Low intensity ABA in young children with ASD/ID: effectiveness, predictors of effects, and costsbenefits

Transcription

1 Low intensity ABA in young children with ASD/ID: effectiveness, predictors of effects, and costsbenefits Robert Didden Icare4autism, Jerusalem, august 2012

2 Autism Spectrum Disorder (ASD) 1. Deficits in communication 2. Deficits in social interaction 3. Restricted, stereotypic behaviors and interests Present before 3 years, early identification and diagnosis Comorbid ID: Severe intellectual disability to high functioning (IQ > 70)

3 Prognosis Prognosis is unfavorable regarding: living independently, work, relationships and psychological well-being Even worse in case of comorbid ID, IQ < 50 (see Bildstedt, Gillberg & Gillberg, 2005) Lower levels of functioning regarding self-help, especially in the area of communication and socialisation (see Kraijer, 2000) Increased stress in parents, especially predicted by presence of challenging behaviors (see e.g. Peters-Scheffer, Didden, & Korzilius, 2012)

4 Need for early intervention Brain plasticity (Dawson, 2008) Learned behaviors are the basis for later development and skill acquisition Intervention from 2-3 years of age

5 Many interventions for ASD/ID ABA, PECS, Sensory integration, Teacch, dolphin therapy, facilitated communication, music therapy, vitamins, diet, medication etc. Absence of evidence base for most therapies Dutch National Health Counsil (2009): ABA most effective for children with ASD

6 What is Applied Behavior Analysis? Applying principles derived from learning theory Teaching adaptive skills, reducing challenging behavior Different methods and models, e.g.: Discrete Trial Teaching (Lovaas) Pivotal Response Training (Koegel) Videomodeling Social skills training Etc.

7 Early intervention ABA programs Early intervention, preferably starting before 3.5 year Comprehensive teaching curriculum (attention, imitation, matching, language, self-help, social skills, challenging behavior Intensive 1-1 training Treatment implemented in daily living environments Parent participation is crucial for generalization and maintenance of results Trainers should be supervised by certified ABA trainer and trained to attain high procedural fidelity

8 Content of early intervention ABA training sessions Basic skills: Attention and concentration Communication Imitation Following instructions Other skills: Self-help, o.a. feeding, dressing (pre) school skills (e.g., matching to sample) Social interaction Play All skills are practised during a training session: many learning opportunities or trials per session (e.g. up to 100 trials)

9 A trial: 3 elements (e.g. PECS) Stimulus Trainer says: give me the picture for (car) Response Child gives picture (depicting a car) to trainer Consequence Child receives car = functional reinforcer

10 Teaching skills: breaking down skills in small steps Task analysis: put on coat Prompts and reinforcement (for subtasks)

11 Prompting: providing help Preventing errors Increase opportunities for reinforcement Decrease and increase help: prompt fading - physical help - modeling - instructions

12 Effectiveness of intensive early intervention ABA Meta-analysis (see Peters-Scheffer, Didden, Korzilius & Sturmey, 2011) Selection of studies RCT s Diagnosis ASD Age children < 10 years IQ, developmental age, language and communication, self-help

13 Outcomes 11 studies; N = 344 Children aged between years IQ between 27 and 76 at start treatment 47% autism, 12.79% PDDnos, 40%? Treatment: hours ABA per week lasting 10 to > 24 months Controls hours treatment as usual

14 Outcomes Total IQ improved in experimental groups (on average) 12 points more than controls Similar results for receptive and expressive language, adaptive skills (communication, socialization, self-help skills)

15 Improvement in IQ: large differences between studies

16 Predictors of treatment effectiveness Number of hours of ABA Young age High IQ at start treatment Supervision: more gives better results Crucial factor? Quality of trainers/training (e.g., high procedural integrity)

17 Low intensity early intervention ABA (DTT model) ABA/DTT is provided by a center for children with ASD/ID Range of 4 to 10 hours of 1-1 training (next to regular program in child day care centers or schools) Trainers, direct care staff and parents receive instruction on how to generalize learned skills High procedural reliability and integrity accomplished by: - Written manuals - Monthly meetings of all professional staff/trainers and often parents (roleplay, instruction etc) - Trainers receive video feedback on training sessions

18 Is low intensive early intervention ABA also effective? (Peters-Scheffer, Didden, Mulders & Korzilius, submitted) Pre-post test control group design (n=40) All children receive group training provided in day care centers and including individualized therapies: 16 to 36 hours of treatment as usual Experimental group received between 4 to 10 hours of DTT additional to group program Duration: 24 months

19 Outcomes after 2 years Developmental age m (controls + 9)* IQ pts (controls - 0.7)* Adaptive skills (VABS) Total + 19 m (controls + 6.9)* Communication + 20 m (controls + 8)* Daily living + 18 m (controls + 7)* Socialisation m (controls + 7)* Language (e.g., Peabody) Receptive: (controls + 4.5)* Expressive: NS *significant difference

20 Outcomes after 2 years: differences between groups Autism (ADOS, CARS) Total * Communication * Sociale interaction * Symptom severity (CARS) * Social-emotional (SEEC) Interpersonal relations * Play and leisure time * Behavior (CBCL, BFRS-r): Emotional/behavioral * Behavioral flexibility NS Parental stress (NOSI-K mother) Stress : NS *significant

21 Time x treatment effect? The progress in child development is larger after 1 year than after 2 years

22 Predictors of positive treatment outcomes Significant predictors of effectiveness: Hours of training per week And Developmental age at baseline IQ Adaptive behaviors Receptive language skills Play skills

23 What predicts treatment fidelity? (Peters-Scheffer, Didden, Korzilius & Sturmey, submitted) 34 trainers, 35 children (3,5-10 years old) ABA/DTT training sessions Method Each session was videotaped Treatment fidelity was measured Next to this: questionnaires were completed by trainers on their attitude toward children with disabilities, their personality, experience with ABA training, etc

24 Predictors of treatment fidelity Feedback (i.e., error correction, reinforcement) was the most difficult part of ABA program (trainers made most errors) Lower fidelity when: More warmth and affection towards children with disabilities More negative emotions by child during training More openness and curiosity by trainers

25 Were the effects also clinically significant? This question relates to for example a change in diagnosis following treatment Diagnosis ASD and ID were set by an independent psychologist/psychiatrist following 2 years of treatment

26 Percentage of children who changed diagnosis of ASD after 2 years of low intensity ABA ABA (n=20) Controls (n = 20) Diagnosis ASD did not change 45% 80% Autism > PDD-NOS 45% 20% Autism > No ASD 5% 0% PDD-NOS > No ASD 5% 0%

27 Clinical significance 2: change in level of ID ABA Controls No change in level of ID 45% 95% Profound > Severe 15% 5% Severe > Moderate 25% - Moderate > Mild 10% - Borderline > None 5% -

28 Parental observations (experimental group) Parents noted that their child: Listens better Has more attention for other people (joint attention skills) Imitates better Communicates more often and better Is more able to concentrate

29 Benefits and costs: impact on parents and family 96% of parents were positive about the low intensity ABA program Benefits for parents (and child) - Manage their child s behavior - Believe in child s potential to learn and develop - More positive perspective (future) - Child may remain within family Costs: - Adverse effects on work and leisure time - Lack of privacy - Family income (hiring trainers etc.) - Other people (professionals) train their child in home setting

30 Financial cost-benefit analysis of EIBI Costs of EIBI and estimated costs for education, (supported) work and (sheltered) living for individuals with ASD in the Netherlands are applied in a cost-offset model (see Peters-Scheffer, Didden, Korzilius, & Matson, 2012). Costs of EIBI between and euro (per child) Longterm: benefits outweigh costs lifetime saving per person with ASD as a result of early ABA = euro = US $

31 Why is ABA not implemented more often? Parents have difficulty in getting the program financed Shortage of qualified trainers Misunderstand of what ABA is ( punishment, teaching tricks ) Professionals are unaware about ABA and its effectiveness, they are not convinced about the effectiveness or believe ABA is not suitable for ASD Cognitive models (of ASD) are dominant for many professionals