**7. Challenges to EIBI**

Ongoing analysis of the outcomes of EIBI in comparison to other treatment programs is clearly continuing to capture the interest of many researchers with five studies alone dem‐ onstrating outcomes between 2011 and 2012. Indeed, given the growing international recog‐ nition of EIBI as the recommended approach to autism intervention, this ongoing investigation and demonstration of effects is vital. Such demonstrations and continuous rig‐ or in testing this approach with children with autism diagnoses, substantiates the view that intensive early intervention using the scientific precision of behaviour analysis, can be a very powerful intervention (Howlin, 2010; Granpeesheh, Tarbox & Dixon, 2009).

However, despite publication of the numerous studies outlined above, criticism of meth‐ odological stringency and dependent variables analysed within and across them, has been documented.

*"Remarkably, despite thousands of ABA-EIBI studies on specific core deficits, and related challenging behaviours and skills, and EIBI studies as well, some researchers still question the efficacy of these methods"* (Matson, Tureck, Turygin, Beighley & Rieske, 2012, p.1413).

One of the most pronounced criticisms of EIBI research for some time is that large multi-ele‐ ment randomized clinical trials are required to provide a definitive scientific demonstration of its effectiveness in autism treatment (Spreckley & Boyd, 2009). We, and others, (e.g., Keenan & Dillenberger, 2011; Matson et al. 2012) do not support this view and we encourage the reader to examine an excellent rebuttal of the reasons that the gold standard, randomized controlled tri‐ al in research evaluation, is in actual fact inappropriate for the design and evaluation of indi‐ vidualised treatment protocols (see Keenan &Dillenberger, 2011 for a thorough analysis).

One criticism presented in relation to the overall interpretation of the studies outlined in this chapter involves the issue that large idiosyncratic differences occur across children diag‐ nosed with autism. Because of the extensive discrepant features and their expression across the condition, Howlin (2010) stresses the need to determine which components of the inter‐ vention work best for specific individuals and under what set of circumstances. Smith et al. (2010) also suggest that ongoing research is necessary in identifying key moderating varia‐ bles in EIBI outcomes. Specifically, they pose the question of what are the most effective components, and the amount of such components, in producing marked changes in core au‐ tism symptoms and additional problems. Other researchers have also emphasised this point (Alessandri, Thorp, Mundy, & Tuchman, 2005; Granpeesheh et al. (2009). For some, deter‐ mining predictor variables such as personal characteristics affecting outcomes has been a fo‐ cus. For example, Itzchak and Zachor (2009) demonstrated that the presence of an intellectual disability and significantly delayed adaptive skills in young children with au‐ tism was a major risk factor and a predictor of weaker outcomes for EIBI. They also showed that children who were 30 months of age or younger responded significantly better to early intervention. A more recent study by Perry et al. (2011) showed that variables including younger age and higher intellectual functioning at onset of intervention were predictors of greater positive effects. Not surprisingly, Perry et al. (2011) also found that duration of inter‐ vention was a predictor of positive outcomes for young children undergoing EIBI- the lon‐ ger the child participated in the intervention, the better the outcome.

Fava et al. (2011) compared the outcomes of 12 children receiving EIBI and 10 children re‐ ceiving "eclectic" intervention after six months of treatment. EIBI was delivered by trained therapists, in a clinic-based setting, and by intensively trained and supervised parents, in a home-based setting, with children receiving 14 hours per week on average. Children in the "eclectic" group typically received approximately 12 hours per week. After six months of in‐ tervention, the EIBI group showed significantly greater increases in intellectual functioning, and significantly greater decreases in autism symptomatology and challenging behaviour. Both groups, however, showed significant gains in adaptive functioning. Parents in the "eclectic" group showed significant reductions in stress over the course of treatment while

Ongoing analysis of the outcomes of EIBI in comparison to other treatment programs is clearly continuing to capture the interest of many researchers with five studies alone dem‐ onstrating outcomes between 2011 and 2012. Indeed, given the growing international recog‐ nition of EIBI as the recommended approach to autism intervention, this ongoing investigation and demonstration of effects is vital. Such demonstrations and continuous rig‐ or in testing this approach with children with autism diagnoses, substantiates the view that intensive early intervention using the scientific precision of behaviour analysis, can be a

However, despite publication of the numerous studies outlined above, criticism of meth‐ odological stringency and dependent variables analysed within and across them, has

*"Remarkably, despite thousands of ABA-EIBI studies on specific core deficits, and related challenging behaviours and skills, and EIBI studies as well, some researchers still question the efficacy of these methods"* (Matson, Tureck, Turygin, Beighley &

One of the most pronounced criticisms of EIBI research for some time is that large multi-ele‐ ment randomized clinical trials are required to provide a definitive scientific demonstration of its effectiveness in autism treatment (Spreckley & Boyd, 2009). We, and others, (e.g., Keenan & Dillenberger, 2011; Matson et al. 2012) do not support this view and we encourage the reader to examine an excellent rebuttal of the reasons that the gold standard, randomized controlled tri‐ al in research evaluation, is in actual fact inappropriate for the design and evaluation of indi‐ vidualised treatment protocols (see Keenan &Dillenberger, 2011 for a thorough analysis).

One criticism presented in relation to the overall interpretation of the studies outlined in this chapter involves the issue that large idiosyncratic differences occur across children diag‐ nosed with autism. Because of the extensive discrepant features and their expression across the condition, Howlin (2010) stresses the need to determine which components of the inter‐

very powerful intervention (Howlin, 2010; Granpeesheh, Tarbox & Dixon, 2009).

no changes in parental stress were observed for the EIBI group.

**7. Challenges to EIBI**

582 Recent Advances in Autism Spectrum Disorders - Volume I

been documented.

Rieske, 2012, p.1413).

While EIBI programs provide strong adherence to the framework and foundational princi‐ ples of learning within ABA, some investigators have followed a particular "brand name" approach (Healy, Leader & Reed, 2010). There are a number of different ABA approaches that have been outlined in a variety of sources (some examples include: Greer, Keohane & Healy, 2002; Koegel & Koegel, 2006; Lovaas, 1981; Lovaas & Smith, 1989; Sundberg & Mi‐ chael, 2001). Often this "branding" can lead to obfuscation for the reader in interpreting what "type" of EIBI/ABA program is best. However, these approaches are all built on the same bedrock sharing important common features- intensity in program delivery (up to 40 hours weekly for at least three years), one-to-one teaching where the individual requires such intensive instruction, and discrete-trial reinforcement-based methods (in both massed trial formats and natural environmental teaching opportunities) incorporated within the sci‐ entific stringency of a behaviour analytic framework (Matson et al. 2012).

Magiati and Howlin (2001) have argued that many of the EIBI studies employ different measurements across participants and at baseline and follow up thereby compromising interpretation and reliability. For example, Eikeseth et al. (2002) and Howard et al. (2005) did not use the same tests at baseline and at follow up phases. Inconsistencies in partici‐ pant characteristics across groups (lack of matching: (e.g., Eldevik, Eikeseth, Jahr, & Smith, 2006; Fenske, Zalenski, Krantz, & McClannahan, 1985) have also been critiqued within the studies. In addition, different investigators examined various settings for EIBIsome were clinic-based (Ben-Itzchak et al., 2007; Eldevik et al., 2006) others were com‐ munity-based (Cohen et al., 2006; Eikeseth et al. 2002; Eikeseth et al., 2007; Eikeseth et al., 2012; Eldevik et al., 2012; Flanagan et al., 2012; Howard et al. 2005; Magiati et al., 2007), while others were home-based (Reed et al., 2007a; Reed et al., 2007b; Remington et al., 2007; Sheinkopf & Siegel, 1998;Smith et al., 2000). This variation in measures/settings across studies may provide challenges in the generalisation of intervention outcomes to different environments (Mudford et al., 2009).

However, we believe that it is critical to be able to assess the effectiveness of EIBI across par‐ ticipants who may reflect different tracts on the spectrum i.e., those with more severe core autism symptoms, presence of challenging behaviours, less linguistically able; impaired IQ; co-morbid or co-occurring problems etc. In this sense it appears important to utilise a wide range of instruments in the assessment procedure, not only to examine autism severity but also measures of intellectual functioning, adaptive behaviour, challenging behaviour, comorbid psychopathology and educational functioning.

While some authors have provided criticism in response to their interpretation of the EIBI outcome studies summarised within this chapter (e.g., Shea, 2004), others have acknowl‐ edged the long-term effects of such an intervention resulting from the best empirically vali‐

Early Intensive Behavioural Intervention in Autism Spectrum Disorders

http://dx.doi.org/10.5772/54274

585

Prior to 2009 six EIBI descriptive review papers were published each analysing meth‐ odologies, variables and outcomes from different perspectives (e.g., Eikeseth 2009; Granpeesheh et al. 2009; Howlin, Magiati & Charman, 2009; Matson and Smith 2008; Reichow & Wolery, 2009; Rogers and Vismara, 2008). As well as these research re‐ views, Eldevik et al. (2010) gathered individual participant data from 16 group design studies on behavioural intervention for children with autism, resulting in individual participant data for 309 participants in an EIBI group, 39 participants in an alternate treatment comparison group, and 105 in a control group-no treatment group. Their analysis revealed that more children who underwent behavioral intervention achieved significantly greater change in IQ and adaptive behaviour compared with the compari‐ son and control groups (see Eldevik et al. 2010). We encourage the reader to examine these papers in order to discern the conventional acclaim of EIBI as an acknowledged

More importantly, since 2009 EIBI research for young children with ASD has been subject to six meta-analytic reviews (Eldevik et al. 2009; Makrygianni and Reed 2010; Reichow and Wolery 2009; Peters-Scheffer, Didden, Korzilius & Sturmey, 2011; Spreckley and Boyd 2009; Virue´s-Ortega, 2010). A meta-analysis is a particular type of statistical method for integrat‐ ing results from many individual studies. This type of statistic can be useful for obtaining an overall estimate of whether or not an intervention is effective and, if so, what the size of the benefits are (i.e., the effect size). The overwhelming findings from five of the six meta-analy‐ ses conducted between 2009 to 2012 (Eldevik et al. 2009; Makrygianni and Reed 2010; Peters-Scheffer et al., 2011; Reichow & Wolery 2009; Virue´s-Ortega 2010) concluded that EIBI was an effective intervention strategy for many children with ASD, accelerating development, improving IQ and adaptive skills compared to those receiving no intervention or alternate

Most recently, Reichow (2012) presented an overview of the five meta-analyses on EIBI for young children with ASD. He concluded that the collective and accumulating evidence sup‐ porting EIBI from meta-analytic studies cannot be dismissed. Reichow's impressive dissec‐

*"Furthermore, the current evidence on the effectiveness of EIBI meets the threshold and criteria for the highest levels of evidence-*

*based treatments across definitions … Collectively, EIBI is the comprehensive treatment model for individuals with ASDs with the*

*greatest amount of empirical support and should be given strong consideration when deciding deciding treatment options for*

tion of the investigations of EIBI to date achieves the following assertion:

dated interventions (e.g., Granpeesheh, Tarbox & Dixon, 2009).

intervention for ASD.

diverse standard care treatments.

*young children with ASDs"* (Reichow, 2012, p. 518.)

Treatment integrity including initial training of therapists and parents along with continual supervision is often not reported in studies yet many authors have written on the impor‐ tance of adherence to the scientific rigor of ABA (Symes, Remington, Brown & Hastings, 2006). While many of the studies reviewed referred to training either for therapists or pa‐ rents, detail on the fidelity of treatment delivery was not measured. Where some have inves‐ tigated adherence to strict training protocols, highly effective outcomes can be demonstrated using EIBI (see McGarrell, Healy, Leader, O'Connor & Kenny, 2009).

Critiques of the initial results reported by Lovaas (1987) concerning the effectiveness of EIBI were dominant amongst the most vociferous arbiters, especially given that exact replication of such results is not evident to date. Indeed, this is one of the greatest challenges faced by many EIBI researchers. The children undergoing EIBI treatment in the Lovaas study made remarkable gains of up to 30 IQ points and were not noticeably different from neuro typical developing children after 3 years of the intervention. Replications of this original study have certainly attempted to address the methodological criticisms by incorporating more rigorous experimental design including random assignment to groups (Sallows and Graupner 2005; Smith et al. 2000). However, studies to date have yet to achieve the extent of the outcomes reported by Lovaas (1987).

It is clear that over time the methodological criticisms of the earlier studies have been ad‐ dressed by more recent investigators. Some of the recent published studies have employed larger small sample sizes, comparison groups, random assignment of the children to groups, matched characteristics across groups and standardising measures used for assessment be‐ tween and within children (e.g., Flanagan et al., 2012)

Certainly, consistency in measures at baseline and follow-up has improved with most of the studies published between 2011-2012 implementing the same measures at entry and output for the majority of variables measured (Eikeseth, et al., 2012, Eldevik, et al, 2012; Fava et al., 2011; Flanagan et al., 2012; Strauss et al., 2012). Furthermore, it is worth noting that most re‐ cent studies on EIBI are employing a more extensive battery of measures to assess the effects of EIBI- in addition to IQ and adaptive behaviour which was the focus of earlier research. For example, Fava et al. (2011) and Strauss et al. (2012) measured autism symptomatology, language functioning, challenging behaviour, comorbid psychopathology, and parental stress as outcomes of EIBI. Eikeseth et al. (2012) and Flanagan et al. (2012) also examined au‐ tism symptomatology as a dependent variable. This focus on increasing evaluation of treat‐ ment outcomes is a welcome development in EIBI research. Examining the impact of EIBI on the core symptoms of autism, challenging behaviours and comorbid psychopathology pro‐ vides an exciting avenue for future research.

While some authors have provided criticism in response to their interpretation of the EIBI outcome studies summarised within this chapter (e.g., Shea, 2004), others have acknowl‐ edged the long-term effects of such an intervention resulting from the best empirically vali‐ dated interventions (e.g., Granpeesheh, Tarbox & Dixon, 2009).

However, we believe that it is critical to be able to assess the effectiveness of EIBI across par‐ ticipants who may reflect different tracts on the spectrum i.e., those with more severe core autism symptoms, presence of challenging behaviours, less linguistically able; impaired IQ; co-morbid or co-occurring problems etc. In this sense it appears important to utilise a wide range of instruments in the assessment procedure, not only to examine autism severity but also measures of intellectual functioning, adaptive behaviour, challenging behaviour, co-

Treatment integrity including initial training of therapists and parents along with continual supervision is often not reported in studies yet many authors have written on the impor‐ tance of adherence to the scientific rigor of ABA (Symes, Remington, Brown & Hastings, 2006). While many of the studies reviewed referred to training either for therapists or pa‐ rents, detail on the fidelity of treatment delivery was not measured. Where some have inves‐ tigated adherence to strict training protocols, highly effective outcomes can be demonstrated

Critiques of the initial results reported by Lovaas (1987) concerning the effectiveness of EIBI were dominant amongst the most vociferous arbiters, especially given that exact replication of such results is not evident to date. Indeed, this is one of the greatest challenges faced by many EIBI researchers. The children undergoing EIBI treatment in the Lovaas study made remarkable gains of up to 30 IQ points and were not noticeably different from neuro typical developing children after 3 years of the intervention. Replications of this original study have certainly attempted to address the methodological criticisms by incorporating more rigorous experimental design including random assignment to groups (Sallows and Graupner 2005; Smith et al. 2000). However, studies to date have yet to achieve the extent of the outcomes

It is clear that over time the methodological criticisms of the earlier studies have been ad‐ dressed by more recent investigators. Some of the recent published studies have employed larger small sample sizes, comparison groups, random assignment of the children to groups, matched characteristics across groups and standardising measures used for assessment be‐

Certainly, consistency in measures at baseline and follow-up has improved with most of the studies published between 2011-2012 implementing the same measures at entry and output for the majority of variables measured (Eikeseth, et al., 2012, Eldevik, et al, 2012; Fava et al., 2011; Flanagan et al., 2012; Strauss et al., 2012). Furthermore, it is worth noting that most re‐ cent studies on EIBI are employing a more extensive battery of measures to assess the effects of EIBI- in addition to IQ and adaptive behaviour which was the focus of earlier research. For example, Fava et al. (2011) and Strauss et al. (2012) measured autism symptomatology, language functioning, challenging behaviour, comorbid psychopathology, and parental stress as outcomes of EIBI. Eikeseth et al. (2012) and Flanagan et al. (2012) also examined au‐ tism symptomatology as a dependent variable. This focus on increasing evaluation of treat‐ ment outcomes is a welcome development in EIBI research. Examining the impact of EIBI on the core symptoms of autism, challenging behaviours and comorbid psychopathology pro‐

morbid psychopathology and educational functioning.

584 Recent Advances in Autism Spectrum Disorders - Volume I

tween and within children (e.g., Flanagan et al., 2012)

vides an exciting avenue for future research.

reported by Lovaas (1987).

using EIBI (see McGarrell, Healy, Leader, O'Connor & Kenny, 2009).

Prior to 2009 six EIBI descriptive review papers were published each analysing meth‐ odologies, variables and outcomes from different perspectives (e.g., Eikeseth 2009; Granpeesheh et al. 2009; Howlin, Magiati & Charman, 2009; Matson and Smith 2008; Reichow & Wolery, 2009; Rogers and Vismara, 2008). As well as these research re‐ views, Eldevik et al. (2010) gathered individual participant data from 16 group design studies on behavioural intervention for children with autism, resulting in individual participant data for 309 participants in an EIBI group, 39 participants in an alternate treatment comparison group, and 105 in a control group-no treatment group. Their analysis revealed that more children who underwent behavioral intervention achieved significantly greater change in IQ and adaptive behaviour compared with the compari‐ son and control groups (see Eldevik et al. 2010). We encourage the reader to examine these papers in order to discern the conventional acclaim of EIBI as an acknowledged intervention for ASD.

More importantly, since 2009 EIBI research for young children with ASD has been subject to six meta-analytic reviews (Eldevik et al. 2009; Makrygianni and Reed 2010; Reichow and Wolery 2009; Peters-Scheffer, Didden, Korzilius & Sturmey, 2011; Spreckley and Boyd 2009; Virue´s-Ortega, 2010). A meta-analysis is a particular type of statistical method for integrat‐ ing results from many individual studies. This type of statistic can be useful for obtaining an overall estimate of whether or not an intervention is effective and, if so, what the size of the benefits are (i.e., the effect size). The overwhelming findings from five of the six meta-analy‐ ses conducted between 2009 to 2012 (Eldevik et al. 2009; Makrygianni and Reed 2010; Peters-Scheffer et al., 2011; Reichow & Wolery 2009; Virue´s-Ortega 2010) concluded that EIBI was an effective intervention strategy for many children with ASD, accelerating development, improving IQ and adaptive skills compared to those receiving no intervention or alternate diverse standard care treatments.

Most recently, Reichow (2012) presented an overview of the five meta-analyses on EIBI for young children with ASD. He concluded that the collective and accumulating evidence sup‐ porting EIBI from meta-analytic studies cannot be dismissed. Reichow's impressive dissec‐ tion of the investigations of EIBI to date achieves the following assertion:

*<sup>&</sup>quot;Furthermore, the current evidence on the effectiveness of EIBI meets the threshold and criteria for the highest levels of evidencebased treatments across definitions … Collectively, EIBI is the comprehensive treatment model for individuals with ASDs with the greatest amount of empirical support and should be given strong consideration when deciding deciding treatment options for young children with ASDs"* (Reichow, 2012, p. 518.)
