Autism Intervention

Running head: BEST PRACTICES IN AUTISM INTERVENTION

Best Practices in Autism Intervention: A Critical Review of Intensive Behavioural Intervention (IBI) Pasquale Veleno University of Calgary

Autism Intervention Abstract Autism is a pervasive developmental disorder characterized by impairments in social interaction, behaviour, communication and language development. Research has

demonstrated an increase in overall incidence of autism spectrum disorders (ASDs), though it appears that a broader definition of autism, increased awareness, and more systematic assessment practices may account for this phenomenon. Given the increased prevalence of autism, it is prudent to critically evaluate current assessment and intervention practices in order to improve and inform future service delivery. This paper critically evaluates IBI intervention for autism using Upah and Tillys (2003) quality indicator model.

Autism Intervention Autism is a pervasive developmental disorder characterized by impairments in

communication and language development, social skill deficits, restricted, repetitive and/or stereotypic behaviour, and resistance to change (American Psychiatric Association, 2000). There is evidence to suggest that individuals with autism spectrum disorder (ASD) have impaired abilities to execute higher-level cognitive processes, including problem solving and other complex goal directed behaviour involving spatial working memory and response inhibition (Luna et al., 2006). Baron-Cohen, Leslie, and Frith (1985) hypothesize that children with ASD have impairments in meta-representation, which underlie their difficulties with social understanding and communication (Mash & Barkley, 2003). Autistic children are a heterogeneous group with diverse needs, however. Research indicates that symptoms of autism are typically present prior to 12 months of age, and diagnosis is common before the age of 3 years (Baranek, 1999; Lord, 1995; Osterling & Dawson, 1994). While the etiology of autism remains unclear, there are genetic and neurological links that remain an ongoing focus of continued investigation. Prevalence rates of this childhood disorder are estimated to range from 10 to 20 cases per 10, 000 people (Filipek, Accardo et al, 2000), with boys three to four times more likely to develop autism than girls (Bryson, Clark, & Smith, 1988; Fombonne, 1999; Steffenburg & Gillberg, 1986; Volkmar, Szatmari, & Sparrow, 1993). Further to this, research has demonstrated an increase in overall incidence of ASDs, though it appears that a broader definition of autism, increased awareness, and more systematic assessment practices may account for this phenomenon (Perry & Condillac, 2003). Given that the prevalence of autism is not as rare as once thought, it is prudent to evaluate current assessment and intervention practices in order to inform and improve

Autism Intervention future service delivery. Upah and Tilly (2004) developed a 12-component quality indicator model as a best practice standard for designing, implementing and evaluating quality interventions (p.484). This paper attempts to summarize the available literature

pertaining to the use of IBI, and seeks to critically evaluate the quality and appropriateness of IBI programming as it relates to autism intervention, using Upah and Tillys model as a frame of comparison. Applied Behaviour Analysis (ABA), and more specifically, Intensive Behavioural Intervention (IBI), is a commonly used intervention for young autistic children. ABA is defined as the science in which procedures derived from the principles of behaviour are systematically applied to improve socially significant behaviour to a meaningful degree and to demonstrate empirically the procedures employed were responsible for the improvement (Baer, Wolf, & Risley, 1968). According to the behavioural analytic viewpoint, autism is a syndrome consisting of behavioural deficits and excesses that have a neurological basis, which are nonetheless amenable to change in response to specific, carefully programmed, constructive interactions with the environment (Green, 1996). Intensive Behavioural Intervention (IBI) is a comprehensive form of early intervention, derived from principles of Applied Behaviour Analysis (ABA), for young children with autism spectrum disorders. This intervention is characterized by intensive, i.e., 20 to 40 hours per week, direct teaching in a one-to-one capacity, for the purposes of addressing skill deficits and improving behaviour. IBI incorporates many techniques based on learning theory, where programs are individualized and administered by trained staff, under the guidance or supervision of a psychologist, to produce an empirically based approach to intervention (Perry & Condillac, 2003). Dawson and Osterling (1997) describe

Autism Intervention the six elements which appear to be common to effective intervention programs: appropriate curriculum content, supportive teaching environments and generalization strategies, predictability and routine, functional approach to problem behaviors, plans for transition from preschool classroom, and family involvement.

Research has shown that IBI can result in dramatic improvements for children with autism (Anderson, Avery, DiPietro, Edwards, & Christian, 1987; Birnbrauer & Leach, 1993; Fenske, Zalenski, Krantz, McClannahan, 1985; Harris, Handleman, Gordon, Kristoff, & Fuentes, 1991; Lovaas, 1987; Maurice, 1993; McEachin, Smith, & Lovaas, 1993; Perry, Cohen, & DeCarlo, 1995). Further to this, research has shown some evidence regarding the overall superiority of this approach when compared with alternate autism interventions (Lovaas & Smith, 1989; Schribman, 1988; Schreibman, Charlop, & Milstein, 1993; Smith, 1993). Problem Identification Quality intervention is preceded by the clear identification and definition of the problem. Upah and Tilly (2004) define a problem as the difference between what is expected and the actual student behaviour or performance (p. 484). The step is a particularly important one insofar as it helps to establish and clarify the intent to resolve the difference between current performance and desired outcomes, while simultaneously acknowledging that the students performance is significantly different from that of his/her peer group. This step consists of three subcomponents: a behavioural definition; baseline data; and, problem validation.

Autism Intervention

As it pertains to early autism intervention, comprehensive IBI programs are reliant on early screening and referral programs to promote early diagnosis and early intervention in this regard. Filipek et al. (1999) distinguish between developmental surveillance, which involves routine screening for all children, more specific screening for autism spectrum disorders and full assessment/diagnosis. Several tools have been developed, including the Rourke Baby Record and the Nipissing Developmental Screen, in Ontario, to assist in the early identification of children who may need to be assessed for possible autism. Though this is not a component of IBI per se, it is an integrated step in an effective, holistic, quality assessment and intervention program. An operational definition serves to provide an objective, clear and complete definition of the behaviour so as to facilitate recognition of target behaviours for the purposes of data collection, assessment and intervention (Hawkins & Dobes, 1977; Howel & Nolet, 2000; Kazdin, 1982; Tilly, Reschly, & Grimes, 2000; Upah and Tilly, (2004). As is the case with all teaching methods based on the principles of Applied Behaviour Analysis (ABA), IBI requires that target behaviours have clearly defined operational descriptions, which allow an individual reading the support plan to easily identify the occurrence or nonoccurrence of problem behaviour (ONeil et al., 1997). This quality indicator can be adapted and applied to various domains of function, including cognitive, academic and behavioural realms, respectively. In order to evaluate program effectiveness, it is essential that the students current level of functioning be established prior to the introduction of treatment. By doing so, a baseline is established which facilitates the evaluation of student progress by allowing the comparison between pre-treatment and post-treatment conditions. This requires that a

Autism Intervention number of dimensions of the target behaviour be considered, including the frequency, intensity, duration and discrimination of the behaviour(s) (Griffiths & Hingsburger, 1991; Sulzer-Azaroff & Mayer, 1991). Further to this, it is important to establish a manner to systematically measure the behaviour which takes into account how the data will be

collected, under what conditions and settings the data will be collected, who will collect the data, and how often the data will be collected (Upah & Tilly, 2003). Ideally, baseline data is collected over a period of several days or weeks, and over the course of several sessions and/or settings so as to provide an accurate reflection of contingencies maintaining the behaviour (Martin & Pear, 2003). The collection of baseline data further serves to provide necessary information required for problem validation, and program evaluation (Upah & Tilly, 2003), and remains an integral, i.e., expected, component of all IBI programming. Problem validation refers to the attempt to confirm the existence and magnitude of a problem by summarizing the discrepancy between student performance and expected outcomes (Upah & Tilly, 2003; Howell & Nolet, 2000). This is typically accomplished by comparing performance outcomes to appropriate group norms, where possible. If performance outcomes are deemed to be significantly discrepant, then the problem is considered validated and further assessment is required for the purposes of informing an individualized intervention approach (Upah & Tilly, 2003). Sulzer-Azaroff and Mayer (1991), suggest that consideration should be given to whether behavioural intervention is warranted prior to moving forward with the development of a behavioural plan. This is a best practice approach specific to ABA. Conditions that would indicate intervention is necessary would include: the identification of problems and goals; requests for assistance from multiple sources; the individual is deemed to be functioning differently from peers

Autism Intervention (comparison group); and noticeable changes in individual behaviour. In meeting these criteria, IBI seeks to validate the existence of problematic behaviours or performance outcomes.

As it pertains to autism, screening and diagnostic procedures exist to identify at-risk children in order to facilitate early intervention. Early intervention is considered to help speed the child's overall development, reduce inappropriate behaviors, and lead to better long-term functional outcomes (Anderson, Avery, DiPietro, Edwards, & Christian, 1987; Birnbrauer & Leach, 1993; Fenske, Zalenski, Krantz, McClannahan, 1985; Harris, Handleman, Gordon, Kristoff, & Fuentes, 1991; Lovaas, 1987; Maurice, 1993; McEachin, Smith, & Lovaas, 1993; Perry, Cohen, & DeCarlo, 1995; NYSDH, 1999). In order to facilitate early screening and intervention, a number of measures need to be taken. These include incorporating parental feedback regarding developmental milestones and associated delays, consulting appropriate medical professionals and using evidence-based screening devices; and taking a best practice approach to diagnosis by incorporating norm-referenced measures, direct interviews, observations and informal assessment procedures (Filipek et al., 1999; NYSDH, 1999, Sattler, 2008). According to Perry and Condillac (2003), clinical practice should also be consistent with relevant legislation, professional college regulations, standards, ethics, agency policies, and other relevant guidelines. In Ontario, the Regulated Health Professions Act (RHPA) defines diagnosis as a "controlled act" which may only be performed by professionals registered with either the College of Psychologists or the College of Physicians and Surgeons (p.35). Further to this, the Ontario Association for Behaviour Analysis (ONTABA) Standards of Professional Practice indicate, the service recipient's biological, medical, past history, and developmental factors should be

Autism Intervention addressed and considered prior to, or concurrent with, the behavioural assessment (p.3). As such, comprehensive programs geared toward addressing wide-ranging problems associated with autism, such as IBI, successfully incorporate a best practice approach into the formal screening and assessment process prior to providing services to children and their families. This further provides empirically based problem validation.

Problem Analysis The five steps involved in Upah and Tillys (2003) problem analysis process include: identifying relevant known information; identifying relevant unknown information; generating a hypothesis; validating the hypothesis; and, linking the assessment information to the design of the intervention. Applied Behaviour Analysis procedures necessitate the gathering of behavioural information for the purposes of developing hypotheses that will guide future interventions. Direct evaluation is important insofar as it allows for a determination to be made regarding child progress, and guides objective, clinical decision-making (Anderson, Taras, and Cannon, 1996). This is typically accomplished by completing a functional assessment or functional analysis. A functional assessment is a process used to identify and define events in an environment that predict and maintain problem behaviours (Martin & Pear, 2003). Functional assessment helps to determine the function of behaviour, using a bio-psychosocial model, to ascertain the biomedical, environmental and functional variables impacting upon behavioural presentation. In Ontario, for example, ABA practitioners are required, as per the Ontario Association for Behaviour Analysis (ONTABA) Standards of Practice, to uphold professional standards that require the satisfaction of the empirical approach, which

Autism Intervention 10 encompasses the baseline condition, hypothesis validation, and intervention design conditions, respectively. Accordingly, the ONTABA Standards of Practice stipulate that behaviour(s) of concern need to be clearly defined and measurable, selected with the service recipient (where feasible), and be of relevance to improving the service recipient's well-being and quality of life. An analysis of behaviour-environment interactions should be conducted, typically using descriptive and functional analyses to identify possible setting events and discriminative stimuli controlling the occurrence of the behaviour, and reinforcers maintaining the behaviour. The contextual, social, and cultural aspects of the behaviour also should be considered (p.3). Research indicates that treatments based on the results of functional analyses are at least twice as effective as other treatments for individuals with autism and developmental disabilities (Carr et al., 1999). Further to this, the completion of a functional assessment is considered a necessary and expected component of professional practice within the field of Applied Behaviour Analysis, and hence IBI (ONeil et al, 1997). Additionally, comprehensive IBI programs develop curricula which emphasizes five basic domains, including: the ability to attend to important elements of the environment; imitation skills; receptive and expressive language skills; play skills; and, social skills (Dawson and Osterling, 1997; NYSDH, 1999). Curriculum is determined by conducting a wide-ranging skills assessment of the child prior to intervention and includes the use of a common tool used to accomplish this task such as the Assessment of Basic Language and Learning Skills Revised (ABLLS R). Once this has been accomplished, goal selection can proceed, based on acquired domain-specific information.

Autism Intervention 11 Plan Implementation The next phase of Upah and Tillys 12-step model is concerned with plan implementation, which encompasses four major subcomponents of the problem-solving process. These include: goal setting, intervention plan development, measurement strategy, and decision-making plan (Upah and Tilly, 2003). Applied Behaviour Analysis, and IBI programs in particular, attempt to establish goals by stating objectives in behavioural terms, which specify when the behaviour will occur; what the expected behaviour will look like; and, and by providing a clear determination of mastery criteria. Anderson, Taras & Cannon (1996) provide an example of how IBI incorporates this requirement in a typical plan of instruction, i.e., When instructed (Do this), Evelyn will imitate 10 randomly presented motor movements with 80% accuracy across three consecutive sessions(p. 183). Further to this, when developing a plan for instruction, the authors propose that the components of the plan require consideration of the following questions: a. What is the behavioural objective? b. How is the target behaviour defined?

c. Where and when will training occur? d. What materials will be needed? e. What reinforcers will be required to motivate the child to learn? f. How will progress be measured? g. What are the steps for teaching the program? What are the conditions for moving to the next step? h. How will materials and instructions be presented?

Autism Intervention 12 i. What is a correct response? What is an incorrect response? j. How will generalization and maintenance be encouraged? Furthermore, IBI programming attempts to incorporate instructional methods such as discrete-trial training (DTT), which includes specific environmental and direct teaching requirements, and response guidelines, utilizing behavioural technologies to promote skill acquisition, generalization and maintenance (Lovaas, 1983; Cooper, Heron & Heward, 1987; Anderson, Taras, & Cannon, 1996). IBI programming attempts to clearly delineate what the desired goals are, in conjunction with providing direction with regarding the process taken to achieve outcomes, while outlining data collection and monitoring strategies. In so doing, IBI meets or approximates Upah and Tillys (2003) criteria for the plan implementation phase for quality interventions, and begins to address some of the remaining components of the program evaluation phase of the model. Program Evaluation The final phase of Upah and Tillys model for quality interventions describes a process to evaluate program effectiveness. The subcomponents making up this phase consist of: progress monitoring, formative evaluation, treatment integrity, and summative evaluation. IBI programming appears to meet the aforementioned criteria in a number of ways. Romanczyk (1996) outlines the requirements for performance measurement in IBI programming by suggesting that consideration be given to the accuracy of performance, the rate of performance (response per unit of time), nonresponding versus incorrect responding, and the pattern of responding. Thisprovides us with the minimal

Autism Intervention 13 information necessary to evaluate progress (p.201). Data is gathered regularly and graphed to ascertain performance trends. By comparing the performance data, gathered over multiple sessions and performed over a period of days/weeks/months, to baseline levels of performance, it can be objectively determined whether the intervention is producing desired results. This meets the progress monitoring and formative evaluation criteria outlined in Upah and Tillys (2003) model. Treatment integrity is facilitated, with respect to IBI programming, by utilizing a team-based approach, and by training all mediators involved in the implementation of programs, including families. In Ontario, all IBI programming is supervised by a registered psychologist, who, as the clinical supervisor, is responsible for overseeing the individual program, while providing clinical consultation to the Senior Therapist, responsible for program design, and Instructor Therapist, responsible for program implementation. Incorporating a multi-tiered approach that fosters accountability ensures treatment integrity. Additionally, to ensure program integrity, all intervention plans are written, mediators are trained and observed in the natural setting, and regular observations are arranged to ensure program fidelity while providing consultation and further training, as required. Once treatment is deemed complete, progress is evaluated and summarized in a formal report format, on the basis of objective data, recorded on an ongoing basis, updated frequently, and reviewed weekly (Johnson, Meyer, & Taylor; 1996). In so doing, IBI programming fulfills Upah and Tilleys (2003) final criteria for summative evaluation.

Autism Intervention 14 In conclusion, IBI uses methods and principles of Applied Behaviour Analysis to address skill deficits in young children with autism spectrum disorders to affect optimal learning. Interventions are empirically driven, individualized, and intensive, ranging from 20 to 40 hours of direct one-to-one instruction per week. Specific, behavioural definitions are provided in order to identify target goals, implement systematic procedures, and outline contingencies for program revision. Further to this, IBI programming incorporates systems for data collection, ongoing monitoring and assessment and evaluation. Lastly, progress is summarized using empirical means to outline gains across a number of different domains of function. Based on a review of the current literature, it appears that this intervention successfully meets or approaches most, if not all, of Upah and Tillys (2003) model of quality indices for best practice in designing, implementing and evaluating interventions.

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Autism Intervention 19 Volkmar, F.R., Szatmari, P., & Sparrow, S.S. (1993). Sex differences in pervasive developmental disorders. Journal of Autism and Developmental Disorders, 23, 579-591.