There has been a proliferation of therapies for autism over the past several decades, fueled in large part by the increased focus on the diagnosis, prevention, and treatment of this disorder (Jacobson, Foxx, & Mulick, 2005). The urgency to find an effective intervention after a child has been diagnosed with autism can lead parents and professionals to implement so-called “alternative” therapies that are not yet supported by science (Goin-Kochel, Myers, & Mackintosh, 2007; Hanson et al., 2007; Wong & Smith, 2006). For example, some physicians have begun to prescribe various medical treatments, such as chelation therapy, dietary restrictions, and large doses of vitamins, based solely on anecdotal information or uncontrolled case studies (Jacobson et al.; Simpson, 2005).
As a result, many practicing behavior analysts are working with clients who are receiving multiple forms of intervention, including those that are currently unproven (Smith & Antolovich, 2000). Caregivers and professionals also might question behavior analysts about the likely effectiveness of alternative treatments. According to the Behavior Analyst Certification Board® “Guidelines for Responsible Conduct,” behavior analysts are “responsible for review and appraisal of likely effects of all alternative treatments, including those provided by other disciplines…” (p. 14). An appraisal based on review of the current literature is challenging when the intervention has not yet been subjected to adequate scientific scrutiny. In such cases, behavior analysts should inform caregivers and professionals that the science is lacking and caution them about using such unproven therapies.
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Appraisal could be extended to an experimental analysis when caregivers are not dissuaded from employing unproven therapies. A behavior analyst could offer his or her expertise in the measurement and analysis of behavior to help evaluate therapeutic outcomes. Caregivers are most concerned about the effects of a therapy for their own children, and behavior analytic methods provide the ideal means for generating this type of information. For example, behavior analysts have evaluated such therapies as facilitated communication, a gluten-free and casein-free diet, and the drug secretin for individual children (Irvin, 2006; Montee, Miltenberger, & Witrrock, 1995; Richman, Reese, & Daniels, 1999).
One unproven intervention that has garnered attention among parents and autism professionals is hyperbaric oxygen therapy (Schechtman, 2007). Hyperbaric oxygen therapy (HBOT) involves the inhalation of oxygen (20% to 100% concentration) inside a pressurized chamber. The pressure provided by the HBOT chamber (typically 1.3 to 1.5 absolute atmospheres [ATA]) promotes the dissolution of oxygen into the blood. The oxygen is then circulated near dormant or injured tissue in the body. HBOT has been used to treat a variety of medical problems. Among those uses currently recognized by the Food and Drug Administration (FDA) are the treatment of burns, gas gangrene, carbon monoxide poisoning, decompression sickness, certain problem wounds, and exceptional blood loss (McDonagh et al., 2003). HBOT also has been used to treat a variety conditions for which there is little evidence of benefit, such as strokes, traumatic brain injury, and cerebral palsy. (Adamides, Winter, Lewis, Cooper, Kossmann, & Rosenfeld, 2006; Carson, McDonagh, Russman, & Helfand, 2005; Liptak, 2005; McDonagh et al., 2003).
Recently, several authors have suggested that HBOT can improve the symptoms of autism by reversing neurological abnormalities that might be associated with this disorder (Buckley, 2005; Rossignol & Rossignol, 2006). Although such neurological abnormalities have not been verified and no controlled studies have been conducted on the behavioral outcomes of HBOT with this population, some authors have reported benefits for children even with low pressures (1.3 ATA in the portable chambers approved by the FDA for home use) and less than 100% oxygen concentrations (i.e., 21% to 40% FiO2; see Buckley, 2005). These findings have led to speculations that HBOT might prove beneficial for children with autism by improving socialization, language, and attending (among other abilities) and by reducing problem behavior.
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For this reason, some physicians are now prescribing HBOT therapy for children with autism. Typically, prescriptions are for 60-min sessions (i.e., “dives”) in the chamber to occur once or twice per day, five days per week. Parents are actively seeking facilities that can provide this service or purchasing portable hyperbaric chambers that are FDA-approved for in-home use. Parents and physicians are reporting improvements in language and cognition, as well as decreases in problem behavior, within 10 to 40 dives (Buckley, 2005; Rossignol & Rossignol, 2006). This unproven therapy is estimated to cost more than $15,000 per person (McDonagh et al., 2003). Potential side effects, although rarely reported with mild (low-pressure) HBOT of 40 dives, include seizure; oxygen toxicity; aspiration; and pain, rupture, or hemorrhage in the ear.
In light of the potential costs associated with this unproven therapy (in the form of time, expense, and potential physical side effects), behavior analysts should work closely with caregivers who have secured HBOT services for their children. Controlled evaluations using behavior analytic methods are ideal for determining if unproven therapies like HBOT offer any benefits beyond those afforded by ongoing behavioral services.
In this paper, we describe the methods and results of a behavior analytic evaluation of HBOT, along with the considerations and challenges that arose when conducting this type of study. The purpose of the study was to conduct a systematic evaluation of this unproven therapy with several children who were attending a day program for children with autism. After receiving a hyperbaric oxygen chamber from a private donor, the program director decided to provide this therapy to children whose parents requested it. However, the director wanted to systematically evaluate the outcomes for these children. Three parents who had requested HBOT services through the day program but whose children had not yet initiated the therapy were invited to participate in the controlled evaluation.
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