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Posted by Dad on August 25, 2000 at 06:20:27:

FEAT DAILY NEWSLETTER Sacramento, California http://www.feat.org
"Healing Autism: No Finer a Cause on the Planet"
______________________________________________________
August 24, 2000

SPECIAL REPORT

Dr. Lovaas Comments on the Mistaking of his Work - Part 3

Dr. Ivar Lovaas is the UCLA scientist who developed a treatment
sometimes labeled ABA-DTT. Dr. Lovaas has written this report to answer a
variety of questions and mistaken assertions about his work. This is the
third of six installments in the series.
To read the first installment, go to:
http://www.feat.org/lovaas/intro.htm
For the second installment: http://www.feat.org/lovaas/body.htm

In this installment, Dr. Lovaas addresses:

* Are the claims made of certain treatment aspects ignored?
* Is the treatment cost-effective?
* Are parents satisfied with intensive behavioral treatment?
* Does the UCLA project focus on stimulus control and functional
analysis
* Quality Control on Treatment.
* Additional Misunderstandings
* How valid are the testimonies at Fair Hearings?

The complete report, with references, will be made available on the
FEAT website at the conclusion of the series.


CLARIFYING COMMENTS ON THE UCLA YOUNG AUTISM PROJECT
Ivar Lovaas, Ph.D. August 2, 2000

J. Are the claims made of certain treatment aspects ignored?
(1) Children become dependent and do not acquire concepts. Parents
who have sought consultation about UCLA from TEACCH staff have been warned
that trying to meld the two programs (UCLA and TEACCH) may result in great
confusion...and considerable anxiety...for the autistic child, and that
the
UCLA program promotes dependence...focusing mainly on compliance training,
and does not help the children to understand concepts." TEACCH further
claims that "operant conditioning programs are very effective with mentally
retarded persons, but such procedures are not as effective with autistic
persons (Mesibov, 1993). Greenspan (1992) presented behavioral schools
of
thought as an example of a common unhelpful approach that ignores the
delayed childs many needs and would result in disorder patterns to
become
stereotyped and more perseverative as (the children) grow (p. 5).
There are no data to support these claims. In contrast, there is
abundant evidence that behavioral treatment can help autistic children
acquire complex behaviors such as language and social interaction
(Schreibman, 1988). TEACCH apparently assumes that children diagnosed with
autism suffer from a life-long disability and, accordingly, has designed
treatment programs which involve the students enrollment in special
education throughout their educational career. Outcome data from TEACCH
are
consistent with this pessimistic inference (Lord & Schopler, 1989).
However, as mentioned earlier, McEachin, Smith, & Lovaas (1993) follow-up
data show major and lasting improvements in the language, emotional, and
social behavior of children diagnosed with autism when treated with
intensive behavioral intervention
(2) Investigators from UCLA-NPI and TEACCH have suggested that while
intensive behavioral treatment may raise intellectual functioning, it does
not foster independence. A direct comparison of independence as assessed
by
a measure called the Vineland Adaptive Behavior Scales exists and can be
used to address this claim. The UCLA YAP data were collected on all
intensively treated children at an average age of 13 years (McEachin et al.
1993). The UCLA-NPI (Neuropsychiatric Institute) data were collected on
children originally seen at age 2-3 when these children had reached an
average age of 15 (Freeman et al. 1991). The TEACCH data were collected
only on high functioning autistic children at an average age of 14 years
(Venter et al. 1992). The means at UCLA, UCLA-NPI, and TEACCH, expressed
as
standard scores, were as follows:

Vineland Scale UCLA YAP UCLA-NPI TEACCH
Communication 75.1 56.6
47.6
Daily Living Skills 73.1 54.6
49.1
Socialization 75.5 51.6
38.1
Composite 71.6 50.3
41.6

As can be seen, intensively treated children from UCLA YAP appear to
function substantially more independently in all areas when compared to
children from UCLA-NPI or TEACCH. (Greenspan has yet to publish treatment
outcome data in a peer-reviewed journal).
(3) In his review of Social and Behavioral Interventions from the
prestigious NICHD conference (Autism 1995: NIH-State-of-the-Science),
McIlvane (1996) appears to make the same mistake as Gresham and MacMillan
(1997, see below) when he states that flexible behavior over time are more
meaningful than changes in measurements such as IQ. Assignment to regular
classes as the criterion for successful outcome is often meaningless
because
it reflects local political and legal mandates more than individual child
need or status. As in other domains of intervention research, studies are
needed to determine the long-term effects of all interventions
(particularly
early intervention) (p. 148). It is difficult to understand the purpose
of
making such statements when the author was familiar with the McEachin,
Smith, & Lovaas (1993) outcome data from the UCLA project.
(4) Gresham and MacMillan (1997) argued that the intensive
treatment group and the control group differed in terms of the amount of
attention they received, and that the children could have improved because
of therapist characteristics such as warmth and encouragement. There is no
data to support that attention and warmth by adults facilitates the
improvement of children with autism. Although Bettelheim based his
treatment on this faulty notion.
(5) These authors further imply that the increase in IQ scores was
not due to cognitive gains, but rather due to changes in the childs
ability
to show what they already know (p. 190). We know of no data-based research
supporting this assertion but we are familiar with many studies refuting it
(reviewed by Rutter, 1983).
(6) Gresham and MacMillan (1997) also claim that subjects were
post-tested with different measures than they received at pretest,thereby
making the results of these different testings uninterpretable (p. 189).
Do Gresham and MacMillan suggest that one should give a three year old the
same tests as a thirteen year old? They refer to the Bristol et al. (1966)
NIH criteria for treatment outcome research to discredit our research and
add some concerns of their own as follows:
1. The UCLA project is based, in part, on principles of operant
learning, however the primary teaching method relies on discrete trial
discrimination learning and compliance with simple commands (p. 6).
Answer: Discrete trials and discrimination learning is not separate from
operant learning but an integral part of such learning. Furthermore,
compliance was not a primary teaching method in the UCLA treatment method.
These misunderstandings on the part of Gresham and MacMillan reflect their
lack of knowledge about the treatment employed.
2. Gresham and MacMillans states: We do, however, fault him
(Lovaas) for failing to randomly assign subjects to treatments.(p. 11).
Answer: An account of why we refrained from using a matched pair random
assignment was provided earlier (see Section B). Matched pair random
assignment is considered an ideal method for assignment, but with a small
number of subjects (e.g. 19 in each group) the assignment could well end up
with an unequal distribution (Kazdin,1980). Evidence for random
assignment
in the UCLA project is based on similarity between Control Group I and
experimental group at intake (similar scores on 19 of 20 pretreatment
variables). Nevertheless, it is possible that some variable, not yet
identified as predictive of outcome, could have been unequally distributed,
a problem which faces all investigators.
If a parent of an autistic child was to be informed that their child
would be assigned to a no-treatment control group, the parents very likely
would not participate. Instead they would hire their own behavioral
therapists. Anyone attempting to use a matched pair random assignment in
autism today would not be able to do so including Gresham and MacMillan,
when and if they themselves decide to engage in treatment and treatment
outcome research. Difficulties encountered by patients in accepting random
assignment to either experimental treatment or standard procedures is a
problem in medical research as well. There are numerous alternatives, such
as the use of wait-list controls, multiple baseline designs, comparison
groups, etc.
3. We do fault him (i.e. Lovaas) for failing to employ measures
that tapped more discrete behaviors (morethan global IQ and educational
placement) (p.11). Answer: Gresham and MacMillan were aware of the
McEachin et al. (1993) follow-up which assessed the subjects on many
dimensions relevant to autism (see Section D). McEachins Ph.D. thesis,
which formed the basis for the 1993 publication was also referenced in the
1987 study. Why they chose to ignore data from these publications can
perhaps only be answered by Gresham and MacMillan.
4. Pretest scores were optimized by reinforcing compliant
behavior during testing and did not describe how this compliant behavior
was reinforced. By doing so they violated standardized test
administration procedures (p.8). Answer: We did describe the procedure
used during pre-testing, which were consistent with those developed by
Freeman (1976). The intent of Freemans procedure is to obtain a more
valid
assessment of the childs intellectual potential when non-compliance is
reduced. In effect, we biased outcome against us by using Freemans
procedure, not using that procedure is likely to have resulted in lower
intake IQ scores and a larger increase in IQ scores at follow-up.
5. Social class of the children was not measured (which would)
restrict the extent to which one can generalize findings (p. 10). Answer:
We did measure family characteristics [( number of siblings in the family
(1.26 in each group), socioeconomic status of the father (Level 49 vs.
Level
54 according to 1950 Bureau of the Census standards,) boys to girls (16:3
vs. 11:8)] Lovaas (1987) (p.6). (See also Section C).
6. (Control 2 subjects were not treated by (the Young Project)
but were receiving some unspecified form of treatment (p. 6). Answer:
Control group II subjects received services which are commonly available to
autistic children in the community, special education and speech therapy.
The poor outcome in this group is consistent with outcome data from other
investigations of such services.
7. Smith and Lovaas are unwilling to concede any limitations on
which the effectiveness of (the Young Autism Project) resides What
explains this apparent refusal to admit to a single limitation in these
investigations? (p. 10). Answer: We have identified limitations and
cautions both in regard to outcome data and treatment integrity. Already
30
years ago Lovaas presented an invited address to parents and professionals
on Strengths and Weaknesses of Operant Conditioning Techniques for the
Treatment of Autism (Top Priorities for Mentally Ill Children. 2nd
Annual
meeting and Conference of the National Society for Autistic Children. June
24-27, 1970, (30-41) San Francisco). In the Lovaas 1987 report we warn
that
a number of measurement problems remain to be solved (p.8) and illustrate
this by describing difficulty in measuring play behavior, communicative
play
and IQ scores. We warned that the term normal functioning raises
questions
about whether these children truly recovered from autism (p.8) Other
cautions about the 1987 follow-up were reviewed in Sections I to III. We
also expressed caution about therapist requirements (extensive
theoretical
and supervised practical experience in one-on-one behavioral treatment
(p.
8). Many treatment variables are left unexplored, such as effect of
normal
peers (p.8). Mention is made of the limitations .on generalization of
our data to older autistic children (p.8). McEachin et al. (1993)
repeated
the need for replication: The most important void for research to fill at
this time is replication by independent investigators (p. 370) and
repeated
the extensive training requirements on therapists. We then go on to
describe another void, namely to better serve the children who did not
achieve normal functioning, suggesting that perhaps such children require
new and different interventions that have yet to be discovered (p. 370).
Does this sound like a refusal to admit to a single limitation as Gresham
and MacMillan have expressed?
8. Greshman and MacMillan do also cite Schopler et al. (1989) to the
effect that our subjects were clearly not representative of all children
with autism (p. 9). Answer: In Section A we provided data indicating how
data from Schoplers (1989) sample was not representative and misleading.
We also presented our data (on diagnosis, child characteristics, etc.)
supporting our claim that the samples used in the Lovaas (1987) study were
in fact representative of children with autism. Gresham and MacMillan did
also fail to indicate the inclusion of Control Group II in helping insure
representativeness of the Lovaas (1987) sample. Instead, Gresham and
MacMillan (1997) statesit is unclear why this group was included in the
design other than because it represented a conveniently available, patched
up control group (p. 187). Answer: The use of Control Group II was
explicitly described to help insure that .the referral process did not
favor the project cases because there were no significant differences
between Control Group I and II at intake or follow-up, even though Control
Group II subjects were referred to others by the same agency (p. 7).
Furthermore, the poor outcome in the similarly constituted Control Group
I
and II would seem to eliminate spontaneous recovery as a contributing
factor
to the favorable outcome in the experimental group (p. 8). Gresham and
MacMillan refer to both studies. Why they have chosen to ignore these data
can perhaps best be answered by them.
Although it may seem to be reasonable to specify whether the samples
are representative of other clients diagnosed with autism, the value of
such
an undertaking depends on the usefulness of the diagnosis of autism in
research and treatment. There seems to be some consensus building that
there are many causes of autism, hence there are likely to be many and
different kinds of autism, requiring different kinds of treatment and
preventive measures. This is analogous to what is happening in cancer
research where many kinds of cancers have been identified with different
causes requiring different treatments and yielding different outcomes. In
treatment research, the definition of different kinds of autism can best be
determined by identification of different kinds of causes and treatment
outcomes, that is, based on a functional analysis rather than the
traditional identification based on communality in the appearance of the
behavioral topographies. This also holds, not just in the case for the
behavioral grouping called autism, but for the separate behaviors involved
in that grouping. For example, self-injurious behavior enjoy three
different kinds of determinants, positive, negative or sensory
reinforcement
which varies across clients. The treatment for each is different so that a
particular kind of treatment (e.g. contingent social isolation) will
decrease one kind of self injury, increase another, and leave a third kind
of self-injury unaltered. What is required for the effective treatment of
self-injurious behaviors is a functional analysis (a cause-effect analysis)
of the particular kind of self-injurious behavior confronting the
practitioner.

Kanners diagnosis of these children is based on behaviors of similar
physical appearances. That is, behaviors like mutism, echolalia, social
isolation, emotional aloofness, rituals and self-injury, low scores on IQ
tests, etc. may look similar to the observer. However, as stated above,
similar looking behaviors may have different causes and therefore may not
belong together, i.e. respond in a similar way to the same intervention.
What is often forgotten in traditional autism research is the fact that the
diagnosis of autism is an hypothesis. That is, the diagnosis is based on a
guess that there exist an underlying organizing force tying the behaviors
(symptoms) together. Kanners diagnosis has shown itself to be a poor
hypothesis, given that, in the 55 years after Kanner proposed the
diagnosis,
no cause or treatment for autism has been found. The most effective
treatment addresses the problems of these children on a behavior by
behavior
basis and there is little evidence of generalization of treatment effects
across behaviors. Although searching for the cause of and treatment for
autism may seem like a noble effort, Kanners hypothesis may well be
misleading and delaying the discovery of effective treatments for these
children. The sooner the hypothesis is rejected, the more productive of
causes and treatments our search may be. See also Hacking (1999, p.
112-115) description of autism (and schizophrenia) as social
constructions
and problems associated with large-scale public acceptance of such
constructs.
9. The added benefit of the Lovaas program, given the high cost,
should be examined (p. 12). The precious economic resources for
education (p. 12) is sited as a reason to be concerned about cost of
treatment. Answer: An approximation to the substantial savings involved
in
implementing behavioral treatment has been provided later in this paper
(Section K).
The treatment of children with autism has cost a great deal of money
in other ways as well. In D.B. v. Greenwich, Frank Gresham testified for
one day as an expert witness to defend Greenwich, Connecticuts 10 hours
per week ABA program. Expert witnesses such as Gresham are able to charge
large fees for their services. Ultimately, Gresham admitted under oath
that
the Districts per hour presentation of ABA programs was only 1/4 of the
frequency which Dr. Gresham considered to be appropriate.
In California, Gresham testified on behalf of another district in an
effort to defeat a child seeking reimbursement for a forty hour per week
program. The district lost and the hearing officer held that a 40 hour per
week ABA program was precisely what the child needed. To date, Gresham has
only testified on behalf of school districts and apparently has never been
involved with any district which has prevailed.

In May of 1999, in T.H v. Palatine, a federal district in
Illinois, after a protracted two-year court battle, held that a school
districts offer of services in a multiple-handicap class was absurd and
directed the district to pay for the childs home-based ABA program, as
well
as the familys attorneys fees. Significantly, the family had offered to
settle the entire dispute at the outset for only $18,000. Ultimately, this
district was compelled to pay out more than $300,000, including the school
districts own attorneys fees.
We are in full agreement with Gresham and MacMillans
concerns about families receiving services from therapists who have
received less than optimal training and less supervision in delivering
early
and intensive behavioral intervention. Earlier in this paper (see Section
E) we described the training requirements for sites involved in the
replication project. It is of major concern to us to learn of providers
who
present themselves as competent in providing the UCLA model and may site
the
UCLA follow-up studies as support for their treatments. Except for staff
at
the replication sites, we know of no providers who have been recently
trained in the UCLA model and sought to be updated. Without updating
treatment quality is likely to suffer (Wolf et al. 1995). Also, few if any
provide clinic-based treatment as in the Lovaas (1997) report, but rely on
workshop-based treatments where the family hires staff to be trained in one
to three days of workshops, with supervision one to three month apart.
Hardly any provide outcome data.
We estimate that outcome data documenting normal functioning from
such
services will be less than 10 percent. This does not imply that the
children
will fail to make improvements. Behavioral interventions (as in Applied
Behavior Analysis) is based on thousands of scientific papers in Learning
and Behavior reported in peer-reviewed journals over more than a hundred
years. There are ample data supporting the effectiveness of behavioral
treatments addressing self-help skills, reduction in self-injury, community
functioning, peer-play, school adjustment, language development, and so
forth, all of which should help the child become both more competent and
self-sufficient. The problem is that, for children who fail to reach normal
functioning and fail to become integrated and learn from typical peers,
services need to continue, for example by the parents efforts. If not the
client will regress, showing little if any benefit from earlier treatment
as
was demonstrated in the Lovaas et al. (1973) outcome study. We are also
seriously concerned about efforts (some of which are supported by federal
grants) to compare the UCLA Young Autism Project against alternate forms of
treatment, using staff who have not been trained in UCLA procedures and
have
yet to demonstrate quality control on treatment. These problems are also
discussed below (in Section V).
There are many issues involved here. One important issue is centered
on the failure of alternate treatments to document effectiveness on normed
tests in peer-reviewed journals. This includes services such as special
education, speech therapy, sensory motor training, floor-time, option
method, psycho-dynamic therapy, holding therapy, gentle teaching, etc.
Parents win support in Fair Hearings, not because the behavioral treatment
their children receive answers all or most problems. Rather, behavioral
treatment can demonstrate, in an objective data-based manner, that their
children have made improvements when other services fail to do so. The law
is rational, and by that is meant that it is data-based. One fortunate
consequence of Fair Hearings may be to stimulate research on treatments for
autistic children and to report, at an early date and in peer-reviewed
journals, whether such treatments and treatment combinations are effective
or not. If not effective, the treatment should not be offered and /or
warnings about their potential ineffectiveness and/or harm should be posted
as is required in medicine. If not we will continue to mislead parents and
waste childrens lives.

A major and welcomed step ahead would be for Special Education to
take
advantage of what is known in behavioral treatments. Behaviorists are
delivering a form of special education, the earliest efforts being
represented in the work of Itard (1932) some 200 years ago. Itard,
considered the father of special education, gave impetus to the work of
persons like Montessori, Sullivan, Kephart and Fernald. Anyone who reads
Itards descriptions of his treatments will recognize their similarity to
behavioral ones. Itards treatments did not survive and ended up going
nowhere (except perhaps in the use of sensory integration) because Itard
did
not know how to objectively document treatment outcomes. Let us not once
more make that mistake.

K. Is the treatment cost-effective?
The price of treatment is often mentioned as a reason for not funding
forty hours per week of one-on-one intervention. The cost is estimated at
$60,000 per year, or $120,000 for the average of two years required for
normal functioning at which point the best-outcome children no longer
require further special services. This contrasts to the cost of more than
$2,000,000 dollars of life-long protective care. Regarding expense, 77% of
the children in the UCLA-NPI study were inpatients at the hospital. The
average stay at UCLA-NPI was about a month at a cost of approximately $1000
per day. These children then attended special education classes which have
yet to document their effectiveness. The children are expected to need
life-long protective care. At TEACCH, the costs per year are lower
(estimated by Lord and Schopler in a 1994 article as $1200 per year).
However, the children continued to be enrolled at the completion of
TEACCH's
study, and the expectation seems to be that they will be enrolled
throughout
their lives. For a more detailed analysis of the cost-effectiveness of
behavioral intervention, see Jacobson, Mulick and Green (1998).

L. Are parents satisfied with intensive behavioral treatment?
The UCLA project has been accused of being stressful for parents.
Our
data show otherwise. On a 7-point rating scale (7 being "completely
satisfied") the UCLA project received a mean rating from parents of 6.9 for
clients served since 1991. On a different survey, data from 140 parents who
rated UCLA workshops on a 5-point scale across six dimensions (from "Was
therapist polite and sensitive to parent's needs?" to "Would you recommend
a
similar workshop to others?") show ratings to be 4.9, 4.9, 4.8, 4.9, 4.5,
4.9 (4.5 on the question "How effectively do you think you can now
implement
behavioral techniques?").


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