WHAT IS EVIDENCE BASED PRACTICE?
For children with Autism Spectrum Disorders…and others.
What is an Evidence Based Practice or EBP?
Recently there have been two primary projects which have complied vast amounts of research in order to make an in-depth analysis of the research on autism treatment. As a result of those two projects we have a good idea of what is currently considered EBP for children with ASD (Autism Spectrum Disorders).
One of those projects provided the results which can be found at: http://www.nationalautismcenter.org/pdf/NAC%20Ed%20Manual_FINAL.pdf
Another slightly older overview of research can be found at: http://www.nap.edu/openbook.php?record_id=10017&page=231
Please see: Evidence Based Practice in Autism: Presenters: Patricia Schetter, M.A., BCBA & Aaron Stabel, M.A., BCBA at: http://www.ucdmc.ucdavis.edu/mindinstitute/videos/video_autism.html for an explanation of the two projects.
What are some of the comprehensive interventions for young children with Autism which have been found to represent EBP?
ABA: Behavior Analysis is the scientific study of behavior. Applied Behavior Analysis is the application of the principles of learning and motivation from Behavior Analysis, and the procedures and technology derived from those principles, to the solution of problems of social significance. Many decades of research have validated treatments based on ABA.
Also known as the Early Start Denver Model is a well researched combination of behavioral and developmental therapy. It has produced very good results with children who’s IQ is as low as 35 (the lowest or one of the lowest of any of the well researched established models providing excellent outcomes).
DIR®/Floortime™ The Developmental, Individual Difference, Relationship-based The objectives of the DIR®/Floortime™ Model are to build healthy foundations for social, emotional, and intellectual capacities rather than focusing on skills and isolated behaviors. http://www.icdl.com/dirFloortime/overview/index.shtml
PRT: Pivotal Response Treatment … Pivotal Response Teaching, and Pivotal Response Training, PRT focuses on targeting “pivotal” behavioral and skill areas.
TEACCH: Treatment and Education of Autistic and Related Communication Handicapped Children
The foundation of this structured teaching intervention is the modification of the environment to assist the child in the learning process. The focus of this intervention is on organizing the child’s physical environment to facilitate overall task success, capitalizing on visual strengths typically displayed by students with ASD and minimizing reliance on auditory processing/verbal expression. http://www.teacch.com/
What are some of the Models/Packages which have been found to meet EBP for children with ASD?
· Antecedent Package … These interventions adjust the environment and interactions before the behavior and are meant to either increase or decrease a subsequent behavior. This includes understanding and adjusting “setting events” as well as the more immediate stimulus right before a behavior.
· Behavioral Package … These interventions include traditional behavioral conditioning and rely heavily on positive and negative reinforcement.
· Comprehensive Behavioral Treatment for Young Children … This treatment is eclectic in nature with many aspects of ABA and related interventions.
· Joint Attention … These interventions help to develop the foundational skills required for focusing or paying attention to the same object or person, and at the same time, as another person. This essential skill is often difficult for children with autism.
· Modeling … These interventions use either video or live modeling of appropriate behaviors/skills to help individuals develop those same behaviors or skills. It is often used with other interventions which incorporate reinforcement.
· Naturalistic Teaching Strategies … These interventions concentrate on natural reinforcement and natural consequences in the natural environment, training, support, and behavioral objectives contextualized in the natural routines and environment for the child.
· Peer Training Package … These interventions use specifically selected and trained peers to work with and help the child develop appropriate skills and behaviors through structured settings and learning opportunities.
· Pivotal Response Treatment … This intervention focuses on pivotal behaviors in the natural setting.
· Schedules … The use of schedules, charts, picture directions or schedules, etc., often with reinforcement to include natural reinforcers. (Music and other sounds can be used as triggers and cues for schedules when helpful.)
· Self-management … Teaching basic self-management skills (similar to concepts in Steven Covey’s writing) with the assistance of feedback and reinforcement.
· Story-based Intervention Package … The use of stories specifically designed to teach skills to children. Social Stories is an example.
However, it is important to note that these packages are only EBP according to the specific age and diagnosis of the child as found in the National Autism Center’s research as referenced above.
How can I know if someone is providing EBP?
Simply saying or writing that one of the models listed above is being used is not sufficient. The treatment must be evident in practice, must reflect fidelity to model, and cannot merely represent one technique within a model or comprehensive treatment. For example, saying that discrete trial, provided in isolation without the entire applicable ABA treatment package, represents an EBP is erroneous and not adhering to fidelity of model. Further, providing ABA without significant and direct parental (primary care provider) involvement does not represent fidelity to model or treatment design.
You must compare the comprehensive package or specific model to what is actually being provided to ascertain fidelity of treatment.
Is there another way to know if someone is providing EBP?
Progress is another way to look for fidelity to treatment according to EBP. For children with ASD who are higher functioning (roughly with an IQ of 35 or higher or functioning at 50% of chronological age or higher) there should be significant progress in IQ and/or functioning level. For children who are lower functioning, there should be significant improvement in behavior.
What if they are providing something other than those models/interventions listed above?
As always, “the proof is in the pudding.” If a child is making significant progress according to standardized assessment (significant progress being defined as a standard deviation improvement in IQ over a period of one year or one year improvement in BI over the same period) then for this child, perhaps the evidence is in the outcome.
What if they claim model/package they are using is based on an EBP?
Fidelity to model and the integrity of a program are very important. Quite often someone develops a program which they claim is based on an EBP; however key components of the EBP have been left out. Understanding the model they are basing their treatment on, the research behind it, and how what they are doing is the same or different…can be very difficult.
What about children with a diagnosis other than or in addition to ASD?
There are a number of similarities in EBP treatment of children with ASD and EBP treatment of children with other diagnoses.
If the child has diagnosis other than ASD or the child with ASD is being provided a completely different intervention, how can I know if it is EBP?
Ask the provider to provide the research. There should be more than one research project evidencing the treatment practice for children with the same diagnosis as well as functioning level. The provider must be providing the intervention with fidelity to the research.
Is there any difference in quality of research and does some research represent EBP while other research does not?
Yes. There is tremendous difference in the quality of research, even research which has been published. Much of the research on intervention for children with disabilities does not represent EBP.
How do I know the difference between good research and bad when it comes to treatment of children with disabilities?
Discerning the difference between good and bad research often requires you to use your best “critical thinking” skills (see: http://en.wikipedia.org/wiki/Critical_thinking and http://criticalthinkinginfoanddiscussion.blogspot.com/ ).
Read the Methods or Design section first.
1. Find out if the subjects were randomly chosen and randomly assigned to the control or treatment group. What were the preferences in choosing subjects and were there ANY preferences, one way or another, in assigning them to the control or treatment groups? One of complaints about some of the early research on autism treatment was how the children were assigned to treatment or control.
2. How were the children evaluated at the beginning, during, and at the end of the research? Did the evaluators know which children/families were a part of the treatment group and which were not? In the best designs the evaluators will not know this information.
3. Was there consistency in the implementation of the treatment?
Read the rest of the research article and look for obvious flaws in the design or statistical analysis.
1. Did an outside disinterested party do the statistical analysis? It is better if the answer is yes.
2. Does the statistical analysis actually make a good representation of the outcomes for both the control and treatment groups? (Looking at some of the raw data can be helpful).
How do I know if the research represents EBP?
The easiest and quickest answer is that it will have been reported and substantiated by one of the projects mentioned in the video or publications referenced above; however, there has been some additional research since the project AND those projects are targeted towards children with ASD.
Here is a fairly simple answer:
1. The research will meet the qualities as listed in the answer to the question just above.
2. The research will have been duplicated at least once and preferably more than once.
3. The research will present a model/intervention which provides substantial positive outcomes for the child and family.