Overview of the National
Autism Center’s National
Standards Report: An Update on
“Best Practices”
Richard J. Cowan, Ph.D., NCSP
Kent State University
Evidence-Based
Interventions
Questionable
Vs. Promising
National Standards Project
“Best Practices”
Approaches to Intervention


Attitudes, values, and beliefs shape our
approach to working with children who
demonstrate disruptive behaviors
Our approach to working with children is also
influenced by what we know about various
schools of thought about behavior
explanations (e.g., psychodynamic vs.
behavioral)
Approaches to Intervention (continued)

Psychodynamic/Psychoanalytic



Medical/Biological



Prescriptions
Over the counter agents
Behavioral/Educational


Relates back to childhood
“couch therapy”
Arranging antecedents and consequences
Comprehensive Approach
How to Determine the Best Approach

Start with evidence-based interventions


Research shows the treatment made a
statistically significant change in children’s
behavior—statistically significant vs. clinically
significant
Find evidence-based practices in professional
journals or ask experts—but ask experts to tell
you what the research shows about the
effectiveness of the intervention.
Levels of Research/Evidence of
Effectiveness

Questionable interventions


Although there is a clear lack of scientific
evidence, these interventions continue to be
promoted
Promising interventions

There exists some research to support the
effectiveness of these interventions; however, we
still need to approach them with caution and make
sure they are applicable to this child in this
situation
Questionable Interventions









Psychoanalysis
Sensory Integration Therapy
Auditory Integration Therapy
Equestrian Therapy
Dolphin Therapy
Holding Therapy
Options Therapy
Rapid Prompting
Neurological
Refuted Intervention:
Reprogramming
Facilitated Communication
Herbert et al., 2002; National Research Council, 2001
Questionable Interventions (cont’d)





Social Stories
Sensory Diets
Floor Time (Greenspan)
Diets/Vitamins/Supplements
Chelation Therapy
(removing toxins)

Recreational Therapies


Aquatic, Art, Music, etc.
Relationship Development
Intervention (RDI)

Focuses on transition,
relaxation and flow
Herbert et al., 2002; National Research Council, 2001
Promising Interventions

Applied Behavior Analysis (ABA)



Positive Reinforcement
Negative Reinforcement
Differential Reinforcement




Planned Ignoring + Positive Reinforcement
Token Economy Systems
Discrete trial training
Thousands of studies demonstrating efficacy of
ABA-based interventions for individuals with
disruptive behavior (Maurice, Green, & Luce,
1996, 2001)
Promising Interventions

Discrete Trial Training



Not just Lovaas (analog) discrete trial training
There exists a range of evidence-based
approaches to DTT (Analog – Naturalistic)
Naturalistic approaches to DTT have proven
equally effective as analog approached

In addition, generalization and spontaneity are
enhanced, as compared to analog approaches alone
Promising Interventions

Educational Interventions



Comprehensive Programs



TEACCH (Teaching and Education of Autistic and related
Communication handicapped Children)
PECS (Picture Exchange Communication System)
Learning Experiences: An Alternative Program for
Preschoolers and Parents (LEAP)
Denver Health Sciences Program
Medical Interventions

Think about the implications of medical interventions as a
“ready to learn” process
Medical Interventions




Stimulants, SSRI’s, and other classes of medication
These are helpful for TREATING SYMPTOMS
Each medicine targets a specific symptom/set of
symptoms; however, there is no cure for autism!
What is our role in medical intervention?



Making sure the child takes his/her medication to
maximize performance in the classroom
Monitoring the symptoms associated with the
medication to help make decisions about the
effectiveness of meds
Making certain that you view medication as one
component in a comprehensive approach to education
Recommended Practice
National Research Council (2001)
“Effective preschool programs for children with ASD include:
 Entry into intervention programs as soon as the diagnosis is
suspected,
 Active engagement in intensive instructional programming for
a minimum of the equivalent of a full school day, 5 days a
week (at least 25 hours a week), with full year programming
varied according to the child’s chronological age and
developmental level,
 Repeated, planned teaching opportunities generally organized
around relatively brief periods of time for the youngest of
children (e.g., 15-20 minute intervals), including sufficient
amounts of adult attention in one-on-one and very small group
instruction to meet individualized goals,
Recommended Practice
National Research Council (2001) (continued)



Inclusion of a family component, including parent training,
Low student/teacher ratios (no more than two young children
with ASD per adult in the classroom), and
Mechanisms for ongoing program evaluation and assessment
of individualized children’s progress, with results translated
into adjustments in programming” (p. 175)
http://www.nationalacademies.org/nrc/
http://www4.nationalacademies.org/news.nsf/isbn/0309075777?OpenDocument
Additional Recommendations
National Research Council (2001)



Sufficient individual attention every day so that Individual
Family Service Plan (IFSP) and Individualized Education
Program (IEP) objectives may be addressed with adequate
intensity
Successful interactions with typically-developing children
Instruction in the areas of functional spontaneous
communication, social interaction, play skills, and cognitive
skills taught in a manner to facilitate generalization, proactive
and effective approaches to challenging behavior, and
functional academic skills
Evidence-Based
Interventions
Questionable
Vs. Promising
National Standards Project
“Best Practices”
National Standards Project (NSP)
(National Autism Center, 2009)


The major goal of the NSP is to serve as a single
guide for parents, caregivers, educators, and service
providers
Additionally, the NSP aims to:




Provide the strength of evidence supporting educational
and behavioral treatments that target core characteristics
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 evidence-based
practice for ASD
What is the purpose of the National
Standards Project?



To identify the level of research support
currently available for educational and
behavioral interventions used with individuals
with ASD (up to age 22).
To help families, educators, and service
providers understand how to integrate critical
information in making treatment decisions.
To identify limitations of the existing research
involving individuals with ASD.
(NAC, 2009)
Findings: Three Levels of
Evidence

“Established” (total of 11 treatments)




“Emerging” (total of 22 treatments)


Produce beneficial outcomes
Known to be effective for individuals on the autism
spectrum
Overwhelming majority of these interventions were
developed in the behavioral literature (e.g., applied
behavior analysis, behavioral psychology, and positive
behavior support).
Have some evidence of effectiveness, but not enough for
us to be confident that they are truly effective
“Unestablished” (total of 5 treatments)

There is no sound evidence of effectiveness
(NAC, 2009)
Established











Antecedent Package (99 Studies)
Behavioral Package (231 Studies)
Comprehensive Behavioral Treatment for Young Children (22
Studies)
Joint Attention Intervention (6 Studies)
Modeling (50 Studies)
Naturalistic Teaching Strategies (32 Studies)
Peer Training Package (33 Studies)
Pivotal Response Treatment (14 Studies)
Schedules (12 Studies)
Self-Management (21 Studies)
Story-Based Intervention Package (21 studies)
(NAC, 2009)
Antecedent Package

The modification of situational events that typically
precede the occurrence of a target behavior

Alterations are made to increase the likelihood of
success or reduce the likelihood of problems
occurring

Treatments falling into this category reflect the fields
of applied behavior analysis (ABA), behavioral
psychology, and positive behavior supports (PBS)
(NAC, 2009)
Antecedent Package (Cont’d)











Behavior chain interruption
Behavioral momentum
Choice
Contriving motivational operations
Cueing and prompting/prompt fading
procedures
Environmental enrichment
Environmental modification of task demands,
social comments, adult presence, inter-trial
interval, seating, and familiarity with stimuli
Errorless learning
Errorless compliance
Habit reversal
Incorporating echolalia, special interests,
thematic activities, or ritualistic/obsessive
activities into tasks
(NAC, 2009)
Behavioral Package

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 the fields of
applied behavior analysis, behavioral psychology, and
positive behavior supports
Examples include:







Behavioral sleep package
Behavioral toilet training/dry bed training
Chaining
Contingency contracting
Contingency mapping
Differential reinforcement strategies
Discrete trial teaching
(NAC, 2009)
Behavioral Package (Cont’d)

Examples include:












Functional communication training
Generalization training
Mand training
Noncontingent escape with instructional fading
Progressive relaxation
Reinforcement
Scheduled awakenings
Shaping
Stimulus pairing with reinforcement
Successive approximation
Task analysis
Token economy
Comprehensive Behavioral Treatment for Young Children
(CBTYC)*

Reflects research from comprehensive treatment
programs that involve a combination of applied
behavior analytic which are delivered to young
children in a variety of settings and involve a low
student-to-teacher ratio

All studies falling into this category met the strict criteria of:




Targeting the defining symptoms of ASD
Having treatment manuals
Providing treatment with a high degree of intensity
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,
behavioral inclusive programs, or early intensive behavioral intervention
Naturalistic Teaching Strategies


Primarily child-directed interactions used to teach
functional skills in the natural environment
Often involve:






Providing a stimulating environment
Modeling how to play
Encouraging conversation
Providing choices and direct/natural reinforcers
Rewarding reasonable attempts
Examples include:




Incidental teaching
Milieu teaching
Embedded teaching
Prelinguistic milieu teaching
(NAC, 2009)
Pivotal Response Treatment*

Focus on targeting “pivotal” skills:






Motivation to engage in social communication
Self-initiation
Self-management
Responsiveness to multiple cues
Goal of very widespread and fluently integrated
collateral improvements
Also includes:


Parent involvement in the intervention delivery
Implementation in the natural environment
*This treatment is an expansion of Natural Language Paradigm
Story-Based Intervention Package


Involve a written description of the situations under
which specific behaviors are expected to occur
Stories may be supplemented with:





Prompting
Reinforcement
Discussion
Etc.
Social Stories™ are the most well-known storybased interventions

They seek to answer the “who,” “what,” “when,” “where,”
and “why” in order to improve perspective-taking.
(NAC, 2009)
Second Level of Evidence: Emerging










Augmentative and Alternative Communication Device
(14 studies)
Cognitive Behavioral Intervention Package (3 studies)
Developmental Relationship-based Treatment (7 studies)
Exercise (4 studies)
Exposure Package ( 4 studies)
Imitation-based Interaction (6 studies)
Initiation Training (7 studies)
Language Training-Production (13 studies)
Language Training-Production & Understanding) (7
studies)
Massage/Touch Therapy (2 studies)
(NAC, 2009)
Emerging (Second Level, Cont’d)












Multi-component Package (10 studies)
Music Therapy (6 studies)
Peer-mediated Instructional Arrangement (11 studies)
Picture Exchange Communication System (13 studies)
Reductive Package (33 studies)
Scripting (6 studies)
Sign Instruction (11 studies)
Social Communication Intervention (5 studies)
Social Skills Package (16 studies)
Structured Teaching (4 studies)
Technology-based Treatment (19 studies)
Theory of Mind Training (4 studies)
(NAC, 2009)
Unestablished Treatments

Academic Interventions (10 studies)





One size fits all; Traditional approaches
Auditory Integration Training (3 studies)
Facilitated Communication (DO NOT USE!)
Gluten- and Casein-Free Diet (3 studies)
Sensory Integrative Package (7 studies)
(NAC, 2009)
Auditory Integration Training



This intervention involves the presentation of
modulated sounds through headphones
Attempts to retrain an individual’s auditory
system
The goal is to improve distortions in hearing
or sensitivities to sound
(NAC, 2009)
Gluten- and Casein-Free Diet




These interventions involve elimination of an individual’s
intake of naturally occurring proteins gluten and casein
Early studies suggested that the Gluten- and CaseinFree diet may produce favorable outcomes but did not
have strong scientific designs
Better controlled research published since 2006
suggests there may be no educational or behavioral
benefits for these diets
Potential medically harmful effects have begun to be
reported in the literature
(NAC, 2009)
Sensory Integrative Package

These treatments involve establishing an
environment that stimulates or challenges the
individual to effectively use all of their senses
as a means of addressing overstimulation or
understimulation from the environment
(NAC, 2009)
Evidence-Based Practice (NRC, 2009)

Research Findings


These should be given serious consideration
first “because… (a) the treatment produced
beneficial effects and (b) they are not associated
with unfavorable outcomes” (NRC)
Professional Judgment


This involves input from professionals with
established expertise in the treatment and
education of individuals with ASD
Data-based decision making is critical!
Evidence-Based Practice (NRC, 2009)

Values and Preferences




Treatment contrary to the values of family
members
Treatment resulted in ineffective outcomes or
undesirable side-effects
Client rights
Capacity


The treatment has never been implemented in an
existing system
A “local expert” does not possess formal training
in the technique