HT: Anyone familiar with the Stanley Greenspan floor time method? A client told me about a book called Engaging Autism. I'm not familiar with this book or the specifics of this "method". Thoughts?
RC: Google DIR, or developmental individual relationship based intervention. It's pretty popular, but not much research supporting its efficacy. Floor-time/DIR Approach
KC: Unless things have changed it is not evidence-based treatment.
OY: Well, it works...
Behaviorbabe: Try going to the National Autism Center's National Standards Report or other publications for research - rather than the internet. This treatment is not evidence-based. Technically, BCBA's who recommend such treatments (over more effective, established treatments) are directly violating the BACB code of Ethics.
RC: It has no research to support that it works.
RC: I would still recommend going to their website and learning about it. Educating yourself is the best way to advocate against treatments that are lacking in research.
Behaviorbabe: You may find good guidance, suggestions and solutions here. These are my notes from last Friday's Ethics talk at Endicott presented by Drs. Zane, Dorsey and Weiss.
Behaviorbabe: Here is the link to the full NAC National Standards Report.
OY: Well, it works nonetheless. Besides, if it doesn't, what harm can it do?
KC: OY, as Behaviorbabe pointed out BCBA's are bound ethically to only recommend evidence-based treatments, regardless of whether or not it "works"
MK: What harm can it do? Research shows that early intervention is important. We know that. So, that means that we have a small window of time in a child's life when interventions are going to be most effective. The harm that can happen from using treatments that are not evidence based is that we (practitioners, parents, teachers) can lose important time (and money) investing in something that has not been demonstrated (through research) when we could have been implementing methods that research and practice show to be effective time and time again. From my point of view that is harmful.
OY: I understand your point.
I do recommend DIR/Floortime --especially one of its variants-- for children with CP since it can do things ABA can't.
Handling children with special needs is a lot like cleaning a house. In order to do it efficiently and effectively, we need many different tools. A broom, a wet cloth, a broom...
I don't think that we should stop evidence based treatments and pursue Floor time, since we can actually do both. They have tools that we don't have, and we have tools that they don't have.
KC: I will stick to evidence based treatments.
OY: Go ahead, as long as it works well. That means you have chosen the right tool for the job.
KC: Exactly : )
OY: ABA is like a robber who crashes his car into your fence, smashes your front door, then systematically cleans up your house room by room.
Floortime is like a thief who picks your back door, sneaks in, and takes what he needs to take.
Both methods can do wonders. In some cases direct confrontation yields the most result, in some cases sneaky and stealthy is preferable, and in some other cases it's better if the robber and the thief works together.
KC: Why the "robber take"?
KC: Do you understand the mission of ABA?
OY: Well, that's the best comparison that I can come up with... It's not about the "taking"... It's about accomplishing a mission.
RJ: Yeah... that still makes no sense, except for that little bit about ABA being systematic. You seem to imply that they are done unwillingly, and the Floortime leaves the person with less than what he started with, and ABA he has what he started with, but it's neat and organized?
OY: You just gave me a headache.
KC: Yikes. Are you a BCBA or BCABA candidate Yandi?
RJ: Someone did present on floortime last year at AutismNJ. I don't recall who that was, and it's too late now for me to start digging around to see if I have anything from that session or who presented it.
NSV: If I went to a medical doctor for an illness, I would want him to treat me with medications that have been proven to work. I wouldn't want to complicate and/or potentially weaken the effects of the treatment by taking medications that have not shown to be effective, but were recommended to me by a different professional.
NSV: I do wonder what you meant when you said floor time can do things that ABA can't do. What would that be?
Behaviorbabe: It's often difficult to have cogent conversations over the Internet. Not really anyone's fault, per se - just potentially an inept communication system for such conversations. My main points are this: 1- BCBA's have an ethical obligation to recommend evidenced-based interventions. 2- The "harm" is in wasting precious time that should be focused on promoting outcomes supported by evidenced procedures that are published in peer-reviewed, scientific journals. 3- Behavior analysis is a scientific approach aimed at producing socially-significant behavioral changes for improving the quality of life for individuals, communities and for society as a whole...did I mention - behavior analysts have an ethical obligation to promote scientifically proven, effective, evidence-based procedures?
PJ: This is making me laugh.
RJ: In more seriousness, what if the parent insists upon trying something, like floortime, despite the lack of evidence. I'm not talking about something that has a potential to be directly harmful, but those things for which the known potential harms are things such as wasting time and money. From what I've seen, the kids did make gains. We're going to come across parents who are absolutely insistent upon trying some other treatments. Can we ask them, or the providers of those treatments to tell us what improvements we can expect to see, and experimentally evaluate to determine if those things actually do occur?
NSV: Parents can, and sometimes do insist on treatments such as floor time. That's fine, as it's their decision as the parent. As a BCBA though, I do not recommend or provide those services. I think it would be difficult to evaluate the services if you are not overseeing the treatment.
Behaviorbabe: This very topic was discussed in last week's ethics presentation at Endicott and some very helpful suggestions were provided. I encourage anyone interested in this topic to read through the notes I posted. Anyone who is already or who is planning to become a BCBA should become read through and become familiar with the BACB Ethics and Discipline page.
MM: I think it is important to first understand what ABA is before making claims about what it can and cannot do. ABA is the science of behavior change. Looking at HOW to change behavior. To equate ABA as an entire science to a certain approach such as Lovaas or VB or NET or PRT or any other abbreviation you want to throw out there is a huge error. ABA is NOT DTT. ABA is NOT mand training. ABA is NOT any other technique I could list here. ABA is the ability to analyze what is happening in the environment and determining how to teach the skills that are needed or reduce the behaviors that are in excess. While doing that, one may incorporate a multitude of different techniques and strategies that are research based. Whether behavior analysts want to admit it or not, we need to be open to people from other disciplines telling us WHAT to teach and while Floortime is not evidence based and there are other strategies that are not evidence based there are disciplines and people who have better explored WHAT to teach than behavior analysts. The people who have been looking at WHAT to teach need to listen to behavior analysts on HOW to teach it and behavior analysts need to listen more to the people who have been determining WHAT to teach. Sorry for the rant but it drives me insane when people think that ABA is sitting at a table drilling a child or that it doesn't focus on relationships or play etc. A program incorporating the principles of behavior analysis can and should work on ALL skills that the client needs and the behavior analyst should be VERY on top of what ALL of the research says about WHICH skills are necessary to teach first for whichever population they are working with.
DM: This is a very interesting line of discussion for the ABAI list. There are many very good issues being raised. The first, and perhaps most important is "why not try non-evidence based practices, they cannot hurt.". While it is true that they may not cause direct harm, trying something with no basis to predict a successful outcome, delays other treatments which are evidence based. On the other hand, there is peer-reviewed research that some of these Fad treatments such as Sensory Integration can cause direct harm (see Iwata). The basic problem is two fold, first there is no national standard such as the Food and Drug Administration to control what can be used/recommended, and second, we have no ethical standards for our profession which prohibit the use/recommendation of such non-evidence based practices. Yandi seems to represent the general public opinion regarding limits on practice - Don't worry about science or evidence, if it feels good....do it. Clearly not from a well trained Behavior Analyst. As to Megan, I suggest you read Science and Human Behavior before making such comments. Behavior Analysis IS the science of human behavior.
MM: Sorry for the confusion Michael Dorsey I intended my explanation to be equivalent to what you are saying...it is the science of human behavior...typically focusing on how we learn, how behavior changes. My phrase "behavior change" is intended to encompass the idea of human behavior...I should not have been so specific
GS: Pivotal Response Training and Natural Environment Teaching are methodologies, which share some characteristics with Floortime. They have a strong child directed element but are behavior analytic. If the parent is interested in Floortime you may offer those as alternatives. Of course any well-designed DTT program that embeds discrete trials into play routines and other high interest activities can be both educative and intrinsically reinforcing for the child. Proper and frequent reinforcer assessment and a little creativity in programming works wonders.
Behaviorbabe: Greg - raises a great point...sometimes it comes down to our operational definition.
RJ: Good point Greg, and when I saw the videos of it at Autism NJ, there definitely looked to be some elements that were similar to NET and PRT. The kids they showed also did make gains. Could it be that they were receiving some evidence-based treatment, albeit called by a different name? It could have been that they simply would have made progress anyway. I suspect some of it may have had to due with a drastic increase in attention that the kids received once they started it.
In an ideal world, we'd explain simply explain why they shouldn't do it, and it would end there. If anyone has resolved all such issues in that manner, I'm very jealous. In reality, I think sometimes we have to evaluate and show the parent that whatever they insisted upon trying isn't worthwhile.
IE: Good points by Megan and Greg
SM: There are a lot of good points made above. It seems to me that Floortime as well as Relational Development Intervention (RDI) are both examples of people taking a part of what would not be considered an appropriate ABA/VB program and calling it something else. Robert Schramm does a good gob of explaining this in the case of RDI. But the bottom line for BCBAs is that Floortime by itself is not an evidence based practice and as several have mentioned should not be practiced by BCBAs. As alluded to by RJ, SG, MM and DM, a skilled behavior analyst should be able to identify the behavior analytic processes occurring within Floortime or any other technique and help their client understand what is happening and what more needs to be done or what should be done instead.
MK: M and SG you said very well what I was thinking as I was reading the posts last night after my comment, but could not articulate. Thanks for your posts so I can better articulate this point in future conversations that I am sure I will have eventually.
CJ: Great discussion
NOTE: Click HERE to read the BACB Guidelines for Responsible Conduct