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ABA and speech therapy: approaches to improve language ...
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ABA and speech therapy: approaches to improve language development of children with autism Anna Weston, B.S. & Abbie Olszewski, Ph.D., CCC-SLP University of Nevada, Reno Introduction Speech-language pathologists (SLP) work with individuals who have been diagnosed with autism spectrum disorders (ASD). ASD is a neurodevelopmental disorder that includes deficits in social interactions and speech and language abilities (NINDS, 2016). Two common approaches to improving social interaction and language skills are speech therapy services and applied behavior analysis (ABA). Speech therapy is defined as an approach that addresses speech, language, and communication difficulties in individuals. Speech therapy can focus on difficulties like speech sound production, receptive language, expressive language, and cognition (Justice, 2010). ABA is defined as an approach that is designed to make positive changes in a person’s behavior such as communication and social skills (ASHA, 2016). It is unclear if children would demonstrate better language skills if they received a combination of these services or speech only. Case Scenario • I am a speech-language pathologist graduate student at the University of Nevada, Reno. • One of my clients is a 7-year-old boy with autism named Phillip whose parents are debating if they should enroll Phillip in ABA services in addition to speech therapy. • In the past, I worked as an in-home ABA provider for a 5-year-old boy with autism. He received ABA for 5 months and had improvements. Once he received speech therapy and ABA services combined, I noticed additional improvements in his language. • During graduate school I have learned the importance of early intervention and how multidisciplinary approaches can benefit children with autism. • I am curious if the combination of speech therapy and ABA will increase language development more than speech therapy alone. Methods Search Terms : • Speech therapy and autism; applied behavioral analysis and autism; speech therapy, ABA, and autism; autism Electronic Databases: • PsychINFO, Pubmed, Google Scholar Appraisal: • 9 articles: 2 Case studies, 2 Quasi-experimental studies, 1 Randomized controlled trial, 1 Single Subject study, 1 Systematic Review, 1 Multi-group, and 1 Retrospective study • At least 85% reliability with independent reviewer with all 9 articles Appraisal • A Critical Appraisal of Treatment Evidence (CATE) was used for treatment articles to evaluate reliability and clinical significance based off of 8 appraisal points. The points used were: treatment comparison, random assignment of participants, participants that are related to my clinical question, similarity between groups, blinding, if valid and reliable measures were used, if there was statistical significance and if there was practical significance (Gillam & Gillam). • Each study received a rating based on an 8 point scale. The articles received a rating of suggestive if they scored 7-8 points, Compelling if they scored 4-6 points, and Equivocal if they scored 0-3 points. • 85% interrater reliability was achieved. • 5 articles were selected citing direct relevance to this study. Authors (Date) Research Design Appraisal Participants (Diagnosis, Age) Dependent Variable Results Ben-Itzchak & Zachor (2006) Non-experimental Compelling N = 25 • DX: autism • Age: 20-32 months • Imitation • Receptive language • Expressive language • Play skills • Nonverbal skills All participants performed significantly better on all outcome measures from Pre to Post testing after ABA services: • Imitation: (p < 0.001) • Receptive language: (p < 0.001) • Expressive language: (p < 0.001) • Play skills: (p < 0.001) • Nonverbal skills: (p < 0.001) Dawson, Rogers, Munson, Smith, Winter, Greenson, Donaldson, & Verley (2009) Experimental Compelling N = 48 • DX: autism • Age: 18-30 months • G1: Early Denver Start Model (EDSM): 24 children • G2: Assess-and-monitor (A/M): 24 children • Receptive language • Expressive language Receptive language From Pre to Post testing, after the assigned intervention: • 1 st year: G1 improved 17.8 points and G2 improved 9.8 points. These results were not significant, and p-values were not reported. • 2 nd year: G1 improved 18.9 points and G2 improved 10.2 points. These results were significant, and p-values were not reported. Expressive language From Pre to Post testing, after the assigned intervention: • 2 nd year: G1 improved 12.1 points and G2 improved 4.0 points. These results were significant, and p-values were not reported. Mukherjee, Rupani, Dave, Subramanyam, Shah, & Kamath (2013) Non-experimental Compelling N = 18 • DX: autism • Age: 4-15 years • Eye contact • One-step commands • Expressive language skills • Imitation • Receptive language skills: • Social information • Pre-academic skills • Rote counting • Writing • Cognitive skills • Attention • Meaningful utterances • General knowledge • Signs • Abstract language All participants performed significantly better on the following outcome measures after each year of a combination of speech therapy, ABA, and occupational therapy services: • Eye contact: (p < 0.001) • One-step commands: (p < 0.001) • Expressive language skills: (p < 0.001) • Imitation: (p < 0.001) • Receptive language skills: (p < 0.001) • Social information: (p < 0.001) • Pre-academic skills: (p < 0.001) • Rote counting: (p < 0.001) • Writing: (p < 0.001) • Cognitive skills: (p < 0.001) • Attention: (p < 0.001) • Meaningful utterances: (p < 0.001) All participants performed significantly better on the following outcome measures after 2 years of a combination of speech therapy, ABA, and occupational therapy services: • General knowledge: (p < 0.001) • Signs: (p < 0.001) No participants performed significantly better on the following outcome measures after 3 years of a combination of speech therapy, ABA, and occupational therapy services: • Abstract language skills: (p = 0.055) At the beginning of this study, 7 of the 18 children were nonverbal. At the end of this study, 15 of the 18 children were able to verbalize to some degree Stahmer & Ingersoll (2004) Non-experimental Compelling N = 20 • DX: autism • Age: average of 28 months • Early childhood development (BSID- II) • Adaptive functioning- Communication (VABS) • Adaptive functioning- Social (VABS) • Functional communication skills • Functional social interaction skills • Functional play skills All participants performed significantly better on all outcome measures from Pre to Post testing after being enrolled in the Children’s Toddler School (CTS) Program for at least 6 months: • Early Childhood Development (BSID-II): (p < 0.01) • Adaptive functioning- Communication (VABS): (p < 0.005) • Adaptive functioning- Social (VABS): (p < 0.05) • Functional communication skills: (p < 0.01) • Functional social interaction skills: (p < 0.01) • Functional play skills: (p < 0.01) Zachor, Ben-Itzchak, Rabinovich, & Lahat (2006). Experimental Compelling N = 39 • DX: autism • Age: 22-34 months • G1: Eclectic- Developmental (ED) principles: 19 children • G2: ABA: 20 children • Language and communication • Reciprocal social interaction All participants in both groups (G1 & G2) performed significantly better on the following outcome measures after the assigned intervention: • Language and communication: (p < 0.01) • Reciprocal social interaction: (p < 0.01) Discussion External Evidence: • Both ABA and speech therapy increased language abilities in children with autism. In the one study that provided a combination of speech therapy and ABA services to all participants, all participants made significant gains in language development, especially those that were enrolled in the program at a younger age. The authors discussed that these significant gains were due to the combination of the approaches. (Mukherjee et. al, 2014). Internal Evidence to Client/Caregiver: • Phillip’s parents have expressed concerns regarding his behaviors. They are open to the idea of enrolling Phillip in both speech therapy and ABA services. They are trying to figure out how it will fit into their schedule. EBP decision: • Since ABA and speech therapy are proven to improve language abilities, we decided to keep Phillip in speech therapy and the parents will also enroll Phillip in ABA services. • To determine if speech therapy is still working, I will evaluate his language abilities after 3 months. References American Speech-Language-Hearing Association (ASHA) (2016). Autism: Treatment. Retrieved from http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935303§ion=Treatment Ben-Itzchak, E., & Zachor, D. A. (2006). The effects of intellectual function and autism severity on outcome of early behavioral intervention for children with autism. Research in Developmental Disabilities, 28, 287-303. doi: 10.1016/j.ridd.2006.03.002 Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2009). Randomized, controlled trial of an intervention for toddlers with autism: The early start Denver model. Official Journal of the American Academy of Pediatrics, 125, 17-23. doi: 10.1542/peds.2009-0958 Gillam, S., & Gillam, R. (2008). Teaching graduate students to make evidence-based intervention decisions: Application of a seven step process with an authentic learning context. Topics in Language Disorders, 28(3), 212-228. doi: 10.1097/01.TLD.0000333597.45715.57 Justice, L. M. (2010). Communication sciences and disorders. Boston, MA: Pearson Education, Inc. Mukherjee, S., Rupani, K., Dave, M., Subramanyam, A., Shah, H., & Kamath, R. (2013). Evaluation of effectiveness of integrated intervention in autistic children. Indian Journal of Pediatrics, 81, 339-345. doi: 10.1007/s12098-013-1169-6 National Institute of Neurological Disorders and Stroke (NINDS) (2016). Autism spectrum disorder fact sheet. Retrieved from http://www.ninds.nih.gov/disorders/autism/detail_autism.htm Stahmer, A. C., & Ingersoll, B. (2006). Inclusive programming for toddlers with autism spectrum disorders: Outcomes from the children’s toddler school. Journal of Positive Behavior Interventions, 6, 67-82. doi: 10.1177/1362361310392253 Zachor, D. A., Ben-Itzchak, E., Rabinovich, A., & Lahat, E. (2007). Change in autism core symptoms with intervention. Research in Autism Spectrum Disorders, 1, 304-317. doi: 10.1016/j.rasd.2006.12.001 Purpose The purpose of this study was to determine if children with ASD and delayed language develop more language skills (as measured by semantics, syntax, morphology, pragmatics, and phonology) when they receive a combination of speech therapy and ABA services compared to only speech therapy services.
Transcript of ABA and speech therapy: approaches to improve language ...
ABA and speech therapy: approaches to improve language development of children with autism
Anna Weston, B.S. & Abbie Olszewski, Ph.D., CCC-SLP University of Nevada, Reno
Introduction Speech-language pathologists (SLP) work with individuals who have been diagnosed with autism spectrum disorders (ASD). ASD is a neurodevelopmental disorder that includes deficits in social interactions and speech and language abilities (NINDS, 2016). Two common approaches to improving social interaction and language skills are speech therapy services and applied behavior analysis (ABA). Speech therapy is defined as an approach that addresses speech, language, and communication difficulties in individuals. Speech therapy can focus on difficulties like speech sound production, receptive language, expressive language, and cognition (Justice, 2010). ABA is defined as an approach that is designed to make positive changes in a person’s behavior such as communication and social skills (ASHA, 2016). It is unclear if children would demonstrate better language skills if they received a combination of these services or speech only.
Case Scenario • I am a speech-language pathologist graduate student at the University of Nevada, Reno. • One of my clients is a 7-year-old boy with autism named Phillip whose parents are debating if they
should enroll Phillip in ABA services in addition to speech therapy. • In the past, I worked as an in-home ABA provider for a 5-year-old boy with autism. He received
ABA for 5 months and had improvements. Once he received speech therapy and ABA services combined, I noticed additional improvements in his language.
• During graduate school I have learned the importance of early intervention and how multidisciplinary approaches can benefit children with autism.
• I am curious if the combination of speech therapy and ABA will increase language development more than speech therapy alone.
Methods Search Terms : • Speech therapy and autism; applied behavioral analysis and autism; speech therapy, ABA, and
autism; autism Electronic Databases: • PsychINFO, Pubmed, Google Scholar Appraisal: • 9 articles: 2 Case studies, 2 Quasi-experimental studies, 1 Randomized controlled trial, 1 Single Subject study, 1 Systematic Review, 1 Multi-group, and 1 Retrospective study • At least 85% reliability with independent reviewer with all 9 articles Appraisal • A Critical Appraisal of Treatment Evidence (CATE) was used for treatment articles to evaluate
reliability and clinical significance based off of 8 appraisal points. The points used were: treatment comparison, random assignment of participants, participants that are related to my clinical question, similarity between groups, blinding, if valid and reliable measures were used, if there was statistical significance and if there was practical significance (Gillam & Gillam).
• Each study received a rating based on an 8 point scale. The articles received a rating of suggestive if they scored 7-8 points, Compelling if they scored 4-6 points, and Equivocal if they scored 0-3 points.
• 85% interrater reliability was achieved. • 5 articles were selected citing direct relevance to this study.
Authors (Date) Research Design
Appraisal
Participants (Diagnosis, Age)
Dependent Variable Results
Ben-Itzchak & Zachor (2006) Non-experimental Compelling
N = 25 • DX: autism • Age: 20-32 months
• Imitation • Receptive language • Expressive language • Play skills • Nonverbal skills
All participants performed significantly better on all outcome measures from Pre to Post testing after ABA services: • Imitation: (p < 0.001) • Receptive language: (p < 0.001) • Expressive language: (p < 0.001) • Play skills: (p < 0.001) • Nonverbal skills: (p < 0.001)
Dawson, Rogers, Munson, Smith, Winter, Greenson, Donaldson, & Verley (2009) Experimental Compelling
N = 48 • DX: autism • Age: 18-30 months • G1: Early Denver Start
Model (EDSM): 24 children
• G2: Assess-and-monitor (A/M): 24 children
• Receptive language • Expressive language
Receptive language From Pre to Post testing, after the assigned intervention: • 1st year: G1 improved 17.8 points and G2 improved 9.8 points. These results were not significant, and p-values were not
reported. • 2nd year: G1 improved 18.9 points and G2 improved 10.2 points. These results were significant, and p-values were not
reported. Expressive language From Pre to Post testing, after the assigned intervention: • 2nd year: G1 improved 12.1 points and G2 improved 4.0 points. These results were significant, and p-values were not
reported. Mukherjee, Rupani, Dave, Subramanyam, Shah, & Kamath (2013) Non-experimental Compelling
N = 18 • DX: autism • Age: 4-15 years
• Eye contact • One-step commands • Expressive language skills • Imitation • Receptive language skills: • Social information • Pre-academic skills • Rote counting • Writing • Cognitive skills • Attention • Meaningful utterances • General knowledge • Signs • Abstract language
All participants performed significantly better on the following outcome measures after each year of a combination of speech therapy, ABA, and occupational therapy services: • Eye contact: (p < 0.001) • One-step commands: (p < 0.001) • Expressive language skills: (p < 0.001) • Imitation: (p < 0.001) • Receptive language skills: (p < 0.001) • Social information: (p < 0.001)
• Pre-academic skills: (p < 0.001) • Rote counting: (p < 0.001) • Writing: (p < 0.001) • Cognitive skills: (p < 0.001) • Attention: (p < 0.001) • Meaningful utterances: (p < 0.001)
All participants performed significantly better on the following outcome measures after 2 years of a combination of speech therapy, ABA, and occupational therapy services: • General knowledge: (p < 0.001)
• Signs: (p < 0.001)
No participants performed significantly better on the following outcome measures after 3 years of a combination of speech therapy, ABA, and occupational therapy services: • Abstract language skills: (p = 0.055) At the beginning of this study, 7 of the 18 children were nonverbal. At the end of this study, 15 of the 18 children were able to verbalize to some degree
Stahmer & Ingersoll (2004) Non-experimental Compelling
N = 20 • DX: autism • Age: average of 28
months
• Early childhood development (BSID-II)
• Adaptive functioning- Communication (VABS)
• Adaptive functioning- Social (VABS) • Functional communication skills • Functional social interaction skills • Functional play skills
All participants performed significantly better on all outcome measures from Pre to Post testing after being enrolled in the Children’s Toddler School (CTS) Program for at least 6 months: • Early Childhood Development (BSID-II): (p < 0.01) • Adaptive functioning- Communication (VABS): (p < 0.005) • Adaptive functioning- Social (VABS): (p < 0.05) • Functional communication skills: (p < 0.01) • Functional social interaction skills: (p < 0.01) • Functional play skills: (p < 0.01)
Zachor, Ben-Itzchak, Rabinovich, & Lahat (2006). Experimental Compelling
N = 39 • DX: autism • Age: 22-34 months
• G1: Eclectic-Developmental (ED) principles: 19 children
• G2: ABA: 20 children
• Language and communication • Reciprocal social interaction
All participants in both groups (G1 & G2) performed significantly better on the following outcome measures after the assigned intervention: • Language and communication: (p < 0.01) • Reciprocal social interaction: (p < 0.01)
DiscussionExternal Evidence: • Both ABA and speech therapy increased language abilities in children with autism. In the one study
that provided a combination of speech therapy and ABA services to all participants, all participants made significant gains in language development, especially those that were enrolled in the program at a younger age. The authors discussed that these significant gains were due to the combination of the approaches. (Mukherjee et. al, 2014).
Internal Evidence to Client/Caregiver: • Phillip’s parents have expressed concerns regarding his behaviors. They are open to the idea of
enrolling Phillip in both speech therapy and ABA services. They are trying to figure out how it will fit into their schedule.
EBP decision: • Since ABA and speech therapy are proven to improve language abilities, we decided to keep Phillip in
speech therapy and the parents will also enroll Phillip in ABA services. • To determine if speech therapy is still working, I will evaluate his language abilities after 3 months.
References American Speech-Language-Hearing Association (ASHA) (2016). Autism: Treatment. Retrieved from http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935303§ion=Treatment Ben-Itzchak, E., & Zachor, D. A. (2006). The effects of intellectual function and autism severity on outcome of early behavioral intervention for children with autism. Research in Developmental Disabilities, 28, 287-303. doi: 10.1016/j.ridd.2006.03.002 Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2009). Randomized, controlled trial of an intervention for toddlers with autism: The early start Denver model. Official Journal of the American Academy of Pediatrics, 125, 17-23. doi: 10.1542/peds.2009-0958 Gillam, S., & Gillam, R. (2008). Teaching graduate students to make evidence-based intervention decisions: Application of a seven step process with an authentic learning context. Topics in Language Disorders, 28(3), 212-228. doi: 10.1097/01.TLD.0000333597.45715.57 Justice, L. M. (2010). Communication sciences and disorders. Boston, MA: Pearson Education, Inc. Mukherjee, S., Rupani, K., Dave, M., Subramanyam, A., Shah, H., & Kamath, R. (2013). Evaluation of effectiveness of integrated intervention in autistic children. Indian Journal of Pediatrics, 81, 339-345. doi: 10.1007/s12098-013-1169-6 National Institute of Neurological Disorders and Stroke (NINDS) (2016). Autism spectrum disorder fact sheet. Retrieved from http://www.ninds.nih.gov/disorders/autism/detail_autism.htm Stahmer, A. C., & Ingersoll, B. (2006). Inclusive programming for toddlers with autism spectrum disorders: Outcomes from the children’s toddler school. Journal of Positive Behavior Interventions, 6, 67-82. doi: 10.1177/1362361310392253 Zachor, D. A., Ben-Itzchak, E., Rabinovich, A., & Lahat, E. (2007). Change in autism core symptoms with intervention. Research in Autism Spectrum Disorders, 1, 304-317. doi: 10.1016/j.rasd.2006.12.001
Purpose The purpose of this study was to determine if children with ASD and delayed language develop more language skills (as measured by semantics, syntax, morphology, pragmatics, and phonology) when they receive a combination of speech therapy and ABA services compared to only speech therapy services.
