A synthesis of six related TEACCH-based outcome studies for Autism
Spectrum Disorders (ASD)
Paul Probst,
Department of Psychology, University of Hamburg
Symposium paper presented at the XXX International Congress of Psychology, Capetown,
South-Africa, 22-27 July, 2012
[Symposium
Symposium "Evidenced-based
"Evidenced-based interventions
interventions for
for Autism
Autism Spectrum
Spectrum Disorders
Disorders (ASD):
(ASD):
International
International concepts
concepts and
and outcomes",
outcomes (Convener:
Convener: Paul
Paul Probst)
Probst]
update: 28.11.2012,
[email protected] , Homepage: http://www1.unihamburg.de/Paul.Probst/ Email: [email protected]
THEORETICAL BACKGROUND
1. State-of-the-art autism concept
 Autism-Spectrum Disorders (DSM 5/ ICD-11-Draft, 2010)
 Deficits in Social Communication and Interaction
 Restricted Patterns of Behavior, Interests, and Activities
 Onset in early childhood (1-3 yr.)
 Etiology: Neurodevelopmental disorder with strong genetic
influencing early brain development;
component
 Prevalence: total: 0.4 % [conservative estimation]
 Tertiary prevention: i. e. preventing disability progression and associated suffering
by alleviating behavioral symptoms and strengthening compensatory abilities;
2. Caregiver-Stress-Coping- Tertiary Prevention Model (adapted from Pakenham
et al., 2005; Antonovsky, 1993: "Sense of Coherence"/ SOC)
INDIVIDUAL with ASD:
TERTIARY INTERVENTION:
* Enhancing abilities
 Individual (ASD)-Focused (Need for SOC)
* Reducing obstruct. deficits
 Caregiver-Focused (Need for SOC )
DEMANDS &
STRESSORS
Caregiver
Adaptive
RESSOURCES
APPRAISAL
of Stressors
Caregiver
COPING:
Problem-/
EmotionFocused
Family/ Classroom/
Group home/
Workshop/
FUNCTIONING
3. CONCEPT of TEACCH
 Structured Teaching, & Educational Guiding
 Visually structuring (e. g. visual schedules, choice boards)
 Clear verbal and nonverbal directions/ instructions
 Prompting and behavior shaping
 Consequence-based interventions (natural reinforcements, mild
punishments, such as strict "No")
 Social-communicative, self-management and daily living skills training
 Professional-Caregiver Cooperation
 International Program Dissemination professional training;
AIMS OF THE SYNOPSIS STUDY:
Can key components of the TEACCH program be generalized to the
situation of individuals with ASD in German-speaking countries in terms
of effectiveness and social acceptance
METHODS
 Participants: children, adolescents and adults with ASD; parents teachers and educators
als cargivers
 Instruments: behavioral observation, questionnaires, interviews
 Data analysis : quantitative and qualitative procedures
RESULTS: Study 1
- Topic
- Design
Single subject social communication training study in a residential
home. - Pre (baseline)-Post-design,
Participants
- 7-yr-old girl (L) with ASD and severe intellectual disability, averbal,
self-injuring behaviors (PICA);
- TEACCH-trained therapist (master's student)
(1) Enhancement of social communication; (2) Reduction of
challenging behavior; (3) teaching a valid autism disability concept to
caregivers
(1) 12-session-communication training using structured teaching
methods (schedule, choice-board management; (2) oral discussions
with caregivers
(1) video-based systematic behavior observation;
(2) Behavior Problems Inventory (BPI);
(3) qualitative interview data analysis
Aims of
intervention
Intervention
methods
Outcome
measurement
Study 1-Figure 1
Pictorial Schedule
for L
1= Foto & Name-Card for L
2= Go-to-your-WorkPlace-Card
3= Recreation-Card=
"Go to your Choice-Board!"
Study 1-Figure 2
Two ElementPictorial Schedule
for L [see bottom
line]
* Listening-to-Favourite-Music-Card;
* Flapping-Glove-Card (favourite activity)
RESULTS: Study 1-continued: OUTCOMES
Communication
training
Improved autonomous and spontaneous management of picture
schedule and choiceboard, compared with baseline
Challenging
behaviors (PrePost)
(1) Reduced problems in BPI-Full-Scale
(2) Reduction in BPI-item "Pica" from "daily" to " monthly ";
(3) Reduction in BPI-Item "Biting/ Cruel" from "weekly" to
"monthly"
Positive evaluation of the 12-session training intervention as
helpful and relieving: (a) child less aggressive, more predictable
and communicative; (b) better understanding of functional
aspects of challenging behaviors
Social acceptance
by caregivers
RESULTS: Study 2
-Topic
- Design
Participants
Aims of
intervention
Intervention
methods
Outcome
measurement
Outcomes of a 3 -year TEACCH-based intervention in a residentialvocational setting
Pre-Post [retrospective]-design
- Three male adults with ADS and intellectual disability;
- TEACCH-trained staff supervisor and educators
(1) Reduction of disruptive behaviors and enhancement of social
communication abilities; (2); social acceptance of the TEACCH approach
by residential-vocational staff
(1) Implementation of TEACCH components (e. g. schedules, work
systems) for individals with ASD; (2) Education, training & supervision of
staff members
(1) Matson Evaluation of Social Skills [...] (MESSIER)
(2) Developmental Behaviour Checklist f. Adults (DBC-A
(3) BPI, (4) TEACCH evaluation caregiver interview
Study 2: Figure 1: Individualized Work system for person T:
T follows a Left-to-Right Routine: (1) Taking working
materials from the shell on the left (organized in a TopDown-Order); (2) carrying out the task (e. g. matching
picture cards) on the desk; (3) putting the completed task to
the box to his right
Study 2: Figure 2: Typical matching task for T
RESULTS: Study 2-continued: OUTCOMES
Disruptive and
Challenging
behaviors (PrePost)
(1)
DBC-A-Disruptive: significant decrease for all three
individuals: M-RCI (Reliable Change Index) = 2.43; (p <0.05)
Evaluation by
caregivers
Overall, positive evaluation: (a) report enhanced communication
between caregivers and clients with ASD; (b) more independence
and autonomy of clients; (c) less aggressive beahviors in T.
(d) criticism: possibility of reduced flexibility
(2)
DBC-A-Total-Problem-Behavior: significant decrease (MRCI= 2,55);
RESULTS: Study 3
- Topic
- Design
Outcomes of education and skills group parent training for ASD
Pre-3-mo-Follow-up-design
Participants
(1) 24 parents (83% mothers) of 23 children with ASD (M-age= 8.9);
trainer and assistant trainer with TEACCH /ABA expertise
Aims of
intervention
(1) Teaching an adequate concept of ASD ; (2) Enhancing parents'
emotional and social experiences by parent-to-parent communication;
(3) Teaching structured educational strategies & skills
Intervention
methods
(1) 3-session small group training (in total 24 h); teaching methods
included lectures, group discussion, video and in-vivo modelling; role
play, assignment of homework;
Outcome
measures
(1) 23-item-Parent Evaluation of Training Effects on Daily Family Life
Questionnaire; (2) Home Diary Experience Questionnaire (Follow-up)
RESULTS: Study 3-continued-a: Figure 1
Results of the follow-up "Parent Evaluation of Training Effects on Daily Family Life
Questionnaire"
100%
97%
90% 86%
84%
80%
76%
74%
68% 72%
70%
60%
50%
40%
30%
20%
10%
0%
m
ea
tt
ul
or lpf
pp he
su rs
to he fu l
er
ac elp
sf
te
h
an as
l
ng
Tr
s
ni l pfu
nt
ai
e
re
tr
e
th
Pa cal
at
ep
ti
nc cli m
ac
co
Pr
y
l
th
i
m
al
m
is
fa
he
ut
A
n t ill s
ed
e
ov ar
sk
P
pr
al
Im
nt
ed
ov are
p
pr
Im ed
ov
pr
Im
Effects of parent group training on family life
Note: The y-coordinate
describes the percentage
of parents evaluating the
effects of the parent
group training as
"moderately" or "strongly
positive" (with scores of
2 or 3 on the 3-point
Likert scale); the xcoordinate includes seven
categories of reported
effects on daily family life
RESULTS: Study 3-continued-b: OUTCOMES
Parent Evaluation
of Traing Effects
Questionnaire
Home Diary
Experience
Questionnaire
The great majority of parents (about 70-90%) report
 improved parental skills in daily family life
 improved mental health of parents
 improved family climate
 positive effects of exchanging experiences with other parents
(parents-as-teachers concept)
 experienced helpfullness of both theoretical (autism disability
concept) and practical parent training components
 beneficial transfer of training elements to child support team
12 of 16 responding parents (75%) reported one or more
implementation of structured teaching methods ( picture
schedules, physical structure, task organization)
RESULTS: Study 4
- Topic
- Design
-Outcomes
of a TEACCH-based teacher training program for ASD
-- Pre-Post/ Follow-up design
Participants
- 10 special school teachers teaching students with intellectual disabilities and
ASD in a contained classroom setting
- 10 special school students with ASD, mean age = 10 yrs.
Aims of
intervention
-Child-related
effects: reduction of child behavioral symptoms in classroom
- Teacher-related effects: (a) Reduction of teachers' stress level; (b)
Implementing structured learning strategies in classroom
Three half-day teacher group training plus individualized teacher support in
classroom (average amount of support: 3h). Training was carried out within two
small group settings
- Classroom Child Behavioral Symptom Questionnaire; School Situation Q.
Outcome
measurement (Barkley, 1987); Classroom Teachers' Stress Reaction Q.; Implementing
Structured Learning Strategies in Every School Life Q.
Intervention
RESULTS: Study 4 continued-a: Figure 1
48-Item-Classroom Child Behavioral Symptom Questionnaire: Pre-Post outcomes:
mean overall score
106
105
104
103
102
101
100
99
98
97
Pre
Post
Classroom Child Behavioral
Symptom Scale
Pre-Post effect size d = 0.66
T- test for repeated
measures, p<0.05
RESULTS: Study 4 continued-b: Table 1
48-Item-Classroom Child Behavioral Symptom Questionnaire: Pre-Post outcomes on item
level
Behavioral Symptoms
Pre-Post effect sizes (d) [ttest]
“Child does not do as he or she is told and does not
accept rules and respect limits"
1.28 [p<0.01]
“ ... has little motivation to find out or do something
new "
0.69 [p<0.05]
“ ... plays with light switches"
0.63 [p= 0.05]
RESULTS: Study 4 continued-c: Figure 2
16-Item School Situation Questionnaire (SSQ, Barkley, 1987): Overall Intensity score
[5-point Likert scales: 1= "situation (e.g., "group work", "gym" or "toilet")= not
problematic", 5= "... is highly problematic"]
Effect size d= 0.54, t-test:
p= 0.10, (=5!)
3
2,5
2
Pre
Post
1,5
1
0,5
0
School Situation Questionnaire
RESULTS: Study 4 continued-d: Figure 3
48-Item-Classroom Teachers' Stress Reaction Questionnaire: Pre-Post-Outcomes: M-overallscore
98
96
94
92
90
Pre
Post
88
86
84
82
Classroom Teachers' Stress Reaction
Scale
Pre-Post effect size d = 0.67 [ttest, p<0.05]
RESULTS: Study 4 continued-e: Table 2
48-Item-Classroom Classroom Teachers' Stress Reaction Questionnaire: Pre-Post outcomes
Teacher stress reactions related to behavioral
symptoms
Pre-Post effect sizes (d) [t-test]
“Child does not do as he or she is told and does not
accept rules and respect limits"
0.75 [p<0.05]
“ ... requires a teacher only for him- or herself during 0.63 [p= 0.05]
class"
“ ... does not show any interest for the world around
him or her"
0.63 [p= 0.05]
RESULTS: Study 4 continued-f: Figure 4
Implementing Structured Learning Strategies in Everyday School Life Questionnaire: Outcomes
Semi-structured questionnaire
with open-ended response
sections
Results:
 9 of 10 teachers applied ≥ 1 structured
learning strategy [over period of > 2
months]
 M= 1.8 strategies [SD= 1.5]
RESULTS: Study 5
- Topic
- Design
-Outcomes
Participants
-
Aims of
intervention
Social- Comm.
Intervention
of a TEACCH-based social communication enhancement
intervention for individuals with ASD
-- Descriptive-observational study
3 individuals with ASD and Intellectual Disability (2 boys, both aged 12.; 1
woman, aged 25); - 3 student training facilitators (1 B.Sc.-level/Psychol., 2
BA-level/ Ed.); - 3 parents (mothers) ; - program supervisor (PP)
-Enhancing social-communicative functioning during programmed play
activities
-- Social acceptance of the program's goals, methods and effects by parents
Comprising 21 centre-based weekly one-hour sessions including both small
group and one-to-one settings. :
Component 1: Using Structured Teaching (e.g. visually structuring the
individuals environment, such as delivering schedules)
RESULTS: Study 5-continued-a
SocialCommunicative
Intervention
Component 2: Using play activities including
 closed-ended functional play (e. g. puzzles);
 open-ended functional play (e.g. playing a rhythm instrument);
 closed-ended cooperative play (e.g. Picture Lotto)
 open-ended cooperative play (e.g. improvising in playing instrument)
 symbolic play (e.g. talking with toy animals)
Parent-professional
discussion group
Comprising 3 two-hour sessions with parents, facilitators and program
supervisor. Activities included
 Presentation of the program in terms of aims and methods;
 Exchange of autism-related information and experiences;
 Presentation of selected video sequences showing childrens' activities
during program followed by discussion on practical applicability of
Structured Teaching and some play activities
RESULTS: Study 5-continued-b: Figure 1
Example of delivery of "visually structuring":
picture schedule for S. [woman with ASD and
severe intellectual disability, aged 25]
Note: The picture schedule, attached in the small group room is to be followed
vertically from top to bottom. The schedule includes: (1) name card and (2) photo
indicating the participant S of this schedule; (3) a (coloured) card containing table and chair
symbolizing a request for movement: "Go with your facilitator to the one-to-one-room"; (4),
(5) and (6) three cards in the colours of red, green and blue (shown as grey/white, white,
grey) indicating three different play activities to be performed together with her facilitator. S
finds the play materials in three boxes on which corresponding and identical coloured
symbol cards have been attached; (7) the next (yellow) card with the smiley symbol directs S
to a box containing her favourite play activities from which she can select one; (8) the last
card functions as a directive for movement ("transit card") and tells S to go to the small
group room and participate in musical activities there (singing popular songs accompanied
by guitar). The corresponding identical card is attached on the outside of the group room
door. (9) The movable arrow indicates what play task (4 to 7) is now active.;
RESULTS: Study 5-continued-d
Outcome measures


Systematic Child behavioral observations (based on videotaped
therapy sessions; using "partial interval time-sampling method") for
4 variables: Cooperative Behavior (including, for example,
behavioral criteria such as "Participant follows directions",
"participates in social routines and games"; "acts together with
another person with sharing common focus"); (2) Non-Cooperative
Behavior (e.g. "shows challenging behavior"); (3) Spontaneous
Communication ("initiates communicative situation by verbal
expression or nonverbal expression, such as taking hands of
facilitator); (4) Responsive Communication ("reacts to another
person verbally or nonverbally")
Parent Program Evaluation Questionnaire (adapted from
Mattejat & Remschmidt, 1998):
RESULTS: Study 5-continued-c: Figure 2
Mean percentage of Social-Communicative Behaviours
80,00%
70,00%
60,00%
50,00%
40,00%
30,00%
20,00%
10,00%
0,00%
small group
one-to-one
R
C
om
.
om
.
m
B
p.
.
ns
.C
nt
po
es
o
Sp
.
eh
oo
B
-C
on
p.
oo
N
C
m
.
Note: Percentage
(%) of 15-second
observation
intervals in which
participants
showed
(1) Cooperative,
(2) NonCooperative
Behaviours ;
(3) Spontaneous
(Verbal / V or
Nonverbal/ NV)
Communication ;
(4) Responsive (V
or NV )
Communication
RESULTS: Study 5-continued-d: Table 1
Results of the 11-item Parent Program Evaluation Questionnaire [selected
items], 4-point Likert scale [0= I strongly disagree, 4= I totally agree]
Item
M (SD)
(1) Overall , the program was helpful for my child
2.7 (.58)
(2) The facilitator who implemented the program expressed empathy for
the problems of my daughter/ son and the resulting demands on the
family
(8) I felt sufficiently involved in the program
4.0 (.00)
(10) I have got a deeper understanding of my child's abilities and deficits
through contacts with the facilitatot by discussion and watching video
samples of program sessions
2.7 (.58)
(11) Overall, I am satisfied with the program
3.7 (.58)
4.0 (.00)
RESULTS: Study 5-continued-e
Child-related
Outcomes
Parent-related
outcomes
-Overall,
the results (see Figure 2) suggest that beneficial settings were
established in the social communication enhancement program which
enabled the individuals with autism to show more social-cooperative and
communicative behaviours than they usually show within the family, and thus
substantially exceeding the parent-reported informal baseline.
- All three clients showed a wide range of social communicative behaviours,
participating (a) in functional, social and symbolic play of different kind and
level, and (b) in social routines of following schedules and visually
structured learning system (cf. Figure 1).
Parent-Professional Relationship quality was very positive, with a mean of
3.9, the Effectiveness of the program intervention was also evaluated
positively, but to a lesser extent (M = 2.6). The Global evaluation of the
program was clearly positive, with a mean of 2.9. The high program
satisfaction is reflected by the mean rating of 3.7 (item 11).
RESULTS: Study 6
- Topic
- Design
- Outcomes of a TEACCH-based child-parent in-home training
- Descriptive Pre-Post-Follow-up single subject study
Participants
5-yr-old boy with ASD, averbal, normal visuospatial intelligence
Aims of
intervention
(1) Enhancement of functional communication; (2) Reduction of
challenging behavior (aggression, temper tantrums; (3) Promotion of
elementary verbal skills (naming); (4) parent education & training; (5)
teacher support; (5) broad-spectrum parent support
(1) 20 in-home child and parent sessions (à 3h= 60h) over 22 mo; (2)
Broad-spectrum parent counselling (10h); (3) classroom visits (15h); (4)
interactions with community agencies (10h, e. g. therapist expert reports);
Video-based Behavioral observations; behavioral observation inventories,
questionnaires, standardized tests (Peabody Picture Vocabulary Test)
Multimodal
interventions
Outcome
measurement
RESULTS: Study 6-continued-a: OUTCOMES
Child
Parent
Teacher
(1) Improved functional communication (nonverbal and verbal, e.g.
requesting, rejecting); (2) acquisition of low-level verbal abilities (e. g.
naming, expression of 2-3-word phrases, enhanced verbal comprehension);
(3) improved behavioral functioning (less aggressive, less vocal stereotypies,
more on-task behavior in preacademic and play activities); (4) successful
transition from preschool to primary school, attending an inclusive class
with full-time aide;
(1) Implementation of structured teaching in daily life; (2) enhanced quality
of the parental autism disability concept; (3) positive evaluation of in-home
training
(1) Implementation of structured teaching in classroom; (2) enhanced
quality of the teacher autism disability concept
Community (1) Provision of social support (e. g. social welfare benefits); (2) assisting
parents in school placement and transition issues; (3) allocation of
classroom aide ;
CONCLUSIONS
 Overall, the results of all six studies indicate evidence for positive outcomes of
TEACCH-based interventions across multiple individuals, ages, settings and
outcome measures
 Limitations: (1) threats to internal validity (sample size, lack of control groups);
(2) threats to external validity (selective samples, single-study)
 Overall, TEACCH-based interventions: (1) lead to clinically and
educationally relevant effects across different settings; (2) show sufficient social
validity across different caregivers; (3) support the assumption that they are also
practicable in German-speaking countries, and compatible with local health care
interventions
 Further research is urgently needed, in particular for controlled replication studies
Thank you for your attention!
Acknowledgement to Collaborators:
 Tobias Leppert, Ph.D; M.S; Florian Jung, M.S; Jan
Email: [email protected]
Micheel, M.S; Iain Glen, M.S; Petra Steinborn, M.Ed.
For related publications see:
 Petia Gewohn, M.S; Christoph Faecks, M.S; Stefanie
Brakemeier, M.S; Marzena Radzij, M.S; Julia Spreitz, MS;
 Probst & Leppert (2008): Brief report: Outcomes of a
teacher training program [...]. Journal of Autism &
Dev.elopmental Disorders, 38, 1791-1796.
 Parents, teachers, and educators (participants)
 Children, adolescents and adults with ASD (participants)
 Probst, Jung, Micheel & Glen (2010). Tertiary
prevention [...]. Life Span and Disability, 13 (2), 129-167
 Probst & Glen (2011). TEACCH-based interventions
for families [...]. Life Span & Disability, 14 (2), 111-138.
See Homepage: http://www1.unihamburg.de/Paul.Probst/ for download