Thoughtful consumers should consider that just as we ask questions to seek quantitative evidence, we should also ask questions to seek qualitative evidence: Is the targeted skill useful? Is it necessary? Is it ethical? Is the individual simply memorizing the skill with little or no understanding of how it connects to other skills and competencies? Does it relate to the core challenges of this individual? Does it promote a better quality of life? Does it move the individual towards independence? If we can't answer these questions in the affirmative for any/all interventions we use, then it's time to reevaluate.
Evidence-Based Practice (EBP) is a term that is now commonplace amongst educators, therapeutic professionals, and parents. Rightly so - we all want evidence for our actions! But what exactly does the phrase "evidence-based" mean in the context of our practices? Where did it come from and how does it relate to the Social Thinking® methodology?
|Administrator:||"I hear your students talking about Detectives and Superheroes. What exactly are you teaching?"
|Teacher:||"I'm using the Superflex™ curriculum. It's part of Social Thinking and fits in our school-wide Positive Behavioral Intervention and Supports initiative."
|Administrator:||"I can see the kids love it."
|Teacher:||"Yeah, they are learning self-awareness/control, and perspective-taking-all part of our commitment to Social Emotional Learning. I'm also able to link my teaching to the academic standards."
|Administrator:||"Hmmm....PBIS, Social Emotional Learning and standards are all great, but you know we only use Evidence-Based Practices in our district. Is this an EBP? If so, where's the evidence?"
The Evidence Dilemma
In medicine, evidence has long been considered critical for determining whether a drug or therapy will help or hurt a patient. In the early '70s, having evidence to support the effectiveness and efficiency of medical treatments gained more attention as a way to improve health care management. This emphasis on evidence was referred to as: empirically validated treatment (EVT) or empirically supported treatment (EST) and included a rather rigid definition of what needed to be done to prove an intervention worked or not. Typically the desired evidence came from conventional research approaches including clinical trials, which by and large, were administered under controlled laboratory conditions. This all made a lot of sense in the context of wanting clear evidence that would ultimately improve the delivery of effective and efficient healthcare. When no research or data were available, investigators were urged to conduct more scientific inquiries, particularly in the form of clinical trials. Thus, according to the traditional medical model, "evidence" meant empirical data from controlled studies.
The Other Side of the Evidence Coin
In a parallel universe around the same time, psychologists and those practicing in mental health and working with complex family dynamics believed the conventional medical model of evidence should be broadened. They argued that it was critical to consider the values of the client/family and the expertise of the therapist. They rallied to make a change in the definition of what is considered evidence.
But, it wasn't until 2006 that the American Psychological Association (APA) took a stand and defined evidence to not only include the best available external research, but also value patient/client/family characteristics as well as clinician expertise and internal data. This brilliant three-pronged description, based on the original work from Sackett (1996), is now considered to be the gold standard definition of Evidence-Based Practice (EBP) for the APA, the American Speech-Language-Hearing Association (ASHA), Council for Exceptional Children (CEC), and a host of others.
This definition embodies the perspective of Social Thinking® methodology (ST) as an Evidence-Based Practice. ST utilizes the available research as a guidepost to support the foundation of our methodology. ST values the role of patients/clients/families. Finally, ST encourages clinician training and ongoing documentation of client change. The methodology, however, would not be considered an empirically validated treatment at this time. And, while we are actively working to generate additional empirical support for the multitude of strategies and frameworks, it can (and will) take many years for the research base to build.
Words Matter: EBP ≠ EVT
Consider this: An Evidence-Based Practice (EBP) may (or may not) be an Empirically Validated Treatment (EVT).
An EVT may (or may not) meet the criteria for EBP, but some EBPs are EVTs.
Confused yet? Bottom line: They are not the same thing. One does not automatically envelop the other and the bi-directionality is not automatic. Unfortunately, some in the professional community use the terms interchangeably. Demands are made that only EBPs are allowed with certain clients, but in truth they are demanding that everyone use EVT without a clear understanding of the difference.
Quantity Matters, But Quality Matters Too
We wholeheartedly support the notion that data is a critical component for any intervention. We also promote-with as much gusto-that interventions should be meaningful to the clients and families we serve. We've never (and will never) state that Social Thinking is right for everyone or that it's a quick fix. We actually don't believe, nor would we ever state, that our clients or families need "fixing." Rather the goal of Social Thinking is to empower each person to be as independent and self-aware as possible, and gain competencies based on his or her level and style of learning. We don't state that we cure or that our strategies and models "work." Instead, we believe in outcomes, outcome data, and each therapist's ability to measure and use common sense around the importance of the individual as a whole.
A quick note on the term OUTCOME: In a nutshell, outcomes (for the purposes here) refer to what happens as a result of the intervention. Sometimes the outcome data are reported quantitatively (e.g., percent correct) and sometimes qualitatively (e.g., quality of life, sense of self, social relationships). Plenty of studies report outcome data for specific skills in specific populations. For instance, teaching skill acquisition via discrete trials has a tremendous database for young children with autism and is considered an EVT. But consider that skill acquisition may not equate to the ability to generalize that skill outside of the treatment setting. Yes, skills are important but what good are skills without the ability to use them in a meaningful way in real life?
What about Social Thinking® - Where's the Evidence?
Critics or thoughtful consumers asking, "where's the evidence" are welcome. In fact, any approach or intervention that touts, "we are the only approach you can use for those on the autism spectrum" (or ADHD or Social Communication Disorders or any other diagnosis for that matter) should set off alarms in all of us. There is no "one size fits all" social intervention program that has empirical validation for all individuals across all learning styles and learning abilities (Wong et. al, 2014). In fact, the wise consumer will want to take a deeper look at the motivation of individuals who make blanket assertions or threats and see through claims that their approach is the "right" or only approach for all. Doesn't common sense dictate that individual variation in learning styles and temperaments would mean that we need many and varied approaches from many and varied professionals? Case in point: the US Department of Education's recent letter to schools admonishing exclusionary practices related to ABA therapists and speech/language pathologists.
So, where is the evidence related to Social Thinking? First of all, Social Thinking is not a single treatment tool, so the question about evidence needs to change to relate to the specific component of the methodology. Critical to note is that Social Thinking is not a set of behaviors that you teach. It is not a step-by-step "cookbook", nor is it one single program or approach. Social Thinking is a cognitive-based methodology that focuses on the dynamic and synergistic nature of social interpretation and social communication skills, both of which require social problem solving. The methodology is developmental, utilizing aspects of empirically-supported behavioral and cognitive behavioral principles, as well as stakeholder input as a way to translate evidence-based concepts into conceptual frameworks, strategy-based frameworks, curricula, activities, and motivational tools (e.g., Superflex, games, etc.). Sorry - we know that definition is a real mouthful.
Consider that the following approaches are known to be EBP and EVT for specific ages: modeling, naturalistic intervention, peer-mediated intervention, self-management, social skills training, social narratives, reinforcement, and visual supports. Those familiar with the Social Thinking® methodology will notice and appreciate that each of these EVTs are infused within and across our varied strategies and frameworks. Many of the components of Social Thinking also fit well into Positive Behavioral Intervention and Supports (PBIS). And while PBIS is not an approach, it is an empirically based framework that encourages schools to consider the uptake of a variety of practices. In the same vein, CASEL's five Social and Emotional Learning (SEL) Core Competencies are empirically based and are reflected within and throughout the Social Thinking® methodology. For those readers who would prefer a deeper dive into the external research that supports the MANY components of the Social Thinking® methodology, please look at the article on the Social Thinking website entitled, Research to Frameworks to Practice: Social Thinking's Layers of Evidence.
So, What's the Verdict?
The Social Thinking® methodology is client-centered first and foremost. We utilize the most relevant external evidence available, value client/family feedback, and consider the expertise and insights of those involved. Ultimately, the success of any methodology should be measured by valid data reflecting client change.
Given the three-pronged definition of EBP, the Social Thinking® methodology clearly falls within this definition. And, while there are currently nine published studies related to specific components of the larger Social Thinking® methodology, we know we are in our infancy in terms of empirically supported research. We are just beginning to collect organized outcome data related to very specific areas of the methodology. Stay tuned over the next few years as we add empirical support for the individual components of what we do. In fact, if you'd like to become part of our research-based community, please sign up here and we will let you know about upcoming projects.
American Psychological Association. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285.
Sugai, G., & Simonsen, B. (2012). Positive behavioral interventions and supports: History, defining features, and misconceptions. Center for PBIS & Center for Positive Behavioral Interventions and Supports, University of Connecticut.
Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. BMJ, 312(7023), 71-72.
Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., Brock, M., Plavnick, J., Fleury, V., & Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.