NAC Findings & Conclusions

8/7/2019 NAC Findings & Conclusions

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Copyright © 2009 National Autism Center41 Pacella Park DriveRandolph, Massachusetts 02368

We have endeavored to build consensus among experts rom diverse elds o study and theoreticalorientation. We collaboratively determined the strategies used to evaluate the literature on thetreatment o Autism Spectrum Disorders. In addition, we jointly determined the intended use othis document. We used a systematic process to provide all o our experts multiple opportunities toprovide eedback on both the process and the document. Given the diversity o perspectives held byour experts, the in ormation contained in this report does not necessarily refect the unique viewso each o its contributors on every point. We are pleased with the spirit o collaboration theseexperts brought to this process.





in memory of edward g. carr, ph.d., bcba

This report is dedicated to the memory o Dr. Ted Carr, an internationally recognized leader in the treatment o Autism Spectrum Disorders and in

the feld o Positive Behavior Supports.

From the outset, Ted was a major contributor to the National Standards Project. He played a pivotal role in shaping the methodology used in the Project. Ted understood that the value o the National Standards Project was based not only on the scientifc validity o its design and implementation, but also on its social validity within the broader community. We are grate ul to Ted or his insight ul input, and his persistent ocus on ensuring that this document be use ul to amilies,

educators, and service providers.

Throughout his career, Ted o ten led the charge or the intelligent care and compassionate and respect ul treatment o individuals with

Autism Spectrum Disorders and other developmental disabilities. We at the National Autism Center, along with countless organizations and

pro essionals throughout the world, will miss him and keenly eel his loss.



vi }

Table of Contents

Acknowledgments ix

Contributors x

1 Introduction 1

About the National Standards Project. . . . . . . . . . . . . . . 1

About the National Autism Center . . . . . . . . . . . . . . . . 2

2 Overview of the National Standards Project 3

What is the Purpose? . . . . . . . . . . . . . . . . . . . . . 3

What was the Process? . . . . . . . . . . . . . . . . . . . . . 4

Developing a Model . . . . . . . . . . . . . . . . . . . . . 4

Identifying the Research . . . . . . . . . . . . . . . . . . . 4

Ensuring Reliability . . . . . . . . . . . . . . . . . . . . . 6

About the Scientific Merit Rating Scale . . . . . . . . . . . . . 6

Treatment Effects Ratings . . . . . . . . . . . . . . . . . . 7

Strength of Evidence Classification System . . . . . . . . . . . 9

3 Outcomes 11

Established Treatments . . . . . . . . . . . . . . . . . . . . 11

Detailed Summary of Established Treatments . . . . . . . . . . . 17

Emerging Treatments . . . . . . . . . . . . . . . . . . . . . 20

Unestablished Treatments . . . . . . . . . . . . . . . . . . . 22

Ineffective/Harmful Treatments . . . . . . . . . . . . . . . . . 24

4Recommendations for Treatment Selection 25



{ vii

5 Evidence-based Practice 27

6 Limitations 29

7 Future Directions 33

Future Directions for the Scientific Community . . . . . . . . . . 33

Future Directions with Methodology . . . . . . . . . . . . . . . 34

Future Directions for the National Standards Report . . . . . . . . 36

Appendix 1: Inclusionary and Exclusionary Criteria 37

Appendix 2: Scientifc Merit Rating Scale 38

Appendix 3: Treatment E ects 43

Appendix 4: Treatment Target Defnitions 44

Appendix 5: Names and Defnitions o Emerging andUnestablished Treatments 45

References 49

Index 51





{ ix

Acknowledgments

There are many challenges in undertaking a project o this nature. A series o complex decisions must be made over thecourse o several years that infuence the use ulness o the nal document. I would like to take the opportunity to thankthe extraordinary number o pro essionals, amily members, and organizations that have made this task easier.

I have had the good ortune to receive eedback rom amily members and individuals on the autism spectrum atthe numerous con erences at which I have discussed the National Standards Project. Your input has infuenced boththe process we have used and this nal document. I hope you continue to provide us eedback as we develop utureeditions o the National Standards Project. I have also received eedback at these con erences rom pro essionals

representing di erent elds o expertise and theoretical orientations. These pro essionals grapple with the very compli-cated process o providing best practices in homes, schools, and communities. Thank you or your assistance and yoursustained input to the National Standards Project.

I am also grate ul to the pro essionals and lay members o the autism community who provided very detailed eedbackat various stages o this project. It would be hard to overstate the importance o your contributions. Your disparateviews aided in the development o the review process and the completion o this document. Many o you are identi-

ed in our contributors section. I appreciate the consistent support o our expert panelists and conceptual reviewerswho contributed tirelessly throughout this process. The input o amilies and pro essionals was also essential to thedevelopment o this project.

The National Standards Project could not have been completed without an important group o organizations and indi-viduals. We appreciate both their willingness to underwrite the costs associated with the project and their consistentneutrality regarding the outcomes reported in this document. May Institute has supported the National StandardsProject rom its inception. Most costs associated with the rst plenary session which began the development othis project were provided by the Autism Education Network (AEN). Without the support o Michelle Waterman andJanet Lishman o AEN, the early development o this project would have been ar more challenging. Additional costs

or the project were underwritten by the Cali ornia Department o Developmental Services. We also appreciate thesupport and eedback we received rom the Oversight and Advisory Committees through the Cali ornia Department oDevelopmental Services and the pro essionals involved in the “Autism Spectrum Disorders: Guidelines or E ectiveInterventions” document that will be available soon.

Susan M. Wilczynski, Ph.D., BCBAExecutive Director, National Autism CenterChair, National Standards Project



x }

Contributors

Pilot TeamsTeam 1Gina Green, Ph.D., BCBA-D

Joseph N. Ricciardi, Psy.D., ABPP, BCBA

Team 2Brian A. Boyd, Ph.DKara Anne Hume, Ph.D.

Mara V. Ladd, Ph.D.Samuel L. Odom, Ph.D.Hanna C. Rue, Ph.D.

Research AssistantsLauren E. Christian, M.A.

Jesse Logue, B.A.

Document Commentators Jennifer D. Bass, Psy.D.Bridget Cannon-Hale, M.S.W.Nancy DeFilippis, B.A.Natalie DeNardo, B.A.

Marcia Eichelbeger, B.S.Stefanie Fillers, B.A., BCABA Mary Elisabeth Hannah, M.S.Ed., BCBA Kerry Hayes, B.A.Deborah Lacey Kelli Leahy, B.A.Linda Lotspeich, M.D.Dana Pellitteri, B.A.Nicole Prindeville, B.A.Hanna C. Rue, Ph.D.

Annette Wragge, M.Ed.

Computer Consultant Jeffrey K. Oresik, M.S.

EditorsHeidi A. Howard, M.P.A.Patricia Ladew, B.S.Eileen G. Pollack, M.A.

Graphic Designer Juanita Class

Statistical ConsultantTammy Greer, Ph.D.

AdvisorsCarl J. Dunst, Ph.D.Dean L. Fixsen, Ph.D.Gina Green, Ph.D., BCBA-DCatherine E. Lord, Ph.D.Dennis C. Russo, Ph.D., ABBP, ABPP

Expert PanelistsSusan M. Wilczynski, Ph.D., BCBA (Chair)

Jane I. Carlson, Ph.D., BCBA Edward G. Carr, Ph.D., BCBA Marjorie H. Charlop, Ph.D.Glen Dunlap, Ph.D.Gina Green, Ph.D., BCBA-D

Alan E. Harchik, Ph.D., BCBA-DRobert H. Horner, Ph.D.Ronald Huff, Ph.D.Lynn Kern Koegel, Ph.D., CCC-SLPRobert L. Koegel, Ph.D.Ethan S. Long, Ph.D., BCBA-DStephen C. Luce, Ph.D., BCBA-D

James K. Luiselli, Ed.D., ABPP, BCBA-DSamuel L. Odom, Ph.D.Cathy L. Pratt, Ph.D.Robert F. Putnam, Ph.D., BCBA

Joseph N. Ricciardi, Psy.D., ABPP, BCBA Raymond G. Romanczyk, Ph.D., BCBA-DIlene S. Schwartz, Ph.D., BCBA Tristram H. Smith, Ph.D.Phillip S. Strain, Ph.D.Bridget A. Taylor, Psy.D., BCBA Susan F. Thibadeau, Ph.D., BCBA-DTania M. Treml, M.Ed., BCBA

Conceptual Model ReviewersBrian A. Boyd, Ph.D.

Anthony J. Cuvo, Ph.D.Ronnie Detrich, Ph.D., BCBA

Wayne W. Fisher, Ph.D.Lauren Franke, Psy.D., CCC-SP

William Frea, Ph.D.Lynne Gregory, Ph.D.Kara Anne Hume, Ph.D.Penelope K. Knapp, M.D.

John R. Lutzker, Ph.D.David McIntosh, Ph.D.Gary Mesibov, Ph.D.Patricia A. Prelock, Ph.D., CCC-SLPSally J. Rogers, Ph.D.Mark D. Shriver, Ph.D.Brenda Smith Myles, Ph.D.Coleen R. Sparkman, M.A., CCC-SLP

Aubyn C. Stahmer, Ph.D., BCBA-DPamela J. Wolfberg, Ph.D.

John G. Youngbauer, Ph.D.

We also thank a number o amilies who provided input but did not wish to have their names made public.



{ xi

Article Reviewers Amanda N. Adams, Ph.D., BCBA Amanda K. Albertson, M.A.Keith D. Allen, Ph.D., BCBA

Angela M. Arnold-Seritepe, Ph.D. Judah B. Axe, Ph.D., BCBA Jennifer D. Bass, Psy.D.Barbara Becker-Cottrill, Ed.D.

Stacy Lynn Bliss Fudge, Ph.D.Brian A. Boyd, Ph.D. James E. Carr, Ph.D., BCBA Stephanie Chopko, M.A.Costanza Colombi, Ph.D.Shannon E. Crozier, Ph.D., BCBA Elizabeth Delpizzo-Cheng, Ph.D., BCBA, NCSPRonnie Detrich, Ph.D., BCBA Melanie D. Dubard, Ph.D., BCBA Stephen E. Eversole, Ed.D., BCBA-D

Adam B. Feinberg, Ph.D., BCBA-DLaura F. Fisher, Psy.D.

Wayne W. Fisher, Ph.D. William Frea, Ph.D. William A. Galbraith, Ph.D., BCBA Katherine . Gilligan, M.S., BCBA Gina Green, Ph.D., BCBA-D

racy D. Guiou, Ph.D., BCABA Neelima Gutti, B.S.Lisa M. Hagermoser Sanetti, Ph.D.

Alan E. Harchik, Ph.D., BCBA-DPatrick F. Heick, Ph.D., BCBA-DTomas S. Higbee, Ph.D., BCBA Kara Anne Hume, Ph.D.Maree Hunt, Ph.D.Melissa D. Hunter, Ph.D.Heather Jennett, Ph.D., BCBA Kristen N. Johnson-Gros, Ph.D., NCSPDebra M. Kamps, Ph.D.

Amanda M. Karsten, M.A.Shannon Kay, Ph.D., BCBA Courtney L. Keegan, M.Ed., BCBA Penelope K. Knapp, M.D.

Daniel J. Krenzer, M.S.Mara V. Ladd, Ph.D.Courtney M. LeClair, M.A.Celia Lie, Ph.D.Ethan S. Long, Ph.D., BCBA-D

James K. Luiselli, Ed.D., ABPP, BCBA-DElizabeth A. Lyons, Ph.D., BCBA

Gwen Martin, Ph.D., BCBA Britney N. Mauldin, M.S. Judy A. McCarty, Ph.D., NCSP, BCBA J. Christopher McGinnis, Ph.D., NCSP, BCBA Christine McGrath, Ph.D., NCSPVictoria Moore, Psy.D.Oliver C. Mudford, Ph.D., BCBA Dipti Mudgal, Ph.D.Samuel L. Odom, Ph.D.Gary M. Pace, Ph.D., BCBA-DHeather Peters, Ph.D.Marisa Petruccelli, Psy.D.Katrina J. Phillips, Ph.D., BCBA Patricia A. Prelock, Ph.D., CCC-SLP

Jane E. Prochnow, Ed.D.Robert F. Putnam, Ph.D., BCBA Sarah G. Reck, B.A.Henry S. Roane, Ph.D., BCBA Lise Roll-Peterson, Ph.D., BCBA Hannah C. Rue, Ph.D.Dennis C. Russo, Ph.D, ABBP, ABPP

Jana M. Sarno, M.A.Stephanie L. Schmitz, Ed.S.Mark D. Shriver, Ph.D.

Jennifer M. Silber, Ph.D., BCBA orri Smith ejral, M.S., BCBA ristram H. Smith, Ph.D.

Debborah E. Smyth, Ph.D.

Aubyn C. Stahmer, Ph.D.CarrieAnne St. Armand, M.B.A., M.S., BCBA Ravit R. Stein, Ph.D.Catherine E. Sumpter, Ph.D.Bridget A. aylor, Psy.D., BCBA Susan F. Tibadeau, Ph.D., BCBA-DMatthew J. incani, Ph.D.

Jennifer Wick, M.A.Susan M. Wilczynski, Ph.D., BCBA Pamela S. Wolfe, Ph.D.

April S. Worsdell, Ph.D., BCBA



1 } Findings and Conclusions

1Introduction

About the National Standards ProjectThe National Standards Project, a primary initiative o the National Autism

Center, addresses the need or evidence-based practice guidelines or

Autism Spectrum Disorders (ASD).

The National Standards Project seeks to: ◖ provide the strength o evidence supporting educational and behavioral treatments

that target the core characteristics o these neurological disorders

◖ describe the age, diagnosis, and skills/behaviors targeted or improvement associ-

ated with treatment options

◖ identi y the limitations o the current body o research on autism treatment

◖ o er recommendations or engaging in evidence-based practice or ASD

Who will beneft rom national standards? We believe that parents, caregivers, educators, and service providers who must

make complicated decisions about treatment selection will beneft rom national stan-

dards.



National Standards Project { 2

About the National Autism CenterThe National Autism Center is dedicated to serving children and adolescents

with Autism Spectrum Disorders (ASD) by providing reliable in ormation, pro-

moting best practices, and o ering comprehensive resources or amilies,

practitioners, and communities.

An advocate or evidence-based treatment approaches, the National Autism Centeridenti es e ective programming and shares practical in ormation with amilies about

how to respond to the challenges they ace. The Center also conducts applied research

as well as develops training and service models or practitioners. Finally, the Centerworks to shape public policy concerning ASD and its treatment through the develop-

ment and dissemination o national standards o practice.

Guided by a Pro essional Advisory Board, the Center brings concerned constituentstogether to help individuals with Autism Spectrum Disorders and their amilies pursue

a better quality o li e.



2Overview of the National

Standards ProjectWhat is the Purpose?

The National Standards Project serves three primary purposes:

1. To identi y the level o research support currently available or educational and

behavioral interventions used with individuals (below 22 years o age) 1 with AutismSpectrum Disorders (ASD). These interventions address the core characteristics o

these neurological disorders. Knowing levels o research support is an importantcomponent in selecting treatments that are appropriate or individuals on the autism

spectrum.

2. To help parents, caregivers, educators, and service providers understand how tointegrate critical in ormation in making treatment decisions. Speci cally, evidence-

based practice involves the integration o research ndings with {a} pro essionaljudgment and data-based clinical decision-making, {b} values and pre erences o

amilies, and {c} assessing and improving the capacity o the system to implementthe intervention with a high degree o accuracy.

3. To identi y limitations o the existing treatment research involving individuals with

ASD.

We hope that the National Standards Project will help individuals with ASD, theiramilies, caregivers, educators, and service providers to select treatments that support

people on the autism spectrum in reaching their ull potential.

1 For the purpose o this report, we use the phrase “individuals with Autism Spectrum Disorders” to re er to individuals onthe autism spectrum who are under 22 years o age.




What was the Process?

Developing the ModelThe National Standards Project began with the development o a model or evalu-

ating the scienti c literature involving the treatment o ASD by a working groupconsisting o Pilot Team 1 and outside consultation rom methodologists 2.The process

or the initial development o the National Standards Project is outlined in Flowchart

1. We developed a model based on an examination o evidence-based practice guide-lines rom other health and psychology elds 3 as well as rom 25 experts (see expert

panel) attending planning sessions or the National Standards Project. This model wassent to the original experts as well as an additional 20 experts (see conceptual review-

ers) who represent diverse elds o study and theoretical orientations. The model wasmodi ed based on their eedback and then served as the oundation or data collection

procedures.

Identifying the ResearchPrior to data collection, we identi ed the ASD treatment articles that should be

included in our review. These treatments were generally designed to address the coreeatures o these neurological disorders. A number o these studies also addressed the

associated eatures o ASD. The studies were conducted in a wide variety o settings

such as universities, university-based clinics, medical settings, and schools and wereconducted by a broad range o pro essionals (e.g., psychologists, speech-language

2 The pilot team relied on the ollowing sources: Sidman (1960); Johnston & Pennypacker (1993); Kazdin (1982; 1998);New York State Department o Health, Early Intervention Program (1999) and; Task Force on Promotion and Dissemination o

Psychological Procedures (1995).3 These systems were developed based on an examination o previous evidence-based practice guidelines including

the Agency or Healthcare Research and Quality (West, King, Carey, Lohr, McKoy et al., 2002), American PsychologicalAssociation Presidential Task Force on Evidence-Based Practice (2003), and the Task Force on Evidence-Based Interventionsin School Psychology (APA, 2005). These were also based on an examination o publications about evidence-based practiceby authors {a} Chambless, Baker, Baucom, Beutler, Calhoun, Crits-Christoph, et al., (1998) and {b} Horner, Carr, Halle, McGee,Odom, & Wolery (2005).




Develop initial version of conceptual model

Conceptual reviewers and expertpanelists review conceptual model

Modify conceptual model

Remove articles based onexclusionary criteria

Begin article reviews using theScientific Merit Rating Scale

Complete article reviews

Treatment categorization

Establish reliability of article reviewers

Pilot Team 1 develops initial systems

for evaluating the literature

Expert panel convenes planning sessions

Develop coding manual and codingform based on conceptual model

Identify pilot articles

Establish reliability of pilot team

Literature search identifiesinitial abstracts for consideration

Apply inclusionary andexclusionary criteria

Identify additional articles

Identify article reviewers

Complete analysis using Strengthof Evidence Classification System

Flowchart 1} Process of the Initial Development of the National Standards Project




pathologists, educators, occupational or physi-

cal therapists). Search engines produced atotal o 6,463 abstracts or consideration; an

additional 644 abstracts were identi ed by ourexperts, attendees to national autism con er-

ences, and project participants who reviewedrecent book chapters. These abstracts were

compared against our inclusion/exclusion

criteria (see Appendix 1). An additional 413articles were removed by trained eld review-ers (described below). We included 724

peer-reviewed articles in our nal review.

Because more than one study was publishedin several o these articles, a total o 775

research studies were reviewed and analyzed.

Ensuring ReliabilityTo ensure a high degree o agreement (i.e.,

reliability) among reviewers, the coding oarticles began with observer calibration. Thatis, a pilot team reviewed articles and made

modi cations to a coding manual until interob-server agreement reached an acceptable level

(>80%). All eld reviewers then received acopy o the coding manual, the coding orm,

and a pilot article to code. Field reviewerswho reached an acceptable level o agree-

ment (>80%) were invited to review articles

or the National Standards Project.

About the ScientificMerit Rating ScaleWe developed the Scienti c Merit Rating

Scale as a means o objectively evaluatingwhether the methods used in each study

were strong enough to determine whether ornot a treatment was e ective or participants

on the autism spectrum. This in ormationallows us to determine i the results are

believable enough that we would expect simi-lar results in other studies that used equal or

better research methodologies.

We then applied each o the dimensions

(listed below) included in the Scienti c MeritRating Scale in the same way to each article.

This allowed us to consistently answerquestions relevant to the scienti c merit o

each study speci cally related to individualswith ASD. Table 1 briefy describes some o

the questions answered with the Scienti cMerit Rating Scale. (A detailed outline o the

Scienti c Merit Rating Scale is available inAppendix 2.)

The fve dimensions o the ScientifcMerit Rating Scale include:

1. experimental rigor o the research design;

2. quality o the dependent variable;

3. evidence o treatment delity;

4. demonstration o participant ascertain-ment; and

5. generalization data collected.




Each category was weighted. Dimensions that have been consistently acknowl-

edged as essential in research since the rst studies were published were given

stronger weights. Factors that have most recently been considered important weregiven lesser weights. The weights assigned were as ollows: Research Design (.30) +

Dependent Variable (.25) + Participant Ascertainment (.20) + Procedural Integrity (.15) +Generalization (.10).

Treatment Effects RatingsIn addition, each study was examined to determine i the treatment e ects were:

{a} bene cial, {b} ine ective, {c} adverse, or {d} unknown.

◖ Bene cial is identi ed when there is su cient evidence that we can be con dentavorable outcomes resulted rom the treatment.

◖ Unknown was identi ed when there was not enough in ormation to allow us tocon dently determine the treatment e ects.

Table 1} Examples of Questions Addressed withthe Scientific Merit Rating Scale


Rating} Scores all between 0 and 5 with higherscores representing higher indications oscientifc merit specifc to the ASD population

Design:Two classes o research design were considered

Measurement of Dependent Variable:Two types o data were

considered

Measurement of Independent Variable

Participant Ascertainment

Generalizationof Tx Effect(s)

Group

Answersquestionssuch as:

Single-subject

Answersquestionssuch as:

Test, scale,checklist,etc.Answersquestionssuch as:

DirectbehavioralobservationAnswersquestionssuch as:

Answers questions suchas:

Answers questions such as:

Answers questions such as:

How manypartici-pants wereincluded?

How manygroups wereincluded?

Were relevantdata lost?

What wasthe researchdesign?

How many

comparisonswere made?

How manydata pointswerecollected?

How manypartici-pants wereincluded?

Were relevantdata lost?

Was the

protocolstandardized?

What are thepsychometricproperties?

Were theevaluatorsblind and/orindependent?

What type o

measurementwas used?

Is thereevidence oreliability?

How muchdata werecollected?

Is there evidence the treat-

ment was implementedaccurately?

How much treatment delitydata were collected?

Is there evidence o reliabil-ity or treatment delity?

Who delivered the

diagnosis?Was the diagnosiscon rmed?

Were psycho-metrically soundinstruments used?

Were DSM or ICDcriteria used?

Were objective data

collected?Were maintenanceand/or generaliza-tion data collected?



◖ Ine ective is identi ed when there is su -

cient evidence that we can be con dentavorable outcomes did not result rom the

treatment.

◖ Adverse is identi ed when there is su -

cient evidence that the treatment wasassociated with harm ul e ects.

Appendix 3 outlines the criteria or treat-ment e ects.

The reason separate scores are required

to determine scienti c merit and treatmente ects is they tap into separate but equally

important concerns related to each study. Forexample, a study could have a very strong

research design (high scienti c merit) butshow that the treatment was actually ine ec-

tive. Decision-makers should be aware o a

nding o this type.

Similarly, a study could have a relatively

weak research design (lower scienti c merit)

but show that the treatment was e ective.Scientists would not necessarily believe the

treatment was actually e ective in this casebecause the outcomes could be due to some

actor other than the treatment (e.g., thepassage o time, some unknown variable that

was not accounted or in the study, etc.).

Once we coded all studies, we combinedthe results o the Scienti c Merit Rating Scale

and the Treatment E ects Ratings to identi y

the level o research support that is currently

available or each educational and behavioral

intervention we examined. We identi ed38 treatments 4. The term “treatment” may

represent either intervention strategies (i.e.,therapeutic techniques that may be used in

isolation) or intervention classes (i.e., a com-bination o di erent intervention strategies

that have core characteristics in common).

Whenever possible, we combined interven-tion strategies into treatment classes inorder to lend clarity to the e ectiveness o

the treatment. When this was not possible,

we reported results on isolated interventionstrategies. The experts involved in the project

provided eedback when reviewing earlierdra ts o this report. That is, they were given

the opportunity to provide input three timesbe ore the nal 38 treatments were identi ed.

A ter we identi ed the treatments, weapplied the Strength o Evidence Classi ca-tion System criteria.

4 Reliability in the orm o interobserver agreement was .92 ortreatment categorization.




Strength of Evidence Classification SystemThe Strength o Evidence Classi cation System can be used to determine how

con dent we can be about the e ectiveness 5 o a treatment. Ratings refect the level

o quality, quantity, and consistency o research ndings or each type o intervention.There are our categories in the Strength o Evidence Classi cation System. 6 Table 2

identi es the criteria associated with each o the ratings.

These general guidelines can be used to interpret each o these

categories:

◖ Established . Su cient evidence is available to con dently determine that a treat-ment produces avorable outcomes or individuals on the autism spectrum. That is,

these treatments are established as e ective.

◖ Emerging. Although one or more studies suggest that a treatment producesavorable outcomes or individuals with ASD, additional high quality studies must

consistently show this outcome be ore we can draw rm conclusions about treat-ment e ectiveness.

◖ Unestablished . There is little or no evidence to allow us to draw rm conclusionsabout treatment e ectiveness with individuals with ASD. Additional research may

show the treatment to be e ective, ine ective, or harm ul.

◖ Ine ective/Harm ul. Su cient evidence is available to determine that a treatmentis ine ective or harm ul or individuals on the autism spectrum.

5 Pro essionals o ten describe a treatment as “e ective” when it has been shown to work in real world settings such ashome, school, and community. For the purposes o this report, the word “e ective” re ers to studies conducted in real world,clinical, and research settings.

6 The Strength o Evidence Classi cation System was modi ed to its current our-point ormat to ease interpretation o out-comes or the general public. Although the Strength o Evidence Classi cation System was modi ed rom a six-point ormat,the interpretation o outcomes remains identical across ormats. For example, all treatments that were previously identi edas having su cient evidence o e ectiveness did not vary across the two systems.




Established Emerging Unestablished Ineffective/Harmful

Severala published, peer-reviewed studies

• Scienti c Merit Rating Scalesscores o 3, 4, or 5

• Bene cial treatment e ectsor a speci c target

These may be supplementedby studies with lower scoreson the Scienti c Merit RatingScale.

Fewb published, peer-reviewedstudies

• Scienti c Merit Rating Scalescores o 2

• Bene cial treatment e ectsreported or one dependentvariable or a speci c target

These may be supplementedby studies with higher or lowerscores on the Scienti c MeritRating Scale.

May or may not be based onresearch

• Bene cial treatment e ectsreported based on very poorlycontrolled studies (scores o0 or 1 on the Scienti c MeritRating Scale)

• Claims based on testimonials,unveri ed clinical observa-tions, opinions, or speculation

• Ine ective, unknown, oradverse treatment e ectsreported based on poorlycontrolled studies

Severala published, peer-reviewed studies

• Scienti c Merit Rating Scalesscores o 3

• No bene cial treatment e ectsreported or one dependentmeasure or a speci c target(Ine ective)

OR

• Adverse treatment e ectsreported or one dependentvariable or a speci c target(Harm ul)

Note: Ine ective treatments areindicated with an “I” and Harm-

ul treatments are indicatedwith an “H”

a Several is de ned as 2 group design or 4 single-subject design studies with a minimum o 12 participants or which there are no con-ficting results or at least 3 group design or 6 single-subject design studies with a minimum o 18 participants with no more than 1 studyreporting conficting results. Group and single-case design methodologies may be combined.

b Few is de ned as a minimum o 1 group design study or 2 single-subject design studies with a minimum o 6 participants or which noconficting results are reported.* Group and single-subject design methodologies may be combined.

*Conficting results are reported when a better or equally controlled study that is assigned a score o at least 3 reports either {a} ine -ective treatment e ects or {b} adverse treatment e ects.

Table 2} Strength of Evidence Classification System




3Outcomes


Established TreatmentsWe identifed 11 treatments as Established (i.e., they were established as

e ective) or individuals with Autism Spectrum Disorders (ASD). Established

Treatments are those or which several well-controlled studies have shown

the intervention to produce benefcial e ects. There is compelling scientifc

evidence to show these treatments are e ective; however, even among

Established Treatments, universal improvements cannot be expected to

occur or all individuals on the autism spectrum.

The ollowing interventions are Established Treatments:◖ Antecedent Package

◖ Behavioral Package

◖ Comprehensive Behavioral Treatment or Young Children

◖ Joint Attention Intervention

◖ Modeling

◖ Naturalistic Teaching Strategies

◖ Peer Training Package

◖ Pivotal Response Treatment

◖ Schedules

◖ Sel -management

◖ Story-based Intervention Package

Each o these treatments is de ned below. Whenever possible, we providedexamples o treatment strategies associated with each Established Treatment. These

examples should also be considered Established Treatments or individuals with ASD.The number o studies conducted that contributed to this rating is listed in brackets

a ter the treatment name.




Established Treatments with defnitions and examples:

◖ Antecedent Package {99 studies}. These interventions involve the modi cation o situ-

ational events that typically precede the occurrence o a target behavior. These alterations aremade to increase the likelihood o success or reduce the likelihood o problems occurring.

Treatments alling into this category refect research representing the elds o applied behav-ior analysis (ABA), behavioral psychology, and positive behavior supports.

Examples include but are not restricted to: behavior chain interruption ( or increasing behaviors); behavioralmomentum; choice; contriving motivational operations; cueing and prompting/prompt ading procedures; envi-ronmental enrichment; environmental modi cation o task demands, social comments, adult presence, intertrialinterval, seating, amiliarity with stimuli; errorless learning; errorless compliance; habit reversal; incorporatingecholalia, special interests, thematic activities, or ritualistic/obsessional activities into tasks; maintenance inter-spersal; noncontingent access; noncontingent rein orcement; priming; stimulus variation; and time delay.

◖ Behavioral Package {231 studies}. These interventions are designed to reduce problembehavior and teach unctional alternative behaviors or skills through the application o basic

principles o behavior change. Treatments alling into this category refect research repre-senting the elds o applied behavior analysis, behavioral psychology, and positive behavior

supports.

Examples include but are not restricted to: behavioral sleep package; behavioral toilet training/dry bed train-ing; chaining; contingency contracting; contingency mapping; delayed contingencies; di erential rein orcementstrategies; discrete trial teaching; unctional communication training; generalization training; mand training; non-contingent escape with instructional ading; progressive relaxation; rein orcement; scheduled awakenings; shaping;stimulus-stimulus pairing with rein orcement; successive approximation; task analysis; and token economy.

Treatments involving a complex combination o behavioral procedures that may be listed elsewhere in this docu-ment are also included in the behavioral package category. Examples include but are not restricted to: choice +embedding + unctional communication training + rein orcement; task interspersal with di erential rein orcement;

tokens + rein orcement + choice + contingent exercise + overcorrection; noncontingent rein orcement + di erentialrein orcement; modeling + contingency management; and schedules + rein orcement + redirection + responseprevention. Studies targeting verbal operants also all into this category.




◖ Comprehensive Behavioral Treatmentor Young Children{22 studies}. This

treatment refects research rom compre-

hensive treatment programs that involvea combination o applied behavior analytic

procedures (e.g., discrete trial, inciden-tal teaching, etc.) which are delivered to

young children (generally under the age

o 8). These treatments may be deliveredin a variety o settings (e.g., home, sel -

contained classroom, inclusive classroom,community) and involve a low student-to-

teacher ratio (e.g., 1:1). All o the studiesalling into this category met the strict

criteria o : {a} targeting the de ningsymptoms o ASD, {b} having treatment

manuals, {c} providing treatment with ahigh degree o intensity, and {d} measuring

the overall e ectiveness o the program(i.e., studies that measure subcomponents

o the program are listed elsewhere in this

report).

These treatment programs may also bere erred to as ABA programs or behav-

ioral inclusive program and early intensive

behavioral intervention.

◖ Joint Attention Intervention {6 studies}.

These interventions involve building oun-dational skills involved in regulating the

behaviors o others. Joint attention o teninvolves teaching a child to respond to the

nonverbal social bids o others or to initiatejoint attention interactions.

Examples include pointing to objects, showing items/activities to another person, and ollowing eye gaze.

◖ Modeling {50 studies}. These interven-tions rely on an adult or peer providing a

demonstration o the target behavior thatshould result in an imitation o the tar-

get behavior by the individual with ASD.Modeling can include simple and com-

plex behaviors. This intervention is o tencombined with other strategies such as

prompting and rein orcement.

Examples include live modeling and video modeling.




◖ Naturalistic Teaching Strategies{32 studies}. These interventions involveusing primarily child-directed interactions

to teach unctional skills in the naturalenvironment. These interventions o ten

involve providing a stimulating environ-ment, modeling how to play, encouraging

conversation, providing choices and direct/

natural rein orcers, and rewarding reason-able attempts.

Examples o this type o approach include butare not limited to ocused stimulation, incidentalteaching, milieu teaching, embedded teaching,and responsive education and prelinguistic milieuteaching.

◖ Peer Training Package {33 studies}.These interventions involve teaching

children without disabilities strategies oracilitating play and social interactions with

children on the autism spectrum. Peersmay o ten include classmates or siblings.

When both initiation training and peer

training were components o treatmentin a study, the study was coded as “peer

training package.” These interventionsmay include components o other treat-

ment packages (e.g., sel -management orpeers, prompting, rein orcement, etc.).

Common names or intervention strategies includepeer networks, circle o riends, buddy skillspackage, Integrated Play Groups™, peer initiationtraining, and peer-mediated social interactions.

◖ Pivotal Response Treatment {14 stud-

ies}. This treatment is also re erred toas PRT, Pivotal Response Teaching, and

Pivotal Response Training. PRT ocuses ontargeting “pivotal” behavioral areas — such

as motivation to engage in social commu-nication, sel -initiation, sel -management,

and responsiveness to multiple cues, with

the development o these areas havingthe goal o very widespread and fuently

integrated collateral improvements. Keyaspects o PRT intervention delivery also

ocus on parent involvement in the inter-vention delivery, and on intervention in the

natural environment such as homes andschools with the goal o producing natural-

ized behavioral improvements.

This treatment is an expansion o Natural LanguageParadigm which is also included in this category.

◖ Schedules {12 studies}. These interven-tions involve the presentation o a task list

that communicates a series o activities or

steps required to complete a speci c activ-ity. Schedules are o ten supplemented by

other interventions such as rein orcement.

Schedules can take several orms including written

words, pictures or photographs, or work stations.




◖ Sel -management {21 studies}. These

interventions involve promoting indepen-dence by teaching individuals with ASD to

regulate their behavior by recording theoccurrence/non-occurrence o the target

behavior, and securing rein orcement ordoing so. Initial skills development may

involve other strategies and may include

the task o setting one’s own goals. Inaddition, rein orcement is a component o

this intervention with the individual withASD independently seeking and/or deliver-

ing rein orcers.

Examples include the use o checklists (usingchecks, smiley/ rowning aces), wrist counters,visual prompts, and tokens.

◖ Story-based Intervention Package{21 studies}. Treatments that involve awritten description o the situations under

which speci c behaviors are expected tooccur. Stories may be supplemented with

additional components (e.g., prompting,rein orcement, discussion, etc.).

Social Stories™ are the most well-known story-based interventions and they seek to answer the“who,” “what,” “when,” “where,” and “why” inorder to improve perspective-taking.



The Established

Treatments identifed

in this document arise

rom diverse theoretical

orientations or felds o study.

However, certain trends emerged rom

an examination o these Established Treatments.

Approximately two-thirds o the Established

Treatments were developed exclusively rom the

behavioral literature (e.g., applied behavior analy-

sis, behavioral psychology, and positive behavioral

supports). O the remaining one-third, 75% repre-

sent treatments or which research support comes

predominantly rom the behavioral li terature.

Additional contributions were made rom the non-

behavioral literature emanating rom the felds o

speech-language pathology and special education.These researchers o ten gave strong emphasis to

developmental considerations. Less than 10% (i.e.,

Story-based Intervention Package) o the total

number o Established Treatments arose rom the

theory o mind perspective. Interestingly, even

these interventions o ten included a behavioral

component.

This pattern o fndings suggests that treatments

rom the behavioral literature have the strongest

research support at this time. Yet it is important

to recognize that treatments based on alternative

theories, in isolation or combined with behavioral

interventions, should continue to be examined

empirically. Further, it demonstrates that all treat-

ment studies can be compared against a common

methodological standard and show evidence

o e ectiveness. Despite the preponderance o

evidence associated with the behavioral litera-

ture, it is important to acknowledge the important

contributions non-behavioral approaches aremaking at present, and to und research

examining both the behavioral and

non-behavioral literature as

we move orward.





Detailed Summary of Established TreatmentsMost treatments are not intended to address every treatment target (i.e., skills to

be increased or behaviors to be decreased). Similarly, they may not be developed with

the expectation that they will target every age or diagnostic group. For example, jointattention is a skill set that typically develops in very young children. Knowing this, we

would expect to see most o the research on joint attention conducted with in ants,toddlers, or preschool-aged children. In act, this is exactly what our review shows.

However, whenever a treatment could reasonably be e ective or di erent treatmenttargets, age groups, or diagnostic groups, researchers should set as a goal to extend

research into these di erent targets or groups.

Table 3 shows which Established Treatments have demonstrated avorable out-

comes or each treatment target, age group, or diagnostic group. Although not allEstablished Treatments should be expected to apply to each o these areas, many o

these interventions could be applied to a broader array o treatments. A brie summaryollows.

Treatment Targets

Established Treatments have demonstrated avorable outcomes or many treat-ment targets. See Appendix 4 or de nitions or each o the treatment targets.

◖ Antecedent Package, Behavioral Package, and Comprehensive Behavioral Treat-

ment or Young Children have demonstrated avorable outcomes with morethan hal o the skills that are o ten targeted to be increased (see Table 3 or

examples).

◖ Behavioral Package has demonstrated avorable outcomes with three-quarters o

the behaviors that are o ten targeted to decrease (see Table 3 or examples).

◖ Other Established Treatments have demonstrated avorable outcomes with a

smaller range o treatment targets. In many cases, this provides a rich opportu-nity to extend research ndings.




Age GroupsEstablished Treatments have dem-

onstrated avorable outcomes with

many age groups.

◖ Behavioral Package has demon-

strated avorable outcomes withall age groups.

◖

Antecedent Package, Compre-hensive Behavioral Treatment or

Young Children, Modeling, andSel -management have demon-

strated avorable outcomes withtwo-thirds o all age groups.

◖ Naturalistic Teaching Strategieshave demonstrated avorable

outcomes with one-hal o all agegroups.

◖ Only one Established Treatmenthas been associated with avor-

able outcomes or the early adultage group. Further investigation is

necessary or this age group.

◖ Other Established Treatments have

demonstrated avorable outcomeswith a small range o age groups.

In many cases, this provides a richopportunity to extend research

ndings.

Diagnostic GroupsEstablished Treatments have dem-

onstrated avorable outcomes with

many diagnostic groups.

◖ Behavioral Package, Compre-

hensive Behavioral Treatment orYoung Children, Joint Attention

Intervention, Modeling, Naturalis-tic Teaching Strategies, and Peer

Training Package have demon-strated avorable outcomes with

most diagnostic groups.

◖ A ew Established Treatments

(i.e., Modeling and Story-basedIntervention Package) have been

associated with avorable out-comes or Asperger’s Syndrome.

Further investigation is necessaryor this diagnostic group.

◖ Other Established Treatments havedemonstrated avorable outcomes

with a smaller range o diagnostic

groups. In many cases, this pro-vides a rich opportunity to extend

research ndings.




Skills Increased

Academic Communication Higher Cognitive Functions Interpersonal Learning Readiness

Behavioral Package Antecedent PackageBehavioral PackageCBTYCJoint AttentionModelingNTSPeer TrainingPRT

CBTYCModeling Antecedent PackageBehavioral PackageCBTYCJoint AttentionModelingNTSPeer TrainingPRTSel -managementStory-based

Antecedent PackageBehavioral PackageNTS

Motor Personal Responsibility Placement Play Self-Regulation

CBTYC Antecedent PackageBehavioral PackageCBTYC

Modeling

CBTYC Antecedent PackageBehavioral PackageCBTYC

ModelingNTSPeer TrainingPRT

Antecedent PackageBehavioral PackageSchedules

Sel -managementStory-based

Table 3} Established Treatments with Favorable Outcomes Reported

Ages

0-2 3-5 6-9 10-14 15-18 19-21

BehavioralCBTYCJoint AttentionNTS

AntecedentBehavioralCBTYCJoint AttentionModelingNTSPeer TrainingPRTSchedulesSel -management

AntecedentBehavioralCBTYCModelingNTSPeer TrainingPRTSchedulesSel -managementStory-based

AntecedentBehavioralModelingPeer TrainingSchedulesSel -managementStory-based

AntecedentBehavioralModelingSel -management

Behavioral

Diagnostic Classification

Autistic Disorder Asperger’s Syndrome PDD-NOS

AntecedentBehavioralCBTYCJoint AttentionModelingNTS

Peer TrainingPRTSchedulesSel -managementStory-based

ModelingStory-based

Behavioral PackageCBTYCJoint AttentionModelingNTSPeer Training

Behaviors Decreased

Problem Behaviors Restricted, Repetitive, Nonfunctional Behavior,Interests, or Activities

Sensory/EmotionalRegulation

General Symptoms

Antecedent PackageBehavioral PackageCBTYCModelingSel -management

Behavioral PackagePeer Training

Antecedent PackageBehavioral PackageModeling

CBTYC

Antecedent=Antecedent Package; Behavioral=Behavioral Package; CBTYC=Comprehensive Behavioral Treatment or Young Children; JointAttention=Joint Attention Intervention; NTS=Naturalistic Teaching Strategies; Peer Training=Peer Training Package; PRT=Pivotal ResponseTreatment; Story-based=Story-based Intervention Package




Emerging TreatmentsEmerging Treatments are those or which one or more studies suggest the

intervention may produce avorable outcomes. However, additional high

quality studies that consistently show these treatments to be e ective or

individuals with ASD are needed be ore we can be ully confdent that the

treatments are e ective. Based on the available evidence, we are not yet in

a position to rule out the possibility that Emerging Treatments are, in act, not

e ective.

A large number o studies all into the “Emerging” level o evidence. We believescientists should nd ertile ground or urther research in these areas. The number o

studies conducted that contributed to this rating is listed in parentheses a ter the treat-ment name.

The ollowing treatments have been identifed as alling into the Emerginglevel o evidence:

◖ 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}

◖ 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 o Mind Training {4 studies}

Each o these treatments is de ned in Appendix 5. Interested readers may wish to re er to the ull

National Standards Report or additional details regarding these treatments.




Unestablished TreatmentsUnestablished Treatments are those or which there is little or no evidence

in the scientifc literature that allows us to draw frm conclusions about the

e ectiveness o these interventions with individuals with ASD. There is no

reason to assume these treatments are e ective. Further, there is no way to

rule out the possibility these treatments are ine ective or harm ul.

The ollowing treatments have been identifed as alling into theUnestablished level o evidence:

◖ Academic Interventions {10 studies}

◖ Auditory Integration Training {3 studies}

◖ Facilitated Communication {5 studies}

Note: The National Standards Project ollowed strict inclusionary/exclusionary

criteria. As a result, we eliminated a large number o studies on the treatment o Facilitated Communication that {a} involved adults 22 years o age or older,{b} involved individuals with in requently occurring co-morbid conditions, and

{c} ocused on the adult acilitators (as opposed to the individuals with ASD).Although our results indicate Facilitated Communication is an “Unestablished

Treatment,” we believe it is necessary to make readers aware that a number o

pro essional organizations have adopted resolutions advising against the use o acilitated communication. These resolutions are o ten related to concerns

regarding “immediate threats to the individual civil and human rights o the person with autism…” (American Psychological Association, 1994).




◖ Gluten- and Casein-Free Diet {3 studies}

Note: Early studies suggested that the Gluten- and Casein-Free diet may pro-

duce avorable outcomes but did not have strong scientifc designs. Better controlled research published since 2006 suggests there may be no educational

or behavioral benefts or these diets. Further, potential medically harm ul e ects have begun to be reported in the literature. We recommend reading the ollowing

studies be ore considering this option:

1. Arnold, G. L., Hyman, S. L., Mooney, R. A., & Kirby, R. S. (2003). Plasma amino acids profles in children with autism: Potential risk o nutritional def-

ciencies, Journal o Autism and Developmental Disabilities, 33, 449-454.

2. Heiger, M. L., England, L. J., Molloy, C. A., Yu, K. F., Manning-Courtney, P., & Mills, J. L. (2008). Reduced bone cortical thickness in boys with autism or

autism spectrum disorders. Journal o Autism and Developmental Disorders,38, 848-856.

◖ Sensory Integrative Package {7 studies}

Each o these treatments is de ned in Appendix 5. Interested readers may wish to re er to the ull

National Standards Report or additional details regarding these treatments.

There are likely many more treatments that all into this category or which no research has been

conducted or, i studies have been published, the accepted process or publishing scienti c work

was not ollowed. There are a growing number o treatments that have not yet been investigated

scienti cally. These would all be Unestablished Treatments. Further, any treatments or which stud-

ies were published exclusively in non-peer-reviewed journals would be Unestablished Treatments.




Ineffective/Harmful TreatmentsIne ective or Harm ul Treatments are those or which several well-controlled

studies have shown the intervention to be ine ective or to produce harm ul

outcomes, respectively. At this time, there are no treatments that have su f-

cient evidence specifc to the ASD population that meet these criteria.

This outcome is not entirely unexpected. When preliminary research ndings sug-gest a treatment is ine ective or harm ul, researchers tend to change the ocus o their

scienti c inquiries into treatments that may be e ective. That is, research o ten stops

once there is a suggestion that the treatment does not work or that it is harm ul. Fur-ther, research showing a treatment to be ine ective or harm ul may be available with

di erent populations (e.g., developmental disabilities, general populations, etc.). Ethicalresearchers are not going to then apply these ine ective or harm ul treatments speci -

cally to children or adolescents on the autism spectrum just to show that the treatmentis equally ine ective or harm ul with individuals with ASD.

See the Evidence-based Practice section to learn how practitioners’ knowledge o

interventions outside the ASD population should be integrated into the decision-makingprocess.



Treatment selection is complicated and should be made by a team o indi-

viduals who can consider the unique needs and history o the individual with

Autism Spectrum Disorder (ASD) along with the environments in which he or

she lives. We do not intend or this document to dictate which treatments can

or cannot be used or individuals on the autism spectrum.

Having stated this, we have been asked by amilies, educators, and service provid-

ers to recommend how our results might be help ul to them in their decision-making.As an e ort to meet this request, we provide suggestions regarding the interpretation

o our outcomes. In all cases, we strongly encourage decision-makers to select anevidence-based practice approach.

Research ndings are not the sole actor that should be considered when treat-

ments are selected. The suggestions we make here re er only to the “research

ndings” component o evidence-based practice and should be only one actor consid-ered when selecting treatments.


4Recommendations for

Treatment Selection



Recommendations based on research fndings:

◖ Established Treatments have su cient evidence o e ectiveness. We recommendthe decision-making team give serious consideration to these treatments because

{a} these treatments have produced bene cial e ects or individuals involved in theresearch studies published in the scienti c literature, {b} access to treatments that

work can be expected to produce more positive long-term outcomes, and {c} thereis no evidence o harm ul e ects. However, it should not be assumed that these

treatments will universally produce avorable outcomes or all individuals on theautism spectrum.

◖ Given the limited research support or Emerging Treatments, we generally do notrecommend beginning with these treatments. However, Emerging Treatments

should be considered promising and warrant serious consideration i EstablishedTreatments are deemed inappropriate by the decision-making team. There are

several very legitimate reasons this might be the case (see examples in the

Pro essional Judgment or Values and Pre erences sections o Chapter 5).

◖ Unestablished Treatments either have no research support or the research that hasbeen conducted does not allow us to draw rm conclusions about treatment e ec-

tiveness or individuals with ASD. When this is the case, decision-makers simply donot know i this treatment is e ective, ine ective, or harm ul because researchershave not conducted any or enough high quality research. Given how little is known

about these treatments, we would recommend considering these treatments only a ter additional research has been conducted and this research shows them to pro-

duce avorable outcomes or individuals with ASD.

These recommendations should be considered along with other sources o criticalin ormation when selecting treatments (see Chapter 5).





5Evidence-based Practice

One o the primary objectives o this document is to identi y evidence-based

treatments. We are not alone in this activity. The National Standards Project

is a natural extension o the e orts o the National Research Council {2001},

the New York State Department o Health, Early Intervention Division {1999},

and other related documents produced at state and national levels.

Knowing which treatments have su cient evidence o e ectiveness is likely

to — and should — infuence treatment selection. Evidence-based practice, however, ismore complicated than simply knowing which treatments are e ective. Although we

argue that knowing which treatments have evidence o e ectiveness is essential, othercritical actors must also be taken into consideration.

We have identifed the ollowing our actors o evidence-based practice:

◖ Research Findings . The strength o evidence ratings or all treatments being

considered must be known. Serious consideration should be given to EstablishedTreatments because there is su cient evidence that {a} the treatment produced

bene cial e ects and {b} they are not associated with un avorable outcomes (i.e.,there is no evidence that they are ine ective or harm ul) or individuals on the

autism spectrum.

Ideally, treatment selection decisions should involve discussing the bene ts ovarious Established Treatments. Despite the act there is compelling evidence to

suggest these treatments generally produce bene cial e ects or individuals onthe autism spectrum, there are reasons alternative treatments (e.g., Emerging

Treatments) might be considered. A number o these actors are listed below.

◖ Pro essional Judgment . The judgment o the pro essionals with expertise in

Autism Spectrum Disorders (ASD) must be taken into consideration. Once treat-ments are selected, these pro essionals have the responsibility to collect data todetermine i a treatment is e ective. Pro essional judgment may play a particularly

important role in decision-making when:

◗ A treatment has been correctly implemented in the past and was not e ectiveor had harm ul side e ects. Even Established Treatments are not expected to

produce avorable outcomes or all individuals with ASD.




◗ The treatment is contraindicated based on other in ormation (e.g., the use o extra-stimulus

prompts or a child with a prompt dependency history).

◗ A great deal o research support might be available beyond the ASD literature and shouldbe considered when required. For example, i an adolescent with ASD presents with

anxiety or depression, it might be necessary to identi y what treatments are e ectiveor anxiety or depression or the general population. The decision to incorporate outside

literature into decision-making should only be made a ter practitioners are amiliar with theASD-speci c treatments. Research that has not been speci cally demonstrated to be e ec-

tive with individuals with ASD should be given consideration along with the ASD-speci ctreatments only i compelling data support their use and the ASD-speci c literature has not

ully investigated the treatment.

◗ The pro essional may be aware o well-controlled studies that support the e ectivenesso a treatment that were not available when the National Standards Project terminated its

literature search.

◖ Values and Pre erences . The values and pre erences o parents, careproviders, and the

individual with ASD should be considered. Stakeholder values and pre erence may play a par-ticularly important role in decision-making when:

◗ A treatment has been correctly implemented in the past and was not e ective or had

harm ul side e ects.

◗ A treatment is contrary to the values o amily members.

◗ The individual with ASD indicates that he or she does not want a speci c treatment.

◖ Capacity . Treatment providers should be well positioned to correctly implement the interven-tion. Developing capacity and sustainability may take a great deal o time and e ort, but all

people involved in treatment should have proper training, adequate resources, and ongoingeedback about treatment delity. Capacity may play a particularly important role in decision-

making when:

◗ A service delivery system has never implemented the intervention be ore. Many o thesetreatments are very complex and require precise use o techniques that can only be devel-

oped over time.

◗ A pro essional is considered the “local expert” or a given treatment but he or she actuallyhas limited ormal training in the technique.

◗ A service delivery system has implemented a system or years without a process in place

to ensure the treatment is still being implemented correctly.




Like other projects o this nature, there are limitations to the National

Standards Project. Readers should be amiliar with these limitations in order

to use this document most e ectively.

We have indentifed the ollowing limitations:

◖ This document ocuses exclusively on research involving individuals with Autism

Spectrum Disorders (ASD) who are under 22 years o age. ◗ This document does not include a review o the literature or children “at risk”

or ASD. New evidence suggests that very young children who are eventuallydiagnosed with autism have a genetic predisposition that alters their interactions

with the typical learning environment. 7 This area is especially important becauseproviding e ective interventions (e.g., behavioral interventions) to these in ants

may be the rst critical step to altering early brain development 8 so that the neu-ral circuitry regulating social and communication unctions more e ectively.

◗ This document does not include a review o the adult ASD literature.

◗ This document is not an exhaustive review o all treatments or all individuals.

There are treatments that might have solid research support or related popula-tions (e.g., developmental disabili ties, anxiety, depression, etc.) but have limited

or no evidence o research support or individuals with ASD in the National Stan-dards Report. See Chapter 5 or how this might infuence treatment selection.

◖ As noted in the treatment classi cation section o this report, determining thecategories or treatments presents a real challenge. This is equally true whenever

comprehensive reviews o the literature are completed or any diagnostic group.Some o our experts suggested making the unit o analysis larger or some catego-

ries; others suggested making the unit o analysis smaller or most categories. In

the end, we attempted to develop categories that “made sense.” We expect that

7 Klin, A., Lin, D.J., Gorrindo, P., Ramsay, G., & Jones, W. (2009). Two-year-olds with autism orient to non-social contingen-cies rather than biological motion. Nature, 1-7. doi:10.1038/nature07868.

8 Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention o autism spectrum disorders.Development and Psychopathology, 20 , 775-803.

6Limitations




many readers may be interested in more

detailed analysis using a smaller unito analysis, or data using on a di erent

arrangement o treatment categoriesbased on a larger unit o analysis.

We look orward to your eedback toguide the next version o the National

Standards Project.

◖ This review included an examination omost group and single-subject researchdesign studies but did not include every

type o study.

◗ For this report, we only lookedat research that was designed to

answer questions about the measur-

able e ectiveness o an interventionbased on quanti able data. We

did not look at research that was

designed to explore questions aboutthe perceived quality o an interven-tion or the experiences o the children

based on qualitative data.

◗ There are studies relying on single-case or group design methods that

were not included in this reviewbecause they ell outside the com-

monly agreed-upon criteria orevaluating the e ectiveness o study

outcomes. The experts involved inthe development o these Standardsmade the decision to include only

those methodologies that are gen-erally agreed-upon by scientists as

su cient or answering the question,“Is this treatment e ective?”.

◗ We only included studies that have

been published in pro essional jour-nals. It is likely that some researchers

conducted studies that provideddi erent or additional data that have

not been published. This could infu-ence the reported quality, quantity, or

consistency o research ndings.

◖ When establishing interobserver agree-ment (IOA), eld reviewers were askedto examine the coding manual and rate

the pilot article they received. Ideally, wewould have conducted a training session

be ore they began rating the articles.

Also, the pilot articles were selectedrandomly. Now that we have identi ed

articles with the highest, moderate, andlowest ratings or both single-subject

and group research designs, we will usethese articles or establishing IOA in

uture versions o the National StandardsProject.

◖ We did not include articles reviewedin languages other than English. This

has the potential to infuence the rat-ings reported in this document. For

example, a study that was not includedin this review was published in French

on Integrated Play Groups™ (Richard& Goupil, 2005). We hope to include

volunteer eld reviewers rom across

the world who can e ectively review thenon-English literature in the next version

o the National Standards Project.




◖ The National Standards Project did not evaluate the extent to which treatment

approaches have been studied in “real world” versus laboratory settings. We hopeto shed light on this issue in uture versions o the National Standards Project.

◖ One o the primary purposes o the National Standards Project was to identi ythe level o research support currently available or a range o educational and

behavioral interventions. We did not set as our goal the determination o the levelo intensity required or delivery o these interventions. The next version o the

National Standards Project may provide urther analysis in this area. In the interim,

we believe treatment providers should continue to ollow the recommendations orintensity o services provided by the National Research Council regarding childrenless than 8 years o age. Speci cally,

We argue that unless compelling reasons exist to do otherwise, intervention

services should be comprised o Established Treatments and they should be deliv-ered ollowing the speci cations outlined in the literature (e.g., appropriate use o

resources, sta to student ratio, ollowing the prescribed procedures, etc.).

“ The committee recommends that educational services begin as soon as a child is suspected o having

an autistic spectrum disorder. Those services should include a minimum o 25 hours a week, 12 months

a year, in which the child is engaged in systematically planned, and developmentally appropriate edu-

cational activity toward identi ed objectives. What constitutes these hours, however, will vary accord-

ing to a child’s chronological age, developmental level, speci c strengths and weaknesses, and amilyneeds. Each child must receive su cient individualized attention on a daily basis so that adequate

implementation o objectives can be carried out e ectively. The priorities o ocus include unctional

spontaneous communication, social instruction delivered throughout the day in various settings,

cognitive development and play skills, and proactive approaches to behavior problems. To the extent

that it leads to the acquisition o children’s educational goals, young children with an autistic spectrum

disorder should receive specialized instruction in a setting in which ongoing interactions occur with

typically developing children.

”




◖ Writing a report o this type can be quite time-consuming. The National Standards

Project terminated the literature review phase in September o 2007. Additionalstudies have been published in the interim that are not refected in the current

report. This means that i a review were conducted today, the strength o evi-dence ratings or a given treatment may have improved or be altered. We intend

to regularly update this document to assist decision-makers in their selection otreatments. In the meantime, pro essionals should amiliarize themselves with the

literature published since the all o 2007.

◖ Ideally, research answers important questions beyond treatment e ectiveness.This report does not review the ollowing areas that may be important in selectingtreatments:

◗ Cost-e ectiveness;

◗ Social validity;

◗ Studies examining mediating or moderating variables. Mediating variables can

help explain why a treatment is e ective. Moderating variables can make a di er-ence in the likelihood a treatment is e ective or a given subpopulation; and

◗ Research supporting Established Treatments may have been developed in analog

settings (e.g., highly structured research settings), which may not refect realworld settings accurately.

Despite its limitations, we sincerely hope this document is use ul to you. We also recognize that

even more in ormation might be help ul. For example, there may be new or di erent ways o orga-

nizing in ormation that you believe could be use ul. I you would like to help shape the direction o

the next version o the National Standards Project, please provide eedback to the National Autism

Center at in [email protected].




Future Directions for the ScientificCommunityOne o the goals o the National Standards Project is to identi y limitations

o the existing literature base. We believe we have done so in two ways: {a}

we have identifed areas benefting rom or requiring uture investigation

and {b} we have developed the Scientifc Merit Rating Scale and Strength o

Evidence Classifcation System, against which uture research can be com-

pared. We expand on these issues below.

There is room or additional research or all treatments. It will be important toextend the current research base or Established Treatments to all reasonable treat-

ment goals, age groups, and diagnostic groups. Additional research must be conductedor treatments alling in the Emerging and Unestablished Treatment categories to

determine i {a} the treatments are e ective and {b} the treatments are ine ective orharm ul. High quality research is perhaps most important or treatments alling into the

Unestablished Treatments category.

7Future Directions




Future Directions with MethodologyFive dimensions were identifed or the Scientifc Merit Rating Scale: {a}

research design, {b} dependent variable, {c} treatment fdelity, {d} partici-

pant ascertainment, and {e} generalization (see Table 3). We identifed these

dimensions based on the most recent scientifc standards that are being

advocated in behavioral and social science research. However, scientifc

standards change over time.

For example, there were no psychometrically sound instruments speci cally

designed to diagnose Autism Spectrum Disorders (ASD) available when the earlieststudies included in this review were conducted. I there had been, the instruments

would look very di erent today based on changes in the diagnostic criteria over the

years. For this reason, it is not surprising that many older studies did not achieve thehighest possible ratings in this area.

Similarly, it is only recently that evidence o treatment delity has been consistently

emphasized by the scienti c community. This means that although many studies maydo an excellent job o describing the procedures used, they still received low rat-

ings on their ability to provide evidence that they completed all procedures exactly asprescribed. This leaves room or improvement in the scienti c literature in either the

research design or the extent to which scientists report on these important variables.

We encourage researchers to strive to meet the most rigorous standards o scien-

ti c merit in uture research. We hope the Scienti c Merit Rating Scale will assist them




in doing so. But it is also essential that journal editors recognize the importance o the

ve dimensions o scienti c merit identi ed in this report. Important in ormation maysometimes be cut rom articles due to space limitations. We hope that researchers will

be able to point to the Scienti c Merit Rating Scale as an example o critical in orma-tion that should never be removed rom scholarly work.

The Strength o Evidence Classi cation System may be expanded over time to

refect additional scienti c lines o inquiry. For example, it is reasonable to use alternatecriteria or di erent research designs, which is why we did so in the current version

o the Strength o Evidence Classi cation System. However, i qualitative research

is included in the next version o the National Standards Project, the current versiono the Strength o Evidence Classi cation System would be insu cient to accurately

evaluate these studies.




Future Directions for the NationalStandards ReportWe aim to address many o the limitations o the current National Standards

Report in uture documents.

For example, we expect: ◖ To review literature covering the li espan. This will include a special section on chil-

dren “at risk” or ASD.

◖ To reconsider the inclusion o qualitative studies or other types o peer-reviewed

studies that are currently excluded.

◖ To modi y treatment classi cation based on eedback rom the many experts in the

autism community.

◖ To examine the extent to which treatments have been studied in “real world”

versus laboratory settings.

◖ To add reviewers who can accurately interpret peer-reviewed articles published innon-English journals.

With additional unding, we hope to help address questions related to cost e ec-

tiveness, social validity, studies examining mediating variables, and e ectiveness otreatments in real world settings.

We suspect that this report will raise additional questions that we hope to address

in uture publications. Our ultimate goal is to answer relevant questions related toevidence-based practice in response to the changing expectations o pro essionals and

the needs o amilies, educators, and service providers.



37 } Appendices

Inclusionary Criteria

The National Standards Project is a systemic review o the behavioral and educational treatment literatureinvolving individuals with Autism Spectrum Disorders (ASD) under the age o 22. For the purposes o thisreview, Autism Spectrum Disorders were de ned to include Autistic Disorder, Asperger’s Syndrome, andPervasive Developmental Disorder — Not Otherwise Speci ed (PDD-NOS).

Exclusionary Criteria

Participants who were identi ed as “at risk” or an ASD or who were described as having “autisticcharacteristics” or “a suspicion o ASD” were not included in this review.

Studies were included i the treatments could have been implemented in or by school systems, includingtoddler, early childhood, home-based, school-based, and community-based programs.

Studies in which parents, care providers, educators, or service providers were the sole subject o treatmentwere not included in the review. I these adults were one subject but data were also available regardingchanges in child behavior or skills, the study was retained, but only those results pertaining to the child’sbehavior or skills were included in the review.

Articles were only included in the review i they had been published in peer-reviewed journals.

Studies examining biochemical, genetic, and psychopharmacological treatments were excluded (seeexception below). These treatments have not historically ocused on the core characteristics o ASD.We made the decision to include curative diets because pro essionals are o ten expected to implementcurative diets across a variety o settings with a high degree o delity and the treatment is intended toaddress the core characteristics o ASD.

Results or study participants who were diagnosed with both ASD and co-morbid conditions that donot commonly co-occur with ASD were excluded rom this review because their results could skew theoutcomes.

Articles were excluded i they did not include empirical data, i there were no statistical analyses availableor studies using group research design, i there was no linear graphical presentation o data or studies

using single-case research design, or i the studies relied on qualitative methods.

Studies were excluded i their sole purpose was to identi y mediating or moderating variables.

Articles were excluded i all participants were over the age o 22 or i a study included participants bothover and under the age o 22, but separate analyses were not conducted or individuals under the age o22. We anticipate the next version o the National Standards Project will expand the ocus o the review toinclude treatments involving participants across the li espan.

Articles were excluded rom the National Standards Project i they were published exclusively inlanguages other than English.

Appendix 1} Inclusionary and Exclusionary Criteria



Findings and Conclusions: National Standards Project ( 38

Appendix 2} Scientifc Merit Rating Scale

Research Design Measurement of Dependent Variable


(procedural integrity or treatment fdelity)



Group Single-subject a Test, scale,

checklist,etc.

Directbehavioralobservation

Number ogroups: two ormore

Design:Randomassignmentand/or nosigni cantdi erencespre-Tx

Participants: n> 10 per groupor su cientpower orlower numbero participants

Data Loss: nodata loss

A minimumo threecomparisonso control andtreatmentconditions

Number odata pointsper condition:> ve

Number oparticipants: >three

Data loss:no data losspossible

Type omeasurement:Observation-based

Protocol:standardized

Psychometricpropertiessolid instru-ment

Evaluators:blind andindependent

Type omeasurement:continuousor discon-tinuous withcalibrationdata showinglow levels oerror

Reliability:IOA > 90% or

kappa > .75Percentageo sessions:Reliabilitycollected in >25%

Type o condi-tions in whichdata werecollected: allsessions

Implementation accuracymeasured at > 80%

Implementation accuracymeasured in 25% o totalsessions

IOA or treatment delity> 80%

Diagnosedby a quali edpro essional

Diagnosis con rmedby independent andblind evaluators orresearch purposesusing at least onepsychometricallysolid instrument

DSM or ICDcriteria or commonlyaccepted criteriaduring the identi edtime period reportedto be met

Objective data

Maintenance datacollected

AND

Generalization datacollected acrossat least two o the

ollowing: setting,stimuli, persons

SMRS} Rating 5



39 } Appendices

SMRS} Rating 4







checklist,etc.



Design:Matchedgroups; Nosigni cantdi erencespre-Tx; or bet-ter design

Participants: n> 10 per groupor su cientpower orlower numbero participants

Data Loss:some dataloss possible

A minimumo threecomparisonso control andtreatmentconditions

Number odata pointsper condition:> ve

Number oparticipants: >three

Data loss:some dataloss possible

Type omeasurement:Observation-basedmeasurement

Protocol:standardized

Psychometricpropertiessu cient

Evaluators:blind

OR

independent

Type omeasurement:continuous ordiscontinu-ous with nocalibrationdata

Reliability:IOA > 80% orkappa > .75

Percentageo sessions:Reliabilitycollected in >25%

Type o condi-tions in whichdata werecollected: allsessions


Implementation accuracymeasured in 20% o totalsession or ocused interven-tions only

IOA or treatment delity:not reported

Diagnosis provided/con rmed byindependent andblind evaluators orresearch purposesusing at least onepsychometricallysu cient instrument

Objective data


AND

Generalization datacollected acrossat least one o the





SMRS} Rating 3







checklist,etc.



Design: Pre-Txdi erencescontrolledstatistically orbetter design


A minimumo twocomparisonso control andtreatmentconditions

Number odata pointsper condition:> three

Number oparticipants:> two


Type omeasurement:Observation-basedmeasurement

Protocol:non-stan-dardized orstandardized

PsychometricpropertiesadequateEvaluators:neither blindnor indepen-dent required



Percentageo sessions:Reliabilitycollected in >20%

Type o condi-tions in whichdata were col-lected: all orexperimentalsessions only


Implementation accuracymeasured in 20% o partialsession or ocused interven-tions only


Diagnosis provided/con rmed byindependent

OR

blind evalua-tor or researchpurposes using atleast one psycho-metrically adequateinstrument

ORDSM criteria con-

rmed by a quali eddiagnostician orindependent and/orblind evaluator

Objective data


OR





41 } Appendices

SMRS} Rating 2






Group Single-subject a

Test, scale,checklist,etc.


Number ogroups andDesign: I twogroups, pre-Txdi erencenot controlledor betterresearchdesign

OR

a one grouprepeatedmeasures pre-test/post-test

designData Loss:signi cantdata losspossible


Number odata pointsper Tx condi-tion: > three

Number oparticipants:> two

Data loss: sig-

ni cant dataloss possible

Type omeasurement:Observation-based orsubjective


Psychometricpropertiesmodest

Evaluators:neither blind

nor indepen-dent required



Percentage osessions: Notreported

Type o condi-

tions in whichdata werecollected: notnecessarilyreported

Operationalde nitions areextensive orrudimentary

Control condition isoperationally de ned at aninadequate level or better

Experimental (Tx) proceduresare operationally de ned at arudimentary level or better


Implementation accuracyregarding percentage ototal or partial sessions: notreported


Diagnosis with atleast one psycho-metrically modestinstrument

OR

diagnosis providedby a quali ed diag-nostician or blindand/or independentevaluator with nore erence to psycho-metric properties oinstrument

Subjective dataMaintenance datacollected

AND

Generalization datacollected acrossat least 1 o the





SMRS} Rating 0

SMRS} Rating 1

Does not meetcriterion or ascore o 1




Does not meet criterion or ascore o 1

Does not meetcriterion or a scoreo 1

Does not meetcriterion or a scoreo 1

a For all designs except alternating treatments design (ATD). For an ATD, the ollowing rules apply:

{5} Comparison o baseline and experimental condition; > ve data points per experimental condition, ollow-up data collected, carryover e eminimized through counterbalancing o key variables (e.g., time o day), and condition discriminability; n > three; no data loss{4} Comparison o baseline and experimental condition; > ve data points per experimental condition; carryover e ects minimized through coubalancing o key variables (e.g., time o day), OR condition discriminability; n > three; some data loss possible{3} > ve data points per condition, carryover e ects minimized counterbalancing o key variables OR condition discriminability; n > two; somloss possible{2} > ve data points per condition; n > two; signi cant data loss possible{1} > ve data points per condition; n > one; signi cant data loss possible{0} Does not meet criterion or a score 1






Group Single-subject a

Test, scale,checklist,etc.


Number ogroups andDesign:two group,post-testonly or betterresearchdesign

OR

retrospectivecomparison oone or morematchedgroups

Data loss:signi cantdata losspossible


Number oparticipants:> one

Data loss: sig-ni cant dataloss possible

Type omeasurement:Observation-based orsubjective


Psychometricpropertiesweak

Evaluators:Neither blind

nor indepen-dent required


Type o condi-tions in whichdata werecollected: notnecessarilyreported

Operational

de nitions areextensive orrudimentary

Control condition isoperationally de ned at aninadequate level or better

Experimental (Tx) proceduresare operationally de ned at arudimentary level or better

IOA and procedural delitydata are unreported

Diagnosis providedby {a} review orecords

OR

{b} instrument withweak psychometricsupport

Subjectiveor subjectivesupplemented withobjective data


OR





43 } Appendices

Appendix 3} Treatment E ects

Beneficial TreatmentEffects Reported

Unknown TreatmentEffects Reported Ineffective Effects Reported Adverse Treatment

Effects Reported

Single:A unctional relation is estab-lished and is replicated at leasttwo times

For all research designs:The nature o the data does notallow or rm conclusions aboutwhether the treatment e ectsare bene cial, ine ective, oradverse

Single:A unctional relation was not estab-lished and

{a} results were not replicated but atleast two replications were attempted

{b} a minimum o ve data points werecollected in baseline and treatmentconditions

{c} a minimum o two participantswere included

{d} a air or good point o comparison(e.g., steady state) existed

Single:A unctional relation is estab-lished and is replicated at leasttwo times

The treatment resulted ingreater de cit or harm on thedependent variable basedon a comparison to baselineconditions

ATD:Moderate or strong separationbetween at least two dataseries or most participants

Carryover e ects wereminimized

A minimum o ve data pointsper condition

ATD:No separation was reported andbaseline data show a stable pattern oresponding during baseline and treat-ment conditions or most participants

ATD:Moderate or strong separationbetween at least two dataseries or most participants

Carryover e ects wereminimized

A minimum o ve data pointsper condition

Treatment conditions showedthe treatment produced greaterde cit or harm or most or allparticipants when compared tobaseline

Group:Statistically signi cant e ectsreported in avor o thetreatment

Group:No statistically signi cant e ects werereported with su cient evidence ane ect would likely have been ound*

*The criterion includes: {a} there wassu cient power to detect a smalle ect {b} the type I error rate wasliberal, {c} no e orts were made tocontrol or experiment-wise Type Ierror rate, and {d} participants wereengaged in treatment

Group:Statistically signi cant ndingreported indicating a treatmentresulted in greater de cit orharm on any o the dependentvariables




Academic Tasks required or success with school activities

Communication Tasks that involve nonverbal or verbal methods o

sharing experiences, emotions, in ormationHigher Cognitive Functions

Tasks that require complex problem-solving skillsoutside the social domain

Interpersonal Tasks that require social interaction with one ormore individuals

Learning Readiness Tasks that serve as the oundation or success ulmastery o complex skills in other domains

Motor Skills Tasks that require coordination o muscle systemsto produce a speci c goal involving either nemotor or gross motor skills

Personal Responsibility Tasks that involve activities embedded into every-day routines

Placement 1

Identi cation o a placement into a particularsetting

Play Tasks that involve non-academic and non-workrelated activities that do not involve sel -stimu-latory behavior or require interaction with otherpeople

Sel -Regulation Tasks that involve the management o one’s ownbehaviors in order to meet a goal

Appendix 4} Treatment Target Defnitions

Skills Targeted or Increase

1 Although placement is not a “skill,” it represents an important accomplishment toward which intervention programs strive.

Skills Targeted or Decrease

General Symptoms General Symptoms includes a combination o symptoms that may be directly associated with ASD or may be aresult o psychoeducational needs that are sometimes associated with ASD

Problem Behaviors Behaviors that can be harm ul to the individual or others, result in damage to objects, or inter ere with theexpected routines in the community

Restricted, Repetitive, Non unctional patterns o behavior, interests, or activity (RRN) Limited, requently repeated, maladaptive patterns o motor activity, speech, and thoughts

Sensory or Emotional Regulation (SER) Sensory and emotional regulation re ers to the extent to which an individual can fexibly modi y his or her levelo arousal or response to unction e ectively in the environment



45 } Appendices

Augmentative and Alternative Communication Device (AAC) These interventions involved the use o highor low technologically sophisticated devicesto acilitate communication. Examplesinclude but are not restricted to: pictures,photographs, symbols, communication books,computers, or other electronic devices.

Cognitive Behavioral Intervention Package These interventions ocus on changing every-day negative or unrealistic thought patternsand behaviors with the aim o positively infu-encing emotions and/or li e unctioning.

Developmental Relationship-based Treatment These treatments involve a combination oprocedures that are based on developmentaltheory and emphasize the importance o build-ing social relationships. These treatmentsmay be delivered in a variety o settings (e.g.,home, classroom, community). All o the stud-ies alling into this category met the strictcriteria o : {a} targeting the de ning symp-toms o ASD, {b} having treatment manuals,{c} providing treatment with a high degreeo intensity, and {d} measuring the overalle ectiveness o the program (i.e., studies thatmeasure subcomponents o the program arelisted elsewhere in this report). These treat-

ment programs may also be re erred to as theDenver Model, DIR (Developmental, IndividualDi erences, Relationship-based)/Floortime,Relationship Development Intervention, orResponsive Teaching.

Exercise These interventions involve an increase inphysical exertion as a means o reducingproblems behaviors or increasing appropriatebehavior.

Exposure Package These interventions require that the individualwith ASD increasingly ace anxiety-provokingsituations while preventing the use o mal-adaptive strategies used in the past underthese conditions.

Imitation-based Interaction These interventions rely on adults imitatingthe actions o a child.

Initiation Training

These interventions involve directly teachingindividuals with ASD to initiate interactionswith their peers.

Language Training (Production) These interventions have as their primarygoal to increase speech production. Examplesinclude but are not restricted to: echo relevantword training, oral communication training,oral verbal communication training, structureddiscourse, simultaneous communication, andindividualized language remediation.

Appendix 5} Names and Defnitions o Emerging andUnestablished Treatments

Emerging Treatments




Language Training (Production &Understanding) These interventions have as their primarygoals to increase both speech productionand understanding o communicative acts.Examples include but are not restricted to:total communication training, position objecttraining, position sel -training, and languageprogramming strategies.

Massage/Touch Therapy These interventions involve the provision odeep tissue stimulation.

Multi-component Package These interventions involve a combination omultiple treatment procedures that are derived

rom di erent elds o interest or di erenttheoretical orientations. These treatments donot better t one o the other treatment “pack-ages” in this list nor are they associated withspeci c treatment programs.

Music Therapy These interventions seek to teach individualskills or goals through music. A targeted skill(e.g., counting, learning colors, taking turns,etc.) is rst presented through song or rhyth-mic cuing and music is eventually aded.

Peer-mediated Instructional Arrangement

These interventions involve targeting aca-demic skills by involving same-aged peers inthe learning process. This approach is alsodescribed as peer tutoring.

Picture Exchange Communication System This treatment involves the application o aspeci c augmentative and alternative commu-nication system based on behavioral principlesthat are designed to teach unctional commu-nication to children with limited verbal and/orcommunication skills.

Reductive Package These interventions rely on strategiesdesigned to reduce problem behaviors in theabsence o increasing alternative appropri-ate behaviors. Examples include but are notrestricted to water mist, behavior chain inter-ruption (without attempting to increase anappropriate behavior), protective equipment,and ammonia.

Scripting These interventions involve developing averbal and/or written script about a speci cskill or situation which serves as a model orthe child with ASD. Scripts are usually prac-ticed repeatedly be ore the skill is used in theactual situation.

Sign Instruction These interventions involve the direct teachingo sign language as a means o communicat-ing with other individuals in the environment.



47 } Appendices

Social Communication Intervention These psychosocial interventions involvetargeting some combination o social com-munication impairments such as pragmaticcommunication skills, and the inability tosuccess ully read social situations. Thesetreatments may also be re erred to as socialpragmatic interventions.

Social Skills Package These interventions seek to build social inter-action skills in children with ASD by targetingbasic responses (e.g., eye contact, nameresponse) to complex social skills (e.g., how toinitiate or maintain a conversation).

Structured Teaching Based on neuropsychological characteristicso individuals with autism, this interventioninvolves a combination o procedures that rely

heavily on the physical organization o a set-ting, predictable schedules, and individualizeduse o teaching methods. These proceduresassume that modi cations in the environment,materials, and presentation o in ormationcan make thinking, learning, and understand-ing easier or people with ASD i they areadapted to individual learning styles o autismand individual learning characteristics. Allo the studies alling into this category metthe strict criteria o : (a) targeting the de ningsymptoms o ASD; (b) having treatment manu-

als; (c) providing treatment with a high degreeo intensity; and (d) measuring the overalle ectiveness o the program (i.e., studies thatmeasure subcomponents o the program arelisted elsewhere in this report). These treat-ment programs may also be re erred to asTEACCH (Treatment and Education o Autisticand related Communication-HandicappedChildren).

Technology-based Treatment These interventions require the presentationo instructional materials using the medium ocomputers or related technologies. Examplesinclude but are not restricted to Alpha Pro-gram, Delta Messages, the Emotion TrainerComputer Program, pager, robot, or a PDA(Personal Digital Assistant). The theoriesbehind Technology-based Treatments may varybut they are unique in their use o technology.

Theory o Mind Training These interventions are designed to teachindividuals with ASD to recognize and iden-ti y mental states (i.e., a person’s thoughts,belie s, intentions, desires and emotions) inonesel or in others and to be able to take theperspective o another person in order to pre-dict their actions.




Unestablished Treatments

Academic Interventions These interventions involve the use o traditional teaching methods to improve academic per ormance.Examples include but are not restricted to: “personal instruction”; paired associate; picture-to-textmatching; The Expression Connection; answering pre-reading questions; completing cloze sentences;resolving anaphora; sentence combining; “special education”; speech output and orthographic eed-back; and handwriting training.

Auditory Integration Training This intervention involves the presentation o modulated sounds through headphones in an attempt toretrain an individual’s auditory system with the goal o improving distortions in hearing or sensitivitiesto sound.

Facilitated Communication This intervention involves having a acilitator support the hand or arm o an individual with limitedcommunication skills, helping the individual express words, sentences, or complete thoughts by using akeyboard o words or pictures or typing device.

Gluten- and Casein-Free Diet

These interventions involve elimination o an individual’s intake o naturally occurring proteins glutenand casein.

Sensory Integrative Package These treatments involve establishing an environment that stimulates or challenges the individual toe ectively use all o their senses as a means o addressing overstimulation or understimulation romthe environment.



49 } References

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Dawson, G. (2008). Early behavioral interven-tion, brain plasticity, and the prevention oautism spectrum disorders.Development and Psychopathology, 20 , 775-803.

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(2008). Reduced bone cortical thickness inboys with autism or autism spectrum disor-ders. Journal o Autism and Developmental Disorders, 38 , 848-856.

Horner, R., Carr, E., Halle, J., McGee, G., Odom,S., & Wolery, M. (2005). The use o single-subject research to identi y evidence-basedpractice in special education.Exceptional Children, 71(2), 165-179.

Johnston, J. M. & Pennypacker, H. S. (1993).Strategies and tactics o behavioral research (2nd ed.). New Jersey: LawrenceErlbaum Associates.

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Kazdin, A. E. (1998).Methodological issues and strategies in clinical research(2nd ed.).Washington, DC: American PsychologicalAssociation.

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51 } Index

Index} Treatment Names

A

Academic Interventions 22, 48

Adult Presence (environmentalmodi cations o ) 12

Alpha Program 47

Ammonia 46

Answering Pre-reading Questions 48

Antecedent Package 11, 12, 17, 18, 19

Applied Behavior Analysis (ABA)12, 13

Auditory Integration Training 22, 48

Augmentative and AlternativeCommunication Device 20, 45

B

Behavioral Inclusive Program 13

Behavioral Momentum 12

Behavioral Package 11, 12, 17, 18, 19

Behavioral Sleep Package 12

Behavioral Toilet Training/Dry BedTraining 12

Behavior Chain Interruption 12, 46

Buddy Skills Package 14

C

Chaining 12

Choice 12, 14

Circle o Friends 14

Cognitive Behavioral InterventionPackage 20, 45

Completing Cloze Sentences 48

Comprehensive Behavioral Treatment orYoung Children 11, 13, 17, 18, 19

Contingency Contracting 12

Contingency Mapping 12

Contriving Motivational Operations12

Cueing 12

D

Delayed Contingencies 12

Delta Messages 47

Developmental, Individual Di erences,Relationship-based 45

Developmental Relationship-basedTreatment 20, 45

Di erential Rein orcement Strategies12

Discrete Trial Teaching 12

Dry Bed Training 12

E

Early Intensive Behavioral Intervention13

Echolalia (incorporating into tasks) 12

Echo Relevant Word Training 45

Embedded Teaching 14

Emotion Trainer Computer Program47

Environmental Enrichment 12

Errorless Compliance 12

Errorless Learning 12

Exercise 12, 20, 45

Exposure Package 20, 45

Expression Connection 48

F

Facilitated Communication 22, 48

Familiarity with Stimuli (environmentalmodi cations o ) 12

Floortime 45

Focused Stimulation 14

Functional Communication Training12

G

Generalization Training 12

Gluten- and Casein-Free 23, 48




P

Pager 47

Paired Associate 48

PDA (Personal Digital Assistant)47

Peer Initiation Training 14

Peer-mediated InstructionalArrangement 21, 46

Peer-mediated Social Interactions 14

Peer Networks 14

Peer Training Package 11, 14, 18, 19

Peer Tutoring 46

Personal Instruction 48

Picture Exchange CommunicationSystem 21, 46

Picture-to-Text Matching 48

Pivotal Response Treatment 11, 14, 19

Position Object Training 46

Position Sel -training 46

Priming 12

Progressive Relaxation 12

Prompting/Prompt Fading Procedures 12

Protective Equipment 46

H

Habit Reversal 12

Handwriting Training 48

IImitation-based Interaction 20, 45

Incidental Teaching 13, 14

Individualized Language Remediation45

Initiation Training 14, 20, 45

Integrated Play Groups™ 14, 30, 50

Intertrial Interval 12

J

Joint Attention Intervention 11, 13, 18, 19

L

Language Programming Strategies 46

Language Training (Production)20, 45

Language Training (Production &Understanding) 20, 46

Live Modeling 13

M

Maintenance Interspersal 12

Mand Training 12

Massage/Touch Therapy 20, 46

Milieu Teaching 14

Modeling 11, 13, 18, 19

Multi-component Package 20, 46

Music Therapy 21, 46

N

Naturalistic Teaching Strategies 11, 14,18, 19

Natural Language Paradigm 14

Noncontingent Access 12

Noncontingent Escape with InstructionalFading 12

Noncontingent Rein orcement 12

O

Oral Communication Training45

Oral Verbal Communication Training45



53 } Index

RReductive Package 21, 46

Rein orcement 12, 13, 14, 15

Relationship Development Intervention 45

Resolving Anaphora 48

Responsive Education and PrelinguisticMilieu Teaching 14

Responsive Teaching 45

Ritualistic/Obsessional Activities 12

S

Scheduled Awakenings 12

Schedules 11, 12, 14, 19, 47

Scripting 21, 46

Seating (environmental modi cationso ) 12

Sel -management 11, 14, 15, 19

Sensory Integrative Package 23, 47, 48

Sentence Combining 48

Shaping 12

Sign Instruction 21, 46

Simultaneous Communication 45

Social Comments (environmental

modi cations o ) 12

Social Communication Intervention21, 47

Social Skills Package 21, 47

Social Stories™ 15

Special Education 48, 49

Special Interests (incorporating intotasks) 12

Speech Output and OrthographicFeedback 48

Stimulus-Stimulus Pairing with

Rein orcement 12

Stimulus Variation 12

Story-based Intervention Package 11, 15,16, 18, 19

Structured Discourse 45

Structured Teaching 21, 47

Successive Approximation 12

T

Task Analysis 12

Task Demands (environmental modi cationso ) 12

TEACCH (Treatment and Education oAutistic and related Communication-handicapped CHildren) 47

Technology-based Treatment 21, 47

Thematic Activities 12

Theory o Mind Training21, 47

Time Delay 12

Token Economy 12

Total Communication Training 46

V

Video Modeling 13

Visual Prompts 15

W

Water Mist 46









Documents

NAC Findings & Conclusions