The debatable argument between Drs. Sally Rogers and Doreen Granpeesheh.
In 2009, Drs. Sally Rogers, a professor and researcher at the University of California, Davis (UC Davis), who went on to lead the DSM-5 panel by adding the new "Social Communication Disorder"—which is technically a milder form of Autism Spectrum Disorder (ASD)—leading to many families not being able to access services, and Geraldine Dawson, who was the chief scientist of Autism Speaks at the time and is a professor and researcher at Duke University, published the largest, randomized control trial (RCT) on an early intervention for autism called the Early Start Denver Model (ESDM), a modality that combines the Denver Model—a developmental, play therapy implemented for 15 to 20 hours per week—with a scientifically proven naturalistic, play-based form of Early Behavioral Intervention (EBI) called Pivotal Response Treatment (PRT), which uses Mand ("request") Training. The placebo in the control group was speech and occupational therapy.
The study showed that 29% of the children from the experimental group had milder autism symptoms subsequent to treatment, and they were re-diagnosed with pervasive developmental disorder - not otherwise specified (PDD-NOS). It was later praised by the American Academy of Pediatrics, and is listed as the seventh evidence-based intervention in the research literature, along with Early Intensive Behavioral Intervention (EIBI)—or 30 to 40 hours per week of Discrete Trial Training (DTT) along with Incidental Teaching (or Mand Training) for generalization of skills, Pivotal Response Treatment (PRT), Picture Exchange Communication System (PECS), Social Stories, and the atypical antipsychotic drugs Risperidone (Risperdal) and Aripiprazole (Abilify). Nevertheless, three replicated studies on the ESDM were not able to reproduce these results and it is still listed as an "emerging treatment."
Early Intensive Behavioral Intervention (EIBI) remains the only "well-established" early intervention in the research literature for teaching children with autism.
The 2009 study led to several controversial events: a paper featured in the Los Angeles Times, an interview with Dr. Rogers, and a statement written in the Academic Press by Dr. Doreen Granpeesheh, one of Dr. Ivar Lovaas'—who pioneered EIBI—leading graduate students at the University of California, Los Angeles (UCLA). Dr. Granpeesheh founded and currently runs the Center for Autism and Related Disorders (CARD), the nation's most enormous agency providing early, intensive ABA therapy services, which is headquartered in Los Angeles, California. She posted a hostile blog on CARD's official website in response to the LA Times (and to Dr. Rogers).
Dr. Rogers was interviewed after her study was published in 2009 and was asked why most states in the country still refuse to fund EIBI if it is considered the "gold-standard." She responded, "That's due to the lack of randomized control trials (RCTs). The only [RCT] on Discrete Trials in 2000 showed 27% were successfully mainstreamed."
Dr. Granpeesheh posted on that blog post, "I made it clear to the interviewer that it would have been unethical to do a [RCT] on the 1987 study because there was no other treatment to compare it to at the time and the placebo in the control group would've been no hours of treatment, so instead the control group received the same treatment for 10 hours per week. And the reason why the only [RCT] showed 27% were successfully mainstreamed—as opposed to 47%—is because the only [RCT] done, the experimental group was only done for 25 hours per week. Lovaas' experimental group was 40 hours per week."
Both were featured in the controversial LA Times article "Families cling to hope of autism 'recovery' " (2011), and its abstract states the following: "An autism treatment called [discrete trial teaching, or DTT] has wide support and has grown into a profitable business. It has its limits, though, and there are gaps in the science."
The second replicated study in 2005 (Sallows & Graupner, 2005) was not a RCT since it only compared the same treatment for less hours, though like the 2000 study, it did randomly assign the participants. Also, this study's experimental group consisted of an intensity of 35 hours per week and that was the study which successfully reproduced Lovaas' 1987 study results: 48% were the 'best outcome kids' in regards to being successfully mainstreamed in regular classrooms without any specialized supports and the remaining 90% still made significant gains in their language, IQ, and adaptive functioning. Despite this, literature reviews indicated that not all the participants in the study received DTT; some received other less intensive forms of ABA, such as pivotal response treatment (PRT), which means it did not stay true to the treatment fidelity (Rogers & Vismara, 2008; Smith & Iadarola, 2015), but what the study did show is that when the form of ABA implemented was tailored to the child's learning style, the numbers were as high as the 1987 study.
A year later in 2006, among Lovaas' other leading graduate students from UCLA, the late Tristram Smith along with his colleagues at the University of Rochester Medical Center conducted the third replicated study—though not randomized, but employed for 35 to 40 hours per week—which only showed that 29% were the rapid learners and best outcome children; for the remaining 90%, the IQ—not the language—scores were as high as the 1987 study (Cohen, Amerine-Dickens, & Smith, 2006).
However, those are not the only studies showing ABA in the treatment of autism to be effective. In 2001, the US National Research Council exclusively referred to both structured and play-based EBIs as "state-of-the-art" for teaching children of that population.
Moreover, according to Myers & Johnson (2007) in Pediatrics—the official journal for the American Academy of Pediatrics, "The effectiveness of [structured] ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology, and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive [structured] early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior, as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups."
Hyman, Levy, & Myers (2020) then wrote in that same journal, "Most evidence-based treatment models are based on principles of ABA... ABA interventions vary from highly structured adult-directed approaches (eg, discrete trial training or instruction, verbal behavior applications, and others) to interventions in natural environments that may be child led and implemented in the context of play activities or daily routines and activities and are altered on the basis of the child’s skill development (eg, pivotal response training, reciprocal imitation training, and others). To determine what intervention is most appropriate, the behavioral clinician works with the family and child to determine which skills to target for development and maintenance and what goals are appropriate... A comprehensive ABA approach for younger children, also known as early intensive behavioral intervention, is supported by a few randomized controlled trials (RCTs) and a substantial single-subject literature. When only RCTs are considered, few interventions have sufficient evidence to be endorsed either for children younger than 12 years or for adolescents. Children younger than 12 years receiving more hours per week of ABA were found to be more likely to achieve the individualized goals identified in their programs. In retrospective studies, more intense ABA therapy was associated with achieving optimal developmental outcomes."
Tristram Smith and colleagues co-authored an updated literature review that was published in the Journal of Clinical Child and Adolescent Psychology in 2015 which stated the following: "As already mentioned, Rogers and Vismara (2008) classified the Lovaas model as a well-established treatment. Four subsequent quasi-experimental studies on this model met our criteria for inclusion (Eikeseth, Klintwall, Jahr, & Karlsson, 2012; Eikeseth, Smith, Jahr, & Eldevik, 2007; Eldevik, Hastings, Jahr, & Hughes, 2012; Peters-Scheffer, Didden, Mulders, & Korzilius, 2010). One study (Eikeseth et al., 2007) was a follow-up of a report reviewed by Rogers and Vismara (Eikeseth, Smith, Jahr, & Eldevik, 2002). All studies indicated that the Lovaas model has large effects on IQ, adaptive behavior, or both... In addition, all of the findings from recent studies must be viewed with caution because they were obtained in quasi-experimental rather than experimental studies... At the time of the previous review (Rogers & Vismara, 2008), most group studies centered on a single treatment, the UCLA/Lovaas model of individual, comprehensive ABA. This intervention continues to have stronger empirical support than other comprehensive treatments."
Going back to Dr. Rogers' interview, the interviewer asked, "I know the Lovaas 1987 study reported that 47% fully recovered from the autism spectrum by early adolescence. No one has been able to reproduce those results since. What's your take on it?" She responded, "I honestly think they were all misdiagnosed. I don't believe there is a cure. Whenever you hear about the miraculous success stories about the kids who fully recover over a period of time, I think it's because they never had it to begin with."
Dr. Granpeehseh responded on CARD's blog post, "And when Dr. Rogers commented how she thought 'all the kids in Lovaas' 1987 study were misdiagnosed because she doesn't believe there is a cure,' I worked directly with the families in that study. That's an insultment to all the families who been through hell and back with their child."
It is important to note that in 2013, Dr. Deborah Fein led a massive study at the University of Connecticut (UConn)—which was sourced in a number of peer-reviewed journals—indicating that the small minority (25%) of children who fully overcame ASD (the authors called it an “optimal outcome”) obtained structured EIBI for approximately three years as youngsters, but they still had the infused head growth that's only seen in individuals with autism. Dr. Geraldine Dawson, co-developer of the Early Start Denver Model (ESDM) and who led the 2009 study on the ESDM, endorsed and interviewed Dr. Fein on her study, which was recorded on YouTube.
Dr. Rogers added in that 2009 interview, "And I do want to add that the '87 study did use electric shocks as a last resort if the child couldn't be restrained, and that was the study endorsed by the Surgeon General's office in 1999. Look, Discrete Trials showed to work in a small group of learners. But, it's important to know that the field of Behavior Analysis is evolving, and hopefully, we can begin to move beyond Discrete Trials as a whole."
Dr. Granpeesheh finished CARD's blog post by writing, "And the electric shocks were such a long time ago, they're almost obsolete at this point and it wasn't even relevent to mention in the paper that the '87 study used them."
To get back at Dr. Rogers, when Dr. Granpeesheh became the editor-in-chief of the "Evidenced-Based Treatment for Children with Autism: The CARD Model" (2013) book published by the Academic Press, she wrote in the research section, "In a review of autism research by Dr. Sally Rogers, who is widely acknowledged as one of the world's premier autism researchers, comprehensive ABA-based intervention for children with autism was found to be 'well-established' (Rogers & Vismara, 2008). It is worth noting that Dr. Rogers is not an ABA professional or researcher; rather, she is a developmental psychologist who advocates for the Denver model of autism treatment, a model oriented more to developmental than behavioral psychology. That is, Dr. Rogers has nothing to gain personally by advocating for ABA treatment and is offering her highly respected opinion from outside the discipline of ABA."
Another crucial detail: A recent 2018 Cochrane literature review (Brignell et al., 2018)—one of the largest, most reliable research databases—indicated that because of the heterology of ASD, we now have a wide range of different learning styles. They noted a recent study conducted by Paul et al. (2013) at the Yale Child Study Center, which revealed that young children on the autism spectrum with lower receptive language skills only acquire speech from DTT whereas those with higher receptive language skills learn faster from the naturalistic, play-based form of ABA.
So, it is clear that the reason each current randomized comparison study on 25 hours per week of PRT had shown to be more effective in fostering speech than those who obtained the same hours per week of DTT is because most diagnosed have higher receptive language skills.
Despite this, 30 to 40 hours per week of DTT is still needed for the children with lower receptive language skills, and who otherwise become distracted from their natural environment.
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