The Emperor's new clothes: Eclecticism in autism treatment

(Karola Dillenburger, 2011; Research in Autism Spectrum Disorder 5 (2011) 1119-1128, originally published online 22 January 2011; DOI 10.1016/j.rasd.2010.12.008)

Although ABA is more and more recognized as the scientific way to go, many European governments prefer an eclectic model as they argue that it is more children-centred and pragmatic. This paper shows why ABA is truly practical and child-centred.

Autism Spectrum Disorder affects social interactions, flexibility and behavior (APA, DSM- IV-TR, 2000). Even though, there is a lot of research ASD can still only been diagnosed by observing the behavior and by listening to reports of others (Keenan, Dillenburger, Doherty, Byrne & Gallagher, 2010).

As the number of children with autism has risen dramatically (Fombonne, 2005), and the costs are as high as 3.2 million $ per individual if he or she is not properly treated (CDC, 2010), it will be important to look for the most appropriate treatment. This is also important in terms of quality of life and psychological well-being for families (Dillenburger, Keenan, Doherty, Byrne, & Gallagher, 2010).

Even though, it is crucial to accept differences that will continue to exist, one must also educate and intervene further (Baron-Cohen, 2008; Helt et al., 2008; Jordan, 2008; Lamb, 009; Markram, Rinaldi, & Markram, 2007). Unesco Salamanca Statement (CSIE, 2010) shows that inclusion is the best possibility to show acceptance. How can children with autism learn skills that are required for social interaction (CSIE, 2010; Oxoby, 2009)?

There are many interventions that originally come from various professions (Archart-Treichel, 2010). Furthermore, there are parents who have developed their own intervention, some of them are described in books some require exclusive training.

Recommendations from governments
Many governments have discussed the most successful interventions, results vary (NSP, 2009, Mudford et al., 2009; Task Group on Autism, 2002; Task Force on Autism, 2001; Dunlop et al., 2009; Weinmann et al., 2009; Perry & Condillac, 2003). Some recommend treatments based on ABA, some prefer treatment to be eclectic. Clinical and social results, as well as financial efficiency in North America suggest that interventions based on principles of behavior are the way to go (Cooper, Heron, & Heward, 2007). Systematic reviews of research literature demand that health insurances cover diagnosis and treatment of autism, including ABA (ATAA, 2010). Many states have already signed it while others are still waiting for introduction. The same is true for Canada.

The eclectic approach
The governments in most of Europe, except Norway, promote the eclectic approach which allows for a range of interventions, as there is no definitive evidence that supports one treatment over the other (Task Force Autism, 2001, p.117). What is the eclectic approach? Many different interventions are selected from different available interventions, according to identified needs (Gladwell 2010). The approach is viewed as flexible and child-centred. Therefore, it is financially supported in Europe.

So why does North America has a different approach?

What to think about:

  • An eclectic model integrates new methods, but it won't develop them themselves.

  • Some methods in an eclectic model are evidence-based; some might even be controversial (Jacobson et al, 2005; Perry, 2000; Perry & Condillac, 2003; Tweed, Connolly, & Beaulieu, 2009).

  • Nobody knows the effect of the mixture of the interventions. Howard et al (2005) found ABA to be more effective than the eclectic approaches. One must do a comprehensive component analysis to differ between synergetic effects and effects of particular interventions (Osborne & Reed, 2008).

  • Theoretical bases of the methods may sometimes contradict themselves.
    They don't have a coherent theoretical base.

  • It is difficult to train staff in eclectic teaching. The effective methods require a lot of university training, and it will be impossible for one person to be qualified in all interventions. Therefore the eclectic model may seem scientific, but it doesn't use valid scientific methodology that can be tested, and therefore the approach lacks supporting evidence. Science is doubt, pseudoscience promises certainty (Gardner, 1957).

ABA is not one specific method of intervention, but it is
"a scientific approach for discovering environmental variables that reliably influence socially significant behavior and for developing a technology of behavior change that takes practical advantage of those discoveries" (Cooper, et al., 2007; p.3)

You always apply ABA if you use the basic principles of behavior. And as you always behave in some way (you even behave if you are only feeling), you should use the knowledge of behavior to address socially relevant behavior (Baer, Wolf, & Risley, 1968; Newman, 1992; 1998).

First of all you must define target behavior, by talking to the clients and their caregivers. Target behavior is socially or educationally relevant and ambitious (Lamb 2009). It is always appropriate and individually tailored for each child, also curricula may be used as a base (ACE, 2011). Second, the function of behavior is analyzed by looking for contingencies, therefore, appropriate interventions can be developed (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994). Afterwards, a baseline is established and intervention is introduced while more data is collected to be able to ensure the effectiveness of intervention or to be able to adjust them to new requirements.

As soon as a behavior is learned, procedures should take place so that generalization happens and so that the behavior is maintained across situations, people and time.

As all is based upon behavior principles, there are several interventions. Some are especially popular such as discrete trial teaching and natural environment teaching.

However, all of them are based on Functional Behavior Analysis or Assessment and are individualized for each child (Iwata et al., 1982/1994)

There exist a lot of scientific papers about the evidence of ABA (Eldevik et al., 2010) and there are also more and more meta-analyses. Some people who are favoring the eclectic approach claim nevertheless that one can't tell the effectiveness of ABA without Randomised Controlled Trials (RCT), as they are the gold-standard in scientific research (Morris, 2009). At the same time they don't demand RCTs for the eclectic approach (Keenan & Dillenburger, 2011). But RCTs were designed to test drugs not medical procedures. So it is difficult to demand them. Nonetheless, there are some RCTs that have compared ABA with parts of eclectic treatments " ABA was more effective in all of these in changing a range of behaviors (Birdnbrauer & leach, 1993; Cohen, Amarine-Dickens, & Smith, 2006; Eikesetz, 2009; Eikesetz, Smith, Jahr & Eldevik, 2007; Eldevik et al., 2009, 2010; Howard et al., 2005; Magiati, Charman, & Howlin, 2007; Rogers & Vismara, 2008; Sheinkopf & Siegel, 1998; Smith, Groen & Wynn, 2000; Zachor et al., 2007).

When using ABA-based procedures it is necessary to include a well qualified behavior analyst to plan a child-centred and individualized treatment. Behavior Analysis is a profession that is recognized internationally. (BACB, 2010)

Despite all of that, ABA is still criticized as a single approach that is inflexible and rigid in comparison to an eclectic approach (McConkey 2007). This opinion is based on misinterpretation and bad knowledge about ABA (Jordan 2001) that doesn"t consider that ABA is a unified parsimonious approach that is flexible, individualized and firmly rooted in data-based, scientific research evidence.

Reasons for differences in reports and guideline
When a child is diagnosed with Autism, parents are faced with a "forced choice". Either they go for ABA, which is seen as to rigid (Jordan, 2008) or as best practise (Chiesa, 2005), or mix different interventions together in an eclectic approach, which is seen as more flexible (McConkey et al., 2007) or inconsistent and ineffective (Howard et al, 2005). A reason for different opinions about which treatment to use is more often based on "work experience" than on scientific findings (DfES, 2002; NIASA 2003). But when spending that amount of taxpayers" money it should be best practice to base decisions on research than on opinions. And if experts are included in the decision making they should be highly knowledgeable. Unfortunately, all of the reports from European governments are written without consulting adequately qualified experts in ABA, the lack of that was pointed out several times, without resulting effective change (Gladwell 2010, Mattaini, 2008; PEAT, 2008). Therefore, guidelines are inaccurate.

Only the Scottish government (Dunlop et al., 2009) reacted on this kind of criticism (about inaccurate and out-dated description of ABA, as well as mentioning no recent research papers) from parents so far and has withdrawn their initial recommendations. Now. they revise their report with the help of a well-known behavior analyst.

Category mistakes
ABA is not one specific kind of intervention. Instead it is a whole amount of different approaches based on principles of behavior. Unfortunately, many European governments make the mistake to consider ABA to be one method (Chiesa, 2005; Cooper et al., 2007; Dillenburger & Keenan, 2009.

In fact ABA is a child-centred and pragmatic approach, which could also be called eclectic (Leidermann, 2010) as a behavior analyst uses a "broad range of interventions resources and develops and adjusts individually tailored additional interventions on the basis of continuous data collection." In reality it isn't called eclectic as ABA is not applying interventions by chance, but is to be planned carefully. Selected interventions are based on continuously recorded data to be able to adjust to momentarily problems.

Even if there is a lot of research about Autism Spectrum Disorder and its treatment and even if a lot of money is spent, there are studies who report that parents are twice as likely to experience psychological problems (Keenan et al, 2002), stress (Burrows 2010) as well as some uncertainty about which treatment to use (Lamb, 2009).

So why don't governments admit flaws and mistake in their reports for the sake of parents and children? The reason might be, that it is difficult to admit that a lot of time and money and belief has been spent on less effective treatment in the past, or that it is difficult to admit a marginal knowledge of behavior analysis.

This paper tried to reveal reasons for different opinions from American and European governments regarding the most effective treatment of autism. When paying more attention on these reasons in the future it might be possible to deliver best treatment possible for children with autism, and therefore, to increase the quality of life for affected families as well as to decrease associated costs (decreasing the amount of help required in special school by treating a child with ABA, mounted to 208 500$ per child for 18 years) (Chasson et al., 2007).

Summing up, the eclectic approach is a fancy name for pseudoscientific ways of working, ABA is science.

To read the full study, please click here.
Elsevier. 6277 Sea Harbor Drive, Orlando, FL 32887-4800. Tel: 877-839-7126; Tel: 407-345-4020; Fax: 407-363-1354; Publication date: 2011

For the permission to post this study we thank Dr Karola Dillenburger BCBA-D; Clinical Psychologist (HPC)


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