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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, 1993
by John J.
McEachin, Tristram Smith, and 0. Ivar Lovaas
University of California, Los Angeles
(For more information about The Childhood Learning Center contact the Center
or http://www.tclc.com/ for further information.)
After a very intensive behavioral intervention an experimental group of 19
preschool-age children with autism achieved less restrictive school placements
and higher IQs than did a control group of 19 similar children by age 7
(Lovaas, 1987). The Present study followed-up this finding by assessing
subjects at a mean age of 11.5 years. Results showed that the experimental
group preserved its gains over the control group, The 9 experimental subjects
who had achieved the best outcomes at age 7 received particularly extensive
evaluations indicating that 8 of them were indistinguishable from average
children on tests of intelligence and adaptive behavior. Thus, behavioral
treatment may produce long-lasting and significant gains for many young
children with autism.
Infantile autism is a condition marked by severe impairment in intellectual,
social, and emotional functioning. Its onset occurs in infancy, and the
prognosis appears to be extremely poor (Lotter, 1978). For example, in the
longest prospective follow-up study with a sound methodological design, Rutter
(1970) found that only 1 of 64 subjects with autism (fewer than 2%) could be
considered free of clinically significant problems by adulthood, as evidenced
by holding a job, living independently, and maintaining an active and
age-appropriate social life. The remaining subjects showed numerous
dysfunctions, such as marked oddities in behavior, social isolation, and
florid psyche pathology. The majority of subjects required supervised living
conditions.
Professionals have attempted a wide variety of interventions in an effort to
help children with autism. For many years, no scientific evidence showed that
any of these interventions brightened the children's long term prognosis
(DeMyer et al., 1981). However, since the 1360s, one of these interventions,
behavioral treatment, has appeared promising. Behavioral treatment has been
found to increase adaptive behaviors such as language and social skills, while
decreasing disruptive behaviors such as aggression (DeMyer, Hingtgen,
&Jackson, 1981; Newsom & Rincover, 1983; Rutter, 1985). Furthermore,
behavioral treatment has been continuously refined and improved as a result of
ongoing research efforts at a number of sites (Lovaas & Smith, 1888). Some
recent evidence has indicated that behavioral treatment has developed to the
point that it can produce substantial improvements in the overall functioning
of young children with autism (Simeonnson, Olley, & Rosenthal, 1987).
Lovaas (1987) provided approximately 40 hours per week of one-on-one
behavioral treatment for a period of 2 years or more to an experimental group
of 19 children with autism who were under 4 years of age. This intervention
also included parent training and mainstreaming into regular preschool
environments. When re-evaluated at a mean age of 7 years, subjects in the
experimental group had gained an average of 20 IQ points and had made major
advances in educational achievement. Nine of the 19 subjects completed first
grade in regular (non special education) classes entirely on their own and had
IQs that increased to the average range. By contrast, two control groups
totaling 40 children, also diagnosed as autistic and comparable to the
experimental group at intake, did not fare nearly as well. Only one of the
control subjects (2.50/a) attained normal levels of intellectual and
educational functioning.
These data suggest that behavioral treatment is effective. However, the
durability of treatment gains is uncertain. In one prior major study, Lovaas,
Koegel, Simmons, and Long (1973) found that children with autism regressed
following the termination of treatment. Other studies have shown that children
with autism may display increased difficulties when they enter adolescence
(Kanner, 1971; Waterhouse & Fein, 1984). Also, as was stated in the first
follow-up (Lovaas, 1987), "Certain residual deficits may remain in the
normal functioning group that cannot be detected by teachers and parents and
can only be isolated on closer psychological assessment, particularly as these
children grow older" (p. 8). This possibility points to the need for a
more detailed assessment and for continued follow-ups of the group over time.
The present investigation contained two parts: In the first part we examined
whether several years after the evaluation at age 7, the experimental group in
Lovaas's (1987) study had maintained its treatment gains. Subjects in the
experimental group and one of the control groups completed standardized tests
of intellectual and adaptive functioning. The groups were then contrasted with
each other, and their current performance was compared to their performance on
previous assessments. The second part of the investigation focused on those
subjects who had achieved the best outcome at the end of first grade in the
Lovaas (1987) study (i.e., the 9 subjects who were classified as normal
functioning out of the 18 in the experimental group). We examined the extent
to which these best-outcome subjects could be considered free of autistic
symptomatology. A test battery was constructed to assess a variety of possible
deficits: for example, idiosyncratic thought patterns, mannerisms, and
interests; lack of close relationships with family and friends; difficulty in
getting along with people; relative weaknesses in certain areas of cognitive
functioning, such as abstract reasoning; not working up to ability in school;
flatness of affect; absence or peculiarity in sense of humor. Possible
strengths to be identified included normal intellectual functioning, good
relationships with family members, ability to function independently,
appropriate use of leisure time, and adequate socialization with peers.
Numerous methodological precautions were taken to ensure objectivity of the
follow-up examination.
Method
Subjects and Background
Characteristics of the subjects and their treatment have been described
elsewhere (Lovaas, 1987) and will only be summarized here. The initial
treatment study contained 38 children who, at the time of intake, were very
young (less than 40 months if mute, less than 46 months if echolalic) and had
received a diagnosis of autism from a licensed clinical psychologist or
psychiatrist not involved in the study. These 38 subjects were divided into an
experimental group and a control group. The assignment to groups was made on
the basis of staff availability. At the beginning of each academic quarter,
treatment teams were formed. The clinic director and staff members then
determined whether any opening existed for intensive treatment. If so, the
next referral received would enter the experimental group; otherwise, the
subject entered the control group. The experimental group contained 19
children who received 40 or more hours per week of one-to-one behavioral
treatment for 2 or more years. The control group was comprised of 19 children
who received a much less intensive intervention (10 hours a week or less of
one-to-one behavioral treatment in addition to a variety of treatments
provided by community agencies, such as parent training or special education
classes). The initial study also included a second control group, consisting
of 21 children with autism who were followed over time by a nearby agency but
who were never referred for this study. However, these 21 subjects were not
available for the present investigation. On standardized measures of
intelligence, the second control group did not differ from either the
experimental group or the first control group at intake, nor did it differ
from the first control group when evaluated again when the subjects were 7
years old. These findings suggest that, as measured by standardized tests, (a)
the children with autism who were referred to us for treatment were comparable
to children with autism seen elsewhere and (b) the minimal treatment Provided
to the first control group did not alter intellectual functioning.
Statistical analysis of an extensive range of pretreatment measures confirmed
that the experimental group and control group were comparable at intake and
closely matched on such important variables as IQ and severity of disturbance.
The mean chronological age (CA) at diagnosis for subjects in the experimental
group was 32 months. Their mean IQ was 53 (range 30 to 82; all IQs are given
as deviation scores). The mean CA of subjects in the control group was 35
months; their mean IQ was 46 (range 30 to 80). Most of the subjects were mute,
all had gross deficiencies in receptive language, none played with peers or
showed age-appropriate toy play, all were emotionally withdrawn, most had
severe tantrums, and all showed extensive ritualistic and stereotyped
(self-stimulatory) behaviors. Thus, they appeared to be a representative
sample of children with autism (Lovaas, Smith, & McEachin, 1989). Lovaas
(1987) reported a more complete presentation of the intake data.
The children in the experimental group and control group received their
respective treatments from trained student therapists who worked in the
child's home. The parents also worked with their child, and they received
extensive instruction and supervision on appropriate treatment techniques.
Whenever possible, the children were integrated into regular preschools. The
treatment focused primarily on developing language, increasing social
behavior, and promoting cooperative play with peers along with independent and
appropriate toy play. Concurrently, substantial efforts were directed at
decreasing excessive rituals, tantrums, and aggressive behavior. (For a more
detailed description of the intervention program, see the treatment manual
[Lovaas et al., 1980] and instructional videotapes that supplement the manual
[ Lovaas & Leaf, 1981].)
At the time of the present follow-up (1984-1985), the mean CA of the
experimental group children was 13 years (range = 9 to 19 years). All children
who had achieved normal functioning by the age of 7 years had ended treatment
by that point. (Normal functioning was operationally defined as scoring within
the normal range on standardized intelligence tests and successfully
completing first grade in a regular, non special education class entirely on
one's own.) On the other hand, some of the children who had not achieved
normal functioning at 7 years of age had, at the request of their parents,
remained in treatment. The length of time that experimental subjects had been
out of treatment ranged from O to 12 years (mean = 5), with the
normal-functioning children having been out for 3 to 9 years (mean = 5).
The mean age of subjects in the control group was 10 years (range 6 to 14).
The length of time that these children had been out of treatment ranged from 0
to 9 years (mean 3). Thus, experimental subjects tended to be older and had
been out of treatment longer than had control subjects. This difference in age
occurred because the first referrals for the study were all assigned to the
experimental group due to the fact that referrals came slowly (7 in the first
3.5 years) and therapists were available to treat all of them. (As noted
earlier, subjects were assigned to the experimental group if therapists were
available to treat them; otherwise, they entered the control group.)
Statistical analyses were conducted to test whether a bias resulted from the
tendency for the first referrals to 80 into the experimental group. For
example, it is conceivable that the first referrals could have been higher
functioning at intake or could have had a better prognosis than subsequent
referrals, If so, the subject assignment procedure could have favored the
experimental group. To assess this possibility, we correlated the order of
referral with intake IQ and with IQ at the first follow-up (age 7 years).
Pearson correlations were computed across both groups and within each group.
These analyses indicated that the order in which subjects were referred was
not associated with intake IQ or outcome IQ. Consequently, although the
tendency for the first referrals to enter the experimental group created a
potential bias, the data indicate that this was unlikely.
Procedure
The assessment procedure included ascertaining school placement and
administering three standardized tests. Information on school placement was
obtained from subjects' parents, who classified them as being in either a
regular or a special education class (e.g., a class for children with autism
or mental retardation, language delays, multi-handicaps, or learning
disabilities). The three standardized tests were as follows:
1. Intelligence test. The Wechsler Intelligence Scale for Children-Revised
(Wechsler, 1974) was administered when subjects were able to provide verbal
responses. This included all 9 best-outcome experimental subjects plus 8 of
the remaining 10 experimental subjects and 6 of the 19 control subjects. For
subjects who were not able to provide verbal responses, the Leiter
International Performance Scale (Leiter, 1959 and the Peabody Picture
Vocabulary Test-Revised (Dunn, 1981) were administered. All of these tests
have been widely used for the assessment of intellectual functioning in
children with autism (Short & Marcus, 1986).
2. The Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti,
1984). The Vineland is a structured interview administered to parents
assessing the extent to which their child exhibits behaviors that are needed
to cope effectively with the everyday environment.
3. The Personality Inventory for Children (Wirt, Lachar, Klinedinst, &
Seat, 1977), This measure is a 6OO-item true-false questionnaire filled out by
parents that assesses the extent to which their children show various forms of
psychological disturbance (e.g., anxiety, depression, hyperactivity, and
psychotic behavior).
These three tests were intended to provide a comprehensive evaluation of
intellectual, social, and emotional functioning. All of the tests have been
standardized on average populations. Hence, they provide an objective basis
for comparing subjects to children without handicaps across the various areas
that they assess.
Data were obtained on all subjects except one girl in the control group, who
was known to be institutionalized and functioning very poorly. The 9
best-outcome subjects (those who had been classified as normal functioning at
age 7) received particularly extensive evaluations, as outlined later. Of the
28 remaining subjects, 17 were evaluated by staff members in our treatment
program, and 11 received evaluations from outside agencies such as schools or
psychology clinics. (In some cases, the outside agencies did not administer
all of the measures in this battery.)
Evaluation of Best -Outcome Subjects. To ensure objectivity in the evaluation
of the best-outcome subjects, we arranged for blind administration and scoring
of all tests for these subjects as follows. A psychologist not associated with
the study recruited advanced graduate students in clinical psychology to
administer the tests. The examiners were not familiar with the history of the
children, and the psychologist told them simply that the testing was part of a
research study on assessment of children. The psychologist advised them that
the nature of the study necessitated providing only certain standard
background information: age, school placement and grade, and parent's name and
phone number. To increase the heterogeneity of the sample and to control for
any examiner bias, each examiner also tested one or more subjects who were
matched in age to the experimental subjects and had no history of behavioral
disturbance. The examiners were randomly assigned an approximately equal
number of subjects for testing at the experimental group and the comparison
group. Two experimental subjects were not living in the local area. Therefore,
for each of them, the psychologist recruited a tester from the subject's
hometown area as well as an age-matched control subject, and data were
collected as just described. In addition, the child's examiner filled out a
clinical rating scale following a structured interview that covered a list of
standard topics, including friendships, family relations, and school and
community activities. The interview was designed both for eliciting content
and for sampling interpersonal style. The rating scale consisted of 22 items,
each scored 0 (best clinical status) to 3 (marked deviance) points. The items
were designed to include likely areas of difficulty for children with autism
of average intelligence (e.g., compulsive or ritualistic behavior, empathy for
and interest in others, a sense of humor) as well as areas of potential
difficulty for the general child population (e.g., depressed mood, anxiety,
hyperactivity). (The complete scale and a copy of instructions for the
clinical interview can be obtained by writing to the third author).
Results
Experimental Versus Control Group
This first section examines the overall effects of treatment through
comparison of the follow-up data from the 13 subjects who received the
intensive (experimental) treatment to the data from those who received the
minimal (control) treatment. Data were obtained from all subjects on school
placement and from all but one subject in the control group on IQ. On the
Vineland, scores were obtained for 18 of 19 experimental subjects and 15 of 19
control subjects. The lowest availability of follow-up scores was on the
Personality Inventory for Children, with scores for 15 experimental subjects
and 12 control subjects.
The subjects in the control group who had Personality Inventory for Children
scores did not appear to differ from subjects who were missing these scores,
as compared on tests for differences in intake IQ, IQ at 7 years old, or IQ in
the present study.
As noted earlier, 17 of the 28 subjects who were not in the best-outcome group
were evaluated by Project staff members, 11 were evaluated by outside
agencies, and 1 was not evaluated. To check whether Project staff members were
biased in their evaluations or in their selection of which subjects to
evaluate, we used i tests to compare subjects they evaluated to those
evaluated by outside agencies on intake IQ, IQ at age 7 years, and TQ in the
present study. No significant differences between subjects evaluated by
Project staff members and those evaluated by outside agencies were found.
School Placement. In the experimental group, 1 of the 9 subjects from the
best- outcome group who had attended a regular class at age 7 (J. L.) was now
in a special education class. However, 1 of the other 10 subjects had gone
from a special education class to a regular class and was enrolled in a junior
college at the time of this follow-up. The remaining experimental subjects had
not changed their classification. Overall, then, the proportion of
experimental subjects in regular classes did not change from the age 7
evaluation (9 of 19, or 47%). In the control group, none of the 19 children
were in a regular class, as had been true at the age 7 evaluation. The
difference in classroom placement between the experimental group and the
control group was statistically significant, X2 (1, N= 38)= 19.05, P<. 05.
Intellectual Functioning. The test scores for the experimental group and
control group on intellectual functioning, adaptive and maladaptive behaviors,
and personality functioning are summarized in Table 1. As can be seen in the
table, the experimental group at follow-up had a significantly higher mean IQ
than did the control group. This difference was significant, t(3~) = 2.97, P
< .01. Eleven subjects CS8"/o) in the experimental group obtained
full-scale IQs of at least 80; only 3 subjects ~17%) in the control group did
as well. The scores were similar to those obtained by the experimental group
and control group at age 7 (mean IQs of 83 and 52, respectively), indicating
that the experimental group had maintained its gains in intellectual
functioning between age 7 and the time of the current evaluation,
Adaptive and Maladaptive Behavior. On the Vineland, the mean overall or
composite score was 2 in the experimental group and 48 in the control group.
(The average score for the general population on this test is 100, with a
standard deviation [SD] of 15.) On the three subscales--Communication, Daily
Living, and Socialization-each score closely paralleled the Composite score.
The interaction between the groups and the subscales was not significant,
indicating that across the three subscales, the experimental group
consistently scored higher than did the control group. As can be seen in Table
1, Maladaptive Behavior was significantly higher in the control group, t(31)=
2.33, P<.05. The mean score for the control group was in the clinically
significant range whereas that of the experimental group was not. (Scores of
~3 and above are considered to be indicative of clinically significant levels
of maladaptive behavior at ages 6 to 9 years; 12 or above, at 12 to 13 years;
and 10 or above, at 14 years and older.) Thus, the findings indicate that the
experimental group showed more adaptive behaviors and Fewer maladaptive
behaviors than did the control group.
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