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Evidence-based Practices and Autism Spectrum Disorders: Navigating a Sea of ChallengesOpening ActivityA. List practices you use with students with ASDDescribe reasons why you use each practice1.2.3.4.5.B. Rating Practices on a Continuum of EvidenceWeaker -----------------------------------Strength of rPractices
2/18/2016Learning OutcomesEvidence-based Practices andAutism Spectrum Disorders:Participants will:Navigating a Sea ofChallenges1.Summarize the critical EBP elements2.Identify at least 3 questions thatpractitioners can ask when using EBPPaul G. LaCava & Richard L. Simpson3.Describe a process for choosing, usingand evaluating EBPMSLBD 2016Terminology Evidence-based Peerreviewed Scientifically based Research based Effective Validated Established Promising Emerging And others Teaching Practice Intervention Treatment Model Package Training Special Education And others PsychINFO Database SearchKey words – “evidence-based practice”and “autism”4003001999 – 2015: 600 total20010002000 - 200419992. Process of integration of best researchevidence with other factors, such as clinicalexpertise, patient values, etc. (Institute of Medicine, 2001)2010 - 2015EBPEBP is typically seen in two ways1. Programs, interventions, methods, etc. that havebeen proven to be effective by rigorous researchand review standards (Cook and Odom, 2013)2005 - 2009Learner’spreferences,values, rsPrizant called these narrow and appropriateapproaches to EBP (2011)1
2/18/2016ASD and the Need for EBP Legacy of ineffective, overvalued and nonvalidated methods Ethical and moral imperatives Federal mandates: NCLB and IDEA/IDEIA Limited opportunities to make a difference(need for timely use of maximally effective strategies) A student who loses the equivalent of four weeks time dueto ineffective interventions every school year from age 3-22years will lose in excess of 76 weeks ( 2 entire academicyears!) due to use of ineffective interventions.Effective Practices and ASD Promotion of so-called educational effective practices,including evidence-based methods and practices, scientificallysupported interventions, and research-validated methods insupport of learners with ASD, follows a similar track to theeffective practice movement in medicine. Sackett and colleagues (1966), pioneers in the advancement ofmedically-focused evidence-based practices, describedevidence-based practices as “the conscientious, explicit, andjudicious use of current best evidence in making decisionsabout the care of individual patients. The practice ofevidence-based medicine means integrating individual clinicalexpertise with the best available external clinical evidencefrom systematic research” (Sackett et al., 1996, p. 71).State of Kansas Pilot DataEffective Practices and ASDRelative to ASD, EBP features Reliable and scientifically-valid evaluation or research design Clearly explained procedures that generated behavioral,developmental and/or educational outcomes Scientifically supported research designs and evaluation methodsNo Child Left Behind (NCLB, 2001) Act: Educatorsbase their programs and teaching on scientificallysupported research, i.e., supported by “rigorous,systematic, and objective procedures to obtainreliable and valid knowledge relevant to educationactivities and programs”. EBP thus have reliably andobjectively demonstrated capacity to producepositive outcomes.Resistance to EBP Charmand appeal of interventions/treatmentspromising gains and progress that exceedmore proven methods Novel and unproven strategies fit well withnotions that individuals with ASD aremysterious and possess myriad untappedpotential Novel and unproven strategies empower hope Lack of definitive causal explanations oracknowledged best courses of treatment andinterventionResistance to EBP Stakeholderswillingness to gamble on finding along-awaited key to significant progress Itis naïve to believe that people are “moved byevidence” and “change their views if eventsrefute their beliefs” (Paul Krugman, 2009) Peopletend to believe “we are all capable ofthe extraordinary” (Kripal, 2013) (e.g., 2011 APpoll found 8 in 10 Americans believed in angels,including 4 in 10 people who never went tochurch)2
2/18/2016Scientific Method and Ways of Knowing Educators’decision making strategies,including policy formation andjudgments of effectiveness ofeducational techniques: Personal experience and personal beliefsCommon senseExpert testimonyPolitical, spiritual and administrative influenceScience Knowledgeable individuals use reasonable/logical modelsand objective information/data to create and testhypotheses via use of objective dataFundamental Effective-PracticeProgram ElementsFundamental Effective-PracticeProgram ElementsCritical Foundational Element 1:Commitment to selecting, using withfidelity, and evaluating scientificallysupported methodsCritical Foundational Element 2:Thoughtful and deliberate consideration ofthe unique and individualized needs oflearners with ASD Increases chances educators don’t select orprematurely abandon a potentially useful andeffective intervention. Without understanding why a method or methodimplementation failed, we are likely to repeat ourmistakes and waste precious time and resources.Fundamental Effective-PracticeProgram ElementsCritical Foundational Element 3: Resolutecommitment among stakeholders to a collaborativeand dynamic decision-making process Regularly scheduled collaborative team meetings open to multiple stakeholders,including parents and community personnel Designated professional staff team leaders who are personally knowledgeable ofstudent’s needs and who are responsible for monitoring and reporting student’sinstructional programs and progress participate in meetings Training, supervision and communication support that ensures that all schoolstaff implement students’ programs in accordance with agreed upon protocol Training for parents and families that permits them to correctly applyinterventions and treatments in home and community settings Problem solving and dispute resolution processes to respond to disagreementsand related issues Resources and a structure to make sure that there are appropriate follow-upactions on decisions made at stakeholder meetingsIndividualized Curricula and Programs thatAddress Salient Characteristics of ASD: Social interaction, communication/language, behavioral, daily andindependent living, academic/pre-academic/functional academic skills No universally most-appropriate focused practices without consideringsuitability for individual learners and without carefully and individuallytailoring these methods for unique student needs Students with ASD are heterogeneous and display a range ofcharacteristics and functioning levels; thus they need individuallycrafted interventionsIntervention Choice Guidelines Qualified personnel use effective methods Effective methods are used with appropriateintensity and fidelity Effective methods are used to accomplishmeaningful outcomes Individualized program goals are addressedusing effective methods Ongoing assessment and documentation ofstudent progress3
2/18/2016What Proof Supports InterventionEffectiveness? Research documented gains; and degree to which atarget individual is similar to research participants. Discriminate between scientifically valid andevidence-based research methods and those lackingthese characteristics Discriminate objective and scientific research reportsfrom pseudoscience (e.g., anecdotally-based webreports, marketing/promotional brochures, purelypersonal testimony) Skepticism and caution directed towards methodspromising extraordinary and universal improvementsthat far exceed outcomes reported for more testedstrategiesHow Well Does an Intervention Fitan Individual’s Unique Needs? Perceived match of interventions with needs, valuesand life styles of individual students and families Independent of supporting research, qualitativefactors (e.g., child’s learning style, personality,idiosyncratic preferences, family circumstances) mightaffect the application of an intervention Discussions include quality-of-life factors, perceivedpractical benefits of particular interventions, students’penchants and characteristics related to adoptingcertain methodsHow Will Selected InterventionsFor Individuals Be Evaluated What target behaviors will be measured asevidence of progress (e.g., social interactioninitiations, spoken words)? Who will conduct agreed upon evaluationsand how often will interventions be evaluated? What standards or criteria will be used todetermine if an intervention should becontinued or changed?How Well Does an Intervention Fitan Individual’s Unique Needs? Discussions not intended to replacestakeholders’ consideration of interventionsbased on empirical scientific variables but ratherto broaden the vetting standards by includinginformal and qualitative considerations as a partof the deliberation process Stakeholders consider possible negative sideeffects, challenging circumstances/requirementsassociated with using a method, such as financialimpactGeneral Themes of EffectiveProgramming for Learners with ASD Early intervention is essentialTypes of EBP Reviews Literature reviews or meta-analyses of oneparticular intervention or method Active engagement for at least 25hours/week Reviews of a single area/domain Depending on needs, appropriatestudent-teacher ratio (e.g., 2:1) Broad reviews of a range of ASD practices.These include evaluations of comprehensiveprograms or focused interventions or both. Intervention intensity is important Parent and family participation is essential Regular data-based monitoring ofindividualized goals4
2/18/2016Simpson et al. (2005)Broad ReviewsWhile there have been reviews done by avariety of organizations, the following aremost relevant to education.2005 - Simpson et al.2015 – National ProfessionalDevelopment Center on ASD (Wong et al.)2015 – National Autism CenterConducted a subjective review of 37commonly used or purportedinterventions and programs for children andyouth in 5 categories such as interpersonalrelations, cognitive, medical, etc.Each method rating was based on many factors:treatment description, age, reported outcomes,risks, costs, implementer characteristics, etc.Simpson et al. Findings4 Scientifically Based Practices including LEAP,DTT, ABA, PRT13 Promising Practices including Social Stories,PECS, incidental teaching, CBM, etc.18 Limited Supporting Information forPractices including Gentle Teaching, Power Cards,Pet Therapy, Floor time, AIT, RDI, etc.2 Not Recommended including FacilitatedCommunication and Holding TherapyWong et al., 2015 In2007, the NPDC had identified 24 EBP 2015update - reviewed focused behavioral,educational or developmental interventionsfor children and youth ages birth to 21 Reviewedliterature (1990– 2011) with strictcriteria and rated each method as: EBP orother interventions with some supportWong et al. Findings Includedinformation on definitions, outcomes,and participants for: 27EBP including reinforcement, prompting,DTT, time delay, modeling, PECS, etc. 24other interventions with somesupport including music therapy, sensory diet,touch therapy, AIT, direct instruction, etc.National Autism Center In2009, the NAC completedthe National StandardsProject Phase 1 – identified11 established practices Findingswere updated in 2015 - NationalStandards Project Phase 2 Reviewof literature for interventions andtreatment packages up to 2012 Targetgroup: up to age 225
2/18/2016NAC Findings, 201514 Established Treatments includingBehavioral Package, Modeling, PRT, etc.18 Emerging Treatments including PECS,Cognitive Behavioral Intervention Package,AAC, Music Therapy, etc.13 Unestablished Treatments includingAcademic Interventions, AIT, FC, etc.Other Considerations ReviewdifferencesNAC Findings, 2015 Targetgroup: adults 22 and older Examined literature: up to 2012Findings1 Established Intervention – BehavioralPackage1 Emerging Intervention – vocational package4 Unestablished InterventionsMethodology Choices andStudents with ASD1. Programs based on effective methods Gender2. Provision of appropriate intensity Race/ethnicity3. Emphasis on meaningful outcomes Age4. Creation of an individualized program Other5. Documentation of student progressRecommendations forSelecting Interventions Keyquestions to ask when discussingthe programming and methodologyelements for students with ASD What are the anticipated outcomes of theoption? What are the potential risks? How will the method be evaluated? What proof exists to support the efficacy of themethod? What options would be excluded if a particularmethod was adopted?What are the anticipatedoutcomes of the option?1. Do outcomes promoted by an optionmatch a students’ identified needs?2. Does the option promote significanteducational gain or merely addresssymptoms?3. How similar is the student to otherswho have benefited from the approach?6
2/18/2016What are the potential risks?1. Are there health or behavioral risks forthe student?2. Are there risks for parents/families and/orschool personnel?3. What impact will the treatment have onthe quality of life for the student and hisfamily?4. If the treatment/intervention fails, whatare the implications?What proof exists to support theefficacy of the method?1. Is the treatment published in peer-reviewed journals?2. Does efficacy information come from a variety ofsources?3. Are the studies validating effectiveness of high quality?4. Is empirical validation available, or does support comeprimarily from personal testimonials?5. Do proponents claim the option has universal utility?How will the method be evaluated?1. How will progress be demonstrated?2. How frequently will the interventionbe evaluated?3. Who will conduct evaluations?4. What criteria will be used todetermine if a treatment should becontinued or discontinued”What options would be excluded if aparticular method was adopted?1. How does the treatment rate in terms ofrestrictiveness and intensity?2. Are there less restrictive/intensivealternatives that may be equally effective?3. Are there other options that are betterresearched than this one?4. Does the treatment option consider thefunctional communication and socializationneeds of the student?Keeping the Door Open forInnovation and AdvancementBalance Current Push for EBP Useand Innovative/PioneeringSearch for New EffectiveInterventionsExamples:An EBP ProcessIntegrates all of the EBP elements, criticalquestions to ask, etc. into a process See handout Based on the work of: Simpson et al.,2005; NAC, 2015; NPDC, 2015; LaCava &Shogren, 2012, Reichow et al., 2010,Prizant, 2011 Power Cards Consequence Maps7
2/18/2016An EBP Process – (LaCava, 2016) Baseline Data Observable &Measurable Research evidenceabout behavior/skill& practiceTargetBehavior/Skill Evidence-based or Promisingpractices options Risk/benefits How will you evaluate Can team use with fidelity Professional experienceReview Practice Options –Choose and Tailor Practice How has thisbehavior/skill beenaddressed before What was learned Legalconsiderations Other assessmentneeded Do practices match the learner’sstrengths, preferences, etc. Learner/family input Can the practices be used innatural settings, by typicalproviders, etc. Are practices cost effective andacceptable Training Coaching Implementationand data plan MaterialsPlan, Use &MonitorPractice Data collection Fidelity checks Assess socialvalidity Troubleshooting Data baseddecision making What was learned Capacity to use withother learners How can practiceinform researchFinal Steps If reach goal,choose new skill Generalization andmaintenance Celebrate successA Few Resources Ohio Center for Autism and Low Incidence –Autism Internet Moduleshttp://www.autisminternetmodules.org/ National Professional Development Center onASD http://autismpdc.fpg.unc.edu/ Simpson et al. (2005). ASD: Interventions andTreatments for Children and Youth National Autism Centerhttp://www.nationalautismcenter.org/Thank you!For feedback, questions orcomments, please contact:Paulplacava@ric.eduRichrichsimp@ku.edu8
An EBP Process – (LaCava, 2016) Baseline Data Observable &Measurable Research evidenceabout behavior/skill& practiceTargetBehavior/Skill How has thisbehavior/skill beenaddressed before What was learned Legalconsiderations Other assessmentneeded Evidence-based or Promisingpractices options Risk/benefits How will you evaluate Can team use with fidelity Professional experienceReview Practice Options –Choose and Tailor Practice Do practices match the learner’sstrengths, preferences, etc. Learner/family input Can the practices be used innatural settings, by typicalproviders, etc. Are practices cost effective andacceptable Training Coaching Implementationand data plan MaterialsPlan, Use &MonitorPractice Data collection Fidelity checks Assess socialvalidity Troubleshooting Data baseddecision making What was learned Capacity to use withother learners How can practiceinform researchFinal Steps If reach goal,choose new skill Generalization andmaintenance Celebrate success
The CUEing Process WorksheetChoosing, Using, and Evaluating Evidence-based Practices (EBP) for Students withAutism Spectrum Disorders (ASD)Learner: Date:Team members:Target behavior/skill: Related to IEP GoalBIPObservable and measurable definition of target behavior/skill:A. Background Information – answer each question and then add details as needed in the space provided1. Have you taken baseline data on the target behavior/skill?YES / NO2. Have you considered how this target behavior/skill been addressed in the past (practicesused, results, etc.)?YES / NO3. Have you considered any relevant legal factors?YES / NO4. Is a functional behavior assessment, task analysis or other assessment needed?YES / NOB. Choosing EBP1. Have you reviewed the research evidence for this target behavior/skill?2. Which reviews have you used? Evidence-based Practices for Children, Youth and Young Adults with ASD, NationalProfessional Development Center on ASD, 2014/Wong et al., 2015 National Autism Center’s National Standards Project Phase 2, 2015 ASD Interventions and Treatments for Children and Youth, Simpson et al., 2005 Evidence-based Practices and Treatments for Children with ASD, Reichow et al., 2010 Educating Children with Autism, National Research Council, 2001 Other P. LaCava, 2016 p. 1YES / NO
3. What EBP have been identified as possible options (considering skill/behavior, age, ASD severity, etc.)?Have You Considered the Following?EBP OptionsUnique learnerstrengths, interests,needs, values, etc.Learner &family inputProfessionalexperience &judgmentCapacity (cost,setting, personnel,fidelity, etc.)Benefits &Risksa.b.c.d.e.4. If no EBP are available or chosen, what promising practices can you consider?Have You Considered the Following?Promising Practices OptionsUnique learnerstrengths, interests,needs, values, etc.Learner &family inputProfessionalexperience &judgmenta.b.c. P. LaCava, 2016 p. 2Capacity (cost,setting, personnel,fidelity, etc.)Benefits &Risks
5. Which EBP or promising practice will you use?(explain rationale for using)6. Explain how you will evaluate the chosen practice (who will take data, method type, how often, how will you knowwhen to change tactics, etc.).7. What training, coaching, resources, other supports are needed?C. Using EBP1. Implement chosen practice2. Continue to collect, summarize and present data as planned3. Troubleshoot as needed4. Monitor treatment fidelity5. Adjust practice as needed based on data and other factors6. Assess social validity – was progress socially meaningful and important, was the method cost effective, did the learner,and team members accept it, was it easily implemented in natural settings, etc.)7. Continue generalization and maintenance phases as neededD. Final Steps1. Celebrate successes!2. What was learned by the team?3. Is there capacity to use this practice with other learners?4. How can this practice and results inform research and practice?5. Choose new target behavior/skill P. LaCava, 2016 p. 3
Evidence-based Practices and Autism Spectrum Disorders: Navigating a Sea of ChallengesCase StudyWork in small groups of 3 to 5 people on this activity. You may use handout notes, the CUEing ProcessWorksheet, the internet or other sources to help you.1. Read the following case study.James is a 7 year old, first grade boy diagnosed with autism spectrum disorder. He is liked by his peersbecause of his happy personality and huge knowledge base. James knows lots of facts about a variety oftopics – outer space, rain forests, Star Wars, presidents, etc. He has a special interest in playing with Legos,using any type of computer technology, and learning about air conditioners. He has been included ingeneral education classes since kindergarten and typically does well with academics given a variety ofaccommodations and individualized instruction. Visual supports have been particularly effective in helpingJames understand routines, schedules, expectations, and choice making. Parents reported that discrete trialtraining when James was 3 years old was not successful. James strongly and negatively reacted to thecontrolled and repetitive procedures he was asked to follow. His current academic skills are close to gradelevel except for writing. James does not like to write and will ask to use a computer for written work.Despite inclusion efforts, strong parental support, teacher knowledge of autism, and peer acceptance, Jamestypically does not initiate or engage with peers at recess or during less structured times throughout theschool day as well as in community outings.Specific skills that are lacking include: initiating conversations with peers, being able to join games thathave already begun, taking turns in conversations, not monopolizing conversations with his favorite topics,and recognizing and taking into account others’ thoughts and feelings.Even when staff has gotten James engaged with recess games and activities he is prone to display social andbehavior problems. For instance, James will quickly run away from the group and retreat to the edge of theplayground where he will recite favorite facts about air conditioners and other idiosyncratic interests.When he encounters any issues or barriers to success, getting what he wants, etc., James will pick at his skinuntil it bleeds and/or pull his eyelashes out; bright lights are very bothersome to James and he will get upand run out of settings if he thinks the lights are too bright – this has caused safety issues when he has runout of the school or when on community outings.2. Considering the above information, list what you consider to be James’s top strengths and concerns.StrengthsConcerns
3. Identify your top concern and then work through the EBP process that follows.Behavior/skill to address:4. Choosing a Practicea. What initial questions do you need to ask about this behavior/skill?b. What sources will you use to help identify possible EBP to address this behavior/skill?c. What EBP or promising practices options will you consider to address this behavior/skill?d. Determine your top choice and explain why you want to use it to address this behavior/skill.5. Tailoring the Practicea. What are the potential outcomes and risks of using this practice?
b. What other EBP elements/factors must you consider before implementing the EBP?c. What is your plan to evaluate this EBP (data collection method, who, when, etc.)?d. What training, coaching, resources, other supports are needed?6. Implementation and Evaluationa. Who will implement, when, with what degree of intensity, etc.?b. How will you monitor treatment fidelity?c. How will you assess social validity of the practice?d. How meaningful do you think it will be to address this behavior/skill?
Participants will: 1. Summarize the critical EBP elements 2. Identify at least 3 questions that practitioners can ask when using EBP 3. Describe a process for choosing, using and evaluating EBP Terminology Evidence-based Peer reviewed Scientifically based Research based Effective Validated Established Promising Emerging
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