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)