Cost–benefit estimates for early intensive behavioral intervention for young children with autism—general model and single state case

Clinical research and public policy reviews that have emerged in the past several years now make it possible to estimate the cost–benefits of early intervention for infants, toddlers, and preschoolers with autism or pervasive development disorder—not otherwise specified (PDD—NOS). Research indicates that with early, intensive intervention based on the principles of applied behavior analysis, substantial numbers of children with autism or PDD—NOS can attain intellectual, academic, communication, social, and daily living skills within the normal range. Representative costs from Pennsylvania, including costs for educational and adult developmental disability services, are applied in a cost–benefit model, assuming average participation in early intensive behavioral intervention (EIBI) for three years between the age of 2 years and school entry. The model applied assumes a range of EIBI effects, with some children ultimately participating in regular education without supports, some in special education, and some in intensive special education. At varying rates of effectiveness and in constant dollars, this model estimates that cost savings range from $187,000 to $203,000 per child for ages 3–22 years, and from $656,000 to $1,082,000 per child for ages 3–55 years. Differences in initial costs of $33,000 and $50,000 per year for EIBI have a modest impact on cost–benefit balance, but are greatly outweighed by estimated savings. The analysis indicates that significant cost-aversion or cost-avoidance may be possible with EIBI. © 1998 John Wiley & Sons, Ltd.     

It can be done: an example of a behavioral Individualized Education Program (IEP) for a child with autism

With state agencies and scientists recommending Early Intensive Behavioral Intervention (EIBI) for children with autism, the demand for qualified behavior consultants exceeds the supply. Consequently, children with autism are either receiving alternative, ineffective, and unsubstantiated treatments or are receiving EIBI programming from unqualified personnel. Additionally, when school districts are approached to provide services, the resulting Individualized Education Programs (IEPs) are typically not behavioral and lack the detailed and specific objectives required for children with autism. This article was written to provide parents and educators with an objective and quantifiable IEP, which has been used as a guideline for treatment for a 4‐year‐old boy with autism. Copyright © 2000 John Wiley & Sons, Ltd.     

Videoconference to supervise early intensive behavioral intervention: A preliminary evaluation of acceptability

At present, early intensive behavioral intervention (EIBI) for children with autism spectrum disorders is the intervention that has the strongest empirical support. EIBI requires frequent supervision by qualified professionals. Norway, like many other countries, has a shortage of qualified supervisors, particularly in rural regions. This study used a reversal design to investigate how supervisors and supervisees perceive the quality of EIBI supervision and the local team's preparedness when supervision was provided either on-site or via videoconference. Calculations were made on how much time could be saved on travel when part of the supervision was provided via videoconference. There were no significant differences in the supervisors' and supervisees' ratings of on-site and videoconference supervision. Moreover, the supervisors found the local EIBI teams to be better prepared when supervision was provided via videoconference, and the videoconference supervision meetings were shorter. The study discusses the implications of these findings for the accessibility of EIBI and case capacity and proposes some areas for further research.     

Teaching behavior analysts in an early intensive behavioral intervention setting to conduct a structured mealtime protocol

Children with autism spectrum disorder often display feeding problems, such as consumption of a limited variety of foods. It is also common for these children to be enrolled in early intensive behavioral intervention (EIBI) services for comprehensive treatment. Combined, these factors make it possible that behavior analysts will have a role in a child's clinical care related to feeding. However, given that the etiology of pediatric feeding disorders is complex and multifactorial, clinicians should ensure they have sufficient training and a setting that is appropriate for assessment and treatment. Therefore, we evaluated the effects of behavioral skills training in an EIBI setting to conduct a structured mealtime protocol. Training resulted in increases in procedural integrity, and we replicated these effects for all participants.     

The cost of ethics legislation: a look at the Patient Self-Determination Act

The Patient Self-Determination Act (PSDA) requires hospitals to ask patients upon admission whether they have an advance directive. Although the PSDA has received extensive criticism, little attention has been paid to the cost of the law, either during its legislative course or following its implementation. Nonetheless, several tangible and intangible costs are associated with the PSDA. Such costs may be incurred by different parties. This paper examines the costs and benefits of the PSDA and illustrates the extent of some of its tangible costs. The incremental start-up cost for one institution's response to the PSDA is estimated to be $49,304 ($1.31 per admission) and the total implementation cost of the program to be $114,528. In addition, the national incremental start-up cost for hospitals to implement the PSDA is estimated to be between $43,625,114 and $101,569,922. Finally, the potential implications of the PSDA for future governmental health care ethics regulation are discussed.     

A cost-effectiveness analysis of classwide math intervention

Given limited resources, schools are encouraged to consider not only what works, but also at what cost. Cost-effectiveness analysis offers a formal methodology to conceptualize and calculate the ratio of the costs to implement an intervention to its effects (i.e., incremental cost-effectiveness ratios). This study used the ingredients method to analyze secondary data from a randomized controlled trial (N = 537 fourth- and fifth-grade students) to calculate the cost-effectiveness of a classwide math intervention, and provides an overview of cost-effectiveness analysis for readers unfamiliar with the formal methodology. For fourth-graders, the incremental cost-effectiveness ratio was $169.07, indicating it cost $169.07 per student for a 1 standard deviation increase in scaled scores on the state assessment. For fifth-graders, there was no statistically significant effect on the state assessment, but there were improvements in curriculum-based measurement (CBM) scores with incremental cost-effectiveness ratios ranging from $65.08 to $469.12, depending on the type of CBM probe and implementation context. Additionally, using number-needed-to-treat (i.e., the number of participants who must be provided with the intervention to prevent one failure on the state assessment), the cost was $126.90 to prevent failure on the state assessment for one fourth-grade student receiving special education services or for one student who scored below the 25th percentile on the prior year's state assessment. Implications and directions for future research are discussed.     

Improvements in problem behavior in a child with autism spectrum diagnosis through synthesized analysis and treatment: A replication in an EIBI home program

A recent study described a synthesized treatment where a functional analysis was based on an open‐ended interview and combined with functional communication and delay‐tolerance training. The treatment resulted in a reduction in problem behaviors and an increase in appropriate requests. Most of the analysis and intervention were done in a clinic setting, and required weekly visits by the family. This present study is a systematic replication, where we conducted the same synthesized treatments, with a young child with Autism Spectrum Disorder (ASD) enrolled in a home‐based Early Intensive Behavior Intervention program, EIBI. Outcomes were similar with a marked reduction in problem behaviors and an increase in appropriate requests. These findings suggest that it is possible to conduct this intervention in a home setting, with weekly consultations with parents. Our study show the utility of the synthesized treatment in an EIBI program in a home setting and how this can contribute to client time and costs.     

An Assessment of Time Involved in Pre-test Case Review and Counseling for a Whole Genome Sequencing Clinical Research Program

Whole genome sequencing (WGS) is being used for evaluation of individuals with undiagnosed disease of suspected genetic origin. Implementing WGS into clinical practice will place an increased burden upon care teams with regard to pre-test patient education and counseling about results. To quantitate the time needed for appropriate pre-test evaluation of participants in WGS testing, we documented the time spent by our clinical research group on various activities related to program preparation, participant screening, and consent prior to WGS. Participants were children or young adults with autism, intellectual or developmental disability, and/or congenital anomalies, who have remained undiagnosed despite previous evaluation, and their biologic parents. Results showed that significant time was spent in securing allocation of clinical research space to counsel participants and families, and in acquisition and review of participant’s medical records. Pre-enrollment chart review identified two individuals with existing diagnoses resulting in savings of $30,000 for the genome sequencing alone, as well as saving hours of personnel time for genome interpretation and communication of WGS results. New WGS programs should plan for costs associated with additional pre-test administrative planning and patient evaluation time that will be required to provide high quality care.     

IMPROVING SOCIAL SKILLS AND DISRUPTIVE BEHAVIOR IN CHILDREN WITH AUTISM THROUGH SELF-MANAGEMENT

The literature suggests that children with autism typically are unresponsive to verbal initiations from others in community settings, and that such unresponsiveness can lead to problematic social interactions and severely disruptive behavior. The present study assessed whether self-management could be used as a technique to produce extended improvements in responsiveness to verbal initiations from others in community, home, and school settings without the presence of a treatment provider. The results showed that children with autism who displayed severe deficits in social skills could learn to self-manage responsivity to others in multiple community settings, and that such improvements were associated with concomitant reductions in disruptive behavior without the need for special intervention. The results are discussed in terms of their significance for improved development of social skills in children with autism.     

Educational level signals unobserved abilities of people with high functioning autism spectrum disorders

The effect of educational level on employment of people with high functioning autism spectrum disorders (HFASD) was examined. If education augments natural abilities to accomplish tasks in people with HFASD, then those with more education would have comparative advantages in both obtaining and retaining jobs. In contrast, if education did not augment natural abilities and only signaled unobservable abilities, one would expect an advantage only in obtaining a job, but not in retention. 22 people with HFASD replied to questionnaires regarding their history of education and employment. Those with job experience had higher educational levels than those with no job experience, but educational level was not significantly different between groups with and without more than one year of job experience. Educational level seems to be associated with abilities, but probably the unobserved abilities underlie both educational attainment and employment history.     

Ethical considerations of the short-term and long-term health impacts, costs, and educational value of sustainable development projects

There are over 800 seventh to tenth grade students at the College d’Enseignment Generale (CEG) School in Azové, Benin. Like most children in the developing world, these students lack access to clean water and basic sanitation facilities. These students suffer from parasitic infection and health ailments which could be directly offset with short term aid to supply water and medical aid. Promoting proper sanitation and providing the technology to implement water and wastewater treatment in the community will decrease childhood and maternal disease and mortality rates in Azové. However, these measures may take several years to implement and will require a significant investment in the infrastructure of the school. Is it ethical to spend $10,000 towards the long-term goals of providing water and sanitation to the students of CEG Azové, compared to spending the same amount on short-term relief efforts? This paper addresses the ethical dilemma of dealing with immediate medical needs in developing countries while trying to implement sustainable technologies. The views and frustration of students working on the project are discussed, as they realize the monetary and short-term impacts on human health when implementing sustainable technologies. The opportunity costs associated with the education principles of sustainable development were also considered. The anticipated costs and health impacts in the short-term and long-term will be evaluated for a period of 1, 2, 5 and 10 years.     

Early intensive behavioral intervention: emergence of a consumer-driven service model

Parents are becoming influential stimulators and shapers of public policy in regard to educational services for their children. Increasingly, this advocacy has created a controversy about the role of applied behavior analysis as a foundation for early intensive behavioral intervention in autism. Uncertainties exist in policy regarding the role of behavior analysis in early intervention and the capacity of behavior analysis to field a trained work force. Based on contacts with parents of children with autism and information available in a variety of forms on the Internet, there is a rising demand for fundamentally better early intervention services that are available and accessible, provide active intervention, and are based on principles of behavior analysis. Contemporary movements in special and early education, however, appear to be nonconducive to scientifically based treatments, and school districts seem hostile to an increasing role for behavior analysis and to the establishment of services that are responsive to changing parental priorities for the education of their children with autism and related disorders.     

Structural Family Therapy and Autism Spectrum Disorder: Bridging the Disciplinary Divide

ABSTRACT

Applied Behavior Analysis (ABA) is an evidence-based practice approach for the treatment of individuals with autism. The systemic effects of autism suggest that family therapy would considerably enhance the treatment of individuals with autism. Marriage and family therapy (MFT) training does not routinely include exposure to autism beyond the associated diagnostic criteria. Structural Family Therapy (SFT) is a systemic model that is familiar to those trained in family therapy and appropriate for the needs of families affected by autism. Therefore, the authors have used SFT as a foundation for supervising MFT trainees working in an autism treatment setting.     

The Presence of Odd Pricing in the Texas State Lottery1

We examined 443 drawings from the Texas state lottery from 1992 to 1997 to determine whether odd pricing effects would be found in multimillion-dollar lotteries. Specifically, we predicted that many more lottery tickets than expected would be purchased when the jackpot amount was $10 million than when it was $9 million. Three findings emerged. First, the higher the jackpot, the more tickets were purchased. Second, odd pricing effects were found at $10 million such that approximately 670,000 more tickets were purchased than expected. Third, controlling for the jackpot amount, there were approximately 620,000 fewer tickets purchased for each drawing per year. This final finding provides evidence that people are becoming less interested in multimillion-dollar lotteries.     

Traduction et adaptation du TEI-SF afin de documenter l’acceptabilité sociale de l’intervention comportementale intensive

Early intensive behavioral intervention is more widely used in large-scale community-based services in Autism Spectrum Disorder. There is an increased need to evaluate the social acceptability of these programs. The present study used a measure of social acceptability as part of a social validation procedure to evaluate a community-based EIBI offered in inclusive childcare, as well as two focused interventions associated with this program. To do so, the Treatment Evaluation Inventory Short-form (TEI-SF) questionnaire was adapted and translated to French. The validation results for the TEI-SF, as well as for the social acceptability of the EIBI programs and procedures, are presented. The results are the first evidence of the validity of the TEI-SF (adapted and translated to French), presenting scores of validity of intervention and a favourable perspective related to the early intensive behavioral intervention and opening the door to further research.     

Parental Perceptions of Services Provided for Children with Autism in Jordan

Providing formal support for children with autism and their parents is important and mandatory to improve children’s abilities and enhance the capabilities of parents. The present study attempted to investigate the perceptions of parents of children with autism regarding the services provided in Jordan. A questionnaire consisting of five sections was designed and distributed to a sample of 60 parents of children with autism (5–18 years old) among four special education institutions in Jordan. The questionnaire addressed five domains: demographics, type and number of received services, methods and difficulties of obtaining services, parents’ satisfaction, and parents’ perceived needed services. The results revealed that the service delivery system with which parents interacted was composed of multiple places and providers, but had several difficulties. Parents participating in this study expressed an average satisfaction with the received services. Issues pertaining to the cost of services, parents-professional partnerships, and overall quality of services were seen by parents as sources of low satisfaction. On the other hand, parents expressed the need for early intervention, family counseling, and community awareness services. Further suggestions and implications are presented in the study.     

Are children with autistic spectrum disorders susceptible to contour illusions?

Children with autism have been shown to be less susceptible to Kanisza type contour illusions than children without autism ( Happé, 1996 ). Other authors have suggested that this finding could be explained by the fact that participants with autism were required to make a potentially ambiguous verbal response which may have masked whether or not they actually perceived the illusory contours ( Ropar & Mitchell, 1999 ). The present study tested perception of illusory contours in children with autism using a paradigm that requires participants to make a forced choice about the dimensions of a shape defined by illusory contours. It was reasoned that accuracy of the participant on this task would indicate whether or not children with autism could perceive illusory contours. A total of 18 children with autistic spectrum disorder, 16 children with special educational needs not including autism and 20 typically developing children completed an experimental task which assessed perception of Kanisza‐style rectangles defined by illusory contours. There were no significant differences between the performance of the children with autism and either of the two control groups, suggesting that perception of illusory contours is intact in autism.     

The external validity of Asperger disorder: lack of evidence from the domain of neuropsychology

The present study compared individuals with high-functioning autism (HFA) and Asperger disorder (AD) in intellectual, motor, visuospatial, and executive function domains. Participants with AD demonstrated significantly higher Verbal and Full Scale IQ scores, significantly larger Verbal-Performance IQ discrepancies, and significantly better visual-perceptual skills than those with HFA. Once the superior intellectual abilities of the AD group were controlled (both statistically through analysis of covariance and by examining IQ-matched subgroups of HFA and AD participants), no significant group differences in motor, visuospatial, or executive functions were evident, save a marginally significant trend toward poorer fine motor performance in the AD group. This suggests that AD may simply be "high-IQ autism" and that separate names for the disorders may not be warranted. The relation of these findings to theories of autism and AD are discussed.