Journal of Autism and Developmental Disorders, Vol. 33, No.

2, April 2003 (© 2003)

Effects of a Model Treatment Approach on Adults

with Autism1

Mary E. Van Bourgondien,1,2 Nancy C. Reichle,1 and Eric Schopler1

The study evaluated the effectiveness of a residential program, based on the TEACCH model,
in improving the quality of the treatment program and the adaptation of individuals with autism
with severe disabilities. The results indicated that participants in the Carolina Living and
Learning Center experienced an increase in structure and individualized programming in the
areas of communication, independence, socialization, developmental planning, and positive
behavior management compared to participants in control settings. The experimental program
was viewed as a more desirable place to live than the other settings, and the families were
significantly more satisfied. Based on exploratory analyses, the use of the TEACCH methods
over time were related to a decrease in behavior difficulties. There was no difference in the
acquisition of skills.

KEY WORDS: Autism; adults; residential; treatment outcome; longitudinal.

INTRODUCTION been developed in urban, suburban, and rural settings.

Most programs emphasize the use of special education,
Effects of a Model Treatment Approach on Adults developmental, and behavioral techniques to optimize
with Autism the residents’ development of new skills and their abil-
ity to function independently in the community (Holmes,
Residential programs for individuals with devel-
1990; LaVigna, 1983; Lettick, 1983; Van Bourgondien
opmental disabilities have been in existence for almost
& Reichle, 1997). The programs may vary in the use of
two centuries (Hilton, 1987). However, Schopler and
specific teaching strategies, the vocational curriculum,
Hennike (1990) pointed out that the distinction between
family involvement, size, and staff training procedures.
the diagnosis and treatment of autism versus other de-
The research on the effectiveness of these residen-
velopmental disabilities has been relatively recent. As
tial treatment models for individuals with autism is lim-
a result, the first residential treatment programs de-
ited. A few studies have demonstrated that specific
signed specifically for adults with autism were devel-
independent living skills can be taught to adults in res-
oped in 1970s and 1980s (CSAAC, 1995; Holmes, 1990;
idential settings (LaVigna, 1983; Smith & Belcher,
LaVigna, 1983; Lettick, 1983; VanBourgondien &
1985). There are also a number of case reports that doc-
Reichle, 1997; Wall, 1990). These community-based
ument the difficulties presented by adults with autism in
treatment programs for individuals with autism have
residential settings (Everard, 1976; Kanner, Rodriquez,
& Ashender, 1972; Mesibov & Shea, 1980; Van Bour-
gondien & Elgar, 1990). Brown (1991) utilized case
1
Division TEACCH, University of North Carolina at Chapel Hill, studies to demonstrate how individualizing a person with
Chapel Hill, North Carolina. autism’s daily schedule and providing choices increases
2
Correspondence should be sent to Mary E. Van Bourgondien, Ph.D.,
Division TEACCH, CB# 7180, University of North Carolina at
meaningful participation in daily activities and reduces
Chapel Hill, Chapel Hill, North Carolina 27599–7180; e-mail: challenging behaviors. Elliot, Dobbin, Rose, and Soper
mvan2@email.unc.ed (1994) demonstrated that exercise significantly reduced

131
0162-3257/03/0400-0131/0 © 2003 Plenum Publishing Corporation
132
the behavior problems in a group of six men with autism.
Reese, Sherman, and Sheldon (1998) utilized a single
subject design to show the effectiveness of differentially
reinforcing other behaviors (DRO) to reduce the fre-
quency of aggressive and disruptive behaviors in an adult
with autism.
Comparison studies between treatment settings
are even more scarce. Sherman, Barber, Lorimer,
Swinson, and Factor (1988) compared the relative ef-
fectiveness of residential versus home-based and out-
patient treatment conditions for young children with
autism. The results of behavioral observations and psy-
chometric assessments indicated that all three treat-
ments were almost equally effective and that both
nonresidential groups achieved slightly better results.
Because children with autism become adults who are
likely to move away from their families in order to
have an independent life of their own, more informa-
tion is needed regarding the effectiveness of various
treatment options.
The purpose of the present study was to evaluate the
effectiveness of a model residential program in improv-
ing the quality of the treatment program and the adapta-
tion of individuals with autism with severe disabilities.
The central goal of this study was to measure the degree
to which the treatment settings were individualized to
meet the unique needs of the residents with autism to
maximize their ability to function as independently as
possible in the community. In addition, the study exam-
ined the families’ satisfaction with the treatment program
and the changes in each subject’s behaviors and skills
over time as a function of their treatment setting.
The hypotheses of the study were as follows:
1. Participants who moved to the experimental
treatment setting would experience an increase
in structure and individualized programming in
the areas of communication, independence
through the use of visual systems, social and
leisure skills, developmental planning, and pos-
itivˇˇˇˇhavior management compared to partic-
ipants in the control settings.
2. The families would report greater satisfaction
for treatment settings that exhibit these indi-
vidualized treatment strategies.
3. Over time, participants receiving these spe-
cialized interventions will show an increase in
their overall adaptive skills.
4. Over time, participants receiving these types of
interventions will decrease the frequency of
problem behaviors compared to controls.
Van Bourgondien, Reichle, and Schopler
METHOD
Participants
The study participants, 32 adolescents and adults
with autism, were recruited from applicants to the ex-
perimental treatment program, the Carolina Living and
Learning Center (CLLC). The CLLC is a combined res-
idential and vocational training program designed and
operated by Division TEACCH (Treatment and Educa-
tion of Autistic and Related Communication handicapped
Children) of the University of North Carolina at Chapel
Hill. The CLLC employs the TEACCH psychoeduca-
tional model to maximize the degree to which each res-
ident can function as independently as possible in the
community (Van Bourgondien & Reichle, 1996, 1997).
The program is located on a 79-acre farm and empha-
sizes farming and landscaping as its vocational curricu-
lum. Throughout the 24-hour program, the staff members
base their treatment strategies on a thorough under-
standing of the thinking and learning of the person with
autism (Schopler & Mesibov, 1995). This individual-
ized approach to teaching new skills and decreasing be-
havior problems focuses on teaching the residents to use
their strengths and visual skills to help compensate for
their deficits in other areas. The participants were placed
into the treatment condition based on “a systematic, fair
assignment process” (Landesman, 1987) involving a part-
random, part-clinical/administrative assignment of sub-
jects. Eligible applicants were matched into three groups
based on cognitive abilities, communication skills, degree
of autism, overall level of behavioral difficulties, and
degree of supervision needed. Two participants from each
group were assigned to the treatment group (n ⫽ 6) based
on a part-random, part-clinical assignment procedure.
The remaining participants were living in one of three
control conditions: group homes (n ⫽ 10), institutions
(n ⫽ 6), or family homes (n ⫽ 10). Table I includes a
comprehensive participant profile by treatment group.
The proportion of males to females was 81% to 19%
(i.e., approximately 4:1). The average age of study par-
ticipants at baseline was 25 years (range ⫽ 16–48 years).
The racial composition of the sample included 26 Cau-
casian and 6 African-American participants, which is
slightly under-representative of the African-American
population in North Carolina.
The vast majority of the study participants (85%)
were functioning in the moderate to severe/profound
ranges of mental retardation. An average Adaptive Be-
havior Composite score of 25 (range ⫽ 20–55) on the
Vineland Adaptive Behavior scales supports these clini-
Effects of a Model Treatment Approach on Adults with Autism 133

Table I. Participants Characteristics at Baseline by Treatment Group

CLLC Family homes Group homes Institutions

Characteristics (n ⫽ 6) (n ⫽ 10) (n ⫽ 10) (n ⫽ 6)

Age—years (SD) 23.7 (4.4) 26.6 (5.1) 27.8 (8.5) 21.5 (5.0)
Gender—female/male 0/6 2/8 2/8 2/4
Race—African 1/5 2/8 1/9 2/4
American/White
CARSaM(SD) 37.3 (5.3) 35.6 (6.9) 34.7 (3.9) 37.2 (2.9)
Intellectual levelbM(SD) 3.73 (.8) 4.0 (1.3) 3.7 (1.5) 4.2 (1.0)
VABSc composite M(SD) 26.7 (11.2) 25.2 (11.5) 24.9 (10.4) 23.5 (8.6)
Additional psychiatric 2/4 0/10 1/9 0/6
diagnosis—yes/no
Visual impairment—yes/no 0/0 1/9 0/10 0/6
Hearing impairment—yes/no 0/6 3/7 2/8 0/6
Residential placement* 3/3 2/8 6/4 6/0
before age 18—yes/no
Aggression and/or self-injury 3/3 2/8 5/5 4/2
at baseline—yes/no
Total behavior control 1.5 (1.4) .3 (.5) 1.4 (2.0) 1.7 (2.0)
medications—M(SD)

* chisq ⫽ 9.94 p ⫽ .02.

a
Childhood Autism Rating Scale.
b
Ratings of 1 (borderline to average) to 5 (severe profound).
c
Vineland Adaptive Behavior Scale.

cal ratings (Sparrow, Balla, & Cicchetti, 1984). The av-
erage score on the Childhood Autism Rating Scale for the
study participants (CARS) (Schopler, Reichler, & Ren-
ner, 1985), was 36 (range ⫽ 21–46) indicating moderate
to severe autism.
A behavioral profile of the sample indicated that
50% exhibited either aggression toward others or self-
injury at baseline. Similarly, 53% of the sample were
receiving at least one medication for behavioral control.
A striking 53% of the study participants had experienced
at least one residential placement before the age of 18.
Baseline comparisons of participants by residen-
tial group (see Table I) revealed initial comparability
on participants’ characteristics, with the exception of
the participants having residential placements before
age 18. The participants with autism in the family home
group were significantly less likely (X2 ⫽ 9.94, p ⫽ .02)
than all other groups to have experienced a residential
placement before age 18.
Outcome Measures
Quality of Treatment Program: Structure and
Individualized Programming Measures
The Environmental Rating Scale (ERS) (Van Bour-
gondien, Reichle, Campbell, & Mesibov, 1998) was uti-
lized as a measure of environmental adaptation and in-
dividualized programming based on the TEACCH phi-
losophy for the study participants. The ERS consists of
32 items, scored from 1 to 5, grouped conceptually into
five subscales: Communication (5), Structure (6), So-
cial and Leisure Skill Development (6), Developmental
Assessment and Planning (8), and Behavior Manage-
ment (7). Higher scores indicate greater environmental
adaptation for the individual. The research assistants
scored the ERS based on semistructured interviews of
the caregiver and tours of the residential setting. Psy-
chometric properties of the ERS have been established
(Van Bourgondien et al., 1998). The project coordina-
tor accompanied the research assistants on 25% of the
visits to conduct reliability checks. Intraclass correla-
tions ranged from .89 to .92 for the subscale scores, with
a total score intraclass correlation of .94.
A Global Rating form was completed by the re-
search assistants following each residential visit. The
ratings include a 1 (no programming) to 5 (excellent
programming) indication of the overall degree of pro-
gramming provided in the setting. In addition, to denote
overall desirability of the setting, the research assistant
indicated on a 150-mm line his/her feelings about the
setting as a place to live. Higher scores indicate more
favorable impressions.
134
Family Satisfaction Measures
At the conclusion of the study, all families com-
pleted a Family Satisfaction Questionnaire, also devel-
oped for the study. The questionnaire included eight items
regarding the families’ overall satisfaction with the
placement and their offsprings’ general well-being. In
addition, satisfaction with the following aspects of the
residential environment were rated: physical environment
(two items), direct care staff (six items), and administra-
tive staff (five items). All questionnaire items range from
1 (very dissatisfied) to 5 (very satisfied). Alphas for the
measure range from .63 to .86.
Measures of Participant Skills
At each time period, the skills of the adolescents and
adults with autism were measured using the Adolescent
and Adult Psychoeducational Profile (AAPEP) (Mesibov,
Schopler, Schaffer, & Landrus, 1988). Through direct as-
sessment and caregiver interviews, the AAPEP provides
a client profile in six functioning areas: vocational skills,
independent functioning, leisure skills, vocational be-
havior, functional communication, and interpersonal be-
havior. Skills in each area are rated as passing, emerging,
or failing. Higher scores indicate greater numbers of pass-
ing and emerging skills in the given area. Adequate reli-
ability and validity have been established for the AAPEP
(Mesibov et al., 1988).
Confirmatory factor analyses were conducted on
the APPEP scores in an effort to create an index of par-
ticipant skills. All variables loaded significantly on a
single factor with a resulting coefficient alpha of .96.
The skill index scores may range from 0 to 8, with
higher scores indicating more skills successfully passed
by the participant with autism.
Measures of Participant Behaviors
The behaviors of the study participants were rated
by their residential caregivers using the Autism Be-
havior Inventory (Van Bourgondien & Mesibov, 1989)
and the Vineland Maladaptive domain of the Vineland
Adaptive Behavior Scales (Sparrow, et al., 1984). On
the Autism Behavior Inventory, caregivers are asked to
rate both the frequency of each behavior and the de-
gree to which the behavior causes a problem. The in-
ternal consistency coefficient alphas were .69 for the
frequency scores and .73 for the problem index.
The Vineland Maladaptive Domain is composed
of two parts; Part 1 describes minor maladaptive be-
haviors, and Part 2 describes more serious maladaptive
behaviors. The psychometric properties of the Vineland
are well established (Sparrow et al., 1984).
Van Bourgondien, Reichle, and Schopler
Confirmatory factor analyses were conducted on
the two written measures of negative behavior in an ef-
fort to create an index of negative behavior. All vari-
ables loaded significantly on a single factor, with a
resulting coefficient alpha of .88. The negative behav-
ior factor score ranges from 0 to 4, with higher scores
indicating more frequent behaviors and more disrup-
tion from the behaviors.
Participant behaviors also were directly observed
by research assistants at each time period using a mod-
ification of Landesman’s behavior observation system
(1987). Each participant was observed for 20 minutes
in three settings (work, meal, transition), resulting in
60 minutes of direct observation per time period. Using
an interval system of observing for 10 seconds and then
recording, the research assistants coded the major be-
havior of the study participant according to an estab-
lished hierarchy. Problematic and stressful behaviors
defined individually for each participant received top
priority for recording, followed by other negative be-
haviors, including stereotypical behaviors. Scores for
the observed negative behaviors may range from 0 to
40, with higher numbers indicating the presence of more
negative behaviors. Reliability observations were con-
ducted with the project coordinator for 25% of the date,
yielding very acceptable kappas ranging from .83 to .99.
Procedures
Each study participant received the complete bat-
tery of assessment measures at four time periods of
approximately 6-month intervals. The two baseline as-
sessments occurred 6 months and 1 month before the
treatment participants moving into the CLLC. The final
two assessments occurred at 6 and 12 months after the
move to the CLLC. If study participants in the control
settings moved during the course of the study, data was
utilized from only one of their living environments to
create stability. The setting in which the control par-
ticipant lived for the majority of the time periods was
selected for inclusion.
RESULTS
General linear modeling (GLM) procedures were
used at Time 4 to compare the treatment and control
groups on the quality of the treatment program and the
families’ satisfaction with the program. Appropriate
follow-up analyses were conducted as necessary. The
GLM procedure using difference scores also were uti-
lized to compare changes in program quality over time
by study groups.
Effects of a Model Treatment Approach on Adults with Autism 135

Degree of Specialized Treatment Programming
The Environmental Rating Scale (ERS) was used to
compare the quality of programming provided in family
homes, community-based group homes, and institutions,
compared to the specialized treatment setting. The results
indicated that the CLLC, the specialized treatment set-
ting, demonstrated significantly greater use of commu-
nication adaptations ( p ⫽ .0003), visual structure ( p ⫽
.0001), socialization programming ( p ⫽ .0057), and pre-
ventative behavior management approaches ( p ⫽ .0001)
than the other three settings. (See Table II for Means and
Standard Deviations). The CLLC also developed pro-
gramming based on significantly more developmental
assessment and planning than the family homes or insti-
tutions ( p ⫽ .002).
Participants in this specialized treatment group (as
measured by the ERS) experienced an increase in pro-
gramming and structure over time after moving into the
CLLC ( p ⬍ .01). (See Table III for Means and Stan-
dard Deviations). The programming and structure for
the three control groups did not change over time.
Supporting these results were clinical global rat-
ings that indicated significantly greater programming
( p ⫽ .0001) and significantly better general impressions
of the desirability of the living situation ( p ⫽ .0001) for
the CLLC compared to the other three settings (See
Table IV for Means and Standard Deviations). The
group homes were rated as a significantly more desir-
able setting than were the institutions.
The Autism Survey (Stone, 1987), a written mea-
sure of common misconceptions about autism, was com-
pleted by the residential caregivers. Higher scores on this
six-point scale indicate greater levels of understanding
of autism. The scores (X ⫽ 4.77 range ⫽ 3.4–5.8) indi-
cated that parents and professionals in all treatment set-
tings were generally knowledgeable about autism and
aware that autism is not an emotional disorder and that
autism is a developmental disability.
Family Satisfaction
Of the 22 families whose offspring were in out-
of-home placements, 18 responded to this family sat-
isfaction measure (5/6 CLLC, 10/10 group homes,
3/6 institutions) at the conclusion of the study. See
Table V for results of Family Satisfaction Survey. The
results indicated significant differences between set-
tings in the families’ general satisfaction with their
sons’ and daughters’ placement, progress, and activi-
ties (p ⫽ .05). Parents of the participants living in the
CLLC were significantly more satisfied with their
child’s care and treatment than were families whose
offspring were living in the group homes. The general
satisfaction ratings from parents of residents in insti-
tutions did not differ significantly from either of the
other two groups. There were also significant differ-
ences between groups in the families’ satisfaction with
the direct care staff members (P ⫽ .05), the adminis-
trators (P ⬍ .05) and the impact of the placement on
the family (p ⬍ .05). The CLLC parents were signifi-
cantly more satisfied with the direct care staff of the
program than were the parents of group home partici-
pants. Although the paired comparisons were not sta-
tistically significant, the families of the subjects in the
CLLC and in institutions gave higher satisfaction rat-
ings for the administration of the programs and the im-
pact of the placement on the family than did the parents
of the group home participants. There were no signif-
icant differences between groups in their satisfaction
with the physical living environment.

Table II. ERS: Means (standard deviations) Time 4

Communication Structure Socialization Developmental Behavior, Total

(F ⫽ 8.89, (F ⫽ 16.90, (F ⫽ 5.27, (F ⫽ 6.24, (F ⫽ 15.67, (F ⫽ 10.76,
p ⫽ .0003) p ⫽ .0001) p ⫽ .0057) p ⫽ .0025) p ⫽ .0001) p ⫽ .0001)
X (SD) X (SD) X (SD) X (SD) X (SD) X (SD)

CLLC 4.10 (.37)a 4.14 (.29)a 3.78 (.53) a

4.12 (.24)a 4.43 (.37)a 4.11 (.31)a
(n ⫽ 6)
Family homes 2.57 (.58)b 2.20 (.57)b 2.40 (.80)b 2.68 (.84)b 2.29 (.76)b 2.67 (.60)b
(n ⫽ 8)
Group homes 2.74 (.76)b 2.69 (.41)b 2.76 (.69)b 3.20 (.48) 2.80 (.32)b 3.04 (.34)b
(n ⫽ 11)
Institutions 2.20 (.72)b 2.28 (.10)b 2.33 (.73)b 2.50 (.33)b 2.71 (.38)b 2.85 (.35)b
(n ⫽ 5)

Means with different letters (a,b ) are significantly different from each other.
ERS scores range from 1 to 5, with higher scores indicating greater environmental adaptation for the individual.
136 Van Bourgondien, Reichle, and Schopler

Table III. CLLC Subjects ERS Scores at Time 1 (before special placement) and Time 4

Communication Structure Socialization Developmental Behavior Total

(F ⫽ 9.11, (F ⫽ 9.83, (F ⫽ 6.94, (F ⫽ 8.08, (F ⫽ 17.30, (F ⫽ 11.81,
p ⫽ .0003) p ⫽ .0002) p ⫽ .0014) p ⫽ .0006) p ⫽ .0001) p ⫽ .0001)
X (SD) X (SD) X (SD) X (SD) X(SD) X (SD)

Time 1 3.0 (.65) 2.58 (.62) 2.81 (.76) 3.00 (.63) 3.31 (.38) 3.09 (.43)
Time 4 4.1 (.37) 4.14 (.29) 3.78 (.53) 4.12 (.24) 4.43 (.37) 4.11 (.31)

ERS scores range from 1 to 5, with higher scores indicating greater environmental adaptation for the individual.

Given the importance of community involvement individual and population curves can be estimated, (2)
in programs for individuals with disabilities, items re- the timing and number of measurements can differ
lated to family satisfaction with community involve- among subjects, and (3) predictors can change for dif-
ment and peer interaction were analyzed separately. ferent assessments on the same subject. Separate mod-
The families were significantly (F ⫽ 3.77, p ⬍ .05) els were fit for four skill and behavior indices: skill index,
more satisfied with the community involvement of the index of caregiver report of negative behaviors, and di-
CLLC participants (X ⫽ 5, SD ⫽ 00) compared to rectly observed negative behaviors with and without
the group home participants (X ⫽ 3.10, SD ⫽ 1.44). minor stereotypical behaviors. Growth curves were fit by
The institution group (X ⫽ 3.33, SD ⫽ .58) was not treating subject and time as random effects and all other
significantly different from the other two groups (F ⫽ predictors as fixed effects in the models. The following
2.31, p ⫽ .13). Groups were comparable on family variables were considered as predictors in the models:
satisfaction with peer interactions. living environment, Environmental Rating subscale
scores, knowledge of autism, family collaboration, resi-
Adaptive Skills and Behaviors dential placement before age 18, leaving a residential
placement as a result of behavior problems, presence of
To assess whether skills and behaviors changed aggression or self-injury, a dual psychiatric diagnosis,
over time and how trends differed among the living en- total behavioral/psychiatric medications, and total seizure
vironments, growth curve models were fit to the data medications. These variables were chosen in part to test
based on the general linear mixed model (also called hi- the original hypotheses that specialized interventions will
erarchical linear models) (Burchinal, Bailey, & Snyder, affect skills and behaviors over time. The remaining vari-
1994). Given the small sample size and the unequal size ables were chosen as indicators of the severity of an
of the groups, results of this analysis should be consid- individual’s behavioral difficulties at baseline.
ered exploratory. Like traditional repeated measures For each outcome area, 10 models were examined.
ANOVA models, mixed models can account for the sys- The first model addressed the question of whether there
tematic correlation among repeated measurements within is a linear trend over time for this index and whether it
subjects, but they have several advantages: (1) both differs by group. If the first model found no significant
changes over time, then a second model explored the ab-
solute difference between the treatment group at each
Table IV. Global Ratings of Degree of Programming and
Desirability of the Setting Means and Standard Deviations time and the average of each control setting. The results
of the control settings could be averaged because of the
Programming Desirability absence of significant change over time in model 1. This
(F ⫽ 12.04, (F ⫽ 13.56, model then asked whether the average for each control
p ⫽ .0001) p ⫽ .0001) group differed from the CLLC group at 6 and 12 months
CLLC (6) 5.00 (.00)a 135.83 (4.02)a after they entered the specialized treatment setting.
Family homes (8) 2.25 (.89)b 69.13 (25.89)b,c Depending on which model was valid, the predictor vari-
Group homes (11) 3.00 (1.10)b 75.36 (35.28)b ables were added to the model(s) to control for baseline
Institutions (5) 2.60 (.89)b 33.60 (24.2)c differences among the subjects in the different groups re-
a,b,c
sulting from these variables and to account for variation
Means with different letters are significantly different from each
other. Programming Range: 1 (no programming) to 5 (excellent
attributable to extraneous sources.
programming). Desirability Range: 1–150; higher scores indicate The final six models explored the impact of the en-
greater desirability. vironment on these indices of skills and behaviors over
Effects of a Model Treatment Approach on Adults with Autism 137

Table V. Family Satisfaction Survey: Means and Standard Deviations

Satisfaction
General Environmental Direct care Administration with effect of
satisfaction satisfaction satisfaction satisfaction placement on family
(F ⫽ 3.59, p ⫽ .05) (F ⫽ 2.21, p ⫽ .14) (F ⫽ 4.31, p ⫽ .03) (F ⫽ 3.64, p ⫽ .03) (F ⫽ 4.29, p ⫽ .03)

CLLC 4.65 (.21)a 5.00 (.00) 4.93 (.10)a 4.96 (.09) 4.40 (.82)
(n ⫽ 5)
Institution 3.96 (.38) 4.83 (.29) 4.72 (.19) 4.80 (.35) 4.50 (.50)
(n ⫽ 3)
Group home 3.34 (1.14)b 3.95 (1.28) 3.48 (1.27)b 3.49 (1.42) 3.35 (.82)
(n ⫽ 10)

ab
Means with different letters are significantly different from each other.
Range ⫽ 1 (very dissatisfied) to 5 (very satisfied).

time for all subjects combined. Although the CLLC pro- Skills Index
vided significantly more autism-specific programming
The results of the first and second models indi-
according to the TEACCH method than the control set-
cated that there were no significant changes in the
tings as a group, individual control settings were also
AAPEP scores over time regardless of setting. When
utilizing these techniques. Given the small sample size,
the predictor variables were added, the presence of
combining the groups together allowed for a more pow-
seizures was a significant (F ⫽ 3.28, p ⫽ .04) predic-
erful assessment of the impact of the environment, as
tor of lower skills.
measured by the ERS on the skills and behaviors of the
When all participants were grouped together and
persons with autism, over time. Within each of these
the ERS subscales were treated as a continuous vari-
final models, the questions were as follows:
able across settings, there was no relationship between
1. Is there a relationship between the outcome and the current environment or changes in the environment
this current aspect of the environment (subscale over time and the outcome scores in the skills index.
of the ERS)?
2. Is there a relationship between the outcome and
the difference between the current environment Negative Behavior Index
and the previous environment?
The negative behavior index was a statistically con-
3. Does the relationship between the outcome and
structed score derived from the behavior questionnaire
the current environment depend on the differ-
results. The results of the first model indicated that there
ence between the current environment and the
were no significant trends over time or group differences
previous environment?
in trends of the negative behavior index. In the second
Table V includes the means and standard devia- model, the results indicated that the CLLC group at Time
tions for the Skill Index, Negative Behavior Index, and 4 were reported to display more negative behaviors than
Behavior Observations across settings. the average scores for subjects living at home (t ⫽ 1.98,

Table VI. Means (Standard Deviations) of Skill Index, Negative Behavior Index
and Negative Behavior Observations

Negative
Index of negative Negative behavior behavior observations
Skills index behaviors observations without stereotypies

CLLC 3.5 (1.5) 1.8 (.3) 16.8 (6.8) .7 (.6)

Homes 3.3 (2.1) 1.4 (.6) 20.4 (11.7) 4.2 (5.8)
Group home 3.1 (2.1) 1.6 (.5) 16.0 (12.8) 2.0 (2.3)
Institution 2.6 (1.8) 1.6 (.6) 24.2 (12.5) 6.5 (9.0)

Note: Control group scores are the mean of Times 1, 2, 3, and 4. CLLC scores represent Time 4 data.
138
p ⫽ .05). Adding the predictor variables to these mod-
els indicated that, regardless of setting, individuals who
were described as aggressive to themselves or others at
baseline had higher rates of negative behavior at Time
4, whereas those who were not reported to be aggres-
sive at baseline had significantly less overall negative
behaviors at Time 4 (r ⫽ ⫺.31, p ⫽ .04).
When all subjects were grouped together and the
ERS subscales were treated as continuous variables,
there were significant relationships between the outcome
on the negative behavior index and the current environ-
ment and the changes in the environment over time. Par-
ticipants who were currently being reported to exhibit
more behavior problems had environments that were
being adapted to meet their communication needs (r ⫽
.20, p ⫽ .03). Participants who experienced an increase
in adaptive communication programming over time were
more likely (r ⫽ ⫺.13, p ⫽ .07) to exhibit fewer nega-
tive behaviors over time as reported by caregivers.
There was a complex relationship between change
in visual structure and the negative behavior index (r ⫽
⫺.22, p ⬍ .0005). If the individual’s program had
become less structured over time, then at Time 4 there
was a relationship between higher levels of structure
currently being used with higher frequencies of nega-
tive behavior. For individuals who experienced an
increase of visual structure over time, higher visual
structure in the current environment (Time 4) was as-
sociated with lower levels of current negative behaviors
(r ⫽ ⫺.22, p ⬍ .0005).
A similar relationship was found between changes
in behavior techniques over time, current use of be-
havior techniques, and the negative behavior index (r ⫽
⫺.4, p ⫽ .01). If the subject experienced a reduction
in positive/preventive behavior planning over time,
then there was a relationship at Time 4 between higher
positive/preventive behavior programming and higher
levels of reported negative behavior. However, for in-
dividuals whose program changed in the direction of
increased positive/preventive behavioral programming
over time, higher levels of behavior programming at
Time 4 were associated with lower levels of current re-
ported behavior problems, and higher levels of reported
behavior problems were associated with less preven-
tive behavioral approaches.
Behavior Observations
Negative behaviors were also measured with di-
rect observation. Again, the direct observation results
were summarized into a single score of negative be-
haviors. The results indicated that, regardless of living
Van Bourgondien, Reichle, and Schopler
situations, there was a significant increase in these be-
haviors over time (r ⫽ 2.6, p ⬍ .00001). A closer ex-
amination indicated that this finding was largely due to
an increase in minor stereotypies (e.g., body rocking,
hand flapping) over time. Analyses of observed nega-
tive behaviors without minor stereotypies indicated no
significant changes over time. There was no difference
in the observed frequency of these behaviors between
residential settings. None of the subject predictor vari-
ables were significantly related to the observed nega-
tive behaviors.
DISCUSSION
The results of this study supported the hypothesis
that participants who moved into the experimental treat-
ment program based on the TEACCH philosophy ex-
perienced a higher quality of treatment as compared to
the participants in the control settings. Compared to their
own baseline and compared to the control groups, the
participants in the CLLC experienced a significant in-
crease in the presence of structure and individualized
programming in the area of communication and social
skill development, the use of visual systems to promote
independence, the use of developmental planning, and
positive, preventive behavior management strategies. The
CLLC was also rated as a significantly more desirable
place to live.
Further evidence that these changes reflected a bet-
ter quality of life were the significant differences be-
tween the CLLC and the group home settings in the
families’ satisfaction with the programs. These find-
ings, however, are limited by the small sample size and
the relatively low return rate for the participants living
in institutional settings.
These statistically significant differences in treat-
ment environments were also very striking from a clin-
ical perspective. Based on the information obtained in
the ERS interviews, the CLLC provided significantly
more visual structure, a major component of the
TEACCH method, to ensure that the residents were able
to use their skills independently of staff members’
prompts, whereas the other programs did not empha-
size independence as a goal. As a result, the residents
in the control settings were highly dependent on the
presence of others and verbal prompting to understand
their world and to be able to use their skills. Another
major distinction between the programs was the em-
phasis at the CLLC on integrating communication, so-
cialization, and other treatment goals throughout the
day in meaningful ways. The other settings tended to
Effects of a Model Treatment Approach on Adults with Autism
have more discrete teaching sessions with less empha-
sis on functional or meaningful goals that could be gen-
eralized into the community. Finally, the behavior
management approach used at the specialized treatment
setting (CLLC) emphasized a more preventive approach
to managing behavior using less restrictive or negative
consequence measures than the other settings.
The significant differences between the program-
ming and desirability ratings of the CLLC versus fam-
ily homes merits some discussion. The parents whose
offspring were still at home frequently reported that
they no longer were able to provide the teaching, struc-
ture, or life experiences that they knew their adult chil-
dren wanted and needed. By definition, these were
families of adults with severe disabilities who were
looking for out-of-home placement. It was obvious to
the interviewers and the parents that these adults were
not in optimal teaching settings despite the good care
and attention of their parents.
The results concerning comparison of participant
skills and behaviors were based on hierarchical linear
modeling and should be considered exploratory given
the small number of participants and unequal group
sizes. Not surprisingly, the exploratory results of the
skill comparison using the AAPEP did not show either
statistically or clinically significant changes in the de-
velopmental levels of participants over time, regardless
of settings. As evidenced by the description of the par-
ticipants at baseline, the sample consisted of adults with
multiple severe disabilities. Although these adults were
born at a time in history when early identification of
autism and early intervention were minimal, most had
been receiving some form of educational programming
for several years. Therefore, one would not expect to
see significant changes in their overall development in
an 18-month period. Future studies need to employ in-
dividualized measures of skill acquisition that are more
sensitive to the type of growth one is likely to see in
adults with multiple severe handicaps. Measures in fu-
ture studies should also examine the degree to which
the individuals can use their skills independently in a
wide variety of settings including the community.
The exploratory analyses of the changes in nega-
tive behaviors over time provided some interesting hy-
potheses for future studies.
First, the impact of providing autism-specific treat-
ment in the form of using visual structure, adapted
communication training, and preventive behavioral ap-
proaches across all groups over time was significantly
related to a reduction in behavior problems over time.
Conversely, settings that reduced the use of visual sys-
tems, communication adaptations, or preventive ap-
139
proaches to behavior problems over time experienced an
increase in the frequency of negative behaviors in the
adults with autism they served. These results suggest that
the positive impact of these strategies is something that
develops over time and that the changes in the environ-
ment need to be maintained to continue the positive
behavioral effects. If one thinks of these treatment strate-
gies as prosthetic devices that help the individuals with
autism compensate for their deficits (similar to glasses
or hearing aids), it makes sense that their continued use
is necessary to maintain the positive effects.
A second area for future research that is suggested
by the behavior results relates to the impact of transi-
tioning adults with autism to new living environments.
Across all settings, the clinical reports indicated that
when individuals with autism moved to new settings,
there was a tendency for behavior problems to become
worse. There were 16 participants (including the 6
CLLC participants) who changed living environments
in the course of the study. For analyses purposes, the
control settings were averaged over time and the ob-
servations made after any move in these groups was
excluded, while by definition all of the CLLC partici-
pants moved. This factor may account for the Time 4
differences in reported negative behaviors between par-
ticipants living at home and participants at the CLLC.
A second study (Van Bourgondien & Reichle, AAMR
presentation), which examines the impact of moving
into a new setting on the skills and behaviors of adults
with autism, supports this notion.
The results of this study should be considered to
be preliminary findings and not conclusive. As with
any treatment study there are real-life factors that need
to be considered. First, the sample was selected from a
group whose families were actively seeking admission
to the specialized program. And although some of those
who were not admitted to the CLLC found an alterna-
tive program for their adult children, it is not surpris-
ing that these families were not as satisfied with their
childrens’ placements as were the families whose chil-
dren entered the special program.
Second, the sample size is small and unequal,
which makes the choice of appropriate statistical
procedures difficult. The use of hierarchical linear
models to examine the trends over time should be
considered exploratory. Given the sample size and
the exploratory nature of these analyses, the results
should be interpreted as suggestive of areas for fur-
ther evaluation.
In summary, the results of this study supported the
hypothesis that participants in the experimental treat-
ment setting, Division TEACCH’s CLLC, experienced
140
an increase in structure and individualized programming
in the areas of communication, independence through
the use of visual systems, social skills, developmental
planning, and positive, preventive behavior management
compared to participants in the control settings. The ex-
perimental program was viewed subjectively by re-
search staff members as a more desirable place to live
than the other settings; of the families who returned their
surveys, these parents were significantly more satisfied
with the treatment their adult children received.
In this population of adults with multiple severe
disabilities, exploratory analyses revealed no signifi-
cant changes in skills regardless of treatment program.
The increased use of visual systems, adapted commu-
nication techniques, and positive, preventive behavior
management strategies over time is significantly related
to a decrease in behavior difficulties.
ACKNOWLEDGMENT
This study was supported by the National Institute
of Mental Health Grant MH44626–01.
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