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Posted by Dad on August 23, 2000 at 06:05:48:

FEAT DAILY NEWSLETTER Sacramento, California http://www.feat.org
"Healing Autism: No Finer a Cause on the Planet"
______________________________________________________
NEWS EDITOR: FEAT@feat.org NEWS SEARCH:
http://www.feat.org/search/news.asp
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August 22, 2000

SPECIAL REPORT

Dr. Lovaas Comments on the Mistaking of his Work

Dr. Ivar Lovaas is the UCLA scientist who developed the premier early
intervention autism treatment model sought today by parents for their newly
diagnosed ASD children. The treatment is Applied Behavior Analysis
utilizing a defined Discrete Trial Training (ABA-DTT) format, also known as
the UCLA Model.
Over the years, since the introduction of the model in 1981, Dr.
Lovaas has collected the misconstruing and misrepresenting of this work
from
all corners. In this series of postings over the next six days in the FEAT
Daily Newsletter, Dr. Lovaas seeks to answer these matters. In this
installment he addresses:
* Did subject selection result in a representative sample of
autistic
children?
* Did subject assignment result in equivalent groups?
* Did family characteristics effect outcome?
* Is the treatment replicable?
This document should prove to be of enormous value to those
advocating
ABA-DTT programs, when encountering the misinformation addressed here. The
complete report 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

Unfortunately, misunderstandings about the UCLA model have been very
common, dating back as far as 1967 when Bettelheim accused Lovaas of
"stripping the patients of (their) humanity" treating them like Pavlovian
dogs" and comparing operant conditioning procedures to lobotomy
(Bettelheim,
1967: p. 410-411). Erroneous information has continued over time and this
is a serious problem because such information hinders parents and
professionals from making appropriate decisions about services for children
with autism. It may also cause funding agencies to set inappropriate
priorities for research and treatment and may create an atmosphere of
mistrust that inhibits collaborative work on identifying effective
therapies.
Reluctantly, therefore, we have concluded that it is necessary to
summarize
and correct some of the more persistent misunderstandings about the UCLA
model. Detailed and peer-reviewed descriptions of the UCLA model of early
intervention for children with autism have been presented in a treatment
manual and associated videotapes (Lovaas & Leaf, 1981; Lovaas et al., 1981;
currently under revision), as well as several articles (Lovaas, 1993; Smith
& Lovaas, 1998; Smith, Donahoe, & Davis, 1999). We have also reported
research on outcomes that children receive with this intervention (Lovaas,
1987; McEachin, Smith, & Lovaas, 1993; Smith, Eikeseth, Klevstrand, &
Lovaas, 1997; Smith, Groen, & Wynn, 1999; Smith, Klevstrand, & Lovaas,
1995). Moreover, in these publications, we have discussed the strengths
and
weaknesses of the UCLA model and research pertaining to this model.
The following discussion focuses on issues regarding the children who
have participated in our research, the experimental design of this
research,
the nature of the treatment that children received, assessments of the
effect of this treatment on children and their parents, conclusions drawn
from these assessments, cost of intervention and concerns about testimony
in
Fair Hearings. After reviewing all the distortions which have been
expressed about the UCLA project an attempt is made to account for these
(see "Why all the Distortions" (pp. 41-43). A distinction is made between
Clinic-based versus Workshop-based services as these services generate
different kinds of treatment outcome. The paper ends with an expression of
optimism about future progress in treatment research.

A. Did subject selection result in a representative sample of
autistic children?
Schopler, Short, & Mesibov (1989) wrote that the Lovaas (1987) intake
criteria resulted in a restricted and biased sample of high-functioning
subjects who had a favorable prognosis regardless of treatment. That is,
they argued that the sample of autistic children used in the Lovaas (1987)
study was not representative of young children with autism. In addition,
Schopler & Mesibov (1988) claimed that the Lovaas (1987) criteria for
selecting subjects would have excluded 57% of their referrals.
A printout of intake data we received from Dr. Short shows that
Schopler et
al.'s (1989) own partipcants had IQ scores quite comparable to the Lovaas
(1987) participants (i.e., mean IQ of 60 in Lovaas, 1987 versus 57 in Lord
&
Schopler, 1989). However, the TEACCH sample had a preponderance of
children
with a chronological age of 40-45 months. This distribution is atypical of
the general population of children with autism (which should be evenly
spread over the age ranges rather than concentrated in the oldest range).
Also, only 5% of the TEACCH sample spoke in recognizable words-a
considerably lower rate than the generally accepted figure of 50% (observed
at UCLA and numerous other sites). It appears to us that Schopler &
Mesibov
(1988) have made errors in their calculations and/or the TEACCH sample is
atypical of young autistic children, not the UCLA sample (Smith, 1994).
Note also that the higher-functioning subjects in the Lord & Schopler
(1989)
study showed the least improvement over time (rather than the most, as the
authors hypothesized in connection with the Lovaas, 1987 study). In the
only other large-scale investigation of IQ scores in preschool children,
Freeman et al. (1985) reported very similar results (i.e., higher
functioning children with autism showed the least improvement).

B. Did subject assignment result in equivalent groups?
(1) Assignments to the experimental or control group were made on the
basis
of therapist availability which was determined prior to family contact with
the clinic. That is, if it was decided that enough therapists were
available
to provide intensive treatment, then the next family who contacted the
clinic would be enrolled in the experimental group. If there were not
enough therapists available, the family would be assigned to Control Group
I. In the project's initial proposal to the National Institute of Mental
Health (NIMH), a matched pair assignment procedure was planned (MH 11440,
"Experimental Studies in Childhood Schizophrenia," submitted 8/25/72, p.
21). The use of matched pair random assignment was presented to parents in
Santa Barbara by Dr. Robert Koegel who participated in the early stages of
the Young Autism Project. However, parents threatened a protest at the
next
meeting of the National Society for Autistic Children (the forerunner of
the
Autism Society of America) in San Diego. NIMH was contacted about this
situation and Lovaas received approval to assign children to groups based
on
therapist availability, which is a generally accepted procedure in clinical
research (Kazdin, 1980) and one that has been employed in several highly
regarded studies on children with autism (e.g., Bartak & Rutter, 1973;
Howlin & Rutter, 1987). All subjects remained in the groups to which they
were assigned at intake. Only two subjects dropped out, and these subjects
were not replaced. Therefore, the original composition of the groups was
essentially preserved.
(2) The experimental group and Control Group I received the same
assessment
battery at intake. The groups did not differ on nineteen of the twenty
pre-treatment variables; the twentieth variable, CA at onset of treatment,
was not related to outcome.
(3) The number of control group subjects who were predicted to achieve
normal functioning had they received intensive treatment was approximately
equal to the number of experimental subjects who actually did achieve
normal
functioning with intensive treatment. This prediction was based on a
multiple regression equation combining the twenty pre-treatment variables.
Thus, the subject assignment procedure yielded groups that were comparable
to each other prior to treatment on factors that predicted outcome,
supporting the inference that the assignment had produced equivalent
groups.
(4) Control Group I, which received up to ten hours per week of
one-on-one
behavioral treatment, did not differ at post-treatment from Control Group
II, which received no treatment from the UCLA project. Both groups
achieved
substantially less favorable outcomes than the experimental group. Because
the three groups (experimental, Control Group I, and Control Group II) were
similar to one another at pre-treatment, this result confirms that our
subjects had problems that responded only to intensive treatment rather
than
problems such as being unrepresentative of other children with autism, or
noncompliant and holding back, masking an underlying, essentially normal
level of functioning that would enable them to respond to small-scale
interventions.

With regard to the Lovaas (1987) study, Baer (1993) described the
subject assignment procedure as "functionally random." It is also
important
to note that in 1981, NIMH approved of a grant request which formed the
basis for the McEachin et al. (1993) follow-up study (MH 11440-15
"Experimental Studies in Child Schizophrenia"). This grant was approved
after an extensive review and site visit by NIMH pertaining to the
experimental design employed in the Lovaas (1987) study. Kazdin (1980), in
discussing random assignment in clinical research, states,
"The essential feature of random assignment is allocating subjects to
groups in such a way that the probability of each subject appearing in any
of the experimental groups is equal" (p.125). He also states, "The usual
way to ensure that subjects are assigned randomly is to determine the
groups
to which subjects will be assigned prior to their arrival to the
experiment" (p.125). He then warns that matched pair random assignment,
when used as a "method of allocating subjects to groups[,] can produce
groups that differ on all sorts of measures" (p.126). Kazdin's warning
indicates that a matched pair random assignment procedure (as initially
proposed by the UCLA project) could have generated unequal groups,
especially when sample size is small and the variables on which subjects
are
to be matched are not proven to be related to outcome. Kazdin stresses the
importance of "reassuring whether there are no differences on measures
prior
to treatment because this situation partially corroborates the assumption
that random assignment has distributed subject characteristics equally
across groups" (p.127).
The Lovaas (1987) study appears to satisfy this condition. The
Surgeon General has also provided a favorable review: "A well-designed
study of a psychosocial intervention was carried out by Lovaas and
colleagues (Lovaas, 1987; McEachin et al., 1993)."(U.S. Department of
Health
and Human Services, 1999.) In short, there is strong evidence that the
superior functioning of the experimental group after treatment was a result
of the treatment itself rather than a biased procedure for selecting and
assigning subjects to the experimental group.

C. Did family characteristics effect outcome?
Children's families ranged from high to low socioeconomic status, with SES
means in the two groups almost identical to the national average (Lovaas,
1987). The correlation between SES and treatment outcome was r(18)=-.13,
indicating a insignificant trend for lower SES families to achieve more
favorable outcomes. Number of siblings was not predictive of outcome.
Thus, although the Lovaas (1987) treatment required family participation, a
diverse group of families was apparently able to meet this requirement.

D. Are follow-up data believable; are treatment effects durable?
(1) In the McEachin et al. (1993) follow-up study, a wide range of
measures
was administered in order to avoid over-reliance on intelligence tests
which
have limitations if used in isolation, such as bias resulting from teaching
the test, selecting a test that would yield especially favorable results,
failing to assess other aspects of cognitive functioning such as social
competence or school performance, and so on (Spitz, 1986; Zigler &
Trickett,
1978).
(2) The follow-up evaluation used well-normed, standardized tests and
double-blind examination procedures (selection of examiners by
professionals
not associated with the project who were blind to the UCLA clinic as the
source of the request, and the use of a normal comparison subjects to
prevent bias that might occur if examiners only tested subjects with
obvious
signs of pathology). Such evaluations allowed for an objective, detailed,
and quantifiable assessment of treatment effectiveness. A particularly
rigorous assessment was given to the best-outcome subjects who demonstrated
normal IQ and school placement at age seven. These assessments included
the
Wechsler Intelligence Scale for Children-Revised, the Personality Inventory
for Children, the Vineland Adaptive Behavior Scales, and a structured
clinical interview designed to identify subtle signs of autism. These
assessments comprised more than twenty five subscales with the scores
indicating that the best outcome group was indistinguishable from normal
controls. The results of the McEachin et al. (1993) follow-up, which
extended several years beyond discharge from treatment for most subjects,
are an encouraging sign that these treatment gains were maintained for an
extended period of time.
Recently, five well-known commentators with diverse theoretical
orientations unanimously agreed that the Lovaas (1987) study and the later
McEachin et al. (1993) follow-up presented compelling evidence that the
experimental clients improved and that the improvement was due to treatment
rather than some extraneous variable ("Commentaries on McEachin, Smith, &
Lovaas," Baer, 1993; Foxx, 1993; Kazdin, 1993; Mesibov, 1993; Mundy, 1993).
For this reason, further follow-ups of these subjects appear merited and
the
UCLA clinic was recently awarded a grant from NIMH to conduct such a
follow-up. This follow-up study is entitled "Long-Term Outcome of Early
Intervention for Autism," 1 R01 MH51156-01A1 (the grant proposal for this
study received the highest priority rating NIMH can provide, namely 100).
The assessment instruments employed in this follow-up are extensive,
reflecting recent advances in detecting residual signs of autism. These
assessments include the WAIS-R, Wisconsin Card Sorting Test, Stanford-Binet
Absurdities Subtest, MMPI-2, Rorschach, Socio-Emotional Functioning, Theory
of Mind, Narrative Discourse Tasks, Social Discourse, and Abstract
Semantics. The importance of such an investigation is also magnified by
the
paucity of available information on the long-term effects of treatment for
clients with autism in any treatment program (cf. Smith, 1993).
The safeguards discussed above provide considerable assurance that
the
favorable outcome of the experimental subjects can be attributed to the
treatment they received rather than to extraneous factors such as
improvement that would have occurred regardless of treatment, biased
procedures for selecting subjects or assigning them to groups, narrow or
inappropriate assessment batteries, biased examiners, and so forth. For
more detailed discussions of these concerns, see Lovaas (1987), Lovaas,
Smith & McEachin (1989), and McEachin et al. (1993).

E. Is the treatment replicable?
McEachin et al. (1993) emphasized that "the most important void for
research
at this time is replication by independent investigators" (p. 370), a
caution similar to that expressed in Lovaas (1987). Some writers (e.g.,
Foxx, 1993) have repeated the concerns about the need to replicate the
Lovaas (1987) study. There are four potential problems pertaining to
replication:
(1) It has been claimed that the treatment procedures employed in the
Lovaas
(1987) study were not adequately specified, and thus not replicable.
Answer: The following considerations suggest that the treatment procedures
are replicable: First, the components of the treatment were published in a
large number of peer-reviewed journals, developed by multiple
investigators,
and often replicated across sites (cf. Newsom & Rincover, 1989; Schreibman,
1988). Second, a 250 page manual (Lovaas et al. 1981) and associated
videotapes (Lovaas & Leaf, 1981) describe the treatment in extensive
detail.
Third, the project has shown that it is possible to train therapists to
provide high-quality treatment of the kind described in the Lovaas (1987)
study. Samples of the one-on-one treatment provided by therapists at
replication sites have been scored by project personnel at Washington State
University for quality control Level I of treatment involving the
appropriate use of instructions, prompts, and reinforcement (using
definitions and scoring systems provided by Koegel, Russo, & Rincover,
1977). The correct use of these procedures ranged from 92% to 100%.
Interrater reliability ranged from 94% to 100% (see R01MH48863-01A1
"Multi-Site Young Autism Project"). To reach quality control Level II on
high-level programming requires basic coursework in learning-theory and/or
applied behavior analysis and has to be followed by a nine-month full-time
internship at UCLA or one of the replication sites. For further details
describing therapist training and supervision, see "Two Kinds of Treatment
Services" at end of manuscript.
(2) It can be claimed that contingent aversives were employed in the
Lovaas
(1987) study, but that many states now prohibit the use of aversives, and
many or most parents may object to such treatment. Either of these factors
would prevent replication of the Lovaas (1987) treatment. However, while
the UCLA Clinic no longer use aversives, we have taken advantage of
alternatives to aversives developed during and after the time the 1987
study
was completed (treatment in the Lovaas, 1987 study took place between
1970-1984).
(3) It may be argued that most agencies are not able to provide the
required
amount of treatment. Answer: Several collaborating sites are involved in
the collaboration. These include the New Jersey Institute for Early
Intervention (Cherry Hill, N.J.); Wisconsin Early Autism Project (Madison,
WI); Community Services for Autistic Adults and Children (Rockville, MD);
Young Autism Project of Pittsburgh, Southwood Community Services, Inc.
(Pittsburgh, PA); Iceland Young Autism Project (Kipavogure, Iceland); Early
Autism Project, Akershus College (Sandvika, Norway); Central Valley Autism
Project (Modesto, CA); Meredith Autism Project (Raleigh, NC); Early Autism
Project, University of Houston (Houston, TX); Early Autism Project (Edina,
MN); Early Autism Project (Spartanburg, SC); Early Autism Project (London,
United Kingdom); Early Autism Project (Sophia University, Tokyo, Japan)
and
Early Autism Project, Ramon Llull University (Barcelona, Spain) are
examples
of sites which have been able to secure staff who have met quality control
standards so as to deliver the intensive treatment as prescribed in the
Lovaas (1987) study as well as testing the effectiveness of different
levels
of intensity.
(4) It has been argued that the Lovaas (1987) treatment may not be
replicated since student-therapists were unequally distributed across
subjects and some may have developed particularly close relationships with
parents, adding unknown variables to the treatment. In fact, the '87 study
took steps to ensure that such variables did not come into play. To help
reduce these factors, each student-therapist worked six hours per week for
six to nine months at which point the practicum course was completed.
During the six to nine months, student-therapists were rotated across
families to provide for a richer exposure to children with autism. In
addition, student-therapists were instructed to behave as professional
persons in a manner consistent with course outlines (no visits to home
outside assigned therapy hours, no meals with family, no visits after
course
completion, no receipt of gifts, and so on). In the Young Autism Project,
student-therapists appointed as supervisors after nine months may stay on
the project for upward of six years, usually as graduate students, but they
are rotated and distributed equally across families.

Ivar Lovaas, Ph.D.
University of California, Los Angeles
Department of Psychology
1285 Franz Hall
Box 951563
Los Angeles, California 90095-1563
FAX (310) 206-6380
http://www.lovaas.com

Tommorows Installment:
* Do treatment outcomes from TEACCH and the Neuropsychiatric
Institute (UCLA-NPI) or other centers equal the outcome from the Young
Autism Project in the Department of Psychology at UCLA (UCLA YAP)?
* Do alternate forms of treatment provide comparable outcomes?
* Do the best-outcome subjects show residual signs of autism?
* Have the outcome data been distorted?


Take Some Mystery out of Autism
>> SUBSCRIBE >>>>> DAN! Conference September 16-17
>>>>>> Baker Megson Shattock Wakefield Gupta Seroussi Rimland
>>>>>> http://www.autism.com/dan/info.html San Diego, California
______________________________________________________
Editor: Lenny Schafer | Eastern Editor: | News Wire: Ron Sleith
schafer@sprynet.com | Catherine Johnson PhD | News: Kay Stammers


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