At this point in time, many speech-language pathologists as well as other professionals are finding themselves in challenging discussions and at times unfortunate conflicts with parents of children with autism regarding the Lovaas program. The interest of families in this program is understandable based on its reported success: 9 of 19 children with autism who participated in an early and intensive behavior modification program achieved normal intelligence test scores and a regular classroom placement at age 7, and these achievements were maintained over a follow-up period ranging from 3 to 12 years. Even those who are critical of the study on methodological grounds generally agree that many fewer children would have achieved a high level of functioning and normal classroom placement without the benefit of the Lovaas program.

Does this mean the Lovaas program should be the "treatment of choice" for children with autism? In other words, is it better than other approaches? Not necessarily--the research to date cannot answer these important questions for us. Several issues to be considered are (1) the age of the child, (2) the treatment strategy; (3) individual differences among children with autism; and (4) intensity of intervention.

Age of child. With regard to the age of the child, Lovaas and his collaborators believe that the delivery of this intervention during the preschool years was critical to the its success. Children were an average of 35 months old when they entered the program and were not enrolled in the program if they were older than 46 months. For children who had not achieved a normal classroom placement during their kindergarten year, the intensive program was continued for a total of six or more years; however, this continuation into the school-age years resulted in only one additional child achieving normal intelligence test scores and regular classroom placement. Thus, we are unsure about the implications of this research for intervention with school-age children with autism.

Intervention strategy. The Lovaas research did not evaluate the effectiveness of his behavior modification therapy against other intervention strategies. The comparison intervention used with the control group was the same type of behavior therapy, but less intensive (10 hours or less per week compared to 40 hours or more). Thus, it is possible that the intensity of the intervention was more important than the specific strategies used or behaviors targeted. In terms of short-term impact, there is some evidence that a "natural language paradigm (NLP)" as implemented by the Koegels and their colleagues may be more effective in enhancing language acquisition and interaction in children with autism than a more traditional behavior modification approach as described by Lovaas (1981). The NLP involves (1) use of functional stimulus items chosen by the child; (2) natural reinforcers; (3) reinforcement of communicative attempts even if they are not "correct;" and (4) intervention trials interwoven within a natural exchange. The long-term impact of intensive and early exposure to the NLP has not been evaluated, however. A recent book edited by Koegel and Koegel (1995) describes the NLP and provides an excellent update on the advances in programs for children with autism which have been developed within a behaviorist framework.

       Another important issue in communication intervention is the use of augmentative communication. The emphasis in the Lovaas program is on verbal imitation and production, but there is evidence for benefits of the early introduction of augmentative strategies to children with autism. For instance, Bondy and Frost (1995) have formalized steps for teaching young children with autism to use a Picture Exchange Communication System (PECS) and implemented this approach with 66 preschool children with autism who entered their program without functional speech. All of the children were able to learn to use the PECS at some level, and 73% of the children went on to develop verbal skills. Although there was no comparison group included in the study, Bondy and Frost pointed out that this percentage is higher than figures cited in the literature that only around 50% of children with autism develop useful verbal skills.

Individual differences among children with autism. Children with autism differ from one another as much as do any children, and it is likely that no one approach will be the best for every child. For example, Layton (1988) investigated the use of different communication treatments with children with autism, including speech-only, sign-only, total communication, and alternating sign and speech training. He found that the children who entered treatment with good verbal imitation skills did equally well in all treatments, but the children who had limited or no verbal imitation skills did most poorly in the speech-only condition. The Lovaas research makes us eager for more information about specific pre-treatment characteristics of children who had the best outcomes with his program, and also for additional research comparing two or more distinct treatment approaches and analyzing factors that could help us predict which approach will be best with which child and family.

Intensity of treatment. The Lovaas program provided children in the experimental group with one-to-one intervention for at least 40 hours per week for a minimum of two years. To my knowledge, there have not been any other reports regarding intervention programs which approach this level of intensity of treatment. Among the control group in the Lovaas study, (10 hours per week or less intervention), none "recovered" based on the criteria of a normal intelligence test score and placement in a regular classroom at age 7. We don't know if there is a straight line correlation between intensity of intervention and outcome or if there is some threshold amount of intervention needed to achieve optimal outcome. The answer to this question also may be affected by individual differences in children, with some children requiring more intensive intervention than others to achieve optimal results.

       With these issues in mind, how can clinicians on the "front line" respond to parents who want the Lovaas program for their child? I would suggest the following strategies:

       (1) Maintain objectivity and an open mind regarding intervention alternatives.

       (2) Acknowledge the parents' hopes for the best possible long-term outcome for their child, and communicate an attitude of optimism and hopefulness yourself.

       (3) Read the original sources describing the Lovaas program and its evaluation as well as critiques of this research. The program has been described in detail by Lovaas (1981). The evaluation of the program's impact on children at age seven as well as a follow-up study are presented in Lovaas (1987) and McEachin, Smith and Lovaas (1993). The January, 1993 issue of the American Journal of Mental Retardation contains this latter article as well as critiques of the research by several other investigators who have worked in the field of autism. Also, become informed about advances in behavioral/educational treatment of children with autism since Lovaas first initiated the Young Autism Project in 1970. The Koegels' (1995) book will be helpful in the latter regard.

       (4) Separate the issues of intervention strategies from intervention intensity and discuss one at a time.

       (5) Provide parents with information about the different intervention strategies that have been used effectively to promote communication and social skills in children with autism. In addition to the Koegels' book, a book edited by Quill (1995) provides a broad range of information about various approaches and will be of particular interest to speech-language pathologists and special educators as well as to parents. Discuss the fact that there have been very few direct comparisons of intervention strategies, so we don't know which is "best." Also discuss the issue of individual differences among children with autism, and the fact that a single approach will probably not be the best for every child.

       (6) If there is a disagreement with parents about the preferred strategy, agree on the common goal of figuring out what is the best strategy for this child and collaborate on a plan to evaluate the strategies. Perhaps parents could observe some sessions using alternating strategies, or the SLP or other interventionist could videotape sessions to be viewed with the parents later. If the parents are already working with their child at home, it is invaluable for persons in the educational setting to observe a home session as well. The SLP can also collect data during several sessions using each type of approach and discuss the results with the child's parents.

       (7) I have found the issue of intensity of intervention to be the most difficult to resolve. The intensity of direct intervention by the SLP must considered in relation to the child's total intervention program and the strength of the SLP's consultative role to the child's teachers and parents. At least at the preschool level, the case is growing for an intensive total intervention program as the optimal model. However, school districts may not be able to fund the optimal program. Sometimes I think we must acknowledge that, while we can provide a program which will be beneficial to the child, we (in publicly funded programs) cannot necessarily provide the optimal intensity of intervention. With administrative support, public school personnel could explore possibilities for "public-private partnerships" which would work with organizations such as local Autism Society of America chapters or other parent groups, civic groups, private grant foundations, and local high schools and/or colleges to train parents, paraprofessionals, and volunteers, and to organize a program which would increase parents' access to more intensive services than can be provided by the school program alone.

       Some additional resources which will be helpful to both parents and professionals are available though the Autism Society of America. There is a FAX-on-Demand system which can be accessed by calling 1-800-FAX-0899; documents will be faxed to the caller free of charge. You can request a list of the more than 25 documents available. These include documents on Asperger's Syndrome, Educating Children with Autism, Facilitated Communicatio, and Early Intervention, as well as bookstore lists for the Michigan Chapter and North Carolina Chapter bookstores (both of which stock a wide range of titles related to autism). There are also packets available by mail; more information on these is available by calling 1-800-3AUTISM or writing to ASA at 7910 Woodmont Ave., Suite 650, Bethesda, MD 20814-3015.

Bondy, A.S. & Frost, L.A. (1995). Educational approaches in preschool. In E. Schopler & G. Mesibov (Eds.), Learning and cognition in autism (pp. 311-333). New York: Plenum.

Koegel, R.L. & Koegel, L.K. (1995). Teaching children with autism: Strategies for initiating positive interactions and improving learning opportunities. Baltimore: Brookes.

Layton, T.L. (1988). Language training with autistic children using four different modes of presentation. Journal of Communication Disorders, 21, 333-350.

Lovaas, O.I. (1981). Teaching developmentally disabled children: The ME book. Austin, TX: Pro-Ed.

Lovaas, O.I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.

McEachin, J.J., Smith, T., & Lovaas, O.I. (1993). Long-term outcome for children with autism who received early intensive behavior treatment. American Journal on Mental Retardation, 97, 359-372.

Quill, K.A.(1995). Teaching children with autism: Strategies to enhance communication and socialization. Albany, NY: Delmar.

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September 23rd, 1997