Applied Behavior Analysis - Efficacy in Autism

Efficacy in Autism

ABA-based techniques are often used to treat autism, so much so that ABA itself is often mistakenly considered to be synonymous with therapy for autism. ABA for autism may be limited by diagnostic severity and IQ. The most influential and widely cited review of the literature regarding efficacy of treatments for Autism is the National Research Council's book Educating Children with Autism (2001) which clearly concluded that ABA was the best research supported and most effective treatment for the main characteristics of Autism. Some critics claimed that the NRC's report was an inside job by behavior analysts but there were no board certified behavior analysts on the panel (which did include physicians, speech pathologists, educators, psychologists, and others). Recent reviews of the efficacy of ABA-based techniques in autism include:

• A 2007 clinical report of the American Academy of Pediatrics concluded that the benefit of ABA-based interventions in autism spectrum disorders (ASDs) "has been well documented" and that "children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior."
• Researchers from the MIND Institute published an evidence-based review of comprehensive treatment approaches in 2008. On the basis of "the strength of the findings from the four best-designed, controlled studies," they were of the opinion that one ABA-based approach (the Lovaas technique created by Ole Ivar Lovaas) is "well-established" for improving intellectual performance of young children with ASD.
• A 2009 review of psycho-educational interventions for children with autism whose mean age was six years or less at intake found that five high-quality ("Level 1" or "Level 2") studies assessed ABA-based treatments. On the basis of these and other studies, the author concluded that ABA is "well-established" and is "demonstrated effective in enhancing global functioning in pre-school children with autism when treatment is intensive and carried out by trained therapists."
• A 2009 paper included a descriptive analysis, an effect size analysis, and a meta-analysis of 13 reports published from 1987–2007 of early intensive behavioral intervention (EIBI, a form of ABA-based treatment with origins in the Lovaas technique) for autism. It determined that EIBI's effect sizes were "generally positive" for IQ, adaptive behavior, expressive language, and receptive language. The paper did note limitations of its findings including the lack of published comparisons between EIBI and other "empirically validated treatment programs."
• In a 2009 systematic review of 11 studies published from 1987–2007, the researchers wrote "there is strong evidence that EIBI is effective for some, but not all, children with autism spectrum disorders, and there is wide variability in response to treatment." Furthermore, any improvements are likely to be greatest in the first year of intervention.
• A 2009 meta-analysis of nine studies published from 1987–2007 concluded that EIBI has a "large" effect on full-scale intelligence and a "moderate" effect on adaptive behavior in autistic children.
• In 2011, investigators from Vanderbilt University under contract with the Agency for Healthcare Research and Quality performed a comprehensive review of the scientific literature on ABA-based and other therapies for autism spectrum disorders; the ABA-based therapies included the UCLA/Lovaas method and the Early Start Denver Model (the latter developed by Sally Rogers and Geraldine Dawson). They concluded that "both approaches were associated with ... improvements in cognitive performance, language skills, and adaptive behavior skills." However, they also concluded that "the strength of evidence ... is low," "many children continue to display prominent areas of impairment," "subgroups may account for a majority of the change," there is "little evidence of practical effectiveness or feasibility beyond research studies," and the published studies "used small samples, different treatment approaches and duration, and different outcome measurements."

A 2009 systematic review and meta-analysis by Spreckley and Boyd of four 2000–2007 studies (involving a total of 76 children) came to different conclusions than the aforementioned reviews. Spreckley and Boyd reported that applied behavior intervention (ABI), another name for EIBI, did not significantly improve outcomes compared with standard care of preschool children with ASD in the areas of cognitive outcome, expressive language, receptive language, and adaptive behavior. In a letter to the editor, however, authors of the four studies meta-analyzed claimed that Spreckley and Boyd had misinterpreted one study comparing two forms of ABI with each other as a comparison of ABI with standard care, which erroneously decreased the observed efficacy of ABI. Furthermore, the four studies' authors raised the possibility that Spreckley and Boyd had excluded some other studies unnecessarily, and that including such studies could have led to a more favorable evaluation of ABI. Spreckley, Boyd, and the four studies' authors did agree that large multi-site randomized trials are needed to improve the understanding of ABA's efficacy in autism.