Wednesday, December 19, 2007

After Colorado Arbitrator's Decision, More Information About Lovaas Model of Applied Behavioral Analysis

Last month, an arbitrator ruled in favor of a Colorado family which fought to have its health insurance company reimburse them for autism-related services for their young daughter—specifically for Applied Behavior Analysis (ABA) sessions which the insurance company denied. The arbitrator ruled that the insurer, Anthem Blue Cross Blue Shield, improperly denied the family's claims for two years worth of services worth about $110,000.

You can read more background in this Autism Bulletin story from December 9: Colorado Family Wins Insurance for Autism Services. One of the points the arbitrator made in her decision was that "Anthem erroneously equates ABA therapy with Lovaas therapy—an approach which has received considerable justifiable scientific criticism. ABA therapy is based upon incidental teaching and pivotal response training, which Dr. Strain testified is the standard of care when dealing with autistic children."

That quote puzzled me because I had read Ole Ivar Lovaas, now a professor emeritus at University of California at Los Angeles, was one of the founders of ABA. So I wrote to the Los Angeles-based Lovaas Institute, which provides autism services using Lovaas' method, and asked them to help me understand more about them and what this arbitrator could have been talking about.

Below is the response I received from Scott Cross, clinical director, and Vincent J. LaMarca, of the institute's human resources department. Both cite their credentials as board-certified behavior analysts, or BCBAs.

On behalf of Dr. Lovaas and the Lovaas Institute, thank you for your inquiry. I can understand from the blog posting why you would have questions about the relationship between “Lovaas therapy” and ABA.

First, you are correct that in laymen’s terms “Lovaas therapy” is “a type of ABA.” In fact, we are more likely to refer to our program as the “Lovaas Model of Applied Behavior Analysis.” We provide behavioral treatment, based on the principles of applied behavior analysis, researched under the direction of Dr. Lovaas, and replicated by other professionals at other sites throughout the world.

Second, the quote from the arbitrator is somewhat curious. On one hand, it states “Lovaas therapy…has received considerable justifiable scientific criticism.” On the other hand, it promotes applied behavior analysis (ABA) by mentioning the Surgeon General report and the National Institute of Mental Health’s publication. This is curious because, after stating, “Thirty years of research demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior,” the Surgeon General report’s next sentence states, “A well-designed study of a psychosocial intervention was carried out by Lovaas and colleagues (Lovaas, 1987; McEachin et al., 1993).” The National Institute of Mental Health’s publication also mentions Dr. Lovaas. Immediately after citing the Surgeon General report, it states that the work of Dr. Lovaas “laid a foundation for other educators and researchers.”

It’s possible that what is really meant in the arbitrator’s decision is that Anthem was wrong in making a decision on applied behavior analysis by only consulting studies associated with the Lovaas Model of Applied Behavior Analysis. Applied behavior analysis is a scientific discipline with a wealth of research. While Dr. Lovaas is honored to have contributed to that research, it is but the tip of the iceberg. One need only peruse the Journal of Applied Behavior Analysis to understand why a claim that ABA therapy is “investigational and experimental” is incorrect. There are a multitude of research articles demonstrating the efficacy of applied behavior analysis in teaching new skills to children, adolescents, and adults with autism.

Finally, it is somewhat disconcerting that the testimony, as depicted in the arbitrator’s decision, appears not only to place the Lovaas Model and applied behavior analysis in opposition (as it shouldn’t), but also to downplay some of the Lovaas Model’s treatment procedures in early intervention. It is an enormous oversight that discrete trial teaching (while not the only ABA instructional strategy) is left out of the testimony as an important component of an ABA program. Consider that all of the multi-site replications have been initially discrete trial based and have explicitly stated so in their method sections.

Behavioral treatment for children with autism is currently undergoing a lot of branding, with Verbal Behavior, the Lovaas Model, and Pivotal Response Teaching as the three names used most frequently. To what extent this is helpful or harmful to treatment is an important discussion in which we at the Lovaas Institute are currently taking part with other professionals. We would agree that there is a need for researchers to clarify the similarities and differences of different approaches as well as to study which approaches are more helpful for which children.

In the meantime, I would point out that while the Lovaas Model of Applied Behavior Analysis may have received scientific criticism, the National Academy of Science report (mentioned by Dr. Strain) also states that the Lovaas Model (a.k.a. Young Autism Project) “has generated the most rigorously controlled early intervention research published to date.”

And since that publication in 2001, two replication studies of the Lovaas Model have been published by independent authors, again demonstrating the effectiveness of our approach (Sallows & Graupner, 2005 and Cohen et al., 2006).

Sallows, Glen O. & Graupner, Tamlynn D. (2005). Intensive Behavioral Treatment for Children with Autism: Four-Year Outcome and Predictors. American Journal on Mental Retardation, 110 (6), 417-438.

Cohen, Howard, Amerine-Dickens, Mila, Smith, Tristram. (2006). Early Intensive Behavioral Treatment: Replication of the UCLA Model in a Community Setting. Journal of Developmental & Behavioral Pediatrics, 27 (2), 145-155.


Scott Cross, PhD, BCBA
Vincent J. LaMarca, BCBA


Regina F. said...

A Brief History of Behavior Analysis and Autism
Richard W. Malott

"...Over 30 years ago, a clinical psychologist did some time at the University of Washington, the source of most of the early research on applied behavior analysis. Inspired and informed by his Washington training, the clinician went to LA and put his own spin on behavior analysis, as he started working with children whose behavioral repertoires had so many deficits of functional behavior and so many excesses of dysfunctional behavior that they were labeled autistic. He didn’t do anything new, except possibly disregard all of his education in traditional clinical psychology. All he did was apply training procedures that had been in use for many years in the basic behavior-analysis research labs—procedures whose effectiveness had been well documented in peer-reviewed scientific publications..."

Autism Reality NB said...

Very informative posts on the Colorado Arbitral award. Thank you.

Regina F. said...

Thank you for the report on the award in Colorado and for the comments from the Lovaas Program.
I apologize for a lengthy comment, but I wanted to touch on the issue of the arbiter's comments on the Lovaas program, which are somewhat confusing, but somewhat understandable, in light of the statement from LIFE. I am glad that clinicians are getting together to clarify the issues.
It is common for many to think that ABA = DTT, and that the procedure, or specific application of the procedure in a teaching model is the science. You are correct that to date, the studies which cite the 47-48% outcome rates are those of the LIFE clinic supervised programs, and while other programs may have comparable outcomes on a group basis, I have not seen those numbers reported as yet. I also note that there is work currently being done to identify which students respond best to which model/which procedures in order to further tailor intervention.

Applied behavior analysis (ABA) is the science of human behavior documented over a wide range of populations, interventionists, settings and behaviors; it is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior (Baer, Wolf & Risley, 1968; Sulzer-Azaroff & Mayer, 1991).

Some of the models/teaching strategies under the umbrella of ABA, incorporating procedures which are not necessarily restricted to, or originating with any single one. The common thread is systematic instruction based on principles of learning theory, data-taking and data analysis to measure effectiveness of instruction and skill mastery:
*EIBI (sometimes referred to synonymously as "Lovaas" therapy--a combination of intensive discrete-trial training (DTT) and systematic generalization), DTT--a procedure using Sd-response-consequence-intertrial interval,
*PRT/NLP=Pivotal Response Training/Natural Language Paradigm(Schreibman, Koegel(s): responsiveness to multiple cues, motivation, self-management, and self-initiations, based on concept of "pivotal skills",
*Precision Teaching: (O.Lindsley)--teaching based on free-operant responding, daily measurement and analysis of rate changes via the Standard Celeration Chart,
*Incidental Teaching (Hart and Risley, McGee)-In setting language program within routines and harnessing motivation and teaching communication within those routines,
*Milieu-Mand model (Rogers-Warren & Warren )A version of incidental teaching with a structured protocol,
*Verbal Behavior (Partington, Sundberg, Michael)-utilizing Skinner's Analysis of Verbal Behavior to analyze the function of a verbal operant to assist transfer of language to different functions. Some programs commonly include procedures such as: interspersed trials (Dunlap), rapid pacing (Carnine, et. al.), errorless learning (Touchette, et. al.),and instruction in the natural environment.
*LEAP (Strain) inclusion focus and peer-mediated social skill intervention
*CABAS (Greer)-counted trials, use of the learn unit=number of opportunities to respond within an instructional setting,

Michael Goldberg said...

Thanks Regina for those informative background notes on ABA. I'm sure readers will find them useful. Supervision and data collection are both key issues when it comes to managing effective ABA programs. I keep hearing this point and some of your notes reiterate that message.

Thanks also to Autism Reality NB, who I understand is a parent and blogger in New Brunswick. Thank you for participating here.

:-j said...

I can't speak to exactly what the arbiter meant by referring to Lovaas' work in ... let's just say a less than flattering manner, I can shed a little light on the process by which the arbiter decides these cases.
The arbiter is a legal professional. He or she is not a researcher or scholar of any kind except the law and perhaps in thier particular area of expertise. Instead, they rely on the briefs of the opposing sides. These briefs are prepared by lawyers with the assistance of experts in the field to make their case. The arbiter will more closely examine arguments in which there is considerable difference of opinion. But if not, they will pretty much take the matter as presented. That is why it is important for opposing counsel to not allow broad or inaccurate assertions go unchallenged.
Regarding the statement about Lovaas, I would imagine the plaintiff's cousel was referring to Lovaas' earlier work from the 1970s that involved the use of aversives. While effective, the statement that it came under criticism is certainly valid.
But still, I'm just guessing.

Jeff Konrade-Helm
Programs Director
Autism Society of Colorado

Michael Goldberg said...

Thank you Jeff for this comment. Please feel encouraged to keep us informed about issues important to Colorado.

Regina F. said...

I think that the criticisms were on scientific grounds of experimental assignment, replication, cost and prediction of outcome.

The nature of these criticisms and the citations to the replies are noted in the introduction, p.417
Sallows, G.O., and Graupner, T.D. (2005). Intensive Behavioral Treatment for Children With
Autism: Four-Year Outcome and Predictors. American Journal on Mental Retardation. 110(6):417-438.

Other that might be relevant,
Ivar Lovaas, Ph.D., August 2nd, 2000
Full citations:
Lovaas, O.I., Smith, T., McEachin, J.J. (1989). Clarifying comments on the young autism study: Reply to Schopler, Short and Meisbov. Journal of Consulting and Clinical Psychology. 57(1): 165-167

Smith, T., & Lovaas, O. I. (1997). The UCLA Young Autism Project: A reply to Gresham and McMillan. Behavioral Disorders, 22, 202–218.

Smith, T., McEachin, J. J., & Lovaas, O. I. (1993). Comments on replication and evaluation of outcome. American Journal on Mental Retardation, 97, 385–391.