Evidenced Based Practices for Autism
Evidence-Based Practice and Autism Spectrum Disorders: The National Standards Project
By Susan M. Wilczynski
In September 2009, the National Autism Center announced the completion of its multiyear National Standards Project. The National Standards Project serves to support parents and professionals and answers one the most pressing questions asked by school psychologists: “How do we effectively treat the growing number of students with autism spectrum disorders (ASD)?”
The National Standards Project resulted in two reports that identify the strength of evidence supporting a broad range of interventions that target the core and associated characteristics of ASD. The Findings and Conclusions Report of the National Standards Project (abbreviated report) and the National Standards Report (extended technical report) are both free and available at www.nationalautismcenter.org. The remainder of this article briefly describes the methods applied, the major outcomes, and the implications of this report for school psychologists.
The Project began with input from 45 autism experts who specialized in treatment and/or applied research. This team of experts developed the conceptual model for evaluating the literature. Over 7,000 abstracts spanning a 50 year period were compared against the inclusionary and exclusionary criteria, yielding a total of 775 studies for analysis. Each of the studies was reviewed in terms of the quality of the (a) research design, (b) dependent measure, (c) treatment fidelity, (d) participant ascertainment, and (e) generalization. Scores for each of these variables were combined and resulted in a Scientific Merit Rating Scale (SMRS) score. Treatment Effects Ratings were also assigned to each article. The Treatment Effects Rating was based on the type of outcomes reported: (a) beneficial, (b) unknown, (c) ineffective, or (d) adverse.
Once SMRS scores and Treatment Effects Ratings were assigned, results were aggregated across studies for each of the 38 treatment categories. The Strength of Evidence Classification System was used to classify treatments based on the quality, quantity, and consistency of research findings. Treatments were classified as “Established Treatments” if a sufficient number of high quality studies had been published to allow scholars to confidently determine that they produced beneficial outcomes. Treatments were identified as “Emerging Treatments” if one or more studies suggested that they produced beneficial outcomes—but not enough high quality studies clearly demonstrated this effect. Treatments for which no studies were published or published studies that received poor ratings were classified as “Unestablished Treatments.” Finally, a fourth category was developed for “Ineffective or Harmful Treatments,” although no treatments fell into this category.
Importantly, information about the extent to which favorable outcomes were reported based on treatment targets (e.g., communication, interpersonal, problem behaviors, etc.), ages, and diagnostic groups is also provided in the National Standards Report. Six age groups were identified for children between 0 and 21 years of age. Outcomes were described in terms of three subpopulations: autistic disorder, Asperger’s syndrome, and pervasive developmental disorder—not otherwise specified.
Eleven different interventions were identified as “Established Treatments.” These intervention categories include: 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, and Story-based Intervention package. Established Treatments are described below, but more detailed descriptions can be found in the National Standards Report (2009).
The vast majority of approaches (22 out of 38) fell into the Emerging Treatments category. Five approaches fell into the Unestablished Treatments category. There is no sound evidence for these treatments. In two cases (facilitated communication and the gluten- and casein-free diet), cautionary statements accompany the analyses. The vast majority of the treatments demonstrated to be effective emerged from the behavioral literature. This finding is consistent with previous reviews of the literature. However, a number of these treatments have received research support from the fields of speech-language pathology and special education, with more researchers placing a strong emphasis on developmental considerations.
The results of the National Standards Project are important to school psychologists because knowing what research says about the treatment of ASD is essential for evidence-based practice. According to the professional conduct manual of the National Association of School Psychologists (NASP, 2000), NASP “promote[s] educationally and psychologically healthy environments for all children and youth by implementing research-based, effective programs.…” The National Standards Project will first and foremost help busy school psychologists keep abreast of ASD treatment research.
The National Standards Report (2009) also provides more detailed analyses that will prove useful to the practicing school psychologist. For example, Table 8 of the report identifies the extent to which favorable outcomes have been reported for Established Treatments based on the age, diagnostic population, and treatment targets associated with improvements. Even if school psychologists restrict their recommendations to the 11 Established Treatments that were identified, knowing the skills or behaviors that have been targeted in the literature or the populations (age, diagnostic group) may help them make even more directed recommendations.
Despite the advantages of having access to these detailed analyses, school psychologists are advised against selecting treatments exclusively based on the research findings reported in the National Standards Report (2009). The National Standards Report strongly advocates for decision-makers to adopt the process of evidence-based practice, and research findings clearly play a central role in this process. Yet, according the Report, evidence-based practice involves the integration of research findings with (a) professional judgment and data-based clinical decision-making, (b) the values and preferences of families, including the individual on the spectrum, and (c) capacity to implement an intervention with sufficient treatment fidelity. Thus, if a treatment has been implemented with integrity in the past but did not produce favorable outcomes, school psychologists should advocate against the treatment even if it is identified as an Established Treatment in the National Standards Report. School psychologists should continue as they do now in facilitating a positive relationship with the family, ensuring their voices are heard during the selection of treatments. Finally, school psychologists have a major responsibility to ensure that treatments are being accurately implemented and that initial training and ongoing coaching are provided to school staff serving students on the autism spectrum.
In an effort to further support school professionals as they provide services to students on the autism spectrum, the National Autism Center has also developed a manual entitled Evidence-Based Practice and Autism in the Schools. This document can be downloaded for free from their website (www.nationalautismcenter.org).
Susan M. Wilczynski, PhD, is the executive director of the National Autism Center and chair of the National Standards Project.
National Association of School Psychologists. (2000). Professional conduct manual. Retrieved December 11, 2009, from http://www.nasponline.org/standards/ProfessionalCond.pdf
National Autism Center. (2009). Findings and conclusions of the National Standards Project: Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, MA: National Autism Center.
National Autism Center. (2009). National Standards Report: National Standards Project — Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, MA: National Autism Center.
Established Treatments Based on the National Standards Report
These interventions involve the modification of situational events that typically precede the occurrence of a target behavior. These alterations are made to increase the likelihood of success or reduce the likelihood of problems occurring. Treatments falling into this category reflect research representing the fields of applied behavior analysis (ABA), behavioral psychology, and positive behavior supports. This category includes a broad array of strategies such as prompting, behavioral momentum, environmental modification of tasks, etc.
These interventions are designed to reduce problem behavior and teach functional alternative behaviors or skills through the application of basic principles of behavior change. Treatments falling into this category reflect research representing the fields of applied behavior analysis, behavioral psychology, and positive behavior supports. This category includes a broad array of antecedent and/or consequent strategies such as delayed contingencies, differential reinforcement strategies, discrete trial teaching, and functional communication training. These treatments may involve a complex combination of behavioral procedures.
Comprehensive Behavioral Treatment for Young Children
This treatment reflects research from comprehensive treatment programs that involve a combination of applied behavior analytic procedures (e.g., discrete trial, incidental teaching, etc.) that are delivered to young children (generally under the age of 8). These treatments may be delivered in a variety of settings and involve a low student-to-teacher ratio. These treatment programs may also be referred to as ABA programs or behavioral inclusive programs and early intensive behavioral intervention.
Joint Attention Intervention
These interventions involve building foundational skills involved in regulating the behaviors of others. Joint attention often involves teaching a child to respond to the nonverbal social bids of others or to initiate joint attention interactions. Examples include pointing to objects, showing items/activities to another person, and following eye gaze.
These interventions rely on an adult or peer providing a demonstration of the target behavior that should result in an imitation of the target behavior by the individual with an ASD. Modeling can include simple and complex behaviors. This intervention is often combined with other strategies such as prompting and reinforcement. Examples include live modeling and video modeling.
Naturalistic Teaching Strategies
These interventions involve using primarily child-directed interactions to teach functional skills in the natural environment. These interventions often involve providing a stimulating environment, modeling how to play, encouraging conversation, providing choices and direct/natural reinforcers, and rewarding reasonable attempts. Examples of this type of approach include but are not limited to focused stimulation, incidental teaching, milieu teaching, embedded teaching, and responsive education and prelinguistic milieu teaching.
Peer Training Package
These interventions involve teaching children without disabilities strategies for facilitating play and social interactions with children on the autism spectrum. Peers may often include classmates or siblings. Common names for intervention strategies include peer networks, circle of friends, buddy skills package, integrated play groups, peer initiation training, and peer-mediated social interactions.
Pivotal Response Treatment
This treatment is also referred to as PRT, pivotal response teaching, and pivotal response training. PRT focuses on targeting “pivotal” behavioral areas—such as motivation to engage in social communication, selfinitiation, self management, and responsiveness to multiple cues—with the development of these areas having the goal of very widespread and fluently integrated collateral improvements. Key aspects of PRT intervention delivery also focus on parent involvement in the intervention delivery and on intervention in the natural environment such as homes and schools with the goal of producing naturalized behavioral improvements. This treatment is an expansion of natural language paradigm which is also included in this category.
These interventions involve the presentation of a task list that communicates a series of activities or steps required to complete a specific activity. Schedules are often supplemented by other interventions such as reinforcement.
These interventions involve promoting independence by teaching individuals with ASD to regulate their behavior by recording the occurrence/nonoccurrence of the target behavior and securing reinforcement for doing so. Initial skills development may involve other strategies and may include the task of setting one’s own goals. In addition, reinforcement is a component of this intervention with the individual with ASD independently seeking and/or delivering reinforcers. Examples include the use of checklists (using checks, smiley/frowning faces), wrist counters, visual prompts, and tokens.
Story-Based Intervention Package
These interventions include treatments that involve a written description of the situations under which specific behaviors are expected to occur. Stories may be supplemented with additional components (e.g., prompting, reinforcement, discussion, etc.). Social stories are the most well known story-based interventions and they seek to answer the “who, what, when, where, and why” questions in order to improve perspective-taking.