ABA TechAssessment

Technology Assessment Form (Summary of Evidence) Name of New Technology: Applied Behavior Analysis as treatment for Autism Spectrum
Disorders Date of Original Review: September 2000 Dates of Previous Reviews Completed: April 2002, September 2004, September 2008, December 2010 Date Most Recent Review Completed: 9/14/11 Date Review Approved by the Clinical Technology Assessment Committee: 9/16/11
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1. Description of the technology
Previous Definition The UBH New Technology Review originally completed in September 2000 (re-reviews completed in April 2002, September 2004, & September 2008 Applied Behavior Analysis (a.k.a. Intensive Early Intervention, Lovaas Therapy, Lovaas UCLA Program, Intensive Behavioral Analysis, and Discrete Trial Training) is a behavioral approach to the treatment of Autistic Spectrum Disorders that seeks to reinforce adaptive behaviors and reduce maladaptive behaviors in children with Autistic Spectrum Disorders. Specific deficits related to the core symptoms of an ASD are targeted and may include areas such as imitation, attention, motivation, compliance and initiation of interaction, and adaptive behaviors are incrementally taught and positively reinforced.
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Current Definition For this review, the UBH definition of Applied Behavior Analysis is a behavioral/educational approach that seeks to reinforce adaptive behaviors and reduce maladaptive behaviors in children with Autistic Spectrum Disorders only, and is focused on the treatment of deficits. Applied Behavior Analysis behavioral/educational treatments are not diagnostically specific, but are applied to populations where there is need according to the presence of specific task deficits. For clarity, Applied Behavior Analysis is a field of practice, not a specific treatment. Treatment programs such as Intensive Early Intervention, Lovaas Therapy, Lovaas UCLA Program, Intensive Behavior Analysis, Discrete Trial Training, etc. should not be used interchangeably with the term Applied Behavior Analysis. The aforementioned categories are treatment approaches and methodologies that incorporate strategies and procedures from the field of Applied Behavior Analysis. For the purpose of this review, ABA treatments are categorized and grouped according to the National Standards Project (NSP) evidence review categories. The NSP categories grouped ABA strategies and procedures with a similar focus. Reviewing the treatments by the NSP categorization and grouping of treatment approaches allows the review and subsequent recommendations to align with the evidence review and ranking performed by the NSP. The NSP developed the Strength of Evidence Classification System for the purposes of their review. The purpose of this evidence ranking was to objectively determine the degree of confidence pertaining to the effectiveness of a treatment. Ratings reflect the level of quality, quantity, and consistency of research findings for each type of intervention. There are four categories in the Strength of Evidence Classification System. Categories of the NSP with general definitions are as follows: Established. Sufficient evidence is available to confidently determine that a treatment produces favorable outcomes for individuals on the autism spectrum. That is, these treatments are established as effective. Emerging. Although one or more studies suggest that a treatment produces favorable outcomes for individuals with ASD, additional high quality studies must consistently show this outcome before we can draw firm conclusions about treatment effectiveness. Unestablished. There is little or no evidence to allow us to draw firm conclusions about treatment effectiveness with individuals with ASD. Additional research may show the treatment to be effective, ineffective, or harmful. Ineffective/Harmful. Sufficient evidence is available to determine that a treatment is ineffective or harmful for individuals on the autism spectrum.
The categories of treatment defined as ABA for this review are those that the NSP ranked as established. CTAC has reviewed the evidence of those established treatments and mapped the NSP ranking of evidence criteria to the criteria used by CTAC. Since established is the highest ranked evidenced category for NSP, by mapping of the NSP established to what is found to be the highest evidence equivalent CTAC evidence category, there are implications that other NSP categories ranked lower than established will map to a subsequent lower CTAC evidence category. The treatment grouping considered ABA for this review are as follows: Antecedent Package: 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. Examples include but are not restricted to: behavior chain interruption (for increasing behaviors); behavioral momentum; choice; contriving motivational operations; cueing and prompting/prompt fading procedures; environmental enrichment; environmental modification of task demands, social comments, adult presence, intertrial interval, seating, familiarity with stimuli; errorless learning; errorless compliance; habit reversal; incorporating echolalia, special interests, thematic activities, or ritualistic/obsessional activities into tasks; maintenance interspersal; noncontingent access; noncontingent reinforcement; priming; stimulus variation; and time delay. Behavioral Package: These interventions are designed to reduce problem behaviors 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. Examples include but are not restricted to: behavioral sleep package; behavioral toilet training/dry bed training; chaining; contingency contracting; contingency mapping; delayed contingencies; differential reinforcement strategies; discrete trial teaching; functional communication training; generalization training; mand training; noncontingent escape with instructional fading; progressive relaxation; reinforcement; scheduled awakenings; shaping; stimulus-stimulus pairing with reinforcement; successive approximation; task analysis; and token economy. Treatments involving a complex combination of behavioral procedures that may be listed elsewhere in this document are also included in the behavioral package category. Examples include but are not restricted to: choice + embedding + functional communication training + reinforcement; task interspersal with differential reinforcement; tokens + reinforcement + choice + contingent exercise + overcorrection; noncontingent reinforcement + differential reinforcement; modeling + contingency management; and schedules + reinforcement + redirection + response prevention. Studies targeting verbal operants also fall into this category. 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.) which are delivered to young children (generally under the age of 8). These treatments may be delivered in a variety of settings (e.g., home, self-contained classroom, inclusive classroom, community) and involve
a low student-to-teacher ratio (e.g., 1:1). All of the studies falling into this category met the strict criteria of: {a} targeting the defining symptoms of ASD, {b}having treatment manuals, {c} providing treatment with a high degree of intensity, and {d} measuring the overall effectiveness of the program (i.e., studies that measure subcomponents of the program are listed elsewhere in this report). These treatment programs may also be referred to as ABA programs or behavioral inclusive program 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. Modeling: 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 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. When both initiation training and peer training were components of treatment in a study, the study was coded as peer training package. These interventions may include components of other treatment packages (e.g., self-management for peers, prompting, reinforcement, etc.). 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, self-initiation, 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. Schedules: 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. Schedules can take several forms including written words, pictures or photographs, or work stations. Self-management: 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 ones 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 treatments 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 in order to improve perspective-taking. Applied Behavior Analysis is a field of practice, not a specific treatment. Treatment programs such as Intensive Early Intervention, Lovaas Therapy, Lovaas UCLA Program, Intensive Behavior Analysis, Discrete Trial Training, etc. should not be used interchangeably with the term Applied Behavior Analysis. The aforementioned categories are treatment approaches and methodologies that incorporate strategies and procedures from the field of Applied Behavior Analysis.
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Other treatments for autism spectrum disorders for the purpose of this review are considered outside the scope of ABA. This includes the following: 1. Relationship Development Intervention (RDI), 2. TEACCH or structured teaching, 3. the Early Start Denver Model, and 4. DIR/Floortime. These treatments are not considered to be components of Applied Behavior Analysis but separate and distinct treatments for ASD.
1. What population is the technology used with?
All ABA treatments for this review are applied to both genders and are defined according to descriptions and categories reported by the National Standards Project (NSP) and the related specific age categories as follows: Infant/toddlers (ages 0-3) Preschool (ages 3-5) Elementary (ages 6-9) Middle school (ages 10-14) High school (ages 15-18) Early adult (ages 19-21)
2. What diagnosis or clinical condition is the technology used for?
For the purpose of this review, ABA is reviewed as it is applied as an intervention for deficits found in Autism Spectrum Disorders (ASD) which includes Autism, Aspergers, and Pervasive Developmental Disorders NOS. Childhood Disintegrative Disorder and Rhetts Disorder are not included in this review as these diagnoses were excluded from the National Standards Project, the New Zealand Review, and the Meta Analysis.
3. What aspect(s) of treatment is the technology used for?
Applied Behavior Analysis is a field of practice, not a specific treatment. Treatment programs such as Intensive Early Intervention, Lovaas Therapy, Lovaas UCLA Program, Intensive Behavior Analysis, Discrete Trial Training, etc. should not be used interchangeably with the term Applied Behavior Analysis. The aforementioned categories are treatment approaches and methodologies that incorporate strategies and procedures from the field of Applied Behavior Analysis. ABA-based treatments are behavioral/educational intervention strategies used in all stages of the treatment process; with the exception of addressing co morbid psychiatric diagnoses associated with ASD The following components are considered valid processes within the scope of ABA-based treatment: Assessment: To include functional behavioral assessment (FBA) of maladaptive behaviors as well as assessment of functional skills (e.g., language and communication deficits, social deficits, ADL deficits, etc.) Treatment: To include behavioral intervention strategies that increase functional skills (e.g., language and communication skills, social skills, and ADL skills, etc.) and remediation of maladaptive behaviors (e.g., self-injury, aggression, perseverative behavior, etc.) Maintenance: To include behavior analytic strategies and procedures that maintain decreases in maladaptive behavior as well as establish skill mastery and fluency obtained in the behavioral treatment stage. Prevention: To include strategies and procedures that identify antecedents or pre-cursor events leading to maladaptive behavior in the assessment stage as well as behavior intervention strategies to decrease the likelihood of the occurrence of maladaptive behavior once these antecedents are identified. Behavior wellness: Once treatment goals are met, behavior intervention strategies can be designed to maintain
behavioral gains as well as allow for generalization of behavioral benefits to new environments and/or tasks. For clarity, Applied Behavior Analysis is a field of practice, not a specific treatment. Treatment programs such as Intensive Early Intervention, Lovaas Therapy, Lovaas UCLA Program, Intensive Behavior Analysis, Discrete Trial Training, etc. should not be used interchangeably with the term Applied Behavior Analysis. The aforementioned categories are treatment approaches and methodologies that incorporate strategies and procedures from the field of Applied Behavior Analysis.
How is it applied in a clinical setting?
ABA-based therapy is applied through both direct (i.e., face-to-face) services to the individual and indirect (i.e., consultation) services to the individuals support system (e.g., parents, caretakers, etc.). The major characteristics of application would be: Direct observation of the individual A strong commitment to empirical evaluation of treatments and intervention techniques; A general belief that therapeutic experiences must provide opportunities to learn adaptive or prosocial behavior; Specification of treatment in operational and hence, replicable terms; Evaluation of treatment effects through multiple-response modalities, with particular emphasis on overt behavior. *Kazdin & Hersen (1980). One ABA-based strategy, early intensive behavioral intervention, is for children aged 2-6 years old and may occur at a high rate of 30-40 hours per week. Behavioral intervention at a lesser level of intensity (15-25 hours per week) may be provided based on the individuals level of need as determined by the treating provider. Behavioral intervention for children age 6 and above often involves a lesser level of intensity of 5-20 hours per week and is usually focused on specific areas of need. Similar to the psychotherapeutic approach, treatment based on the principles of Applied Behavior Analysis is individualized and one or all of the above forms may be used to create a more specialized program for each individual child. The essential difference between ABA and other behavioral health intervention approaches is that traditional psychotherapeutic approaches attempt to change thought processes in order to influence overt behavior. ABA attempts to change the overt behavior to in turn affect thought processes.
Training required to implement the technology?
The following are the training requirements met by Board Certified Behavior Analysts prior to being accepted to sit for the national exam: There are three categories of experience: Supervised Independent Fieldwork, Practicum, and Intensive Practicum. BCBAs accrue experience one category at a time. Practicum and Intensive Practicum are accrued only in a BACB
approved university experience program. 1. Supervised Independent Fieldwork BCBAs complete 1500 hours of Supervised Independent Fieldwork in behavior analysis. During the Supervised Independent Fieldwork activity, the BCBAs primary focus was on learning new behavior analytic skills related to the BACB Third Edition Task List. Activities adhered to the dimensions of applied behavior analysis identified by Baer, Wolf, and Risley (1968) in the article Some Current Dimensions of Applied Behavior Analysis published in the Journal of Applied Behavior Analysis. BCBAs were encouraged to have experiences in multiple sites and with multiple supervisors. Appropriate experience activities included: 1. Conducting assessment activities related to the need for behavioral interventions, 2. Designing, implementing, and monitoring behavior analysis programs for clients, 3. Overseeing the implementation of behavior analysis programs by others, 4. Other activities normally performed by a behavior analyst that are directly related to behavior analysis such as attending planning meetings regarding the behavior analysis program, researching the literature related to the program, talking to individuals about the program; plus any additional activities related to oversight of behavioral programming such as behavior analyst supervision issues, or evaluation of behavior analysts' performance. The supervisor will determine if activities qualify. 2. Practicum (University only): Students must complete 1000 hours of Practicum in behavior analysis within a university experience program approved by the BACB. The distribution of Practicum hours must be at least 10 hours per week, but not more than 25 hours per week, for a minimum of 3 weeks per month. 3. Intensive Practicum (University only): Students must complete 750 hours of Intensive Practicum in behavior analysis within a university experience program approved by the BACB. The distribution of Intensive Practicum hours must be at least 10 hours per week, but not more than 25 hours per week, for a minimum of 3 weeks per month. Amount of Supervision Required: Supervised Independent Fieldwork: The distribution of hours is at least 10 hours per week, but not more than 30 hours per week, for a minimum of 3 weeks per month. BCBAs are supervised at least once every 2 weeks for 5% of the total hours they spend in Supervised Independent Fieldwork. Total supervision must be at least 75 hours. A supervisory period is two weeks.
Practicum: Supervised at least weekly for 10% (7.5% minimum) of the total hours they spend in University Practicum. Total supervision must be at least 100 hours (75 minimum). A supervisory period is one week. Intensive Practicum: supervised at least twice weekly for 15% (10% minimum) of the total hours they spend in Intensive University Practicum. Total supervision must be at least 112.5 hours (75 minimum). A supervisory period is one week. Individuals do not start accumulating experience until they have begun the coursework required to meet the BACB coursework requirements.
Supervisor Qualifications: During the experience period, the supervisor must be: 1. A Board Certified Behavior Analyst in good standing, or 2. Approved University Experience: A faculty member who has been approved by the BACB as an instructor in the universitys approved course sequence. The supervisor may not be the student's relative, subordinate or employee during the experience period. The supervisor will not be considered an employee of the student if the only compensation received by the supervisor from the student consists of payment for supervision. Nature of Supervision: The supervisor must: a. observe the clinician engaging in behavior analytic activities in the natural environment at least once every two weeks. b. the supervisor must provide specific feedback on their performance. c. during the initial half of the total experience hours, observation is concentrated on clinician-client interactions. This observation may be conducted via web-cameras, videotape, videoconferencing, or similar means in lieu of the supervisor being physically present. d. supervision may be conducted in small groups of 10 or fewer for no more than half of the total supervised hours in each supervisory period. The remainder of the total supervision hours in each supervisory period must consist of direct one-to-one contact. Supervision hours may be counted toward the total number of experience hours required.
Discipline or educational level required implementing the technology?
A doctoral or masters degree from a recognized educational program within the United States or Canada. The program must be from an institution of higher education fully or provisionally accredited by a regional, state, provincial or national accrediting body OR An institution of higher education located outside the United States or Canada that, at the time the applicant was enrolled and at the time the applicant graduated, maintained a standard of training equivalent to the standards of training of those institutions accredited in the United States. ABA is a branch of psychology similar to psychotherapy and is made up of many different intervention strategies and procedures based on systematic study of overt behavior. For example, the American Psychological Association recognizes ABA as a branch of psychology and supports a special interest group of psychologists who utilize behavior analytic principles in practice within its organization (Division 25) The applicant must complete 225 classroom hours of graduate level instruction in the following areas: a. b. c. d. e. f. g. Ethical considerations 15 hours Definition & characteristics and Principles, processes & concepts - 45 hours Behavioral assessment and Selecting intervention outcomes & strategies - 35 hours Experimental evaluation of interventions - 20 hours Measurement of behavior and Displaying & interpreting behavioral data - 20 hours Behavioral change procedures and Systems support 45 hours Discretionary 45 hours
What is the training process to assure fidelity?
Upon completion of the educational requirements, the supervised independent fieldwork, practicum, intensive practicum clinicians are approved to sit for a national examination. Written demonstration of ABA knowledge BCBAs have successfully passed a nationally recognized examination adopted and approved by the Behavior Analyst Certification Board related to the principles and practice of the profession of applied behavior analysis. Monitoring of clinicians implementation of ABA with demonstration of success: All clinicians will have completed a necessary clinical practicum demonstrating competency in ABA through practicum and coursework before being deemed competent for practice as outlined by the Association of Behavior Analysis International. The following section on behavioral change procedures is summarized from the Behavior Analyst Certification Boards Guidelines for Responsible Conduct:
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The behavior analyst: designs programs that are based on behavior analytic principles, including assessments of effects of other intervention methods, involves the client or the client-surrogate in the planning of such programs, obtains the consent of the client, and respects the right of the client to terminate services at any time. Describing Conditions for Program Success. The behavior analyst describes to the client or client-surrogate the environmental conditions that are necessary for the program to be effective. Environmental Conditions that Preclude Implementation. If environmental conditions preclude implementation of a behavior analytic program, the behavior analyst recommends that other professional assistance (i.e., assessment, consultation or therapeutic intervention by other professionals) be sought. Environmental Conditions that Hamper Implementation. If environmental conditions hamper implementation of the behavior analytic program, the behavior analyst seeks to eliminate the environmental constraints, or identifies in writing the obstacles to doing so. Approving Interventions. The behavior analyst must obtain the clients or client-surrogates approval in writing of the behavior intervention procedures before implementing them. Reinforcement/Punishment. The behavior analyst recommends reinforcement rather than punishment whenever possible. If punishment procedures are necessary, the behavior analyst always includes reinforcement procedures for alternative behavior in the program. Avoiding Harmful Reinforcers. The behavior analyst minimizes the use of items as potential reinforcers that maybe harmful to the long-term health of the client or participant (e.g., cigarettes, sugar or fat-laden food), or that may require undesirably marked deprivation procedures as motivating operations. On-Going Data Collection. The behavior analyst collects data, or asks the client, client-surrogate, or designated others to collect data needed to assess progress within the program.
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Program Modifications. The behavior analyst modifies the program on the basis of data. Program Modifications Consent. The behavior analyst explains program modifications and the reasons for the modifications to the client or client-surrogate and obtains consent to implement the modifications. Least Restrictive Procedures. The behavior analyst reviews and appraises the restrictiveness of alternative interventions and always recommends the least restrictive procedures likely to be effective in dealing with a behavior problem. Termination Criteria. The behavior analyst establishes understandable and objective (i.e., measurable) criteria for the termination of the program and describes them to the client or client-surrogate. Terminating Clients. The behavior analyst terminates the relationship with the client when the established criteria for termination are attained, as in when a series of planned or revised intervention goals has been completed. Certification process by the vendor or credible specialty organization: Certification processes are based upon successful completion of the clinicians health related board licensing requirements as set forth by their respective state or commonwealth or certification as a BCBA or BCBA-D by the Behavior Analyst Certification Board. Process to maintain competency post-training: All clinicians maintain post-training competency by completion of the requisite number of Continuing Education Units required by their licensing board or certification body. The current standards for CEUs are determined by the Behavior Analyst Certification Board. For graduate level behavior analysts, the BACB requires 36 hours of continuing education be obtained through the following types of events: Type 1: Completion of graduate level college or university courses, for BCBAs, or undergraduate or graduate, college or university courses, for BCaBAs. Course content must be entirely behavior analytic. Courses must be from any of the following: A United States or Canadian institution of higher education fully or provisionally accredited by a regional, state, provincial or national accrediting body; or An institution of higher education located outside the United States or Canada that, at the time the applicant was enrolled and at the time the applicant completed the course maintained a standard of training equivalent to the
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standards of training of those institutions accredited in the United States. One academic semester credit is equivalent to 15 hours of continuing education and one academic quarter credit is equivalent to 10 hours of continuing education. Any portion or all of the required number of hours of continuing education may be applied from this category during any three-year certification period. Type 2: Completion of events sponsored by providers approved by the Behavior Analyst Certification Board. Any portion or all of the total required number of hours of continuing education may be applied from this category during any threeyear certification period. Type 3: Completion of a seminar, colloquium, presentation, conference event, workshop or symposium not approved by the BACB, or engaging in supervision activities, only if they relate directly to the practice of behavior analysis. A maximum of 25 percent of the total required number of hours of continuing education may be applied from this category during any three-year certification period. Type 4: Instruction by the applicant of a category 1 or 2 continuing education event, on a one-time basis for each event, provided that the applicant was present for the complete event. A maximum of 25 percent of the total required number of hours of continuing education may come from this category during any three-year certification period. Type 5: Credentialing events or activities initiated and pre-approved for CEU by the BACB. A maximum of 25 percent of the total required number of hours of continuing education may come from this category during any three-year certification period. Type 6: Passing, during the third year of the applicants certification period, the BACB certification examination appropriate to the type of certification being renewed. BCBAs may only take the BCBA examination; BCaBAs may only take the BCaBA examination for continuing education credit. Passage of the appropriate examination shall satisfy the recertification continuing education requirement for any three-year certification period. (Certificants do not have to re-qualify under current standards, they should apply for examination under the "retake" option and pay that fee)
Safety of the technology:
What are the potential areas of harm? Side effects of ABA are comparable to other forms of behavioral health interventions. Any adverse effects of ABA would likely be due to a poorly trained clinician. For example, inappropriate use of punishers, reinforcement of
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maladaptive behavior by the clinicians or support staff could have adverse effects. Potential results from malfunctioning of the technology The technology cannot malfunction; only be misapplied. Risk management processes for ABA practitioners? Risk management procedures for practitioners involved in behavior analytic treatments of ASD would include: Requirement of 36 continuing education credits and recertification every three (3) years for BCBAs. These requirements are to ensure competency in the practitioners respective field as may pertain to behavior analytic treatments of ASD (e.g., BACB approved CEUs, APA approved CEUs, etc.) Reportability and accountability to the Behavior Analyst Certification Board in relation to Ethical and Professional Conduct Guidelines. AND/OR Reportability and accountability to the practitioners respective state licensing board in relation to Ethical and Professional conduct as outlined by that board Key Issues to be answered by the evidence
1) What is the strength of the evidence for specific ABA intervention treatments used with individuals with Autism Spectrum Disorders (ASD)? 2) For which populations are each of these interventions appropriate? 3) What are the limitations of the treatment research reviewed?
Clarification of the review process The CTAC review of Applied Behavior Analysis (ABA) as a treatment methodology for autism spectrum disorders will be based on technical reviews of the literature completed in three publications: 1) The National Standards Project (NSP), published by the National Autism Center 2) The Technical Review of Published Research on Applied Behaviour Analysis Interventions for People with Autism Spectrum Disorder published by Auckland Uniservices Limited for the New Zealand Ministry of Education and Ministry of Health (the New Zealand Review) 3) A 2010 meta-analysis by Javier Virus-Ortega published in the Journal of Clinical Psychology Review.
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The National Standards Project, of the National Autism Center, a private clinical program based in Randolph, MA conducted a complex multifaceted review of all available evidence from early childhood through adolescence funded by grants. The National Standards Projects goal was to: Provide the strength of evidence supporting treatments that target the core characteristics of these neurological disorders Describe the age, diagnosis, and skills/behaviors targeted for improvement associated with treatment options Identify the limitations of the current body of research on autism treatment offer recommendations for engaging in evidencebased practice for ASD.
The NSP reviewed 775 peer reviewed studies utilizing a variety of interventions pertaining to the treatment of ASD. To ensure a high degree of fidelity amongst its reviewers, the NSP trained its reviewers to criterion (interobserver agreement >80) through the use of pilot articles before allowing reviews of the actual articles. All but four reviewers maintained this level of IOA during a subsequent reliability check and the four that did not, were removed from the review. The second review was a publication conducted for the New Zealand Ministry of Education and Ministry of Health by a task force of researchers at various Universities in New Zealand (e.g., Auckland, Waikato, Canterbury, Wellington, and Massey University) as well as individuals in private psychological practice. The reason for the review was in response to a call by the New Zealand Ministries of Health and Education for an assessment of the effectiveness of behaviorally-based interventions as determined by studies published between 1998 and 2007. The data used for the review were gained from two sources: Existing analyses of peer-reviewed publications previously collected by the National Autism Center National Standards Project From additional publications that met the appropriate criteria as defined by the Ministries of Health and Education that had not been included in the NSP.
Studies were only included if the met or exceeded a score of 2.0 on the SMRS. In total, 463 studies of the 770 were retained from the NSP database along with 45 New Zealand unique studies that met inclusion criteria for the NZ review but were not part of the NSP database. Similar to the NSP, the 13 New Zealand reviewers underwent extensive training on the Strength of Evidence Classification System (SECS) and the Scientific Merit Rating Scale (SMRS) coding schemes. The New Zealand teams reliability of coding was reviewed by New Zealand- and NSP-trained coders and determined to be generally high (80% or better on 10 of 12 categories). The third review of the behavior analytic literature was a meta-analysis conducted by Javier Virus-Ortega. The purpose of the review was to use meta-analytical methods in an attempt to quantify the effectiveness of ABA-based interventions. Previously, problems with reviewing the Applied Behavior Analytic (ABA) literature included inconsistent methodological features with regard to research design, sampling methods and quality standards, intervention features were highly variable including treatment intensity, duration, the intervention model itself, format of treatment delivered, and participants were highly variable with regard to their pre-intervention Proprietary Information of OptumHealth. Copyright 2011 OptumHealth Behavioral Solutions by United Behavioral Health 15
functioning and age. Lastly, studies use a variety of different metrics when reporting outcomes making it difficult to implement standard meta-analytical procedures. Studies targeting specific behaviors or procedures were discarded; only those studies using comprehensive, intensive, and long-term ABA-based intervention were reviewed. The Virues-Ortega paper attempted to Ascertain the collective effectiveness of ABA-based intervention for Autistic Disorder and Pervasive Developmental Disorder, NOS Estimate ABA-based intervention effectiveness in terms of as many outcome variables as possible in order to provide a comprehensive assessment of its effects Analyze the effect of study characteristics including intervention duration and intensity, study design, intervention model and intervention delivery format.
Twenty-two original, peer-reviewed, and empirically-based research published between January 1985 and April 2009 were included in the meta-analysis. Unlike the NSP and New Zealand reviews, studies could be published in any language. Interventions must have been comprehensive, intensive (e.g., at least 10 hours a week), lasted a minimum of 45 weeks in duration, and be based on the principles of Applied Behavior Analysis (ABA). Unlike the NSP and New Zealand reviews which focused on both specific (e.g. problem behavior) and comprehensive skill areas, studies that focused only on very specific areas (e.g., joint attention, problem behavior) were not included in the meta-analysis. Another difference between the meta-analysis and both the NSP and New Zealand reviews is that only group studies with at least five subjects per group were reviewed. Studies using single subject designs were excluded from the analysis. Other exclusion criteria included the following: a) Epidemiological studies b) Anecdotal, qualitative or non-standardized outcome measures c) Studies that did not include pre-test measurement d) Purposely biased subject selection e) Studies that lacked mean and standard deviation data or were not extractable from descriptive data or statistical tests in the manuscript. A total of 323 subjects were included in the Virues-Ortega review. Age ranges were 22.6 to 66.3 months. Intervention duration and intensity ranged from 48 to 407 weeks and from 12 to 45 weekly hours. The data collected from all the selected studies included the following: a) participant characteristics such as mean pre-intervention age in months, percentage of male participants, pre-intervention IQ, and b) intervention characteristics including intervention intensity, duration (weeks), total intervention duration (intensity multiplied by duration), intervention delivery format, clinic- or parent managed home-based supervised by professionals, model of ABA intervention such as either the UCLA model (13 studies) vs general ABA model (9 studies), study design (e.g., RCT, nonrandomized control trial), sample size, outcomes variables, assessment instruments, reported pre- and post-test outcome values (mean and standard deviation), and study quality. Proprietary Information of OptumHealth. Copyright 2011 OptumHealth Behavioral Solutions by United Behavioral Health 16
Study quality was assessed by trained investigators using the Downs and Black checklist for randomized and non-randomized studies of health care interventions. Interrater agreement in the final number of trials to be included in the meta-analysis reached 90.9%.
The results of the New Zealand Review are noted after corresponding NSP categories within the Clinical Diagnosis/Condition section of this report. Therefore the framing of the technology and the subsequent review of evidence will be according to the framing set by the NSP. Supplemental information will be provided from the New Zealand Review. Statistical analyses results will be provided as applicable from the Virus-Ortega meta-analysis. To align with the NSP framing, the technology will be on behavioral treatments of Autism Spectrum Disorders. ABA specific information will be provided from the New Zealand Review and supported by the 2010 meta-analysis. For the purpose of this review, NSPs Strength of Evidence Classification System, (SECS) will be reviewed as it was applied to designating NSPs established treatments. Using this methodology, CTAC will review for the alignment and/or misalignment of the NSPs SECS criteria and resulting review of the established treatments to the CTAC criteria. The assumption made within this review process is that the ranking of NSPs established treatments can serve as a proxy to compare with the CTAC criteria. Since the NSPs established ranking criteria is based on the highest ranked evidence within the NSP SECS methodology, then it is also assumed the mapping of the NSPs established treatments to CTAC ranking categories will help to cascade the comparative rankings of the other NSP categories to CTAC criteria. For example, if NSP SECS the established treatment evidence is aligned with the CTAC proven category then the other SECS ranking categories will map to a lower level CTAC ranking.
Evidence Ranking Per the National Standards Project The National Standards Project created the Scientific Merit Rating Scale (SMRS) and assigned each study a score ranging from 0-5. These scores were assigned based on five critical dimensions of scientific rigor and used to determine the extent to which the interventions were effective. A score of zero indicated the study did not demonstrate experimental rigor whereas a score of 5 indicated a high level of rigor on the five critical dimensions. The five critical dimensions were 1) research design, 2) measurement of the dependent variable, 3) measurement of the independent variable, 4) participant ascertainment and 5) generalization. From the SMRS scores, the studies were then placed into a strength of evidence classification system which were broken down into four categories: established, emerging, unestablished or ineffective/harmful category. The following tables are a breakdown of the strength of evidence reported by the National Standards Project (NSP) for each treatment package on the right, mapped to the CTAC evidence criteria on the left. In the Quantity of Evidence section of each table, are the total
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number of studies reviewed by the NSP for that category and the corresponding number of studies that met the NSP criterion of established (e.g. score of 3, 4, 5) which was based on the NSPs Scientific Merit Rating Scale (SMRS). Note that the number of studies meeting the emerging category were included in this description for the purpose of clarity and were not separated out within the written paper published by the NSP. Antecedent Package:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 109* Number of studies meeting established rating: 4 Single Subject Research Design (SSRD)
* the NSP report listed the antecedent package as having 99 studies; a total of 109 were sent for final tally
1) Quantity of Evidence: PROVEN: 3 or more published, peer-reviewed studies Study design ranking will rely on UHC hierarchy of evidence
2) SMRS Score: PROVEN: average of at least 4.0; EMERGING: average of at least 3.0
Of the 109 studies reviewed: average SMRS score of 1.38 (range: 0-4) Of the 4 studies: average SMRS score of 3.25 (range: 3-4)
Hierarchy of Clinical Evidence (list number of studies reviewed for each category): ***Note*** for specific breakdown of what SMRS scores indicate at both group and single-subject level, please refer to PPT titled CTAC Levels of Evidence and Mapping to NSP slides 6-11
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) ___ Group observational studies (SMRS = 3) _1_ Single-subject observational studies (SMRS = 4) _3_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 3-5 yrs o 6-9 yrs o 10-14 yrs
3) Treatment Effects: PROVEN: group - statistically significant effects reported in favor of the treatment; single - functional relationship established and replicated at least two times
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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. Examples include but are not restricted to: behavior chain interruption (for increasing behaviors); behavioral momentum; choice; contriving motivational operations; cueing and prompting/prompt fading procedures; environmental enrichment; environmental modification of task demands, social comments, adult presence, intertrial interval, seating, familiarity with stimuli; errorless learning; errorless compliance; habit reversal; incorporating echolalia, special interests, thematic activities, or ritualistic/obsessional activities into tasks; maintenance interspersal; noncontingent access; noncontingent reinforcement; priming; stimulus variation; and time delay.
Behavioral Package:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 250* Number of studies meeting established rating: 17 SSRD
* the NSP report listed the behavioral package as having 231 studies; a total of 250 were sent for final tally
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) ___ Group observational studies (SMRS = 3) _1_ Single-subject observational studies (SMRS = 4) _16_Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies
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This intervention category demonstrated favorable outcomes with all age groups.
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. Examples include but are not restricted to: behavioral sleep package; behavioral toilet training/dry bed training; chaining; contingency contracting; contingency mapping; delayed contingencies; differential reinforcement strategies; discrete trial teaching; functional communication training; generalization training; mind training; noncontingent escape with instructional fading; progressive relaxation; reinforcement; scheduled awakenings; shaping; stimulus-stimulus pairing with reinforcement; successive approximation; task analysis; and token economy. Treatments involving a complex combination of behavioral procedures that may be listed elsewhere in this document are also included in the behavioral package category. Examples include but are not restricted to: choice + embedding + functional communication training + reinforcement; task interspersal with differential reinforcement; tokens + reinforcement + choice + contingent exercise + overcorrection; noncontingent reinforcement + differential reinforcement; modeling + contingency management; and schedules + reinforcement + redirection + response prevention. Studies targeting verbal operants also fall into this category. Comprehensive Behavioral Treatment for Young Children:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 22 Number of studies meeting established rating:6 group design, and 1 SSRD studies
2) SMRS Score: PROVEN: average of at least 4.0; EMERGING: average of at least 3.0)
Of the 22 studies reviewed: average SMRS score of 2.18 (range: 1-3) Of the 7 studies: average SMRS score of 3.0 (range:
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3)
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) _6_ Group observational studies (SMRS = 3) ___ Single-subject observational studies (SMRS = 4) _1_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 0-2 yrs o 3-5 yrs o 6-9 yrs
This treatment reflects research from comprehensive treatment programs that involve a combination of applied behavior analytic procedures (e.g., discrete trial, incidental teaching, etc.) which are delivered to young children (generally under the age of 8). These treatments may be delivered in a variety of settings (e.g., home, self-contained classroom, inclusive classroom, community) and involve a low student-to-teacher ratio (e.g., 1:1). All of the studies falling into this category met the strict criteria of: {a} targeting the defining symptoms of ASD, {b} having treatment manuals, {c} providing treatment with a high degree of intensity, and {d} measuring the overall effectiveness of the program (i.e., studies that measure subcomponents of the program are listed elsewhere in this report). These treatment programs may also be referred to as ABA programs or behavioral inclusive program and early intensive behavioral intervention. Joint Attention Intervention:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 7* Number of studies meeting established rating: 1 group design, and 3 SSRD studies
*the NSP report listed the joint attention package as having 6 studies; a total of 7 were sent for final tally
2) SMRS Score:
Of the 7 studies reviewed: average SMRS score of
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PROVEN: average of at least 4.0; EMERGING: average of at least 3.0)
Of the 4 studies: average SMRS score of 3.25 (range: 3-4)
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) _1_ Group observational studies (SMRS = 3) _1_ Single-subject observational studies (SMRS = 4) _2_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 0-2 yrs o 3-5 yrs
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. Modeling:
Summary of Strength of Evidence Classification: Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 56* Number of studies meeting established rating:14 Single Subject studies
*the NSP report listed the modeling package as having 50 studies; a total of 56 were sent for final tally
2) SMRS Score: PROVEN: average of at least 4.0;
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EMERGING: average of at least 3.0 Of the 14 studies: average SMRS score of 3.14 (range: 3-4)
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) ___ Group observational studies (SMRS = 3) _2_ Single-subject observational studies (SMRS = 4) _12 Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 3-5 yrs o 6-9 yrs o 10-14 yrs o 15-18 yrs
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 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:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 32 1) Quantity of Evidence: PROVEN: 3 or more published, peer-reviewed studies Study design ranking will rely on UHC hierarchy of evidence Number of studies meeting established rating: 2 group design, and 5 Single Subject studies
Of the 32 studies reviewed: average SMRS score of 1.94 (range: 0-4)
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EMERGING: average of at least 3.0
Of the 7 studies: average SMRS score of 3.29 (range: 3-4)
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) _2_ Group observational studies (SMRS = 3) _2_ Single-subject observational studies (SMRS = 4) _3_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 0-2 yrs o 3-5 yrs o 6-9 yrs
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 pre-linguistic milieu teaching. Peer Training Package:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 33 1) Quantity of Evidence: PROVEN: 3 or more published, peer-reviewed studies Study design ranking will rely on UHC hierarchy of evidence Number of studies meeting established rating:1 group design, and 6 Single Subject studies
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EMERGING: average of at least 3.0 Of the 7 studies: average SMRS score of 3.0 (range: 3)
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) _1_ Group observational studies (SMRS = 3) ___ Single-subject observational studies (SMRS = 4) _6_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 3-5 yrs o 6-9 yrs o 10-14 yrs
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. When both initiation training and peer training were components of treatment in a study, the study was coded as peer training package. These interventions may include components of other treatment packages (e.g., self-management for peers, prompting, reinforcement, etc.). 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:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 14 1) Quantity of Evidence: PROVEN: 3 or more published, peer-reviewed studies Study design ranking will rely on UHC hierarchy of evidence Number of studies meeting established rating:4 Single Subject studies
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Of the 14 studies reviewed: average SMRS score of 2.0 (range: 0-3) Of the 4 studies: average SMRS score of 3.0 (range: 3)
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) ___ Group observational studies (SMRS = 3) ___ Single-subject observational studies (SMRS = 4) _4_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 3-5 yrs o 6-9 yrs
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, self-initiation, 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. Schedules:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 12 1) Quantity of Evidence: PROVEN: 3 or more published, peer-reviewed studies Study design ranking will rely on UHC hierarchy of evidence Number of studies meeting established rating:4 Single Subject studies.
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___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) ___ Group observational studies (SMRS = 3) _1_ Single-subject observational studies (SMRS = 4) _3_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 3-5 yrs o 6-9 yrs o 10-14 yrs
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. Schedules can take several forms including written words, pictures or photographs, or work stations.
Self-management:
Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 22* 1) Quantity of Evidence: PROVEN: 3 or more published, peer-reviewed studies Study design ranking will rely on UHC hierarchy of evidence Number of studies meeting established rating: 6 Single Subject studies
*the NSP report listed the self-management package as having
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21 studies; a total of 22 were sent for final tally
Of the 22 studies reviewed: average SMRS score of 1.83 (range: 1-3) Of the 6 studies: average SMRS score of 3.0 (range: 3)
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) ___ Group observational studies (SMRS = 3) ___ Single-subject observational studies (SMRS = 4) _6_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 3-5 yrs o 6-9 yrs o 10-14 yrs o 15-18 yrs
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 ones 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:

Summary of Strength of Evidence Classification: (Proven level vs. Emerging level vs. Unproven level) Total studies reviewed in this category: 21 1) Quantity of Evidence: PROVEN: 3 or more published, peer-reviewed studies Number of studies meeting established rating: 4 Single
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Study design ranking will rely on UHC hierarchy of evidence
Subject studies
___ CMS Natl Coverage Decisions ___ Statistically robust, well-designed RCTs ___ Group observational studies (SMRS = 4) ___ Group observational studies (SMRS = 3) _1_ Single-subject observational studies (SMRS = 4) _3_ Single-subject observational studies (SMRS = 3) ___ Natl Guidelines & Consensus Statements ___ Evidence-based guidelines from Natl Societies This intervention category demonstrated favorable outcomes with the following age groups: o 6-9 yrs o 10-14 yrs
These treatments 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 in order to improve perspectivetaking.
Per the New Zealand Review: The review method and evidence ranking by the New Zealand team was consistent with the NSP process. The New Zealand review was based on an analysis of the specific components of the behavioral intervention package, the type of behaviors assessed (per the Ministry of Education supplied classification see table 4) and the impact of the interventions utilized (by using the NSP Strength of Proprietary Information of OptumHealth. Copyright 2011 OptumHealth Behavioral Solutions by United Behavioral Health 29
Evidence Classification System). Studies evaluated by the New Zealand team were given the same SECS category of emerging, unestablished, ineffective and harmful based on the SMRS scores. One difference of The New Zealand review from the NSP was that it focused solely on behavior analytic intervention studies (ABA) for individuals without any particular age limit and was described as a subset of the NSPs review scope. Unlike the NSP, other approaches (e.g., developmental-pragmatic) were excluded in the New Zealand review. The results from the NZ review supported the results within the NSP review. Corresponding categories from the New Zealand Review along with outcome measures follow the NSP equivalents.
Per the Virues-Ortega meta-analysis: The instruments for evaluating a given outcome differed across studies; therefore effect sizes were used to obtain standardized measurement of the effect of the intervention on the outcome variables. As effect size is a measure of the relative strength or effectiveness between two variables, a moderate to high effect size such as reported in all domains included in the Virues-Ortega meta-analysis, demonstrates a positive correlation between implementation of ABA-based therapy and skill development. The table below summarizes the effect size from the domain areas reviewed.
Domain area reported IQ Nonverbal IQ Receptive Language Expressive Language Adaptive behavior composite
Study size and Number of participants 18 studies and 311 participants 10 studies and 146 participants 11 studies and 172 participants 10 studies with 164 participants 15 studies with 232 participants
Pooled Effect Size 1.19 (95% CI; 0.91 1.47) 0.65 (95% CI; 0.17 1.16) 1.48 (95% CI; 0.96 1.97) 1.47 (95% CI; 0.85 2.08) 1.09 (95% CI; 0.70 1.47)
Summary of Technology Assessment completed by Hayes: Hayes (October 2010) conducted a review of Intensive Behavioral Intervention obtained from a search of the peer-reviewed literature published between 1966 and October 2010. The review referenced the 2010 Virus-Ortega Review. However, the report did not include the National Standards Project (2009) or the New Zealand Review (2009). Hayes summary conclusion follows: There is some evidence that suggests that treatment of young autistic children with intensive behavioral intervention (IBI) therapy, also called Lovaas or applied behavior analysis (ABA) therapy, may promote gains in cognitive function, language skills, and adaptive behavior. However, although almost all studies suggested improvements in children treated
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with IBI compared with other treatments, most studies had major limitations in design and methodology, including lack of randomization procedures, small sample sizes, and a lack of blinded assessments to determine treatment effects. Although the initial work by Lovaas suggested that some high-functioning autistic children who undergo IBI therapy can achieve normal school performance and behavior, these findings have not been replicated by other investigators. Based on the available evidence, a Hayes Rating of C is assigned to the use of IBI therapy for the treatment of autism in children.
Review Summary Applied Behavior Analysis (ABA) is a behavioral/educational approach that seeks to reinforce adaptive behaviors and reduce maladaptive behaviors in children with Autistic Spectrum Disorders, and is focused on the treatment of deficits. ABA-based treatments are not diagnostically specific, but are applied to populations where there is need according to the presence of specific skill deficits. ABA is rendered either directly by a Board Certified Behavior Analyst (BCBA) or licensed mental health clinician or medical professionals with additional training in ABA or by a paraprofessional, care giver or family member under the supervision of the BCBA or licensed mental health clinician. The education and training of this discipline contains all the elements of an evidenced based training and has the elements to deliver the treatments with fidelity on a higher scale than most psychotherapy treatments render in the community. This is based on the heavy reliance on continuous more objective measurement of the response of the interventions to demonstrate effectiveness on an individual level and give clearer indications of when treatment plan changes need to occur. ABA has no notable safety risk beyond those associated with behavioral therapy. Adverse techniques are not a part of the treatment approach. The National Autism Centers National Standards Project (NSP) was a review of educational/behavioral treatments for the autism spectrum disorder (ASD) population under the age of 22. The review was conducted on studies published between 1957 and 2007. Exclusionary criteria included individuals at risk for an ASD or children who did not have a clinical diagnosis of an ASD, studies that were not published in English, and those studies that examined biomedical interventions were largely excluded. Specifically, medication trials, nutritional supplement studies, and complementary and alternative medical interventions were excluded with the exception of curative diets. Curative diets were included because it was the view that professionals across a wide range of settings are often expected to implement curative diets with a high degree of fidelity. The NSP chose to exclude those individuals with co-morbid conditions not commonly co-occurring with ASDs. Only those co-morbid conditions that more commonly occur with an ASD (e.g., mental retardation, language impairments, depressions, anxiety, ADHD, etc.) were included. Other exclusions included studies that did not include empirical data for single subject designs or when statistical analyses were not available for group research designs. For the purpose of this technology review, the NSP categories and ranking of intervention packages was mapped against the CTAC hierarchy of evidence criteria. The New Zealand review contained most of the same articles reviewed by the NSP and replicated the NSPs classifications.
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Established Treatments as defined by the NSP: Based on their review of the educational/behavioral interventions for individuals with autism spectrum disorders who were under 22 years old, the National Standards Project concluded that the following treatment packages were established (score of 3, 4, or 5) in terms of the strength of evidence classification system (avg. SMRS scores are in parenthesis beside each package): Antecedent package (3.25), Behavioral package (3.06), Comprehensive Behavioral treatment for Young Children (3.0), Join Attention Intervention (3.25), Modeling (3.14), Naturalistic Teaching Strategies (3.29), Peer Training, Package (3.0), Pivotal Response Treatment (3.0), Schedules (3.25), Self-management (3.0), and Story-based Intervention Package (3.25). The NSP further noted that of the established treatments, approximately two-thirds were developed exclusively from the behavioral literature, i.e., applied behavior analysis, behavioral psychology, and positive behavior supports). Of the remaining one-third, 75% represent treatments from the behavioral literature. Summary of Research Evidence Strengths: The strengths of this review will be discussed in terms of the National Standards Report as the New Zealand Review was based on most of the same studies (463 articles out of 508) as the NSP and replicated the NSPs findings. The NSP is the largest report to date, evaluating 775 publications in peer-reviewed journals for individuals under 22 years old with a diagnosis of Autistic Disorder, Aspergers Syndrome, or PDD-NOS. The review occurred across disciplines including psychologists, speech-language pathologists, educators, occupational or physical therapists and behavior analysts. Input from this cross-disciplinary group of experts was purposeful to be as transparent as possible. The National Standards Project maintained a high level of rigor in the development of the model, creating a model that was consistent with other evidenced-based practice guidelines from other related health and psychology fields and from 25 experts in autism spectrum disorders as well as an additional 20 expert for the conceptual reviews. The review was based on studies that were of quantitative measurement; qualitative studies were not included in the review. Consequently, the NSP included a newly developed measurement system, the Scientific Merit Rating Scale (SMRS). The SMRS is the only scale currently available to aid reviewers and create an objective measure in ranking evidence based on single case studies which was the majority of the study evidence for intensive behavioral treatments for autism spectrum disorder. The goal of the SMRS was to allow the reviewers to consistently evaluate the scientific merit of each study included in the analysis. Steps were taken to establish a high level of reliability amongst reviewers, including creating a coding manual, training raters to a specified criterion, and evaluation of the field reviewers level of interobserver agreement. No other comprehensive reviews, with the exception of the New Zealand review, have included an evaluation of reliability of the reviews. The breadth of the studies reviewed was comprehensive, reviewing all studies associated within a given treatment. Initially, 71 treatment categories were proposed and resulted in a final 38 types of treatment categories specific to autism spectrum disorders. The review included treatments commonly sought by families and included the behavioral and educational treatments from ABA,
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behavioral psychology, positive behavior supports. Approximately two thirds of the established treatments were developed exclusively from the behavioral literature (e.g., ABA, behavioral psychology, and positive behavior supports). Seventy-five percent of the remaining one third represented treatments for which research support comes predominantly from the behavioral literature. These results were supported by the New Zealand review. The meta-analysis provided several characteristics that could allow for general conclusions to be made as to the effectiveness of Applied Behavior Analysis as a treatment for autistic disorder and pervasive developmental disorder, not otherwise specified. From the review, there was a large effect of ABA-based therapy on IQ, language (expressive and receptive), and adaptive behaviors. A moderate effect was found within the area of non-verbal IQ. Language related outcomes (e.g., IQ, receptive and expressive language, communication) were distinctively superior to non-verbal IQ, social functioning and daily living skills, with effect sizes approaching 1.5 for receptive and expressive language and communication. This is particularly noteworthy given the qualitative impairments in communication that occur with a diagnosis of autism. An effect size of 1.19 (as in the case of IQ) means that the score of the average person in the experimental group is 1.19 standard deviations above the average person in the control group. Meta-regression analysis provided a clear account of the impact of intervention intensity and duration that is not obvious from simple examination of individual studies. An overall finding was that language skills tended to benefit more from intervention duration while functional and psychosocial adaptive behaviors benefitted more from intervention intensity. The highest magnitude of response effects were demonstrated for receptive and expressive language. Most control groups received eclectic interventions such as special education, sensory integration, TEACCH and others; therefore, a preliminary comparison between ABA-based intervention and other forms of treatment of autism was available. Summary of Research Evidence Weaknesses: Eleven treatment packages were scored as established by the National Standards Project (NSP). Of these eleven treatment packages, all came out of the field of Applied Behavior Analysis (ABA) and were based on the Operant Conditioning paradigm. Of the 775 studies reviewed by the NSP, 578 studies were categorized in one of the eleven treatment packages. Of the 578, 78 received emerging scores (SMRS of 3, 4, or 5). However, only ten of the 78 studies were based on group design which means over 99% of the studies were based on single subject research. CTAC held a special meeting to review and discuss the merit of single case studies in light of this issue with current ASD research. The result of the discussion was to include the ranking of single case studies with high ranking on the rigor of the research design. However the CTAC still felt in order to demonstrate clear effectiveness and generalization of the effect, there needed to be confirmatory studies using a group or randomized trial design. Sound single case studies could add to the strength of the evidence demonstrated by a well designed group or randomized clinical trial study but could not be considered as the sole method for establishing proven evidence.
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Additional concerns were that the studies evaluated do not provide information as to the effectiveness of the interventions for individuals above 21 years old. Further, since the NSP did not evaluate treatment effects for individuals above 21 years old, it is unknown as to whether any of the eleven established treatment packages would produce favorable results for individuals in this older group. The NSP and New Zealand reviews included studies specific to the Autism Spectrum Disorders, however there are limited established treatments (e.g., Modeling and Story-based intervention) for Aspergers syndrome. The lack of established treatments for Aspergers disorder especially within the comprehensive behavioral treatment for young children, make it difficult to address whether individuals with Aspergers disorder would benefit from this type of treatment. Likewise, for individuals in the 19-21 age range, the behavioral treatment package is the only established treatment. There are limited studies on the effects of behavioral intervention for Aspergers syndrome specifically and therefore best practice for Aspergers syndrome is unclear. It is difficult to ascertain best practice from this review within certain populations (e.g., Aspergers syndrome), certain age ranges (e.g., 19-21), treatment intensity levels (e.g., 10 or 40 hours per week), treatment overlap (e.g., can an antecedent package and a behavioral package be combined and what type of learning results) or the level of severity that can benefit most from the established treatments. Some of these questions were not necessarily goals of the NSP but would be beneficial in determining best practice guidelines for all individuals across the spectrum. A comparison between the ABA interventions models (e.g., Lovaas vs general ABA model) is needed as well as measurement of the fidelity of the interventions which was lacking within the studies reviewed in the meta-analysis. Adding fidelity measures would help to determine what these approaches may have in common. Randomization to group assignment was seldom implemented for the studies found, and the use of quasi-random assignment strategies may raise ethical and internal validity concerns. General quality standards of clinical studies of randomization, blindness, intention to treat analysis, and the use of prospective designs were inconsistently used. Although random-effects meta-analysis and sensitivity analysis may partially compensate for this deficit, somewhat different results might well be found if studies employ such higher methodological standards.
Conclusions: Using CTACs Strength of Evidence Classification, none of the Applied Behavior Analysis (ABA) treatment packages for Autism Spectrum Disorders (ASD) that were reviewed and recommended as Established by the National Standards Project, and supported by the New Zealand review and Virus-Ortega meta-analysis, meet the CTAC criteria for Proven.
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Instead, the evidence for these treatments falls within CTACs level of Emerging Technology. Table 1 below identifies which ABA treatment packages for ASD fall into the CTAC Emerging category, and for which age groups. Two treatment approaches specifically were found to be emerging for Aspergers disorder, modeling and story-based intervention only.
TABLE 1 ABA Treatment Approaches
Applicable Age Group 3-14 yrs

All age groups
Quantity of Evidence
All studies reviewed per package/ Number of established studies
Average SMRS Score

All studies reviewed per package/ Number of established studies
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 Instruction
109/4 SSRD studies

250/17 SSRD Studies
1.38/3.25
1.35/3.06
0- 9 yrs 0- 5 yrs 3- 18 yrs 0- 9 yrs 3- 14 yrs 3- 9 yrs 3- 14 yrs 3- 18 yrs 6- 14 yrs
22/6 group design and 1SSRD studies 7/1 group and 3 SSRD studies 56/14 SSRD studies 32/2 group design and 5 SSRD studies 33/1 group design and 6 SSRD studies 14/4 SSRD studies 12/4 SSRD studies 22/6 SSRD studies 21/4 SSRD studies
2.18/3.0 2.71/3.25 2.04/3.14 1.94/3.29 1.83/3.0 2.0/3.9 2.08/3.25 1.83/3.0 1.81/3.25
Further support for an emerging classification is indicated by the medium to large effect sizes from the domains reviewed by the metaanalysis. The 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 and pervasive developmental disorder, not otherwise specified. What can be derived from the meta-analysis is that an ABA-based treatment approach provides an indication that the therapy is effective at changing behavior by increasing skills in the core areas affected by an ASD diagnosis. What are not clear at this point are the specific ABA approaches that produce this (positive) change in behavior. The education and training of the Board Certified Behavior Analyst discipline contains all the elements of evidenced based training and has the elements to deliver the treatments with fidelity on a higher scale than most psychotherapy treatments render in the
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community. This is based on the heavy reliance on continuous and more objective measurement of the response of the interventions to demonstrate effectiveness on an individual level and give clearer indications of when treatment plan changes need to occur.
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References American Academy Of Pediatrics (2001). Policy Statement: The Pediatrician's Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children (RE060018) Pediatrics, 107, 1221-1226. Association for Behavior Analysis International (2009). The ABAI Model Licensing Act, Educational Standards, and the Protection of the Profession. Auckland Uniservices Limited (2009). Technical Review of Published Research on Applied Behaviour Analysis Interventions for People with Autism Spectrum Disorder. Auckland Uniservices Limited. Auckland, NZ Behavior Analyst Certification Board (2009). Standards and Applications for Examination. www.bacb.com Cohen, H., Amarine-Dickens, M., & Smith, T. (2006). Early intensive behavioral treatment: Replication of the UCLA Model in a community setting. Developmental and Behavioral Paediatrics, 27, 145155. Committee on Children With Disabilities (2001). Technical Report: The Pediatrician's Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children. Pediatrics, 107, e85. Cooper, J. O., Heron, T.E. and Heward, W.L. (2007) Applied Behavior Analysis, 2nd Edition. Prentice Hall, Inc. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2009). Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model. Pediatrics, 16-24.
Eikeseth, S., Smith, T., Jahr, E., & Eledevik, S. (2002). Intensive behavioral treatment at school for 47-year-old children with autism: A 1-year comparison controlled study. Behavior Modification, 26, 4968. Eikeseth, S., Smith, T., Jahr, E., & Eledevik, S. (2007). Outcome for children with autism who began intensive behavioral treatment between age four and seven: A comparison controlled study. Behavior Modification, 31, 264278. Filipek, P.A., Accardo, P.J., Baranek, G.T., Cook,. E.H., Dawson, C., Gordon, B., Gravel, J.S., Johnson, C.P., Kallen, R.J., Levy, S.E., Minshew, N.J., Prizant, B.M., Rapin, I., Rogers, S.J., Stone, W.L., Teplin, S., Tuchman, R.G., & Volkmar, F.R. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism and Developmental Disorders. 29, 439-484.
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Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatment for young children with autism. Research in Developmental Disabilities, 26, 359383. Kazdin, A. E. & Hersen, Hersen, M. (1980). The current status of behavior therapy. Behavior Modification, 4, 283-302. Koegel, L.K., and R.L. Koegel (1999a). Pivotal response intervention I: Overview of approach. Journal of the Association for the Severely handicapped, 24:174-185. [148] Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 39. Maine Administrators of Services for Children with Disabilities (2000). Report of the MADSEC Autism Task Force. MADSEC, Manchester, ME. McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Long-term outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 97, 359372. Myers, S.M., Johnson, C.P., and the Council on Children With Disabilities(2007) Management of Children With Autism Spectrum Disorders, Pediatrics, 120, 1162-1182. Originally published online Oct 29, 2007; DOI: 10.1542/peds.2007-2362 National Autism Center (2009). The National Standards Project- Addressing the need for evidence based practice guidelines for autism spectrum disorders. National Autism Center. Randolph, MA. National Research Council (2001). Educating Children with Autism, Committee on Educational Interventions for Children with Autism, Division of Behavioral and Social Sciences and Education, Washington, D.C.: National Academy Press. Remington, B., Hastings, R. P., Kovshoff, H., degli Espinosa, F., Jahr, W., Brown, T., et al. (2007). A field effectiveness study of early intensive behavioral intervention: Outcomes for children with autism and their parents after two years. American Journal of Mental Retardation, 112, 418438. Sallows, G. O.,& Graupner, T. D. (2005). Intensive behavioral treatment for children with autism: Four-year outcome and predictors. American Journal of Mental Retardation, 110, 417438. Satcher, D. (1999). Mental health: A report of the surgeon general. U.S. Public Health Service. Bethesda, MD.
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Schreibman, L., & Koegel, R. L. (2005). Training for parents of children with autism: Pivotal responses, generalization, and individualization of interventions. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatment for child and adolescent disorders: Empirically based strategies for clinical practice (2nd Edition). (pp. 605-631). Washington, D. C.: American Psychological Association. Volkmar, F., Cook, E.H., Pomeroy, J., Realmuto, G. & Tanguay, P. (1999). Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (Supplement), 32s-54s
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Appendix A Cross Walk Grids
Grid Key National Standards Project New Zealand Review Virues-Ortega Review
40
Antecedent Package
Behavioral Package
Comprehensive Behavioral Package
Joint Attention Package
Modeling
Naturalistic Teaching
Peer Training
Pivotal Response Training
Schedules
SelfManagement
Storybased intervention
Communication Higher Cognitive Learning Readiness Placement Interpersonal Personal Responsibility Self-Regulation Problem Behaviors Restricted, Repetitive, Nonfunctional General Symptoms Sensory or Emotional Regulation Play
Table 1. Established treatments by behavioral domains as outlined in the National Standards Project.
Anteced ent Package
Behaviora l Package
Comprehensiv e Behavioral Package
Joint Attentio n Package
Modelin g
Naturalisti c Teaching
Peer Trainin g
Pivotal Respons e Training
Schedule s
SelfManagemen t
Storybased interventio n
Autism Aspergers NOS
Table 2. Established treatments by ASD diagnosis as outlined in the National Standards Project
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Antecedent Package
Behavioral Package
Modeling
Peer Training
Schedules
SelfManagement
Storybased intervention
0-2 3-5 6-9 1014 1518 1921
Table 3. Established treatments by age group as outlined in the National Standards Project
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Antecedent Package
Behavioral Package
Modeling
Peer Training
Schedules
SelfManagement
Story-based intervention
Antecedent Exposure Behavioural FCT Social skills PECS Verbal behaviour Reductive Early IBI [intensive behavioural intervention] Joint attention Modelling Naturalistic teaching Peer training PRT [pivotal response training] Schedules Self-management Scripting
Table 4. NSP treatment packages mapped to NZR treatment approaches
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Higher Cognitive Learning Readiness
Problem Behaviors Restricted, Repetitive, Nonfunctional
Communication
Self-Regulation
Personal Responsibility
Interpersonal
Sensory or Emotional Regulation
General Symptoms
Placement
Development of functional and spontaneous communication Development of cognitive (thinking) skills Social development and relating to others Development of independent organizational skills and other behaviors Prevention of challenging behaviors and substitution with more appropriate and conventional behaviors Reducing challenging behaviors Engagement and Flexibility in Developmentally Appropriate Tasks and Play and Later Engagement in Vocational Activities Receptive Language Expressive Language General language skills Communication General IQ Non-verbal IQ Daily living skills Socialization Motor skills Adaptive Behavior Composite
Table 5. National Standards Project behavioral domains matched to New Zealand Review and Virues-Ortega meta-analysis behavioral domains.
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Play
Appendix B Reference Listing of Critical Studies for Intervention Packages

Antecedent Package Baker, M.J. (2000). Incorporating the thematic ritualistic behaviors of children with autism into games: Increasing social play interactions with siblings. Journal of Positive Behavior Interventions, 2(2), 6684. Davis, C. A., Brady, M. P., Hamilton, R., McEvoy, M. A., & et al. (1994). Effects of high probability requests on the social interactions of young children with severe disabilities. Journal of Applied Behavior Analysis, 27(4), 619-637. Ducharme, J.M., Sanjuan, E., & Frain, T. (2007). Errorless compliance training : Success-focused behavioral treatment of children with asperger syndrome. Behavioral Modification, 31(3), 329-344. Grindle, C.F., & Remington, B. (2004). Teaching children with autism using conditioned cue-value and response-marking procedures: A socially valid procedure. Research in Developmental Disabilities, 25(5), 413-429.
Behavioral Package Apple, A.L., Billingsley, F., & Schwartz, I.S. (2005). Effects of video modeling alone and with self-management on compliment-giving behaviors of children with high-functioning ASD. Journal of Positive Behavior Interventions, 7(1), 33-46. Carr, E. G., & Carlson, J. I. (1993). Reduction of severe behavior problems in the community using a multicomponent treatment approach. Journal of Applied Behavior Analysis, 26(2), 157-172. Charlop-Christy, M. H., & Haymes, L. K. (1996). Using obsessions as reinforcers with and without mild reductive procedures to decrease inappropriate behaviors of children with autism. Journal of Autism and Developmental Disorders, 26(5), 527-546. Charlop-Christy, M. H., & Haymes, L. K. (1998). Using objects of obsession as token reinforcers for children with autism. Journal of Autism and Developmental Disorders, 28(3), 189-198. Durand, V. M., & Carr, E. G. (1991). Functional communication training to reduce challenging behavior: Maintenance and application in new settings. Journal of Applied Behavior Analysis, 24(2), 251-264. Gena, A., Couloura, S., & Kymissis, E. (2005). Modifying the affective behavior of preschoolers with autism using in-vivo or video modeling and reinforcement contingencies. Journal of Autism and Developmental Disorders, 35(5), 545-556. Haring, T. G., Kennedy, C. H., Adams, M. J., & Pitts-Conway, V. (1987). Teaching generalization of purchasing skills across community settings to autistic youth using videotape modeling. Journal of Applied Behavior Analysis, 20(1), 89-96. Harris, S. L., Handleman, J. S., & Alessandri, M. (1990). Teaching youths with autism to offer assistance. Journal of Applied Behavior Analysis, 23, 297-305. Lee, R., & Sturmey, P. (2006). The effects of lag schedules and preferred materials on variable responding in students with autism. Journal of Autism and Developmental Disorders, 36(3), 421-428. McConnachie, G., & Carr, E. G. (1997). The effects of child behavior problems on the maintenance of intervention fidelity. Behavior Modification, 21(2), 123-158. Nuzzolo-Gomez, R., Leonard, M. A., Ortiz, E., Rivera, C. M., & Greer, R. D. (2002). Teaching children with autism to prefer books or toys over stereotypy or passivity. Journal of Positive Behavior Interventions, 4(2), 80-87.
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Pelios, L. V., MacDuff, G. S., & Axelrod, S. (2003). The effects of a treatment package in establishing independent academic work skills in children with autism. Education & Treatment of Children, 26(1), 1-21. Rincover, A., & Newsom, C. D. (1985). The relative motivational properties of sensory and edible reinforcers in teaching autistic children. Journal of Applied Behavior Analysis, 18(3), 237-248. Ross, D. E., & Greer, R. D. (2003). Generalized imitation and the mand: Inducing first instances of speech in young children with autism. Research in Developmental Disabilities, 24(1), 58-74. Sidener, T. M., Shabani, D. B., Carr, J. E., & Roland, J. P. (2006). An evaluation of strategies to maintain at practical levels. Research in Developmental Disabilities, 27(6), 632-644. Thiemann, K. S., & Goldstein, H. (2001). Social stories, written text cues, and video feedback: Effects on social communication of children with autism. Journal of Applied Behavior Analysis, 34(4), 425-446.
CBTYC Package Cohen, H., Amerine-Dickens, M., & Smith, T. (2006). Early intensive behavioral treatment: Replication of the UCLA model in a community setting. Journal of Developmental and Behavioral Pediatrics, 27(2), 145155. Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2007). Outcome for children with autism who began intensive behavioral treatment between ages 4 and 7. Behavior Modification, 31(3), 264-278. Harris, S. L., Handleman, J. S., 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(3), 281-290. Lovaas, O. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55(1), 3-9. Sallows, G. O., & Graupner, T. D. (2005). Intensive behavioral treatment for children with autism: Four-year outcome and predictors. American Journal of Mental Retardation: AJMR, 110(6), 417-438. Smith, T., Eikeseth, S., Klevstrand, M., & Lovaas, O. (1997). Intensive behavioral treatment for preschoolers with severe mental retardations and pervasive developmental disorder. American Journal on Mental Retardation, 102(3), 238-249. 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(4), 297-309.
Joint Attention Intervention Martins, M. P., & Harris, S. L. (2006). Teaching children with autism to respond to joint attention initiations. Child & Family Behavior Therapy, 28(1), 51-68. Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young children with autism: A randomized controlled intervention study. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 47(6), 611-620. Jones, E. A., Carr, E. G., & Feeley, K. M. (2006). Multiple effects of joint attention intervention for children with autism. Behavioral Modification, 30(6), 782-834. Rocha, M. L., Schreibman, L., & Stahmer, A. C. (2007). Effectiveness of training parents to teach joint attention in children with autism. Journal of Early Intervention, 29(2), 154-172.
Modeling Package Apple, A. L., Billingsley, F., & Schwartz, I. S. (2005). Effects of video modeling alone and with selfmanagement on compliment-giving behaviors of children with high-functioning ASD. Journal of Positive Behavior Interventions, 7(1), 33-46.
46
Buffington, D. M., Krantz, P. J., McClannahan, L. E., & Poulson, C. L. (1998). Procedures for teaching appropriate gestural communication skills to children with autism. Journal of Autism and Developmental Disorders, 28(6), 535-545. Buggey, T., Toombs, K., Gardener, P., & Cervetti, M. (1999). Training responding behaviors in students with autism: Using videotaped self-modeling. Journal of Positive Behavior Interventions, 1(4), 205-214. Charlop-Christy, M. H., Le, L., & Freeman, K. A. (2000). A comparison of video modeling with in vivo modeling for teaching children with autism. Journal of Autism and Developmental Disorders, 30(6), 537-552. Charlop-Christy, M. H. & Daneshvar, S. (2003). Using video modeling to teach perspective taking to children with autism. Journal of Positive Behavioral Interventions, 5(1), 12-21. Gena, A., Krantz, P. J., McClannahan, L. E., & Poulson, C. L. (1996). Training and generalization of affective behavior displayed by youth with autism. Journal of Applied Behavior Analysis, 29(3), 291-304. Gena, A., Couloura, S., & Kymissis, E. (2005). Modifying the affective behavior of preschoolers with autism using in-vivo or video modeling and reinforcement contingencies. Journal of Autism and Developmental Disorders, 35(5), 545-556. Haring, T. G., Kennedy, C. H., Adams, M. J., & Pitts-Conway, V. (1987). Teaching generalization of purchasing skills across community settings to autistic youth using videotape modeling. Journal of Applied Behavior Analysis, 20(1), 89-96. Jahr, E., Eldevik, S., & Eikeseth, S. (2000). Teaching children with autism to initiate and sustain cooperative play. Research in Developmental Disabilities, 21(2), 151-169. Nikopoulos, C. K. & Keenan, M. (2007). Using video modeling to teach complex social sequences to children with autism. Journal of Autism and Developmental Disorders, 37(4), 678-693. Reeve, S. A., Reeve, K. F., Townsend, D. B., & Poulson, C. L. (2007). Establishing a generalized repertoire of helping behavior in children with autism. Journal of Applied Behavior Analysis, 40(1), 123-136. Schreibman, L., Whalen, C., & Stahmer, A.C. (2000). The use of video priming to reduce disruptive transition behavior in children with autism. Journal of Positive Behavior Interventions, 2(1), 3-11. Sherer, M., Pierce, K. L., Paredes, S., Kisacky, K.L., Ingersoll, B., & Schreibman, L. (2001). Enhancing conversation skills in children with autism via video technology. Which is better, self or other as a model? Behavior Modification, 25(1), 140-158. Shipley-Benamou, R., Lutzker, J. R., & Taubman, M. (2002). Teaching daily living skills to children with autism through instructional video modeling. Journal of Positive Behavior Interventions, 4(3), 165-175.
Naturalistic Teaching Strategies Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-implemented enhanced milieu teaching on the social communication of children with autism. Topics in Early Childhood Special Education, 22(1), 2954. Ingersoll, B., & Schreibman, L. (2006). Teaching reciprocal imitation skills to young children with autism using a naturalistic behavioral approach: Effects on language, pretend play, and joint attention. Journal of Autism and Developmental Disorders, 36(4), 487- 505. McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1986). An extension of incidental teaching procedures to reading instruction for autistic children. Journal of Applied Behavior Analysis, 19(2), 147-157. McGee, G. G., & Daly, T. (2007). Incidental teaching of age-appropriate social phrases to children with autism. Research & Practice for Persons with Severe Disabilities, 32(2), 112-123.
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Olive, M. L., de la Cruz, B., Davis, T. N., Chan, J. M., Lang, R. B., OReilly, M. F., & Dickson, S. M. (2007). The effects of enhanced milieu teaching and a voice output communication aid on the requesting of three children with autism. Journal of Autism and Developmental Disabilities, 37, 1505-1513. Wong, C. S., Kasari, C., Freeman, S., & Paparella, T. (2007). The acquisition and generalization of joint attention and symbolic play skills in young children with autism. Research & Practice for Persons with Severe Disabilities, 32(2), 101-109. Yoder, P., & Stone, W. L. (2006). Randomized comparison of two communication interventions for preschoolers with autism spectrum disorders. Journal of Consulting and Clinical Psychology, 74(3), 426-435. Peer Training Kamps, D. M., Royer, J., Dugan, E., Kravitz, T., Gonzalez-Lopez, A., Garcia, J., et al. (2002). Peer training to facilitate social interaction for elementary students with autism and their peers. Exceptional Children, 78, 173-187. Kohler, F. W., Strain, P. S., Hoyson, M., & Jamieson, B. (1997). Merging naturalistic teaching and peer-based strategies to address the IEP objectives of preschoolers with autism: An examination of structural and child behavior outcomes. Focus on Autism and Other Developmental Disabilities, 12(4), 196-206. Lee, S., Odom, S. L. & Loftin, R. (2007). Social engagement with peers and stereotypic behavior of children with autism. Journal of Positive Behavior Interventions, 9(2), 67-79. Nelson, C., McDonnell, A. P., Johnston, S. S., Crompton, A., & Nelson, A. R. (2007). Keys to play: A strategy to increase the social interactions of young children with autism and their typically developing peers. Education and Training in Developmental Disabilities, 42(2), 165-181. Sainato, D. M., Goldstein, H., & Strain, P. S. (1992). Effects of self-evaluation on preschool childrens use of social interaction strategies with their classmates with autism. Journal of Applied Behavior Analysis, 25(1), 127-141. Thiemann, K. S., & Goldstein, H. (2004). Effects of peer training and written text cueing on social communication of school-age children with pervasive developmental disorder. Journal of Speech, Language, and Hearing Research: JSLHR, 47(1), 126-144. Tsao, L., & Odom, S. L. (2006). Sibling-mediated social interaction intervention for young children with autism. Topics in Early Childhood Special Education, 26(2), 106-123. Pivotal Response Training Harper, C. B., Symon, J. B. G., & Frea, W. D. (2008). Recess is time-in: Using peers to improve social skills of children with autism. Journal of Autism and Developmental Disorders, 38, 815-826. 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(3), 285-295. Stahmer, A. C. (1995). Teaching symbolic play skills to children with autism using pivotal response training. Journal of Autism and Developmental Disorders, 25(2), 123-141. Thorp, D. M., Stahmer, A. C., & Schreibman, L. (1995). Effects of sociodramatic play training on children with autism. Journal of Autism and Developmental Disorders, 25(3), 265-282. Schedules Krantz, P. J., MacDuff, M. T., & McClannahan, L. E. (1993). Programming participation in family activities for children with autism: Parents use of photographic activity schedules. Journal of Applied Behavior Analysis, 26(1), 137-138. Hume, K., & Odom, S. (2007). Effects of an individual work system on the independent functioning of students with autism. Journal of Autism and Developmental Disabilities, 37, 1166-1180.
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MacDuff, G. S., Krantz, P. J., & McClannahan, L. E. (1993). Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26(1), 89-97. Morrison, R. S., Sainato, D. M., Benchaaban, D., & Endo, S. (2002). Increasing play skills of children with autism using activity schedules and correspondence training. Journal of Early Intervention, 25(1), 5872. Self-Management Delano, M. E. (2007). Improving written language performance of adolescents with asperger syndrome. Journal of Applied Behavior Analysis, 40(2), 345-351. Newman, B., Buffington, D. M., OGrady, M. A., McDonald, M. E., et al. (1995). Self-management of schedule following in three teenagers with autism. Behavioral Disorders, 20(3), 190-196. Newman, B., Reinecke, D. R., & Meinberg, D. L. (2000). Self-management of varied responding in three students with autism. Behavioral Interventions, 15(2), 145-151. Sainato, D. M., Strain, P. S., Lefebvre, D., & Rapp, N. (1990). Effects of self-evaluation on the independent work skills of preschool children with disabilities. Exceptional Children, 56(6), 540-549. Stahmer, A. C., & Schreibman, L. (1992). Teaching children with autism appropriate play in unsupervised environments using a selfmanagement treatment package. Journal of Applied Behavior Analysis, 25(2), 447-459. Strain, P. S., Kohler, F. W., Storey, K., & Danko, C. D. (1994). Teaching preschoolerswith autism to selfmonitor their social interactions: An analysis of results in home and school settings. Journal of Emotional and Behavioral Disorders, 2(2), 78-88. Story-based Intervention Package Bock, M. A. (2007). The impact of social-behavioral learning strategy training on the social interaction skills of four students with asperger syndrome. Focus on Autism and Other Developmental Disabilities, 22(2), 88-95. Delano, M., & Snell, M. E. (2006). The effects of social stories on the social engagement of children with autism. Journal of Positive Behavior Interventions, 8(1), 29-42. Sansosti, F. J., & Powell-Smith, K. A. (2006). Using social stories to improve the social behavior of children with asperger syndrome. Journal of Positive Behavior Interventions, 8, 43-57. Scattone, D., Wilczynski, S. M., Edwards, R. P., & Rabian, B. (2002). Decreasing disruptive behaviors of children with autism using social stories. Journal of Autism and Developmental Disorders, 32(6), 535543.
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ABA TechAssessment

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Technology Assessment Form (Summary of Evidence) Name of New Technology: Applied Behavior Analysis as treatment for Autism Spectrum

1. Description of the technology

1. What population is the technology used with?

2. What diagnosis or clinical condition is the technology used for?

3. What aspect(s) of treatment is the technology used for?

How is it applied in a clinical setting?

Training required to implement the technology?

Discipline or educational level required implementing the technology?

What is the training process to assure fidelity?

Safety of the technology:

Of the 7 studies reviewed: average SMRS score of

PROVEN: average of at least 4.0; EMERGING: average of at least 3.0)

Of the 4 studies: average SMRS score of 3.25 (range: 3-4)

2) SMRS Score: PROVEN: average of at least 4.0;

Of the 56 studies reviewed: average SMRS score of

2) SMRS Score: PROVEN: average of at least 4.0;

Of the 32 studies reviewed: average SMRS score of 1.94 (range: 0-4)

EMERGING: average of at least 3.0

Of the 7 studies: average SMRS score of 3.29 (range: 3-4)

2) SMRS Score: PROVEN: average of at least 4.0;

Of the 33 studies reviewed: average SMRS score of

*the NSP report listed the self-management package as having

21 studies; a total of 22 were sent for final tally

Story-based Intervention Package:

Study design ranking will rely on UHC hierarchy of evidence

TABLE 1 ABA Treatment Approaches

Applicable Age Group 3-14 yrs

Average SMRS Score

109/4 SSRD studies

0- 9 yrs 0- 5 yrs 3- 18 yrs 0- 9 yrs 3- 14 yrs 3- 9 yrs 3- 14 yrs 3- 18 yrs 6- 14 yrs

2.18/3.0 2.71/3.25 2.04/3.14 1.94/3.29 1.83/3.0 2.0/3.9 2.08/3.25 1.83/3.0 1.81/3.25

Appendix A Cross Walk Grids

Comprehensive Behavioral Package

Joint Attention Package

Pivotal Response Training

Anteced ent Package

Comprehensiv e Behavioral Package

Joint Attentio n Package

Pivotal Respons e Training

Autism Aspergers NOS

Comprehensive Behavioral Package

Joint Attention Package

Pivotal Response Training

0-2 3-5 6-9 1014 1518 1921

Comprehensive Behavioral Package

Joint Attention Package

Pivotal Response Training

Table 4. NSP treatment packages mapped to NZR treatment approaches

Higher Cognitive Learning Readiness

Problem Behaviors Restricted, Repetitive, Nonfunctional

Sensory or Emotional Regulation

Appendix B Reference Listing of Critical Studies for Intervention Packages

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