Sunday, July 20, 2014

Why ABA for Autism? Because Children with Autism Disorders Deserve Evidence-Based Intervention and ABA Meets That Standard

Autism Canada Foundation, a Canadian autism charity,  promotes itself as "The PREMIER Resource for Information on Autism Spectrum Disorders" but  typically downplays the importance of evidence support for ABA as the Premier autism intervention while promoting interventions with less substantial  evidence bases as determined by study and  credible authorities.

 Why criticize Autism Canada Foundation an autism charity? Why ABA for Autism? Why Evidence Based Intervention?  Because, as stated by Couper and Sampson in the Medical Journal of Australia 11 years ago,  ineffective therapies, while they may be immediately harmless, waste the child's valuable therapy time and parents' money.  Delay in implementing effective treatment may have a negative impact on the child's ultimate outcome.  ABA is the only intervention to date that meets the evidence based standard in every credible review, a fact downplayed by the Autism Canada Foundation.

ABA has for many years been confirmed by study and credible authorities as  the most substantially evidence based effective autism intervention.  If parents choose to try other methods they should in fact make informed choices. Autism Canada is a charitable organization which will be staging an autism conference this October called Changing the Course of Autism 2014.  The brochure highlights RDI and the Son-Rise program but makes no express mention of  Applied Behavior Analysis.  

As the following credible reviews indicate RDI and Son-Rise are not supported by the same level of evidence of their effectiveness as ABA ( I can't find any authoritative review mentioning any level of evidence  support for Son-Rise).   What the Autism Canada conference attendees are unlikely to be informed is that when it comes to autism therapies it  is not a close call - ABA was and remains the most substantiated, evidence based, effective autism intervention. 

The US Surgeon General, the MADSEC Maine Administrators of Services for Children with Disabilities (Maine Autism Task Force) Report (2000 revision),  American Academy of Pediatrics, Management of Children with Autism Spectrum Disorders, and a recent article in the Canadian Medical Association Journal all confirm ABA as the most effective autism intervention (specific treatment necessary for associated medical conditions - eg. seizures, gastro intestinal).  And as Couper and Sampson wrote ... Children with autism deserve evidence based intervention:

1. Couper and Sampson - Children with autism deserve evidence based intervention.

Children with autism deserve evidence-based intervention  
Jennifer J Couper and Amanda J Sampson
Med J Aust 2003; 178 (9): 424-425.

Jennifer J Couper and Amanda J Sampson, in the 2003 editorial in the MJA, reviewed some of the evidence in support of the effectiveness  of behavioral interventions for autism. The authors stressed the importance of an evidence based approach to autism interventions:

"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." 

- [Bold Highlighting Added - HLD]

Couper and Sampson reviewed the evidence at that time (2003) in relation to behavioral treatment for autism:

The early intervention that has been subjected to the most rigorous assessment is behavioural intervention. There is now definite evidence that behavioural intervention improves cognitive, communication, adaptive and social skills in young children with autism. In 1987, Lovaas showed apparent recovery, persisting into adolescence, in nine of 19 young children who received an intensive home-based intervention based on applied behavioural analysis, a scientific method of reinforcing adaptive and reducing maladaptive behaviours.5,6 Subsequent studies also showed that behavioural intervention caused significant, albeit somewhat lesser, gains.7-11 This has modified the orthodox view that autism is always a severe, lifelong disability. Criticisms of the adequacy of the design and power of these studies are being addressed by the multisite Lovaas replication Early Autism Project. The first US site has released data (Wisconsin Early Autism Project).12 Again, after three to four years of intensive applied behavioural analysis intervention, about half the preschool children with autism acquired near-normal functioning in language, performance IQ and adaptability. Ninety-two per cent of intervention children acquired some language. Control children who received special education showed no gains in IQ or adaptability.12

2. American Academy of Pediatrics - Management of Children with Autism Spectrum Disorders, (2007, reaffirmed 2010)

The American Academy of Pediatrics article Management of Children With Autism Spectrum Disorders, Scott M. Myers, MD, Chris Plauch√© Johnson, MD, MEd, the Council on Children with Disabilities (2007), reaffirmed (2010):

"Applied Behavior Analysis

Applied behavior analysis (ABA) is the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior and to demonstrate that the interventions used are responsible for the observable improvement in behavior. ABA methods are used to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. ABA focuses on the reliable measurement and objective evaluation of observable behavior within relevant settings including the home, school, and community. 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"

As with every other major research review of the effectiveness of early autism interventions only ABA, applied behavior analysis, received the highest rating: E  - Established/Eligible based on evidence.

 4. Canadian Medical Association Journal, Autism spectrum disorder: advances in evidence-based practice (2014)

 An article in the January 13, 2014 issue of the Canadian Medical Association Journal, Autismspectrum disorder: advances in evidence-based practice, confirms what American authorities have told us for decades, from the US Surgeon General to MADSEC and the American Academy of Pediatrics, ABA still represents evidence based, effective best treatment practice while "Research on non-ABA–based treatments is sparse and shows limited efficacy.":

" Autism spectrum disorder: advances in evidence-based practice "What treatments and interventions are available, and are they effective?

 The goal of existing interventions is to facilitate the acquisition of skills, remove barriers to learning and improve functional skills and quality of life.

 Behavioural interventions

  Current best practices for preschool-aged children with ASD include a focus on improving language, cognitive and adaptive skills using applied behaviour analysis (ABA) techniques.58 Applied behaviour analysis refers to the application of empirically derived learning principles(i.e., the antecedent–behaviour–consequence contingency) to produce meaningful changes in behaviour.59 Such strategies are carefully engineered and implemented through a variety of approaches (e.g., discrete trial teaching to more naturalistic learning contexts) to teach skills and reduce problem behaviour. Applied behaviour analysis interventions can be provided in a variety of settings (e.g., home, specialized treatment centres, specialized or public schools) by a range of front-line therapists, ideally supervised by a psychologist or board-certified behaviour analyst who specializes in ASD.

 A recent overview of meta-analyses60 found significantly enhanced outcomes associated with early intensive ABA-based treatment (typically for 2–3 yr) in four of five included meta-analyses (effect sizes 0.30 to > 1); these findings have since been bolstered by a sixth meta-analysis.61 Gains appear to be greatest in verbal intelligence quotient (IQ) and language communication domains,62,63 for children with stronger pretreatment skills, if treatment is started earlier,64 and with greater intensity or duration of intervention. 60–62,64 These gains achieved in various domains have been summarized in a recent Cochrane review.63 Although the overall quality of evidence is low, it is the best evidence available. A recent study in Ontario reported predictors of outcome that account for some heterogeneity in treatment response.65

 A recent RCT supported the efficacy of ABA-based intervention in toddlers by showing improvements in IQ, adaptive skills and diagnostic classification.37 Models vary, notably by how ABA principles are implemented, but everyday contexts (e.g., free play v. “tabletop”) and activities based on the child’s interests (v. therapist’s agenda) have advantages, including greater generalization of learning.66 Questions remain about which forms and intensities of treatment are most effective for which children.

 Research on non-ABA–based treatments is sparse and shows limited efficacy.67 Translation of evidence-based intervention into community practice is being evaluated, including in Canada.68 A key question is whether effective high-quality programs can be less costly and more sustainable; the findings from Nova Scotia are promising.38 Studies of the effectiveness of treatment programs for older children, youth and adults with ASD are scarce. Benefits have been reported for structured teaching practices, including ABA based interventions, for a wide range of skill deficits and maladaptive behaviours.58" [Highlighting added - HLD]

Hopefully conferences such as the Autism Canada Foundation 2014 conference are not seeking to change the course of autism intervention away from evidence based interventions toward largely  anecdotal approaches.  Hopefully attendees and those who access the conference information will be informed of the importance of evidence based support for autism interventions and the level of credible evidence in support of ABA effectiveness, a level of evidence support which remains unmatched by ANY other behavioural, social or educational intervention.

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