IBI For Young Children Running head: IBI FOR YOUNG CHILDREN

Letter of Intent: Intensive Behavioural Intervention (IBI) for Young Children with Autism Pasquale Veleno Supervisor: Mone Palacios University of Calgary August 18, 2009

IBI For Young Children Letter of Intent: Intensive Behavioural Intervention (IBI) for Young Children With Autism Problem Statement The objective of this project is to determine whether children with Autism Spectrum Disorders (ASD) younger than four years of age benefit from early intensive

behavioural intervention (IBI). Although research has shown that intervention prior to the age of five is a predictor for success (Anderson, Avery, DiPietro, Edwards, & Christian, 1987; Harris & Handelman, 2000), few studies have examined the value of IBI for children with autism between the ages of two and four years of age. The research is unclear about the possible benefits and feasibility of utilizing an intensive behavioural approach with very young children with autism. Further study is required to ascertain whether comprehensive IBI programming is appropriate for the very young child, and to help establish optimal age of treatment onset. This study will attempt to examine the effects of intensive behavioural intervention on children with autism between the ages of two and four years. Rationale Autism is a pervasive developmental disorder characterized by impairments in communication and language development, social skills, and behaviour (American Psychiatric Association, 2000). Intensive Behavioural Intervention (IBI) is a comprehensive form of early intervention, derived from principles of Applied Behaviour Analysis (ABA), commonly used for young children with autism spectrum disorders. IBI has been shown to effectively remediate some symptoms of autism (Eikeseth, 2009), typically resulting in improved intellectual functioning, improvements in language, social

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skills, self-help skills, and reduced problematic behaviour (Green, 1996). Autism however, is a heterogeneous disorder whereby individual variables have been noted to impact intervention outcomes (Matson & Smith, 2008). It is speculated that individual characteristics including the childs age at treatment onset, for example, can influence treatment success (Eikeseth et al., 2002; Green, 1996; Harris & Handleman, 2000). Specifically, while much research has been dedicated to studying the impact of behavioural intervention with children over the age of four, it is unclear to what extent IBI can benefit younger children with autism. The potential benefits of early intervention can have significant positive effects on an individuals adaptive functioning and quality of life. Evidence of a link between early behavioural intervention and successful school integration exists (Lovaas, 1987; Maurice, 1993; Perry et al., 1995). Moreover, the remediation of the symptoms of autism can save the Canadian government millions of dollars by reducing the need for future specialized support services and care. In a study by Jacobson, Mulick, and Green (1998) assessing the cost-benefit analysis of providing IBI services to children with autism, the authors estimate an overall cost savings of approximately $3,000,000 per child by the time the child reaches the age of 55 years. Given the aforementioned reasons, it is important to determine whether clinical findings related to early behavioural intervention could be replicated with younger populations. To that end, this project will involve the empirical evaluation of outcome research, for the purposes of determining the value of providing IBI services to children less than four years of age.

IBI For Young Children Relevant Literature

While previous literature on the topic suggests that the age of the individual receiving IBI services may play a role in treatment outcomes, little research has directly addressed this issue specifically (Granpeeshseh, Dixon, Tarbox, & Wilke, 2009). A study by Howard, Sparkman, Cohen, Green, and Stanislaw (2005) compared a group of preschool children with autism receiving IBI, to a comparison group receiving eclectic intervention, and a second comparison group in a non-intensive public early intervention program. Measures of cognitive, language, and adaptive skills were taken pre-intervention and approximately 14 months subsequent to the introduction of intervention. Findings showed that the IBI group had statistically significant higher scores across all skill domains except motor skills when compared to the other two group, thereby contributing to the notion that early behavioural intervention may offer benefits for young children with autism, however it remained unclear whether the findings were specifically influenced by participant age at treatment onset. Fenske, Zalenski, Krantz, and McClannahan (1985) compared outcomes for nine children who accessed IBI services prior to 60 months of age to nine children who entered the same treatment program after 60 months of age. Results indicated that children who accessed IBI services prior to 60 months of age were more likely to attain placement in public school classrooms and residence in parents homes. Similarly, a study by Harris and Handleman (2000) found that younger age at intake was related to placement in regular education at discharge.

IBI For Young Children

Research indicates that symptoms of autism are typically present prior to 12 months of age, and diagnosis is common before the age of three years (Baranek, 1999; Lord, 1995). Although diagnosis of autism may occur at younger ages than in the past, and access to services may have improved (Jacobson, 2000), many children with autism still do not have an opportunity to begin treatment until they are at least 4 years old (Eikeseth, Smith, Jahr & Eldevik, 2002). Current best practice guidelines suggests that individuals with autism spectrum disorders should access behavioural interventions as young as possible in order to maximize gains (Granpeeshseh et al., 2009). Specifically, the New York State Department of Health Guidelines (1999) recommend that IBI should be offered to children with autism, aged zero to three. Methodology Participants Participants will be boys and girls, with an independent, preexisting diagnosis of ASD, between the ages of 24 months and 48 months, who have been referred for early intervention services through one of three community autism service providers within the greater Toronto area: Toronto Preschool Autism Services (TPAS), Kinark Autism Services, and Erinoak Child and Family Services. Individuals meeting criteria will be randomly assigned to either a waitlist (control) group or a treatment group. Participants will be treated in accordance with the CPA Canadian Code of Ethics guidelines. Parental consent will be obtained prior to participation in this study. Data collection and analysis Baseline data for all subjects will be collected to ascertain the childs level of functioning across all relevant domains. Autism symptom severity will be assessed, using

IBI For Young Children the ICD-10, for each participant prior to random, blind assignment to either the control group or treatment group, and will be repeated after one year as a means of comparison. Autism symptomatology severity will be used as a dependent variable. Behavioural data for participants in the treatment group condition will also be

collected and noted every three months via clinical records originating from participation in IBI services. This will be done in order to assess both short-term and long-term gains of the participants within this group. Behavioural objectives that the child will have mastered, based on a criterion of 80% accuracy over the course of three consecutive sessions, will be recorded. Collected data will be compared with baseline conditions after a one-year period to help determine treatment success. Program Characteristics Children assigned to the treatment condition will immediately receive 20 hours of direct IBI services a week for the duration of one year. Each childs program will be individualized to address specific areas of need and skill deficits across a number of domains, including: academic, functional, social/behavioural, and language/communication. To ensure program consistency and fidelity, all intervention programs will share the following characteristics: one-to-one intervention by trained instructor therapists; employment of behavioural teaching technologies, including discretetrial training; use of behavioural principles including reinforcement, extinction, generalization, shaping, chaining, etc. to promote skill acquisition; involvement including supervision and consultation of senior therapist and psychologist; parental involvement; empirical methods of data collection and evaluation; and, ongoing program assessment and revision, as necessary.

IBI For Young Children Ethical Considerations Letters detailing the nature and purpose of the study will be sent out to families

with children who meet the aforementioned criteria. Furthermore, families will be assured of the confidential and anonymous nature of the data collection, and will be asked to provide signed written consent for participation prior to being randomly assigned to one of the treatment group or control group conditions, respectively. All prospective parents of participants will be informed of the option to withdraw from the study at any time, without reprisal. Children assigned to the control group condition will be subject to the maximum one-year waitlist requirement before IBI services will be offered. Parents of children in the control group condition will be informed that they will remain on a waitlist for direct IBI services for an undetermined period of time equaling no greater than one calendar year, as is typical for services of this nature. In the interim, these parents will be offered free participation in monthly psycho-educational workshops touching upon relevant themes such as behaviour management principles, toilet training, behavioural skill building, etc. Any and all collected data and documentation related to this study will be stored in a secure, locked filing cabinet in the investigators home office. All documents will be destroyed and safely discarded at the conclusion of the study. Furthermore, all participants in this study and their families will be provided with study results subsequent to the completion of the research process. Implications The evaluation of this outcome research will provide a better understanding of whether very early behavioural intervention is appropriate and beneficial for children with

IBI For Young Children autism. This research project can serve to assist professionals in providing improved services to individuals with autism and their families, reduced costs of care, and reduced parental stress. Findings from this project may help indirectly contribute to the modification and improvement of autism screening process by highlighting and acknowledging the importance and value of earlier intensive behavioural intervention. Results will offer ideas for future research. Finally, and most importantly, results from this study may help contribute to improving the adaptive functioning of children with autism, thereby facilitating increased independence, successful transition to school, and improved overall quality of life.

References

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Anderson, S. R., Avery, D. L., DiPietro, E. K., Edwards, G. L., & Christian, W. P. (1987). Intensive home-based early intervention with autistic children. Education of Children, 10(4), 352-366. Baranek, G.T. (1999). Autism during infancy: A retrospective video analysis of sensorymotor and social behaviors. Journal of Autism and Developmental Disorders, 29, 213-224. Ben-Itzchak, K. E., & Zachor, D. A. (2007). The effects of intellectual functioning and autism severity on outcome of early behavioral intervention for children with autism. Research in Developmental Disabilities, 28, 287303. Birnbrauer, J.S. & Leach, D.J. (1993). The Murdoch early intervention program after 2 years. Behaviour Change, 10, 63-74. Bristol, M.M., Cohen, D.J., Costello, E.J., Denckla, M., Eckberg, T.J, Kallen, R., Kraemer, H.C., Lord, C., Maurer, R., McIlvane, W.J., Minishew, N., Sigman, M., & Spence, M.A. (1996). State of the science in autism: Report to the National Institute of Health, Journal of Autism and Developmental Disorders, 26, 121-154. Eikeseth, S. (2009). Outcome of comprehensive psycho-educational interventions for young children with autism. Research in Developmental Disabilities, 30, 158 178. Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7-year-old children with autism: A one-year comparison controlled study. Behavior Modification, 26, 4968. Fenske, B. C., Zalenski, S., Krantz, P. J., &McClannahan, L. E. (1985). Age at intervention and treatment outcome for autistic children in a comprehensive and Treatment

IBI For Young Children 10 intervention program. Analysis and Intervention in Developmental Disabilities, 5, 4958. Granpeesheh, D., Dixon, D.R., Tarbox, J., Kaplan, A.M., & Wilke, A.E. (2009). The effects of age and treatment intensity on behavioural intervention outcomes for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 10, 1-9. Green, G. (1996). Early behavioral intervention for autism: What does the research tell us? In C. Maurice, G. Green, & S. C. Luce (Eds.), Behavioral intervention for young children with autism: A manual for parents and professionals (pp. 29Austin, TX: PRO-ED. Harris, S. L., & Handleman, J. S. (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 and Developmental Disorders, 30, 137142. Harris, S.L., Handleman, J.S., Gordon, R., Kristoff, B., & Fuentes, F. (1991). Changes in cognitive and language functioning of preschool children with autism. Journal of Autism and Developmental Disorders, 21, 281-290. Howard, J.S., Sparkman, C.R., Cohen, H.G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Research in Developmental Disabilities, 26, 359-383. 44).

Huff, R.C. (1996). Community-based early intervention for children with autism. In C. Maurice, G. Green, & S. C. Luce (Eds.), Behavioral intervention for young

IBI For Young Children 11 children with autism: A manual for parents and professionals (pp. 331- 342). Austin, TX: PRO-ED. Jacobson, J. W. (2000). Early intensive behavioral intervention: Emergence of a consumer driven service model. Behavior Analyst, 23, 149-171. Jacobson, J.W., Mulick, J.A., & Green, G. (1998). Cost-benefit estimates for early intensive behavioral intervention for young children with autism General model and single state case. Behavioral Interventions, 13, 201-226. Lord, C. (1995). Follow-up of two-year olds referred for possible autism. Journal of Child Psychology and Psychiatry, 36, 1365-1382. Matson, J. L. (2007a). Current status of differential diagnosis for children with autism spectrum disorders. Research in Developmental Disabilities, 28, 109118. Matson, J. C. (2007b). Determining treatment outcome in early intervention programs for autism spectrum disorders: A critical analysis of measurement issues in learning based interventions. Research in Developmental Disabilities, 28, 207218. Matson, J.L., & Smith, K.R.M. (2008). Current status of intensive behavioral interventions for young children with autism and PDD-NOS. Research in Autism Spectrum Disorders, 2, 60-74. New York State Department of Health. (1999). Autism/Pervasive Developmental Disorders. Clinical practice guidelines technical report. New York: Author. Sinclair, C., & Pettifor, J. (2001). Companion Manual to the Canadian Code of Ethics for Psychologists (3rd ed.). Ottawa: Canadian Psychological Association.

IBI For Young Children 12 Schreibman, L. (2000). Intensive behavioral/psychoeducational treatments for autism: Research needs and future directions. Journal of Autism and Developmental Disorders, 30, 5, 373-378.