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Interventions for Autism Spectrum Disorders: What is the Evidence Base


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Title: Interventions for Autism Spectrum Disorders: What is the Evidence Base

Interventions for Autism Spectrum Disorders What
is the Evidence Base?
  • Dr Kate Sofronoff
  • School of Psychology
  • University of Queensland

Presentation Overview
  • What is the current situation for parents
  • How do we establish an evidence base
  • What does the evidence look like
  • Evidence based approaches
  • Applied Behaviour Analysis
  • Parent training
  • Communication systems
  • Using CBT with a child with Asperger syndrome

Current Situation
  • cures for autism 322,000 entries
  • you could be living with a new child in a matter
    of a few weeks
  • Homeopathic cures
  • elixirs that carry energetic messages to the
  • Detoxification
  • Faith healers
  • Treatments that sound scientific but have no
    basis in science
  • Heavy reliance on testimonials
  • Miracle cures

What Evidence is Good Enough?
  • Between group comparisons
  • Randomized controlled trials
  • One group receives the intervention while the
    second group receives an alternative treatment or
    is on a wait-list
  • Design produces strong evidence
  • Quasi-experimental designs
  • Groups matched but not randomly assigned
  • Often used if treatment is lengthy e.g. ABA
  • Single subject case designs
  • Takes a baseline measure and compares this with
    the intervention phase
  • Testimonials
  • Unvalidated

Useful Websites
  • Australian website
  • Raising children network
  • US website
  • Association for Science in Autism Treatment
  • UK website
  • National Autistic Society

What do we Know from these Methods?
  • RCTs
  • Risperidone shown to be effective to reduce
    aggression (McCracken et al., 2002)
  • Secretin shown to be ineffective across 14 RCTs
    (Williams, Wray Wheeler, 2005)
  • Parent training is effective (Tonge et al., 2006
    Whittingham et al., 2009)
  • Anxiety interventions effective (Chalfant et al.,
    2006 Sofronoff et al., 2005)
  • Anger intervention probably effective (Sofronoff
    et al., 2007)
  • Computer-based social skills intervention
    probably effective (Beaumont Sofronoff, 2009)
  • Quasi-experimental designs
  • ABA methods shown to be effective but still
    require RCTs to confirm (Lovaas et al., 1987
    Remington et al., 2007)
  • Case studies
  • ABA methods demonstrate effectiveness (Goldstein,
    2002 McConnell, 2002)
  • Facilitated Communication (FC) reported gains to
    do not reflect actual improvement (Mostert, 2001)

Evidence Based Approaches
  • We should use approaches that have demonstrated
  • Evaluate the strength of the evidence
  • Watch out for pseudoscientific jargon especially
    in a non-scientific context, for anything that
    offers a cure, for anything that relies on
    testimonials, for anything that is very
    expensive, or seems dangerous
  • Evidence suggests that interventions for children
    with autism should be behaviourally based
  • Skill building by breaking tasks into small
  • Reinforcing attempts
  • Functional analysis of behaviours
  • Use of visual as well as verbal prompts and cues
  • Emphasis on functional communication
  • Parent involvement in intervention is considered
    best practice ( Remington et al., 2007 Sofronoff
    et al., 2005, 2007 Tonge et al., 2006
    Whittingham et al., 2009)

Applied Behaviour Analysis
  • Dates back to Skinner who demonstrated that food
    rewards (immediate positive consequences) lead to
    behaviour changes.
  • Most common type of intervention is discrete
    trial learning
  • A program is based on these principles but is a
    comprehensive intervention that occurs across
    settings and behaviours
  • Recommended for young children
  • To increase skills
  • To decrease problem behaviours

Applied Behaviour Analysis
  • Analysis of the behaviour (functional analysis)
  • What is the motivation for the behaviour?
  • Attention, access to something, avoidance,
  • What is the reinforcer for the behaviour?
  • How can the child achieve the same reinforcement
    in a more appropriate way
  • Break tasks down
  • Chaining (Ask Say Do Backwards Learning)
  • Provide reinforcement for approximations
  • Fade reinforcers over time
  • Errorless learning

Evidence Base
  • There is a lot of evidence to demonstrate that
    behaviorally based interventions show positive
    results for children with autism
  • Discrete trial/direct instruction
  • Lovaas (1977). The autistic child Language
    development through behavior modification. New
    York Irvington
  • Lovaas (1987).behavioral treatment and normal
    educational and intellectual functioning in young
    autistic children. Journal of Consulting and
    Clinical Psychology, 55, 3-9.
  • Sheinkopf Siege (1998). Home-based behavioral
    treatment of young children with autism. Journal
    of Autism and Developmental Disorders, 28, 15-23.
  • Remington, Hastings, Kovshoff et al. (2007).
    Early intensive behavioral intervention Outcomes
    for children with autism and their parents after
    two years. American Journal on Mental
    Retardation, 112, 418-438.
  • Reed, Osborne Corness (2007). Brief report
    Relative effectiveness of different home-based
    behavioral approaches to early teaching
    intervention. Journal of Autism and
    Developmental Disorders, 37, 1815-1821.

Evidence Base
  • For Normalized Behavioral Intervention
  • Systematic application of behavioral principles
    sometimes referred to as incidental teaching
  • Some trials have found that these interventions
    are more effective than discrete trials
  • Delprato (2001). Comparisons of discrete-trial
    and normalized behavioral language intervention
    for young children with autism. Journal of
    Autism and Developmental Disorders, 31, 315-325.

Some Difficulties
  • 20-40 hours per week
  • Cost, availability
  • Parents may believe this is the only effective
  • Parents sometimes disempowered by the process
  • How long to continue?
  • What happens at the end of time?

Behaviour Management by Parents
  • It is possible to use ABA principles to work
    individually with a child and also to train
    parents to use the same principles in their
    approach to parenting
  • It is not inconsistent to have the interventions
    running concurrently

Stepping Stones Triple P
  • Forms part of the Triple P - Positive Parenting
  • Strategies based on ABA principles
  • Includes functional analysis of behaviour
  • Includes functional communication training
  • Introduces additional strategies from the
    disability literature
  • Promotes positive strategies to increase child
    skill development
  • Aims to help parents deal with behaviour problems
    and developmental issues
  • Aims to prevent development of more severe
    behavioural and emotional problems by increasing
    parental skills and confidence

Program Content 10 Sessions
  • Two sessions of assessment
  • Two sessions on positive parenting
  • Increasing desirable behaviour
  • Managing misbehaviour
  • Three home visits
  • Two sessions on planned activities
  • A closure session
  • The specific content and exercises within each
    module are determined based on the needs of the

RCT Stepping Stones with parents of a child with
  • Whittingham, Sofronoff Sheffield (2006).
    Stepping Stones Triple P A pilot study to
    evaluate acceptability of the program by parents
    of a child diagnosed with an autism spectrum
    disorder. Research in Developmental Disabilities,
    27, 364-380.
  • Whittingham, Sofronoff, Sheffield Sanders
    (2009). Stepping Stones Triple P A randomized
    controlled trial with parents of a child
    diagnosed with an Autism Spectrum Disorder.
    Journal of Abnormal Child Psychology, 37,
  • Program delivered in small groups (3-5 families)
  • Assessment and practice sessions delivered
  • Families grouped by severity of diagnosis
  • Groups run by UQ Interns
  • Weekly supervision and treatment protocols

Child Outcomes
  • Decreases in Problem Behaviour (Eyberg Child
    Behaviour Inventory)
  • Significant decreases in Problem and Intensity
    scores moved from the clinical range to the
    non-clinical range
  • A third of the treatment group experienced
    reliable and clinically significant change for
    Intensity Scale (34.5) and Problem Scale (37.9)
  • Effects maintained at follow-up six months later

Results Child Behaviour
Parenting Style
  • Parents reports of their parenting style showed
    significant changes
  • From more permissive to more assertive
  • From using raised voice and threats to more calm
    and clear
  • From talking and explaining a lot to giving clear

Parenting Over-Reactivity
Results for Parents
  • Increases in parental efficacy and satisfaction
    (Being a Parent Questionnaire)
  • Increases in parental satisfaction during
    Stepping Stones (maintained at follow up six
    months later)
  • Sleeper effect for parental confidence

Case Study Increasing Behaviour
  • Melissa aged 4 diagnosed with ASD and acquired
    brain injury
  • Parents reported Melissa would rarely play alone.
    If other family members were busy (e.g. during
    the morning routine) Melissa would interrupt and
    become aggressive
  • Monitoring revealed that Melissa would not play
    alone for longer than one minute. Melissa would
    watch television alone for 10-15 minutes in the

Strategies Used from Stepping Stones
  • Provide engaging activities - ensuring that
    Melissa was set up in an appropriate activity
    when expected to engage in solo play
  • Activity schedule- A play schedule was created
    that alternated between joint activities and solo
    play. Solo play began as 30 second activities
    and was progressively extended
  • Descriptive praise and back-up rewards -
    Melissas parents used praise Youre playing so
    well by yourself and back-up rewards when
    Melissa engaged in solo play

  • Melissa engaged in solo play for 10-15 minutes
    several times a day
  • Reported by parents but also observed via video
  • Decreases in interrupting and aggression
  • Decreases in child behaviour problems on ECBI
    Intensity scale pre 173.63 post 152.43
  • This is still quite high and reflects the
    frequency of the behaviours
  • Decreases in child behaviour problems on ECBI
    Problem scale pre 18 post 1
  • Reflects possibly a change in parent attitude to
    some behaviours rather than the absence

Case Study Teaching New Skills
  • Jonathon aged 5 diagnosed with Asperger Syndrome
  • Difficulty managing frustration resulting in
    meltdowns, including yelling, screaming and
  • Fear of the dark and of sleeping alone resulting
    in non-compliance and meltdowns at bedtime

Strategies Used
  • Ask, say, do - to teach emotional regulation
  • Strategies to stay calm
  • Behaviour chart- to reinforce brave behaviour
  • Stickers and back-up reward after 5 attempts
  • Going into darkened bedroom for progressively
    longer periods of time to hunt for treasure
  • Exposure

  • Decreases in fear of the dark
  • Based on parent monitoring
  • Decreases in non-compliance and aggression
    (including at bedtime)
  • Based on parent report
  • Decreases in child behaviour problems as measured
    by the ECBI Intensity scale pre 149 - post 80
  • Change from clinical to non-clinical range
  • Decreases in child behaviour problems as measured
    by the ECBI Problem scale pre 17 post 2
  • Change from clinical to non-clinical range, may
    also reflect a change in parent perceptions of

Case Study Managing Misbehaviour
  • Elliott, aged 6 diagnosed with Asperger Syndrome
  • Frequent non-compliance with instructions which
    sometimes escalated to yelling
  • Especially after school
  • Frequent whining and demanding
  • Emotion regulation
  • Refusal to dress himself (has the skill)
  • Associated with access to preferred activity

Strategies Used
  • Establish clear ground rules- rules written by
    the family together, including rule use a
    friendly voice
  • Clear, calm instructions- particularly parents
    learning to decrease the number of instructions
    given to 2 start instructions and 1 stop
  • Directed discussion- for minor rule breaking due
    to forgetfulness, including whining
  • Emotion release strategies - frustration
  • Planned ignoring- planned ignoring used for
    Elliotts whining if it persisted
  • Quiet time- Quiet time used for Elliotts
    non-compliance, including refusal to dress
  • Behaviour chart rewards for efforts to dress

  • Elliott more accepting of the family rules as the
    rules were clearer and Elliott felt that he was
    involved in making them
  • Increase in compliance
  • Decrease in whining
  • Elliott is now dressing himself
  • Decreases in child behaviour problems as measured
    by the ECBI Intensity scale pre 136- post 114
  • Decreases in child behaviour problems as measured
    by the ECBI Intensity scale pre 17- post 4

  • Picture Exchange Communication System (PECS)
  • Typically six phases
  • Spontaneous requests for items
  • Use greater persistence and generalize
  • Ask child to discriminate
  • Sentence strips
  • Extends sentences
  • Child taught to comment on environment

Evidence Base
  • Several early studies have reported an increase
    in non-verbal communication
  • Some children also described as acquiring some
    spoken language (Ganz Simpson, 2004)
  • Two Randomised Controlled Trials
  • Howlin, Gordon, Pasco, Wade Charman (2007).
    The effectiveness of Picture Exchange
    Communication System (PECS) training for teachers
    of children with autism a pragmatic, group
    randomised controlled trial. Journal of Child
    Psychology and Psychiatry, 48, 473-481.
  • Yoder Stone (2006). Randomized comparison of
    two communication interventions for preschoolers
    with autism spectrum disorders. Journal of
    Consulting and Clinical Psychology, 74, 426-435.

Cognitive Behaviour Therapy for Children with
Asperger Syndrome
  • CBT needs to be modified to accommodate the
  • Teach about emotions
  • Use visual aids to work through scenarios
  • Use concrete methods to demonstrate degrees of
  • Incorporate meaningful analogies
  • special interest if possible

Programs with an Evidence Base
  • Sofronoff, Attwood Hinton (2005). A randomised
    controlled trial of a CBT intervention for
    anxiety in children with Asperger syndrome.
    Journal of Psychology and Psychiatry and Allied
    Disciplines, 46, 1152-1160.
  • Chalfant, Rapee Carroll (2007). Treating
    anxiety disorders in children with high
    functioning autism spectrum disorders A
    controlled trial. Journal of Autism and
    Developmental Disorders, 37, 1842-1857.
  • Sofronoff, Attwood, Hinton Levin (2007). A
    randomized controlled trial of a CBT intervention
    for anger in children with Asperger syndrome.
    Journal of Autism and Developmental Disorders,
    37, 1203-1214.
  • Beaumont Sofronoff (2008). A multi-component
    social skills intervention for children with
    Asperger syndrome The Junior Detective Training
    Program. Journal of Child Psychology and
    Psychiatry, 49, 743-753.

Anger ManagementSofronoff, Attwood, Hinton
Levin (2007). A randomized controlled trial of a
CBT intervention for anger in children with
Asperger syndrome. Journal of Autism and
Developmental Disorders, 7, 1203-1214.
  • Six sessions of two hours
  • Groups ran on Saturday (morning and afternoon)
  • 3 children were assigned to a group with 2
  • A larger parent group was run at the same time as
    the child groups
  • WL completed questionnaires pre and post and were
    then invited to do the program

  • Dylan is being Teased (Attwood, 2004)
  • Child generates strategies
  • What Makes me Angry (Faupel et al., 1998)
  • Parent monitoring of anger
  • Parent confidence in managing the childs anger
  • Parent rating of the childs confidence in
    managing their own anger
  • Childrens Inventory of Anger parent form
  • 4 subscales frustration, physical aggression,
    peer relationships, authority relationships
  • Qualitative questionnaire
  • Parents and teachers

  • Repeated measures ANOVAs across time (pre post
    follow-up) and between groups (Intervention
  • Parent reports of anger (ChIA-P)
  • Parent monitoring of anger
  • Parent confidence
  • Dylan is Being Teased (child strategies)
  • Qualitative parent reports
  • Qualitative teacher reports

Parents Reports of Anger
Frustration (Parent Report)
Parent Confidence
Dylan is Being Teased
Qualitative Parent Reports
  • 75 response rate completion anonymous
  • All parents who responded indicated that they had
    found the program useful
  • Four main themes emerged
  • Parents had learned practical strategies both
    from the therapist and from other parents
  • They felt comfortable and validated sharing
    experiences in the sessions
  • They learned that they were managing better than
    they had previously thought
  • They were able to talk with their child using the
    language of the program

Qualitative Parent Reports
  • Parents were asked if their child had
    demonstrated any behaviours that they attributed
    to the program
  • 34 parents responded to the question and 25 (74)
    indicated that they could identify positive
    behavioural changes while 9 (26) said that so
    far they could not see any behavioural changes
  • The changes fell into 3 main themes
  • 47 said that their child used strategies learned
    in the program to manage anger
  • 59 said their child was more able to talk about
    feelings, to think things through, seemed more
    confident and easier to get along with
  • 29 said their child had made a friend in the
    program and this had resulted in a more positive
    attitude in the child

Qualitative Teacher Reports
  • 18 teachers were able to be contacted by phone
    for a brief interview and were asked a series of
  • Firstly they were asked if they knew that the
    child had completed the program and if so who
    told them about this
  • All had heard from the childs mother
  • In response to have you noticed any change in
    the childs ability to manage anger since
    completing the program? 16 (88) responded YES
    and 2 (12) said NO
  • 3 themes emerged from the YES responders
  • All were aware of the child trying to use
    strategies to manage anger at least sometimes
  • 19 (3) said the child would ask to withdraw when
    feeling angry
  • 56 (9) said the child now had a language with
    which to talk about anger and this helped reduce
    the number of outbursts

  • We have the start of an evidence base for this
  • Very important to have parents involved
  • Some gains noted by teachers
  • Some gains not captured by the standard measures
  • Qualitative information is useful
  • Gains across programs seem to be cumulative
  • Limitations of small sample size, reliance on
    parent reports and short follow-up

Social SkillsBeaumont Sofronoff (2008). A
Multi-component Social Skills Intervention for
Children with Asperger Syndrome The Junior
Detective Training Program. Journal of Child
Psychology and Psychiatry, 49(7), 743-753.
  • 7-week program for parents and child
  • Interactive computer game
  • Developed specifically to target social
    understanding issues
  • Small group sessions
  • To practice skills
  • Parent sessions
  • Teacher handouts
  • Trial in NSW through ASPECT schools in 2010

Secret Agent Society - Game
  • Level 1
  • Facial expression
  • Body posture/movement
  • Voice tone
  • Level 2
  • Identification of feelings from body clues and
  • Degrees of emotion
  • Situational clues of emotions
  • Integrating face, body, voice and situational
  • Level 3
  • Anger management Anxiety management Apologising
  • Bullying and teasing Coping with mistakes Team
  • Meeting new people Playing with others Talking
    to others
  • Trying new things Winning and losing

Results Social Skills (Parent Report)
Emotion Regulation Skills
Secret Agent Society
  • Video

  • Kate Sofronoff
  • School of Psychology
  • The University of Queensland