Journal of Autism and Developmental Disorders, Vol. 30, No.

5, 2000

Intensive Behavioral/Psychoeducational Treatments for Autism: Research Needs and Future Directions
Laura Schreibman1

It is widely acknowledged that, to date, the forms of treatment enjoying the broadest empirical validation for effectiveness with individuals with autism are those treatments based upon a behavioral model and that such treatments are best implemented intensively and early in the childs development. This paper describes several features important in the success of this model and presents remaining issues to be addressed for improving treatment effectiveness. While it is appreciated that there is no one size fits all treatment for children with autism, there is as yet no established protocol for relating specific child, family, target behavior, and treatment variables to individualized treatment regimens. Future research needs to include well-conceived and methodologically rigorous investigations allowing for the determination of these important variables.
KEY WORDS: Intensive behavioral treatment; autism.

INTRODUCTION It is now widely acknowledged that, to date, the forms of treatment enjoying the broadest empirical validation for effectiveness with individuals with autism are those treatments based upon a behavioral model. These treatments all have as their foundation the systematic application of the psychological principles of learning to human behavior. This form of treatment is derived from the experimental analysis of behavior, which is a science dedicated to understanding the laws by which environmental events determine behavior. By understanding these laws, we can develop applications to change behavior. The science wherein these principles are applied to the improvement of socially important behaviors is known as applied behavior analysis, and the development of the behavioral treatment of autism is largely the result of this field of science. The first demonstrations of the effectiveness of this treatment model were provided in the 1960s when highly structured operant learning programs were employed to improve the condition of children with autism (e.g.,
1

University of California, San Diego, California.

Lovaas, Berberich, Perloff, & Schaeffer, 1966; Lovaas, Freitag, Newson, & Whalen, 1967). These early programs had a tremendous impact because they were the first to affect empirically validated gains in children with autism after no other form of treatment had been successful. These behavioral programs were successful in increasing language, social, play, and academic skills, as well as in reducing some of the severe behavioral problems often associated with the disorder. However, as effective as these early demonstrations proved to be, enthusiasm was somewhat tempered when generalization and follow-up data indicated some limitations to their effectiveness (e.g., Lovaas, Koegel, Simmons, & Long, 1973). It is a testament to the behavioral model and its emphasis on careful data collection and analysis that specific areas requiring further research were identified. Subsequent research has addressed these areas, allowing for improvement in the effectiveness of treatments based on this model. Along these lines, the field has evolved and broadened to include comprehensive behavioral packages and behavioral strategies that have more widespread and durable treatment outcomes. Many of these recent behavioral treatment extensions have been put to the empirical test (with varying 373
0162/3257/00/1000-0373$18.00/0 2000 Plenum Publishing Corporation

374 degrees of experimental rigor). Space constraints preclude describing the extensive literature in this area here in any detail, and it is not the purpose of this paper to present a comprehensive and inclusive discussion of the research in this area. Rather, it is the intent of this paper to make some general comments about the current state of behavioral treatments and where future research needs to be directed.

Schreibman opportunities, following the childs lead in initiating learning events, and the provision of direct, naturally occurring consequences. Effective behavioral treatments all have in common an appreciation of the importance of understanding how children with autism utilize environmental stimulation and how they benefit from carefully planned and predictable stimulus presentation. This has required a good deal of research aimed at understanding the attentional patterns of these children and at structuring teaching situations in a way that maximizes learning. Discrete Trial Training, Incidental Teaching, Pivotal Response Training, Division TEACCH, and their relatives all depend greatly on utilizing carefully structured and/or carefully chosen naturally occurring environmental stimuli. Generalization and maintenance of treatment effects are not passive phenomena that can be expected to occur with treatment. Rather, we know that these important treatment effects must be addressed actively. A treatment that fails to demonstrate generality and durability should not be considered optimally effective. Despite its impressive effects in terms of teaching important behaviors to children with autism, the highly structured discrete trial model encountered problems with generality. Specifically, some of the problems noted included cue dependency, lack of spontaneity and self-initiated behavior, rote responding, and failure to generalize behavioral gains across settings and responses (e.g., Schreibman, 1997). In response to such problems, several very effective behavioral strategies added components (e.g., parent training) to highly structured discrete trial training (e.g., Smith, Eikeseth, Klevstrand, & Lovaas, 1997). In another important approach, strategies that utilize more naturalistic, child-initiated interventions and natural settings were developed. Such efforts have yielded more generalized responding, increased spontaneity, and improved efficiency in teaching acquisition and generalization simultaneously (e.g., Schreibman & Koegel, 1996; Schreibman, 1997). In addition, studies have reported that, compared to more highly structured (i.e., discrete trial) teaching, naturalistic behavioral interventions are associated with more positive affect on the part of the children and their treatment providers (e.g., parent) and fewer disruptive behaviors (Koegel & Egel, 1979; Schreibman, Kaneko, & Koegel, 1991). Another benefit of these naturalistic treatments is the ease with which they can be learned by parents, siblings, peers, and other nonprofessionals and the ease with which they can be incorporated into the childs everyday natural settings, including the home, the classroom,

WHAT WE KNOW A good place to start is by briefly describing what we now know about intensive behavioral treatments for children with autism. By intensive we mean behavioral treatments that are delivered in high dosage (e.g., many hours per day) and/or in many of the childs daily environments. Intensive interventions can be extremely effective (e.g., Schreibman, 1997). It has been demonstrated that such treatments can produce significant improvement in the behavior of individuals with autism. Such demonstrations include increases in a wide range of skills as well as reductions in challenging behaviors. Furthermore, we also now know that applying effective interventions when children are very young (e.g., under the age of 34 years) has the potential for achieving substantial and widespread gains and even normal functioning in a certain number of these youngsters (e.g., Connor, 1998; Lovaas, 1987; Rogers, 1998). Several treatment protocols that have substantial empirical validation emphasize the carefully controlled structure of the learning situation. Discrete Trial Training (e.g., Lovaas, 1981) is perhaps the most highly structured of the behavioral interventions, typically focusing on repetitive practice and a highly structured form of trial presentation. A trial (or learning event) consists of a concise and consistent instruction or question, the childs response, and a specific consequence, the nature of which is determined by the childs response. Learning trials are typically presented in blocks. More loosely structured and naturalistic treatment strategies, such as Incidental Teaching (e.g., Hart & Risley, 1980; McGee, Daly, Izeman, Mann, & Risley, 1991), Natural Language Paradigm or Pivotal Response Training (e.g., Koegel, ODell, & Koegel, 1987; Laski, Charlop, & Schreibman, 1988; Schreibman & Koegel, 1996), Milieu Teaching (e.g., Kaiser & Hester, 1996), and their relatives, utilize protocols with a broader interpretation of the concepts of instruction and consequence. These more loosely structured treatments all involve capitalizing on naturally occurring teaching

Intensive Behavioral/Psychoeducational Treatments in Autism and the community. Examples of behavioral interventions that utilize naturalistic interventions include the Walden Program at Emory University which utilizes Incidental Teaching in integrated (children with autism and typical peers) classrooms for toddlers and preschoolers (McGee, Daly, & Jacobs, 1994), the Learning Experiences, an Alternative Program (LEAP) at the University of Colorado at Denver which focuses on teaching typical peers to be treatment providers for their classmates with autism (Strain, Kohler, & Goldstein, 1996), and Division TEACCH, which although more formally structured, focuses on teaching the children with autism skills appropriate to naturalistic settings (Mesibov, Schopler & Hearsey, 1994). More extensive generalization and better maintenance of treatment effects are achieved when parents are trained to be major treatment providers (e.g., Lovaas et al., 1973; Schreibman & Koegel, 1996). Many studies describe the effectiveness of parent training programs and the enhanced treatment benefit achieved via such programs. In addition, training of siblings and peers, as noted above, has proven to be effective, especially for achieving generalization. This is not surprising since the teaching occurs in the very environments in which we wish to see generalized responding and given the involvement of natural teaching agents such as parents, siblings, and peers. There is a great deal of heterogeneity in outcome. Anyone who does clinical research with this population reports that some children improve a great deal, some show moderate improvement, and yet others fail to improve. What this tells us is that there is no onesize-fits-all treatment for children with autism. Different children may benefit from different approaches.

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WHAT IS NOT KNOWN While treatment effectiveness has progressed greatly, there is still much we do not know. Treatment programs that are research based allow us to identify crucial remaining issues that will inform future research. How do we develop individualized treatment protocols for children with autism? The heterogeneity in treatment outcome is well known and is doubtlessly related to the heterogeneity of the population involved. Thus, questions regarding the relative effectiveness of one treatment compared to another may be the wrong questions to ask at this time. The right questions are likely those that allow us to determine a priori which treatment or treatment components will be most beneficial for individuals. The development of individualized

treatments should allow us to maximize treatment gains for all children with autism. Although we now appreciate the importance of developing individualized treatments, we do not as yet have a knowledge of how best to tailor interventions to the needs of specific children (cf. Dawson & Osterling, 1996; Rogers, 1998). The variability in treatment effects clearly indicates the influence of multiple variables that affect outcome. To reduce this variability, we need to better understand how these important variables interact. What are the important child variables that determine the effectiveness of specific treatment procedures? This is perhaps the most obvious source of outcome variability. Chronological age, degree of cognitive impairment, language level, and the specific behavioral profile manifested by a child are likely to influence treatment effectiveness. Also, the assessment of important precursors and correlates of language and social engagement (e.g., qualitative level of play ability, joint attention) are likely to prove useful in treatment designs. What important family variables need to be considered? Factors such as parental stress, parental depression, marital adjustment, and perceived community support are examples of potentially significant variables. For example, a parent who is very depressed or highly stressed may be less able to provide intensive treatment to the child. In this case, parent training is not likely to be a preferred option as a method of treatment delivery. What is the influence of ethnicity and cultural factors? To illustrate, families from cultures that do not place a high value on child independence at an early age might be less likely to embrace self-management as a specific treatment intervention for their child, whereas families from cultures placing a high value on child independence may readily utilize such procedures. Which important treatment variables need to be considered? It is probably the case that treatment procedures are more likely to be implemented if they are easily learned, pleasant to use, perceived to be effective, and can be readily incorporated into the daily routine of the family. The reality is that even though a particular form of intervention may be proven to be superior to another, if it falls the above criteria, it may not be used. How do specific target behaviors relate to treatment outcome? Which target behaviors respond more readily to particular forms of intervention? How well we understand specic behaviors relates directly to how well we can treat them. Some behaviors, such as self-injury

376 and language, have been the focus of research for many years, and thus we are better able to effectively treat these behaviors (although we certainly have a way to go in terms of improving our effectiveness). Other behaviors have proven to be more difficult either because we do not yet have a good understanding of the behavior (e.g., social relating) or because we have little control over their maintaining variables (e.g., self-stimulation). How do the variables listed above interact with each other to determine treatment outcome? Obviously we are not dealing with simple relations here. The interactions of these various factors are surely complex, yet very important in determining individualized treatment programs. What key prognostic indicators suggest eventual treatment outcomes? How do the various variables listed above allow us to suggest eventual treatment outcome and ultimate functioning of the individual with autism? How can this knowledge inform future long-term planning for families, schools, and the community? What information is helpful for making treatment decisions about older individuals with autism? While early intervention is certainly preferable, older individuals with autism require appropriate treatment. The variables listed above remain important but it is likely that some of the relationships will change for these older individuals. WHAT WE NEED It is apparent that future research directives should address the important relationships needed for the development of individualized prescriptive treatments for children with autism. This work is complex and difficult and requires the sustained efforts of many laboratories for some time to come. Treatment research must employ strict empirical designs that allow for sound inferences regarding the parameters of treatment effectiveness. There are several features we should look for in such research. 1. The inclusion of appropriate control groups and/or conditions is essential in determining the effectiveness of a given treatment or treatment component. Too many studies to date have involved an experimental (treatment) group and a no-treatment (or reduced level of treatment) control group. Essentially this allows us to determine only if a treatment is better than no (or less) treatment but it allows us to determine little else. Specifically, we do not know if any treatment would have led to superior improvement. What we need are comparative studies allowing for determination of

Schreibman differential effects of specific treatments or treatment components. 2. It is crucial that studies utilize well-chosen and well-specified populations. This is essential if we are to better determine which specific subpopulations within the autistic spectrum are to benefit from a specific form of treatment. Such specification would also allow us to draw comparisons across different studies. This means investigators must carefully delineate the treatment population involved by clearly and precisely describing the participants being studied. This is particularly important (and perhaps more difficult) when dealing with a disorder such as autism where there is such wide variability in the manifestation of the disorder. For example, are the investigators including individuals with Autistic Disorder but excluding individuals with Pervasive Developmental Disorder Not Otherwise Specified or individuals with Asperger Disorder? It is the sad state of affairs that too many of the treatment studies reported in the literature involve poorly chosen and/or poorly specified samples such that other researchers are hindered in their attempts to replicate these earlier findings. 3. Relatedly, treatment research should include appropriate and comprehensive diagnostic assessment of study populations. State of the art assessments such as the Autism Diagnostic InterviewRevised (Lord, Rutter, & LeCouteur, 1994) and the Autism Diagnostic Observation Schedule-Generic (Lord et al., 2000) are wellvalidated instruments that are now widely used and accepted. It would be very helpful if treatment studies utilized such validated diagnostic assessments allowing for some diagnostic standardization across investigations. 4. Investigators must utilize appropriate randomized assignment or matching of research participants. Such controls are essential to the design of a sound empirical study, as they avoid systematic bias that may confound treatment results. Again, the existing treatment literature includes many studies where such randomized assignment or appropriate matching was not used. 5. Sound empirical work in this area requires that the integrity of the independent variable be demonstrated. This means that investigators must include assessment of the accuracy of implementation of their treatment. Here we ask if the treatment procedures described in the study were actually employed as intended. For various reasons, it is possible that the actual implementation of treatment deviates from the experimental protocol and if this is the case, we are unable to determine the effects of the intended treatment.

Intensive Behavioral/Psychoeducational Treatments in Autism 6. For maximum benefit, treatment research should employ appropriate and comprehensive assessment batteries that allow us to evaluate treatment effects in detail. Outcomes measured in limited areas (e.g., improvements in IQ only) may give us little information regarding the totality of the treatment impact. What is needed is a battery of assessments, both specific and more global, that gives us a comprehensive yet detailed picture of treatment effects. Such batteries can help inform and direct future research by demonstrating the parameters of treatment effectiveness such as specific areas where the treatment is, and is not, effective. In addition, some standardization or at least assessment consistency would allow for comparisons across studies. Since the generality and maintenance of treatment effects remain important features of effective treatment, we need more research focusing specifically on interventions that enhance these aspects of treatment outcome. This requires not only the identification of treatment components that lead to effective and efficient generalized effects, but also the inclusion of appropriate assessments to evaluate the parameters of generalization (see above). We need systematic research on how the rapidly emerging information on neurological and genetic factors in autism can be incorporated into behavioral treatments. Since such organic factors will undoubtedly prove to be important child variables, this should prove to be an extremely fruitful area of research. The interaction between biological variables and treatment may in fact be bidirectional, especially very early on in development. Thus while biology may influence treatment effectiveness, it may also be the fact that early intensive treatment may alter the biology of the child in important ways (cf. Courchesne, Yeung-Courchesne, & Pierce, 1999). This presents a particularly exciting and provocative speculation. We need to achieve more effective dissemination of our treatment findings. The field of autism treatment has been characterized by the appearance of a wide range of bogus and marginal treatments (Facilitated Communication is a prime example of a treatment that enjoyed initial widespread popularity until it was demonstrated to be bogus.) This is in spite of the development of effective treatment strategies. Much of this problem may be attributed to the failure of the research community to effectively disseminate findings to the main consumers of these ndingsparents, teachers, and other treatment providers. It is painfully obvious that more effective dissemination of treatment research ndings is needed to protect the families from worthless

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and expensive treatments and to prevent children from wasting time in ineffective programs. We need to be more efficient at responding to input from these consumers. Difficulties in communication occur in both directions. We not only need to be better at disseminating research results to parents and other direct consumers, effective communication from parents and other consumers to the research community needs to be maximized. We need research focusing on ways to coordinate treatment services for children with autism. We recognize that treatment requires the involvement of the childs total environment. How best can we integrate treatment between the childs home, the school, and the many other services frequently included in the childs overall treatment plan? Just planning for a variety of comprehensive services is not enough. We need to actively pursue the study of effective and efcient treatment coordination. Finally, and extremely important, we must insist on independent replication of treatment research findings. Replication is the essence of believability in research. Replication of research findings helps ensure that we stay on the right track and are not led into blind alleys suggested by single study results. CONCLUSION As can be concluded from the above discussion, there is a good deal to be done in treatment research. Yet the progress we have made to date has been substantial and gives us good reason to be optimistic for the future. Careful, well-conceived, well-controlled intervention studies will undoubtedly lead to improved programs for children with autism and their families. It is only through directed research by investigators in many different laboratories that the challenge presented by these children can be adequately addressed. These children deserve the effective and efficient treatment programs such research will surely provide. ACKNOWLEDGMENT Preparation of this paper was facilitated by U.S. Public Health Service Research Grant MH39434 from the National Institute of Mental Health. REFERENCES
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