Analysis Of Shirley Jacksons The Lottery - 954 Words

The Shrouding Visage Since the emergence of the written word humans around the world have used literature to convey emotions and invoke thought within others. This invocation of thought and conveyance of emotion arises not only from the words themselves, but also through the usage of literary elements that enhance the overall transmission of the authors message. Shirley Jackson’s â€Å"The Lottery† displays a masterful usage of literary elements to better convey Jackson’s general purpose, such as through the deep symbolism and underlying theme; however, Jackson’s true provocation of emotion is accomplished through her quintessential use of point of view. The objective point of view is indispensable within â€Å"The Lottery† because of the creation†¦show more content†¦Furthermore, point of view is momentous within the lottery because of its creation of the drama, or action of the story by limiting the information one is aware of. During â⠂¬Å"The Lottery†, the major conflict, or drama, happens towards the end of the story. First Tessie Hutchinson begins saying â€Å"It wasn’t fair† (pp. 141) after her family wins the town’s lottery. This unexpected reaction creates a dramatic scene that escalates quickly until â€Å"A stone hit her on the side of the head.† (pp. 142) and begins the end of Tessie’s life. This dramatic and unexpected series of events is brought on because of the point of view the author has written the story in, if it was not for the limited perspective that Jackson chose to exploit, then by the end of the story it would be unknown that the town’s lottery is not the traditional monetary lottery, but instead a violent way to control the population of the town by killing the winner every year. Therefore, the point of view of the story is not only crucial for creating suspense, but also the drama of the story. Lastly, point of view in Shirley Jackson’ s version of â€Å"The Lottery† is vital in creating situational irony. At the beginning of the story the only thing that the narrator exposes is that there is a big ceremony going onShow MoreRelatedAnalysis Of Shirley Jacksons The Lottery841 Words   |  4 PagesSecond World War. In the short story â€Å"The Lottery†, Shirley Jackson used persecution and tradition to demonstrate how scapegoating justified unfair killing. Both of these aspects relate to the World War that preceded only a couple years before the story was written. The persecution was blind and done once a year as a tradition that everyone expected to happen. Therefore, the story’s main idea was to let the reader imagine what the real meaning of the lottery was. At first, Jackson described the townRead MoreAnalysis of Shirley Jacksons The Lottery490 Words   |  2 Pages In Shirley Jackson’s â€Å"The Lottery,† the theme of the story is dramatically illustrated by Jackson’s unique tone. Once a year the villagers gather together in the central square for the lottery. The villagers await the arrival of Mr. Summers and the black box. Within the black box are folded slips of paper, one piece having a black dot on it. All the villagers then draw a piece of paper out of the box. Whoever gets the paper with the black dot wins. Tessie Hutchinson wins the lottery! Everyone thenRead MoreAnalysis Of Shirley Jacksons The Lottery1303 Words   |  6 Pagespowerful force (qtd. in AZQuotes). In Shirley Jacksons chilling story The Lottery, a town celebrates a special custom of stoning people to death every year. Jackson perf ectly depicts a possible event that may occur from blindly following tradition without evaluating the purpose or usefulness of it in the first place. Jackson’s use of plot, theme, and symbolism reveal the evil reality of blind faith, tradition, and their consequences. Initially, Jackson’s twisted plot reveals the infinite, viciousRead MoreAnalysis of Shirley Jacksons The Lottery Essay776 Words   |  4 Pagesâ€Å"The Lottery† is a short story by Shirley Jackson, first published on June 26, 1948. The story was initially met with negative critical reception due to its violent nature and portrayal of the potentially dangerous nature of human society. It was even banned in some countries. However, â€Å"The Lottery† is now widely accepted as a classic American short story and is used in classrooms throughout the country. Jackson’s story takes a critical look at what can result when the customs and laws that governRead MoreAnalysis of Shirley Jacksons The Lottery Essays4601 Words   |  19 Pages Shirley Jackson’s famous short story, â€Å"The Lottery,† was published in 1948 and remains to this day one of the most enduring and affecting American works in the literary canon. â€Å"The Lottery† tells the story of a farming community that holds a ritualistic lottery among its citizens each year. Although the text initially presents audiences with a close-knit community participating in a social event together on a special day, the shocking twist at the work’s end—with the death of the lottery’s â€Å"winner†Read MoreAnalysis of John Steinbecks Chrysanthemums and Shirley Jacksons The Lottery1500 Words   |  6 PagesExamining The ChrysanthemumS The Lottery Examining The Chrysanthemums The Lottery In the WWII period, women entered the workforce is massive numbers a statistical anomaly that had never existed in American society or hardly any other modern society, ever. They became empowered and more women realized a wider range of their capabilities. A few decades after WWII, the feminist movement would rise to change the course of womens history again. The success and fervor of the feminist movementRead MoreAn Analysis of Shirley Jacksons The Lottery and Flannery OConnors A Good Man Is Hard to Find1360 Words   |  5 PagesShirley Jackson The Lottery Shirley Jacksons short story The Lottery depicts life in a provincial American town with rigid social norms. Mr. Summers symbolizes everything that is wrong with the town; he represents blind adherence to ritual, social rigidity, and resistance to change. His name corresponds with the seasonal setting of The Lottery, too, drawing attention to the importance of his character in shaping the theme of the story. Summers is in charge of the central motif of the storyRead More Shirley Jacksons The Lottery 946 Words   |  4 PagesShirley Jackson is said to be one of the most â€Å"brilliant and influential authors of the twentieth century.† â€Å"Her fiction writing is some of the most important to come out of the American literary canon.† (http://shirleyjackson.org/Reviews.html) Jackson wrote many short stories and even some books. They are more on the dark, witchlike side, however. Kelleher explains that Jackson stated in some interviews that she practiced magic. No one re ally knows if she was serious while practicing witchcraftRead MoreUse of Symbolism in The Lottery by Shirley Jackson1146 Words   |  5 Pagesbulb represents ideas that just sparked into a character’s head. In the short story, â€Å"The Lottery† by Shirley Jackson, a village has just entered the month of June, meaning that the lottery is to begin. When everyone was present, the heads of the households’ names were called one by one to pick up a slip of paper. It was then discovered that the Hutchinson family was the chosen family to participate in the lottery again. When Mr. Hutchinson, Mrs. Hutchinson, Bill Jr., Nancy, and Little Dave each gotRead MoreSymbolism in The Lottery, by Shirley Jackson Essay example1173 Words   |  5 PagesWhen most people play the lottery today, they think about having wealth. Generally, people who win are happy about it whether they win one dollar or a million. The lottery in our society has grown to support education and it is often worth several million dollars. Usually, the winner of the lottery gains a lot of recognition for the money they win. But what would happen if there was a small town where people held a yearly lottery in which the â€Å"winner† was the member of the town who was not sacrificed

Implementing A Project Management Methodology - 1769 Words

The use of structured methodologies in IT Project management is increasingly recognised as one of the fundamental drivers in reducing the likelihood of incomplete and costly IT project failures. The need for a systematic approach has been highlighted through a number of survey results on the failure of IT Projects. These results demonstrate that the significant issues associated with failed projects include the lack of; a defined project organisation, policy and procedures, implementation plans and integrated methods (Taylor 2003). It is apparent that these recognised issues can be significantly reduced through the implementation of standard project management methodologies. Lind and Culler (2013) completed research of 116 firms†¦show more content†¦Ã¢â‚¬ ¢ Standardised project management provides consistency across the organisation. †¢ Roles and responsibilities are clearly defined and each individual on the team is aware of their expectations. †¢ Projects that are not working or no longer meet the business case are quickly identified, thus allowing for early intervention. †¢ Greater accountability and performance for project teams. (McHugh Mairà ©ad 2006) The following case studies have been implemented using the PRINCE2 methodology and demonstrate how a structured methodology for IT Project Management can facilitate successful project outcomes. Example 1: Raise your glasses – the water s magic! Strategic IT at SA Water: a case study in alignment, outsourcing and governance (Thorogood et al. 2004) South Australian Water (SA Water) is responsible for the supply of the majority of South Australia’s water. Prior to 1999, SA Water had a record of IT underperformance and a reputation not completing IT projects. In 1999, a new CIO was appointed to improve the dire IT situation. Changes were made and immediately a new project management methodology was adopted: PRINCE2. As a result, clear structures began to be implemented. Both internal and external project managers were required to have training in PRINCE2. The Waterscope project was selected to be a showcase PRINCE2 project in May 2001. The goal of the project was to provide timely information on water quality needed to manage

The Variasian Experience Analysis Art Essay Free Essays

VariAsian was held at the University Cultural Centre Dance Studio in NUS on 12th March 2011. It was the 6th NUS Arts Festival and they had many different creative persons from different Fieldss and different states to come down and execute in jubilation of this festival. The public presentation was about the disregarded times of the past. We will write a custom essay sample on The Variasian Experience Analysis Art Essay or any similar topic only for you Order Now With the new and up universe of engineering, we tend to bury the memories and the things we one time loved buttocks. What we used to play with when we were kids such as the five rocks, hopscotch and the congkak is now replaced with high engineering games such as the play-station games and the iPhones. The new coevals of childs are now exposed to the new appliances that would do the traditional games ‘disappear ‘ even faster. Sometimes as life base on ballss us by, we tend to go forth those memories behind to be forgotten whereas VariAsian brings us back to the life we used to hold, when everything was simple and was about holding merriment with friends compared to the complexnesss of the current engineerings that people are so caught up with now. ‘When the bell rings†¦ ‘ by Sufri Juwahir was the gap act of the eventide. He was invited to be a invitee choreographer in this production. This piece was performed in silence and the terpsichoreans used the sound of their motions, their breath their linguas and the slippers that they wore throughout the piece as their music. It started out with five pupils have oning bag battalions and slippers with ice pick in their custodies. They walked onto the phase with boxes laid out as chairs and continued to eat their icy comeuppances. They easy started speaking and before you could register what they said, their words became sounds. Like a codification linguistic communication that merely your friends that know you would understand, but the people that does non cognize you every bit good, would non. The conversation started acquiring intense and looked like they were reasoning or contending over something, like how childs would reason over bantam things. One started to travel off from the others, one Saturday on the floor alternatively of the ‘chair ‘ , one was being nescient to everything that is around her and merely concentrating on eating her ice pick while the other two tried to work out the state of affairs. I reminded me of how I was when I was a pupil in primary school during my lunch interr uption. My friends and I would ever play with the five rocks and hopscotch. Sometimes when there are misinterpretations or merely kick unreasonable statements, we would travel off in different waies but the following twenty-four hours, it would travel back to the same modus operandi with the games and it would be a normal twenty-four hours in school. It was the same for this piece of work. They developed from words to sounds so from sounds into motions. They were confronting different waies and at their ain single infinite on phase. The blocks on phase were moved and were now their private infinite, their safe topographic point. They were ‘speaking their heads ‘ through motions, seeking to talk what they feel. The motions that we used were about similar but after awhile, they started making the same motions like they were doing up for the battle. They easy came together and stacked the boxes into a wall for a game of fell and seek. They would take bends to conceal behind the wall of blocks and making the same motions. The 1s that were caught would take a block and played a game of ‘hitting the slipper ‘ . Two of them that we caught formed a pyramid of their slippers on top of the blocks and the game is to strike hard it down with another slipper. One by one got caught and every bit shortly as the two misss formed their pyramid, the remainder mes sed with it and destroyed it intentionally over and over once more like how toughs in schools would pick on you over and over. It happened once more and once more until the two misss picked up their slippers and started dancing with the slippers on their custodies, standing up for themselves against those toughs. They broke out and they all were playing their single games. Some played with their bags, some played with a friend and one was playing the congkak, a long disregarded game, by herself in the corner. It felt like she was conveying back the memory of the game or conveying back an old memory of something she had forgotten for rather some clip and so did the others. All their motions were related to that congkak in one manner or another. Either doing sounds and noises like the beads that hits the wooden base or puting on the floor like the congkak and merely moves when person touches it or places it someplace else. When the miss played with the existent congkak, the others fol lowed her by imitated the motions or the sounds like they were remembering the yearss of their childhood when they used to play that game. Like how when you were younger, you had more freedom to make whatever you wanted with lesser jobs and things to believe about. The lone thing that mattered was that every twenty-four hours that was spent was an gratifying one. This piece was concentrating more on the narrative is wants to state alternatively of the technique and the motion as it was largely gestures that were used and game playing. It was a public presentation that people can associate to and can see themselves in it as it was something that everyone has gone through earlier in their lives. It was about the memories that we keep throughout our lives and the ideas that are most cherished to you. There might be times when you merely want to throw a specific memory off but no affair what you do, you can look to allow it travel. It depends on us if we want those memories to populate on or non. We have the power to do it come back or let it to vanish everlastingly. Traditions that used to be so close to our Black Marias that was passed down to us from our great grandmas are now on the brink of extinction due to the engineering that has been overmastering our universe. How it can take away traditions and take off cherished memories that have yet to go through down to our coevals of kids. Even though those memories or experiences that we ‘ve went through are mistily at that place, it will ever linger in our heads particularly those that affairs. As for the 2nd piece, it had more of an wellbeing and playful sort of feel compared to the first. ‘Variasian ‘ which is the name of this piece was choreographed by Zaini Mohd Tahir. He is the Artistic Director, the Resident Choreographer and the laminitis of the NUS Dance Ensemble. This piece was besides about the games we play and how games used to be simpler when we were younger and how it became more complex as we grew older but we ne’er stop playing. It merely advanced into a more technological version of the traditional games. Some games we grew up with and some had to turn up with us but we still play. There were a choir standing at the sides of the phase when we walked into the studio of where it took topographic point. As I sat down, they started singing. I had thought I walked into the incorrect public presentation infinite. After they were done with the first vocal, the terpsichoreans came out and started running about on phase playing the really old and traditional game that people still play today, the ‘scissors, paper, rock ‘ game. When the say the word ‘stone ‘ , they had to remain still in whatever place they were in and travel when the said the remainder. Watching them reminded me of how I used to love playing that game during recess period when I was in primary school. The volume and the velocity of the game increased as each unit of ammunition passed until it got so feverish and helter-skelter in the public presentation infinite. Their voices got louder and louder every 2nd and it felt like it could make the other side of the school evidences. Th en all of a sudden there were silence and terpsichoreans started vanishing into the wings go forthing half the sum of terpsichoreans on phase. As the terpsichoreans were easy vanishing, the choir sang a slow and dramatic vocal while walking through the infinite on phase, from one side to the other like altering the chapter in a narrative or a drama. The terpsichoreans get downing dancing with flow like motions that looked like they were drifting through the infinite. Their motions and the choir mashed and complimented each other attractively like a absolutely fitted pealing on your finger. Their motions were insistent throughout the piece but they changed it a small by utilizing cannons and different degrees. Once the vocal was over, the terpsichoreans at the side wings rolled in with a cute, wellbeing vocal that came on. It sounded like a vocal you would here when you play a specific game in the arcade. The terpsichoreans were like the life in the games with green and pink lighting , it made it experience like we were besides in the game. Some were ‘crabbing ‘ sideways while the others are running and jumping around them like they were supposed to catch them in order to win. That had to be my favorite portion of the whole public presentation. Then there was a sudden alteration in music and a techno like vocal came on and all the terpsichoreans ran off except for one cat, merely standing at that place like it was his clip to reflect and acquire the limelight, and that ‘s what he did. He started ‘Para Para ‘ dancing entirely in the center of the phase. Para Para is an arcade game that you play entirely where there are colored pointers lined with electronic detectors, and you have to dance and hit all the pointers to win. Slowly all the terpsichoreans came on phase and joined him in his game of Para Para but one by one they could n’t catch up and died like they lost the game. One by one collapsed onto the floor and including t he male terpsichorean who looked like the male monarch of the game. Surprisingly, the last one standing was a miss and she walked off with an evil laughter with deathly music following her as she left the phase. It was such an unexpected stoping for the piece and I think it made it more interesting and made an impact on me. I left the public presentation with that stoping tarriance in my caput throughout the dark. The eventide was a really interesting one as it genuinely spoke to me and I could associate to both pieces in many ways. It was a dark that took me through memory lane. How to cite The Variasian Experience Analysis Art Essay, Essay examples

Autism and Evidence-based Practice free essay sample

This document represents a remarkable collaboration by a diverse group of stakeholders all committed to a single goal – improving the lives of children and youth with Autism Spectrum Disorders. The vision and support of the Maine Department of Education and the Maine Department of Health and Human Services enabled this work to be done, while Lindsey Tweed and Nancy Connolly provided the leadership that kept the project moving forward. We received invaluable input and guidance from a variety of viewpoints, including people with autism, parents, educators, providers, researchers, and policymakers. This was a challenging task requiring countless hours of article review and discussion over a one-year period. Although opinions differed at times, enthusiasm for the project never waned, and consensus was achieved. Throughout this involved process, the focus was always on the children and families impacted by Autism Spectrum Disorders. We are grateful to the consumers and families who shared their stories, experiences, and opinions, and who gave meaning to our work. The members of the Committee collaboratively developed a common understanding of research and evidence-based practice, selected interventions to evaluate, and outlined a literature review and rating process. The Committee collectively endorses the findings and conclusions expressed herein. However, due to the diversity of perspectives and experiences within the Committee, the conclusions and thoughts on each position in this document do not necessarily represent the individual opinions of each member or the organization they represent. Page 5 CHILDREN? S SERVICES EVIDENCE-BASED PRACTICE ADVISORY COMMITTEE MEMBERS OF THE AUTISM SPECTRUM DISORDERS PROJECT Nancy Connolly (Co-Chair) Special Education Consultant Department of Education Lindsey Tweed (Co-Chair) Director of Clinical Policy and Practice Children? s Behavioral Health Services Department of Health and Human Services Amy Beaulieu (Staff) Policy Associate, Cutler Institute Muskie School of Public Service University of Southern Maine Amy Benham Special Education Teacher, Autism Program Winslow Elementary School Sharon Brady Director of Special Services Riverside RSU #26 Betty Carolin Clinical Coordinator Charlotte White Center Janine Collins Consumer Advocate Research Associate University of Maine Center for Community Inclusion Disability Studies Nancy Cronin PDD Systems Change Coordinator Maine Developmental Disabilities Council Cathy Dionne Parent Co-Director Autism Society of Maine Page 6 Cynthia Dodge Director of Clinical Services Spurwink Services Roxy Hennings Director of Continuous Quality Improvement Division of Juvenile Services Department of Corrections Alan Kurtz Research Associate University of Maine Center for Community Inclusion Disability Studies James Pelletier Program Manager Department of Health and Human Services Division of Child Welfare Lora Perry Parent Executive Director of ABA Services Providence of Maine Matthew Siegel Medical Director Developmental Disabilities Program Spring Harbor Hospital Maine Medical Center Lynn Silva Assistant Director of Student Support Services Portland Public Schools Erica Thompson Special Services Administrator, MSAD # 54 Distinguished Educator Child Development Services Interventions for Autism Spectrum Disorders STATE OF THE EVIDENCE EXECUTIVE SUMMARY| Introduction| The number of children in Maine with Autism Spectrum Disorders (ASD) has increased significantly over the past decade. Since 2000, the number of children receiving Special Education services for ASD in Maine schools jumped from 594 to 2,231in 2008 – an increase of 276%. A recent study estimated that the total cost of caring for a person with autism over his or her lifetime can reach $3. 2 million, with more than $35 billion spent collectively per year (Ganz, 2007). To conserve already scarce resources and offer the best possible services to children with ASD, it is necessary to identify and understand the treatments and methods that produce positive outcomes as proven by research. Science helps to clarify some of the confusion about what â€Å"works† and enables evidence-informed treatment decisions, thus saving precious time and resources. Autism Spectrum Disorders are a category of neurodevelopmental disorders characterized by distinct and pervasive impairment in multiple developmental areas, particularly social skills and communication (American Psychological Association, 2000). Children with ASD exhibit atypical patterns of social interaction and communication that are not consistent with their developmental age. These patterns become apparent in the first few years of life and are generally lifelong challenges (Schieve, Rice, Boyle, Visser, Blumberg, 2006). Early, intensive identification and intervention can greatly improve outcomes for children with ASD (Eikeseth, Smith, Jahr, Eldevik, 2007). Early and effective treatment also offers opportunity for significant cost/benefit improvement through regained productivity of individuals with ASD and their caregivers (Ganz, 2007). Evidence-Based Practice| Evidence-based practice is a framework for integrating what is known from research into real-world settings in a manner that responds to the individual characteristics and values of the individual being served. There are three main components to evidence-based practice (APA Presidential Task Force on EvidenceBased Practice, 2006; Burns Hoagwood, 2002): Best Research Evidence: In order to integrate research into practice, it is critical to be aware of the scope and quality of the literature. The quality and type of research is an important factor in the evaluation of evidence. Efficacy, the extent to which the treatment had the desired effect on the outcomes, is the critical determinant of empirical evidence (Chorpita, 2003). Clinical Expertise Judgment: Practitioners in an evidence-informed framework exercise their clinical judgment to select methods that address the client? s needs by taking into account the client? s Page 7 environment, life circumstances, strengths, and challenges (APA Presidential Task Force on Evidence-Based Practice, 2006). Values: Evidence-based practice is consistent with the child and family? s values and perspectives (APA Presidential Task Force on Evidence-Based Practice, 2006; Chambless Hollon, 1998; Chorpita, 2003). Engaging families in the process of evaluating, identifying, and implementing evidence-based interventions is critical. Family engagement promotes collaboration between families and practitioners and better informs individual treatment planning. This project focused on the first factor in evidence-based practice – best research evidence. The purpose of this work was twofold: Systematically review the research literature for treatment in ASD and subsequently determine the levels of empirical evidence for treatments commonly used for children with ASD. It is hoped that addressing this first element of evidence-based practice will enable providers, families, and systems to use the latest research to better inform treatment planning, decision making, policy making, and resource development. Process| In response to a growing need for information on evidence-based treatments for ASD, the Maine Department of Education and the Maine Department of Health and Human Services led a partnership of stakeholders in a systematic review of the latest research on treatment for ASD. This review was designed as an update to the Maine Administrators of Services for Children with Disabilities (MADSEC) Autism Task Force Report issued in 2000, one of the first efforts in Maine to review the treatment literature for ASD. Over the course of a year, laypersons, state agency staff, providers, and researchers, reviewed more than 150 studies of 43 different treatments for children with ASD. The Committee objectively reviewed the research using a validated rubric, the Evaluative Method for Determining Evidence-Based Practice in Autism (Reichow, Volkmar, Cicchetti, 2008), and assigned each intervention a level of evidence rating. The quality of each study was carefully evaluated using a set of primary and secondary quality indicators and factored into the determination of the level of evidence using a corresponding rating scale. Levels of Evidence| Established Evidence: The treatment has been proven effective in multiple strong or adequately rated group experimental design studies, single-subject studies, or a combination. Results must be replicated in studies conducted by different research teams. Promising Evidence: The intervention has been shown effective in more than two strong or adequately rated group experimental design studies or at least three single-subject studies. Additional research is needed by separate teams to confirm that the intervention is effective in across settings and researchers. Preliminary Evidence: The intervention has been shown effective in at least one strong or adequately rated group or single-subject design study. More research is needed to confirm results. Page 8 Studied and No Evidence of Effect: Numerous (three or more) strong or adequately rated studies have determined that the intervention has no positive effect on the desired outcomes. Insufficient Evidence: Conclusions cannot be drawn on the efficacy of the intervention due to a lack of quality research and/or mixed outcomes across several studies. Evidence of Harm: Studies or published case reports indicate that the intervention involves significant harm or risk of harm, including injury and death. Findings| Level of Evidence Intervention Category Intervention(s) Established Evidence Applied Behavior Analysis Applied Behavior Analysis for Challenging Behavior Applied Behavior Analysis for Communication Applied Behavior Analysis for Social Skills Early Intensive Behavioral Intervention (EIBI) Augmentative and Communication Picture Exchange Communication System (PECS) Alternative Pharmacological Approaches Applied Behavior Analysis Applied Behavior Analysis for Adaptive Living Skills Augmentative and Communication Promising Evidence Halperidol (Haldol) – Effective for aggression Methylphenidate (Ritalin) – Effective for hyperactivity Risperidone (Risperidol) – Effective for irritability, social withdrawal, hyperactivity, and stereotypy Voice Output Communication Aid (VOCA) Alternative Psychotherapy Preliminary Evidence Cognitive-Behavioral Therapy (CBT) for Anxiety Applied Behavior Analysis Applied Behavior Analysis for Academics – Numeral recognition, reading instruction, grammatical morphemes, spelling. Applied Behavior Analysis for Vocational Skills Augmentative and Communication Sign Language Alternative Developmental, Social-Pragmatic Models Developmental, Social-Pragmatic Models Eclectic Models Diet Nutritional Approaches Vitamin C – Modest effect on sensorimotor symptoms only Pharmacological Approaches Atomoxetine (Strattera) – Effective for attention deficit and hyperactivity Clomipramine (Anafranil) – Effective for stereotypy, ritualistic behavior, social behavior Page 9 Level of Evidence Intervention Category Intervention(s) Clonidine (Catapres) Effective for hyperactivity, irritability, inappropriate speech, stereotypy, and oppositional behavior Psychotherapy CBT for Anger Management Sensory Integration Therapy Touch Therapy/Massage Other Hyperbaric Oxygen Treatment Studied and No Evidence of Effect Pharmacological Approaches DMG Secretin Insufficient Evidence Applied Behavior Analysis Applied Behavior Analysis for Academics – Cooperative learning groups Augmentative and Communication Facilitated Communication Alternative Diet Nutritional Approaches Developmental, Social Pragmatic Models Guanfacine (Tenex) Intravenous Immunoglobin Melatonin Naltrexone (Revia) SSRIs: Citalopram (Celexa), Fluoxetine (Prozac) Valproic Acid (Depakote) Sensory Integration Therapy Auditory Integration Training Sensory Integration Training Social Skills Training Social Skills Training Social Storiesâ„ ¢ Other Page 10 DIR/Floortime RDI SCERTS Solomon? s PLAY model Pharmacological Approaches Evidence of Harm Gluten-Casein Free Diets Omega-3 Fatty Acid Supplements Vitamin B6/Magnesium Supplements TEACCH Pharmacological Approaches Intravenous Chelation Using Edetate Disodium Conclusions| Based on its investigation of the research literature, the Committee concludes the following: The research clearly indicates that there are effective treatments for some core deficits and related challenges of ASD. For instance, comprehensive behavioral treatment has some of the most compelling evidence which emphasizes the importance of early and intensive intervention for children with ASD. Substantial investment in quality research is needed to further define effective treatment for ASD. Research specific to educational and behavioral interventions for children with ASD in the context of schools is seriously lacking. This is of deep concern since children receive a great deal of services through the education system. Comparative research on the efficacy of various treatment models would be very valuable. There is a dearth of research on treatment of older youth, adolescents, and adults with ASD. This is worrisome given that the number of adults with ASD is expected to significantly increase in the coming years as children with ASD mature. Families should be informed consumers of treatment and ask questions of providers about the nature and quality of the research behind the treatment their child is receiving. Providers need to make treatment decisions in active partnership with families while integrating relevant research into their practice and treatment planning process. Resources are needed to build capacity throughout Maine in order to efficiently and effectively deliver evidence-based treatments to children in their schools, homes, and communities. This requires resources for training, evaluation, and workforce development. For example, ABA has some of the best evidence for treatment in ASD yet Maine has only 26 certified ABA practitioners, with most located in the southern counties. Evidence-based practice does not seek to dictate the interventions that should be used at the expense of others. Rather, it is a framework to integrate what is known from research into real-world practice in a manner that is accessible to families, responsive to what children need, and consistent with what providers can accomplish given available skills and resources. The first step toward evidence-based practice is creating awareness of what the best available research says. It is no longer enough to use what we believe works, we must consider what we know works in order to close the gap between science and practice, utilize limited resources wisely, and best serve Maine children with ASD. Page 11 Interventions for Autism Spectrum Disorders STATE OF THE EVIDENCE INTRODUCTION| Recent statistics indicate that the number of children diagnosed with Autism Spectrum Disorder (ASD) has skyrocketed – the latest figures suggest that approximately 1 in 91 children in the United States are currently diagnosed with ASD (Kogen, Blumberg, Schieve, Boyle, Perrin, Ghandour, et al. , 2009). In Maine, the rate is thought to be even higher with an estimated 1 in 77 children identified with ASD – the second highest rate in the nation (Thoughtful House Center for Children, 2009). In response to increasing demand for services for children with ASD in our schools and communities, the Maine Departments of Education and Health and Human Services partnered with members of the community to assess the research and determine the level of scientific evidence for interventions currently available for ASD. This project continued the efforts of the Children? s Services Evidence-Based Practice Advisory Committee (â€Å"the Committee†) to study and disseminate information on the scientific evidence for treatments of childhood behavioral health conditions. This work also serves as a comprehensive update to the Autism Task Force Report issued in 2000 by the Maine Administrators of Services for Children with Disabilities (MADSEC). To the best of the Committee? s knowledge, the MADSEC report was the first multidisciplinary effort in Maine to objectively examine the research for select interventions for ASD. In the years since MADSEC issued its report, the breadth and depth of the research of ASD has evolved; in fact, more than 2,100 studies regarding autism have been published in peer-reviewed journals since 2001i. Given the significant number of children with ASD being served in Maine and advances in research over the last decade, a new review of the literature is timely and appropriate. The Committee evaluated peer-reviewed research for more than 40 interventions for children and youth with ASD, including psychosocial, behavioral, developmental, complementary, educational, and pharmaceutical treatments. A wide variety of treatment options have been developed for children with ASD and it can be difficult for parents, educators, and practitioners to know what could be most effective given each child? s unique circumstances. Science helps to clarify some of the confusion about what â€Å"works. † Well-designed studies can show that some interventions are very effective for certain symptoms or behaviors while others are not. The implications of this information are profound; understanding what works as demonstrated by research can inform choices that improve lives (Steele, Roberts, Elkin, 2008). Page 12 How to Use This Report| This document is intended to provide an updated view of the best available research evidence for treatments for Autism Spectrum Disorders. Certain stakeholders may find this report especially useful: Families, Educators, Practitioners: Evaluating and selecting treatments can be a daunting task. This report provides an objective evaluation of the best available research evidence for the myriad of treatment options currently available for ASD (Steele, et al. , 2008). Policymakers: As Maine continues to enhance its system of care, it is hoped that policymakers will consider this information in their decision making so that all children in Maine have sufficient access to evidence-based interventions. Business Community Leaders: ASD touches the lives of many families in the places where we live and work. The Committee hopes that sharing information on effective treatment methods inspires leadership, innovation, and support among business and community leaders to improve service delivery systems. Researchers: Describing the amount and quality of research behind available treatments draws attention to areas needing further research and investigation. Children with ASD truly have a spectrum of challenges and abilities therefore treatments should be tailored to reflect their individuality. It is not enough to simply use any evidencebased treatment they are not â€Å"one size fits all. † The treatments discussed in this report vary widely in their focus, intensity, duration, and methods, and thus must be carefully evaluated and matched to a child? s unique needs. It is not the intention of this report to indicate what interventions should or should not be used; families should always decide what treatment best meets the needs of their child. Children have a right to treatment that is reflective of their individual strengths and challenges and that accommodates any change in the nature and intensity of their needs (Office of Child and Family Services, March 2008). However, families and providers should seek the most current and complete research information to factor into their decisions regarding treatment. As â€Å"Treatment† â€Å"Intervention† Treatment is generally understood as a service used to correct or alleviate a specific medical condition, issue, or problem. The effectiveness of treatment is usually evaluated and measured based on the individual? s outcome (Barker, 1999). Intervention includes treatment, but also encompasses other services or activities practitioners use to address or prevent an individual? s problems (Barker, 1999). Intervention is a term sometimes used in social work, education, and other ecological, cross-disciplinary fields to describe services that address the problems of an individual. The Committee reviewed â€Å"treatments† and â€Å"interventions† without regard to the field or entity that might utilize them. These terms are used interchangeably in this report. Page 13 science continues to evolve, it is expected that ASD treatment will be further refined. Therefore, periodic reassessments of the scientific literature will be needed so that families and providers have current information in order to inform their choices and decisions. PROJECT ORGANIZATION| The Children? s Services Evidence-Based Practice Advisory Committee formed in 2007 as the childfocused Subcommittee of the DHHS EvidenceBased Practice Advisory Committee. The Committee is charged with reviewing the research base for treatments of childhood behavioral health disorders in order to better inform policy, practice, and resource development in Maine. It is not a policy-making entity, but an advisory body that informs state agency work. The Committee is led by Children? s Behavioral Health Services, a division of the Office of Child and Family Services. Departnent of Education DHHS EvidenceBased Practice Advisory Committee Childrens Services Evidence-Based Practice Advisory Committee Autism Spectrum Disorders Project FIGURE 1: PROJECT ORGANIZATION A diverse group of stakeholders convened in 2007 to review and rate the research on psychosocial treatments for disruptive behavior disorders (Beaulieu, 2008). Following this successful review, the Committee turned its attention to ASD due to a growing concern about the needs of this population. The Maine Departments of Education and Health and Human Services agreed to jointly lead this project in recognition of the mutually important roles that education and behavioral health systems play in serving children with ASD. The Muskie School of Public Service provided technical assistance, research support, and data analysis to the project through a cooperative agreement with the Office of Child and Family Services. Due to the nuances involved in ASD research and the relevance of this issue across systems, the Committee incorporated stakeholders and experts in the field of ASD, including parents, an adult with ASD, educators, providers, and advocates. The Autism Spectrum Disorders project began in August of 2008. Initial work focused on establishing common language and understanding about ASD, research methodology, and evidence-based practice. Following a review of the literature, the Committee adopted a systematic review process with a corresponding rating scale to organize the work. ABOUT AUTISM SPECTRUM DISORDERS| Definition| Autism Spectrum Disorders, also referred to as Pervasive Developmental Disorders (PDD), are a category of neurodevelopmental disorders that include: Page 14 Autistic Disorder (autism); Pervasive Developmental Disorders-Not Otherwise Specified (PDD-NOS); Asperger? s Syndrome; Rett? s Disorder; and Childhood Disintegrative Disorder. ? ? ? Autism Spectrum Disorders are now more common than childhood cancers in the United States. (Gloeker, Percy, Bunin, 2005) Due to their lower prevalence and differing symptom profile, Childhood Disintegrative Disorder and Rett? s Disorder were not included ? ? ? in this review. Research of treatments for ASD generally does not include children with these two diagnoses. Studies that focused on children with Autistic Disorder, PDD-NOS, and/or Asperger? s Syndrome were reviewed. Because functional ability and expression of symptoms can vary widely among children with these diagnoses, from profound disability to high functioning, they are said to exist on a â€Å"spectrum. † The Committee chose to use the term â€Å"Autism Spectrum Disorders† rather than Autism or PDD in recognition that no two children are impacted by these disorders in exactly the same manner or to the same degree. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Autism Spectrum Disorders (ASD) are characterized by distinct and pervasive impairment in multiple developmental areas, primarily social skills and communication (American Psychiatric Association, 2000). These disorders are marked by the presence of stereotypical behavior such as hand flapping and body rocking, as well as by excessive preoccupation with certain objects, interests, or activities. Children with ASD exhibit patterns of social interaction and communication that are not consistent with their developmental age. These patterns become apparent in the first few years of life and are generally lifelong challenges (Schieve, Rice, Boyle, Visser, Blumberg, 2006), although with early and effective intervention, children can often learn new skills and improve existing ones. Prevalence| Studies have consistently documented a significant increase in the number of children identified with ASD across the United States over the last 15 years (Centers for Disease Control and Prevention, Maine Children Classified with Autism in 2009; Hollenbeck, 2004; Schieve, et al. , 2006). Special Education 2000-2008 While it is not known if this increase is attributa2231 ble to how ASD is identified and diagnosed, an 276% 1760 2500 2000-2008 actual increase in prevalence, or a combination 2000 of factors, the number of children identified with 1500 594 ASD in Maine and across the country has been 1000 500 growing. ASDs are now the second most common 0 developmental disability after mental retarda2000-01 2006-07 2008 tion (Centers for Disease Control and Prevention, 2009). A recent national survey of parents by Source: Department of Education, 2009 Page 15 U. S. Department of Health Human Services estimated that 1 in 91 children ages 3-17 years old were currently diagnosed with ASD (Kogen, et al. , 2009). This is a substantial increase from earlier estimates by the Centers for Disease trol of 1 in 150 children (Centers for Disease Control and Prevention, 2009). MaineCare Recicipients with ASD 2000-2008 3000 281% 2000-2008 1929 2451 2000 1000 643 0 Prevalence in Education| 2000 2006 2008 Education data echo this trend. Federal data Source: Department of Health and Human Services, gathered for the Individuals with Disabilities in 2009 Education Act (IDEA) indicate that the number of Maine children ages 6-22 with ASD receiving Special Education services grew by 1672% between 1992 and 2003 (Hollenbeck, 2004). This is pared to a nationwide 834% increase in children ages 6-17 with ASD between 1994 2006 (Centers for Disease Control and Prevention, 2009). Maine Department of Education data shows this trend is likely to continue. Since 2000, the number of children in Maine schools classified with ASD has increased by 276% (Department of Education, 2009). Prevalence among Medicaid Recipients| Utilization data from the Medicaid program also shows an increase in the prevalence of ASD in Maine. Between 2000 and 2008, the number of people with ASD who received MaineCare services increased by 281%. The significant growth of ASD in Maine? s systems of care underscores the need for planful resource and capacity development in order to adequately address the needs of this expanding population (Department of Health and Human Services, February 2009). WHAT IS EVIDENCE-BASED PRACTICE? | Evidence-based practice is the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture, and preference. American Psychological Association Page 16 Evidence-based practice has been a priority in the behavioral health and education fields over the past decade. The growing need for high-quality children? s behavioral health services has increased the demand for treatments that are proven to produce better outcomes (Levant, 2005; New Freedom Commission on Mental Health, 2003). The education system has also emphasized the use of evidence-based practice through legislation and policy such as No Child Left Behind (Coalition for EvidenceBased Policy, December 2003). For example, federal education policy calls for educators to address the needs of students struggling with academics and behavior with interventions supported by research (Gresham, 2007). The emphasis on inter- Control condition: A comparison group of subjects in a research study that receive treatment as usual, or are placed on a waiting list for the treatment under study. Efficacy: The strength of the causal relationship between the treatment and its intended outcomes Does it work? Effectiveness: An assessment of how well the treatment generalizes to real-world settings. Randomized Controlled Trial: A type of research study in which subjects are randomly selected to receive the experimental intervention or a control condition. Single-Subject Design: A type of research that measures effects of an intervention at the level of the individual under carefully controlled conditions. ventions backed by research necessitates a common derstanding of evidence-based practice. Defining and coming to a common understanding of â€Å"evidence† is not simple (Chambless Hollon, 1998; Chorpita, 2003). Our current understanding of evidencebased practice in behavioral healthcare is largely rooted in the work of American Psychological Association Task Forces (Task Force on Promotion and Dissemination of Psychological Procedures, 1995; Task Force on Psychological Intervention Guidelines of the American Psychological Association, 1995). These Task Forces developed some of the first guidelines on research-informed practice (Chambless, et al. , 1996). The Committee has endorsed the American Psychological Association? s definition of evidence-based practice: Evidence-based practice is the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture and preference (APA Presidential Task Force on Evidence-Based Practice, 2006). This definition acknowledges that evidence-based practice does not exist in a vacuum, and that research, clinical practice, and client values influence each other. Although the terms are often used interchangeably, the meanings of â€Å"evidence-based practice† and â€Å"evidencebased treatment† are distinct. Evidence-based treatment refers to specific treatments or intervention models that have proven effective for specific problems in certain circumstances by numerous scientific studies (Levant, 2005). Evidence-based practice bridges the science-to-practice gap by using research evidence to inform clinical practice in the context of the client? s needs and environment. There are three core components to evidence-based practice: Best research evidence, clinical expertise and judgment, and client values and voice (APA Presidential Task Force on Evidence-Based Practice, 2006; Burns Hoagwood, 2002). Best Research Evidence| The main element in the determination of research evidence is efficacy (Chorpita, 2003). Efficacy refers to the strength of the causal relationship between the treatment and its intended outcomes. In other words, does the treatment have the desired effect on the target behavior or skill? Efficacy is established Page 17 â€Å"Life Journey through Autism: A Parent’s Guide to Research† is an informative guide for families. through well-designed research studies in which outcomes are observed and measured and compared to a no-treatment condition. The quality and type of a research study is an important factor in the evaluation of evidence. Research studies are conducted using different methods to varying levels of scientific integrity. Available at: Well-designed research is highly controlled, meaning that the www. researchautism. org families and children are carefully screened and selected to fit the parameters of the research, and administration of the treatme