Sunday, March 11, 2007

Myths and Misrepresentations about ABA and Lovaas (1)

The Lovaas, and related ABA, studies are amongst the most frequently discussed of autism topics. They attract criticism both rational and irrational, amateur, professional, and pseudo-professional, informed and ill informed. One of the knocks against the Lovaas studies is that they purportedly were based on study groups which did not represent lower functioning autistic persons. Lisa Jo Rudy of the About Autism Spectrum Disorders site has attempted to dispel this myth:

http://autism.about.com/od/alllaboutaba/f/toohiforaba.htm

"Ironically, one of the myths about the 1987 study is that children did well because a high-functioning sample group was used. However, in his study, Lovaas reported that 17 out of 19 patients scored in the mentally retarded range on IQ tests.

In the 2005 replication study, 10/23 children were nonverbal prior to treatment. In the 2006 replication study, all subjects had “developmental delays comparable to other children with autism”. Thus, in early intensive behavioral treatment studies, every effort is made to create a representative sample of children diagnosed with autism rather than one skewed with learners who have a normal IQ or are already verbal.
"

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.
Smith, T., Groen, A. D., Wynn, J. W. (2000). Randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal of Mental Retardation, 105, 269-85.
Sallows, Glen O. & Graupner, Tamlynn D. (2005). Intensive Behavioral Treatment for Children with Autism: Four-Year Outcome and Predictors. American Journal on Mental Retardation,110 (6), 417-438.


ABA, and Lovaas, deserve the critical examination they receive. The Lovaas initiated ABA revolution in autism treatment is successful in part because it is data based and can withhold such critical examination. Any claim for efficacy must be based on evidence not philosophy. So too criticism should be based on the evidence, facts and careful, rational, analysis. Ill informed, predisposed hostility to ABA, and the Lovaas studies, can only cause harm to autistic children in need of effective treatment and educational assistance.

7 comments:

Alyric said...

"So too criticism should be based on the evidence, facts and careful, rational, analysis."

Absolutely. For once we can agree on something. I love the Sallows and Graupner study - for demonstrating so beautifully that the therapy is not the critical factor in the outcome. When your experimental group, which should do really well is outperformed by the control group, which should do much less well, the random element is the therapy - in this case ABA. No t that the study is useless - far from it. At least they took their results and tried to figure out why the kids were fast or moderate learners based on their intake data. That's really valuable stuff and will be more so when someone figures out how to tailor interventions based on the data. What they did not do was replicate Lovaas - quite the opposite I would have thought.

The most comprehensive critique of the Lovaas study is one out of British Columbia:

Centre for Health Services and Policy Research, British Columbia Office of Health Technology Assessment, Autism and Lovaas treatment: A systematic review of
effectiveness evidence, July 2000


If I remember correctly that's the one that details why IQ is a poor measure of outcome -pure serendipity, that is if you don't rig the deck by excluding older kids who aren't echolaic (good sign of language development) from the experimental group.

I read somewhere that Lovaas did exclude the severely mentally retarded from the study - on the grounds that it just wasn't possible to determine whether the kids were really autistic or not. Could they check for Fragile X back then? Some sense in that I suppose considering that the diagnosis is purely behavioural. It does mean that Lisa Jo isn't really correct to call this a myth. The spectrum does include the severely mentally retarded. If Conor is as you say he is, he would not have been eligible for the UCLA project.

Autism Reality NB said...

The BCOHTA study was prepared by the BC government at a time when it was resisting attempts to require provision of ABA services in BC. The BC government, and most jurisdictions in Canada now recognize the efficacy of ABA in autism treatment.

In the Auton trial decision the BC government expert who tried testified Dr. Gresham, agreed with the parents experts that ABA was the treatment of choice for autism and that treatment should not be delayed.

"[52] Current research has established, with some certainty, the efficacy of early intervention in assisting many children to achieve significant social and educational gains. The expert witnesses agree that the most effective behavioural therapies are those based on principles of ABA. There are no effective competing treatments. As Dr. Gresham stated, “there is no question that ABA is the treatment of choice for children presenting with autistic disorder based on over 35 years of research in the field.” He emphasized the fact that although replication of the Lovaas study was necessary, treatment should not be delayed awaiting the outcome."

The court also noted biases in the BCOHTA report which included failing to talk to any ABA practicioners.

"[48] The BCHOTA Report exhibits an obvious bias towards supporting the Crown’s position in this litigation. That detracts significantly from its usefulness."

With respect to your statement that " I read somewhere that Lovaas did exclude the severely mentally retarded from the study - on the grounds that it just wasn't possible to determine whether the kids were really autistic or not." do you have a source, preferably a credible source, but at least a name, for that claim?

Here is what McEachin testified to during the Auton trial:

"[37] The Crown referred extensively to literature criticizing the scientific methodology of the Lovaas study. One criticism is that the children placed in the experimental group may have had high IQs to begin with. Dr. McEachin flatly denies that suggestion. He testified that those children were fully representative of the spectrum of autistic children in the general population and that their IQs were equivalent to those of the children in the control group."

The Auton trial involved testimony of many experts and was subjected to much public scrutiny. The sworn testimony of Dr. McEachin surely deserves much more weight than your unknown, unamed, "I heard it somewhere" claim that serverly mentally challenged autistic children were excluded.

You would be well served to read the court summary of the expert testimony in Auton rather than repeating erroneous anonymous comments about the Lovaas study.

Astrid van Woerkom said...

Quote:
"The BCOHTA study was prepared by the BC government at a time when it was resisting attempts to require provision of ABA services in BC. The BC government,
and most jurisdictions in Canada now recognize the efficacy of ABA in autism treatment."



So what is it in the *study* that is biased? You see, a study isn't biased just because the people preparign, funding or conducting it have a particular hypothesis. Besides, if it did, all current ABA studies conducted or prepared ro funded by people or organisatiosnt hat endorse ABA , are biased towards getting positive results.

Autism Reality NB said...

Astrid

The conclusion that the BCOHTA report was biased was a conclusion made by the Justice of the British Columbia Supreme Court. I already set out one of the examples of bias that the Court mentioned. Here are the Court's description of the BCOHTA and its biases in full:

"[42] Drs. Bassett, Green, and Kasanjian prepared the report entitled “Autism and Lovaas treatment: A systematic review of effectiveness evidence” (the “BCHOTA Report”). The foreword to that report describes the methodology utilized in BCHOTA projects generally. It states that “reports are reviewed internally, and then sent for external review to experts from a variety of academic or clinical disciplines. Comments and suggestions are considered before a final document is produced.” That statement clearly implies that the BCHOTA Report, which was prepared for the purpose of this litigation, was subjected to external peer review before it was filed as an exhibit in these proceedings. However, Dr. Bassett testified that, as at the date of the hearing, the BCHOTA Report was out for external review and only one response had been received. He described the BCHOTA Report as the final document for these proceedings but not the final document for the purpose of publication.

[43] Dr. Bassett and his colleagues did not consult with any psychiatrists or clinicians who are known to support Lovaas Autism Treatment. They spoke with only one external medical consultant, Dr. Miller, who commented that the incidence of autism might appear higher than it actually is because of a tendency to label a child with autism or ASD to obtain access to services. On the basis of that single anecdotal comment, the BCHOTA Report states:

A more recent problem has emerged in relation to estimates of the incidence of autism. It appears that, at least in the BC context, problems with the diagnosis of autism may not simply be due to problems in the application of validated diagnostic criteria. The possibility arises that children with other pervasive development disorders may nonetheless be diagnosed with autism in order to gain access to services linked to that diagnosis."







[44] The Executive Summary of the BCHOTA Report begins with the following statement:

This systematic review examined whether early intensive behavioural therapy for children with autism results in normal functioning, or essentially a cure. The scientific validity of this curative claim is central both to legal proceedings brought on behalf of several children in British Columbia against the Province seeking an intensive behavioural program; and to cost-benefit analyses and clinical guidelines used for planning autism treatment programs.





[45] The BCHOTA Report reiterates that Drs. Lovaas and McEachin claim that their treatment “normalized or cured children with autism.” As noted earlier, neither Dr. Lovaas nor Dr. McEachin -- nor the petitioners -- assert such a claim.

[46] The BCHOTA Report criticizes the Lovaas study because it used a small number of children and further suggests that the reported findings of benefits may have been achieved by assembling a high-functioning group of autistic children. Dr. Bassett was unable to suggest how one would assemble a high functioning group and agreed, in cross-examination, that he was unaware of any evidence to contradict Dr. Baer’s opinion that such a selection could not be made.

[47] While the BCHOTA Report criticizes the methodology of the Lovaas and McEachin studies and the absence of replication at length, it adds little if anything to the existing debate in the scientific journals on the subject.

[48] The BCHOTA Report exhibits an obvious bias towards supporting the Crown’s position in this litigation. That detracts significantly from its usefulness.

Astrid van Woerkom said...

Mr. Doherty,
Why has there never been criticism of this study in peer-reviewed journals? (I assume, if you hav eot cite a court proceeding) Judges may be legal experts,b ut they are not autism experts or ABA experts, aso I wonder why you take ajudge's opinion on the effectiveness of ABA for scientific evidence.

I would, by the way, agree on the external review issue - external review is one factor in preventing bias -, but I might wonder whether other (pro-ABA) studies have more (and balanced) external review.

Why are the claims Lovaas allegedly made (cure, normalization, etc.) which he allegedly didn't make, so significant that they invalidate the whol report?

As for [48], that was exactly what I was asking you before: why is a report biased jsut because the people who do the research, have a particular stand on the subject of research? If this is true, Lovaas' reports are all biased.

Autism Reality NB said...

Astrid

I set out the instances in the Auton judgment which the judge cited as indicating bias in the report. You do not appear to have read my comments carefully.

BIAS

1)The report authors did not consult any supporters or practicioners of ABA.

2) The report authors claimed that the study group participants may have had high IQ's to begin with an assertion that was contradicted by McEachin's sworn testimony.

3. The report authors spoke to one external medical consultant and on the basis of his speculation about autism diagnosis increases arising from efforts to gain access to services they based their conclusion that in fact diagnoses of autism were increasing for that reason.

4. The report authors implied that their report had been been sent out for peer review but, by the time of trial, only the one medical consultant.

ABA Efficacy

The Court simply summarized the unanimous opinions of ALL the experts who testified including those who testified for the government when it stated that:

"The expert witnesses agree that the most effective behavioural therapies are those based on principles of ABA. There are no effective competing treatments. As Dr. Gresham stated, “there is no question that ABA is the treatment of choice for children presenting with autistic disorder based on over 35 years of research in the field.”

Anonymous said...

Hi,

I just wanted to respond to a comment made by alyric about the Sallows and Graupner (2005) study -

alyric wrote that the paper demonstrates "that the therapy is not the critical factor in the outcome". I thought it might be important to recognise that both therapeutic groups DID recieve ABA based intervention. The authors note "All children received treatment based on the UCLA model" (Sallows and Graupner, 2005, p. 420). They also note (p 422) that some elements of PRT (R. Koegel and Koegel, 1995) were used while the work of Maurice, Green and Luce (1996) was also drawn on.

Table 1 indicates mean hours of ABA for the two treatment groups to be 38.6 (Clinic-driected) and 31.67 (Parent-directed). during year one with similar hours for year two of the program. If you look at the data reported prior to combining scores the clinic directed group of rapid learners that met criteria for best outcomes is close to 38% while 60% of the parent directed rapid learners met criteria for best outcomes. All recieved ABA intervention.

One confound that may be at play that may account for some of the variance is alluded to by the authors when they report that parents "...were encouraged to to extend the impact of treatment by practicing newly learned material with their child throughout the day..." (p 420). It begs the question as to if the parents who were more engaged in "directing" home based programs were in fact also more inclined to extend therapy hours as they had a more intimate knowledge of programs?

The primary question the authors attempted to address seems to have been whether a Community based program could achieve similar results to what Lovaas (1987) did (without using aversives) (p419). If you think about it... the entire program, both parent directed and clinic directed service models, were in fact facets of the WEAP community based program... it appears that as such, they are pretty darn close to in fact achieving such outcomes.