Audio & Notes (3 of 4) from 4/8/09 House Health Care Committee Mtg.

Rough notes from the
Audio recording of the 4/8/09 Public Hearing of HB 3000, House Health Care Committee.

Continuation of second blog post on testimony before the Committee.
Notes pick up after testimony by Ms. Lorri Unumb, Attorney, Senior Council of Autism Speaks.
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This post is on the testimony of Dr. Gina Green, Ph.D., Board Certified Behavior Analyst-Doctoral (BCBA-D), Executive Director of the Association of Professional Behavior Analysts (APBA).

[Blog author note:
Because this is a summary of some points of an audio presentation, this is not an exact transcript nor should it be quoted as direct statements of the participants--readers should listen to, and consult the full audio of the Committee Meeting for the proceedings of the full meeting and testimony given.]

Running time of the audio 2:22:09

hr:min:sec
1:46:50 - Rep. Greenlick - Asks Dr. Green to introduce herself. (Dr. Green is testifying by telephone).
1:46:56 - Gina Green - Have been working with autism for a number of years and legislation for a couple.
[Blog author's note: Dr. Gina Green, Ph.D., BCBA-D, is the Executive Director of the Association for Professional Behavior Analysts (APBA) was at one time the Research Director at The New England Center for Children, a large, and widely known program for children with autism in Massachusetts, and has co-authored many research articles on treatment of autism through Early Intensive Behavioral Intervention (EIBI), a noted article on the cost analysis of social savings achieved through EIBI, and the popular book, Behavioral Interventions for Young Children with Autism: A Manual for Parents and Professionals (1996).]

1:47:18 - Rep. Greenlick helps Dr. Green with a couple of procedural things with slides.
1:47:30 - Gina Green - Because of time constraints (I'm) jumping ahead in presentation to cover the main points, with emphasis on the scientific evidence supporting ABA.
[Blog author note: Powerpoint shared at the public hearing. Author: Dr. Gina Green, Ph.D., BCBA-D. All copyrights preserved. Posted with Dr. Green's kind permission. Do not reproduce or redistribute.]
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Publish at Scribd or explore others: Science Research evidence autism

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Behavior analysis is a natural science of behavior that, like other sciences, has developed research methods that are particular subject matter. Some of those include direct observation and measurement of behavior, because behavior is what we are interested in studying, changing and improving. We are also focused by definition individual behavior as it unfolds over time and interacting with the environment, so the research methodology and research designs are what are referred to as single-case research designs or within-subject designs, that are truly real experiments, rigorous experiments when done properly, where an individual's behavior is intensively studied under both control and treatment conditions. The term "single-case" is a misnomer in that although the focus is on one's behavior, there is often more than one participant in these studies and you can repeat these studies across any number of participants, and aggregate data across them. The focus in this scientific approach is on clinically significant changes in individual behavior, a person's condition improved over their baseline or control condition or status, so it's not the traditional kind of group design study where you get a group that gets a treatment, another that does not, and then there's some comparison of average scores of some measure from each of those groups compared statistically. You can make a strong case that some measure on a group really doesn't tell you anything about what happened to the individual members of the group and comparing mathematical abstractions like group averages statistically doesn't give you very much information about how each person in the group did or did not do in response to the treatment. So there's growing recognition of the benefits of these within-subject single case designs, they are now included in a number of protocols for developing evidence-based practice guidelines, in fact have been adapted, at least one kind of single case design has been adapted by medical researchers and referred to as N of 1 research designs. Some leaders of the evidence-based medicine movement such as Gordon Guyatt,, has picked up these designs and views them as superior to to the typical between-group, randomized clinical trials.

[Blog author's note on reference, Guyatt,G., Rennie, D.,Meade, M.O.,& Cook, D.J User's Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd edition, McGraw-Hill, (2008). Link is to the JAMAevidence website ]

1:50:54 - Rep. Greenlick -Y..y..yuh, we aren't into a research methodology discussion here, but I think that's a slightly overstated case that N of 1 is superior to randomized clinical trials of groups, I would be happy to have that discussion with you offline.
1:51:09 - Gina Green - There's an exact reference in my slides as to the source of that information. There are difference approaches to science and research; randomized clinical trials actually have a number of disadvantages when it comes to extrapolating from them to the individual client or patient, and that's what these folks in evidence based practice in medicine have recognized, and why they are piloting N of 1 studies.

But those are the foundation of what we do today in applied behavior analysis interventions for people with autism rest on literally hundreds of studies using these single case experimental designs, to evaluate specific behavior analysis techniques for increasing functioning in virtually all
areas, and also for reducing problem behaviors that put people with autism at pretty serious risk with a future jeopardized by those behaviors, and there is ample evidence in reviews and meta-analyses showing the effectiveness of ABA use for dealing with those problem behaviors.

The intervention model that most people refer to as ABA therapy is a model that combines many of those evidence-based specific techniques into a package and into a comprehensive program for youngsters with autism, where all of their skill deficits, behavioral difficulties, and so on are addressed, in a very intensive way, and these are the studies that have gotten the most attention in the last 10 years or so. These are generally children under the age of 6 receiving 25-40 hours a week of highly individualized ABA intervention done in a variety of settings, but typically begins in the home. It's a very dynamic, very, very individualized, with the goal for each and every child, of helping them develop skills that will help their functioning and help them stay healthy and successful in the short run and also in the long run.

There have now been a number of studies on this early intensive comprehensive model of ABA treatment and you see them summarized in my slide number 9 . The first group to do this and to document the effectiveness of course was the UCLA group, Ivar Lovaas and his colleagues--they have now published at least 7 controlled studies, and other behavior analysts have published 4 studies...
1:54:26 - Rep. Greenlick - We now have 15 minutes and 5 more people who wish to testify, so..
1:54:29 - Gina Green - Okay,
1:54:30 - Rep. Greenlick - If you could wrap it up...
1:54:32 - Gina Green - If we can jump up and look at slide 10, the main findings from these studies demonstrated that applied behavior analysis comprehensive, intensive early intervention produces substantial improvement--much more than typical treatment, eclectic intervention, and lower intensity ABA treatment in all these areas, and for many children, there are large enough improvements that they are able to function almost normally with very little ongoing specialized help from the age of 6 or 7 or 8 years old. Other children make more modest gains but are doing better
than if they had not received that treatment. Other interventions, even done with similar intensity, 1:1, for the same number of hours have resulted in minimal effects, and in some cases children have even regressed in some studies.

I just want to point out that there have been a couple of recent meta-analyses of research on intensive early intervention ABA for autism. I am familiar with the Commission Report that was done here in Oregon, and I do believe that there are more studies done since that time and the meta-analyses that I'm going to talk about just for a second here incorporate the more recent studies and did a much more thorough and informed evaluation of the research.

One of them was published recently in the Journal of Autism and Developmental Disorders, you see summarized on slide 12, did find--meta-analysis methods, I am not an expert on those, but they do allow an unbiased way of aggregating data across studies and letting us know what size effects might have been produced by an intervention, in this meta-analysis...

[Blog author note on referenced meta-analysis: Reichow, B. & Wolery, M. (2009). Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA Young Autism Project model. Journal of Autism and Developmental Disorders, 39(1), 23-41.
DOI: 10.1007/s10803-008-0596-0]

1:56:40 -Rep. Greenlick- I am going to have to ask you to end this testimony, we have other people who want to testify. Could you send us this material?
1:56:46 - Gina Green - The actual studies?
1:56:48 - Rep. Greenlick - Yeah.
1:56:55 - Gina Green - Both of the metaanalyses, one is summarized on page 12, while the other more recent one on slide 13; both of them found clear evidence that ABA produces moderate to large effects in improving the functioning of children with autism, and recommended that it be the intervention of choice. I can send you both those meta-analysis papers if you'ld like.

[Blog author note on referenced meta-analyses:
Slide 12: Reichow, B. & Wolery, M. (2009). Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA Young Autism Project model. Journal of Autism and Developmental Disorders, 39(1), 23-41.
DOI: 10.1007/s10803-008-0596-0

Slide 13: Eldevik, S., Hastings, R.P., Hughes,C., Jahr,E., Eikeseth,S., & Cross, S.C. (In Press- Publication May,2009), Journal of Child and Adolescent Clinical Psychology.
Description of study:" A systematic literature search for studies reporting effects of Early Intensive Behavioral Intervention (EIBI) identified 34 studies, nine of which were controlled designs having either a comparison or a control group. We completed a meta-analysis yielding a standardized mean difference effect size for two available outcome measures: change in full-scale intelligence (IQ), and/or adaptive behavior composite (ABC). Effect sizes were computed using Hedges'™ g. The average effect size was 1.10 for change in IQ (95% confidence interval (CI) = .87, 1.34); and .66 (95% CI .41, .90) for change in ABC. These effect sizes are generally considered to be large and moderate, respectively. Our results support the clinical implication that at present, and in the absence of other interventions with established efficacy, EIBI should be an intervention of choice for children with autism."]

1:57:13 - Rep. Greenlick - Yes, thank you, I would. Thank you very much. Would you like to stay on and listen?
1:57:20 - Gina Green - Sure, I'd love to if that's okay.

Conclusion of Dr. Gina Green's testimony.

Next, and last, blog post on the meeting will be remaining testimony from parents, a Portland teen who achieved normalization as a child through EIBI/ABA and is "doing great", and representatives from Blue Cross/Blue Shield, and Kaiser Family Foundation.