NEW YORK, USA

Ekspertgruppe fremhæver 27 interventioner


I 2009 udgav det amerikanske National Autism Center anbefalinger om interventioner til børn med autisme. Anbefalingerne udpegede 11 interventioner, som var veldokumenterede mens 22 andre interventioner endnu ikke havde et tilstrækkeligt forskningsmæssigt underlag. Nu har en ny ekspertgruppe - National Professional Development Center on Autism Spectrum Disorders - udsendt aktuelle anbefalinger baseret på en ny gennemgang af den forskningsmæssige dokumentation. Ekspertgruppen fremhæver 27 teknikker og procedurer som evidens-baserede. Hovedparten af disse interventioner er adfærdsanalytiske.

Anbefalingerne er baseret på 456 forskningsartikler, som er blevet udvalgt blandt mange tusinde forskningsrapporter fra perioden 1990 – 2011. Kun forskning om børn og unge (op til 22 år) med autisme er medtaget og kun forskning, der opfylder en række kvalitetskrav, er medtaget.

På denne baggrund er ekspertgruppen nået frem til 27 forskellige fokuserede interventioner, der opfylder kriterierne for evidensbasering. Altså et betydelig højere antal interventioner end de 11, som den tidligere ekspertgruppe – fra National Autism Center – nåede frem til i 2009. Forskellene i antal veldokumenterede interventioner skyldes dels, at den nye ekspertgruppe anvender andre og mere detaljerede afgrænsninger mellem interventioner, og dels, at der i mellemtiden er gået 5 år. I den periode er nogle af de interventioner, der i 2009 blev betegnet som lovende, avanceret til at blive veldokumenterede.

I skemaet er der en samlet oversigt over de 27 evidens-baserede interventioner.


Evidens-baserede fokuserede interventioner

 

 

 

 

 

Empirisk grundlag

Engelsk betegnelse

Dansk betegnelse

Definition

Gruppe-studier (n)

Single Subject Studier (n)

Antecedent-based intervention (ABI)

Antecedent-intervention

Arrangement of events or circumstances that precede the occurrence of an interfering behavior and designed to lead to the reduction of the behavior .

0

32

Cognitive behavioral intervention (CBI)

Kognitiv adfærdsbehandling

Instruction on management or control of cognitive processes that lead to changes in overt behavior .

3

1

Differential reinforcement
of Alternative,
Incompatible, or
Other Behavior (DRA/I/O)

Differentiel forstærkning

Provision of positive/desirable consequences for behaviors or their absence that reduce the occurrence of an undesirable behavior . Reinforcement provided: a) when the learner is engaging in a specific desired behavior other than the inappropriate behavior (DRA), b) when the learner is engaging in a behavior that is physically impossible to do while exhibiting the inappropriate behavior (DRI), or c) when the learner is not engaging in the interfering behavior (DRO) .

0

26

Discrete trial teaching
(DTT)

Discrete Trial Teaching

Instructional process usually involving one teacher/service provider and one student/client and designed to teach appropriate behavior or skills . Instruction usually involves massed trials . Each trial consists of the teacher’s instruction/presentation, the child’s response, a carefully planned consequence, and a pause prior to presenting the next instruction .

0

13

Exercise (ECE)

Fysisk træning

Increase in physical exertion as a means of reducing problem behaviors or increasing appropriate behavior .

3

3

Extinction (EXT)

Extinktion

Withdrawal or removal of reinforcers of interfering behavior in order to reduce the occurrence of that behavior . Although sometimes used as a single intervention practice, extinction often occurs in combination with functional behavior assessment, functional communication training, and differential reinforcement .

0

11

Functional behavior assessment (FBA)

Funktionel adfærdsudredning

Systematic collection of information about an interfering behavior designed to identify functional contingencies that support the behavior . FBA consists of describing the interfering or problem behavior, identifying antecedent or consequent events that control the behavior, developing a hypothesis of the function of the behavior, and/or testing the hypothesis .

0

10

Functional communication
training (FCT)

Funktionel kommunikationstræning

Replacement of interfering behavior that has a communication function with more appropriate communication that accomplishes the same function . FCT usually includes FBA, DRA, and/ or EX .

0

12

Modeling (MD)

Modellering

Demonstration of a desired target behavior that results in imitation of the behavior by the learner and that leads to the acquisition of the imitated behavior . This EBP is often combined with other strategies such as prompting and reinforcement .

1

4

Naturalistic intervention
(NI)

Intervention i naturlige omgivelser

Intervention strategies that occur within the typical setting/activities/routines in which the learner participates . Teachers/service providers establish the learner’s interest in a learning event through arrangement of the setting/activity/routine, provide necessary support for the learner to engage in the targeted behavior, elaborate on the behavior when it occurs, and/or arrange natural consequences for the targeted behavior or skills .

0

10

Parent-implemented intervention (PII)

Forældre-implementeret intervention

Parents provide individualized intervention to their child to improve/increase a wide variety of skills and/or to reduce interfering behaviors . Parents learn to deliver interventions in their home and/or community through a structured parent training program .

8

12

Peer-mediated instruction and intervention (PMII)

Kammeratformidlet intervention

Typically developing peers interact with and/or help children and youth with ASD to acquire new behavior, communication, and social skills by increasing social and learning opportunities within natural environments . Teachers/service providers systematically teach peers strategies for engaging children and youth with ASD in positive and extended social interactions in both teacher-directed and learner-initiated activities .

0

15

Picture Exchange Communication System
(PECS)

PECS

Learners are initially taught to give a picture of a desired item to a communicative partner in exchange for the desired item . PECS consists of six phases which are: (1) “how”to communicate, (2) distance and persistence, (3) picture discrimination, (4) sentence structure, (5) responsive requesting, and (6) commenting .

2

4

Pivotal response training
(PRT)

Pivotal Response Training

Pivotal learning variables (i .e ., motivation, responding to multiple cues, self-management, and self-initiations) guide intervention practices that are implemented in settings that build on learner interests and initiative .

1

7

Prompting (PP)

Prompting

Verbal, gestural, or physical assistance given to learners to assist them in acquiring or engaging in a targeted behavior or skill . Prompts are generally given by an adult or peer before or as a learner attempts to use a skill .

1

32

Reinforcement (R+)

Forstærkning

An event, activity, or other circumstance occurring after a learner engages in a desired behavior that leads to the increased occurrence of the behavior in the future .

0

43

Response interruption/ redirection (RIR)

Responsafbrydelse/omdirigering

Introduction of a prompt, comment, or other distracters when an interfering behavior is occurring that is designed to divert the learner’s attention away from the interfering behavior and results in its reduction .

0

10

Scripting (SC)

Scripts

A verbal and/or written description about a specific skill or situation that serves as a model for the learner . Scripts are usually practiced repeatedly before the skill is used in the actual situation .

1

8

Self-management (SM)

Selvforvaltning

Instruction focusing on learners discriminating between appropriate and inappropriate behaviors, accurately monitoring and recording their own behaviors, and rewarding themselves for behaving appropriately .

0

10

Social narratives (SN)

Sociale historier

Narratives that describe social situations in some detail by highlighting relevant cues and offering examples of appropriate responding . Social narratives are individualized according to learner needs and typically are quite short, perhaps including pictures or other visual aids .

0

17

Social skills training (SST)

Træning af sociale færdigheder

Group or individual instruction designed to teach learners with autism spectrum disorders (ASD) ways to appropriately interact with peers, adults, and other individuals . Most social skill meetings include instruction on basic concepts, role-playing or practice, and feedback to help learners with ASD acquire and practice communication, play, or social skills to promote positive interactions with peers .

7

8

Structured play group
(SPG)

Strukturerede legegrupper

Small group activities characterized by their occurrences in a defined area and with a defined activity, the specific selection of typically developing peers to be in the group, a clear delineation of theme and roles by adult leading, prompting, or scaffolding as needed to support students' performance related to the goals of the activity .

2

2

Task analysis (TA)

Trinanalyse

A process in which an activity or behavior is divided into small, manageable steps in order to assess and teach the skill . Other practices, such as reinforcement, video modeling, or time delay, are often used to facilitate acquisition of the smaller steps .

0

8

Technology-aided instruction and intervention (TAII)

Teknologi-understøttet intervention

Instruction or interventions in which technology is the central feature supporting the acquisition of a goal for the learner . Technology is defined as “any electronic item/ equipment/ application/or virtual network that is used intentionally to increase/maintain, and/or improve daily living, work/productivity, and recreation/leisure capabilities of adolescents with autism spectrum disorders”(Odom, Thompson, et al ., 2013) .

9

11

Time delay (TD)

Tidsforsinkelse

In a setting or activity in which a learner should engage in a behavior or skill, a brief delay occurs between the opportunity to use the skill and any additional instructions or prompts . The purpose of the time delay is to allow the learner to respond without having to receive a prompt and thus focuses on fading the use of prompts during instructional activities .

0

12

Video modeling (VM)

Videomodellering

A visual model of the targeted behavior or skill (typically in the behavior, communication, play, or social domains), provided via video recording and display equipment to assist learning in or engaging in a desired behavior or skill .

1

31

Visual support (VS)

Visuel støtte

Any visual display that supports the learner engaging in a desired behavior or skills independent of prompts . Examples of visual supports include pictures, written words, objects within the environment, arrangement of the environment or visual boundaries, schedules, maps, labels, organization systems, and timelines .

0

18

Kilde: Autism Evidence-Based Practice Review Group. (2014): 20-22.

Af de 27 anbefalede interventioner er de 19 tydeligt adfærdsanalytiske. Det er enten basis-elementer i alle former for anvendt adfærdsanalyse – fx trinanalyse, forstærkning, prompting, differentiel forstærkning og Discrete Trial Teaching m.v. – eller det er interventioner, der primært er blevet udviklet inden for adfærdsanalytiske fagkredse og dokumenteret af adfærdsanalytiske forskere. Det drejer sig bl.a. om kammeratformidlet læring, modellering, scripts og videomodellering. De fokuserede interventioner, der ikke er adfærdsanalytiske, er fysisk træning, kognitiv adfærdsbehandling, forældre-implementerede interventioner, sociale historier, social træning, strukturerede legegrupper, teknologi-formidling træning samt visuel støtte. Især den sidstnævnte er bemærkelsesværdig fordi der er tale om en intervention, der udspringer af TEACCH-baserede fagkredse - dvs. fagfolk, der arbejder inden for traditionen Treatment and Education of Autistic and related Communication-handicapped CHildren. Til gengæld er TEACCH-interventionen strukturerede arbejdsstationer ikke medtaget som en evidens-baseret intervention – her er dokumentationen mangelfuld.

I rapporten fremhæves også en række lovende interventioner, som dog endnu ikke kan karakteriseres som evidens-baserede. Det gælder bl.a. træning af delt opmærksomhed og gensidig imitationstræning. I begge tilfælde er den forskningsmæssige dokumentation omfattende og overbevisende, men disse interventioner frasorteres fordi dokumentationen kun er udført af enkeltstående forskergrupper. Læs om træning af delt opmærksomhed og gensidig imitationstræning på ABAforum.dk


Det er vigtigt, at være opmærksom på, at disse 27 interventioner ikke nødvendigvis er effektive ift. de autistiske kernesymptomer – afvigende sociale og kommunikative færdigheder samt stereotypier. De effekter, der er undersøgt og som danner grundlag for evidens-baseringen, omfatter ikke nødvendigvis de autistiske kernesymptomer men et eller flere andre mål for interventionen – fx problemadfærd, delt opmærksomhed, legefærdigheder, kognition, skoleparathed, skolemæssige færdigheder, motoriske færdigheder, arbejdsmarkedsparathed samt mental helse. Og i en del tilfælde omfatter dokumentationen kun en bestemt aldersgruppe af børn eller unge med autisme.  

I lighed med den tidligere ekspertgruppe, fokuserer de nye anbefalinger på enkeltstående procedurer og teknikker – kaldet fokuserede interventioner - i stedet for helhedsorienterede interventionsmodeller. De helhedsorienterede modeller er fx UCLA Young Autism Program, ESDM (Early Start Denver Model) og TEACCH. Helhedsorienterede modeller er ’pakker’, der adresserer en lang række læringsmål for børn med autisme, og som samtidig giver anvisninger på, hvordan træning og undervisning bedst kan tilrettelægges. De helhedsorienterede modeller er beskrevet i de såkaldte curriculum-bøger – interventionsprotokoller - som giver anvisninger på træningens og undervisningens form og indhold (se oversigten over curriculum-bøger på ABAforum.dk).

Til forskel fra de helhedsorienterede modeller, så er de fokuserede interventioner mere begrænsede og målrettede i deres læringsindhold og i deres målsætninger. De fokuserede interventioner adresserer typisk en velafgrænset færdighed og indbefatter typisk teknikker eller procedurer for, hvordan disse færdigheder kan opnås. Som eksempel på fokuserede interventioner kan man nævne Discrete Trial Teaching (DTT), differentiel forstærkning og kammeratformidlet læring.

Mens de helhedsorienterede interventioner oftest dokumenteres forskningsmæssigt i længerevarende gruppeundersøgelser, hvor man følger og sammenligner grupper af børn, der modtager interventionen i fx en 2-årig periode og hvor man tester børnene før og efter interventionen, så kan de fokuserede interventioner også dokumenteres i mindre ambitiøs og ikke så ressourcekrævende forskning. Typisk i kraft af de såkaldte single subject studier (som ikke nødvendigvis kun omfatter en person), men hvor man følger et begrænset antal børn i løbet af en kortvarig interventions- og opfølgningsperiode. I denne form for forskning indgår ikke statistiske sammenligninger mellem grupper af børn, og i stedet fungerer de enkelte børn som deres egen kontrolperson. Fx ved at man tester barnet i en baseline inden interventionen, man følger barnets færdigheder i løbet af interventionen, og når man stopper interventionen kan man igen måle barnets færdigheder. Denne måde at dokumentere effekter af træning på er nærmere beskrevet i artiklen Evidensbaserede teknikker i interventioner for småbørn med autisme på ABAforum.dk.

Når ekspertgruppen har valgt at fokusere på de fokuserede interventioner, så har det den store fordel, at mængden af relevant forskning bliver forøget betydeligt. Mens gruppeundersøgelser er besværlige og dyre at gennemføre og forudsætter et stort team af forskere og test-psykologer, så kan single subject studier gennemføres af enkelte forskere.

Lige som der er bestemte metodiske krav til at gruppestudier af interventioner kan betegnes som forskning af høj kvalitet og med høj grad af evidens, så er der udviklet tilsvarende standarder for single subject forskning. Det er sådanne standarder, som ekspertgruppen anvender, når de skal vurdere evidensen i forskellige former for autisme-intervention.

For at en fokuseret intervention kan betegnes som evidensbaseret, skal den forskningsmæssige dokumentation opfylde et af tre kriterier:

De nye anbefalinger er udarbejdet af medarbejdere ansat på University of North Carolinas National Professional Development Center on Autism Spectrum Disorders (NPDC). NPDC er et stort forsknings- og udviklingsprojekt, som er igangsat af og finansieret af U.S. Department of Education, og omfatter et samarbejde mellem 11 forskellige universiteter og forskningscentre i USA..

Autism Evidence-Based Practice Review Group. (2014). Evidence-Based Practices for Children, Youth, and Young Adults with Autism Spectrum Disorder. Chapel Hill, NC: Frank Porter Graham Child Development Institute, University of North Carolina.

De tidligere anbefalinger af fokuserede, enkeltstående interventioner var udarbejdet af National Autism Center. Anbefalingerne er offentliggjort i 2 rapporter.

The National Autism Center. (2009). National Standards Report: the national standards project — addressing the need for evidencebased practice guidelines for autism spectrum disorders. Randolph, MA: National Autism Center.

The National Autism Center. (2011). Evidence-Based Practice and Autism in the Schools - a guide to providing appropriate interventions to students with autism spectrum disorders. Randolph, MA: National Autism Center.

 

Joi Bay /26.02.2014