The National Standards Project– Phase 2

The National Standards Project– Phase 2
Diana Askings McCarty, B.S. University of Utah School Psychology Program February 24, 2016 Superheroes social skills training, Rethink Autism internet intervention, parent training, evidence-based practices classroom training, functional behavior assessment: An autism spectrum disorder, evidence-based practices training track for school psychologists US Office of Education Personnel Preparation Grant H325K12306 William Jenson, Ph.D., Elaine Clark, Ph.D., Julia Hood Ph.D., & John Davis, Ph.D.

Overview Introduction Methodology Results
National Autism Center & National Standards Project Evidence-Based Practice Methodology Scientific Merit Rating Scale Intervention Effects Rating Scale Strength of Evidence Classification System Subclassification System Results NSP-Phase 1 NSP-Phase 2 Other Systematic Reviews—NPDC The National Professional Development Center on Autism Spectrum Disorder (NPDC)

Introduction Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social interactions/communication and by restricted, repetitive patterns of behavior ASD occurs in approximately 1 in every 68 births (CDC, 2014) Societal costs for each individual with ASD across the lifespan is estimated at $3.2 million (Ganz, 2007) Intervention selection is complicated A large number of interventions are available Different levels of intervention support The research is often confusing to parents, educators, and service providers Confusing and conflicting-With more research being done, we get a better picture of what works…but that means there are many changes Various degrees of quantity, quality, and consistency of research studies (National Standards Project-Phase 2, 2015)

The National Autism Center
May Institute’s Center for the Promotion of Evidence-based Practice “…a nonprofit organization dedicated to disseminating evidence-based information about the treatment of autism spectrum disorder (ASD), promoting best practices, and offering comprehensive and reliable resources for families, practitioners, and communities.” Training Public Policy Research May Institute: founded 60 years ago in Randolph, Mass. With 160 locations in >12 states Nonprofit org. that provides educational, rehabilitative, and behavioral services to individuals with ASD and other developmental disabilities, brain injury, mental illness, & other behavioral health needs. Also training, research, consultation, and resources (National Standards Project-Phase 2, 2015;

What is the National Standards Project?
The National Standards Project (NSP) is a comprehensive analysis of the interventions available for individuals with ASD Strength of evidence supporting interventions Age, diagnosis, and skills/behaviors targeted Limitations of research Evidence-based practice recommendations If you use effective intervention, the lifetime cost can be reduced by 65% (Jarbrink & Knapp, 2001) The NSP was a primary initiative of the NAC to address the need for evidence based practice guidelines for ASD provide the strength of evidence supporting educational and behavioral interventions that target the core characteristics of these neurological disorders describe the age, diagnosis, and skills/behaviors targeted for improvement associated with intervention options identify the limitations of the current body of research on autism interventions offer recommendations for engaging in evidence-based practice for ASD $3.2 million To inform intervention decisions (both educational and behavioral) Specifically to target the core characteristics of ASD (National Standards Project-Phase 2, 2015)

Evidence-Based Practice (EBP)
“…the integration of the best research evidence, professional judgment, and values and preferences of clients.” (Sackett et al., 2000) EBP has become the standard in the fields of medicine, psychology, education, allied health, and ASD Key Elements of EBP Professional Judgment Values and Preferences Capacity Research Findings Professional Judgment: make data-based decisions; use individualized treatments (e.g., comorbidity & various presentations); new research Values and Preferences: of parents, care providers, and the individual with ASD Capacity: you need to be able to implement it correctly; training; ability; resources; feedback at all levels Research Findings: consider established treatments with strong evidence to support it (NSP) (National Standards Project-Phase 2, 2015)

Scientific Merit Rating Scale (SMRS)
Developed to objectively evaluate the strength of each study’s methodology Research Design Experimental control; number of participants/groups; attrition; type of research design Measurement of the DV Accurate and reliable data that represent the most direct/comprehensive target sample Measurement of the IV Intervention fidelity; implementation accuracy; percentage/type of sessions for data collection Participant Ascertainment Well-established diagnostic tools/procedures were used to determine participant inclusion; use of the DSM or ICD Generalization & Maintenance Effects Objectively demonstrating intervention effects across time, settings, stimuli, responses, or persons Ratings from 0 (poor)  5 (strong) How strong is the research design? Independent scholars can draw firm conclusions due to well-controlled variables 5 dimensions of experimental rigor Research Design: demonstrated experimental control w/# of participants/groups, attrition or intervention disruption, and type of research design Used to just be generalization Measurement of the DV: accurate and reliable data, most direct and comprehensive sample of the target skill/behavior, psychometric properties/reliability of DV, blind evaluators Measurement of IV: degree of intervention fidelity which was reliably measured, implementation accuracy, the % and type of sessions during which data were collected Participation ascertainment: well-established diagnostic tools/procedures were used to determine eligibility for participant inclusion and the extent diagnosticians/evaluators were independent/blind to intervention conditions; use of the DSM or ICD (International Classification of Diseases) Generalization: degree of objectively demonstrating the spread of intervention effects across time, settings, stimuli, responses , or persons (National Standards Project-Phase 2, 2015)

Differences: Used to be > for group and single subject (NOT ATD) Measurement of IV used to be >=80% (National Standards Project-Phase 2, 2015)

(National Standards Project-Phase 2, 2015)

SMRS Scores Composite score Score of 3, 4, or 5 Score of 2
Research Design (.30) + Dependent Variable (.25) + Participant Ascertainment (.20) + Procedural Integrity (.15) + Generalization (.10) Score of 3, 4, or 5 Sufficient scientific rigor Score of 2 Initial evidence about intervention effects, but more rigorous research is needed Score of 0 or 1 Insufficient scientific rigor/evidence to suggest whether the intervention was or was not beneficial, ineffective, or harmful Rounded to nearest whole number Same for both phases (National Standards Project-Phase 2, 2015)

Intervention Effects Rating Scale
Beneficial Sufficient evidence to support favorable outcomes resulted from the intervention Ineffective Sufficient evidence to support favorable outcomes did not result from the intervention Unknown Not enough information to confidently determine the intervention effects Adverse (NSP-1) Sufficient evidence that the intervention was associated with harmful effects How effective was the intervention? Separate criteria for group, single-subject and alternating intervention designs Group: statistically significant differences Single subject: whether or not a functional relationship was established AID: extent to which separation was reported, carryover effects were minimized, and the number of data points were sufficient NSP-2 did not identify adverse intervention effects either, so it was not included in the report (National Standards Project-Phase 2, 2015)

Group: statistically significant results reported
Single-case: functional relationship established Alternating Treatments Design (National Standards Project-Phase 2, 2015)

Strength of Evidence Classification System
Unestablished Little/no evidence to draw firm conclusions about intervention effectiveness Emerging Additional high quality studies must consistently show favorable outcomes to draw firm conclusions Established Sufficient evidence to determine that an intervention produces favorable outcomes How confident we should be about the effectiveness of the intervention (quality/quantity/consistency) (National Standards Project-Phase 2, 2015)

Strength of Evidence Classification System
SEVERAL: used to be no more than 1 conflicting report FEW: used to be 1 group study and no conflicting reports (National Standards Project-Phase 2, 2015)

Intervention Subclassification
Phase 1 was broken down into Treatment Targets, Age Groups, and Diagnostic Groups Intervention Targets (14 targets in 2 categories) Skills Increased Academic, Communication, Higher Cognitive Functions, Interpersonal, Learning Readiness, Motor Skills, Personal Responsibility, Placement, Play, Self-Regulation Behaviors Decreased General Symptoms, Problem Behaviors, Restricted/Repetitive/Nonfunctional Patterns of Behaviors/Interests/Activity (RRN), Sensory or Emotional Regulation (SER) Age Groups 0-21 years 22+ years To be more confident and specific about intervention outcomes and to identify where the literature could be extended Used to be further broken down by 6 Age Groups and 3 Diagnostic Groups Higher cognitive functions: complex problem-solving skills outside social domain (e.g., executive functioning & IQ) Interpersonal: social interaction (social play fits here) Learning Readiness: precursor skills to academic success (e.g., imitation, following instructions, attending, sitting) Personal Responsibility: everyday routine tasks; daily living skills Placement: not really a skill, but an accomplishment (e.g., placement from SPED to Gen. Ed.) Self-Regulation: managing your own behavior to meet a goal (e.g., self/time-management) General Symptoms: combo of symptoms associated directly w/ASD Problem behaviors: SIB, harm/damage to others/objects, interfere with routines RRN: Limited, frequently repeated, maladaptive, patterns of motor, speech, and thoughts SER: flexibly modify their level of arousal/response to function effectively in the environment (e.g., anxiety, depression, sleep problems) (National Standards Project-Phase 2, 2015)

Subclassification Process
Identify all studies associated with a given intervention Identify relevant variables in each of the studies Identify the SMRS Score and the Intervention Effects Ratings for each relevant variable Identify the quality, quantity, and consistency of research findings for relevant variables Determine if there is evidence suggesting favorable outcomes for relevant variables Relevant variables were target and age Favorable outcomes: few studies with SMRS scores of 2, 3, 4 or 5 showing beneficial intervention effects Strength of Evidence (National Standards Project-Phase 2, 2015)

Phase 1 Released in 2009 7,038 abstracts initially identified
Research published between 1957 to 2007 7,038 abstracts initially identified 775 studies after inclusion/exclusion criteria were applied Unrelated to ASD Unrelated to the treatment of ASD Not empirical articles 38 treatment categories identified by an expert panel Reliability IOA .92 Project started in 2005 Before September 2007 The term “treatment” may represent either intervention strategies (i.e., therapeutic techniques that may be used in isolation) or intervention classes (i.e., a combination of different intervention strategies that hold core characteristics in common) The NSP2 expert panelists agreed to adapt the term “intervention” as opposed to “treatment” or “strategy.” Members of the expert panel urged the change in the hopes of providing clarification to readers. The term “treatment” is often used in medical literature and can be inferred as resulting in a “cure.” Intervention is a term widely used in the behavioral and educational literature to indicate that something is adjusted in the environment to alter an individual’s behavior. Interventions can consist of an isolated component or a “package” Hard to classify when there are different names for the same thing and packages with various components There were combined by the NSP chair and expert panel to minimize overlap between categories Started with 71  41 38 (National Standards Report, 2009)

Inclusionary & Exclusionary Criteria
Published in peer-reviewed journals Diagnosed with ASD Autistic Disorder, Asperger’s Syndrome, and Pervasive Developmental Disorder-NOS The treatments could be implemented in school systems, early intervention, home, hospital, and/or community-based programs Exclusionary Rhett’s Disorder, Childhood Disintegrative Disorder, “At Risk” for ASD, & uncommon co-morbid conditions Only educational and behavioral treatments that target the core characteristics of ASD Non-empirical research Primary purpose to identify mediating or moderating variables Over the age of 22 Non-English publications Common-comorbid: (MR, language impairments, depression, anxiety, OCD, or ADHD) Included studies that had separate analyses (comorbid and age) Peer Review: researchers submit their work for scrutiny by experts in their fields of study. The scientific methods used in the article must meet a minimum criterion for scientific usefulness and articles are sometimes published when the scientific methods are not especially good but the results are thought-provoking enough that it might inspire researchers to conduct better research in the area. Curative diets were still included Criteria for ASD used by the Centers for Disease Control and Prevention, the developmental trajectory is often different for these groups, and there is controversy in the field about whether or not these should be considered in the same category (National Standards Report, 2009)

Results- “Established”
11 treatments had sufficient evidence to confidently determine that the treatment produces beneficial effects Antecedent Package (99) Behavioral Package (231) Comprehensive Behavioral Treatment for Young Children (22) Joint Attention Intervention (6) Modeling (50) Naturalistic Teaching Strategies (32) Peer Training Package (33) Pivotal Response Treatment (14) Schedules (12) Self-management (21) Story-based Intervention Package (21) Studies (__) “treatments from the behavioral literature have the strongest research support at this time” Antecedent Package: behavioral momentum, choice, prompting, environmental modification Behavioral Package: differential reinforcement, DTT, reinforcement, shaping, token economies Comprehensive Behavioral Treatment for Young Children: comprehensive treatment programs that have a combo of ABA procedures for young children (i.e., ABA programs or behavioral inclusive program/early intensive behavioral intervention) Joint Attention Intervention: pointing, showing, following eye gaze Modeling: adult or peer demo of a simple to complex target behavior (live and video modeling) Naturalistic Teaching Strategies: child-directed interactions in the natural environment (incidental teaching, embedded teaching, etc.) Peer Training Package: teaching children w/out disabilities (e.g., siblings/classmates) how to play and interact w/ children with ASD Pivotal Response Treatment: targeting pivotal behavioral areas (motivation, self-management, respond to multiple cues) for collateral improvements (typically taught by parents) Schedules: task list of steps/activities using words, pictures, photos, or work stations Self-management: promoting independence by teaching behavioral regulation using reinforcers (checklists, wrist counters, visual prompts, tokens) Story-based Intervention Package: written description of the situation a specific behavior is to occur (Social Stories) using the 5 Ws (National Standards Report, 2009)

Results- “Emerging” 22 treatments had 1+ studies to suggest beneficial intervention effects, but additional high quality studies are needed to draw firm conclusions Augmentative and Alternative Communication Device (14) Multi-component Package (10) Music Therapy (6) Cognitive Behavioral Intervention Package (3) Peer-mediated Instructional Arrangement (11) Developmental Relationship-based Treatment (7) Picture Exchange Communication System (13) Reductive Package (33) Exercise (4) Scripting (6) Exposure Package (4) Sign Instruction (11) Imitation-based Interaction (6) Social Communication Intervention (5) Initiation Training (7) Social Skills Package (16) Language Training—Production (13) Structured Teaching (4) Language Training—Production & Understanding (7) Technology-based Treatment (19) Massage/Touch Therapy (2) Theory of Mind Training (4) Augmentative and Alternative Communication Device: high or low tech devices to facilitate communication (pics, symbols, computers, communication books) Cognitive Behavioral Intervention Package: changing everyday negative/unrealistic thought patterns/behaviors Developmental Relationship-based Treatment: combo of developmental procedures to build social relationships (Denver model ESDM, DIR Floortime, relationship development intervention) Exercise: increase physical exertion, decrease behavior problems and increase appropriate behavior Exposure Package: face anxiety-provoking situations and decrease maladaptive strategies used in the past Imitation-based Interaction: adults imitating the actions of the child Initiation Training: directly teaching the child w/ASD to initiate peer interaction Language Training—Production: to increase speech production (e.g., oral communication training and echo relevant word training) Language Training—Production & Understanding: increase speech production and understanding (e.g., total communication training & language programming strategies) Massage/Touch Therapy: deep tissue stimulation Multi-component Package: catchall; combo of multiple treatments from different fields that do not fit into the other treatment “packages” Music Therapy: teach skills or goals through music and the music is eventually faded Peer-mediated Instructional Arrangement: involving same-aged peers in the learning process to teach academic skills (i.e., peer tutoring) Picture Exchange Communication System: specific augmentative/alternative communication system taught using behavioral principles Reductive Package: to reduce problem behaviors but NOT increase alternative appropriate behaviors (e.g., water misting, behavior chain interrupting, protective equipment, ammonia) Scripting: using a verbal/written script about a specific skill/situation as a model Sign Instruction: direct teaching of sign language Social Communication Intervention: psychosocial intervention to target a combo of social/communication impairments like reading a social situation (i.e., social pragmatic interventions) Social Skills Package: build social skills by targeting basic (eye contact, answer to name) to complex (maintain/initiate conversation) social skills Structured Teaching: combo of procedures to modify the environment, materials, and presentation of info to make learning easier and individualized (TEACCH) Technology-based Treatment: present instructional material using computers and other tech. devices Theory of Mind Training: to recognize and identify mental states in oneself or others; take other perspective to predict their actions (National Standards Report, 2009)

Results- “Unestablished” &“Ineffective/Harmful”
5 treatments had little to no evidence to draw firm conclusions about treatment effectiveness Academic Interventions (10) Auditory Integration Training (3) Facilitated Communication (5) Gluten- and Casein-Free Diet (2) Sensory Integrative Package (7) 0 identified studies indicated sufficient evidence that a treatment is ineffective or harmful Ethical reasons Not published Academic Interventions: traditional teaching methods to improve academic performance (e.g., SPED, paired associate, handwriting training) Auditory Integration Training: modulated sounds through headphones to retrain an individual’s auditory system and improve distortions in hearing or sensitivities to sound Facilitated Communication: facilitator physically assist an individual to communicate using a keyboard/pictures/typing device Gluten- and Casein-Free Diet: eliminate the intake of the naturally occurring proteins gluten and casein Sensory Integrative Package: establishing an environment that stimulates/challenges the individual to use all of their senses due to over/understimulation Perhaps due to ethical reasons—stop once negative effects are found Not published (National Standards Report, 2009)

Limitations & Discussion
Since Phase 1, the DSM criteria for ASD has changed Did not include individuals with ASD 22+ years old “At risk” or comorbid not included Treatment categories Only quantitative studies All articles were in English Did not evaluate “real world” vs. laboratory settings Treatment intensity not evaluated Literature review ended in September 2007 (National Standards Report, 2009)

Phase 2 Released April 2, 2015 To provide updated information on intervention effectiveness Reviewed studies between 2007 and February 2012 Included studies with adults 22+ years old Reviewed studies since 1987 27 articles identified Category Revision “Established” interventions are presented in more detail World Autism Awareness Day Technically all established interventions could be labeled a behavioral intervention, but the category “behavioral interventions” is when a combination of strategies/elements are used (National Standards Project-Phase 2, 2015)

Phase 2—Goals Primary goals
Identify peer-reviewed intervention outcome studies for individuals with ASD since the publication of NSP-1 Review interventions for individuals across the lifespan Incorporate feedback received regarding NSP-1 categorization To help parents, caregivers, educators and service providers understand how to integrate evidence-based interventions into a well-rounded, individualized educational/behavioral program 4 goals (National Standards Project-Phase 2, 2015)

Process of the NSP-Phase 2
(National Standards Project-Phase 2, 2015)

Expert Panel Hanna C. Rue, Ph.D., BCBA-D (Chair)
Grace Baranek, Ph.D., OTR/L Jane I. Carlson, Ph.D., BCBA-D Alice Carter Ph.D. Marjorie H. Charlop, Ph.D., BCBA Ronnie Detrich, Ph.D. Melanie DuBard, Ph.D., BCBA-D Glen Dunlap, Ph.D. Peter Gerhardt, Ed.D. Lynne Gregory, Ph.D. Robert H. Horner, Ph.D. Kara Anne Hume, Ph.D. James K. Luiselli, Ed.D., ABPP, BCBA-D Daniel Martin, Ph.D., BCBA Gail McGee, Ph.D. Samuel L. Odom, Ph.D. Cathy L. Pratt, Ph.D. Patricia A. Prelock, Ph.D., CCC-SLP Robert F. Putnam, Ph.D., BCBA-D Sally J. Rogers, Ph.D. Carol M. Schall, Ph.D. Ilene S. Schwartz, Ph.D., BCBA-D Mark D. Shriver, Ph.D. Tristram H. Smith, Ph.D. Brenda Smith Myles, Ph.D. Aubyn C. Stahmer, Ph.D., BCBA-D Pamela J. Wolfberg, Ph.D. John G. Youngbauer, Ph.D. Composed of 27 nationally recognized scholars, researchers, and other leaders representing diverse fields of study that have demonstrated expertise in the field of ASD through research/clinical practice Selection of professionals is vague Add other contributors? NSP2 page 10 Feedback from parents and professionals (National Standards Project-Phase 2, 2015)

(National Standards Project-Phase 2, 2015)

Inclusionary & Exclusionary Criteria
Published in peer-reviewed journals Diagnosed with ASD Autistic Disorder, Asperger’s Syndrome, and Pervasive Developmental Disorder-NOS The interventions could be implemented in school systems, early intervention, home, hospital, vocational and/or community-based programs or clinic settings Exclusionary “autistic characteristics” or “suspicion of ASD”, & uncommon co-morbid conditions (except for individuals 22+) Only educational and behavioral treatments that target the core characteristics of ASD Non-empirical research Primary purpose to identify mediating or moderating variables Non-English publications Since Phase 1, the DSM criteria for ASD has changed…but they only included articles until 2012 prior to the publication of the DSM-5 Autistic characteristics or suspicion of ASD is the similar to “at risk” Curative diets were still included Common-comorbid: (ID, language impairments, depression, anxiety, OCD, or ADHD) Included studies that had separate analyses (comorbid) (National Standards Project-Phase 2, 2015)

Presentation Established Intervention: briefly describes the intervention and it’s previous level of evidence if applicable Basic Facts: # of articles in NSP-1 and NSP-2; age range, skills increased; behaviors decreased Detailed Description: more details; how to implement; various types Example: Examples of implementation Recommended Readings: articles that they suggest for further information Online Resources: For further training (National Standards Project-Phase 2, 2015)

Results- “Established” Under 22 years old
(National Standards Project-Phase 2, 2015) Results- “Established” Under 22 years old 14 interventions had sufficient evidence to confidently determine that the intervention produces beneficial effects (**: NSP-1 “emerging”; underlined: Different from NSP-1) Behavioral Interventions (NSP-1=298 NSP-2=155) Peer Training Package (NSP-1=43 NSP-2=3) Cognitive Behavioral Intervention Package ** (NSP-1=3 NSP-2=10) Pivotal Response Treatment ® (NSP-1=11 NSP-2=6) Comprehensive Behavioral Treatment for Young Children (NSP-1=21 NSP-2=20) Schedules (NSP-1=11 NSP-2=2) Language Training—Production ** (NSP-1=10 NSP-2=2) Scripting ** (NSP-1=6 NSP-2=5) Modeling (NSP-1=51 NSP-2=28) Self-management (NSP-1=21 NSP-2=10) Natural Teaching Strategies (NSP-1=27 NSP-2=3) Social Skills Package ** (NSP-1=14 NSP-2=21) Parent Training (NSP-1=37* NSP-2=11) Story-based Intervention (NSP-1=21 NSP-2=15) ARTICLES not STUDIES reviewed Used to be 11…gained 5, combined 1, lost 1 Behavioral Interventions: A combo of Antecedent Package, Behavioral Package, and Joint Attention Intervention? (established in NSP-1); interventions that modify the antecedents or consequences of a behavior using basic principles of behavior change; Technically all established interventions could be labeled a behavioral intervention, but the category “behavioral interventions” is when a combination of strategies/elements are used Cognitive Behavioral Intervention Package: moved from emerging….had 3 studies before. Cognitive restructuring of everyday negative/unrealistic thought patterns/behaviors Comprehensive Behavioral Treatment for Young Children: comprehensive treatment programs that have a combo of ABA procedures for young children (i.e., ABA programs or behavioral inclusive program/early intensive behavioral intervention EIBI) Language Training—Production: moved from emerging…had 13 studies before. To increase speech production (e.g., oral communication training and echo relevant word training) Modeling: adult or peer demo of a simple to complex target behavior (live and video modeling) Natural Teaching Strategies: child-directed interactions in the natural environment (incidental teaching, embedded teaching, etc.); increases interpersonal/play, learning readiness, and communication skills 0-9 Parent Training: NEW to NSP…changed to highlight role of caregivers in providing a therapeutic environment; many of the 37 indicated as NSP-1 were in the Behavioral Package category Peer Training Package: teaching children w/out disabilities (e.g., siblings/classmates) how to play and interact w/ children with ASD to acquire new behavior, communication, and social skills within the natural environment (inclusion); Project LEAP & circle of friends; increase learning readiness, communication and interpersonal skills, decreases RRBs 3-14 Pivotal Response Treatment: targeting pivotal behavioral areas (motivation, self-management, respond to multiple cues) for collateral improvements (typically taught by parents in natural environments) Schedules: task list of steps/activities using words, pictures, photos, or work stations to help with transitions and increase independence Scripting: Using a verbal/written script about a specific skill/situation as a model Self-management: promoting independence by teaching behavioral regulation using reinforcers (checklists, wrist counters, visual prompts, tokens) Social Skills Package: Build social skills by targeting basic (eye contact, answer to name) to complex (maintain/initiate conversation) social skills Story-based Intervention Package: written description of the situation a specific behavior is to occur (Social Stories) using the 5 Ws; Pixton $8.99/month; increases communication/learning readiness, interpersonal and self-regulation, decreases problem behaviors; 3-14

Results- “Emerging” Under 22 years old
18 interventions had 1+ studies to suggest beneficial intervention effects, but additional high quality studies are needed to draw firm conclusions Augmentative and Alternative Communication Devices Massage Therapy Multi-component Package Developmental Relationship-based Treatment Music Therapy Picture Exchange Communication System Exercise Exposure Package Reductive Package Functional Communication Training Sign Instruction Imitation-based Interaction Social Communication Intervention Initiation Training Structured Teaching Language Training—Production & Understanding Technology-based Intervention Theory of Mind Training Used to be 22…4 moved to established; 1 added; 1 removed Augmentative and Alternative Communication Device: high or low tech devices to facilitate communication (pics, symbols, computers, communication books) Developmental Relationship-based Treatment: combo of developmental procedures to build social relationships (Denver model ESDM, relationship development intervention) Exercise: increase physical exertion, decrease behavior problems and increase appropriate behavior Exposure Package: face anxiety-provoking situations and decrease maladaptive strategies used in the past Functional Communication Training: Used to be a part of the behavioral package? Differential reinforcement for alternative responses Imitation-based Interaction: adults imitating the actions of the child Initiation Training: directly teaching the child w/ASD to initiate peer interaction Language Training—Production & Understanding: increase speech production and understanding (e.g., total communication training & language programming strategies) Massage Therapy: deep tissue stimulation Multi-component Package: catchall; combo of multiple treatments from different fields that do not fit into the other treatment “packages” Music Therapy: teach skills or goals through music and the music is eventually faded Peer-mediated Instructional Arrangement was removed…? Picture Exchange Communication System: specific augmentative/alternative communication system taught using behavioral principles Reductive Package: to reduce problem behaviors but NOT increase alternative appropriate behaviors (e.g., water misting, behavior chain interrupting, protective equipment, ammonia) Sign Instruction: direct teaching of sign language Social Communication Intervention: psychosocial intervention to target a combo of social/communication impairments like reading a social situation (i.e., social pragmatic interventions) Structured Teaching: combo of procedures to modify the environment, materials, and presentation of info to make learning easier and individualized (TEACCH) Technology-based Intervention: present instructional material using computers and other tech. devices Theory of Mind Training: to recognize and identify mental states in oneself or others; take other perspective to predict their actions (National Standards Project-Phase 2, 2015)

Results- “Unestablished” Under 22 years old
13 interventions had little to no evidence to draw firm conclusions about intervention effectiveness Animal-assisted Therapy SENSE Theatre Intervention Auditory Integration Training Sensory Intervention Package Concept Mapping Shock Therapy DIR/Floor Time ** Social Behavioral Learning Strategy Facilitated Communication Social Cognition Intervention Gluten-free/Casein-free Diet Social Thinking Intervention Movement-based Intervention Used to be 5…gained 9; 1 removed (academic interventions?) DIR/Floor time used to be under Developmental Relationship-based treatment for NSP-1 which is “emerging” Animal-assisted therapy: dog, horse, dolphin, fish, hamsters Auditory Integration Training: modulated sounds through headphones to retrain an individual’s auditory system and improve distortions in hearing or sensitivities to sound Concept mapping: graphical representation of concepts DIR/floortime: playing on the floor Facilitated Communication: facilitator physically assist an individual to communicate using a keyboard/pictures/typing device Gluten- and Casein-Free Diet: eliminate the intake of the naturally occurring proteins gluten and casein Movement-based intervention: dancing SENSE: using acting with peers to teach social skills Sensory Integrative Package: establishing an environment that stimulates/challenges the individual to use all of their senses due to over/understimulation Social behavioral learning strategy: social skills intervention…one study Social cognition intervention: social skills intervention…no information Social thinking intervention: a social skills website…no information (National Standards Project-Phase 2, 2015)

Results- 22+ years old Earliest study published in 1987
1 “established” intervention Behavioral Interventions (17) 1 “emerging” intervention Vocational Training Package 4 “unestablished” interventions Cognitive Behavioral Intervention Package Modeling Music Therapy Sensory Integration Package More research is needed Vocational Training Package: Cognitive Behavioral Intervention Package and Modeling are “established” interventions for children under 22 years old Music Therapy is “emerging” for children under 22 years old Sensory Integration Package is “unestablished” for children under 22 years old (National Standards Project-Phase 2, 2015)

Intervention Selection
A team of individuals should consider the unique needs of the individual as well as the environment that they live in (e.g., family situation, community, cultural and ethnic background) Consider implementing “established” interventions Do not begin with “emerging” interventions but consider them if an “established” intervention is inappropriate or unsuccessful at producing positive outcomes. Only consider “unestablished” interventions if additional research produces supportive results It is complicated! So many factors are involved… DO NOT assume that interventions will universally produce favorable outcomes (National Standards Project-Phase 2, 2015)

Limitations & Future Directions
Only published, peer-reviewed research through January 2012 Lack of information on race/ethnicity, gender, or SES Intervention categories Remember–even “established” interventions will not be effective for all individuals with ASD More research is needed to identify variables that predict who will likely respond to intervention Interventions for “high-risk siblings” Level of functioning, intervention intensity, & social validity Qualitative studies Non-English studies Impact of cultural diversity Subjective classification used (expert panel) Cost-effectiveness Social validity Studies examining mediating or moderating variables Research supporting Established Treatments may not reflect real world settings accurately (National Standards Project-Phase 2, 2015)

Other Systematic Reviews
Centers for Medicare and Medicaid Services (CMS) disorders-services-asds-final-report-environmental-scan Agency for Healthcare Research and Quality (AHRQ) tism-update pdf The National Professional Development Center on Autism Spectrum Disorder (NPDC) There are seven recent, nationally recognized systematic reviews AHRQ did not include many single-case research studies (only RCTs) 73% was single-case research in NSP-2 NSP 1 & 2 include data from studies and is the largest review of its kind for individuals with ASD One common finding: interventions based on the principles of ABA had evidence of being effective (National Standards Project-Phase 2, 2015)

Comprehensive Treatment Models vs Focused Intervention Practices
Evidence-Based Practices for Children, Youth, and Young Adults with ASD The goal of the NPDC was to promote the use of evidence-based practices (EBPs) for children and youth with ASD, birth to 22 years of age Comprehensive Treatment Models vs Focused Intervention Practices TEACCH, ESDM, UCLA Young Autism Program DTT, Pivotal Response Training, Prompting, Video Modeling 1st review released in 2010 ( ) 24 interventions identified as EBP Very similar results to NSP-1 Current review 2014 ( ) funded by the US Department of Education (Office of Special Education Programs and the Institute of Education Science) The work of the NPDC was a collaboration among three universities—the University of North Carolina at Chapel Hill, the University of Wisconsin at Madison, and the MIND Institute, University of California-Davis Autism, autistic disorder, ASD, Asperger syndrome, or PDD-NOS With co-occurring conditions: ID, Speech/Language impairment, seizure disorder, sensory impairment, and ADHD CTM: set of practices designed to achieve a broad learning or developmental impact on the core deficits of ASD FIP: address a single skill or goal of a student with ASD (operationally defined for a specific learner over a shorter amount of time) All but 6 identified by NSP-1 (5 of 6 as emerging practices) 2 not identified by NPDC (Wong et al., 2014)

Methodology National set of external reviewers (N=159) Inclusion
Individuals with ASD under 22 years old Co-morbid conditions Behavioral, developmental, or educational interventions and outcomes implemented at home, school, or the community Compared to no intervention or alternative intervention Experimental group, quasi-experimental group, or single-case design Literature search 29,106 articles (ASD/Interventions)  456 articles Articles categorized EBP determined E.g., Association for Behavior Analysis International, Council for Exceptional Children, Universities, etc. Experience/knowledge about ASD & course/training on group design or SCD research methods Online training 80% or higher accuracy on 1st article assigned (2 opportunities) More SCD or group training and established IOA (IOA on 41% of articles) IOA individual group = 84%; IOA individual single = 92%; IOA summary group = 74%; IOA summary single = 77% No medical or nutritional/special diets included (Wong et al., 2014)

Evidence-Based Practice Criteria
At least 2 high quality experimental or quasi-experimental group design articles Conducted by at least 2 different researchers or research groups At least 5 high quality single case design articles Conducted by at least 3 different researchers or research groups Having a total of at least 20 participants across studies A combination of at least 1 high quality experimental or quasi-experimental group design article and at least 3 high quality single case design articles Conducted by at least 2 different research groups 48 group design articles 408 single case design articles Most participants were between 6-11 years old, diagnosed with autism, with no co-morbid conditions

Results 27 interventions identified as evidence-based practices
(Wong et al., 2014) Results 27 interventions identified as evidence-based practices Antecedent-based Intervention (0;32) Pivotal Response Training (1;7) Cognitive Behavioral Intervention (3;1) Prompting (1;32) Differential Reinforcement of Alternative, Incompatible, or Other Behavior (0;26) Reinforcement (0;43) Response Interruption/Redirection (0;10) Discrete Trial Teaching (0;13) Scripting (1;8) Exercise ** (3;3) Self-management (0;10) Extinction (0;11) Social Narratives (0;17) Functional Behavior Assessment (0;10) Social Skills Training (7;8) Functional Communication Training ** (0;12) Structured Play Group (2;2) Modeling (1;4) Task Analysis (0;8) Naturalistic Intervention (0;10) Technology-aided Instruction and Intervention ** (9;11) Parent-implemented Intervention (8;12) Time Delay (0;12) Peer-mediated Instruction and Intervention (0;15) Video Modeling (1;31) Picture Exchange Communication System ** (2;4) Visual Supports (0;18) 14 in NSP-2 1st number =group n; 2nd number =single case n Underlined = established in NSP-2 ** = emerging

Discussion 24 interventions identified were not classified as EBP, but had some support; more research is needed Foundational applied behavior analysis techniques have the most support Idiosyncratic Behavioral Intervention Package Many similarities to NSP Developing online modules (AFIRM) for each of the 27 identified practices Currently modules are available for 24 practices previously identified Categories added from 1st review: Cognitive behavior interventions, exercise, modeling, scripting, structured play groups, technology-aided instruction Most support: prompting and reinforcement IBIs not classified as EBP BUT made up of EBPs (Wong et al., 2014)

References Centers for Disease Control and Prevention. (March 28, 2014). Morbidity and mortality weekly report. Retrieved February 16, 2016, from Ganz, M. L. (2007). The lifetime distribution of the incremental societal costs of autism. Archives of Pediatrics Adolescent Medicine, 161(4), Jarbrink, K. and Knapp, M. (2001). The economic impact of autism in Britain. Autism: the international journal of research and practice, 5(1), doi: / National Autism Center. (2009). National standards report. Retrieved January 31, 2016, from National Autism Center. (2015). Findings and conclusions: National standards project, Phase 2. Retrieved January 31, 2016, from Odom, S. L., Collet-Klingenberg, L., Rogers, S. J., & Hatton, D. D. (2010). Evidence-based practices in interventions for children and youth with autism spectrum disorders. Preventing School Failure, 54(4), Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. London, UK: BMJ Books. Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H., & McPheeters, M. (2011). Therapies for children with autism spectrum disorders. Comparative effectiveness review, Number 26. AHRQ publication No.11-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., Brock, M. E., Plavnick, J. B., Fleury, V. P., Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with autism spectrum disorder. Journal of Autism and Developmental Disorders. doi: /s z. Young, J., Corea, C., Kimani, J., & Mandell, D. (2010). Autism spectrum disorders (ASDs) services: Final report on environmental scan (pp. 1-59). Columbia, MD: IMPAQ International.

Thank you. NSP-1: http://www. nationalautismcenter
Thank you! NSP-1: NSP-2:

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