings for children with autism, indicating that treatment should be based on methods with confirmed scientific evidence combined with clinical expertise. It clearly makes sense to develop guidelines to filter out questionable treatments, which give false hope to parents and professionals and which waste energy, resources and the child’s time. Having a catalogue of validated interventions for children with autism would definitely be helpful to consumers as well as service providers.

So far – so good, but what exactly is "evidence" for treatment success; what can be considered a positive treatment outcome and which research evidence is sufficient? Some may argue that behavioral interventions have demonstrated their effectiveness, in sound single-case and group studies, over the last forty years and that placement in less restrictive settings can be seen as a long-term success. In this context, the Intensive Early Intervention study by Lovaas at UCLA is usually cited, indicating that 47% of the participating two- to four-year-old children were integrated into regular classes after two years of forty-hour per-week behavioral intervention (Lovaas, 1987). Over the past years, several replications of this project have been reported with most, unfortunately, not achieving the extent of the original research findings (e.g., Remington & Brown, in print; Eikeseth, Smith Jahr, & Eldevik, 2002; Birnbrauer, & Leach, 1993). These and other studies suggest that the impact of intensive intervention can vary considerably, depending on the scope of the program, the fidelity of the implemented treatment, staff and parent involvement and the intensity of the program.

Evidence-Based Intervention is related to Research Support Theoretical Underpinning Causal Relation to Treatment Success

Other colleagues may point to widely-accepted educational interventions, which are considered "Best Practice Methods", such as the TEACCH program (Mesibov et al, 1994). While some argue this program is less backed by research, good empirical support for its foundations has been demonstrated (Mesibov & Shea, in preparation). The structured teaching method, characteristic of TEACCH, is clearly matched to the needs of the individual with autism for clear visual support, functional tasks and predictable work environments. Furthermore, it is obvious, that this method has been the chosen treatment in many autism centers around the world. There is no question that interventions such as this, based on matching treatments to core deficits of children with ASD, replications of positive outcomes over varying autism centers, as well as providing wide appreciation for an approach, qualify as 'Best Practice' methods.

There are other "camps", which have specific intervention targets in mind, such as ‘Augmentative Communication,’ ‘Verbal Behavior,’ ‘SCERTS,’ ‘Integrated Play’, ‘Social Perspective-Taking’ or even ‘Parent-Training,’ to name just a few. They all touch on components of treatment, which are important for many individuals with ASD. With the wide selection of treatment options, parents are in a quandary when facing the difficult task of selecting the best treatment for their child, while researchers, clinicians and educators struggle with the decision which method has sufficient evidence. Should my non-verbal child be in a PECS program (Picture Exchange Communicative System) or should we aim for Verbal Behavior Intervention? In addition to school services, should I take a parent-training course, enroll my child in Integrated Play Groups or invest in additional home interventions through trained professionals? Questions such as these require extensive clinical expertise, good understanding of the child with ASD, the family and cultural context, as well as the treatment paradigm in question. Besides general research evidence for the respective interventions, treatment success is more likely if the child in question is comparable to the participants of the original research.

It should meanwhile be clear that anecdotal accounts of improvements in treated areas alone are no longer sufficient. Positive expectancy, novelty or uncontrolled external factors all threaten the validity of individual case reports. Social Validity data also seem insufficient by themselves, such as parents raving about positive changes, since they might be biased, having spent effort, money and hope on a treatment method. So again, different arguments may need to be combined: if a treatment has a clear relation to established theories (such as the Theory of Mind), demonstrates effectiveness in treating specific individual problems and is acknowledged by parents or teachers as having caused the changes, then it can be considered ‘preliminary evidence’ that this method can be helpful to a comparable individual.

The above does not imply that we should stand still and be content with basing our decisions for treatment on a collection of eclectic arguments. A continuum of standards may be helpful to discriminate treatments, which are unacceptable to ideal interventions based on sufficient empirical evidence and application.

While it may sound easy to parents/consumers to find which treatment works the best and fastest for their individual child, we stand before a tremendous task, which may need to be tackled by a representative panel of experts from different professions and different treatment directions.

Amongst others, the following questions need to be clarified:

• What group of individuals with ASD are we focusing on? (Individuals with Autism/Asperger Syndrome? What is their age range, IQ range, skills-profile, interest/motivation etc?)
• What goals are targeted in specific interventions? (long/short term goals; competency/educational/behavioral goals; individual/family/community goals, etc).
• What are selection criteria and cut-offs for interventions? (unacceptable/acceptable/ideal criteria)
• What are necessary components of treatment packages, such as Pivotal Response Training, TEACCH or Social Skills training?
• What are crucial treatment factors, which effect changes in programs as different as ABA, Verbal Behavior, Pivotal Response Training, Integrated Playgroups, TEACCH or the SCERTS model? (Prizant, Wetherby, Rubin, Laurent & Rydell 1999)
• What external factors contribute to treatment success? (parent involvement/integration/support-systems, etc)
• What are predictors for treatment success, such as characteristics of children, who require certain interventions? (Sherer & Schreibman, 2005).

In addition to the above, we also need more knowledge about the effectiveness of treatments at both ends of the spectrum. There is an urgent need to understand why some children with ASD do not benefit from intensive interventions. We also should make sure that some of the outstanding treatment successes pointed out by their proponents are not related to maturational changes in children less severely disabled or external factors not associated with the treatment. We need more treatment studies comparing control subjects on waiting lists to specific interventions, as well as different treatment components to each other (Howard et al, 2005). While these studies pose enormous methodological challenges, guidelines for dealing with the problems have been outlined (Schreiber, 2006; Lord, C. et al, 2005; Kazdin & Nock, 2003).

More Research is Needed to Understand Common Factors in different Treatment Methods Crucial Components of Treatment Packages Predictors for Treatment Success Maturational Factors External Influences

Most critical clinicians and educators have long moved beyond a ‘one size fits all’ attitude, when it comes to deciding on treatments for children with ASD. They are aware that we are dealing with a wide spectrum of problems, which requires a spectrum of interventions. Not every child with autism fits the characteristics of the participants in the above-cited Early Intervention studies by the ABA pioneers – so not everybody needs the quoted forty hours of weekly, one-to-one discrete trial intervention, just as well as not everybody requires an augmentative communication device, PECS training, a TEACCH environment or Social Perspective Intervention.

The Wide Spectrum of Problems of Individuals with ASD requires a Wide Spectrum of Interventions.

We need to remember that even if a treatment has demonstrated its effectiveness for a certain group, this does not imply that every individual benefits. Instead of the top-down question, ‘Which child can benefit from Precision Training, Peer Mediated Learning or Activity Based Instruction?’, bottom-up questions should be asked, which aim at the needs of the individual with autism. Which treatment matches the individual’s needs for what teaching target at what time in his development in what context? In discussions for standards regarding evidence-based interventions, guidelines are crucial for decision-making to assure the most effective treatment of individuals with ASD.

Through the forty-year history of autism treatment, we have learned a lot about highly specific interventions that tend to be successful with certain children. Especially in the behavioral field, single-subject designs have clearly demonstrated the effect of component techniques, be it ‘Interrupting Behavior Chains,’ ‘Time Delay’ or ‘Sensory Reinforcement.’ We now are entering the exciting phase of matching treatments to learning features, interests and therapy goals of individuals with autism (Bernard-Opitz. 2005 & in print). Comparable to designer drugs, designer treatments should be an aim in services for children with autism: just as an Aspirin can not cure every single headache, a multitude of proven interventions is required, which can be matched to the individual needs of the child with ASD.

Preliminary guidelines for effective treatment programs, such as the one by the National Institute of Mental Health can give parents and professionals some directions with making the right choices (NIMH, 2004).

“An effective treatment program will build on the child's interests, offer a predictable schedule, teach tasks as a series of simple steps, actively engage the child's attention in highly structured activities, and provide regular reinforcement of behavior. Parental involvement has emerged as a major factor in treatment success.”

While guidelines and standards for evidence-based interventions are discussed and developed in various countries (Wilczynski, 2006, US National Standard Project; Jordan, UK, 2005; Perry & Condillac, 2003, Canada; Hoagwood et al, 2001, US), we should all continue our commitment to evidence-based `Best Practices’ by disseminating articles, which are either based on scientific evidence, have a scientific foundation or have the support of parents or experienced professionals. And hopefully this will contribute to bringing best practices to the children we care about.

Vera Bernard-Opitz, Ph.D.
Clinical Psychologist
For more information please visit http://www.verabernard.org
Email: verabernard@cox.net

References

• Hoagwood, K. et al (2001) Evidence-based practice in child and adolescent mental health services, Psychiatric Services, 52: 1179-1189.
• Howard, J.S., Sparkman, C.R., Cohen, H.G., Green, G. & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatments for young children with autism, Research in Developmental Disabilities, 26(4), 359-83.
• Jordan, R. (2005) Evidence-based Practice in education in ASD, 4th International Symposium for Intervention in ASD, Editor: S. Bölte, Frankfurt University.
• Lovaas, O.I. (1987) Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.
• Mesibov, G. & Shea, V. Evidence-based practices, autism and the TEACCH Program, in preparation.
• National Institute of Mental Health (2004) Autism Spectrum Disorders (Pervasive Developmental Disorders). http://www.nimh.nih.gov/publicat/autism.cfm
• Perry, A. & Condillac, R. (2003) Evidence based practices for children and adolescents with autism spectrum disorders, Children’s Menal Health, Ontario.
• Prizant, B.M. & Rubin, E. (1999) Contemporary issues in interventions for children with Autism Spectrum Disorders, Journal of the Association of Persons with Severe Handicap, 24(3), 199-208.
• Sherer, M.R. & Schreibman L. (2005) Individual behavioral profiles and predictors of treatment effectiveness for children with autism. Journal of Consulting and Clinical Psychology. 73(3), 525-38.
• Wilczynski, S. M. (2006) The National Standards Project: Part II: The project and its goals. Second Annual Best Practices in Autism Treatment & Methodologies Education Conference 2006, San Jose, California.

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