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 Report: Management 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.

New York Times' Slanted Article On DIR/Floortime and Autism

The New York Times has published in its print and online editions a lengthy piece by Melissa Fay Greene promoting DIR/Floortime. The article acknowledges to some extent the value of ABA as an autism intervention but implies that ABA is outdated and that DIR/Floortime is a new modern improved form of autism intervention. The usual cliches about ABA being rote learning are trotted out along with the positive buzzwords used to promote DIR/Floortime "relationship", "respectful of the child". The article indicates that experts do not endorse any one method.

What the article does not do is mention the fact that there is no empirical evidence to support the effectiveness of DIR/Floortime as an autism intervention. The MADSEC Autism Task Force Report (2000 rev. ed.) described DIR Flootime as without scientific evaluation of any kind.

MADSEC Autism Task Force Report, page 6:

• Without scientific evaluation of any kind:
Greenspan’s DIR/”Floor Time,” Son-Rise.


MADSEC Autism Task Force Report, page 43:

Discussion

There have been no peer-reviewed, published studies of Greenspan’s DIR/Floor Time’s
effectiveness for children with autism.

Conclusions

There have been no peer-reviewed, published studies of Greenspan’s DIR/Floor Time’s
effectiveness for children with autism. Researchers should consider investigation using research protocols. Professionals considering Greenspan’s Floor Time should portray the method as without peer-reviewed scientific evaluation, and should disclose this status to key decision makers influencing the child’s intervention.

The American Academy of Pediatrics reviewed autism interventions in Management of Children with Autism Spectrum Disorders(2007) and stated, at page 5, with respect to RID that:

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

The article also fails to indicate the value of ABA as an autism intervention and the large body of evidence supporting its effectiveness:

MADSEC (2000)

Conclusions

There is a wealth of validated and peer-reviewed studies supporting the efficacy of ABA
methods to improve and sustain socially significant behaviors in every domain, in individuals
with autism. Importantly, results reported include “meaningful” outcomes such as increased
social skills, communication skills academic performance, and overall cognitive functioning.
These reflect clinically-significant quality of life improvements. While studies varied as to the
magnitude of gains, all have demonstrated long term retention of gains made.

Other major contributions of ABA to the education and treatment of individuals with autism
include:

• a large number of empirically-based systematic instruction methods that lead to the
acquisition of skills, and to the decrease/elimination of aberrant behaviors;
• a technology for systematically evaluating the efficacy of interventions intended to affect
individual learning and behavior; and
• substantial cost/benefit.

Over 30 years of rigorous research and peer review of applied behavior analysis’ effectiveness
for individuals with autism demonstrate ABA has been objectively substantiated as effective
based upon the scope and quality of science. Professionals considering applied behavior
analysis should portray the method as objectively substantiated as effective. Methods of applied behavior analysis should be considered to evaluate the effectiveness of any intervention used to help individuals with autism. Researchers should continue to vigorously investigate behavioral intervention as the most promising area of research and treatment benefitting individuals with autism known today. Early interventionists should leverage early autism diagnosis with the proven efficacy of intensive ABA for optimal outcome and long-term cost benefit.


American Academy of Pediatrics (2007)

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

The New York Times is still a news source of great influence. When it is using that influence in promoting interventions for children with autism, a neurological disorder, it should do its homework and present an accurate and credible review of the professional literature. Simply offering a guest column to a promoter of an intervention lacking in empirical verification of its effectiveness does a disservice to autistic children whose decision makers, family or public, could be misled by the NYT and its weighty reputation.

autism