Evaluation of Early Intervention
Phil Reed
Swansea University
Research Partners
Contributing Local Authorities
•
•
•
•
•
•
•
•
•
•
Bexley
Brighton & Hove
East Sussex
Hertfordshire
Kent
Medway
Surrey
West Berkshire
West Sussex
Wokingham
The young people with autistic spectrum problems, and
their families, who kindly participated in these
studies.
Co-Researchers
•
•
•
•
Lisa A. Osborne.
Emma M. Waddington.
Mark Corness.
Nikki Brown.
Early Interventions for Autistic
Spectrum Disorders (ASD)
• Helping people with ASD to function more independently:
– Promotes their quality of life.
– Relieves the psychological and financial strains on their families.
– Ultimately relieves the financial pressures on external supporting
agencies.
• Intervention is more effective if offered early, rather than
remedially later.
• Such early interventions are now a Governmental priority
in the United Kingdom.
• There is a clear need to evaluate early interventions in
terms of their impact on the problems associated with
ASD.
The Child with Autism
Theory of Mind
Central
Coherence
Problems
Extreme ‘Male
Brain’:
Systematising
Executive
Dysfunction
Central Deficits and Differences
• Research has illuminated much about the nature of
ASD.
• A great deal of this knowledge concerns deficits in
people with ASD, or their differences from the
non-autistic population.
• This basic knowledge can help guide the ‘search
space’ in the development of early interventions.
• Unfortunately, this work has lead to little in the
way of direct information about how to affect
successful early interventions.
A Possible Model of Early Influences
Early Teaching
Interventions:
ABA & Special
Nursery
Family:
Stress & Coping
Pre-Academics
Social Skills
Intellectual
Abilities
School:
Mainstream or
Special
Issues in the Evaluation of Early
Interventions
• The Range of Possible Early Interventions:
– Type:– ABA or Special Nursery.
– Characteristics:– Time Input, Teaching Strategies.
• Extra-Interventional Factors:
– Parental Factors:– Stress, Coping Strategies.
– Staff Factors:– Training, Confidence, Experience.
• The Range of Measures Taken:
– Intellectual, Social-Emotional Functioning.
• The Generality of the Sample:
– Severity of ASD, Clinic-Based or Community-Based.
A Possible Model of Early Influences
Early Teaching
Interventions:
ABA & Special
Nursery
Family:
Stress & Coping
Pre-Academics
Social Skills
Intellectual
Abilities
Early Teaching Interventions for
Autistic Spectrum Disorders
• Many interventions have been suggested as offering benefit
to some children with ASD.
• Some interventions focus on the parents (e.g., EarlyBird),
and some on the child (e.g., Special Nursery, Portage).
• Current debate has centred on Applied Behaviour Analysis
(ABA).
• An early ABA approach was
outlined by O. Ivar Lovaas
(1987).
• ABA has developed
substantially over the last two
decades.
The ‘Lovaas’ Approach
Intervention Overview
• 40 hours per week.
• 2-3 hours per session.
• 8-14 'drills' (tasks) per
session.
• 5-10 minutes per ‘drill’
(task).
• 5 minutes 'down time'
between ‘drills’ (tasks).
Curriculum Overview
Year 1: Aims to reduce selfstimulation and aggression;
and develop ‘compliance’ with
commands, imitation, and
play.
Year 2: Focuses on expressive
language, and interactive play.
Year 3: Deals with emotional
expression, pre-academic
skills, and observational
learning.
Outcome Effectiveness of ‘Lovaas’
Studies
1.4
1.2
1
Effect Size
Lovaas (1987)
Over three years:
• Gains of up to 30 IQ
points.
• 50% of sample not
distinguishable from
non-autistic peers in
classroom.
• Clinically relevant
improvements.
0.8
0.6
0.4
0.2
0
Eikeseth et
al
Lovaas
McEachlin
et al
Shallow & Smith et al
Graupner
Threats to Validity
Reviews have suggested difficulties in extrapolating from
these studies.
Threats to Internal Validity
Threats to External Validity
Instrumentation: Different tests
used at baseline and follow-up,
not perfectly compatible.
Control Groups: Not equated to
experimental groups for
prognosis (e.g., gender
imbalances).
Outcome Measures: Is IQ the
appropriate measure for this
population? Results using other
measures are very mixed.
Samples: Clinic-based samples
may not reflect the gains made
in ‘typical’ home-based
intervention programmes.
ABA in the Community:
Reed, Osborne, & Corness (2006, JADD)
• Investigated the effectiveness of ABA programmes:
– Conducted in the home.
– High or low intervention time input.
– Measured: intellectual, educational, and adaptive functioning.
• Children:
–
–
–
–
Identified as being on the Autistic Spectrum.
2:6 to 4:0 years old at the start of their teaching intervention.
Just starting their teaching intervention.
Only receiving one teaching intervention (ABA).
Measures
Child Measures
Intellectual Functioning:
• Psycho-Educational Profile.
Educational Functioning:
• British Abilities Scale (PreSchool).
Behavioural Functioning:
• Vineland Adaptive Behaviour
Scale.
• Conners’ Parent and Teacher
Rating Scales (Short Form).
Family Measures
• Parent Stress: Questionnaire
on Resources and Stress.
• Parenting Style: Parent-Child
Relationship Inventory.
• Child’s History: Your Child’s
History Questionnaire.
• Intervention Profile: Parents’
and Supervisors’/Teachers’
Questionnaires on Intervention.
ABA in the Community:
Reed, Osborne, & Corness (2006, JADD)
• High intensity:
• Low intensity:
– n = 13.
– Time = 12hrs/wk.
• Well matched on
baseline measures:
– mean IQ = 50.
• Follow-up after 9 to
10 months.
Change (follow-up minus baseline)
– n = 14.
– Time = 30hrs/wk.
20
**
**
High
Low
15
10
*
5
0
Intellectual (PEP-R)
-5
Educational (BAS)
Adapative Behavior
(Vineland)
ABA in the Community:
Reed, Osborne, & Corness (2006, JADD)
• However, not a
straight-forward
relationship
between time
input and gains.
35
30
25
Overall Gain
• High intensity
gives better gains
than low intensity.
• Replicates clinicbased ABA over
shorter period.
Gain = 42.7 – 0.5 Hours
20
p < 0.05
15
10
5
0
0
5
10
15
20
25
Hours per week
30
35
40
ABA Compared to Alternative Early
Teaching Interventions:
Reed, Osborne, & Corness (2006; Exceptional Children)
Compared ABA, Special Nursery, and Portage.
• Children were identified in conjunction with the
Local Authority:
– ASD diagnosis, 2:6 to 4:0 years old, at the start of their
intervention, and receiving only one intervention.
• Children were visited by an Educational
Psychologist, and the baseline measures were
taken.
• After 9 to 10 months, the follow-up measures
were taken.
ABA Compared to Alternative Early
Teaching Interventions:
Reed, Osborne, & Corness (2006; Exceptional Children)
• Well matched on baseline
measures:
– mean IQ = 50.
25
ABA
Change (follow-up minus baseline)
• ABA:
– n = 12.
– Time = 30hrs/wk.
• Special Nursery:
– n = 20.
– Time = 13hrs/wk.
• Portage:
– n = 16.
– Time = 9hrs/wk.
Nursery
20
Portage
15
10
5
0
PEP-R
-5
BAS
VAB
Impact of Time Input and Initial
Autistic Severity on Child Outcomes
40
Composite Change Score
30
20
10
0
-10
60
70
-30
-40
-60
90
100
110
Initial GARS Score
-20
-50
80
ABA
Nursery
Portage
120
Effectiveness of Early Teaching
Interventions
• ABA is effective in the community over a shorter
period of time than in Lovaas’ (1987) study,
especially for educational outcomes.
• Special Nursery is also effective, including for
adaptive behaviours.
• Temporal input is most effective at around 20
hours per week.
• Initial autistic severity impacts on outcomes for
Special Nursery and Portage, but not for ABA.
Predictors of Success:
Reed, Osborne, & Waddington (2006)
• Different early teaching
interventions produce
differential effects on child
outcomes.
• Which skills impact most
on subsequent school
success?
• ABA promotes academic
performance.
• Examine the child
outcomes after they start
school.
• Special Nursery promotes
adaptive behaviours and
social skills.
• Use teachers’ ratings of
problem behaviours:
– 12 to 18 months after starting
school.
– Strengths and Difficulties
Questionnaire (SDQ).
Predictors of Success:
Reed, Osborne, & Waddington (2006)
• For children in Mainstream
Schools:
SDQ Problem Score
– Former ABA children have the
fewest behavioural problems.
– Former Special Nursery children
have the fewest peer problems.
Mainstream
• A similar pattern occurs in Special
Schools:
4
3
2
1
0
ABA
Nursery
Portage
Conduct
Hyperactivity
Peer
Hyperactivity
Peer
Special
SDQ Problem Score
– This may depend on whether
exclusion or progress is the index.
7
6
5
Emotional
– Former ABA children fare worse
than they do in Mainstream School.
• Whether ‘behaviours’ or
‘friendships’ are more important
to ultimate success is unknown.
9
8
9
8
7
6
5
4
3
2
ABA
Nursery
1
0
Portage
Emotional
Conduct
Prior Training and Outcomes Archive Analyses: Waddington & Reed (2006)
• Based on analyses of
archive materials for
90 children in school.
• Would this facilitate
continued inclusion in
school without
behavioural skills?
Effect of Prior Social Skills Training
Age Equivalent
• On-going work
suggests that social
skills training can
facilitate academic
performance.
10
9
8
7
6
5
4
3
2
1
0
No
Yes
Reading
Spelling
Comprehension
Summary of Early Intervention
Effectiveness
• Several early teaching interventions are effective, but
for different aspects of behaviour:
– ABA for intellectual and behavioural skills.
– Special Nursery for adaptive functioning and social skills.
• Optimal intervention suggestion:
– 20 hours/wk 1:1 ABA intervention at start.
– Moving to a more social setting after about a year.
• Social skills appear to be important for subsequent
successful school functioning, but children will probably
need behavioural ‘compliance’ as well.
The Role of Parents in Early
Intervention Effectiveness
• Three lines of evidence point to the importance of the
relationship between the parents and the outcomes of early
teaching interventions:
– Levels of stress experienced by parents of children with ASD are
enormously high, compared to those experienced by parents of children
with almost any other type of disability or health problem.
– Numerous interventions target the parents of children with ASD, and
have noted improvements in the children’s behaviours.
– Hastings (2002) has suggested a theoretical link between children’s
problem behaviours and parental stress, although much of the evidence
for this link is correlational, and does not allow causal directionality to
be determined.
The Role of Parents in Early
Intervention Effectiveness
• Three lines of evidence point to the importance of the relationship between
the parents and the outcomes of early teaching interventions:
– Levels of stress experienced by parents of children with
ASD are enormously high, compared to those
experienced by parents of children with almost any
other type of disability or health problem.
– Numerous interventions target the parents of children with ASD, and
have noted improvements in the children’s behaviours.
– Hastings (2002) has suggested a theoretical link between children’s
problem behaviours and parental stress, although much of the evidence
for this link is correlational, and does not allow causal directionality to
be determined.
Stress in Parents of Children with ASD:
Osborne, McHugh, Saunders, & Reed (2006)
• Psychometric analyses
of parental stress reveal
higher stress levels for
parents of children with
ASD than for parents of
children with other
difficulties.
30
Incapacity
25
Child
Pessimism
20
QRS Score
• Analysis of parent
focus groups, just after
diagnosis, revealed
very high levels of
stress induced by the
process.
Family
15
10
5
0
Autism
Fragile-X
Tubercular
Sclerosis
Learning
Disabilities
The Role of Parents in Early
Intervention Effectiveness
• Three lines of evidence point to the importance of the relationship between
the parents and the outcomes of early teaching interventions:
– Levels of stress experienced by parents of children with ASD are
enormously high, compared to those experienced by parents of children
with almost any other type of disability or health problem.
– Numerous interventions target the parents of children with ASD, and
have noted improvements in the children’s behaviours.
– Hastings (2002) has suggested a theoretical link between
children’s problem behaviours and parental stress, although
much of the evidence for this link is correlational, and does
not allow causal directionality to be determined.
Hastings (2002):
Model for Learning Disabled Children
Child
Behaviour
Problems
Parenting
Behaviour
Parental
Stress
Child Behaviour Problems and
Parental Stress
• Child behaviour problems are
associated with parental stress.
• Studies equate child behaviours
across developmentally delayed and
non-developmentally delayed
groups.
– Donenberg & Baker (1993).
– Dumas, Wolf, Fisman, &
Culligan (1991).
– Floyd & Gallagher (1997).
• No differences in reports of parental
stress across the two groups.
• A study is needed to show that
differences in child behaviour
problems are associated with
differences in parental stress levels,
when the children’s disability and
severity are matched.
Design of Previous Studies:
Disabled Children
+ Behaviour Problems -> High Parental Stress
Non-Disabled Children
+ Behaviour Problems -> High Parental Stress
Design of Present Study:
Disability (Autism)
+ High Behaviour Problems -> High Stress
Disability (Autism)
+ Low Behaviour Problems -> Low Stress
Child Behaviour Problems and Parental Stress:
Osborne & Reed (2006)
• 66 children with ASD, and their parents, were recruited.
• The parents completed a Conners’ Rating Scale about
their children’s behaviours, and a Questionnaire on
Resources and Stress (QRS) regarding themselves.
• The children were assessed for their autistic severity,
intellectual functioning, and adaptive behaviour.
• The parents completed the Conners’, and the QRS, again
nine to ten months later.
• The children were divided into high and low problem
behaviour groups, equated for their autistic severity,
intellectual functioning, and adaptive behaviour.
Child Behaviour Problems and Parental Stress:
Osborne & Reed (2006)
Parental Stress (Total QRS)
32
Low Problem
Behaviours
High Problem
Behaviours
30
28
Correlations between child
behaviour problems at
baseline and parental stress
(total QRS) at follow-up:
Oppositional
Hyperactivity
ADHD
26
24
0.179 non-sig.
0.249 sig.
0.165 non-sig.
22
20
Oppositional
Hyperactivity
ADHD
Cognitive
There is strong evidence that
parental stress impacts on child
behaviour problems.
Correlations between parental
stress (total QRS) at baseline
and child behaviour
problems at follow-up:
Oppositional
Hyperactivity
ADHD
0.326 sig.
0.256 sig.
0.299 sig.
Parental Stress and Child Behaviour
Problems
• There is some evidence that child behaviour problems, and not
the level of disability, are related to parental stress.
• There is no strong evidence that child behaviour problems come
prior to parental stress.
• If anything, the evidence suggests that parental stress seems to
come prior to the child behaviour problems (these are different
from the autism itself).
• Can it be shown that parental stress impacts on the effectiveness
of early teaching interventions?
Parental Stress Mediates Child Outcomes of
Early Teaching Interventions:
Osborne, McHugh, Saunders, & Reed (2006)
Change (follow-up - baseline)
20
PEP-R
BAS
VAB
15
10
5
0
Low Time
Low Stress
-5
Low Time
High Stress
High Time
Low Stress
High Time
High Stress
• Parents were divided into
high and low stress
groups.
• Interventions were divided
into high and low time
input.
• High stress reduces the
impact of high time
interventions.
• This suggests that parent
training/counselling is
very important.
The Relationship Between Parental
Stress and Early Interventions
• Stress is a major factor in parents of children with
ASD.
• Parental stress may impact on their children’s
behaviours, and it reduces the efficacy of early
teaching interventions.
• Help for parents must be built into the intervention
programme, in addition to focusing on the child.
• Helping the parents will help the child.
Evaluating Early Interventions
Multiple elements for evaluation.
• Early Teaching Interventions:
– ABA and Special Nursery appear to be effective.
• Child Characteristics:
– Key skills: academic abilities and social behaviours.
• Family Characteristics:
– Parental stress and coping strategies need to be
addressed.
Evaluation of Early Intervention
Phil Reed
Swansea University
p.reed@swansea.ac.uk