Treatment Integrity in Autism

Supporting children with special needs requires individualized and effective intervention strategies. It is very important for families, teachers, administrators, and school-based support personnel to be knowledgeable about evidence-based approaches to adequately address these unique needs and help minimize the gap between research and practice. An evidence-based practice can be defined as a strategy, intervention, treatment, or teaching program that has met rigorous peer review and other standards and has a history of producing consistent positive results when experimentally tested and published in peer-reviewed professional journals. The success of an intervention depends on the interaction between the age of the child, their developmental level and individual characteristics, strength of the intervention, competency of the professional, and a critical component termed treatment integrity.

A consistent finding in the literature is that higher levels of treatment integrity are associated with better outcomes. Thus, it is essential that treatment integrity information be collected when implementing interventions so as to distinguish between ineffective interventions and potentially effective treatments implemented with poor integrity. While implementing intervention procedures with textbook accuracy consistently in “real-world” settings presents a challenge, practitioners should attempt to implement procedures with high levels of integrity as often as possible. Direct and indirect methods  can be used to document the extent to which behavioral interventions agreed upon during consultation are being implemented as intended by the change agent (e.g. teacher or parent). 

Although systematic observation is the most direct means of assessing treatment integrity, this procedure is vulnerable to reactivity effects and tends to be a labor-intensive activity, which is not always possible given the time constraints and logistical problems encountered in most practice settings. There are, however, less direct methods that can be utilized to monitor the integrity of intervention plans. They include: (a) self-reporting; (b) permanent products; (c) behavioral interviews; and (d) performance feedback. While these methods are less intrusive, they tend to be less accurate because they rely primarily on self-reports. 

The social significance of intervention outcomes or social validity is also of critical importance. Consumers must feel assured that the selected intervention strategies are effective and appropriate, and that the social objectives are important to achieve. If the intervention lacks social validity, they are less likely to apply the effort necessary to implement the intervention, thus reducing intervention fidelity. Educators, parents and families expect (and hope) that research will produce interventions and treatments that will improve quality of life of children. Thus, the measurement of treatment integrity and social validity should be a standard feature of intervention practice and research.

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools (Second Edition). London and Philadelphia: Jessica Kingsley Publishers.

Key References and Further Reading

Bruhn, A. L., Hirsch, S. E., & Lloyd, J. W. (2015). Treatment integrity in school-wide programs: A review of the literature (1993-2012). The Journal of Primary Prevention, 36, 335-349.

Brand, D. (2014). Topical articles: Treatment Integrity: Why it is important regardless of discipline. Science in Autism Treatment, 14(2), 6-7, 9-11.

Cochrane, W. S., & Laux, J. M. (2007). Investigating school psychologists’ perceptions of treatment integrity in school- based interventions for children with academic and behavior concerns. Preventing School Failure, 51, 29-34.

DiGennaro Reed, F. D., & Codding, R. S. (2014). Advancements in procedural fidelity assessment and intervention: Introduction to the special issue. Journal of Behavioral Education, 23, 1-18.

Gresham, F. M., Gansle, K. A., Noell, G. H., Cohen, S. & Rosenblum, S. (1993). Treatment integrity of school-based behavioral intervention studies: 1980–1990, School Psychology Review 22, 254–72.

Gresham, F. M., MacMillan, D., Beebe-Frankenberger, M. E. & Bocian, K. M. (2000). Treatment integrity in learning disabilities intervention research: Do we really know how treatments are implemented? Learning Disabilities Research and Practice, 15, 198–205.

Gresham, F. M. (2009). Evolution of the treatment integrity concept: Current status and future directions. School Psychology Review, 38(4), 533-541.

Hagermoser Sanetti, L. M., & Kratochwill, T. R. (2008). Treatment integrity in behavioral consultation: Measurement, promotion, and outcomes. International Journal of Behavioral Consultation and Therapy, 4, 95-114.

Lane, K. L., Bocian, K. M., MacMillan, D. L. & Gresham, F. M. (2004). Treatment integrity: An essential – but often forgotten – component of school-based interventions, Preventing School Failure, 48, 36–43.

Noell, G. H., Witt, J. C., Slider, N. J., Connell, J. E., Gatti, S. L., Williams, K. L., Keonig, J. L., Resetar, J. L. & Duhon, G. J. (2005). Treatment implementation following behavioral consultation in schools: A comparison of three follow-up strategies. School Psychology Review 34, 87–106.

Sanetti, L. M., & Kratochwill, T. R. (2014). Introduction: Treatment integrity in psychological research and practice. In L. M. Sanetti & T. R. Kratochwill (Eds.), Treatment integrity: A foundation for evidence-based practice in applied psychology. Washington, DC: American Psychological Association.

Skolnik, Samantha, "School Psychologists’ Integrity of Treatment Integrity" (2016). PCOM Psychology Dissertations. 397. http://digitalcommons.pcom.edu/psychology_dissertations/397

Wilkinson, L. A. (2005). Bridging the research-to-practice gap in school-based consultation: An example using case studies. Journal of Educational and Psychological Consultation,16, 175-200. 

Wilkinson, L. A. (2006). Monitoring treatment integrity: An alternative to the ‘consult and hope’ strategy in school-based behavioural consultation. School Psychology International, 27,426-438.

Wilkinson, L. A. (2007). Assessing treatment integrity in behavioral consultation. International Journal of Behavioral Consultation and Therapy, 3, 420-432.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Positive Behavior Support for Children With Autism

Positive Behavior Support (PBS)

The problem behaviors of children on the autism spectrum are among the most challenging and stressful issues faced by schools and parents. The current best practice in treating and preventing unwanted or challenging behaviors utilizes the principles and practices of positive behavior support (PBS). PBS has been demonstrated to be effective with individuals across a wide range of problem behaviors and settings. 

Although used successfully both in the classroom and school-wide, PBS is not a specific intervention per se, but rather an approach that has evolved from traditional behavioral management methods. PBS refers to a set of research-based strategies that are intended to decrease problem behaviors by designing effective environments and teaching students appropriate social and communication skills. PBS utilizes primary (universal, school-wide), secondary (targeted group), and tertiary ( individual support) levels or tiers of intervention, each level providing an increasing level of intensity and support. 

Functional Behavior Assessment (FBA)

An essential component of PBS is a functional behavior assessment (FBA) to help determine the events that influence and maintain an individual student’s persistent and challenging behavior. FBA methods are considered best practice in identifying and designing behavioral intervention plans for students who demonstrate serious problem behaviors that require more intensive and individualized supports. An important goal of a functional assessment is to identify antecedents or environmental situations that will predict the occurrence and nonoccurrence of the student’s challenging behavior. Another goal is to obtain and expand information that will improve the effectiveness and efficiency of intervention strategies. FBA identifies the function(s) that the behavior appears to serve for the student. For example, a student might exhibit challenging behaviors with the goal of escape or the goal of seeking attention. When the curriculum is difficult or demanding, he or she may attempt to avoid or escape work through challenging behavior (e.g., refusal, passive aggression, disruption, etc.). Similarly, they may use challenging behavior to get focused attention from adults and peers, or to gain access to a preferred object or participate in an enjoyable activity. Problematic behavior may also occur because of sensory aversions. Because students with ASD also have significant social and pragmatic skills deficits, they may experience difficulty effectively communicating their needs or influencing the environment. Thus, challenging classroom behavior may serve a purpose for communicating or a communicative function. When we understand the goal of student behavior then we can begin to teach alternative replacement behavior and new interactional skills. 

The process of conducting an FBA is best described as (a) an strategy to discover the purposes, goals, or functions of a student’s behavior; (b) an attempt to identify the conditions under which the behavior is most likely and least likely to occur; (c) a process for developing a useful understanding of how a student’s behavior is influenced by or relates to the environment; and (d) an attempt to identify clear, predictive relationships between events in the student’s environments and occurrences of challenging behavior and the contingent events that maintain the problem behavior.   
An FBA can be conducted in a variety of ways. There are two general assessment tools to assist in the collection of information about the variables and events that surround the occurrence (or nonoccurrence) of the student’s challenging behavior. The first are interviews and rating scales that provide information from the individuals (parents, teachers) who know the student best, along with the student themselves. The second method is direct observation of the student in his or her natural daily environments. One observation strategy for collecting observational information is the A-B-C format. The observer records the Antecedent to the behavior (what happened immediately before the behavior), describes the Behavior, and the Consequence of the behavior (what happened immediately after). 

Behavior Intervention Plan (BIP)

A behavior intervention plan or BIP is a written, individualized support plan based on a functional assessment of the child’s challenging behavior that utilizes behavioral interventions and supports to reduce behaviors that interfere with the learning progress and/or increase adaptive, socially appropriate behaviors that lead to successful learning for the student. A BIP is considered a legal document that incorporates a comprehensive set of procedures and support strategies that are selected based on the individual student’s needs, characteristics, and preferences and supports the goals and objectives of the IEP. Positive behavioral intervention plans include (a) modifications to the environment; (b) teaching skills to replace problem behaviors; (c) effective management of consequences; and (d) promotion of positive life-style changes. It is essential that behavior support plans have a replacement skill included in them to create long-term changes to behavior that generalizes across settings. If the child needs a BIP to improve learning and socialization, the BIP can be included as part of the IEP and aligned with the goals in the IEP.  The following steps are a general guide to developing a comprehensive student behavior intervention or support plan. 

• The behavior support plan should be developed collaboratively and begin with a functional behavior functional behavior assessment (FBA) of the problem behavior to understand the student and the nature of the challenging behavior in the context of the environment.

• Next, the professional team examines the results of the functional assessment and develops hypothesis statements as to why the student engages in the challenging behavior. The hypothesis statement is an informed, assessment-based explanation of the challenging behavior that indicates the possible function or functions served for the student. This includes a description of the behavior, triggers or antecedents for the behavior, maintaining consequences, and purpose of the problem behavior.
• Once developed, the hypothesis provides the foundation for the development of intervention strategies. The focus of intervention plan is not only on behavior reduction, but for also teaching appropriate, functional (generally communicative) skills that serve as alternative/replacement behaviors for the undesirable behavior. Changes should be identified that will be made in the classroom or other setting to reduce or eliminate problem behaviors. Prevention strategies may include environmental arrangements, personal support, changes in activities, new ways to prompt the student, and changes in expectations. These strategies should be integrated into the student's overall program and daily routines, rather than being separate from the curriculum.  

• A positive behavior intervention plan must be implemented as planned (with integrity). Following implementation of the plan, the team regularly reviews and evaluates its effectiveness and makes modifications as needed. The design and implementation of a behavior support plan should be considered a dynamic process rather than one with a specific beginning and end. Overtime, the plan will need to be adjusted as the student's needs and circumstances change.  

Research indicates that PBS can be effective for reducing and preventing problem behaviors of children with ASD. For example, a review of published research studies found that in cases where PBS strategies were used, there was as much as an 80% reduction in challenging behavior for approximately two-thirds of the cases studied. The Individuals with Disabilities Education Act (IDEA) has endorsed PBS as a preferred form of intervention for managing the problematic behavior of students with disabilities and requires that "positive behavioral interventions, strategies, and supports" be used when addressing the needs of students who demonstrate persistent challenging behavior that impedes their learning or the learning of others. 

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

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Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).