Whenever a crisis arises anywhere there always seems to be someone willing to sell a magic solution to the problem. Autism disorder diagnoses are soaring, the costs of treating these serious neurological disorders are soaring, the costs of not treating autism disorders, in terms of increased state funded adult autism care are also soaring. A solution must be found so what is the solution?
For years parents and professionals have been urging government and educational service providers to implement evidence based approaches to treating and educating autistic children. The ASD's are serious neurological disorders that require a serious evidence based approach. And time is important in the developmental life span of children to ensure the maximum results.
In Children With Autism Deserve Evidence Based Interventions, The Evidence for Behavioural Therapy, Jennifer J Couper, Head, Endocrinology and Diabetes Centre Women's and Children's Hospital, North Adelaide, and University of Adelaide, SA and Amanda J Sampson, Ultrasonologist, Royal Women’s Hospital, Carlton, VIC reviewed the professional literature on autism interventions and discussed some of the moral issues relevant to provision of evidence based interventions for children with autism:
"While ineffective therapies may be harmless, they waste parents’ money and the child’s valuable therapy time. Furthermore, the delay in implementing effective treatment may compromise the child’s outcome."
In New Brunswick the Inter Departmental Committee on Autism Services met for 18 months before concluding that there were precious few autism specific services in New Brunswick. One of the strengths of the IDC Report finally issued in November 2001 though was an emphasis on provision of evidence based interventions for autistic children. Now, however, the New Brunswick Department of Education, without consulting the Autism Society New Brunswick, is engaged in what it describes as a pilot project involving AutismPro, a non-evidence based autism intervention tool created in part in New Brunswick and advocated for strenuously by senior levels of the New Brunswick Department of Education. The establishment of this pilot project, especially when established in secrecy by Department officials, represents a significant departure from the commitment to evidence based interventions made in the 2001 IDC Report.
In fact the entire world is being tempted to abandon the evidence based approach to autism disorder interventions and instead is being sold a much different approach - the "somewhat" evidence based approach of AutismPro, a commercial, untested, unstudied, unverified, product sold by Virtual Experts Clinic Inc. Unfortunately civil servants looking for cheap solutions, especially senior education bureaucrats looking to maintain control over their department costs and agendas, are eager to adopt this product which is advertised as based on "evidence based interventions" a somewhat questionable claim.
VEC Inc., the owner of AutismPro, is a master of SelfPromotion. VEC Inc's self congratulatory PR releases on the business newswire services ensure that the world is led to believe that AutismPro is a can't miss product, the magic bullet solution to the world's growing autism crisis. What none of the AutismPro SelfPromotion information does is indicate how the product in any way meets an evidence based standard as an effective autism intervention. Quite the contrary, the VEC Inc's own public statements suggest that AutismPro is NOT an evidence based effective autism intervention; or at best might be properly described as "somewhat" evidence based.
Evidence Based Autism Interventions
On the AutismPro website under AutismPro Research AutismPro Uses Evidence-Based Methods it states that the AutismPro product offers three "evidence based" methods of autism intervention: Behavioral,Developmental,Social Behavior. (It would be interesting to know if the symbols eg. heart for social, were intended to attract users to specific methods)
These groupings of methods are simply categories of intervention types, not actual interventions. Many of the interventions listed under these three categories are not in fact recognized as evidence based effective interventions for autism, at least not in any of the major reviews of autism interventions conducted in the last 10 years. There have been several reviews conducted by US state and federal agencies.
In the MADSEC (Maine Administrators of Services for Children with Disabilities) Autism Task Force Report, February 2000 (Rev. Ed. ) it was concluded that:
Based upon a thorough examination of numerous methodologies considered as interventions for children with autism, the MADSEC Autism Task Force has characterized the interventions reviewed as follows:
• Substantiated as effective, based upon the scope and quality of research:
Applied behavior analysis.
In addition, applied behavior analysis’ evaluative procedures are effective not only with behaviorally-based interventions, but also for the systematic evaluation of the efficacy of any intervention intended to affect individual learning and behavior. ABA’s emphasis on functional assessment and positive behavioral support will help meet heightened standards of IDEA ‘97. Its emphasis on measurable goals and reliable data collection will substantiate the child’s progress in the event of due process.
• Shows promise, but is not yet objectively substantiated as effective for individuals with autism using controlled studies and subject to the rigors of good science:
Auditory Integration Training, The Miller Method, Sensory Integration, and TEACCH.
• Repeatedly subjected to the rigors of science, which leads numerous researchers to
conclude the intervention is not effective, may be harmful, or may lead to unintended consequences:
Facilitated Communication.
• Not scientifically evaluated:
Greenspan’s DIR/”Floor Time,” Son-Rise.
The MADSEC Autism Task Force Report Rev. Ed. was issued in 2000. Since then there have been other studies and professional review of autism interventions. Very recently, on October 29, 2007, the American Academy of Pediatrics issued its on-line review of educational interventions for autistic children Management of Children With Autism Spectrum Disorders in which it conducted a review of educational interventions for autistic children and concluded with respect to ABA that:
"The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology21,25,27,28 and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings.29–40 Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups.31–40.
Other methods and interventions offered by AutismPro did not fare so well in the AAP review of the evidence basis for effectiveness as an autism intervention. Starting with the best of the rest (TEACCH) and working downward in the AAP summary the evidence of effectiveness goes from scant to non-existent:
Several reports have documented progress in children who have received TEACCH services as well as parent satisfaction and improvement in parent teaching skills, but these reports were not from controlled studies of treatment outcomes.44–49 In a controlled trial, Ozonoff and Cathcart50 found that children treated with a TEACCH-based home program for 4 months in addition to their local day treatment programs improved significantly more than children in the control group who received local day treatment services only.
Developmental Models
Developmental models are based on use of developmental theory to organize hypotheses regarding the fundamental nature of ASDs and design approaches to address the deficits. The Denver model, for example, is based largely on remediating key deficits in imitation, emotion sharing, theory of mind, and social perception by using play, interpersonal relationships, and activities to foster symbolic thought and teach the power of communication.12 This program has shifted from a center-based treatment unit to service delivery in homes and inclusive school environments. Several studies have demonstrated improvements in cognitive, motor, play, and social skills beyond what would be expected on the basis of initial developmental rates in children who are treated according to the Denver model, but controlled trials are lacking.51–54
Relationship-focused early intervention models include Greenspan and Wieder's developmental, individual-difference, relationship-based (DIR) model,55 Gutstein and Sheely's relationship-development intervention (RDI),56 and the responsive-teaching (RT) curriculum developed by Mahoney et al.57,58 The DIR approach focuses on (1) "floor-time" play sessions and other strategies that are purported to enhance relationships and emotional and social interactions to facilitate emotional and cognitive growth and development and (2) therapies to remediate "biologically based processing capacities," such as auditory processing and language, motor planning and sequencing, sensory modulation, and visual-spatial processing. Published evidence of the efficacy of the DIR model is limited to an unblinded review of case records (with significant methodologic flaws, including inadequate documentation of the intervention, comparison to a suboptimal control group, and lack of documentation of treatment integrity and how outcomes were assessed by informal procedures55) and a descriptive follow-up study of a small subset (8%) of the original group of patients.59 RDI focuses on activities that elicit interactive behaviors with the goal of engaging the child in a social relationship so that he or she discovers the value of positive interpersonal activity and becomes more motivated to learn the skills necessary to sustain these relationships.56 Some reviewers have praised the face validity of this model, which targets the core impairment in social reciprocity. However, the evidence of efficacy of RDI is anecdotal; published empirical scientific research is lacking at this time. One study reported beneficial effects of RT on young children with ASDs or other developmental disabilities.58 Parents were taught to use RT strategies to encourage their children to acquire and use pivotal developmental behaviors (attention, persistence, interest, initiation, cooperation, joint attention, and affect). Children in both groups improved significantly on nonstandardized play-based measures of cognition and communication and standardized parent ratings of socioemotional functioning. Although a control group was lacking and the potential role of concurrent educational services was unclear, the improvements were beyond what the authors expected from maturational factors alone.58
The AAP Report continues with an evaluation of other interventions for which there is some evidence of efficacy as autism interventions but only ABA intervention boasts a lengthy history as an evidence based effective intervention for autism:
All treatments, including educational interventions, should be based on sound theoretical constructs, rigorous methodologies, and empirical studies of efficacy.15 Proponents of behavior analytic approaches have been the most active in using scientific methods to evaluate their work, and most studies of comprehensive treatment programs that meet minimal scientific standards involve treatment of preschoolers using behavioral approaches.16,38 However, there is still a need for additional research, including large controlled studies with randomization and assessment of treatment fidelity. Empirical scientific support for developmental models and other interventions is more limited, and well-controlled systematic studies of efficacy are needed.
The professional reviews of autism interventions indicate that only behavioral based approaches to autism intervention have a substantial empirical or evidence based of support for their efficacy. Of the behavioral interventions ABA is by far the most studied, subjected to rigorous study providing evidence of efficacy. The developmental and social categories of intervention listed on the AutismPro website do not enjoy anywhere near the same evidence basis for claims of efficacy in treating autism. As said in the AAP Report:
All treatments, including educational interventions, should be based on sound theoretical constructs, rigorous methodologies, and empirical studies of efficacy.15 Proponents of behavior analytic approaches have been the most active in using scientific methods to evaluate their work, and most studies of comprehensive treatment programs that meet minimal scientific standards involve treatment of preschoolers using behavioral approaches.16,38 However, there is still a need for additional research, including large controlled studies with randomization and assessment of treatment fidelity. Empirical scientific support for developmental models and other interventions is more limited, and well-controlled systematic studies of efficacy are needed.
AutismPro Is an Eclectic Intervention Tool
AutismPro does not actually appear to offer a specific evidence based intervention. Although it references ABA (usually as being ABA "based") in some of its press releases and on its web site it does not appear that a straightforward ABA intervention is offered. As VECInc states on its web site in You Asked About AutismPro AutismPro borrows elements from various intervention methods, which methods themselves have stronger or weaker evidence bases in support of their efficacy. By taking elements of these programs and combining them in a new eclectic mix VECInc. is essentially creating a new intervention altogether; one with no evidentiary basis for its efficacy.
Does AutismPro incorporate such therapeutic teaching methods as Applied Behavior Analysis and DIR/Floortime?
Somewhat. AutismPro integrates the fundamental components behind the continuum of well-researched behavioral, developmental, and social methods for teaching a child with autism and organizes them into clear choices, recommendations and training within the Strategy Plan section of the program.
Does AutismPro incorporate such strategies as TEACCH, PECS, and Social Stories?
Somewhat. AutismPro integrates the fundamental principles behind dozens of well-researched strategies for adapting the environment or activity for a child with autism, and organizes them into clear choices, recommendations and training within the Support Plan section of the program.
How does AutismPro help me choose a method of instruction?
AutismPro saves you time and effort by organizing the confusing and intimidating range of commonly accepted educational therapy methods in autism into a series of educated and supported choices. You choose the philosophical approach (behavioral, social and developmental) with which you feel most comfortable, and you’re free to make modifications to suit your child’s needs.
Does AutismPro introduce new methods for autism therapy?
No. The methods in AutismPro are a comprehensive integration of strategies from commonly accepted educational therapy options in autism, delivered on a new platform and organized according to a new cohesive conceptual framework. With AutismPro you get practical descriptions rather than a confusing list of strategy names, allowing you to more easily compare choices and make decisions.
Eclectic is one of those buzz words like community, inclusion, natural etc. which imply that the objects they describe are inherently good in some undefined way. Studies of eclectic approaches to educating autistic children do not support that belief. As stated in the AAP Report:
Most educational programs available to young children with ASDs are based in their communities, and often, an "eclectic" treatment approach is used, which draws on a combination of methods including applied behavior analytic methods such as DTT; structured teaching procedures; speech-language therapy, with or without picture communication or related augmentative or alternative communication strategies; SI therapy; and typical preschool activities. Three studies that compared intensive ABA programs (25–40 hours/week) to equally intensive eclectic approaches have suggested that ABA programs were significantly more effective.31,32,34 Another study that involved children with ASDs and global developmental delay/mental retardation retrospectively compared a less intensive ABA program (mean: 12 hours) to a comparably intensive eclectic approach and found statistically significant but clinically modest outcomes that favored those in the ABA group.33 Although the groups of children were similar on key dependent measures before treatment began, these studies were limited because of parent-determined rather than random assignment to treatment group.
The Medium is the Message
AutismPro is an eclectic autism intervention because it selects principles and elements of various interventions. And those interventions themselves enjoy varying degrees of evidence based supports. As a new eclectic mix it is impossible to say that AutismPro is itself an "evidence based" intervention tool. The use of the internet also raise questions about the extent to which AutismPro can accurately be described as "evidence based". Autism is a neurological disorder which often presents serious environmental issues for autistic children. A specific location, even if identical in all obvious aspects to another location, may be problematic for an autistic child. Slight environmental changes may have dramatic effects on an autistic child not always obvious to someone else.
Autism is not a motor vehicle registry or corporate affairs data bank both of which lend themselves readily to two way internet based communication of significant information. Autism is a very "environment sensitive" condition. The further removed in place and time that persons, whether actual advisors, or program writers, are from the specific environment involved, the less likely they will be able to offer reliable solutions to autism challenges. Delivery of autism interventions by internet is something in itself which is radically new. To suggest that an internet based intervention service which is promoted as revolutionary is also evidence based is illogical, inconsistent and inaccurate.
autism
Evidence Based Autism Interventions
On the AutismPro website under AutismPro Research AutismPro Uses Evidence-Based Methods it states that the AutismPro product offers three "evidence based" methods of autism intervention: Behavioral,Developmental,Social Behavior. (It would be interesting to know if the symbols eg. heart for social, were intended to attract users to specific methods)
These groupings of methods are simply categories of intervention types, not actual interventions. Many of the interventions listed under these three categories are not in fact recognized as evidence based effective interventions for autism, at least not in any of the major reviews of autism interventions conducted in the last 10 years. There have been several reviews conducted by US state and federal agencies.
In the MADSEC (Maine Administrators of Services for Children with Disabilities) Autism Task Force Report, February 2000 (Rev. Ed. ) it was concluded that:
Based upon a thorough examination of numerous methodologies considered as interventions for children with autism, the MADSEC Autism Task Force has characterized the interventions reviewed as follows:
• Substantiated as effective, based upon the scope and quality of research:
Applied behavior analysis.
In addition, applied behavior analysis’ evaluative procedures are effective not only with behaviorally-based interventions, but also for the systematic evaluation of the efficacy of any intervention intended to affect individual learning and behavior. ABA’s emphasis on functional assessment and positive behavioral support will help meet heightened standards of IDEA ‘97. Its emphasis on measurable goals and reliable data collection will substantiate the child’s progress in the event of due process.
• Shows promise, but is not yet objectively substantiated as effective for individuals with autism using controlled studies and subject to the rigors of good science:
Auditory Integration Training, The Miller Method, Sensory Integration, and TEACCH.
• Repeatedly subjected to the rigors of science, which leads numerous researchers to
conclude the intervention is not effective, may be harmful, or may lead to unintended consequences:
Facilitated Communication.
• Not scientifically evaluated:
Greenspan’s DIR/”Floor Time,” Son-Rise.
The MADSEC Autism Task Force Report Rev. Ed. was issued in 2000. Since then there have been other studies and professional review of autism interventions. Very recently, on October 29, 2007, the American Academy of Pediatrics issued its on-line review of educational interventions for autistic children Management of Children With Autism Spectrum Disorders in which it conducted a review of educational interventions for autistic children and concluded with respect to ABA that:
"The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology21,25,27,28 and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings.29–40 Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups.31–40.
Other methods and interventions offered by AutismPro did not fare so well in the AAP review of the evidence basis for effectiveness as an autism intervention. Starting with the best of the rest (TEACCH) and working downward in the AAP summary the evidence of effectiveness goes from scant to non-existent:
Several reports have documented progress in children who have received TEACCH services as well as parent satisfaction and improvement in parent teaching skills, but these reports were not from controlled studies of treatment outcomes.44–49 In a controlled trial, Ozonoff and Cathcart50 found that children treated with a TEACCH-based home program for 4 months in addition to their local day treatment programs improved significantly more than children in the control group who received local day treatment services only.
Developmental Models
Developmental models are based on use of developmental theory to organize hypotheses regarding the fundamental nature of ASDs and design approaches to address the deficits. The Denver model, for example, is based largely on remediating key deficits in imitation, emotion sharing, theory of mind, and social perception by using play, interpersonal relationships, and activities to foster symbolic thought and teach the power of communication.12 This program has shifted from a center-based treatment unit to service delivery in homes and inclusive school environments. Several studies have demonstrated improvements in cognitive, motor, play, and social skills beyond what would be expected on the basis of initial developmental rates in children who are treated according to the Denver model, but controlled trials are lacking.51–54
Relationship-focused early intervention models include Greenspan and Wieder's developmental, individual-difference, relationship-based (DIR) model,55 Gutstein and Sheely's relationship-development intervention (RDI),56 and the responsive-teaching (RT) curriculum developed by Mahoney et al.57,58 The DIR approach focuses on (1) "floor-time" play sessions and other strategies that are purported to enhance relationships and emotional and social interactions to facilitate emotional and cognitive growth and development and (2) therapies to remediate "biologically based processing capacities," such as auditory processing and language, motor planning and sequencing, sensory modulation, and visual-spatial processing. Published evidence of the efficacy of the DIR model is limited to an unblinded review of case records (with significant methodologic flaws, including inadequate documentation of the intervention, comparison to a suboptimal control group, and lack of documentation of treatment integrity and how outcomes were assessed by informal procedures55) and a descriptive follow-up study of a small subset (8%) of the original group of patients.59 RDI focuses on activities that elicit interactive behaviors with the goal of engaging the child in a social relationship so that he or she discovers the value of positive interpersonal activity and becomes more motivated to learn the skills necessary to sustain these relationships.56 Some reviewers have praised the face validity of this model, which targets the core impairment in social reciprocity. However, the evidence of efficacy of RDI is anecdotal; published empirical scientific research is lacking at this time. One study reported beneficial effects of RT on young children with ASDs or other developmental disabilities.58 Parents were taught to use RT strategies to encourage their children to acquire and use pivotal developmental behaviors (attention, persistence, interest, initiation, cooperation, joint attention, and affect). Children in both groups improved significantly on nonstandardized play-based measures of cognition and communication and standardized parent ratings of socioemotional functioning. Although a control group was lacking and the potential role of concurrent educational services was unclear, the improvements were beyond what the authors expected from maturational factors alone.58
The AAP Report continues with an evaluation of other interventions for which there is some evidence of efficacy as autism interventions but only ABA intervention boasts a lengthy history as an evidence based effective intervention for autism:
All treatments, including educational interventions, should be based on sound theoretical constructs, rigorous methodologies, and empirical studies of efficacy.15 Proponents of behavior analytic approaches have been the most active in using scientific methods to evaluate their work, and most studies of comprehensive treatment programs that meet minimal scientific standards involve treatment of preschoolers using behavioral approaches.16,38 However, there is still a need for additional research, including large controlled studies with randomization and assessment of treatment fidelity. Empirical scientific support for developmental models and other interventions is more limited, and well-controlled systematic studies of efficacy are needed.
The professional reviews of autism interventions indicate that only behavioral based approaches to autism intervention have a substantial empirical or evidence based of support for their efficacy. Of the behavioral interventions ABA is by far the most studied, subjected to rigorous study providing evidence of efficacy. The developmental and social categories of intervention listed on the AutismPro website do not enjoy anywhere near the same evidence basis for claims of efficacy in treating autism. As said in the AAP Report:
All treatments, including educational interventions, should be based on sound theoretical constructs, rigorous methodologies, and empirical studies of efficacy.15 Proponents of behavior analytic approaches have been the most active in using scientific methods to evaluate their work, and most studies of comprehensive treatment programs that meet minimal scientific standards involve treatment of preschoolers using behavioral approaches.16,38 However, there is still a need for additional research, including large controlled studies with randomization and assessment of treatment fidelity. Empirical scientific support for developmental models and other interventions is more limited, and well-controlled systematic studies of efficacy are needed.
AutismPro Is an Eclectic Intervention Tool
AutismPro does not actually appear to offer a specific evidence based intervention. Although it references ABA (usually as being ABA "based") in some of its press releases and on its web site it does not appear that a straightforward ABA intervention is offered. As VECInc states on its web site in You Asked About AutismPro AutismPro borrows elements from various intervention methods, which methods themselves have stronger or weaker evidence bases in support of their efficacy. By taking elements of these programs and combining them in a new eclectic mix VECInc. is essentially creating a new intervention altogether; one with no evidentiary basis for its efficacy.
Does AutismPro incorporate such therapeutic teaching methods as Applied Behavior Analysis and DIR/Floortime?
Somewhat. AutismPro integrates the fundamental components behind the continuum of well-researched behavioral, developmental, and social methods for teaching a child with autism and organizes them into clear choices, recommendations and training within the Strategy Plan section of the program.
Does AutismPro incorporate such strategies as TEACCH, PECS, and Social Stories?
Somewhat. AutismPro integrates the fundamental principles behind dozens of well-researched strategies for adapting the environment or activity for a child with autism, and organizes them into clear choices, recommendations and training within the Support Plan section of the program.
How does AutismPro help me choose a method of instruction?
AutismPro saves you time and effort by organizing the confusing and intimidating range of commonly accepted educational therapy methods in autism into a series of educated and supported choices. You choose the philosophical approach (behavioral, social and developmental) with which you feel most comfortable, and you’re free to make modifications to suit your child’s needs.
Does AutismPro introduce new methods for autism therapy?
No. The methods in AutismPro are a comprehensive integration of strategies from commonly accepted educational therapy options in autism, delivered on a new platform and organized according to a new cohesive conceptual framework. With AutismPro you get practical descriptions rather than a confusing list of strategy names, allowing you to more easily compare choices and make decisions.
Eclectic is one of those buzz words like community, inclusion, natural etc. which imply that the objects they describe are inherently good in some undefined way. Studies of eclectic approaches to educating autistic children do not support that belief. As stated in the AAP Report:
Most educational programs available to young children with ASDs are based in their communities, and often, an "eclectic" treatment approach is used, which draws on a combination of methods including applied behavior analytic methods such as DTT; structured teaching procedures; speech-language therapy, with or without picture communication or related augmentative or alternative communication strategies; SI therapy; and typical preschool activities. Three studies that compared intensive ABA programs (25–40 hours/week) to equally intensive eclectic approaches have suggested that ABA programs were significantly more effective.31,32,34 Another study that involved children with ASDs and global developmental delay/mental retardation retrospectively compared a less intensive ABA program (mean: 12 hours) to a comparably intensive eclectic approach and found statistically significant but clinically modest outcomes that favored those in the ABA group.33 Although the groups of children were similar on key dependent measures before treatment began, these studies were limited because of parent-determined rather than random assignment to treatment group.
The Medium is the Message
AutismPro is an eclectic autism intervention because it selects principles and elements of various interventions. And those interventions themselves enjoy varying degrees of evidence based supports. As a new eclectic mix it is impossible to say that AutismPro is itself an "evidence based" intervention tool. The use of the internet also raise questions about the extent to which AutismPro can accurately be described as "evidence based". Autism is a neurological disorder which often presents serious environmental issues for autistic children. A specific location, even if identical in all obvious aspects to another location, may be problematic for an autistic child. Slight environmental changes may have dramatic effects on an autistic child not always obvious to someone else.
Autism is not a motor vehicle registry or corporate affairs data bank both of which lend themselves readily to two way internet based communication of significant information. Autism is a very "environment sensitive" condition. The further removed in place and time that persons, whether actual advisors, or program writers, are from the specific environment involved, the less likely they will be able to offer reliable solutions to autism challenges. Delivery of autism interventions by internet is something in itself which is radically new. To suggest that an internet based intervention service which is promoted as revolutionary is also evidence based is illogical, inconsistent and inaccurate.
autism
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