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In Many Memories of Late Autism Experts Drs. Ivar Lovaas (IBI) and Bernie Rimland
I heard behavior modification [now called applied behavior analysis or ABA] might be helpful to autistic children, and I subsequently visited UCLA, where psychologist Ivar Lovaas was pioneering this method. "It's amazing," Lovaas tells me. "All these years we've known how well it worked for Helen Keller, but no one [ever] thought to try it on autistic children."— Afterword by Dr. Bernie Rimland in "Let Me Hear Your Voice" (1993) by Catherine Maurice
Early intensive behavioral intervention (EIBI) is a treatment approach that is based upon the principles of applied behavior analysis (ABA) and the research of Ivar Lovaas and colleagues at the UCLA Young Autism Project... Influenced by theories of learning and motivation, practitioners of EIBI refer to it as "the science of teaching."— Susan Hepburn, 2013, Springer Link
Behavior analysis is the scientific study of behavior. Applied behavior analysis (ABA) is the application of the principles of learning and motivation from behavior analysis, and the procedures and technology derived from those principles, to the solution of problems of social significance.... Specifically, ABA refers to a systematic approach to the assessment and evaluation of behavior and the application of interventions that alter behavior.— Center for Autism and Related Disorders (CARD), Inc.
The late Drs. Ivar Lovaas and Bernie Rimland transformed the way we view and treat autism today.
The late Drs. Ivar Lovaas and Dr. Bernie Rimland transformed the way we view and treat autism today, passing away in 2010 and 2006, respectively.
Lovaas proved Behavior Modification, now called Applied Behavior Analysis (ABA), to be an effective teaching tool for children with autism at the University of California, Los Angeles (UCLA) in 1987, where he utilized the technique for a number of years.
His early work with this population of children and their parents led to the formation of the National Society for Autistic Children (currently known as the Autism Society of America), which he co-founded with Dr. Bernie Rimland, whose book Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behavior first published in 1964 changed the mental health community's perspective on autism by doing rid with the "Refrigerator Mother" theory that the condition was somehow triggered from poor parenting styles.
Not only did Dr. Rimland happen to detect autism in his own son, Mark—who was a client of Lovaas' at the UCLA Young Autism Project, but his son also partially served as the basis for Dustin Hoffman's lead role in the film Rain Main (1988), considered one of the very first—and among the most memorable—to shed light on the condition.
Throughout the late 1960s and '70s, Lovaas and colleagues implemented aversive consequences, such as electric shocks and spanking, to stop a child's aggressive and self-injurious behaviors. They even yelled "no!" if answering inaccurately and also rewarded—or reinforced—correct responses and when otherwise behaving properly. As time passed, the technique became abolished, and Lovaas and colleagues only used presumed reinforcers as well as extinction (the process by which all reinforcement becomes discontinued) to change behavior and teach new skills.
According to Mace (1994) in the Journal of Applied Behavior Analysis, we were beginning to move "beyond behavior modification" with "a return to behavior analysis" in the mid-1980s (also see, i.e., Walsh, 1997; Pelios, Morren, Tesch, & Axelrod, 1999; Mace & Critchfield, 2010).
Derived from B.F. Skinner's early work in the 1930s through '50s, Applied Behavior Analysis (ABA) is an evidence-based approach to learning that applies the principles of Operant Conditioning, manipulating antecedent stimuli and consequences (including reinforcement and extinction) to initially analyze such environmental contingencies before attempting to change behavior. By identifying the antecedent first, the practitioner can accurately determine the causes and function of the behavior as well as anticipate the procedures that will work most efficiently (this is often accomplished through data collection, assessments, and behavior management plans).
While ABA is broadly studied for a variety of diagnoses in a number of other situations (i.e., Pediatric Feeding Therapy or Organizational Behavior Management), board certified behavior analysts (BCBAs) tend to utilize behavioral interventions exclusively for children on the autism spectrum.
Early Intensive Behavioral Intervention (EIBI) is a sub-discipline of ABA that encompasses several proven teaching strategies (both structured and play-based) for children with autism and other developmental disabilities under the age of 5 and implemented at an intensity of 25-40 hours per week. EIBI is typically practiced within the family's homes as well as in agencies, such as schools and clinics.
Lovaas' intensive therapy, called Discrete Trial Teaching (DTT), involves highly-trained behavior analysts instructing 40 hours per week of repeated and structured techniques of teaching by visually prompting eye contact, modeling and manually prompting speech, as well as teaching a wide array of other skills, and rewarding correct responses with praise and child-preferred reinforcers.
As oppose to the old days, we now know from cutting-edge research that the only way for the child to be successfully taught is by generalizing what they have learned from DTT in their day-to-day lives—as well as in such naturalistic settings as the school environment—by using a more playful, child-led approach; this encompasses a range of techniques that fall underneath the term Natural Environment Training (NET), which includes such Mand Training* procedures (see note below) as Incidental Teaching, Pivotal Response Treatment (PRT), and the Early Start Denver Model (i.e., see Green, 2001; Myers & Plauché, 2007; Eikeseth et al., 2007; Dawson et al., 2010; Mohammadzaheri et al., 2014).
As he further detailed in the book Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think, Dr. Stanley Greenspan's developmental model consists of joining the child's restricted interests and repetitious play activities (i.e., singing the same song multiple times, moving a toy car back and forth, etc.) before expanding their play repertoire to engage them emotionally. Often implemented by caregivers and occupational therapists, many parents have successfully formed meaningful relationships with their child when using this approach.
In addition, a new program called The PLAY Project, which trains parents how to implement Floortime, recently revealed quite promising results in the Journal of Developmental and Behavioral Pediatrics: A large, randomized control study indicated that child-parent relationships—as well as interpersonal social-emotional growth—were gained in children with autism who faced profound social withdrawal (see Solomon et al., 2014).
In my opinion, if the child is isolated, Floortime should initially be used for the relationship aspect and once the child has formed a relationship with their caregivers and therapists, then the goal is to replace the child's self-stimulatory (or "stimming") behavior—such as rocking and hand-flapping—with new behaviors that fulfills the same purpose (this principle is derived from ABA). After that, DTT and NET—the two teaching techniques used in EIBI—should be started promptly to teach the child how to establish eye contact and acquire speech as well as enhance their academic and adaptive (daily living) skills. This is to be followed by other ABA-based procedures (i.e., Social Skills Training) to teach the child how to interact properly with their peers and form friendships.
Drawing back to 1987, Lovaas and colleagues at UCLA proved in a study that after 38 youngsters with autism obtained structured EIBI for three years, 47%—9 out of 19 children in the experimental group—obtained "normal educational and intellectual functioning" (Lovaas, 1987) and were successfully mainstreamed in regular classrooms. Of the total children, 95% also managed to foster enormously in their IQ, verbal communication, and daily living skills. Further, by the time the 'best outcome' children reached early adolescence, a follow-up study in 1993 indicated that 8 of them (or 42%) fully recovered to the point where they no longer "showed signs of emotional disturbance and demonstrated adequate development in adaptive and social skills within the normal range" (McEachin, Smith, & Lovaas, 1993, p. 368).
Several federal organizations within the United States, including the American Academy of Pediatrics, National Research Council, New York State Department of Health, and Surgeon General, all acknowledge the validity of early, intensive ABA-based therapies, endorsing them as the most effective means for teaching children with an autism spectrum disorder (ASD). In addition to being the only approach "well-established" in the research literature, it is shown to be highly effective throughout countless single-subject design studies.
According to a report on Mental Health made by the Surgeon General in 1999, "Thirty years of research have demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior." He also acknowledged that Lovaas' 1987 study was "well-designed," and by 2001, the National Research Council referred to EIBI procedures as "state-of-the-art."
While Lovaas went on to establish The Lovaas Institute—an organization in Los Angeles, California that he headed since its foundation in 1993 until his death, most of his graduate students have become quite flourished professionals in the field (many of whom formed their own practices).
Some graduate students of Lovaas' in the 1970s included Drs. Laura Schreibman and Robert Koegel. Together, they pioneered Pivotal Response Treatment (PRT) with Koegel's wife, Lynn, a speech pathologist who has her doctorate in educational psychology. The Koegels' also co-founded and run the Koegel Autism Center at the University of California, Santa Barbara (UC Santa Barbara, or UCSB) while Schreibman directs the Autism Intervention Program at the University of California, San Diego (UCSD).
Drs. Tristram Smith and Doreen Granpeesheh were Lovaas' senior supervisors in the late 1980s. Smith even co-authored the 1993 follow-up study alongside Lovaas and colleague Dr. John McEachin, who went on to co-found the Autism Partnership with another graduate student, Dr. Ron Leaf, and their main office is located in Seal Beach, California.
In 1990, Granpeesheh founded and currently runs the Center for Autism and Related Disorders (CARD), Inc., the nation's most enormous agency providing EIBI services for children with ASD, which is headquartered in Los Angeles, California.
Shortly before becoming a big-name scientist in the field of ABA at the University of Rochester Medical Center (URMC), Smith designed the first replicated study—and only randomized control trial—on structured EIBI in 2000, which he conducted with Drs. Annette Groen and Jacquie Wynn, who were Lovaas' clinic supervisors during the time of the 1987 study, and Wynn now directs the Center for Autism Spectrum Disorders at Nationwide Children's Hospital in Columbus, Ohio. The study's experimental group was, however, limited to 25 hours per week instead of the original 40 hours implemented in the 1987 study; this most likely explains why the children's progress was restricted to 27% striving in mainstream classrooms.
Even though there has yet to be any other randomized control trial on structured EIBI, it was not until the second replicated study by Sallows and Graupner (2005)—which, similar to the 2000 study, had at least managed to randomly assign the participants, but contrasted drastically, as this study's experimental group consisted of 35 hours per week—that the outcomes first made evident by Lovaas (1987) were successfully validated. The research verified once again that, when treated with structured EIBI, 48% of the experimental group were striving in mainstream classrooms, with 90% of the total children producing drastic gains in their IQ, verbal communication, and daily living skills.
Howard et al. (2005) even revealed in a non-randomized comparison study that another group of children who received structured EIBI outperformed those who had undergone non- ABA-based 'eclectic intervention.' It should be noted, however, that this study was originally supposed be a randomized comparison study—a form of RCT—but the states ended up refusing to fund the intensity of the intervention. Subsequently, the researchers had to accommodate to the families' financial needs by allowing them to choose which group to be in.
Further, although the second replicated randomized study by Sallows and Graupner (2005) did reproduce the results first seen by Lovaas (1987), it was not a RCT since there was no "placebo effect" in the control group; in other words, the same treatment was compared for less hours.
Because of this, a number of states—to the exclusion of Vermont, Connecticut, Wisconsin, and possibly others—view the research design limitations on EIBI as though it were a drug treatment (see Keenan & Dillenburger, 2011), and therefore, refuse to fund the necessary hours or the treatment all together.
To add, many families—who cannot afford to pay the rather high costs of $60-$70 thousand annually—still have to win lawsuits against their school districts through the Individuals with Disabillities Education Act (IDEA) just to receive funding for 25 hours per week of EIBI. As of recently, some are even relying on their health insurance plans, such as Medicaid, to fund up to 40 hours per week.
With regards to fully recovery from autism, such outcome occurs in approximately 25% of individuals (see Helt et al., 2008). Studies also reveal this 'optimal outcome' to occur among children who received 40 hours per week of EIBI as opposed to other modalities (see Dawson et al., 2012; Orinstein et al., 2014).
While some children do fully recover from the autism spectrum after a varying length of time—which is evident among individuals who were diagnosed at an early age by many well-trained clinicians before they no longer met any criteria for the disability (but continue to often have co-morbid attention issues and/or anxiety), it is crucial for parents to focus more on their child's learning potential.
Since there is no guaranteed cure for ASD* (see note below), most individuals will continue to have the disability but gain new skills as they grow older—with some becoming quite flourished as adults (take Drs. Temple Grandin and Stephen Shore as well as the young college student Jake Barnett, for example).
Nevertheless, it should be noted that some parents look at—and become involved in—treatment modalities outside of the ABA realm which lack scientific evidence and can be inefficacious as well as potentially fatal because of it (see Sinha, Silove, & Williams, 2006). The staff from these organizations often try to sell you their books and free parent testimonial videos and make false claims about their success rates and even guarantee 'miraculous cures' (i.e., see Williams & Wishart, 2003; Association for Science in Autism Treatment, 2010; Mruzek, 2012; Moran, 2014).
This is why parents—especially when they find themselves being emotionally vulnerable—should be cautious of such interventions and have their children involved in therapies that are vigorously studied and empirically validated. To date, high-quality ABA-based procedures are the only set of interventions with such reputation and evidence.
And finally, with that said, my advice to parents is this: Before utilizing such high-quality Early Intensive Behavioral Interventions, Floortime should first be implemented for the youngsters who lack interest in engaging with adults as this can also increase their desire to learn from their therapists' in any ABA-based program.
*Mand Training is a Verbal Behavior (VB) training procedure based on the verbal operant mand, or having the child request for something. It serves as the basis for such naturalistic ABA-based teaching procedures as Incidental Teaching and Pivotal Response Treatment (PRT).
*Sometimes the term "cure"—as used here—refers to the individuals who fully overcame the social communication and learning deficits without any changes occurring in their physiology (for more information, see Catherine Maurice's (1996/2001) ABA training manuals and the Fein et al. (2013) study from the University of Connecticut).
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