IntroductioniThe Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

Copyright © 2011 by SKF Books, Inc. All rights reserved.
No part of this book may be reproduced in any form or by
Any means without the prior written permission of the publisher.
Any errors and omissions are the responsibility of the author.
Library of Congress Control Number: 2010919311
Freeman, Sabrina Karen, 1958 –The complete guide to autism treatments. A parent’s handbook:
Make sure your child gets what works! / Sabrina Freeman
Includes bibliographical references and index.
ISBN 978-0-9657565-7-0
1. Autism in children—Treatment. 2. Autism—Treatment. I. Title
RJ506.A9F725 2011618.92’85882’06
C2011-900064-9
Published by:
SKF Books, Inc.
1050 Larrabee Avenue #104-357
Bellingham, WA 98225
Printed in the U.S.A.
Second Edition

Disclaimer: The cover photo is being used for illustrative purposes only and any person depicted in thatphoto is a model.

iiIntroduction

Contents
Foreword ..................................................................................... ix
Introduction .............................................................................. xix
Section One: What Works and What Doesn’t? ............1
Cost of Autism Treatment .....................................................................3
Half-baked Research ............................................................................4
1.1 Behavioral Therapies ............................................................................5
What is Behaviorism as it Applies to Autism ...........................7
What is Applied Behavior Analysis?.............................7
What is Intensive Behavioral Treatment? .....................9
Is the IBT Program Home-based or Center-based?......9• Home-based Intensive Behavioral Treatment .......................11• School-based Intensive Behavioral Treatment .....................25• Offshoots of Intensive Behavioral Therapies........................39-Pivotal Response Training and the Natural Learning
Paradigm ....................................................................39-Positive Behavior Support .........................................53-Verbal Behavior Therapy ...........................................61-Fluency Training ........................................................67
1.2 Other School-based Therapies (non-behavioral) ................................81• TEACCH (Treatment and Education of Autistic andRelated Communication Handicapped Children) ................83• The Playschool (Colorado Health Sciences Center) .............95• Giant Steps ..........................................................................105• The Higashi School/Daily Life Therapy .............................113• Walden Preschool ...............................................................121iii

The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

1.3 Child-lead/Parent-facilitated Therapies ............................................ 131• Floor-Time (Greenspan’s Developmental, Individual
Difference, Relationship Model - DIR) .............................. 133• Options Institute/Son-Rise Program ....................................... 143• Relationship Development Intervention (RDI) .................. 151• The Learning to Speak Program ............................................ 159
1.4 Biomedical Therapies ........................................................................ 167• Diet/Nutrition Therapy (Gluten and Casein-free Diet) ........ 169• Chelation Therapy ................................................................. 183• Intravenous Immunoglobulin .............................................. 191• Secretin ............................................................................... 197• Vitamin B6 and Magnesium ................................................ 205
1.5 Speech and Language Therapies ....................................................... 217• Fast ForWord Program ....................................................... 219• The Hanen Method ............................................................. 227• Lindamood-Bell Learning Processes .................................. 235• The SCERTS Model ........................................................... 241
1.6 Miscellaneous Therapies .................................................................. 249• Art Therapy ......................................................................... 251• Auditory Integration Training ............................................. 255• Cranio-sacral Therapy .......................................................... 267• Dolphin-assisted Therapy ....................................................... 273• Exercise Therapy ................................................................ 281• Facilitated Communication Training .................................. 289• Holding Therapy ................................................................. 309• Music Therapy .................................................................... 317• Pet-facilitated Therapy .......................................................... 327• Sensory Integration Therapy .............................................. 335• Vision Therapy ................................................................... 349

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Introduction

Section Two: How Do We Know What Works andWhat Doesn’t ............................................................................. 359
2.1 Why care about science? ................................................................... 362
2.2 Why we can’t always rely on experts? ............................................. 363• Experts” do not always know about science ............................ 363• They may not value science ..................................................... 364• Advancement trumps quality concerns ..................................... 364• Some experts’ motives are not always pure ............................. 365• The scientific method versus pseudo-science ........................... 366
Using the scientific method to protect your child ................. 370
What if the treatment method is too new fordata collection? ..................................................................... 370• What about anecdotes? Can we use them at all? ..................... 371• We need to care about theory ................................................... 373
What is a theory? .................................................................. 374
Good research is motivated or driven by theory ................... 375
2.3 How do we generalize results in autism research? ............................. 378
2.4 Using science to move closer to the truth ......................................... 379• Testing theory ........................................................................... 379• Experiments are not optional .................................................... 382• Peer review - necessary but not sufficient ................................ 382• Uncover the funding source for the study ................................ 383• Finding the peer-reviewed journal articles ............................... 386• Is the journal peer-reviewed? ................................................. 387
2.5 Analyzing a study ............................................................................. 389• How many groups are there in the study? ................................ 389
Is it a Between-Subjects Design? .......................................... 390
Is it a Within-Subjects Design? ............................................ 395
Is it a Between-Within Subjects Design? ............................. 398
Is it a Factorial Design? ........................................................ 401
Is it a Single-Subject Case Design? ...................................... 403
What’s the problem with Single-Subject Case Designs? ...... 406v

The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

• How many children should there be in each experimentalgroup? ...................................................................................... 408• What is the ideal number? ........................................................ 408• What is acceptable? .................................................................. 409• How are children in a study assigned to the experimentalgroups? .................................................................................... 410• What is being measured and how? ........................................... 413
Autism (the Dependent Variable) .............................................. 413
Treatment (the Independent Variable) .................................... 415• Who collects the data? .............................................................. 418• Who administers the treatment? ............................................... 420• Did research results happen by chance? .................................... 421• Is the study biased and how can bias be avoided? ................... 422
Bias type 1: History ............................................................. 422
Bias type 2: Maturation ....................................................... 423
Bias type 3: Treatment contamination ................................. 423
Confounding variables in general ..........................................425
2.6 How researchers mistakenly ruin their own
well-designed studies ............................................................ 426
2.7 How can bias be avoided? ................................................................ 428
2.8 When is it time to apply the results to children? ................................ 429• Is the research far enough along? ............................................. 430• Testing on human subjects ....................................................... 431

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Introduction

2.9 Red flags for quackery ...................................................................... 432

Conclusion ........................................................................................ 435
Afterword........................................................................................ 437

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viii

Foreword

Foreword
Dr. Richard Foxx, Ph.D. BCBA-D1
Few conditions have been as fraught with fad, controversial, unsupported,
disproven, and unvalidated treatments as autism (Foxx, 2008). The
underlying reasoning for this relates directly to science being misunderstoodor ignored by parents, professionals, and paraprofessionals. Many people
simply do not understand how science works, and this includes any parents
and paraprofessionals with no scientific background. Many professionals
also do not understand science, typically because their education featured
no scientific training or it was greatly deemphasized. Unfortunately, thisis the case for many of the professionals who work directly with children
with autism. There are other professionals who understand science butchoose or have chosen to ignore it for professionals or monetary gain.
Sabrina Freeman (2007) recognized all of these factors and decided
to do something to help. The result is The Complete Guide to Autism
Treatments: A Parent’s Handbook: Make Sure Your Child Gets What
Works! Although the book is written for parents, professionals will greatly
benefit either because they will now understand how to evaluate thescience behind treatments or have a reference to give to parents. The bookalso would serve nicely in a graduate course on autism, ethics, or behavior
analysis. The piece de resistance is that Freeman is both the mother of achild with autism and an accomplished social scientist with a PhD from
Stanford. Two of her other books, Teach Me Language (Freeman &1

Reprinted by permission, The Behavior Analyst, Spring 2010ix

The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

Dake, 1997) and Science for Sale in the Autism Wars (Freeman, 2003),
are directly related to autism and attest to the depth of her scholarship.
Freeman’s gift is that she writes about what some view as complex
subjects in simple understandable language. Indeed, she points out thatthe scientific method is not difficult to understand and that knowledge ofit permits rational decision making when it comes to evaluating the next
treatment or purported cure. Freeman’s objective is to protect thousandsof children from quackery while providing parents and professionals withevaluative tools for judging the effectiveness of a treatment.
The book is organized into two sections: “What Works and What Doesn’t”
and “How Do We Know What Works and What Doesn’t.” Section 1 isdesigned to produce informed consumers who will seek a treatment for
their children because they know it has scientific validity. Anyone with agood background in science will find this section well done and extremely
helpful. Those with little background in science are encouraged to read
Section 2 first in order to have the background to fully appreciate thein-depth evaluations available in Section 1.
In Section 1 every major treatment option is exposed to the following
questions: What is it? What evidence do practitioners have that this really
works? What does the therapy actually look like? Would I try it on mychild? What else do I think? What additional studies would I like to see
the researchers do in this field? Who else recommends for or against thetreatment? So you are still on the horns of a dilemma? What’s the bottom
line? The answers are typically spot on, in this reviewer’s opinion, andare consistent with Freeman’s reputation as a tireless advocate for therights of children with autism to receive science-based treatment. The
literature review is exhaustive.
Under behavioral therapies, Freeman examines applied behavior analysis,
intensive behavioral treatment (IBT) that is home or center based, schoolbased IBT and what she refers to as offshoots of IBT, including pivotalxForeword

response training and the natural learning paradigm (PRT/NLP), positive
behavior support (PBS), verbal behavior therapy, and fluency training.
Freeman reports that she implemented an intensive home-based behavioral
treatment program based on the pioneering work of Ivar Lovaas (Lovaas,
1987) and that her daughter, who is now an adult, made incredible gains.
That said, she cautions readers that her anecdotal reporting of this outcome
should not sway them to use the method, even if it comes from someone
who respects science. Rather, she states that what should be convincing is
the “abundance of scientific evidence behind the method” (p. 18) and it was
just such evidence that led her to choose to use IBT with her child.
High-quality school-based IBT programs are supported by scientific research.
Although all children benefited from these programs, the most significant
gains were made by children who began treatment before the age of 5 years.
Had she lived in New Jersey when her daughter was young, Freeman would
have seriously considered sending her to the Princeton Child Development
Institute. The offshoots of IBT receive a fair evaluation based on theliterature to date, and the kinds of studies suggested for researchers working
in the various areas are excellent. Freeman’s review finds PRT/NLP to bepromising, but it does not have enough research evidence to suggest that itis globally effective in ameliorating the condition of autism. Based on thescientific research to date, verbal behavior therapy is described as an emerging
treatment but not one that should be applied solely to ameliorate the symptoms
or conditions of autism. A similar bottom line is given for fluency training,in that there is limited evidence that points to its appropriate use for certain
deficiency characteristics of autism.
Freeman’s bottom line on PBS is that “there is no evidence to conclude that
PBS is anything more than a philosophy rather than a science. Consequently,
there is no evidence to demonstrate that PBS ameliorates the condition ofautism” (p. 59). She urges PBS researchers to abandon the antiscience,anti-intellectual discipline they have developed and return to the field of
applied behavior analysis where they can compete with behavior-analytic
researchers and “have their PBS research properly scrutinized and evaluatedxi

The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

by their ABA academic peers” (p. 58). Her final point on PBS is that its
literature makes autism appear to be an entirely different disability. In
the PBS autism world, children “seem to be very mild, and the behavior
problems are all easy to control, as long as the environment is ‘reengineered.’ Children with self-injurious behavior do not seem to be achallenge for this group” (p. 58). Her caveat is that perhaps the children
in PBS studies are “not classically autistic” (p. 58). After reviewing theliterature and based on living in a region where PBS is used extensively
by school districts and with governmental support, Freeman expresses
her opinion that “positive behavioral support is a very dangerous field
for children with autism” (p. 56). Her reasoning is that PBS is a kind ofreligion of political correctness that “denies children with autism accessto proven, science-based treatment methods” (p. 56). She even finds
the term “positive” attached to behavior support as offensive because it“carries a presumption that the PBS practitioner is different and apartfrom his ‘evil’ ABA behaviorist counterpart” (p. 57).
In the “Other School-Based Therapies” section, Freeman reviewed
TEACCH, the Colorado Health Sciences Center playschool, Giant
Steps (Canada), Higashi/daily life therapy, and the Walden preschool.
Her bottom line is that there is not enough research evidence to date toconclude that TEACCH is an effective treatment or that the Playschool
autism intervention substantively improves the condition of autism. She
finds insufficient evidence that the Higashi school or Walden preschool
have an effective curriculum for decreasing the symptoms associatedwith autism or treating and educating children who have it. She foundno evidence in support of Giant Steps.
The “Child-Led/Parent-Facilitated Therapies” section includes the floortime (Greenspan/developmental, individual difference, relationship)model (DIR), Options Institute/Son-Rise program, relationshipdevelopment interventions (RDI) and the Learning to Speak program.
Two therapies, DIR and RDI, had not generated enough scientific evidence
to conclude that they were effective treatments for children with autism.
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There was no evidence in support of Son-Rise and the Learning to Speakprograms as effective treatments. Freeman had personal experience with
DIR a number of years ago, because she chose it for her child when she was
first diagnosed. The DIR philosophy, which turns everything the child does
into a social interaction, was personally very appealing, and this treatment
was being offered by the psychiatrist who had diagnosed her daughter. Soon
after, Freeman abandoned DIR because, despite its personal appeal, there
were no data to support it. Her bottom line was “my child was wasting hertime and I was wasting my money” (p. 139).
The biomedical therapies are familiar to many parents of children with autism.
They include the diet and nutrition therapies of gluten- and casein-free diets,the candida diet, the nutritional deficiency diet, the ketogenic diet, chelation
therapy, intravenous immunoglobulin therapy, secretin therapy, and Vitamin
B6 and magnesium therapy. Although these theories have been around for 30
years, none have any independent scientific support. Until there is, Freeman
regards their use as pure experimentation on a child.
Chelation therapy consists of removing harmful metal toxins from thebody by introducing chelating agents into the body. These bind with themetal ions and then are expelled. Chelation is a recognized treatment
for children with lead poisoning but not for children with autism, who
do not have chronic heavy metal toxicity. Although many fad treatments
are costly in terms of money and time lost, chelation can lead to horrible
medical complications, including death. Freeman’s bottom line is chilling.
Chelating a child with no signs of heavy metal poisoning is engaging in
high-risk experimentation. There is no evidence to support chelation as
an effective therapy for children with autism.
There is not enough evidence to support any type of diet and nutrition therapy
as an effective treatment for improving the symptoms that characterize
autism. Unfortunately, parents are drawn to these approaches because they aresomething the parent can control and follow, and they fit with the parent’s roleof nurturer and provider of sustenance. Joining diet and nutrition interventions
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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

as pure experimentation are intravenous immunoglobulin therapy, secretin
therapy, and Vitamin B6 and magnesium therapy. Although Freeman
is never shy about expressing her opinion based on her review of theliterature, she always provides a list of public and private agencies thatrecommend against a treatment or state that it failed the scientific versionof the sniff test.
The speech and language therapies include the Fast ForWord program,the Hanen method, Lindamood-Bell learning processes, and the SCERTs
model. None of the four have any evidence to support their use as
effective treatments to improve the language impairment associated with
autism or ameliorate its symptoms. Freeman would especially like to see
the developers of the SCERTS model test their protocol against its maincompetitor, intensive behavioral treatment. She makes this suggestion
for a number of therapies, especially those that are critical of intensive
behavioral treatment.
The miscellaneous therapies section is a veritable rogues’ gallery. Allof the classic fads are present, including auditory integration training,craniosacral therapy, dolphin-assisted therapy, facilitated communication
training, holding therapy, sensory integration therapy, and vision therapy.
Others on the list include art therapy, music therapy, and pet-facilitatedtherapy. Because art and music therapies are regarded as relatively
harmless and not prohibitively expensive, most professionals tend to
give them a pass when harmful interventions are discussed. Art therapy
has no evidence of support, and there is not enough evidence for music
therapy to be considered an effective treatment for the symptoms ofautism. Freeman recommends removing the term therapy from music,
and I would add art. Some children with autism enjoy music and art,
and they can be used as reinforcers and for training in leisure activities.
In this limited role, both can have a place in a child’s program.
Although a dolphin ride may be reinforcing for a child with autism at
the Dolphin Center ($2,000 per week for 1 to 3 weeks of treatment),xivForeword

there is no scientific evidence that it is an effective treatment. This type oftherapy fits in the category of those that are essentially ignored by scientists,
because it is seen as not harmful but simply expensive. And, it is not thetype of day-to-day therapy that would replace an effective intervention likeapplied behavior analysis. It is best used by parents who have money andlike salt-water vacations.
Freeman’s advice regarding pet-facilitated therapy is that “there is nodownside to owning an obedient, loving dog” and “the experience may begreat for your child; however, do not expect therapeutic results” (p. 332).
Given that there is insufficient evidence to conclude that this therapy iseffective, a dog from the pound will serve as nicely as a costly, speciallytrained therapy dog.
Vision therapy and craniosacral therapy are not commonly used for individuals
with autism, although they are recommended for other conditions, ailments,
diseases, and disabilities. There is no evidence or insufficient evidence torecommend either for autism or any other problem. Quackwatch (a leading
Web site designed to expose harmful therapies) has craniosacral therapy
on its list of nonrecommended treatments. The use of vision therapy forchildren with learning disabilities, in the form of eye exercises or speciallytinted glasses, is not supported by any pediatric or pediatric ophthalmology
professional academy.
Much as been written criticizing and condemning auditory integration
therapy, facilitated communication training, holding therapy, and sensory
integration therapy (Jacobson, Foxx, & Mulick, 2005) and Freeman continues
the practice. These therapies are particular insidious because they takevaluable time away from effective therapy and are highly seductive forparents who desperately want to help their children with autism. Auditory
integration therapy is not only ineffective; it can be very costly. I know ofseveral situations in which parents who could ill afford to do so have spent
thousands of dollars on this treatment. Holding therapy is psychoanalytically
based and has followed the general course of psychoanalysis in the U.S.,
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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

which is to say that it has fallen out of favor over time and is most likely
to be practiced or implemented in New York City. It has gone the wayof Bruno Bettelheim, refrigerator mothers, and the notion of a child with
autism having “attachment issues.”
Sensory integration therapy has been a boon to occupational therapy,
because the underlying premise is that autism is a form of sensory
dysfunction. Although there is little or no evidence regarding its efficacy,
countless children with autism receive it in school as a legally mandated
part of their individualized educational program. Parents like it because
a sensory intervention that is designed to address a child’s neurologicalneeds has just the right amount of mind-body feel. Children seem to likeit because having a perky occupational therapist brush your arms, push
you on a swing or merry-go-round, or squeeze your arms is a pretty good
way to spend a “treatment session.”In the hall of shame of fads and autism, nothing ranks higher thanfacilitated communication. This therapeutic intervention is proof positivethat H.L. Menken had it right when he said that “No one ever went broke
underestimating the intelligence of the American public.” It would be badenough if facilitated communication were simply worthless and costly,
but it also carries risks for parents and guardians, given the number ofthem who have been falsely accused via facilitated communications ofsexually molesting their children and charges. Anyone whose child isreceiving facilitated communication is just a disturbed facilitator awayfrom being charged with a sex crime.
On a positive note, there is some evidence that exercise therapy may havesome limited, short-term effect on the stereotypic behavior of individuals
with autism. And, no one can argue that engaging in exercise is notgood for all of us, especially those prone to obesity. Freeman endorses
incorporating exercise into a child’s daily life, but cautions that any
programmatic efforts should involve a behavior analyst, objectives, andsome data monitoring so that valuable therapeutic time is not wasted.
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Section 2 provides the basic rules and tools that enable one to evaluate theautism treatments described in Section 1. Freeman goes beyond the scientificmethod to look at how science is funded, how bias can slip in, the politics
of research, and what constitutes pseudoscience. Her goal in this section is
to inoculate parents from incompetent researchers or illegitimate purveyorsof autism treatment in order to protect the children from the quackery thatis pervasive in autism.
Freeman meets this goal admirably. She begins the section by asking “Whycare about science?” followed by a discussion of “experts and researchers”
that the readers of this journal will recognize as a Brandisian lifting the rockand letting the sunshine in. Although autism researchers and experts knowwhat Freeman is telling parents here, most have been reluctant to share itwith those outside our inner circle. For example, Freeman cautions that“there are some very intelligent, talented researchers who produced biased
research which they often have published in peer-reviewed journals” (p. 384).
Her discussion of the world of academic publishing is revealing on multiple
levels. Consider these topical headings: “Advancement Trumps Quality
Concerns,” “Peer Review – Necessary But Not Sufficient,” and “Uncover
the Funding Source for the Study.”
A mini course in experimental design is included that discusses the advantages
and disadvantages of between- and within-subject designs, factorial designs,
and single-subject case designs. Freeman’s discussion of how studies becomebiased and how to avoid it is excellent, as is her treatment of the different
types of bias. Being a social scientist, Freeman knows her way around thewaterfront when she illustrates how researchers mistakenly ruin their own
well-designed autism treatment studies. She concludes the book with red
flags for quackery.
This book is a must read for any parent who has a child with autism, because
within its pages lies the unvarnished truth regarding what works and doesn’t
work and how to make the distinction. If you work with parents, encouragethem to buy a copy. If you work at a school or agency, make sure this bookxvii

The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

is in the library. If you teach behavior analysis, use the book to expose
your students to an author whose writing is elegant, straightforward, andbrutally honest.
For a true understanding of the source of the passion that drove Freeman
to write this book, read Science for Sale in the Autism Wars (2003)
that describes a landmark legal battle between families with children
with autism and government and academic mercenaries. Although I
would never wish for anyone to go through what Sabrina Freeman has
experienced in her lengthy fight to have science be applied to her daughter,
she took her disappointment and rage and turned them into two very
thought-provoking books for which parents with children with autism
and those of us who treat them should be very grateful.
Dr. Richard Foxx, Ph.D. BCBA-D

Professor of Psychology
Adjunct Professor of Pediatrics
Penn State University
References
Foxx, R.M. (2008). Applied behavior analysis (ABA) treatment of autism: The
state of the art. Child and Adolescent Psychiatric Clinics of North America, 17, 821834.
Freeman, S.K. (2003). Science for sale in the autism wars. Lynden, WA: SKF
Books.
Freeman, S.K. (2007). The complete guide to autism treatments. A parent’s handbook: Make sure your child gets what works. Lynden, WA: SKF Books.
Freeman, S.K., & Dake, L. (1997). Teach me language. Langley, BC: SKF Books.
Jacobson, J., Foxx, R.M., & Mulick, J. (Eds.). (2005). Controversial therapies fordevelopmental disabilities: Fads, fashion and science in professional practice. London: Routledge.
Lovaas, O.I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 2-9.

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Introduction

Introduction
The Complete Guide to Autism Treatments was inspired by parents ofchildren afflicted with autism. I have spoken to thousands of parents
about various treatments and answered the same questions over andover again. Many times I gave tutorials to individual parents. I realizedthat parents need a clear way to understand how science works so they
can make appropriate treatment decisions for their children.
In addition, professionals and paraprofessionals need to have a better
understanding of the scientific method so they do not inadvertently
recommend a treatment with no science behind it to the parents of thechildren they work with. It is crucial that professionals remember that theyhold considerable status and legitimacy in the eyes of parents, and with that
legitimacy comes responsibility — a responsibility to not inadvertently
send parents down the road of quackery in autism treatments.
Currently, many parents find it difficult to evaluate autism treatments fortheir child. They are forced to rely upon experts who may or may not know
enough about the science to provide accurate information. Therefore,
in a sense, parents need to become experts themselves. Fortunately, thescientific method is not difficult to understand. It simply needs to belaid out in a form that is understandable. All parents, professionals andparaprofessionals alike need to know how to make informed choices
about which therapies to use to treat the child’s autism. After reading thisbook, my sincere hope is that everyone will be able to evaluate the next,
new purported treatment or cure that comes along. It is very important

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to be able to ask the right questions and to find the flaws in the sciencebehind the purported treatment, or to find the evidence that, in fact,
the treatment is effective. At a minimum, understanding the scientificmethod will protect thousands of children from quackery and, hopefully,
provide parents and professionals with the tools to find treatments thatare effective for autism.
I must apologize in advance to many deceased philosophers of scienceinsofar as I am going to make short shrift of most of their concepts;
however, parents of children with autism and the professionals they rely
upon only need to know enough about scientific theories and theoreticallymotivated research to protect their children from quackery and the vendorsof “snake oil” treatments for autism. Parents of children with autism
are better off when they understand statistics and how they are used toreport study findings. Only then will consumers be able to evaluate claims
about autism treatments that are supported through the use (or misuse)of statistics. In short, this book is designed to give those who care about
the futures of children with autism the information they need to makesure their child “Gets What Works!”
The book is organized into two sections. In Section One, we scrutinize therange of treatment options offered to parents of children with autism anduse the tools of the scientific method to evaluate each treatment to help
create informed consumers of autism treatment services. Section Two isdesigned to provide a background in science for parents or professionals
who are newcomers to the scientific method. This section is a must-readfor consumers who plan to independently scrutinize the next autism
treatment introduced into the marketplace. For those who may not havea background in science, I suggest that Section Two be read first as aprimer, prior to reading about specific autism treatments. Otherwise,
the first section is best read by topic, as a reference, or sequentially as acomprehensive guide to autism treatments.

xxSection One: What Works and What Doesn’t?

Section One

What Works andWhat Doesn’t?

1

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

2Section One: What Works and What Doesn’t?

This section groups similar autism treatment approaches together. Although
the typology may not be perfect because some treatments do not easily lendthemselves to a specific orientation, this categorization is probably the easiest
way for readers to wade into the deep, murky world of available autism treatments(I use the word “treatment” very loosely for some of these methods).
When reading a section on a particular method, I have introduced the methodwith no editorializing. In other words, I present the treatment method in theclearest way available based upon what the treatment professional has said about
his or her method. No matter how wild or wacky an idea may sound, we must
look at the data rather than rely on our intuition to determine if the treatment
method is absurd or sensible.
After introducing the method, I then look at the evidence that supports theclaims made by those who teach or practice the method. In this subsection, I
highlight concerns about the studies and then give readers a chance to evaluate
my comments. Finally, I provide a “Bottom Line” regarding each treatment.
Science is defined by debate; therefore, I welcome readers to disagree with me
regarding my evaluations based on the scientific evidence. The goal of this book
is to have consumers critically evaluate autism treatments so they are 100 percent
informed about a treatment before they attempt it on a vulnerable child.

Cost of Autism treatment
Because I am also a parent (and an ethical human being), I refuse to evaluate atreatment based on economics. There is a very serious political debate raging
among policy makers about the number of resources children with autism should
receive relative to other children with special needs. Aside from the draconianand heartless nature of these debates, the arguments are also flawed because
this group of children needs to be treated and educated rather than warehoused.
Unfortunately, highly bureaucratized systems concerned with short-termbudgeting (civil servants forgetting their primary function), regularly attempt to3

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

provide children with treatments that are economical rather than effective, asa means to ration resources.
In addition, there is a trend to ration treatment based upon an autistic child’sfunctioning level. It is particularly disturbing to see a child with severe autism
not given the intervention required due to the degree of severity. As a result oftreatment rationing, much litigation takes place revolving around treatment forchildren with autism. This book does not enter the turbulent treatment rationing
debate, although it is self-evident that as advocates for their children, parents
need to fight for the most appropriate treatment available, regardless of cost to
the health care or educational systems.

Half-baked Research
One of the primary shortcomings of most research in the autism field is that
researchers tend to apply their findings prematurely on children. It seems as
though an autism treatment researcher or practitioner need only develop aninteresting idea and desperate parents are happy to volunteer their children to
receive the treatment. Unfortunately, much of this research is still very much in
the experimental stage (and lacks evidence that it is effective). Well-meaning
parents and professionals who are uninformed how research must proceed
to determine a treatment’s effectiveness often recommend this experimental
treatment to parents of autistic children. This observation is particularly truein the area of biomedical therapies for autism.
In this section, I have included every treatment offered to parents, irrespectiveof whether it has been discredited, is still in the experimental stage (half-baked),or whether it is considered best practice. After evaluating the data, it is up to
consumers — the parents — to decide whether or not to experiment with theirchild. However, it is very important to note that some of the unsubstantiatedtreatments may actually be harmful for the child. Some caution is advisable.
As will become evident throughout Section One, I strongly recommend against
pursuing these potentially harmful treatments.

4Section One: What Works and What Doesn’t?

Behavioral Therapies
p Home-based Intensive Behavioral Treatmentp School-based Intensive Behavioral Treatment
p Offshoots of Intensive Behavioral Therapies

5

Section 1.1

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

6Section One: What Works and What Doesn’t?

Behavioral Therapies
What is Behaviorism as it Applies to Autism?
In the world of autism therapies, there is a considerable amount of research
conducted on various types of behaviorism. Behavioral methods or schoolsof thought may be different in terms of their goals for the child (e.g., which
behaviors they would like to increase or decrease or which skills they would
like the child to acquire). However, keep in mind that the actual method they
are relying upon has the same origin. It all flows from the work of B.F. Skinner,
the grandfather of behaviorism.
Behavioral intervention for individuals with autism involves behavior
modification based on B.F. Skinner’s principles of operant conditioning, used
to decrease undesirable behaviors and to teach and encourage new and desirable
behaviors. Behavioral practitioners and theorists analyze human functioning
based only on those behaviors that are overt and observable, as opposed to making
inferences about internal mental states.1 Behavioral theory proposes that theuse of reinforcement and punishment techniques to eliminate non-functional ordestructive behavior, while building up the frequency and variety of alternative
behaviors, will provide a basis for aiding development.
What is Applied Behavior Analysis?
When it comes to autism, over the last forty-five years behaviorists have taken
lessons from research done on animals, and have significantly modified thosetechniques for use with many people, including those with autism. The techniquesthat this field has established are not simply to teach people with a wide variety ofproblems how to “behave;” rather, through behavioral techniques that originate

7

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

in the field of Applied Behavior Analysis (ABA), treatment professionals areable to change self-destructive or maladaptive behaviors so that persons afflictedwith autism can attain a large repertoire of important life skills, including
communication, academic, social, self-help, and foundation skills which promoteindependence.
The field of Applied Behavior Analysis is very broad: the treatment of autism
is only a small but growing part of this field. The certifying body, the Behavior
Analyst Certification Board defines ABA as follows: “Applied behavior analysis
is a well-developed discipline among the helping professions, with a maturebody of scientific knowledge, established standards for evidence-based practice,
distinct methods of service, recognized experience and educational requirementsfor practice, and identified sources of requisite education in universities.”2 In
terms of autism, government agencies occasionally attempt to define the fieldof ABA as a young, emergent field that has insufficient data on efficacy* or,conversely, that there is not enough data on the application of ABA principles
for children with autism six years of age and older. This is categorically untrue,
as is evident by hundreds of studies conducted from 1980 to the present done inthis field, most of which were conducted with adults, not children.3
It is important to understand that not all those certified in Applied Behavior
Analysis necessarily have the expertise to design and implement an intensive
behavioral treatment program for children with autism. Before parents set up
an intensive behavioral treatment program with a behavior analyst, they needto make sure that this professional has the requisite experience with a range ofautistic children.

For more information on the way the governments have warped and distorted the field of ABA
to avoid paying for treatment for children with autism, I encourage you to read, Science for Salein the Autism Wars.4*

8

Section One: What Works and What Doesn’t?

What is Intensive Behavioral Treatment?
Intensive Behavioral Treatment (IBT) for children with autism is centered on
the idea that the use of behavioral principles in a highly intensive manner (e.g.,
forty hours per week of treatment) is effective in ameliorating the symptoms ofautism. Researchers have found that the global development of children with
autism can be influenced through the use of 1) operant conditioning, 2) techniques
researched and applied from the field of behavior analysis, and 3) findings fromthe literature on child development. In other words, since autism is a Pervasive
Developmental Disorder, IBT can be used to intervene positively in the outcomeof autistic disorder by forcing development that is not occurring naturally. It
was hypothesized, and later supported, by research that the child’s delay ordisorder in language, social development, cognition, and overall functioning
can be mitigated or eliminated with early IBT. Although some describe IBT
as devoid of developmental influences from the theories of child development,
this is, in fact, not the case.
Is the IBT Program Home-based or Center-based?
According to practitioners of IBT, when done competently, treatment shouldtake place during every waking hour of the child’s life in order to maximize thechild’s developmental window. Whether a child participates in a home-based
behavioral treatment program or a center-based treatment program is generally
a decision made by the child’s parents. There are differences in philosophy
regarding these two options when it comes to integration versus segregation.
The data generated by home-based programs is more plentiful and generally
stronger than that of center-based programs. This may have less to do withcomparative effectiveness of the two program approaches, but rather reflects theprolific nature of those researchers who conduct studies on home-based treatment
programs. In the next few pages, I will introduce the traditional home-based andschool-based intensive behavioral treatment programs, and then discuss autism
treatment offshoots from the behaviorism field.
9

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

10Section One: What Works and What Doesn’t?

Behavioral Therapies: Home-based Intensive
Behavioral Treatment
What is Home-based Intensive Behavioral Treatment?
The pioneer in treating children with autism in a home-based milieu is Dr. O.
Ivar Lovaas of the University of California at Los Angeles (UCLA), with thework he initiated in the 1960s and 70s at the Young Autism Project. Manyworldwide sites were originally established to replicate the ground-breaking
autism treatment work of Lovaas first published in 1987. Today, intensive
home-based treatment programs for children with autism are now quite popular.
Although there are many reputable practitioners who never trained at either theYoung Autism Project or associated replication sites, as a result of the treatment
protocol developed and tested by Lovaas and colleagues, home-based IBT
programs have come to be referred to by parents as “The Lovaas Method” ofApplied Behavior Analysis, or “Lovaas-type ABA.”* Unfortunately, there is at
this time no systematic way to differentiate those practitioners who are doing acompetent job of programming for an Intensive Behavioral Treatment programfrom those who are unqualified, much to the frustration of both parents and*This branding is disturbing to many reputable academics1 because they are concerned about a focus oroverreliance on specific techniques rather than the use of data-driven changes based on the principles of
ABA. They are also concerned that branding precludes new science-based advances. Although these
are legitimate concerns, consumers (the parents making crucial treatment decisions for their children)
find that branding provides some protection from every Tom, Dick or Harry who wants to hang out his
shingle and claim he knows how to create, maintain, and supervise a science-based behavioral treatment
program. Many critics of branding claim that certification in ABA should be sufficient to protect parents
from incompetent or unqualified providers. I disagree as there are Board Certified Behavior Analysts whocreate programs exclusively relying on certain techniques that are without sufficient evidence of efficacy.
It is my view that the ethical guidelines of the self-policing board certifying body is not sufficient protection
for consumers when it comes to efficacy. Hopefully, one day there will be a Board Certified Behavior
Analyst specialization in autism and branding will fall out of favor. However, until that time, I predictthat parents will continue to brand and use this shortcut to refer to the home-based Intensive Behavioral
Treatment program that originally created the results from the landmark 1987 Lovaas study, even thoughmany of the techniques have been refined and improved since the 1970s and 80s.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

ethical academics in this field. In the field of intensive behavioral treatment ingeneral, but home-based treatment in particular, it is still very much a case of
caveat emptor.
Early behavioral treatment for children with autism applies behavior modification
principles to teach children with autism in their homes and communities under
the watchful eye of their parent or caregiver. This intervention identifies skill
deficits (areas of weakness) which have resulted in the child’s lack of successin typical learning situations, and targets them for “manual” acquisition of
the necessary skills. The difficulty that children with autism typically have in
learning naturally from the environment is targeted by breaking down skills andinstructions into their smallest components. The child first acquires each step
separately, then chains them together and eventually masters the entire skill. To
make the skill acquisition process easier, several methods are used. Currently,
the common structures in competent IBT programs include: direct instruction(the child being directly taught the part of the skill by a therapist); 1:1 therapist
to student ratio (one adult to one child); discrete trial training (a therapist-led,
highly structured teaching technique); discrimination training (another highly
structured technique that teaches through direct comparison); prompting andfading strategies (a technique that helps the child learn by prompting or giving
hints for the correct answer and then fading the prompts or hints once the learning
has taken place); shaping (a technique which takes the skill level of the childand, through well-planned reinforcement, teaches the child to improve his or
her skill level); and chaining (a technique by which a complex skill is taught byteaching a number of simple skills and connecting these simple skills to masterthe complex skill); and using a variety of reinforcement strategies (a techniqueto reward the child for the correct response). The basic curriculum includes
imitation skills, receptive language skills, toy play, and self-help skills. Oncethese components have been mastered, the more advanced curriculum includes

12Section One: What Works and What Doesn’t?

expressive language skills, abstract language and interactive play (with otherchildren). Further advancement has the child overcome deficits in both thehome and school environments where the curriculum includes pre-academic
and academic abilities (such as weather and calendar skills), socialization
skills, cause-effect learning and observational learning. The goal of this stage
is to prepare these children to learn “naturally” from the school environment.
Intensive Behavioral Treatment programs follow a basic hierarchy of skills;
however, they are highly individualized and flexible based on the skill level ofeach child.
Importantly, in Intensive Behavioral Treatment programs, non-learning behaviors(e.g., self-destructive or maladaptive) are targeted for elimination using a variety
of behavioral techniques. Originally, the treatment protocol employed extinction(ignoring the behavior), time-out (removing the child from the situation for ashort period of time), physical restraint (holding the child’s hands if he or she
were hurting him or herself), verbal reprimands (telling the child “no” or “stop”),
types of differential reinforcement (e.g., rewarding the child for not engaging ina particular behavior), and redirection (involving the child in another activity tointerrupt a nonfunctional behavior). Many of these techniques are used today;
however, time-outs and physical restraint have fallen out of favor with many
practitioners.
What evidence do practitioners have that thisreally works?
Our wide literature search netted over 100 articles on comprehensive IBT
programs. Most of the publications were commentaries about the original
studies and the replications of Lovaas’ work. In terms of peer-reviewed articles
presenting data on IBT, there were fourteen (14) articles. In each and every study

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

where the treatment fidelity was high,2,3,4,5,6,7,8,9,10 children in the experimentalgroup significantly improved over children in the control group. Even in someof the parent-directed groups,9,11 the children in the experimental group faredmuch better than the control group that did not receive the intensive treatment.
There are a few studies in which the parent-directed therapy was not sufficiently
rigorous, and therefore, the children did not make substantial gains.13,15,16 The
above articles will be now presented and discussed.
The original Lovaas study (1987), showed extremely promising results fortreatment efficacy. The outcomes indicated that 47% of the experimental group(n=19) achieved normal functioning, 40% were assigned to classes for the
language delayed and 10% were assigned to classes for the autistic/retarded.
In contrast, only 2% of the control group (n=40) achieved normal functioning.
Forty-five percent were placed in classes for the language-delayed with the other
53% placed in classes for the autistic and mentally retarded.15 The experimentalgroup made average IQ gains of over 30 points. These treatment gains wereassessed five years later and found to be maintained, with the exception of twochildren.5 One of these children moved back into a language delayed class;however, another child joined a mainstream class and, therefore, outcome
percentages remained stable.
Smith and colleagues (1997), undertook a replication of these results througharchival data; however, they used participants who were in the lowest functioning
range. Their results confirmed that treatment gains were achieved, even with themost challenging population of autistic children. Average IQ gains made were
ten points on average (+/-2) for the experimental group, versus an average threepoint decrease in the control group. At intake, no child in either the experimentalor the control group had any speech; however, at follow-up, ninety-one percent(10/11) of the experimental group used spoken words functionally, versus twenty

14

Section One: What Works and What Doesn’t?

percent (2/10) in the control group. It is important to note that the Smith etal. (1997) study selected children with diagnoses of autism and severe mental
retardation, making these results that much more impressive. As mentioned
earlier, there are several other designs replicating the results of Intensive
Behavioral Treatment.3,4,7,8,9,10.11,12,13,14 Although most of the above studies werehome-based, even those studies where the children were in a pre-school,7,8 showeda significant component of home-based treatment.
The majority of studies that attempt to replicate Lovaas’ original work generally
use control groups, creating a between-subjects design. Anderson (1987) is an
exception: they used a within-subjects design with fourteen children receiving
treatment. Between-subjects designs (using a control group) are often used tocontrol for confounding variables which could influence the outcome or resultsof the studies (see the next section of the book for a discussion on the role of acontrol group). The one methodological problem which exists in the studies
was the absence of random assignment to the experimental and control groups.
Due to parental protest at the time Lovaas conducted his original study, he wasunable to use randomization to assign children to groups. The National Institutesof Health (the funding source of the study), gave their blessing to Lovaas to use
a different technique to assign children to groups. To diffuse parental concerns,
Lovaas assigned children to experimental condition based on funding and distancefrom the UCLA clinic. In addition, he matched children in the control andexperimental groups to guarantee that the two groups were similar at intake.**
Baer (1993) referred to this technique as functionally random assignment and argued that it could be equallyas convincing as random assignment providing the researchers did not control the way the children wereassigned. Baer explains that because assignment to control or experimental group was based on resources,a variable out of the experimenter’s control, there is no reason why this procedure could not have createdtrue randomization. He states: “the child’s status as a best-potential case or a worst-potential case, even if
perceptible to the clinician, could not have affected the availability of those resources at the moment that thechild was available for assignment, and so, in my judgment, the assignment was functionally random.”17

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

In addition to matching, Lovaas (1987) varied treatment intensity between thecontrol and experimental groups to determine whether high-quality, low intensity
treatment would have positive effects. It did not.
None of the replications of the original study randomly assign children to groups
because it is ethically impossible to do so due to the original data which showsthe effectiveness of the treatment. In order to overcome this problem, Sheinkopf
and Siegel (1998) used matched pairs assignment. The Smith et al. (1997) article
examined archival records and attempted to match the groups based on age, IQ,
diagnosis, language and behavior. Each study used a variety of widely-accepted
measures of the dependent variable, autism.
Results indicate significant improvement for the experimental group in all
home-based behavioral intervention studies. As mentioned above, the mostdramatic results came from the study by Lovaas (1987), which reported anaverage of thirty point IQ gains in the experimental group. This program also
had the highest intensity of treatment at forty hours per week for two or more
years. The McEachin (1993) study is a follow-up on the children from the
Lovaas (1987) study, which shows that these children maintained their gains
and subsequent school placements. In addition, the Sallows et al. (2005) study
not only replicated the original Lovaas (1987) study demonstrating that theexperimental group significantly improved over the control group, but showed
the level of improvement of the children in the experimental group rivals that of
the Lovaas best outcome children. An additional study, Cohen et al. (2006) used
a quasi-experimental design with twenty-one-age and IQ-matched children in acommunity-based setting over a three-year period. They found that the children
who received IBT based on the UCLA protocol fared significantly better than thematched children attending special education classes.10 One study that requires
particular mention is the Howard et al. (2004) study in which IBT was contrasted

16

Section One: What Works and What Doesn’t?

with high quality, intensive eclectic programming. The Howard et al. study
clearly demonstrates that eclectic treatments for autism are not as effective as
IBT based on the principles of Applied Behavior Analysis.
What does the therapy actually look like?
Since the data demonstrate2 that an average of thirty to forty hours per week ofintensive intervention is crucial for best outcome to be achieved, the ideal therapy
program will have the child engage in therapy forty hours per week. The rationale
for this level of intensity comes from typically developing children. Children
without autism engage in at least forty hours per week of active learning;
however, for them it is a naturalistic, incidental type of learning. Since autistic
children do not generally learn useful skills or information naturally from theirenvironment during their free time, this learning needs to be facilitated, andis best done through structured learning for approximately the same amountof time as that which occurs for their typically developing peers. The UCLA
protocol starts therapy in an intensive one to one intervention in which skill
acquisition occurs using highly structured forms of learning. The therapy
first takes place in the home, typically with young college students trained astherapists, and eventually progresses into the preschool setting. As the child’s
abilities increase, the structure of the teaching decreases and learning begins
to happen more naturalistically. The eventual goal for children who have gone
through the program is to achieve independent learning, from their environment,in the same manner as occurs with typically developing children. In good IBT
programs, naturalistic learning is programmed for children only once they are
ready, and not before. The ideal scenario occurs when the autistic child is able
to enter kindergarten independently and learn naturalistically in the same manneras that child’s peers.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

Would I try it on my child?
Yes, I would and I did. My child began an intensive, home-based behavioral
treatment program based on the work of Dr. Lovaas when she was four years
old. I chose this method before it became popular (approximately 1992) because
it was the only treatment that had any high quality between subject-designed
studies to evidence the effectiveness of the treatment. My decision was basedon science, which indeed bore fruit as my daughter did make incredible gains.
It is important to remember, though, that my anecdotal reporting regarding mychild’s gains should not sway you to use this method. Anecdotal reports areunreliable to use when making the important decision about treatment methods
to use with your child, even if the anecdote comes from someone who respects
science. What should convince you, when choosing one method over another,is the abundance of scientific evidence behind the method. It was scientificevidence that led me to choose IBT for my child.
What else do I think?
Although it is very frustrating to parents, the lack of any known cause of autism
makes the behavioral treatment approach ideal because its effectiveness does notdepend on an underlying theory of cause. Based on the evidence provided by thisgroup of studies, it can be concluded that home-based behavioral intervention,using the best practices models that can be found in the UCLA protocol and its
close approximations, is an effective method for the treatment for autism. As
is illustrated by the Smith (1997) study, this intervention is effective, even for
the autistic and severely mentally retarded population which, in my opinion,
presents the greatest challenge before us as parents and professionals.

18Section One: What Works and What Doesn’t?

What I find particularly appealing about home-based IBT is that the parent is thecase manager. In other words, the child is under the watchful eye of those wholove him or her. In addition, the concept that my toddler or pre-schooler is able
to enjoy all the experiences of typically developing children, with a therapist
helping to facilitate this interaction, rather than the child being segregated fromthe earliest age (to access more expertise), is very appealing. After speaking tothousands of parents, I found that the philosophy of integration and normalization
is a philosophy that is more comfortable for a parent of a newly-diagnosed childto accept. Although this philosophy may or may not be a contributing factor
for the effectiveness of a behavioral treatment protocol, it is fortunate when
the treatment protocol naturally accommodates inclusion and integration, andavoids stigmatization.
One issue that parents should be aware of in running home-based IBT programsis that if the fidelity of the treatment is not sufficiently high (i.e. the program
is not “tight” or implemented correctly), some of the data indicate that thechild’s gains will suffer. That said, the parent-directed group which received
three hours of supervision every other week in the Sallows and Graupner(2005) study was of such high quality that their children fared as well as theclinic-directed children.18 This finding was unexpected and important, though,because it demonstrated that parent-directed treatment programs with minimal
supervision (six hours a month) can produce excellent outcomes.
Critics of IBT (and there are many), claim that this treatment is a mechanistic
program which essentially turns children into robots. These programs are also
criticized because some claim that the children do not generalize their skills fromthe therapy sessions into the natural environment. As I previously mentioned,
a good behavioral intervention program must be individually designed andcustomized for each child. The program grows and is modified with the19The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

child’s developing skills and, as a result, the program becomes increasingly lessstructured as the child becomes better able to learn in that format. Generalizationof skills is programmed into any quality behavioral intervention program to ensurethat skills taught “at the table” will also be taught to be useful for the child in
their everyday living. This is widely recognized in the field of IBT as a key goalfor programmers. In short, good IBT programs do incorporate generalizationand do not create “robots.” Critics also charge behavioral therapists as being
abusive to children through the use of verbal and physical aversives. Fortunately,
the use of physical aversives* and other techniques, such as physical restraints,
are not part of the home-based treatment protocol (and have not been for overtwenty years).
In the original Lovaas study (which began in the early 1970s), a mild physicalaversive (a slap on the thigh) was used with a small subset of the children.
This physical aversive was dropped from the protocol approximately twentyfive years ago. Currently, the Lovaas Institute For Early Intervention (LIFE)
uses the techniques of extinction, redirection, differential reinforcement andteaching alternate forms of behavior. The use of physical aversives no longer
occurs through practitioners from the institute or at any of the treatment sites
affiliated with the UCLA Young Autism Clinic, or by any reputable independentpractitioners using the UCLA protocol.
What additional studies would I like to see theresearchers do in this field?
At this point, there are a large number of IBT research replication sites, both in
the United States and throughout the world (www.Lovaas.com lists the worldwide*
Today, if physical restraints are to be used (which may be necessary if the child is severely self-injurious),
they are generally used only as needed, in highly controlled institutional settings such as hospitals, where
there is video monitoring, precise data collection and, depending upon jurisdiction, judicial surveillance.

20Section One: What Works and What Doesn’t?

replication sites). The replication sites are designed to do exactly what their nameimplies: replicate the original study published by Lovaas and associates in 1987.
These replication sites use the original protocol from the Lovaas (1987) study witha few exceptions. Replicating the treatment protocol utilizing rigorous scientificmethod is crucially important for our children. Unfortunately, the randomization
to either a control or experimental condition increasingly becomes problematic
because the more evidence that is gained regarding the effectiveness of thismethod, the more unethical it becomes to have a control group of children who
do not receive an intensive amount of this type of treatment. Due to the relentlessrationing of health care* and education for children with autism, continued
replication of the Lovaas’ initial landmark study (Lovaas, 1987) by independent
investigators is particularly important concerning the politics of autism policies
rather than the science of autism treatment.
Who else recommends for or against home-based
behavioral treatment as a method for the treatmentof autism?
There is a large number of reputable organizations that have conductedindependent reviews endorsing IBT as best practices. The New York State
Department of Health’s clinical practice guidelines (1999) regarding the use of
IBT as a treatment for autism, was based largely on five studies, all conductedby Lovaas and colleagues, or from partial replications of the protocol developed
by Lovaas and colleagues. Largely based on these five studies, the New York
Report concludes: “It is recommended that principles of applied behavior analysis*

The incorporation of Intensive Behavioral Treatment will be fought by those in the autism industry
offering competing treatments and by governments and their policy analysts who do not want to pay forthis treatment. They are attacking the science behind IBT purely because they are self interested. The moreevidence that is published about the efficacy of IBT, the less likely it is that they will be able to continue
to deny children with autism best practices treatment.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

(ABA) and behavior intervention strategies be included as an important elementof any intervention program for young children with autism.”19 In addition, aU.S. Surgeon General, Dr. David Satcher, had the following to say about Lovaas’
work: “Thirty years of research demonstrated the efficacy of applied behavioral
methods in reducing inappropriate behavior and in increasing communication,
learning, and appropriate social behavior. A well-designed study of a psychosocial
intervention was carried out by Lovaas and colleagues (Lovaas, 1987; McEachin
et al., 1993). Up to this point, a number of other research groups have provided
at least a partial replication of the Lovaas model.”20 It is important to rememberthat this report was published in 1999 prior to the publication of additional
studies replicating these results. Additional organizations endorsing IBT include
the American Academy of Pediatrics (2001),21 the National Research Council(2001),22 and the American Academy of Child and Adolescent Psychiatry.23
So you’re still on the horns of a dilemma?
If you are still thinking about whether or not to set up a home-based behavioral
treatment program for your child, you might want to read Lovaas (2003),24
Maurice et al. (1996),25 and Leaf et al. (1999)26 to gain an in-depth understandingof how home-based treatment programs are administered. In addition, I encourage
you to view the videotape, “Behavioral Treatment for Children with Autism”
available in most university libraries or to be purchased on-line at the Cambridge
Center for Behavioral Studies.27 This videotape chronicles Lovaas’ researchfrom the late 1960s to the late 1980s and provides an overview of the original
treatment protocol.

22Section One: What Works and What Doesn’t?

What’s the bottom line?
Based on the scientific research to date, there is substantial evidence that homebased Intensive Behavioral Treatment is effective for children with autism.
In addition, treatment gains appear to be long-term and for a broad range offunctioning levels.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

24Section One: What Works and What Doesn’t?

Behavioral Therapies: School-based Intensive
Behavioral Treatment
School-based Intensive Behavioral Treatment shares many of the components ofhome-based Intensive Behavioral Treatment programs except that these programs
are based in preschool settings, which are often segregated or integrated with ahigh ratio of autistic children to typically developing children. The main issue
with school-based IBT programs is treatment fidelity. In other words, how muchof the day is the child actually receiving quality autism treatment, and how muchof the day is the child only receiving care-giving. Although this characterization
may appear somewhat blunt, this is indeed a concern with many school-based
programs. Below we will highlight three programs that produced data and discusseach program separately.
What does school-based IBT look like?
Princeton Child Development Institute
The Princeton Child Development Institute (PCDI) is a nonprofit society thatruns a preschool, a school and two teaching homes. In addition, they offer
supported employment and career development for adults.1 The PCDI is notaffiliated with a university; however, research is conducted with some of thechildren enrolled in the PCDI and findings are published in peer-reviewed
journals. Programs are individualized for each child based on that child’s skills
and deficits. Each child’s curriculum is implemented using the principles ofapplied behavior analysis. A curriculum for a student at the PCDI would typically
include nonverbal and verbal imitation, receptive instructions, toy play, receptive
and expressive language skills, reading and academic programs and social
initiations. These programs are delivered using a variety of techniques, which

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

include discrete trial training, incidental teaching, use of time delay, visualschedules and video modeling, as appropriate. Direct instruction is used at the
PCDI, using a teacher-to-student ratio that ranges from one-to-two to one-tofive. Problematic (i.e. maladaptive) behaviors are targeted for elimination using
a variety of well-established behavioral strategies that originate from the richfield of applied behavior analysis.
Douglass Developmental Disabilities Center
The Douglass Developmental Disabilities Center (DDDC) is a therapeutic,
experimental preschool which is affiliated with the Department of Psychology
at Rutgers University and is located on the university campus. The DDDC
is designed to research the treatment and education of children with autism;accordingly, staff and doctoral students in psychology administer the center.
The DDDC has organized the preschool into three classrooms, each grouping
children based on ability. One of the goals is to move the children from a small
group into a larger group setting once the child can function in that setting. A
typical curriculum at the DDDC includes the following: expressive and receptive
language skills (teaching the child to communicate as well as understand what isbeing said to him); gross and fine motor skills (working on the child’s coordination
with his entire body as well as using his fingers and hands on smaller tasks);
affect (understanding and expressing emotion); self-help (daily living skills to
promote independence); cognition (teaching concepts that are pre-academicor academic in nature); socialization (which includes interacting with others,
promoting a concept of self, and controlling and promoting various behaviors).
In this broad curriculum, the various teaching programs or units are taught using
direct instruction with one teacher to one child, or in a group setting. Each childreceives between thirty-five and forty-five hours of instruction per week, twelve
months per year.2

26Section One: What Works and What Doesn’t?

LEAP Program for Preschoolers
The LEAP program (Learning Experience Alternative Program for Preschoolers
and Parents) for preschoolers with autism promotes an integrated early childhood
education occurring across home, school and community settings. LEAP uses
behavioral practices and developmentally appropriate strategies to implement
the curriculum. A component of the LEAP philosophy is to teach a child with
autism to learn from his peers.3 Within the curriculum, children are taught totransition from one activity to another, select play, and follow routines andgroup activities. Independent play is taught through: 1) having the child model
peers; 2) breaking the task down into smaller more manageable parts; 3) directteaching (instruction); 4) cuing the child to the correct answer (prompting), and5) rewards or reinforcements. Social interaction is taught by creating a structured
environment, using peers, teacher involvement, rewards and role-playing
scripts. Language is taught using “milieu teaching” (which includes incidental
teaching) and direct instruction at the beginning. Teaching style is both childand teacher directed. The classroom has three teachers to sixteen children, (tentypical children and six children with autism). Problematic behaviors are dealt
with by using preventative and positive strategies. To prevent poor behaviors,
LEAP employs class rules, daily schedules, activities, instructional materials,
staff assignments and choice-making. They also use something they term
“Individualized Preventative Strategies,” such as opportunities for adult or peer
attention, waiting activities, choices and decreasing task demands.
What evidence do the practitioners have that schoolbased IBT really works?
The literature on school-based autism programs is replete with descriptions ofprograms that have very little data supporting them. The exception to this is27

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

represented by five articles that report significant gains with children who haveattended school-based IBT programs.4,5,6,7,8 Fenske et al, (1985) published an
outcome study for eighteen subjects, nine under age five, nine over age five at
the PCDI. Of the nine students under age five, six of them indicated a positive
outcome as a result of the intervention. Of the nine students over age five, only
one indicated a positive outcome. Positive outcome for this study was measured
by whether the child could live at home and attend a public school or whether
the child continued to require treatment services.* Positive outcome is definedvery strictly and does not include the gains of those who required ongoingtreatment (and, therefore, remained in treatment at the institute). This group’s
gains were not reported as they were in the negative outcome group based onliving arrangements (which is an indirect way to measure progress). In addition,
the study compared older children with younger children: there was no control
group for comparing results of no treatment or a different treatment, to the one
being offered to both groups of children in this study. Fortunately, these results
are similar to those of many of the home-based behavioral treatment studies(which use very similar techniques). Therefore, we have some confidence
that the outcome of the children from the study conducted at the PCDI was a
result of the curriculum and not a result of the children simply getting older
and maturing.
Three outcome studies published by the DDDC provide data on the individuals
enrolled in their programs.5,6,7 Methodological weaknesses do exist in all threestudies. The Harris et al. (1990) study compares three groups of children assigned
to different types of classrooms (ten children with autism - five per group, andfour typical peers). Classroom assignment is based on severity of behavior,
which is problematic because it introduces a relevant variable to autism —These findings were significant at a level of p < .02; please see Section Two for a discussion on the meaningof significance levels.

*

28

Section One: What Works and What Doesn’t?

behavior. The authors themselves categorize this study as a “quasi-experimental
design.”9 They found that the children did make gains in language development.
They also found that integration versus segregation did not influence rate ofdevelopment; however, due to the design flaws of this study, the data regarding
integrated versus segregated settings must be viewed as tentative.
Unlike the Harris et al. 1990 study, the other two studies — Handleman et al.
(1991) and Harris et al. (2000) — do not state the criteria by which participants
were assigned to classrooms. Due to this missing information, we do not know
which classroom is responsible for the gains the children made. In other words,
is there an effect created by an integrated or segregated classroom or is thisvariable irrelevant? Second, can the improvements seen be attributed to theoriginal functioning level of the children, or are they due to the techniques usedin the classrooms themselves? Put another way, if the subjects assigned to theintegrated classroom have more skills that make them capable of learning in agroup setting, how representative are they of the autistic population or how similar
are they to the other group which is comprised of children with less skills? The
ability to learn in a group is an important goal for all autistic children; however,a large amount of one-on-one teaching or intervention is very often required
before a child can actually learn in a group setting. Specifically, in order for achild with autism to learn from a group, that child needs to be able to first learn
through observation and then understand group instruction.
The Harris et al (1990) study indicates that their subjects, as a group, could becharacterized as “high-functioning.”10 Unfortunately, the lack of representation of
the population of children with autism as a whole makes it difficult to generalize
the results, and the fact that the varied groups of children did not have different
forms of treatment (or no treatment), makes it difficult to judge whether or not
the treatment is responsible for the gains. Fortunately, in the later study the29The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

researchers did publish the children’s pre-and post IQ scores, which indicatethat some of the children did improve significantly (using a within-subjects
design for the study).
The Harris et al. (2000) study follows the original 27 children who spent time at
the DDDC between 1990 and 1992. Therefore, I will focus on this latest study
as it encompasses the long term results of children who purportedly made gains
at the DDDC using widely acceptable IQ measures. These researchers studied
the relationship between the age and IQ of the children when they entered the
DDDC program and their eventual school history. The researchers found thatthose children who entered the program prior to their fourth birthday were more
likely to be in regular education than children who entered the program at alater age. In addition, the intake IQ of these children influenced their eventual
educational outcomes. Fortunately, the researchers used a few different tests tomeasure improvement in the children (including widely accepted IQ measures*),which provides the reader with a good degree of confidence that the gains
observed did, indeed, occur.
There is one study with outcome data from the LEAP preschool model. The data
showed that children made gains in eight out of eight areas measured.8 Theseeight areas — fine motor manipulation and writing, language comprehension
and labeling, cognitive counting and matching, and gross motor object andbody movement12 — were measured using only one assessment of the dependent
variable: the Learning Accomplishment Profile (LAP). Unfortunately, the LAP
is not an assessment measure that has been widely proven to be reliable andvalid and is not widely used by psychologists in testing children with autism.
The Harris et al study (2000) reports IQ testing using the Stanford-Binet test which is widely accepted.
They also use the CARS and the LAP which are less widely accepted measures. In previous studies, however, children were tested using the Peabody Picture Vocabulary Test-Revised (PPVT-R)6 and the Vineland
Adaptive Behavior Scales: Survey Form.11*

30

Section One: What Works and What Doesn’t?

In addition, there was no blind, independent evaluator measuring these eight
dependent variables. The assessments were performed by the teacher, which
introduces rating bias; consequently, it is unwise to trust the results of the
LAP.
Unfortunately, there are several other methodological weaknesses which do
not allow the conclusion that the LEAP model is an effective intervention forchildren with autism. The study design lacked a control group. The various
tests were not done independently prior to and after the study, and commonly
accepted psychometric measures were not used. Consequently, it is very difficult
to know whether the gains made were a result of the intervention or simply due
to the child growing older.
Regarding the children in the study, only six children were involved, andthe diagnosis for these children was “autistic-like.” An additional concern
regarding the study was that the diagnosis of the children was not made by anindependent clinician. These children were labeled “autistic-like” simply basedon observations along the following criteria: self-stimulation; minimal or nofunctional speech; prolonged tantrums; minimal or no positive interaction withpeers; mild to severe range of mental retardation based on McCarthy Scales ofChildren’s Abilities (MSCA).13 It is not stated in the article, who it is that madethe observation or administered the MSCA. This lack of rigor in research could
result in bias in the classification of the participants as autistic or autistic-likeand could also result in errors in diagnosis, e.g., that these children may havebeen PDD or PDD-NOS but were erroneously labeled “autistic-like.” Therefore,
the participants were not representative of the typical autistic population. The
Diagnostic Statistical Manual (DSM - III or IV) would have been a more reliablemeasure.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

What does the therapy actually look like?
IBT is often run in a preschool or school setting; however, the PCDI also runs twoteaching homes. Their preschool and school programs are limited to twenty-fivestudents at any given time and services are provided in-home and community
settings as well. Staff are initially trained by the PCDI and regularly evaluated.
The various school and teaching home programs are integrated to foster
consistency and resources are shared between programs. Progress is assessedin areas of behavior, instructional procedures and family satisfaction.
Staff at the DDDC use a variety of teaching techniques depending on the level ofthe child and the content being taught. They instruct using discrete trial training,
incidental teaching and communication training. Discrete trial training is a very
efficient, systematic, behavioral teaching technique where a child works with ateacher one-on-one, breaking down concepts to make it easier to teach. In contrast,
incidental teaching is a method which attempts to teach a child by focussing upon
the information the child needs to learn when he or she has the opportunity tolearn it naturally. The belief is that the concept will be more meaningful when it
is relevant to the child. The third teaching technique, communication training,uses comprehensive speech and language instruction implemented by a teacher,following the recommendation of the speech therapist.14
Problematic behaviors are targeted for elimination using the typical, scientificallysubstantiated behavioral techniques customized to the child. Examples of thesemethods include a variety of techniques such as time-outs, verbally reminding thechild and overcorrection. Every two weeks a speech and language pathologist
assesses the progress of each child. In addition, children’s progress is measured
by using a variety of psychometric tests such as the Stanford-Binet IV, the Battelle
Developmental Inventory and the Learning Accomplishment Profile.
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Section One: What Works and What Doesn’t?

The LEAP preschool model is applied for fifteen hours per week, twelve months
per year. Students with autism are integrated with typical peers in a classroom
setting. In the study by Hoyson, Jamieson and Strain (1984), there were sixteen
students in the classroom, ten typical students and six students with autism. The
curriculum is individualized for the student, and parents are viewed as partners in
the “educational” process. They use a method of individualized group instruction
termed TRIIC, the acronym for “[Tri-I (Innovative, Integrative, Individualized)
Curriculum] for mainstreaming.”15 In this form of instruction, each child is given
individual objectives in three skill areas, and the teacher designs and implementsa group lesson plan that meets the needs of all the children in the group.
Would I send my child to a school-based Intensive
Behavioral Treatment program?
The decision to send one’s toddler off to a treatment facility, even if it is in apreschool, is a difficult one. I would be very careful to establish how much of
the day is treatment-based and how much is preschool. If I had lived in New
Jersey when my child was very young, I would have thought very seriously about
sending my child to the PCDI. However, I would have been vigilant to makesure that the child received treatment every minute of every day. As a parent,
I’ve seen too many preschools that claim they are providing treatment, when
in fact they are providing childcare. This is a serious problem. Government oruniversity affiliation is no guarantee that the autism expertise is sufficient to run
a treatment program. Among the worst preschool programs that actually claim
to be ”therapeutic,” are government-funded and staffed programs with a pricetag of $2.5 million dollars to treat twenty-five (25) children!
In interviewing the school staff, I would need to know how the school programand home program are coordinated and monitored. In addition, I would need to33

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

see evidence that the ratio of one teacher to more than one student is effective.
This is particularly important at the beginning of treatment when most children
with autism do not have the skills to pay attention, understand instructions
or sit at a table. I would also have questions about how the skills learned atschool are going to be generalized across settings (i.e., school to home) for
children who are not receiving any therapy outside the classroom. If thesequestions were answered to my satisfaction, then I might have enrolled mychild. Most importantly, I would need to know when the child is destined toleave the therapeutic program and is slated to be integrated with his typicallydeveloping peers.
My child required one-on-one treatment from the outset, as she did not haveany skills that would have allowed her to learn in a group setting. Therefore,
as long as she could be placed initially in the preparatory classroom (with one
teacher to one child), I would have considered the DDDC program. I would bequite nervous about my child moving to learn in a group-setting to the exclusionof one-on-one teaching which is, in my view, much more efficient than groupteaching. Eventually, we want and need our children to learn in a group setting;however, it may take the preschool some years to achieve that goal. I would
require assurances that it is my decision when she is ready for the group setting
and that the decision was only motivated by what is best for my child, rather
than some budgetary constraints requiring more “efficiency” and, therefore,
moving her away from a one-on-one treatment setting.
Although the LEAP curriculum sounds like an acceptable curriculum for children
with autism, there is not enough evidence that the children make substantial
gains; therefore, I would not enroll my child in a LEAP program. The integrated
classroom is an interesting idea since it makes sense that a child with autism
should be with typically developing children. However, I would like to see

34Section One: What Works and What Doesn’t?

a child with autism learn a number of skills prior to integration, in order for
integration to be worthwhile. If my child needed to be mainstreamed, I would
prefer to mainstream the child into a setting that was not therapeutic in nature
but rather was the kind of setting where parents would send their typicallydeveloping children. Once my child were taught to learn through modellingthe behaviors of others, the last thing I would desire is for her to be exposed to(and possibly model) other autistic children who might engage in repetitive,
self-stimulatory or other maladaptive behavior.
What else do I think?
What is particularly compelling about the PCDI is that although they concentrateon early intervention, if the child has not graduated from the preschool into akindergarten for typically developing children, then that child continues in atreatment program. The parents are not suddenly left with the impression thatthey are on their own because their child is already too old to be in an intensive,
behavioral treatment program. The aging out issue is a criticism of many IBT
programs that tend to concentrate on the younger children and wash their handsof the older children even though these children may require more treatment.
It’s a particularly common occurrence among government-funded programs
worldwide, where the sooner the children can graduate from IBT, the less money
the government has to spend.
With respect to the measure used by LEAP – the Learning Accomplishment
Profile (LAP) – this measure does not give a comprehensive assessment of
all relevant areas of development and, therefore, does not adequately assess
its own intervention strategies. Specifically, issues such as IQ and behavioral
change are not assessed, and language assessment is limited to naming andcomprehension. In addition, LEAP claims to target social interaction, independent

35

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

play, functional skills and peer teaching; however, none of these content areas
are assessed in the outcome study. The only areas assessed by the LAP are theeight areas that they identify (fine motor writing and manipulation, gross motor
object and body movement, cognitive matching and counting, and language
naming and comprehension). This measure excludes some very importantskill deficit and behavioral excess areas. Furthermore, there is no evidence that
self-stimulatory or other maladaptive behaviors are targeted for elimination.
While LEAP uses strategies to prevent such behaviors, there is no mention of
how behaviors are targeted when they occur. Due to the nature and frequencyof these non-learning behaviors, it is essential that behaviors which obstructlearning are controlled and, ideally, eliminated.
What kind of study would I like to see the school-based
IBT researchers do?
There are several important factors I would like to see in future outcome
studies on school-based IBT programs. More data is required to compare theprogress of subjects in experimental versus control groups, creating groups
with varied types and intensity of intervention. The dependent measure of
positive versus no positive outcome needs to be defined and operationalized
more explicitly. Specifically, the additional use of IQ and language assessment
indicators would be helpful in further examining outcome, particularly ingroups of different ages. A measure which indicates the amount of progress
being made, even by those individuals who require continued treatment, must
be incorporated in future research. These variables would ideally be measured
by at least one independent evaluator who is blind to the assignment of subjects
to groups. In addition, factors such as treatment intensity (home and school),
student-to-teacher ratio, dual diagnoses and age at treatment initiation need tobe controlled more stringently in order to determine the many factors which
influence treatment outcome.
36Section One: What Works and What Doesn’t?

In terms of LEAP specifically, new outcome data is required before any
conclusions can be made about the LEAP model and its efficacy. The Scientific
Review of Mental Health Practice had the following to say about LEAP:“Although certain aspects of the LEAP program appear promising, the paucityof the available research, and especially the absence of controlled research,preclude judgments about its usefulness.”16 Of the utmost importance is theneed for a control group in any further investigations. This is required in orderto determine the source of the changes found in the results. Also, it would benecessary to provide an experimental design which includes a larger subject
pool of children diagnosed with autism by an independent source. Ideally,
these children would be assessed for baseline levels of ability using various
measures including IQ, behavior and more extensive language measurement.
These assessments should also be administered by independent evaluators who
have no knowledge of the experiment, rather than teachers or other individuals
directly involved with the experiment.
Who else recommends for or against the School-Based
IBT for the treatment of autism?
There are many organizations that recommend ABA throughout the child’s life
and in every setting. The Association for Science in Autism treatment describes
ABA as being effective across a variety of settings including school and home.17
In addition, the Behavior Analyst Certification Board uses children in school
settings as an example of the application of ABA.18 After examining the data, nobona fide scientist would disagree with the delivery of school-based behavioral
treatment to treat the condition of autism. The question, however, is whether
treatment should be designed by the school-based or home-based professionals
consulting with the parent.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

So you’re still on the horns of a dilemma?
If the question is where to enroll the child — in an ABA school or a homebased program — the answer depends upon where the child can receive the best
program. The parent needs to determine whether the ABA school in the area
(if it exists) is of a high quality. If not, then a home-based program may be theonly option, bringing in competent professionals from the community or, if thatis impossible, then flying in professionals from a different region, or in somecases, another country.
What’s the bottom line?
The scientific research to date collected on children who attend high quality,
school-based, Intensive Behavioral Treatment programs provides evidence toconclude that their condition improved in school-based treatment settings andthat although the most significant gains were made by those children who begantreatment before the age of five, older children made significant gains as well.

38Section One: What Works and What Doesn’t?

Offshoots of Intensive Behavioral Therapies:
Pivotal Response Training and the Natural
Learning Paradigm
What is Pivotal Response Training/the Natural Learning
Paradigm?
Pivotal Response Training/the Natural Learning Paradigm (PRT/NLP) is atechnique to motivate individuals with autism to respond to multiple cues. PRT/NLP targets an autistic person’s lack of motivation and tendency to concentrateon one stimulus at the expense of other stimuli or “the big picture” (termed
stimulus overselectivity) by targeting these two areas which are consideredpivotal. These behaviors are considered to be pivotal because the theory isthat changing them results in a change in many other behaviors.1 The goal of
the intervention is to provide an easy-to-implement strategy which can also be
used in the community.2 PRT uses some principles of behavior modification
to teach the person with autism. The components of the intervention are: 1)
ensuring attention; 2) interspersing maintenance tasks (tasks that have alreadybeen mastered); 3) allowing the child to lead; 4) giving the child multiple
cue instructions; 5) providing reinforcement immediately; 6) providing
reinforcement contingently (rewarding the person based on their answer); 7)
providing reinforcement that is directly related to the behavior or task, and 8)
providing reinforcement for any goal-directed attempt at responding. PRT is
designed to discourage the individual from engaging in aggressive, self-injurious,
self-stimulatory and ritualistic behaviors; however, how these behaviors should
be dealt with is not specified. The Natural Learning Paradigm encompasses thephilosophy of Pivotal Response Training, which defines the learning as child-led
in a non-demanding setting where Pivotal Response Training occurs.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

What evidence do the practitioners have that thistechnique works?
PRT/NLP relies upon literature which studies the lack of joint attention behaviors
characteristic of children with autism3 and the ramifications of the lack of joint
attention on the development of speech and language.4 Although there has notbeen a single study comparing children in a comprehensive Pivotal Response
Training program to a well-settled behavioral treatment program (such as Lovaas
and colleagues created), Pivotal Response researchers have found a positive
relationship between very targeted interventions and an increase in speech.5
Although there are dozens of articles which relate to naturalistic teaching
and, by extension Pivotal Response Training, there are currently twelve peerreviewed journal articles providing outcome data on individuals with autism
who have been treated using PRT/NLP.4,6,7,8,9,10,11,12,13,14,15, 16 These twelve studies
concentrate on encouraging language through play, encouraging social behavior
and/or sociodramatic play or comparing the natural language paradigm versus amore structured adult led approach, which they refer to as analog teaching. In
almost all the studies, the sessions were videotaped and subsequently coded bydifferent researchers whose coding was compared to ensure consistency. This
safeguard was important because in some of the studies, peers or parents, notprofessionals, were involved in sessions with the autistic child. In most of thestudies, the interobserver agreement (the agreement between those researchers
who coded the sessions) was relatively high, i.e., in Laski et al. the interobserver
agreement did not drop below seventy-seven percent (77%) and at times was ashigh as ninety-eight percent (98%).17
Eleven of the twelve studies were single-subject case designs (see the next section
for an in-depth discussion on SSCD) utilizing a small number of children (withthe largest study involving ten children), most of whom had a diagnosis based40Section One: What Works and What Doesn’t?

on a version of the Diagnostic Statistical Manual (DSM). Over the last eighteen
years, proponents of PRT/NLP have published data on a total of fifty-one children
who were involved in very short term and/or low intensity experiments (often
lasting no more than thirty minutes a week over three months and often less thanthat). The majority of children in these studies were over three years of age,with many between the ages of five and ten years, some of whom were very highfunctioning.15,16 Based on these children, results have been reported that children
with autism utilizing PRT/NLP have more prosocial behavior, improvements insocial skills (and play), and an improvement in speech and language. Althoughthese results sound encouraging, the studies as a whole have several serious
drawbacks. Due to the complexity of the studies and the various claims made,each claim will be discussed separately.
Is Pivotal Response Training/Naturalistic Learning
Paradigm more effective for language acquisition?
PRT/NLP researchers and proponents claim that naturalistic teaching, whenused for speech and language, is more effective than the traditional researchsupporting discrete-trial training.16,17,18,19,20 This may have occurred with thesubjects in their experiments; however, this claim cannot be generalized to the
population of children with autism for two reasons: 1) the small number of children
per study (usually two or three children in each design) is too few children to
make generalizations about the effectiveness of PRT/NLP for the overall autistic
population and none have any follow-up after the study to see whether theobserved gains were permanent;* 2) the data from PRT/NLP is based on children
with varying degrees of language impairment who have had discrete trial training
There is one study where the researchers retrospectively studied intervention data from children who
did well or poorly in prior treatment. Unfortunately, they used retrospective pre-intervention archival
data and compared it to the postintervention data rather than following the children from their study
longitudinally.
*

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

learning histories prior to being part of these studies. Naturalistic or incidental
learning is predicted to be more efficient for children who had achieved somecompetency in language and/or who had extensive amounts of past treatmentusing discrete trial training. The reasoning here is the child has already achieved
the skills needed to learn in a more natural setting.15 This is an important point
because the suggestion that comes out of the PRT/NLP literature is to abandon
one of the most important techniques for some children in the ABA toolbox-- discrete trial training. This would be a severe mistake with a child who
appears to be completely unteachable (which is common for children with
autistic disorder), and for which discrete trial training may be the only option
at the beginning of a treatment program.
One study4 compared naturalistic teaching with more structured teaching todetermine which was more efficient. They found that naturalistic teaching
was much more motivating than structured teaching. However, this study has
a fundamental flaw which seriously undermines the results of the study.* In thenaturalistic condition, the clinician used highly-motivating three-dimensional
items to teach the target sounds; whereas, the analog condition used picture
cards with the items on the cards to teach the same sounds, and then praised thechild and reinforced the child’s correct response with food or a desired object.
This research demonstrates that using a desired object to teach a sound (or any
concept for that matter) will be more powerful because what is being taught
is intrinsically rewarding. However, it does not demonstrate that naturalistic
teaching is more efficient. This study needs to be done with the clinician in bothconditions using the highly-reinforcing three-dimensional items to teach, in both
The way analog vs. naturalistic teaching is defined confuses the fundamental differences. In Koegel, Koegel
and Carter (1999), they define the difference between naturalistic and analog teaching very strictly, making
the point that in analog teaching the child has no choice.14 There is, however, no contradiction between
analog teaching and giving a child a choice of the activity he or she would like to do first. The difference
has more to do with the child-led versus adult-led nature of the actual teaching trial.

*

42Section One: What Works and What Doesn’t?

the structured (analog) and naturalistic conditions. Otherwise, the differencesin teaching techniques are being confused with differences in: 1) degree ofreinforcement, and 2) the relevance of the reinforcer to what is being taught.*
Do children with autism emit less disruptive
behaviors with PRT/NLP?
The second claim made by proponents of PRT/NLP is that children emit lessdisruptive behaviors using the naturalistic teaching paradigm.21 It is plausiblethat initially there would be a difference between adult-led and child-led therapy
in terms of disruptive behavior. It makes perfect sense that behavior will not
be a concern if no demands are made of a child. However, the real question iswhether these children will progress to the point where they can cope in situations
where their ideas or way of doing things is not adopted, and be able to learn
to do what others require of them without emitting disruptive behavior, as all
typically developing children are expected to learn from an early age. Anotherpoint worth emphasizing is that in good analog teaching, disruptive behaviors
should not occur on a regular basis even when demands are placed on the child.
I suggest that the researchers have inadvertently compared a naturalistic learning
environment to a poor analog teaching environment where the reinforcementlevels are insufficient. In other words, the two different types of programs wereof a different quality. They compared a high-quality naturalistic-teaching programwith a very poor-quality adult-led analog program.
As previously mentioned, the learning histories (previous types of treatments)of these children need to be taken into account. One set of researchers describe
For this study to be valuable, there should be four conditions: 1) analog condition, relevant reinforcer; 2)analog condition, irrelevant reinforcer; 3) NLP condition, relevant reinforcer, and 4) NLP condition, irrelevant
reinforcer. Although we can predict that condition four will be the least successful, it is not clear whether
condition one or three will be more efficient. In short, the variable of reinforcer needs to be controlled.
*

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

a child who actually says “No cards.”22 This indicates to me that this child has
experienced poorly delivered therapy which has created an aversion to learning.
A poor therapy experience prior to the current study may have seriously biased
the results of that study as would any child’s prior learning history (one of theissues researchers using single-subject case designs studies must address).
Do children with autism increase their social and playskills with PRT/NLP?
There have been a few studies8,9,10,11,12,16 which attempt to use PRT/NLP to increase
the ability of autistic children in these areas. One study has been published in
two separate articles, one concentrating on language and toy play,11 the otherobserving social behavior.12 Both of these articles appear to be a replication of theearlier published findings.8 This study, conducted on two children with autism,
and two typically developing peers, reports positive changes in social language
and play skills. The children were ten years old and had language abilities overthree years of age prior to entering the study. Although their language ability
is not at age level, it is at a degree much higher than many young children with
autism, so their skills might not be representative of children with classic autism.
This was also the case of a more recent study which used two children who wereeight and nine years of age16 (treatment programs for children with autism typicallybegin in the toddler years).
An additional question concerns the validity of findings regarding play. These
children with autism may have memorized repertoires that they learned fromtypically developing children when in therapy, and then use when playing withanother group of children. In other words, creative pretend play does not occur.
Although this criticism may seem hypercritical, and I think that children with
autism may benefit by memorizing a number of scripts to use while playing

44Section One: What Works and What Doesn’t?

with peers, it is important to differentiate whether the child is reproducing playrepertoires or whether he or she is truly engaged in pretend play (the two can bedifferentiated by the uniqueness of each session without peer prompting). Two
alternative hypotheses to explain the results are that: 1) an autistic child may beincorporating a peer into rigid, role playing, which is not about joint attention ortrue social engagement, but simply the use of a peer as a “tool” for a higher levelof self-stimulatory or repetitive behavior, or 2) the child may be using memorized
scripts which are activated when particular toys are present. In addition, one
study counted the number of play date invitations made after the intervention.
This measure may have more to do with the parent’s ability to be reinforcing to
the typical peers than any actual increase in friendship.16
Another article published by Stahmer10 was far superior to the above studies
and allows us to unravel the complexity of the findings on play. This study
used a control group who provided language training, had more extensive
dependent measures, made sure the observers were “blind” to the condition of
the participants and reported the statistical significance of the results (a “p”
value). An important contribution of this study is the researcher’s honesty when
she suggests that for individuals without a certain level of language ability, theintervention may not be developmentally appropriate.23 Stahmer discusses one
child whose stereotyped play interfered with his learning and noted that the“children with the best language skills were the most creative and spontaneous
during play.”24 This is an illuminating point because this data demonstrates that
if Pivotal Response Training does ameliorate autism, it is only so for a highfunctioning subset of children or a subset of children who have reached a certain
level with well-settled IBT programs. Stahmer’s research is important because
it introduces the concept that PRT/NLP may be useful for a certain subset ofchildren with autism but not effective (or premature) for another group of children
who do not possess the prerequisite skills.

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Do skills learned through PRT/NLP generalize acrosssettings and people?
The ability of children with autism to generalize play skills based on thistreatment method remains debatable. It is still an open question whether thechildren who benefitted from Pivotal Response training in the above-mentioned
studies already had (prior to PRT/NLP treatment) many of the skills needed tolearn and generalize symbolic, complex and creative play. We are still uncertain
regarding whether it was the method of intervention or rather the children’s
readiness to generalize that made the difference, if indeed, these children did
actually generalize play and social skills at all.
The claim that PRT/NLP skills will generalize across settings and people ismore convincing when the consequence of using language is reinforcing. To
illustrate, if a child learns to ask for juice and receives juice every time he asks,
the data suggest that this skill will generalize across settings. Whether or nota less reinforcing request will generalize is still an open question. One study25
attempts to address this problem by gradually changing hidden reinforcing items
in a bag to less preferred ones, without affecting the spontaneity of the childasking, “What’s that?” referring to the hidden item in the bag. Whether or not
this question will be a permanent part of the child’s asking repertoire down theroad is unknown, although it is plausible that this skill may be maintained aslong as the reward is unpredictable. Nowhere is there any compelling evidence,
however, that this question-asking skill will generalize more or less successfully
if it were taught using an analog method (as long as the skill were generalized
after being taught).

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Section One: What Works and What Doesn’t?

What does the therapy actually look like?
PRT/NLP is described as the use of “loosely controlled environments [e.g.
a playground] and that utilizes shared control [e.g. turn taking] and multiple
exemplars [e.g. many toy materials].”26 Techniques such as turn-taking
opportunities, working on mastered skills and gaining the child’s attention areused to set the child up for success. Parents are trained to use these techniques with
their children to encourage language development and use. The three variables
that structure the learning situation are described in the PRT/NLP manual as: 1)
the child is given an instruction, question or spontaneous opportunity to respond;2) the child responds, and 3) the child is given a consequence.27 Although thissounds very similar to the traditional one-on-one behavioral treatment procedure,
the natural consequence of the instruction or opportunity is of importance. To
use their illustration: a child is cold while playing outside; the mother tells thechild to put on a coat, and the child does. The natural consequence is that thechild plays outside again, but this time he feels warm.28 Natural consequencessuch as those illustrated above can be highly motivating and, therefore, usefulwhen teaching and maintaining a skill as the reward is always present (in thiscase, warmth).
Would I try it on my child?
If my child were recently diagnosed, I would not rely upon PRT/NLP to ameliorate
her autism due to the lack of data reporting efficacy for young children who
are not yet speaking. This is an example of a promising area of research that isleaving the laboratory too early and being incorporated prematurely by parents
and educational systems prematurely. Because I wanted to provide my childwith the most evidence-based treatment, PRT/NLP would not have been my
choice. That said, in established, well-settled behavioral treatment programs,

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natural consequences that are reinforcing should be used whenever possible.
This principle is a foundation in the PRT/NLP literature.
What else do I think?
Most of these studies do not sufficiently rely upon standardized outcome
measures. The behavioral outcomes are generally measured by researchers whoare part of the study as are the emotional and social outcomes (with the exceptionof the occasional study where they use the Vineland Adaptive Behavior Scales —a test which looks at a variety of behaviors). In addition, the social and language
behaviors (the operationalization of the dependent measure) occasionally use
researcher observation alone. This is not an adequate or unbiased measure oftreatment outcome and there is no indication within some of the studies about
who is rating the observations. In addition, one study includes a measure ofteacher reported social behaviors within the classroom.29 In my view, this isa biased measure of change because it is not clear how much information theteacher has about the study (as she was instrumental in choosing peers for the
study).30
The authors of the PRT manual claim that it is designed for any child, including
those who are nonverbal. This conclusion is premature because subjects in all of
the studies had baseline language abilities that were higher than those typicallyfound in the population of young autistic children. In contrast, Stahmer (1995)
suggests that for individuals without sufficient language ability, the intervention
might not be developmentally appropriate.10 In other words, if a child is not
speaking yet, it is too soon for PRT.
This intervention approach emphasizes that the task must be child-led. The
manual states that the child must be able to choose the topic of an activity and48

Section One: What Works and What Doesn’t?

when to stop the activity. Concurrently, the authors state that disruptive behavior
is not acceptable and parents must take control until the child is capable of nondisruptive behavior. It is not clear how this philosophy meshes with the child-led
philosophy and how parents are to “take control” in this framework. It is likelythat a child who has had no intervention at all, and subsequently has few skills,
will be very resistant to initiating or remaining involved in an interaction.
Another issue of concern for the child-led approach is the lack of motivation
when the material is difficult or intrinsically non-reinforcing. It is unlikely thata child will initiate learning difficult concepts, as he or she has no understandingof them and the concepts might not be relevant. In addition, when a child is inschool, that child will be expected to participate in classroom learning, as do his
peers. This will be an additional challenge unless the child has learned how to
sit and learn material that is perhaps not intrinsically motivating. In addition,
the application of this method in a mainstreamed classroom is problematic. The
requirement that peers undergo extensive training in order to learn the strategies
proposed by PRT/NLP is highly unrealistic.
Another problem with this approach is “where to begin.” The authors recommendthat instructions given to the child should be multi-cued instructions. Children
with autism do not typically understand multi-cued instructions. Indeed, theyneed to be taught how to understand multi-cued instructions and there is notechnique offered to guide parents in how to teach this to their children. Prior
to using Pivotal Response Training, it can be argued that children need to betaught a variety of single instructions before they are expected to understandmulti-cued instructions.
The last point I need to make regards efficiency. If we are required to wait forchildren with autism to initiate everything they need to learn, I am concerned

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that we will lose precious time that early intervention requires, and the futureof these children may be compromised. In addition, it is extremely inefficient
to find a direct, natural consequence for everything that the child must learn.
Another difficulty with this offshoot of behaviorism is that it smacks of the“parent as therapist” ideology of how autism should be addressed, whereinparents, as opposed to professionals, deliver most or all of the “treatment.”6,31,32
Laski et al. actually report on a parent-training as a positive outcome when
they state:This study presented a promising new parent-training program designed
to increase autistic children’s Verbal Behavior. Post treatment increases inparents’ requests for vocalizations from their autistic children were observedin the generalization settings. Additionally, parents showed evidence ofgeneralizing these behaviors with the siblings of their autistic children. These
generalization effects are encouraging in that they may provide additional
support of the motivating qualities of natural language programs for bothparent and child...33 (emphasis added).

It goes without saying that it is not the parents with the neurological disorder,
it’s their child. The assumption that increased parent vocalization will cause
increased child vocalization is not sufficiently supported by data. In addition,
the expectation that the parents must be responsible for the therapeutic treatmentof their child plays into the rationing of health care for children with autism,
which governments will happily entertain if they receive academic justification
for it.**

The concept of parent as therapist is particularly offensive when one considers the fact that parents ofchildren with autism also have to make a living like everyone, at the some time as being responsible for
their autistic child’s progress. I’d like to suggest that the free-wheeling 1950s “Leave it to Beaver” family
unit is rare in 21st century modern society and would like to see any of these researchers be productivein their academic careers undertaking the role of therapist for their autistic children. Only in the field ofautism are our children considered so unworthy that the responsibility of treatment falls on the family
instead of on professionals in the field.

50Section One: What Works and What Doesn’t?

What kind of study would I like to see the researchers do
on Pivotal Response training and the Natural Learning
Paradigm?
There may be a place for the use of PRT/NLP in the education of individuals with
autism; however, exactly where and/or if it can be used effectively needs to beestablished. For individuals who have some language ability and are able to learn
somewhat incidentally, i.e., they do not require mass trials of repetition in orderto retain certain pieces of information, Pivotal Response behaviors may be a good
method of prompting generalization of desired behaviors. Research to determine
exactly who, and how much, this approach can help is desperately required. It
also needs to be determined how effective this intervention is when compared toother treatments. I would like to see a between-within subject design utilizing
a comprehensive protocol based on the PRT/NLP paradigm as compared to an
intensive, well-settled behavioral treatment program. In addition, it is crucial
that the PRT/NLP researchers use standardized language and IQ measures prior
to and after the study to determine to what extent autism has been amelioratedusing their protocol. The authors claim that one of the benefits of PRT is that the
behavior will occur in natural environments; however, this has yet to be supported
by high quality, long-term evidence. Clearly, a well designed, longitudinal study
with large numbers needs to be conducted prior to recommending this method
to anyone responsible for the treatment of children with autism.
Who else recommends for or against Pivotal Response
Training as a method for the treatment of autism?
The Developmental Behavioral Pediatrics On-line (a site closely connected with
the American Academy of Pediatrics) has reviewed PRT and states: “Althougheach of the components of the Pivotal Response intervention model has been

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extensively tested, there are no randomized trials comparing PRT to any
other intervention model. The only published follow-up study was done
retrospectively.” 32,34 Other than that, PRT/NLP has been protected fromcriticism as it falls under the general rubric of ABA which is a well-establisheddiscipline.
So you’re still on the horns of a dilemma?
I would recommend that prior to embarking on a program reliant solely on PRT/
NLP, that you have your child in a well-settled behavioral treatment program andawait more data which demonstrates that a comprehensive behavioral treatment
program using PRT/NLP is more effective than a traditional behavioral treatment
program. That said, the incorporation of natural consequences when possible
into a well-settled behavioral treatment program is certainly a powerful way toreinforce skills or positive behavior.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence that Pivotal
Response Training/The Natural Learning Paradigm is globally effective inameliorating the condition of autism. There is some very preliminary evidence
to suggest that this method can be used to target symbolic play skills in someindividuals with autism who possess above average language abilities. However,further studies with larger sample sizes and standardized testing are required toappropriately evaluate the method.

52Section One: What Works and What Doesn’t?

Offshoots of Intensive Behavioral Therapies:
Positive Behavioral Support
What is Positive Behavioral Support?
Positive Behavioral Support (PBS) is behaviorism guided by philosophy.
Practitioners of this method claim that it is a new field that has its roots in applied
behavior analysis, the inclusion movement and person-centered values.1 The
philosophy promotes the inclusion of people with disabilities in mainstream
society. By re-engineering the environment, it is claimed by PBS proponents thatthe individual’s quality of life is enhanced and thereby, behavior problems can be
minimized. What appears to differentiate PBS from other forms of behaviorism isthe promotion of educational systems to take responsibility in the re-engineeringof environment and the practice of PBS. Proponents claim that the eliminationof problem behavior is not the direct focus of PBS, but rather, a fortunate byproduct. They state: “the primary intervention strategy involves rearranging theenvironment to enhance life-style and improve quality of life rather than operating
directly on reducing problem behavior per se.”2 They differentiate PBS fromother forms of behaviorism by their “Life-span Perspective” and suggest thatmeaningful change may be slow and, in fact, may take decades.
Positive Behavioral Support is differentiated from traditional behaviorism by theemphasis on “ecological validity,” which proponents define as the applicabilityof the science to real-life settings. In other words, their vision is for parents,
teachers and job coaches, rather than professionals, to practice PBS. An additional
component of the PBS philosophy is “stakeholder participation” which they define
as a consumer-driven, rather than an expert-driven, applied science. In otherwords, the consumer is supposed to become an active participant in delivering the53

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PBS treatment. The third concern of PBS practitioners is that the interventions
be measured not by their “objective effectiveness” but rather by the impact on
the person’s quality of life (e.g., is the person happy and in an acceptable living
arrangement).
What evidence do the practitioners have that thisreally works?
Here is where Positive Behavioral Support becomes somewhat tricky to evaluate.
Since PBS practitioners have themselves often come from the field of applied
behavior analysis (ABA), some spending most of their academic career inthis field, it is very difficult to separate much of the research they cite that has
been done on ABA from the research that has been done on PBS specifically.*
A comprehensive database search netted sixty-five (65) articles on Positive
Behavioral Support (attempting to differentiate PBS from ABA). Of thesesixty-five articles, there were only six articles presenting experimental data ofany kind on children with autism. Of those six articles, one study concerned
parent perceptions of an early intervention program,3 seven case studies were
presented in four articles,3,4,5,6,7,8 one single-subject case design demonstrated adecrease in disruptive behavior,7 and one article reported on parent-professional
collaboration.8 Aside from these articles, all other articles to which PBS lays
claim actually flow from the field of ABA. Another concern regards the timeline for progress; PBS proponents evaluate changes made along the life span.
Understandably, it is very difficult to evaluate a treatment’s value if its effect isobservable only over decades.

*

Proponents seem to have expropriated decades of research in applied behavior analysis as theirown when they are demonstrating the efficacy of an intervention.12

54Section One: What Works and What Doesn’t?

What does the therapy actually look like?
The difference between PBS and ABA is not in what you see, but rather, in thedesign of the interventions. The process that the PBS practitioner goes throughis much the same as that of a behavior analyst, although the terminology isdifferent. The PBS practitioner does a Functional Behavioral Assessment (FBA)
to determine the function of the child’s behavior and then designs an intervention
to reduce or, ideally, prevent the behavior from occurring again. However,the behavioral intervention that is chosen may or may not differ from that of a
traditional behavior analyst, depending less upon what might actually be the idealintervention, and more upon the PBS view of the feasibility of the intervention in
the “real world.” In other words, the behavior to replace the problematic behavior
must be: “acceptable to caregivers; appropriate to the setting; within a person’s
skill set or easy to learn,”9 and appears to be more concerned with philosophy
rather than science-based measures of treatment outcomes.
Would I try it on my child?
I have refused, and am vigilant, to protect my daughter from anyone with thistreatment perspective whether they be an autism “professional” or a teacher. In
my view, PBS is a case of political correctness interfering with science. I wantto ensure that my child’s treatment is not influenced by “resources” in the system
at any one time (or lack thereof — most often the case). Specifically, I do notdesire that the educational system be responsible for her “support” because thisrigid, calcified system has shown itself time and time again to be a receptacle forincompetence when it comes to children with autism.10,11 School districts often
fund programs based upon the PBS philosophy because it is: a) politically correctand in line with the prevailing educational philosophy for typically developing

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students, and b) is inexpensive, as untrained (or insufficiently trained) employees
are expected to implement the interventions.
It is crucial that all the tools in the ABA toolbox are at the disposal of theprofessionals who design and implement my child’s treatment program, andnot only the ones that have been deemed as “acceptable” or “philosophicallypure” according to the school district, but also the ones that may not have any
relevance in my child’s life or her autism treatment needs.
When philosophy, rather than data, influences decisions it is harmful. When
my child was very young, prior to her being mainstreamed in school, she
required an intensive one-on-one ABA treatment regime to reach the point where
mainstreaming was desirable and possible. Without that work, her mere physicalproximity to typically developing children would have been of no use. PBS
might make everyone in the system feel as if they are good people; however,children with autism need to progress to the point where: 1) mainstreaming is
actually of benefit to them, and 2) they are treated with dignity in a mainstream
setting and not treated like the token disabled person whose disruptive nature issimply tolerated due to political correctness. This is all too often the case when
philosophy, rather than science, guides decisions.
What else do I think?
In my opinion, Positive Behavioral Support is a very dangerous field for children
with autism. The reason this philosophy is dangerous (aside from the obvious
which is research being subjugated by a form of religion – and I think PBS isa type of religion of political correctness), is that it denies children with autism
access to proven, science-based treatment methods. Frankly, I find even the term
Positive Behavioral Support offensive. The fact that it is “positive” behavior

56Section One: What Works and What Doesn’t?

support carries a presumption that the PBS practitioner is different and apart fromhis “evil” ABA behaviorist counterpart. In fact, traditional behavior analysts
have very stringent ethical guidelines that practitioners are required to follow
in order to be certified.12 All academic research done on human subjects must
pass university ethics boards and any clinical treatment that may be considered
ethically questionable cannot be conducted by reputable practitioners without
judicial oversight. It is no longer the freewheeling 1950s where many ethicallyquestionable activities can take place behind the walls of government institutionsin the name of therapy. There are laws now in place which protect disabled
people from direct harm.
I also find it interesting that PBS practitioners see no contradiction between
inclusion and mainstreaming, and redesigning the environment to accommodate
children with autism. To illustrate, if we do not teach children with autism to beable to cope with the general chaos of life, how are we going to have them go
into a shopping mall and function properly? Asking the mall administration toturn off the music in the elevators prior to a child entering is not practical!
I live in a region where Positive Behavioral Support is used extensively byschool districts and is wholeheartedly supported by government. This region
happens to be an area where autism policy is functionally in the 1950s in termsof efficacy. Consequently, there is a large and steady exodus of parents out ofthe public school system into the private system, or home-schooling, due to thisglobally ineffective and harmful philosophy which masquerades as an applied
behavioral science.
One final point on PBS: when one reads the literature from Positive Behavioral
Support, autism appears to be an entirely different disability. These children
seem to be very mild, and the behavior problems are all easy to control, as long57

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as the environment is “re-engineered.” Children with self-injurious behavior do
not seem to be a challenge for this group. Perhaps children who participate in
PBS studies are not classically autistic. My caveat regarding the type of children
participating in PBS studies is also supported by Durand and Rost13 who truthfully
caution those reading the literature on PBS that there may be a selection bias in
the subjects for the studies that they do conduct.
What kind of study would I like PBS researchers to do?
I think that this group of researchers should abandon the anti-science, antiintellectual discipline they have developed. They should return to the fieldof applied behavior analysis, compete with researchers in that field and havetheir PBS research properly scrutinized and evaluated by their ABA academic
peers.
Who else recommends for or against Positive Behavior
Support as a method for the treatment of autism?
Mulick and Butter (2005)14 provide a very useful, in-depth critical analysis of
Positive Behavior Support that I highly recommend prior to even thinking about
using this so-called autism treatment method. Mulick and Butter lay out thecomplete history of Positive Behavior Support and expose the pseudo-scienceof PBS in detail.
So you’re still on the horns of a dilemma?
If you are still not sure whether your child should be in a behavior management
program based on Positive Behavior Support, I would encourage you to ask
the purveyors of PBS how they intend to measure short-term outcomes. You
need to make sure that these outcomes objectively measure the child’s progress
58Section One: What Works and What Doesn’t?

(measuring behavior and IQ) and not the approval rating or opinions of others
about how the child is progressing. In addition, it is crucial to ensure that thegoals are short-term and substantive, rather than fuzzy, long-term quality-of-lifegoals which can be easily manipulated to appear rosy.
What’s the bottom line?
Based on the scientific research to date, there is no evidence to conclude that PBS
is anything more than a philosophy rather than a science. Consequently, there isno evidence to demonstrate that PBS ameliorates the condition of autism.

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Section One: What Works and What Doesn’t?

Offshoots of Intensive Behavioral Therapies:
Verbal Behavior
What is Verbal Behavior?
In 1957, B.F. Skinner (the grandfather of behaviorism) published a book called
Verbal Behavior.1 In this book, Skinner applied his ideas about learning to
Verbal Behavior. Specifically, Skinner defined various types of Verbal Behavior
that humans exhibit. This typology improved behaviorist understanding of
how different parts of language are developed and enabled them to teach thevarious functions of language and set up an environment to promote the use of
these parts of language. Sundberg and Partington (1998) take Skinner’s ideas
and apply them to teaching language to children with autism in a user-friendly
format designed for the nonacademic audience. They define the various typesof verbal behavior and provide a discussion of each language repertoire in theirbook, Teaching Language to Children with Autism or Other Developmental
Disorders. They describe these language repertoires as: receptive (complying
with or following directions); echoic (repeating what others have said); imitation(copying actions); tact (labelling); mand (asking); RFFC- Receptive by Function,
Feature, and Class (identifying items based on their description); intraverbal(answering questions on a more conceptual level); textual (reading words), andwritten (scribing words that are heard).2
Put simply, Verbal Behavior Therapy is an attempt to utilize the principles of
behaviorism to teach children with autism to communicate. The concept ofverbal behavior has existed for approximately fifty years; the primary impetusof verbal behavior is the application of the ideas of B.F. Skinner to children with
autism. Although Sundberg and Partington have been working on these ideas
since approximately 1978, this area has become increasingly popular in the last

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ten years because ideas regarding how to teach language to children with autism
are presented in a more accessible format than was previously available. In
addition, there has always been a need to target language acquisition for children
with autism as these children have significant language deficits.
What evidence do the practitioners have that thisreally works?
Here’s where the difficulty begins. Although the ideas of Skinner regarding verbal
behavior are compelling and theoretically rich, the testing of these ideas has lagged
far behind. Unfortunately, what little data does exist is not necessarily on children
with autism.3 A comprehensive literature search using all the major academic
databases did not net even one study to provide evidence that a comprehensive
Verbal Behavior program would significantly improve the language ability ofchildren with autism, and/or facilitate more comprehensive or global improvementin their condition. However, Verbal Behavior researchers have done studies
concentrating on evoking manding (asking)4,5 and increasing vocal behavior.6
This area will hopefully bear more fruit with additional studies.
What does the therapy actually look like?
The teaching sessions are initially one-on-one (one therapist to one student) andthey look very similar to traditional, well-settled behavioral treatment programs.
Prior to working with the child to teach the various parts of language, thereis 1) a language assessment using a Behavioral Language Assessment Form7
that determines which skills the child has mastered and which skills need to
be developed, and 2) an emphasis on making the therapeutic setting fun andreinforcing. The first skill they generally teach is Manding (which is teaching
the child to request). Typically, the therapist has an item the child wants but
needs help to acquire. This system can be used with children who cannot

62Section One: What Works and What Doesn’t?

communicate vocally by using sign language or an augmentative communication
system. Children are taught to request items they see and then items they cannot
see. They are generally taught to mand using single words at first even when
they are capable of using full sentences. Eventually, the child incorporates more
words into the sentence and is able to mand without prompting or artificiallysetting up a reinforcing situation. In other words, the child requests because hetruly desires or needs something. Over time, other parts of Verbal Behavior aretaught.
From my reading of the verbal behavior material, there does not seem to be aconsensus on how many hours per week a Verbal Behavior Therapy program
should run. Data is taken throughout, generally using a data collection systemdesigned by the pioneers of the application of Verbal Behavior, Sundberg andPartington.7 For a user-friendly description of Verbal Behavior Therapy andsamples of the data, the Mariposa School has created an easy to understandtraining manual.8
Would I try it on my child?
Although I would not place my child in a program that worked solely using
Verbal Behavior Therapy, if she were younger I would be open to applying the
VB empirically supported areas to her program. I see very little difference insome of the techniques used in traditional IBT programs, although the terminology
is different. At this point, my daughter already has amassed the skills that haveempirical support from the Verbal Behavior literature the traditional way, in abest practices, outcome-based behavioral treatment program. Therefore, at thispoint those areas would no longer be appropriate for her based on her level oflanguage development.

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What else do I think?
Practitioners in the area of Verbal Behavior do not appear to sufficiently address
the issue of behaviors that interfere with learning. Indeed, there are those who
believe that autism is primarily a disorder preventable with Verbal Behavior
Therapy.9. 10 Their thesis is that the various nonsocial (or anti-social) behaviors
we see exhibited by people with autism are a result of the “core” deficit, which isa disorder of Verbal Behavior. Drash and Tudor (2004) state: “Conceptualizing
autism as a contingency-shaped disorder of Verbal Behavior may provide a newand potentially more effective paradigm for behavioral research and treatment in
autism”11 Although this is an interesting proposition, it has not yet been supported
by data; therefore, it is premature for parents to be told by those providing Verbal
Behavior Therapy to end all other forms of behavioral treatment. It would bemuch safer to incorporate those techniques which have some empirical support(albeit limited) such as the research done on the teaching mands for information.5
That said, based on the limited empirical support, it is important to track the child’s
progress with data to make sure that the child is aquiring more language.
What kind of study would I like to see the researchers
working on Verbal Behavior do?
This is an exciting, emerging area in which there is much work to be done.
Oak and Dickson (1989)12 did a review of the literature and found very little
empirical support. Other researchers in this field are calling for more studies tobe conducted. I was particularly pleased to find an article written by Carr andFirth (2005)13 calling for additional empirical support. These academics suggest(and I wholeheartedly agree) that there needs to be research done comparing the
UCLA model (pioneered by Lovaas and colleagues) and the Verbal Behavioral
model as there is no documented outcome from comprehensive Verbal Behavior

64Section One: What Works and What Doesn’t?

programs. More research needs to be conducted on individual Verbal Behavior
techniques in order for Skinner’s theory of Verbal Behavior to be refined to reflect
the empirical research done on this population of children.
Who else recommends for or against Verbal Behavior asa method for the treatment of autism?
I could not find any organizations with an official stance on Verbal Behavior as
it is classified under the umbrella of ABA, which is a science-based discipline.
Therefore, it is for the consumer to rely on the community of academics in thefield of applied behavior analysis to call for additional research, as did Carr andFirth (2005).
So you’re still on the horns of a dilemma?
If you would like to incorporate Verbal Behavior into your behavioral treatment
program, make sure that you monitor the progress of the child, quantifying thegains using cold, hard data. In addition, the child should be assessed using
psychometric testing on a yearly basis by a psychologist with no connection to thepractitioners of Verbal Behavior. Moreover, it is important to monitor behavioral
gains to see whether progress in Verbal Behavior is having a positive, neutral or
negative effect on other behaviors indicative of autism. Monitoring behavior is
crucial: if the child’s behavioral gains begin to erode, it is important to recognize
the behavioral backslide and take steps to reverse the trend.
What’s the bottom line?
Based on the scientific research to date, there is no data to suggest that a pure
Verbal Behavior program will ameliorate the condition of autism; however,certain techniques used by practitioners promoting Verbal Behavior do have
limited empirical support. In short, this field is still emerging.
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Section One: What Works and What Doesn’t?

Offshoots of Intensive Behavioral Therapies:
Fluency Training
What is Fluency Training?
Fluency can be defined most simply as accuracy plus speed, or quality plus
pace.1 Proponents of Fluency Training argue that the way traditional behaviorists
measure whether a person has acquired a skill must take into account if the student
provides the correct answer or not, and how long it takes the student to present
the correct answer. To illustrate, if a student is asked, “What’s your name?” andit takes the student five minutes to answer, does the student actually have theskill? The answer here is obviously “no.”Precision Teaching is the field that studies and applies fluency techniques tolearning. This field has influenced many areas of life, including educational
systems (specifically in the areas of numeracy and literacy), competitive athletics,
and organizational productivity.2 Precision teaching is not new. In fact, manyof us have been taught our multiplication tables using this very technique. Those
researchers and practitioners in the field of Precision Teaching have found thatbehavioral fluency is associated with positive learning outcomes. Binder (1993)
describes these general outcomes as “retention and maintenance of skills andknowledge; endurance or resistance to distraction; and application or transferof training”3
Although the vast majority of research has been conducted on non-autistic
students, this teaching method is now used by some on children with autism.
Some practitioners in the field of applied behavior analysis have incorporated
fluency techniques in their comprehensive treatment programs for children with
autism in areas where the skill lends itself to mastery through fast and frequent

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repetition. Other practitioners have abandoned most other tools in the ABA
toolbox (including discrete trial training), and rely solely on fluency-based
instruction.
What evidence do the practitioners have that this really
works?
The field of Precision Teaching is quite broad, laying claim to many peer-reviewed
journal articles published on Fluency; however, data published on the use of
Fluency for children with autism, specifically, is scarce. Five years ago there wasalmost no data on Fluency and autism. Since that time, approximately fifty papers
and poster presentations have been made at ABA conferences; the proponents
of Fluency have established a peer-reviewed journal, and they are also taking
submissions from those collecting data on fluency instruction (primarily using
a celeration chart – the chart used by these practitioners to measure Fluency).
After a comprehensive literature search in many databases and through fugitive
literature searches, I found eight articles providing data which measure theinfluence of Fluency-based instruction for specific skills on children with autism.
Examples of skills taught using Fluency include improving speech intelligibility,4labelling pictures,5 teaching visual pattern imitation,6 reading comprehension,7
joint attention,8 prepositions,9 and answering informational WH questions.10
Although this increased publication stream is a step forward for this emerging
field as it applies to autism, almost all the articles were published in the recently
established Journal of Precision Teaching and Celeration. In order to gain
acceptance as a well-settled methodology for autism, these practitioners needto publish in well-established behavioral journals as well. It is particularly
problematic that these practitioners have abandoned the well-establishedbehavioral journals as the lion’s share of the articles published on autism and68Section One: What Works and What Doesn’t?

Fluency in the Journal of Precision Teaching and Celeration are written by thefounder of the journal.
What does the therapy actually look like?
The fundamentals of each skill are learned in a fast-paced way, with progressrecorded on a celeration chart (a form of time-based measurement). The childis taught by practicing the skill rather than being told what to do (e.g., the useof flash cards would be common). The information would also be asked using
what Fluency practitioners refer to as six multiple learning channels which arecomprised of See-Write, Hear-Say, Free (recall) Write, See-Say, Free (recall)
Say, Hear-Do. These channels constitute different ways to introduce and teachskills. Repetition through a varied number of learning channels is hypothesized
to improve the learning and retention process and, thereby, achieve Fluency(once again, defined as accuracy and rate).
Would I try it on my child?
Although I recognize that rate plus accuracy is important to truly master any
skill, there is insufficient data demonstrating that a behavioral treatment program
utilizing Fluency instruction exclusively (not taking advantage of the manydifferent tools in the behavioral toolbox), will improve my child’s abilities. I
would have no problem, however, utilizing Fluency as a technique to teacha particular skill that has been well-established to benefit from role learning(such as memorizing multiplication tables or a vocabulary list); however, if mychild were young, I would be very wary of replacing discrete trial training with
Fluency-based instruction, as the former is a well-established technique usedwith autistic children, whereas the latter technique is still emergent as applied tochildren with autism. That said, I think there are some skills that lend themselvesbetter to this teaching method than do others.
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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

What kind of study would I like to see the researchers
working on Fluency do?
I would like to see the progress of children who have undergone Fluencybased instruction measured using nonfluency-based, standardized instruments.
Specifically, IQ and language proficiency measures both pre and post treatment
are necessary for these studies to track improvement. Because these practitioners
use single-subject case designs exclusively, standardized measures are crucial
to determine whether the children’s gains are genuine. This is also the reason it
is imperative for Fluency practitioners to publish their results in peer-reviewed
journals of which they are not on the editorial boards. I am very optimistic
regarding the potential of Fluency-based instruction to teach children with autism
who have obtained a basic level of learning competence. However, prior to using
a novel approach which may or may not produce the same positive outcomes,
Fluency needs to be scrutinized more closely by those practitioners in the area of
applied behavior analysis. In addition, I would like to see Fluency researchers
create a between-subject design using their curriculum and comparing it tochildren in a best-practices, intensive, behavioral treatment program.
Who else recommends for or against Fluency asa method for the treatment of autism?
This method has not yet gained much popularity as a comprehensive treatment
for autism, although Fluency-based instruction is used in some programs as one
technique in the ABA toolbox. Therefore, there is very little debate about Fluency;
however, I expect that this may change as more parents choose to use Fluencybased instruction exclusively for their child’s autism treatment program.

70Section One: What Works and What Doesn’t?

So you’re still on the horns of a dilemma?
If you would like to try Fluency-based instruction, I would recommend thatyou use a behavioral consultant who incorporates Fluency as one technique ina comprehensive treatment program, rather than use consultants who attempt
to target everything through Fluency-based instruction. In addition, I would
have my child tested once a year, using a variety of psychometric and language
assessment tests conducted by a psychologist with no emotional or financial
investment in Fluency-based instruction.
What’s the bottom line?
Based on the scientific research to date, there is insufficient evidence to determinethat an Intensive Behavioral Treatment program relying solely on the use of
Fluency-based instruction will ameliorate the condition of autism, although there
is limited evidence that points to the appropriate use of Fluency-based instruction
for certain deficiences characteristic of autism.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

Endnotes for Intensive Behavioral Treatment
Introduction
1
Lieberman, D.A. 2nd Edition. 1993. Learning, Behavior and Cognition. Belmont, CA:
Wadsworth Publishing.

Behavior Analyst Certification Board. <http://www.bacb.com/pages/aboutBAs.html> (accessed
Nov. 8, 2005).
2

3

Matson, J. L., D.A. Benavidez, L.S. Compton, T. Paulawskyyj, and C. Baglio. 1996. “Behavioral
Treatment of Autistic Persons: A Review of Research from 1980 to the Present.” Research in
Developmental Disabilities. No. 17, No. 6, p. 433-465.
4
Freeman, S.K. 2003. Science for Sale in the Autism Wars: Medically necessary autism treatment,
the court battle for health insurance and why health technology academics are enemy number
one. Langley, BC: SKF Books, Inc.

Home-based Treatment
Metz, B., J.A. Mulick, and E.M. Butter. 2005. “Autism: A late 20th century fad magnet.” In
J.W. Jacobson, R.M. Foxx, and J.A. Mulick, eds., Controversial Therapies for Developmental
Disabilities: Fad, Fashion, and Science in Professional Practice, NJ: Lawrence Erlbaum
Associates, p. 237.
1

Lovaas O.I. 1987. “Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children.” Journal of Consulting and Clinical Psychology, Vol. 55,
No. 1, pp. 3-9.

2

3

Anderson, S.R., D.L. Avery, E.K. DiPietro, G.L. Edwards, and W.P. Christian. 1987. “Intensive
Home-based Early Intervention With Autistic Children.” Education and Treatment of Children,Vol., 10, Vol. 4, pp. 352-366.
4

Birnbrauer, J.S., and D.J. Leach. 1993. “The Murdoch Early Intervention Program After 2
Years.” Behavior Change, Vol. 10, No. 2, pp. 63-74.
McEachin, J.J., T. Smith, and O.I. Lovaas. 1993. “Long-Term Outcome for Children With
Autism Who Received Early Intensive Behavioral Treatment.” American Journal on Mental
Retardation, Vol., 97, No. 4, pp. 359-372.
5

Smith, T., S. Eikeseth, M. Klevstrand, and O.I. Lovaas. 1997. “Intensive Behavioral Treatment
for Preschoolers With Severe Mental Retardation and Pervasive Developmental Disorder .”American Journal on Mental Retardation, Vol. 102, No. 3, pp. 238-249.

6

7

Eikeseth, S., T. Smith, E. Jahr, and S. Eldevik. 2002. “Intensive Behavioral Treatment at Schoolfor 4 to 7 Year-Old Children With Autism: A One-Year Comparison Controlled Study.” Behavior
Modification, Vol. 26, pp. 49-68.
8Howard, J.S., C.R. Sparkman, H.G. Cohen, G. Green, and H. Stanislaw. 2005. “A Comparison

72Section One: What Works and What Doesn’t?

of Intensive Behavior Analytic and Eclectic Treatments for Young Children With Autism.”
Research in Developmental Disabilities, Vol. 26, pp. 359-383.
Sallows, G. O., and T.D. Graupner. 2005. “Intensive Behavioral Treatment for Children With
Autism: Four-Year Outcome and Predictors.” American Journal on Mental Retardation, 2005,
Vol. 110, No. 6, pp. 417-438.
910Cohen, H., M. Amerine-Dickens, and T. Smith. 2006. “Early Intensive Behavioral Treatment:
Replication of the UCLA Model in a Community Setting.” Journal of Developmental and
Behavioral Pediatrics, Vol. 27, No. 2S, pp. S145-55.
11

Sheinkoph, S.J., and B, Siegel. 1998. “Home-based Behavioral Treatment of Young Children
With Autism.” Journal of Autism and Developmental Disorders, Vol. 28, No. 1, pp. 15-23.
12Smith, T. 1993. “Autism.” In T.R. Giles ed., Handbook of effective psychotherapy, NY: Plenum,pp. 107-133.
13

Smith, T., A. Groen, and J. Wynn. 2000. “Randomized Trial of Intensive Early Intervention
for Children with Pervasive Developmental Disorder.” American Journal on Mental Retardation,
Vol. 105, pp. 269-285.
14

Butter, E.M., J. Mulick, and B. Metz. 2006. “Eight Case Reports of Learning Recovery inChildren with Pervasive Developmental Disorders After Early Intervention.” Behavioral
Interventions, Vol. 21, No. 4, pp. 227-243.
Bibby, P., S. Eikeseth, N.T. Martin, O.C. Mudford, and D. Reeves. 2002. “Progress andOutcomes for Children With Autism Receiving Parent-Managed Intensive Interventions.”
Research in Developmental Disabilities, Vol. 23, pp. 81-104.
14

15

Lovaas, O.I., (see n. 2 above), p. 3.

16Baer, D.M. 1993. “Commentaries on McEachin, Smith, and Lovaas: Quasi-Random Assignment
Can Be As Convincing As Random Assignment.” American Journal of Mental Retardation,
Vol. 97, No. 4, p. 374.
17

Sallows, G.O., T.D. Graupner, (see n. 9 above), p. 433.

18

Guralnick, M., ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany, NY: New York State Department of Health, p. IV-15.
19

Satcher, D. 1999. Mental health: A report of the surgeon general. U.S. Public Health Service.
Bethesda, MD www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html#autism(accessed Jan. 11, 2006).
20

American Academy of Pediatrics. 2000. “Policy Statement: The Pediatrician’s Role in the
Diagnosis and Management of Autistic Spectrum Disorder in Children.” Pediatrics, Vol. 107,
pp. 1221-1226. www.aap.org/policy/re060018.html (accessed June 18, 2000).

73

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!
21
National Research Council. 2001. Educating children with autism, Committee on Educational
Interventions for Children With Autism, Division of Behavioral and Social Sciences andEducation, Washington, DC: National Academy Press. http://books.nap.edu/books/0309072697/
html/index.html (accessed May 5, 2006).
22

Volkmar, F., E.H. Cook, J. Pomeroy, G. Realmuto, and P. Tanguay. 1999. “Practice Parameters
for the Assessment and Treatment of Children, Adolescents, and Adults With Autism and Other
Pervasive Developmental Disorders.” Journal of the American Academy of Child and Adolescent
Psychiatry, Vol. 38 (sup), pp. 32S-54S.
Lovaas, O.I. 2003. Teaching individuals with developmental delays: basic intervention
techniques. Austin, TX: Pro-Ed, Inc., pp. 323-325.

23

Maurice, C., G. Green, and S.C. Luce. 1996. Behavioral intervention for young children with
autism. Austin, TX: Pro-Ed, Inc.
24

25
Leaf, R., and J. McEachin. 1999. A work in progress: Behavior management strategies and acurriculum for Intensive Behavioral Treatment of autism. New York, NY: DRL Books, L.L.C.

Cambridge Center for Behavioral Studies. http://store.ccbsstore.com/default.asp (accessed
May 5, 2006).

26

Centre-based Treatment
1

McClannahan, L.E., MacDuff G.S., and Krantz, P.J. 2002. “Behavior Analysis and Intervention
for Adults with Autism.” Behavior Modification, Vol. 26, No. 1, pp. 9-27.
2Harris, S.L., and J.S. Handleman. 2000. “Age and IQ at Intake as Predictors of Placement for
Young Children With Autism: A Four-to-Six-Year Follow-Up.” Journal of Autism Developmental Disorders, Vol. 30, No. 2, p. 139.
3

Strain, P.S., and L.K. Cordisco. 1994. “Chapter 5: The Creative Curriculum for Early Childhood.” In S,L. Harris and J.S. Handleman, eds. Preschool Education Programs for Children
With Autism. Austin, TX: Pro-Ed, Inc.
4

Fenske, E.C., S. Zalenski, P.J. Krantz, and L.E. McClannahan. 1985. “Age at Intervention andTreatment Outcome for Autistic children in a Comprehensive Intervention Program.” Analysis
and Intervention in Developmental Disabilities, 1985, Vol. 5, pp. 49-58.
5

Handleman, J.S., S.L. Harris, D. Celiberti, E. Lilleleht, and L. Tomchek. 1991. “Developmental
Changes of Preschool Children with Autism and Normally Developing Peers.” The
Transdisciplinary Journal, Vol. 1, No. 2, pp. 137-143.
6

Harris, S.L., J.S. Handleman, B. Kristoff, L. Bass, and R. Gordon. 1990. “Changes in Language
Development Among Autistic and Peer Children in Segregated and Integrated Preschool Settings.”
Journal of Autism and Developmental Disorders, Vol. 20, No. 1, pp. 23-31.
Harris, S.L., and J.S. Handleman. (see n. 2 above).

774Section One: What Works and What Doesn’t?

8

Hoyson, M., B. Jamieson, and P.S. Strain. 1984. “Individualized Group Instruction of Normally
Developing and Autistic-Like Children: The LEAP Curriculum Model.” Journal of the Division
for Early Childhood, Vol. 8, No. 2, pp. 157-172.
Harris, S.L., J.S. Handleman, B. Kristoff, L. Bass, and R. Gordon, (see n. 6 above), p. 25.

9

10

Harris, S.L., J.S. Handleman, B. Kristoff, L. Bass, and R. Gordon, (see n. 6 above), p. 24.

11
Harris, S.L., and J.S. Handleman. 1994. “Chapter 5: The Douglass Developmental Disabilities
Center.” In S.L. Harris and J.S. Handleman, eds. Preschool Education Programs for Children
With Autism. Austin, TX. Pro-Ed, Inc., p. 74.
12

Hoyson, M., B. Jamieson, and P.S. Strain, (see n. 8 above), p. 159.

13

Hoyson, M., B. Jamieson, and P.S. Strain, (see n. 8 above), p. 165.

14

Harris, S.L., and J.S. Handleman, (see n. 11 above), p. 77.

15

Hoyson, M., B. Jamieson, and P.S. Strain, (see note 8 above), p. 158.

16
The Scientific Review of Mental Health Practice, www. srmhp.org/0101/autism.html (accessed
Jan. 11, 2006).
17

Association for Science in Autism treatment, www.asatonline.org/about_autism/autism_info04.
html (accessed Feb. 21, 2006).
Behavioral Analyst Certification Board, www.bacb.com/consum_frame.html (accessed Feb.
21, 2006).
18

Offshoots:a) Pivotal Response Training
1
Koegel, R.L., L. Schreibman, A. Good, L. Cerniglia, C. Murphy, and L.K. Koegel. 1989. How
To Teach Pivotal Behaviors to Children With Autism: A Training Manual. Santa Barbara CA:
University of California.

Koegel, R.L., et al., (see n. 1 above).

2

3
Bruinsma, Y., R.L. Koegel, and L.K. Koegel. 2004. “Joint Attention and Children With Autism:
A review of the Literature.” Mental Retardation and Developmental Disabilities, Vol.10, pp.
169-175.
4Koegel, R.L., S. Camarata, L.K. Koegel, A. Ben-Tall, and A.E. Smith. 1998. “Increasing SpeechIntelligibility in Children with Autism.” Journal of Autism and Developmental Disorders, Vol.
28, No. 3, pp. 241-251.
Koegel, et al., (see n. 4 above), p. 246.

5

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

6

Laski, K.E., M.H. Charlop, and L. Schreibman. 1988. “Training Parents to Use the Natural
Language Pardigm to Increase Their Autistic Children’s Speech.” Journal of Applied Behavior
Analysis, Vol. 21, No. 4, pp. 391-400.
7Koegel, R.L., L.K. Koegel, and A. Surratt. 1992. “Language Intervention and Disruptive
Behavior in Preschool Children with Autism.” Journal of Autism and Developmental Disorders,Vol. 22, No. 2, pp. 141-153.
8

Pierce, K., and L. Schreibman. 1995. “Increasing Complex Social Behaviors in Children with
Autism: Effects of Peer-Implemented Pivotal Response Training.” Journal of Applied Behavior
Analysis, Vol. 28, No. 3, pp. 285-295.
9

Thorp, D.M., A.C. Stahmer, and L. Schreibman. 1995. “Effects of Sociodramatic Play Training
on Children with Autism.” Journal of Autism and Developmental Disorders, Vol. 25, No. 3,
p. 265.
10

Stahmer, A.C. 1995. “Teaching Symbolic Play Skills to Children with Autism Using Pivotal
Response Training.” Journal of Autism and Developmental Disorders, Vol. 25, No. 2, pp. 123141.
11

Pierce, K., and L. Schreibman. 1997. “Using Peer Trainers to Promote Social Behavior inAutism: Are They Effective at Enhancing Multiple Social Modalities?” Focus on Autism andOther Developmental Disabilities, Vol. 12, No. 4, pp. 207-218.
12

Pierce, K., and L. Schreibman. 1997. “Multiple Peer Use of Pivotal Response Training toIncrease Social Behaviors of Classmates with Autism: Results from Trained and Untrained
Peers.” Journal of Applied Behavior Analysis, Vol. 30, No. 1, pp. 157-160.
13
Koegel, L.K., S.M. Camarata, M. Valdez-Menchaca, and R.L. Koegel. 1998. “Setting
Generalization of Question-Asking by Children With Autism.” American Journal on Mental
Retardation, Vol. 102, No. 4, pp. 346-357.
14

Koegel, R.L., Y. Shoshan, and E. McNerney. 1999. “Pivotal Response Intervention II:
Preliminary Long-Term Outcome Data.” Journal of The Association for Persons with Severe
Handicaps, Vol. 24, No. 3, pp. 186-198.
15

Koegel, L.K., C.M. Carter, and R.L. Koegel. 2003. “ Teaching Children With Autism SelfInitiations as a Pivotal Response.” Topics in Language Disorders, Vol. 23, No. 2, pp. 134145.
16

Koegel, R.L., G.A. Wener, L.A. Vismara, and L.K. Koegel. 2005. “The Effectiveness ofContextually Supported Play Date Interactions Between Children With Autism and TypicallyDeveloping Peers.” Research and Practice for Persons with Severe Disabilities, Vol. 30, No.
2, pp. 93-102.
17

Laski, K.E., M.H. Charlop, and L. Schreibman, (see n. 6 above), p. 394.

18

Koegel, R.L., et al., (see n. 4 above), p. 246.

19

Koegel, R.L., L.K. Koegel, and A. Surratt, (see n. 7 above), p. 150.

76

Section One: What Works and What Doesn’t?

20

Delprato, D.J. 2001. “Comparisons of Discrete-Trial and Normalized Behavioral Language
Intervention for Young Children with Autism.” Journal of Autism and Developmental Disorders,Vol. 31, No. 3, pp. 315-325.
21

Koegel, R.L., L.K. Koegel, and A. Surratt, (see n. 7 above), p. 149.

22

Koegel, R.L., et al., (see n. 4 above), p. 246.

23

Stahmer, A.C., (see n. 10 above), p. 137.

24

Stahmer, A.C., (see n. 10 above), p. 139.

25

Koegel, L.K., et al., (see n. 13 above), p. 351.

26

Pierce, K., and Schreibman, (see n. 11 above), p. 208.

27

Koegel, R.L., et al., (see n. 1 above), p. 9.

28

Koegel, R.L., et al., (see n. 1 above), p. 9.

29

Pierce, K., and L. Schreibman, (see n. 8 above), p. 288.

30

Pierce, K., and L. Schreibman, (see n. 8 above), p. 287.

31

Schreibman, L., W.M. Kaneko, and R.L. Koegel. 1991. “Positive Affect of Parents of Autistic
Children: A Comparison Across Two Teaching Techniques.” Association for Advancement of
Behavior Therapy, Vol. 22, No. 4, p. 488.
32

Koegel, R.L., A. Bimbela, and L. Schreibman. 1996. “Collateral Effects of Parent Training
on Family Interactions.” Journal of Autism and Developmental Disorders, Vol. 26, No. 3, pp.
347-359.
33

Laski, K.E., M.H. Charlop, and L. Schreibman, (see n. 6 above), pp. 398-399.

34

Lisa Benaron. 2006. Pivotal Response Intervention Model. Pediatric Development and Behavior,www. dbpeds.org (accessed May, 5, 2006).
b) Positive Behavioral Support

Carr, E.G., et al. 2002. “Positive behavior support: Evolution of an applied science.” Journalof Positive Behavior Interventions, Vol. 4, pp. 4-16, 20.
1

Carr, E.G., et al., (see n. 1 above), p 7.

2

Wehamn, T., and L. Gilkerson. 1999. “Parents of Young Children With Special Needs Speak Out:
Perceptions of Early Intervention Services.” Infant-Toddler Intervention: The Transdisciplinary
Journal, Vol. 9, No. 2, pp. 137-167.

3

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

4

Buschbacher, P.W., and L. Fox. 2003. “Understanding and Intervening With the Challenging
Behavior of Young Children With Autism spectrum disorder.” Language, Speech and Hearing
Services in Schools, Vol. 34, No. 3, pp. 217-227.
5

McCurdy, B.L., M.C. Mannella, and N. Eldridge. 2003. “Positive Behavior Support in Urban
Schools: Can We Prevent the Escalation of Antisocial Behavior?” Journal of Positive Behavior
Interventions, Vol. 5, No. 3, pp. 158-170.
6

Lucyshyn, J.M., G. Dunlap, and R.W. Albin. 2002. Families and Positive Behavior Support:
Addressing problem behavior in family contexts. Baltimore, MD: Paul H. Brookes Publishing,p. 465.
7

Boettcher, M., R.L. Koegel, E.K. McNerney, and L.K. Koegel. 2003. “A Family-Centered
Prevention Approach to PBS in a Time of Crisis.” Journal of Positive Behavior Interventions,Vol. 5, No. 1, pp. 55-59.
8

Marshall, J.K., and P. Mirenda. 2002. “Parent-Professional Collaboration for Positive Behavior
Support in the Home.” Focus on Autism and Other Developmental Disabilities, Vol. 17, No.
4, pp. 216-228.
Fucilla, R. 2005. “Post-crisis Intervention for Individuals with Autism spectrum disorder.”Reclaiming Children and Youth, Vol. 14, No. 1, pp. 44-51.
9

10
Sallows, G.O., and T.D. Graupner. 2005. “Intensive Behavioral Treatment For children With
Autism: Four-Year Outcome and Predictor.” American Journal on Mental Retardation, Vol.
110, No. 6, pp. 417-438.
11

Zane, T. 2005. Fads in special education: An overview. In J.W. Jacobson, R.M. Foxx, J.A.
Mulick eds. Controversial Therapies for Developmental Disabilities: Fad, Fashion, and Sciencein Professional Practice, NJ: Lawrence Erlbaum Associates, p. 175.
Behavior Analyst Certification Board, www.bacb.com/becom_frame.html (accessed June, 13,2006).
12

Durand, V. M., and N. Rost. 2005. “Does It Matter Who Participates In Our Studies?” Journalof Positive Behavior Interventions, Vol. 7, No. 3, pp. 186-188.
13

14
Mulick, J.A., and E.M. Butter. 2005. Positive Behavior Support: A paternalistic utopian
delusion. In J.W. Jacobson, R.M. Foxx, J.A. Mulick eds. Controversial Therapies forDevelopmental Disabilities: Fad, Fashion, and Science in Professional Practice, NJ: Lawrence
Erlbaum Associates, p. 385.

c) Verbal Behavior
1

Skinner, B.I. 1957. Verbal Behavior. NY: Appleton-Century-Crofts.

Sundberg, M.L., and J.W. Partington. 1998. Teaching Language to Children with Autism or
Other Developmental Disorders. Danville, CA: Behavior Analysts, Inc., p. 298.

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3

Braam, S.J., and A.Poling. 1983. “Development of IntraVerbal Behavior in Mentally Retarded
Individuals Through Transfer of Stimulus Control Procedures: Classification of Verbal
Responses.” Applied Research in Mental Retardation, Vol. 4, pp. 279-302.
4

Drash, P.W., L. R. High, and R.M. Tudor. 1999. “Using Mand Training to Establish an Echoic
Repertoire in Young Children with Autism.” The Analysis of Verbal Behavior, Vol. 16, pp. 2944.
5
Sundberg, M.L., M. Loeb, L. Hale, and P. Eigenheer. 2002. “Contriving Establishing Operations
to Teach Mands for Information.” The Analysis of Verbal Behavior, Vol. 18, pp. 15-29.
6Miguel, C. F., J.E. Carr, and J. Michael. 2002. “The Effects of a Stimulus-Stimulus Pairing
Procedure on the Vocal Behavior of Children Diagnosed with Autism.” The Analysis of Verbal
Behavior, Vol. 18, pp. 3-13.
Behavior Analysts, Inc., www.behavioranalysts.com (accessed Dec. 28, 2006).

7

The Mariposa School, http://www.MariposaSchool.org (accessed Dec. 28, 2006).

8

9Drash, P.W., and R.M. Tudor. 2000. “Is Autism a Preventable Disorder of Verbal Behavior? A
Response to Five Commentaries.” The Analysis of Verbal Behavior, Vol. 20, pp. 55-62.
10

Drash, P.W., and R.M. Tudor. 2004. “An Analysis of Autism as a Contingency-Shaped Disorderof Verbal Behavior.” The Analysis of Verbal Behavior, Vol. 20, pp. 5-23.
Drash, P.W., and R.M. Tudor, (see n. 10 above), p. 5.

11Oah, S., and A.M. Dickinson. 1989. “A Review of Empirical Studies of Verbal Behavior.” The
Analysis of Verbal Behavior, Vol. 7, pp. 53-68.

12

13
Carr, J.E., and A.M. Firth. 2005. “The Verbal Behavior Approach to Early and Intensive
Behavioral Intervention for Autism: A Call for Additional Empirical Support.” Journal of Earlyand Intensive Behavioral Intervention, Vol. 2, No. 1, pp. 18-27.

d) Fluency
1

Binder, C. 1988. “Precision Teaching: Measuring and Attaining Exemplary Academic
Achievement.” Youth Policy, Vol. 10, No. 7, pp. 12-15.
The Fluency Project, http://www.Fluency.org (accessed Feb. 13, 2007).

2

3
Binder, C. 1993. “Behavioral Fluency: A New Paradigm.” Educational Technology, pp.
8-14.
4

Fabrizio, M.A., S. Pahl, and A. Moors. 2002. “ Improving Speech Intelligibility ThroughPrecision Teaching.” Journal of Precision Teaching and Celeration, Vol. 18, No. 1, pp. 25-27.

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

5

Moors, A., and M.A. Fabrizio. 2002. “Using Tool Skill Rates to Predict Composite Skill
Frequency Aims.” Journal of Precision Teaching and Celeration, Vol. 18, No. 1, pp. 28-29.
6Fabrizio, M.A., and K. Schirmer. 2002. “Teaching Visual Pattern Imitation to a Child With
Autism.” Journal of Precision Teaching and Celeration, Vol. 18, No. 1, pp. 80-82.
Fabrizio, M.A., K. Schirmer, and K. Ferris. 2002. “Tracking Curricular Progress With Precision.”
Journal of Precision Teaching and Celeration, Vol. 18, No. 2, pp. 78-79.
78Fabrizio, M.A., K. Schirmer, E. Vu, A. Diakite, and M. Yao. 2003. “Analog Analysis of Two
Variables Related to the Joint Attention of a Toddler With Autism.” Journal of Precision Teaching
and Celeration, Vol. 19, No. 1, pp. 41-44.
9King, A., A.L. Moors, and M.A. Fabrizio. 2003. “Concurrently Teaching Multiple Verbal
Operants Related to Preposition Use to a Child With Autism.” Journal of Precision Teaching
and Celeration, Vol. 19, No. 1, pp. 38-40.
10Zambolin, K., M.A. Fabrizio, and S. Isley. 2004. “Teaching a Child With Autism to Answer
Informational Questions Using Precision Teaching.” Journal of Precision Teaching andCeleration, Vol. 20, No. 1, pp. 22-25.

80Section One: What Works and What Doesn’t?

Other School-based Therapies Section 1.2
p TEACCH
p The Playschool (Colorado Health Sciences Center)p Giant Stepsp Higashi/Daily Life Therapy
p The Walden Preschool81The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

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Section One: What Works and What Doesn’t?

Other School-based Therapies: TEACCH
What is TEACCH?
TEACCH (Treatment and Education of Autistic and Related Communication
Handicapped Children) is a state run agency for individuals with autism andtheir families, and provides both a center-based and a community outreachprogram. Families can choose from a variety of treatment options to best meettheir individual circumstances and needs. TEACCH views three levels of needwhich must be addressed: those of the child; those of the family, and thoseof the community.1 The goal is to help foster independence and happinessfor every child in the programs. In order to accomplish this, the TEACCH
philosophy supports the individualization of programs not only for the child,
but also for the family and community. In the center-based program, student toteacher ratios are not limited at the preschool age level; however, at the schoolage level, ratios are limited to six children per one teacher. The curriculum
emphasizes structured teaching and involves educational continuity acrosssettings. To accomplish this, TEACCH proponents claim that the layout of theclassroom and the way the environment is engineered help promote the child’s
independence. Classroom goals for each child include cognitive, fine motor, eye/hand integration, organizational skills, self-help skills, receptive and expressive
language, and social interaction.
These programs are taught using structured teaching (i.e., clear, predictable, andrule-based), visual schedules (i.e., using pictures or lists to organize the child’sday), environmental accommodation (i.e., organizing the classroom to minimize
distraction) and a combination of other cognitive and behavioral approaches. To
address problematic behaviors, the TEACCH model designs the environment
and uses daily schedules to prevent problematic behaviors before they occur.

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They also use functional analysis (analyzing a behavior with respect to its
function) and, where necessary, the occasional time-out (removing the childfrom the situation).
The Home-Based component of TEACCH services uses programs whichemphasize visual strengths, pre-academic or pre-vocational skills, structured
teaching, a schedule and a communication system. In the outcome study by
Ozonoff and Cathcart (1998), the individualized curriculum was programmed to thechild, based on the baseline scores (from a measure called the Psychoeducational
Profile – Revised [PEP-R]), which indicated the child’s strengths and weaknesses.
The home program lasted ten weeks, wherein parents and two therapists met foran hour per week to work with the child. While one therapist worked, parents
and the other therapist observed and discussed techniques used. Based on theirobservations, parents were instructed to work with their child for a half hour per
day using the techniques taught by TEACCH staff.
What evidence do the practitioners have that thisreally works?
There is little outcome data available to evaluate the efficacy of the center-based
TEACCH program. After combing through over fifty publications written on the
TEACCH method, I could only find three peer-reviewed articles which provide
outcome data on children who participated in a TEACCH program.2,3,4 The
Lord and Schopler study (1989) reports results for children who participated in
the TEACCH program and found that despite the program, the children did not
improve significantly based upon IQ scores. In their original study, Lord andSchopler took seventy-one autistic children and compared them with seventyone non-autistic, communicatively-handicapped children who also attended a
TEACCH program. Their findings regarding children with autism were that84

Section One: What Works and What Doesn’t?

the IQ scores were stable despite treatment. They state: “...IQs at age 4 years
were found to be highly correlated with performance IQ at age 10 years forboth groups. Absolute difference scores and group means were also equivalent
for both samples, with no difference in patterns of change or the relationshipbetween performance IQ and language status...”5 In other words, despite the
TEACCH curriculum, according to Lord and Schopler’s research, there was no
significant gain in IQ scores for either group of children who participated in the
TEACCH curriculum.
The next outcome study6 presents data which addresses the TEACCH homebased program. The home-based study, conducted by Ozonoff and Cathcart(1998) divided the children in two groups. One group of eleven children
received a home-based TEACCH program where parents were taught to workwith their children. The other group of eleven children were not provided withany competing treatment. After four months of treatment, the children in theexperimental group tested significantly better on fine motor and gross motor
skills as well as nonverbal conceptual skills. Their overall skills, based on thePsychoeducational Profile – Revised (PEP-R), also improved over the control
group.
It is important to appropriately evaluate the results of the Ozonoff and Cathcart(1998) study. Of note is that all the children in the study were in local day
treatment programs in Utah, which, as the authors point out, is a state that relies
heavily upon discrete trial training in their special educational programs. In
addition, the home-based program relied on TEACCH methods, which included
structured teaching administered by parents who were taught by the researchers.
The results of their study actually tell us that for children with discrete trial
training learning histories (i.e., intensive behavioral treatment), more intervention
is better than less intervention; however, their study does not tell us that the85

The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

TEACCH intervention is responsible for the gains. The question remains
whether the TEACCH home-based program, delivered by using parents (andtheir free labor) is as effective as the same number of hours in a home-based
ABA program utilizing structured methods, such as discrete trial training, using
IBT professionals.
Despite the critique above, this study does show much more in the way of positive
results than the original TEACCH study; however, due to the weaknesses of thestudy, these results need to be taken with caution. One of the study’s weaknesses isthat the only measure used to define level of autism (the dependent variable) bothat the pre-test and post-test is the Psychoeducational Profile – Revised (PEP-R).
While the CARS was used pretreatment to determine autism, no mention of
the CARS posttreatment results were made. The CARS scores were negatively
correlated with change scores, which means that those children who had better
CAR scores (indicating milder autism), fared better with the home-program thanthose children who were more severely affected. No individual CARS scores weremade available at pre or post treatment, and only the average CARS scores forthe group were available at pretreatment. Therefore, even if we accept the CARS
scores as being a valid measure of autism, we have no information whether thechild improved based on the treatment as measured by the CARS score.
In terms of the measure of the dependent variable (which is autism), the PEP-R
is not sufficient when used on its own, because we do not have the amount ofvalidity information that we have for other, more widely-used measures. It isessential that if the PEP-R is used, it should be in addition to other, more accepted
measures which have proven validity.* The areas assessed by the PEP-R are
imitation, perception, fine motor, gross motor, eye-hand integration, cognitive*

It is also problematic that both the CARS and the PEP-R are measures designed by one of the authors of
the study.

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performance and cognitive verbal skills. I am not convinced that the variablesof perception, fine motor, gross motor and eye-hand integration are importantmeasures to gauge the degree of autism. The PEP-R does not measure behavior,
which is a vital aspect of functioning that must not be ignored. In addition to the
PEP-R measure, these authors should have measured cognitive level by using
tried and tested psychometric measurements to compare IQ scores pre and post
experiment.
An additional issue is that the dependent variables (to measure autism) were
measured by, “different testers, none of whom were blind to group assignment.”7
In fact, the PEP-R was administered to the experimental group by their graduate
student therapist, while the control group was administered the PEP-R by theauthors. This introduces the possibility of experimenter bias in measuring thedependent variable and undermines our confidence in the results reported.
The final study which reports positive effects of the TEACCH program isPanerai et al., (2002). This Italian study compared a group of eight children
who participated in a residential TEACCH program set up at a hospital with agroup of eight children who were integrated into the regular school system witha special education assistant where the staff did not use any techniques specific toteaching children with autism. The children in the TEACCH program improvedin many different areas relative to the control group (and these improvements
were statistically significant). This finding is not surprising because the control
group was not given any autism-specific treatment. What is an unfortunate
finding, though, is that after one year of treatment based on the Vineland Adaptive
Behavioral Scales, there was no significant difference between the experimental
and control groups when it came to receptive and expressive communication.
In other words, a key deficit in children with autism — the ability to speak andcomprehend the spoken word — was not improved with this therapy, even though87The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

the TEACCH program is designed specifically for children with autism. In
addition, Table Eight of the Italian TEACCH study demonstrates that genericallytrained support teachers do no better than babysit children with autism whenattempting to integrate them into an educational system.8 Although this study
is certainly valuable due to the comparison of TEACCH with an educational
program with no autism-specific expertise, it does not shed light on thecomparison between other effective treatments, such as those from the behavioral
field, which is the main competitor treatment to TEACCH.
What does the therapy actually look like?
Since TEACCH services are center-based , community based, and home-based,
it is difficult to describe the services as a whole. The TEACCH classroom looks
different than a typical classroom, with very few so-called “distractions” on
the walls and on the boards. Children typically sit in a classroom cubicle so as
not to be distracted by other activity in the classroom. Each child has a list oftasks that must be completed independently. Independent task completion is ahigh priority because the TEACCH philosophy is based on the foundation thatthe child will be placed in a vocation in which he will have to complete jobs
independently. TEACCH emphasizes parental involvement and the training ofparents as cotherapists. TEACCH outreach programs have not been describedin sufficient detail to illustrate how the home and community programs look;however, they do speak of a number of treatment options which occur across
many different settings, i.e., home, community, and workplace.
What else do I think?
Given the philosophy of TEACCH, which involves the accommodation ofstrengths and weaknesses, rather than targeting weaknesses for intevention andelimination, children with autism who are involved in TEACCH programs may
88Section One: What Works and What Doesn’t?

not be given opportunitites to overcome these deficits and function in a more
typical way. Frankly, I do not understand how the TEACCH paradigm promotes
integration of people with autism. It seems to me that this philosophy would
tend to result in the segregation of autistic children because how can people
with autism function in a mainstream setting without working on deficits withthe goal of either eliminating or reducing the problems associated with those
deficits? Proponents of TEACCH do not profess to eradicate autism; rather, theirphilosophy is the “goal of improved adaptation”9 for children with autism. Morerecently, I was quite dismayed to come across an article by Jennett et al. (2003)
in which autism was actually referred to as a “culture,” rather than a neurologicaldisorder — a widely recognized health problem. They state: “This contrasts witha primary value of the TEACCH approach of respecting the culture of autism(Mesibov and Shea, in press, emphasis added).”10 It is most unfortunate when
researchers define autism in this manner because if we magically transform autism
into a culture, the argument absolves governments, insurance companies, andothers of all responsibility to provide treatment to this most vulnerable group ofchildren, for the fundamental reason that a culture is generally accepted, rather
than targeted, for treatment as a pathology.
The International Journal of Mental Health highlighted the TEACCH programworldwide when one of the TEACCH proponents, Schopler, became a guest
editor at the journal. Despite the fact that no less than two issues of this journal
were devoted to TEACCH, not a single article reported compelling data on theefficacy of the treatment method.11 What is impressive about the TEACCH Modelis not so much its purported value in ameliorating autism, but rather its ability to
proliferate worldwide, which is quite amazing given that this model is supported
by so little data showing treatment efficacy. The TEACCH Model has been
adopted by various systems in over twenty countries, including Belguim, Israel,
Italy, Japan, Kuwait, Spain, Sweden, the United Kingdom, and even France,

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where many psychiatrists still approach autism in a misguided, outdated Freudianmanner where the mother is blamed for causing the autism. I would like to suggestthat the reason behind the TEACCH proliferation is twofold: first, the TEACCH
model is relatively easy and inexpensive for educational systems to adopt, andsecond, the TEACCH proponents are expert at integrating into existing systems(such as the educational system) in order to propagate the method.
It is also of some concern that the one measure for autism relied upon so heavily
in TEACCH studies is the PEP-R. Children could be taught how to perform wellon the dependent measure, which may inflate the actual progress made as thedependent measure is so narrow (particularly in the areas of fine and gross motor
skills). In addition to this, behavior is not adequately tested and the two criticallyimportant dependent measures for individuals with autism, IQ and language, need
to be more comprehensively tested pre and post study of the TEACCH method,
and rely upon blind testers using widely accepted psychometric measures.
A problematic part of the one home-based TEACCH study3 is its length. The
program was ten weeks of supervision (one hour per week). After this period,
parents (whose labor is free) became the ones solely in charge of programmingand implementing the curriculum for a half hour per day. Although this may becost-effective for governments and educational systems, it is unlikely to be enoughtime to create meaningful change for children with autism. The authors appear
to be well aware of the resource problem, wherein Ozonoff and Cathcart (1998)
state: “We hope these results will encourage teachers and other professionals todevise cost-efficient means of extending programing into the home”12 (emphasis
added). I’m not sure when cost-effectiveness became the responsibility of
researchers; however, it is a dangerous day when researchers trying to push afield forward are worried about government expenditures.

90Section One: What Works and What Doesn’t?

Finally, the TEACCH philosophy emphasizes the satisfaction and happiness ofthe parents who participated in the TEACCH study. More emphasis appears to
be placed on parental satisfaction than on the effectiveness of autism treatment.
Although, as a parent I am glad that they care about my happiness, I firmly believethat the progress of the child must remain the paramount concern of researchers
and that the elements of each child’s program must be motivated by that child’s
future and not a happiness rating for parents.
Would I try it on my child?
At this point there are two reasons I would not enroll my child in a TEACCH
program. First, the data is not sufficientaly strong to convince me that the
TEACCH way is the best way. Second, call me fussy, but I want my child to beenrolled in a school or a treatment program that is going to squeeze out every
last ounce of her potential and not “accomodate” her deficits. I want a programto actively target her deficits with the goal of eradicating or minimizing those
deficits. In terms of happiness, I believe that my child’s happiness is linked toher independence: and her independence and integration into society is dependent
upon how capable an adult she will become. My happiness is directly linked toher reaching her fullest potential.
What kind of study would I like to see the TEACCH
people do?
The authors of TEACCH’s outcome studies point out that there are problems withthe study (they refer to it as “confounding variables”) that prevent acceptanceof their positive results as accurate.13 I would like to see them rectify this issue
by designing a study which includes the following elements, at minimum: anexperimental and control group with at least twenty children per condition (pergroup). The control group (the group not receiving the treatment) would be

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children enrolled in regular special education in the United States (where there isstrong federal legislation protecting children in the educational system). Resultsof this study would at least determine whether a TEACCH classroom is superior
to a standard special education classroom. Next, it would be valuable to compare
the TEACCH method against a classroom which relies heavily upon discrete
trial training (a structured data-supported technique) and the various principles
of applied behavior analysis as teaching techniques. In addition, autism (thedependent variable) should be measured using many tests which are relevant to
deficits common in autism (such as language, behavior, and IQ). To achieve this,each child in the study should be given a full range of well-accepted tests whichmeasure these three areas. These tests should be administered by psychologists
who are in no way related to the study. If the results from a study with theabove elements demonstrate that children do indeed benefit significantly with a
TEACCH program, then this could be considered a treatment option for somechildren. However, more research on the TEACCH model is required before
any conclusions can be made about its effectiveness.
Who else recommends for or against TEACCH asa method for the treatment of autism?

In 1999, the New York State Department of Health issued a well done and very
thorough report on clinical best practices for the treatment of autism in young
children. Data from the center-based TEACCH program was not reviewed
because of its lack of rigorous study design; however, the home-based study
was reviewed (included in the New York Report in the parent training section).
They concur that in the Ozonoff and Cathcart (1998) study (where children were
simultaneously receiving treatment in the day), those children whose parents
were trained (given eight to twelve sessions of home-based training) improvedon the PEP-R outcome measure relative to the children whose parents did notreceive training.14
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So you’re still on the horns of a dilemma?
If you are still contemplating the merits of a TEACCH program, consider what
The Association for Science in Autism treatment has to say. This organization
provides a rather lukewarm reception to TEACCH when it states: “Research
conducted by TEACCH and anecdotal reports suggest TEACCH shows promise
15,16
but it is not objectively substantiated as effective by independent researchers”(emphasis added).17 This is quite true. Independent researchers should consider
further investigation using well established research protocols. Professionals
considering TEACCH methods should consider that the TEACCH program lacks
independent verification of its effectiveness, and should disclose this status to
key decision makers influencing the child’s intervention.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence to conclude
that the TEACCH model is effective for the treatment of children with autism.

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Endnotes for TEACCH
1

Lord, C., and E. Schopler. 1989. “ The Role of Age at Assessment, Developmental Level andTest in the Stability of Intelligence Scores in Young Autistic Children.” Journal of Autism andDevelopmental Disorders, Vol. 19, pp. 483-499.
2.

Lord, C., and E. Schopler, (see n. 1 above).

Ozonoff, S., and K. Cathcart. 1998. “Effectiveness of a Home Program Intervention For YoungChildren With Autism.” Journal of Autism and Developmental Disorders, Vol. 28, No. 1, pp.
25-32.
3

Panerai, S., L. Ferrante, and M. Zingale. 2002. “Benefits of the Treatment and Education ofAutistic and Communication Handicapped Children (TEACCH) Programme as ComparedWith a Non-specific Approach.” Journal of Intellectual Disability Research, Vol. 46, No. 4,
pp. 318-327.
4

5

Lord, C. and E. Schopler. 1989. “Stability and assessment results of autistic and nonautistic
language-impaired children from preschool years to early school age.” Journal of Child
Psychology and Psychiatry, Vol. 30, No. 4, pp. 575-90.
Ozonoff, S., and K. Cathcart, (see n. 3 above).

6

Ozonoff, S., and K. Cathcart, (see n. 3 above).

7

Panerai, S., L. Ferrante, and M. Zingale, (see n. 4 above).

8

Schopler, E., and G.B. Mesibov. 2000. “Cross-Cultural Priorities in Developing Autism Services.”
International Journal of Mental Health, Vol. 29, No. 1, pp. 3-21.

910Jennett, H.K., S.L. Harris, and G.B. Mesibov. 2003. “Commmitment to Philosophy, Teacher
Efficacy and Burnout Among Teachers of Children With Autism.” Journal of Autism andDevelopmental Disorders, Vol. 33, No. 6, pp. 583-593.
Schopler, E., and G.B. Mesibov, (see n. 9 above).

11

12

Ozonoff, S., and K. Cathcart, (see n. 3 above).

13

Ozonoff, S., and K. Cathcart, (see n. 3 above), p. 30.

14

Guralnick, M. ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany (NY): New York State Department of Health, pp. IV51-52.
15

Lord, C. and E. Schopler, (see n. 5 above).

Lord, C. and E. Schopler, 1994. “TEACCH services for preschool children.” In S.L. Harrisand J.S. Handleman, eds. Preschool education programs for children with autism. Austin, TX:
Pro-Ed. pp. 87-106.
16

Association For Science in Autism treatment (ASAT), www.asatonline.org/about-autism-info14.
html (accessed Nov. 21, 2005).
17

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Other School-based Therapies: The Playschool
What is The Playschool?
The Playschool is a preschool developed at the Colorado Health Sciences Center
which offers a developmentally based curriculum focussing on the symbolic
thought, communication and social/emotional development of the child with
autism. The major premise is that active learning in early childhood takes placethrough play. The philosophical orientations which influenced the developmentof the Playschool curriculum is Mahler’s Theory of Development of Interpersonal
Relationships,* Piaget’s theory of Cognitive Development, and Pragmatics
Language Theory of Development.1 The instruction style at the Playschool ischild-led (an orientation which has the child set the agenda for what he would
like to do). The curriculum includes language, affect (emotion), play and thedevelopment of social relationships. This model focuses on communicative
intent, non-verbal communication, child as integrator and organizer of his
experience, child-led activities as a basis for communication, and the naturalenvironment as the setting for development of language.1 These are all essentially“reactive language” strategies. The language part of the curriculum is based ona model termed INREAL (INclass REActive Language) where the speech andlanguage pathologist (SLP) joins the child in the classroom as a teacher rather
than pulling the child out into a resource room.2 In this setting, the SLP reacts
to (rather than directs) the child to facilitate language acquisition.

*
The importance of Mahler’s Theory of Development of Interpersonal Relationships to thePlayschool, is the attachment-separation-individuation process of interpersonal development.
This process is hypothesized to take place at the earliest age and is seen to be important in autism
by some because the theory describes both early separation experiences and the importance ofsocial connectedness in ego development.

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At the Playschool, an emphasis is placed on the development of positive
emotions and a happy relationship between the child and the adult. The adultis required to initiate and maintain social experiences by joining the child’s
activities, and thereby turn them into social experiences. In addition, learning is
encouraged through the use of “planned physical space” which takes into accountstructure, routine, sensory stimuli and other engaging materials. Specifically,
distractions are minimized so that the child can concentrate on the activity
at hand. Through play, the child is encouraged to learn actively by the adultteaching developmentally appropriate skills.
The techniques used by this method to address problematic behaviors are either
ignoring or redirecting inappropriate behavior. In addition, attempts are made toincrease the individual’s repertoire of alternative, acceptable behaviors. Existing
behaviors are not targeted for decrease. Occasionally, the child may be removed
from the setting; however, it is not clear from the literature which situation
or behavior calls for removal. Behaviors that are considered maladaptive arehandled based on the developmental or emotional meaning of the behavior.3 It
is unclear exactly how injurious or destructive behaviors are handled other than
the application of time-out or redirection procedures.
What evidence do the practitioners have that thisreally works?
Although the Playschool model has been described often in the literature on
early intervention, it was extremely difficult to find any research data on thismethod. After a comprehensive database search, I netted four articles.1,4,5,6* On
closer inspection, it appears as if the children involved in the earlier studies were
included in the 1991 study, which looks at outcome data for seventy-six children*

Rogers wrote many more articles on early intervention; however, in this section we included only thosearticles which were highly relevant to the Playschool model.

96Section One: What Works and What Doesn’t?

from 1981 to 1991, forty-nine of whom had autism. Because these children’s
data have been summarized by the 1991 article through reviewing their chartsfrom 1981, I will discuss the study as presented in the 1991 article (the 1989
article reported on thirty-one of those forty-nine children with autism).
Rogers et al. report that children with autism made statistically significant gains
on cognitive, language, fine and gross motor, and social and emotional measures
after six to nine months of participation in the Playschool program. This study
used a variety of tests including IQ, the Childhood Autism Rating Scale (CARS),
the Early Intervention Developmental Profile and Preschool Profile (EIPPP) and avariety of language and communication scales. A large number of rating measuresfor one study is promising; unfortunately, the EIPPP was rated by the classroom
teacher, who is an inappropriate person to be carrying out the assessment,
given her interest in seeing improvement. Although the administrators of the
CARS and Developmental Profile scales were not familiar with the expected
outcome (hypothesis) of the study, we do not have that assurance in terms of
those administering the IQ and Language tests. In addition, the testing was not
sufficiently standardized, with many children completing a variety of IQ andlanguage tests. The authors address the IQ standardization issue by creatinga standardized score which takes the child’s mental age and divides it by thechronological age. However, the lack of standardization is still not ideal as thesecircumstances open the door to possible influences (also called experimental
confounds or bias) that may make the data meaningless.
Another problem with this between-within subject design is the comparisongroup. These researchers compare children with autism to children with a variety
of behavioral and non-autistic developmental disorders. This may have been
important for the researchers’ purposes; however, it is irrelevant when it comesto determining the efficacy of one autism treatment protocol over another (which

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is important for our purpose). Put simply, these studies lack an appropriate
control group; therefore, the design is inadequate for examining outcome data.
Rogers (1998) recognizes the lack of a control group as being problematicwhen she states: “The two models [The Denver Playschool and LEAP] await
the application of methodologies involving control groups of matched children,
random assignment, blind raters, numerous outcome measures, and long-term
follow-up before the effectiveness of the models can be evaluated according to
the EST [Empirically Supported Treatments] criteria.”7
In order to address the issue of an inadequate control group, the researchers use
prediction analysis which is designed to take into account the concept that thechildren are improving based on the treatment and not simply due to maturation.
Based on this analysis, they would have expected the children to develop only
seven months of progress in a nineteen-month period. However, the children
with autism actually gained seventeen months of language in the nineteen-month
period, at which point the gains stabilized but did not increase. Although this isinteresting and certainly suggests that this method is better than doing nothing,the important question remains whether the Playschool model is better than othertreatment methods for children with autism. In other words, could children
with autism have actually surpassed their typically developing peers with early
intensive intervention rather than lagged slightly behind, thereby, narrowing but
never closing the gap? The latter point is what Rogers et al. (1991) suggest.
An additional concern regards the individual progress of those children with
autism in the study. Since only the average (mean) scores of the group of children
with autism were presented, we have no way to check whether some children
gained significantly, relative to others who did not. It would be interesting to
see whether a subset of the children with milder autism improved at a greaterrate than those more severely impacted. For that, we would need each subject’s

98Section One: What Works and What Doesn’t?

pre and post scores which, unfortunately, were not presented in the 1991 or the
1987 Rogers et al. studies.
What does the therapy actually look like?
The Playschool curriculum is delivered in a classroom setting, with six to twelve
children, one teacher and two aides, although the Playschool Outreach Project
took place in five special education classrooms in Colorado, in which there wasat least one child with autism. No other information regarding the composition ofthese classrooms is provided in the literature on the Playschool method of autism
intervention. While the articles discuss the general components of the curriculumthat is taught, there is insufficient information on the specific content and I was
unable to locate a published manual which lays out the treatment protocol in
sufficient detail. It is known that some of the children were also provided with
one-on-one psychotherapy sessions using play techniques. Although there issome variation, the Playschool is described as involving four and one-half (41/2) hours per day, twelve months per year.8 In the Rogers et al. (1991) study,
the average time spent by children at the Playschool was eighteen months.
What else do I think?
Based on the information provided, it is difficult to determine exactly what
the intervention at the Playschool looks like. The program is implemented ina classroom setting utilizing a structured environment and routine; however, it
is unspecified as to how, precisely, this is accomplished. The researchers write,“the whole environment operated as an ego structure that regulates, mediates,
selects, focuses, and organizes sensory stimulation for the children to maximize
learning.”9 Unfortunately, it does not state how these goals are accomplished or
how this environment maximizes learning. Equally unclear is the content of the99The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

curriculum. The basis for all teaching apparently was done through play; however,no more information than this is provided. It is not stated what the children learn
through play, or what kinds of play tasks occur. The lack of clarity surrounding theprocedures used makes it a difficult model to evaluate and replicate. In addition,
reported results from the study are confusing and inconsistent due to the typeof measures used and their lack of standardization. As a result, it is difficult toassess the significance of the observed changes. The intervention seems likea “hodgepodge” of approaches, some of which are conflicting, i.e., a child-led
developmental approach combined with non-specific behavioral approaches.
Finally, these researchers are sympathetic to the psychiatric approach to autism
intervention which has not been demonstrated to be effective for children with
autism. They state: “...there has been a strong tendency in the intervention field
to eschew the ‘psychiatric’ approach. Unfortunately, this may have also led torelative neglect of sound treatment strategies for addressing the social, emotional,
communicative, and ego deficiencies of children with Pervasive Developmental
Disorders.”10 Unfortunately, these researchers do not present any data or evidence
for the sound psychiatric treatment strategies to which they refer. In my view,that’s a serious problem.
Would I try it on my child?
Based on the data that has been collected from the Playschool autism intervention
program, if my child were of preschool age, I would not put her into the Playschoolpreschool program. Although my personal philosophy would very much like to
see a child-led approach be successful for autistic children, the studies published
to date simply provide no evidence that this treatment program is effective forchildren with autism. Therefore, I would not have my child participate in thePlayschool autism intervention program.

100Section One: What Works and What Doesn’t?

What kind of study would I like to see the Colorado
Health Sciences researchers do?
In order to be able to adequately assess the Colorado Health Sciences “Playschool”
program as an effective intervention for children with autism, there needs to be
improvements to the methodology used in their outcome studies. Although they
published a study which describes how important it is to train teams to implement
the program model,1 there does not appear to be a strict treatment protocol thatall practitioners must follow. Increasing the quality (or fidelity) of the treatment
through a more explicit methodology, will increase the strength of the conclusions
that can be made about the program based on evidence.
Currently, the available assessment of the Playschool program has insufficient
controls to objectively make conclusions regarding its efficacy. What I would
consider to be the essential components of future research done on the Playschool
program would be: a randomly assigned control and experimental group;
valid and reliable assessment measures; independently diagnosed subjects with
autism; independent assessment of valid dependent measures; results based onstandardized calculations, rather than a developmental rate, and an evaluation of
the statistical and clinical significance of the results. It would be more valuable
to have all of these components present in one outcome study, rather than several
studies using only some of these important research requirements. To date, it
is impossible to conclude that the Playschool program has beneficial effects
for individuals with autism, because in the existing studies, the lack of control
prevents the results from being attributed to the intervention alone. Additionally,further comparative research is required to assess whether the Playschool
approach is as effective as current, evidence-based alternatives.

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Who else recommends for or against The Playschool asa method for the treatment of autism?
As compared to many other methods, there has been little attention paid to thePlayschool program by parents or professionals, probably because this model
has not been adopted on a broad basis. Consequently, there are no reputableorganizations taking a stand either way regarding the program. That said, it isimportant to understand that the underlying philosophy of the Playschool istreatment through play. To see what many organizations have said about the lackof science behind the role of “play” in the treatment of children with autism,please refer to the section in this book on the DIR “Floor-Time” model.
So you’re still on the horns of a dilemma?
I would like to leave you with a thought to ponder. This treatment model has
been around since 1981. We are now twenty-five years on, and there has notbeen a single replication of this model using a between-subject design. Rogers
recommended that a controlled study be done on this treatment model back in
1998. We are still waiting. As your child has only one chance to have effective
early intensive treatment, and the Denver Playschool model has not beenmeasured against other intensive treatment methods with better outcome data,
please understand that choosing this method — exclusively — will block more
effective early intensive treatment options. Consequently, in my opinion, you
would be engaging in experimentation with your child.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence to conclude
that the Playschool autism intervention method is effective in substantively
improving the condition of autism.
102Section One: What Works and What Doesn’t?

Endnotes for Playschool
1

Rogers, S., H.C. Lewis, and K. Reis. 1987. “An Effective Procedure for Training Early Special
Education Teams.” Journal of the Division for Early Childhood, Vol. 11, No. 2, pp. 180-188.
2
Weiss, R. 1981. ”INREAL intervention for language handicapped and bilingual children.”
Journal of the Division of Early Childhood, Vol. 4, pp. 40-51.

Rogers, S., H.C. Lewis and K. Reis, (see n. 1 above), p. 82.

3

4

Rogers, S., et al. 1986. “An approach for enhancing the symbolic, communicative, andinterpersonal function of young children with autism or severe emotional handicaps.” Journalof the Division of Early Childhood, Vol. 10, No. 2, pp. 135-45.
5

Rogers, S.J. 1989. “An Effective Day Treatment Model for Young Children With Pervasive
Developmental Disorders.” The American Academy of Child and Adolescent Psychiatry, Vol.
28, No. 2, pp. 207-214.
6

Rogers, S.J., and D.L. DiLalla. 1991. “A Comparative Study of the Effects of a Developmentally
Based Instructional Model on Young Children with Autism and Young children with Other
Disorders of Behavior and Development.” Topics in Early Childhood Special Education, Vol.
11, No. 2, pp. 29-47.
7

Rogers, S.J. 1998. “Empirically Supported Comprehensive Treatments for Young Children with
Autism.” Journal of Clinical Child Psychology, Vol. 27, No. 2, pp. 168-179.
Rogers, S.J., H.C. Lewis and K. Reis, (see n. 1 above), p. 208.

8

Rogers, S.J., H.C. Lewis, and K Reis, (see n. 1 above), p. 208.

9

10

Rogers, S.J., H.C. Lewis, and K. Reis, (see n. 1 above), p. 213.

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104Section One: What Works and What Doesn’t?

Other School-based Therapies: Giant Steps
What is Giant Steps?
The Giant Steps approach to autism intervention is based on a program developedin Montreal by Berringer in 1981. Subsequently, a Giant Steps school opened in
St. Louis. The program develops Individual Education Plans (IEPs) for each child,
which utilize a variety of therapies. The Giant Steps practitioners describe theirmix of therapies as follows: The child receives, “speech therapy, occupational
therapy, music therapy, play therapy/social communication, academic enrichment,
acquired daily living skills, and a nutritional component.”1 The proponents of
the Giant Steps-St. Louis model* describe it as an ‘holistic’ approach whichuses multiple disciplines to address all the components that they determine to be
relevant for the individual with autism. Kim and colleagues (1998), provide asample of this cross-disciplinary programming, where, for example, if a child isworking on letter recognition, the occupational therapist will expose the child toletters of different textures, the music therapist will introduce a musical exercisethat uses letters, and the speech/language pathologist will engage the child in alanguage exercise that is related to teaching letters.
Another part of the Giant Steps autism intervention curriculum involves the useof what their therapists term “invitational equipment.” Therapists encourage
the student to use a particular piece of equipment by making it exciting. They
explain these enticements, or invitations, as a way to allow the students to“reduce avoidance behaviors ... at their own rate,” and to expose these students
to “exploration of objects and activities in a nonthreatening way.”2 The third
component of the Giant Steps program is to develop consistency between the*

We focus on the St. Louis program because the Montreal program has no publications based on theMontreal site.

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school and home because this continuity is thought to maximize the child’s
progress. The Giant Steps therapists act as a liaison between both the school“shadow” (classroom aide) and the parents regarding specific behaviors orsituations that arise. The philosophy of Giant Steps is to ultimately integrate thechild into the neighborhood school. The classroom shadow provides information
to the therapists at Giant Steps on how to adapt the child’s program so it isconsistent with the neighborhood school curriculum.
What evidence do the practitioners have that thisreally works?
Unfortunately, there is no published research showing whether the Giant Steps
program is actually effective or not for its participants. There is a detailed
description of the program published in the Focus on Autism and other
Developmental Disabilities (1998), but no systematically collected outcome data.
In the article describing the Giant Steps — St. Louis program, the authors state:“The purpose of this article is to describe the Giant Steps — St. Louis program bypresenting data collected during its first year of evaluation.”3 The description of
the Giant Steps — St. Louis program is detailed; however, there is no meaningful
data collected on whether the program is effective. The authors themselves statethis to be the case as well: “However, the effectiveness of the program is yet
to be proved. An evaluation examining child outcomes, family satisfaction andcost-effectiveness will provide additional information on the efficacy of this new
program.”4 It is notable that the researchers formally admit that at this point they
have no data regarding effectiveness. I first did a comprehensive database searchin late 1998 and found only one descriptive article on this program. My latest
database search was done in 2006 and there is still no additional data publishedon Giant Steps.**The database searches included Psychological Abstracts (PsycINFO), Medical Abstracts (MEDLINE),
Educational Abstracts (ERIC) and the Cochrane Data-bases of Systematic Reviews (CDSR).

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What does the therapy actually look like?
Typically, a child will be in a Giant Steps program for half the day and in his
neighborhood school for the remaining half. While at the Giant Steps program, thechild may attend a general class for half an hour where the child works on a variety
of typical school tasks such as spelling, punctuation or reviewing a schedule. The
next three hours are spent participating in a variety of therapy sessions. Thesesessions typically include music therapy, several short sensory integration therapy
sessions, an academic session and an occupational therapy/speech therapy session
with another child and two therapists. Lunchtime and the afternoon may be spent
with a shadow teacher or aide at the child’s local school. While at school, theGiant Steps shadow adapts and modifies the curriculum where necessary andencourages peer interaction and friendships.
What else do I think?
The abstract of the article on Giant Steps — St. Louis indicates that it will
present, “data collected during its first year of evaluation.”5 As it turns out, thisso-called data consists of quotes taken from the director of the program andfrom members of the board of directors from an interview with an unidentified
individual. It also includes a single case study, which merely outlines the daily
routine of one participant of the program. There is no information in the article
regarding the efficacy of this treatment intervention for any individual with
autism. In addition, this article was written seven years ago, yet no peer reviewed
journal article presenting any data on the effectiveness of the program has been
published since.
From the original article on the Giant Steps program, it is unclear how therapists
teach academic deficits or address behavioral excesses. In addition, the article
contains no information to indicate how or even if the therapists or aide evaluate
the effects of the intervention, if any, on the child. There is mention in the article
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about which disciplines are employed (such as sensory integration and speech
and language); however, there appears to be no explanation regarding why these
disciplines are relevant and how they are applied. For example, the authors
mention the use of a “nutritional component” to the IEP’s; however, the only
mention of an intervention for expanding a child’s diet is “to expose the childto different food choices across school activities and at home.”6 The theories
behind many of the anecdotal “interventions” chosen by Giant Steps appear
quite weak and are unsupported by the data. Not only is there no evidence ofthe effectiveness of treatment outcome, there is no reason to believe that thetreatment will be effective in ameliorating autism.
In short, I am unable to conclude that Giant Steps is a viable treatment option
for individuals with autism because there is insufficient data to show that the
curriculum is effective for children with autism. Individualized therapy is only
as good as the method upon which it is based, and unfortunately, Giant Steps uses
many therapies that are not scientifically substantiated such as music therapy,
sensory integration therapy, speech therapy or play therapy. Despite this lackof evidence, Giant Steps relies heavily upon these therapies.
Would I enroll my child in a Giant Steps program?
I would not enroll my child in a Giant Steps program because they have notshown any evidence that their school is effective. However, there are many
aspects of their program that do appeal to me intuitively. For example, the factthat they try to prepare the child to integrate into his local school and target manydifferent areas of deficit, such as peer interaction and classroom skills, is positive;
however, good intentions are not sufficient. I would need to see a rigorous study
that provides evidence of the effectiveness of the Giant Steps program before
considering it for my child.

108Section One: What Works and What Doesn’t?

What kind of study would I like to see the Giant Steps
people do?
If the Giant Steps curriculum is to be considered a legitimate educational
option for children with autism, I would need to see a study conducted which
incorporates the following components: first, every child in the study would need
to be diagnosed with autistic disorder or Pervasive Developmental Disorder Not
Otherwise Specified (PDD-NOS). Next, there would need to be an experimental
and a control group; the control group could be children with autism in the publicschool system and/or children using another well-settled type of therapy. In
addition, I would like to see at least twenty children per experimental condition,
each child tested on at least two widely-used, commonly-accepted autism
measurements, before and after the Giant Steps intervention. Moreover, I would
require that the researchers who administer the pre and post tests to the autistic
children be uninformed as to which children are in the Giant Steps program andwhich are in the control group. Furthermore, the children in the control groupwould need to receive the same amount of one-on-one time as the children in the
Giant Steps program. All the children in the public school setting would need tohave a full-time aide trained in the other methods that were being compared.
Upon completion of the study, if the children enrolled in the Giant Steps program
fare better than the children in the public school system, with full-time support,then we would know that the Giant Steps program is, indeed, superior to the
public education system for children with autism. The next step would be for
the Giant Steps practitioners to test their intervention model against the otherresearch-oriented schools and home-based intensive intervention models designed
for children of autism.

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Does anyone recommend for or against Giant Steps asa method for the treatment of autism?
Due to the lack of popularity of this type of school and the lack of publications
generated by this group, there has not been much interest amongst the autism
community. Therefore, researchers preparing clinical guidelines for the treatmentof autism, such as the New York State Department of Health Report on Autism
Treatment7 have not included Giant Steps in their analyses. Although Giant Steps
was not evaluated by the New York Report, various components that comprise
the Giant Steps curriculum were. The New York Report evaluated music therapy,
play therapy and sensory integration therapy and recommended against these
therapies as treatments for autism.7
So you’re still on the horns of a dilemma?
If the lack of outcome data doesn’t dissuade you from enrolling your child in a
Giant Steps program, please understand that without augmenting your child’s
program with a well-settled treatment program, you may be completely wasting
your child’s valuable developmental window.
What’s the bottom line?
Based on the scientific research to date, there is no evidence that Giant Steps
has an effective school-based curriculum which improves any of the symptoms
of autism in children.

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Endnotes for Giant Steps
1

Kim, S., L. Richardson, G. Yard, M. Cleveland and K. Keller. 1998. “Giant Steps – St. Louis:
An Alternative Intervention Model for Children with Autism.” Focus on Autism and Other
Developmental Disabilities, Vol. 13, No. 2, pp. 101-107.
Kim, S., L. Richardson, G. Yard, M. Cleveland and K. Keller, (see n. 1 above), p. 103.

2

Kim, S., L. Richardson, G. Yard, M. Cleveland and K. Keller, (see n. 1 above), p. 101.

3

Kim, S., L. Richardson, G. Yard, M. Cleveland and K. Keller, (see n. 1 above), p. 106.

4

Kim, S., L. Richardson, G. Yard, M. Cleveland and K. Keller, (see n. 3 above), p. 101.

5

Kim, S., L. Richardson, G. Yard, M. Cleveland and K. Keller, (see n. 2 above), p. 103.

6

7

Guralnick, M., ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany (NY): New York State Department of Health, pp. IV-15 to 21, IV-14.

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Other School-based Therapies: Daily Life
Therapy/The Higashi School
What is Daily Life Therapy?
Daily Life Therapy (DLT) is an educational model which originated in Japan.
It is based upon the method pioneered by Dr. Kiyo Kitahara. The model isschool-based and integrates students with autism and their typically developing
peers. Quill, et al. (1989) describe the following five principles which underline
the therapy: 1) physical exercise; 2) an art-based curriculum (music, art andmovement components); 3) group instruction; 4) learning through imitation,and 5) highly structured routines.
The Daily Life Therapy model uses vigorous physical exercise to address
stereotypic and undesirable behaviors. Proponents of this approach believe thatchildren with autism have high levels of beta-endorphins (a neurotransmitter thatblocks pain and boosts the immune system), due to being in states of chronic
hyper-arousal. They claim that intense physical exercise results in the natural
release of these beta-endorphins, which has a positive impact on behavior.1 A
second component of DLT is a curriculum which is largely based on different
art forms, which include the above-mentioned music, art and movement. The
rationale behind this curricular content is to develop the child’s strengths, to givechildren the opportunity to express themselves and to develop self-esteem.2
Using the Daily Life Therapy model, learning is taught through gross-motor andvisual-motor imitation, and verbal imitation.3 The Daily Life Therapy in Japan
integrates autistic peers and uses peer models to facilitate imitation; however,this component of the program is not available in the Daily Life Therapy school
in Boston. Consequently, the Boston Higashi School is a segregated setting.

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What evidence do the practitioners have that thisreally works?
Although we netted several articles which discuss the DLT method, there were
only three articles devoted solely to this method and only one study with outcome
data which is based on the Boston Higashi school. There are currently no studies
published on the Japanese DLT schools. The Boston study4 is an observational
study with no pre and post measures taken on children in the study. In addition,
this study lacks a control group. Without these measures or a control group, there
is no way to conclude that the improvements purportedly made by the subjects
were a result of the treatment. An additional weakness of the study is that only
six children participated and there were no IQ scores available for these children
prior to attending the school. Furthermore, by the end of the observational study,
only three of the original six children remained in the study. Unfortunately, thesignificance of such a small number of children in the study becomes readily
apparent when analyzing the results. Data from the study demonstrate that oneof the children’s appropriate responses actually decreased during intervention.
Because of the small sample size, we could mistakenly conclude that there wasapproximately a seventeen percent (16.67%) decrease in appropriate responses
over the course of the therapy. Also, while it appears that some improvement
occurred in attending and with inappropriate responding amongst the children
in the study, no significance values (“p value”) are provided to determine thechances that these results did not, in fact, happen by chance. Without these“significance” scores, it is difficult to conclude that meaningful changes occurredwith these children via Daily Life Therapy. In short, there are so many flaws in
the design of this study, that I can make no conclusions whatsoever regarding
the efficacy of Daily Life Therapy.

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What else do I think?
As mentioned above, the results of the study indicate that there was no
improvement made in the participants’ measure of “appropriate responding,” andthat one subject actually decreased in level of appropriate responses. Larkin andGurry (1998) address the significance of this issue well in their discussion of DLT.
In fact, they point out that while some progress was noted in behavioral issues,“the lack of progress in Appropriate Responses is very important.”5 They describethat the target students, “appeared not to learn to follow specific directions or tocomprehend what the teacher was asking them to do.”6 While students may be
behaving and attending more appropriately, it must be established what they arelearning in regard to academics, language and communication skills. Larkin andGurry (1998) describe the early curriculum as “nurturing,” and they speculatethat the reason for seeing no progress in appropriate responses may be that there
are few demands placed on the youngest students. In other words, Larkin andGurry suggest that due to a lack of emphasis on appropriate responses, there has
been no progress in this area.
What does the therapy actually look like?
Group instruction is provided in a classroom setting, with classroom sizes ranging
from six to ten students. The student-to-teacher ratio is, on average, eight students
to one teacher (8:1). The group of students is viewed as a whole and it is group
achievement which is viewed as being paramount. Redirection is used exclusively
to maintain the unity of the group.7 Finally, independence is fostered throughstrict daily classroom routines in art, music and movement. The entire day ison a schedule and the beginning of each new activity is preceded by some typeof routine, such as an imitation routine using physical exercise.

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Would I try it on my child?
Based on the research to date, very little can be concluded about the efficacy of
Daily Life Therapy. The lack of data from the Japanese school forces parents toevaluate the therapy based solely on the single study of the Boston Higashi schoolin Massachusetts, which was established in 1987. I would not enroll my childin the Higashi school simply because the data is inconclusive. More research is
required before it can be considered as a viable treatment option. However, someof the ideas of the Japanese Higashi curriculum such as: 1) physical exercise
to decrease stereotypic behavior; 2) peer interaction; 3) imitation skills, and 4)
a highly structured environment are compelling. Taken alone, there is some(although not comprehensive) evidence that the four elements in the Higashi
curriculum listed above may be important for children with autism. Anotherreason I would not be inclined to put my child in this school is the lack of emphasison teaching children with autism academic and functional skills. Although“attending” behavior and a decrease in inappropriate behavior are important,the reason for their importance is to have the child’s deficiencies appropriately
addressed, preventing anti-learning behaviors from blocking progress.
What kind of study would I like to see theHigashi School do?
If the Higashi School is to be considered a legitimate educational option forchildren with autism, I would need to see strong data from a study which has, atminimum, a hypothesis stating that those children who participate in the Higashi
School over the period of a year are expected to show a decrease in the symptoms
associated with autism (based on commonly-accepted, rigorously-tested measures
for autism). In addition, I would like to see a control group consisting ofautistic children in the public school system, thereby creating a well-controlled
study with at least twenty children per experimental condition in the study.
116Section One: What Works and What Doesn’t?

Furthermore, several widely-used, commonly-accepted autism measurements
need to be administered to each child, before and after the treatment. Moreover,
the researchers giving the autistic children the pre and post measure for autism
must not know which children are in the Higashi School and which are in thecontrol group (the children not enrolled in the Higashi school). Another importantcriterion for the study is that all the children in the experimental group should
be enrolled in the same Higashi school.
Upon completion of the study, if the children in the Higashi School fair better
than the children in the public school system, then we would know that theHigashi School is indeed a viable alternative to the public education system forchildren with autism. The next step would be for the Higashi School to test its
intervention model against the other specialty school programs and home-based
intensive behavioral intervention models designed for children of autism.
Who else recommends for or against Daily Life Therapy
as a method for the treatment of autism?
This innovative model gained popularity when it was introduced to the U.S. in
1987. The autism treatment model did not flourish in North America; therefore,
the lack of interest did not motivate the international autism research community
to further study this school. Consequently, we could not find clinical practiceguidelines or other evaluations that address the efficacy of the Higashi Schoolmodel.
So you’re still on the horns of a dilemma?
The Higashi model is not an option for most parents due to the small number ofschools adopting this model; however, if you do live near one of the few sitesthat offer this program and would like to enroll your child, I would suggest that

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you consider the fact that due to the lack of data showing that this method iseffective, you may want to augment your child’s treatment with a well-settled
treatment program so that your child will progress at least when not at school.
What’s the bottom line?
Based on the scientific research to date, there is insufficient evidence that Daily
Life Therapy has an effective curriculum for decreasing the symptoms associatedwith the condition of autism in children.

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Endnotes for the Higashi School/Daily Life Therapy
1

Quill, K., S. Gurry, and A. Larkin. 1989. “Daily Life Therapy: A Japanese Model for EducatingChildren With Autism.” Journal of Autism and Developmental Disorders, Vol. 19, No. 4, pp.
625-635.
Quill, K., S. Gurry, and A. Larkin, (see n. 1 above), p. 633.

2

Quill, K., S. Gurry, and A. Larkin, (see n. 1 above), p. 631.

3

4Larkin, A.S., and S. Gurry. 1998. “Brief Report: Progress Reported in Three Children With
Autism Using Daily Life Therapy.” Journal of Autism and Developmental Disorders, Vol. 28,
No. 4, pp. 339-342.
Larkin, A.S., and S. Gurry, (see n. 4 above), p. 341.

5

Larkin, A.S., and S. Gurry, (see n. 4 above), p. 341.

6

Quill, K., S. Gurry, and A. Larkin, (see n. 1 above).

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Other School-Based Therapies: The Walden
Preschool
What is the Walden Preschool?
Originally established in 1985, the Walden Preschool offers a full-time classroom
integrating children with autism into a group with their typically developing
peers. The Walden Preschool is based on the Toddler Center Model, a day care fortypical children. The philosophy of the school is one of integration, with a focus
on incidental teaching (unstructured and opportunistic) to facilitate language andsocial interaction. The curriculum is broken down according to first and second
year goals. The goals within the first year are to facilitate the following objectives:social responsivity in the child towards teachers, materials and activities; verbal
objectives such as choice-making and natural language consequences; play anddaily living skills.1 The second year format focuses on peer social interaction andkindergarten readiness.2 To achieve the above goals set out in the curriculum,
teachers use incidental techniques (natural learning), an engineered setting (where
the classroom is set up in a way that fosters learning particular skills) and childpreferred activities and materials (to entice the child to use certain materials).
The environment is described as a “free-choice” classroom in which teachers
must successfully “market” materials and activities to the children.3 The student
to teacher ratio is 3:1 (three children to one adult).
There are generally fifteen to eighteen children per class in this program, sevenstudents with autism and eight to eleven typical peers. The instruction style ischild-led with respect to learning, with the exception of some direct instruction toteach social interaction skills to both typically developing and autistic students.
No student undergoes compliance training to avoid inadvertently decreasing
spontaneous initiations between student and teacher. Behavior problems are

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addressed proactively by attempts at engineering the environment, the use ofchild-preferred activities and materials, limiting the classroom rules, minimizing“down time,” and teaching replacement behaviors. The belief is that increasing“fun” decreases behavior problems.4 Once maladaptive behaviors occur, theauthors explain that natural and logical consequences are used in response. The
Walden Preschool also claims to use only so-called “positive” behavior strategies,
although they also describe the use of time-out procedures. On rare occasions, astudent may require an individualized behavior management procedure. However,they claim that behavior management procedures are generally avoided at theWalden Preschool. Since the establishment of the original Walden Preschool
and Toddler Programs, there have been some modifications to the model. These
will be discussed in the evidence section below.
What evidence do the practitioners have that this really
works?
There is currently no evidence that the original Walden Program is an effective
intervention for children with autism. The only available information regarding
outcomes of students at Walden are provided in book chapters5,6 describingpreschool programs for individuals with autism, rather than in peer-reviewed
journal articles. The original data reports that the rate of verbalization for children
with autism increased from four to thirteen percent (4 – 13%). Rates of peerinteractions increased in six out of fourteen students with autism; however, it isunspecified how much increase was observed. Unfortunately, no trial-by-trial
data is taken in the classroom. Assessments are based only on time samples onvideotape. The nature and quality of language and interaction changes observed isunclear. It is unreported whether or not these changes are statistically significant,or if they could have been achieved simply by two years of maturation alone.
Also, peer interaction changes were assessed using the indirect measure of how
many times students with autism were approached by their typical peers. This
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assessment might not be a valid measure of gain in social interaction but, rather,merely measure the gains made by typical students in approaching their autistic
counterparts.
More updated programs describe multiple zones (teaching stations) with a teacher
in charge of each zone, rotating from zone to zone every fifteen minutes. The
idea behind this setup is to increase opportunities for incidental teaching,7 which
is a significant component of the Walden philosophy. In addition, the newer
rendition of the Walden School model provides one-on-one teaching pullout
sessions in a different room. Although the original Walden model used incidental
teaching exclusively, the Children’s Toddler School (the CTS Program based in
San Diego) incorporates discrete trial training (a highly structured behavioral
teaching technique). This might be a much better model for the child, as it
introduces discrete trial training into the CTS Program; however, this no longer
qualifies as a partial replication of the original Walden program, but rather, asignificant departure in philosophy and technique. In fact, the Stahmer et al.8
model uses a large variety of techniques, including incidental teaching, pivotal
response training, discrete trial training, structured teaching, and Floor-Time.9
The results of the Stahmer et al. study now reflect a melange of techniques, someof which have no evidence that they are, in any way, effective. For our purposes,
the results of this quasi-experimental design are unfortunate because they mightlead some parents to adopt a basketful of techniques, ninety-five percent of which
may be ineffective. In my opinion, these researchers have done a disservice,as they have now further confused the question of efficacy in autism treatment.
In addition, two children in the study received additional in-home therapy,
and one of those children received ten hours of discrete trial training per week
(which is highly effective). Unfortunately, the results of the study are all doneby comparing the mean scores at entry with the mean scores at exit. Therefore,

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we have no idea whether a few children pulled up to the mean considerably, or
whether all the children contributed almost equally to the scores. The statistics
presented suggest that a few children were responsible for a higher post meanscore.* Also, available publications give no indication whether the gains were
due to discrete trial training, Floor-Time, pivotal response training, incidental
teaching, or structured teaching. The researchers agree when they state: “Given
that this program contains several elements (i.e., inclusive classroom, special
skills training, parent training and support), it is not possible to determine which
components were responsible or necessary for the children’s progress.”10 The
authors continue: “In all probability, the combination of these three elements
contributed to the children’s process.”11 This claim is one for which they haveno support and which is not substantiated by science.
What does the therapy actually look like?
The original Walden Preschool classroom operates out of Emory University, as
part of the Emory Autism Resource Center. It is a full-time classroom which
is attended year round. All students with autism must receive at least one
independent diagnosis before admittance. Teaching occurs using incidental
techniques, which are described by McGee, Daly and Jacobs12 as follows: 1) thenatural environment is arranged to attract the child; 2) the child then initiates theteaching experience; 3) the initiation by the child is treated as an opportunity toelaborate by the teacher; 4) the child’s expected response is confirmed by theteacher, and 5) the access to the desired material or activity is granted contingent
upon the desired response. Teachers are assigned to “zones” (teaching stations)
within the classroom, based on activities, and are responsible for engagement
and redirection of the students within that teaching station.
*

The standard deviations are very large particularly when it comes to measuring communication - at intake
M = 71.1, (s.d. 13.9) and at exit M = 79.3 (s.d. 17.1).

124Section One: What Works and What Doesn’t?

Would I try it on my child?
Although my child is far beyond the preschool stage, I would have never put
her into a program that uses the Walden Preschool model primarily because
these researchers have not provided any reliable data whatsoever to show thatincidental teaching actually works. In terms of their partial replication, they add
everything but the “kitchen sink” to the Walden Preschool and this confounds
the data. Simply put, I would not enroll my child in this program because I haveno guarantee that most of the techniques used have any data supporting them.
Unsupported eclecticism in autism treatment is highly problematic.
What else do I think?
Inherent in the incidental approach (non-structured, opportunistic teaching) toteaching individuals with autism, is the requirement that the teaching experience
be initiated by the child. One of the diagnostic criteria for autistic disorder is asevere deficit in social interaction, which includes social initiations. Despite thegreatest effort by teachers, these “initiations” occur on a very infrequent basis,
relative to typically developing children. This results in fewer learning experiences
for the child afflicted with autism than that of the typical child. In addition to
fewer opportunities, the child with autism often requires mass repetitions of
information (or practice) in order for knowledge or skill development to occur.
The combination of fewer opportunities to learn and the requirement for greater
exposure in order to learn, leads me to suggest that the incidental technique(where every opportunity must be anticipated and acted upon to maximize
interaction) may not be intensive enough to maximize the child’s development.
This is particularly important during the early years of the child’s life, when
optimal potential for learning exists. While the chapter on the Walden Preschool
method claims that research shows incidental teaching maximizes learning in this125

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population, there is actually little peer-reviewed data on incidental learning onchildren with autism 13,14,15,16,17,18 and that which does exist, works only on very
narrow, specific skills, with very few children, and does not control for priorlearning histories, which may severely bias upward the purported effectivenessof the technique. In short, although I applaud the preschool’s attempt to include
children with autism into a mainstream setting, successful inclusion takes much
more work than simply putting the children together and watching the magic
happen.
The preschool seems to recognize the need for one-on-one sessions for certain
skills; however, these sessions in the original program19 occur for only a short
fifteen minutes at a time, no more than five times per day with an emphasis placedon the importance of learning as a group.
What kind of study would I like to see the Walden
people do?
In order to objectively assess the effectiveness of the Walden program forindividuals with autism, it is necessary to have controlled research which
determines whether their program is effective in producing significant change(that is not associated with maturation alone), in areas relevant to the diagnostic
deficits and excesses associated with the disorder. Once significant change
has been demonstrated, the efficacy of the program needs to be compared tothe efficacy existing programs that are already effective. I would need to see
evidence that the learning which occurs in the Walden program is the same as, or
better than, that which occurs in other treatment programs. Specifically, insteadof confounding the variables by using an eclectic approach, proponents of theWalden School should create an experiment where children are assigned toconditions in which incidental teaching, Floor-Time, pivotal response training, or
structured teaching are used exclusively. Then the outcomes between conditions
126Section One: What Works and What Doesn’t?

need to be compared. Unfortunately, I doubt that researchers would be able tofind enough parents to agree to have their children in this kind of study, sincethese methods do not represent state-of-the-art inclusion programs for children
with autism despite what these researchers claim.20
Who else recommends against the Walden Preschool
Model as a method for the treatment of autism?
Although we could not find any reputable organizations that recommend for oragainst the Walden Preschool, many organizations have come out recommending
against many components of the Walden Preschool model described by Stahmer
et al. (2004). For information on recommendations of each particular component
in the latest incarnation of the Walden Model, I suggest that you go to the sectionsin the book which analyze the efficacy of Floor-Time, Pivotal Response Training,
TEACCH, and behavioral treatment.
So you’re still on the horns of a dilemma?
For parents evaluating autism treatment programs, the Walden School presents a
difficult challenge, as eclecticism is generally thought of as being a good thing;
however, it is crucial to recognize that in the world of autism treatment, there is a
program around every corner supposedly offering “state-of-the-art” intervention
techniques and it is often difficult to deconstruct baby-sitting from actual autism
treatment. It is important to remember, though, that every moment your childis not engaged in genuine science-based treatment, your child’s valuable time
is being wasted by perhaps well-meaning adults who may care deeply aboutchildren, but simply do not have data to support the treatment techniques they
practice and endorse. In other words, the road to hell is often paved with goodintentions.

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What’s the bottom line?
Based on the scientific research done to date, there is insufficient evidence
to support the claim that either the original Walden Preschool or the updated
Children’s Toddler School has an effective curriculum for the treatment or
education of children with autism.

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Endnotes for Walden Preschool
McGee, G.G., T. Daly, and H.A. Jacobs. 1994. “ The Walden Preschool.” In S.L. Harris, andJ.S. Handleman, eds., Preschool Education Programs for Children With Autism. Austin, TX:
Pro-Ed., pp. 127-162.
1

McGee, G.G., T. Daly, and H.A. Jacobs, (see n. 1 above).

2

McGee, G.G., T. Daly, and H.A. Jacobs, (see n. 1 above).

3

McGee, G.G., T. Daly, and H.A. Jacobs, (see n. 1 above).

4

McGee, G.G., T. Daly, and H.A. Jacobs, (see n. 1 above).

5

McGee, G.G., Morrier, M. and Daly, T. 2000. “The Walden Preschool.” In S.L. Harris and J.S.
Handleman, eds., Preschool Educational Programs for Children with Autism. 2nd ed. Austin,
TX: Pro-Ed., pp. 157-190.
6

7

Stahmer, A.C., and B. Ingersoll. 2004. “Inclusive Programming for Toddlers with Autism
spectrum disorders: Outcomes From the Children’s Toddler School.” Journal of Positive
Behavior Interventions, Vol. 6, No. 2, pp. 67-82.
Stahmer, A.C., and B. Ingersoll, (see n. 7 above).

8

Stahmer, A.C., and B. Ingersoll, (see n. 7 above), p. 72.

9Stahmer, A.C., and B. Ingersoll, (see n. 7 above), p. 80.

10Stahmer, A.C., and B. Ingersoll, (see n. 7 above), p. 80.

1112McGee, G.G., T. Daly, and H.A. Jacobs, (see n. 1 above).

Farmer-Dougan, V. 1994. “Increasing Requests by Adults with Developmental Disabilities
Using Incidental Teaching by Peers.” Journal of Applied Behavior Analysis, Vol. 27, No. 3,
pp. 533-544.

13

Miranda-Linne, F., and L. Melin. 1992. “Acquisition, Generalization, and Spontaneous Useof Color Adjectives: A Comparison of Incidental Teaching and Traditional Discrete-Trial
Procedures for Children with Autism.” Research in Developmental Disabilities, Vol. 13, No.
3, pp. 191-210.

14

McGee, G.G., et al. 1992 “ Promoting Reciprocal Interactions via Peer Incidental Teaching.”
Journal of Applied Behavior Analysis, Vol. 25, No. 1, pp. 117-126.

15

Elliott, R.O. Jr., et al. 1991. “Analog Language Teaching Versus Natural Language Teaching:
Generalization and Retention of Language learning for Adults with Autism and Mental
Retardation.” Journal of Autism and Developmental Disorders, Vol. 21, No. 4, pp. 433-447.
16

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17
McGee, G.G., et al. 1986. “An Extension of Incidental Teaching Procedures to Reading
Instruction for Autistic Children.” Journal of Applied Behavior Analysis, Vol. 19, No. 2, pp.
147-157.
18

McGee, G.G., et al. 1985. “The Facilitative Effects of Incidental Teaching on Preposition Use
by Autistic Children.” Journal of Applied Behavior Analysis, Vol. 18, No. 1, pp. 17-31.
19

McGee, G.G., T. Daly, and H.A. Jacob, (see n. 1 above).

20

McGee, G.G., T. Daly, and H.A. Jacobs, (see n. 1 above), p. 80.

130Section One: What Works and What Doesn’t?

Child-lead/Parent-facilitated
Therapies

Section 1.3

p Floor-Time (Greenspan/Developmental, Individual

Difference, Relationship Model – DIR)
p Options Institute/Son-Rise Program
p Relationship Development Intervention (RDI)p The Learning to Speak Program

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132

Section One: What Works and What Doesn’t?

Child-lead/Parent-facilitated Therapies:
Floor-Time
What is Floor-Time?
Floor-Time (also referred to as the Developmental, Individual Difference,
Relationship Model – DIR) is rooted in a developmental approach to autism
therapy. However, there are components of the psychodynamic (or Freudian)paradigm involved as well. This model is often referred to as the “Greenspan”
method, named after the researcher who developed the treatment model. The
philosophy of this approach is to turn everything the child does into a social
interaction.1 Greenspan et al. state: “...the earliest therapeutic goals are tomobilize shared attention, engagement, and intentional back-and-forth signaling.
Interactive experiences enable the child to abstract a sense of self and form
higher level cognitive and social capacities.”2 When interacting with the child,the parent is instructed to focus on the child’s strengths, rather than weaknesses.
The ratio is one adult to one child and the teaching style is child-led. As a result,parents are instructed to follow the child’s lead and allow the child to guide which
activity and interaction will occur. The curriculum follows a four-stage process,designed as follows; Floor-Time I, Attention, Engagement, and Intimacy;
Floor-Time II, Two-way Communication; Floor-Time III, Feelings and Ideas;
and Floor-Time IV, Logical Thinking. Each component addresses a different
developmental issue to be targeted by parents interacting with the child on thefloor. The curriculum emphasizes emotions and empathy. Behavior is addressedusing a six-step procedure which includes: 1) Small steps; 2) Floor-Time; 3)
Solve problems symbolically; 4) Empathize; 5) Create expectations and limits,and 6) The “Golden Rule” (more Floor-Time). This procedure is supposed to
be followed for all problematic behaviors in autism, including sleeping, eating,discipline, toilet training, stubbornness and negativity, unusual fear, silly and133

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anxious behavior, self-stimulation, repeating stories repetitively and swearing.
Proponents of this method maintain that all behaviors must be accepted, insofar
as the model’s premise is that parental “acceptance” will teach the child to accept
his or her own feelings and, subsequently, build a loving, interactive relationshipwith the parent.3
What evidence do the practitioners have that this really
works?
There is currently no clinically-validated evidence that the Floor-Time intervention
is effective for individuals with autism. Currently, there is only anecdotal
evidence from case studies which purport that children have benefited from thisintervention: unfortunately, there are no controlled scientific studies testing theeffectiveness of the Greenspan/DIR method. A comprehensive database search
netted nine articles. Most of the articles were descriptive in nature, discussing
the developmental perspective underpinning the Floor-Time intervention method.
There were no outcome studies with controls that have produced data to support
this method of autism therapy. The only difference between literature searches
that I did ten years ago and today, is that now there have been case studies
published. In fact, Greenspan and Wieder, retrospectively present 200 case studies
of children who have undergone this therapy in a book they have published, as
well as a report on these children in the Journal of Developmental and Learning
Disorders.4 In addition, Wieder and the Greenspan did a follow-up study on
sixteen children, ages twelve through seventeen. However, once again, theirreliance on case studies is problematic due to the notorious lack of reliability ofcase studies, since there are no experimental controls. In their articles and books,
proponents of the Greenspan/DIR method make many claims about what theycall the “relationship based, affect cueing” approach (which refers to the way
we process emotional information), but they offer absolutely no independent
evidence that this approach is effective.
134Section One: What Works and What Doesn’t?

Proponents of the Greenspan/DIR approach are particularly critical of thetreatment with the most scientific support at this time, and specifically namebehavioral autism intervention as being responsible for more stereotyped andmore repetitive behavior as the children grow.5 In other words, the Greenspan/
DIR Model accuses intensive behavioral treatment of creating behaviors thatare characteristic of autism. These beliefs contradict existing research, whichshows that behavioral approaches can lead to treatment gains in the child with
autism.*What does the therapy actually look like?
Proponents of Greenspan’s DIR method propose that parents engage in FloorTime with their children for twenty to thirty minute periods of uninterrupted
time, from six to ten times per day. During this time, the goal is to create social
interaction between the parent and child, which can be accomplished if parents,“follow [their] child’s lead and play at whatever captures [their] interest;”
however, they add that it needs to be done in a way that, “encourages [their]child to interact with [them].”6 In order to practically apply this, it is advisedthat several tools be included to help facilitate the interaction. Parents are
instructed in the Floor-Time method to use the “sensory interests” of the child,empathy, and vocal tone to interact with the child. They are also encouraged toadapt to the mood of the child, imitate the child and be “playfully obstructive.”
Proponents also state that children aim to please by nature, and as a result, if the

It is not surprising that proponents of treatments without evidence supporting their efficacy would critiquethose treatments with overwhelming supporting data; however these claims further confuse parents whoneed to know the state of the science when it comes to autism treatment. We could accurately characterize
the rivalry between DIR and behavioral treatment as one of dueling philosophies. Unfortunately for
proponents of DIR, the field of behavioral treatment wins hands down when it comes to scientific support
with data-based evidence produced from controlled studies. For a review of the behavioral literature, please
see the section on behavioral treatment.

*

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child is having difficulties, it is often necessary to lower the expectations placed
upon the child.
What else do I think?
Practitioners of the Floor-Time method mention that, while it may be tempting towork on language skills, color recognition or other age appropriate behavior, theyclaim such an approach is ultimately not effective, in their view.7 Unfortunately, inthe case of autism, age-appropriateness is difficult to gauge because these children
vary so much. However, if one waits until the child is ready (which is also difficult
to define), the child may never be taught the skills which approach the level ofhis peers. There is much data in the literature on intensive behavioral treatmentthat contradicts the “wait and see” philosophy. Proponents of Greenspan’s
DIR method also state that it is tempting to want to work on behaviors such as
head-banging, throwing tantrums, repetitively opening and closing doors, butthey urge that the primary goal of the treatment program is that the child mustfeel calm and focused. Unfortunately, it may be critical to intervene and help
a self-injurious child as waiting may endanger the child’s health. It could bea health concern if the child engages in self-injurious behaviors without adultintervention to end them.
In addition, the goals of the Floor-Time/DIR program are quite vague and assessedprimarily through parental observation. Examples of questions the parent mustask when assessing the child are: “Can the child calm himself or herself?”; Can
the child be warm and loving?”; “Can the child engage in two-way gesturalcommunication, express a lot of subtle emotion, and open and close many circles
in a row?”; “Can the child engage in pretend play and or use words to convey
intentions or wishes?”; “Can the child connect thoughts logically and hold aconversation for a sustained period of time?” Unfortunately, these are extremely

136Section One: What Works and What Doesn’t?

subjective assessments. Parents will often have no point of reference to assessand evaluate information necessary to answer these types of questions. I likely
would have answered these questions incorrectly regarding my child when she
was young. Parents simply do not have the skill set required to accurately assess
their child’s behavior and language accurately. I would further note that a large
number of professionals in the field of autism do not have these skills either.
Floor-Time/DIR practitioners claim that if parents are distracted or nervous,
they will not be successful at helping the child tune in and stay calm, which istheir prerequisite for success in the program. Also, parents are cautioned that
their own feelings of depression, irritability or anger could well disrupt theirchild’s treatment session. According to the Floor-Time/DIR philosophy, it isessential for parents to act like someone with whom the child would want toplay. The above philosophy harkens back to the old Bettleheimian philosophyof blaming the parent if the child is not showing improvement as a result ofintervention. Floor-Time/DIR proponents also include parental withdrawal
as a factor which can contribute to autistic behavior. This view that parents
are, in any way, the cause or contributors to autistic behavior simply cannot
be countenanced as it is based purely on conjecture with no empirical support
whatsoever. Greenspan et al. state: “Sally coped with her disappointment in her
son by withdrawing from him emotionally... Sally slowly let her emotions thaw.
As mother and son both opened up their range of communication, a chemistry
evolved between them.8 In my opinion, “mother withdrawal” is a convenient
way of explaining away lack of progress when using the Floor-Time/DIR method(since if no progress is obvious, the blame can be laid at the ground of the internal
emotional state of the mother — a very subjective measure). This disclaimer
is a common red flag for ineffectual interventions. The “curriculum” (and I
use the term loosely) emphasizes the child’s strengths and focuses on “social”
interactions; however, it is unclear how the skill deficits are overcome using the137The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

Floor-Time/DIR method. Without intervention in these deficit areas, mainstreaming will be a goal that is simply unattainable for most of these children.
There are several flawed assumptions made by Floor-Time/DIR proponents,
the most obvious is that by forcing the adult into a situation with the child, it
becomes a social interaction. This idea is particularly problematic with selfstimulatory and ritualistic behavior. The parent may become incorporated by thechild as part of the self-stimulatory act or as part of some perseverative routine(such as a memorized play routine that must be followed precisely over and overagain); however, this does not necessarily mean that the child is interacting withthe parent in a social way. Through incorporating the parent in a rigid routine,
the child may avoid the parent’s intrusion and continue to engage in behaviors
that are intrinsically asocial or defined as antisocial based on societal norms.
Greenspan et al., define adult interaction with an autistic child as interactive:“by drawing your child’s motor behavior into interaction you are also making
it purposeful rather than self-stimulatory. Your child is now using his muscles
to act or communicate intentionally.”9 While attempting to make these typesof interactions more social, it is quite possible that the adult may inadvertently
reinforce harmful perseverative behaviors, thereby increasing their frequency.
These perseverative behaviors may have no communicative intent for the child,whatsoever. Nowhere in the DIR literature do I see these problems acknowledged
and addressed.
Would I try it on my child?
When my child was diagnosed many years ago, I chose this child-led
method of treatment because I found the philosophy very compelling and the
diagnosing psychiatrist offered this treatment. Many of the ideas regardingchild-development and fostering a sense of the social self were attractive since
autism is characterized by social deficits. Unfortunately, very quickly I learned138

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that well-intentioned philosophy and effectiveness of treatment are completely
unrelated. Although the child-led philosophy fit my personality well, I ultimately
had to reject this method based on the fact that there was no data supporting its
effectiveness; my child was wasting her time and I was wasting my money.
What kind of study would I like to see Floor-Time/DIR
practitioners do?
I would like to see DIR practitioners assess whether or not this particularintervention is effective for individuals with autism. As a result, a controlled
study with relevant dependent measures such as DSM-IV diagnosis, autism
rating scales and IQ testing is required. We would need pretests and posttests for each child. Behavioral measures would be particularly important
here, to assess whether or not the maladaptive behaviors increase or decreasein frequency as a result of this intervention. DIR needs to be compared withexisting treatments, to assess whether its results can match the efficacy of othertreatments. Unfortunately, this may be difficult to do; in order to create twogroups of children who are randomly assigned, all parents must agree to havetheir child assigned to one or the other group in the study. As most parents
have very strong views once they are introduced to the two methods, it isdoubtful researchers could find a group of parents who would agree to random
assignment. The ethics of random assignment in autism treatment studies
are highly questionable, particularly in this case, if the DIR method is to becontrasted with an already well-settled method.
The research would also need to measure how the child’s social interactions
benefit from this approach. Can the child interact with peers and others ininteractions that are meaningful to both, and in ways that the children willencounter in their natural environment and throughout their lives? A major
challenge for these researchers will be in objectively defining and measuring

139The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

dependent measures of subjective experience, such as emotion, empathy,
quality of relationships and the child’s acceptance of his or her own and others’
emotions. It is understandable why DIR practitioners have no research to support
their claims, considering that operationalizing a child’s “sense of their own
personhood”– the primary goal of this intervention – is near impossible to do inan accurate and reliable way. Unfortunately, until Floor-Time/DIR practitioners
agree to offer their method for scientific scrutiny in the form of a controlled
experiment, we will not know whether their technique has any value to offer theautism treatment community.
Who else recommends for or against Floor-Time/DIR asa method for the treatment of autism?
The New York State Department of Health Report (1999) did a comprehensive
literature review of the DIR method developed by Greenspan et al. They
concluded the following: “...There is currently no adequate scientific evidence(based on controlled studies using generally accepted scientific methodology)
that demonstrates the effectiveness of DIR-based interventions for young children
with autism. Therefore, the use of these approaches cannot be recommended asa primary intervention method for young children with autism.”10 In addition,
The Association for Science in Autism Treatment suggests that professionals
need to disclose to those making treatment decisions for the child, the fact that
there is no peer-review of this treatment method.11 Further, Autism-Watch whichis affiliated with “Quackwatch” considers this treatment method “Unsettled or
Investigational.”12
So you’re still on the horns of a dilemma?
If you choose this method for your child, you need to understand that the method
is purely experimental. I urge you to have your child assessed using traditional

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psychometric measures by an independent, licensed psychologist prior totreatment and visit the psychologist yearly to gauge whether there is any objective
improvement in your child’s condition. Understand, however, that you will notknow how far your child may have progressed with treatments which are morescientifically substantiated than the Floor-Time/DIR method, as you will havespent valuable time on an unsettled treatment when your child is young and mostready for developmental progress.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence to conclude
that DIR is an effective treatment for children with autism.

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Endnotes for Floor-Time
1

Greenspan, S.I. 1992. Infancy and early childhood: The practice of clinical assessment
and intervention with emotional and developmental challenges, Madison, CT: International
Universities Press.
2

Greenspan, S.I., and S. Wieder. 19991. “A functional developmental approach to autism
spectrum disorders.” Journal of the Association for Persons with Severe Handicaps, Vol. 24,
No. 3, p. 152.
Greenspan, S.I., S. Wieder, and R. Simons. 1998. The child with special needs: Encouraging
intellectual and emotional growth. Reading, MA, US: Addison-Wesley/Addison WesleyLongman, Inc.
3

Greenspan, S.I., and S. Wieder. 1997. ”Developmental patterns and outcomes in infants andchildren with disorders in relating and communicating: A chart Review of 200 cases of children
with autistic spectrum diagnoses.” Journal of Developmental and Learning Disorders, Vol. 1,
No. 1, pp. 87-141.
4

Greenspan, S.I., (see n. 1 above).

5

Greenspan et al., (see n. 3 above), p. 124.

6

Greenspan et al., (see n. 3 above), p. 419.

7

Greenspan et al., (see n. 3 above), p. 364.

8

Greenspan et al., (see n. 3 above), p. 364.

910Guralnick, M. ed. 1999. Clinical practice guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years), Albany (NY): New York State Department of Health, p. IV-58.
11

The Association for Science in Autism treatment. www,asatonline.org/about_autism/autism_info10.html, (accessed Apr. 18, 2005).
12

Autism-Watch, www.autism-watch.org, (accessed Apr. 18, 2005).

142Section One: What Works and What Doesn’t?

Child-lead/Parent-facilitated Therapies: Options
Institute/Son-Rise Program
What is Options?
The Son-Rise program, run at the Options institute in Massachusetts, isdesigned for individuals with a variety of diagnoses, including Autism andPervasive Developmental Disorder. The program is home-based and, notably,
is implemented by parents and their staff of volunteers. The philosophy of the
program is total acceptance of the child (including all behaviors). According
to the institute, there is no behavior that is inappropriate; therefore, adults areencouraged to accept all behaviors and try to understand them in the context
of the child’s world.1 In order to convey the message of total acceptance anda non-judgmental attitude towards the child, adults are instructed to engage inwhichever behavior their child chooses.2 The ratio of intervention is 1:1 (oneadult to one child), and the teaching style is child-led (where the adult follows thechild’s interest and does not dictate the structure or the content of the interaction).
The program philosophy maintains that the child is the best person to guide what
learning should occur. No predetermined tasks are taught; what the programattempts to do, instead, is encourage participation and motivation.3
What evidence do the practitioners have that thisreally works?
There is currently no data to suggest that this intervention is effective. After
doing a comprehensive literature search, we netted only two published articles,
neither of which presented any outcome data. One article studies family stressamong those parents who chose the Son-Rise method for their child and theother described the Son-Rise program itself. In short, there is no data concerning
efficacy. The Kaufmans, who are the main proponents of this approach, claim
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their child recovered from autism via the Options method. They have written
about their own experience, and a made-for-television movie was made about
their story. Other than these sources, the institute relies upon the anecdotalreporting of parents who have completed the program. Unfortunately, thesereports represent an unspecified number of people, with no objective methodof assessment. In addition, the subjective parental reporting has taken place
after considerable financial cost on the part of parents which biases the parents’observations because they are heavily invested (emotionally and financially) in
the outcome.
When contacted by this author, the institute reported that they have not produced
any “statistics” because they have been too busy helping as many children as
possible. They reported that the lack of data was due to the time and money that
research would involve.4 While I was informed that they have, “seen radical, if
not miraculous results from this approach,” their brochure does go on to caution
that, “doing a Son-Rise program is no guarantee of any results.”5What does the therapy actually look like?
The Options Institute offers a series of Son-Rise programs from Start-up to“Maximum Impact.” These are available at various teaching centers, including
Massachusetts, Illinois, Northern California and Rotterdam. The programruns from four to five days and offers training to parents on how to understandand teach their children. The approach emphasizes parental involvement. The
focus is on parental acceptance of the child and their child’s special needs, andon developing a relationship or bond between parent and child. The cost of
the intervention varies with the amount of courses and consultation the parent
seeks from the institute’s staff. The courses range from $1500 – $2000 (USD).
Information provided by the Options Institute indicates that parents can spend

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anywhere from a few hundred dollars to $13,000 USD. Hours of intervention
are unspecified; however, the Institute recommends as many hours as possible.
One-to-one intervention at the Institute takes place in a separate room, freefrom distractions. The techniques used do not include the use of any physicalprompting or guiding of the child. The parent is instructed to take on a nonjudgmental attitude and imitate whatever the child does. Apart from this, it isrelatively unclear exactly what techniques are employed.
What else do I think?
The philosophy and the practice of the Son-Rise programs seem somewhat
contradictory. While the philosophy emphasizes the acceptance of all behaviors
and the rejection of imposing adult priorities upon children, the program
proceeds to spend the maximal number of hours possible intervening to teachsocialization skills and other new behaviors.6 Additionally, Son-Rise literaturestates that no predetermined tasks are taught; rather, the child is allowed tocreate the child’s own learning situations.7 At the same time, the intensive SonRise Program teaches parents and others how to determine baselines, observe
behaviors and chart progress.8 The catalogue also states that parents are taught,“proven educational tools,” to facilitate the growth of the child.9 This would
appear to indicate that recording behavioral change is emphasized, which
seems to contradict the philosophy of the program. This is an important point
because the Institute contrasts itself with behavioral and Lovaasian interventions(Intensive Behavioral Treatment) by claiming that the Options Institute accepts
the children rather than trying to modify them or judge some behaviors as better
than others.10 If this were true, then what would be the purpose of charting
behavioral change?
As is discussed in Section Two, the emphasis on objective assessment ofprogress is stressed within the field of research on treatment outcomes. Without
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the criterion of objectivity, individuals who have a stake in observing positive
results might give biased reports. This is particularly important with parental
reporting, as there is no one with a greater investment in a child than the parents.
For researchers who are examining outcomes of interventions for childhood
disorders, independent assessment is particularly significant. It is not difficult
to understand that for parents who are desperate for help and respite from thedaily challenges of having a child with autism, merely having a professionalwith whom to consult would likely improve their state of mind. The Options
approach seems to emphasize changing the perspective of the parents on theirchild’s disorder. They focus on having the parents view the diagnosis as a giftor special challenge, one that should not be negative, but rather an opportunity.
It is likely that helping parents accept the diagnosis of their child and remove
their own sense of grief has an effect on how the parent views the child. As aresult, it may seem as though the child is improving, merely because the parents
are feeling better. While this may seem to be a helpful experience for parents,
it can also be viewed as inadvertently exploiting their desperation and need forhelp. Most importantly, the Options philosophy prevents the child from receiving
intervention that is effective in helping to achieve important skills which willlead to greater independence.
Finally, the Options website, brochure information and e-mail correspondence
received from the Institute, all make a point of contrasting their approachwith Lovaas’ intensive behavioral treatment protocol, or other behavioral
methodologies. They emphasize the many ways in which their methods are in
opposition to the methods employed by Lovaas and applied behavior analysis,
despite the efficacy indicated by the large amounts of behavioral research. The
catalogue11 also discourages the use of contradictory interventions, as they can
result in confusion for the child. This may steer parents away from interventions
that have been proven more effective, toward the Son-Rise program that has not146Section One: What Works and What Doesn’t?

been proven effective. What I find disturbing is the amount of marketing hypethat accompanies the information regarding Options (particularly the glossy
brochures and video tapes attempting to sell the parent on the method).
Would I try it on my child?
I would not try this method on my child because proponents of Son-Rise offer
no scientific evidence whatsoever that their method works. Although thephilosophy of total acceptance may be instinctively appealing to loving parents
who are desperate to have their child or toddler protected from the cruel outside
world, there is no appeal to me (as a loving parent) in a treatment that may becompletely ineffective, and indirectly harmful by replacing my child’s chanceat receiving evidence-based treatment.
What kind of study would I like to see the Options
proponents do?
First, I would like to see them acknowledge that this population of children
deserves the kind of best possible outcome from treatments that only controlled
and unbiased research can offer. Next, I would like to see some validation of theclaims that are being made. Controlled outcome data on the progress being madeby children exposed to this intervention is desperately needed. The Instituteshould explicitly clarify the methods they are using, so that others can replicate
and evaluate the approach. If they are unable to produce outcome data themselves,
there may be others willing to do so. However, in order to do this, they need toprovide detailed information regarding their procedures.

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Who else recommends for or against Options asa method for the treatment of autism?
One organization that recommends against the “Son-Rise” method is Quackwatch.
This organization is on the lookout for treatments with insufficient or no sciencebehind them and has listed the Options method on its dubious treatmentsroster.12
So you’re still on the horns of a dilemma?
In the final analysis, you are in charge of which treatment you use with yourchild. However, be forewarned that there are no peer-reviewed journal articles
reporting data on the effectiveness of Son-Rise/Options. Therefore, if you use
this method on your child, you are simply experimenting. Unfortunately, thisscientifically unsubstantiated method may be indirectly harmful because it iswasting your child’s valuable time when he or she could be receiving treatmentthat is beneficial and scientifically substantiated.
What’s the bottom line?
Based on the scientific research to date, there is no evidence to conclude that the
Son-Rise/Options method is an effective treatment for children with autism.

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Endnotes for Son-Rise/Options Institute1

Kaufman, N., and S.L. Kaufman. undated. The “HEART” of What We Teach. The Son-Rise
Program at The Option Institute. [Catalogue], p. 7.
C. Egan, personal communication, April 14, 2000).

2(

Kaufman, N., and S.L. Kaufman, (see n. 1 above), p. 6.

3

C. Egan, (see n. 2 above).

4

Kaufman, N., and S.L. Kaufman, (see n. 1 above), p. 5.

5

Kaufman, N., and S.L. Kaufman, (see n. 1 above).

6

Kaufman, N., and S.L. Kaufman, (see n. 1 above), p. 5.

7

Kaufman, N., and S.L. Kaufman, (see n. 1 above), p. 15.

8

Kaufman, N., and S.L. Kaufman, (see n. 1 above), p. 15.

910Kaufman, N., and S.L. Kaufman, (see n. 9 above), p. 15.

Kaufman, N., and S.L. Kaufman, (see n. 1 above), p. 19.

11

12

Kaufman, N., and S.L. Kaufman, (see n. 1 above).

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Child-lead/Parent-facilitated Therapies:
Relationship Development Intervention (RDI)
What is Relationship, Development Intervention
Therapy?
Proponents of Relationship, Development Intervention (RDI) characterize
autism as a disorder in which the afflicted persons are not purportedly interested
in connecting emotionally with other people.1 This approach attempts to teachpeople with autism to value interpersonal relationships by enjoying sharedexperiences, as opposed to interacting simply to attain a preferred object orgoal. The pioneer of this method, Dr. Steven Gutstein, describes the approachas “teaching emotional intelligence” rather than teaching children to “fake”
conformity by memorizing social scripts.2 The goal is to teach people with autism
to value relationships and thereby increase their quality of life. Proponents of
RDI make it clear that this is not a cure for autism, although they suggest thatRDI Therapy will establish neural pathways in the area of the brain that regulates
emotion and motivation.3
What evidence do the practitioners have that thisreally works?
Although there are several books authored by Gutstein and Sheely, at this point
there is only one peer-reviewed journal article that presents data on the efficacy of
RDI.4 The article has been accepted for publication by The Journal of Autism andDevelopmental Disorders.* The one study was a retrospective between-subject*

The Journal of Developmental and Behavioral Pediatrics has published abstract reporting results of an
RDI study that looks almost identical to the study that is to be published in the Journal of Autism andDevelopmental Disorders; however, that study is not presented with the abstract.

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design with seventeen children having autism spectrum disorder in the treatmentgroup and fourteen children in the control group. Most of the children in thecontrol group received an unspecified type of behavioral intervention. The othertwo children participated in weekly social skills groups. Gutstein reports thatthe group of children who received RDI Therapy scored better on the Autism
Diagnostic Observation Schedule (ADOS) and were more likely to move from
special education to regular education classes than the control group.
Although these results sound promising, there were several serious flaws in the
study. The author points to the following limitations: first, the children were asmall sample and high functioning without significant cognitive impairment.5 In
addition, this was a retrospective study and there was neither random assignment
nor subject matching. Aside from the author’s critique, there are two other issues
that indicate the two groups were different from the outset of the study (prior
to the treatment). The children in the RDI group were: 1) one year younger,and 2) had higher IQs than the control group (an additional twelve points on
average). Finally, and arguably the most substantive flaw in the study, is that
there were more children with an Asperger’s Syndrome (AS) diagnosis in the
RDI group than in the control group. Unfortunately, the considerable difference
between groups at the outset of the study makes a between-subject comparison
misleading.
In terms of the pre and post scores for the RDI group of children, it is difficult
to discern the actual improvement of each child as individual scores for eachchild were not presented.* It is difficult to establish whether all the children
in the RDI group benefitted, or rather, whether the twenty-nine children withAsperger’s Syndrome benefitted tremendously (which raised the mean scores*

The pre-mean results are compared to the post-mean results rather than a within-subject analysis
being conducted to compare each child’s pre and post treatment scores.

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for the entire RDI group significantly). If, indeed, these result are accurate, thenit is crucial that the profile of the children who improve be defined explicitly;
unfortunately, in the promotional literature, RDI Therapy is claimed to be of
benefit for all people on the autism spectrum.6 Based on the data presented,
however, there is no evidence supporting this claim.
What does the therapy actually look like?
This is a parent-directed therapy. Parents learn the technique through videotapes, consultants and books, and then parents conduct approximately nine (9)hours a week of therapy (according to the study and the promotional literature).
That said, the promotional literature also describes RDI as a lifestyle that isincorporated into the family.
The program teaches six areas of Relationship Intelligence in which children with
autism spectrum disorders are claimed to be deficit. These areas are discussed insome length in Gutstein et al. (2002) where the authors make a case for teachingsocial competence to adults with Asperger’s Syndrome (AS). They argue thattherapy can help develop experience-sharing relationships and, thereby, improve
the quality of life for people with AS. During RDI Therapy, foundation skills
are taught through simple shared interaction. These skills are then built uponwith adults guiding the child until such time as the child is competent enoughto be moved to peer interaction. Initially, these interactions would take place indistraction-free environments and gradually move to more typical settings. The
technique is implemented from the earliest age through turn taking and social
games (e.g., peek-a-boo) as a conduit to facilitate the interaction. Gutstein has
written several books which describe these interactive cognitive exercises andactivities in some depth.7,8153

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What else do I think?
This is a relatively new therapy which may or may not bear fruit. I find theconcept of teaching people afflicted with Asperger’s Syndrome to increase theirrelationship intelligence compelling. I have concerns with the promotional
website that claims that RDI will work for all people afflicted with autism spectrum
disorder, even those who are severely autistic, non-verbal, and cognitively
impaired. The website claims that even non-verbal children will benefit because
RDI “dramatically increases children’s motivation to communicate and to use
meaningful reciprocal language.”9 In addition, RDI is said to “be helpful witha number of problems like ‘stimming’...”10 However, the peer-reviewed article
does not present sufficient data which supports these claims. My major concern
is that a parent will implement an RDI program with a severely afflicted child,hoping to get the results reported on the website (in the form of testimonials)
and thereby, not look at best practices for autism treatment and waste that child’svaluable time.
Would I try it on my child?
There is insufficient data on RDI for me to experiment with this treatment on
my child; however, as this is a relatively new treatment, I am very interested inreading and evaluating future studies. Although I am very skeptical about RDI
Therapy being effective on young children with autism, or children with autism
who are pre-verbal, I am somewhat more hopeful that RDI will be effective
for persons with Asperger’s Syndrome and, perhaps, people with very highfunctioning autism. However, until I see some firm evidence to this effect, I
would not experiment with my child.

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What kind of study would I like to see proponents of
RDI do?
I would like to first see RDI Therapy tested on adolescents and adults withAsperger’s Syndome prior to tests conducted on individuals with autism. The
study design should be a double-blind (where neither the experimenter, the childor his parents know who is receiving the treatment), between-subject design using
random assignment to conditions. Although the RDI researchers do not like IQ
testing as a measure for progress, it is still important that they incorporate severalof these measures into their studies. Specifically, cognitive measures need to be
used in addition to the Autism Diagnostic Observation Schedule, ADOS (whichmeasures play, social interaction, and communication) to offer a preliminary
evaluation of the RDI program.
Who else recommends for or against RDI Therapy asa method for the treatment of autism?
RDI has only recently been introduced into the world of autism treatment as a
new alternative. Therefore, there has not been much written that either supportsor refutes the method.
So you’re still on the horns of a dilemma?
Since there is insufficient data supporting this method, it is important to understandthat using this method on a child essentially amounts to experimentation. Thatsaid, as long as effective treatment is being provided to the child and RDI does
not interfere with the provision of the primary treatment, the biggest gamble isspending money on a treatment that may not be effective. As the RDI is taught
to parents and then administered by the parents to the child, there is a limit to155The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

the cost; however, it is important to take into account the energy drain on theparent for a treatment that is not yet shown to be effective.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence that RDI isan effective treatment for decreasing the symptoms associated with autism.

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Endnotes RDI Therapy
1

Gutstein, S. E. 2004. “The Effectiveness of Relationship Development Intervention in
Remediating Core Deficits of Autism-Spectrum Children. Journal of Developmental & Behavioral
Pediatrics, Vol. 25, No. 5, p. 375.
Gutstein, S.E., (see n. 1 above), p. 30.

2

Gutstein, S.E., (see n. 1 above), p. 30.

34Gutstein, S., and R. Sheely. 2002. Relationship Development Intervention Activities for YoungChildren. London: Jessica Kingsley Publications.
Gutstein, S., and R. Sheely, (see n. 4 above), p. 9.

56Gustein, S., and R. Sheely. Introductory Guide for Parents, Going to the Heart of Autism,
Asperger’s Syndrome & Pervasive Development Disorder, www.rdiconnect.com (accessed Oct.
25, 2005).
Gutstein, S., and R. Sheely. 2002a. Relationship Development Intervention with Young Children,
Social and Emotional Development Activities for Asperger Syndrome, Autism, PDD and NLD.
London: Jessica Kingsley Publishers.

7

8
Gutstein, S.E., and R.K. Sheely. 2002b. Relationship Development Intervention with Older
Children, Adolescents and Adults: Social and Emotional Development Activities for Asperger
Syndrome, Autism, PDD and NLD. London: Jessica Kingsley Publishers.

Gutstein, S., and R. Sheely, (see n. 6 above).

910

Gutstein, S., and R. Sheely, (see n. 6 above).

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Child-lead/Parent-facilitated Therapies: The
Learning to Speak Program
What is the Learning to Speak Program?
Learning to Speak is a program designed for parents to teach their languagedelayed children to speak. The method was designed for children considered
intellectually normal with speech delays not associated with mental retardation.1
It is important to note that this program was not designed for children with
autism specifically, and is recommended only for children with autism who are
not intellectually impaired. The Learning to Speak manual (1984) was designed
for individuals who have a minimum mental age of 12 months. Parents areadvised that they may need professional help if their children’s delays exceed 10months.2 According to Zelazo (1984), the Learning to Speak Program is basedon the developmental foundations of language and some principles from thefield of behaviorism.3 The curriculum is progressive: first sounds and words
are taught; then two-word combinations are introduced; and finally, complex
sentences are taught. In order to accomplish these goals, the manual suggests
using the techniques of non-verbal imitation, verbal imitation, contingent rewards
and prompts.
The program begins with assessment of the level of language of each child. Formal
language instruction occurs at the level on which the child is assessed. Skills
are then generalized to other settings. Parents are urged to use contingencies(rewards), events outside of the sessions (such as bathtub time, getting dressed),
and props (such as toys or three-dimensional objects) to encourage language. The
ratio is one child per teacher (who is generally the parent) and the instruction
style is a combination of child-led and adult-led.

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The Learning to Speak manual also offers suggestions on how to overcome noncompliant or resistant behavior in order to enable learning to occur. Resistantbehaviors are addressed by removing all rewards for those behaviors, while
simultaneously rewarding alternative, more desirable behaviors. The two specificbehavior reduction strategies mentioned in the manual are extinction (ignoring or
removing attention from a behavior), and time-out (removing the child from thestimulating activity or by removing the stimulating activity from the child).
What evidence do the practitioners have that thisreally works?
There is currently no evidence that this is an effective intervention for individuals
with autism. After doing a database search (psychinfo, medline, eric, andCochrane Collection) on the Learning to Speak program and research conductedby Zelazo (the developer of the method), we found over ten journal articles.
However, most of the articles were theoretical in nature. After excluding
the descriptive articles devoid of data testing the method, we netted only one
peer-reviewed study. Although this one peer-reviewed article does provide a
description of data,4 according to Zelazo5 the data described has not been peerreviewed. Despite the lack of peer-review for the data, it is important to mention
that Zelazo did report improvement among children with autism (although theforty-four children in the study proportedly were diagnosed with “developmental
delays of unknown etiology [cause]”6 and not autism). Zelazo reports statisticallysignificant improvement on many verbal measures and compliance behaviors,
which is not surprising considering that part of his method borrows from basic
behavioral principles.

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What does the therapy actually look like?
The recommended intensity of this program is twelve minutes per day, five days
per week until the various levels have been completed. To provide the child withthe feeling of success, the session begins and ends each day with the practiceof mastered material; the middle of the session focuses on new material. Whenthe child provides a correct response, he or she receives both tangible rewards(e.g., food) and social rewards (e.g., verbal praise). To teach the child the correct
response, the adult uses imitation and shapes verbal approximations (e.g., thesound “cu” will be shaped into the word “cup”). Early stages of therapy include
both nonverbal and verbal imitation where the adult shapes the child’s sounds into
single words. Once sixty single words have been acquired, these words are firstpaired into two word sentences and then eventually into complex sentences.
What else do I think?
There is currently no peer-reviewed research to support this intervention forchildren with autism. It is also not clear that the authors actually intended
this intervention to be used for individuals with autism. It appears as though
the method was designed for a different group of children and then applied tochildren with autism, despite the lack of data for the method on this populationof children. In addition, the Zelazo Method uses a very low level of treatment
intensity (only twelve minutes per day). Based on what we know about autism
and the difficult nature of the condition, particularly when it comes to language,
twelve minutes daily would appear to be far too low to meet the serious needs ofthe individual afflicted with autism. Presumably, this is why Zelazo et al. (1984),
recommend a minimum mental age of twelve months and professional guidance
for individuals with delays greater than ten months. These recommendations ineffect work to exclude most untreated individuals with autism, whose delays
would generally exceed those mentioned by the authors. This would also include
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children without mental retardation who receive low scores on IQ tests due toone of the hallmarks of autism amongst young children, which is noncompliance.
In other words, if the child does not cooperate during the testing, his score will be
deceptively low and he will be excluded from the population Zelazo recommends
for the therapy. Additionally, authors do not make it clear how to structure thelearning situation. For compliant children, it is recommended that they sit in achair; however, for noncompliant children, parents are instructed to follow thechild’s lead and accept unstructured learning situations. The authors do notaddress how the noncompliant child will learn from this method.
Other areas of potential confusion for parents using the Zelazo Method regard
problematic behavior and prompting. The authors recommend the use of prompts
to facilitate success for their children; however, they do not discuss the systematic
fading of prompts towards independence. In addition, the behavioral strategies
of extinction and time-out are mentioned, but parents are not told how to selecta strategy based on the function of the behavior for the child. If a behavior does
not serve the purpose of gaining attention for the child, then ignoring the behavior
will not likely be successful. Moreover, if a child is acting out as a form of escapefrom a situation or task, the use of time-out will actually reward the child formisbehaving. In short, the entire field of behaviorism is much more complex
than the way it is presented in the Learning to Speak program.
The Learning to Speak program manual discusses many effective learning
strategies (e.g., shaping, prompting, behavioral intervention, compliancetraining and the use of imitation to facilitate language acquisition); however,there is nowhere near enough information provided in order for these strategies
to be applied effectively. It is unrealistic to expect parents to implement thisprogram based on the limited information in the manual. In addition, the manual
oversimplifies language development and teaching for individuals who have162

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particular delays in these areas. Finally, it is interesting that in this method, it
is only parents with minimal training who are expected to be competent speechtherapists for their children. This is the perfect type of therapy that governments
and health insurance companies can endorse because it costs them very little
money, as parents are free labor. In fact, proponents of this method consider
parents ideal therapists because they are with their children much during theinfant and toddler years. Zelazo states in his 1997 article, “These factors, alongwith a more exclusive reliance on parents as therapists, render Learning to Speakan extremely efficient intervention program in both time and financial cost to
the taxpayer, although it is intensive for parents initially”7 (emphasis added).
It is my view that researchers doing pure research should not be concernedwith government policy or taxpayer money; their main priority should beresearch that moves the autism treatment field forward in terms of efficacy andsuccessful outcomes for the children. Another troubling part of this researchis the funding source. According to Zelazo, the Office of Special Education
looked at preliminary data prior to funding this research project to the tune of$750,000.8* That kind of interference in science is a red flag in my case.
Would I try it on my child?
I would not try the Learning to Speak Method on my child simply because there
is no independent data which provides evidence for the efficacy of this method
for autism. If the method were scientifically substantiated (and not directly
supported by the Office of Special Education), requiring only twelve minutes a
day to make a significant difference in the life of a child with autism, it might beworth trying. However, the concept that such a low level of treatment intensity,

Although it is not clear from the article, it appears as if the Office of Special Education thatfunded this research is a U.S. agency. Their research was funded from the Office of Special
Education (No. G00760379) and the Tufts-New England Medical Center Hospital.
*

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and a vaguely defined method would be able to generate positive outcomes with
autistic children who have such serious developmental and language disorders,
seems far too good to be true, and consequently, difficult to believe without more
serious evidence.
What kind of study would I like to see Zelazo andColleagues do?
The language program described in this manual requires the same evaluation as
any treatment option. There needs to be controlled research evaluating the effectsof this program. These researchers need to use standardized, widely accepted
diagnostic protocols to define all the children in his study and the method would
require implementation by highly skilled practitioners for the same amountof time daily (rather than using parents as therapists), in order to increase theconsistency and skill in the delivery of the therapy. The study would have torandomly assign children to experimental and control groups or at least matchthe children in each condition with the control group receiving generic speech
and language therapy for the same amount of time per day. Most important, alldirect ties to government special needs stakeholders must be severed prior toembarking on any research which tests the efficacy of this treatment method.
Who else recommends for or against the Learning toSpeak program?
This is a rather obscure treatment method which targets language therapy.
Consequently, there is little written by others in the autism field regarding thistreatment for children with autism. In addition, there is no debate in the field
about the efficacy of this treatment, partially because it has been developed in
Canada and is not widely supported by state governments in the United States.
As governments come to rely on this method more for children with autism, there

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may be a debate opened up about the lack of evidence regarding the efficacy of
the Learning to Speak program. However, up to this point, we know of only
one government that has attempted to provide this training to parents of children
with autism– the Government of Newfoundland/Labrador, Canada.
What’s the bottom line?
There is no evidence suggesting that this is an effective intervention for individuals
with autism. In fact, there is no evidence to suggest that this intervention waseven designed for use on individuals with autism.

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Endnotes for the Learning to Speak Program
1
Zelazo, P. R. 1984. Learning to Speak: A Manual for Parents. Hillsdale, NJ: Lawrence
Erlbaum Associates, Inc.
2

Zelazo, P. R., (see n. 1 above).

3

Zelazo, P. R. 1997. “Infant-Toddler Information Processing Treatment of Children with
Pervasive Developmental Disorder and Autism: Part II. Infants and Young Children, Vol. 10,
No. 2, p. 4.
4

Zelazo, P. R., (see n. 3 above).

5

Zelazo, P. R., (see n. 3 above), p. 11.

6

Zelazo, P. R., (see n. 3 above), p. 7.

7

Zelazo, P. R., (see n. 3 above), p. 6.

8

Zelazo, P. R., (see n. 3 above), p. 8.

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Biomedical Therapies

Section 1.4

p Diet/Nutrition Therapy (Gluten and Casein-free Diet)
p Chelation Therapy
p Intravenous Immunoglobulin Therapy
p Secretin
p Vitamin B6 and Magnesium

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Biomedical Therapies: Diet/Nutrition Therapy
What is Diet/Nutrition Therapy?
The use of diet or nutrition therapies to treat autism takes many forms, each witha unique explanation about how certain types of foods are negatively purported
to affect a child with autism. While all of the interventions have been groupedin the same section, an explanation of each of the underlying theories will be
provided separately.
Gluten and Casein-free Diets
The first and most popular diet intervention involves the elimination or reductionof gluten or casein, or both in the diet of an autistic person. The belief in thisdietary intervention is based primarily on the age at which the disorder isdiscovered. Researchers hypothesize that there is a relationship between theonset of autism and significant dietary changes, believed to involve food derived
peptides (which are proteins).1 As a result, researchers in these studies havecategorized individuals with autism into three subgroups; types A, B1 and B2.
Type A is comprised of children who developed autism late (late onset infantile
autism or childhood onset PDD). This group is given a gluten-free and casein(milk products) reduced diet, due to the retrospective observation that when theirgluten intake increased, the autism appeared to be caused (for 90 percent of thesechildren).2 The next group of children is categorized as Type B1 because theirautism was observed as early onset with later regression. They were given gluten
and casein-free diets, as were those children categorized as Type B2, early onset
infantile autism, without worsening symptoms. Researchers in this field believethat the early onset was due to the fact that only milk was being consumed at
this stage and must therefore be the cause of the onset of autism.3

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Candida Diet
Another offshoot of Nutrition therapy is the Candida diet, which is thought tobe an effective treatment for autism by its proponents. It is hypothesized that
Candida albicans (yeast) can become overabundant and deprive the body ofnutrition by interfering with digestion.4 In turn, this is said to interfere withneurotransmission in the brain. Some believe that this can lead to several
disabilities, of which autism is included.
Ketogenic Diet
Another diet that is claimed to originate from the treatment of epilepsy andcancer is the Ketogenic Diet.5 Proponents of the diet, as it applies to autism,
hypothesize that the Ketogenic Diet helps metabolize glucose in children with
autism and, thereby, lessens the symptoms of autism.
Nutritional Therapy
Another popular treatment for autism is the use of vitamins and minerals totreat what are considered, by proponents, to be nutritional imbalances. These
researchers claim that by balancing the body’s chemistry, the symptoms of people
with autism will decrease.6 Proponents test children for over eighty nutritional
deficiencies (examples of the chemicals that these researchers claim to havefound to be “out of balance” are copper, zinc, lead, cadmium and sodium).
Then they give the children additives to purportedly create balance in the bodychemistry.*

The most popular deficiency diets are those that recommend Vitamin B6 and magnesium. Due to the
popularity of Vitamin Therapy, a separate section has been devoted to the analysis of that treatment.

*

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What evidence do the practitioners have that thisreally works?
Our database searches netted dozens of articles discussing various types ofnutritional diet therapies intended for the treatment of autism. Once we rejected
the reviews, commentaries and testimonials due to their lack of controlled data,
we were left with very few peer-reviewed journal articles that supported theefficacy of Diet/Nutrition Therapy.
Gluten and Casein-free Diets
Our search netted eight articles* which collected behavioral data on theeffectiveness of Gluten and Casein-free Diets for autism. Once we excluded
a survey article12 and an article documenting referral of nutritional therapies,13
we were left with six articles on this approach to autism intervention.1,2,14,15,16,17
This research is affiliated with two groups, one at the Department of PediatricResearch at the University of Oslo, Norway (the Reichelt Knivsberg group) andthe other at the Department of Paediatrics of the University of Rome.14
Specifically, only one of these studies has a control group,17 which leaves
opportunities for many confounding variables (other uncontrolled influences) to
explain results or changes. An additional problem with a lack of control groupwhen the studies are conducted over months or years is that there is no control
over maturation effects (improvements that may naturally occur as childrenage). The gains that were made due to maturation alone (or the fact that manyof these children were in specialized educational environments and perhaps
improving) were not taken into account in these studies; yet these gains may have

There were five additional articles found in our Gluten and Casein search; however, these were excluded
because they simply measured increased peptide levels without testing the diet and without using any
traditional measures for autism.7,8,9,10,11*

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been responsible for the observed improvement. (Please see Section Two foran explanation on the weaknesses of within-subject designs). The Knivsberg
et al. (2002) study does have a control group, which is a major improvement
over the other five studies on Gluten and Casein-free Diets.
An additional weakness of this group of studies is that the measures of thedependent variables of autism are flawed. The reported results on behavior
change were done by parents in several of the studies,1,2,16 (For a discussion
regarding the dangers of relying on parental reporting, please see Section
Two). In addition, in the Lucarellie et al. (1995) study, it was not specified
who administered the measures. Furthermore, all these researchers use tests
that have questionable validity when it comes to autism. The Diagnosis of
Psychotic Behavior in Children (DIPAB) was developed in 1975 for psychosis,
not autism.18 Our knowledge of autism has increased significantly in the last
thirty years and we are now able to differentiate between autism and psychosis.
With that increased knowledge, there are also independently validated measuresthat should have been used instead. Additional outdated and non-autism specificmeasures that have been used in this research is a non-verbal cognitive testdeveloped forty-seven years ago (the C-Raven test – Raven, 1958), the Illinois
Test of Psycholinguistic Abilities developed thirty-seven years ago,19 and a
Norwegian Autism Observation Scale designed twenty-four years ago.20 An
additional measure of questionable validity is the Behavior Evaluation Scale(BSE) that has not been independently validated using already agreed upon,validated autism scales.
Yet another problem with all the studies is that only one of them16 was single
blind. None of the other studies had sufficient controls against experimenter bias.
The 2002 study conducted by Knivsberg et al. was a significant improvement on
all the studies which have preceded this study; however, the 2002 study suffers

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from several flaws. Although information on autistic traits was collected (oftenwith outmoded testing) and individual reports were written on each child’s levelof functioning, there was no objective behavioral measure (e.g. amount of selfstimulatory behavior per day per child) that could be compared pre-and post
treatment. In addition, parents were heavily involved in the study and knew towhich experimental group their child was assigned. The project leader, however,
did not. In short, although this study was the best published so far for this methodof autism intervention, the flaws in the study make it premature to accept it asevidence that supports the effectiveness of the Gluten and Casein-free Diet.
Candida Diet
In terms of evidence for the efficacy of the Candida Diet, we only found one study4
and that study only presents case histories which are completely uncontrolled.
In addition, in the two case studies described by Adams and Conn (1997),
both of the children were involved in educational treatment concurrently. Thisfurther confuses (confounds) the results of this retrospective study. Moreover,parental reporting was relied upon heavily in these two case histories. Finally,
improvement was not objectively measured.
Nutritional Deficiency Diet
We found only one peer-reviewed journal article on Nutrition Therapy (excluding
all the articles written about Vitamin B6 and Magnesium). The researcher,
Isaacson (1996), concludes that after supplementing the children with a varietyof vitamin and mineral supplements, there was “significant general improvement
in all symptoms.”21 There are several methodological problems with this study.
First, the chemical imbalances that were identified were determined using hairanalysis, which can be a controversial procedure, particularly when done by acommercial laboratory.22 Second, the relationship between autism and chemical
imbalance has not yet been established. Finally, the conclusion that children

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improved is based on one follow-up visit in a retrospective study. There are no
criteria laid out for how the improvement was measured, and the improvement
is examined retrospectively. This opens the results up to recall bias, which inthis case is doubly problematic because the recall is being made by parents who
are not unbiased even in the best of scenarios.
Ketogenic Diet
We netted only one peer-reviewed journal article on the Ketogenic Diet.
Evangeliou et al. (2003) did a within-subject design which included thirty
children with autism. A number of children stopped the diet prior to completionof the study (40 percent) which left eighteen out of the original thirty children
remaining in the study. The researchers found that two of the children
significantly improved, eight patients improved less significantly and there wasminor improvement for an additional eight patients (these improvements were
measured with the Childhood Autism Rating Scale, CARS). The researchersreport significant improvement with two children (a twelve point change in
the CARS) to the extent that these children were able to attend a mainstream
school. (Yet, it was not specified if there was an in-class aide or if the children
were functioning in class independently).
Although this study reported promising results and did have some impressive
controls (e.g., the children were administered the diet in a hospital throughout
the study, and the psychiatrist who evaluated the children did not know whichchildren were in the study and which were not), there are several limitations
to the study. The CARS is one screening device for autism; however, more
psychometric testing needs to be done with those children to be able to measure
meaningful change. In addition, observational data which measures the relative
decrease of stereotypy and other self-stimulatory behaviors characteristic tochildren with autism must be collected. Furthermore, we must consider that174

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those who worked in the hospital were not blind to the treatment. They knew
which children were on the diet and could have influenced the outcome of thestudy (see Section Two on self-fulfilling prophecy). Another critique of thestudy is that 40 percent of the children in the study withdrew prior to study
completion. Although we still have pre-and post measurements of those children
who remained, the large attrition rate does not inspire confidence, particularly
when the authors claim that all children benefitted from the study.
An additional unexplained finding is that the children’s improvement wasmaintained long after they discontinued the diet. This could be due to a longterm effect of the diet; however, an alternate explanation is that there is a
confounding variable completely unrelated to the diet, which is responsible forthe improvement. That said, these findings are sufficiently robust with a small
subset of the children in the study that they invite replication by other researcherswith no relationship to this research group.
What does the therapy actually look like?
Gluten/Casein-free Diet
The gluten/casein-free diet attempts to eliminate all products which contain gluten(such as most breads, cakes and other carbohydrates which contain wheat) and all
products which contain casein (such as milk and cheese). The diet is generally
carried out for a year and monitored. Once parents are convinced that the dietis working, they end up keeping the child on the diet permanently. Parents
generally control the diet in consultation with a nutritionist and, sometimes, a
medical doctor.
The Candida Diet
The Candida diet follows a complex seven stage procedure developed by
MacFarland (1992). The body is said to be detoxified by eliminating a large
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variety of foods (such as milk products, corn products, sugars) from the diet.
Gradually, foods are then reintroduced. It is unclear from the article as to how
reintroducing certain foods balances the yeast; however, the concept is that as aresult of the therapy, the body’s yeast level is supposed to come into balance.
The Ketogenic Diet
The Ketogenic Diet was adapted for children to make sure that thirty percent of
the child’s daily intake comes from medium-chain triglyceride oil (found in foods
such as coconut oil). The rest of the child’s food must be balanced as follows: 30
percent cream, 11 percent fat, 19 percent carbohydrates and 10 percent protein.5
This modified diet, the John Radcliffe diet, was adapted due to its purported
ease of management. The researchers do not go into detail about how long thechildren should remain on the diet; however, children in the study were on thediet for four weeks and then diet-free for two weeks, over a six month period.
What else do I think?
Many parents are attracted to diet/nutrition interventions because it is a nonmedicinal approach that appears to be relatively easy to follow. People often
gravitate to this type of intervention due to the observation that their child with
autism either has strong food preferences, food aversions, or gastrointestinal
discomfort or distress. I suspect that some of the anecdotal results may be a
product of a small subset of children who may have allergies which make themmiserable. Once they feel better, perhaps some of their behaviors improve simply
because they are not suffering. This finding, however, has no effect on autism
intrinsically; rather, it may be that children with autism are often under-served
by mainstream medicine because they don’t have the verbal ability to complain
about feeling physical discomfort whether due to allergy or illness.
The question about the relationship between autism and nutrition remains. We
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simply do not know whether a relationship exists. What we do know is that it isvery important to take the uncontrolled, anecdotal reporting of this relationshipskeptically. Only the true experimental design can begin to shed light on whether
or not there is a relationship between diet/nutrition and autism. Unfortunately,
to date none of the research conducted utilizes a true experimental design withadequate controls and an accepted measurement of the dependent variable, autism.
To illustrate this lack of accepted measure for autism, whether we are measuringchemicals in hair analysis or peptides* in urine (which are heavily used in manyof these studies), these tests do not measure the degree of autism. Only widely
accepted behavioral and psychometric measures that have been validated to test
autism should be used to determine the degree of autism before the diet and thedegree of autism during and after the nutritional intervention.
Would I try it on my child?
I would not try Diet/Nutrition Therapy on my child until some better data is
produced to convince me that there is any truth to the idea that diet can ameliorate
the symptoms of autism. That said, if I were worried that my child were allergic
to any food source, I would go to a mainstream allergist and have her tested. I
would not expect the elimination of an allergin to improve her autism; rather, I’d
expect the elimination of the allergin to eliminate the allergic reaction (which
has not been shown to have any relationship to autism).

*This area is concerned with a particular class of opioid peptides (which are a type of aminoacid). The opioid peptides that are associated with milk – casomorphin, and gluten – gluten
exorphin, are hypothesized to be the culprits in reference to autism.

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What kind of study would I like to see proponents of
Nutrition Therapies do?
At this point, none of the nutrition therapies have established a relationshipbetween nutrition and autism. Prior to conducting any research on treatment, thegluten/casein-free diet researchers must first firmly establish a causal relationshipbetween peptide levels and autism. Specifically, they need to demonstrate a
direct relationship between the excess of opioid peptides (amino acids that havethe effect similar to opiates in the brain) and behaviors characteristic of autism.
Either the opioid peptide – autism relationship needs to be established, or the
researchers should only use behavior scales to measure the degree of autism
prior to and after the diet.
If and when researchers can demonstrate these relationships, then they needto study whether there is a particular subset of people with autism who may
hypothetically benefit from this type of intervention. In other words, the researchquestion should be whether there is a particular subset of the autistic populationof children who have components of their diet which are causing their autistic
characteristics? If so, then, and only then, is there justification for investigation
into treatment. Well-controlled research into the efficacy of diet intervention
for individuals with autism should not use measures that are biomedical; rather,measures used for autism must be standard behavioral measures because autism
is a behavioral diagnosis. Until such time as we have a firm biomedical indicatorwhich can measure degree of autism, an indicator which, at this point, still eludes
us, nutritional studies cannot reasonably make any claims of autism improvement
based on biomedical measures.
There are two studies that I would like to see independently replicated. The firststudy is the Knivsberg et al. 2002 study. They need to use updated, internationallyaccepted measures for autism and a double-blind design where children are either
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being fed the Gluten/Casein-free diet, or another diet that is accepted as healthy.
As mentioned before, double-blind means that neither the researchers nor theparents can know which children are assigned to which group (experimental
or control). The second study that needs to be independently replicated is the
Ketogenic Diet as the results of a subset of those children who remained in the
study appear robust. First, proponents of the Ketogenic Diet need to determine
the way in which Ketone bodies* affect the brain, and more specifically, autism,
which is a disorder of the brain. Without an independent replication either
supporting or refuting these findings, the Ketogenic Diet could turn into the next
fad where children with autism are subjected to yet another treatment without
sufficient evidence. In addition, proponents of the Candida Theory need to first
firmly establish the relationship between an overgrowth of yeast and autism.
Who else recommends against Diet /Nutrition Therapy
as a method for the treatment of autism?
There is a long line of organizations recommending against Diet/Nutrition
Therapies as a treatment for autism. According to the New York State Department
of Health Report on Best Practices for Autism, “The use of special diets thateliminate milk-products, gluten products, or other specific foods from the diet
is not recommended for the treatment of autism in children.”23 In addition,
Quackwatch (a health-related watchdog organization) considers Dietary
Supplements a “Doubtful or Discredited Treatment.”24 Another organization thatconsiders the science behind gluten and casein-free diets as methodologicallyweak is the Association for Science in Autism Treatment (ASAT).25 The
American Academy of Child and Adolescent Psychiatry in their practice*

Ketone bodies are the three chemicals that are a by-product of the process by which fat is broken
down in the body.

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parameters of assessment and treatment also recommend against these diets.26 In
a technical report on autism, the American Academy of Pediatrics states: “Thepresence of allergies or food intolerance in children often stimulates families to
explore unconventional diets... Another recent investigation failed to document
a higher prevalence of hypersensitivity to common food allergens in children
with ASD, compared with controls.”27
So you’re still on the horns of a dilemma?
It might interest the reader to know that these theories have been around formany years. The first accounts suggesting that diet could influence autism dateback to 1981.28 Twenty-five years have passed and there is still no independentscientific support for the various theories on diet and nutrition. Therefore, it might
be a good idea to wait until this research is done and published in peer-reviewed
journals; otherwise, you are essentially engaging in pure experimentation withyour child.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence that Diet/
Nutrition Therapies of any kind are an effective treatment for improving thesymptoms associated with autism.

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Endnotes for Diet /Nutrition Therapies
1

Reichelt, K.L., H. Scott, A.M. Knivsberg, F. Nyberg, and V. Brandtl. 1990. “Childhood Autism:
A Group of Hyperpeptidergic Disorders. Possible Etiology and Tentative Treatment.” BetaCasomorphins and Related Peptides. Uppsala: Fyrris Tryck, pp. 163-173.
2

Reichelt, K.L., A.M. Knivsberg, G. Lind, and M. Nodland. 1991. “Probable Etiology andPossible Treatment of Childhood Autism.” Brain Dysfunction, Vol. 4, No. 6, pp. 308-319.
Reichelt, K.L., H. Scott, A.M. Knivsberg, F. Nyberg, and V. Brandtl, (see n. 1 above).

34
Adams, L., S. Conn. 1997. “Nutrition and Its Relationship to Autism.” Focus on Autism andother Developmental Disabilities, Vol. 12, No. 1, pp. 3-58.
5

Evangeliou, A., J. Vlachonikolis, H. Mihailidou, M. Spilioti, A. Skarpalezou, N. Makaronas, etal. 2003. “Application of a Ketogenic Diet in Children With Autistic Behavior: Pilot Study.”
Journal of Child Neurology, Vol. 18, No. 2, pp. 113-118.
6

Isaacson, R.H., M. M. Moran, A. Hall, B.J. Harman, M.S.W. Prehosovich and M. A. Prehosovich.
1996. “Autism: A Retrospective Outcome Study of Nutrient Therapy.” Journal of Applied
Nutrition, Vol. 48, No. 4, pp. 110-118.
7

Reichelt, K.L., H.K. Hamberfer, and G. Saelid. 1981. “Biologically Active Peptide
Containing Fractions in Schizophrenia and Childhood Autism.” Advances in Biochemical
Psychopharmacology, Vol. 28, pp. 627-643.
8

Israngkun, P.P., H.A.L. Newman, S.T. Patel, V.A. Duruibe, and A. Abuissa. 1986. “Potential
Biochemical Markes for Infantile Autism.” Neurochemical Pathology, Vol. 5, pp. 51-70.
9Reichelt, K.L., G. Saelid, T. Lindback, et al. 1986. “Childhood Autism: A Complex Disorder.”Biological Psychiatry, Vol. 21, pp. 1279-1290.
10Shattock, P., A. Kennedy, R. Rosell, and T. Berney. 1990. “Role of Neuropeptides in Autism
and Their Relationships With Classical Neurotransmitters.” Brain Dysfunction, Vol. 3, pp.
328-345.
Reichelt, K.L., A.M. Knivsberg, M. Nodland, and G. Lind. 1994. “Nature and Consequencesof Hyperpeptiduria and Bovine Casomorphins Found in Autistic Syndromes.” Developmental
Brain Dysfunction, Vol. 7, pp. 71-85.
11

12Cornish, E. 2002. “Gluten and Casein Free Diets in Autism: A Study of the Effects on Food
Choice and Nutrition.” Journal of Human Nutritional Dietetics. Vol. 15, No. 4, pp. 261-269.
13

Bowers, L. 2002. “An Audit of Referrals of Children With Autistic Spectrum Disorder to theDietetic Service.” Journal of Human Nutritional Dietetics, Vol. 15, pp. 141-144.
Lucarelli, S., T. Frediani, A.M. Zingoni, F. Ferruzzi, O. Giardini, F. Quintieri, et al. 1995. “FoodAllergy and Infantile Autism.” Panminerva-Medica, Vol. 37, No. 3, pp. 137-141.

14

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

15

Knivsberg, A.M., K. Wiig, G. Lind, M. Nodland, et al. 1990. “Dietary Intervention in Autistic
Syndromes.” Brain Dysfunction, Vol. 3, Nos. 5-6, pp. 315-327.
16

Knivsberg, A.M., K.L. Reichelt, M. Nodland, and T. Hoien. 1995. “Autistic Syndromes andDiet : A Follow-up Study.” Scandinavian Journal of Educational Research, Vol. 39, No. 3,
pp. 223-236.
17

Knivsberg, A.M., K.L. Reichelt, T. Hoien and M. Nodland. “A Randomised, Controlled Studyof Dietary Intervention in Autistic Syndromes.” 2002. Nutritional Neuroscience, Vol. 5, No. 4,
pp. 251-261.
18

Knivsberg, A.M., K.L. Reichelt, M. Nodland, and T. Hoien, (see n. 16 above), p. 225.

19

Kirk, S.A., J.J. McCarthy, and W.D. Kirk. 1961. Illinois test of psycholinguistic abilities (ITPA).
Urbana: University of Illinois Press.
20

Tafjord, M. 1982. Obsevasjon av fornutsetnninger for lek og aktivitet, Observasjonsskjema.
[Observation of prerequisites for play and activity: Observation schedule], Oslo: Statens
Spesiallaererhogskole.
21

Isaacson, R.H., et al., (see n. 6 above), p. 112.

22
Barrett, S. 1985.“Commercial Hair Analysis, Science or Scam?” Journal of the American
Medical Association, Vol. 254, No. 8, pp. 1041-1045.
23

Guralnick, M. Ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany (NY): New York State Department of Health, p. IV-104.
24

Quackwatch, http://www.autism-watch.org, (accessed Apr. 18, 2005).

Association for Science in Autism Treatment (ASAT), http://www.asatonline.org/resources/
library/informed_choice.html, (accessed May 10, 2005).
25

26

The American Academy of Child and Adolescent Psychiatry in Their Practice, http://www.
aacap.org/AACAPsearch/SearchResults.cfm, (accessed Feb. 21, 2006).
27

Committee on Children with Disabilities. Technical Report. 2001. “The Pediatrician’s Rolein the Diagnosis and Management of Autistic Spectrum Disorder in Children.” Pediatrics,
Vol. 107, No. 5, p. e85, www.aacap.org/clinical/parameters/summaries/autism.htm, (accessed
Feb. 21, 2006).

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Biomedical Therapies: Chelation Therapy
What is Chelation Therapy?
Chelation Therapy is the process by which harmful metal toxins are extracted
from the body. Chelating agents (two types of amino acids) are injected into thechild to bind to these metal ions and remove them from the body. This therapy
is used on individuals with autism, based on the belief that autistic behaviors area result of chronic metal toxicity in the child. It is thought that if the chelating
agents can remove the offending toxins from the body, the symptoms of autism
will improve. It is further hypothesized that the metals are introduced into the bodyfrom the environment through air, water, ingested orally or absorbed through thehands. In addition, the toxin of thermerisol (given through childhood vaccinations
until recently) has been added to this list of contributing toxins.
What evidence do the practitioners have that thisreally works?
Currently, there is no scientific data published in peer-reviewed journals tosuggest that Chelation Therapy is an effective treatment for individuals with
autism. Our database searches found no articles with outcome data regarding theeffectiveness of chelation in improving the symptoms of autism. To date, there
is only anecdotal support in the form of parental reports. (Please see Section
Two for a discussion on the dangers of anecdotal parental reporting in autism
treatment studies). Included in anecdotal evidence is a book by Hallaway andStrauts (1995), who provide a parental report about the treatment of Hallaway’s
twin boys using Chelation Therapy.
It is important to note that screening children for lead poisoning (not autism) is
well accepted in mainstream medicine and lead toxicity is a legitimate health
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problem that is treatable using chelation. The American Academy of Child andAdolescent Psychiatry, adopted guidelines for lead screening and treatment in
1995, using blood tests. If a child shows elevated levels of lead in his or her
blood, the mainstream medical profession typically recommends treatmentusing a form of chelation that differs from the chelation used on autistic children(calcium EDTA versus disodium EDTA). However, at this point, the hypotheses
that metal toxicity causes autism, and that chelation will cure or successfully
treat autism, have not been sufficiently tested and there is no evidence to support
the claims. Consumers are confused about chelation being an accepted practicefor children who have ingested “true” heavy metals that cannot be flushed outof the body any other way.
There are many correlational studies that have determined the symptoms of leadpoisoning in animals and humans. There are also many reports of lead poisoning
and an increased number of persons affected with a variety of symptoms. It
appears that the symptoms are extremely varied and diverse, affecting people indifferent ways. At this point, it is unclear whether lead poisoning, or any heavy
metal poisoning, plays any role in the cause of autism. Although it is beyond
the scope of this book, the reader should know that chelation is being praised byits practitioners as being a cure for everything from clogged arteries to sexual
disfunction.
What does the therapy actually look like?
Chelation Therapy for the treatment of autism involves either oral or intravenous
agents (depending on the chelating agent used), to remove harmful toxins fromthe bloodstream. The intravenous dosage takes anywhere from ten minutes to overthree hours to administer, depending on the agent required.1 When chelation isused to treat a variety of ailments other than its traditional use (lead poisoning),
it is often done over a much longer period of time. Side effects vary with the184Section One: What Works and What Doesn’t?

type of agent used. They can include convulsions, severe constipation, bowel
paralysis, acute toxicity, kidney failure and allergic reactions. In addition, there
have been deaths associated with chelation and over fifteen state medical licensing
boards have taken action against practitioners of Chelation Therapy.2
What else do I think?
Lead poisoning is an important environmental issue which does have far reachingeffects on human and animal health. It might be possible that occasionally a childwith autism might have been exposed to lead; however, the symptoms would be
typical of lead poisoning, not autism. To date, there is no experimental evidence
which examines the issue of lead poisoning in individuals diagnosed as having
autism and the purported therapeutic effects of treating these individuals with
Chelation Therapy. Although the question regarding the relationship between
thermerisol (mercury) in vaccines and autism has not been definitively answered,
the theory that chelation can extract thermerisol and repair possible damage to thebrain, has no supporting evidence. Proponents of Chelation Therapy suggest that
autism is a result of heavy metal poisoning; however, they have no evidence tosupport this assertion. The diagnosis of autism is based on a variety of behavioral
characteristics, and as of 2006, there is still no commonly-accepted, biologicalmarker associated with autism. In other words, we can’t do things like find atumor, count blood cells or measure lead levels to determine whether the childhas autism. After Chelation Therapy, we still can’t use a biological marker tosee if there has been significant improvement in the child’s degree of autism.
Proponents of chelation use hair analysis,* which is not yet accepted by the

Although hair analysis is typically used to determine drug abuse (in the field of toxicology), it
is not widely accepted that heavy metal poisoning can be determined through hair analysis. For
an in-depth discussion on the shaky ground of hair analysis, Quackwatch has done a wonderful
job of exposing the weaknesses of commercial hair analysis.3*

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mainstream medical community for this application. Arguably, these commercial
labs also have an economic incentive to be in the hair analysis business.
Would I try it on my child?
My child does not suffer from the majority of symptoms that are well accepted
as being caused by lead poisoning; however, if she did, I would have her tested
by a reputable physician — for lead poisoning, not autism. In addition I would
not allow the diagnosis to be done with hair sampling from a commercial
laboratory because they have an economic incentive to find toxicity. Moreresearch needs to be done before a relationship between heavy metal toxicity
and autism is established, particularly as the risks of chelating a child with
autism are kidney failure and death. In short, I would never put my child at
risk with a treatment that has no peer-reviewed evidence about its efficacy andhas a very poor safety record.
What kind of study would I like to see the chelation
practitioners do?
Prior to any study on chelation for autism, proponents of this method need tofind a more reliable way to measure toxicity than commercial hair analysis alone.
Once there is evidence that some children with autism have high levels of heavy
metals in their blood, then a study could be done only with those children who
have elevated levels of the toxin in question. Every child with autism who is acandidate for chelation due to excessive levels of metal toxicity would then needto receive a diagnosis of autism by an independent registered psychologist who
would also measure each child in the study using autism rating scales, IQ andobjective behavioral tests or measures (taking great care to avoid any parental
reporting in the study design). Each child would need to be randomly assigned

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to an experimental and control group, without experimenter knowledge regarding
which children are in which group. After the treatment or placebo (given to thegroup not receiving the treatment), each child would need to have the same batteryof tests performed by the psychologist prior to the study. For confidence in the
results, I would suggest a study should include twenty children per group, fora total of forty children in the proposed study. If the results were to show that,for example, cognitively impaired children’s IQ rise significantly with Chelation
Therapy, that would show us that the hair sampling technique effectively identifies
children who have heavy metal poisoning and that the heavy metals do indeed
affect cognitive ability of children afflicted with autism. That, in itself, would nottest the “chelation treats autism” hypothesis. However, if there is a significant
difference between objective behavioral measures and scales rating severity ofautism before and after the treatment, that would tell us that chelation does havean effect on the degree of autism within this group of children. A study such as
this would be able to teach us much about the relationship between autism andchelation. Unfortunately, I think that this kind of study would be potentiallyharmful considering the lethal effects of Chelation Therapy on some children.
This is a serious ethical obstacle to any future chelation study.
Who else recommends for or against chelation asa method for the treatment of autism?
There are several medical associations and a few consumer groups that warn
against Chelation Therapy in general, and a few refer to autism chelation
treatments specifically. The American Academy of Pediatrics states:...there is no evidence that Chelation Therapy will improve developmental
function when given to treat mercury toxicosis. Moreover, chelating agents canhave significant toxicity (e.g. hepatoxicity) and precipitate allergic reaction.182
Chelation Therapy is therefore not recommended for the purpose of improving
neuro-developmental function in children with ASD.4

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In addition, the National Council Against Health Fraud recommends against
Chelation Therapy. They state: “The National Council Against Health Fraud
believes the Chelation Therapy is unethical and should be banned and that
Chelation Therapy of autistic children should be considered child abuse.”5
An additional resource established to debunk scientific quackery is Quackwatch.
They have an entire website devoted to the issue of chelation, for a variety of
medical conditions. Particularly interesting on their website are documents
surrounding several court cases which were launched either due to the death of
an individual after chelation, or the suspension of professional licenses from avariety of chelation practitioners.
So you’re still on the horns of a dilemma?
Before you decide whether or not to put your child through chelation, I
would strongly suggest that you read the guidelines of the American College
of Preventative Medicine Practice Policy Statement, which describes theconditions under which a child may be at risk for heavy metal poisoning and, if
so, which proper steps to take.6 If your child does not meet the at-risk criteria,
please understand that in chelating your child, you are engaging in high-risk
experimentation that, in isolated cases, can result in death.
What’s the bottom line?
Based on the scientific research to date, there is no evidence that Chelation
Therapy is an effective treatment for decreasing the symptoms of autism inchildren.

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Endnotes for Chelation Therapy
Hallaway, N., and Strauts, Z. 1995. Turning lead into gold: How heavy metal poisoning canaffect your child and how to prevent and treat it. Vancouver, BC: New Star Books Ltd.

1

Quackwatch, www.quackwatch.org/01QuackeryRelatedTopics/hair.html, (accessed Feb. 16,
2006).

2

Quackwatch, (see n. 2 above).

3

4

Committee on Children With Disabilities. 2001. “Technical Report: The Pediatrician’s Rolein the Diagnosis and Management of Autistic Spectrum Disorder in Children.” Pediatrics, Vol.
107, No. 5, p. e85, www.pediatrics.aappublications.org/cgi/content/full/107/5/e85, (accessed
Feb. 13, 2006).
5

The National Council Against Health Fraud. undated. NCAHF, Policy Statement on Chelation,www.ncahf.org, (accessed Aug. 9, 2005).
Lane, W. G. 2001. “Screening for elevated blood lead levels in children.” American Journalof Preventive Medicine, Vol. 20, No. 1, p. 78-82, www.acpm.org/pol_practice.htm#several,(accessed Feb. 16, 2006).
6

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Biomedical Therapies: Intravenous Immunoglobulin
What is Intravenous Immunoglobulin Therapy?
Intravenous Immunoglobulin (IVIG), a form of blood/plasma, is used as atherapy for autoimmune disorders and is actually considered medically necessary
for dozens of conditions. It is paid for by insurance companies such as Aetna.
The theory posited by proponents of IVIG therapy, is that there is a relationshipbetween autism and autoimmune disorders. Some researchers have suggested
that autism is an immune-related disorder, and have treated autism using IVIG toaddress the autoimmune phenomenon that they claim to observe in individuals
with autism.1 Although there are some differences in the way that IVIG isadministered, typically the treatment itself involves the administration of IVIG
every four weeks for at least six months.
What evidence do the practitioners have that thisreally works?
Our database search netted three articles which present data on IVIG therapy.1,2,3
None of these studies used control groups or random assignment and two of thethree studies measured the dependent variable, autism, in a problematic manner.
The results of the first preliminary study indicated that behavioral, speech andcognitive improvements were observed in ten autistic individuals who weretreated with a six month course of IVIG.1 Unfortunately, the dependent variable,
autism, was operationalized in an unstructured and extremely subjective way.
Various behavioral therapists, speech therapists and psychiatrists involved in
the child’s life reported changes, and these reports were subsequently converted
into an arbitrary rating scale using numbers one through four (1-4) to indicate
degree of improvement. In addition, no “p-values” were reported to indicate
whether or not the changes in this rating scale were statistically significant.
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Despite the researchers’ conclusion that children with autism improved, theinsufficient rating scales prevent us from making any meaningful conclusions
based on the results of this study. The potential for bias in the dependent measureis high, and the lack of control prevents changes observed from being attributed
to the intervention. An additional flaw in this study design is that some of thesechildren were in behavioral and speech/language therapy programs at the time.
Without controlling the variable of “other therapies” by utilizing a control group,
one cannot attribute, with confidence, any results to the IVIG therapy. To his
credit, an IVIG researcher named Gupta, states that: “a controlled double-blind,placebo-controlled multicenter study is being planned.”4 We very much lookforward to that study.
The second IVIG study was conducted on ten children with autism (Pliopys,
1998). It also did not go into sufficient detail to tell us how the dependent variable,
autism, was measured prior to the study. This is not a small point. If we cannot
properly measure the degree of a child’s autism at the beginning of a study, we
will assuredly not be able to accurately measure the degree of autism after thetreatment has been applied in the study. Pliopys reported no improvement in nineout of the ten subjects; however, one child appeared to improve dramatically.
Unfortunately, due to the lack of rigor in the pre and post measures of autism,
we have no idea whether the improvement actually occurred and, if it did,whether the improvement can be attributed to the IVIG treatment. This isunfortunate because if there is a subset of children who do benefit, it would be
beneficial to know which subset of children may be candidates for this therapy.
The last study we found in our search, the DelGiudice-Asch et al. (1999) study,
gave IVIG Therapy to five children with autism and found no improvement
among the children. The difference in this study from the two earlier studies isthat these researchers measured the dependent variable, autism, utilizing four
different psychometric and autism scales. Their ability to objectively measure
improvement in post treatment makes this the strongest of the three studies.
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What does the therapy actually look like?
IVIG treatment is a two hour intravenous administration of a course of
immunoglobulin, a protein antibody found within the bloodstream which binds
to antigens (substances which create an immune response, i.e., an allergic
reaction, in the body) and subsequently deactivates them. Maintenance doses
are given every four to six weeks; however, at treatment outset, they may haveto be administered at higher rates. The cost of this procedure is approximately$100 U.S. per gram, including procedural costs (approximately $3000 USD per
treatment). Subjects are first prescribed a course of Benadryl to combat possible
side effects, which include dizziness, nausea, abnormally rapid beating of theheart, headache, fever and muscle pain.
What else do I think?
It is quite difficult for consumers to differentiate between IVIG as an experimental
procedure or an accepted best practice treatment, because it is used so commonly
for a variety of disorders. This treatment operates under the assumption that
autism somehow involves possible infectious agents and or immune deficiencies.1
Yet, importantly, all the possible explanations for how and why IVIG may beeffective for individuals with autism are, at this point, unproven. If indeed autism
may be an immune-related disorder for some individuals, we need firm evidence
establishing this to be the case. IVIG is postulated to work by either suppressing
particular antibodies or by easing brain inflammation; however, these researchers
have insufficient evidence to claim that autism is caused by particular antibodies
or brain inflammation. As autism cannot yet be diagnosed and measured bylooking at a physiological marker (e.g., a blood test), the auto-immune theoryof autism remains as a theory, still to be supported by data.

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Would I try it on my child?
If researchers could make the link between auto-immune disorders and autism,and show that IVIG does indeed ameliorate the condition of autism, I would bevery interested in providing this therapy for my child. However, until the researchis done, I would not subject my child or my wallet to this treatment.
What kind of study would I like to see the researchers
studying the effects of Intravenous Immunoglobulin do?
I would like to see a randomly assigned, double-blind, placebo-controlled
crossover study, with subjects receiving IVIG treatment. The dependent measuresused to evaluate the effectiveness of the intervention should be well-validated andmeasure IQ or cognitive functioning, language and behavior. These measures
should be assessed by raters who do not know the purpose of the study. In
addition, an analysis of severity, frequency and longevity of side effects should
also be done. Finally, the results should be reported using statistical levels ofsignificance, so we know the results are likely not due to chance.
Who else recommends against Immunoglobulin therapy
as a method for the treatment of autism?
There are several associations that warn against IVIG treatment for autism. The
New York State Department of Health has the following to say about the therapy:“It is strongly recommended that intravenous immune globulin therapy not be
used as a treatment for autism in children because of the substantial risks andlack of proven benefit associated with this intervention.”5 In addition, the policy
statement of the American Academy of Pediatrics reads: “Unproven therapies also
may be based on pathophysiology and limited research, but they lack accepted
standards of proven effectiveness (e.g., the use of immunoglobulins in the194Section One: What Works and What Doesn’t?

treatment of autism).’’6 In May, 2005, this policy was reaffirmed. Furthermore,
Dr. Marie Bristol-Powers of the National Institute of Child Health and Human
Development states: “Treatment studies do not support the clinical use of IVIG,
which would support a immunological factor in autism.”7
So you’re still on the horns of a dilemma?
You might want to read Hyman et al. (2000),8 in which they speak about thelure of complimentary and alternative medicare. Keep in mind that if IVIG iseventually found to be effective, there will be controlled studies available todemonstrate its efficacy. Before this happens, please understand that you areengaging in pure experimentation with your child if you employ IVIG treatmentin the effort to ameliorate autism.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence that the useof Intravenous Immunoglobulin (IVIG) is an effective treatment for decreasing
the symptoms associated with autism.

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Endnotes for Immunoglobulin therapy
1Gupta, S., S. Aggarwal, and C. Heads. 1996. “Dysreglated Immune System in Children With
Autism: Beneficial Effects of Intravenous Immune Globulin on Autistic Characteristics.” Journalof Autism Developmental Disorders, Vol. 26, pp. 439-452.
Piloplys, A.V. 1999. “”Response to Letter by dr. Gupta Concerning The Treatment of Autistic
children With Intravenous Immunoglobulin.” Journal of Child Neurology, Vol. 14, No. 3, pp.
203-205.

2

3

DelGuidice-Asch, G., L. Simon, J. Schmeidler, C. Cunningham-Rundles, and E. Hollander.
1999. “Brief Report: A Pilot Open Clinical Trial of Intravenous Immunoglobulin in Childhood
Autism.” Journal of Autism and Developmental Disorders, Vol. 29, No. 2, pp. 157-160.
Gupta, S., S. Aggarwal, and C. Heads, (see n. 1 above), p. 451.

4

5Guralnick, M., ed. 1999. Clinical practice guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany (NY): New York State Department of Health, p. IV-91.
6

Committee on Children with Disabilities. 2001. “Technical Report: the Pediatricians Role in
the Diagnosis and Management of Autistic Spectrum Disorder in Children.” Pediatrics, Vol.
107, No. 5, p. e85, http:pediatrics.aapublications.org/cgi/content/full/105/5/e85, (accessed Feb.
16, 2006).
Bristol-Powers, M. 2001. “The Etiology of Autism and NICHD Research.” National Instituteof Child Health & Human Development, Washington, DC: National Academy of Sciences.

7

8

Hyman, S.L., and S.E. Levy. 2000. “ Autistic Spectrum Disorders: When Traditional Medicine
is Not Enough.” Contemporary Pediatrics, Vol. 10, p. 101.

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Biomedical Therapies: Secretin
What is Secretin Therapy?
Proponents of Secretin Therapy believe that the use of secretin (a gastrointestinal
peptide which is a kind of hormone), for individuals with autism, results in an
improvement of autistic behavior. Some researchers believe that there may be
a link between the brain and gastrointestinal functioning in autistic children.
Specifically, these researchers hypothesize that gastrointestinal difficulties foundin people with autism contribute to the cause of autism, and that by forcing
the pancreas to greatly increase the production of flui1d, there is significant
improvement in the symptoms of people suffering with autism.1
What evidence do the practitioners have that thisreally works?
Two literature searches, one in 2000 and one in 2006, were conducted. The 2000
literature search uncovered four articles, two of which were between-subject,double-blind, placebo designs. The first study included twenty-five children
and the second study used sixty children. Neither of those studies reported any
improvement in the symptoms associated with autism. One of these designs wasdone in two stages; the first stage was designed to identify children who seemed
to be the most likely candidates to improve using secretin. These children were
given secretin injections, and using the CARS measure, parents reported any
improvement that might have occurred. Those children who were seen to benefit,
were assigned to the double-blind, placebo, crossover study.* This procedure*

In this study design, one group initially receives the treatment and the other receives the
non-treatment. In the next stage, the groups are switched so that the original group receiving
the treatment then receives the non-treatment, and the non-treatment group then receives thetreatment. Neither the researchers nor the patients (nor their parents) know when each groupis receiving the treatment.
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was an attempt on the part of the researchers to create an experiment where if
indeed secretin is an effective treatment for autism, they would be most likely
to find that result. Although I believe that parental reporting is very unreliable,
I respect the fact that these researchers attempted to create conditions wheresecretin may have been most likely to have a positive effect. Despite thisdesign, no meaningful results were reported.2,3 The other articles were simply
case studies.1,4Another comprehensive literature search in 2006 found much more research
had been conducted on secretin. This search netted twenty articles that present
data on the effects of secretin treatment. Of these 20 articles, five showed that
secretin had an effect on the subjects’ autism and fifteen articles demonstrated noeffect. The question is, what differentiates the five studies that report results fromthe fifteen that do not? Of the five positive studies, only two are randomized,
double-blind, placebo controlled trials.5,6* The third study is a non-randomized
study with no placebo condition7 and the fourth study is an uncontrolled trial inwhich the researchers rely on weekly parental reporting to assess improvements,using a questionnaire designed to measure symptoms.8 The final study1 in thisgroup was a case study reporting on three children. The study that deservesattention is the Kern et al. (2002) study, as their experiment was well designed,
utilizing controls, employing different measures for autism and differentiatinggroups of children into those with gastrointestinal distress and those without.
Their study is notable because for the dependent variable, autism, they used the*

The Jun et al. 2000 study is published by Tzu Chi Medical Journal which is a journal publishedby the Buddist Compassion Relief Tzu Chi Foundation founded in 1989. This article was notfound in the mainstream journals, i.e., Medline, Cochrane Collection, and is not available
through regular channels. A request to purchase this article through the journal received no
reply. Therefore, we could not review the journal. Although the journal claims it uses a peerreview process, because 99 percent of the scientific data bases do not list the journal as one of
the thousands of journals in existance, it is questionable whether the findings reported by thearticle are scientifically sound.
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Aberrant Behavior Checklist (ABC), parts of the MacArthur Communicative
Development Inventory (CDI) and a Global Assessment scoring as well. In
addition, the researchers used a GI assessment rating (it should be noted,
however, that the CDI and the GI ratings relied on parental reporting). They
found statistically significant and meaningful differences between the two groups,
primarily in the Irritability, Agitation and Crying ratings.*
In contrast, of the fifteen studies that found no effect for secretin, thirteen wererandomized, double-blind, placebo-controlled studies and of those, six included
a cross-over design, clearly a much more rigorous design than most of the studies
which reported results. Of note is that of the fifteen studies, five studies9,10,11,12,13
used porcine secretin rather than synthetic secretin to control the potentiallydiffering effects of these two types of secretin. Porcine secretin was used toaddress criticism about the lack of results to the synthetic rather than the natural
hormone (referred to as biologic or porcine). In fact, Unis et al. (2000), usedboth types of secretin in an effort to find out if there is a difference. They foundnone. Finally, the company sponsoring the research, Repligen, reported thatat the beginning of this year their clinical trials did not find any benefit for thechildren in the study.14
What does the therapy actually look like?
Different researchers used various techniques to measure gastrointestinal distressprior to treatment using Secretin. In the Horvath et al. (1998) study, secretin wasgiven during an upper gastrointestinal endoscopy (while inserting a small scopein the upper GI tract) for each patient. The patients were put under a general*
The “Irritability, Agitation and Crying” ratings were significant (p < .05). Although theseresearchers also report other findings as significant, their p values are too high for me to agree
regarding statistical significance (p < .08 and p < .10).

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anesthetic, and biopsies of the esophagus, stomach and duodenum were taken.
In addition, pancreatic and intestinal digestive enzymes were measured. Before
the biopsies were taken, secretin was injected in order to stimulate the secretionof pancreatic juice (to make the pancreas secrete enzymes). In other studies,patients received an intravenous dose of secretin on a one time basis or over
two or three visits. In Horvath et al. (1998), the gastric juices were collected
and analyzed, and the tissues from the esophagus, stomach and duodenum were
examined under a microscope. A sample of juice from the pancreas was taken
before the secretin was given, and three additional samples were taken during
the ten minute period that followed. All three patients received a follow-up dose
three to eight months later. Although the studies differed somewhat, most ofthem used a single dose of secretin. In contrast, Sponheim et al (2002), used acontrolled design where each child was given three doses of secretin over threemonths. They also found that secretin has no effect on the disorder of autism.
What else do I think?
In the articles that reported any meaningful results, the children were all sufferingfrom chronic diarrhea. The diarrhea could be responsible for interfering withlearning and possibly exacerbating autistic behavior. One can reasonably expectthat diarrhea may work to foster a poor disposition in the sufferer. If indeed thediarrhea abates and the digestive system improves, this could help the overallbehavior of the child to improve. It is understandable how this observation
inadvertently lead a researcher or parent to conclude that secretin has improved
the symptoms of autism in a child. However, it is possible that the autism
may not have improved at all; rather, the symptoms of gastrointestinal distress
may have disappeared or been ameliorated, which would lessen the degree of
irritability, improve concentration and the general well-being in many children,
but not (importantly) children with autism exclusively.

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An additional significant complication within this area of research is that it
is unclear to what extent children may have been involved in other treatment
programs. One child had reportedly undergone high-dose steroid therapy andintravenous immunoglobulin treatment, without any reported effect. Anotherchild had been placed on an elimination diet specifically to treat the diarrhea,
which also had no effect. The researchers provide no timeline for theseinterventions, making the need for a control group all the more important insome of these studies.

Would I try it on my child?
My child does not suffer from chronic gastrointestinal distress. However, if she
did, I would make sure that we visited a reputable gastrointestinal specialist to
attempt to treat the GI tract and not blame her behavior on autism, but rather, on
the fact that she was suffering. It has been my observation over the last fourteen
years that children with autism are often underserved by the medical community
because it is so difficult to differentiate behaviors with a non-physiological sourcefrom those caused by an underlying medical condition that may be successfully
treated, for the simple reason that the autism frequently blocks communication
between the child and the doctor.

What kind of study would I like to see the researchers
looking at secretin do?
After all the research done regarding the relationship between autism and secretin,
this question appears to have had considerable research funding already spentin this research area. I would be interested, though, to see whether secretin
is a potential treatment for gastrointestinal distress in general, not simply for

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children with autism. If indeed secretin is a treatment for certain GI conditions,then everyone suffering may benefit, including children with autism; however,this research would be unrelated to autism specifically.
Who else recommends against secretin as a method forthe treatment of autism?
The New York State Department of Health Report was the first out of the gate
in 1999 when they stated: “The use of hormone therapies (such as ACTH or
secretin) is not recommended as a treatment for autism in young children,
until such methods have been shown to be effective and safe for use in thisage.”15 Since then there have been a few others who have also recommended
against the use of secretin as a treatment for autism. Quackwatch (2005)16 hasrecommended against secretin, as has the American Academy of Child andAdolescent Psychiatry (2002).17 The Committee on Children with Disabilitiesof the American Academy of Pediatrics, also recommends against the use of
secretin for autism treatment. They state: “This and more recent studies havefailed to demonstrate any scientific evidence to justify the use of secretin infusion
to treat children with ASD.”18
So you’re still on the horns of a dilemma?
I recommend that you read Sturmey (2005),19 who does an in-depth review ofthe literature on secretin and concludes that secretin is ineffective. Based on
the literature to this point, the use of secretin to treat autism can be regarded ascompletely experimental.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence that Secretin
is an effective treatment for improving the symptoms of autism in children.

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Endnotes for Secretin
1

Horvath, K., G. Stefanatos, K.N. Sokolski, R. Wachtel, L. Nabors, and J.T. Tildon. 1998.
“Improved Social and Language Skills After Secretin Adminstration in Patients With Autistic
Spectrum Disorders.” Journal of the Association for Academic Minority Physicians, Vol. 9,
No. 1, pp. 9-15.
2Chez, M.G., and C.P. Buchanan. 2000. “Reply to B. Rimland’s ‘Comments on Secretin andAutism: A Two-Part Clinical Investigation’.” Journal of Autism and Developmental Disorders,Vol. 30, No. 2, pp. 87-94.
3
Sandler, A.D., K.A. Sutton, J. DeWeese, M.A. Girardi, V. Sheppard and J.W. Bodfish. 1999.
“Lack of Benefit of a Single Dose of Synthetic Hyman Secretin in the Treatment of Autism andPervasive Developmental Disorder.” [see comments] New England Journal of Medicine, Vol.
341, No. 24, pp. 1801-1806.
4

Richman, D.M., R.M. Reese and D. Daniels. 1999. “Use of Evidence-based Practice as a Method
for Evaluating the Effects of Secretin on a Child with Autism.” Focus on Autism and Other
Developmental Disabilities, Vol. 14, No. 4, pp. 204-211.
5Jun, S.S., P_.C.H. Kao and Y.C. Lee. 2000. “Double Blind Crossover Study of Secretin/Secrepan
Treatment for Children With Autistic Symptoms.” Tzu Chi Medical Journal, Vol. 12, No. 3,
pp. 173-181.
Kern, J.K., S. Van Miller, P.A. Evans and M.H. Trivedi. 2002. “Efficacy of Porcine Secretin
in Children With Autism and Pervasive Developmental Disorder.” Journal of Autism andDevelopmental Disorders, Vol. 32, No. 3, pp. 153-160.
6

Robinson, T.W. 2001. “Homeopathic Secretin in Autism: A Clinical Pilot Study.” The British
Homeopathic Journal, Vol. 90, No. 2, pp. 86-91.

7

Lonsdale, D. 2000. “A Clinical Study of Secretin in Autism and Pervasive Developmental Delay.”
Journal of Nutritional Environmental Medicine, Vol. 10, No. 4, pp. 271-280.

89Corbett, B., K. Khan, D. Czapansky-Beilman, N. Brady, P. Dropik, D.Z. Goldman, et al. 2001.
“A Double-blind, Placebo-controlled Crossover Study Investigating the Effect of Porcine Secretin
in Children With Autism.” Clinical Pediatrics, Vol. 40, No. 6, pp. 327-331.
Unis, A.S., J.A. Munson, S.J. Rogers, E. Goldson, J. Osterling, R. Gabriels, et al. 2002. “ A
Randomized Double-blind, Placebo-controlled Trial of Porcine Versus Synthetic Secretin for
Reducing Symptoms of Autism.” Journal of the American Academy of Child & Adolescent
Psychiatry, Vol. 41, No. 11, pp. 1315-1321.
10

Owley, T., W. McMahon, E.H. Cook, T. Laulhere, M. South, L.Z. Mays, et al. 2001. “Multisite,
Double-blind, Placebo-controlled Trial of Porcine Secretin in Autism.” Journal of the American
Academy of Child & Adolescent Psychiatry, Vol. 40, No. 11, pp. 1293-1299.

11

12
Roberts, W., L. Weaver, J. Brian, S. Bryson, S. Emelianova, A.M. Griffiths, et al. 2001. “RepeatedDoses of Porcine Secretin in the Treatment of Autism: A Randomized, Placebo-controlled Trial.”
Pediatrics, Vol. 107, No. 5, p. E71.

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13

Honomichl, R.DE., B.L. Goodlin-Jones, M.M. Burnham, R.L. Hanse and T.F. Anders. 2002.
“Secretin and Sleep in Children With Autism.” Child Psychiatry and Human Development,
Vol. 33, No. 2, pp. 107-123.
14

Autism: Secretin Therapy Found Unsuccessful. Pediatric Alert 01600184, 2004, Vol. 29, No.
2, pp. 8-9.
15

Guralnick, M., ed. 1999. Clinical practice guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany (NY): New York State Department of Health, p. IV-87.

Quackwatch, http://www.quackwatch.org/01quackeryrelatedtopics/autism.html, (accessed
Oct. 5, 2005).
16

17

American Academy of Child and Adolescent Psychiatry, Policy Statement, 2005, http://www.
aacap.org/publications/policy/ps39.htm#top, (accessed Aug. 8, 2005).
18

Technical Report. 2001. “The Pediatrician’s role in the Diagnosis and Management of Autistic
Spectrum Disorder in Children.” Pediatrics, Vol. 107, No. 5, pp. 1-18.
19
Sturmey, P. 2005. “Secretin is an Ineffective Treatment for Pervasive Developmental Disabilities:
A Review of 15 Double-blind Randomized Controlled Trials.” Research of Developmental
Disabilities, Vol. 26, No. 1, pp. 87-97.

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Biomedical Therapies: Vitamin B6 andMagnesium
What is Vitamin B6-Magnesium Therapy?
Proponents of Vitamin B6-Magnesium Therapy have reported that the urine ofpeople with autism has higher than average levels of a particular type of acidcalled homovanillic acid (HVA), produced when dopamine is metabolized.1
This finding has lead these researchers to suggest that people with autism
metabolize dopamine differently than those without autism.2 In other words,
dopamine (which is a neurotransmitter) is hypothesized to be used differently
within the bodies of autistic people than those without autism. These researchers
administered pyridoxine (vitamin B6) to those who had higher than normal levels
of HVA and noticed that their autistic subjects experienced a decrease in thelevel of HVA in their urine. Their biochemical measures attempt to determine
the amount of dopamine and homovanillic acid in the urine.
These researchers also employ electrophysiological measures (using electrodes)
to argue that children with autism have abnormal response times to sound andlight.* Vitamin B6 and Magnesium Therapy is hypothesized to alter the child’s
perception of sound and light in the brain.3 Specifically, these researchers expectthat the Vitamin B6 and Magnesium Therapy should decrease the amount of
dopamine used up by the body (metabolized), and correct abnormalities in thechild’s response times to sound and light.** The researchers recommend a large
dosage of both B6 and magnesium for an indefinite period of time. Although
they are not explicit in the relationship between this treatment and behaviors*
Abnormal response times to sound and light has been conceptualized in this literature by the term “averagecortical evoked responses.”**

Whether the abnormalities in the child’s responses have been corrected or not are measured by corticalevoked responses.

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associated with autism, these researchers predict that behaviors characteristic ofautism will decrease. As autism is measured largely on behavior, if Vitamin B6- Magnesium Therapy is effective, we should expect to see behaviors associatedwith autism diminish as a result of this treatment.
What evidence do the practitioners have that thisreally works?
We did a comprehensive database search and found much written about vitamin
B6 and magnesium as a treatment for autism. There were over thirty articles
either presenting data, reviewing data or debating the merits of the treatment.
When we filtered out the commentary from the research articles, we netted
twenty studies. Once we excluded the case studies,4,5 the Parent Survey6 and thesubjective behavioral reporting,7 we were left with sixteen studies to review on
Vitamin B6 - Magnesium Therapy. Of the studies which report positive results,
fourteen were done by two groups of researchers: Barthelemy, Martineau andLeLord, and Rimland. These researchers use physiological pre-and post treatment
measures. As interesting as this may be, prior to accepting the notion that any
physiological changes are actually indicators that the treatment is effective, theseresearchers must first demonstrate how these physiological changes (such as
response time to sound and light) are in any way relevant to autism. Althoughover a quarter of the studies were double-blind, random assignment,* and placebo
controlled (with additional studies designed as crossover studies where the groups
alternated receiving either the treatment or the placebo), they all share a design
shortcoming. The operationalization of their measure of the dependent variable,
autism, is problematic. These studies all measure autism using behavioral scales

Nye et al. (2005) rejected all the studies due to the lack of rigor in their design in terms of inadequate concealment of randomization and more than a twenty percent attrition rate of subjects. Despite these critiques,
we decided to look at the studies because they did have some form of randomization procedure.
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that are not widely accepted by researchers in the field of autism. Instead, theyuse measures that they have designed themselves or that were designed in thehospital doing the research, rather than measures that have been designed andtested independently (e.g., the Autism Behavioral Checklist, ABC, the Childhood
Autism Rating Scale, CARS, the Autism Diagnostic Interview - Revised,
ADI-R, the Autism Diagnostic Observation Schedule, ADOS). The Behavior
Summarized Evaluation Scale (BSE) was developed by Barthelemy (1981) andused in Martineau et al. (1985), Martineau et al. (1986) and Martineau et al.
(1988). A modified BSE scale, called the Echelle Bretonneau III was used by
Jonas et al. (1984). The Bretonneau II was used by Barthemelemy et al. (1983),
Lelord et al. (1981) and Barthelemy et al. (1980). In addition, a Target Symptoms
Checklist was developed by Rimland (1978) but not independently tested forvalidity. In 1986 and 1997, Barthelemy et al. attempted to validate the BSE Scale.
In 1997 they added nine additional items to the scale and compared their scalewith Rimland’s E2 scale, rather than other well-established scales in the field ofautism assessment. In short, the scales used by proponents of Vitamin B6 andMagnesium Therapy need to be independently validated using well-excepted
autism scales, rather than relying on each others’ unvalidated scales or validating
their own scales with other unvalidated scales.
Unfortunately, these measures for autism lack the validity and reliability that othermeasures have gained as a result of repeated use and evaluation by a much wider
group of researchers. In terms of the biochemical and physiological measures(e.g., the average cortical evoked response), there is no data to suggest either
biochemical measures or electrophysiological measures increase or decrease
the symptoms associated with autism. In other words, increases or decreases
in these measures have no scientifically-established relationship to the typicalsymptoms of autism which are, at this point, behaviorally-defined as we do nothave any other way to measure autism.

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In contrast, the two studies that found no results8,9 did use widely recognizedmeasures. Tolbert (1993) used the Ritvo-Freeman Real Life Rating Scale for
Autism, validated by Freeman et al. (1986). Findling et al. (1997) used a varietyof accepted measures including the Childhood Autism Rating Scale (CARS), theClinical Global Impression Scale (CGI), the Children’s Psychiatric Rating Scale(CPRS), the NIMH Global Obsessive Compulsive Scale (OCS), and additional
Parent and Teachers Rating Scales (the PRS and TRS) to measure autism (thedependent variable in the research).* It is important to use widely-recognized,
standardized measures in all autism research because these measures have beentested for accuracy in measuring autism by many diverse researchers throughout
many years of research. Findling et al. need to be commended in their attempt
to use a large variety of measures, affording every opportunity to capture anytreatment effect, even if only a small or targeted one.
Although it can be seen as a positive step to see researchers innovate and attempt
to measure autism in a better way, it is crucial that any newer, more accurate
scales have significant overlap with the older less precise measures, to make surethat the newer scale is indeed measuring autism more accurately. The measuresused in the studies that report positive results do not give us that assurance due totheir lack of rigorous testing and their apparent choice not to use well-establishedmeasures.
The second issue associated with several of the studies in the Vitamin B6Magnesium literature is that those who rated the autistic subjects after the study
were not blind to all conditions of the treatment3,4,10,11 or the details about who
These measures were a combination of accepted autism scales (the Childhood Autism Rating Scale (CARS),
developed and validated by Schopler et al. 1980 and Dilalla et al. 1994), or widely-accepted measures fromthe field of child psychiatry and psychology (the Clinical Global Impression Scale (CGI) National Instituteof Mental Health, 1985; the Children’s Psychiatric Rating Scale (CPRS) (Campbell et al. 1985); NIMH
Global Obsessive Compulsive Scale developed by Insel et al. (1983).

*

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completed the behavioral measures were not clear.12 In other words, in manyof these studies, the researchers were not blind to the fact that these autistic
individuals were given vitamin B6 and magnesium. Put simply, the problem of
non-blind raters introduces bias in the evaluation portion of the experiment. A
third problem with three of the studies has to do with lack of a control group.4,13,14
In addition, of the fourteen articles, five studies did not give autistic people in thecontrol group a placebo. Therefore, those who were responsible for the care of
the person with autism knew that he or she was either in the control or treatmentgroup. That is a problem for objective research to move forward, insofar as
the care giver’s behavior towards the autistic subject may have reflected thatknowledge and unduly influenced the outcome.
Another critique of over one-third of the studies is that the researchers did notreport significance levels (i.e., did the results happen by chance?). We do notknow whether the behavioral results of vitamin therapy are meaningful if theresearchers involved do not report the significant levels (p-values). Without thep-values, we do not know whether these results may have happened randomly
or due to the treatment. Four of the studies4,13,15,16 report changes without a pvalue. Lelord et al. (1981) report that “none of the trends associated with B6
responsiveness is statistically significant”17 for the first phase of the study. In
the second phase, children are presented as improved or not improved (using
aggregate statistics with p-values); however, we are given little other informationin terms of how meaningful these improvements are.* Finally, although the urine
samples are used to measure the amount of vitamins secreted by the children,these measures do not in themselves measure the degree of autism, and therefore,cannot be used to measure an improvement in the symptoms of autism.
*
Figure 1 does not clarify which questions show statistically significant improvement and which do not. In
addition, there is no table representing a comparison between pre-test, placebo, and post test scores with pvalues. It is up to the reader to attempt to extrapolate the raw data from the figure.

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What does the therapy actually look like?
The administration of the vitamin B6 and magnesium can be in pill or liquidform. Although there are variations, according to the proponents of this therapy,
the vitamin should be given to the person twice per day. In the studies that wereconducted, children typically received thirty mg/kg of vitamin B6 and ten to
fifteen mg/kg of magnesium lactate per day.
What else do I think?
Based on science, there are many questions left unanswered with this treatment
method . We still have no idea whether vitamin B6 and magnesium, in fact,
benefits people with autism. If there is a population of people with autism who
may benefit, then we need to find out which persons afflicted with autism are thebest candidates for this treatment. We also need to know the effect of megadosesof vitamin B6 and magnesium over a prolonged period. In addition, will thoseindividuals who may benefit from the treatment need to increase the dose due
to satiation and will that be problematic, considering how high the dose is at
the beginning of the treatment? Prior to asking these questions, though, is the
major question regarding whether Vitamin B6-Magnesium Therapy is indeed
effective. It is not possible to conclude, based on the given data, that vitamin
B6-magnesium has any effect on autism and its associated behaviors. Mixed
results are found in the literature; therefore, additional well-controlled and welloperationalized research is required to evaluate the effectiveness of vitamin B6magnesium treatment. In addition, more research is essential regarding the shortand long term side effects before this treatment can be endorsed by the scientificcommunity and (most importantly) used by parents.

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Would I try it on my child?
I would not try this therapy on my child for several reasons. First, my childdoes not tolerate strange tasting liquids and does not like to swallow pills. So,
before I have a daily battle on my hands, I need to know that this is scientifically
substantiated. Second, let’s say I can manage to teach her to like her daily dose
(hidden in ice-cream), how can I trust my observation as to whether this treatment
is working? I may want the treatment to work so desperately that I may see
progress that, in fact, may not be there, or I may be so cynical that I do not see
the benefits that are actually taking place. Third, I am somewhat concerned about
any possible side effects of high doses of magnesium, about which my daughter
may or may not complain.
What kind of study would I like to see the vitamin B6 andmagnesium proponents do?
I would like the proponents of Vitamin B6 and Magnesium Therapy to replicate thestudy done by Findling et al. (1997), utilizing the more mainstream measurementsof the dependent variable (autism) in his study and include various forms of IQ
testing as well. In addition, the pre-and post psychometric measures must be
administered by psychologists who are completely unaware that the children tobe evaluated are in a study. Furthermore, I would like to see a well-documented,
rigorous, random assignment procedure with no one invested in the study who isknowledgeable as to which condition the child is assigned. If the parents are toadminister the pill, they must not know the experimental condition of their child,and they must not be given the responsibility of taking data of any kind. Finally,
the researchers must publish their new results in a peer reviewed journal and share
their experimental procedure in sufficient detail so the scientific community canproperly attempt to replicate these findings.

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Who else recommends against Vitamin Therapy as amethod for the treatment of autism?
There are several groups which recommend against Vitamin B6-Magnesium
Therapy for autism. The New York Report has the following to say aboutvitamin therapy: “Administering high does of vitamin B6 (pyridoxine) andmagnesium is not recommended as an intervention for autism in young children... Administering high doses of any type of vitamin or trace mineral is notrecommended as a treatment for autism in young children.”18 In addition, theAssociation for Science in Autism Treatment (ASAT) states, “A number ofscientific reviewers have concluded that many of those treatments have proved
ineffective or harmful. The research that appears to support several othertreatments is methodologically weak, and still others have yet to be evaluatedcarefully. These include ... vitamin megadoses.”19 In addition, the American
Academy of Child and Adolescent Psychiatry also recommends against vitamins20
and the American Academy of Pediatricians says the following about vitamins:“[Studies] have been criticized for their methodological shortcomings and failure
to address the issue of safety of use.”21
So you’re still on the horns of a dilemma?
Considering that research on Vitamin B6 and Magnesium Therapy has been
available since 1968, and there has not been even one independent replication ofthese studies a good thirty-eight years later, you might want to consider waiting
until an independent replication of this research is published; otherwise, you areengaging in pure experimentation.

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What’s the bottom line?
Based on the scientific research to date, there is insufficient evidence to validate
Vitamin B6-Magnesium Therapy as an effective treatment for improving thesymptoms of autism.

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Endnotes for Vitamin B6 and Magnesium Therapy
1Martineau, J., C. Bathelemy, B. Garreau, and G. Lelord. 1985. “Vitamin B6, Magnesium andCombined B6-MG: Therapeutic Effects in Childhood Autism.” Society of Biological Psychiatry,Vol. 20, No. 5, pp. 467-478.
2

Barthelemy, C., B. Garreau, I. Ledet, D. Ernoug, J.P. Muh, and G. Lelord. 1981. “Behavioral
and Biological Effects of Oral Magnesium, Vitamin B6 and Combined Magnesium - Vitamin
B6 Administration in Autistic Children.” Magnesium-Bulletin, Vol. 2, pp. 150-153.
Martineau, J., C. Barthelemy, C. Cheliakine, and G. Lelord. 1988. “Brief Report: An Open
Middle-term Study of Combined Vitamin B6-Magnesium in a Subgroup of Autistic children
Selected on Their Sensitivity to This Treatment.” Journal of Autism and Developmental
Disorders, Vol.18, No. 3, pp. 435-447.
3

4Martineau, J., C. Barthelemy, and G. Lelord. 1986. Long-term Effects of Combined Vitamin
B6-Magnesium Administration in an Autistic Child.” Society of Biological Psychiatry, Vol. 21,
No. 5-6, pp. 511-518.
5
Clark, J.H. 1993. “Symptomatic Vitamin A and D Deficiencies in an Eight-year-old With
Autism... Intake Consisting of Only French Fried Potatoes and Water for Several Years.” Journalof Parenteral and Enteral Nutrition, Vol. 17, No. 3, pp. 284-286.
6

Rimland, B. 1988. “Controversies in the Treatment of Autistic Children: Vitamin and Drug
Therapy.” Journal of Child Neurology, Vol. 3, pp. S68-72.
Moreno, H. 1992. “Clinical Heterogeneity of the Autistic Syndrome: A Study of 60 Families.”
Investigacion Clinice, Vol. 33, No. 1, pp. 13-31.
78

Tolbert, L., T. Haigler, M.M. Waits, and T. Dennis. 1993. “Brief Report: Lack of Response in
an Autistic Population to a Low Dose Clinical Trial of Pyridoxine Plus Magnesium.” Journalof Autism and Development Disorders, Vol. 23, No. 1, pp. 193-199.
9
Findling, R.L., K. Maxwell, L. Scotese-Wojtila, J. Huan, T. Yamashita, and M. Wiznitzer. 1997.
“High-dose Pyridozine and Magnesium Administration in Children With Autistic Disorder: An
Absence of Salutary Effects in a Double-blind, Placebo-controlled Study.” Journal of Autism
and Developmental Disorders, Vol. 27, No. 4, pp. 467-478.
10

Rimland, B., E. Callaway, and P. Dreyfus. 1978. “The Effect of High Doses of Vitamin B6
on Autistic Children: A Double-blind Crossover Study.” American Journal of Psychiatry, Vol.
135, No. 4, pp. 472-475.
11

Lelord, G., J.P. Muh, C. Barthelemy, J. Martineau, B. Garreau, and E. Callaway. 1981. “Effectsof Pyridoxine and Magnesium on Autistic Symptoms -- Initial Observations.” Journal of Autism
and Developmental Disorders, Vol. 11, No. 2, pp. 219-230.
\
12
Menage, P., G. Thibault, C. Barthelemy, and G. Lelord. 1992. “CD4 = CD45RA +T Lymphocyte
Deficiency in Autistic Children: Effect of a Pyridoxine-Magnesium Treatment.” Brain
Dysfunction, Vol. 5, No. 5-6, pp. 326-333.

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13

Martineau, J., C. Barthelemy, S. Rux, and B. Gareau. 1989. “Electrophysiological Effects ofFenfluramine or Combined Vitamin B6 and Magnesium on Children With Autistic Behaviour.”Developmental Medicine and Child Neurology, Vol. 31, No. 6, pp. 721-727.
14
Rimland, B. 1974. “An Orthomolecular Study of Psychotic Children.” Child Behavior Research,
Vol 3, No. 4, pp. 371-377.
15

Jonas, C. T. Etienne, C. Barthelemy, and J. Jouve. 1984. “Clinical and Biochemical Value ofMagnesium + Vitamin B6 Combination in the Treatment of Residual Autism in Adults.” Thérapie,
Vol 39, No. 6, pp. 661-669.
Lelord, G., E. Callaway, J.P. Muh, J.C. Arlot, D. Sauvage, B. Garreau, et al. 1978. “Modifications
in Urinary Homovanillic Acid After Ingestion of Vitamin B6; Functional Study in Autistic children(author’s translation).” Revue Neurologique (Paris), Vol. 134, No. 12, pp. 797-801.

16

17

Lelord, G., et al., (see n. 11 above).

18

Guralnick, M. ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany(NY): New York State Department of Health, p. IV-99.
Association for Science in Autism treatment (ASAT). www.asatonline.org/resources/library/
informed_choice.html, (accessed Aug. 25, 2006).

19

20

Szymanski, L, B.H. King. 1999. “American Academy of Child and Adolescent Psychiatry
Working Group on Quality Issues: Practice Parameters for the Assessment and Treatment ofChildren, Adolescents and Adults with Mental Retardation and Comorbid Mental Disorders.”
Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 38, p. 30.
21

Committee on Children With Disabilities. 2001. “Technical Report: The Pediatricians Rolein the Diagnosis and Management of Autism spectrum disorders in Children.” Pediatrics, Vol.
107, p. 13.

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Speech and Language Therapies Section 1.5
p Fast ForWord Program
p The Hanen Method
p Lindamood-Bell Learning Processes
p The SCERTS Model

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Section One: What Works and What Doesn’t?

Speech and Language Therapies: Fast ForWord
What is Fast ForWord?
Fast ForWord is a computer training program designed to improve children’s
understanding of speech and language. The proponents of this method workon various parts of language “by modifying speech acoustically to create an
expanded form of the successive speech components.”1 According to the Fast
ForWord developers, there are seven exercises which make up the Fast ForWord
program. Each exercise is said to adapt to natural speech and attempts toaddress: 1) auditory processing (the ability to differentiate sounds, words, andrelevant language from noise); 2) phonological analysis (where the function andsimilarities of the sounds are targeted), and 3) language skills.
What evidence do the practitioners have that thisreally works?
At this point, there is one study that has been conducted to test the Fast ForWord
computer program, part of which included children with autism and Pervasive
Developmental Disorder not otherwise specified (PDD-NOS); however, thisstudy was not published in a peer reviewed journal.2 It is also unfortunate thatthe principal investigator, Tallal, did not improve the study to be of sufficientquality for peer review as this researcher is no stranger to the peer review process,with over twenty peer-reviewed journal articles to her name, published on thesubject of language.
A positive characteristic of the study is that it includes twenty-nine participants
with autism or PDD-NOS. This is a large number of participants in the field ofautism research (two or three subjects seems to be the norm in most research
projects conducted on children with autism). In addition, the results appear
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promising. The researchers presented results that are highly significant on eachof the outcome tests. They note that fifteen of the twenty-nine children with
PDD improved significantly.*
Unfortunately, there are several weaknesses associated with this research. The
study was conducted by eighty-four professionals working at thirty-five different
sites across North America. It is a design flaw to have so many professionals
involved in one study at so many different locations. Despite the fact that thecomputer is collecting the data (so inter-observer reliability is not a problem),
I would be nervous about the lack of standardization. We do not know whatelse occurs with the child during the sessions. Were professionals at some sites
helping the child one-on-one, whereas at other sites might have been letting
the child complete the program independently? Were some of the children
receiving standard speech and language therapy concurrently or were they all
receiving no other language therapy aside from this program? In addition, it is
not clear whether these children were involved in other therapies at the sametime or before. We need these points clarified in the article which presents thepromising data.
Another flaw in the study design was that each clinician decided which preand post language tests should be used on their client. Lack of standardizationin testing is an important concern. All children should have had the sametests used for the pre-and post testing. We would then be able to compare theresults of all the children in the study and control the tendency for clinicians torecommend a particular test because it is thought that the child’s gain could bemeasured better using one test over another. In short, whatever is done with one
child, needs to be done with every child. If the researchers thought that some*

The actual data demonstrated these children improved by one or more standard deviations on every tested
measure (which is a meaningful result).

220Section One: What Works and What Doesn’t?

children do better with one test over another, then both tests must be given toeach child. For research purposes, my preference is that researchers administera range of tests to each child. An additional weakness in their 1997 study is thatthe clinician who administered the test might profit from the service provided.
This study was done at thirty-five sites where Fast ForWord is being offered
for a price; unfortunately, it is essential that the experimenter have no vested
interest in the outcome of the study. In other words, the outcome of the study
should have no bearing on whether or not a clinician is going to have data which
may encourage parents to have their children use the Fast ForWord computer
program. In terms of experimenter effects in general, the clinician who knowsthat the child is going to be in a study, should not assess that child in that study.
Under such circumstances, bias could occur. Put simply, a researcher with noprofit motive should be conducting the pre and post tests.
Another weakness of the study is the absence of a control group. This isproblematic because researchers using a within-subject design cannot control
for other variables which may contribute to the improvements observed. In
addition, without a control group, if the researchers who test the children prior
to and after the study know that these children are in the study, then they also
know that these children are receiving the treatment. A single-blind test could
easily avoid this problem, where the clinicians doing the pre and post testing
would know nothing about the study and would not know that some children
have received this treatment, whereas others did not.
Another flaw of note in the 1997 study is that the Society of Neuroscience
Reprint Series is not peer-reviewed, but rather a journal supported by the
Scientific Learning Corporation, which is the company that provides the Fast
ForWord computer program. In addition, the research supports this corporation.
Unfortunately, the presentation of the results in the Society for Neuroscience is

221The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

unwittingly deceptive to the untrained observer as the results of the study arepresented in a very compelling way and have an aura of legitimacy. If theseresearchers were to test the results of the Fast ForWord program in a mannerthat could be peer reviewed, this would help parents of children with autism
tremendously.
What does the therapy actually look like?
Children start the Fast ForWord program either in a clinic or in their homes.
In both settings, the sessions are one hundred minutes per day, five days per
week, for a minimum of four weeks. The initial four weeks are approximately$2,450 USD within the clinic and $2,050 USD when done within the home.*
Both the clinic and home programs require additional costs for pre-testing andconsultation, as well as additional weeks, if recommended. The home programs
also have optional computer rental for US $219.95 per month.
The Fast ForWord computer programs use computer-generated speech, which has
been digitally modified.3 The developers of Fast Forword hypothesize that the
problem for many individuals with language learning difficulties is the speed ofprocessing, rather than the speech itself.4 As a result, the Fast Forword program
dramatically slows down and expands parts of language in order to make auditory
discrimination easier.5 The content of the program includes sound exercises, andmore complex word exercises. Each of these exercises is comprised of five levelsof difficulty, with one being low complexity and speed, and five being comparable
to natural speech.6 These programs are presented in a game format, and include
rewards in the form of onscreen animation and token economy systems.

These prices are approximate and may have increased due to inflation from the time they were originallyquoted.
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Section One: What Works and What Doesn’t?

At any given level, the individual is maintained at a minimum of eighty percent
accuracy to ensure success, and the Scientific Learning Corporation provides
ongoing performance evaluation.7
What else do I think?
The use of Fast ForWord for individuals with autism assumes pre-existingskills which many children with autism may not possess (including language
comprehension). Therefore, in order for a child with autism to use thiscomputerized treatment program, the child must have a minimal level of language
comprehension, which means that we must logically use other methods to firstbring the child to the level where he or she could take advantage of this computerbased therapy. An additional difficulty for children with autism is the amountof focus required to use the computer program. The autistic child must be able
to pay attention and focus for quite a long time, as this method requires one
hundred minutes per day for twenty to sixty days. This attention span may bedifficult for some children with autism to achieve.
Would I try it on my child?
I would love to try this method on my child. She has the attention span andenough language comprehension to be a candidate. There is no down side for her
because I do not see this as a risky treatment and the theory targeting various areasof language has strong intuitive appeal. However, until I can see more evidence
that Fast ForWord is effective, i.e., via a peer-reviewed study with better controls,
I’m going to wait to absorb the inconvenience of taking my child to a practitioner
who offers this therapy, to possibly waste her time during a summer holiday andspend the large sum that this method requires. The principal researcher of theFast ForWord system is quite honest when she discusses the fact that the Fast
ForWord program is based on three assertions that are still highly debatable.
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In fact, she states: “Fast ForWord could be a big step Backward.”8 That said,
this company is quite prolific in terms of developing new products.
What kind of study would I like to see the Fast ForWord
researchers do?
I would like to see a study using a randomly-assigned experimental and control
group with experimenters who are blind about which condition the child isassigned. In addition, they need to use consistent, commonly-accepted pre-andpost measures administered to each child in the study, and there needs to be acentral site administering the treatment and the placebo. If these practitioners
want to do a within-subject design with no control group, we would need tosee guarantees that the children were not receiving any other additional therapy
concurrently. In addition, the children would need to be tested at many different
points, prior to, during and after the completion of the study. Furthermore,
the researcher needs to ensure that all the children in the study received an
independent diagnosis of autism or PDD-NOS. Moreover, it would be prudent
for these children to have a battery of generally-accepted psychometric tests
administered to discern whether the therapy has any effect on IQ. Finally, it
would be advantageous to have the children tested long after the treatment has
been provided to determine whether or not the gains are maintained.
If the results do show that children in the treatment group significantly improvetheir language skills relative to the control group, then I would be very interested
in having my child try this therapeutic language program. I truly do hope that thiscomputer training program is tested independently as these are researchers who
have created a system that, if effective, could be easily adopted by educational
systems and Speech and Language Pathologists.

224Section One: What Works and What Doesn’t?

Who else recommends for or against Fast ForWord asa method for the treatment of autism?
At this time, there are no reputable sources recommending for or against Fast
ForWord for children with autism.
So you’re still on the horns of a dilemma?
I would recommend reading Tallal’s article in the American Speech-LanguageHearing Association, where she frankly speaks about the experimental nature of
the Fast ForWord program,8 in order to put this research initiative in its proper
context.
What’s the bottom line?
Based on the scientific research to date, there is insufficient evidence that the Fast
ForWord method of autism intervention is an effective treatment for improving
the language impairment in autism. We eagerly await more data.

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Endnotes for Fast ForWord
1

Tallal, P. et al. 1997. Rapid Training-Drive Improvement in Language Ability in Autistic andOther PDD Children. Berkley (CA): Scientific Learning Corporation: Society for Neuroscience,Vol. 23, p. 490.

Tallal, P., and M. Merzenich. 1997. Fast forword Training For Children With LanguageLearning Problems: Results from a National Field Study by 35 Independent Facilities. Rutgers
University, University of CA at San Francisco (CA): American Speech-Language-Hearing
Association, Boston, MA.
2

3
Bolton, S. 1998. “Auditory Processing and Fast ForWord.” Curriculum/Technology Quarterly.
Vol. 7, No. 2, pp. 2-4.

Tallal, P. et al., (see n. 1 above).

4

Bolton, S., (see n. 3 above).

5

Bolton, S., (see n. 3 above).

6

Bolton, S., (see n. 3 above).

7

Tallal, P., and M. L. Rice. 1997. “ Evaluating New Training Programs for Language Impairment.”
American Speech-Language-Hearing Association, Vol. 39. No. 3, pp. 12-13.

8

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Speech and Language Therapies: The
Hanen Method
What is the Hanen Method?
The Hanen Method was developed by the Hanen Centre, a Canadian, nonprofit organization established in 1975 that develops programs to help train
professionals and parents in early language intervention. In 1992, they publishedtheir original manual called “It Takes Two to Talk”1 and in 1999, they publisheda manual entitled, “More Than Words.”2 These two manuals outline the Hanen
method for teaching children with autism to communicate. The program takes asocial-interactionist perspective on autism treatment, and emphasizes learning
communication in everyday activities. To accomplish this, practitioners use
emotion (affect), predictability, structure and visual aides. The child leads hisor her own communication development, while the parent acts as a facilitatorof interaction.
In order to promote language development, parents are instructed to follow the‘4 I’s’. These are: 1) “Include the child’s interests,” which involves joining inon whatever the child is doing, with the purpose of teaching joint attention; 2)“Imitate what the child does,” which is done to capture the child’s attention andshow the children that they have an effect on other people; 3) “Intrude,” insist on
joining the child, and 4) “Interpret,” which involves rephrasing what the child istrying to say with the purpose of modeling so the child can imitate.3 In addition tothese guidelines, parents are told to play “People Games” in which they employ
four techniques that go by the acronym “R.O.C.K.” These techniques include:
R - Repeat what you do and say with the purpose of showing the child how
to communicate; O - Offer the child the opportunity to take a turn by pausing
at the same place in the games; C - Cue the child to take a turn, first using

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“explicit signals” and then turning to natural signals, and K - Keep it fun! Keep
it going! This is accomplished by the parent being very animated so the childwill want to stay involved.4 The program the Hanen Centre espouses applies
the 4 “I’s” and the “R.O.C.K.” guidelines to routines, songs, books and toys inorder to facilitate learning in individuals with autism.
What evidence do the practitioners have that thisreally works?
To date, there is no evidence to suggest that this method is effective. The Hanen
Centre was contacted and they indicated that they had no research to offer on theefficacy of this intervention for autism. In addition, a comprehensive databasesearch netted no evidence whatsoever regarding the efficacy of the Hanen method
on children with autism. Several studies were conducted on children withlanguage delays; unfortunately, these children had a variety of developmental
delays, none were identified as having a firm diagnosis of autism.5,6,7
What does the therapy actually look like?
Typically, the Hanen program involves hiring a speech and language pathologist(SLP) to teach a group of parents who all share the cost of the twelve to thirteen
week course.* The course is two and one half hours per week and involves anorientation, an assessment of parent-child interaction, eight training sessions,
three video feedback sessions, and a report by the Speech and Language
Pathologist (SLP). The report by the SLP appears to be the only system forobjectively evaluating treatment effects. This is problematic as the SLP has a

When we first started researching this book, this was the primary offering for parents. Since that time,the Hanen Centre has become more prolific in disseminating their methods and offers a variety of different
training modules, and additional books and videos.
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vested interest in the program’s success. In addition, there appears to be nostandardization among the practitioners who evaluate the progress using
this method as each SLP measures progress according to her own criteria
and assessment measures. Also problematic is that there is no system of datacollection to evaluate how the child responds when the parents implement the
program.
What else do I think?
Hanen provides a couple of disclaimers which are of great interest. One
specifies that the Hanen program, “Is not designed to replace other treatments.”8
Specifically, the website states that the Hanen program is not designed to replace
Applied Behavior Analysis (ABA) for individuals with autism. If ABA is being
used, they encourage the Hanen approach to be integrated within the home.
Unfortunately, these programs may not be entirely complimentary because theHanen method: 1) encourages a child-led approach in the natural environment,
and 2) encourages parental involvement in the child’s preferences, including
self-stimulatory behavior. These two components are in opposition to an ABA
approach, which initially uses a direct instruction approach to learning. Hereteaching occurs with the therapists breaking tasks down into small components
and teaching directly to the child, prior to the tasks being generalized to thenatural environment. ABA also targets self-stimulatory behaviors for elimination
or replacement because these behaviors are seen to interfere with the child’s
ability to learn. However, some of the components of the Hanen method are
strikingly similar to ABA programs, including the use of positive feedback forappropriate behavior, as well as the use of prompting and prompt fading. Hanen
also encourages repetition and routine, which are generally-accepted components
of many ABA programs.

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A second disclaimer that the Hanen website includes relates to their teachingapproach. As one of the 4 “I’s,” the Hanen method encourages that the parent
imitate what the child does. This is done in order to show the child that he or
she has an effect on others. The Hanen website then includes the statement that,“not all ASD kids will imitate on their own,” and that “for these kids a morestructured approach is recommended.”8 Although this statement acknowledges
that the Hanen method may not be appropriate for some children with ASD,
it may inadvertently give parents of children with autism the impression thatthe Hanen method is effective for a considerable number of children on theautism spectrum. Unfortunately, many children with autism are not going to
respond to the child-led, unstructured approach, which is the very reason that
this intervention is being sought by parents – that it is child-led. To say that
not all of these children are able to imitate is a significant understatement. The
majority of children with autism are unable to imitate without being taught todo so, which is one of the reasons that they have not been able to learn language
from the natural environment.
In addition, the concept that the teaching of turn-taking and “people games” issufficient to address the complex deficits and detrimental maladaptive behaviors
characteristic of autism, is highly misleading. A more accurate statement would
be that perhaps some of the children can acquire routines using this method aslong as they already have imitation and attending skills, and can be disengaged
from self-stimulatory and self-injurious behaviors in order to participate in social
interaction. However, this excludes the vast majority of the autistic population
prior to effective intervention and does not address the issue that learning
opportunities occur infrequently in the natural environment, are often academic
in nature (e.g., writing, math, etc.) and/or are cognitively overwhelming for thechild.

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Would I try it on my child?
I would not try this therapy on my child, either alone or in combination withanother treatment method (as recommended by the Hanen Centre) due to thecomplete lack of evidence provided by proponents of this method as it applies
to children afflicted with autism. Not only is there no evidence regarding theeffectiveness of this method, the philosophy of the method is not compellingwhere children with autism are concerned. Unfortunately, despite the lack ofevidence for the Hanen method in the area of autistic disorder, this child-led
method appears to be the method of choice amongst Speech and Language
Pathologists in Canada. Fortunately, for parents in the United States, the Hanen
method has not gained wide acceptance thus far. Therefore, it is somewhat easier
to find a Speech and Language Pathologist who does not use the Hanen method
for children with autism in the U.S. as compared to Canada.
What kind of study would I like to see the practitionersof the Hanen Method do?
I would like to see the Hanen Centre produce some outcome data on the efficacyof their treatment approach, specifically for children with autism. It would be
encouraging to see a study using a control group and several reliable and valid
outcome measures which gauge the improvements in language, taking maturation
effects over time into account. In addition, outcome measures should address acomprehensive examination of the skill deficits and behavioral excesses of thispopulation. An independent clinician would make the diagnosis of autism andwould administer base-line and post-treatment measures. Furthermore, a Speechand Language Pathologist with no interest in the outcome of the study should
administer standardized language tests. If an initial experiment indicates that the
Hanen method is worthwhile for this population, its treatment effects should becompared with other interventions that have proven efficacy in autism treatment.
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A comparative study would establish which treatment programs offer the childthe best possible outcome. This will allow parents to make informed choices
based on the state of the science.
Who else recommends for or against the Hanen Method
for the treatment of autism?
Due to the lack of popularity of the Hanen Method in the United States, muchattention has not been paid to it (in contrast to Canada, where, as mentioned
before, this method is widely used by Speech and Language Pathologists totreat autism). Consequently, neither Quackwatch, nor any federal or state
governmental agencies have conducted comprehensive reviews of the Hanen
Method in their clinical practice guideline evaluations.
So you’re still on the horns of a dilemma?
If you are interested in using the Hanen method despite the lack of data supporting
this method, I suggest that you have your child evaluated by a clinical psychologist
with no vested interest in the Hanen Method, and then use a Speech and Language
Pathologist on a short term basis to provide the treatment. I would then returnto the same psychologist and have the child tested again to determine whether
or not the child has benefitted from the additional use of the Hanen Method. It
would be most unfortunate to waste your child’s time using the Hanen Method
exclusively when there are other methods with better evidence regarding efficacy
for autism treatment.
What’s the bottom line?
Based on the scientific research to date, there is no evidence that the Hanen
Method is an effective method for improving the language impairment associatedwith autism.
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Endnotes for the Hanen Therapy
Manolson, A. 1992. It Takes Two to Talk. Toronto, ON: A Hanen Centre Publication.

1

2

Sussman, F. 2002. More Than Words: The Hanen Program for Parents of Children With
Autism spectrum disorder. Toronto, ON: The Hanen Centre, www.hanen.org, (accessed Feb.
21, 2006).
Sussman, F., (see n. 2 above).

3

Sussman, F., (see n. 2 above).

45

Girolametto, L.E. 1988. “Improving The Social Conversation Skills of Developmentally
Delayed Children: An Intervention Study.” Journal of Speech and Hearing Disorders, Vol.
53, pp. 156-167.
6

Tannock, R., L.E. Girolametto, and L. Siegel. 1992. “The Interactive Model of Language
Intervention: Evaluation of its Effectiveness for Pre-School-Aged Children with Developmental
Delay.” American Journal of Mental Retardation, Vol. 97, No. 2, pp. 145-160.
7Girolametto, L., P.S. Pearce, and E. Weitzman. 1996. “The Effects of Focused Stimulation for
Promoting Vocabulary in Young Children With Delays: A Pilot Study.” Journal of Children’sCommunication Development, Vol. 17, No. 2, pp. 39-49.
The Hanen Centre, www.hanen.org, (accessed Feb. 21, 2006).

8

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Speech and Language Therapies: Lindamood-Bell
Learning Processes
What is the Lindamood-Bell Learning Processes?
According to the Lindamood-Bell Corporation, Lindamood-Bell Centers of
Learning are designed to offer programs that develop the “sensory-cognitive”
processes, which proponents state are the basis for learning academic skills suchas, “reading, spelling, math, visual-motor skills, language comprehension, andcritical thinking.”1 The centers offer clinical, school and workshop programs
addressing the many academic skill deficits seen in learners of all ages. There
are several different curricula and materials designed and sold by LindamoodBell and their publishing company, Gander Educational Products. The particularcurriculum is determined for each child based on initial assessments.
What evidence do the practitioners have that thisreally works?
There is currently no evidence that the Lindmood-Bell learning processes are aneffective intervention for individuals with autism. Lindamood-Bell do have overa dozen peer-reviewed journal articles on different learning disabilities such as
dyslexia, spanning from 1991 to 2002. The latest comprehensive database searchin 2006 found no peer-reviewed studies on the efficacy of this method for children
with autism. The Research and Development Department at Lindamood-Bell
were contacted by us in the past for information regarding outcome data on theuse of their products for individuals with autism. They shared plans to collectdata on their method; unfortunately, the design they described does not meet theminimum standards of rigor for scientific inquiry. According to Lindamood-Bell,
there will be no experimental design; rather, they will select a handful of students,
in an unspecified manner, and present pre-and post Lindamood-Bell results.
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The information provided to me indicates that there will not be a sufficiently large
number of students to perform group statistics and there will be no independent
diagnosis of autism required for the children in the prospective research at
Lindamood-Bell. Finally, the case studies will be reported in their own brochure
information — they will not be published within a peer-reviewed journal.
What does the therapy actually look like?
The particular Lindamood-Bell programs which are used for individuals with
autism are unspecified. The practitioners give each client a battery of tests toassess where the problems lie and then determine the program which best serves
the needs of the client. The programs are available to students in either a clinicalor school setting. Costs for the programs vary, depending on the individual
assessment of the student. They have over forty centers which offer one-toone instruction with trained personnel, throughout the United States and one
practitioner in the United Kingdom.
Would I try it on my child?
I would very much like to try this curriculum on my child; however, I would firstrequire some evidence that these curricula are effective for children with autism
before investing time and money on the method. I would be very interested inunderstanding which prerequisite skills are necessary, prior to purchasing thematerials. I would also like to see some evidence that children with autism benefit
as long as they have the prerequisite skills. This is one of those unfortunate
situations where there may be some very valuable materials here for autism;however, without any rigorous testing of these materials on children with Autistic
Spectrum Disorder, we will never know with certainty whether what they haveto offer is valuable for children with autism.

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What else do I think?
Despite the current lack of peer-reviewed supportive research on LindamoodBell products and services for individuals with autism, informational material
regarding international conferences on the topic claim to have research-driven
programs for developing language and literacy. However, nowhere is it specified
where the available research on these products can be found as it relates
specifically to children with autism specifically. Several speakers report casestudies with individuals “on the autistic spectrum.” Unfortunately, case studies
are an inappropriate assessment of any given treatment modality because there
is no control over confusing (confounding) variables which may be responsible
for the changes observed. Also, the autistic spectrum is a diverse and varied one.
It ranges from individuals diagnosed with Rett’s syndrome and severe autism, toindividuals who are diagnosed with Asperger’s syndrome. There is a great dealof both “inter” and “intra” diagnostic variability in autism spectrum disorders
and, as a result, there is great diversity in the number and severity of skill deficits.
Moreover, the kinds of programs offered by Lindamood-Bell have prerequisite
skills that might only be attained by a small portion of individuals with an autistic
spectrum disorder. This is not an insignificant point insofar as it is the overallvalue of the method for this group of children.
Informational material provided by Lindamood-Bell indicates that they approach
autism as a “Language Processing Spectrum Disorder.” While language is
an important skill deficit for this population, there are other skill deficits andbehavioral excesses that do not pertain to language processing but which also
form diagnostic criteria for the disorder. These other skill deficits and excesses
are not addressed through the kinds of academic programs provided in the
Lindamood-Bell system.

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What kind of study would I like to see the Lindamood-Bellpractitioners do?
I would like to see them conduct research which can stand up to the scrutiny ofpeer review, rather than work that is published solely in marketing materials.
Also, clarification is required on exactly who, if anyone, can benefit from these
programs. Specifically, what kinds of language prerequisites are required in orderto successfully learn the skills being targeted? We do not know. Additionally,
how useful and generalizable are the skills being acquired? Once again, we do
not know. The child is being assessed with pre-and post tests, so what exactly
is being assessed? Does the child acquire a skill or learn material? Does thelearning acquired through a Lindamood-Bell program generalize to other settings,
tasks and materials? We similarly do not know these things either, which areholes that need to be filled.
Who else recommends for or against Lindamood-Bell asa method for the treatment of autism?
The Lindamood-Bell system is not widely used by parents of children with autism.
Therefore, there has been little scrutiny among those in the autism communityand no official statements from reputable organizations regarding the state of
the science with Lindamood-Bell materials.
So you’re still on the horns of a dilemma?
Despite the lack of data supporting this method for children with autism, if
you are still interested in using the method, I suggest that you have your childevaluated by a clinical psychologist with no vested interest in the Lindamood-Bell
Learning Process and then use one of their consultants so that you are sure thatthe treatment fidelity is high. I would then go back to the same psychologist and238Section One: What Works and What Doesn’t?

have the child retested to determine whether or not the child has benefitted in any
way from this learning system. It is important to follow your child’s progressusing generally accepted tests rather than measures created, or supplied by, thepractitioner who is providing the treatment.
What’s the bottom line?
Based on the scientific research to date, there is no evidence that the LindamoodBell Learning Processes are an effective treatment for improving the language
impairment that is characteristic of autism.

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Endnotes for Lindamood-Bell
Lindamood-Bell Learning Processes (n.d.). San Luis Obispo, CA. p. 1.

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Speech and Language Therapies: The SCERTS
Model
What is the SCERTS Model?
The SCERTS Model is an approach that concentrates on improving thecommunication and social ability of children with autism. SCERTS (which
stands for Social Communication Emotional Regulation, and Transactional
Support1) concentrates on enhancing the child’s joint attention skills, in order toimprove his ability to communicate with others. In addition, this model targets
the child’s ability to use symbols and thereby improve communication, playand creative language. Further, emotional regulation is taught to improve thechild’s self-regulation, ability to find emotional support in others and be able
to handle overwhelming sensations that practitioners refer to as dysregulation.
The SCERTS Model also concentrates the child’s ability to use a variety ofeducational, interpersonal, family and professional supports. The goals are taught
in a developmental sequence, in different settings and, often, in a natural andinclusive environment (such as a school). This method could be categorized as
one that is based upon a developmental perspective.
What evidence do the practitioners have that thisreally works?
There is no data supporting the SCERTS Model. Proponents claim that thismodel has been developed based on over twenty years of research and that it is“consistent with recommended tenets of ‘evidence-based’ practice”;2 however,
the articles that they use to support the model are mostly theoretical. In short,there is a conspicuous lack of well-designed studies (evidence) supporting thisphilosophy. Other than the publications from the developers of the SCERTS
Model, the areas of “empirical” support for the SCERTS Model come out of
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the Positive Behavioral Support literature (which is long on philosophy andshort on data), the Floor-Time literature (which also suffers from a lack of data)
and the Hanen literature (which is not empirically supported either). Please
see the various sections in the book for more detail on each of the areas which
are relied upon by the SCERTS Model. Proponents claim that their model isconsistent with the recommended practices for autism treatment; however, until
the SCERTS Model is independently tested, its claim of empirical support ishighly questionable.
What does the therapy actually look like?
The SCERTS model uses one-on-one instruction for children who need more
support, or group instruction for those who need less support. The intervention
takes place in the school classroom and uses a structured special educationteaching approach, utilizing a variety of prompting methods when necessary.
Proponents claim that they take advantage of the children’s strengths totarget their weaknesses (e.g., using visual rather than auditory teaching). To
the untrained eye, at times the model in the classroom looks like traditional
structured special education teaching. When SCERTS is used in a segregatedsetting, there is typically a special educational teacher and a number of school
aides are assigned to several children. There is also a play component where
the children are encouraged to engage in pretend play. An additional facet ofthe program incorporates opportunities for the children to use different types ofapparatus typically found in Sensory Integration Therapy, e.g., special swings.
Another facet of the curriculum addresses the ability of children to regulate theiremotions by giving them the tools to feel better, e.g., to ask for help if they arehaving difficulty. Teachers and aides will also soothe a child by applying physicalpressure techniques based on the literature on Sensory Integration Therapy. The
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is upset. There is an integrated component of the program which helps typical
peers learn to relate to children with autism spectrum disorder.
The curriculum is adapted or modified to emphasize visual strategies in theform of pictures with which to communicate, i.e., through the use of the Picture
Exchange Communication System (PECS), and encourages the child to readbooks about emotions. Parents are looked upon as collaborators and includedin the educational process by incorporating the PECS icons in the home.
Practitioners of the SCERTS Model also provide emotional support for parents
For an in-depth demonstration of the SCERTS Model, developers of the model
have produced three videos illustrating their model for children needing varied
amounts of support. The first video is an introduction and overview of the modeland the other video-tapes show the SCERTS model on children who initiallyneed considerable support and then, subsequently, less support.
Would I try it on my child?
While most of the concepts in the SCERTS Model seem appealing (particularly
the part where the school system is actually supposed to be cooperative and listen
to parents), if my child were starting out with little language and poor attention
skills, I would not utilize this method. The SCERTS Model does incorporate
visual strategies, which are important for many children with autism spectrum
disorder (including the PECS system). However, I would want my child tograduate quickly from PECS to text and verbalization because it is preferable
to communicate in the world verbally (if possible). I did not see proponentsof the SCERTS Model present sufficient strategies in their literature to curb
various self-stimulatory and anti-learning behaviors characteristic of autismthat blocks attention. I would be concerned that my daughter would not makeenough progress due to the interference of problematic behaviors. In addition,

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although play, communication and creative language sound like wonderful goals,
until there is evidence that these goals have been met using this method, I would
not have my child enrolled in the SCERTS educational program.

What else do I think?
Much of the SCERTS Model is concerned with: 1) how adults and schools systems
make decisions about children with autism spectrum disorder, and 2) the support
that families and professionals require to be successful, rather than about theefficacy of the model for autism intervention. Quite troubling is that the SCERTS
Model has all the appearance of being a method designed to rehabilitate existing,inadequate schools systems so they can adapt to coping with autistic children
in the school, rather than offer the most effective treatment possible for autism
spectrum disorder. It was in 1982 when one of the developers of the SCERTS
Model first started discussing the role of the Speech and Language Pathologist in
the assessment and intervention of children with autism.3 It is over twenty-four
years later, and although proponents of SCERTS have written much about this
topic and developed a model, they still have not tested their model independently.
In short, an independent test on the SCERTS Model is long overdue.

What kind of study would I like to see the SCERTS
practitioners do?
Due to their claim that the SCERTS Model addresses what practitioners define
as the “core” challenges of children with autism,4 it is time for the SCERTS
Model to test their protocol against the main competitor which is, at this point,
Intensive Behavioral Treatment. To do this, I’d like to see a between-subject

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design utilizing a variety of autism measures including IQ tests, and Speechand Language measures. Proponents of SCERTS disagree with utilizing IQ
and post-intervention placement measures. They state: “These measures may
not be ecologically valid because they do not measure changes within naturalenvironments, do not address the core ‘deficits’ in ASD, and are particularly
problematic for infants and young children.”5 The discounting of thesemeasures results in a lack of objective testing; therefore, along with their goalsof measuring improvement in communication, motivation, social competence
and generalization of skills, SCERTS researchers would be well advised to use
the widely accepted measures from autism research as well (which includes
cognitive testing and behavioral measurement).
Who else recommends for or against SCERTS asa method for the treatment of autism?
Although the SCERTS Model has not been recommended specifically by any
reputable clinical practice guidelines, the New York State Department of HealthReport has recommended against the DIR method, upon which SCERTS claims
to be partially based. For more detail on the lack of scientific support for theother models upon which the SCERTS Model rests, please read the sections inthis book on the Hanen Method and Positive Behavioral Support.
So you’re still on the horns of a dilemma?
Despite the lack of data on the SCERTS Model, if you still would like toessentially experiment with your child by placing him in a school system that
adopts this model, I would encourage you to have an independent, licenced
psychologist take baseline data prior to beginning the SCERTS program, andthen have the child retested at regular intervals (e.g., yearly) to ensure that some245

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progress is actually being made. If there is no objectively-measured progresswithin one year, it would be wise to choose an alternative, well-settled autism
treatment for your child.
What’s the bottom line?
Based on the scientific research to date, there is no evidence that the SCERTS
Model is an effective treatment to ameliorate the symptoms associatedwith autism.

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Endnotes for the SCERTS Model
1

Prizant, B.M., A. Wetherby, E. Rubin, and A.C. Laurent. 2003. “The SCERTS Model: A
Transactional, Family-Centered Approach to Enhancing Communication and Socioemotional
Abilites of Children With Autism spectrum disorder.” Infants and Young Children, Vol. 16, No.
4, pp. 296-316.
Prizant, B.M., A. Wetherby, E. Rubin, and A.C. Laurent, (see n. 1 above), p. 298.

2

Prizant, B.M. 1982. “Speech-Language Pathologists and Autistic Children: What is Our
Role? Part 1. Assessment and Intervention Considerations. Part II. Working With Parents
and Professionals.” American Speech and Hearing Association Journal, Vol. 24, pp. 463-468,
531-537.
3

Prizant, B.M., A. Wetherby, E. Rubin, and A.C. Laurent, (see n. 1 above), p. 313.

4

Prizant, B.M., A. Wetherby, E. Rubin, and A.C. Laurent, (see n. 1 above), p. 313.

5

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Miscellaneous Therapies
p Art Therapy
p Auditory Integration Training
p Craniosacral Therapy
p Dolphin Assisted Therapy
p Exercise Therapy
p Facilitated Communication Training
p Holding Therapy
p Music Therapy
p Pet-facilitated Therapy
p Sensory Integration Therapy
p Vision Therapy

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Miscellaneous Therapies: Art Therapy
What is Art Therapy?
Art Therapy is based on the philosophy that through the artistic process, we
can reach a person with autism. Although there does not seem to be a singular
philosophy which drives Art Therapy as applied to children with autism, there
is a Freudian overtone from this work which assumes that people with autism
require their ego to be developed, and that Art Therapy can accomplish thisgoal.1 In addition, Art Therapy is believed to help children with autism organize
their sensory world (i.e., help process the incoming information from their fivesenses).2 Furthermore, Bentivegna et al. (1983) provide a case study about achild who attended psychotherapy and art therapy concurrently. The child is
described as able to communicate with the outside world through his artwork.
There does not appear to be a uniform Art Therapy protocol that is embraced bypractitioners; rather, there is a variety of philosophies which promote the use ofart to “reach” the child with autism.
What evidence do the practitioners have that thisreally works?
Despite a thorough search through many data bases, I did not net any peerreviewed journal articles reporting data on the efficacy of Art Therapy for persons
with autism. The eight articles found tend to analyze communication throughthe artwork and compare an autistic person’s artwork to the typical population;
however, none of these articles even attempt to show how Art Therapy actuallyameliorates the condition of autism. One article3 chronicles the attempted use ofart as a way to integrate children with autism with their non-disabled peers. These
researchers found that art was a good medium to increase the social behavior

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of the non-disabled peers toward the children with autism. However, there wasnothing inherent in Art Therapy that improved the condition of autism.
What does the therapy actually look like?
Although there does not seem to be one distinctive protocol utilized to work withchildren with autism using Art Therapy, materials and activities which promotecreativity4 are introduced to the child. Art Therapy, as described by Buck et al.
(1984), appears to be client-led, having the person with autism independently
explore the art materials that are presented.
What else do I think?
Some forms of Art Therapy have much in common with Sensory Integration
Therapy, because the child experiences the materials in a sensory manner. In
addition, there seems to be a undercurrent of Freudian or Bettleheimian philosophy
in Art Therapy, yet there is no data supporting either Freud’s or Bettleheim’s
philosophy when it comes to autism. In fact, Bettleheim’s philosophy regarding
the supposed cause of autism (the refrigerator mother hypothesis — “cold,
uncaring mother”) has been thoroughly discredited.
Would I try it on my child?
No I would not. I would be more than willing to have my child take art lessons
as a form of productive leisure or as a hobby, if she enjoyed art. However, I haveseen absolutely nothing in the scientific literature to indicate that Art Therapy
even deserves the word “Therapy” attached to it.

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What kind of study would I like to see the Art Therapy
practitioners do?
Prior to rigorously testing Art Therapy, there needs to be a defined treatment
protocol developed. Once the independent variable of Art Therapy is defined
objectively and operationalized so that it can be tested, only then is the supposed
treatment protocol worthy of the term “therapy.” However, not only is there
no well-defined protocol for Art Therapy, but there isn’t even a theory that
hypothesizes why Art Therapy should work for children with autism. Clearly,
this is a fundamental prerequisite for testing this method.
Who else recommends for or against Art Therapy asa method for the treatment of autism?
Art Therapy has been ignored, for the most part, by those writing clinical practiceguidelines, as this therapy is not considered dangerous nor is it prohibitively
expensive: therefore, parents have nowhere to go to check on the efficacy of
Art Therapy.
So you’re still on the horns of a dilemma?
Due to the complete absence of any data on the effectiveness of Art Therapy, I
would caution against the use of this so-called treatment, especially if it is to the
exclusion of validated autism treatment. Art Therapy has not been demonstrated
to be harmful; however, I would expect no results other than perhaps an enjoyableleisure time activity for your child. I would stress again that Art Therapy cannot
be characterized as therapy for autism.
What’s the bottom line?
Based on the scientific research to date, there is no evidence to conclude that
Art Therapy is an effective treatment for improving the symptoms characteristicof autism.
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Endnotes for Art Therapy
Scanlon, Kathleen. 1993. “Art Therapy with Autistic Children.” Pratt Institute Creative Arts
Therapy Review, Vol. 14, p. 37.

1

Scanlon, K., (see n. 1 above).

2

3

Schleien, S., T. Mustonen, and J. E Rynders. 1995. “Participation of children with autism andnon-disabled peers in a cooperatively structured community art program.” Journal of Autism
and Developmental Disorders, Vol. 24, No. 4, pp. 397-413.
4

Bentivegna, S., L. Schwartz, and D. Deschner. 1983. “The use of art with an autistic child inresidential care.” American Journal of Art Therapy, Vol. 22, pp. 51-56.

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Section One: What Works and What Doesn’t?

Miscellaneous Therapies: Auditory Integration
Training
What is Auditory Integration Training?
Auditory Integration Training (AIT) was developed by Dr. Guy Berard in the
1960s and was popularized in the United States by Dr. Alfred Tomatis, as atreatment for many cognitive or behavior problems, including autism. Berardsuggests that autism is due, in part, to distortions in hearing, which create
avoidance behaviors in individuals with autism, particularly as a reaction to
extremely acute sounds.1 Auditory Integration Training was developed to lessen
autistic behaviors by “re-educating” the hearing system. Auditory re-education
is believed to take place through mechanical massage of the different parts ofthe ear (ossicles, eardrum and cochlea) and, thereby, correct auditory distortions.
There is no clear data on how exactly Auditory Integration Training works in theear, but several explanations are available in the literature.
What evidence do the practitioners have that thisreally works?
Our database research found many published and unpublished articles on Auditory
Integration Training (AIT). Most of those articles were either only opinion
pieces, reviews, or commentary. There were twenty-eight studies in which
researchers actually collected data on the AIT intervention; however, most were
either unpublished, presented at conferences, or published in non-peer reviewed
journals, pamphlets or short books. Not surprisingly, most of the studies whichwere unpublished or published in non-peer-reviewed newsletters or reports
found that AIT was of benefit (please see page Section Two for a discussion
on the importance of peer review). There were in total, nine peer-reviewed
studies which presented data. Of these nine, three were case studies2,3,4 which
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lack scientific rigor, and two were open pilot studies (the researchers were notblind to experimental procedures) with no control groups or appropriate withinsubject design procedures.5,6 There are four peer-reviewed studies on AIT which
randomly assign subjects to either experimental or control groups (where thosein the control group received a placebo treatment that closely mimicked thetreatment procedure). Two of the studies reported results which they attributed to
AIT.7,8 In contrast, two of the studies reported either no effect of AIT on autism9
or reported effects which could not be attributed to AIT.10
These four studies merit closer examination. In the first study where researchersreported positive results for AIT,11 seventeen autistic children and adolescents
participated. Each subject had a diagnosis of autism from an independentagency. The researchers matched pairs of subjects in terms of the subject’s age,sex, hearing sensitivity and possible ear infections, and then randomly assigned
subjects from the matched pair to the control or experimental condition (which
is a good idea as seventeen subjects is not a large number and matching pairs
helps ensure that the two groups are similar); however, the one variable that
researchers did not use to match children in the study was degree of autism (using
objective behavioral and IQ measures). Unfortunately, degree of autism is themost important variable that should have been used for matching.
There were several major flaws in the study. First, the researchers over-relied uponparental reporting, using the Aberrant Behavior Checklist (ABC), the Hearing
Sensitivity Questionnaire (HSQ) and the Fisher’s Auditory Problems Checklist(FAPC). An additional problem with the study is that only the ABC research
instrument was used to measure improvement in the children’s behaviors. Ideally,
several autism measures should have been used to ensure that the reported results
are accurate. Furthermore, the researchers did not succeed in creating two groups
that were similar. Their strongest measure for autism, the Aberrant Behavior

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Checklist (ABC), demonstrated that the groups were significantly different at
the outset of the study. Although they attempted to deal with this problem byusing statistical procedures (they subtract the pretest score from the three monthscore to measure the change only), this completely undermines the belief that
random assignment and matching did, in this case, create two groups which weresimilar at the beginning of the first study. In other words, this major flaw calls
into question all the results of these researchers’ studies. After attempting toaccount for the basic flaw of the two research groups of children being initiallydifferent, these researchers did find a difference in the groups after the treatment
based on the ABC scores and in four of the sub-scales in the ABC. However, due
to initial difference between groups, I consider these results unreliable to arriveat any conclusions about how well AIT works to treat autism.
The second study12 showed major improvements in the experimental design overthe initial study.13 Eighty children participated in the study and were randomly
assigned to the study groups. It is notable that eighty children in autism-related
research is an impressive number of subjects for one study. Noteworthy also
is that all children in the experiment were diagnosed from an independentagency. The study tested the children prior to and after the treatment, by using
a variety of psychometric measures: the Autism Behavior Checklist (ABC); theDevelopmental Behavior Checklist (DBC) in a teacher and parent version; partsof the Peabody Picture Vocabulary Test(PPVT), and the Leiter International
Performance Scale (LIPS). The study followed the children for twelve months
after the completion of the study. The use of a number of tests to rate variables
which are indicators of autism, administered by teachers and psychologists,
is a significant improvement over prior studies testing AIT. In this study, an
independent psychologist tested the children using the ABC, LIPS, and PPVT
measures and trained the child to go through a specialized hearing test (anaudiometric assessment). In addition, there were tests to demonstrate that

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different researchers, taking the same data, recorded the same results (please see
Section Two for a discussion on inter-observer reliability).
Bettison’s results show that the groups were indeed similar prior to treatment,
which is important because a study needs to compare one group to another.
(This improvement is in contrast to the study conducted by Rimland (1994), in
which the groups were different prior to treatment). This finding gives me ahigh degree of confidence that as long as there are no other serious flaws in the
study, we can take the results of the Bettison study seriously.
What did Bettison find? Well, her results are quite interesting. She found thatthe children improved in both the experimental and the control group. When
comparing the experimental and control group after the treatment, there wasno significant difference between each group of children on most measures(specifically the Autism Behavior Checklist (ABC), the Developmental Behavior
Checklist (DBC), and the IQ tests). In other words, both sets of autistic children
improved — even the children who did not receive the auditory integration
training but, instead, listened to unmodified music. Put simply, the Auditory
Integration Training itself had no effect on degree of autism. Many of the
improvements of both groups are statistically significant, which is somewhat
perplexing. Mudford et al. (2005) suggest that this may be an experimental
artifact. Specially, they suggest that the improved scores may be the result of
administering the same questionnaires multiple times (each child would havebeen evaluated with the questionnaire ten times — five times by the parent andfive times by the teacher on five different occasions). The results of particularinterest are the improvement of both groups on two cognitive tests (the PPVTand the LIPS). Unfortunately, despite the statistical significance, the standard
deviation of the results is very large (which increases the possibility that results
could have happened by chance alone). In addition, the behavior test administered258

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by the teacher (the DBC) provided an interesting result. The control group had astatistically significant, but weak, change. Of note is that when the teacher andthe parents fill out the exact same questionnaire (the DBC), the improvements
the parents see are much greater than what the teacher records, which further
exemplifies my profound mistrust of parental reporting.* Keep in mind that theteachers and parents are observing the same children. Bettison also makes thesame observation, that parental reporting is inflated due to parental high hopes
for their children.
Aside from the hypothesized questionnaire effect, there are other possibilities
about why both groups improved. First, there may be another influence present
at the same time as the experiment but not a result of the experiment. Whatcauses this confounding influence may not be clear; however, the fact that the
study compares two groups, allows us to make sure this unintended influence
does not fool us into thinking that the Auditory Integration Training actually
has an effect. Another explanation for the improvement of both groups is that
there may be no effect other than maturation effects, paired with the effect ofthe various educational or other treatment programs in which the children areenrolled. In short, based on the results of the best designed study on AIT, there isinsufficient evidence to conclude that auditory integration training is an effective
treatment for children with autism.
Another question that arises from this research is the premise upon which thistherapy is based: AIT practitioners assume that auditory distortions do exist
in the first place.14 This belief has not yet been verified due to the obstacle ofaudiometrically testing individuals with autism.15*

The teacher scores for the experimental group were 42.93 before, and 40.33 after the experiment. The
teacher scores for the control group were 44.85 before, and 38.30 after the experiment; Parent scores forthe experimental group were 64.80 before, and 52.88 after the experiment. Parent scores for the control
group were 63.13 before, and 47.20 after the experiment.

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There is also evidence to support the hypothesis that AIT is not an effective
treatment for autism. Zollweg et al.16 used a double-blind experimental design
and found that the behavior of both the treatment and control groups improved
slightly (based on the Aberrant Behavior Checklist [ABC]) which once again, as
in the Bettison study, suggests that AIT was not responsible for the improvement.
By far the best design study in this literature is Mudford et al. (2000).17 These
researchers measure autism using behavioral rating scales, direct observation andpsychometric measures in a crossover design (i.e., the children in the experimentexperience both the experimental and control conditions) where the children
were randomly assigned in terms of base-line measures. They found no results
and conclude that “no children could be identified as benefiting from auditory
integration training to a clinically or educationally significant degree.”18
What does the therapy actually look like?
Auditory Integration Training involves the electronic processing of music which
has been modulated and filtered through headphones. The music typically contains
tracks with a fast tempo and wide frequency.19 There are two types of auditory
integration training offered, the Berard method and the Tomatis method. These
two methods differ in the underlying theory, amount of treatment and in typeof sounds used. The Berard method was developed to address the supposed
auditory perception problems which result in autism. The Tomatis method wasdeveloped to address the purported disruption in the mother-child bond which
he believes occurs in utero due to the mother’s use of harsh and cold tones. As aresult, Berard targets hypersensitivity to sound whereas Tomatis targets listening
and comprehension. To address the hypersensitive perception to certain sounds,
the Berard approach attempts to filter out frequencies to which the individual isthought to be overly sensitive. These frequencies are selected based on hearing
tests done with special audio equipment prior to AIT.20 In order to accomplish

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change in listening and comprehension, the Tomatis approach consists of threephases that 1) filter out low frequency sounds, leaving only high frequency
sounds which are said to “energize” the brain, as well as recreate sounds fromwithin the womb; 2) recreate sounds from after birth, and 3) have the individual
read aloud.
The Berard and Tomatis approaches also differ with respect to frequency andduration of training. While the Berard method recommends no more than ten
hours of AIT, administered over ten days in two, half hour sessions per day, theTomatis approach recommends much higher levels of AIT. There are two options
for intensity and duration in the Tomatis method. For individuals with autism,
it is recommended that they receive 150-200 hours of AIT over six to twelve
months. There is also a short course that can be administered which involves
two and one-half to three hours per day for ten to twelve days.
What else do I think?
The reported presence of side effects is an important issue in the use of AIT.
Research is required to examine whether or not this training method creates any
side effects. Monville21 noted tantrums and aggression in ten percent of children,
while Link22 reported that one third of the children may have experienced seizures,and that there was an increase in negative behavior and perseveration. In addition
to this, Link23 reports the possibility of AIT inducing seizures in individuals
diagnosed with Landau-Kleffner syndrome.
Auditory Integration Training (AIT) is a method of treatment for individuals with
autism which is used often, despite the distinct lack of supportive research. It
is of great financial cost to parents and there may be the possibility of negativeside effects. The abundance of anecdotal evidence on AIT, particularly the261

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book, Sound of a Miracle: A Child’s Triumph over Autism,24 which purports
AIT as a cure for autism, has made AIT popular, despite the distinct lack ofmethodologically sound data.
Would I try it on my child?
At this point I would not try AIT on my child. There is not enough good sciencebehind this treatment and I am somewhat concerned about the reported side
effects of aggression, tantrums, and seizures. In addition, the cost of using an
unproven treatment in time and money is a further factor in my decision not tohave my daughter undergo this treatment. When my daughter was first diagnosed
fourteen years ago, I did research AIT as a serious option because she seemed tohave very sensitive hearing and would be a candidate for this method. However,once I researched the amount and quality of scientific evidence for this method,
I decided to wait for more evidence. Now I’m still waiting; however, now there
have been a few well done studies which strongly support the contention thatAIT does not ameliorate the symptoms associated with autism.
What kind of study would I like to see the Auditory
Integration Training practitioners do?
I would like to see the Mudford et al.25 design replicated by Rimland and Edelson(two proponents of AIT) utilizing the same measures for the dependent variable ofautism that Mudford et al. (2000) used. In addition, this replication would needto have psychologists with no relationship to AIT administer the various measuresused. If the results of the 2000 study were replicated, then parents would know
with more certainty that AIT is not an effective treatment for autism.

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Who else recommends for or against Auditory Integration
Training as a method for the treatment of autism?
There are many professionals and organizations recommending against AIT. In
a 1998 policy statement authored by the American Academy of Pediatrics, theystate that: “Although two investigations indicated AIT may help some children
with autism, as yet there are no good controlled studies to support its use. ... Until
further information is available, the use of these treatments [AIT] does not appear
warranted at this time, except within research protocols.”26 In addition, the New
York Department of Health issued a report on best practices for the treatmentof children with autism. Regarding Auditory Integration Training, they havethis to say: “The one study that met criteria for evidence about efficacy foundno differences in children receiving auditory integration training and children
listening to unmodified music. Because of the lack of demonstrated efficacy
and the expense of the intervention, it is recommended that auditory integration
training not be used as an intervention for young children with autism.”27 Further,
the Association For Science in Autism treatment (ASAT) states: “Professionals
considering AIT should portray the method as experimental and should disclose
this status to key decision makers influencing the child’s intervention.”28
So you’re still on the horns of a dilemma?
If you are still wondering whether you should try Auditory Integration Training,
I suggest you read the Mudford article29 which critically reviews this treatment
in comprehensive detail. It is important to recognize that AIT, at this point, isentirely experimental and that the scientific evidence is growing to support theview that AIT is an ineffective treatment for autism.

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What’s the bottom line?
Based on the scientific research to date, there is not enough evidence to conclude
that Auditory Integration Training is an effective treatment for autism

264Section One: What Works and What Doesn’t?

Endnotes for Auditory Integration Training
1

Berard, G. 1993. Hearing Equals Behavior. New Canaan, CT: Keats.

Link, H.M. 1997. “Auditory Integration Training (AIT): Sound therapy? Case Studies ofThree Boys With Autism Who Received AIT.” British Journal of Learning Disabilities. Vol.
25, pp. 106-110.

2

3

Madell, J.R., and D.E. Rose. 1994. “Auditory Integration Training.” Face to Face, American
Speech-Language-Hearing Association, pp. 14-18.
4Brown, M.M. 1999. “Auditory Integration Training and Autism: Two Case Studies.” British
Journal of Occupational Therapy, Vol. 62, No. 1, pp. 13-18.
Gillberg, C., M. Johansson, S. Steffenburg, and O. Berlin. 1997. “Auditory Integration Training
in Children With Autism. Brief Report of an Open Pilot Study.” Autism, Vol. 1, No. 1, pp. 97100.
5

Rimland, B., and S.M. Edelson. 1994. “The Effects of Auditory Integration Training on Autism.”
American Journal of Speech Pathology, Vol. 5, pp. 16-23.

6Rimland, B., and S.M. Edelson. 1995. “A Pilot Study of Auditory Integration Training in Autism.”
Journal of Autism and Developmental Disorders, Vol. 25, No. 1, pp. 61-70.

7

Bettison, S. 1996. “The Long-Term Effects of Auditory Training on Children With Autism.”
Journal of Autism and Developmental Disorders, Vol. 26, No. 3, pp. 361-374.

89
Mudford, O.C. et al. 2000. “Auditory Integration Training for Children With Aut ism: No
Behavioral Benefits Detected.” American Journal on Mental Retardation, Vol. 105, No. 2, pp.
118-129.

Zollweg, W. 1997. “The Efficacy of Auditory Integration Training: A Double Blind Study.”
American Journal of Audiology, Vol. 6, No. 3, pp. 39-47

10

11

Rimland, B., and S.M. Edelson. 1995. “Brief Report: A Pilot Study of Auditory Integration
Training in Autism.” Journal of Autism and developmental Disorders, Vol. 25, No. 1, pp. 6269.
12

Bettison, S., (see n. 8 above).

13

Rimland, B., S.M. Edelson, (see n. 11 above).

14Link, H.M., (see n. 2 above).

15

Link, H.M., (see n. 2 above).

16

Zollweg, W., (see n. 10 above).

17

Mudford, O.C. et al., (see n. 9 above).

18

Mudford, O.C. et al., (see n. 9 above).
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19

Link, H.M., (see n. 2 above).

20

Link, H.M., (see n. 2 above).

Monville, D., and N. Nelson. 1994. Parental Perceptions of Change Following AIT for Autism.
Presented to the American speech-Language-Hearing Conference, New Orleans.
21

22

Link, H.M. (see n. 2 above).

23

Link, H.M. (see n. 2 above).

24
Stehli, A. 1991. The Sound of a Miracle: A Child’s Triumph Over Autism. New York:
Doubleday.
25

Mudford, O.C. et al., (see n. 9 above).

Committee on Children with Disabilities. 1998. ”Auditory Integration Training and Facilitated
Communication for autism.” Pediatrics, Vol. 102, No. 2, p. 433.
26

27
Guralnick, M. ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorder s, Assessment and Intervention for Young Children(age 0-3 years). Albany (NY): New York State Department of Health, p. IV-63.

Association for Science in Autism treatment (ASAT), www.asatonline.org/about_autism/autism_info08.html, (accessed Aug. 19, 2005).

28

29

Mudford, O.C. et al., (see n. 9 above).

266Section One: What Works and What Doesn’t?

Miscellaneous Therapies: Craniosacral Therapy
What is Craniosacral Therapy?
Craniosacral Therapy is a technique whereby the practitioner softly touches
and manipulates the head of a person with autism. According to those whopractice Craniosacral Therapy, the manipulation of the head is done to release
restrictions in the Craniosacral system (CSS). The theory behind this therapy
is that the patient benefits because the treatment creates changes to the central
nervous system. The philosophy that accompanies the practice of Craniosacral
Therapy emphasizes natural alternative medicine rather than traditional western
medicine. Specifically, there is a belief that so-called “energy cysts” develop inareas of prior physical trauma and/or emotional shock.1 In addition, cells andorgans are thought to have a consciousness and practitioners have the patientcommunicate with the brain using imagery and dialogue.2 Explanations as towhy Craniosacral Therapy is thought to be effective for individuals with autism
are not well developed. The therapy does make claims that it can be used fortreatment as well as prevention of autism.3
What evidence do the practitioners have that thisreally works?
Our extensive database searches found no peer-reviewed journal articles on
Craniosacral Therapy reporting outcome information on this treatment for autism.
The only facts available regarding the effects of this type of therapy are casehistories reported by Upledger who pioneered the use of this treatment. Basedon material generated by the Upledger Institute, it is reported that the use of
Craniosacral Therapy on infants acts in a preventative way for many childhood
disorders, including autism. However, there are no peer-reviewed studies as ofyet to support these claims. Despite the lack of peer-review, Craniosacral Therapy
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has generated much non-peer reviewed literature in the form of promotional andteaching materials (over one hundred monographs, newspaper articles, newsletter
entries, a dozen books, and ten videotapes).
There has been one non-peer reviewed study examining the differences between
autistic individuals before and after the therapy. The researchers compared blood,
specific physical characteristics and did a hair mineral analysis of individuals
with autism to typically developing individuals. When they found unspecified
abnormalities, they then used Craniosacral Therapy to treat and thereby correctthese supposed differences amongst the autistic subjects. The authors studied
twenty-five out of fifty-one individuals enrolled in the Genessee Intermediate
School District Center for Autism. The most obvious flaw in this research is thatthese researchers do not establish the relevance of the physical, blood and hairmineral abnormalities as they specifically relate to autism. It has not yet been
determined that these abnormalities are characteristic, of or relevant to, autism.
Specifically, these researchers do not assess whether these symptoms are related
to the various deficits and excesses which characterize autism and are used tomake the behavioral diagnosis of autism. In other words, did the lessening ofthese purported abnormalities indeed improve the degree of functioning, thebehaviors, or the communication skills in the autistic individual? The researchers
do not address this central question. In formal terms, the dependent variable ofautism is not operationalized properly (please see Section Two for a discussion
on the operationalization of the dependent variable).
What does the therapy actually look like?
Craniosacral Therapy addresses the craniosacral system in the human body,
including the membranes and fluid surrounding the spinal cord, brain, and theskull, face and mouth bones, down to the tailbone.4 In Craniosacral Therapy the268Section One: What Works and What Doesn’t?

practitioner uses a light touch (defined as 5 grams of pressure or less), aroundthe area defined as the “Craniosacral system.”
What else do I think?
There is no peer-reviewed, published data regarding how well (or if) Craniosacral
Therapy works and there is too little information regarding what is actually
supposed to happen as a result of this therapy. Data that does exist in the literature
with regards to Craniosacral Therapy and individuals with autism does notinclude an evaluation of its use as a treatment for autism. It has only been used
as an intervention for certain physical symptoms, which are neither necessarilya result of autism nor are symptoms that contribute to the diagnosis of autism.
This therapy does not address the serious language, social and play deficits, or the
behavioral excesses, such as self-stimulation, rigidities and ritualistic behaviors
often characteristic of autism.
Would I try it on my child?
I would not try this on my child because I have not seen any evidence that thistherapy could be effective in ameliorating the symptoms of autism. This is agreat example of a therapy backed only by theory, but no evidence whatsoever,being offered up to parents (at a considerable cost per hour) as a purportedly
legitimate intervention.
What kind of study would I like to see the practitioners of
Craniosacral Therapy do?
There needs to be further research into the theory underlying the use of
Craniosacral Therapy for individuals with autism. Specifically, researchers need
to use a controlled design to assess whether Craniosacral Therapy is effective

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in the reduction of the various well defined and generally-accepted symptoms
characteristic of autism. There needs to be double-blind, pre-and post testing
using commonly-accepted tests for autism and the researchers must not know
which children are in the experimental and control groups. In addition, before I
am convinced that Craniosacral Therapy works as a treatment for autism, I needto see a well-designed study with outcome data published in an academic, peerreviewed journal and replicated, before recommending Craniosacral Therapy.
Who else recommends against Craniosacral Therapy asa method for the treatment of autism?
There have not been any organizations or groups who have recommended
against this therapy for children with autism because Craniosacral Therapy is
not a commonly-used treatment for autism; however, when this therapy is used
on individuals with other conditions and diseases, Quackwatch recommends
against this treatment.5
So you’re still on the horns of a dilemma?
If you are still thinking of this therapy to lessen the degree of autism in your child,
I would suggest that you visit any reputable neurosurgeon to have him share his
medical opinion regarding the effectiveness of Craniosacral Therapy.
What’s the bottom line?
Based on the scientific research to date, there is no scientific evidence that
Craniosacral Therapy is an effective therapy for autism.

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Endnotes for Craniosacral Therapy
11999. For Continuing Education, Continuing Care. Palm Beach Gardens, FL: The Upledger
Institute, Inc., p. 4.
(see n. 1 above), p. 6.

2(see n. 1 above), p. 5.

3(see n. 1 above), p. 2.

4

Barrett, S. “Craniosacral Therapy.” http://www.quackwatch.org/01Quackery Related Topics/
cranial.html, (accessed Feb. 13, 2006).

5

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Miscellaneous Therapies: Dolphin-assisted
Therapy
What is Dolphin-assisted Therapy?
Dolphin-assisted Therapy (DAT) is the practice of having persons with special
needs swim with dolphins. Practitioners of this therapy have differing opinions
on how the therapy method helps, whom it helps and what effects can be expectedfrom this therapy. We originally found two sources of information on thisintervention, one from “Dolphin Reef” in Eilat Israel,1 and the other from “Island
Dolphin Care” based in Florida.2 Our latest search netted several different DAT
programs, including one in Crimea in the Ukraine.3
The concept of using dolphins as a treatment for autism came from the observationof a diver in Israel, who observed that when people came to see the dolphins,
they often expressed many emotions (including happiness, excitement and tearsof joy). This led the diver to believe that human exposure to dolphins may be atherapeutic, emotional process for some people.
The practitioners in Dolphin Reef (Israel) claim that Dolphin-assisted Therapy
addresses some of the cognitive and emotional needs of the child. The cognitive
issues are addressed on the diving platform, where the child watches the dolphinsswim in the water, then feeds the dolphins and adjusts to the diving gear. Somehand signals are often taught to the autistic person to communicate with thedolphins. Then, when the child is ready and willing, he or she is moved into thewater with the dolphins. In the water, the child learns to interact with the dolphin.
The dolphin’s non-judgmental attitude toward the individual with special needs
is theorized to be extremely helpful in having the individual “accept himself or

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herself.” Practitioners believe that learning to socially interact with dolphins
will then generalize to improvement in social interaction with people.
The practitioners of Dolphin-assisted Therapy in Florida do not make the same
claims about the effects of this therapy as do the Israeli practitioners. The
Floridians propose that some changes may be seen in the child after therapy;
however, these changes are attributed to the child’s purported increase in selfesteem, confidence and motivation,2 as opposed to any healing effect of dolphins.
In fact, the Island Dolphin Care website states that, while some believe in these
healing properties, there is very little scientific evidence to support these beliefs.1
In addition to this, they state clearly that there may be little or no improvement forchildren with behavioral problems, extreme fears or those who are moderately orseverely autistic or disabled. In addition to time in the water with the dolphins,
the Island Dolphin Care site creates a psycho-educational program for the child,using behavioral and educational techniques in a classroom setting.
What evidence do the practitioners have that thisreally works?
There is no evidence that Dolphin-assisted Therapy is an effective intervention
for autism. Our comprehensive database searches found four articles on DAT,
but only one Belgian article that attempts to measure the efficacy of Dolphinassisted Therapy. This study evaluated whether Dolphin-assisted Therapy
enhanced the learning of autistic children, specifically measuring attention andmotivation. Unfortunately, the study’s flaws were so great that the researchers
themselves could not make any conclusions about whether dolphins had atherapeutic effect on children with autism.4 Therefore, there are no publishedstudies with reliable outcome data to evaluate the effectiveness of Dolphinassisted Therapy for children with autism. In marked contrast, there is no274

Section One: What Works and What Doesn’t?

shortage of non-peer reviewed information on DAT. In one television broadcast
on dolphin therapy (funded by the Government of Canada) entitled, “The Body,
Inside Stories,” the audience is taken to Eilat, Israel, where a section of the Red
Sea is cordoned off to house several dolphins. The film proceeds to claim thatthe treatment is very effective, not only for individuals with autism, but also for
those with other disorders. The documentary follows the treatment of a groupof adolescents and adults with autism who are brought down to Dolphin Reef
for DAT. The claim is made that individuals with autism can hear the sounds ofdolphins, that typically developing persons are unable to hear. These dolphin“voices” are hypothesized to draw autistic people out of their isolated world.
Despite the observation that some individuals with autism seem to have moresensitivity to sound, there is no research to suggest that individuals with autism
have the ability to hear dolphin sounds that others cannot hear. In addition, thefilm provides anecdotes of people who claim to have directly benefitted fromthe intervention (please refer to Section Two for a discussion of the use andabuse of anecdotal information). The claim of the Israeli proponents of Dolphinassisted Therapy is that the autistic individuals were more “relaxed” after theintervention. In addition, dolphin therapy is claimed to be worthwhile because
1) it will provide more contact with others, and 2) individuals with autism will
be happier, use more language and need less medication. There was no evidence
presented in the broadcast regarding these kinds of supposed gains, nor is there
any peer-reviewed, published literature which supports the notion that meaningful
outcomes result from Dolphin-assisted Therapy.
What does the therapy actually look like?
In Eilat, Dolphin-assisted Therapy involves three, four day sessions, of anunspecified duration. At Island Dolphin Care in Florida, therapy generally is
conducted from one to three weeks. It costs approximately $2,000 USD per

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week, which includes five dolphin sessions and four classroom sessions. In boththese centers, the autistic person wearing a life jacket, is placed in the water. The
therapist helps the child become comfortable with the water and the dolphin.
With the help of the therapist, the child interacts with the dolphin and is given
rides on top of the dolphin as it swims around the pool.
What else do I think?
This type of “intervention” can be extremely appealing to parents who aredesperate for an effective intervention for their child. Most tempting about thisintervention is that it presents itself as a “quick-fix” option which sounds pleasantand enjoyable for both the family and the affected child.
It is likely that many of the reported positive changes seen in the child after
Dolphin-assisted Therapy from Island Dolphin Care, may be attributable toeducational and behavioral techniques used on the child and shown to the parents,
rather than any healing properties of dolphins. Put simply, a dolphin ride may
be a very reinforcing experience to a child. To their credit, the Island Dolphin
Care website repeatedly denies that there are any miracle cures or healing that
occurs through the use of Dolphin-assisted Therapy. They emphasize that it is
not a medical treatment, and that no medical cures or changes in diagnoses havebeen observed or should be expected from Dolphin-assisted Therapy.
Based on the fact that there is no evidence whatsoever to support this type oftherapy, I cannot seriously consider Dolphin-assisted Therapy as a “therapy” at
all for individuals afflicted with autism. While this may be a great vacation spot
for families who have members with special needs, it should not be confusedwith valid treatment for this serious disorder.

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Would I try it on my child?
I would not enroll my child in this therapy with the expectation of any progress.
If I thought my child would enjoy swimming with dolphins and I had theextra cash for a holiday in sunny Israel or Florida, I would love to give her theexperience. However, I would not dignify the experience by using the term
therapy or treatment and, again, I would have no expectations for any measurable
improvement in her autism.
What kind of study would I like to see Dolphin Therapy
researchers do?
If the practitioners of this method make therapeutic claims regarding DolphinAssisted Therapy, then I would expect to see research which meets the minimal
scientific criteria for well designed studies. In addition, I would like to see theIsland Dolphin Care practitioners provide rigorous research supporting thenotion that their psycho-educational programming is worthwhile for families
of individuals with autism. It is possible that they are using standard, wellestablished teaching techniques for children with autism. However, it is notmade clear from their promotional materials whether or not their educational
techniques are innovative and untested or based upon well-established educational
standards.
Who else recommends against Dolphin Assisted Therapy
as a method for the treatment of autism?
None of the professional or academic associations which evaluate treatment
claims have studied the claims made for Dolphin-assisted Therapy. I believe thislack of interest is because this type of intervention is simply not taken seriously
by scientists in the field of autism research or treatment. Moreover, no one

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sees it as a dangerous intervention, and therefore, it has been largely ignored.
A treatment that is quite expensive, but unproven, is not generally of concern
to the scientific community, unless it is actually harmful to the child. It may,
however, be of concern to the community of parents (to which I belong) who
have to shell out large sums of money to have their child participate in unproventreatments.
So you’re still on the horns of a dilemma?
Our literature search did not produce even a single, peer-reviewed article withreliable data on this kind of therapy. Therefore, based on the information we’ve
provided in this section, it is up to the reader to decide whether experimenting
with Dolphin-assisted Therapy is worth the money and time.
What’s the bottom line?
Based on the scientific research to date, there is no evidence that Dolphin-assisted
Therapy is an effective treatment for individuals with autism.

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Endnotes for Dolphin-assisted Therapy
Dolphin Reef, www.dolphinreef.co.il, (accessed Feb. 16, 2006).

1

Island Dolphin Care, www.dolphinsplus.com/dolphin-therapy.htm, (accessed Feb. 16, 2006).

2

Dolphin-assisted Therapy, www.dolphinassistedtherapy.com, (accessed Feb. 16, 2006).

3

4Servais, V. 1999. Some comments on context embodiment in zootherapy: The case of theautidolfijn project. Anthrozoos, Vol. 12, pp. 5-15.

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Miscellaneous Therapies: Exercise Therapy
What is Exercise Therapy?
The use of exercise as an intervention for individuals with autism is based on thetheory that the physiological effects of exercise decrease some of the symptoms ofautism. Those who recommend this intervention believe that through exercise, thebody creates certain chemicals that help reduce self-stimulatory and rigid behavior
amongst people with autism. They hypothesize that physiological changes in thebrain caused by strenuous physical activity can help individuals with autism. The
result of these chemical changes, they maintain, is that stereotypic or repetitive
behavior decreases. Based on an area of research that looks at the effect ofphysical exercise on motivation, attention, aggression and other emotions, theseresearchers believe that exercise is an effective intervention which can target
many of these areas in people with autism.1
What evidence do the practitioners have that thisreally works?
Our database searches netted forty-one entries on exercise and autism.* Of
those, nine peer-reviewed studies on exercise indicate initial improvement. Allof these studies demonstrate positive results, specifically reporting decreases instereotypic or repetitive behaviors in subjects who underwent exercise therapy.
The following statistical significance scores (p values)** were reported for three of*

There are many more articles which discuss the effects of exercise on individuals with various types ofdevelopmental delays; however, these studies did not address autism specifically.
In Rosenthal-Malek and Mitchell (1997), after exercise, the adolescent subjects exhibited less selfstimulatory behaviors (p less than or equal to .01 and .001), got higher scores on academic tests (p < .05),
and completed more of their workshop tasks (p < .01).2 In Elliott et al. (1994), the problematic behaviorsof the autistic adults meaningfully decreased after the vigorous exercise condition (p < .001).3 In Watters
and Watters (1980), self-stimulatory behaviors decreased after physical exercise as well (p = .05).4

**

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the studies. In Rosenthal-Malek and Mitchell (1997), after exercise the adolescentsubjects exhibited less self-stimulatory behaviors, got higher scores on academic
tests, and completed more of their workshop tasks.2 In Elliott et al. (1994), theproblematic behaviors of the autistic adults meaningfully decreased after thevigorous exercise condition.3 In Watters and Watters (1980), self-stimulatory
behaviors decreased after physical exercise, as well.4 Levinson and Reid (1993),
found that rigorous exercise (jogging) did decrease stereotypic behavior but thatthe effect of exercise was not apparent one and one-half hours after exercise.
No effects were found for mild exercise (walking).5 Allison et al. (1991) foundthat exercise (jogging) and medication in combination, significantly decreased
aggression, better than exercise or medication alone in a single subject case design(SSCD) involving an adult autistic male subject.6 Using a SSCD, Celiberti etal. (1997) found that exercise did have the effect of decreasing physical selfstimulatory behavior. Of note is that the researchers report sustained behavioral
changes more than forty minutes after jogging.7 Kern et al. (1984, 1982), also
report similar results from vigorous exercise (jogging). They found that it
decreased stereotypic behaviors and increased task-oriented behavior amongst
children with autism.8,9 Powers et al. (1992) reported similar results using roller
skating, rather than jogging, as the form of exercise.10
On the whole, these studies were designed and executed quite well. Somestudies have observers who did not know which subject was in the experimental
or control conditions. This “blind” procedure limited any bias that could comefrom those researchers recording the results. In addition, as mentioned above,
three of the studies used statistical significance scores (p values). The p values inthese studies indicate statistically significant levels of improvement in common
negative autism behaviors, due to physical exercise. Celiberti et al. (1997) reportclinically significant results of exercise as well7 (please see Section Two for a
discussion regarding significance).

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A few of these studies measured behavior in a competent manner. They recorded acomprehensive list of self-stimulatory behaviors of the children in the study. The
self-stimulatory behaviors were recorded for a short period of time on a schedule(e.g., for five minutes of every fifteen minute interval before the exercise and thenafter the exercise). This objective measure is extremely helpful to determine thetrue outcome of the therapy.
Most of the research on exercise employs Single Subject Research Designs wherea base-line is measured, and then the treatment is given and withdrawn, given
and withdrawn. In the case where the behavior is easy to observe and measure,an SSRD is appropriate (please see Section Two for a discussion on SSRD).
Collectively, the numbers of subjects in this area of the literature is very small(thirty-six persons with autism over a thirty-year period). In addition, most of
the studies were conducted in the early 1990s. The largest study used sevensubjects in a design where each person experienced both conditions repeatedly.
This study was designed to compare subjects with themselves in both the control
and experimental conditions. The results would give us more confidence if
the number of children in the studies was much higher and the research morecurrent.
What does the therapy actually look like?
In every study, subjects participated in some kind of physical activity. In mostof the studies, the children or adolescents jogged anywhere from eight to twenty
minutes per exercise session. In other studies, the subjects used a treadmill
moving four miles per hour or exercised using rollerskates. It is important tokeep in mind that the physical activity described was used for research purposes
only and was not necessarily chosen because it was the best form of exercise.

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What else do I think?
The theory underlying exercise therapy for individuals with autism intuitively
makes sense. We know the benefits of cardiovascular exercise for everyone.
For individuals with autism, exercise may also serve to decrease many of thestereotypic deficits and excesses associated with autism. In other words, the welldocumented physiological changes associated with exercise for the population
at large may also have the effect of decreasing observed stereotypic behaviors
in individuals with autism.11
Exercise therapy appears to address the inherent differences between the amountof energy expended by some children with autism and their typically developing
peers. Typical children seem to spend hours a day engaged in nonstop action,
while many autistic children are either not active, or they spend hours engaging
in activities which may not be as physically strenuous. Engaging the child in
appropriate cardiovascular activity seems to temporarily replace inappropriate
behavior, while maintaining or increasing the amount of energy the child
expends.
Although exercise seems to have an effect, it is important to remember that theeffects of physical exercise on self-stimulatory behaviors seem to be short term
only. For benefits to be maintained, the autistic person may need to exercise
directly before the academic routine. In addition, no studies have been done todate on the satiation effects of exercise, and the consequences that satiation might
have on levels of stereotypic or repetitive behavior. In other words, as the childbecomes more fit, do levels of exercise have to be continually increased to get
the same effect or can levels of physical exercise remain the same or decrease,yet still benefit the child by maintaining the decreases in stereotypic behavior?
There is insufficient research at present to answer that question. I am also
concerned that the amount of research done on exercise has actually decreased.

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There is still much we do not know about how or why exercise decreases
stereotypic and aggressive behavior for individuals with autism. Based on theamount of research conducted and the results of that research, we are not in a good
position to decide whether it is worth spending therapeutic time on exercise.
Would I try it on my child?
This is a difficult question for me to answer. I think the data is clear that vigorous
activity does have a suppressing effect on self-stimulatory behavior. I also knowthat exercise will not harm my daughter in any way. In fact, it may increase herhealth and physical well-being. That said, my child’s self-stimulatory behavior
has diminished considerably over the years; therefore, I do not see her as agood candidate for this type of therapy. If, however, the stereotypic behavior
were interfering with her learning, I might have her engage in exercise, andschedule the therapy immediately before she had to sit down and concentrate.
I would, however, take very good data (objective measures) to make sure that
her stereotypic behaviors did indeed diminish after exercise, since it would be
a waste of time if we did not see meaningful results. The biggest hurdle to thiskind of therapy is that it takes time and does not seem to be long-lasting (althoughmore research needs to be conducted on the long term effects). At this point,
based on what little we do know about this method, it makes little sense to do
the therapy with the child on a regular basis unless the therapy helps the childfocus on an activity which immediately follows the Exercise Therapy. Hopefully,
with additional research into Exercise Therapy, we will be able to know how to
use the therapy to get the best results in the least amount of time.

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What kind of study would I like to see Exercise Therapy
researchers do?
As I’ve suggested earlier, more research into this therapy is required, usingmuch larger sample sizes. I would like to see the study by Rosenthal-Malek
and Mitchell (1997), in which they measured self-stimulatory behavior rates,
academic performance and work completion, replicated using a Between-Within
Subject Design with a larger number of children, and done over a longer periodof time. These researchers could then better determine the level and frequencyof exercise necessary. We would be in a much better position to use this therapy
with people afflicted with autism.
In addition, an increased understanding into the use of exercise to control
stereotypic behaviors may answer the question of why exercise lowers levelsof stereotypic behavior. We need to know the physiology behind the effect ofa decrease in self-stimulatory behavior; what is the body chemistry associatedwith Exercise Therapy that is behind the behavioral effects we observe. An
understanding of this may lead to an understanding of the cause of stereotypic
behavior in people with autism, and may help researchers understand the causeof autism and develop effective drugs to treat the disorder.
Who else recommends for or against Exercise Therapy
as a method for the treatment of autism?
For the most part, this area has been ignored by most practitioners and researchers.
There is no money to be made on this kind of research (in the short term), theresearch does not demonstrate the effects to be long lasting and there is nodanger to exercise; therefore, neither much concern nor much interest has been
voiced about exercise therapy from either the community of autism researchersor parents of children with autism.

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So you’re still on the horns of a dilemma?
If you would like to incorporate exercise into your child’s life because you
think it may be healthy for him, that’s fine. However, if you are incorporating
exercise because you think it will be therapeutic for autism, then I would have a
behaviorist set up a program and monitor whether, indeed, the moderate exercise
is having an effect on your child’s behavior. Without setting up an objective way
to measure whether exercise is helping, you may end up doing something that
may not actually be bearing any fruit and may actually be wasting your child’s
therapeutic time, when another more valuable therapy could be administered tobetter effect.
What’s the bottom line?
Based on the scientific research to date, there is some evidence that exercise
therapy is effective for temporarily decreasing stereotypic behavior in people
with autism; however, there is no evidence to show that Exercise Therapy has
any long term effect in ameliorating the symptoms associated with autism.

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Endnotes for Exercise Therapy
1Kern, L. et al. 1982. “The effects of Physical Exercise on Self-Stimulation and Appropriate
Responding in Autistic Children.” Journal of Autism and Developmental Disorders, Vol. 12,
No. 4, pp. 399-419.
2

Rosenthal, M.A., and M. Stella. 1997. “Brief Report: The Effects of Exercise on the SelfStimulatory Behaviors and Positive Responding of Adolescents With Autism.” Journal of Autism
and Developmental Disorders, Vol. 7, No. 2, pp. 193-202.
Elliott, R.O. et al. 1994. “Vigorous, Aerobic Exercise Versus General Motor Training Activities:
Effects on Maladaptive and Stereotypic Behaviors of Adults With Both Autism and Mental
Retardation.” Journal of Autism and developmental Disorders, Vol. 24, No. 5, pp. 565-576.
3

4

Watters, R.G., and W.E. Watters. 1980. “Decreasing Self-Stimulatory Behavior With PhysicalExercise in a Group of autistic Boys.” Journal of Autism and Developmental Disorders, Vol.
10, No. 4, pp. 379-387.
5

Levinson, L.J., and G. Reid. 1993. “The Effects of Exercise Intensity on the Stereotypic
Behaviors of Individuals With Autism.” Adapted. Physical Activity Quarterly, Vol. 10, No. 3,
pp. 255-268.
6

Allison, D.B., V.C. Basile, and R.B. MacDonald. 1991. “Brief Report: Comparative Effects of
Antecedent Exercise and Lorazepam n the Aggressive Behavior of an Autistic Man.” Journalof Autism and Developmental Disorders, Vol. 21, No. 1, pp. 89-95.
7

Celiberti, D.A. et al. 1997. “The Differential and Temporal Effects of Antecedent Exercise on
the Self-Stimulatory Behavior of a Child With Autism.” Research in Developmental Disabilities,
Vol. 18, No. 2, pp. 139-150.
Kern, L, et al. 1984. “The Influence of Vigorous Versus Mild Exercise on Autistic Stereotyped
Behaviors.” Journal of Autism and Developmental Disorders, Vol. 14, No. 1, pp. 57-67.
8

Kern, L. et al., (see n. 8 above).

910Powers, S., S. Thibadeau, and K. Rose. 1992. “Antecedent Exercise and its Effects on SelfStimulation.” Behavioral Residential Treatment, Vol. 7, No. 1, pp. 15-22.
11

Quill, K., S. Gurry, and A. Larkin. 1989. “Daily Life therapy: A Japanese Model for EducatingChildren With Autism.” Journal of Autism and Developmental Disorders, Vol. 19, No. 4, pp.
625-635.

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Miscellaneous Therapies: Facilitated
Communication Training
What is Facilitated Communication?
Facilitated Communication (FC) is a technique which uses physical prompting tohelp individuals with developmental disabilities (including autism) communicate.
The woman who first developed FC, Rosemary Crossley, designed this method
for people who had little or no control of their muscles and, therefore, could
not communicate. Helpers (termed “facilitators”) physically help a person use
a keyboard or letter board by holding their arm, forearm or wrist in a specific
way above a communication board. The hand-over-hand or physical promptingis then supposed to be faded gradually, leaving the person to communicate byhim or herself; however, many people using FC are never able to communicate
independently and need the services of a facilitator permanently. Those who
use FC claim that people with many disabilities (including autism) may haveadvanced literary skills, along with well-developed cognitive skills. In otherwords, they believe that people with autism are smart and able to communicate
at a high level.1 In order to bring out their higher level thoughts and ideas,
people who use FC believe that these disabled people need someone to help themcommunicate. Although independent typing is seen as an eventual goal to work
towards, many do continue to require the help of the facilitator and are never able
to have the facilitation eliminated. It is important to understand that the claims
made by those who developed FC, were originally made about individuals who
did not have good muscle control (people suffering from neuromotor disabilities
such as cerebral palsy). The method and its claims were later applied to persons
with autism.

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What evidence do the practitioners have that thisreally works?
Our literature search uncovered over fifty articles on Facilitated Communication.
This is one of the most controversial treatments in the field of autism. Afterexcluding the literature reviews, theoretical pieces, commentary and replies toeditors (there were over two dozen!), there are thirty* articles which presented
data on Facilitated Communication, showing that FC is not an effective treatment
for autism. All of these articles are published in peer-reviewed journals and someof these articles (which we will speak about later) are very well done, following
the rules of the scientific method. However, in scientific terms, the theory ofFacilitated Communication has been falsified by no less than thirty different
studies. There are a number of articles which present data to show that FC is
purportedly effective; however, most of this data is not presented in peer-reviewed
journals, but rather, in unpublished papers,31 books,32,33,34 internet sites,35,36 andletters to the editor.37 In addition, there is a personal account or narrative written
ostensibly by a person with autism who independently types but who claims
to have learned these typing skills through Facilitated Communication.38 The
data are presented through case studies, surveys, or qualitative studies whichsuffer from a lack of experimental controls and often do not refer to autism
specifically or exclusively.39,40,41,42,43,44,45 After separating these types of papers
from those which actually do attempt to use science to test whether Facilitated
Communication works, there are only seven peer-reviewed journal articles that
present data to support the use of FC.46,47,48,49,50,51,52 After evaluating these articles,*2
Bebko et al., 1996; 3Beck et al. 1996; 4Bomba et al. 1996; 5Burgess et al. 1998; 6Duchan, 1999; 7Eberlin
et al. 1993; 8Edelson et al. 1998; 9Cabay, 1994; 10Hirshoren et al. 1995; 11Kerrin et al. 1998; 12Kezuka,
1997; 13Montee et al. 1995; 14Moore et al. 1993a; 15Moore et al. 1993b; 16Myles et al. 1996a; 17Myles
et al. 1996b; 18Myles et al. 1994; 19Oswald, 1994; 20Perry et al. 1993; 21Perry et al. 1998; 22Regal et al.
1994; 23Simon et al. 1994; 24Simpson et al. 1995; 25Smith et al. 1993; 26Smith et al. 1994; 27Szempruch
et al. 1993; 28Vazquez, 1994; 29Vazquez, 1995; 30Wheeler et al. 1993.

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I am quite confident in concluding that there is insufficient evidence to support
the use of FC for individuals afflicted with autism. Although there are several
studies which report positive results, there is much more compelling evidence
that FC is not effective. In science, the burden is on researchers to demonstratea causal relationship. Each of the following studies attempts to do this, yet all
have limitations.
Olney (2001), reports positive results in a within-subject designed study withnine subjects (six of whom have an autism spectrum disorder), sixty-six percentof whom could type independently. This study reports that the subjects did
better when facilitated by a facilitator in the “blind” condition, compared to theunfacilitated condition. There are a few flaws in this study, the major one beingthat commercially available computer games were used in the blind conditions.
We do not know how familiar either the subjects or the facilitators were with thesecomputer games. The study was done between 1997 and 2001, and publishedin 2001, and the vast majority of those computer games were introduced to themarket in the late 1980s. That is problematic because the facilitator may also
have been familiar with the sequencing (and answers) of some of the games.
As well, the subjects (most of whom could type independently) may also havememorized some of the answers and used the facilitator as a prompt tohigher than when typing independently. Another flaw in the study is that fromthe first to the last facilitated session, nine months elapsed. During this time,
the facilitators and the subjects could have gained experience elsewhere with thecomputer games. These researchers would have been well-advised to simply
use the card stimulus technique utilized by those demonstrating that FC is noteffective, as in this way, the experimenter (who cannot be in any way invested
in the outcome of the study) has full control of the unknown stimulus (which inthis case could be a word on an index card).

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In a single-subject case design, Olgetree et al. (1993), found that a child received
a score of zero out of eight responses in a matching game that was intended tovalidate FC. The play condition of the study did not successfully validate FC
either. The researchers made positive conclusions regarding FC, even though
they report, “it is these authors’ opinion that there is not sufficient evidence tosuggest that L.B. [the child] used FC independently in either play context.”53
In yet another single-subject case design, Weiss et al. (1996), tested a thirteenyear-old boy with autism to attempt to validate FC. Although this study is one of
the strongest in the literature providing evidence that FC is effective with somepeople, it also suffers from control issues. First, the experimenter reads the story
out loud and types the story into the word processor in view of the child. Thenthe experimenter facilitates for the child. The child does respond correctly tosome questions, and inaccurately to others; however, the experimenter knows
the story, so any accurate response could be attributed to the experimenter. In
the third phase, the facilitator is supposedly uninformed; however, we have nodescription of how that is assured. That said, this study is the strongest case study
in the literature, but so far has not been replicated (although over ten years haveelapsed since the original study was done).
Another study done by Sheehan et al. (1996), had three persons with autism andmental retardation use FC in an attempt to validate the method. They claim that
all three subjects did communicate novel information to a naive facilitator. This
study also has a few shortcomings. First, the naive facilitator was in the roomwith the experimenter who presented the original information: “During thisperiod, the naive facilitator who had presented the stimuli to the facilitated speaker
offered encouragement, redirection, feedback and asked clarifying questions of
the speaker.”54 This kind of cueing is a variable which could confound the entire
experiment. Second, one of the subjects could type independently, but at a lower
level of literacy. They describe him as taking the facilitator’s hand for more292

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complex thoughts. One explanation for the difference regarding information thissubject knows, but refuses to type independently, could be a compliance issue,
rather than a knowledge issue (particularly with information to which he responds
verbally). Third, the amount of unknown information was extremely low for
all subjects (average of one unknown piece of information communicated per
session over three sessions). The one subject who communicated an average oftwelve pieces of information per session had more independent communicative
ability than the others; therefore, he may have indeed been communicating withthe help of prompting, which should be faded. Either way, this is not strong
evidence for FC. Even if we take at face value that some true communication
occurred (which appears doubtful), in the best-case scenario, one small pieceof information every six minutes is inefficient. In the worst-case scenario, one
piece of novel information per session (which may be an hour in length) is highly
inefficient. Another study often touted as lending support for FC is Vazquez(1994); however, in her 1995 study, she clearly states: “These results are consistent
with the vast majority of the controlled validation studies to date indicating that
typed messages attributed to nonspeaking persons with autism originate solely
from the facilitator...”55
The largest study done on FC, that reports success with FC, is Cardinal et al.
(1996). This study also suffers from several serious flaws, three of which need tobe highlighted. First, in one study which shows success with FC, only seventeenof the forty-three people in the study were autistic. Other diagnoses include
Cerebral Palsy, Mental Retardation, Down Syndrome and other developmental
disabilities. Unfortunately, participants’ results were not reported based on
diagnosis. Therefore, it is impossible to know which group of people benefitted
from FC. Theoretically, other disabled persons, particularly those with physicaldisabilities such as Cerebral Palsy, could benefit from the use of FC since they havesevere muscle control difficulties and may be unable to type independently.

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The participation in the study of children without autism may account for any
success reported from this study, (although it is outside the scope of this bookto make any conclusions regarding the effectiveness of FC for individuals withother disabilities). Second, the task given to the subjects in this study was to type
one simple word, flashed to them out of a possible one hundred words. These
one hundred words are all very basic. In my opinion, typing a single word outof a list of one hundred simple words does not demonstrate intelligence or highlevel communicative abilities. Moreover, the authors of the study which showed
success using FC, mention that the subjects received higher scores without afacilitator after they had been taught with the facilitator than when they first werescored without a facilitator. In other words, after learning the words, the subjects’scores actually improved. Even the authors observed that the subjects learned
through facilitation and were able to type some correct answers independently.
If this observation by the authors of this study is correct, then why is facilitationnecessary at all? Why don’t the facilitators just teach the students with autism
how to type simple words that the students already know on a keyboard (suchas the words used in the study)?
The ability to type could be taught using words already known by autistic students,using a variety of prompts from obtrusive (such as a full physical prompt), to
unobtrusive (such as a nonphysical modeling prompt) to an eventual fade out ofall prompts. In this way, everyone can be sure that the autistic person is indeed
communicating thoughts at his/her level of communicative ability, with nopossibility of facilitator influence. Without requiring full prompt fading, it canbe convincingly argued that the autistic person will never be able to communicate
on his or her own.
Over two dozen well-executed studies show that once the influence of the
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people employing FC show that they are not able to communicate significantly
better with this method than if they were simply typing on their own. The
best studies use three conditions: facilitated; non-facilitated, and distractor (asillustrated in Wheeler et al. 1993). In the facilitated condition, the autistic person
is shown a picture on a card but the facilitator is not. Then the subject is asked to
identify the picture, through the use of FC. The non-facilitated condition uses thesame procedure, except the autistic person has to type the answer independently.
In the distractor condition, both the subject and facilitator receive their own
cards, which are the same for half of the time and different for the other half ofthe time. This experimental design is very effective in demonstrating that thefacilitator is doing the communicating, not the autistic person. The study design
is elegant because it uses easy stimuli, gives the autistic person an opportunity
to show his cognitive and independent typing skills, and catches the facilitatorin the act of doing the communicating, instead of the autistic person.
In conclusion, the vast majority of the studies in the literature on Facilitated
Communication clearly show that FC is ineffective in experimental trials where
the facilitator did not know the question asked to the person with autism, andtherefore, could not help the person answer correctly . In other words, the successseen in FC is a direct result of the facilitator guiding the autistic person.
What does the therapy actually look like?
The person with autism sits in a chair at a desk and the facilitator takes his or
her arm and helps reach towards the keyboard, often above the area where theperson is to type. The autistic person is then asked a question or shown a card,and is guided by the facilitator. Generally using one finger, the autistic person
types the answer.

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What else do I think?
The fact that the vast majority of controlled studies find no results supporting
Facilitated Communication, does not seem to trouble supporters of FC. They
criticize the studies in two ways. First, they see the experiments as being too“over-controlling.”56 Put simply, they think that there is too much pressure on
the autistic person to perform and as a result, the subject does not cooperate. I
believe that the first criticism is unfounded as in many of the studies reviewed,
the children knew their facilitators prior to the study.3,4,16,22,23,24,26 Also, in manyof these studies the setting for the experiment was comfortable and relaxed in
the child’s regular school setting. To avoid possible anxiety, one experiment
was conducted in the child’s home.3 The second criticism has to do with what
the FC supporters call “one-place-in-time experiments.” Here they claim that
the FC users need more practice than the testing condition allows. I do not
accept the second criticism as valid because in five of the studies reviewed, thechildren had a reasonable amount of experience with FC before the data wascollected (e.g., Vazquez 1994 – one year; Bomba et al. 1996 – ten weeks of daily
individualized instruction; Beck et al. 1996 – six months to two years; Eberlin
et al. 1993 – twenty hours of FC training, and Simon et al. 1994 – five to thirteenmonths experience).
Many FC researchers believe that it is inappropriate to use quantitative scientificmethods to test Facilitated Communication. They prefer qualitative methods
because they believe that the environment will affect the outcome of the study.
Unfortunately, qualitative methods are very unreliable when trying to test whether
a technique is scientifically valid. The responsibility lies with the professionals
who recommend a particular method to come up with an objective way to test
the effectiveness of their intervention method. To this point, the Facilitated
Communication researchers have not suggested a way to test FC objectively.

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This rejection of the scientific method (with all of its tools of empiricism) is a
red flag. Most of the studies that found no results when testing FC did try tocreate a scientific study in an environment where the autistic students would
feel comfortable and able to do their best. In my opinion, the fact that not oneof their relatively well-designed studies found FC useful is a significant finding
and one upon which we can reasonably base conclusions.
I cannot recommend the use of Facilitated Communication for individuals with
autism, due to the overwhelming evidence that the facilitator is influencing theanswers that are being attributed to the autistic person. In addition, it is importantto realize that communication problems in people with autism generally havemore to do with the actual understanding and use of language, not a physicalinability to communicate. As a result, FC does not address the underlying
communication deficits facing individuals with autism. Before typing a clear,coherent sentence, most children with autism first need to be taught to use andcomprehend language. One of the criticisms leveled against those who do notbelieve the claims made by FC practitioners is the assumption that if one cannot
communicate, then one must be mentally retarded.57 I do not share this belief;
autism is characterized by a profound difficulty to communicate. In otherwords, a very bright child with autism may have no ability to communicate(until taught). That does not mean that he or she additionally has a diagnosis of
mental retardation.
Unfortunately, many negative consequences have resulted from the inappropriate
use of FC on children and youth with autism. False reports of physical andsexual abuse have surfaced, due to the influence of the facilitator on the message
ostensibly typed by the autistic person. These very serious accusations havecaused much harm for families and caretakers. Unfounded allegations of abuse(over sixty legal cases)58 are yet another example of what can happen when297

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parents of children with autism put too much faith in the “professionals” without
critically evaluating what these professionals are offering. Once again, this is
why we parents must let science be our guide.
Would I try it on my child?
Absolutely not. My autistic child does not need to be guided on a typewriter totype. In fact, she touch types by herself. I was pleased when we taught her totype independently as this is another means for her to express herself. I should
mention that her communication and cognitive skills are completely in-sync
with her ability to point to and answer questions on an IQ test. Although she ismarginally more articulate in writing or typing than speaking, her communication
skills are not significantly more complex when she types. When my daughter
was very young and did not know how to communicate at all, I did not try FC
with her for two reasons: 1) there is no science behind the method and muchevidence showing that it is ineffective; 2) it did not make sense to me that an
autistic child who does not understand language, could suddenly learn how
to communicate through a keyboard as long as a facilitator was present, but
not when she was on her own, and 3) when too much power is given to the“professionals” who have “special” powers to communicate with the child, theparent is inadvertently putting the child at risk, as happened many times in thehistory of FC. As parents, we are desperate; remember, the road to hell was pavedwith good intentions. There are many uninformed people who regularly attributehigh level language skills to nonverbal children with autism. It is extremely
unlikely that without having been taught high-level skills, the child could havelearned these skills on his or her own. Autism is a condition characterized bydifficulty in communication. My child has learned many of the skills she needs
to communicate and uses those skills regularly; however, she acquired theseskills through a lot of hard work on her part. I have also met many nonverbal

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children who use either a picture communication system or a computer to typeindependently with great effect. However, all these children worked hard tolearn enough language to communicate.
What kind of study would I like to see the FC people do?
At this point, there is enough evidence for us to know that FC is not effective
for children with autism. Therefore, it is highly unlikely that the FC people
could design a study using rigorous science and get positive results. Reputablescientists have been studying this method for over ten years and have not yet
found evidence that the technique works. In short, I would encourage the FC
practitioners to change their focus from facilitated communication to teaching
independent communication for children with autism through a keyboard orsimilar device. No one would think twice about a teacher using hand-over-hand
prompts to teach a child any skill, as long as the prompts are faded in a timely
fashion, with the understanding that without independence, the child does nottruly possess the skill.
For those children with both autism and severe gross or fine motor difficulty (which
is not a primary characteristic of autism), the facilitator must be mechanical innature (a mechanical rest). Edelson et al. (1998) introduced such a mechanismand found that with a mechanical hand-support device that did not include any
human facilitation, six autistic individuals who had extensive experience with
Facilitated Communication, were not able to communicate in any meaningful
way. Clearly in this case, the gross and fine motor issues were not the reason
that the autistic subjects could not communicate independently. In short, there
should be no human influence in Facilitated Communication, because it has beenshown by Burgess et al. (1998) how even the most conscientious facilitator can
inadvertently lead the child by engaging in what they term “automatic writing”

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(also observed amongst those in a hypnotic state, or those using an Ouija
Board).59 Kezuka (1997) also observed the same phenomenon. An additional
reason to make sure that the child is independently communicating through an
augmentative device (if needed) is because it has been shown60 that educators andtherapists working with children with autism using Facilitated Communication
do not have sufficient understanding of scientific validity. They also have little
faith in the scientific method61 and believe that these children are much morecapable than their behavior and other measures indicate.62
Who else recommends against Facilitated Communication
as a method for the treatment of autism?
What’s very interesting about the FC controversy is that there is an unprecedented
number of reputable autism researchers who have jumped into the controversy
and have either done studies which disprove the method or have writtencommentary repudiating the method. As well, there is a long line of reputableorganizations which recommend against FC. In 1993, the American Academyof Child and Adolescent Psychiatry developed a policy statement also endorsedby the American Academy of Pediatrics, regarding Facilitated Communication.
They state: “Studies have repeatedly demonstrated that FC is not a scientificallyvalid technique for individuals with autism or mental retardation. In particular,
information obtained via [FC] should not be used to confirm or deny allegationsof abuse or to make diagnostic or treatment decisions.”63 Their position was
updated in 1997. In 1998, the American Academy of Pediatrics released thispolicy statement: “In the case of FC, there are good scientific data showing it
to be ineffective. Moreover, as noted before, the potential for harm does exist,
particularly if unsubstantiated allegations of abuse occur using FC.”64 The
American Speech-Language-Hearing Association also recommends against
Facilitated Communication. They state: “... experiment investigations have
not only failed to validate facilitated communication, they have also repeatedly
300Section One: What Works and What Doesn’t?

unwittingly authored messages for communicators. Authorship issues continue
to be a major concern of qualitative as well as experimental research.”65 In
addition, in 1999, the New York State Department of Health issued an excellent
report on best practices for the treatment of autism in young children. Regarding
Facilitated Communication, they state: “Because of the lack of evidence
for efficacy and possible serious harm of using facilitated communication,
it is strongly recommended that facilitated communication not be used as anintervention method in young children with autism”66 [emphasis added]. Since
then, the Association for Science in Autism Treatment (ASAT) has joined against
FC. They state: “Accumulated peer-reviewed, empirically-based researchstudies have not supported the effectiveness of facilitated communication.
Equally important, the research has substantiated the potential for great harm.”67
Quackwatch also has much to say about FC. They state: “... many scientificstudies have demonstrated that the procedure is not valid because the outcome
is actually determined by the facilitator.”68
So you’re still on the horns of a dilemma?
If you are still thinking about this form of intervention for your child, I strongly
urge you to read Jacobson et al. (2005), which devotes an entire chapter tothis unsubstantiated treatment and presents the entire history of Facilitated
Communication. This article will give you further background which you
may need to make an informed choice. Remember, it was through this methodthat false allegations were made by facilitators that parents were abusing theirchildren. These children were actually taken away from their families until the
courts got involved and protected the families from false allegations! Due to thehorrendous history involving Facilitated Communication and the courts, there
are many articles written on the harm of relying on Facilitated Communication
as a form of accurate communication from children with autism.69,70,71,72,73,74,75

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I strongly suggest that prior to adopting FC as a communication device for yourchild, that you read the seven articles pertaining to FC and the history of false
allegations of abuse.
What’s the bottom line?
Based on the scientific research to date, there is no evidence that Facilitated
Communication is an effective treatment for individuals with autism. It also
carries risk for parents or guardians of the child with autism.

302Section One: What Works and What Doesn’t?

Endnotes for Facilitated Communication
Borthwick, C., and R. Crossley. 1999. “Language and Retardation.” Psycoloquy, Vol. 10, p.
38.

1

2

Bebko, J.M., A. Perry, and S. Bryson. 1996. “Multiple Method Validation Study of Facilitated
Communication: II. Individual Differences and Subgroup Results.” Journal of Autism andDevelopmental Disorders, Vol. 26, No. 1, pp. 19-43.
3

Beck, A.R., C.M. Pirovano. “Facilitated Communicators’ Performance on a Task of Receptive
Language.” Journal of Autism and Developmental Disorders, 1996, 26(5), pp. 497-513.
Bomba, C., L. O’Donnell, C. Markowitz, and D.L. Homes. 1996. “Evaluating the Impact ofFacilitated Communication on the Communicative Competence of Fourteen Students with
Autism.” Journal of Autism and Developmental Disorders, Vol. 26, No. 1, pp. 43-59.
4

5

Burgess, C.A., I. Kirsch, H. Shane, K.L. Niederauer, S.M. Graham and A. Bacon. 1998.
“Facilitated Communication As An Ideomotor Response.” American Psychological Society,1998, Vol. 9, No. 1, pp. 71-74.
Duchan, J.F. 1999. “Views of Facilitated Communication. What’s the point?” Language, Speechand Hearing Services in Schools, Vol. 30, pp. 401-407.
67Eberlin, M., G. McConnachie, S. Ibel and L. Volpe. 1993. “Facilitated Communication: A
Failure to Replicate the Phenomenon.” Journal of Autism and Developmental Disorders, Vol.
23, No. 3, pp. 507-529.
8

Edelson, S.M., B. Rimland, C.L. Berger, and D. Billings. 1998. “Evaluation of a Mechanical
Hand Support for Facilitated Communication.” Journal of Autism and Developmental Disorders,Vol. 28, No. 2, pp. 153-157.
9

Cabay, M. 1994. “Brief Report: A Controlled Evaluation of Facilitated Communication Using
Open-ended and Fill-in Questions.” Journal of Autism and Developmental Disorders, Vol. 24,
No. 4, pp. 517-527.
Hirshorn, A., and J. Gregory. 1995. “Further Negative Findings on Facilitated Communications.”
Psychology in the Schools, Vol. 32, No. 2, pp. 109-113.

10

11

Kerrin, R.G., J.Y. Murdock, W.R. Sharpton, and N. Jones. 1998. “Who’s Doing the Pointing?
Investigating Facilitated Communication in a Classroom Setting with Students with Autism.”
Focus on Autism and Other Developmental Disabilities, Vol. 13, No. 2, pp. 73-79.
Kezuka, E. 1997. “The Role of Touch in Facilitated Communication.” Journal of Autism andDevelopmental Disorders, Vol. 27, No. 5, pp. 571-593.

1213Montee, B.B., and R.G. Miltenberger. 1995. “An Experimental Analysis of Facilitated
Communication.” Journal of Applied Behavior Analysis, Vol. 28, No. 2, p. 189.
14

Moore, S., B. Donavan, and A. Hudson. 1993. “Brief Report: Facilitator-Suggested
Conversational Evaluation of Facilitated Communication.” Journal of Autism and Developmental
Disorders, Vol. 23, No. 3, pp. 541-553.
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15

Moore, S., B. Donavan, A. Hudson, J. Dykstra, and J. Lawrence. 1993. “Brief Report:
Evaluation of Eight Case Studies of Facilitated Communication.” Journal of Autism andDevelopmental Disorders, Vol. 23, No. 3, pp. 531-538.
Myles, B.S, and R.L. Simpson. 1996. Impact of Facilitated Communication Combined with
Direct Instruction on Academic Performance of Individuals with Autism. Vol. 11, No. 1, http://web13.epnet.com/citation.asp?tb=1&_ug+sid+7AC27503%2 (accessed Sept. 21, 2005).

16

17

Myles, B.S., R.L. Simpson, and S.M. Smith. 1996. “Collateral Behavioral and Social Effects
of Using Facilitated Communication with Individuals with Autism.” Focus on Autism and Other
Developmental Disabilities, Vol. 11, No. 1, pp. 163-169, 190.
18

Myles, B.S., and R.L. Simpson. 1994. “Facilitated Communication with Children Diagnosed
as Autistic in Public School Settings.” Psychiatry in the Schools, Vol. 31, pp. 208-221.
Oswald, D.P. 1994. “Facilitator Influence in Facilitated Communication.” Journal of Behavioral
Education, Vol. 4, No. 2, pp. 191-200.
19

20

Perry, A., S. Bryson, and J. Bebko. 1993. “Multiple Method Validation Study of Facilitated
Communication: Preliminary Group Results.” Journal of Developmental Disabilities, Vol. 2,
No. 2, pp. 1-19.
Perry, A., S. Bryson, and J. Bebko. 1998. “Brief Report: Degree of Facilitator Influence inFacilitated Communication as a Function of Facilitator Characteristics, Attitudes and Beliefs.”
Journal of Autism and Developmental Disorders, Vol. 28, No. 1, pp. 87-90.

21

22

Regal, R.A., J.E. Rooney, and T. Wandas. 1994. “Facilitated Communication: An Experimental
Evaluation.” Journal of Autism and Developmental Disorders, Vol. 24, No. 3, pp. 345-354.
23

Simon, E.W., D.M. Toll, and P.M. Whitehair. 1994. “A Naturalistic Approach to the Validationof Facilitated Communication.” Journal of Autism and Developmental Disorders, Vol 24, No.
5, pp. 647-657.
24

Simpson, R.L., and B. S. Myles. 1995. “Effectiveness of Facilitated Communication With
Children and Youth With Autism.” The Journal of Special Education, Vol. 28, No. 4, pp. 424439.
25

Smith, M.D., and R.G. Belcher. 1993. “Brief Report: Facilitated Communication with Adults
with Autism.” Journal of Autism and Developmental Disorders, Vol. 23, No. 1, pp. 175-183.
26

Smith, M.D., P.J. Haas, and R.G. Belcher. 1994. “Facilitated Communication: The Effects ofFacilitator Knowledge and Level of Assistance on Output.” Journal of Autism and Developmental
Disorders, Vol. 24, No. 3, pp. 357-367.
27

Szempruch, J., and J.W. Jacobson. 1993. “Evaluating Facilitated Communications of People
With Developmental Disabilities.” Research in Developmental Disabilities, Vol. 14, pp. 253264.
28
Vázquez, C.A. 1994. “Brief Report: A Multitask Controlled Evaluation of Facilitated
Communication.” Journal of Autism and Developmental Disorders, Vol. 24, No. 3, pp.
369-379.

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29
Vásquez, C.A. 1995. “Failure to Confirm the Word-Retrieval Problem Hypothesis in Facilitated
Communication.” Journal of Autism and Developmental Disorders, Vol. 25, No. 6, pp. 597610.
30

Wheeler, D.L., J.W. Jacobson, R.A. Paglieri, and A.A. Schwartz. 1993. “An Experimental
Assessment of Facilitated Communication.” Mental Retardation, Vol. 11, No. 1, pp. 49-60.
31

Crossley, R. 1988. Unexpected communication attainments by persons diagnosed as autistic andintellectually impaired. Unpublished paper presented at International Society for Augmentativeand Alternative Communication, Los Angeles, CA.
32

Crossley, R., and A. MacDonald. 1984. Annie’s Coming Out. NY: Viking Penguin.

33

Biklen, D. and D.N. Cardinal. 1997. Contested Words, Contested Science: Unraveling the
Facilitated Communication Controversy. New York, NY: Teachers College Press.

34
Olney, M. 1997. A Controlled study of facilitated communication using computer games. In D.
Biklen and D.N. Cardinal, eds., Contested words, contested science: Unraveling the facilitatedcommunication controversy. New York, NY: Teachers College Press.
35

Borthwick, C., and R. Crossley, (see n. 1 above).

36
Olney, M. 2001. “Evidence of literacy in individuals labeled with mental retardation.” Disability
Studies Quarterly, Vol. 21, No. 2, pp. 1-12.

Calculator, S.N., K. Singer. 1992. “Preliminary Validation of Facilitated Communication.”
Topics in Language Disorders, Vol. 12, No. 1, pp. 9-16.

37

38

Rubin, S., D. Biklen, C. Kasa-Hendrickson, P. Kluth, D.N. Cardinal, and A. Broderick. 2001.
“Independence, Participation, and the Meaning of Intellectual Ability.” Disability & Society,Vol. 16, No. 3, pp. 415-429.
39

Niemi. J., and E. Kärnä-Lin. 2002. “Grammar and Lexicon in Facilitated Communication:
A Linguistic Authorship Analysis of a Finnish Case.” Mental Retardation, Vol. 40, No. 5, pp.
347-357.
Broderick, A.A., and C. Kasa-Hendrickson. 2001. “Say Just One Word at First: The Emergenceof Reliable Speech in a Student Labeled with Autism.” Journal of the Association for Persons
with Severe Handicaps, Vol. 26, No. 1, pp. 13-24.

40

Schubert, A. 1997. “I Want To Talk Like Everyone: On the Use of Multiple Means ofCommunication.” Mental Retardation, Vol. 35, No. 5, pp. 347-354.

41

Crossley, R., and J. R. Gurney. 1992. “Getting the words Out; Case Studies in Facilitated
Communication Training.” Topics in Language Disorders, Vol. 12, No. 4, pp. 29-45.

42

43

Biklen, D., M.W. Morton, D. Gold, C. Berrigan, and S. Swaminathan. “Facilitated
Communication: Implication for Individuals with Autism.” Topics in Language Disorders,Vol. 12, No. 4, pp. 1-28.

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44
Biklen, D., and A. Schubert. 1991. “New words: The Communication of Students with Autism.”
Remedial and Special Education, Vol. 12, No. 6, pp. 46-57.

Biklen, D. 1990. “Communication Unbound: Autism and Praxis.” Harvard Educational Review,Vol. 60, pp. 291-314.

45

46

Broderick, A.A., and C. Kasa-Hendrickson, (see n. 40 above).

47

Cardinal, D.M., D. Hanson, and J. Wakeham. 1996. “Investigation of Authorship in Facilitated
Communication.” Mental Retardation, Vol. 34, pp. 231-242.
Ogletree, B.T., and A. Hamtil. 1993. “Facilitated Communication: Illustration of a Naturalistic
Validation Method.” Focus on Autistic Behavior, Vol. 8, No. 4, pp. 1-10.
48

49

Olney, M., (see n. 36 above).

50
Sheehan, C.M., and R.T. Matuozzi. 1996. “Investigation of the Validity of Facilitated
Communication Through the Disclosure of Unknown Information.” Mental Retardation, Vol.
34, No. 2, pp. 94-107.
51

Vazquez, C.A., (see n. 28 above).

52

Weiss, M.J., S.H. Wagner, and M.L. Bauman. 1996. “A Validated Case Study of Facilitated
Communication.” Mental Retardation, Vol. 34, No. 4, pp. 220-230.
53

Olgetree, B.T., and A. Hamtil, (see n. 48 above), p. 7.

54

Sheehan, C.M., and R.T. Matuozzi, (see n. 50 above), p. 99.

55

Vazquez, C.A., (see n. 29 above), p. 608.

56

Cardinal, D.M., D. Hanson, and J. Wakeham, (see n. 47 above), p. 239.

57

Borthwick, C., and R. Crossley, (see n. 1 above).

58

Margolin, K.N. 1994. “How Shall Facilitated Communication Be Judged? Facilitated
Communication and the Legal System.” In: Shane, H.C. ed., Facilitated Communication. The
Clinical and Social Phenomenon, San Diego, CA: Singular Press, pp. 227-258.
Burgess, C.A., I. Kirsch, H. Shane, K.L. Niederauer, S.M. Graham and A. Bacon, (see n. 5
above), p. 71.
59

60

Kezuka, E., (see n. 12 above).

61
Dillon, K.M., J.E. Fenlason, and D.J. Vogel. 1994. “Belief In and Use of a Questionable
Technique, Facilitated Communication, For Children With Autism.” Psychological Reports,
Vol. 75, pp. 459-464.
62

Dillon, K.M., J.E. Fenlason, and D.J. Vogel, (see n. 61 above), p. 459.

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63

American Academy of Child and Adolescent Psychiatry, http://www.aacap.org/publications/policy/
ps30.htm#TOP, (accessed May 5, 2006).
64

Committee on Children With Disabilities. 1998. “Auditory Integration Training and Facilitated
Communication for Autism.” Pediatrics, Vol. 102, No. 2, pp. 431-433.
65

Technical Report. 1994. Facilitated Communication, American Speech-Language-Hearing
Association Vol. III-113, p. 12. http://www.asha.org (accessed Oct. 3, 2005).
66

Guralnick, M., ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany, NY: New York State Department of Health, p. IV-65.
Association for Science in Autism Treatment (ASAT), http://www.asatonline.org/
about_autism/autism_info09.html, (accessed Oct. 3, 2005).
67

68

Quackwatch, www.autism-watch.org/rx/fc.shtml (accessed Oct. 3, 2005).

69
Howlin, P. 1994. “Facilitated Communication: A Response by Child Protection.” Child Abuse& Neglect, Vol. 18, No. 6, pp. 529-530.
70

Howlin, P., and D.P.H. Jones. 1996. “An Assessment Approach to Abuse Allegations Made
Through Facilitated Communication.” Child Abuse & Neglect: The International Journal, Vol.
20, No. 2, pp. 103-110.
71

Jones, D.P. 1994. “ Autism, Facilitated Communication and Allegations of Child Abuse andNeglect.” Child Abuse and Neglect, Vol. 18, pp. 491-493.
Myers, J.E.B. 1994. “The Tendency of the Legal System to Distort Scientific and ClinicalInnovations: Facilitated Communication as a Case Study.” Child Abuse & Neglect, Vol. 18,
No. 6, pp. 505-513.
72

73

Siegel, B. 1995. “Assessing Allegations of Sexual Molestation Made Through Facilitated
Communication.” Journal of Autism and Developmental Disorders, Vol. 25, No. 3, pp. 319326.
74

Bligh, S., and P. Kupperman. 1993. “Brief Report: Facilitated Communication Evaluation
Procedure Accepted in a Court Case.” Journal of Autism and Developmental Disorders, Vol.
23, No. 3, pp. 553-557.
Starr E. 1994. “Facilitated Communication: A Response by Child Protection.” Child Abuse
and Neglect, Vol. 18, No. 6, pp. 515-527.

75

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Miscellaneous Therapies: Holding Therapy
What is Holding Therapy?
Holding Therapy is a technique developed by Martha Welch, a New York
psychiatrist. This form of therapy requires that the mother hold her autistic childclose to her body, in an attempt to address the belief that the individual with autism
has a need to attach and bond to his or her mother.1 This therapy is based on
the theory that the root cause of autism is the withdrawal of human contact, due
to the disturbed attachment which has supposedly occurred in the child’s earlysocial environment.2 Building upon this idea, the goal of Holding Therapy, is to“repair” the mother-child attachment. This is seen as key, by holding therapists,in the treatment of autism.3 The time that the mother holds the child is designed
to stimulate attachment and bonding between mother and child.

What evidence do the practitioners have that thisreally works?
There is currently no scientific evidence that Holding Therapy is an effective
treatment for individuals with autism. A comprehensive literature search netted
eighteen articles which mentioned Holding Therapy and autism. The best articles
describe case studies.4 Of those articles, only two studies had any data and oneof those is a 1985 controlled study done by Rohmann et al. (written in German).
In this study, although researchers randomly assigned children to experimental
and control groups, the outcome was entirely based on parental reporting, which
is highly problematic. In Holding Therapy, the parent is heavily involved inadministering the actual therapy; therefore, under no circumstances should theparent take data. (Please see Section Two on “self-fulfilling prophecy” for further

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discussion on parental reporting). Additional anecdotal reporting comes primarily
from Welch, the founder of Holding Therapy. Currently, there are no objective,
well-executed, controlled tests of Holding Therapy. In addition, it is unclear
what, if any, other interventions are being implemented concurrently with thesechildren. It is also not clear how long these children undergo Holding Therapy.
There are many unanswered questions about how the “cure” is measured ordetermined. We are not given information about :1) which tests are being used
to measure progress; 2) the significance of the changes being observed, and 3)
whether these children even have an independent diagnosis of autism. Finally,
only the successes of Holding Therapy are reported, which leads to biased results.
If only the successes are reported (through anecdotal evidence only), the consumer
is mislead to believe that this intervention is highly successful. Theoretically,
there could be large numbers of unreported children with autism from this group
who have not benefited from the intervention.
What does the therapy actually look like?
The holding therapists recommend that holding be done at least once a day, forat least one hour per session. It is carried out with the child and mother sitting
face-to-face. This position is reportedly used to maximize the awareness ofboth mother and child to one another.5 The child’s arms and legs are wrappedaround the mother. According to Welch, there are three phases which motherand child experience: 1) confrontation; 2) rejection, and 3) resolution. In theconfrontation phase, both mother and child come to feel anger regarding therelationships they have in their lives. The rejection phase occurs when the childphysically or emotionally resists the holding. During this phase, the mother mustphysically restrain the child while verbally communicating to the child about her
feelings. A desperate struggle reportedly takes place,6 which is then followedby the resolution phase. At this stage, the child stops resisting and mother and310Section One: What Works and What Doesn’t?

child are physically and emotionally “molded.”7 Welch describes the third stage
as including, “tender intimacy with intense eye contact, exploratory touching ...
and gentle conversation.”8What else do I think?
It is widely accepted by researchers today that autism is a neurological disorder.
In addition, autism is understood by most reputable researchers and cliniciansin the field as completely unrelated to any allegedly disrupted bonding process
between mother and child. Given that it is widely rejected that autism is theresult of a disrupted mother-child bond, I have no reason to believe that Holding
Therapy is effective for children with autism. This argument once again places
the responsibility for the child’s disorder directly on the shoulders of the mother.
The origins of this theory are in observations long ago that there is little in theway of what can be considered ‘normal’ interaction between these children
and their mothers. However, it is now widely held that, due to the nature of
the disorder, parents had been trained by the child to interact less as a resultof constant rejection or indifference from the child, not the parent. In otherwords, parents do not cause autism; rather, parents react to the autism. Thisis the nature of the disorder and completely unrelated to good or negligent
parenting. Holding Therapy is one of the few treatments which continues torely on the widely discredited view that the mother is somehow responsible forher child’s autism.
An additional problem with Holding Therapy concerns the researchers’
explanations as to why the therapy may be unsuccessful. When Holding Therapy
fails, it is once again blamed on the mother’s inability to bond with her child.
This fail-safe explanation (also called a circular argument or tautology) should
be a red flag for parents who are evaluating interventions for their children. Any
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treatment that cannot fail, even theoretically, can be said to fail the test of what
scientists call “falsifiability” (see Section Two for a discussion on falsifiability).
Proponents of this method claim that the therapist plays an integral role inassessing Holding Therapy, because only they are able to interpret the messages
being sent between mother and child.9 They alone claim to be able to determine
how the mother’s inabilities frustrate the child and subsequently cause the childto withdraw. This is the second red flag. If a legitimate researcher cannot
measure an effect (even perhaps indirectly), it may as well not exist. In otherwords, for data collection purposes, observational objectivity is crucial.
Would I try it on my child?
I would not try this therapy on my child for two reasons: first, as you haveprobably surmised, my reasoning has to do with science. At this point, there isno science supporting the method. The second reason for my rejection of thistherapy is its entire premise. I find the notion that children with autism suffer
with the affliction because they have not sufficiently bonded to their parents
during early social environment to be seriously flawed. In my opinion, theobserved lack of attachment and purported lack of bonding occurs due to aneurological dysfunction and not due to some activity the mother did or failed
to do. Quite frankly, I’m quite tired of hearing about how autism is somehow
due to lack of bonding between mother and child. This theory harkens backto echoes of Bruno Bettelheim’s “refrigerator mother” theory of autism, which
plagued parents for decades before it was discredited in the 1950s. I would
never try a therapy on my child that is so unfounded, and across the board,anti-mother. The harsh reality is that mothers of children with autism actuallydeserve a medal, not constant criticism from so-called experts about theirsupposed maternal inadequacy.

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What kind of study would I like to see the Holding Therapy
Practitioners do?
Given the highly questionable theoretical basis for Holding Therapy (the“refrigerator mother” theory), it is doubtful that any successful results would
be generated using rigorous science. However, given that there are still a small
number of practitioners using Holding Therapy as an intervention, despite thelack of data, I believe that it needs to be systematically evaluated, according
to generally agreed upon scientific principles which motivate good research.
Specifically, I would like to see the Holding Therapy practitioners conduct a
study that complies with the various criteria for well-designed scientific studies.10
Only after conducting a rigorous study which produces successful outcomes could
we ever consider Holding Therapy a legitimate treatment option for children
with autism. In the absence of any scientifically verifiable results, I would notconsider this a legitimate therapy for autism.
Who else recommends against Holding Therapy as a method
for the treatment of autism?
Holding Therapy was in vogue in the 1980s but has fallen out of favor with mostmembers of the autism treatment community. The Association For Science inAutism treatment considers Holding Therapy to be in the group of treatments thathave yet to be evaluated carefully.11 In addition, Quackwatch has characterized
Holding Therapy accurately, in my view, based on theories which come fromthe field of psychoanalysis and have no effective evidence to date.12 Finally, theNational Council Against Health Fraud does not endorse Holding Therapy forchildren with attachment disorders.13

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So you’re still on the horns of a dilemma?
If the lack of science isn’t enough to dissuade you from considering Holding
Therapy, you may be interested to know that in February 2005, the state of Utahordered practitioners of Holding Therapy to end the practice because it has been
alleged to constitute a form of abuse.14
What’s the bottom line?
Based on the scientific research to date, there is no evidence that Holding Therapy
is an effective treatment for individuals with autism.

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Endnotes for Holding Therapy
Welch, M.G. 1989. “Toward Prevention of Developmental Disorders.” Pre and Peri Natal
Psychology Journal, Vol. 3, No. 4, pp. 319-328.

1

Welch, M.G., (see n. 1 above), p. 321.

2

Welch, M.G., (see n. 2 above), p. 321.

3

4

Stades-Veth, J. 1988. “Autism/Broken Symbiosis: Persistent Avoidance of Eye Contact with
the Mother. Causes, Consequences, Prevention and Cure of Autistiform Behavior in Babies
through Mother-Child Holding.” ERIC ED294344, pp. 33.
5Welch, M.G. 1988. Holding Time. NY: Fireside, p. 25.

Welch, M.G., (see n. 5 above).

6

Welch, M.G., (see n. 5 above), p. 47.

7

Welch, M.G., (see n. 5 above).

8

Welch, M.G. 1983. “Appendix I: Autism Through Mother-Child Holding Therapy.” In Tinbergen,
E.A. and N., Autistic children – New hope for a cure. London: George Allen & Unwin, pp.
323-335.

910
The Consolidated Standard of Reporting Trials (CONSORT), www.consort-statement.org/
downloads/download.htm, (accessed Feb. 13, 2006).
11

Association For Science in Autism Treatment, www.asatonline.org/resources/library/informed_
choice.html, (accessed May 10, 2006).
12
Quackwatch, www.quackwatch.org/01quackeryrelated topics/autism.html, (accessed May 10,2006).
13

The National Council Against Health Fraud, www.ncahf.org, (accessed Aug. 9, 2006).

Consumer Health Digest No. 05-07, www.ncaf.org/digest05/05-07.html, (accessed
Feb. 8, 2006).
14

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Miscellaneous Therapies: Music Therapy
What is Music Therapy?
It is difficult to precisely identify what comprises music therapy, given theextreme variability amongst the approaches outlined by the many studies
examined here. The underlying theories behind music as a therapeutic approach
for individuals with autism are numerous. In fact, the goals of Music Therapy
programs are so varied that Kaplan et al. (2005) actually quantified the different
studies in relation to their goals. They found that 41 percent of the interventions
focus on language and communication, followed closely by 39 percent which
concentrate on behavior and psychosocial goals. In addition, Whipple (2004)
did a meta-analysis on studies which report on Music Therapy for children with
autism, in an attempt to discern whether Music Therapy, in its various forms,
is effective.
Some investigators propose that there is a relationship between music andbehavior or attention.1,2,3,4 Others propose that music can produce increased
engagement,5,6 communication,7,8 and develop relationships.9 Still others claimthat music can enhance memory, learning and cognition,10 or serve as an effective
contingent reinforcer.11 Another group of researchers study the impact of musicas a relaxant for people with autism.12,13,14 And finally, one researcher examined
whether or not individuals with autism have a developmental difference which
gives them preference for music over visual stimuli.15
Music is presented in various styles and tempos, and the teacher to student ratio
varies from one-on-one to group sessions. The only consistent factor across allstudies was that the subjects were exposed to music, in one form or another.

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What evidence do the practitioners have that thisreally works?
Our comprehensive literature search took us to over half a dozen databases,in which we found over fifty articles relating to autism and Music Therapy.
Once we weeded out for studies that only present data on Music Therapy with
autistic subjects, we found twenty-one studies, only fourteen of which were
peer-reviewed. The rest (seven) were either unpublished Master of Arts theses
and Ph.D. dissertations, or presentations at conferences which have not been
subjected to peer-review, and therefore, are of very limited value (and not
discussed here). Of the fourteen peer-reviewed journal articles, we’ve divided
them into successful versus unsuccessful studies.
“Successful” studies
There were eleven studies categorized as “successful” based on the results of theirresearch and of those studies, two were removed due to lack of scientific rigor.14,15
The remaining nine studies involved a total of twenty-seven individuals with
autism. Although these studies reported improvements in various areas, most of
the improvements related to music (which makes sense, because many children
with autism find music reinforcing). The non-music categories did not create thesame results.16 In addition, parents reported better results than the professionals.
To illustrate, in Edgerton (1994) there were eleven children with autism who
took part in the study. This study did not use a standardized communication
instrument; rather, the researchers created their own instrument for the study(the Checklist of Communicative Responses/Acts Score Sheet [CRASS]).
This is problematic in itself, as the CRASS has not been extensively tested forvalidity and reliability (see a discussion in Section Two on the importance ofvalidity). In addition, in terms of the Behavior Change Survey results, thoseevaluating the children all knew that the children had undergone the treatment.

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Predictably, the parents observed the greatest behavior change, which was
negligible, followed by the teachers’ observation. These observations arecompared to the Speech Therapists who reported no change whatsoever.17*
Therefore, although the authors report success, their results actually paint a very
different picture. Another study with one child reported results of increasedsociability and pretend play; an alternative explanation for this increasedsociability and pretend play could have been that the mother was actively
engaging in the child’s perseverative play (plucking out fluff from the bedspread)and ritualized play sequences (defined as a set of behaviors using a toy or doll
done exactly the same way, repetitively), which is not technically pretend play(pretend play can be defined as including original play sequences created by thechild with some variation for each play session).
Another interesting study which reports data from ten children with autism is
Buday (1995). This research tested whether music could help children with
autism learn targeted signs and words. This well done study found that children
learned to vocalize and sign fourteen target words better when those words were
put to music rather than when the words were read out loud while the music wasplaying. The author, quite rightly, cautions the consumer about these results tonote that these children learned the words in an experimental setting. The children
were not tested to see whether they use these words to communicate outsideof the setting, and these words came from rhyming phrases which may haveenhanced their ability for memorization when set to music. Other non-rhymingwords may not have the same effect. In addition, learning a sign or word may
bear no relationship to understanding the word or how and when to use it. This
area requires additional research to discern whether, indeed, music has any true
The parents observation was negligible (mean = 4.8), followed by the teachers at (mean = 4.7). The
Speech Therapists reported no change whatsoever (mean = 4.2) [even a score of mean = 5 would indicate
only a slight change].17*319

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value in speeding up meaningful sign or word acquisition among children with
autism. Note: memorization may be enhanced using this technique; however,more research needs to be done prior to recommending the use of music to aid
in the acquisition of meaningful language comprehension and use.
Another study in the Music Therapy field uses social stories set to music or readto the child regarding a behavior that needs to be eliminated.4 The researchers
found that singing or reading the social story resulted in a decrease in thosebehaviors, more so than in the control condition where no social story was used.
However, only one of the four children in the study responded better when thesocial story was sung rather than when it was read. The study results support theuse of social stories rather than the use of music with social stories.
Finally, one study worth mentioning7 used music as a positive reinforcement
to increase spontaneous speech among children with autism. Although theMusic Therapy field embraces this study, it is actually a study that belongs inthe behaviorist field (the field of applied behavior analysis) because the study
tests music as a reinforcer rather than making conclusions on any potentiallytherapeutic property inherent in music.
“Unsuccessful Studies”
There were three studies which found no strong evidence regarding the effective
use of Music Therapy for children with autism. Hairston (1991) found thatmentally retarded, non-autistic subjects made more gains than mentally retarded,
autistic subjects and that no gains made by autistic subjects were statisticallysignificant. Burleson (1989) found that children with autism or schizophrenia
were more successful on a task when background music was played. Their finding,however, did not reach statistical significance.* Despite this weak finding, more
p < .062.

*

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research could be conducted on the effect of music in focussing autistic children
when they are engaged in a repetitive task. This begs the question, however, as
to why would we want autistic children engaging in repetitive tasks in the firstplace (unless there were a vocational component to be taught). The last study,
Thaut (1987), tested the preferences of autistic children for visual versus musicalstimulus, and found that there was no statistically significant difference in terms
of preference. There was no therapeutic component to this study.

What does the therapy actually look like?
Part of the difficulty in evaluating Music Therapy in the treatment of autism stems
from the different procedures and approaches the many examiners have used.
Not only is the independent variable diverse across the studies, but so too is thedependent variable. Music Therapy has been hypothesized to have a variety ofeffects on different aspects of the autistic population. In general, studies evaluatedhere include the effects of Music Therapy on development, stimuli preferences,
task performance, memory and learning, social interaction and behavior. In
addition, the way in which Music Therapy is presented to the participant varies.
In the studies mentioned above, the therapeutic process included musicalimprovisation, varied beats, varied rhythms, Musical Interaction Therapy andCreative Music Therapy. Adding to the inconsistencies are the subject to therapist
ratios with which the music therapy is presented. For some, it is one-on-one
therapy, while for others it occurs in group or classroom settings.

What else do I think?
The mechanism by which Music Therapy is thought to affect individuals with
autism is unknown, so far. For many, the observation that many individuals with321

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autism enjoy music may create the impression that they are somehow learning or
benefiting from it. While many children with autism do enjoy listening to andplaying music, there is insufficient evidence to conclude that the population ofindividuals with autism at large enjoys music.
Given the diversity of the supporting theories behind music as a therapeutic
process for individuals with autism and the lack of supporting data for the various
theories, it is difficult to conclude that any of them is therapeutic. Theories
include everything from music as a contingent reinforcement, to music as amethod for identifying traumatic attachment events in the individual’s past andto help them to develop insight into their own personalities. While there may
be no apparent negative side effects to Music Therapy, which may account for
its popularity, there appear to be no consistent positive effects either. There are
dangers to using approaches which have not been proven effective, because
they may prevent the use of effective approaches. In addition, there is always
the danger of inadvertently reinforcing undesirable or maladaptive behaviors
when using therapies that do not have established, systematic procedures whichhave been proven effective and are standardized. In other words, music may
be reinforcing to many people with autism and may inadvertently reinforce thewrong things. It is important to recognize this property as music therapists, due
to bad timing, may unwittingly reinforce problematic behaviors through theiruse of music.
Would I try it on my child?
My child is very musical. She is one of those people with autism who is very
musically talented and loves everything to do with music. In fact, most of herlife is spent either playing music (she plays six instruments – three quite well)and writing or composing musical scores. Would I categorize what she does as322

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Music Therapy? Most emphatically, NO. Has music made her life fuller andhappier? YES, without a doubt. For children with autism who enjoy music, it
is clear that music can enhance their life similar to the enrichment typicallydeveloping children receive with music. The difference is that music may be an
important conduit for an autistic person to join a peer group, as music is often
played in groups. In addition, if the autistic person is talented, there may bevocational opportunities in the world of music for that person. In addition, music
is a very good leisure skill; however, what I have described is not therapy. Basedon the research to date, Music Therapy will not ameliorate autism; therefore, I
would not pay for music therapists to work with my child. I have, however, spentconsiderable sums of money to give my child lessons for various instruments,
because music enriches her life immeasurably.
What kind of study would I like to see the Music
Therapists do?
In order to appropriately and accurately evaluate the effects of Music Therapy on
individuals with autism, there needs to be a standardized and well-operationalized
independent variable. In other words, music therapists need to develop a therapy
protocol (the specifics of how the treatment is operationalized); then, that protocol
needs to be tested. This is the first step to understanding the effects of Music
Therapy and enabling the research to be replicated. A therapeutic protocol may
also give us insight into the mechanism by which Music Therapy is effective
if indeed any therapeutic gains are observed. Experimental designs including
control groups, random assignment, significant subject sizes and results that
include statistical levels of significance are overdue in this area. There is muchwork that needs to be done before Music Therapy can be justified as a treatment
option for individuals with autism.

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Who else recommends for or against Music Therapy asa method for the treatment of autism?
The most well-known clinical practice guidelines which recommend against
the use of Music Therapy is the New York State Department of Health clinicalpractice guidelines for autism treatment. The guidelines state: “Because of
the lack of demonstrated efficacy, music therapy cannot be recommended as anintervention method for young children with autism.”18 As Music Therapy has
not been reported to be dangerous for children, professional organizations have,for the most part, ignored this therapy. In addition, since Music Therapy is sopoorly defined, many parents have put their autistic children into lessons andgroup classes and have redefined these classes as being somehow therapeutic,
because their children are engaged in and look forward to the class.
So you’re still on the horns of a dilemma?
If you are still considering Music Therapy for your child, it is important to keep inmind that this therapy has no data to support any claims that the method improves
the symptoms of autism. If music brings joy to your child and gives him skills
that your child can use to be part of a group and/or spend hours of leisure time
productively, then by all means give him or her musical opportunities. I would
suggest that we remove the word “therapy” from the term “Music Therapy,” andthen have the child who enjoys music, enjoy as much of it as possible, from allthat the broad field of music has to offer.
What’s the bottom line?
Based on the scientific research to date, there is not enough evidence todemonstrate that Music Therapy is an effective treatment for improving thesymptoms associated with autism.

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Endnotes for Music Therapy
Durand, V.M., and E. Mapstone. 1998. “Influence of ‘Mood-Inducing’ Music on Challenging
Behavior.” American Journal on Mental Retardation , Vol. 102, No. 4, pp. 367-378.
12

Burleson, S.J., D.B. Center, and H. Reeves. 1989. “The Effect of Background Music on Task
Performance in Psychotic Children.” Journal of Music Therapy, Vol. 26, No. 4, pp. 198-205.
3

Kostka, M.J. 1993. “A Comparison of Selected Behaviors of a Student With Autism in Special
Education and Regular Music Classes.” Music Therapy Perspectives, Vol. 11, pp. 57-60.
4Brownell, M.D. 2002. “Musically Adapted Social Stories to Modify Behaviors in Students With
Autism: Four Case Studies.” Journal of Music Therapy, Vol. 39, No. 2, pp. 117-144.
5

Wimpory, D.C., P. Chadwick, and S. Nash. 1995. “Musical Interaction Therapy for Children
With Autism: An Evaluative Case Study With Two-Year Follow-Up. Brief Report.” Journal ofAutism and Developmental Disorders, Vol. 25, No. 5, pp. 541-553.
6

Wimpory, D.C., and S. Nash. 1999. “Musical Interaction Therapy: Therapeutic Play for Children
With Autism.” Child Language Teaching & Therapy, Vol. 15, No. 1, pp. 17-28.

7Watson, D. 1979. “Music as Reinforcement in Increasing Spontaneous Speech Among Autistic
Children.” Missouri Journal of Research in Music Education, Vol. 4, pp. 8-20.
8Edgerton, C.L. 1994. “The Effect of Improvisational Music Therapy on the Communicative
Behaviors of Autistic Children.” Journal of Music Therapy, Vol. 31, No. 1, pp. 31-62.
9

Toolan, P.G., and S.Y. Coleman. 1994. “Music Therapy, A Description of Process: Engagement
and Avoidance in Five People With Learning Disabilities.” Journal of Intellectual Disability
Research, Vol. 38, No. 4, pp. 433-444.
10

Buday, E.M. 1995. “The Effects of Signed and Spoken Words Taught With Music on Sign
and Speech Imitation by Children With Autism.” Journal of Music Therapy, Vol. 32, No. 3,
pp. 189-202.
11

Hairston, M.P. 1990. “Analyses of Responses of Mentally Retarded Autistic and Mentally
Retarded Nonautistic children to Art Therapy and Music Therapy.” Journal of Music Therapy,
Vol. 27, No. 3, pp. 137-150.
Orr, T.J., B.S. Myles, and J.K. Carlson. 1998. “The Impact of Thythmic Entrainment on a
Person With Autism.” Focus on Autism and Other Developmental Disabilities, Vol. 13, No. 3,
pp. 163-166.
12

13

Wigram, T. 1995. “A Model of Assessment and Differential Diagnosis of Handicap in Children
Through the Medium of Music Therapy.” In T. Wigram, B. Saperston, and P.A. Langhorne,
Handbook of Art and Science of Music Therapy. England: Harwood Academic Publishers, pp.
181-193.
Barber, C.F. 1999. “The Use of Music and Colour Therapy as a Behaviour Modifier.” British
Journal of Nursing, Vol. 8, No. 7, pp. 443-448.

14

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Thaut, M.H. 1987. “Visual Versus Auditory (Musical) Stimulus Preferences in Autistic
Children: A Pilot Study.” Journal of Autism and Developmental Disorders, Vol. 17, No. 3, pp.
425-431.
15

16
Parteli, L. 1995. “Aesthetic Listening Contributions of Dance/Movement Therapy to the Psychic
Understanding of Motor Stereotypes and Distortions in Autism and Psychosis in Childhood andAdolescents.” Special Issue: European Consortium for Arts Therapy Education (ECATE). The
Arts in Psychotherapy, Vol. 22, No. 3, pp. 241-247.
17

Edgerton, C.L., (see n. 8 above), p. 47.

18

Guralnick, M., ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany, NY: New York State Department of Health, p. IV-15 to 21, IV-24.

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Miscellaneous Therapies: Pet-facilitated
Therapy
What is Pet-facilitated Therapy?
Those who practice Pet-facilitated Therapy (also called Animal-Assisted Therapy)
claim that in the same way that peer-mediated therapy helps a child with autism
improve their social behavior, so can the use of pets to change the social behaviorof children with autism. Pet facilitators usually use dogs as the pet of choice andargue that because dogs are socially demanding (licking, barking and tending
to follow a child), their inherent sociability can be harnessed to increase social
interaction for children with autism.
What evidence do the practitioners have that
this really works?
Our comprehensive data search netted three peer-reviewed journal articles (anda number of Master of Science degree theses and presentations at conferences on
this topic, which have been excluded). Only two of the peer-reviewed articles1,2
present data on an increase in the sociability of children with autism throughPet-facilitated Therapy.
The two articles which provide data support the contention that Pet-facilitated
Therapy is responsible for systematically changing the social behavior of thechildren in the study. One study included twelve children with autism between
five and ten years of age. Over several sessions, the therapist established contact
between the child and dog, and taught the child various games and activities
appropriate for dog play. Next, the therapist engaged in turn-taking with the child.
The researchers measured the amount of social interaction and social isolation thatthe child exhibited, and found that the introduction of the dog increased the rate

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of social interaction with the adult and dog. Even after the dog was withdrawn,
the rate of social interaction with an adult improved over the base-line, althoughthat result diminished somewhat over time. The study design was a withinsubject design where base-line measures were taken, treatment followed, andposttreatment measures were subsequently recorded for that child.
Although the study design was acceptable, there is some question about whether
the pet is responsible for increased sociability. To their credit, the researchers
state: “But it was not the dog alone that created the change ... The therapist’s
orchestration of the child-dog and then child-therapist contact was critical.”3
They also refer to prior research in the behavioral literature which demonstrates
the strength of the adult-led, active role in therapy. In addition, they acknowledge
an increase in the social isolation of the child after the study was completed.
The second study was a very well controlled, within-subjects, repeated-measuresdesign in which each child experienced each experimental condition weekly.
The children played with a ball, a stuffed-dog, or a live dog each week, over afifteen-week period, and found significant differences between children in thethree experimental conditions. The child’s behavior was significantly different
in the live-dog condition as compared to the other two conditions. Of note is thatthe hand-flapping (a form of self-stimulatory behavior) increased significantly inthe live-dog condition. In addition, when the live dog was present, the children
paid significantly less attention to the therapist than in the other two conditions.
Based on these results, the authors attribute tentative support for Pet-facilitated
Therapy, although they make it clear that this was research and not therapy.
In other words, they did not attempt to change the behavior of the children in
the study, but rather, wanted to see if the dog alone would elicit the change insociability.4

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The researchers’ interpretation of the results of this study warrant some further
discussion. If we assume that the data was taken accurately and that the results
did indeed occur, the next question is whether their discussion of these results
has merit and whether these results of increase in hand-flapping indicate a result
which is meaningful for the child. The observation regarding the increase inhand-flapping may have been due to the excitement of the presence of a dog,
rather than increased sociability (which is the goal of the study). There are manyother ways to elicit hand-flapping in children with autism, e.g., fast-forwarding
a videotape may create the same excitement. Hand-flapping may simply tell usthat the children were excited at the novelty of a dog. Whether the excitementof the dog would be satiated over time is an open question. Unfortunately, selfstimulatory behaviors such as hand-flapping can disrupt therapy and, thereby,
may need to be controlled in order for the child to focus attention to the task at
hand.
The second notable result is that the children responded less to the therapist
when the dog was present, presumably because the dog is more exciting than thetherapist. This finding may support the contention that a child is less primed fortherapy because of the distraction of a dog. What is unclear, though, is whether
excitement is considered pro-social behavior. Excitement over a dog may haveno relationship whatsoever to the prospect of excitement around people, which is
the hope of the Pet-facilitated therapy folks. They essentially hope to use the dog
as the transitional object toward a relationship with people. We define dogs associal animals; children with autism may be reacting to dogs on a whole different
level that may or not be social. Put simply, children with autism may find dogs
inherently reinforcing due to other doglike properties that may have nothing to
do with canine sociability, such as the way dogs breathe after a run.

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What does the therapy actually look like?
The therapist teaches the child to engage in the care and handling of domestic
animals within a classroom. Often the children are taught to take responsibility
for the daily care routines of the pets.
What else do I think?
I am very skeptical of the term “therapy” in this case. The fact that animals areused does not define the activity as therapy. When we use toys or food, we donot say that the therapy is toy-assisted or food-assisted; rather, the therapy may
be successful based on already, scientifically substantiated techniques. In thiscase, it appears as though the animals may become reinforcing to the children,
not only because they are different and perhaps exciting, but also because they
have predictable routines which may be intrinsically reinforcing to children
with autism. The concept of a reinforcer has been heavily studied in the fieldof behaviorism and may provide a better explanation for the findings than theconcept of a therapeutic pet. I have no issue with using dogs as reinforcers fora child. My sense of unease comes from actually calling this a therapy, and I
have nightmares about parents going out to buy a dog because they think that
their child’s autism will be ameliorated in so doing.
Would I try it on my child?
My child has a dog. In fact, she’s had a very well-trained dog for the last ten
years and has a good relationship with her dog. That said, do I think that the
dog has improved her ability to socially interact with other people and would
I purchase the dog with this expectation? Of course not. One thing that I’ve
noticed (a purely anecdotal observation) is that having a dog makes people more330

Section One: What Works and What Doesn’t?

likely to approach us and ask her questions about her dog. In that respect, the dog
indirectly provides her with social opportunities. In addition, I would use the dog
as a reinforcer if I thought that would help her learning. In my daughter’s case,though, I doubt that the dog is sufficiently reinforcing for her so that it can beused as a reinforcer. In short, the dog does not ameliorate her autism; however,the dog makes her happy and has enriched her life a great deal.
What kind of study would I like to see the Pet-facilitated
Therapists do?
This group of researchers should either look into the literature on reinforcement,
and publish more explicitly based on that literature (if indeed the researchers
agree that it is the reinforcing nature of the pets that is creating improvement)or they need to design an experiment whereby the use of an animal is done withpeople who do not understand the principles of behaviorism. This would separate
the variables of reinforcement from the variable of “pet.” If the introduction ofa pet to children with autism by individuals who make no demands on the childin a child-led environment, created an increase in social interaction relative tochildren in the same situation without a dog, then an argument could be madethat the dog created the social interaction, rather than the adult. The variablesof “pet” and “therapist” must to be isolated.
Who else recommends for or against Pet-facilitated
Therapists as a method for the treatment of autism?
There has been little written that recommends Pet-facilitated Therapy forchildren with autism. As this is not a dangerous therapy (and perhaps because
many people think that every kid should have a dog), this purported therapy
has been all but ignored by Quackwatch, the Association for Science in Autism
treatment (ASAT) and every other reputable clinical guidelines, such as the331The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!

New York State Department of Health Clinical Practice Guidelines on autism.
The sole organization that has taken interest in this area is the Washington State
University College of Veterinary Medicine’s People-Pet Partnership (PPP)
program. They conduct research aimed at understanding the Human Animal
Bond, which includes the bond between animals and children with autism.5
They approach this topic from an animal perspective rather than from the fieldof autism research. Although they do not recommend Pet-facilitated Therapy
for children with autism, this is a research interest of theirs.
So you’re still on the horns of a dilemma?
If you are a dog lover and you are willing to spend the money for a speciallytrained dog, there is no downside risk to owning an obedient, loving dog.
However, I suggest that you go into this endeavour with realistic expectations
about the therapeutic value of the dog. The experience may be great for yourchild; however, do not expect therapeutic results.
What’s the bottom line?
Based on the scientific research to date, there is insufficient evidence to conclude
that Pet-facilitated Therapy is an effective treatment for improving the symptoms
associated with autism.

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Endnotes for Pet-facilitated Therapy
Martin, F., and J. Farnum. 2002. “Animal - Assisted Therapy For Children With P.D.D.” Western
Journal of Nursing Research, Vol. 24, No. 6, pp. 657-670.
1

2

Redefer, L.A., and J.F. Goodman. 1989. “Brief Report: Pet-facilitated Therapy With Autistic
Children.” Journal of Autism and Developmental Disorders, Vol. 19, No. 3, pp. 461-467.
Redefer, L.A., and J.F. Goodman, (see n. 2 above).

3

Martin, F., and J. Farnum, (see n. 1 above).

4

Washington State University College of Veterinary Medicine’s People-Pet Partnership (PPP)
program, www.vetmed.wsu.edu/depts-pppp (accessed Feb. 21, 2006).
5

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Miscellaneous Therapies: Sensory
Integration Therapy
What is Sensory Integration?
According to professionals who practice Sensory Integration Therapy (SIT),
people who suffer from autism have difficulty in processing sensory informationfrom their environment. I am certain that many of us have likely noticed that
our children seem to be sensitive (to an unusual degree) to certain sensory
information, such as sound, touch or taste. These practitioners define sensory
information as information we see, hear, feel, taste and smell. They also consider
sensory information to include the way we see ourselves and our body “in space”
and in relation to objects and people. A clumsy person with autism would be
defined by proponents of SIT as having sensory issues. Those who use Sensory
Integration Therapy as a treatment for autism, describe this technique as a method
to organize the information a person receives so that the person can better utilize.
In their words, Sensory Integration is defined as, “The organization of sensory
input for use, [which is to perceive] ...the body or the world, or an adaptive
response, or a learning process, or the development of some neutral function...”1 Simply put, according to proponents of this intervention method, autism is
a form of sensory dysfunction.
The woman who developed this form of therapy is Ayers. She hypothesizes that
SIT helps a person with autism interact with the environment by coordinating
the central nervous system.2 Ayers claims that in some individuals with autism,
there is a disorder in brain functioning which makes the integration of sensory
stimuli difficult.3 In order to treat this sensory-specific brain dysfunction, those
who practice SIT are of the view that treatment must first identify the person’s
neurological needs, and then stimulate the person in accordance with thoseneeds, to help him or her adapt to this stimulus. In her own words, Ayers sees

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the process as “sensory stimulation and adaptive responses to it according to
the child’s neurological needs.”4 Proponents of SIT believe that for individuals
with autism, learning about the environment and how to act within the sensory
world has somehow been disrupted and must be repaired to address the disorder.
These SIT practitioners claim that the sensory approach improves the ability ofchildren with autism to integrate sensory information.5 Specifically, Sensory
Integration therapists believe that the brain has not yet developed the ability
to integrate environmental stimuli. To overcome this problem, therapists adapt
the environment to meet the needs of the individual’s nervous system. Oncethe environment is adapted to enable the integration of sensation, proponents ofthis intervention method believe that the brain will then be able to reorganize
itself.6 Ayers describes the therapy as follows: “The central idea of this therapy
is to provide and control sensory input, especially the input from the vestibular
system, muscles and joints, and skin in such a way that the child spontaneously
forms the adaptive responses that integrate those sensations.”7
What evidence do the practitioners have that thisreally works?
Our comprehensive literature search found over fifty articles and books on
Sensory Integration Therapy from 1968 through to 2006. There were additional
articles attempting to test whether children with autism have sensory sensitivity,
but these were excluded because they did not discuss Sensory Integration as atreatment for autism. Of those fifty articles, only eleven reported data on SIT asa treatment for children with autism, including three case studies. There werea few studies done on children with other diagnoses; however, as these children
did not suffer from autism, these articles were not included. Although it is apositive step that research is being conducted on this method, most of the studies
were conducted from 1977 to 1992, with three studies published in 1999, one ofwhich is a case study.8 The most recent data reported on SIT was seven years
336Section One: What Works and What Doesn’t?

ago (1999), yet there has been much heated debate in the literature regarding thequality of these studies.9,10,11
All of these SIT studies are plagued by serious flaws. First, only one of thestudies on SIT uses a control group (a fundamental flaw in my view) and when
researchers use a Single-Subject Case Design (SSCD), it is not designed with
sufficient controls. Without sufficient controls, either in a SSCD or a betweensubject design (one with a control group), the results of the study can be attributed
to any number of factors that may have nothing to do with the treatment. In otherwords, there may be many other variables at play, independent of the Sensory
Integration Therapy (which is the independent variable), that may influence resultsof the study. The lack of experimental controls questions the results found by
all the SIT studies, but particularly those of Cook12 and Ayers.13 Both of thesestudies were long-term SSCD studies (Cook’s study was done over two years andAyers’ was one year in duration). There was no control for maturation effects(children develop as they get older) which may have produced improvements insubjects merely through aging, as opposed to any connection to the intervention.
In addition, any finding noted by many of the researchers may have been the
result of other variables occurring at the same time as the therapy. For example,
Ray, et al. (1988),14 designed a case study in which a child learned thirteen new
words over a one month period through the use of a swing. We have no way ofknowing whether the swinging motion created these gains, or rather, the positive
reinforcement of using the swing paired with the attention of the person teaching
the words created enough motivation for the child to attend and, therefore, learn
the new words. Put differently, any observed progress of the child cannot be
confidently attributed to SIT because other variables may have confounded theresults of the various studies.
Unfortunately, the way these SIT studies measure sensory integrative dysfunction(the dependent variable), before and after the therapy, is also problematic. In all

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of the studies, with the exception of Ayers,15 sensory integrative dysfunction (thedependent variable) is being measured either through researcher observation,
parental reporting, or both. I know some of you may be thinking, “What’s
wrong with researcher observation?” While observation is an important tool inmeasuring the effectiveness of a treatment, it is very important that the observer
be independent of the research, quantifying the observed behavior based upongenerally accepted scientific principles of research. This is crucial, particularly
when there is no control group. If there were an experimental and control group,
then researchers associated with each study could make research observations
using pre-and post measures as long as they did not know who was assigned towhich group in the experiment. Each of these studies violates this procedure
because none have a “blind” observer. Parental reporting is also suspect (seethe discussion in Section Two) because it is susceptible to bias.While the Ayers
article uses parental reporting in addition to other measures, these other measures
are also problematic.
Lack of standardization of “before and after” measures for autism and sensory
dysfunction plague this research. The study conducted by Ayers et al.,16 uses avariety of measures to test the sensory dysfunction of the child. Some subjects
were measured on motor proficiency and vocabulary, while others were measured
on language or auditory comprehension. Subjects were also measured using the
Ornitz scale, which measures reaction to sensory input. These measures need
to be standardized for each child and several commonly-accepted measures
for autism, not just sensory dysfunction, are required. An example of lack ofstandardization is in the Case-Smith17 study, in which five children undergo
therapy. Improvements noted include the finding that four children demonstrated“decreased frequency of nonengaged behavior and that three children increased
their frequency of ‘goal-directed’ play.”18 This finding tells us nothing about
whether autism was ameliorated with SIT. There are many other possible

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explanations for this observation that may be independent of Sensory Integration
Therapy but, rather, may be an effect of the child learning a new repertoire ofplay skills based on one-on-one repetitive teaching. In Short, Sensory Integrationneeds to be separated from teaching to see whether it is effective. Case-Smith,et al.,19 dismiss standardized measures as inappropriate due to noncompliance.
Noncompliance is a challenge for many researchers in the field of autism and is nota legitimate justification for a lack of objective measures. Several standardized
measures could be used in addition to the three measures used by Ayers, such asa variety of autism rating scales, psychometric testing and measures of adaptivefunctioning.
An additional flaw in this subfield is the operationalization of autism. It isessential to examine how the dependent variable, autism, is actually being
measured. In the case of the Ayres article, reaction to sensory input is measured.
Unfortunately, reaction to sensory input does not even begin to measure autism.
Psychometric and language tests are wholly ignored in the SIT literature, as well
as a measure of excesses in behaviors common among children with autism.
In a study done by Grandin,20 she reports a decrease in tense and aggressive
feelings in herself when using the “squeeze machine,” which she designed for
personal use. Although this is interesting, the question remains as to whether thesqueeze machine effectively treats (resolves) behavior deficiences or provides any
improvements in intellectual or adaptive functioning (if we accept the findingsthat the squeeze machine does in general calm people with autism). Edelson
et al. (1999)21 attempted to test this hypothesis on twelve children with autism
by randomly assigning subjects to either an experimental or control group.
Although the groups were randomly assigned, the pretreatment mean scores forthe behavioral measure were appreciably different between groups (which meansthat there is no utility to doing a between-subject analysis as the groups weredifferent at the outset), and there were not enough data points for withdrawing

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and introducing the treatment to allow a within-subject design analysis (as iscommon in SSCDs). Although one could argue that the Edelson et al.22 study
operationalized autism in a meaningful way, i.e., behaviorally (although theyused a parent rating scale which is less reliable than a professional rating scale),
the above mentioned issues work to exclude their study as evidence to support
the efficacy of Sensory Integration Therapy.
Additional lack of operationalization includes the study done by Ayers,23
where she reports a sixty percent “good response” versus a forty percent “poorresponse” to SIT. Here she is measuring the subjects’ reaction to stimuli. This
does not address the important, measurable deficits and excesses of autism. An
additional article by Cook,24 has a similar flaw in the study in that the checklist
used is specific to sensory dysfunction issues, as opposed to language, IQ gains,and behavioral gains which are predictive of functioning. The McClure et al.
article (1991)25 measures the level of self-stimulatory behavior and self-injury
in a case study. Behavioral excesses are a problem for many individuals with
autism; consequently, it is a very good idea to measure these variables in autism
treatment research. Unfortunately, this study also suffers from some of the flaws
discussed above; specifically, while the researchers were providing Sensory
Integration Therapy with the self-injurious subject, the subject was also given a
variety of other treatments including medication. McClure et al.25 mention thatthese other treatments may have influenced the behavior of the subject. In short,the experimenters confounded their study (confused it with other variables),which renders the data meaningless. The confounding variable of “medication”
is a crucial piece of information because it tells us that we cannot conclude,with confidence, whether or not the treatment was effective. Finally, most of
the studies were non-rigorous case studies,26,27 which may give us insight into
those individuals being studied, but cannot be used to make any conclusions
whatsoever about efficacy of SIT for the broader population of children afflictedwith autism.
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Confounding variables seem to be a recurring flaw in the research that has been
done on Sensory Integration. The Cook28 and Ayers et al.29 studies do not control
the variable of education. In other words, what other intervention the child may
have experienced prior to the Sensory Integration treatment study is not accountedfor. The results of these two case studies are confounded by the enrollment inpreschool for both subjects, one for two years and one for more than eighteenmonths. The first subject received compliance training in the preschool setting,at the same time as that child received Sensory Integration Therapy, which could
explain many of the gains he made over the two-year period. Both subjects
were taught using structured activities across, “all domains of development,”30
and the second subject in the study had a one-to-one aide at school. We cannot
conclude that the gains achieved by these two subjects were in any way related
to the SIT they received. They could just as easily be attributed to structured
behavioral intervention.
What does the therapy actually look like?
Sensory Integration Therapy encourages the child to play using different kindsof gym equipment. Many of the activities that sensory integration specialists do
use commonly available playground equipment such as scooters, swings (special
bolster swings and typical playground swings), and playground merry-go-rounds.
In addition, they often brush and/or rub the child’s skin to apply sensory stimuli
to the body. Sensory integrationists will use many different kinds of equipment
to create the different types of sensation they require the child to experience.
Those advocating deep pressure stimulation, use a Hug Machine, designed byTemple Grandin.31 The child enters this device and is then squeezed.

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What else do I think?
Based on the studies published to date, we cannot reasonably conclude that
Sensory Integration Therapy is a science-based form of treatment for autism.
Unfortunately, the outcome variables being measured are often irrelevant to thecondition of autism and the results are not supported by rigorous experimental
designs. Many factors basic to conclusive outcomes, such as a variety of sufficientexperimental controls, are simply not present. The observation that some children
with autism have sensory sensitivity does not logically lead me to the conclusionthat Sensory Integration Therapy would be effective in lessening the sensitivity,
or even if it does (which has not been determined), that this somehow ameliorates
the many symptoms of autism.
Would I try it on my child?
I started hearing about Sensory Integration Therapy in 1992, when my child
was diagnosed. At that time, there was insufficient evidence for the efficacyof this treatment and the same remains true today. At this point, I do not see
enough evidence to use this method on my child and, although I do not see themethod as extremely harmful, I do see it as taking time away from other more
worthwhile things a child requires. If one day there is firm scientific evidence
that Sensory Integration Therapy can indeed improve my child’s autism, thenI will most probably try the therapy. Until that day, I will not subject her to
Sensory Integration Therapy.
What kind of study would I like to see the Sensory
Integration people do?
I would like to see a study with at a minimum the following elements: first, itis critical to create a hypothesis that states that children who undergo sensory342

Section One: What Works and What Doesn’t?

integration therapy are more likely to see a decrease in autistic symptoms
compared to those who do not receive this treatment. It is imperative that
commonly accepted tests to measure autism be widely used, administered by aregistered psychologist who has no knowledge of the study. This needs to be done
to ensure that all the children in the study do indeed have autism or Pervasive
Developmental Disorder-Not Otherwise Specified (PDD-NOS). In addition,
each child should be tested on widely accepted psychometric tests, which areadministered before and after the treatment. The psychologist who does thepre- and post tests, should not know which children are in the treatment groupand which children are in the control group. All the children should be treatedat the same site, including those children in the control group. There should be
at least twenty children per group in the experiment, with at least forty children
total in the study.
The children in the control group could play in the playground for the sameamount of time as the children in the treatment group. They could use typicalplayground equipment, creating a placebo (fake treatment) that mimics theexperience of the experimental group in every way aside from the Sensory
Integration Therapy. If replicated results demonstrate that the children in thetreatment group score significantly better on these commonly accepted measures,
then we could conclude that this therapy works to ameliorate autism. At thistime we are a very long way from that.
Who else recommends against Sensory Integration asa method for the treatment of autism?

The New York State Department of Health has the following to say regarding
Sensory Integration Therapy: “There is currently no adequate scientific evidence(based on controlled studies using generally accepted scientific methodology)

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that demonstrates the effectiveness of sensory integration for young children
with autism. Therefore, the use of this method cannot be recommended as a
primary intervention method for young children with autism.”32 Since the New
York Report was published, there have been several reviews33,34,35 supporting its
original findings. In addition, the Association for Science in Autism treatment(ASAT) also supports the view that Sensory Integration does not have sufficientevidence to consider it as an effective treatment for autism.36 Quackwatch37 also
lists this therapy as “questionable.”
So you’re still on the horns of a dilemma?
Smith, et al.38 have written a good, in-depth analysis of Sensory Integration
Therapy and demonstrate that there is no evidence regarding efficacy for thistreatment method. These researchers have done a great service to the Sensory
Integration research community because they have suggested several study
designs by which Sensory Integration can be objectively tested for efficacy where
decreasing self-injurious behavior is concerned. These tests desperately need
to be conducted because, at this time, there are thousands of children receiving
Sensory Integration Therapy, despite the absence of convincing evidence that it
works. In short, if you decide to use this therapy for your child, remember you
are engaging in experimentation. There is no excuse for the proponents of SIT
to avoid conducting this research, as other reputable researchers in the field haveset out the experimental design required to demonstrate whether or not Sensory
Integration Therapy is truly effective. For a spirited discussion in the literatureon this controversial therapy, Goldstein (2003)39 is worth a read, as is the Smith etal. chapter in Controversial Therapies for Developmental Disabilities (2005).38

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What’s the bottom line?
Based on the scientific research to date, there is not enough evidence to showthat Sensory Integration Therapy is an effective treatment for improving thesymptoms associated with autism.

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Endnotes for Sensory Integration Therapy
1.

Ayers, A.J. 1979. Sensory Integration and The Child. Los Angeles, CA: Western Psychological
Services.
Ayers, A.J., (see n. 1 above).

2

Ayers, A.J., (see n. 1 above).

3

Ayers, A.J., (see n. 1 above).

4

5

Cook, D.G. 1991. “ A Sensory Approach to the Treatment and Management of Children With
Autism.” Focus on Autistic Behavior. Vol. 5, No. 6, pp. 1-19.
Ayers, A.J., (see n. 1 above).

6

Ayers, A.J., (see n. 1 above).

7

8

Stagnitti, K., P. Raison, and P. Ryan. 1999. “Sensory Defensiveness Syndrome: A Paediatric
Perspective and Case Study.” Australian Occupational Therapy Journal, Vol. 4, No. 46, pp.
175-187.
9

Dawson, G., and R. Watling. 2000. “Interventions to Facilitate Auditory, Visual and Motor
Integration in Autism: A Review of the Evidence.” Journal of Autism & Developmental
Disorders, Vol. 30, No. 5, pp. 415-421.
10

Goldstein, H. 2000. “Commentary: Interventions to Facilitate Auditory, Visual and Motor
Integration: ‘Show Me The Data’.” Journal of Autism & Developmental Disorders, Vol. 30,
No. 5, pp. 423-425.
11

Edelson, S.J., B. Rimland, and T. Grandin. 2003. “Commentary: Response to Goldstein’s
Commentary: Interventions to Facilitate Auditory, Visual and Motor Integration: ‘Show Me
The Data’.” Journal of Autism and Developmental Disorders, Vol. 33, No. 5, pp. 551-552.

12

Cook, D.G., (see n. 5 above).

13

Ayers, A.J., and L.S. Tickle. 1980. “ Hyper-responsivity to Touch and Vestibular Stimuli as a
Predictor of Positive Response to Sensory Integration Procedures by Autistic Children.” The
American Journal of Occupational Therapy, Vol. 34, No. 6, pp. 375-381.
14

Ray, T.C., L.J. King, and T. Grandin. 1988. “The Effectiveness of Self-initiated Vestibular
Stimulation in Producing Speech Sounds in an Autistic Child.” The Occupational Therapy
Journal of Research, Vol. 8, No. 3, pp. 186-190.
15

Ayers, A.J., and L.S. Tickle, (see n. 13 above).

16

Ayers, A.J., and L.S. Tickle, (see n. 13 above).

Case-Smith, J., and T. Bryan. 1999. “The Effects of Occupational Therapy With Sensory
Integration Emphasis on Preschool-Age Children With Autism.” The American Journal of
Occupational Therapy, Vol. 53, No. 5, pp. 489-497.
17

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18

Case-Smith, J., and T. Bryan, (see n. 17 above).

19

Case-Smith, J., and T. Bryan, (see n. 17 above).

20

Grandin, T. 1992. “Calming Effects of Deep Touch Pressure in Patients with Autistic Disorder,
College Students and Animals.” Journal of Child and Adolescent Psychopharmacology, Vol.
2, No. 1, pp. 63-72.
21

Edelson, S.M., D. Arin, M. Bauman, S.E. Lukas, J. H. Rudy, M. Sholar, and B. Rimland. 1999.
“Auditory Integration Training: A Double-Blind Study of Behavioral and Elecrophysiological
Effects in People with Autism.” Focus On Autism and Other Developmental Disabilities, Vol.
14, No. 2, pp. 73-81.
22

Edelson, S.M. et al., (see n. 21 above).

23

Ayers, A.J., and L.S. Tickle, (see n. 13 above).

24

Cook, D.G., (see n. 5 above).

25

McClure, M.K., and M. Holtz-Yotz. 1991. “The Effects of Sensory Stimulatory Treatment
on an Autistic Child.” The American Journal of Occupational Therapy, Vol. 45, No. 12, pp.
1138-1142.
26
Larrinton, G.G. 1987. “A Sensory Integration Based Program with a Severely Retarded/Autistic
Teenager: An Occupational Therapy Case Report.” Occupational Therapy in Health Care, Vol.
4, No. 2, pp. 101-107.
27

Stagnitti, K., P. Raison, and P. Ryan, (see n. 8 above).

28

Cook, D.G., (see n. 5 above).

29

Ayers, A.J., and L.S. Tickle, (see n. 13 above).

30

Cook, D.G., (see n. 5 above).

31

Grandin, T., (see n. 20 above).

32

Guralnick, M., ed. 1999. Clinical Practice Guideline: Report of the Recommendations.
Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children(age 0-3 years). Albany, NY: New York State Department of Health, p. IV-60.
33

Dawson, G., and R. Watling, (see n. 9 above).

34

Goldstein, H., (see n. 10 above).

Baranek, G.T. 2002. “Efficacy of Sensory and Motor Interventions for Children With Autism.”
Journal of Autism and Developmental Disorders, Vol. 32, No. 5, pp. 391-422.

35

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The Complete Guide to Autism treatments: Make Sure Your Child Gets What Works!
36
Association for Science in Autism Treatment (ASAT), www,asatonline.org/about-autism/autisminfo12.html, (accessed Feb. 16, 2006).
37

Quackwatch, www.quackwatch.org, (accessed Feb. 16, 2006).

Smith, T., D.W. Mruzek, and D. Mozzingo. 2005. “Sensory Integrative Therapy.” In:
Controversial Therapies for Developmental Disabilities. J.W. Jacobson, R.M. Foxx, J.A. Mulick.
Mahwah, NJ: Lawrence Erlbaum Associates, pp. 331-347.
38

Goldstein, H. 2003. “Response to Edelson, Rimland, and Grandin’s Commentary.” Journal ofAutism and Developmental Disorders, Vol. 33, No. 5, pp. 553-555.
39

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Miscellaneous Therapies: Vision Therapy
What is Vision Therapy?
The use of Vision Therapy in autism treatment stems from the concept that people
with autism are not social because they experience visual dysfunction. In otherwords, their vision is somehow being disturbed. The “ambient” visual system,
which is said to be responsible for the perception of space (and thereby movement,
depth perception and position of one’s body in space), is thought to be impaired
in some persons afflicted with autism. Symptoms experienced by people with
autism, such as toe-walking, abnormal posture, head tilts and abnormal gaze, areclaimed by Vision Therapy researchers to result in the person with autism being
unable to experience normal vision. According to these researchers, they do not
have, “an integrated visual precept of events and objects in their environment.”1
From this theory, these researchers claim that this impairment results in theindividual being unable to recognize the consequences of their actions, due tothe inability to track their own position in space.
Vision Therapy is conducted by having the autistic person wear special “ambient
lenses” which are thought to improve posture, correct head tilts, and improvecoordination in such activities as catching a ball. According to Kaplan andcolleagues, “the symptoms demonstrated by autistic children may be an adaptation
to an ambient visual system that has distorted the appearance of the spatialenvironment.”2 By using these special glasses, the purported distortion of vision
is claimed to be lessened or eliminated.

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What evidence do the practitioners have that thisreally works?
After a comprehensive literature search, eight articles on Vision Therapy relating
to autism were found. Of those eight articles, only two studies involving theuse of prism lenses for individuals with autism report any outcome data. The
first study was weak; however, the second study corrected many of the flaws of
the first study.
Published in 1996, the first study is a within-subjects design, in which the firstauthor recorded data based on the use of the lenses. This introduced the possibilityof experimenter bias influencing the results, as it is generally accepted that theperson who designs the study and predicts the outcome should not be collecting
the data; rather, someone who has no knowledge of the research hypothesis
should be involved in data collection. In addition, these researchers did notuse a standardized behavioral measure to measure behaviors. They did notinclude a measure of behaviors such as self-stimulatory and/or self-injurious
behaviors, among others, which are characteristic of the autistic population. The
measures they did use are typically not representative of children with autism.
Specifically, they measured behaviors in the first study by observing children
watching television with correct or incorrect prisms and describing the head
position (erect, slanted backward, slanted forward, or tilted to the side), body
posture (erect, slanted backward, slanted forward, or tilted to the side), and facial
expression (from hypertense to relaxed). In addition, they measured how well
the children caught a ball when seated. In short, there was no measurement of
behaviors that are typically considered characteristic to autism and define thediagnosis of autism.
The second study conducted by Kaplan and his colleagues (1998), although flawed
as well, is a vast improvement over the first study. The experiment is a double350

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blind, crossover design with two randomly-assigned groups (see Section Twofor a discussion on this type of design). Another improvement was the additionof a dependent variable assessment of behavior, as measured by the Aberrant
Behavior Checklist (ABC). This assessment was used before, during and after
each of the four phases of the experiment. This improvement provided theresearchers with an opportunity to see behavioral differences at different points
to be used for comparison. Unfortunately, the ABC measure was used by thechild’s parents to report behavior (and, by this time, you all know what I think
about parental reporting!). Despite my criticisms regarding the ABC measure
for autism, these improvements in methodology were necessary in order to better
assess the effects of “prism lenses” on autism. The researchers did not use anyother traditional autism measurement tool alongside the ABC, and although the
Aberrant Behavior Check list is an accepted measurement tool, it was designed to
be used on moderately to profoundly retarded people, not children with autism.3
In short, this measure was not designed to gauge improvement in autism throughthe application of special eye glass lenses.
The results of the second study found no significant changes in orientation andattention, as measured by their four performance tasks of ball catch, televisionviewing while seated, television viewing while on a balance board, and visualball tracking. The results of this second, better-designed study, contradict theresults of the first poorly-designed study (although even if they did see changes
in their measures, these researchers have not established the relevance of theirmeasures as they apply to autism).
In terms of behavioral improvement, the results are quite perplexing and close
to meaningless. Based on the ABC scale, behavior showed an interesting
trend by decreasing for two months and then increasing!* In other words, theThis result was statistically significant (p < .05).

*

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children’s behavior improved slightly for two months and then deteriorated fortwo months. There are several questions that need to be answered in order tointerpret these results. First, did the children’s behavior improve as a result of
the Vision Therapy “prism lenses,” or did their behavior improve for anotherreason that is not readily apparent to us? The researchers claim that the special
glasses actually created an improvement in behavior. It is important to state thatthe improvement was actually quite minuscule, partially because these subjects
had very few behavior problems to begin with (scoring at base-line less than one
point on a four point scale, with zero indicating no behavioral issues and three
indicating severe behavior). The largest difference between research groups wasless than one point (0.45 difference). Although statistically significant, it is sosmall that it is virtually meaningless in terms of improvement for the person with
autism. In other words, the five categories of behavior problems – irritability,
lethargy, stereotypy, hyperactivity, and excessive speech – improved by a mere
0.45 of a four point scale and this tiny improvement disappeared by the fourth
month of the study.
Do we have any alternative explanations for this observed, small, short-term
decrease in problematic behaviors? One possible explanation could be that thechildren in the experimental group were intrigued with the novelty of the glasses
as they were somewhat different from the regular glasses (and they perceived
the glasses as somehow interesting). In short, the novelty of the glasses may
have affected their behavior, but the effect diminished over time. Unfortunately,
the researchers do not report the pre-and post scores of the ABC measure foreach subject. Therefore, the reader cannot decide whether the difference ismeaningful for even one child, in terms of the autism-related problems which
affect the child (as we are only presented the average scores per condition andnot the score for each child).

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An additional flaw with the study is that there were originally twenty-three autistic
persons scheduled to participate in the research. Five of the twenty-three (three inthe experimental group and two in the control group) did not participate because
they refused to wear the glasses or would break the glasses. Those children withthe worst behavioral problems may not have participated. This self-selection
concern is not terribly problematic because the study is a between-subjects design.
However, if the ABC measure is not a sufficiently sensitive instrument to pick up
differences in degree of autism, and the five people with the most problematic
behaviors are excluded from the study, then the ABC may not accurately assess
the effect of the behavior of the persons with autism who remain in the study
because they have few behaviors. Ironically, if indeed the prism glasses do havean effect, then the effect would be larger if the children with greater behavioral
excesses were included in the study. Unfortunately, they were not, significantly
diminishing the value of the study.
What does the therapy actually look like?
The therapy simply requires that the person wear the “prism lense” glasses much
like we wear regular eye glasses for daily living.
Would I try it on my child?
At this point, I would not try this on my child. There are major flaws in the Vision
Therapy study, including the use of parental reporting on the ABC scale to gauge
behavioral problems. The results of behavioral regression are unexplained andthe social significance of the findings is questionable.

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What else do I think?
Although I was encouraged to see that the vision researchers use a betweensubjects research design (rare in the world of autism research), arguably thebiggest issue with the use of Vision Therapy for individuals with autism is the lackof connection between improved vision and autism. Autism cannot be assumed
to be a disorder where the cause lies purely in visual dysfunction. While thecause so far remains unknown, there is insufficient evidence to conclude thatvision alone is impaired amongst persons afflicted with autism. Using dependentmeasures such as the ability to catch a ball, and the ability to improve posture, do
not even begin to address the serious and often debilitating symptoms of autism.
Improved vision in a child with autism may have no relationship whatsoever
to improving the degree of autism and common aspects of the disorder, such as
self-stimulatory behavior, self-injury, and difficulties in communication. Other
studies observe the ability of a child to better reproduce a grid pattern.4 Why
the ability to reproduce a grid would in itself be considered relevant to autism
is also unclear.
Based on the evidence to this point, I cannot conclude that prism lenses
ameliorate the symptoms of autism. While minimal improvement in behavior(as measured by the ABC) is temporarily seen for approximately two months,
these improvements appear to be diminished at follow up. It is necessary toprovide further research on the longer-term effects of this intervention.
What kind of study would I like to see the Prism Lenses
researchers do?
I would like to see a study that includes the replication of the Kaplan, et al.
(1997), with a randomly assigned experimental and control group, much likethe one these researchers already have; however, more subjects per condition
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are necessary, particularly because researchers claim to have observed minimal,
short-term results. A larger study would be able to more easily recreate thoseresults, if they are real. In addition, the researchers need to give the subjects preand post tests which measure autism more accurately and do not rely on parental
reporting. Ideally, a psychologist with no knowledge about the experiment,
but with experience in administering a variety of well-accepted, psychometricassessment measures, should administer the tests. Among those tests, ideally there
should be some standardized IQ tests to measure improvement in the subjects.
Finally, I would like to see this study done over a considerable length of time, toensure that if, indeed, there is an effect, the effect is measurable. If there is noeffect, we could make a clear statement discarding this treatment method fromthe long list of treatment options for autism.
Who else recommends for or against Vision Therapy asa method for the treatment of autism?
The treatment of autism using prism lenses was never very popular; however,
Vision Therapy has been offered for a number of years to people with a varietyof ailments and learning disabilities. For a history of Vision Therapy in general,
the Scientific Review of Mental Health Practice (SRMHP) presents a summary of
the many remarkable claims of vision therapists through the ages. The SRMHP
also touch on autism: they do not recommend Vision Therapy as a treatment
option for the disorder.5
So you’re still on the horns of a dilemma?
Ten years ago there was considerable interest in Vision Therapy among parentsof children with a variety of learning disabilities. Consequently, the American
Academy of Pediatrics, the American Association for Pediatric Ophthalmology
and Strabismus and the American Academy of Ophthalmology joined forces and

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created a joint policy statement which declares: “No scientific evidence exists forthe efficacy of eye exercises (“vision therapy”) or the use of special tinted lenses
in the remediation of these complex pediatric neurological conditions.”6 Although
this was not written for autism, the arguments used by those promoting Vision
Therapy are the same as those applied to learning disabilities in general.
What’s the bottom line?
Based on the scientific research available to date, there is insufficient evidence toshow that Vision Therapy is an effective treatment for improving the symptoms
associated with autism in children.

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Endnotes for Vision Therapy
Kaplan, M., D.P. Carmody, and A. Gaydos. 1996. “Postural Orientation Modifications inAutism in Response to Ambient Lenses” Child Psychiatry and Human Development, Vol. 27,
No. 2, pp. 81-91.
1

Kaplan, M., D.P. Carmody, and A. Gaydos, (see n. 1 above), p. 83.

2

3

Aman, M.G., N.N. Singh, A.W. Stewart, and C.J. Field. 1985. “The Aberrant Behavioral
Checklist: A Behavior Rating Scale for the Assessement of Treatment Effects.” American
Journal of Mental Deficiency, Vol. 89, No. 5, pp. 485-491.
4

Lovelace, K., H. Rhodes, and C. Chambliss. 2002. “Educational Applications of Vision Therapy:
A Pilot Study on Children with Autism.” Resource in Education, ERIC/DGE 458766.
Scientific Review of Mental Health Practice (SRMHP), http//www.srmhp.org/archives/visiontherapy.html, (accessed Nov. 5, 2006).
5

American Academy of Pediatrics, American Association for Pediatric Ophthalmology andStrabismus, and American Academy of Ophthalmology. Joint policy statement: Learning
Disabilities, Dyslexia and Vision, http//www.aao.org/member/policy/disability.cfm, (accessed
Feb. 16, 2006).

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Section Two

How Do We Know
What Works andWhat Doesn’t?

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Section Two introduces the reader to the basic rules that the scientific method
relies upon to evaluate autism treatments in Section One of this book. Thissection is written in a straight forward, user-friendly way so everyone can accessthe knowledge tools necessary for the evaluation of autism treatments. Thissection talks not only about the scientific method, but also gives the reader an
introduction to the process by which science is funded and how bias can easily
creep into research if proper precautions are not taken to separate the influenceof the funders from the scientists. Aside from the politics of research, thissection describes what comprises the scientific method and how it is different
from pseudo-science, which is often relied upon by purveyors of unsubstantiatedtreatments. I address the importance of understanding: (1) the role of theory; (2)how theory motivates research, and (3) if you do not understand what a theory
is supposed to do, how you can potentially be hoodwinked — convinced that atreatment is effective when there is in fact no data supporting that treatment. I
describe how we use science to move closer to the truth which, in our case, isvital to our children’s futures.
Next, I give you the tools to be able to analyze a study. Then, I lay bare the large
number of pitfalls with which poor research is plagued, so you will be able toidentify those potholes. Furthermore, once we know what the study shows us
about autism, I discuss how, when and whether the results of the study can begeneralized to the population of children afflicted with autism. I also discuss theimportant role of repeating studies (replications) for the goal of applying results
to the real world. That would include your child, which is, presumably, why
you are reading this book! Moreover, you are provided with a list of red-flags
to watch out for when evaluating autism treatments. The goal of this section isbasically to inoculate you from incompetent researchers or illegitimate purveyorsof autism treatment and, thereby, protect your child with autism from the quackery
that runs rampant in the field of autism treatment. Finally, you will be able to361

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understand the analysis of the science behind all the popular autism treatments
presented in the first section and, hopefully, be able to apply principles of thescientific method to the next big autism treatment fad that comes your way.

2.1 Why care about science?
The Scientific Method is a solid, time-tested, reliable way to uncover evidence
to support or refute an idea. In practical terms, the scientific method can protect
you from wasting your child’s time and your money. Regarding autism, someineffective treatments are very expensive and many may bankrupt you quickly.
In addition, using science to analyze treatments can protect your child fromphysical harm. Some treatments are actually physically invasive, such as
experimental brain surgery. The scientific method can also protect you fromwasting your child’s opportunity to get effective treatment. Some treatments
are not intrinsically harmful; however, they waste your child’s precious time
when they preclude the child from receiving treatment that is truly therapeutic.
Therefore, these treatments are indirectly harmful. Using science to analyze
treatments can also protect you from turning your family’s life upside down.
There is a collection of unproven treatments that are not harmful per se, but simply
an enormous burden to incorporate into the life of your family. Science can help
you avoid implementing these ineffective treatments on your child. Another groupof treatments are not expensive and burdensome and, therefore, not a serious
threat to the well-being of your child; however, they have no science behind themand, therefore, may be of no value whatsoever. All the above reasons illustrate
how important it is to know the effectiveness of a treatment before choosing to
implement it with your child. In other words, in order to truly improve yourchild’s condition, you need to know whether there is science behind the method
you are considering to use with your child.

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2.2 Why we can’t always rely on experts
There are several reasons why experts (and purported experts) may not always
be a good source of knowledge. There are many experts in the field who aretremendously important for children with autism. However, the parent is notalways in the best position to judge whether the so-called “expert” truly is anexpert or whether the self-anointed expert is simply out to sell a product or service
that the expert wants the parent to buy. Experts may not be a good source of
information because: (1) they may not know the state of the science in autism
treatment; (2) they may not value science; (3) personal advancement in academe
may trump quality concerns, and/or (4) their motives may not be pure as in thecase of gold-plated quackery.
“Experts” do not always know about science
The first question you must ask is: “Who are these so-called experts, and whereis their expertise?” There are many people who work with autistic children
who may be experts in their individual fields; however, most of them do notknow how to properly evaluate scientific research. Therefore, if a parent asks
an autism therapist or consultant about a variety of treatments or cures, most ofthem will typically not be qualified to tell you about the state of the science inautism treatment. Put simply, they do not know how to evaluate knowledge
claims and the studies supporting those claims. This is true for most therapists
and consultants who provide treatments that are not science-based as well as manyof those who actually provide science-based treatment. They may be intimatelyfamiliar with their subfield, but have not done the research or do not have theskills to evaluate autism treatment in areas where they do not work.

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They may not value science
There is yet another subgroup of treatment professionals who do not think that
their method can be scientifically proven because it cannot be measured. This
group desperately wants sticklers for science to “compromise” on the science. I
recently went to a conference where an experimental treatment was introduced
and the accompanying books and videotapes were available for sale. When I
challenged the author privately about the fact that there is no evidence regarding
this method and that if she really wanted to improve this field, she would try toconvince those pushing the treatment to do some research. She asked me thisquestion: “Can’t you bend a little on the science?” Clearly, scientific evidence
is not important for some autism “experts;” yet their presentations attempt toappear very science-based. This particular lecture was introducing a biomedical
treatment and the lecture consisted of a multimedia production supported withmany charts, graphs and computer-generated brain animations.
Advancement trumps quality concerns
In a researcher’s life, the cliche “publish or perish” is absolutely true. The
more researchers publish, the better for their careers. A long list of academic
publications can lead to a permanent position at a university (tenure), more
respect in their field, more grants and the likelihood that those researchers will
push the field forward. In fact, I am familiar with one department in which there
was actually debate about linking salaries to amount published and docking
professors if they did not pump out enough publications!
There is obviously something that the “publish or perish” doctrine fails to
capture — quality of research and quality of publication. Every field has its
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attempt to publish in second or third tier journals that may lack the prestige ofthe preeminent journals. The quality of the journal is based on the quality ofthe editorial board, which decides the research papers to accept and the ones toreject. Journal quality is tied to academic advancement; researchers understandthis point but parents often do not. As parents of children with autism, we mustalso understand the advancement dynamic within the university; otherwise, wewill take any study that has simply been published anywhere and assume thatit has been done correctly and reviewed by others who know how to evaluate
research properly. Unfortunately, this is often not the case; there are some very
low quality journals and newsletters which publish any and all information on
autism, accurate or not. Remember, all anyone requires to set up a publication
is a computer with publishing software. A researcher does not need a licence,just a lot of “chutzpah.” In short, researchers need to publish: consequently,
many will try to publish their studies wherever they are able, even if the studies
are poorly designed or executed and the publications are of similarly dubious
quality.
Some experts’ motives are not always pureIn addition to the serious problem that many treatment professionals lack expertisein the scientific method, we know that some treatment professionals profit fromthe treatment they recommend; therefore, they are loathe to point out the lackof science regarding their method because then you will not buy their product orpurchase their services. I have found this to be often the case when treatments
are sold with glossy brochures and testimonials from other parents, describing
how the treatment purportedly changed their child’s life. It is important not tobe impressed by very well-dressed, articulate, and confident public speakers.
The demeanor of the speaker has nothing to do with whether or not there is any
bona fide data supporting the treatment being sold.

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For the above reasons, you need to be able to evaluate autism treatments bylooking at their scientific evidence, or discovering their lack of scientific evidence.
In short, please learn the phrase, “Show Me the Data” and know what to do
once you see the data. To summarize, you need the power to be able to evaluate
the treatment without the editorializing or persuasion of others. Although
professional incompetence is not nearly as morally upsetting as professional
greed, it is nonetheless equally as dangerous to children with autism. We parents
are a desperate bunch who are thirsting for a cure; however, remember the moralof the story — Bad Data is Worse Than No Data.
The scientific method versus pseudo-science
So hang on, É here we go.
To differentiate between real science and pseudo-science, it is crucial tounderstand the purpose of science and what rules scientists must follow in orderfor science to tell us anything meaningful. Put simply, science is the way to
uncover facts and genuine relationships. The scientific method is simply a groupof rules that, when followed precisely, can help us discover facts about whatever
we are studying. In the case of autism, science can help us discover and test
treatments for autism, and be able to know whether those treatments work.
Science is the way to test the many claims made by others. In the same way as
biologists use the rules of the scientific method to uncover facts about the natural
world, so do sociologists and psychologists use the same method to uncoverfacts about the social world or about aspects of human behavior. In the caseof autism treatment, science can test treatments claimed to work by one groupof researchers, and see if indeed the claims of those scientists are correct. Put
simply, in the same way as the scientific method is the underpinning of western
civilization’s technological base including modern medicine, researchers in
autism must also use the scientific method to acquire (and substantiate) a better

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understanding of autism. Using the scientific method, researchers can uncover
relationships that exist, i.e., treatments that improve or ameliorate autism, andthen other researchers can test those relationships to make sure they exist. Whenothers test those relationships, they can replicate the studies to see whether
the results the first scientist found will occur again (that the results are real).
Noteworthy in this discussion is that experiments are the only reliable way todetermine whether a treatment really works. Shortly, you will learn much more
about how experiments work, as they are key to evaluating autism treatments.
The question boils down to this: How can we tell the difference between pseudoscience and the “Real Deal”? The best way to know the difference between
science and pseudo-science (or outright fraud) is to look at the rules and how
they may have been broken. When researchers are engaged in pseudo-science,
there are generally three rules that they breach. Here are the fingerprints:
Rule 1: The results of an autism treatment study must be observableby someone other than the original researcher(s).
Put another way, an observation needs also to be seen by someone else. Therefore,
if a researcher claims that a child with autism has improved, other people need
to objectively see the same improvement at the same time. Otherwise, as far
as science is concerned, the improvement claimed never happened. In pseudoscience, only the original researchers can “see” the results.
Rule 2: An independent researcher must be able to reproduce
results of the original study.
The second rule is a relative to the first rule. Any result observed in researchmust be reproducable by somebody else. In other words, a different researcher,using the same method as the first researcher, should be able to come up with
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similar results. Replication is a “must do” for the scientific method in general,and important for autism treatments in particular, because there is so much fraud
being perpetrated against parents and their afflicted children. In pseudo-science,no one can replicate the results except the same researchers. This is a big red
flag.
Rule 3: The research question must have a way that it can bedisproven.
All research questions that are being asked must, theoretically, have a way by
which they can be proven wrong. Put simply, the scientist needs to be able todescribe a scenario or situation where his or her hypothesis is not supported.
For example, if the theory states that giving vitamin B6 and magnesium toa child with autism will decrease the symptoms of autism (those symptoms
measured objectively), then the scientist must also describe what will happen
if the theory is wrong. In other words, what is it going to look like if vitamin
B6 and magnesium treatment doesn’t work. In pseudo-science, every incorrect
result is either explained away or simply ignored.
Every result that does not support the original researcher’s prediction is dismissed
by delegitimizing a second group of researchers that may have found contrary
findings. It is difficult to dismiss negative findings published in peer-reviewed
journals; however, it still occurs on a regular basis because there is a fortune to
be made by offering unsubstantiated autism treatment services, even when they
have been scientifically discredited.
Pseudo-science is non-science dressed up to look like science. Pseudo-science
uses an impressively large vocabulary; tables and graphs are used, typically bypeople with MDs and/or PhDs behind their names, often in different fields to the368Section Two: How Do We Know What Works and What Doesn’t?

one being researched. In autism research, there are many examples of dentists,
nurses and general practitioners (instead of neurobiologists) doing brain researchor providing unsubstantiated autism treatments. It is important to make surethat those doing the research have an MD or PhD in a field related to the kindof research being conducted. I have seen very sophisticated presentations bypeople who have absolutely no background in the area in which they are working,and who also often do not understand the scientific method. These experts willoften tell you that, in their professional opinion, a specific treatment is effective.
Bona-fide scientists will not pontificate, using only their opinion, without backing
up their position with hard data. In short, pseudo-science breaks the rules ofthe scientific method but it cloaks the research in symbols of legitimacy using
persuasive techniques more common to advertising than science.
A typical red flag for quackery is the use of sophisticated multimedia techniques.
When presentations are too slick and technical, in a showy Hollywood fashion,
do not be impressed. A brain scan tells us nothing about how much data (if any)
the researcher has gathered. In fact, the slicker the graphics and animations,the more money the researcher likely has to waste on expensive animations. As
grant money is hard to come by, bona fide scientists do not usually squander it on
glossy brochures and multimedia presentations. They generally use simple slides
and do not appear to be “selling” the treatment. Academic researchers are also
generally tentative in making the claims that they do make. The reason for this isthat they follow the scientific method which supports a healthy dose of skepticism.
Science can provide evidence that a treatment works (sometimes a small amountof evidence, other times a compelling amount of evidence); however, scientists
do not like to say that they have actually “proven” that a treatment works. They
will generally say that the evidence supporting the treatment is strong or weak,
but will not usually refer to their research as “proof.”

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Using the scientific method to protect your child
As an intelligent and savvy consumer, you have a right to see any and allscientific evidence which either supports or negates the claim that an autism
treatment is effective. Before starting any treatment, as the parent you should
ask for a bibliography of academic journal articles published on the methodby the practitioners recommending or providing the service. If the “experts”
on any particular method cannot give you any of the material that you request,
chances are there’s not scientific evidence available yet to support their claims
that the treatment ameliorates autism. Your answer as to whether this method isscientifically-supported is then easy. In other words, no data equals no sciencein support of the so-called treatment method being touted by the so-called expert.
Most fringe treatment methods will not have any science behind them, whichmakes evaluating them relatively easy.
What if the treatment method is too new for datacollection?
If a treatment method is new, you have the option to wait for supporting evidence.
Those practitioners of the method should be working on a study to test the method,prior to offering it to the public. At this point, you can always sit back, keep
your money in the bank and wait for the data. Occasionally, there are effective
treatments that need more scientific scrutiny and the parent may only wait a shorttime; however, this is rare. In my personal experience as a parent waiting forgood data to substantiate a variety of treatment methods, it is rare that after ten
or fifteen years of hearing about a treatment method, a scientific study is done,
and the treatment method is suddenly supported by quality data. The opposite
is more often true. More typical is the scenario where a method which is notscientifically supported is used by many parents. Finally, a reputable researcher
will actually test the method and find that there is scientific evidence to show themethod is completely ineffective.
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The lag time between discovering a promising treatment which actually works
on children and having that treatment scientifically tested is often short because
science moves very quickly when it looks as though there is real possibility fora new discovery. At this point, many researchers jump in and compete to see
who can find the significant results first. A good example of this phenomenon
is the large number of researchers looking for the gene(s) for autism. Ten years
ago, there were only one or two university research programs targeting autism.
Today, there are research groups around the world competing in this area because
the chances that a discovery may occur are good.
What does take a considerable amount of time, however, is a treatment that mustfirst be tested on animals in the lab. This type of research is difficult because it ishard to approximate autism in rats or monkeys (although researchers are working
this problem). Research that uses animal models does not typically suffer the
problems of pseudo-science or quackery as, generally, these researchers do notprematurely offer treatments for autism; rather, they painstakingly and responsibly
research autism to be able to eventually treat the disorder biochemically. These
researchers do not regularly offer half-baked treatments and, therefore, I address
them only in passing.
What about anecdotes? Can we use them at all?
What is the role of anecdotal evidence in autism research? For our purposes,
an anecdote is defined as a personal story or observation about how a childpurportedly improved when he was given a particular type of treatment. The
question is this: can we legitimately use anecdotes in scientific research for
autism treatment or is it just a waste of time?

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One might be surprised to know that anecdotes are actually very useful if usedcorrectly, but disastrous if used incorrectly. Scientists use anecdotes to start
thinking about questions to research — that is a good use. In other words,
anecdotes can motivate science. Think about all the surprising findings that havebeen discovered by chance or by scientists simply having hunches. Hunches
are great to start scientists thinking. Although the hunch may be caused by an
anecdote, that’s where its usefulness ends. In short, once the research question
is developed, then the role of the anecdote is over. An anecdote gives a scientist
an interesting idea to study. Researchers do not jump to conclusions the minutethey suspect an interesting relationship. On the contrary, they set up a way to test
their hunch, according the generally-accepted principles of sound research.
Unfortunately, many parents use anecdotes in a disastrous way. We hear astory from a friend, see a news piece or read an autobiography and then startadministering the treatment to our child. Children are not well-served throughthis use of anecdotal evidence, and neither is science. In addition, this is the way
to create considerable and unnecessary hardship in both the life of the parent
and child.
Let’s illustrate this point with the following scenario: a scientist goes toThanksgiving dinner at her friend’s house every year, for years, and sees thatDavid, a child with autism at the same thanksgiving dinner, becomes lucid. He is
attentive, talks to people, sits appropriately and is the model child. After a few
years of observing this interesting change in behavior, the scientist wonders if
the improvement in behavior is caused by the food the child is eating, specifically,
the tryptophan in the turkey? The scientist proceeds to design an elaborate
experiment to test this possibility. She happens to mention this to her friend,David’s mother. What do you think David’s mother does? I’m sure most of372Section Two: How Do We Know What Works and What Doesn’t?

us can guess what she does because we’ve probably all had this instinct. The
mother runs to the store, starts cooking and feeds this child turkey for breakfast,
lunch and dinner, every single day.
Why does the mother go out and specifically buy turkey for the child? Perhaps
it’s the pumpkin pie for thankgiving dinner that is responsible for the effect on
the child’s behavior. Since we cannot tell what is responsible for the change
in the child, we need to do an experiment to test the various possibilities. Put
simply, we need to separate the possible influence of the pumpkin pie from thetryptophan in the turkey. We can easily do this with an experiment.
Herein lies the problem with anecdotal evidence. As parents, we search for thatcure and jump on every hope or idea, regardless of the scant evidence that thetreatment will actually make a difference. In the process, we absorb unnecessary
cost and inconvenience in our lives and we waste a child’s valuable window ofopportunity for effective autism treatment. In the worst-case scenario, we canactually endanger our children, subjecting them to harmful procedures. Thisis how seductive anecdotal evidence can be. It is important to be skepticaland decide whether you want to spend time, money and endure disruption on atreatment for which support is purely anecdotal. Unfortunately, in the worldof autism treatments, there is an epidemic of anecdotes fueling unsubstantiatedtreatments. In short, quackery is alive and well in the world of autism treatment.
The reasons why anecdotal evidence perpetuates itself will become clearer when
we discuss how to properly evaluate experiments; for now, remember, anecdotes
and their cousins, testimonials, are trouble waiting to happen.

We need to care about theory
I was prepared to ignore the role of theory in autism treatment, because I thought

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we could get away without it, and I didn’t want anyone falling asleep reading thisbook; however, after speaking to some very intelligent parents who were being
swayed by beautiful theories with no data to support those theories, I realizedthat I have to explicitly define what a theory is and address the role of theory in
the evaluation of autism treatments.
Why do we care about theory? I’m bringing up the topic of “theory” for four
reasons. First, good research is motivated or driven by theory. Second, beautiful,logical, precise theories can be quite compelling and convincing, and also 100
percent wrong! Third, through theory, we can easily generalize our results to
the real world and know which treatments to provide to our children. Finally,
it is important not to trust your “gut” when judging a theory. This is a common
trap which parents are snared into on a regular basis.
What is a theory?
A theory is simply a set of sentences that explain and predict causal relationships.
In autism research, often a theory is simple with maybe one or two sentences
describing the relationship between two statements. An example of a knowledge
claim that is the important part of the theory for our purposes is: Treatment A
can cure autism.
A theory generally takes the form of sentences that are conditional. So, forexample, one theory claims that the reason children have autism is because
their blood contains too much lead and other heavy metals. The theory goeson at length as to why these heavy metals injure the brain. Then the theory
claims that removing these toxins is going to improve the child’s condition. The
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• IF a child has high blood toxicity levels, THEN he will be
more likely to develop autism than a child without high blood
toxicity.
• IF a child with autism has high blood toxicity levels, THEN
removing those toxins will ameliorate the autism.
In addition, a theory will have conditions under which it is believed to hold or becorrect. These conditions are known scope conditions, which tell us under which
conditions the theory applies. I will address scope conditions in more depth laterin the book, as it is a very relevant and neglected part of autism research, but for
now, we only need to know that scope conditions are part of a theory.
Good research is motivated or driven by theory
It is crucial to remember that in high quality research, a theory always motivates
the research. In other words, good researchers always have a theory that they aretrying to support or refute. If you come across research with no theory, beware.
These researchers do not understand the way science works and chances are thatthey are not going about the research process correctly.
There are all kinds of predictive sentences that you could make out of a theory
which, to the average person, appear very logical, elegant and even beautiful.
This is where parents often get duped! Here is the important point to consider:
the theory may be right or it may be wrong. But the logic of the theory has
absolutely nothing to do with whether a theory is right or wrong. Thomas
Huxley, put it very well when he described the tragedy of science as when
we witness “the slaying of a beautiful theory by an ugly little fact.”1 Good

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researchers understand this point all too well. Huxley’s point is that the theory
may be perfect in every way, except for the unfortunate problem that the facts,
or in this case, one ugly little fact, gets in the way by disproving the theory. In
other words, the theory does not mesh with observations or facts that stubbornly
cannot be explained away.
The concept of theory is very important in autism research because, when done
properly with competent researchers, we can know whether there is evidence tosupport the theory, or whether the theory is flat out wrong! That’s how parents
should approach the many kooky autism treatment theories out there. We needtheories to motivate research and we need that so researchers can show us thedata. Put simply, we just cannot accept a treatment based on its theory alone.
It is important to make sure that the data support the idea that the treatment iseffective.
Through theory, if we can create the same important conditions that made thetreatment effective, we can generalize our results to the real world and know what
to do with our children. In my opinion, autism is such a devastating neurologicaldisorder that it behooves us to attempt to recreate the study conditions which
created substantive change in children. Our children deserve no less than the
lucky children in the experimental group of the successful study. Here is where
the concept of scope conditions becomes important. The question to ask is
this: What are the conditions that must be present in order for the treatment towork? If those conditions can be recreated, then the treatment should logicallywork again. The challenge for parents of children with autism is to replicate
the important conditions present in the study so the treatment that worked in thelaboratory will also work for them in the real world.
The next point has to do with your intuition about judging whether a theory is376Section Two: How Do We Know What Works and What Doesn’t?

true or not. Again, it is important not to trust your “gut” when judging the theory
that supports an autism treatment. This point may disturb some and, in general, I
tell parents to trust their gut, particularly when making decisions about vulnerable
children. If you think something is too good to be true, you are most likely
correct. But here I must reverse my usual position. When it comes to theory,
do not trust your gut.
Let us suppose that a researcher develops a seemingly crazy theory. After you
stop laughing about the absurdity of the theory, do not dismiss it because of its
seemingly bizarre nature. Instead, it is prudent to wait and see whether thedata supports the theory. It is important to remain open-minded while awaiting
research data because, in science, the strangest theories have, periodically, been
supported. Two common illustrations come to mind to help make this point:
whether it was the theory that invisible organisms we now know as germs weremaking people sick, rather than bad smells, or that surgeons washing their handswith soap to kill invisible contagions would result in less people dying in surgery,it becomes clear that we cannot judge a theory based on its initial claims. We
must judge a theory purely based on the evidence.
Another example of a seemingly absurd theory at the time was the use of cobwebs
to heal wounds. Prior to the discovery of penicillin, people used to actually placecobwebs on their wounds to heal them! If I suggested that today, you’d think I
had lost my mind; however, we now know that penicillin can be derived fromcobwebs. The lesson here is to avoid discounting a theory because it may soundfarfetched or absurd. Instead, the reasonable person waits to see what kind ofdata are produced to support or refute the theory. If the data demonstrate thatthe treatment is not effective, then the hypothesis can be said to be falsified.
Although positive data cannot prove that a treatment works (but rather provides
evidence), negative data can actually prove that a treatment does not work.

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2.3 How do we generalize results in autism research?
Can we generalize research results from a study to all children with autism,
without taking theory into account? Here is where autism researchers engage inmuch debate. Typically, when medical researchers conduct clinical trials on atreatment (usually a drug), they go to a statistician and ask how large a sample size
they will need to ensure that the results of the study will apply to the population
at large. In other words, how many people need to be in the study before wecan confidently start using the treatment widely for all people who need it. You
will notice that often the number of people which medical researchers use is up
in the thousands. The statisticians will suggest a number dependent upon the
randomness of the sample. In short, if the statistician is convinced that a few
people represent the population of those who are ill as a whole, then the number
will be low. If the statistician thinks that many people in the study are needed
to represent the population, then the number will be high.
Here is where we run into trouble, where autism research is concerned. How canresearchers make sure that the children with autism in the study are representativeof all children with autism in the population if we can’t randomly choose thechildren? Any statistician who tells the autism researchers that they need hundredsof children in the study in order to provide accurate results, will effectively
destroy the study. In my opinion, the creation of very large sample sizes for
autism research will occur very rarely if at all (aside from drug trials that areheavily underwritten by pharmaceutical companies). Therefore, the key is to
ask how representative the group of children with autism in the study is to the
population at large. If you think that these children are representative of children
with autism, based on the tests that have been done on the children in the study,
you can feel more confident with the results than if you think that these children

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are not representative of the general population of children with autism. This is
an area where much of the controversy in autism treatment research occurs.
However, even if you believe that a particular autism treatment study does nothave a representative sample of children with autism, there is another way togeneralize the results of the study. This way is through the theory behind thestudy. Theory is of crucial importance if we want to easily generalize the resultsof autism studies, using a small numbers of children (which is the norm in mostautism research). I will address the details of generalizing study results later,
but remember for now that we cannot ignore theory, because using theory isa very powerful way to make the results of a study apply to more than simply
one child.

2.4 Using science to move closer to the truth
What is the next step? We have discussed the concept that a researcher has an
idea and then creates an elegant theory. He or she now has to test the theory.
The challenge for a researcher is to find a way to take a piece of the theory andstructure it so that it is operationally testable. The process of testing theory iswhere science gets interesting and fraud becomes easier to differentiate andidentify.
Testing theory
If you remember only one thing from this entire book, remember this one simple
illustration. For our purposes, this simple question is, in a nut shell, what scienceis all about:

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Does A cause B?
There are many different ways to pose the same question. Examples include:
Does one thing cause something else? Does A cause B to happen? Does A causea change in B? This question above (in all its various forms) is important because
it would be beneficial to know the answer before you provide treatment to yourchild. This question can be represented in the following equation:
A —> BFor our purposes in the autism research world, A in the above schematic is theTreatment and B is Autism. Another way of saying this is that A (the treatment)
causes B (autism) to improve, to be ameliorated, or decrease. B (autism) is
what is called in science, the dependent variable (the D.V.) because how severeor mild the variable is will depend upon A (the treatment). A (the treatment)is called the independent variable (the I.V.) because it is independent of what
happens to the autism. To review: we want to know whether A (treatment)
has an effect on B (autism). We want to find that A (the treatment) ---> B (theautism) to decrease, improve or in the best case scenario, be cured. So now, ourequation looks like this:IV (treatment) —> DV (autism)
In science, both the independent variable (A) and the dependent variable (B)can be anything one cares to test. To make this more concrete, we can use
examples of how this concept works and purposely not use examples from theworld of autism. Instead we can use the following examples (which are used in
any introductory class on the scientific method): Does smoking cause cancer?
Do miniskirts cause bull markets? Does larger class-size lead to lower student
achievement?
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In each of these well-known examples, the first variable is the independent
variable and the second variable is the dependent variable. The hypothesis in
the first example is that whether or not someone gets cancer is dependent upon
whether they smoke. The hypothesis in the second example is that miniskirts
cause the stock market to improve. The hypothesis in the third example is thatlarge class sizes cause students to underachieve. Put simply, the independent
variable can be anything that one believes is causing a change in the dependent
variable, which is whatever one is measuring or studying.
By the way, occasionally autism is actually the independent variable. An exampleof this is when researchers study whether autism causes an increase in the divorce
rate among parents of children with autism. So, the equation in such an instancewould look like this:Child’s Autism —> Increase in Divorce Rate.
Although I’m sure this is a legitimate topic to study (when autism is theindependent variable), this kind of research does not help us protect our children
from autism treatment quackery.**

As an aside, although the scientist side of me thinks that the relationship between the child’s autism and theincreased divorce rate is a legitimate topic, the parental side of me is tired of being studient and analyzed.
There is nothing wrong with us – the problem is that our child has a neurological condition that needs tobe treated and hopefully, with good research, we will eventually find a cure. In my opinion, the limited
research dollars for autism treatment should be spent trying to find the cause and cure rather than to fundresearch analyzing parents’ coping mechanisms. That view, however, is a very anti-science view andcomes from years of frustration over the poor state of the science in autism treatment. Scientists should
not make any value judgments regarding the theory being tested; therefore, I will attempt to control myparental opinions.

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Experiments are not Optional
The bottom line in science is that experiments are truly not optional. In order tofind out whether A really does cause B, or whether a particular treatment causesa change in the autism, researchers need to do a well-designed experimentto lay this question to rest. In other words, an experiment is the only way tocollect legitimate evidence to show that the treatment does in fact improve thecondition of autism, or that it does not improve the condition of autism. WhenI use the word “experiment,” I’m not referring to gathering data or informationfrom something that has already happened and then, retrospectively, making anargument as to why it has happened. I am referring to the setting up of a testing
situation, taking measurements before the study, taking measurements after the
study and then seeing whether there is a change in the autism. Shortly, we will
explore how this is done, but first it must be understood that an experiment must
be conducted before any autism treatment can be taken seriously.
Once the experiment is completed and the data analyzed, the next step is forthe researcher to have the results published in a peer-reviewed journal. If theresearcher has not yet published his or her results, or is not planning on publishing
the results, those results may as well not exist for all practical purposes. Often
researchers say that their results are not published in peer-reviewed journals
because the scientific community is “conspiring” against them. If the results
are significant and the study is well done, chances are that the article will be
published, even if these results go against the prevailing beliefs of the scientificcommunity of the time.
Peer review — necessary but not sufficient
The publication of an article in an academic journal does not necessarily provide
enough evidence to show us that the data collected can actually be trusted. There
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is a range of quality in peer-reviewed journals. Peer review is necessary, but on
its own is insufficient, to trust the efficacy of autism treatment. It is crucial thatthe study is designed and executed competently prior to trusting the results.
The peer-review process is the way editors of academic journals decide whether
or not to publish a study in their journal. Generally, the editor sends an article
that has been submitted to a journal, out to three reviewers. These three reviewers
ideally do not know the name of the author but are in the same academic field
and are competent to evaluate the study. The reviewers critique the study andrecommend to the editor to either accept the article, to have the author revise
and resubmit the article based on the reviewers suggestions for more evaluation,or to reject the article outright.
The peer-review process is important because it typically weeds out poorly done
studies from well-done studies; however, even studies that are peer-reviewed
and not of high quality can end up published in low quality, peer-reviewed
journals or journals that have been established by the very people who desire
their poor quality research to be published. In short, peer review helps ensurethat very poorly done studies do not get published; however, it is certainly nota fail-safe process.
Uncover the funding source for the study
Before analyzing the quality of a study, it is very important to ask the following
three questions: 1) Are the “money people” a disinterested source? 2) Is thefunding source a government department that cares about the outcome? 3) Is
the funding source a company whose profit depend on the results of the study?
In short, it is important to uncover who is funding the study and what theiragenda may be. To illustrate, it is a positive sign if the funding source is the
National Science Foundation or another granting agency, with no vested interest
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in the outcome of the study. Agencies with no interest in a study’s outcome,award the researcher funding because he or she presents an interesting theory
and a competent experimental design. It is difficult to receive an arms-length
government grant if the study design is flawed or the researcher is unscrupulous
or incompetent. The main goal of these agencies is to fund researchers to movescience forward in terms of finding the cause, treatment or cure for autism;*
however, if the funding agency has an agenda, then you must be more critical interms of the quality (and honesty) of the data. If the granting agency is eithera government department that cares about the outcome or a private company
trying to sell the treatment they are researching, it is crucial to be careful about
trusting the data published about the treatment protocol. Biased data only setsscience back; yet it is often difficult to discover whether or not the data is biased.
Occasionally, biased data does get published in peer-reviewed journals; however,this is not the norm.
The most important lesson I have learned from my time fighting the autism wars
is that there are some very intelligent, talented researchers who produce biased
research which they often have published in peer-reviewed journals. These*

As a shorthand, you should know that if a researcher gets a grant from one of the following U.S. or Canadianagencies, chances are that the research is being done by reputable scientists: National Institute of Health(NIH); National Institute of Mental Health (NIMH); National Science Foundation (NSF); Centers for
Disease Control (CDC); Science Research Council of Canada (SRCC); Social Science Research Councilof Canada (SSRCC). In addition, chances are that a government granting agency from a democratic country
awards grants to its most promising researchers. If you see articles from other countries with government
granting agencies from those countries, chances are that this government sponsored research is being doneby researchers who know what they are doing. Many researchers in other countries also apply for U.S.
grants when they are eligible. Government granting agencies look for researchers with track records ofgood research or with affiliation to researchers with good research records. In addition, the research idea
is generally reviewed by two or three other scientists in that field to determine whether or not the idea is awaste of taxpayer money. Note that these government grants cannot be connected to specific government
departments. The minute there is any connection directly to a specific governmental department, theconsumer must be extremely careful about trusting research that is generated from that type of grant.

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competent researchers can legitimately be known as academic mercenaries, goodat the peer-review game but quite corrupt where the search for truth is concerned.
Therefore, peer review in itself is not a sufficient safeguard. It is prudent to besuspicious if the granting agency is a state or provincial health, education or social
services department that actually has to pay for autism treatment; remember, it
is in that government’s interests to find inexpensive treatment options that are
effective and expensive, and, in their view, treatment options that are somehow
experimental or ineffective. Trusting research paid for by these governmental
agencies is dangerous.*
Unfortunately, academic corruption occurs all over the world, not only in Canada
and the United States. One group which we must be particularly wary of is theacademics who evaluate emergent health technologies. They often hide behindthe crests of their respective universities, posing as supposedly disinterested
scholars, when actually they are paid handsomely by government to help ration
expensive health treatments and produce junk science to defeat parents’ autism
treatment lawsuits against government. For the complete story on how one groupof corrupt health technologists discredited a science-based treatment for autism,I encourage you all to read Science for Sale in the Autism Wars: Medicallynecessary autism treatment, the court battle for health insurance and why healthtechnology academics are enemy number one.4 This book recounts the storyof how a group of health technologists succeeded in blocking autism treatment
to the entire population of children with autism in Canada. Remember, before*

The most recent example that comes to mind in the world of autism research is the case where a reviewof the science conducted by health policy analysts to defend government in court was discredited by thesitting justice as being obviously biased and this finding was written into the judgment.2 These healthtechnologists then proceeded to present their findings at an international health policy conference and theirreview was given a half-page mention in the International Journal of Health Technology Assessment.3
Since their review of the science was discredited in July 2000, their article has been relied upon by several
researchers whose works have subsequently been published in other peer-reviewed journals.

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trusting research on autism, it is wise to confirm that the granting agency does
not care about, nor have any vested interest in, the ultimate outcome of theresearch.
Finding the peer-reviewed journal articles
The most efficient way to research a treatment is through a home computer or ina university library. The major databases can be accessed from home (at times
for a fee, but often for free). The following four databases are worthwhile: 1)
MEDLINE – The database “Medline” contains descriptions (also called abstracts)of almost every medical journal article published in the last forty years, from1966. Through a website called “PubMed” you can search the MEDLINE5 for
free; 2) PSYCHINFO6 – This database contains descriptions of most psychology
journal articles published in the last two hundred years, from the 1800s. Fora fee, the articles in PsycINFO can be downloaded through its sister database,
PsycARTICLES; 3) ERIC7 – This database has abstracts of most education
journal articles published in the last forty years, from 1966. Often, the journal
articles can be downloaded free; 4) COCHRANE8 – The Cochrane databases
are comprised of three different databases that include all systematic reviews
and clinical trials on treatments. They include peer-reviewed and unpublished“fugitive” literature (such as unpublished government reports) so they must be
viewed more critically than the Medline or info databases. However, they areuseful because it is important to know what government officials are reading to
influence their opinions about funding or not funding research. If there have been
zero reviews on a specific topic, this suggests that the treatment is so experimental
that no one in mainstream academe has chosen it for review.
These databases are the most fruitful places to look up topics relating to autism.
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depending upon the type of treatment you are researching. Once you have logged
on to the database, simply type in the treatment you are trying to research. For
example, if you were researching Vitamin B6 as a treatment for autism, you
could get started by searching “autism Vitamin B6” in any of the databases
suggested above.
It is important to limit your search to: (1) the exact treatment you are researching,and (2) articles that actually test the method and present data. In addition,occasionally databases allow your search to be limited to peer-reviewed articles
only. Once you identify a manageable number of articles, then a one paragraphabstract of each article can be printed. After reading the abstract, you then must
decide if it is worth finding the article to analyze how the research was conducted.
In our Vitamin B6 example, you would have found approximately thirty-six
articles from the “PubMed” database alone (note that less than half of thesearticles report any data). Although this sounds like a large number of articles tofind and read, it certainly is worth doing the research before you commit yourchild to an autism treatment.

Is the journal peer-reviewed?
It is relatively easy to discern whether or not a journal is peer-reviewed. As
mentioned above, some databases actually specify whether or not the article ispeer-reviewed and allow the search to include only the peer-reviewed journals.
In addition, every journal has a section (generally on the inside front or back of
the journal) describing how to submit an article for publication. Often the journal
will tell you that the papers that have been submitted are going to be subjected
to a “blind review” (where the reviewers do not know who authored the study).
Sometimes the journal will actually describe itself as a peer-reviewed journal.

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However, more typically, the indicators of a genuinely peer-reviewed journal
are a huge editorial board, and the journal requiring five copies of the article
with only the title of the work appearing on the copies that are to be sent to thereviewers (omitting the author’s name). This is done so the editor can send thearticle to a reviewer without the reviewer knowing who wrote the article, i.e.,
blind review. This procedure prevents a scientist evaluating a colleague’s researchfavorably because they may be friends or related professionally in some way.

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2.5 Analyzing a study
At this point, I am assuming that you have access to a copy of the study foundfrom an academic journal, available in a university library or for download fromthe worldwide web. Here is a list of all the questions you need to ask to discern
whether the study would meet minimum criteria to be considered as a welldesigned and executed study. In this section, I go through each of the following
questions, in depth, to help you critically analyze any autism treatment study
you choose to evaluate.
• How many groups are there in the study?
• How many children are in each experimental group?
• How are these children assigned to the groups?
• What is being measured and how?
• Who collects the data?
• Who administers the treatment?
• Could the results have happened by chance?
• Is the study possibly compromised by bias and how can bias be
avoided?
How many groups are there in the study?
The first question to be asked is this: “How many experimental groups are in the
study?” The answer to this question exposes the design of the study as certain
study designs use only one experimental group whereas other studies use two
or more. As parents, it is important to understand experimental design, because
the way an experiment is designed is going to provide information on how andwhether the results of that design can be generalized to all children afflictedwith autism. In addition, the experiment’s design provides information about

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possible bias, and how that bias can creep into the design often without the
researchers even knowing.
There are five common experimental design types: between-subjects design;
within-subjects design; between-within subjects design; factorial design; singlesubject case design. I will walk you through each design type in detail, to allow
you to establish which of the following designs is used for the autism treatment
study in which you are interested. It is important to know the differences among
all the research designs, to see whether or not the conclusions presented canlegitimately be made based on the design of the study. Often, researchers in thefield of autism make statements about treatment that the study design cannot
support. As a parent, in order to make informed decisions regarding autism
treatment for your child, you need to be able to understand the study design anduncover the potential flaws on your own. Unfortunately, we cannot trust manyof the “experts” in this field. In the next section of this book, I introduce thecommon study designs you will see in autism treatment research.
Is it a Between-Subjects Design?
In a between-subjects study design, there are at least two groups, one experimentalgroup (the group that gets the treatment), and at least one other group acting as acontrol group, which does not receive the treatment that has been hypothesized
to work. The data are generally taken on each subject and averaged in eachgroup. Then the averages of one group are compared to the averages of theother group.
The best way to explain this process is through illustration. In all my examples,
I am going to use IQ tests, because most of us are familiar with this measurement
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measures used, in addition to IQ scores. The numbers you see in the following
specific examples are IQ scores, with the approximate scores of thirty and below
indicating severe intellectual impairment, thirty to seventy moderate intellectual
impairment, seventy to eighty borderline impairment and eighty to one hundred
representing the normal range of intelligence.

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Between-Subject Design: Table 1

Treatment Group

Control GroupSUBJECTIQ SCORE

1. Johnny71

1. Cori

43

2. Jim63

2. Jack

36

3. Don105

3. Greg51

19. Dave94

19. Jane67

20. Sue62

20. Ed31

Total: 395

Av. = 79

SUBJECT

Total: 228

IQ SCORE

Av. = 45.6

Here is a typical between-subjects design. Officially, this is called an “afteronly design” as the researcher only measures the group after the treatment.
Technically, researchers can design this type of study if they are extremely
confident that the children in both groups are functionally identical. However,
it is preferable in autism research to take measurements of both groups prior
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to the treatment. This design has twenty children in each group, (twenty in theexperimental group and twenty in the control group). The numbers represent
the results of the children at the end of the autism treatment experiment, after thetreatment has been given to the children in the experimental group only.
Suppose the children in the experimental group have been given a type of therapy
for one month and the children in the control group have been in a special
education class for that same month. Further, let’s suppose that the measure
being used is IQ points. In a between-subjects design, one need only compare
the IQ scores of one group with the IQ scores of the other group in the treatment
experiment. In this example, does it look like the treatment worked? Based on
the average of each group, the treatment appears to have worked. But caution isadvised! Based on these raw scores, this conclusion cannot be made. A skilledresearcher will compare the scores using statistics, to make sure that there truly
is a difference between the two groups. There are several comparison tests that
researchers can use. It is important to know now that a between-subjects design
compares two groups of subjects after a treatment has been administered.
Many people question the importance of a control or comparison group, but
a control group is very important to ensure that a change due to the treatment
actually occurred. The best way to emphasize this point is by example. Let’s
suppose that you may have started autism treatment with a group of children
in September and found within the first week that the behavior of most of thesechildren started to go downhill rapidly. You might logically think that the causeof the slide is the treatment and end the study prematurely. The problem withthis thought process is that you do not know whether the treatment created the
behavior problems or whether the first week back in school, with new teachers
and new routines, may have caused the downhill slide.

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This is an obvious error which, hopefully, no competent researcher would make.
A control group acts as insurance, guarding against other influences that may
render the study meaningless. There are numerous other less obvious influencesthat occur (far less obvious than the example above), but we may not always be
sufficiently savvy to recognize them. These “things” or “influences” are known
as variables. In the above example, the variable of “school opening” was anunintended variable and neither controlled for nor eliminated. If there are twogroups, and both groups return to school at the same time, then the behavior ofboth groups should deteriorate at approximately the same rate. The fact that bothgroups deteriorate or improve concurrently tells us that it is not the treatment thathas caused the behavior change, but something else that is affecting both groups
equally and, therefore, will not affect the study results (because the results all
have to do with comparing one group to the other). In short, a good study design
must have at least two groups where one group receives the treatment, the other
does not. Each group’s results are then measured, averaged and compared in
the post-experiment analysis.

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Is it a Within-Subjects Design?
A within-subjects design has no control group. The subject is measured before
the treatment and then after the treatment, or at different points in the experimentand then after the experiment. The pre-treatment scores are compared to thepost-treatment scores.

Within-Subject Design: Table 2
Child

PretestPost-test

Difference

1. Johnny

43

73

+30

2. Jim

36

61

+25

3. Don

51

105

+54

19. Dave

67

94

+27

20. Sue

31

62

+31

Average:

45.6

79

+33.4

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In this within-subjects design, note that there is no formal, separate control group.
The comparison is between the child’s score prior to the treatment and the samechild’s score after the treatment. In this kind of research design, the child acts as
his or her own control. This example is the most simple within-subjects design
because the children are only tested once before, and once after the treatment
is administered. The main analyses that need to be done in this case are to see
whether or not each child improved. The following two analyses could easily
be done in this instance: (1) The pre-treatment scores of all the children could
be averaged and compared to the posttreatment scores averaged; and (2) eachchild’s pre-treatment score could be compared to that child’s post-treatment
score so that the improvement could be observed for each child. From what we
can see in Table 2, you would think that the treatment looks very good. Keepin mind, however, that we still need to use statistics to make sure this is indeed
the case.
The main problem with this type of design is the other variables that may
influence the outcome of the study. To illustrate this point, let’s consider thisexample: children with autism are often affected by the seasons. Some of ourchildren do much better in the spring than in the fall (we do not know why, but
this has been observed). If the study occurs over a one-year period, we may see
behavioral peeks and valleys that correspond with the seasons, rather than withthe treatment. Therefore, a researcher may incorrectly conclude that strawberries
help autism because during strawberry season, the child improves! As ridiculous
as this kind of reasoning may seem, researchers are regularly making logicalerrors such as this; they confuse correlation with causation. The jargon for thistype of error is called a “causal fallacy.” The world of autism “treatments”
are chock full of these causal fallacies, so please be forewarned that without acontrol group, researchers must be much more sensitive to external influences
than when there is a control group used in an autism treatment experiment. The
advantage to a within-subjects design is that the control group is identical to the396Section Two: How Do We Know What Works and What Doesn’t?

experimental group because the child acts as his or her control (as we compare
the child’s own scores prior to and after the treatment is administered). However,the disadvantage is that there is no control group separate and apart from thechildren who receive the treatment.
To summarize, a within-subjects design has only one group. The children aremeasured against themselves before and after the treatment. However, there isno separate control group of children who do not receive the treatment.

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Is it a Between-Within Subjects Design?
A between-within subjects design (in my view, the ideal research design), has
two groups, an experimental and control group. In this design, the two groups
are compared to each other, and each individual child’s pre-treatment scores arecompared to his or her post-treatment scores.
In my opinion, this is the best type of research design because it gives researchers
more information on what they are studying. To illustrate, if a treatment works
on only half of the experimental group, and the scores of the other half of theexperimental group do not change, then by analyzing each subject’s score before
and after the treatment, we can find out which subjects improved and which
subjects did not. Then we can ask the question: “What makes those children
who improved different from those children who did not?” The next experiment
would then use only children with those characteristics indicative of the groupthat improved in the original experiment. These children would be assigned toeither the experimental or control group. This second experiment would thenyield better results (if the treatment is indeed effective). A much stronger result
would move the field closer to discovering new treatments for a subset of children
with autism. In addition, we would know which children benefit most fromthe treatment and then study the children who do not benefit, and ask ourselves
why. We would be able to develop another area of research using the subset ofchildren who did respond to the treatment in the experiment.
Below is an example of a between-within-subjects design. There are two groupsof children (an experimental group with twenty children and a control group withtwenty children). Each child’s IQ is measured before the treatment begins andafter the treatment has been administered.

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Between -Within Subjects Design: Table 3
Experimental Group D

Control Group D

PretestPost-test

PretestPost-test

1. 43

73

+30

1. 41

44

+3

+27

2. 36

61

+25

2. 39

38

-1

+26

3. 51

105

+54

3. 53

57

+4

+50

19. 6794+27

19. 64

66

+2

+25

20. 3162+31

20. 34

37

+3

+28

33.4

T = 46.2 T = 48.4

2.2

T.D. = 31.2

T = 45.6 T = 79

Difference
btw. groups

Note that the children in the control group are tested at exactly the same timeas those in the treatment group (before and after the study). The children in thecontrol group do not receive treatment (although, depending upon the study
design, they may receive what is typically available for children with autism inthe public health or educational system). We analyze the data in the following
way: 1) the total scores of each group before the study are compared (to makesure there was no difference between groups) then after the study (to see if theexperimental group improved as compared to the control group) and 2) eachchild’s scores before the study are compared to his own scores after the study.
Note the “Difference Between Groups” column. In this design, the researchers
also matched a specific child in the experimental group with a child in the control
group and then compared these matched children’s score as well. Matching
two children before assigning one of them to the experimental group and theother to the control group helps further ensure that the two groups are similar

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prior to the treatment being administered. A research claim that the treatment
is responsible for the difference can then be concluded with more confidence,as the groups were similar at the beginning of the study. Matching children isdone occasionally in autism studies.
Why would we want to do a within-subjects analysis as well as a betweensubjects analysis of an autism treatment study? As I mentioned above briefly,
this design allows us to see if some children in the experimental group benefit
more than others. If there is an effect (or, put simply, the treatment works), thenit will show up in the analysis, and will not be drowned out by the data of thechildren who did not respond to the treatment. Take the example of secretin. If
one suspects that secretin has an effect on only 5% of the children with autism(the children with compromised gastro-intestinal systems), a good researcher
would design a study with an in-depth, sensitive analysis of each subject and hisor her scores before and after the treatment. The researcher would never find theeffect of secretin if not for the within-subjects design because the effect would
be diluted among the children in the experimental group who did not improve.
However, a quality experiment would also need the control group’s influence tomake sure that the effect wasn’t caused by something else. We will later discuss
other variables that could possibly confuse researchers to think that there is aneffect, when in fact there is not. The important point here is that by measuringchildren before and after treatment, we can discern: (1) whether the treatment iseffective at all, and (2) if it is effective, for which children.
To summarize, this design has at least two groups of children. Each group’s
results are measured and compared, and each child’s pre-treatment results aremeasured and compared to that child’s post-treatment results.

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Is it a Factorial Design?
A factorial design is rare in autism research; however, it is important to know
about this type of study design if you ever need to evaluate a study which uses
this type of design. A factorial design is simply an experiment where two or
more treatments are being tested at once, and the groups act as controls for eachother. For example, if researchers think they have two treatments that work
for autism, but they want to see if each works alone and/or in combination witheach other, a factorial design would be the design of choice.
Factorial designs are common in drug trials when researchers test two or moredrugs at once. The researcher may want to know whether Drug A works betteralone, or in combination with Drug B, and also, whether Drug B works betteralone or in combination with Drug A. The more drugs that the researchers needto test together, the bigger the study will be. Factorial designs can use morethan two drugs at a time. However, more conditions are required when a larger
number of drugs or treatments are tested. A simple two by two (2 x 2) design(using two drugs) will have four conditions.
Factorial Design: Table 4
Condition 1:
Drug A Given
Drug B Given

Condition 3:
Drug B Given Only

Condition 2:
Drug A Given Only

Condition 4:
No Drug Given

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A three by two (3 x 2) design (using three drugs) will have six conditions (sevenconditions if a no drug condition were included or eight conditions if there werea condition in which three drugs were administered at once).
This table illustrates a factorial design with two different drugs tested (the simplest
factorial design). Here we can think about our thanksgiving dinner example earlier
in this section where we could test the turkey and the pumpkin pie in the same
experiment. Imagine the turkey is A and the pumpkin pie is B. In a more realistic
scenario, in the case of AIDS, for example, where a drug cocktail needs to betested with more than three drugs, the experiment would have a greater number
than four conditions. The beauty of a factorial design (even a simple one) isthat researchers can discern whether: 1) one drug is effective; 2) both drugs are
effective; 3) if neither is effective alone but are very effective in combination,or 4) that neither treatment or drug is effective. In the case where two drugs ortreatments are more effective together than each one alone, this is known as aninteraction effect because the results are due to the interaction between the twotreatments, rather than each treatment alone.
To summarize, in a factorial design, there are at least four groups and two or
more treatments are compared at once. This is a very good design to compare
treatments because the study can tell us whether two or more treatments, given
together, are better than only one treatment given at a time.

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Is it a Single-Subject Case Design?
A single-subject case design (SSCD), also referred to as a single-subject research
design (SSRD), is simply an experiment that uses a single subject (although many
SSCDs may use a small number of subjects rather than one subject). I’m certain
almost every parent of a child with autism has seen or heard of this type of research
design. It is very common in autism research among legitimate clinicians but,unfortunately, among the kooks as well. Due to the overreliance of SSCDs among
pseudo-scientists, it is important to recognize the proper use of SSCDs.
The vast majority of studies done in the field of applied behavior analysis andin rehabilitation research (used by occupational therapists and physiotherapists)are single-subject case designs. Single-subject designs are ideally suited for apatient with an injury and the treatment plan for the person is individualized. In
this case, the use of SSCDs is to rehabilitate that one patient, not to generalizethat treatment plan to another patient or a population of patients with the same
diagnosis.

Single-Subject Case Design: Table 5
A: Treatment

70 IQ

B: Withdrawal of Treatment

50 IQ

A: Treatment

70 IQ

B: Withdrawal of Treatment

55 IQ

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Before describing this type of research, it is worth mentioning that researchers
who legitimately use SSCDs often believe that they are being unfairly attacked
by the scientific community; there is ongoing debate about how this kind ofresearch should be properly used. That said, there is consensus in science thatsingle-subject research is useful in clinical settings, but that it is not appropriate to
generalize specifically from one single-subject research design to the population
at large, which unfortunately happens in autism research a lot!
There are advantages to single-subject research designs versus other study
designs. The first advantage is that the experimenter uses the person as his own
control by comparing that person’s data before the treatment and immediately
after the treatment. Using the same person removes all the possible errors thatcan occur from random, individual differences among people. When modifying
behavior, this design typically observes behavior on a few different occasions
prior to introduction of the treatment. Many researchers conducting an SSRDtype study will then use statistical analysis to ensure that there is a true difference
between the “before treatment” and “after treatment” data. Other researchers do
not use statistics to see the results; they simply look at a graph showing the data
points before and after the treatment (those using statistics are often criticizedbecause there is a debate about which statistical tests are appropriate to use).
These researchers claim that SSRDs are actually better than the other designs
because the internal validity is high - there is no variability between children in
the control and experimental groups because the control and the treatment aredone on the same person.
The hypothetical design above shows a child who enters treatment for six months
and then is given an IQ test. The child is then denied treatment for a year; his
IQ is subsequently measured. The child then enters a treatment program foranother six months and his IQ is measured once again. The child is once again

404Section Two: How Do We Know What Works and What Doesn’t?

taken out of the treatment program for another year and his IQ is subsequently
measured. From this kind of design, we could clearly see whether the child wasbenefiting from treatment, and regressing when not in treatment. For that one
child, it would appear as though the autism treatment has a very strong effect.
For clinical decisions, the single-subject design is very compelling, as we are notgeneralizing to the population at large; rather, we are simply making a clinicaldecision about what treatment does or does not work for that specific child.
When single-subject designs are used in that manner, they do a true service tothe child.
This is particularly true in the case of autistic individuals with self-injurious
behaviors. If a clinician uses techniques to eliminate self-injurious behavior, do
we really care about the fact that there was only one child in the study? Obviously,
we care that this treatment worked for this individual and has now given the childa life with no physical restraints; the individual can go out into the community
with the family. When these kinds of studies are published, they are incredibly
beneficial to other clinicians, offering new and valuable tools in the kit box foruse when the clinician is presented with a similarly self-injurious client.
Single-subject research designs are also very useful because they motivate
different kinds of research which attempt to generate causal relationships. In
fact, a small SSRD-type study using two children, actually motivated Lovaas
to do a large scale between-within subjects design which became the very wellknown autism treatment experiment published in 1987.
To summarize, a single-subject research or case design uses one person in theentire study. This design is common in autism research and is useful in clinicalsettings, but controversial if used improperly by generalizing to the whole
population of children with autism.

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What’s the problem with Single-Subject Case Designs?
There is no debate regarding the importance of the single-subject case design,when used properly; however, it is used improperly all the time. Particularly
troubling is that the single-subject case design method of research is used heavily
by “quacks” because it is cheap and easy to do. These practitioners only needto find one child to experiment with and a mere anecdote, now dressed-up as
genuine research, can quickly morph into a poor single-subject case design. In
addition, case studies often masquerade as single-subject case designs (which
is a problem due to the lack of rigor in a case study).
Another problem among some researchers is their claim that single-subject
designs show A causes B within the general population of children with autism.
Under certain conditions, it is fine to say that a child improved due to thetreatment, if proper experimental controls or safeguards have been put into
place. When this happens, the “Therapeutic Criterion” or the treatment value forthe subject has been met. Unfortunately, from that one child, one cannot makegeneral statements about how effective the treatment would be in general. In
short, the “Experimental Criterion” has not been met from one or two or eventhree single-subject research designed experiments. Single-subject designs are avery valuable way to treat individual clients and probe to see if it is worthwhile
creating a between-subjects experiment with a larger number of subjects (as in
Lovaas’ research mentioned above). If, indeed, we want to generalize results tothe larger population of children with autism, or in other words, want to meetthe experimental criterion, we need to do between-subjects designs with larger
numbers of children. There is no legitimate way to get around that type ofnecessary scientific heavy lifting in autism treatment research.
Proponents of the single-subject case design argue that the solution to thegeneralizability problem is to do many replications, and in this way show406

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that the result can be generalized to the population of children with autism.
They would argue that their studies are equal to between-subjects designs interms of generalization as long as both types of studies replicate their results.
Theoretically, this is a compelling notion; however, in practice it is rare to seea large number of single subject study designs replicated in the field of autism
treatment research.
Researchers who use the SSRD method are also generally proponents of metaanalysis. In a meta-analysis, the researcher combines the results of a large numberof single-subject studies to determine if a given treatment is effective. This isdifficult to do well and has some methodological problems associated with it, but
it is a much better way to add to the body of knowledge in autism research than
generalizing through one single-subject research design (a definite no-no).
Other critics, such as Furedy,11 are adamantly in their opposition to the use of thistype of design. Furedy states, “The ‘single-subject’ design (which really denotes
a design that employs too few subjects to allow statistical inferences concerning
significance to be made) is useful only for the generation, but not for the testingor evaluation, of hypotheses concerning any psychological functions.” Simply
put, critics like Furedy are saying that the problem with single-subject research
designs is that there are not enough children in the study to make sure that theeffect is real, and that the proper use of the single-subject research design is togenerate interesting ideas to test properly.
Although we are not going to end the long-running debate regarding theshortcomings of single-subject designs in autism treatment any time soon, it issafe to say that there are too many methodological problems associated withthis type of research design to rely on its results, exclusively, to generalize
an autism treatment protocol to the autistic population at large. In my view,
single-subject designs are relied upon far too heavily in autism research, often
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by pseudo-scientists. The main points to take away from this discussion arethat there are legitimate researchers using the SSRD method. However, makesure they are using the design in the way it was intended and not simply using
a single-subject case design for quick and cheap research to hoodwink you into
providing a treatment for your child that has not been properly substantiated with
sufficient scientific data. In addition, you can “take it to the bank” that it is notscientifically valid to generalize to the entire population of children with autism
from one single-subject design. Please be careful!
How many children should there be in eachexperimental group?
The answer to this question is very important for any consumer checking
out autism treatment. The answer depends upon the goal of the research. If
researchers plan to generalize their results to the population of autistic peopleor the population of autistic children, then they have to be relatively certainthat those children with autism in the study are similar to autistic children in
the general population. The more representative the experimental group is tothe population at large, the less children are required in the experiment. As
mentioned previously, autism is a spectrum disorder, and children with autism
can be affected to a greater or lesser extent. Therefore, the degree that children
with autism in a study represent the population at large is always a concern forcompetent researchers.
What is the ideal number?
As a general rule, the less the children in a study are representative of all children
with autism, the larger the number of children will be required in that study. Put
differently, if researchers are not using pretreatment measurements to clarify the408Section Two: How Do We Know What Works and What Doesn’t?

type of children with autism in the study, then the larger the group, the more
confident we can be that these children represent the population of children
with autism as a whole. However, we are still not very confident. To avoid thisproblem, in well-conducted studies, researchers do extensive testing to measure
the severity of autism of their subjects before they administer the treatment. If
we generalize the results of each study through the theory the researchers are
testing, and we use an experimental and control group as we discussed earlier,then we avoid this problem providing the experimental and control group are
the same at the outset of the study. In autism research, the number of subjects ineach study is so small and generally without a control group. The big questionof the ideal number becomes problematic.
What is acceptable?
The short answer is this: it depends. If you want to generalize autism treatment
research results directly from a study to the population at large (like researchers
do in drug trials), then you need to have confidence that the children in the study
are truly representative of all the children out there who are afflicted with thedisorder. However, if one generalizes through a theory, then twenty subjects
per condition would be considered a very respectable number. Obviously,
thirty subjects would make us even happier; however, the more unrealistic thenumber of children required for an autism study, the smaller the likelihood thatthe research will actually be conducted. Even twenty children per conditionin an autism study is almost unheard of (unfortunately) and would be a very
respectable goal. The results of each study would then be considered an instance(known as “instantiation”) where the treatment was deemed effective. On theother hand, a negative finding would have to be explained by the theory. Or thetheory would have to be modified to explain the finding. Or the theory would
need to be wholly rejected, in which case the treatment based on the rejected
theory would properly need to be discarded.
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How are children in a study assigned to theexperimental groups?
I am certain many have heard that the most important thing a researcher can dois to randomly assign subjects to experimental groups. The idea behind random
assignment is to ensure that the groups (the experimental and control group) are
the same at the beginning of the study to guarantee that the treatment indeed has
created the differences we may see post-treatment between groups. Random
assignment avoids any possible confusion that any post-treatment differences
between the groups may have been caused by the group assignment procedure.
The easiest way to ensure group equivalence is to randomly assign subjects. Thiscan be done through assigning subjects based on a random numbers table in theback of any statistics book. Today, researchers also use a computer generated
random numbers program. Random assignment can be done very easily, withthe presumption (ethical caveat) that the treatment is not already well established
as being effective. Random assignment is also simple to do with college students
who volunteer for a psychology experiment. If our children were laboratory
mice, we could always randomly assign them to control and experimentalgroups. But our children are not animals. They are our precious children; notonly are they children, but they are disabled children. They are amongst themost vulnerable populations to study and their human rights must be protected
at all costs. Therefore, random assignment in autism treatment studies is notalways ethically possible.
Here is where we wade into the serious issue of ethics in random assignment
for children with autism. To bring this example home to parents, think about
the following: if I believe that my child will benefit from a treatment due topreliminary published results from a study, and that treatment is considered more
effective the earlier it is started, then I will not allow anyone to randomly assign

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my child because I refuse to put my child into the control group (the children who
do not get the treatment). The researcher also has an ethical obligation to tell methat there is evidence the treatment is effective. In addition, that researcher mustalso provide children in the control group with something equally effective inorder to conduct the experiment. To provide an example of how important ethics
is in research, a study on spina bifida comes to mind. The experiment included
pregnant women, who had previously given birth to a child suffering from spina
bifida. The women were separated into a treatment and a control group. The
treatment group received folic acid and the control group did not. It becamevery clear that folic acid was preventing spina bifida; therefore, the researchers
were compelled to stop halfway through the experiment and give all the women
folic acid; otherwise, the women in the control group would have given birth tochildren with spina bifida at a disproportionately higher rate!
The above example illustrates how difficult random assignment can be,
particularly in terms of study replications. Unfortunately, these ethical rules
are breached often with autism. Reputable researchers are understandably
very concerned about this issue. To avoid the problem of assigning a groupof children with autism to a control group, some researchers make due witha treatment group only. One way to avoid pure random assignment is to use
something out of the researcher’s control to determine that subjects are assigned
randomly; placing children in the treatment group when there is grant money
for the experiment and putting children in the control group when there is nomoney is one example of functional random-assignment without breaching ethicalstandards. When pure random-assignment cannot be done ethically, many tests
need to be conducted to ensure that the groups are functionally the same at theoutset of the experiment.
The vast majority of unsubstantiated treatments for autism could easily be tested
through random assignment, as there are no preliminary results to suggest that411

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any of these so-called treatments are effective. It would certainly help parents
to better evaluate the effectiveness of many of these experimental treatments.
However, in the area of behavioral treatment, it is unethical to randomly assigned
children to experimental and control groups because the data showing efficacy of
behavioral treatment and applied behavioral analysis is, at this point, very strong
and clearly out of the experimental (i.e., research) stage. In other words, basedon our knowledge of the state of science in autism treatment, denying children
with autism behavioral treatment to test a completely unsubstantiated treatment is
ethically unacceptable. At the date of this publication, we still have researchers
randomly assigning children to experimental and control groups where neithergroup receives behavioral treatment. Parents do not get full disclosure about
the proven effectiveness of behavioral treatment for autism. Tragically, this issomehow considered to be ethically reasonable by some government-funded
researchers.*
In sum, researchers tend to compensate for the problem of their inability torandomly assign children to conditions, by matching groups and using quasirandom assignment. However, even this is ethically questionable in the caseof behavioral treatment, as this treatment is already considered best practice.
Unfortunately, governments often refuse to accept the science behind thismethod and refuse to fund this form of treatment. Therefore, government-funded
researchers all too often engage in unethical research practices, and thanks topolitics, are able to continue doing so to the exclusion of science. Until bestpractices in autism treatment are firmly established amongst policy-makers andgovernment-funded academics, the unethical research practice of assigning
children to control groups in studies testing behavioral treatment will regrettably
continue.
*

For a discussion on the conduct of government-owned academics and their argument about
the ethical justification for assigning children with autism to experimental and control groups,
Science for Sale in the Autism Wars9 lays out the case in some detail.
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What is being measured and how?
The next question that must be asked in evaluating any study is this: “Howare the variables being measured?” The first variable which we spoke about
earlier, is the Dependent Variable (DV). In our case, the DV is almost always
autism, which needs to be operationalized. In other words, for the purposes ofthe study, the researcher must actually measure the degree to which the child isaffected by autism, before and after the intervention.
Autism (the Dependent Variable)
How do we turn autism (which we live with every day) into something that canbe measured. Remember, we need to measure autism in order to know whether
the child with autism has improved as a result of the treatment being studied in
an experiment. We also need to be able to measure autism in case the autistic
child’s condition worsens during any intervention.
We must measure autism in such a way that the amount of autism (or the severityof autism) is the same, whether I measure it, you measure it or a randomly
selected researcher measures it. It cannot be a mysterious kind of measurementthat only people with “special” powers can do. Autism needs to be measured ina standardized way so that regardless of who measures it, the results are the same(as long as the person can be trained to use the measurement tools properly).
Good researchers use a variety of tests that have themselves been tested again
and again to ensure that they accurately measure degree of autism.
Unfortunately, autism is more difficult to measure, as compared to many
conditions or diseases, because the diagnosis of autism is behavioral and notbiomedical. Put simply, we can’t use a blood sample to establish the degree of413

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a person’s autism. Therefore, testing autism properly creates some challenges.
To meet those challenges, researchers use many well-established IQ tests anddevelopmental measures, as well as autism-rating scales. In addition, researchers
often measure the children’s behavior using time. For example, some researcherscount minutes children are engaged in self-stimulatory behavior and see whether
the amount of self-stimulatory behavior diminishes after treatment. Any study
that uses a large number of measures (that make sense to you) is one sign ofa well-done study. It is a good idea to be skeptical when someone uses a newmeasure or a biological measure for autism in the study. Many parents are often
mislead when someone with a PhD after their name uses a biological measure,
lulled in the belief that a “hard” biological measure can somehow measure autism
accurately. Suspicion is particularly warranted when a study uses a biologicalmeasure without any behavioral measures. In addition, if you see a study thatuses a biological measure and a behavioral measure, and no findings are reported
for the behavioral measure, but findings have been observed for the biologicalmeasure, this discrepancy should be a red flag. How could such a finding occur.
Why would the finding be significant in decreasing the level of autism? Peptides
used in vitamin research are an example of a way to measure autism that has noscience behind it, at least at the time of this publication.
Tests used to measure autism often include the diagnostic criteria from the
Diagnostic Statistical Manual (DSM), a number of standardized tests such as(but not limited to) the Autism Behavioral Checklist (ABC) as well as a varietyof IQ tests. IQ tests do not diagnose autism; however, used in conjunction withother tests, IQ measures provide researchers with some idea of whether the childis on the autism spectrum. This is done by looking at the child’s testing patterns,
i.e., whether the child has peaks and valleys in ability or whether the child’sscores are all consistent. Peaks and valleys would typically show a patternindicating autism, whereas flat, consistent scores would typically signify other414

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kinds of disorders (such as mental retardation). In addition, researchers may try
to measure autism by simply counting how often certain symptoms occur, e.g.,
within a number of twenty-four hour periods or a number of one-hour periods.
Behavioral measures are common when a study is looking into techniques todecrease aggression or self-stimulatory behavior, e.g., researchers may count
how often a child has tantrums in a twenty-four hour period.
The bottom line is that when reading a study, make sure that you agree witha basic premise: the way researchers have measured autism. In technicalterms, evaluate the way the dependent variable has been “operationalized.” If
researchers are measuring autism in a novel way, pay special attention to how
they justify this new measure. Measurement of autism is crucial, because if
study results do not change any of the measures of autism that make sense, thenthe positive results based on their novel measurement of degrees of autism aremeaningless. The level of autism has not changed based on the well-established,reliable, observable measurements of autism. In other words, they can claim that
their new treatment improves autism based on the way they have measured it.
However, when this treatment is given to children who have autism (measured
in the traditional way), the children’s behavior remains the same. If a novel
improvement in the way we measure degree of autism were developed, I would
expect that there would be some overlap with the older behavioral approaches.
In addition, for any new autism measure to be widely adopted, it is importantthat it be tested and then published in a peer-reviewed journal, to demonstrate
its superiority over other measures.
Treatment (the Independent Variable)
The next challenge for any researcher is taking the concept of the treatment andmaking it possible to actually administer. This process is very straightforward
when researching vitamins or drugs. The researcher may spend time on producing
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the treatment, but once the drug or vitamin is produced, then administering the
drug or sugar pill (placebo) is a simple thing to do. It is much more difficult
when the treatment is non-drug or non-vitamin-related. Do not trust treatment
professionals who claim that only their special people can provide the treatment
and that their technique cannot be taught without buying into the philosophy. The
treatment protocol must be thoroughly documented through treatment manuals
and/or videotapes. That is not to say that people administering the treatment do
not need to be highly trained, but rather, there must be an opportunity for others
to be highly trained and a documented protocol followed. Many so-called autism
treatments that are unsubstantiated do not have treatment protocols (documented
treatment methods), and therefore, do not have an objective way to ensure thatthe treatment protocol is being followed. In short, please make sure that the way
the treatment is operationalized: (1) makes sense; (2) is objective, and (3) canbe evaluated whether or not it is being stringently followed.
It is also important that the various outcome measures for autism used in the
study measure the degree of autism consistently. This criterion is called “internalconsistency.” Put simply, if the first measurement shows that the child’s autism
is severe, the second measure should also come up with similar results. If one
measure indicates that the child has severe autism and the next measure showsthat the child is mildly autistic, there is a problem with one of the measures, andthe internal consistency of autism (the dependent variable) is problematic.
In addition, the outcome of the measure must be the same, regardless of when theoutcome is measured. In other words, the way we measure autism must always
give us the same results, whether the child is measured in the morning, noon ornight, or in the winter or summer. If a researcher uses a rating scale to measure
autism, we need to have confidence in the consistency of the child’s score (before
the treatment is administered). Obviously, the more consistent the measure, themore confidence we can have about relying upon it.
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As mentioned before, a key characteristic regarding the measure of the degreeof autism is that the outcome must be the same regardless of who does themeasuring. This is called inter-observer reliability. In other words, thoseobserving the behavior must record it in the same way (give it the same score).
When inter-observer reliability is high, we can be more confident that the degreeof autism is being measured consistently and properly during an autism treatment
experiment.
Even if the measure is reliable, we have to then ask ourselves: Is it valid?
Another way to look at this is by asking this question: “Does the measure really
capture the essence of what autism is and how it has changed as a result of thetreatment?” Put simply: Is autism measured accurately throughout the study?
This is a significant issue in autism studies because autism is difficult to measure.
I’m typically put at ease when I see a study that has used a large number ofdifferent ways to measure autism. The use of many measures to establish
degree of autism, in the same study, is the way researchers make certain themeasurement of autism is as valid as possible, considering that we do not havea biological way to measure autism at this time. To grapple with this problem,
autism research uses many autism measurement scales that have been tested andrefined to improve the validity of the measurement.
The validity of the Treatment (the Independent Variable) is also important. HereI am referring to the treatment actually affecting the degree of autism, and not
another variable that has little to do with the treatment, but appears to occur atthe same time. For example, Dolphin Therapy is hypothesized to be effective
for children with autism because dolphins are thought to communicate (in somemysterious, secret way) with our children. More likely, however, is the thesisthat perhaps dolphins are simply reinforcing to most children with autism, andtherefore, children are more likely to pay attention and learn a skill when in

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the pool with a dolphin. It may be the reinforcement, rather than the intrinsic
powers of the dolphin, that is important for researchers to discern. In short, thevalidity of the treatment must be considered (and shown to be considered) inevery study.
Who collects the data?
Much of the research done in autism treatment is highly flawed with respect todata collection. Although as many as 90 percent of autism researchers might
disagree with me, I am going to suggest that parents should never collect dataon their own children. The reason researchers are going to vehemently disagreewith me on this point is that it takes away all their no-cost manpower for thestudies. Despite the manpower issues, I submit that parental reporting is adisastrous research practice. Scientists know that “no data is better than baddata,” because very poor decisions may be based on bad data. Therefore, if wehave bad data, we will make bad decisions. You may ask why I am so firmly
against the notion of parents collecting data. It’s quite simple: parents have many
motivations for studies to succeed or fail. Some parents are so desperate andhopeful for the magic pill or treatment to work that when they collect data, they
may inadvertently influence the data, without being aware of this. Conversely,
parents can collect biased data and be quite aware that they are doing so, often
understanding the personal, economic implications of a positive or negative result
when data collection may be associated with government respite or treatment
services.
As a parent, I would never trust myself to take treatment data on my own child.
I would be completely unable to do so because I am so invested in the outcome(even though I would try to be objective). I am quite sure, however, that if I
were sufficiently trained, I could do a fine job taking data on your child. This

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reticence of mine, to take data on my own child, is to avoid creating a selffulfilling prophecy. A self-fulfilling prophecy occurs when the experimenter
unintentionally biases the results of the study to confirm the hypothesis.
If you ever need any justification regarding why parents should never take dataon their own children, the following example is but one instance of a parent’s
self-filling prophesies biasing a study. At a large, prestigious hospital in a major
metropolitan area, there was a study done on melatonin (a hormone that is thought
to help regulate sleep among children afflicted with autism). In good faith, theresearchers gave melatonin to parents of children with autism, to administer
thirty minutes before bedtime. The parent was to track the sleep patterns of thechild over a two-week period. What’s wrong with this study? What if I told
you that this was a public hospital? Does that give you any more clues? What
if I told you that in the same region, respite monies from the government weretied to amount of time that the child slept, and that sleep problems were the only
criterion that would realistically qualify most parents of children with autism
for the respite money?
In this type of research design, we have set up the perfect dilemma for the parent.
Parents cannot report on their children’s improvement in sleep to these researchers
because they fear their respite monies may be rescinded. I can guarantee thatthese researchers had no idea that this was occurring among some of the parents,
as the researchers had no intention of passing along the sleep information. In thisillustration, it is easy to conclude that melatonin’s efficacy was most probably
under-reported. In the case of melatonin, that is unfortunate, because melatonin
is a supplement which pharmaceutical companies will not spend time and money
to research because there is no profit to be made from it, (it is inexpensive andwidely available from health food stores). Therefore, this rare opportunity toobjectively test the efficacy of melatonin has been biased toward the hormone
having less positive effect on sleep than it may truly have.
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Who administers the treatment?
Illustrations such as the melatonin example above justify the notion that parents
should not administer the treatment nor record the data on the treatment.
Unfortunately, a study becomes much more expensive when the parent cannot
administer the treatment because the researchers must hire research assistants,
rather than use free parent labor. Aside from poor data recording, parents arealso not as reliable administering the treatment because they have hectic lives.
In addition, I do not trust all parents to provide the proper treatment dosage thatis recommended, because if a parent does not see results, he or she may double
the dose. Remember, we are dealing with a population of parents who may bechronically sleep-deprived and desperate to see positive treatment results fortheir children.
It is the researchers from a study (and not the parents) who are best suited toadminister the treatment and record its data. In addition, those recording the data
should not know which children are in the control group and which children are
in the experimental group of an autism treatment study. In other words, blind isbest. This is particularly important for those taking data at the beginning andupon completion of the study. It is not always possible to hide the experimental
condition from those administering the treatment, particularly if the study lasts
for years, but this should nevertheless be the goal. The less those taking thedata know about the study, the higher the probability that bias will not creep
into the study.
Another good example why those recording the data should not know whichchildren are in which group and why parents should never collect data, is a study
conducted in Manitoba.12 The design of this study was well done. Children
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group before and after the treatment. A psychologist evaluated the children andfound that there was no change in the degree of autism of the children in bothgroups (which means that the intervention or treatment was not successful).
The psychologist used a very well-known test to measure autism (the Autism
Behavioral Checklist — the ABC). In addition, the parents were asked to evaluate
their own child’s progress. The parents reported a very different finding from thepsychologist: they saw improvement in their child. This was true of the parents
whose children were in both the treatment and control groups; however, there wasno difference between the children in the treatment and control groups! Parents
so desperately want to see improvement in their children’s condition that they
perceive improvement when it may not actually exist. In contrast, the psychologist
in this particular study was blind to which children received the treatment andfound no improvement across conditions, which means his conclusions were notbiased by group assignment.
Did research results happen by chance?
Once we are presented with the results of a study which compare the scores of twogroups, then we need to know whether those results are meaningful or whether
they happened by chance. To answer this question, researchers use statisticalmeasures. They ask themselves: “What are the odds that this effect happened
by chance?” In addition, they use something called a “p” value. You may reada study that says, for example, “children in the experimental group increased
their IQ by an average of 20 points, (p = .05).” The p value indicates that on
the basis of probability, ninety-five times out of one hundred, this result did not
happen by chance. Or in other words, five times out of one hundred, this result
may have happened by pure chance. Therefore, the lower the p value in a study
publication, the better. When a researcher presents a finding supported by a pvalue of p = .00001, that is fantastic! This means that the odds that the outcomeof the experiment happened by chance are virtually nil.
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Why should we care about p values? When one evaluates a treatment for autism,
and the Between-Subjects Designed Study either does not have p values, or thep values are .07 or higher, one needs to think about whether those findings are
sufficiently robust. In other words, are the findings of the study correct? In
short, the smaller the p value, the more confident one can be that the results ofthe study do, in fact, reflect reality. Another statistical term that is reported oftenwith p values is the Standard Deviation (SD). For our purposes, it is important toknow whether the SD is large within the group (meaning that the average scoreof the group is quite different from each child’s individual score). If the SD islarge, that means that the average score does not accurately reflect each child’sscore, which indicates a less reliable finding.
Is the study biased and how can bias be avoided?
Many designs (such as some Single-Subject and Within-Subject Designs) sufferfrom flaws that can call into question the entire study. Bias may be created by
the experimental design, yet the experimenter may have no control or may noteven know about the bias. It becomes unclear whether the treatment is causing
the result or whether there is something else causing the result. One of thesetypes of bias is called history.
Bias Type 1: History
History refers to something that has happened between the pre-test and post-test,of which the researcher is unaware. For example, perhaps at the same time as a
vitamin experiment was taking place, some of the parents in the study went toa lecture on behavioral treatment and started a behavioral treatment program.
Enrollment of the children into another program was not controlled by the
researcher, who did not know that the child received another treatment at thesame time as the vitamins were administered.
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Bias Type 2: Maturation
Another influence that can entirely ruin a study on autism treatment is called
maturation. There are two kinds of maturation that we need to recognize. The
first is simply the amount of time that has passed between the pre-test and posttest. The more time that has passed, the more likely that the child has matured.
To illustrate, if researchers start a study with two-year olds and the study is overwhen the child is six years old, that child has matured through the duration of
the study. Cognitive development may be a factor of concern to the researcher.
With autism, development is less of a problem than with typically developingchildren, since autism is a pervasive developmental disorder; however, theresearcher still needs to take maturation into account (the child getting older)
and adjust accordingly.
The second kind of maturation refers to fatigue. A child will often tire over thecourse of a study, if the study has the child work for long periods of time at once.
Fatigue is a common problem when testing children, as the child may give moreaccurate answers, for example, in the first hour than in the second hour. Fatigue
must be avoided if the researcher is to obtain accurate results for the study.

Bias Type 3: Treatment Contamination

Treatment contamination occurs when a treatment is given and then withdrawn.
Occasionally, the treatment has lasting effects even after withdrawal. Treatment
contamination is a common occurrence when testing drugs that stay in a person’s
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autistic children do not metabolize drugs in the same manner as non-autistic
children. Treatment contamination may or may not be important, depending
upon what is being tested and the time period.
A completely different kind of contamination concerns prerequisite skill levels
prior to participation in the experiment. The “learning history” (other treatments
received prior to the new study) of the child before even being asked to participate
in the study, is a possible confounding variable. In other words, the results ofthe study may be partially influenced by the skills that the child has acquired
before the study. Although there will be no effect when comparing a child’s
pre-score with his post-score, learning history does confound the claim that thetreatment under study works for all children with autism, versus a more modest
claim that the treatment works mainly for children with autism who alreadyhave a certain skill set. An example of this type of bias is a study done in New
Jersey on naturalistic learning. Researchers compared children’s skill acquisition
through a technique called Discrete Trial Training (DTT) versus a techniquecalled Naturalistic Learning, to evaluate which of the two was more effective andefficient. The researchers casually mentioned that in New Jersey it is practically
impossible to find children who have not had Discrete Trial Training histories.
This significantly complicates autism treatment studies in New Jersey.
These researchers were not actually studying which autism treatment typewas more effective and efficient, but rather, among children who already had
considerable DTT learning histories, which method was more efficient. This isa very different question. The goal of using DTT is to develop sufficient skills
and provide enough of a foundation to enable children to learn naturally fromtheir environment. It may be that this research tells us something valuable
about naturalistic teaching; however, the scope condition would need to saysomething along these lines, to validate the study’s conclusions: this is based on424Section Two: How Do We Know What Works and What Doesn’t?

children who have had discrete trial treatment. This would need to be added tothe theory to be certain that the hypotheses of the researchers will be supported
in other autism treatment studies where perhaps the children have not received
any discrete trial training treatment.
Confounding Variables in General
The researcher may not be aware of these influences which may affect the outcomeof the study in profound and significant ways. In general, any variable that has
not been considered and controlled may confound an experiment and, thereby,
render the results meaningless. The world of autism research suffers from the
problem of confounding variables to a very disturbing degree.
As mentioned previously, the effect of season is an important consideration
when it comes to research on children with autism. Apparently, children with
autism often fare better in one season rather than another. The reason for theseasonal effect is not clear. If the experiment lasts for one year, the results ofthe study could be skewed unless researchers consider this influence and design
their study accordingly.
Another example of a variable that needs to be considered is sensory sensitivity.
Imagine that in the room where the child receives treatment, there is a florescenttube with a buzzing sound emanating from its transformer. It is possible that thechild may be distracted; the researcher may attribute that distraction to autism
rather than to the buzzing light, or perhaps some other sensory interference of
which the researcher is unaware.
There are many variables that have nothing whatsoever to do with the treatment
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perfect, without a control group that is having the same experience in every way,
aside from being administered the treatment, it is infinitely more difficult tocontrol unknown variables that can confound an experiment. Every researcher
must be aware of this issue. Such awareness helps ensure that the scientificmethod will be used successfully to develop and test effective treatments forchildren afflicted with autism.

2.6 How researchers mistakenly ruin their own
well-designed autism treatment studies
The first mistake that I see commonly in autism publications is the faulty
interpretation of data. Researchers often mistakenly ruin their own studies by
misinterpreting the data. This is why the process of peer review is so crucially
important. Perhaps some researchers may err in their interpretation of a study’s
data; however, their academic peers will use the opportunity to robustly critiquethe study and expose any errors or misinterpretations. In addition, researchers canalso introduce bias by using data collected inaccurately (by parents or untrained
others), or by the observation measure being too subjective (yielding different
results based on who collects the data). This issue is addressed by ensuringthat experimenters standardize their data collection procedures. The accurate
measurement of the dependent and independent variables is vitally important.
Although we’ve spoken about bias that may occur due to type of design chosen,even if the study design is good, there are two other kinds of bias that cancreep into research: demand characteristics and experimenter bias. Demand
characteristics occur when the subject tries to please the experimenter. The
subject attempts to behave to confirm the experimenter’s hypothesis. This is nota huge concern in autism research as the autistic child would likely not care orunderstand the hypothesis, but it is a major influence when the parent is involved

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in taking and reporting the data, for example. This is why, if possible, the parent
should not know the hypothesis of the study, or to which condition the autistic
child has been assigned. Unfortunately, this is not always practical or ethical;
however, when possible, the parent should not know the purpose of the study
and the research group to which their child has been assigned.
The other type of bias, which is a major issue in autism research, is the effect of
the experimenter’s expectations of outcome. Researchers, unfortunately, tend tobe very invested in the outcome of their study: this overzealous commitment totheir hypothesis is often due to potential monetary benefit. On the other hand,
we see some researchers are over-invested because they care profoundly about
this population of children, irrespective of personal gain. These researchers also
want their hypothesis to be supported; therefore, they must take great care to
avoid inadvertently influencing the outcome of the study.
To illustrate this point, I will spotlight a famous study that illustrates the problemof the self-fulfilling prophecy. The researcher, Rosenthal (1968), set up a situation
where he told teachers in a classroom that a subset of their students were “latebloomers.” The children were actually randomly chosen, without the teacher’s
knowledge. At the end of the school year, Rosenthal found that the children who
were expected to excel, did indeed do very well as measured by IQ scores. The
children were actually perceived to be more intellectually gifted and autonomousby their teachers. More alarming was the circumstance that the children who
did so in school (as measured by IQ) but were not expected to do well by theteachers, were actually perceived by the teachers to be less affectionate, lesswell-adjusted, and less interesting.10 The power of the self-fulfilling prophecy
should not be discounted by any competent researcher. The experimental design
must safeguard against this issue.

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2.7 How can bias be avoided?
As I have reiterated throughout the book, the goal of every researcher must be to
avoid bias. This can be done in the following manner: studies should be designedwith a control group; the groups should be the same; subject assignment should be
hidden from the researchers taking and evaluating the data; inadvertent parental
influence should be avoided; the influence of the person being studied should be
eliminated; funding should be received at arms-length, from agencies who haveno interest in the research outcome.
A control group to compare results helps eliminate bias. A control group isparticularly important for the parent or consumer when the treatment claims madeare spectacular. In addition, both groups must have the same characteristics atthe beginning of the study, by random assignment when possible or functional or“quasi-random” assignment when random assignment is an ethically questionable
practice. Further, the assignment to conditions must be concealed from theexperimenter (or at a minimum hidden from those in the research team who
administer the treatment). When possible, external evaluators must be used.
These evaluators, although part of the experiment, must have no idea which
conditions the subjects have been assigned. Moreover, parents must be kept as
uninformed as is ethically possible, to avoid inadvertent parental influence and,
thereby, confound the experiment. In addition, parents should not be involvedin the experimental procedures, including the administration of treatment or datacollection. In the case of autism research, it is important not only to eliminate theinfluence of the autistic person on experimental outcomes, but also to eliminate
the influence of the parent or the person who will most likely accompany thechild while participating in the study.

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2.8 When Is It Time To Apply the Results to Children?
When can we trust the results of a study and apply these results to our children?
In other words, when can we generalize the results? If the children in the study
are representative of the greater population of children with autism, then results
may be generalized directly from the study to the population at large. However,even if the children are not representative of all children with autism, the results
can still be valuable. They simply need to be generalized in a different way.
Here I am referring to the generalization of results through theory.
Although the generalization of results through a theory is more time-consuming
than directly to the population at large, it is often the only way to do so responsibly.
If research results are to be generalized through a theory, to the population ofchildren with autism as a whole, then it is very important to see many studies
which report data that supports the theory. Each study acts as an instance of where
the theory is supported. The more supported instances of the theory or hypothesis,
the more secure we are in the knowledge that the autism treatment in question istruly effective. It is important to keep in mind that Between-Subjects Designs
conducted over a long period of time are much more expensive and difficult thanSingle-Subject Case Designs (SSCDs); therefore, one would expect less of the
Between-Subjects Designed studies to be conducted. That said, a few BetweenSubjects Designs conducted with a large number of children and supporting thetheory would be more valuable than a few SSCDs supporting the theory, because
Between-Subjects Designs have a control group to eliminate variables that may
confound the results of a study, whereas SSCDs do not have this built-in quality
control mechanism. For researchers conducting research using SSCDs, theirresults are also instances that can support their hypotheses. However, many
more replications of their findings are needed in order to generalize confidently
through the theory.
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At this point in autism research, there are too few studies being conducted
on treatment methods; therefore, multiple replications of SSRDs would bequite valuable. Unfortunately, what often happens is that less-than-scrupulous
researchers, who are pushing their latest fad treatment, use perhaps only one
single child research study to generalize their treatment directly to the population.
For studies that can be done over a short period of time, we should expect more
SSRD studies to support the treatments being tested.
In summary, the time to take a treatment seriously is when you see mounting
evidence of its efficacy, irrespective of experimental design. Since SSRDs aremuch easier to do than Between-Subjects Designs, prior to evaluating the use ofa treatment, we should see many more of these study designs which support themethod in question. Currently in autism research, the only area where SSRDs
are consistently used responsibly is in the field of applied behavior analysis.
Is the research far enough along?
The question that remains is this: “When should researchers apply the research
to children with autism?” Pure researchers, who are far from utilizing any of
their knowledge to create a treatment, are not problematic for parents. We
simply need these geneticists, neurobiologists and other pure researchers (whose
research may one day find a cure) to keep toiling in their laboratories. They
rarely push treatments prematurely out of the lab. It is the researchers working inclinical settings who are the most problematic for the consumer. Even reputable
researchers may place children into studies much earlier than is warranted due
to parental pressure. These researchers are in an ethical bind, as they see thedesperation of parents, and they may need human subjects for their experiments;
however, their research may not be ready to be tested. Premature treatment occurs
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to children with autism. Psychiatrists are well aware of the studies on adults
and tell the parents that there are no comparable studies on children with autism.
Nevertheless, parents are often still given the option to experiment on their children
with drugs that have only been properly tested on adults. These ethical issues are
difficult and, in my opinion, should be left up to the parent and the psychiatrist
to weigh the potential benefits against the potential risks for the child. Lessdifficult to discern, however, are researchers who have no data on the efficacy of
their treatment. They offer the treatment as purportedly effective for autism eventhough there are no peer-reviewed studies published on their treatment. Here,parents must use their knowledge of the scientific method to make an informed
decision. I hope this book will be a valuable part of that process.
Testing on human subjects
Experimentation on disabled children is a very touchy subject for researchers. It
is obviously important that the child not be harmed by the treatment; however, as
children with autism cannot give informed consent, their parents do this on theirbehalf. Unfortunately, there are potentially dangerous treatments that parents allow
their children to receive, due only to their faith in the professional pushing thetreatment. Section One of the book discusses these treatments in some detail.
Ethical considerations often interfere with experimental design. A good exampleof this type of interference occurred when parents were to give informed consent
to Lovaas for his landmark study. Parents protested against random assignment
because every parent wanted their child to be in the treatment rather than thecontrol group. Consequently, with the National Institutes of Health’s blessing,
Lovaas had to find another way to randomize the assignment of children to groups(functional random assignment discussed earlier) which had a profound effecton the study design.

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Parental pressure is a major concern in autism treatment. When studying children
with autism, parents pressure researchers on a regular basis. Parents can motivate
research this way; however, they can also pressure researchers to prematurely let
a treatment out of lab. This phenomenon is exemplified in all the studies done on
secretin, due to one family’s ability to bring out the media in a major way. The
ability of parents to shine a spotlight on treatments is a mixed blessing because itis, theoretically, possible that an effective treatment may be discovered this way;
however, more often than not, significant resources are spent on researching atreatment that is proven to be a dead end.

2.9 Red flags for quackery
What are the red flags for quackery you may see when you try to separate fraud
from true science? To review, there are five indicators that when taken together
can signal scientific quackery (junk science) to the consumer (which in our caseis generally the parent of a child with autism). These red flags are: personal
testimonials with no scientific backup; fancy explanations from the articulate,
slick public speakers offering the service; logical arguments about why thetreatment should work; videotapes showing the treatment working, and famous
people using the method.
The red flag most easily observable is one or more personal testimonials without
any scientific backup provided by the person selling the treatment. Often
testimonials take the form of autobiographies, wherein the parent describes
stories of how he or she employed the treatment in question and the child
improved dramatically or was cured of autism. Watch out. These testimonials
are highlighted as a selling tool. In addition, the red flag should start flapping in
the breeze when, in response to your queries about whether there are any peerreviewed journal articles available on the treatment method, the sales person

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answers that science is far too close-minded regarding this research because
government or big business have somehow captured science. Conspiracy
theories which attempt to explain the prevention of publication of science arealways suspect.
Another red flag takes the form of fancy explanations, with a large variety ofglossy sell sheets and videos. Generally, scientists do not waste grant money on
attempting to sell their research, and then take it prematurely out of the lab into
the population at large. Genuine scientists are the least likely to use marketing
tools of persuasion. In all of the treatments that were evaluated in the first sectionof this book, the treatments with absolutely no scientific evidence tended to havethe most well-developed marketing materials.
A third red flag is the presence of several seemingly logical arguments explaining
why the treatment works, but no data supporting the theory. Real scientists arevery quick to state that they are working on a theory that could be wrong. They
will not try to convince you that their unsubstantiated theory is right because it
seems so logical. It is a good sign when the consumer hears that a researcher istentative about the state of the science in autism treatment. When researchers
admit that their assumptions regarding the treatment they are studying may beincorrect, the tentative nature of these researchers should be respected.
Another red flag takes the form of videotapes which demonstrate the therapy andshow you the instant effect of the treatment, once again without peer-reviewed
scientific support. Videotapes are a valuable way to illustrate the treatment;
however, they should not be used to convince consumers that the therapy iseffective. This practice is particularly disturbing when a major news organization
creates a documentary or news piece on a treatment which has no data supporting
its efficacy. This been done on a large number of the unsubstantiated treatments
discussed in Section One.
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A fifth red flag to note is the endorsement of the treatment by celebrities oracademics with credentials. Notoriety as a tool of persuasion to convince you
to try the treatment, or buy a product, is a common technique that should wakeup your quack detector. The use by researchers of their credentials, without
presenting any scientific evidence, regrettably is a very common problem in
autism research. Put simply, data must lead the way for your family and for thewhole autism community. Anything else must be ignored; otherwise, a treatment
with no data may be marketed in such a way that even the most savvy parent
could be convinced that the treatment is effective.

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Conclusion
Now that you have an understanding of the many ways that researchers do,
or do not, use the scientific method to study autism, I’ll leave you with thefollowing thought. Regardless of how compelling, articulate, and intelligent
researchers appear to be, and no matter how tempting, attractive, and elegant
theories regarding treatments appear, the buck stops with data. The best way
to protect your child from quackery is to say SHOW ME THE DATA! Before
you try, buy, or attempt to research any treatment “show me the data,” should be
your mantra. This basic, guiding principle will save you and your child muchtime, money and grief.
Once you receive the data that you have requested, you now have the tools toanalyze the quality of the study upon which the practitioners are basing theirpractice and offering treatment to your child. I sincerely hope that one day weparents of children with autism will look back on the “bad old days” when there
was no cure for autism and parents had to become scientists to protect theirchildren from quackery peddled by the modern snake-oil salesmen of our day.

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Endnotes1

Huxley, T.H. 1969. Evolution and Ethics. New York: Kraus Reprint.

2

Auton et al. vs. the Attorney General et al., July 2000.

3

Bassett K., et al. 2001. “Autism and Lovaas Treatment: a systematic review of effectivenessevidence.” International Journal of Technology Assessment and Health Care, Vol. 17, No. 2,
p. 252.
4

Freeman, S. 2003. Science for Sale in the Autism Wars. Langley, B.C.: SKF Books, Inc.

5

PubMed, http://pubmed.gov; MEDLINE, http://medline.cos.com.
PsycINFO, APA Online, http://www.PsycINFO.com

6
7

ERIC Education Resources Information Center, http://www.eric.ed.gov

8

Cochrane Database of Systematic Reviews, http://www.cochrane.org
Freeman, S., (see n. 4 above).

9

10

Rosenthal, R., and L. Jacobsen. 1968. Pygmalion in the Classroom. N.Y.: Holt, Rinehart andWinston.

11
Furedy, J.J. 1999. “Commentary: On the limited role of the ‘single-subject’ design in psychology: Hypotheses generating but not testing.” J. Behavior Therapy and Experimental Psychiatry, Vol. 30, pp. 21-22.

Jocelyn, L.J., O.G. Casiro, D. Beattie, J. Bow, and J. Kneisz. 1998. “Treatment of children
with autism: a randomized controlled trial to evaluate a caregiver-based intervention program
in community day-care centers,” J. Dev. Behav. Pediatr., Vol. 19, No. 5, pp. 326-34.
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Afterword
An Update to
The Complete Guide To Autism Treatments – 2007 to 2010
Four years ago, a comprehensive literature search on autism treatments wascompleted for the first edition of this book. With the flurry of activity in thisfield, the publicity that autism has garnered recently, and the increased spending of research dollars on autism, the time is right to return to the databases andsearch for new, innovative research on autism treatment.
Once again, I searched every database relevant to autism to uncover every autism treatment offered to parents for their children. The searches included all
the prior databases and the addition of a couple of new ways to search. For
these searches, I captured all the peer-reviewed articles concerning autism treatment published from 2007 through to 2010. In addition, in areas where I could
not uncover any new publications (for example Cranio-sacral Therapy and Vision Therapy), I searched for authors who had previously written articles about
the treatment in the hope of finding a new article that may not have been catalogued by the various databases. After sifting through the innumerable studies
that were published in the last four years, several themes became very clear.
Here, I will report on these themes.

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Lack of Evidence
Despite the large number of articles published recently, only a very few have
any research data contained within the thousands of pages of commentary, description, and review. Remarkably, the vast majority of articles published in
the last four years provide no data, whatsoever! Note that here I am referring
to articles on the treatment of autism, and not on research into the causes ofautism. This is a very important distinction to make because the amount ofresearch being conducted by neurobiologists looking into autism and the brain,
and geneticists studying the genetics associated with autism is growing and is
finally being well-funded (in fact, it is the condition to research for neurobiologists since so many grants are now available). In addition, money is being
invested into a number of studies researching autism using animals models. I
eagerly await a breakthrough in treatments for autism from these pure researchers. As an unfortunate contrast, most of the current treatments for autism being
offered by various treatment providers still have a poor record when it comesto the provision of data to back up claims that promise to improve the conditionof autism in children.
Quality of Data
Not only is there a lack of data in most of the autism treatment articles published from 2007 to 2010, but the quality of data for most treatments that havereported findings has not improved much, if at all. For the most part, the miscellaneous therapies are still characterized by fuzzy thinking, at best, and offer
uncontrolled case study reporting. Some treatment modalities that had no data
to report, now have reports providing data that is of poor quality. There are
more case studies than before; however, I could not find even one scientificallyrigorous study from any of the studies that traditionally had no data to report.

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Indeed, the scourge of the case study appears to be alive and well in the wild
world of “choices” in autism treatment.
Increasing Evidence Against Treatments in Selected
Areas
One bright spot in the field of autism treatment research, is an increased activity
amongst researchers who competently test fringe treatments as these treatments
become popular (this occurred most famously with the debunking of Facilitated
Communication by a variety of studies in the 1990’s). The following researchadds evidence to the lack of effectiveness of the various treatments listed below:
Gluten and casein-free diets
Three studies have reported findings that provide evidence against the treatment.
Two studies1,2 found no difference in the urinary profiles of children with autism
as compared to the population of typically developing children, with one study
using a relatively large sample size (65 boys with autism and 158 boys as controls). If one cannot determine a biomedical marker for autism, then it is premature to use opioid peptides as a response to this diet. Furthermore, it is premature
to offer the gluten/casein-free diet as a treatment (unless another, new biomedical
marker can be found). The third study tested children using this diet in a doubleblind, clinical trial and reported a lack of efficacy for this treatment.3
Sensory Integration
Another treatment that has gained some traction is the use of weighted vests (atechnique employed by some of the practitioners offering Sensory Integration
Therapy). Two studies4,5 found no improvement in children with autism as aresult of the use of weighted vests.

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Dolphin Human Therapy
Although to some, this fringe treatment has not been taken seriously, thousandsof parents have spent considerable time and money on the use of Dolphin Therapy. Due to the extremely expensive nature of the therapy and dubious efficacy claims made by practitioners, the therapy motivated an interesting study
wherein researchers created an animatronic dolphin to see if there would be
any difference in efficacy if the dolphins that interacted with the children weremechanical replicas of the real thing. They found that children were equally
reinforced by the use of a robotic dolphin as they were with real dolphins. This
disproves the theory that dolphins have special, as yet undetermined powers ofconnecting to children with autism. The robotic dolphin study further supports
the contention that Dolphin Therapy is all about creating effective behavioral
reinforcements for children. Surely practitioners can find more convenient reinforcements for children with autism which can be provided at home and in
the community rather than travelling thousands of miles to warm water dolphin
habitats for a week of expensive, inefficient therapy. 6
Tomatis Sound Therapy
Auditory Integration in its various forms has been offered to children with autism over the last forty-five years and has been widely publicized as a miracle
treatment. This was one of the first treatments I came across when my child
was diagnosed with autism in the early 1990s. In 2008, yet another test of Auditory Integration was conducted using a randomized, double-blind, placebocontrolled, crossover design (please see page 389 for a discussion on standard
research methods and their terminology). This study7, like the ones before it,
found no improvement in language amongst children with autism using Tomatis Sound Therapy, adding further to the list of prior studies that disprove thistechnique as an effective treatment for autism.

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Oral Human Immunoglobulin
A recent study8 was conducted on the effect of Oral Human Immunoglobulin on the gastro-intestinal system of children with autism who suffer from GI
dysfunction. A double-blind, placebo-controlled trial was done using a sample
of 125 children with autism. The results showed no significant differences insymptoms related to autism as a result of the treatment.
These newer studies join the significant quantity of published research papers
that demonstrate no evidence of treatment efficacy derived from oral humanimmunoglobulin. It is not surprising that there are additional studies that demonstrate a lack of evidence for these various fringe treatments, once they areclosely scrutinized using the scientific method. The evidence demonstrating thelack of science in autism treatments has actually grown. The onus is now upon
the practitioners of discredited autism treatments to prove otherwise.
New Therapies
Through the latest database search in December 2010, I found five new therapies that are gaining popularity and have recently joined the dozens of currently
offered treatments. I will discuss each new treatment and the effectivenessevidence behind all of them.
Hyperbaric Oxygen Therapy
The use of Hyperbaric Treatment (HBOT) for children with autism has recently
gained in popularity. Although Hyperbaric Treatment has been used appropriately for a number of ailments, the most famous being for ocean divers who
suffer from decompression sickness (the “bends”). Practitioners have recently
been applying HBOT to children with autism. The best study done on HBOT is

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a multicenter, randomized, double-blind, controlled trial, which at first glance
looks compelling.9 I was pleased to see that randomization and controls wereincorporated into the study. The biggest issue with the study mentioned aboveis the way the pre-tests and post-tests are used to determine whether the treatment improves the condition of autism. Only when one looks at the outcome
measures used in the study does it become disappointedly apparent that they
are either very subjective or not appropriately tested. Specifically, the ClinicalGlobal Impression Scale (CGI) is completed by the physician and the parent,
and the two checklists used (The Aberrant Behavior Checklist (ABC), and theAutism Treatment Evaluation Checklist (ATEC)) were designed and are endorsed by a private institute that has a track record for endorsing unsubstantiatedtreatments. Nowhere in the study referenced above is objective, psychometrictesting done by a psychologist who is not affiliated with the study, prior to andafter the study. Another study of note was conducted by researchers working
with children in behavioral treatment programs and not involved in the provision of Hyperbaric Oxygen Therapy.10 Their study (involving three children)
found no improvement in their condition as a result of the HBOT. This small
study was an important first step; however, it is clear that a large, independent
study with appropriate pre-test and post-test measures needs to be conducted inorder to determine whether there indeed is any benefit for children with autism
to undergo this form of therapy. At this point, Hyperbaric Oxygen Therapy
cannot be categorized as a treatment with any evidence that it improves thecondition of autism.
Rapid Prompting Method
The Rapid Prompting Method was developed by the mother of a child with autism, Soma Mukhopadhyay. She found that the techniques she used greatly improved the symptoms of her son. This method, which uses rapid prompting tohelp the child complete a task or answer a question, is now offered by her clinic
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that goes by the name of Halo. To date, there is only anecdotal evidence for theeffectiveness of the treatment presented in the form of testimonials on the Haloweb-site.11 At this point, I could not find any scientific evidence regarding theeffectiveness of this treatment method; therefore, the Rapid Prompting Method
can be categorized as a treatment that is unsubstantiated at this point.
Massage Treatment
In recent years, Massage Treatment is being applied to children with autism.
The most studied massage treatment technique is the Qigong Massage. In themost rigorous study, a therapist provided Qigong Massage Treatment to children for twenty training visits over a five month period. During these visits,parents were also trained to massage their children. Between therapist massages, parents were to give daily massages to their child based on the training
they received. The parents submitted videos to make sure that their massage
technique was done properly. This study reports positive findings; however, thestudy design is highly flawed. First, the attempt to treat children with autism to
improve sensory and self-regulation is problematic because it assumes that a)we know enough about autism and sensory differences, and b) we can measuresensory differences accurately. Second, the study’s measurement of autism ingeneral is problematic. All the data was collected using a variety of checklists
that rely on parental or teacher reporting (the Autism Behavior Checklist – ABC- and the PDD Behavior Inventory - PDDBI). Nowhere in the study is psychometric testing administered by an independent psychologist, which is crucial tothe credible measurement of relative outcome. Prior to using this treatment forchildren with autism, I would encourage these researchers to test its efficacy
with another study that utilizes better outcome measures that are deployed byprofessionals with no prior relationship to the study. 12

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Neurofeedback
Neurofeedback has been used on a myriad of conditions, and is now being
used on children with autism. Due to the difficulty children with autism facein taking specific direction, which is necessary for Neurofeedback to be conducted, only high functioning children were used in the double-blind study thattests this treatment.13 The study demonstrated that children with autism can betaught to control certain brain waves. Even if we take at face value the data thatcertain brain waves were controlled, we do not know the relationship between
that type of brainwave and behavior. Unfortunately, the results they reported
for the speech/language communication, sociability and behavior were all fromthe Autism Treatment Evaluation Checklist (ATEC). This checklist is not awell-established measure for autism treatment, but rather, endorsed by a private
institute, and completed by parents. In order for the Neurofeedback practitioners to make the argument that Neurofeedback does improve the conditionof autism as measured by speech and language, sociability and behavior, theywould have to rely on independent professionals to administer tests prior to andafter the treatment. At this point, there is no evidence that Neurofeedback is aneffective treatment for autism.
Electro-Acupuncture
The newest addition to the autism treatment offerings is Electro-Acupuncture.
In this treatment, needles are inserted into certain areas of the body and thenelectrical stimulation is provided through the needles using an electro-acupuncture machine. In the best study, children with autism were randomly assigned to
one of two groups and the parents were blind to which group their children wereassigned in this double-blind, randomized controlled trial. Although the study
was well designed, the pre-outcome and post-outcome measures are highly
problematic. The significant findings were reported using non-autism specific444Section Two: How Do We Know What Works and What Doesn’t?

outcome measures or parental reporting. The Leiter International Performance
Scale-Revised (Leiter-R) is the one instrument in this study that measures IQ.
It is often used on children with autism and administered by a clinical psychologist. The Leiter-R measure produced no difference between the experimental
and control group. This lack of difference in the Leiter-R suggests that electroacupuncture is not an effective treatment for children with autism.
Most of the above treatments use poor measures of autism (for a discussion of
the importance of an accurate measurement for autism, please refer to Section
II). Unfortunately, none of these therapies have been tested rigorously and now
join the very large group of unsubstantiated treatments that considerably overreach in the efficacy claims they make.
I eagerly await the rigorous testing of these treatments. In order for these treatments to be tested competently, the researchers must be motivated by scienceand the practitioners need to have no stake in the outcome of the science. In
most of the unsubstantiated treatments, those who make the claims of purported
efficacy also tend to be making a living providing the treatment; objective testing is thereby severely compromised.
An Apparent Convergence
Based on studies conducted in from 2007 to 2010, an interesting trend seems
to have emerged. Practitioners are borrowing techniques from other treatments
and incorporating them into their own therapies. This is occurring whether or
not the treatments are science-based. One example of where convergence is occurring in a scientifically rigorous fashion is in the field of behavioral treatment.
One study incorporates music into a behavioral program to increase episodes ofjoint engagement. Although I do not consider this in any way “Music Therapy”,
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sical venues i.e., music classes, choir, band, preferred places for mainstreamingsome children who are also in behavioral treatment programs. The study14,
which was done in a scientifically rigorous manner, demonstrated the better useof musical venues versus toy play sessions for joint engagement. I suspect thatmusic classes have actually been a popular place to mainstream children with
autism since a music class requires no language, and is quite predictable; I was
pleased to finally see a study designed around music in this manner. Note thatthe child was not placed into a music class without any prior treatment to theclass and expected to suddenly be able to participate. The mainstreaming wasdone as part of a comprehensive behavioral treatment program that prepared thechild to be able to take advantage of the musical venue. 14
Another trend I have observed since the 2007 publication of the first editionof this book, is the incorporation of verbal behavior techniques into traditional
early intensive behavioral programs. In one study15, toddlers and preschoolers
were treated using both applied behavior analysis and verbal behavior techniques in a classroom for one year. At the end of the year, the children weremoved into less restrictive environments. Although at first glance the outcomeof this study looks promising, several alarm bells go off when noting the study’s
over-emphasis on economics e.g., the cost per “learn unit” favorably referenced
as being only 52 cents. The fact that ninety-five percent of the children progressed to less restrictive environments is an indirect measure of purported success that tells us nothing about whether the egregious symptoms of autism wereameliorated in any meaningful, measureable way. It tells us only about the
study’s success in saving school districts money rather than about the child’s
actual improvement. The other metric used in the study is whether the classwide cumulative objectives were met. Nowhere in the study could I find external, objective measures for each child that provide evidence that this treatment
program improves the symptoms of autism. These practitioners actually do

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provide behavioral treatment and take data on the various skills acquired; however, if the fidelity of the treatment is compromised by an economic imperative,
researchers in the behavioral field will not be able to claim the kind of treatment
outcomes that their behaviorist colleagues have enjoyed to date.
Another area where autism treatment convergence appears to be happening isin the Hanen Method (see page 227 of this book for a discussion of the Hanen
Method). Instead of improving their data collection techniques through science
and, thereby, adding rigor to test their claims, the Hanen practitioners amalgamated their method with a few other methods (such as TEACCH – see page 83
for a discussion on this method).16 They proceed to make claims regarding theeffectiveness of their treatment even though their method is now blended withother methods. Unfortunately, this lack of fidelity in testing does not move thescience of autism treatment forward, but rather adds to the general confusionin the field. Based on the new data from this 2010 study, regrettably we areno further ahead in determining whether there is any value whatsoever in the
Hanen method.
Art Therapy, which has produced questionable data, has now joined forces
with Group Therapy for children with autism. These practitioners combine Art
Therapy and cognitive-behavioral techniques in Group Therapy in an effort toimprove the social skills of children with autism. Unfortunately, the data collected from this study is from parents and teachers, and not done in a way that
controls for bias. 17
Yet another two groups that have no rigorous data to report as of this writing,are the SCERTS model and Music Therapy. Music therapists have now incorporated music therapy goals into the SCERTS model and presented new datathat supports the claim that these two treatments can work together. What is

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unfortunate here is that neither the SCERTS Model nor the Music Therapy field
have been supported with rigorous data regarding efficacy; therefore, the combination of Music Therapy and SCERTS simply confounds an already dubious
area where we are still waiting for robust outcome data. 18
Parents as Free Labor for Autism Treatment
Although this theme has always been present in the autism treatment literature,
it seems to have accelerated over the last four years since the first edition of The
Complete Guide to Autism Treatments was published. Generally, the parent as
therapist theme was relegated to therapies that had no scientific data supporting them e.g., the Learning to Speak Program, the Options Institute, and the
Floor-time program. One of the most prolific groups of practitioners trying topromote the “parent as free labor” paradigm is the Early Start Denver Model.
Key red flags for the Early Start Denver Model: 1) their push for further reduction of autism treatment intensity is prerequisite to making the concept of“parent as therapist” less abhorrent; 2) their long distance training model, which
minimizes the cost of training the free labor. I would like to submit that insteadof spending all their time on the economics of autism healthcare, time would
be better spent on the improvement of their “treatment” method so that it canbe submitted to the rigors of double-blind, randomized efficacy studies, which
I have been unable to find after all these years. Clearly, it appears as though it
is easier to publish data on how to save money on autism treatment than it is to
produce data on significant treatment results!19, 20, 21
The next group that very much seems to favor the concept of family as therapist,
is Positive Behavioral Support (PBS); they have a long way to go in developing
validated treatment efficacy, yet they are already downloading their experimental “techniques” onto parents.22, 23, 24 Among the other groups attempting to448Section Two: How Do We Know What Works and What Doesn’t?

download their so-called treatments onto parents include the Hanen practitioners,25, 26 the Pivotal Response Training practitioners,27, 28 the DIR/Floor-timepractitioners,29 and the RDI practitioners.30
For the most part, studies testing these dubious treatments are an attempt toprove that parents are “effective” treatment providers and that the amount oftime needed for the intervention is minimal. In this manner, government contractors can utilize questionable science to justify the rationing of resources
and the downloading of treatment responsibility onto families. Combined with
the normal responsibilities of life, it is little wonder that several studies havereported that parents of children with autism have been found to be underproductive, as measured by their socio-economic status!31
The concept of parent as therapist apparently holds out so much promise insome academic circles that a systematic review was done to try to plumb forsome kind of scientific evidence to support the policy of downloading autism
treatment responsibility to parents in the United Kingdom.32 Although the authors of the 2007 study admit that it is difficult to draw conclusions, since theparent as therapist studies are poorly done, the study’s authors have no problem
trumping up the value of parents as free labor for autism treatment. The authors
state, “The review found very few studies that had adequate research designfrom which to draw conclusions about the effectiveness of parent-implemented
early intervention”32; however, they still conclude that “randomized and controlled studies tend to suggest” that parents as therapists are effective [emphasis
added]. Only in the sub-optimal world of autism treatment, would parents everbe considered as “good enough” to function as treatment professionals.
Practitioners in the field of Early Intensive Behavioral Treatment (EIBI) havealso published studies over the last 20 years in which they demonstrate the449

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savings to the system if children receive early, intensive behavioral treatment;
however, this treatment is provided primarily by treatment professionals andparaprofessionals rather than parents as the predominant element of the therapy.
That said, an unfortunate trend is also occurring amongst EIBI practitioners who
actually do have evidence that supports the efficacy of their treatment method.
They are starting to dilute treatment fidelity with parents as therapists as well.
This regrettable trend is occurring in Europe, primarily.33, 34
Competition Between Comprehensive Therapies
It is crucial that autism treatment studies claiming improvements in the condition, always compare their outcomes to the outcomes of relatively well-settled
treatments or best practices. Ethically, in order to offer the new treatment as
a replacement, it is imperative that the treatment outcomes of the newly tested
treatments are equal to or greater than those found in well-settled therapies.
Recently, this appears to be happening.
The TEACCH Program (both residential and home-based with inclusion at
school) was evaluated against inclusive, non-specific education in mainstream
schools. One of the goals was to determine how the TEACCH method works
in a natural setting. Although such a comparison is a good idea, the comparisongroup (children in a nonspecific, inclusive programs) is inappropriate. Theirstudy would have had much more value if they had a comparison group of children in home-based intensive behavioral programs who were mainstreamed,since that treatment modality is the main competitor to the TEACCH model.35
A two-year study36 attempts to compare a novel treatment with the most wellsettled treatment in a British study that compares a nursery school that specializes in autism with an early intensive behavioral intervention program. Although
the experimental groups are appropriate, and they report interesting findings,
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no conclusions can be made regarding efficacy of this study due to its highly
flawed nature. Specifically, there is a lack of random assignment to groups;
there are additional therapies that parents added to their children’s treatment
regime; the gains made by the children in the early intensive behavioral intervention (EIBI) group are smaller than reported in other traditional intensive
behavior treatment programs. These flaws inspire little confidence in the quality of the study. In short, if the EIBI program is of a poor quality and without
sufficient expertise, it would make sense that the groups would not differ at theend of the experiment. This study actually provides evidence as to what occurs
when EIBI treatment is diluted, be it by lack of training or insufficient specialist
oversight. Specifically, the findings that were recorded under ideal conditions
are not replicated.36 That said, at least we are moving in the right direction of
having competitors understand that they must evaluate their program against
the standard of intensive behavioral treatment programs before it can ethicallybe offered to children with autism.
In reviewing new research produced since the first edition of this book, it appears that of all the treatment purveyors in the area of autism, the group of researchers and practitioners that keep adding new evidence regarding treatment
efficacy are those in the field of behavioral autism treatment; specifically, they
are the practitioners utilizing the intensive behavior treatment model. Between
2006 and 2010, there have been several new studies, most of which compare
Intensive Behavioral Treatment to a variety of available offerings in the community. Consistently, the outcome of these studies is clear: Intensive Behavioral Autism Treatment remains the one treatment protocol that continues toshow the most benefit for children afflicted with the condition. According to all
available research, children with autism make the most gains in these types oftreatment programs.37, 38, 39, 40, 41, 42, 43, 44, 45

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In contrast, the number and quality of studies that test the Playschool, Floortime, Options remain few and far between, are highly flawed and do not compare their treatment protocol against best practices.
Individual Techniques
By far, the most common studies that have been published since the 2007 edition of this book have been those that have tested individual techniques forthe treatment of autism. This is a positive step insofar as the manner in whichscientific knowledge is generally accumulated is via small, often tedious steps.
Eventually, these techniques can be amalgamated, put into treatment protocols and, finally, tested. In other words, the way science-based, comprehensive treatment protocols develop is by combining many techniques that are firsttested individually. Noteworthy is that a significant number of recent studies
test Skinner’s Theory of Verbal Behavior using the population of children with
autism. These studies test one particular technique at a time. As of this writing,there is no comprehensive test amalgamating all these Skinnerian techniques
into a general treatment protocol. I do not consider TEACCH a comprehensive
test of this because there is much in TEACCH that has nothing to do with Verbal Behavior. That said, given that some experiments which test verbal behavior techniques are conducted in a scientifically validated manner, it would not
be problematic to incorporate individual, scientifically substantiated techniques
into a traditional intensive behavioral program as long as data is collected on
skill acquisition for each child and there is a compelling reason to incorporate a
new technique i.e., the child is not successful with the technique typically usedin the well-settled treatment. Based on the data, this is where the role of a highly skilled practitioner is required to select the techniques that have a chance ofworking better than the technique being used in the traditional behavioral treatment program. An autism treatment practitioner will typically search throughthe literature if a child is not progressing with the well-settled technique and the452Section Two: How Do We Know What Works and What Doesn’t?

verbal behavior technique is shown to be effective in a controlled study. At thispoint, data on that one child needs to be collected to discern whether the verbal
behavior technique is successful for that one skill. In summary, there is no test
data thus far testing a comprehensive verbal behavior program against a behavioral treatment program, where the verbal behavior program shows equal or
better efficacy; however, verbal behavior techniques that focus on an individual
skill are beginning to emerge from the research literature.
Since 2007, other individual techniques for the treatment of autism have comefrom a variety of fields, where most studies are conducted poorly and without
an understanding of the scientific method.46, 47 One area that keeps on publishing individual techniques is Music Therapy. The studies are improving slowly;
however, there is still such a gap in understanding autism that almost every
study has obvious flaws. An example is a study where children with autism
were taught animal names and symbols through a song; however, these skills
were not generalized. If skills are not generalized, they are useless.46 Anotherexample of lack of emphasis on generalization is a study where children were
taught a morning routine song which was composed by the music therapist,
customized to the child and taught to the teachers.47 The teachers would sing
the song to help children learn the morning routine. Researchers in this study
considered the lesson a success. From my perspective, however, the lesson is
not successful if the technique cannot be faded and the skill generalized to thereal world. One cannot expect the world to sing to a child with autism in orderfor that child to preform a task. The child is not going to be in preschool forever, and if the “treatment” song cannot be faded, the child will be condemned
to a very sheltered life. In addition, the next obvious question is whether there
is a more efficient way to teach children their morning routine. The daunting
challenge for parents of children with autism is that their kids need to acquireso very many skills, building “brick by brick”, it is crucial that these skills be
acquired effectively and efficiently!
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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

Bottom Line – 2011
In summary, the data on selected individual techniques seems to be improving;
however, most fringe treatments have not yet provided data that can justify
their use on children with autism. As of this recent review of the literature, it
is abundantly clear that traditional Intensive Behavioral Treatment continues tobe the comprehensive treatment that has, by far, the most evidence in the scientific literature. Intensive Behavioral Treatment clearly remains the treatmentof choice for children afflicted with autism spectrum disorder. The behavioral
treatment protocol continues to see more encouraging research data added to
the field every year.

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Section Two: How Do We Know What Works and What Doesn’t?

Endnotes for Afterword

Afterword: An Update to The Complete Guide to Autism Treatments – 2007 to 2010
1

Cass, H. et al. 2008. “Absence of Urinary Opioid Peptides in Children with Autism.” Archives
of Disease in Childhood, Vol. 93, No. 9, pp. 745-750.

2

Dettmer, K. et al. 2007. “Autism Andurinary Exogenous Neuropeptides: Development of an
On-line SPE-HPLC-tandem Mass Spectrometry Method to Test the Opioid Excess Theory.”
Analytical & Bioanalytical Chemistry, Vol. 388, No. 8, pp. 1643-1651.

3

Seung, H. et al. 2007. “The Gluten- and Casein-free Diet and Autism: Communication Outcomes from a Preliminary double-blind clinical trial.” Journal of Medical Speech-Language
Pathology, Vol. 15, No. 4, pp. 337-345.

4Reichow, B. et al. 2010. “Effects of Weighted Vests on the Engagement of Children with Developmental Delays and Autism.” Focus on Autism and Other Developmental Disabilities,
Vol. 25, No. 1, pp. 3-11.

5

Reichow, B. et al. 2009. “Brief Report: Effects of Pressure Vest Usage on Engagement andProblem Behaviors of a Young Child with Developmental Delays.” Journal of Autism andDevelopmental Disorders, Vol. 39, No. 8, pp. 1218-1221.

6

Nathanson, D.E. 2007. “Reinforcement Effectiveness of Animatronic and Real Dolphins.” Anthrozoos, Vol. 20, No. 2, pp. 181-194.

7

Corbett, B. et al. 2008. “Brief Report: The Effects of Tomatis Sound Therapy on Language inChildren with Autism.” Journal of Autism and Developmental Disorders, Vol. 38, No. 3, pp.
562-566.

8

Handen, B.L. et al. 2009. “A Double-Blind, Placebo-Control Dysfunction in Children with Autistic Disorder.” Journal of Autism & Developmental Disorders, Vol. 39, No. 5, pp. 796-805.

9

Rossignol, D.A. et al. 2009. “Hyperbaric Treatment for Children with Autism: A Multicenter,
Randomized, Double-blind, Controlled Trial.” BMC Pediatrics, Vol. 9, No. 21, pp. 1-18.

10

11

Lerman, D.C. et al. 2008. “Using Behavior Analysis to Examine the Outcomes of Unproven
Therapies: An Evaluation of Hyperbaric Oxygen Therapy for Children with Autism.” Behavior Analysis in Practice, Vo1. 1, No. 2, pp. 50-58.

S. Mukhopadhyay. 2010. Rapid Prompting Method. www.halo-soma.org (accessed December 1st, 2010).
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12

13

14

15

Silva, L.M.T., et al. 2009. “Qigong Massage Treatment for Sensory and Self-regulation
Problems in Young Children with Autism: A Randomized Controlled Trial.” The American
Journal of Occupational Therapy, Vol. 63, 423-432.
Pineda, J.A. et al. 2008. “Positive Behavioral and Electrophysiological Changes Following
Neurofeedback Training in Children with Autism” Research in Autism Spectrum Disorders,Vol. 2, pp. 557-581.
Kim, J. et al. 2009. “Emotional, Motivational and Interpersonal Responsiveness of Children
with Autism in Improvisational Music Therapy.” Autism: The International Journal of Research and Practice, Vol. 13, No. 4, pp. 389-409.
Greenberg, J. J. et al. 2008. “Starting Off on the Right Foot: One Year of Behavior Analysis
in Practice and Relative Cost.” International Journal of Behavioral Consultation & Therapy,
Vol. 4, No. 2, pp. 212-226.

16

McConkey, R. et al. 2010. “Preschoolers with Autism Spectrum Disorders: Evaluating the
Impact of a Home-based Intervention to Promote their Communication.” Early Child Development & Care, Vol. 180, No. 3, pp. 299-315.

17

Epp, K. M. 2008. “Outcome-based Evaluation of a Social Skills Program using Art Therapy
and Group Therapy for Children on the Autism Spectrum.” Children & Schools, Vol. 30, No.
1, pp. 27-36.

18

19

20

Walworth, D. et al. 2009. “Using the SCERTS Model Assessment Tool to Identify Music
Therapy Goals for Clients with Autism Spectrum Disorder.” Journal of Music Therapy, Vol.
46, No. 3, pp. 204-216.
Vismara, L.A. et al. 2009. “Can One Hour Per Week of Therapy Lead to Lasting Changes inYoung Children with Autism?” Autism, Vol. 13, No. 1, pp.93-115.
Vismara, L.A. et al. 2009. “Dissemination of Evidenced-based Practice: Can We Train Therapists From a Distance?” Journal of Autism & Developmental Disorders, Vol. 39, No. 12, pp.
1636-1651.

21

Vismara, L.A. et al. 2008. “The Early Start Denver model: A Case Study of an Innovative
Practice.” Journal of Early Intervention, Vol. 31, No. 1, pp. 91-108.

22

Binnendyk, L. et al. 2009. “A Family-Centered Positive Behavior Support Approach to theAmelioration of Food Refusal Behavior. An Empirical Case Study.” Journal of Positive Behavior Interventions, Vol. 11, No. 1, pp. 49-62.

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23

Lucyshyn, J.M. et al. 2007. “Family Implementation of Positive Behavior Support for a Child
with Autism: Longitudinal, Single-case, Experimental and Descriptive Replication and Extension.” Journal of Positive Behavior Interventions, Vol. 9, No. 3, pp. 131-150.

24

Lee, S. et al. 2007. “Lessons Learned Through Implementing a Positive Behavior Support
Intervention at Home: A Case Study on Self-management with a Student with Autism andhis Mother.” Education and Training in Developmental Disabilities, Vol. 42, No. 4, pp. 418427.

25

Pennington, L. et al. 2007. “It Takes Two to Talk – The Hanen Program© and Families ofChildren with Motor Disorders: A UK Perspective.” Child-care, Health and Development,
Vol. 33, No. 6, pp. 691-702.

26

27

28

29

30

McConkey, R. et al. 2010. “Preschoolers with Autism Spectrum Disorders: Evaluating the
Impact of a Home-based Intervention to Promote their Communication.” Early Child Development & Care, Vol. 180, No. 3, pp. 299-315.
Baker-Ericzen, J.J. et al. 2007. “Child Demographics Associated with Outcomes in a Community-based Pivotal Response Training Program.” Journal of Positive Behavior Interventions,Vol. 9, No. 1, pp. 52-60.
Nefdt, N. et al. 2010. “The Use of a Self-directed Learning Program to Provide Introductory
Training in Pivotal Response Treatment to Parents of Children with Autism.” Journal of Positive Behavior Interventions, Vol. 12, No. 1, pp. 23-32.
Solomon, R. et al. 2007. “Pilot Study of a Parent Training Program for Young Children with
Autism: The Play Project Home Consultation Program.” Autism: The International Journalof Research and Practice, Vol. 11, No. 3, pp. 205-224.
Gutstein, S.E. 2009. “Empowering Families through Relationship Developmental Intervention: An Important Part of the Biopsychosocial Management of Autism Spectrum Disorders.” Annals of Clinical Psychiatry, Vol. 21, No. 3, pp. 174-182.

31

32

33

Ganz, M.L. 2007. “The Lifetime Distribution of the Incremental Societal Costs of Autism.”
Archives of Pediatrics & Adolescent Medicine, Vol. 161, No. 4, pp. 343-349.
McConachie, H. et al. 2007. “Parent Implemented Early Intervention for Young Children with
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Cordes, R. et al. 2010. “Behavioural Home-based Intensive Programs for Autistic Children
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34

35

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44

Anan, R.M. et al. 2008. “Group Intensive Family Training (FIGT) for Preschoolers with Autism Spectrum Disorders.” Behavioral Interventions, Vol. 23, No. 3, pp. 165-180.

Panerai, S. et al. 2009. “Special Education Versus Inclusive Education: The Role of the TEACCH Program.” Journal of Autism and Developmental Disorders, Vol. 39, No. 6, pp. 874882.

Magiati, I. et al. 2007. “A Two-year Prospective Follow-up Study of Community-based Early
Intensive Behavioural Intervention and Specialist Nursery Provision for Children with Autism Spectrum Disorders.” Journal of Child Psychology and Psychiatry, Vol. 48, No. 8, pp.
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Richards, A.L. et al. 2009. “One-year Follow-up of the Outcome of a Randomized Controlled
Trial of a Home-based Intervention Programme for Children with Autism and Developmental
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Reed, P. et al. 2007. “Brief Report: Relative Effectiveness of Different Home-based Behavioral Approaches to Early Teaching Intervention.” Journal of Autism and Developmental
Disorders, Vol. 37, No. 9, pp. 1815-1821.
Perry, A. et al. 2008. “Effectiveness of Intensive Behavioral Intervention in a Large, Community-based Program.” Research in Autism Spectrum Disorders, Vol. 2, No. 4, pp. 621-642.
Granpeesheh, D. et al. 2009. “The Effects of Age and Treatment Intensity on Behavioral Intervention Outcomes for Children with Autism Spectrum Disorders.” Research in Autism
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Hayward, D. et al. 2009. “Assessing Progress During Treatment for Young Children with Autism Receiving Intensive Behavioural Interventions.” Autism, Vol. 13, No. 6, pp. 613-633.

Zachor, D.A., et al. 2007. “Change in Autism Core Symptoms with Intervention.” Researchin Autism Spectrum Disorders, Vol. 1, No. 4, pp. 304-317.
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Remington, B. et al. 2007. “Early Intensive Behavioral Intervention: Outcomes for Children
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45

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47

Chasson, G.S. et al. 2007. “Cost Comparison of Early Intensive Behavioral Intervention andSpecial Education for Children with Autism.” Journal of Child and Family Studies, Vol. 16,
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Vitamin B6 and Magnesium
Adams, L., and S. Conn. 1997. Nutrition and Its Relationship to Autism. Focus on Autism andOther Developmental Disabilities 12(1): 53-58.
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Kleijnen, J., and P. Knipschild. 1991. Niacin and Vitamin B6 in Mental Functioning: A Review
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Rimland, B. 1996. Form Letter Regarding High Dosage Vitamin B6 and Magnesium Therapy for
Autism and Related Disorders: ARI Publication. San Diego (CA): Autism Research Institute.
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Rimland, B., and S.M. Baker. 1996. Brief Report: Alternative Approaches to the Developmentof Effective Treatments for Autism. Journal of Autism and Developmental Disorders 26(2):237-240.
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Sankar, D.V.S. 1979. Plasma Levels of Folates, Riboflavin, Vitamin B6 and Ascorbate in Severely
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Szymanski, L., and B.H. King. 1999. Summary of the Practice Parameters for the Assessment
and Treatment of Children, Adolescents and Adults With Mental Retardation and Comorbid
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Speech and Language Therapies
Fast Forward
Bolton, S. 1998. Auditory Processing and Fast Forward. Curriculum/Technology Quarterly
7(2): 2-4.
Earle, J. 1998. Fast Forward: Is the Hype Justified? Technology, Educators, and Children With
Disabilities (TECH-N) New Jersey College 9(1): 8-9.
Tallal, P., and M. Merzenich. 1997. Fast forward training for children with language learning
problems: Results from a national field study by 35 independent facilities. Unpublished paper
presented at the annual meeting of the American Speech-Language-Hearing Association. Boston,MA. 11/21/97.
Tallal, P., and M.L. Rice. 1997. Evaluating New Training Programs for Language Impairment.
American Speech Language Hearing Association 39(3): 12-13.
Tallal, P., G. Saunders, S. Miller, W.M. Jenkins, A. Protopapa, and M.M. Merzenich. 1997.
Rapid Training-Driven Improvement in Language Ability in Autistic and Other PDD Children.
Society for Neuroscience, Scientific Learning Corporation 23: 490.

Hannan Method
Bebko, J.M., A. Perry, and S. Bryson. 1996. Multiple Method Validation Study of Facilitated
Communication: II Individual Differences and Subgroup Results. Journal of Autism Development
Disorders 26(1):19-42.
Bomba, C., L O’Donnell, C. Markowitz, and D.L. Homes. 1996. Evaluating the Impact ofFacilitated Communication on the Communicative Competence of Fourteen Students With
Autism. Journal of Autism and Development Disorders 26(1): 43-58.
Girolametto, L. 1997. Development of a Parent Report Measure for Profiling the Conversational
Skills of Preschool Children. American Journal of Speech-Language Pathology 6(4): 25-27.
Girolametto, L.E. 1988. Improving The Social-Conversational Skills of Developmentally DelayedChildren: An Intervention Study. Journal of Speech and Hearing Disorders 53:156-167.
Girolametto, L., P.S. Pearce, and E. Weitzman. 1996. The Effects of Focused Stimulation for
Promoting Vocabulary in Young Children with Delays: A Pilot Study. Journal of Children’sCommunication Development 17(2): 39-49.
Manolson, A. 1992. It takes two to talk. Toronto, ON: Hanen Centre Publication.
Tannock, R., L. Girolametto, and L. Siegel. 1992. Language Intervention With Children Who
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Lindamood-Bell
Koegel, R.L., K. Dyer, and L.K. Bell. 1997. The Influence of Child-Preferred Activities on Autistic
Children’s Social Behavior. Journal of Applied Behavior Analysis 20(3): 243-252.
Lindamood-Bell Learning Processes (n.d). San Luis Obispo, CA.

The SCERTS Model
Prizant, B.M. 1982. Speech-Language pathologists and autistic children: What is our role? Part
I. Assessment and intervention considerations. Part II. Working with parents and professionals.
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Prizant, B.M., A.M. Wetherby, E. Rubin, and A.C. Laurent. 2003. The SCERTS Model, A
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Miscellaneous Therapies
Art Therapy
Bentivegna, S., L. Schwartz, and D. Deschner. 1983. The Use of Art With an Autistic Child in
Residential Care – Case Study. American Journal of Art Therapy 22: 51-56.
Blasco, S.P. 1978. Art Expression as a Guide to Music Therapy – Case Study. American Journalof Art Therapy 17: 51-56. .
Buck, L., F. Goldstein, and E. Kardeman. 1984. Art as a Means of Interpersonal Communicationin Autistic Young Adults. Journal of Psychology and Christianity 3(3): 73-84.
Golomb, C., and J. Schmeling. 1996. Drawing Development in Autistic and Mentally RetardedChildren. Visual Arts Research 22(44): 5-18.
Ishii, T., A. Ishii, T. Ishii, and T. Sugiyama. 1996. Drawings by an Autistic Adult Chronicling a
Day in His Childhood. Visual Arts Research 22(44): 47-55.
Judge, C., and M. Hilgendorf. 1979. Art and the Mentally Retarded. Australian Journal of
Mental Retardation 5(7): 282-288.
Kellman, J. 1996. Making Sense of Seeing: Autism and David Marr. Visual Arts Research2(44): 76-89.
Kellman, J. 1999. Drawing With Peter: Autobiography, Narrative, and the Art of A Child With
Autism. Studies in Art Education 40(3): 258-274.
Milbrath, C., and B. Siegel. 1996. Perspective Taking in the Drawings of a Talented Autistic
Child. Visual Arts Research 22(44): 56-75.
Quill, K. 1989. Daily Life Therapy: A Japanese Model for Educating Children With Autism.
Journal of Autism and Developmental Disorders 19(4): 625-635.
Scanlon, K. 1993. Art therapy with autistic children. Creative Arts Therapy Review 14: 34-42.
Schleien, S.J., T. Mustonen, and J.E. Rynders. 1995. Participation of Children with Autism andNondisabled Peers in a Cooperatively Structured Community Art Program. Journal of Autism
and Developmental Disorders 25(4): 397-412.

Auditory Integration Therapy
Baranek, Grace T. 2002. Efficacy of Sensory and Motor Interventions for Children With Autism.
Journal of Autism and Developmental Disorders 32(5): 397- 422.
Berard, G. 1993. Hearing equals behavior. New Canaan, CT: Keats.
Berkell, D.E., E. S. Malgeri, and M.K. Streit. 1996. Auditory Integration Training for IndividualsWith Autism. Education and Training in Mental Retardation and Developmental Disabilities
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Bettison, S. 1996. The Long-Term Effects of Auditory Training On Children With Autism.
Journal of Autism and Developmental Disorders 26(3): 361-374.
Brown, M.M. 1999. Auditory Integration Training and Autism: Two Case Studies. British Journalof Occupational Therapy 62(1): 13-18.
Committee on Children with Disabilities. 1998. Auditory Integration Training and Facilitated
Communication for Autism. Pediatrics 102(2): 431-433.
Dawson, G. 2000. Interventions to Facilitate Auditory, Visual and Motor Integration in Autism:
A Review of the Evidence. Journal of Autism and Developmental Disorders 30 (5): 415-421.
Dempsey, I., and P. Foreman. 2001. A Review of Educational Approaches for Individuals With
Autism. International Journal of Disability, Development and Education 48(1): 103-116.
Edelson, S.M. 2003. Response to Goldstein’s Commentary: Interventions to Facilitate Auditory,
Visual, and Motor Integration: “Show Me The Data”. Journal of Autism and Developmental
Disorders 33(5): 551-552.
Edelson, S.M., D. Arin, M. Bauman, S.E. Lukas, J. Rudy, H. Jane, M. Sholar, and B.
Rimland. 1999. Auditory Integration Training: A Double-Blind Study of Behavioral andElectrophysiological Effects in People with Autism. Focus on Autism and Other Developmental
Disabilities 14 (2):73-81.
Frankel F., J.Q. Simmons, M. Fichter, and B.J. Freeman. 1984. Stimulus Overselectivity inAutistic and Mentally Retarded Children – A Research Note. Journal of Child Psychology andPsychiatry 25: 147-155.
Gillberg, C., M. Johansson, and S. Steffenburg. 1997. Auditory Integration Training in Children
With Autism. Autism 1(1): 97-100.
Gillberg, C., M. Johansson, and S. Steffenbur. 1998. Auditory Integration Training in Children
With Autism: Reply to Rimland and Edelson. Autism 2(1): 93-94.
Goldstein, H. 2000. Commentary: Interventions To Facilitate Auditory, Visual and Motor
Integration: “Show Me The Data”. Journal of Autism and Developmental Disorders 30(5):423-425.
Goldstein, H. 2003. Response to Edelson, Rimland, and Grandin’s Commentary. Journal ofAutism and Developmental Disorders, 33(5): 553-555.
Guralnick, M. 1999., ed. Clinical Practice Guideline: Report of the Recommendations. Autism/
Pervasive Developmental Disorders, Assessment and Intervention for Young Children (age 0-3
years), Albany (NY): New York State Department of Health, IV-63.
Harris, S.L. 1998. Behavioural and Educational Approaches to the Pervasive Developmental
Disorders. In: Fred R. Volkmar, Autism and Pervasive Developmental Disorders. New York,
NY: Cambridge University Press, 195-208.

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Howlin, P. 1997. When Is A Significant Change Not Significant? Journal of Autism andDevelopmental Disorders 27(3): 347-348.
Link, H. M. 1997. Auditory Integration Training (AIT): Sound Therapy: Case Studies of ThreeBoys With Autism Who Received AIT. British Journal of Learning Disabilities 25(3): 106110.
Madell, J.R., and D.E. Rose. 1994. Auditory Integration Training: Face to Face. Journal of
Audiology 3(1): 14-18.
Monville, D., and N. Nelson. 1994. Parental perceptions of change following AIT for autism.
Presentation. American Speech-Language-Hearing Conference, New Orleans, MS.
Mudford, O.C., B.A. Cross, S. Breen, C. Cullen, D. Reeves, J. Gould, and J. Douglas. 2000.
Cockrane Developmental, Psychosocial and Learning Problems Group, Cochrane Complementary
Medicine. Auditory Integration Training for Children With Autism: No Behavioral Benefits
Detected. American Journal of Mental Retardation 10(2): 118-129.
Rimland, B., and S.M. Edleson. 1991. Improving the Auditory Functioning of Autistic Persons: A
Comparison of the Berard Auditory Training Approach With the Tomatis Audio-Psychophonology
Approach, Technical. Report. 111. San Diego: Autism Research Institute.
Rimland, B., and S.M. Edelson. 1994. The Effects of Auditory Integration Training on Autism.
American Journal of Speech Pathology 3: 16-24.
Rimland, B., and S.M. Edelson. 1995. Brief Report: A Pilot Study of Auditory Integration
Training in Autism. Journal of Autism and Developmental Disorders 25(1): 62-69.
Rimland, B., and S.M. Edelson. 1998. Auditory Integration Training in Children With Autism:
Commentary. Autism 2(1): 91-92.
Schreibman, L. B.S. Kohlenerg, and K.R. Britten. 1986. Differential Responding to Content andIntonation Components of a Complex Auditory Stimulus by Nonverbal and Echolalic Autistic
Children. Special Issue: Stimulus Control Research and Developmental Disabilities. Analysis
and Intervention in Developmental Disabilitites (2): 109-125.
Siegel, B., and B. Zimnitzky. 1998. Assessing ‘Alternative’ Therapies for Communication
Disorders in Children With Autistic Spectrum Disorders: Facilitated Communication and Auditory
Integration Training. Journal of Speech-Language Pathology and Audiology 22 (2): 61-70.
Sinha, Y. 2004. Auditory Integration Training and Other Sound Therapies for Autism Spectrum
Disorders. Cochrane Database Systematic Review (1): CD003681; OMID: 14974028.
Smith, I.M. 1998. Complex Choices: Commentary on Assessing ‘Alternative’ Therapies
for Communication Disorders in Children With Autistic Spectrum Disorders: Failitated
Communication and Auditory Integration Training. Journal of Speech-Language Pathology
and Audiology 22(2): 71-73.
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Tharpe, A.M. 1999. Auditory Integration Training: The Magical Mystery Cure. Language,
Speech, and Hearing Services in Schools 30(4): 378-382.
Ziring, P.R., D. Brazdziunas, W.C. Cooley, T.A. Kastner, M.E. Kummer, L.G. De Pijem, R.D.
Quint, E.S. Ruppert, A.D. Sandler, W.C. Anderson, P. Arango, P. Brgan, C. Garner, M. McPherson,
A.M. Yeargin, C. Johnson, L.S.M. Wheeler, and R.C. Wachtel. 1998. Auditory Integration Training
and Facilitated Communication For Autism. Pediatrics 102(2): 431-433.
Zollweg, W., D. Palm, and V. Vance. 1997. The Efficacy of Auditory Integration Training: A
Double Blind Study. American Journal of Audiology 6(3): 39-47.

Craniosacral Therapy
Barrett, S. 2004. Craniosacral Therapy, http:// www. quackwatch.org, (accessed May 5,2006).
Continuing Education, Continuing Care. 1999. Palm Beach Gardens, FL: The Upledger
Institute, Inc.

Dolphin Therapy
Hulme, P. 1995. Historical Overview of Nonstandard Treatment. ED384156, p. 149.
Lukina, L.N. 1999. The Effect of Dolphin-Assisted Therapy Sessions on the Functional Statusof Children with Psychoneurological Disease Symptoms. Psychological Information 25(6):56-60.
Reppuk, E., and H. Koll. 1989. Structurally Assimilative Therapy for Autistic Disorders.
Frühförderung Interdisziplinär 8(1): 33-36.
Servais, V. 1999. Some Comments On Context Embodiment in Zootherapy: The Case of theAutidolfin Project. Anthrozoos 12(1): 5-15.
Tak-Cho, L.L. Quantec and the Dolphin - Effect, http:// www.mtec-aq.de/autismus_undintrumentelle-biokommunikation.asp?lang=eng, (accessed April 21, 2005).
Walker, L.A. 1999. These Dolphins Help Families Heal. Parade Magazine Key Largo, FL.

Exercise Therapy
Allison, D.B., V.C. Basile, and R.B. MacDonald. 1991. Brief Report: Comparative Effects of
Antecedent Exercise and Lorazepam in the Aggressive Behavior of an Autistic Man. Journalof Autism and Developmental Disorders 21(1): 89-95.
Celiberti, D.A., et al. 1997. The Differential and Temporal Effects of Antecedent Exercise on
the Self-Stimulatory Behavior of a Child With Autism. Research in Developmental Disabilities
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Cowden, J.E., L.K. Sayers, and C.C. Torrey. 1998. Pediatric Adapted Motor Development andExercise: An Innovative, Multisystem Approach for Professionals and Families. Springfield,
IL: Charles C. Thomas Publisher, Ltd.
Davidson-Gooch, L. 1980. Autism Reversal: A Method for Reducing Aggressive-Disruptive
Behavior. Behavior Therapist 3(2): 21-23.
Elliott, R.O, A.R. Dobbin, G.D. Rose, and H.V. Soper. 1994. Vigorous, Aerobic Exercise Versus
General Motor Training Activities: Effects on Maladaptive and Stereotypic Behaviors of Adults
With Both Autism and Mental Retardation. Journal of Autism and Developmental Disorders
24(5): 565-576.
Farrar-Schneider, D. 1994. Aggression and Noncompliance: Behavior Modification. In J.L.
Matson, Autism in Children and Adults: Etiology, Assessment and Intervention. Belmont, CA:
Brooks/Cole Publishing Co., 181-191.
Gutstein, S.E., and R.K. Sheely. 2002. Relationship Development Intervention With YoungChildren: Social and Emotional Development Activities for Asperger Syndrome, Autism, PPD
and NLD. Philadelphia, PA: Jessica Kingsley Publishers, Ltd.
Hellings, J.A., J.R. Zarcone, and K. Crandall. 2001. Weight Gain in a Controlled Study of
Risperidone in Children, Adolescents, and Adults with Mental Retardation and Autism. Journalof Child and Adolescent Psychopharmacology 11(3): 229-238.
Hinerman, P.S., W.R. Jenson, and G.R. Walker. 1982. Positive Practice Overcorrection Combined
With Additional Procedures to Teach Signed Words to An Autistic Child. Journal of Autism andDevelopmental Disorders 12(3): 253-263.
Kay, B.R. 1990. Bittersweet Farms, Journal of Autism and Developmental Disorders 20(3):309-321.
Kern, L, R.L. Koegel, and G. Dunlap. 1984. The Influence of Vigorous Versus Mild Exercise
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516

IndexIndex
A
ABA See Applied Behavior Analysis
ABC See Aberrant Behavior Checklist
Aberrant Behavior Checklist 199, 256, 260, 351, 357
abstract language 13
academic corruption 385
academic deficits 106
academic journal 370, 382-383, 389
academic research 57, 365
academic skills 235
ADOS 155
adult-led 42-43, 159, 328
advancement 13, 77, 363, 364-365
after-only design 392
agency 83, 163, 256-257, 383-386
agenda 95, 383-384
aggression 261-262, 281-282, 415
allegations 297, 300-302, 307
American Academy of Child and Adolescent Psychiatry 22, 74, 179, 182, 184, 202,
204, 212-215, 300, 307
American Academy of Pediatrics 22, 51, 73, 180, 187, 194, 202, 263, 300, 355, 357
American Journal on Mental Retardation 72-73, 76, 78, 265, 325
analog condition 42-43
analog teaching 40, 42-43
Anderson 15, 72
anecdotal evidence 134, 183, 261, 310, 371-373
anecdotal report 18, 93, 144, 177, 310
anecdotes 275, 371-373
Animal-Assisted Therapy 327
Applied Behavior Analysis 7-8, 11, 17, 21, 25-26, 53-54, 58, 65, 67, 70, 76, 92,
129-130, 146, 229, 303, 320, 403, 431
applied science 53, 77
appropriate responding 114-115, 288
Art Therapy 251-255
assessment 30-31, 35-37, 55, 62, 71, 73-74, 94, 101, 111, 122-123, 137, 143-146,
158, 180, 182, 196, 199, 204, 207, 215, 228-229, 235-237, 244, 257266, 305, 307,

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325-326, 347, 351, 355, 385, 426, 436
Association for Science in Autism Treatment 37, 93-94, 140, 187, 212, 215, 263,
266, 301, 307, 315, 348
attachment 95, 309, 312-313, 322
Auditory Integration Training 255, 258-265, 307, 347
Autism Behavioral Checklist 207, 414, 421
Autism Diagnostic Observation Schedule 152, 155, 207
Avery 72
awareness 310, 426
Ayers 335-341, 346-347

B
Baer 15, 73
baseline 37, 48, 84, 145, 245
Behavior Analyst 8, 11, 37, 72, 78
Berringer 105
best practices 18, 21, 62, 92, 154, 179, 263, 301, 412
beta-endorphins 113
Bettleheim 137, 252
between-subject comparison 152
between-subjects design 15, 353, 390, 382-393, 406-407, 422, 429-430
between-subjects analysis 400
between-within subjects design 390, 398, 405
bias 31, 58, 87, 97, 126, 172, 174, 192, 209, 221, 282, 338, 350
biased report 146
Biomedical Therapies 4, 169, 183, 191, 197, 205
biomedical treatment 364
Birnbrauer 72
blind condition 291
blind review 387-388
blind test 90, 221
body movement 30, 36
Bolton 226
Bond 332
Buday 319, 325
Burleson 320, 325C
CAR scores See Childhood Autism Rating Scalecase studies 54,134,173, 198, 206, 236-237, 265, 290, 304-305, 309, 325, 336,
340-341, 406

518

Index

Cathcart 84-85, 90, 92, 94
causal fallacy 396
cause-effect learning 13
center-based 9, 83-84, 88, 92
chaining 12child-led 39, 42-43, 48-49, 95, 100, 121, 133, 138-139, 143, 159, 229-231
child-preferred 121-122
Childhood Autism Rating Scale 97, 208
childhood disorders 146, 267
clinic-directed 19
clinical guidelines 110, 331
clinical trials 199, 378, 386
COCHRANE 386
Colorado Health Sciences Center 95
communication 8, 22, 32, 63, 83-84, 87, 94-95, 97, 105, 115, 124, 133, 136-137,
149, 155, 201, 227, 233, 241, 244-245, 247, 251, 266, 268, 289-291, 295-307,
318, 354
communicative intent 138
community based 88
compliant children 162
comprehension 30, 35-36, 68, 223, 235, 260-261, 320, 338
confounding variables 15, 171, 341, 425
confrontation 310
consistency 32, 40, 105, 164, 416
consultant 71, 153, 238, 363
contagions 377
control group 14-16, 21, 28, 31, 36-37, 45, 85, 87, 91, 98, 109, 114, 116-117, 152,
164, 172, 187, 191-192, 201, 209, 221, 224, 231, 256, 258-260, 271, 309, 323,
337-339, 343, 353-354, 390, 392-400, 410-412, 421, 426, 428-430
Controversial Therapies 72, 78, 344, 348
controversy 300, 305, 379
Cook 74, 203, 337, 340-341, 346-347
cost-effective 90, 106
Craniosacral Therapy 267-271
curriculum 12-13, 25-27, 33-34, 70, 74-75, 83-85, 90, 95, 99-100, 104, 106-110, 113,
115-116, 118, 121, 128, 133, 137, 159, 226, 235-236, 242-243

D
D.V. See Dependent Variable
Daily Life Therapy 113-144, 116-119, 288
daily living skills 26, 105, 121

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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

daily schedules 27, 83
Daly 124, 129-130
DAT See Dolphin-Assisted Therapy
DDDC See Douglass Developmental Disabilities Center
deficits 12-13, 25, 62, 89, 91-92, 107, 126, 137-138, 157, 230-231, 235, 237, 245,
265, 268-269, 284, 297, 340
delays 74, 159-161, 163, 228, 233, 281
dependent measure 36, 45, 48, 90, 101, 139-140, 192, 194, 354
dependent variable 16, 30-31, 86-87, 92, 172, 177, 191-193, 198, 206, 208, 211,
253, 262, 268, 321, 337-339, 351, 380-381, 413
destructive behavior 7, 96
Developmental Disabilities 26, 72-76, 78, 106, 111, 129, 181, 203-204, 288-289,
293, 303-304, 325, 344, 347,-348
diagnosis 16, 31, 40, 73, 124, 139, 146, 152, 172, 178, 182, 185-186, 189, 196, 204,
215, 224, 228, 231, 236, 256, 268-269, 293, 297, 310, 325, 350, 403, 413
Diagnostic Statistical Manual 31, 41, 414
diet 108, 169,170-182, 201
DIR (Developmental, Individual Difference, Relationship Model) See Floortime
direct instruction 12, 26-27, 121, 229, 304
discrete trial training 12, 32, 41-42, 68-69, 85-86, 92, 123-124, 424-425
discrimination training 12
disruptive behavior 43, 49, 54, 76
distractor 295
DLT See Daily Living Therapy
Dolphin-Assisted Therapy 273-279
double-blind 155, 178-179, 192, 194, 197-199, 203-204, 206, 214, 260, 270, 347,
350-351
Douglass Developmental Disabilities Center 26, 75
Down Syndrome 293
Drash 64, 79
DSM-IV 139
DTT See Discrete Trial Training
Durand 58, 78, 325
dysfunction 181-182, 214, 312, 335, 337-338, 340, 349, 354Eearly intensive treatment 102
Early Intervention 20, 35, 50, 54, 72-73, 77, 96-97
eclectic approach 126
eclecticism 125, 127
ecological validity 53

520

IndexEdgerton 318, 325-326
editorial board 70, 365, 388
educational system 4, 47, 53, 55, 67, 88, 90, 92, 224, 399
effectiveness 4, 9, 16, 18-19, 41, 54, 76, 90-94, 98, 106-108, 126, 134, 139, 140,
148, 156, 171, 173, 182, 194, 210, 231, 233, 253, 270, 275, 294, 296, 301, 304,
338, 345, 347, 362, 412, 436
efficacy 8, 11, 14, 21-22, 37, 47, 54, 57, 84, 89, 94, 97, 101, 106-107, 114, 116-117,
123, 126-127, 135, 139, 143, 146, 151, 163-165, 171, 173, 178, 186, 195, 203,
228, 231-232, 235, 244, 250, 253, 263, 265, 274, 301, 324, 340, 342, 344, 347,
356, 383, 412, 419, 430-431, 433
ego deficiencies 100
Eikeseth 72-73
empirical support 63-64, 137, 242
engineered setting 121
environmental accommodation 83
equivalence 410
ERIC 106, 315, 357, 386, 436
ethical guidelines 11, 57
evaluation 3, 101, 106-107, 117, 155, 164, 173, 207, 209, 223, 232-233, 269, 303304, 307, 361, 375, 382, 407
Exercise Therapy 281, 284-288
experimental group 14-16, 85, 87, 101, 117, 173, 259, 343, 352-353, 376, 389-390,
393, 397-400, 408, 410, 420-421
experimental treatment 4, 364, 412
experimenter bias 87, 172, 350, 426
experts 312, 363-365, 369-370, 390
expressive 26, 83, 87
expressive language skills 13, 25, 83
extinction 13, 20, 160, 162
eye/hand integration 83

F
Facilitated Communication 266, 289-290, 295, 297, 299-307
facilitator 227, 288, 291-295, 297-299, 304
falsifiability 312
Fast ForWord 219, 221-226
FC See Facilitated Communication
Fenske 28, 74
Finding 303
fine and gross motor skills 90
fine motor 26, 30, 36, 82, 85-87, 299
fine motor writing 36
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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

Floor-Time 102, 123-124, 126-127, 132, 134-142, 242
Fluency 67-71, 79
folic acid 411
foundation skills 8, 153
functional analysis 84
Functional Behavioral Assessment 55
functional-random assignment 431
funding 15, 163, 201, 383-384, 386, 428

Ggaze 349
gene 371
generalization 20, 41, 50-51, 76, 129, 245, 407, 429
generically trained 88
Giant Steps 105-111
goal-directed 39, 338
goals 7, 26, 59, 83, 99, 121, 133, 136, 241, 244-245, 317
government 8, 21, 33, 35, 50, 57, 89-90, 163-165, 232, 275, 383-386, 412,
418-419, 433
government-funded programs 35
Grandin 339, 341, 346-348
Graupner 19, 73, 78
Greenspan 131, 133-138, 140, 142
gross motor object 30, 36
gross motor skills 85, 90
gross-motor 113
group assignment 87, 410, 421
Guralnick 73, 94, 111, 142, 183, 196, 204, 215, 266, 307, 326, 347
Gurry 123,127, 288
Gutstein 151-153

H
Hairston 320, 325
half-baked treatments 371
hand-flapping 328-329
Handleman 29, 74-75, 94, 129
Harris 28-30, 74-75, 94, 128
head tilts 349
head-banging 136
heavy metal 184-189, 374
Higashi 113-114, 116-117, 119522

Indexhigh functioning 45, 152, 154
Holding Therapy 309-315
home program 40-41, 92, 102, 230
home-based program 32-33, 84, 94, 222
Howard 16-17, 72
Hoyson 33, 74
Hug Machine 340
Huxley 375-376, 436
hyper-arousal 113
hyperactivity 352
hypersensitive perception 260
hypersensitivity 180, 260
hypotheses 45, 184, 407, 425, 429, 436
hypothesis 97, 116, 187, 252, 260, 305, 339, 342, 350, 368, 377, 381, 419,
426-427, 429

I
I.V. See Independent Variable
IBT See Intensive Behavioral Treatment
IEP See Individualized Education Plan 105, 108
imitation 12, 25, 61, 68, 80, 86, 112, 114, 116, 159, 161-162, 230, 325
inappropriate behavior 22, 96, 116, 284
incidental teaching 32, 121, 123, 125, 129, 130
INclass REActive Language 95
inclusion 19, 53, 57, 126-127
independence 8, 26, 83, 91, 114, 146, 162, 299, 305
independent play 27
independent reviews 21
Independent Variable 253, 321, 323, 337, 380-381, 415, 417, 426
individualized preventative strategies 27
individually designed 19
ineffective treatment 204, 263, 362
initiation 76, 121, 124-125
injurious 96
INREAL See INclass REActive Language
instantiation 409
integration 9, 19, 29, 35, 83, 86-87, 89, 91, 107-108, 110, 121, 242, 252 255, 258266, 307, 334, 336-337, 339-347
Intensive Behavioral Treatment 8-9, 11-12, 14, 21, 25, 33, 38, 71-74, 85, 135-136,
145-146, 244
intensive treatment methods 102

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inter-observer reliability 220, 417
Interaction 84-85, 137, 329, 333
interaction 19, 27, 31, 35, 49, 76-77, 83, 107-108, 116, 121-123, 125, 129, 133, 135136, 138-139, 143, 153, 155, 227-228, 230, 274, 311, 321, 325, 327-328, 331, 402
interactive experience 133interactive play 14
International Journal of Mental Health 89
interpersonal development 95
intuition 3, 376
investigations 263, 300
invitational equipment 105
IQ (scores) 15-16, 30, 35-37, 51, 59, 70, 74, 84-85, 87, 90, 92, 97, 114, 139, 152,
155, 162, 187, 194, 224, 245, 256, 258, 298, 340, 355, 390, 393, 398, 403-405,
414, 421, 427
irritability 137, 199-200, 352

J
Jacobs 72, 78, 129-130
Jennett 89, 94
justification 50, 178, 339, 412, 419

K
Kaplan 317, 349-350, 354, 357
Kim 105, 111
Kitahara, Dr. Kiyo 113
Koegel 75-78, 42

Llanguage 9, 12-14, 16, 25-27, 29-30, 32-33, 35-37, 40-42, 44-48, 51-52, 61-64,
70-71, 74, 76-78, 83, 85, 90, 92, 94-95, 97-98, 103, 105, 108, 115, 121-122, 129,136-137, 154, 159, 161-162, 164, 192, 194, 203, 217, 219-220, 222-228, 230-233,
235, 237-239, 241, 243-245, 247, 264, 267, 269, 275, 297-300, 303, 305, 307,
317, 320, 325, 338-340
language-delayed 14, 159
Larkin 115, 119, 288
Laski 40, 50, 76
Leaf 22, 74
LEAP Program 27, 30-31, 33-37, 75
Learning Accomplishment Profile 30, 32, 35
learning channels 69
Learning to Speak 167-168, 171, 174524

Index

Learning to Speak program 159-160, 163-166
Leiter International Performance Scale 257
lenses 349-352, 354-357
lethargy 352
letter recognition 105
level of autism 86, 414-415
licence 245, 365
Lieberman 72
LIPS 256-257
logic 375
Lord 84-85, 94, 206
Lovaas 11, 13-16, 18, 20-22, 40, 64, 72-74, 145-146, 405-406, 431, 436
low intensity experiments 41

Mmagnesium 173, 205-207, 209-215, 368
Mahler 95
mainstream setting 56, 89, 126
mainstreaming 33, 56-57
maladaptive behavior 8, 35-36, 122, 139, 230, 322
mand 61, 63-64, 79
manipulation 30, 36, 267
matched pairs assignment 16
Matson 72
maturation 98, 122, 126, 171, 231, 259, 337, 423
Maurice 22, 74
McClannahan 74
McEachin 16, 22, 72-74
McGee 124-125, 130
mean scores 123, 152, 339
MEDLINE 106, 160, 198, 388, 436
melatonin 419-420
mental age 97, 159, 161
Mental Retardation 80-81, 84, 86-87, 137, 223, 241, 273, 296, 301, 313-314, 333
mental retardation 31, 72, 75, 162, 215, 292, 325
mentally retarded 14, 18, 79, 297, 320, 325
Mesibov 89, 94
meta-analysis 317, 407
methodological weaknesses 28, 31
methodology 68, 101, 140, 351
Metz 72-73
motivation 39, 49, 143, 151, 154, 245, 274, 281, 337, 418

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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

Mulick 58, 72-73, 78, 348
multi-cued instructions 49
Music Therapy 105, 107-108, 110, 317-318, 320-325

N
National Institutes of Health 15, 431
National Research Council 22, 74
naturalistic teaching 40-43, 424
negative finding 303, 368, 409
negative outcome group 28
neurological disorder 50, 89, 311
neurological dysfunction 312
New York Report 21, 92, 110, 212, 344
New York State Department of Health 21, 73, 92, 94, 110-111, 140, 142, 182, 195196, 202, 204, 215, 245, 267, 301, 307, 325-326, 332, 343, 347
non-verbal 95, 154, 159, 172
normalization 19
nutritional component 105, 108Oobjective assessment 145
objectives 33, 121
observation 4, 13, 29, 31, 48, 84, 114, 136, 144, 152, 155, 169, 172, 174, 176, 182,
200-201, 207, 211, 215, 258, 260, 273, 275, 294, 311-312, 318-319, 321, 328, 330,
338-339, 342, 367, 371, 376, 426
observational learning 13
Occupational Therapy 104, 107, 265, 346-347
Olgetree 292
Olney 305-306
one-on-one 29, 32, 34, 47, 56, 98, 62, 109, 123, 126, 220, 242, 317, 321, 339
operant conditioning 7, 9
Options 152, 154-156
Options Institute 143- 147, 149
organization 21-22, 37, 65, 67, 83, 93, 102, 127, 148 179, 227, 238, 263, 270, 300,
324, 332, 335, 433
organizational skills 83
Ornitz scale 338
Ozonoff 84-85, 90, 92, 94

P
p value 114, 199, 209, 281-282, 421-422

526

IndexPanerai 87, 94
parent-directed 14, 19, 153
parent-facilitated 133, 143, 151
parent-training 50
parental involvement 88, 144, 229
parental reporting 144, 146, 172-173, 183, 186, 198-199, 256, 259, 309-310, 338,
351, 353, 355, 418
parental withdrawal 137
Partington 61, 63, 78
PBS See Positive Behavioral Support
PCDI See Princeton Child Development InstitutePeabody Picture Vocabulary Test 30, 257
peer interaction 107-108, 115, 122, 153
peer-mediated therapy 327
peer-reviewed 13, 84, 126, 141, 154, 160-161, 198, 221, 223, 235, 237, 255-256,
267, 269, 275, 279, 281, 301, 318, 386-388, 431, 433
peer-reviewed journal 13, 25, 40, 68, 70, 84, 122, 151, 171, 173-174, 180, 183, 186,
218, 235-236, 250, 267, 270, 290, 318, 326, 368, 384, 386-388, 415, 432
penicillin 377
Peptides 414
peptides 169, 177-178, 181, 414
perseverative behavior 138
Pet-Facilitated Therapy 327-329, 332-333
phenomenon 191, 300, 303, 306, 371, 432
physical aversive 20
physical exercise 113, 115-116, 281-282, 284, 288
physical harm 362
physical restraints 20, 405
physically invasive 362
Piaget 95
Pierce 76-77
Pivotal Response Training/Naturalistic Learning Paradigm 39, 40-41, 45-46, 49, 5152, 75-76, 123-124, 126-127
placebo 186, 192, 194, 197-199, 203, 206, 209, 214, 224, 256, 343, 416
play 12-13, 25-26, 36, 40-41, 44-47, 52, 76, 95-100, 102, 105, 108, 121, 135-138,
155, 182, 184, 227, 241-242, 244, 269, 292, 312, 319, 325-326, 337-339, 341, 343
Playschool Model 96, 98, 103
Playschool Outreach Project 99
Positive Behavior Support 58, 78
positive outcome 28, 36, 50, 70, 164
positive results 86, 91, 146, 206, 208, 256, 281, 291, 299, 415
positive strategies 27

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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

Positive Behavioral Support 53-54, 56-57, 77, 242, 245
Post test 109, 209, 220-221, 239, 271, 342, 355
posture 349-350, 354
pre and post treatment 70, 152
pre-test 86, 422-423
pre-academic 13, 26, 84
Precision Teaching 66, 68-69, 79-80
pretend play 44-45, 136, 319, 242
pre-vocational skills 84
Princeton Child Development Institute 25
prism 350-355
problematic behavior 27, 32, 55, 83, 96, 133, 162, 243, 281-282, 322, 352-353
prompting 12, 51, 63, 145, 229, 242, 289
prompting and fading strategies 12
PRT/NLP See Pivotal Response Training/Naturalistic Learning Paradigm
pseudo-science 58, 361, 366-370
pseudo-scientists 403, 408
PSYCHINFO 160, 388
Psychoeducational Profile 84-86
psychometric measures 31, 91, 141, 177, 211, 257, 260
psychometric testing 65, 174, 339
publish or perish 364
published article 143, 255
published research 106

Q
quackery 188, 271, 361, 363, 369, 371, 373, 382, 406, 432, 435
Quackwatch 140, 148, 179, 182, 185, 188-189, 202, 204, 232, 270-271, 300, 307,
312, 315, 330, 344, 348
quasi-random 73, 412, 428
Quill 113, 119, 288

R
random assignment 15, 73, 98, 139, 152, 155, 191, 205, 211, 257, 323, 410-412,
428, 431
randomization 15, 21, 206
randomized trials 52
rate of development 29
rating scale 97, 191, 208, 340, 357, 416
Ray 337, 346

528

IndexRDI See Relationship Development Intervention
receptive instructions 25
receptive language skills 12, 26
recognition 105, 136
recognized experience 8
red flag 137, 297, 311-312, 368-369, 414, 432-434
redirection 13, 20, 96, 115, 124, 292
reinforcement 7, 12-13, 20, 27, 39, 43, 320, 322, 325, 331, 337, 418
reinforcer 43, 316, 320, 330-331
Relationship Development Intervention 151, 157
relevant reinforcer 43
reliability 134, 207, 217, 220, 258, 318
repetition 51, 68-69, 125, 229
replication 11, 13-14, 16, 20-22, 44, 73, 102, 123, 125, 175, 179, 213, 262 354, 361,
368, 406, 411, 429-430
retrospective study 152, 173-174
reviewers 212, 385
reviews 21, 106, 171, 232, 255, 263, 290, 344, 388, 436
reward 12, 27, 39, 46-47, 159-162, 222
rhyming 319
ritualistic 39, 138, 269
Rogers 96-99, 102-103, 203
Rosenthal 281-282, 286, 288, 427, 436
Rost 58, 78

S
s.d. See standard deviation
safeguard 40, 387, 406, 427
Sallows 16, 19, 74, 78
Satcher 22, 73
SCERTS Model 241-247
schedule 26-27, 83-84, 107, 115, 152, 155, 182, 207, 282-283, 285, 353
school program 32-33, 117, 122
school-based 9, 25, 27-28, 33, 36-38, 83, 95, 105, 110, 113, 121
Schopler 92-93, 97, 102, 216
science-based 11, 55-56, 65, 127, 342, 363-364, 387
scientific evidence 3, 18, 140, 147, 202, 262-263, 270, 274, 309, 342-343, 356, 364,
366, 370, 433-434
scientific method 140, 290, 296-297, 300, 343, 361-362, 365-370, 382, 426, 431,
435
scientific research 23, 38, 53, 59, 65, 70, 93, 102, 110, 118, 128, 141, 146, 156, 180,
188, 195, 202, 213, 225, 232, 239, 246, 253, 264, 270, 278, 287, 302, 314, 324,

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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

332, 344, 356, 363, 371
Scientific Review of Mental Health Practice 37, 75, 355, 357
scientific scrutiny 140, 370
scientific support 135, 180, 245
scientific validity 300
scientifically substantiated 116, 149, 171, 338
scientifically-supported 370
score 97, 162, 257, 291-292, 318, 319, 343, 352, 396, 398-399, 416, 422, 424
secretin 205-212, 400, 432
segregated 19, 29, 74, 119, 242
seizure 261-262
self-destructive 8, 13
self-esteem 114, 274
self-help skills 12, 83
self-injurious 28, 47, 66, 144, 238, 348, 352, 358, 405
self-injurious behavior 20, 39, 58, 136, 230, 340, 344, 350, 405
self-stimulation 31, 134, 269, 288
self-stimulatory behavior 173-174, 229, 281-286, 288, 328-329, 340, 354, 414-415
sensory approach 336, 346
sensory dysfunction 338, 340
sensory information 335-336
sensory input 335, 339
Sensory Integration Therapy 107, 110, 335-337, 339-345
sensory sensitivity 336, 342, 425
sensory stimulation 99, 336
sensory stimuli 96, 335, 341
shaping 12, 162
Siegel 16, 73, 233, 307
significance levels 28, 209
significant change 126, 351
single case study 107
Single Subject Case Design 40, 44, 54, 70, 282, 292, 337, 390, 403, 405-406, 408,
429
Single Subject Research Designs 283
SIT See Sensory Integration Therapy
skill deficit 12, 36, 137, 231, 237
Skinner, B.F. 7, 61-62, 78
Smith 14-16, 18, 65, 72-73, 75, 290, 304, 344, 348
sociability 319, 327-329
social behavior 30, 76, 251, 327
social experiences 96
social interaction 27, 35, 83, 121, 123, 125, 133, 135, 138-139, 155, 230, 274, 321,

530

Index327-328, 331
social language 44
social skills 41, 46, 152
socialization 13, 26, 145
socialization skills 13, 145
societal norm 138
sociodramatic play 40, 76
Son-Rise 143-149
special education 16, 78, 85, 87, 92, 99, 103, 152, 163, 242, 304, 306, 325, 393
speech 14, 31-32, 40-41, 68, 75-76, 78-79, 95, 105, 107, 108, 159, 163-164, 191192, 219-220, 222, 224-228, 231-233, 235, 241, 244-245, 247, 265-266, 300, 303,
305, 307, 319-320, 325, 346, 352
speech therapist 32, 68, 191, 319
SSCD See Single Subject Case Design
SSRD See Single Subject Research Design
Stahmer 45, 48, 76-77, 123, 127, 129
stakeholder participation 53
standard deviation 124, 220, 258, 422
standardized measures 70, 208, 339
standardized score 97
stereotypic behavior 116, 282, 284-288
stereotypy 174, 352
stimulus 39, 79, 291, 321, 326, 335
Strain 33, 74-75
structured teaching 12, 42, 83, 85, 126
structured teaching technique 12
Sundberg 61, 63, 78-79

T
Tallal 218, 225-226
tantrum 31, 136, 261-262, 415
target sounds 42
tautology 311
TEACCH 83, 94
teaching techniques 32, 43, 77, 92, 277
testimonials 154, 171, 365, 373, 432
Thaut 321, 326
The Denver Playschool 98, 102
Theory 95, 179
theory 7, 18, 39, 65, 95, 184, 191, 193, 223, 253, 260, 266, 269, 281, 284, 290, 309,
311-313, 351, 361, 368, 373, 375-379, 381, 386, 409, 425, 429, 433
time-out 13, 32, 84, 96, 122, 160, 162

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The Complete Guide to Autism Treatments: Make Sure Your Child Gets What Works!

Toddler Center Model 121
toe-walking 349
touch 267, 269, 298, 303, 311, 335, 346-347, 355
toy play 12, 25, 44transition 27
treatment contamination 423-424
treatment efficacy 14, 88
treatment gains 14, 23, 135
treatment protocol 11, 13, 19-22, 97, 99, 101, 146, 253, 386, 407, 416
Tudor 64, 79
typically developing 17, 19, 25, 34-35, 43-44, 55-56, 76, 98, 113, 121, 125, 268, 275,
284, 423

U
U.S. Surgeon General 22
UCLA model 64, 73
unbiased measure 48
unbiased research 147
unproven treatment 262, 278, 362
unsubstantiated method 148
unsubstantiated treatment 301, 412

Vvalidation 147, 293, 303-306
Verbal Behavior 58, 69-73, 86-87
Verbal Behavior Therapy 61-65, 79
video modeling 26
Vineland Adaptive Behavioral Scales 87
Vision Therapy 349-350, 352-257
visual dysfunction 349, 354
visual schedules 26, 83
visual strengths 84
visual-motor 113, 235
Vitamin B6 170, 173, 205-207, 209-212, 214-215, 368
vocabulary 30, 69, 233, 257, 338, 368
vocal tone 135

W
Walden 121-129
Weiss 103, 292, 306
Welch 309-311, 315

532

IndexWhipple 317
withdrawal 137, 309, 403, 423
within-subject 328
within-subject analysis 152, 340
within-subjects design 15, 30, 172, 174, 221, 225, 256, 291, 328, 340, 350, 390,
393, 395-397, 400, 422

Z
Zelazo 159, 160-164, 166533