1. Samuel L. Odom University of North Carolina
Moving Beyond the Intensive Behavioral Treatment Vs. Eclectic Dichotomy: Evidence-Based Programs for Students with ASD
Samuel L. Odom
University of North Carolina

2. Preview of Presentation
Increase in ASD prevalence creates demand for services
Comprehensive treatment models
Comparison of two comprehensive treatment models for preschool children
Propose a technical, eclectic approach as one alternative
Require identification of EBPs
Efficacy research on the technical, eclectic approach as future research

3. Autism Mystique
Probably more than any disability, or unique set of abilities, autism has been shrouded in a treatment mystique
The etiology has gone from refrigerator mothers to epigenetics
Treatments are more diverse than any known disabilities
Treatment claims range from amelioration to recovery

4. Defense Against the Dark Arts
Many interventions with no scientific evidence have been recommended for children with ASD

5. Cutting Edge Interventions for Autism (Seri & Lyons, 2012)?
Antifungal treatment
Aquatic therapy
Auditory Integration Therapy
Chelation Removal of Toxic Metals
Craniosacral and chiropractic therapy
Dietary interventions
Hyperbaric oxygen therapy
Medicinal marijuana
Sensory gym
Traditional and indigenous healing
Stem cell therapy

6. Discovery and Current Prevalence

7. DSM 5 Diagnostic Criteria
Impairment in social communication
Restricted repetitive and stereotyped patterns of behavior
Onset prior to the age of three years

8. Demographics 75% are male
Multiple etiologies related to neurobiological causes
Unrelated to socioeconomic status or race
Range of IQ scores, but stretches across the continuum

9. Understanding Intervention Approaches for Learners with ASD
Comprehensive Treatment Models
Focused Intervention Practices
Shorter in duration
Target discrete skills
Represent the bulk of the evidence-base in the ASD literature
Longer in duration
Target multiple developmental domains
At least 30 CTMs & a dearth of empirical evidence for most (Odom, Boyd, Hall, Hume, 2010)

10. History of Disorder and Trends in Treatment in US
Kanner’s Discovery in 1940s
Psychodynamic approaches (Kanner-Bettleheim-Greenspan)
Lovaas application of Applied Behavior Analysis
Structured psycho-educational approach (Project TEACCH)

11. Comprehensive Treatment Strategies
Multiple components (e.g., child-focused instruction, family-focused support)
Broad scope (i.e., they may address several developmental domain or skill areas)
Intensity (i.e., they often occur over an entire instructional day or in multiple settings such as a school/clinic and home)
Longevity (i.e., they may occur over months or even years).

12. Review of CTMs
10 identified by National Academy of Science Committee (2002)
30 found in review and evaluation in 2010 (Odom, Boyd, Hall, & Hume, 2010)
Relative Strong Models
Denver Model (Early Start Denver Model)
LEAP
Lovaas Institute
May Institute
Princeton Child Development Institute
Pivotal Response Treatment
Efficacy studies lacking

13. How Unique Are CTMs
Although CTMs have been described as unique models, there is reason to believe that there are substantial overlaps
TEACCH vs. LEAP Treatment Comparison Study (Boyd, Hume…, & Odom, 2013)
Review of Intensive Behavior Therapy Programs (Odom, Hume, Boyd, & Stabel, 2012)
Position paper on Naturalistic Developmental Behavioral Interventions (Schriebmann et al., 2014)

14. Comparison of Two Model (Boyd, Hume …& Odom, 2014)
9/17/2018
Comparison of Two Model (Boyd, Hume …& Odom, 2014)
TEACCH (Treatment and Education of Autistic and related Communication-handicapped Children)
Theoretical foundation: Cognitive social learning theory
Emphasis on designing environment that accommodates characteristics of ASD
LEAP (Learning Experiences: Alternative Programs for Preschoolers and Parents)
Theoretical Foundation: Blend of ABA and high quality early childhood education
Emphasis on individual programs implemented in naturalistic settings
Inclusion of nondisabled peers

15. Brief Description of “Control”
9/17/2018
Brief Description of “Control”
Overview
Programmatic Features
Teachers in these programs did not adhere to primarily one theoretical model
School administrators and/or teachers helped to identify these classrooms
Teachers reported using an array of evidence-based practices
Some practices included strategies associated with TEACCH (e.g. work systems) or LEAP (e.g., peer-mediated)

16. 9/17/2018
Study Overview
Classes in North Carolina, Colorado, Florida, and Minnesota
LEAP (22 classes)
TEACCH (25 classes)
High Quality Control (28 classes)
Total participants (198 preschool-age children with ASD)
Assessed at Pre and Post on Composite Variables
Autism characteristics
Social interaction
Communication
Sensory and repetitive behavior
Fine motor

17. Conclusions Overview of findings: Interpretation of findings:
High fidelity in programs and overlap on fidelity measures
Children improved over time in all three conditions
On measures that generated age equivalent: changes in developmental growth over time
Interpretation of findings:
May reflect importance of programmatic quality
Difficulty of replicating CTM effects when model developer not involved
Use of a “pragmatic” study design
Overlap of model components between CTMs
Quality—early childhood lit –structural (teacher ed or yrs teaching) vs. process variables (teacher-child interaction, teacher-student attachment)…related to children’s academic & social outcomes.
Our classrooms were all of at least avg. & really above avg. quality based on the quality measure. So, were our “control” classrooms really acting as another active treatment (eclectic practice treatment).
Do you need a foundational level of quality in order to realize treatment effects?
Elements of efficacy—offered booster training & screen classrooms for quality to meet our inclusion criteria
Overlap of supplemental practices as well.

18. Review of IBT and Eclectic Model (Odom, Hume, Boyd, & Stabel, 2012)
Among CTMs Intensive Behavior Therapy has the most evidence of efficacy
In studies, these often compared to eclectic programs.
Odom et al. (2012) reviewed studies that compared Intensive Behavior Therapy (IBT) with eclectic programs.

19. Brief Review of Recent Studies

20. Key Points from Review IBT Programs Eclectic Programs
Range of methods characterized IBT
Overlap in methods between IBT and Eclectic
Professional development and training issues
Constricted setting and age range
Primarily preschool
Limited or no school-age
They appear to be using ABA techniques some of the time
They also appear to be using non-substantiated techniques some of the time

21. Eclecticism and Lessons Learned from Clinical Psychology
Movement to Empirically Supported Treatments in 1990s
Gilliard, James, & Bowman (1994) discuss the need for an eclectic approach
Different forms of eclecticism exists
Unsystematic eclecticism: “a jack-of-all-trades-master-of- none approach” (Gilliland et al.,1994, p. 554)
Technical eclecticism: selection of empirically supported treatments from different theoretical perspectives for use with an individual client (Lazarus & Beutler, 1993)

22. Stahmer, Schriebman, & Cunningham (2011)
Propose a technology of treatment individualization based on
Child Characteristics
Family Characteristics
Service Setting and System
Premise: no single treatment works for all children.
Some evidence that non-ABA treatments have positive effects
Stahmer, A., Schreibman, L., & Cunningham, A. (2011). Toward a technology of treatment individualization for young children with autism spectrum disorders. Brain Research, 1380,

23. A Technical Eclectic Approach
Important to have a conceptual framework or theory of change
Necessary to have a proscribed (manualized) system of assessment, treatment selection, and evaluation
Necessary to stay close to the science in selecting interventions

24. Evidence-Based Individualized Program for Students with Autism (EBIPSA)

25. Evidence-Based Practices

26. What Counts as Evidence?

27. Systematic Reviews of the Literature for Evidence Based Practices (EBPs)
In 2009, 11 “treatments” or practices with an evidence base
Reviewed by National Standard Project from National Autism Center
In 2010, 24 EBPs
National Professional Development Center (NPDC)
Included 10 years,
In 2014, 27 EBPs
Second review by NPDC
Included 22 years,
29,101 possible studies 456 studies
RCT, quasi-experimental, single case design
Strength of evidence for assessment
Based on number, type of studies using each EBP .
In 2010, the National Professional Development Center on ASD (NPDC) reviewed a 10 year period of intervention research (from ), also followed a systematic process, and identified 24 evidence-based practices.
A comparison of the two sets of EBPs found substantial overlap.
This year, the NPDC published an updated review of practices that extended the literature review period from 1990 to It began with identification of over 29,000 possible studies, with the screening process finding 456 acceptable studies.
Odom,
htthttp://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/NPDC_CoachingManual.pdfp://autismpdc.

28. 27 Evidence-Based Practices
Current Review: NPDC
27 Evidence-Based Practices
Antecedent –Based Interventions
Functional Communication Training
Prompting
Structured Play Groups
Cognitive Behavior Intervention
Modeling
Reinforcement
Task Analysis
Differential Reinforcement
Naturalistic Interventions
Response Interruption/ Redirection
Technology-Aided Instruction/ Intervention
Discrete Trial Teaching
Parent-Implemented Interventions
Scripting
Time Delay
Exercise
PECS
Self-Management
Video Modeling
Extinction
Peer-Mediated Instruction/ Intervention
Social Narrative
Visual Supports
Functional Behavioral Assessment
Pivotal Response Training
Social Skills Training
The NPDC staff undertook the current review to broaden and update the previous review.

29. Evidence-Based Practices are Delicious

30. Evidence-Based Individualized Program for Students with Autism (EBIPSA)

31. Quality is Important

32. Interdisciplinary Teaming
Learning Environment
Interdisciplinary Teaming
Program Ecology
Structure & Schedule
Positive Learning Climate
Curriculum & Instruction
Communication
Social Competence
Personal Independence
Functional Behavior
Assessment & IEP
Family Participation
Program
Quality
Learner Outcomes
Transition (MHS only)

33. Autism Program Environment Rating Scale (APERS) Formats
Preschool-Elementary
Inclusion preschools
Self-contained preschools
K-5 (or beginning of middle school) inclusive
K-5 self contained
Middle School-High School
Inclusive classes (assumes multiple classes)
Self-contained classes
Transition programs

34. So, how do you get it into practice?

35. Implementation: The Tie That Binds
“…of what a program consists when it is delivered in a particular setting” (Durlak & DuPre, 2008)
“…a specified set of activities designed to put into practice a … program of known dimensions, (Fixsen, et al., 2005)
“…program delivered to and experienced by participants… and their families (Odom, Hanson, Lieber, Butera, et al., 2008)

36. Fixsen, Blase, Metz, Van Dyke (2013)
(Copyright Dean L. Fixsen and Karen A. Blase, 2009; used with permission.)

37. Ongoing Coaching and Technical Assistance
Rapport and relationship
Mutual respect
Agreed upon goals
Time
Tools
EBP or other practices
Fidelity checklists
Feedback
Planning

38. Implications
Practitioners can build “technical eclectic”/ evidence-supported programs
More research is needed to address focused intervention practices for infants and toddlers with ASD as well as adolescents and young adults with ASD
Better child outcomes dependent on translation of EBPs
Implementation science
Professional development models
Practitioners: using the EBP x age x outcome matrix, can create their own programs using different EBP to make a comprehensive program that is evidence-supported (vs CTM like Lovaas model & ESDM)
Researchers: reveals gaps in research, clear need is for more EI focused intervention research- CTMs for toddlers with ASD is expanding but really need to do focused for practitioners/families to build own technical eclectic programs; they have to extrapolate from the preschool (or older) studies which may not be developmentally appropriate (similar to concept in psychopharmacology- can’t just give same medications to younger children)
Finally- research to practice; emerging field of implementation science
Refer to NPDC- OCALI, coaching model

39. National Professional Development Center on Autism Spectrum Disorders
A multi-university center to promote use of evidence-based practice for children and adolescents with autism spectrum disorders
FPG Child Development Institute, University of North Carolina at Chapel Hill; M.I.N.D. Institute, University of California at Davis Medical Center; Waisman Center, University of Wisconsin at Madison