Autism Treatment Survey: Services Received by Children with Autism Spectrum Disorders in Public School Classrooms

Transcription

1 J Autism Dev Disord (2008) 38: DOI /s ORIGINAL PAPER Autism Treatment Survey: Services Received by Children with Autism Spectrum Disorders in Public School Classrooms Kristen L. Hess Æ Michael J. Morrier Æ L. Juane Heflin Æ Michelle L. Ivey Published online: 11 October 2007 Ó Springer Science+Business Media, LLC 2007 Abstract The Autism Treatment Survey was developed to identify strategies used in education of children with autism spectrum disorders (ASD) in Georgia. Respondents of the web-based survey included a representative sample of 185 teachers across the state, reporting on 226 children with ASD in grades preschool-12th. The top five strategies being used in Georgia (, sensory integration, cognitive behavioral modification, assistive technology, and Social Stories TM ) are recognized as lacking a scientific basis for implementation. Analysis revealed the choice of strategies varied by grade level and classroom type (e.g., general education, special education). Results highlight clear implications for preservice and inservice educator training, and the need for continued research to document evidence-based strategy use in public schools for students with ASD. Keywords Autism Best practices Intervention strategies Public schools As the prevalence of autism spectrum disorders (ASD) increases, more and more children with ASD present for services in public school classrooms (Yeargin-Allsopp et al. 2003). Due to the unique social and communication difficulties that characterize this population, educators agree that students with ASD require specialized services in the schools (National Research Council [NRC] 2001; Simpson et al. 2005). Furthermore, current legislation in K. L. Hess (&) M. J. Morrier L. J. Heflin M. L. Ivey Department of Educational Psychology and Special Education, Georgia State University, P.O. Box 3979, Atlanta, GA , USA ecekhh@langate.gsu.edu general and special education mandates that all educators implement evidence-based educational programs (Individuals with Disabilities Education Improvement Act [IDEA] 2004; No Child Left Behind 2001). Unfortunately, many interventions and treatments being used with children with ASD do not have empirical evidence to substantiate their effectiveness (Heflin and Simpson 1998) and may waste resources as well as preclude the provision of worthwhile interventions in schools (Simpson et al. 2005). The increase in the number of students with ASD along with the explosion in the quantity of ineffective interventions converge to create a critical need to examine the nature, type, and frequency of educational services provided to students with ASD enrolled in public schools. In a recent publication, Simpson and colleagues (2005) evaluated the scientific evidence for 37 interventions and treatments for children with ASD. As a matter of organization, interventions were divided into five broad categories based upon the main feature of the treatment (Simpson et al.). These categories were (a) Interpersonal Relationships, (b) Skill-based, (c) Cognitive, (d) Physiological/Biological/ Neurological, and (e) Other. The interventions included in the book reflect a variety of treatments that families frequently choose. This team of 11 authors participated in discussions about frequently used programs. Then they provided insight and recommendations for inclusion in the final product and acknowledge that their list is not all-inclusive (R. Simpson, personal communication, April 22, 2007). Finally, Simpson and his colleagues conducted thorough reviews of literature for each of the individual treatments and then rated them as follows: (a) scientifically-based, those with evidence of benefit following substantial, scrupulous research, (b) promising practice, those which have been used for time with no or limited adverse results and/or have research

2 962 J Autism Dev Disord (2008) 38: suggestive of beneficial outcomes, but warrant further investigation, (c) limited support, treatments which have limited research and have not been widely used or those with a range of reported results, and (d) not recommended, interventions or treatments that have been proven ineffective or have unfavorable effects on some. Of the 37 treatments evaluated 10.81% (n = 4) were considered scientificallybased, 35.14% (n = 13) were considered a promising practice, 48.65% (n = 18) had limited support for their use, and 5.40% (n = 2) were not recommended for practice with children with ASD. This leads to the question of how this objective classification of interventions compares to treatments children are actually receiving in public schools. Two recent studies incorporating web-based surveys explore treatments parents have tried for their children with ASD (Green et al. 2006; Meyers et al. 2005). These studies provide a picture of the services frequently utilized with this population. Green and colleagues received information from 552 families about 111 different treatments. On average, families were using seven treatments at the time they answered the survey, with one parent employing 47 treatments simultaneously. Parents reported trying an average of eight treatments in their past. Overall, speech therapy was the most common treatment (70% reported using). Visual schedules (43%), sensory integration (38%), applied behavior analysis (36%), and Social Stories TM (36%) completed the top five therapies families used. Meyers et al. found that parents reported using 4.3 therapies on average and had tried 6.5 therapies at some point in their children s treatment histories. The most common therapies reported in this study were social skills training (42%), positive behavior support and drug treatment (41% each), sensory integration therapy (37%), and the picture exchange communication system (PECS) and applied behavior analysis (32% each). Meyers and colleagues (2005) further investigated the use of therapies according to diagnoses given to children by professionals based on the Diagnostic and Statistical Manual IV-Text Revision (DSM IV-TR) criteria (American Psychiatric Association 2004). These authors found that children with a diagnosis of Autistic Disorder reported participating in 4.8 treatments at the time of the survey. Children with Asperger s Disorder and Pervasive Developmental Disorder-Not Otherwise Specified were reported to use fewer therapies, an average of 2.6 and 4.5 respectively. Children with Autistic Disorder also were reported to have tried more therapies in the past than children with the other two diagnoses (i.e., 7.1 vs. 4.8 and 6.6). Furthermore, Green et al. (2006) found that main effects of severity of symptoms and age were both significantly related to the total number of treatments used. Children with severe autism received more treatments than children with mild autism and Asperger s Disorder (8.7, 7.2, 4.5 respectively). Children ages 6 10 received more services than children who were younger than 6 years old, years old, and years old (8.1, 7.6, 6.7, and 4.8 respectively). Taken together, these two surveys indicate that children with ASD are receiving a wide number of treatments. Further, individual child characteristics may be a factor in determining the intervention program(s) parents choose. In the only study examining interventions utilized in public educational settings, Stahmer et al. (2005) used focus groups to investigate techniques employed in community early intervention programs in California. Even though most educators expressed a desire to provide evidence-based interventions, results indicated both researched and non-researched practices were being used. Additionally, when evidence-based programs were employed, significant modifications and adaptations were often reported. Perhaps most importantly, all providers highlighted a lack of adequate training and preparation for teachers and paraprofessionals as a critical concern. The current study was performed to identify the types of treatments, therapies, and interventions currently being utilized by teachers working with students with ASD in Georgia s public schools. The results will create a profile of commonly used strategies to determine whether specific classroom variables (i.e., classroom type, grade level) influence intervention selection. This information may assist research and teaching communities by identifying the types and frequency of use for treatments implemented with students with ASD that have been both demonstrated as effective and have yet to be validated in scientific literature. Basic teacher demographic information will provide information to pinpoint which segments of the education provider population have strengths and gaps in their treatment decisions. Therefore, training programs can better prepare educators at all levels for this growing population of students. Specific research questions were: (a) What are the demographic characteristics of the educators serving children with ASD in the public school systems throughout the State of Georgia?; (b) What classroom strategies are being used by Georgia public school teachers for students with ASD enrolled in their classes?; (c) Do strategies being used with students with ASD differ by classroom type and grade level?; and (d) Are the classroom strategies being used considered best practices for students with ASD? Methodology Survey Development The Autism Treatment Survey (ATS) consisted of a comprehensive list of interventions frequently used by teachers

3 J Autism Dev Disord (2008) 38: of children with ASD in educational practice. A web-based survey allowed for access to a large percentage of teachers and ease of participant response. The authors created the ATS by synthesizing an intervention review compiled previously by Green et al. (2006), the evidenced-based practice guide developed by Simpson et al. (2005), and a review of the National Research Council (2001) text. The final ATS consists of 43 items with forced choice responses. Sixty-nine percent (69%) of the strategies are found in the Simpson et al. compendium and the rest are derived from the other cited sources and review from experts, described in the next section. Simpson s group (2005) acknowledges that they are not intending to have an all inclusive list of possible treatments and interventions for children with ASD. Therefore considerations for inclusion and exclusion were derived from many sources. For convenience and comparison, the ATS items are divided into the same five categories used by Simpson et al.: (a) Interpersonal Relationships, (b) Skill-based, (c) Cognitive, (d) Physiological/Biological/Neurological, and (e) Other. On the ATS, each item is prefaced with the stem: Which strategy do you use the most frequently in your classroom? Teachers then make a choice from a drop down menu listing the relevant treatments for each given category. There were 5 for Interpersonal Relationships, 18 for Skill-based, 6 for Cognitive, 5 for Physiological/Biological/Neurological, and 5 for Other. In addition, teachers were able to select None as a response within each category. To support teacher clarity and promote a common definition of specific strategies, the survey included short descriptors and exemplars and non-exemplars for some of the interventions. For example, augmentative alternative communication (AAC) was defined as aided and unaided communication devices and symbol systems, excluding picture exchange communication system PECS. These descriptions were used for AAC, sensory integration (SI), assistive technology (AT), and Floor Time. The survey item was repeated three times in order for participants to respond for up to three treatments used within a given category. At the end of the survey, there is a place for addition of other treatments not mentioned in the drop down lists. Appendix A provides an example of the text of one survey item. Expert Review, Revisions, and Pilot Survey Once the initial survey was created, four experts in the field of autism treatment and research provided feedback on the constructs and format of the ATS. Once expert feedback was incorporated, but prior to sending out the initial invitation to participate in the ATS, the authors piloted the survey to ensure its validity and reliability. Participants in the pilot testing included teachers who were colleagues of the investigators and Georgia State University (GSU) students enrolled in a graduate-level autism class in the Department of Educational Psychology and Special Education. These volunteers were given access to the URL and password to respond to the ATS questionnaire. The pilot respondents provided additional feedback which was then incorporated into the ATS. The authors met to discuss the final list of recommendations for inclusion. After the second revision, the four experts had another opportunity to comment on the ATS prior to placing the survey online for data collection; all experts indicated that the survey was appropriate for this purpose. Through this validity process the ATS emerged with a variety of treatment choices stemming from literature and expert suggestion for inclusion. Participants Criteria for eligibility to participate in this study included (a) employment as a teacher in a public school system in Georgia at the time of the invitation to participate and (b) inclusion of students with ASD in the participating teacher s classroom. Potentially, all teachers in Georgia who work with children with ASD had access to this survey. However, the sample was limited to those teachers who received the survey URL link and password and subsequently responded. Participant Recruitment An describing the survey and providing the necessary access information was sent to 249 special education directors and autism consultants/autism specialists in 159 counties, representing all school districts in the State of Georgia. Upon receiving the , three county research offices did not give approval for the research to be conducted, reducing potential participants to teachers in 156 of the Georgia counties. In the s, administrators were asked to inform teachers of students with ASD about the survey and forward the URL link and password. In addition to county administrators, the participation was sent to the researchers colleagues who have contact with teachers serving children with ASD. Standard follow-up protocols were used to ensure participant response to the survey (Salant and Dillman 1994). Specifically, an advance notice was sent to all administrators informing them about the upcoming survey. One week later the invitation to participate was sent. Approximately one week after the invitation to participate was sent, a third was sent to remind the special

4 964 J Autism Dev Disord (2008) 38: education directors and autism consultants/autism specialists to forward the URL survey link and password to the appropriate individuals. Three weeks after the reminder, an was sent thanking those who had completed the survey and reminding the rest that the survey was still available. Protection of Human Subjects Research using the ATS was approved by the GSU Institutional Review Board (IRB) as well as by the IRB committees of three public school systems; the remaining systems did not require additional IRB submission. The potential participants were required to read an informed consent form prior to accessing the web-based survey. Documentation of consent was waived once participants clicked the I agree to participate button. The ability to download the survey indicated that participant consent had been provided. Potential participants who chose not to participate after reading the informed consent document clicked a button declining participation and the browser closed. Participants were free to withdraw from the survey at any point with no negative consequences. No identifiable data were collected as part of this research. Basic demographic data (e.g., gender, teacher certificate) were included to analyze the variables related to teacher demographic characteristics. Data Collection Data were collected via an Internet survey using web space provided by GSU at no cost to the researchers. All teachers in Georgia have access to and are required to use computers in their daily work, making this survey accessible to all members of the sample frame. Participants were able to access the web site at their leisure during the specified 3- month period of data collection. Once the potential participant clicked I agree to participate, the survey came up on the screen. The survey took between 30 and 60 min to complete, depending upon the participants length and type of experience with students with ASD as well as prior experience with web-based surveys. There was no direct interaction between participants and researchers unless requested by the participant. The web-based program imported the respondents data directly into Statistical Package for the Social Sciences (SPSS; Apache Software Foundation 2000) for analysis; thus no data editing occurred. Data were reduced as an aggregate based on the specific treatment subcategories used in the development of the ATS. To ensure data analysis were accurate each analysis was repeated for consistency. Results Number of Surveys Submitted During the 3-month data collection period, 234 surveys were received. Inspection of the demographic data enabled the researchers to determine whether respondents qualified for the study. Surveys in which an educator was not currently teaching children with ASD and surveys returned with no responses were excluded from the study. Almost 80% (n = 185) of the surveys were included in the data analysis. According the U.S. Department of Education (2006), there were 3,297 students with an Autism eligibility under IDEA in Georgia s public schools. The results of this study include information from teachers representing 226, or approximately 7%, of those students. Characteristics of Respondents Data collected with the ATS were analyzed for specific categories of responses. Respondents characteristics were analyzed for gender, educational level, years of overall teaching experience, years of experience teaching children with ASD, and current class type. Characteristics of the respondents are displayed in Table 1. Almost all respondents (98.92%) were female. Seventy-nine percent (79%) of respondents were special educators and 21% were general educators. Although the ATS sample had a higher percentage of Caucasians and females than found in Georgia s general teacher population, 77% and 81% respectively (Office of Student Achievement 2005), t-test analysis of ATS respondents compared to overall demographics of Georgia s teachers was non-significant, indicating that these respondents were representative of teachers throughout the state. Intervention and Treatment Strategies Used Frequency counts identified which of the 43 total strategies were most commonly being used as reported by study respondents. Totals were converted to percentages for all treatments used in the schools. The mean number of treatments was determined using standard descriptive statistics available in SPSS. In addition, strategies and treatments listed in the ATS were analyzed according to five intervention and treatment categories (Interpersonal Relationship, Skill-based, Cognitive, Physiological/ Biological/Neurological, and Other) based on Simpson and others (2005). Table 2 shows the percentage of reported overall use according to the broad intervention and treatment category. In addition, it displays the percentage of use

5 J Autism Dev Disord (2008) 38: Table 1 Characteristics of respondent teachers Respondent (n = 185) Classroom Type Collaborative 6.45 Combination 8.60 General Education Resource Self-Contained Other Not answered 1.08 Age M (Range) (22 59) SD 9.47 Highest Degree Earned (%) Bachelor s degree Master s degree Educational specialist degree 4.32 Doctoral degree 0.54 Not answered Overall Years of Teaching Experience M (Range) (1 35) SD 8.42 Years of Teaching Experience with Children with ASD M 4.95 (Range) (0 30) SD 5.06 Certification Category (%) Clear renewable Non-renewable professional 2.16 Non-renewable waiver 1.08 Performance-based renewable 2.70 Not answered Ethnicity (%) African American 6.52 American Indian 0.00 Asian 0.00 Caucasian Latino 1.09 Native Hawaiian 0.00 Other 5.43 Two or more races 2.17 Not answered 3.26 reported for each specific strategy within the broader the five categories. Responding teachers indicated that Skill-based strategies were the most likely to be employed in the public school setting. AT was the most frequently used Skillbased intervention with 22.12% of teachers reporting use assistive technology strategies. Visual schedules and structured teaching were the next likely Skill-based strategies to be utilized, at 15.38% and 14.42% respectively. Interpersonal Relationship strategies were reported as the second most frequent type of intervention strategy used accounting for 22.05% of teachers overall usage. In this category, was most frequently used (49.15%) followed by Floor Time (28.81%) and relational development intervention (RDI; 10.17%). The remaining categories were used with similar frequency, with Other strategies accounting for 11.79%; Physiological/Biological/Neurological accounting for 10.65%; and Cognitive strategies accounting for 8.37% of total use. Many teachers reported to base their classroom structure around the nationally-recognized models of TEACCH (3.78%) and Lovaas UCLA Young Autism Project (1.08%), although 7.03% used an unspecified combination of models in their classrooms. Due to the nature of the Internet survey, there is no documentation of the accuracy of implementation of the various programs found in these classrooms. In addition to treatment models and strategies, teachers also indicated that the children with ASD received other specialty services including: speech/language therapy, 37%, occupational therapy, 24.32% and physical therapy, 8.65%. Classroom Type and Grade Level Analyses Data were analyzed to determine whether either the type of classroom setting or the age of the student with ASD played a role in the specific strategy employed. Table 3 outlines the type of classroom setting and the specific Interpersonal Relationship, Skill-based, Cognitive, Physiological/Biological/Neurological, and Other strategies used in each. All types of classroom settings utilized some strategies, specifically, AT, and cognitive behavior modification. RDI, discrete trial, and auditory integration therapy were reported only by the classrooms led by general educators. Teachers in special education classrooms were the only ones to report using facilitated communication, visual schedules, power cards, and SI. As reported by responding educators, the top strategies used at each grade level are listed in Table 4. SI was the only strategy teachers reported using in each grade level (preschool through high school). Floor Time, Social Stories, and music therapy were reported as being used in preschool, elementary, and middle school settings, but not in high school settings: Social decision making was utilized only in high school classrooms. Preschool teachers were the only ones who did not report using PECS as a Skill-

6 966 J Autism Dev Disord (2008) 38: Table 2 Strategies reported in use by teacher and percentage of reported use in classrooms Category a Percentage of use of overall category Strategies used within category (%) Interpersonal Relationships (49.15%) Floor Time (28.81%) Relational Development Intervention (10.17%) Holding Therapy (8.47%) Pet/Animal Therapy (3.39%) Skill-based Assistive Technology (22.12%) Visual Schedules (15.38%) Structured Teaching (14.42%) Picture Exchange Communication System (11.54%) Discrete trial and verbal behavior (10.58% each) Assessments of Basic Language and Learning Skills and Incidental Teaching (8.65% each) Facilitated Communication (6.73%) Augmentative Alternative Communication (4.81%) Fast ForWord and Pivotal Response Training (2.88% each) Rapid Prompting Method (1.92%) Lindamood-Bell (0.96%) Azrin 24-h Toilet Training (0%) Joint Action Routines (0%) Naturalistic Language Paradigm (0%) Van Dijk Curricular Approach (0%) Cognitive 8.37 (32.89%) Social Stories TM (28.95%) Social Decision-Making (22.37%) Learning Experiences: An Alternative Program for Preschoolers and Parents (7.89%) Cartooning and Power Cards (3.95% each) Physiological/Biological/Neurological Sensory integration (92.86%) Auditory Integration Training and Bolles Sensory Learning (3.57% each) Irlen Lenses (0%) Neurofeedback/Biofeedback (0%) Other Music Therapy (45.16%) Art Therapy (29.03%) Integrated Movement Therapy (19.35%) Self-Injurious Behavior Inhibiting System (6.45%) Interactive Metronome (0%) a Categories are based on Simpson et al. (2005) based strategy, while middle school teachers were the only respondents who reported using RDI and structured teaching. Only elementary school teachers reported using AT, discrete trial, facilitated communication, Fast For- Word, Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP), and power cards. Best Practices To complete this analysis, strategies Georgia teachers reported using were coded according to Simpson et al. s (2005) categories (i.e., (a) scientifically based, (b) promising practice, (c) limited supporting information, (d) not

7 J Autism Dev Disord (2008) 38: Table 3 Top strategies being reported in use by classroom type Classroom Type a General Education Mixed Special Education Other Interpersonal Relationship Skill-based Cognitive Physiological/ Biological/ Neurological Floor Time Relational Development Intervention Assistive Technology Discrete Trial Picture Exchange Communication System Verbal Behavior Cartooning Social Stories Auditory Integration Training Assessments of Basic Language and Learning Skills Assistive Technology Verbal Behavior Cartooning Learning Experiences: An Alternative Program for Preschoolers and Parents Social Decision Making Floor Time Assistive Technology Facilitated Communication Picture Exchange Communication System Visual Schedules Power Cards Social Stories Sensory Integration Other Art Therapy Music Therapy Art therapy Music therapy Discrete Trial Fast ForWord Incidental Teaching Social Stories Sensory integration a General Education = instruction in general education setting including inclusion more than of the day; Mixed = collaborative or combination classrooms; Special Education = resource, self contained autism and other self-contained classrooms; Other = Any classroom model not listed previously recommended); strategies not rated by Simpson and others were coded as not rated. As presented in Table 5, less than one third (28.6%) of Georgia educators used any strategy that has been rated as evidence-based or as a promising practice for children with ASD. Specifically, 7.70% of the respondents reported the use of scientificallybased strategies; 20.90%, the use of promising practices; 27.90%, the use of strategies with limited support; 4.70%, the use of strategies that are not recommended. Thirty three and a half percent (33.5%) responded with the strategies that are not rated by Simpson and colleagues. Discussion Results of this study suggest that fewer than 10% of the strategies used with students with ASD in Georgia Public schools are based upon scientifically based practice. Of the top five strategies utilized in the state of Georgia (Gentle Teaching, SI, cognitive behavioral modification, AT, and Social Stories), none are scientifically based practices as identified by Simpson s group (2005). On a more encouraging note, four of the top five are categorized as promising practices, indicating an emerging body of empirical support. Controversial and unsupported treatments plague the field of autism, resulting in wasted time, energy, and funds. These strategies offer inadequate treatment for individuals with ASD and their families (Simpson et al. 2005). Overall, one-third of the treatments reported to be in use by responding teachers have limited support, suggesting a serious disconnect between the broadly accepted best practice guidelines and current reported classroom practice. Results from this survey support previous findings that many of the strategies used with students with ASD are not evidence based (Green 1999; Stahmer et al. 2005; Wilczynski 2006). Green s results revealed that parents were seeking a similar path in their treatment choices. The parents tended to utilize a combination of validated and invalidated treatments with their children. Surprisingly, almost 40% of the strategies reported as being used by teachers in Georgia public schools were not even mentioned in the recently published Simpson et al. (2005) compendium. This may suggest proliferation of strategies at a rate that exceeds opportunity for accurate chronicling in published literature and a willingness for educators to institute treatments before they have had an opportunity to be validated. Data analysis revealed that treatment selection varies depending upon the grade level and type of classroom placement (special education,

8 968 J Autism Dev Disord (2008) 38: Table 4 Top strategies being reported in use by grade level Grade level Preschool Elementary School Middle School High School Interpersonal Relationship Skill-based Floor Time Incidental Teaching Visual Schedules Floor Time Assessments of Basic Language and Learning Skills Assistive Technology Discrete Trial Facilitated Communication Fast ForWord Incidental Teaching Picture Exchange Communication System Cognitive Social Stories Cartooning Learning Experiences: An Alternative Program for Preschoolers and Parents Power Cards Social Stories Physiological/ Biological/ Neurological Floor Time Relational Development Intervention Picture Exchange Communication System Structured Teaching Verbal Behavior Visual Schedules Cartooning Social Stories Sensory Integration Sensory Integration Auditory Integration Training Sensory Integration Other Music Therapy Art Therapy Music Therapy Art Therapy Music Therapy Assessments of Basic Language and Learning Skills Picture Exchange Communication System Verbal Behavior Social Decision Making Sensory Integration general education, or mixed) for students with ASD. Yet, of the four scientifically based practices outlined by Simpson et al. (2005), only LEAP was designed to target preschool students with ASD. However, it was primarily utilized by these respondents in the elementary schools. In addition, of the four scientifically based practices, pivotal response training (PRT) and LEAP would be most appropriate for a general education or inclusive setting. While this sample did not report frequent use of PRT, LEAP is being implemented in inclusive settings. In addition, several general teachers reported using methodology which is generally not expected in the public school setting, such as auditory integration. This tactic would be difficult to implement in a general education classroom. Unfortunately, due to the nature of the Internet survey, there is no way of confirming the application of the strategy. Future research should identify the factors which contribute to these choices (e.g., state or county mandates, teacher experiences, teacher training programs). Nonetheless, it is clear that the primary determinant of the study respondents selection of teaching strategies is not best practice guidelines. Further, it appears that special educators are using some strategies deemed inappropriate for this student population. The results of this study indicate that there are clear differences in the type of strategy used by grade level and classroom type. Without clear best practice guidelines for children with ASD at different grade levels and classroom settings, teachers have little support for choosing which strategies to use with this population. Thus, educators are left to their own devices when determining which strategy to use. This often leaves them to make this decision based on variables unrelated to the scientific basis for particular strategies. In addition, it may be possible that the school systems are attempting to avoid problems such as litigation by allowing all treatments to be available to all students, rather than creating a curriculum of validated and empirically sound methodology. Limitations There were several limitations in this study. The first relates to a methodological problem. Six potential

9 J Autism Dev Disord (2008) 38: Table 5 Evidence-based rating a and percentage of strategies reported in use in public school classrooms (n = 185) Strategy Rating by Simpson et al. (2005) Percentage in use Limited Support Sensory Integration Promising Practice Promising Practice Assistive Technology Promising Practice Social Stories Promising Practice Floor Time Limited Support 9.19 Social Decision-Making Promising Practice 9.19 Visual Schedules 8.65 Structured Teaching (Treatment and Education of Autistic and Related Communication Handicapped Children TEACCH) Promising Practice 8.11 Music Therapy Limited Support 7.57 Picture Exchange Communication System Promising Practice 6.49 Discrete Trial Training Scientifically-based 5.95 Verbal Behavior 5.95 Assessments of Basic Language and Learning Skills 4.86 Incidental Teaching Promising Practice 4.86 Art Therapy Limited Support 4.86 Facilitated Communication Not Recommended 3.78 Relational Development Intervention Limited Support 3.24 Learning Experiences: An Alternative Program Scientifically-based 3.24 for Preschoolers and Parents Integrated Movement Therapy 3.24 Holding Therapy Not Recommended 2.70 Augmentative Alternative Communication Promising Practice 2.70 Fast ForWord Limited Support 1.62 Pivotal Response Training Scientifically-based 1.62 Cartooning Limited Support 1.62 Power Cards Limited Support 1.62 Rapid Prompting Method 1.08 Self-Injurious Behavior Inhibiting System 1.08 Pet/Animal Therapy Limited Support 0.54 Lindamood-Bell 0.54 Auditory Integration Training Limited Support 0.54 Bolles Sensory Learning 0.54 a Blank = Not rated by Simpson et al. (2005) respondents declined to participate and 39 potential respondents gave consent online and accessed the survey, but did not answer any questions. In the future, the option to view the survey online prior to making the decision to participate may minimize these types of response errors. A second methodological limitation relates to assuring a representative sample. As noted by Scheaffer et al. (2006), the use of web-based surveys has technical advantages for collecting data (e.g., shorter time frames), but researchers do not have full control over online survey distribution once the survey is launched. Another potential problem with online surveys is a higher non-response rate and participants ignoring invitations to participate. Both of these identified problems lead to the need to interpret the results of the current study with caution. As previously described, the ATS was distributed to representatives in each school district in Georgia so that they in turn could identify all current public school teachers of students with ASD. Therefore, by design, all teachers working with students with ASD could potentially complete the survey. However, three of the 249 county administrators in Georgia declined participation and 20

10 970 J Autism Dev Disord (2008) 38: s were returned as undeliverable, minimizing the representative nature of the sample. It is impossible to determine the exact number of teachers in Georgia currently working with students with ASD. At present there are 103,105 prek-12 grade teachers in the state of Georgia (Office of Student Achievement 2005). However, there is no way to determine how many of these teachers work with students with ASD, so there is no way to determine the response rate represented by 234 returned surveys. Teachers in at least 30 different districts responded to the ATS, representing all geographic regions of Georgia, including urban, suburban, and rural areas, rendering the results representative of the state. Approximately 50% of the teachers did not identify their county, making it impossible to be certain of the number of counties represented in this sample. It is possible that receiving the survey link from a county representative resulted in respondents feeling uncomfortable to fully complete the demographic section of the survey. An alternative distribution design would have been to access teachers through Georgia educational websites, thereby minimizing the county role in distribution; however, not all teachers would have been able to access the survey, negatively affecting the sample s representative nature. The online survey methodology created the potential for the survey to be accessible to a large number of participants. Although efforts were undertaken to promote a common understanding of the strategies queried, the researchers could not control for respondents interpretations. Similarly, results presented here are based upon teacher self report. These researchers did not verify the accuracy of teacher reports to determine if teachers were actually using strategies identified. In addition, there is no confirmation that the programs and protocols of the treatments were modified in the classrooms of the respondents. In order to better understand teacher practices, further research should include observational data in addition to teacher self report. Future Research The findings of this study suggest that researchers, teacher trainers, and institutions of higher education must provide more instruction and guidance to practitioners in the field with regard to best practices for teaching students with ASD. In addition, further research should continue to document the types of strategies used in different settings serving students with ASD, and refine the definitions of scientifically based and promising instructional approaches for working with the population. Further, those in leadership positions in the public and private schools should receive training regarding best practices for teaching students with ASD. Academic leaders are involved in curriculum selection and teacher recruitment, employment, and evaluation, and are in positions to ensure that teachers use the most effective strategies to serve this difficult population and avoid the use of strategies that are not recommended or have limited support. Finally, researchers may want to investigate perceived efficacy associated with various interventions. This information, when compared to scientifically verified research results, may help to determine better studies for the future. Acknowledgments We would like to extend a sincere thank you to Glen Dunlap, University of South Florida; Cathy Lord, University of Michigan; Richard Simpson, University of Kansas; and Aubyn Stahmer, University of California at San Diego, for their generous input and feedback into the construction of the Autism Treatment Survey. We also thank William Curlette, Walter Greene, Randy Jones, and Toni Marcovecchio for their assistance with the first draft of the Autism Treatment Survey and online technical support. Thank you to all of the teachers who participated in the pilot project. We are grateful to all the teachers in the State of Georgia who completed the online survey; without them these data could not have been collected. Finally, thank you to the reviewers of the earlier draft of this report. Your feedback was beneficial in improving clarity and offering additional topics for inclusion. For a copy of the Autism Treatment Survey contact K. L. Hess. Appendix A: Example of ATS Item Interpersonal Relationship Intervention 1. Which strategy do you use the most frequently in your classroom?* none Floor Time (Greenspan; Developmental Individual Difference Relationship Based Model) Holding Therapy Pet/animal Therapy RDI (Relational Development Intervention) 2. With how many students do you use this strategy? The value must be between 1 and 20, inclusive. 3. How were you trained in this strategy? Choose the answer that has contributed the most substantially to your use of this technique.** Teacher Preparation Program Half-day Workshop Full Day Workshop Program Developer Local School Inservice Peer Teacher/Therapist Hands-On/Practical Experience Self-Taught Parent Instruction

11 J Autism Dev Disord (2008) 38: County School System Inservice None *This question is repeated 2 more times so that the participant may list Secondary Treatments and Other Treatments **Information regarding these data will be reported in a follow up article. References American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Apache Software Foundation. (2000). SPSS for Windows, version Chicago, IL: Author. Green, G. (1999). Science and ethics in early intervention for autism. In P. M. Ghezzi, W. L. Williams, & J. E. Carr (Eds.), Autism: Behavior analytic perspectives. Reno, NV: Context Press. Green, V. A., Pituch, K. A., Itchon, J., Choi, A., O Reilly, M., & Sigafoos, J. (2006). Internet survey of treatments used by parents of children with autism. Research in Developmental Disabilities, 27, Heflin, L. J., & Simpson, R. L. (1998). Interventions for children and youth with autism: Prudent choices in a world of exaggerated claims and empty promises. Part I: Intervention and treatment option review. Focus on Autism and Other Developmental Disabilities, 13, Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C et.seq.. Meyers, B. J., Goin-Kochel, R. P., & Mackintosh, V. H. (2005, April). Therapies for children with autism spectrum disorders: How many are children using? Poster presented at the biennial meeting of the Society for Research in Child Development, Atlanta, GA. National Research Council. (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press. No Child Left Behind Act of 2001, 20 U.S.C et.seq.. Office of Student Achievement, The State of Georgia. (2005) state of Georgia K-12: Report card for state of Georgia. Atlanta, GA: Author. Salant, P., & Dillman, D. A. (Eds.). (1994). How to conduct your own survey (pp ). New York: John Wiley & Sons. Scheaffer, R. L., Mendenhall, W., III, & Ott, R. L. (2006). Elementary survey sampling. Belmont: Thomson Higher Education. Simpson, R. L., de Boer-Ott, S. R., Griswold, D. E., Myles, B. S., Byrd, S. E., Ganz, J. B., et al. (2005). Autism spectrum disorders: Interventions and treatments for children and youth. Thousand Oaks, CA: Corwin Press. Stahmer, A. C., Collings, N. M., & Palinkas, L. A. (2005). Early intervention practices for children with autism: Descriptions from community providers. Focus on Autism and Other Developmental Disabilities, 20, U.S. Department of Education, Office of Special Education, Rehabilitative Services, Office of Special Education Programs. (2006). Twenty-sixth annual (2004) report to Congress on the implementation of the Individuals with Disabilities Education Act (Vol. 2). Washington, DC: Author. Wilczynski, S. M. (2006). Evidence-based practice and autism spectrum disorders. The ABA Newsletter, 29(3), Yeargin-Allsopp, M., Rice, C., Karapurkar, T., Doernberg, N., Boyle, C., & Murphy, C. (2003). Prevalence of autism in a US metropolitan area. Journal of the American Medical Association, 289,