Thursday, February 10, 2011

Autism Interventions: New York Times, Once Again, Pushes Non Evidence Based Floortime And Ignores Evidence Based ABA

The New York Times is at it again ... pushing Floortime as an autism intervention ... without mentioning the lack of scientific, empirical evidence in support of its effectiveness. In A Child Psychiatrist Talks About Autism the NYT features a column by Dr. Joshua D. Sparrow which promotes Floortime as an intervention for autistic children and encourages parents of autistic children to consider Floortime as an intervention for their children. (And of course, as usual with the NYT there is no mention of the solid base of evidence in support of ABA as an autism intervention):

"One promising treatment for such children is Floortime, a developmental, individualized and relational approach.


After a careful assessment of the child’s unique profile, therapists and parents using the Floortime approach work together to help the child learn to handle sensory stimulation while gradually interacting in more complex and rewarding ways. The goal is to help these children engage in meaningful relationships, expanding their capacity for communication, understanding and complex, abstract thought. One of the keys is to find the child’s motivation, and to use it as fuel for this work. Another is to make the work rewarding by making it fun and pleasurable for child, parent and therapist. But it is hard and time-consuming work, and families of children with autism spectrum disorders deserve all the support we can possibly give them. Experience has shown that children with autism who are given the support they need are able to expand their abilities to relate, to learn and to communicate, especially with their loved ones.


...


For more on autism spectrum disorders and Floortime, see the International Council on Learning and Developmental Disorders Web site.


Among the many helpful and hopeful books on autism spectrum disorders are those by the late child psychiatrist Stanley Greenspan and the psychologist Serena Weider, including “Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate and Think,” and a new one to be published in April by the pediatrician Ricki Robinson, called “Autism Solutions: How to Create a Healthy and Meaningful Life for Your Child.”

The NYT presents this latest Floortime promotional vehicle without mentioning the limited evidence in support of its effectiveness as reviewed by the AAP and the Association for Science in Autism Treatment.



The picture above is from the AAP Publications Retired and Reaffirmed policy page and indicates that in September 2010 the American Academy of Pediatrics Reaffirmed the Clinical ReportManagement of Children with Autism Spectrum Disorders. Pediatrics 2007. The 2007 Report described the lack of empirical, scientifc evidence in support of the efficacy of DIR/Floortime as an intervention for autism spectrum disorders:

"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" 
(page 1165)

The following information is currently found on the ASAT web site and indicates that Floortime is plausible but essentially untested.

Association for Science in Autism Treatment


Developmentally-based Individual-difference Relationship-based intervention (DIR)/Floor Time


...

Research Summary: DIR is widely considered to be a plausible intervention approach (i.e., one that could be effective), but it has not been evaluated in peer-reviewed studies with strong experimental designs (National Research Council, 2001). An uncontrolled study reported favorable outcomes (Solomon et al., 2007).

Recommendations: An important area for future research is to evaluate DIR in studies with strong experimental designs. Professionals should present DIR as untested and encourage families who are considering this intervention to evaluate it carefully.

It isn't clear to me why the NYT pushes Floortime, a non evidence based autism intevention, and ignores ABA,  the most evidence based intervention for autism, as reviewed for several decades by authorities from the US Surgeon General, to state agencies in Maine, New York and California to the Association for Science in Autism Treatment to the American Academy of Pediatrics. I have to assume that the personal biases and prejudices of senior health editors at the New York Times lie behind this persistent attempt to promote non evidence based autism interventions and ignore or put a negative spin on ABA.  I can think of no other reason, rational or not, for the NYT's  misguided autism intervention reporting.

11 comments:

AutisticWisdom said...

Harold,

The article probably has more to do with the preferences of Dr. Sparrow than the NY Times in particular.

I agree Floortime isn't researched enough to be considered evidence-based, and many of the "Floortime apologetics" out there give the typical explanations on why ABA fails - lack of generalization, everything is rote/memorized, your kid is a robot, etc. Of course, we know that is untrue - my daughter generalizes very well, the ABA sessions incorporate generalization from the start and have play activities, etc.

I will say that it is difficult to use ABA to teach the nuances of socialization. Many social skills can be taught in this manner, but others are just too subtle to teach this way.

My sense is that DIR/Floortime may be especially useful for high functioning children who primarily struggle with social skills and are generally fine at communicating and are cognitively unimpaired. Also, I much prefer Floortime to "RDI" which is a proprietary curriculum vs. Floortime which is much more open.

The typical sales pitch people use with me is that ABA won't teach your child to think dynamically. My response is always - no, they will generalize and they do, and secondly, unless your child is high functioning, this probably won't happen anyway. It is more important to me as a parent that my child can communicate and take care of themselves than it is for them to "think dynamically". If it happens, fantastic, but if not, I will be happy with the simple social expressions I get, as I am sure you do with Conor.

Some people are so anti-ABA they will not use it, and I usually recommend Floortime as an alternative if they will not at least attempt ABA... not sure what else they can do.

Anonymous said...

Thank you for this Harold. I feel parents who believe that watered down therapy like Floortime (or play therapy or whatever they are calling it now) is effective are truly clueless. Either that or they don't want to put the time and effort into intensive ABA or think their kids are too "high functioning" for ABA. Here's a piece of advice to parents, NO child is too high functioning for the science behind ABA.

Anonymous said...

Research in Autism is still nascent. Our strategy is to try out everything, as long as there is no risk, and see for ourselves.

It is more important continue with therapy that we can see is helping our child than to simply pursue one because it has some sort of 'validation'!!!

farmwifetwo said...

Actually AW if you have "play" in your ABA, you are using Floortime. Lovaas style ABA is sitting at a table, hours on end, doing rote drills over and over and over again. Then getting a toy for approx 15 sec, having it taken away and again and again and again until the skill is perfected and moving on to the next one. It is disgusting to watch, and my son finally attacked his male T with his fingernails in May... he was never again allowed in my house. That is his only "behaviour" on record and he was 4... he's now 9.

I have a psychometry report that reads "child cannot do same tasks outside of clinical setting". This psychometry exam was done in June, we started in Oct and it was done by ABA's psychometrist. When asked I was told "we do not have a program to do that".

That is ABA. Anything that has to do with play... is Floortime.

We got rid of them officially in October. My son has thrived since then. Why?? B/c he get's treated with respect. Learning is tailored to his needs. And, as the psychometrist said last year "get him to talk, and we'll all be amazed at what he knows". We're working on it. Ironically, we have joint attention and he has upper level speech - using phrases from other sources (friends, books, tv, computer) and twisting them to meet his speech needs YET, we still don't have the 2yr old ability to answer WH questions. So we've applied to the Augmentative Communication Service for help. He's waitlisted. The Teacher told me again last night when we went and heard Dr MacFabe speak "I am shocked daily at what he knows". So am I.

Which is why I'll never assume that Non verbal = ID. And I will never subject him to being "trained" instead of "educated" ever again.

Anonymous said...

Or, to add to the last commenter.....too arrogant to think their child should need ABA. e.g. Estee Klar. There is a prime example of how a parent has some illusion that their child is a high functioning genius so he doesn't need that horrible ABA therapy. She is the most out of touch mom I have come across and her type typically falls for unproven interventions such as play therapy.

Autism Reality NB said...

Thank you FW2 I know when I post a comment about ABA that I will receive your negative experience with ABA and that's fine but the research points, as it has for many years, to ABA as the only evidence backed intervention for autism. Your descriptions of ABA as being Floortime when play is involved is not accurate. Discrete Trial Training can in fact be fun and can be a form of play when done well. But ABA is not just DTT either. It is the application of scientific principles of applied behaviour analysis. It assumes that autistic children are rational and appeals to that rationality.

The old "trained" vs "educated" is not valid. Move past your own personal experience and read the studies by professionals such as those who provided the research for the AAP and ASAT reports. Those studies show substantial gains for autistic children through ABA intervention.

Anonymous said...

FW2, it is clear that you had a dated, horrible ABA team. It does NOT mean the entire ABA industry is like this. Can you not get past your own experience? Many people have wonderful ABA Teams that know how to generalize skills and to also teach wonderful joint attention, play and theory of mind objectives to the kids. You really are so repetitive with your experience. I can't imagine a professional who would WANT to work with you. Really.

AutisticWisdom said...

FWIW, we have rarely done table exercises. Most programming is run on the floor or in a natural setting. "Natural Environment" teaching is often very effective and play-like, but that doesn't make it "Floortime" per se. There is a clear goal for learning, data is taken, and positive reinforcement is used. My daughter running loves her sessions because of all the fun stuff she gets to do and play with. If something becomes aversive we change tactics to make it fun again. That's real ABA.

They used to say (before Lovaas died) that "not even Lovaas does Lovaas" anymore. That style of teaching is going the way of the do-do bird.

Carl said...

our son had 2 years aba before school and ABA trained TA's in school

The present system used here as ABA involves the table time but with longer play time then the 15 seconds that is mentioned by farmwifetwo.

That said at one point my son was handled for a session with his speech therapy at the hospital by an ABA therapist from the Stan Cassidy center and while we are generally pleased with the effectiveness in much of their stuff we were appalled by her methods and in less then 10 minutes my son shut down on her. I suspect based on what i have heard that she was using standard lovas ABA

personal experience the ABA center here and it's methods (which are considered ABA by todays standards and appear to be a less formalized version of Lovas) is that it is excellent and that any time our son had to miss time he was extremely upset with it.

by contrast i find his TA's (due to restrictions of using full ABA in the classroom setting) tend to use a more Lovas based approach with is showing to be less effective.

generally farmwifetwo you had the misfortune of getting an ABA team that was taught using original techniques and failed to advance as the understandings of how best to deal with autism has evolved.

however i do think that anonymous is wrong in one assumption and that is that there are some severly autistic children who are quite intelligent, this does include my son (tho i would hesitate to call him a genius) he is quite computer literate, reads at a J level in school (ahead of most of his peers, and we have caught him reading my steven erikson books tho we take them away when we do because if he does understand them they are a bit to rough for him) with our son we are working on his speech (to some success until a recent regression) because we feel we will only truly be able to guage his abilities at that time and we do not want to hold him back (or push him beyond his means) through lack of understanding of his abilities

Diane Freedman, MS CCC-SLP said...

THanks for your post. As a speech pathologist I have seen ABA work with children with severe and moderate autistic spectrum disorder. It is a very effective strategy when working on discouraging inappropriate behaviors and encouring appropriate ones. Language, however, functions differently and is not a behavior. Children do not learn to use language through Applied Behavioral Analysis. Sure, they might learn to make sounds, form words and make sentences; e.g. I want apple. However, they learn to interact, request, inform, negate, protest... by interacting with their environment, with their caregivers, peers... this is where the floortime and DIR become paramount in the child's development through therapy. WHen a child begins to realize his/her impact on the world will be when he or she will begin to develop the ability to communicate. Please do not negate floortime and play therapy, I have wittnessed its success with many children, particularly those who are sensory seeking and are not able to attend.

Anonymous said...

I love your posting! This debate seems to be raging at every level of the special education community.
Even children who are bright, high functioning and lacking social/emotional pragmatic skills need behavior therapy over play therapy. They need the functional skills of knowing what the performance expectation is in different situations - and this comes from direct instruction approaches, not just psychoanalytical play therapy. I am an educator at a school for children with social and emotional challenges like severe ADHD and HFA. Parents have told me that floortime therapists have actually told them our school would harm their child because we use a positive behavior plan. They do not tell parents that behavior intervention is actually the standard one recommendeded for autism and ADHD. Ironically, I end up needing to defend our school for practicing what is evidence based and recommended. Bizarre.