1. health and fitness
2. disease
3. autism and pdd

Saturday, 27 April 2013
ABA Today is presented by:
Autism Behavioural Intervention Association
p: 03 98300677 | w: www.abia.net.au
Why is ABA Evidence-Based?
4/27/13
Why is ABA
an evidence-based treatment
for autism?
Eric V. Larsson, PhD, LP BCBA-D
The Lovaas Institute Midwest
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
1
Why is ABA Evidence-Based?
4/27/13
ABA is not Medically Necessary?
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Uses rote techniques to create robotic responding
40 hours is unnecessary – robs a child of their childhood
It is all drills at a table – no natural social skills
It is punishment based
It doesn’t work for high functioning children
It doesn’t work for low functioning children
It doesn’t work for older children
It doesn’t work for younger children
It is based upon bribery
Children don’t really recover
It doesn’t take into account the whole child
It denies the child their own self direction
It plays upon the fears of the parents
It is too expensive
It is not used in classrooms
Its curriculum does not take into account pragmatics
The staff are poorly trained
It doesn’t help the parents with the real challenges of daily life
It creates prompt dependency
It creates anxious, and depressed children
It relies upon edible reinforcers
It doesn’t develop advanced abstract language
Low Quality ABA comes from
Low Quality Implementation
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
2
Why is ABA Evidence-Based?
4/27/13
Nationwide Hearings on ABA
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1997-2012
Primarily due to the intense resistance of school districts to
funding in-home and private services, many independent state, federal, and
professional task forces were convened to study intensive early intervention
using behavioral models.
These task forces universally found that the services were appropriate and
effective, and hence medically necessary.
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American Academy of Pediatrics
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British Columbia Supreme Court
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California Legislative Commission
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Maine Administrators of Services for Children
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New York State Department of Health
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U.S. Surgeon General Mental Health Report
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National Research Council
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Autism Research Institute
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Centers for Disease Control
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American Academy of Child and Adolescent Psychiatry
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American Academy of Neurology
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American Psychological Association Division of Clinical Psychology
What is the evidence for ABA?
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
3
Why is ABA Evidence-Based?
4/27/13
B.F. Skinner
  The
Experimental Analysis of Behavior
Analysis of the continuous change in behavior:
Development of the fixed interval scallop
Skinner, 1950
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
4
Why is ABA Evidence-Based?
4/27/13
Analysis of the dynamic change in behavior
vs. the static average
Skinner, 1950
Don Baer, Mont Wolf, Todd Risley
  Applied
Behavior Analysis
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
5
Why is ABA Evidence-Based?
4/27/13
Risley & Wolf (1968)
Contingent Reinforcement of
Accurate Vocal Imitation
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
6
Why is ABA Evidence-Based?
4/27/13
O. Ivar Lovaas
  UCLA:
Early Intensive Treatment for Autism
Lovaas & Simmons (1969)
Gregg's self-injury (head
hitting) over successive
sessions (1 through 7).
The upward moving
hatchmarks in Sessions 3
and 5 mark delivery of
sympathetIc comments,
play, etc., contingent on
self-injury.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
7
Why is ABA Evidence-Based?
4/27/13
Lovaas (1966)
Development of Social
Conditioned Reinforcers
Koegel, Egel, & Williams (1980)
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
8
Why is ABA Evidence-Based?
4/27/13
Parrish, Cataldo, (1986)
Covariation of Compliance and Behavior in Group and Individual Sessions
Why is this data important?
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
9
Why is ABA Evidence-Based?
4/27/13
The Development of the Young Child
How many successful learning trials per day does
the child receive?
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
10
Why is ABA Evidence-Based?
4/27/13
How many inadvertent autistic trials per day does
the child receive?
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To make progress,
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Preventing practice of autistic responding
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the child must practice target responding more often than he is allowed
to practice autistic responding
Throughout the child’s day, he is getting many SDs in natural situations
We must train the parents and staff to ensure that these teachable
moments result in learning new target behavior
At the end of the day, were 80% of his teachable moments
successful?
The Implications of Research in
Applied Behavior Analysis
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Behavior constantly responds to its environment
  Resulting in all of the learned behavior patterns of life
  Inconsistent or maladaptive treatment does not easily result
in progress toward normalcy
Therefore to alter the course of autism
  We must transform the child’s home and community into a
24-hour therapeutic environment
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
11
Why is ABA Evidence-Based?
4/27/13
Does ABA Research Prove This?
Effect of Parent Involvement
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
12
Why is ABA Evidence-Based?
4/27/13
Effect of Intensity
Group Data backed up by
Individual ABA Outcome Data
Lovaas 1987 Child by Child Behavior Data
20
18
Number of Children
16
14
12
10
8
6
4
2
0
Dramatic Complex
Play
Play
Peer Play
Normal
Best
IQ
Outcomes
Pre
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
Severe
MR
Stereotpd Tantrum
Behavior
Mute
Post
13
Why is ABA Evidence-Based?
4/27/13
But is this data replicated?
The Scope of Individualized ABA
Research before 2000
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
14
Why is ABA Evidence-Based?
4/27/13
Research on the Treatment of the
Restricted Range of Interests
Positive Reinforcement to Remediate Stereotyped, Perseverative Tendencies
Significant Researchers:
Ferster, Indiana U.; Wolf, Risley, U. of Washington; Koegel, Dunlap, Rincover, Newsome, Carr, Lovaas,
UCLA; Hall, U. of Washington; Sajwaj, U. of Tennessee; Baer, U. of Kansas; Repp, Dietz, U. of
Georgia; Iwata, Florida State U.; Dyer, The May Institute;
Salient Research Studies: 39
Time Span: 1961 – 1990
Sample Study:
Charlop, M.H., Kurtz, P.F., & Casey, F.G. (1990). Using aberrant behaviors as reinforcers for autistic
children. Journal of Applied Behavior Analysis. 23, 163-182.
Effects of Structure on Stereotyped, Perseverative Tendencies
Significant Researchers:
Lovaas, Schreibman, Koegel, Dunlap, Newsome, UCLA; Foxx, Azrin, U. of Southern Illinois; Iwata, Bailey,
Florida State U.; Repp, Northern Illinois U.; Dyer, The May Institute;
Salient Research Studies: 31
Time Span: 1965 – 1991
Sample Study:
Koegel, R.L, Dunlap, G., & Dyer, K. (1980). Intertrial interval duration and learning in autistic children.
Journal of Applied Behavior Analysis, 13, 91-99.
Research on the Treatment of the
Restricted Range of Interests
Development of Effective Skill Development Strategies
Significant Researchers:
Risley, LeBlanc, Spradlin, U. of Kansas; Touchette, Columbia; Schreibman, Russo, Lovaas, Dunlap,
Rincover, Koegel, UCLA; Dyer, Christian, Luce, The May Institute; Repp, Northern Illinois U.;
Charlop, Claremont College; Heward, Heron, Ohio State U.;
Salient Research Studies: 42
Time Span: 1965 – 1996
Sample Study:
Schreibman, L. (1975). Effects of within-stimulus and extra-stimulus prompting on discrimination
learning in autistic children. Journal of Applied Behavior Analysis, 8, 91-112.
Generalization of Treatment Gains
Significant Researchers:
Wolf, Sulzbacher, U. of Washington; Sulzer, U. of Massachusetts; Sailor, Walker, Baer, Hart, Risley, U. of
Kansas; Wahler, U. of Tennessee; Rincover, Koegel, UCLA; Handleman, Rutgers; McGee, Krantz,
McClannahan, Princeton Child Development Center;
Salient Research Studies: 29
Time Span: 1966 – 1996
Sample Study:
McGee, G.G., Krantz, P.J., & McClannahan, L.E. (1985). The facilitative effects of incidental teaching on
preposition use by autistic children. Journal of Applied Behavior Analysis. 18, 17-32.
Gena, A., Krantz, P., McClannahan, L.E., & Poulson, C.L. (1996). Training and generalization of affective
behavior displayed by youth with autism. Journal of Applied Behavior Analysis, 29, 291-304.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
15
Why is ABA Evidence-Based?
4/27/13
Research on the Treatment of
Language Deficits
Development of Imitation Skills
Significant Researchers:
Baer, Sherman, Garcia, U. of Kansas; Lovaas, UCLA;
Salient Research Studies: 19
Time Span: 1964 – 1994
Sample Study:
Baer, D.M., Peterson, R.F., & Sherman, J.A. (1967). The development of imitation by reinforcing
behavioral similarity to a model. Journal of the Experimental Analysis of Behavior, 10, 405-416.
Development of Basic Language Skills
Significant Researchers:
Michael, U. of Arizona; Salzinger, Columbia U.; Risley, Wolf, U. of Washington; Sloane, Mithaug, Charlop,
Claremont College; Foxx, Southern Illinois U.;
Salient Research Studies: 28
Time Span: 1965 – 1987
Sample Study:
Schumaker, J., & Sherman, J.A. (1970). Training generative verb usage by imitation and reinforcement
procedures. Journal of Applied Behavior Analysis. 3, 273-287.
Research on the Treatment of
Language Deficits
Development of Complex Language Skills
Significant Researchers:
Guess, Baer, Sailor, Garcia, U. of Kansas; Krantz, McClannahan, Princeton Child Development Center;
Smith, Lovaas, UCLA;
Salient Research Studies: 32
Time Span: 1968 – 1992
Sample Study:
Stevens-Long, J, & Rasmussen, M. (1974). The acquisition of simple and compound sentence structure in
an autistic child. Journal of Applied Behavior Analysis. 7, 473-479.
Development of Social Compliance
Significant Researchers:
Baer, Rowbury, Allen, U. of Kansas; Forehand, U. of Georgia; Neef, Russo, Cataldo, Johns Hopkins U.;
Mace, U. of Utah;
Salient Research Studies: 18
Time Span: 1964 – 1988
Sample Study:
Larsson, D. G., & Larsson, E. V. (1983). Manipulating peer presence to program the generalization of
verbal compliance from one-to-one to group instruction. Education and Treatment of Children, 6,
109-122.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
16
Why is ABA Evidence-Based?
4/27/13
Research on the Treatment of
Significant Social Deficits
Development of Social Play Skills
Significant Researchers:
Baer, Allen, Hart, Rogers, Rowbury, Fowler, Kohler, Greenwood, U. of Kansas; Koegel, Dunlap, Dyer,
UCLA; Strain, U. of Pittsburgh; Carr, SUNY Stony Brooke; McEvoy, Vanderbilt;
Salient Research Studies: 31
Time Span: 1968 – 1994
Sample Studies:
Haring, T.G. (1985). Teaching between-class generalization of toy play behavior to handicapped children.
Journal of Applied Behavior Analysis. 18, 127-140.
Pierce, K., & Schreibman, L., (1995). Increasing complex social behaviors in children with autism: Effects
of peer-implemented pivotal response training. Journal of Applied Behavior Analysis, 28. 285-296.
Development of Creativity and Spontaneity
Significant Researchers:
Baer, U. of Kansas; Charlop, Schreibman, Claremont College; Dunlap, Marshall U; Haring, U. of
Washington; Van Houten, Halifax U.; Harris, Rutgers;
Salient Research Studies: 18
Time Span: 1972 – 1995
Sample Studies:
Goetz, E.M., & Baer, D.M. (1973). Social control of form diversity and the emergence of new forms in
children’s block building. Journal of Applied Behavior Analysis. 6, 209-217.
Ingenmey, R., & Van Houten, R. (1991). Using time delay to promote spontaneous speech in an autistic
child. Journal of Applied Behavior Analysis, 24, 591-596.
Research on the Treatment of
Significant Social Deficits
Development of Social Conversation Skills
Significant Researchers:
Garcia, Kamps, U. of Kansas; Strain, U. of Pittsburgh; Neef, Western Michigan State; Charlop, Claremont
College; Koegel, U.C. Santa Barbara; Krantz, McClannahan, Princeton Child Development Institute;
Salient Research Studies: 32
Time Span: 1974 – 1995
Sample Studies:
Camarata, S. (1993). The application of naturalistic conversation training to speech production in children
with speech disabilities. Journal of Applied Behavior Analysis, 26. 173-182.
Development of Group and Classroom Skills
Significant Researchers:
Koegel, Rincover, Russo, UCLA; Favell, U. of North Carolina; Fowler, Baer, Guess, Kamps, U. of Kansas;
Strain, U. of Pittsburgh; Sasso, U. of Iowa;
Salient Research Studies: 26
Time Span: 1967 – 1994
Sample Studies:
Werts, M.G., Caldwell, N.K., & Wolery, M. (1996). Peer modeling of response chains: Observational
learning by students with disabilities. Journal of Applied Behavior Analysis, 29, 53-66.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
17
Why is ABA Evidence-Based?
4/27/13
Service System Research
Staff and Parent Training Procedures
Significant Researchers:
Guess, Baer, Spradlin, U. of Kansas; Koegel, Schreibman, Russo, Rincover, Glahn, UCLA; O’Dell, U. of
Mississippi; McClannahan, Krantz, McGee, Princeton Child Development Center; Strain, U. of
Pittsburgh; Dyer, Luce, The May Institute;
Salient Research Studies: 41
Time Span: 1968 – 1993
Sample Studies:
Koegel, R.L, Russo, D.C., & Rincover, A., (1977). Assessing and training teachers in the generalized use of
behavior modification with autistic children. Journal of Applied Behavior Analysis, 10, 197-205.
Koegel, R.L., Glahn, T.J. & Nieminen, G.S. (1978). Generalization of parent-training results. Journal of
Applied Behavior Analysis, 11, 95-109.
39 Group Replications of Intensive
Treatment Research
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Eldevik, S., Hastings, R., Jahr, E., & Hughes, J.C. (2012). Outcomes of behavioral intervention for
children with autism in mainstream pre-school settings. Journal of Autism and Developmental
Disorders. 42, 210-220.
Leaf, R.B., Taubman, M.T., McEachin, J.J., Leaf, J.B., & Tsuji, K.H. (2011). A program description of
a community-based intensive behavioral intervention program for individuals with Autism Spectrum
Disorders. Education and Treatment of Children. 34, 259-285.
Dawson, G., Rogers, S.J., Munson, J., Smith, M., Winter, J., Greenson, J., et al. (2010). Randomized,
controlled trial of an intervention for toddlers with autism: The early start Denver model. Pediatrics,
125, 17–23.
Smith, I.M., Koegel, R.L., Koegel, L.K., et al. (2010). Effectiveness of a novel community-based early
intervention model for children with autistic spectrum disorder. American Journal on Intellectual
and Developmental Disabilities. 115, 504–523.
Kelley, E., Naigles, L., & Fein, D. (2010). An in-depth examination of optimal outcome children with
a history of autism spectrum disorders. Research in Autism Spectrum Disorders. 4, 526-538.
Kasari, C., Gulsrud, A., Wong, C., et al. (2010). Randomized controlled caregiver-mediated joint
engagement intervention for toddlers with autism. Journal of Autism and Developmental Disorders,
40, 1045–1056.
McGarrell, M., Healy, O., Leader, G., O'Connor, J., & Kenny, N. (2009). Six reports of children with
autism spectrum disorder following intensive behavioral intervention using the Preschool Inventory
of Repertoires for Kindergarten (PIRK). Research in Autism Spectrum Disorders, 3, 767-782,
Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral
therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial.
Journal of Children Psychology and Psychiatry and Allied Disciplines, 50, 224-234.
Perry, A., Cummings, A., Geier, J. D., Freeman, N. L., Hughes, S., LaRose, L., Managhan, T., Reitzel,
J.-A., & Williams, J. (2008). Effectiveness of intensive behavioral intervention in a large, communitybased program. Research in Autism Spectrum Disorders, 2, 621–642.
Osborne, L.A., McHugh, L., Saunders, J. & Reed, P. (2008). Parenting Stress Reduces the
Effectiveness of Early Teaching Interventions for Autistic Spectrum Disorders. Journal of Autism
and Developmental Disorders. 38, 1092–1103
Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2007) Outcome for Children with Autism who began
Intensive Behavioral Treatment Between Ages 4 and 7: A Comparison Controlled Study. Behavior
Modification, 31, 264-278.
Remington, B., Hastings, R.P., Kovshoff, H., degli Espinosa, F., Jahr, E., Brown, T., Alsford, P.,
Lemaic, M., & Ward, N. (2007). Early intensive behavioral intervention: Outcomes for children with
autism and their parents after two years. American Journal on Mental Retardation. 112, 418-438.
Ben-Itzchak, E., & Zachor, D.A. (2007). The effects of intellectual functioning and autism severity on
outcome of early behavioral intervention for children with autism. Research in Developmental
Disabilities, 28, 287–303.
Eldevik, S., Eikeseth, S., Jahr, E., & Smith, T. (2006). Effects of Low-Intensity Behavioral Treatment
for Children with Autism and Mental Retardation. Journal of Autism & Developmental Disorders.
36, 211-224.
Cohen, H., Amerine-Dickens, M., & Smith, T., (2006). Early Intensive Behavioral Treatment:
Replication of the UCLA Model in a Community Setting. Developmental and Behavioral Pediatrics,
27, S145-S155.
Butter, E. M., Mulick, J. A., & Metz, B. (2006). Eight case reports of learning recovery in children
with pervasive developmental disorders after early intervention. Behavioral Interventions, 21,
227-243.
Kelley, E., Paul, J.J., Fein, D., & Naigles, L.R. (2006). Residual language deficits in optimal outcome
children with a history of autism. Journal of Autism and Developmental Disorders. 36, 807-828.
Howard, J.S., Sparkman, C.R., Cohen, H.G., Green G., & Stanislaw H. (2005). A comparison of
intensive behavior analytic and eclectic treatments for young children with autism. Research in
Developmental Disabilities. 26, 359-383.
Sallows, G.O., & Graupner, T.D. (2005). Intensive Behavioral Treatment for Children With Autism:
Four-Year Outcome and Predictors. American Journal on Mental Retardation, 110, 417-438.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
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Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4to 7-year-old children with autism – A 1-year comparison controlled study. Behavior Modification,
26, 46-68.
Green, G., Brennan, L.C., & Fein, D. (2002). Intensive behavioral treatment for a toddler at high risk
for autism. Behavior Modification. 26. 69-102.
Bibby P, Eikeseth S, Martin, N. T., Mudford, O. C., & Reeves, D., (2002). Progress and outcomes for
children with autism receiving parent-managed intensive interventions. Research in Developmental
Disabilities. 23, 81-104.
Mudford, O.C., Martin, N.T., Eikeseth, S., & Bibby, P. (2001). Parent-managed behavioral treatment
for preschool children with autism: Some characteristics of UK programs. Research in
Developmental Disabilities, 22, 173-182.
Smith, T., Buch, G.A., & Gamby, T.E. (2000). Parent-directed, intensive early intervention for
children with pervasive developmental disorder. Research in Developmental Disabilities, 21,
297-309.
Smith, T., Groen, A.D., & Wynn, J.W. (2000). Randomized trial of intensive early intervention for
children with pervasive developmental disorder. American Journal on Mental Retardation.105,
269-285.
Harris, S.L., & Handleman, J.S. (2000). Age and IQ at intake as predictors of placement for young
children with autism: a four- to six-year follow-up. Journal of Autism and Developmental Disorders,
30, 137-142.
Weiss, M. J. (1999). Differential rates of skill acquisition and outcomes of early intensive behavioral
intervention for autism. Behavioral Interventions, 14, 3-22.
Sheinkopf, S., & Siegel, B. (1998). Home-based behavioral treatment for young autistic children.
Journal of Autism and Developmental Disorders. 23, 15-23.
Smith T., Eikeseth, S., Klevstrand, M., & Lovaas, O.I. (1997). Intensive behavioral treatment for
preschoolers with severe mental retardation and pervasive developmental disorder. American
Journal on Mental Retardation. 102, 238-249.
Perry, R., Cohen, I., & DeCarlo, R. (1995). Case study: Deterioration, autism, and recovery in two
siblings. Journal of the American Academy of Child and Adolescent Psychiatry. 34, 232-237.
Smith, T., Klevstrand, M., & Lovaas, O.I. (1995). Behavioral treatment of Rett's Disorder:
Ineffectiveness in three cases. American Journal on Mental Retardation, 100, 317-322.
Birnbrauer, J.S., & Leach, D.J. (1993). The Murdoch early intervention program after 2 years.
Behaviour Change, 10, 63-74.
Harris, S., Handleman, J., Gordon, R., Kristoff, B., & Fuentes, F. (1991). Changes in cognitive and
language functioning of preschool children with autism. Journal of Autism and Developmental
Disorders, 21, 281-290.
Dunlap, G., Robbins, F.R., Dollman, C., & Plienis, A.J. (1988). Early intervention for young children
with autism: A regional training approach. Huntington, WV: Marshall University.
Sherman, J., Barker, P., Lorimer, P., Swinson, R., & Factor, D. (1988). Treatment of autistic children:
Relative effectiveness of residential, out-patient and home-based interventions. Child Psychiatry and
Human Development, 19, 109-125.
Anderson, S. R., Avery, D. L., DiPietro, E. K., Edwards, G. L., & Christian, W. P. (1987). Intensive
home-based early intervention with autistic children. Education and Treatment of Children, 10,
352-366.
Harris, S.L. (1986). Parents as teachers: A four to seven year follow up of parents of children with
autism. Child & Family Behavior Therapy, 8, 39-47.
Fenske, E.C., Zalenski, S., Krantz, P.J., & McClannahan, L.E. (1985). Age at intervention and
treatment outcome for autistic children in a comprehensive intervention program. Analysis and
Intervention in Developmental Disabilities, 5, 49-58.
Strain, P.S., Hoyson, M.H., & Jamieson, B.J. (1985). Normally developing preschoolers as
intervention agents for autistic‑like children: Effects on class deportment and social interactions.
Journal of the Division for Early Childhood. 9, 105‑115.
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Why is ABA Evidence-Based?
4/27/13
9 Meta Analyses of Intensive
Treatment Research
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Reichow, B. (2012). Overview of Meta-Analyses on Early Intensive Behavioral Intervention for Young Children with
Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. 42, 512-520.
Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). A meta-analytic study on the effectiveness of
comprehensive ABA-based early intervention programs for children with Autism Spectrum Disorders. Research in
Autism Spectrum Disorders, 5, 60-69. doi:10.1016/j.rasd.2010.03.011
Eldevik, S., Hastings, R.P., Hughes, J.C., Jahr, E., Eikeseth, S., & Cross, S., (2010). Using Participant Data to Extend
the Evidence Base for Intensive Behavioral Intervention for Children With Autism. American Journal on Intellectual
and Developmental Disabilities. 115, 381-405. DOI: 10.1352/1944-7558-115.5.381
Virués-Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood: Meta-analysis, metaregression and dose–response meta-analysis of multiple outcomes. Clinical Psychology Review. 30, 387-399. doi:
10.1016/j.cpr.2010.01.008
Makrygianni, M.K., & Reed, P. (2010). A meta-analytic review of the effectiveness of behavioural early intervention
programs for children with Autistic Spectrum Disorders. Research in Autism Spectrum Disorders. 4:577-593. doi:
10.1016/j.rasd.2010.01.014
Eldevik, S., Hastings, R.P., Hughes, J.C., Jahr, E., Eikeseth, S., & Cross, S., (2009). Meta-analysis of early intensive
behavioral intervention for children with autism. Journal of Clinical Child and Adolescent Psychology. 38, 439–450.
doi:10.1080/15374410902851739. PMID 19437303.
Reichow, B., & Wolery, M. (2008). Comprehensive synthesis of early intensive behavioral interventions for young
children with autism based on the UCLA Young Autism Project model. Journal of Autism and Developmental
Disorders. 31:23–41. doi:10.1007/s10803-008-0596-0. PMID 18535894.
Bellini, S., Peters, J.K., Benner, L., & Hopf, A. (2007). A meta-analysis of school-based social skills interventions for
children with autism spectrum disorders. Remedial and Special Education. 28, 153-162.
Bellini, S., & Akullian, J. (2007). A Meta-Analysis of Video Modeling and Video Self-Modeling Interventions for
Children and Adolescents with Autism spectrum disorders. Exceptional Children, 73, 261-284.
What are the essential features of
these studies?
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
19
Why is ABA Evidence-Based?
4/27/13
Evidence-Based Levels of Behavior Therapy,
Behavior Analysis, and Clinical Supervision
What is the effective age
for ABA?
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
20
Why is ABA Evidence-Based?
4/27/13
Cost Effective Age Range of EIBI
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The range of age cut-offs in evidence-based EIBI studies were
established for the purpose of controlled research, and were
based upon a number of factors, such as available funding.
They weren’t meant to imply that autism was untreatable after
those ages.
Throughout the EIBI literature, the published range of such age
cut-offs, for the purpose of research, was 48 to 84 months for
the maximum age to begin receiving treatment, and then the
subsequent duration of treatment was one to five years.
Therefore the age of completion of these children’s intensive
treatment was up to 12 years of age.
Social Skills Meta Analysis
 
 
Bellini and colleagues, in 2007, reported the following age
ranges of 155 children who benefited from ABA social skills
training:
“21 studies involved preschool-age children, 23 involved
elementary age children, and 5 studies involved secondary-age
students.” (page 158).
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
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Why is ABA Evidence-Based?
4/27/13
Social Skills Meta Analysis
 
 
 
Reichow and Volkmar, in 2010, reported on 31 studies of
children, aged four to fifteen, who benefited from ABA social
skills training:
“The school-age category had the highest participant total of the
three age categories (N = 291).” (page 156).
“Within the last 8 years, 66 studies with strong or acceptable
methodological rigor have been conducted and published.
These studies have been conducted using over 500 participants,
and have evaluated interventions with different delivery agents,
methods, target skills, and settings. Collectively, the results of
this synthesis show there is much supporting evidence for the
treatment of social deficits in autism.” (page 161).
Aggression – Peer Review
 
 
 
Brosnan and Healy, in 2011, reported on 18 studies of children
aged three to 18, who received effective ABA treatment to
reduce or eliminate severe aggressive behavior:
“All of the studies reported decreases in challenging behavior
attributed to the intervention. Of the studies included, seven
reported total or near elimination of aggression of at least one
individual during intervention in at least one condition.” (page
443).
“only four of the studies conducted follow-up assessments.
However, each of these studies reported that treatment gains
were maintained.” (page 443).
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
22
Why is ABA Evidence-Based?
4/27/13
Anxiety
 
 
 
Lang, et al. in 2010, reported on nine studies which involved
110 children aged nine to 23, who received a variety of forms of
behavior therapy for anxiety.
“Within each reviewed study, at least one dependent variable
suggested a reduction in anxiety following implementation of
CBT.” (page 60).
“CBT has been modified for individuals with ASD by adding
intervention components typically associated with applied
behaviour analysis (e.g. systematic prompting and differential
reinforcement). Future research involving a component analysis
could potentially elucidate the mechanisms by which CBT
reduces anxiety in individuals with ASD, ultimately leading to
more efficient or effective interventions.” (page 53).
Problem Behavior
 
 
Hanley, Iwata, and McCord in 2003, reported on 277 studies
which involved 536 children and adults (70% of the studies
included persons between the ages of 1 and 18, and 37% also
included persons older than 18), who received functional
analyses of problem behaviors. Of these, 96 percent were able
to yield an analysis of the controlling variables of the problem
behavior. The specific functional analysis of individual problem
behaviors is crucial to the successful intervention with those
behaviors.
“Large proportions of differentiated functional analyses showed
behavioral maintenance through social-negative (34.2%) and
social-positive reinforcement (35.4%). More specifically, 25.3%
showed maintenance via attention and 10.1% via access to
tangible items. Automatic reinforcement was implicated in
15.8% of cases.” (pages 166-167).
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
23
Why is ABA Evidence-Based?
4/27/13
Self Injury
 
Iwata and colleagues, in 1994, reported on the effective
treatment of self-injurious behavior with 152 children,
adolescents, and adults. In their sample, 39 were between the
ages of 11 and 20, and 74 were 21 and older. The function of the
self-injurious behavior could be identified in 95% of the
persons, and in 100% of those cases an effective treatment
could then be prescribed.
 
“Results of the present study, in which single-subject designs
were used to examine the functional properties of SIB in 152
individuals, indicated that social reinforcement was a
determinant of SIB in over two thirds of the sample, whereas
nonsocial (automatic) consequences seemed to account for
about one fourth of the cases.” (page 234).
The Evidence Base for Treatment
 
 
 
 
 
 
 
Independent Panels
Peer Review
Long-Term and Group Outcome Studies
  RCTs Randomized Controlled Trials
  Non-Randomized Matched Trials
  Registries
Comparison Data
Meta-Analysis
Cost-Effectiveness Analyses
ABA Applied Behavior Analysis
  Within-Subject Experimental Studies
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
24
Why is ABA Evidence-Based?
4/27/13
Independent Panels
Independent National Reviews
 
 
 
 
 
 
 
 
 
The APA Society for Clinical Child and Adolescent Psychology
American Academy of Pediatrics
The U.S. Agency for Health Care Research and Quality
The National Institute of Mental Health
National Research Council
The State of California
The State of New York
The U.S. Surgeon General
The Center for Disease Control
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
25
Why is ABA Evidence-Based?
4/27/13
Division 53 of the American Psychological Association (the
Society for Clinical Child and Adolescent Psychology)
“Randomized controlled trials have demonstrated positive effects
in both short-term and longer term studies. The evidence
suggests that early intervention programs are indeed beneficial
for children with autism, often improving developmental
functioning and decreasing maladaptive behaviors and symptom
severity at the level of group analysis.”
“Lovaas’s treatment meet Chambless and colleague’s (Chambless
et al., 1998; Chambless et al., 1996) criteria for ‘well-established”’
“Across all the studies we cited, improvements in language,
communication, and IQ, and reduction in severity of autism
symptoms indicate that the core symptoms of autism appear
malleable in early childhood”
Rogers & Vismara (2008)
American Academy of Pediatrics
“The effectiveness of ABA-based intervention in ASDs has been
well documented through 5 decades of research by using singlesubject methodology and in controlled studies of comprehensive
early intensive behavioral intervention programs in university
and community settings.”
“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.”
Myers, Johnson, & the American Academy of Pediatrics Council
on Children With Disabilities, (2007).
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
26
Why is ABA Evidence-Based?
4/27/13
Hawaii Department of Health
“Best Support: Intensive Behavioral Treatment was successful in
three (3) studies, beating alternative treatments in two (2) of
those, and beating a no-treatment control in one (1). Likewise,
Intensive Communication Training was also successful in three
(3) studies, beating alternative treatments in two (2) of those, and
beating a no-treatment control in one (1) study.”
“These results are quite promising in terms of effect size, although
it should be noted that the outcome variables for these studies
mainly involved reductions in the frequency of autistic behaviors
or increases in social communication or other forms of social
exchange (e.g., turn taking). None of these studies claimed that
children were autism free following the intervention programs.
Nevertheless, these findings represent an extraordinary
improvement over the evidence base for interventions for autistic
spectrum disorders in the previous Biennial Report.
Is there a consensus?
 
 
 
Forty-five such independent, meta-analysis, and peer reviews
are available.
Every review cites the obvious positive results of ABA and EIBI
and accepts them as proven.
The reviews are critical evaluations
  in many cases, other non-ABA treatments are assigned to
categories such as
  “insufficient evidence,”
  “unproven,” or
  “potentially harmful.”
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
27
Why is ABA Evidence-Based?
4/27/13
Cost Effectiveness Analyses - CDC
 
 
“The mean medical expenditures for children with ASD were 6
times higher than those of the comparison group.”
“Children with ASD and ID incurred expenditures 2.7 times
higher than did children with ASD and no co-occurring
condition.”
Peacock, G, Amendah, D., Ouyand, L., & Grosse, S.D. (2012) Autism
Spectrum Disorders and Health Care Expenditures: The Effects of CoOccurring Conditions. Journal of Developmental & Behavioral
Pediatrics. 33, 2-8.
Comparison Data
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
28
Why is ABA Evidence-Based?
4/27/13
Comparison Data
Lord & Schopler, 1989
What is the evidence for the
outcomes without ABA
 
 
 
“Health care utilization and costs are substantially higher for
children and adolescents with ASDs”
“mortality is increased as well.”
“Cases of suicide in higher-functioning individuals have been
reported.”
American Academy of Pediatrics (2007)
Howlin (2005)
Liptak, Stuart, Auinger. (2006)
Croen, Najjar, Ray, Lotspeich, Bernal (2006)
Mandell, Cao, Ittenbach, Pinto-Martin. (2006)
Shavelle, Strauss, Pickett (2001)
Pickett, Paculdo, Shavell, Strauss (2006)
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
29
Why is ABA Evidence-Based?
4/27/13
Other Medical Reviews
“Recovery in children with ASD through behavioral and
educational interventions seems possible in a significant minority
of cases.”
Helt, Kelley, Kinsbourne, Pandey, Boorstein, Herbert, & Fein (2008). (The
authors are psychologists and pediatricians at the University of Connecticut,
Queen’s University, the New School, Children’s Hospital of Philadelphia,
and Massachusetts General Hospital).
“The weight of currently available scientific evidence, however,
indicates that ABA should be viewed as the optimal,
comprehensive treatment approach in young children with ASD.”
Barbaresi, Katusic, & Voigt (2006). (The authors are pediatricians at the
Mayo Clinic and at Harvard University).
Meta Analyses
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
30
Why is ABA Evidence-Based?
4/27/13
Meta Analyses of Magnitude of Effect and
Dosage Effects
“Results suggested that long-term, comprehensive ABA
intervention leads to (positive) medium to large effects in terms
of intellectual functioning, language development, acquisition of
daily living skills and social functioning in children with autism.”
“Although favorable effects were apparent across all outcomes,
language-related outcomes (IQ, receptive and expressive
language, communication) were superior to non-verbal IQ, social
functioning and daily living skills, with effect sizes approaching
1.5 for receptive and expressive language and communication
skills.”
“Dose-dependant effect sizes were apparent by levels of total
treatment hours for language and adaptation composite scores.”
Virues-Ortega, (2010)
So what is the controversy?
 
 
 
 
In none of the reviews do the authors systematically refute the
published evidence for ABA treatments of autism.
The most “negative” conclusions that are offered are:
1) ABA does not cure all children of autism
2) ABA is not the only established treatment, nor is it clearly
the best treatment
3) There are not well-established means to identify the best
candidates for treatment
These conclusions can be drawn about any medical treatment
that already enjoys full coverage,
they should not be cause for denying coverage for ABA.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
31
Why is ABA Evidence-Based?
4/27/13
Reports cited as Negative
“There is little question now that early intensive behavioral
intervention is highly effective for some children. However, gains
are not universal, and some children make only modest progress
while others show little or no change, sometimes after extremely
lengthy periods in treatment.”
Howlin, Magiati, & Charman, (2009). (The authors are professors at the
Institute of Psychiatry, King’s College (London, UK) and University College,
London, Institute of Child Health).
Agency for Healthcare Research and Quality
(AHRQ) Comparative Effectiveness Review
“Evidence supports early intensive behavioral and developmental
intervention, including the University of California, Los Angeles
(UCLA)/Lovaas model and Early Start Denver Model (ESDM) for
improving cognitive performance, language skills, and adaptive
behavior in some groups of children.”
“Evidence suggests that interventions focusing on providing
parent training and cognitive behavioral therapy (CBT) for
bolstering social skills and managing challenging behaviors may
be useful for children with ASDs to improve social
communication, language use, and potentially, symptom
severity.”
Warren, et al. (2011)
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
32
Why is ABA Evidence-Based?
4/27/13
AHRQ “Negative” Qualifiers
“All of these studies need to be replicated, and specific focus is
needed to characterize which children are most likely to benefit.”
“Information is lacking on modifiers of effectiveness,
generalization of effects outside the treatment context,
components of multicomponent therapies that drive
effectiveness, and predictors of treatment success.”
AHRQ Review of Alternatives
“No current medical interventions demonstrate clear benefit for
social or communication symptoms in ASDs.”
“Little evidence is available to assess other behavioral
interventions, allied health therapies, or complementary and
alternative medicine.”
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
33
Why is ABA Evidence-Based?
4/27/13
What about the AHRQ?
 
 
 
The AHRQ report reached these positive conclusions about ABA
and EIBI despite:
  excluding a large number of studies
  Sample size less than 10
  excluding all studies published prior to 2000
  Already covered elsewhere
  ADOS
  Bias toward RCTs – Randomized Controlled Trials
  Not experts in ABA for autism, so analysis is lacking
Yet the AHRQ report still found 78 studies of behavioral
interventions, which included 34 studies of EIBI, that met their
criteria for inclusion.
The report of “strength of evidence” is not the same as “strength
of effect.”
Applied Behavior Analysis Answers
the Questions Raised by the AHRQ
 
 
 
 
 
 
Addresses the heterogeneous diagnosis of autism
The outcomes of ABA research are the objective improvements
in the behavior of individual children
Analyzes the individual components of treatment, and the
individual responses to treatment
Addresses the needs for generalization and maintenance
The research is not composed of uncontrolled case studies
  They are powerful within-subject controlled experiments
Provides a model for clinical practice
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
34
Why is ABA Evidence-Based?
4/27/13
Other Standards for Evidence
 
 
 
Smith, 2012: Single-Case Experimental Designs: A Systematic
Review of Published Research and Current Standards
Chambless: 1998: Defining empirically supported therapies.
Kazdin & Weisz, 2010: Evidence based psychotherapies for
children and adolescents.
Evidence Based Practices in
Within Subject Controlled Experiments
Reichow, Volkmar, Cicchetti, (2008)
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
35
Why is ABA Evidence-Based?
4/27/13
Evidence Based Practices in
Within Subject Controlled Experiments
Reichow, Volkmar, Cicchetti, (2008)
Peer Reviews
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
36
Why is ABA Evidence-Based?
4/27/13
ABA Effects on Social Skills
“Within the last 8 years, 66 studies with strong or acceptable
methodological rigor have been conducted and published.”
“These studies have been conducted using over 500 participants,
and have evaluated interventions with different delivery agents,
methods, target skills, and settings.”
“Collectively, the results of this synthesis show there is much
supporting evidence for the treatment of social deficits in
autism.”
Reichow, & Volkmar, (2010).
ABA Effects on Challenging Behavior
“The available intervention technology is reasonably effective at
reducing problem behaviors performed by people with
developmental disabilities, including autism.”
“Reductions of 80% or greater were reported in half to two thirds
of the comparisons.”
“Reductions of 90% or greater were reported for all classes of
problem behavior, and with individuals with all diagnostic
labels.”
Horner, Carr, Strain, Todd, & Reed, (2002)
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
37
Why is ABA Evidence-Based?
4/27/13
National Autism Center (2009)
 
Standards on ABA-researched procedures
 
Established
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antecedent Package
Behavioral Package
Comprehensive Behavioral Treatment for Young Children
Joint Attention Intervention
Modeling
Naturalistic Teaching Strategies
Peer Training Package
Pivotal Response Treatment
Schedules
Self-management
Story-based Intervention Package
Emerging
Unestablished
Ineffective/Harmful
What about Other Treatments?
 
 
The RCT, Randomized Controlled Trial is not well suited to
uncover many of the specific treatments that help the individual
children who are under the Heterogeneous umbrella of autism.
Instead it is single subject laboratory research that can detect
promising therapies.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
38
Why is ABA Evidence-Based?
4/27/13
What evidence are the Policy Makers and
Funders looking for?
 
 
 
They want a system of cost-effective management of autism
services
In addition to the money that they pay out for coverage,
How does the health plan control their own bureaucratic costs?
Effective cost control through
accountability for results
Instead of managing the process,
let’s manage the outcomes.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
39
Why is ABA Evidence-Based?
4/27/13
Cost effectiveness through
Assessment of Value
 
 
 
 
 
Conform with Medical Necessity Guidelines for Rehabilitative
Treatment
Identify evidence-based treatment models.
Identify evidence-based service-delivery models.
Certify the provider organizations who maximize value.
Prescribe the optimal form of treatment, intensity, and service
delivery for each child’s prognosis at intake
 
 
 
 
 
Individual behavioral measures
Complicating conditions
Parent involvement
Service capacity
Prescribe the continuation of care based upon each individual
child’s responsiveness to treatment
Socially Significant
Independence Discharge Objectives
Receptive Language, the child will understand and comply with instructions.
____
Generalized compliance.
____
Distal compliance.
Expressive Language, the child will use functional language with care-providers and natural peers.
____
Intelligible speech.
____
Functional requests.
Pro-social skills, the child will interact appropriately with natural peers.
____
Generalized imitation.
____
Cooperative play with adult.
____
Cooperative play with a typical age-peer.
____
Small-group attending.
____
Maintain two mutual friendships.
Community Living, the child will safely use the community.
____
Walk with adult.
____
Parent Mastery.
____
Participate in community.
Self-Care, the child will attend to personal needs independently.
____
Appropriate nutrition.
____
Appropriate sleep.
____
Independent toileting.
Self-control, the child will control severely health-threatening behavior at all times.
____
Waiting.
____
Self-control of health-threatening behavior
____
Self-control of stereotyped offensive behavior
____
Self-control of physical aggression.
____
Self-control of property destruction.
____
Self-control of bolting behavior
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
40
Why is ABA Evidence-Based?
4/27/13
Socially Significant
Long-Term Service Objectives
 
Accepted standard practice process measures in supported employment
 
 
 
 
Competitive work Averages at least 20 hr per week for each pay period
Integrated work setting has a work group of not more than 8 individuals with
handicaps, and has regular contact with typical co-workers
Ongoing support services provide continuous or periodic job skill training
provided at least twice monthly at the job site
Implicit outcome measures in supported employment
 
 
 
 
 
 
Movement from the more restrictive (sheltered workshop) to a setting with
more independence (work enclave), due to case management.
More accurate placement into services (accurately matching recipients to
services)
Cost-benefit of job retention and increased earnings, as they offset the cost of
the service.
Social Validity of quality of life and reduction of family anxiety.
Quality of implementation of the specialized skills of the practitioner.
Accessibility of services – adequate network, and adequate professional
training system.
Payment Reform
 
 
Payment systems should reinforce best practices and reduce
incentives for abuse.
ABA offers objective criteria for decision making in human
services.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
41
Why is ABA Evidence-Based?
4/27/13
Ivar Lovaas (2003)
“Providers of ABA services who do not report treatment outcome should take
notice of this problem of falling into the same trap of those service
providers who preceded us, of misleading parents and short-changing their
children.
“Today the contingencies are different for the majority of providers who are
reinforced by charging fees for services with minimal or no outcome data
and peer review. We may be drifting off the criterion of data-based
treatment procedures and, if we do, the future may look as bleak for us as
for the Freudians.
“I shudder at the thought of someone receiving a grant to assess long-term
outcome from ABA providers. Will the parents of these children feel that
they have been deceived?
“Now that we are being accepted as fellow citizens and providing what is
considered the ‘treatment of choice,’ we need to be concerned about the
truthfulness of what treatment we offer.”
Opening the road to an enlightened future. In K.S. Budd &
T. Stokes (Eds.), A small matter of proof: The legacy of
Donald M. Baer (pp. 225-332). Reno NV: Context Press.
(c) Eric Larsson, PhD, BCBA-D,
The Lovaas Institute Midwest
42