The present investigation provides a preliminary examination of service providers’ reports of their use of specific treatment practices in EI programs for children with autism. Because little is known about community EI services for children with autism, this study is seen as a first step toward understanding how service providers implement programs. Frontline workers charged with designing, implementing, and tracking EI programming described the interventions they use with children with autism. Although many of the participants may have had only superficial knowledge of specific intervention techniques and the adequacy of their implementation of these techniques is unclear—we thought that beginning with their own descriptions of programming would provide an initial understanding of what community providers thought they were giving young children with autism. Additionally, the statements of these participants would provide some understanding of the permeation of various intervention techniques into the public EI system.
The types of intervention techniques reported as used most often by community providers included those with and without some research base. Although no autism treatments currently meet criteria for well-established or probably efficacious, empirically supported treatment (Lonigan, Elbert, & Johnson, 1998
; Rogers, 1998
), most researchers would agree that of the techniques mentioned by the participants most often, ABA, DTT, PECS, and PRT have a relatively strong evidence base (National Research Council, 2001
; Rogers, 1998
). Floor Time, TEACCH, and sign Language have ease report and record review evidence of success with children who have autism (Greenspan & Wieder, 1997
; Lord & Schopler, 1994
; National Research Council, 2001
), but OT, music therapy, and Social Stories have minimal, if any, research-based evidence of success (e.g., National Research Council, 2001
; Smith, 1996
). It seems, then, that a few evidence-based interventions for children with autism have been translated into public EI systems, as have other programs that do not have a research base.
Although participants expressed a desire to use methods that have been shown to be effective, they had not analyzed the research base for the programs they used. This lack of examination of the evidence speaks to the need to improve training for service providers in the area of evaluation of research and treatment effectiveness. It appears that program marketing, availability of training, provider preference, and external factors such as parent requests influence the use of specific practices more than whether the practice has any evidence of efficacy. Therefore it is critical that the research community examine the methods used to reach EI agencies and families to make research-based practices available and to increase understanding of the difference between a research-based technique and other techniques.
Although service providers are reporting the use of evidence-based practices, they report using these practices in a highly modified form. First, service providers in this study reported combining several methodologies to develop individualized programs based on each child’s specific characteristics. Second, all of the participants reported adapting the program from the training protocol to fit their own program or teaching preferences, as well as the needs of individual children within their program. Finally, the majority of participants felt that adequate training for themselves and the paraprofessionals in their programs had not been provided. All of these factors raise significant issues for the use of evidence-based practices for young children with autism.
First, the idea of combining techniques is controversial and underresearched. The specific treatment methods described by the service providers as evidence based were studied using the specific program in isolation. Little research has been conducted that examines the use of these methods in combination. McGee et al. (1999)
advocated the use of one treatment strategy because of the possibility that multiple treatments will confuse the children. They “take the position that the ‘more is better’ tenet applies to hours of intervention and not to various methods of intervention” (McGee et al., 1999
, p. 144). Other researchers have suggested that an individual child may respond better to one treatment than another (Anderson, 2002
; Anderson & Schreibman, 1999
; Ingersoll, Schreibman, & Stahmer, 2001
; Rogers, 1996
; Sherer, 2002
; Sherer & Schreibman, in press
). A recent study examining a toddler program that combines research-based methods reported results similar to those found in single-technique programs (Stahmer & Ingersoll, 2004
). However, this research is in its infancy, and there has been no documentation of the types of adaptations needed to combine programs or which adaptations may reduce the efficacy of any individual technique.
Second, no examination of the types of adaptations being made, or whether these adaptations alter a technique significantly, has been conducted. Researchers often call for individualization of treatment for young children with autism; however, very little research has suggested exact methods of adaptation based on specific child characteristics (Schreibman & Anderson, 2001
). Finally, no fidelity of implementation research has been conducted in community environments to examine whether community service providers are implementing these methods effectively after what they describe as only minimal training. If a provider dues not understand the philosophy behind the intervention or cannot conduct the treatment with precision, it is highly unlikely that adaptations of the method will be effective.
The majority of participants said they used the most common effective elements reported by researchers as essential to good educational programming (Iovannone et al., 2003
). This finding is important, in that even if the participants are not using specific evidence-based interventions, they may be getting at the common important elements that bridge many of the methodologies. These service providers gave rich examples of how these common elements are used in their programs. Of course, it is impossible to know if these elements are being implemented appropriately, but it is an important first step that the service providers in the community recognize that these are important factors in their programs. As researchers examine fidelity of implementation of specific intervention programs, it will be equally important to study the appropriate implementation of these common elective elements. Currently, there are no standardized methods for measuring these common elements in community programs, nor is it clear if these elements are necessary or sufficient for providing good services to young children with autism.
Providers who participated in the focus groups were those willing to come and talk about their programs. Despite this apparent limitation, we had a good mix of highly evolved programs and those new to serving children with autism. Many of those agencies and districts that did not participate did so passively by not responding to repeated calls. The extent to which the participants’ programs are representative of all service providers in southern California or in other locales is not known. However, anecdotally, the service providers spanned a range of programs similar to those seen in other districts in San Diego and Riverside counties.
Another concern was the extent to which the discussion influenced the participants’ answers. That is, did the service providers come to consensus on a specific program or state that they used intervention techniques because other participants were doing so or because it was what they would rather do? Although this is a valid concern and certainly a limitation to this study, anecdotally, the participants appeared to be honest in their descriptions. Participants in all of the groups were kind to one another and accepting of all responses. Participants using limited research-based interventions were eager to learn from other programs and made plans to exchange information after the focus groups. Research asking service providers individually about interventions is currently being conducted to address these concerns.
Another limitation is that these data are composed completely of self-reported program information. There is no way to know whether the service providers are actually conducting their programs in the way they described and no way to estimate the quality of programming, as no fidelity of implementation data are available. This makes it difficult to understand the adaptations of the programs and the providers’ understanding of how techniques can be adapted. Additionally, there is no way to know whether providers are actually combining techniques or simply using terminology that they think best describes what they are doing. Future research steps will examine concordance between provider report and what actually happens in treatment settings.
Implications for Autism El Services
Legislators and researchers are currently emphasizing the delivery of research-based practices in many areas, including autism services. Therefore, it is critically important to examine the attitudes and experiences of service providers in community-based settings. Although many service providers reported being supportive of the use of evidence-based techniques, most did not have a good understanding of what the research was saying in the area of autism. Most of the providers reported using at least one evidence-based technique; however, these same providers were just as likely to report using poorly researched techniques as well.
These findings provide insight into recommendations for successful translation of research-based practices into EI programs for children with autism. Pragmatic issues regarding the use of the techniques in classroom settings must be addressed. Validity concerns when techniques are combined or modified should also be examined. In addition, adoption of any new intervention is likely to be facilitated by increased marketing to both community agencies and family members, access to low-cost training, and methods for use in group teaching situations.
Additional research is required to provide a more detailed description of EI programming for young children with autism. It will be imperative to survey a wide range of service providers to get a broader picture of methods used in EI settings. A survey will allow for analysis of the use of evidence-based programming, as well as the common elements seen in superior programming, while taking into account provider education and experience, number of children with autism in the area, and other program components. Finally, researchers will need to validate the self-report measures to determine whether providers are using these techniques in the ways they describe, how they are modifying programs, and the amount of training needed to ensure quality programming.