Which autism therapy should I choose?

On January 14th, the Council on Autism Services (CAS) organized a joint conference with the Autism Partnership on the “Evidence and Rationales for Comprehensive Models of Autism Spectrum Disorder Treatment: Divergence and Convergence.” This event was organized as an opportunity to exhibit all the established and emerging approaches to ASD treatment in a fair and systematic manner, while providing a structure in which to compare and contrast each approach in a public forum. The objective of the conference was to give both practitioners and consumers the opportunity to better understand what approaches work, why they are thought to work and how the Autism community can pursue their common goal of collaboratively pursuing and promoting effective treatment.

The primary motivation for this industry-focused comparison was the understanding that the approach and philosophy of autism treatment has significant, long-term impact on developing minds with autism, and that there is currently a growing national need for evidence based services due to:

A rapidly increasing prevalence of autism diagnoses
A struggle in accounting for the differences between standards under Federal Free and Appropriate Education (FAPE)
An expansion of national funding coverage paired with a simultaneous constraint on the amount of funding per individual
A concern that resources may be diverted away from evidence-based services to those that may be more emotionally appealing
The fact that ineffective services impact the individual, their family and society.

Distinguished scientific practitioners of each approach were invited to give a presentation on their given methodology. The only stipulation was that presenters would follow the same basic five point structure in their presentation including:

Overview of methodology
Conceptual tenants behind the method
Basic procedures in implementing treatments
Goal selection and order
Staff training and basic skill requirements

Though all presenters were asked to abide by this structure, some were unable to cover all the content.

At this point it is important to note that the methodologies presented below were the only ones whose practitioners agreed to participate in this public forum and undergo scrutiny and comparison. All others either chose not to participate or simply did not respond.

Presenting on the Ivar Lovaas Model was Dr. Ron Leaf, an integral member of the team that developed this approach at UCLA during the 1980s. This model dates back to the original pioneer study out of UCLA in 1987 in which Lovaas and his team were able to demonstrate the efficacy of a 40-hour Intensive Behavioral Intervention (IBI) program versus that of the control group who only received an average of 10 hours. The results of this study drastically changed services for children with autism while creating the foundation for very important research to follow. Dr. Leaf pointed out that through research the field has been able to demonstrate that 10 hours per week of eclectic therapy (defined as therapy that may involve ABA principles in addition to various other methods) is no different than receiving no therapy.

During his presentation Dr. Leaf also addressed what he deemed to be misconceptions about the Lovaas Model. Firstly, that children involved with the study received an average of 40 hours IBI, not a minimum, that they were very low functioning, and received both 1:1 and group treatment. Dr. Leaf clarified that Lovaas did not abide by rigid written protocols, rather he demonstrated flexibility to respond to each individual child as needed with responses implemented by the highest trained staff and parents. He noted that parents often became trainers themselves due to their rigorous involvement and the training they received alongside the therapists. It was Lovaas’ belief, Dr. Leaf explained, that one could not be taught in isolated, distraction-free rooms, but rather it needed to occur in a more natural chaotic environment. Children were also taught continuously throughout the day, not exclusively through Discrete Trial Instruction (DTI), and food reinforcers were used, but in conjunction with social reinforcers. Above all, Lovaas believed and executed his work with a focus on clinical judgment, not rigid, written protocols, and clinical judgment was only attained through years of experience.

In describing how his team currently implements the Lovaas Method through their organization Autism Partnership, Dr. Leaf emphasized their dedication to staying true to Lovaas’ core principles. It is their belief that a competent Behavior Analyst is one who is constantly evolving, researching and demonstrating flexibility. They have shifted from a home-based to a clinic-based model as this facilitates faster acquisition, has the ability to create social and school practice opportunities and allows for constant supervision of staff which is key to success. They do not abide by strict written protocols, deeming them to be important only when there is a lack of trained staff. They instead prefer to facilitate their staff in developing clinical judgment and know-how on when to respond based on the evidence-based principles that guide their therapy. Therapy focuses primarily on reducing interfering behaviors before moving on to teaching the “learning to learn” skills. Once children demonstrate the skills necessary to learn from a natural setting and from peers, they continue their therapy in settings conducive to that with the same level of intensity and trained staff.

Their staff on-boarding process consists of 700+ hours of training with a technician being deemed as “really good” only after 5-10 years of implementing ABA methods within that role. Coordinators have 10+ years experience, mentors have 19+ and their directors have 40+.

Dr. Leaf expressed the opinion that the field of autism services can seem stuck at times which he attributes to poor, untrained practitioners saying, “Nurses don’t perform surgery and flight attendants don’t fly planes. So why would we let unqualified technicians work with our children with autism?”

Dr. William Ahearn, who joined the New England Center for Children (NECC) in 1996 presented on the NECC model. He opened by noting that NECC is a non-profit, private agency that has been implementing ABA for 40 years. Currently there are home, clinic and residential programs servicing children 3-22 years of age in Boston, MA and Abu Dhabi, UAE. NECC also has partner classrooms with public schools.

Dr. Ahearn stated that the conceptual basis for NECC’s model could be found in Skinner’s radical behaviorism and the science of behavior. NECC’s method begins by examining the function of behavior in order to appropriately target and identify replacement behaviors. The model prefers the least restrictive environment that is still effective, and grounds all methods in ABA principles throughout the lifespan of treatment. Dr. Ahearn described how an FBA couldn’t be effectively done fast (although agreed at times it can be during the early intervention years) in direct contradiction to Dr. Leaf’s suggestion that analysis should be very quick and sometimes only minutes long. Dr. Ahearn went on to emphasize that there are questions to be asked after the primary function has been identified and that the quality of intervening is in the details of this analysis of complex behavior and contingencies.

He explained that NECC uses the Core Skills Assessment and the Autism Curriculum Encyclopedia (ACE), which are the agency’s own assessment and curriculum, and are available for purchase. The results of this individualized assessment are used when choosing goals and designing programs within this model. Measured skill areas include discrimination, VB/communication, social, self-help, health/safety, physical education and community independence. Strategies used within the NECC program include DTT, incidental teaching (video and in vivo), mastery criteria, generalization planning and retesting.

  When speaking about staff training and skill levels Dr. Ahearn explained that NECC has layers of experience ranging from bachelor level teachers through master level supervisors. Their managers and program specialists are master level Board Certified Behavior Analysts (BCBA). He went on to explain that supervisors who oversee the BCBAs often have 5+ years experience and receive 24+ CEU hours annually. Direct staff must also have 100+ hours training prior to working with students, after which they continue with 90 day evaluations, weekly team meetings and quarterly training opportunities adding up to over 100 hours of training per year ongoing.

Dr. Mark Sundberg, a licensed psychologist with over 40 years of clinical experience and the author of the VB-MAPP (considered to be one of the gold standards in the field of ABA with regards to skills assessment and program development), presented the Verbal Behavior (VB) methodology. He began with VB’s basis in Skinner’s analysis of verbal behavior before elaborating that it is this model’s view that language is a behavior that deserves the same level of analysis as interfering behaviors. He continued that the VB therapeutic approach is based on years of human development research and analysis of barriers to learning with Dr. Sundberg’s own VB-MAPP used as the primary assessment tool to identify goals, barriers and help guide service delivery recommendations. The VB model believes that in order to implement the VB-MAPP accurately and thoroughly technicians require hundreds of hours of training and supervision.

Dr. Sundberg said that he focuses all initial therapy on teaching the mand (how to request). It is his opinion that most ABA programs focus on early learning skills (imitation, labeling, receptive understanding etc.) but fail to emphasize the mand and specifically training mands under Motivating Operation control (MO control). Further he believes that the key to a competent staff is a full understanding of the mand and motivation control. Dr. Sundberg went on to explain the variations in how his team will approach learning and language based on identifying the source of control for a behavior and teaching from there using principles of ABA. He felt strongly that an understanding of Skinner’s analysis of verbal behavior and child development combined with assessment tools like the VB-MAPP, enables a team to better identify developmentally appropriate goals and structure learning for greater success.

  He concluded by saying that all behavior analytic programs share the same principles, but where methods and qualities vary is in their packaging and the training required to implement them.

Presenting on the Early Start Denver Model (ESDM) was Dr. Sally Rogers a Director of Training and Mentoring at the MIND Institute, UC Davis, as well as one of the developers of ESDM. Dr. Rogers opened her presentation with a disclaimer that she receives royalties for the sale of her books, programs and templates. In discussing her therapy she referred to it as a “Ford” in comparison to the three other methodologies. She later defined this to mean that the level of training, quality of implementation and results were not as refined as her fellow colleagues, but that her goal is wide dissemination of her therapy as it is more affordable.

Dr. Rogers described ESDM as having a trans-disciplinary approach comprised of elements from ABA, developmental considerations and relationship-focused therapy. She explained that it is designed only for children from 9 months to 5 years of age with goals developmentally sequenced and chosen based on her assessment tool. ESDM focuses on joint attention, symbolic play, imitation, nonverbal and verbal skills, and social interaction. The team is lead by the parent and a doctorate level ESDM-trained professional working in tandem. Together they direct and coordinate all therapy provided by the rest of the team which consists of an OT, SLP, psychologist, educator, pediatrician and BCBA.

Unlike other methods, Dr. Rogers explained that this therapy could take on various models contingent upon availability and access for the child. Therapy can be delivered 1:1 with parent coaching in a preschool, or with parent coaching and parent implementation only. The model’s three underlying beliefs are that a child needs intentional communication before speech, that relationships affect learning and that the child will always initiate the lead. Based on the assessment and the number of hours of service, the team creates goals that include 12-25 objectives.

 ESDM therapy begins with incidental teaching during which the therapist identifies the session’s theme based on targeted goals. Next the therapist facilitates language through the theme, and increases complexity to assess whether the child is ready to progress to another goal in the next session.

Dr. Rogers also explained that a great deal of data was collected throughout each session including trial-by-trial data on skill acquisition and a rating scale for behavioral presentation. All programming and behavior plans are in written templates to maintain consistency across teams. Behavior management is addressed with the existing team and a BCBA may do further assessment or analysis if the initial strategies do not work.

  During her presentation Dr. Rogers was unable to discuss staff training and supervision, but indicated that only her own trainers out of the MIND Institute would be qualified to train on this method. Based on experience in Maine and New Hampshire the training is a two-day (12 hours) workshop. If the workshop is missed, staff are directed to read Dr. Roger’s book.

In comparing these methodologies divergence can be clearly found in two areas. The first is the use of ABA principles, and the second is the level of staff training and competencies. The use of ABA principles is present in all of these methods, however they vary in whether they focus solely on ABA principles or a combination of methodologies borrowed from various philosophical foundations.

The three presenters that focused exclusively on ABA principles (Leaf, Sundberg and Ahearn) demonstrated a high level of concern for positive interactions between therapist and client, a commitment to prioritizing dissemination of ongoing research and application of the methods proven to be consistently effective, all of which required extensive staff training and experience.

Dr. Rogers, unlike the other presenters, focused on incidental teaching within identified themes, team approach across disciplines, an eclectic model based on various philosophies, a significantly abbreviated training requirement and wide dissemination of her therapy given its cost benefits in comparison to other models.

ESDM is an eclectic model, which peer reviewed research and studies have demonstrated are inferior to an intensive behavioral model . (Howard, J.S. et al.  (2014). Comparison of behavior analytic and eclectic early interventions for young children with autism after three years.  Research in Developmental Disabilities, 35, 3326-3344.) Even with this being established, ESDM appears to be growing in influence in our area.   The causes for this could be many but a logical approach to this question would yield decision criteria likely based on ease of implementation, cost, emotion and misinformation rather than best practice or quality of evidence base.

The Lovaas, NECC and VB models view extensive training and competency-based requirements as the key to successful and well-established programming. This sort of training and experience frequently takes hundreds of hours over the course of multiple years to acquire. Differentiating between a successful program versus one that is adequate hinges on staff competencies in the applied field. When it came to ESDM practitioners, Dr. Rogers was unable to speak to that same sort of rigorous training or experience.

ABA is still viewed as the highest standard of quality for training with decades of research and support to demonstrate its efficacy. All behaviors, goals and targets can be taught using ABA principles. It also remains a fluid model, allowing any new methods that meet the high standards of fidelity and efficacy to be incorporated into its ever-evolving field.

As health care professionals it is our ethical responsibility to market and promote what is supported and proven and at this time it can be said that ESDM does not have enough peer-reviewed research across various authors/researchers to be considered an established, evidence-based treatment. Pulling funds from programs that have proven track records of success to support wide dissemination of a program that’s own creator and author identifies as inferior to several other methodologies seems misguided.