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Effects of Low-Intensity Behavioral Treatment: A Review

photo_services_consultation.jpgResearchers from Norway and New York (Eldevik, Eikeseth, Jahr, & Smith, 2006) recently compared 2 groups of children who were either receiving behavioral treatment for 15 hours/week or eclectic (i.e. using multiple treatment approaches) for 12 hours/week.  After 2 years of treatment, the behavioral group made larger gains than the eclectic group.

Many studies support the fact that behavioral treatment is effective and several researchers have stated that this treatment must be intensive, meaningportrait_showcase_children_88.jpg 40 hours of 1:1 intervention.  In the 1st study of intensive behavioral intervention, Lovaas (1987) showed clinically significant gains for 17 out of 19 children with autism while the control group of the other 19 children with only 10 hours or less of intervention showed decreases in IQ.  Although this study has received some criticism due to focusing mostly on IQ changes for treatment outcome and because researchers have not been able to replicate the dramatic results, it is the most commonly cited study in ABA treatment for autism and helped lay the groundwork for many years of research.  Other research studies have also shown positive gains with intensive behavioral intervention, but none as dramatic as the Lovaas study in 1987.  In this paper, ABA is synonymouse with Discrete Trial Training (DTT).  However, as we have discussed in previous postings, it is important to note that DTT does not equal ABA, rather, DTT is one ABA approach.

litldesk.gifThe authors in this paper stated that less intensive ABA (10-20 hours/week) is acceptable when cost, availability of professionals, or concerns from parents about the stress of 40 hours/week on a child & the family are concerns.  The National Research Council recommends 25 hours/week, but they do not state that this intervention must be DTT, or even ABA, but the NRC does state that practices should be evidence-based.  In other words, it is not clear whether or not more natural, peer group settings are as effective (or more effective).  In most situations of quality education, eclectic approaches are provided which have some 1:1 intensive ABA and more natural, peer group instruction.

In this study, 13 boys participated in the behavioral group and 14 boys and autistic_child_556.jpg1 girl participated in the eclectic group.  All children attended regular education classrooms for about 20 hours/week.

Treatment staff were required to complete intensive training in both the behavioral and eclectic treatment group.

The behavioral intervention used was based on the Lovaas manual (1981) and the Behavioral Interventions for Young Children with Autism book (Maurice, Luce, Green) (1996).  An updated Lovaas manual is now available too, if you are interested in this teaching approach!

The eclectic treatment approach consisted of alternative communication (symbol communication or sign language), ABA, total communication, sensory integration therapy, TEACCH program, and other methods based on the experiences of the teachers.

dmbtest1.gifTreatment outcome was determined by IQ testing (Bayley and Stanford-Binet), standardized language assessments (Reynell and PEP-R), the Vineland Adaptive Behavior Scale, nonverbal IQ (Merrill-Palmer), and a pathology scale (No Words, Not Affectionate, No Toy Play, No Peer Play, Stereotypical Behaviors, Severe Tantrums, and Not Toilet Trained).

No significant differences in number of hours of treatment were observed between the 2 groups, both groups received about 12 hours/week of 1:1 for 20 months.  The major difference between the 2 groups were the approaches used, not the intensity.  In the eclectic group, ABA was not used nearly as often as in the behavioral group.

The behavioral group overall did slightly better than the eclectic group, but the drummer_boy.jpgdifference was not clinicially significant.  In this study, the children partipating had lower intellectual functioning overall to start than children in similar studies.  Also, in this study, lower intensity treatment was used (less hours) than in other high intensity treatments in other studies (more hours).  The quality of treatment was also not monitored as closely in the eclectic group as in the behavioral group.  So, it is possible that quality of intervention may account for the difference rather than the actual approach used.  The types of intervention used in the eclectic group were also not closely monitored so it is not clear how much time was spent on each treatment approach.  It is also possible that the difference between the 2 groups may be due to the more systematic, data-driven approach in ABA and that the ABA approach was manualized whereas the other approaches were not necessarily.

The fact that this study was a retrospective one (meaning they went back and looked at these children after 2 years) rather than a planned and controlled investigation is also a limitation that the authors noted.

My opinion:

puzzle2a.gif1) I think this study will get a lot of attention and I appreciate that there are researchers out there trying to answer some of the important questions about number of hours and types of interventions.  I also think that the researchers did an excellent job identifying the limitations of their study and ideas for future research.  My only concern about this paper is that some people may leap to conclusions which the authors probably did not intend to make the readers believe.  I hope to see more studies like this one from this group of researchers addressing some of the limitations they mentioned in their paper and maybe some of the ones I list in this posting. 

2) I don’t think that this study proves that lower intensity treatment is not as effective as higher intensity treatment (nor do I think that was the intention of the authors in this paper) as this study did not directly compare number of hours and the children in this study had lower intellectual functioning to start than children in the other research studies.  I think it is an important study to directly compare # of hours with the same treatment approach within the same study - there is so much controversy over this and the truth is, we still do not know much about the # of hours of intervention.  Many studies have demonstrated effectiveness of ABA treatments with low-intensity (e.g. PRT studies) and many studies have demonstrated effectiveness of ABA with high-intensity (e.g. Lovaas).  I think this study highlights the importance of doing this research, but it does not answer the question about low-intensity vs. high-intensity. 

3) I don’t think this study demonstrates that Discrete Trial Training is superior portrait_showcase_families_62.jpgto other types of intervention because the differences between the groups were not very big and it is not clear what exactly the children were receiving in the eclectic group.  I would like to see a research study comparing evidence-based treatment approaches, it is not clear to me that the eclectic group used evidence-based treatment programs and if they did, which ones did they use and which ones were effective or not?  Also, I would like to see research looking at more structured ABA approaches such as Discrete Trial Training compared to more play-based types of ABA such as Pivotal Response Training (PRT).  I also think it is important to look at treatments that are backed by research, comparing an evidence-based approach (Discrete Trial Training) to a potentially non evidence-based approach may be the main reason a difference between the groups was observed.

254073670206_0_BG.jpg4) Although I think the measures used were interesting, I would like to have seen actual behavioral data on the children - did the children look any different after 2 years of treatment?  Did they use more spontaneous language, were changes in joint attention observed, did the play skills become more age-appropriate, and did the children look more “normal” in behavioral observations?  The problem with only using standardized measurements is that this information gets lost, a simple behavioral observation of the child in a play situation with the experimenter and with the parent, would have been sufficient.  This type of measurement is frequently used in more naturalistic training studies which focus on generalization of skills to the natural environment and I think that kind of measurement, especially in these important studies, would shed more light onto real treatment outcome (rather than just changes in standardized measures).

5) Another thing I would like to have seen in this study is information about generalization of skills - was there a difference in this between the two groups?  How was generalization measured or wasn’t it?  I think that any study looking at treatment outcome for ABA should report generalization - if the skills did not generalize to real-life situations, it is not clear how valuable those skills are.


Positive Behavior Support (PBS)

index_r2_c1.gifThe goal of PBS (Positive Behavior Support) is to apply the principles of behavior analysis in the community to reduce problem behaviors and increase appropriate behaviors which promote a rich lifestyle.  PBS is a type of ABA and is not necessarily in competition (despite the controversy among some that they are different approaches) with other types of ABA as it is often very suitable to use in conjunction with other treatments such as Discrete Trial Training, Pivotal Response Training, Picture Exchange Communication System, and other popular ABA techniques.  PBS typically refers more to dealing with challenging behaviors such as aggression, tantrums, self-injury, etc. and focuses on teaching more appropriate replacement behaviors such as functional communication.

The Association of Positive Behavior Support describes PBS and provides success stories and useful links and resource guides that you can download.  They also host an annual conference, the next one is March, 2007 in Boston, MA and they are now accepting proposals for presentations.  They also have a good newsletter which is free to download and print.

From the Association of Positive Behavior Support:index_r1_c1.gif

Positive behavior support (PBS) involves the changing situations and events that people with problem behaviors experience in order to reduce the likelihood that problem behaviors will occur and increase social, personal, and professional quality in their lives. It is an approach that blends values about the rights of people with disabilities with a practical science about how learning and behavior change occur.  PBS is a set of research-based strategies used to increase quality of life and decrease problem behavior by teaching new skills and making changes in a person’s environment. Positive behavior support combines valued outcomes, behavioral and biomedical science, validated procedures; and systems change to enhance quality of life and reduce problem behaviors such as self-injury, aggression, property destruction, pica, defiance, and disruption. The overriding goal of PBS is to enhance quality of life for individuals and others within social settings in home, school, and community settings. 

biting.jpgPBS is now used in many different situations and settings and with different types of social challenges. Children with and without disabilities participate in the PBS process in schools, at home, and in community settings. In school settings, PBS strategies are used to build a positive climate and include all students, not just children who may engage in more serious problem behavior. Adults with disabilities are actively involved in PBS team processes regardless of their age and where they live and work. The Association for Positive Behavior Support (APBS) has been created to build a community of individuals who are interested in the PBS process and who represent many different voices and perspectives. Family members, school professionals, psychologists, adult service providers, higher education professors, researchers, and community members are all involved in APBS. Regardless of the different settings and individuals involved in PBS processes, the key elements remain the same for individual planning. The PBS process involves a team of individuals working together collaboratively to gather information and create strategies for preventing problem behavior.

Functional Assessment. The cornerstone of PBS is the design anportrait_showcase_children_50.jpgd use of functional (behavioral) assessment to understand what maintains an individual’s problem behavior. Individuals engage in a behavior because it is functional; it helps them acquire some form of reinforcement (e.g., they get something desirable or pleasant, or they avoid something undesirable or unpleasant). A person may engage in problem behavior because circumstances in both the internal and/or external environment (i.e., antecedents, setting events) trigger or ‘set the stage’ for behavior to occur. Functional assessment is a process for identifying the events that trigger and maintain problem behavior. This process involves information gathering through record reviews, interviews, and observations and the development of summary statements that describe the patterns identified. Primary outcomes of the functional assessment process include:

  • A clear description of the problem behaviors
  • Events, times, and situations that predict when behaviors will and will not occur (i.e., setting events)
  • Consequences that maintain the problem behaviors (the function)
  • Summary statements or hypotheses
  • Direct observation data to support the hypotheses

Comprehensive Intervention. The team that forms around a child or adult in order to create a PBS plan should represent all of the situations and settings that are part of the person’s life. Information that is gathered from a functional behavioral assessment helps this team develop and implement behavioral intervention plans that are positive, proactive, educative, and functional. PBS plans include a number of interventions that can be implemented across situations and settings. These interventions include: 1) proactive strategies for changing the environment so triggering events are removed, 2) teaching new skills that replace problem behaviors, 3) eliminating or minimizing natural rewards for problem behavior, and 4) maximizing clear rewards for appropriate behavior. A hallmark of PBS planning is emphasis on improving overall lifestyle quality (relationships, activities, health) as an integrated part of behavior support.

Mindy2sm.jpgLifestyle Enhancement. PBS focuses not only on reducing behavior problems, but on enhancing a person’s overall quality of life. Outcomes include lifestyle improvements such as participation in community life, gaining and maintaining satisfying relationships, expressing personal preferences and making choices, and developing personal competencies. Such improvements in quality of life are facilitated by establishing a positive long-range vision with the individual and his/her family (e.g., through person-centered planning) and establishing natural supports through effective teamwork.

jpbi.jpgA great resource for staying on top of the research and clinical work in PBS is to subscribe to one of my favorite journals, the Journal of Positive Behavior Interventions (JPBI).  If you are going to subscribe to one journal and you work with or have a child with autism, this is one of the most practical journals I have seen as  the research is very applied and accessible to anyone.

Another useful journal, which is a free online journal, on PBS is the Journal of Early and Intensive Behavior Intervention

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