Intensive behavioral treatment at school for 4- to 7-year-old children with autism. A 1-year comparison controlled study

Parent inclusion in Early Intensive Behavioral Intervention: the influence of parental stress, parent treatment fidelity and parent-mediated generalization of behavior targets on child outcomes

Although early intensive behavior interventions have been efficient in producing positive behavior outcome in young children with Autism Spectrum Disorder, there is a considerable variety in the children's progress. Research has suggested that parental and treatment factors are likely to affect children's response to treatment. The purpose of the current study was to examine the interrelating factors that impact children's progress, highlighting the influence of parent inclusion in treatment provision captured by parental stress, how faithfully the parents followed the treatment protocols and the intensity of treatment provided at home. Twenty-four children received cross-setting staff- and parent-mediated EIBI, including continuous parent training and supervision. A comparison group of 20 children received eclectic intervention. Standardized tests were carried out by independent examiners at intake and after six months. The intervention group outperformed the eclectic group in measures of autism severity, developmental and language skills. Parent training and constant parent-mediated treatment provision led to reduced challenging behaviors from the children, increased treatment fidelity and child direct behavior change as measured by performance in correct responding on behavior targets. Variables of treatment progress and potential predictors of child outcome were analyzed in detail and mapped with regard to their relationships drawn from multiple regression analysis. Particularly, the study highlights an association between parental stress and staff treatment fidelity that interferes with decision making in treatment planning and consequently with positive behavior outcome. Such results provide important scientific and clinical information on parental and treatment factors likely to affect a child's response to treatment.

Behavioral interventions for children with autism spectrum disorders

Early intensive behavioral intervention is the only well-established treatment for young children with autism spectrum disorders (ASDs). Less intensive behavioral interventions are also effective for targeted concerns with older children and adolescents. This article describes the core features of behavioral treatments, summarizes the evidence base for effectiveness, and provides recommendations to facilitate family understanding of these interventions and identification of qualified providers. Recommendations are also provided for collaboration between pediatric providers and behavior analysts who are serving families of individuals with ASDs.

Outcomes of behavioral intervention for children with autism in mainstream pre-school settings

We evaluated outcomes for 31 children with autism (2-6 years of age at intake) who received behavioral intervention in mainstream pre-school settings and a comparison group of 12 children receiving treatment as usual. After 2 years, children receiving behavioral intervention had higher IQ scores (Hedges g = 1.03 (95% CI = .34, 1.72) and adaptive behavior composite scores (Hedges g = .73 (95% CI = .05, 1.36). Despite probably fewer intervention hours, these group level outcomes were comparable to studies providing more intensive intervention. Individual child data also showed positive results with 19.4% achieving change at a reliable level for IQ; but a lower percentage than found in recent meta-analysis research. Strengths and weaknesses of the mainstream pre-school delivery model are discussed.

Early intervention in 208 Swedish preschoolers with autism spectrum disorder. A prospective naturalistic study

Early intervention has been reported to improve outcome in children with autism spectrum disorders (ASDs). Several studies in the field have been randomized controlled trials (RCTs). The aim of this study was to assess ASD outcome in a large naturalistic study. Two hundred and eight children, aged 20-54 months, with a clinical diagnosis of ASD were given intervention and monitored prospectively in a naturalistic fashion over a period of 2 years. The toddlers were considered representative of all but the most severely multiple disabled preschool children with ASD in Stockholm county. They fell into three cognitive subgroups: one with learning disability, one with developmental delay, and one with normal intellectual functioning. Data on intervention type and intensity were gathered prospectively in a systematic fashion. Intervention was classified into intensive applied behaviour analysis (ABA) and non-intensive, targeted interventions, also based on ABA principles. Children were comprehensively assessed by a research team before the onset of intervention, and then, again, 2 years later. Change in Vineland adaptive behaviour scales composite scores from intake (T1) to leaving the study (T2) was set as the primary outcome variable. The research team remained blind to the type and intensity of interventions provided. One hundred and ninety-eight (95%) of the original samples stayed in the study throughout the whole 2-year period and 192 children had a complete Vineland composite score results both at T1 and T2. Vineland composite scores increased over the 2-year period. This increase was accounted for by the subgroup with normal cognitive functioning. There was no significant difference between the intensive and non-intensive groups. Individual variation was considerable, but no child in the study was "problem-free" at follow-up. Our data do not support that children with ASD generally benefit more from the most intensive ABA intervention programs than from less intensive interventions or targeted interventions based on ABA.

Autism spectrum disorders--a genetics review

Autism is an etiologically and clinically heterogeneous group of disorders, diagnosed solely by the complex behavioral phenotype. On the basis of the high-heritability index, geneticists are confident that autism will be the first behavioral disorder for which the genetic basis can be well established. Although it was initially assumed that major genome-wide and candidate gene association studies would lead most directly to common autism genes, progress has been slow. Rather, most discoveries have come from studies of known genetic disorders associated with the behavioral phenotype. New technology, especially array chromosomal genomic hybridization, has both increased the identification of putative autism genes and raised to approximately 25%, the percentage of children for whom an autism-related genetic change can be identified. Incorporating clinical geneticists into the diagnostic and autism research arenas is vital to the field. Interpreting this new technology and deciphering autism's genetic montage require the skill set of the clinical geneticist including knowing how to acquire and interpret family pedigrees, how to analyze complex morphologic, neurologic, and medical phenotypes, sorting out heterogeneity, developing rational genetic models, and designing studies. The current emphasis on deciphering autism spectrum disorders has accelerated the field of neuroscience and demonstrated the necessity of multidisciplinary research that must include clinical geneticists both in the clinics and in the design and implementation of basic, clinical, and translational research.

Early diagnoses of autism spectrum disorders in Massachusetts birth cohorts, 2001-2005

OBJECTIVE

We examined trends in autism spectrum disorder diagnoses by age 36 months (early diagnoses) and identified characteristics associated with early diagnoses.

METHODS

Massachusetts birth certificate and early-intervention program data were linked to identify infants born between 2001 and 2005 who were enrolled in early intervention and receiving autism-related services before age 36 months (through December 31, 2008). Trends in early autism spectrum disorders were examined using Cochran-Armitage trend tests. χ² Statistics were used to compare distributions of selected characteristics for children with and without autism spectrum disorders. Multivariate logistic regression analyses were conducted to identify independent predictors of early diagnoses.

RESULTS

A total of 3013 children (77.5 per 10,000 study population births) were enrolled in early intervention for autism spectrum disorder by age 36 months. Autism spectrum disorder incidence increased from 56 per 10,000 infants among the 2001 birth cohort to 93 per 10,000 infants in 2005. Infants of mothers younger than 24 years of age, whose primary language was not English or who were foreign-born had lower odds of an early autism spectrum disorder diagnosis. Maternal age older than 30 years was associated with increased odds of an early autism spectrum disorder diagnosis. Odds of early autism spectrum disorders were 4.5 (95% confidence interval: 4.1-5.0) times higher for boys than girls.

CONCLUSIONS

Early autism spectrum disorder diagnoses are increasing in Massachusetts, reflecting the national trend observed among older children. Linkage of early-intervention program data with population-based vital statistics is valuable for monitoring autism spectrum disorder trends and planning developmental and educational service needs.

Two-Year Outcomes for Children With Autism After the Cessation of Early Intensive Behavioral Intervention

Evidence from recent meta-analytic and narrative review suggests that early intensive behavioral intervention (EIBI) may improve life chances of preschool children with autism. Unfortunately, there are few data indicating whether early gains are maintained after intervention ceases. The purpose of the present study was to establish the 2-year follow-up outcome for children with autism ( N = 41) who had participated in an earlier 2-year controlled comparison of EIBI. Twenty-three children in the intervention group (100% of original sample) and 18 in the treatment-as-usual comparison group (86% of original sample) were located and retested. Group differences favoring intervention substantially diluted in this period but varied significantly between subgroups who had received university-supervised and parent-commissioned interventions, favoring the latter. These groups differed in terms of their baseline characteristics and intensity of intervention. Results strongly suggest a need for better characterization of those children who would benefit from more active maintenance programs.

The importance of production frequency in therapy for childhood apraxia of speech

PURPOSE

This study explores the importance of production frequency during speech therapy to determine whether more practice of speech targets leads to increased performance within a treatment session, as well as to motor learning, in the form of generalization to untrained words.

METHOD

Two children with childhood apraxia of speech were treated with an alternating treatment AB design, with production frequency differing in the 2 treatments. The higher production frequency treatment required 100+ productions in 15 min, while the moderate-frequency treatment required 30-40 productions in the same time period. One child was treated 3 times weekly for 11 weeks; the other child was treated twice weekly for 5 weeks. At the conclusion of each treatment phase, 5 min of probes were administered to determine whether generalization had occurred. Maintenance data to measure performance and learning were collected after a break from treatment.

RESULTS

Both children showed improvement on all targets; however, the targets with the higher production frequency treatment were acquired faster, evidenced by better in-session performance and greater generalization to untrained probes.

CONCLUSIONS

Both treatment designs were effective, though frequent and intense practice of speech resulted in more rapid response to treatment in 2 children whose primary communication difficulty was childhood apraxia of speech.

A systematic review of early intensive intervention for autism spectrum disorders

CONTEXT

Early intensive behavioral and developmental interventions for young children with autism spectrum disorders (ASDs) may enhance developmental outcomes.

OBJECTIVE

To systematically review evidence regarding such interventions for children aged 12 and younger with ASDs.

METHODS

We searched Medline, PsycINFO, and ERIC (Education Resources Information Center) from 2000 to May 2010. Two reviewers independently assessed studies against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes and assigned overall quality and strength-of-evidence ratings using predetermined criteria.

RESULTS

Thirty-four unique studies met inclusion criteria. Seventeen studies were case series; 2 were randomized controlled trials. We rated 1 study as good quality, 10 as fair quality, and 23 as poor quality. The strength of the evidence overall ranged from insufficient to low. Studies of University of California Los Angeles/Lovaas-based interventions and variants reported clinically significant gains in language and cognitive skills in some children, as did 1 randomized controlled trial of an early intensive developmental intervention approach (the Early Start Denver Model). Specific parent-training approaches yielded gains in short-term language function and some challenging behaviors. Data suggest that subgroups of children displayed more prominent gains across studies, but participant characteristics associated with greater gains are not well understood.

CONCLUSIONS

Studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvements in cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs, although the literature is limited by methodologic concerns.

Irish clinicians' views of interventions for children with autistic spectrum disorders

The current study investigated clinicians' perspectives on the effectiveness of interventions designed to support the development of children with autistic spectrum disorders (ASDs). Researchers developed a semi-structured interview which was administered to 11 clinicians involved in the assessment and treatment of ASDs (5 = clinical psychologists, 6 = psychiatrists). Content analysis of qualitative data revealed that Irish clinicians typically endorse an eclectic approach to treatment, combining facets of different methods of interventions in a complementary fashion. The process that clinicians engaged in when evaluating modes of treatment was assessed. Significant variation was observed in how clinicians merge clinical experience with empirical evidence. Challenges which clinicians face in assessing individuals on the autistic spectrum, such as the proliferation of misinformation on interventions, as well as the role of parents in treatment, were also discussed within the interviews. The implications of the findings for understanding the process of selecting interventions for children with ASDs are discussed.

Issues, Policies, and Recommendations for Improving the Education of Learners With Autism Spectrum Disorders

Children and youth with autism spectrum disorders (ASD) create significant challenges to educators and the educational system not only based on their ever-increasing numbers but also because of the questions and debates surrounding how best to provide them an appropriate and effective education. These issues include the skills, knowledge, and professional credentials of educators who teach learners with ASD, which settings are best suited for their educational experiences, and what and how children and youth with ASD should be taught. In this article the authors address these three core elements that underpin the education of pupils with ASD and offer recommendations for improving the present system.

Low intensity behavioral treatment supplementing preschool services for young children with autism spectrum disorders and severe to mild intellectual disability

This study evaluated the effectiveness of low intensity behavioral treatment (on average 6.5h per week) supplementing preschool services in 3-6-year-old children with autism spectrum disorder and severe to mild intellectual disability. Treatment was implemented in preschools (i.e., daycare centers) and a discrete trial teaching approach was used. Twelve children in the treatment group were compared to 22 children receiving regular intervention. At pre-treatment, both groups did not differ on chronological age, developmental age, diagnosis and level of adaptive skills. Eight months into treatment, children receiving behavioral treatment displayed significantly higher developmental ages and made more gains in adaptive skills than children from the control group. No significant differences between groups were found on autistic symptom severity and emotional and behavioral problems.

Social peers rescue autism-relevant sociability deficits in adolescent mice

Behavioral therapies are currently the most effective interventions for treating the diagnostic symptoms of autism. We employed a mouse model of autism to evaluate components of behavioral interventions that improve sociability in mice. BTBR T+tf/J (BTBR) is an inbred mouse strain that exhibits prominent behavioral phenotypes with face validity to all three diagnostic symptom categories of autism, including robust and well-replicated deficits in social approach and reciprocal social interactions. To investigate the role of peer interactions in the development of sociability, BTBR juvenile mice were reared in the same home cage with juvenile mice of a highly social inbred strain, C57BL/6J (B6). Subject mice were tested as young adults for sociability and repetitive behaviors. B6 controls reared with B6 showed their strain-typical high sociability. BTBR controls reared with BTBR showed their strain-typical lack of sociability. In contrast, BTBR reared with B6 as juveniles showed significant sociability as young adults. A 20-day intervention was as effective as a 40-day intervention for improving social approach behavior. High levels of repetitive self-grooming in BTBR were not rescued by peer-rearing with B6, indicating specificity of the intervention to the social domain. These results from a robust mouse model of autism support the interpretation that social enrichment with juvenile peers is a beneficial intervention for improving adult outcome in the social domain. This novel paradigm may prove useful for discovering factors that are essential for effective behavioral treatments, and biological mechanisms underlying effective behavioral interventions.

Toward a technology of treatment individualization for young children with autism spectrum disorders

Although the etiology of autism spectrum disorders (ASD) and early development of the ASD are not yet well understood, recent research in the field of autism has heavily emphasized the importance of early intervention (i.e. treatment before the age of 4 years). Currently, several methods have been demonstrated to be efficacious with some children however no treatment completely ameliorates the symptoms of ASD or works for all children with the disorder. The heterogeneity and developmental nature of the disorder make it unlikely that one specific treatment will be best for all children, or will work for any one child throughout his or her educational career. Thus, this paper examines early research validating different technologies for individualizing treatment. A discussion of current research on pre-treatment characteristics associated with differential outcomes in treatment, including child, family, and practitioner variables; and how specific intervention techniques address each of those pre-treatment characteristics is provided. The ultimate goal of this line of research is to enable practitioners to prospectively tailor treatments to specific children and increase the overall rate of positives outcomes for children with autism. Research that furthers understanding of how to match clients with efficacious treatments will decrease the outcome variability that characterizes early intervention research at present, and provide for the most efficient allocation of resources during the critical early intervention time-period. This type of research is in its infancy, but is imperative if we are to determine a priori which treatment method will be most effective for a specific child.

Using participant data to extend the evidence base for intensive behavioral intervention for children with autism

We gathered individual participant data from 16 group design studies on behavioral intervention for children with autism. In these studies, 309 children received behavioral intervention, 39 received comparison interventions, and 105 were in a control group. More children who underwent behavioral intervention achieved reliable change in IQ (29.8%) compared with 2.6% and 8.7% for comparison and control groups, respectively, and reliable change in adaptive behavior was achieved for 20.6% versus 5.7% and 5.1%, respectively. These results equated to a number needed to treat of 5 for IQ and 7 for adaptive behavior and absolute risk reduction of 23% and 16%, respectively. Within the behavioral intervention sample, IQ and adaptive behavior at intake predicted gains in adaptive behavior. Intensity of intervention predicted gains in both IQ and adaptive behavior.

Effectiveness of medication combined with intensive behavioral intervention for reducing aggression in youth with autism spectrum disorder

BACKGROUND

The use of antipsychotic medications to treat aggression in youths with autism spectrum disorders (ASD) is based on open-label trials and efficacy studies. There are no studies examining the combined effectiveness of antipsychotic medications and intensive behavioral intervention (IBI) to treat aggression in ASD.

METHODS

Youths with ASD and aggressive behavior received IBI. Medication use remained stable during the study period and was coded into antipsychotic, mood-stabilizing, and nonstimulant attention-deficit/hyperactivity disorder (ADHD)/sleep medication classes. Analysis of covariance (ANCOVA) and survival analyses examined the effects of medication classes on the average number of aggressive behaviors and time to behavior plan success.

RESULTS

Thirty-two youths (mean age = 11.16, standard deviation [SD] = 3.31, range = 4-16 years, 75% male) with ASD received aggression reduction plans. Of these, 25 youths were taking at least one psychiatric medication (antipsychotic n = 18, mood stabilizing n = 10, and nonstimulant ADHD/sleep n = 12). Aggression dropped substantially following implementation of IBI (p < 0.001; d = 1.70). Antipsychotic medication use predicted significantly fewer sessions to achieve behavior plan success (chi(2)(1) = 5.67, p = 0.017; d = 0.93). No other medication classes influenced aggressive behavior (largest chi(2)(1) = 0.16, p = 0.694).

CONCLUSIONS

Behavioral treatment combined with antipsychotic medication was the most effective approach to reducing aggressive behaviors in youths with ASD. Mood-stabilizing and nonstimulant ADHD/sleep medications did not contribute to aggression reduction.

Behavioral treatments in autism spectrum disorder: what do we know?

Although there are a large and growing number of scientifically questionable treatments available for children with autism spectrum disorder (ASD), intervention programs applying the scientific teaching principles of applied behavior analysis (ABA) have been identified as the treatment of choice. The following article provides a selective review of ABA intervention approaches, some of which are designed as comprehensive programs that aim to address all developmental areas of need, whereas others are skills based or directed toward a more circumscribed, specific set of goals. However, both types of approaches have been shown to be effective in improving communication, social skills, and management of problem behavior for children with ASD. Implications of these findings are discussed in relation to critical areas of research that have yet to be fully explored.

Neurofeedback for autistic spectrum disorder: a review of the literature

There is a need for effective interventions to address the core symptoms and problems associated with autistic spectrum disorder (ASD). Behavior therapy improves communication and behavioral functioning. Additional treatment options include psychopharmacological and biomedical interventions. Although these approaches help children with autistic problems, they may be associated with side effects, risks or require ongoing or long-term treatment. Neurofeedback is a noninvasive approach shown to enhance neuroregulation and metabolic function in ASD. We present a review of the literature on the application of Neurofeedback to the multiple problems associated with ASD. Directions for future research are discussed.

Applied behavior analytic intervention for autism in early childhood: meta-analysis, meta-regression and dose-response meta-analysis of multiple outcomes

A number of clinical trials and single-subject studies have been published measuring the effectiveness of long-term, comprehensive applied behavior analytic (ABA) intervention for young children with autism. However, the overall appreciation of this literature through standardized measures has been hampered by the varying methods, designs, treatment features and quality standards of published studies. In an attempt to fill this gap in the literature, state-of-the-art meta-analytical methods were implemented, including quality assessment, sensitivity analysis, meta-regression, dose-response meta-analysis and meta-analysis of studies of different metrics. Results suggested that long-term, comprehensive ABA intervention leads to (positive) medium to large effects in terms of intellectual functioning, language development, acquisition of daily living skills and social functioning in children with autism. Although favorable effects were apparent across all outcomes, language-related outcomes (IQ, receptive and expressive language, communication) were superior to non-verbal IQ, social functioning and daily living skills, with effect sizes approaching 1.5 for receptive and expressive language and communication skills. Dose-dependant effect sizes were apparent by levels of total treatment hours for language and adaptation composite scores. Methodological issues relating ABA clinical trials for autism are discussed.

Effectiveness of special nursery provision for children with autism spectrum disorders

The effectiveness of three local authority early teaching interventions for children with autism spectrum disorders (ASDs) was studied. Thirty-three children (2:6 to 4:0 years old) received one of three early teaching interventions: a 1:1 home-based programme, and two different forms of special nursery placement. Measures from the Psycho-Educational Profile, British Abilities Scale, and Vineland Adaptive Behavior Scales were taken over a 10 month period. The study showed moderate effect sizes for improvements in all scales for children attending a generalized special nursery placement, and for those attending a special nursery placement solely for children with ASDs. Children receiving a home-based 1:1 programme with similar intervention hours showed moderate effect sizes for the PEP and BAS but not for the VABS. These data show that special nursery placements can offer benefits to children with ASDs, especially in the area of adaptive behavioural functioning.

Video modeling to train staff to implement discrete-trial instruction

Three new direct-service staff participated in a program that used a video model to train target skills needed to conduct a discrete-trial session. Percentage accuracy in completing a discrete-trial teaching session was evaluated using a multiple baseline design across participants. During baseline, performances ranged from a mean of 12% to 63% accuracy. During video modeling, there was an immediate increase in accuracy to a mean of 98%, 85%, and 94% for each participant. Performance during maintenance and generalization probes remained at high levels. Results suggest that video modeling can be an effective technique to train staff to conduct discrete-trial sessions.

Cognitive and Adaptive Behavior Outcomes of Behavioral Intervention for Young Children With Intellectual Disability

Data from Norway were analyzed to evaluate early behavioral intervention for children with intellectual disabilities. The intervention group ( n = 11) received approximately 10 hours per week of behavioral intervention; the eclectic comparison group ( n = 14) received treatment as usual. After 1 year, changes in intelligence and adaptive behavior scores were statistically significant in favor of the behavioral intervention group (effect sizes of 1.13 for Intelligence quotient (IQ) change and .95 for change in adaptive behavior composite). Approximately 64% of the children in the behavioral intervention group met objective criteria for reliable change in IQ, whereas 14% in the eclectic comparison group did so. These results suggest that children with intellectual disability may profit from behavioral intervention typically provided for children with autism.

Assessing progress during treatment for young children with autism receiving intensive behavioural interventions

This study examined progress after 1 year of treatment for children with autism who received a mean of 36 hours per week one-to-one University of California at Los Angeles Applied Behavior Analysis (UCLA ABA) treatment. Two types of service provision were compared: an intensive clinic based treatment model with all treatment personnel ( N = 23), and an intensive parent managed treatment model with intensive supervision only ( N = 21). A non-concurrent multiple baseline design across participants ( N = 13) examined whether progress was associated with ABA treatment or confounders. Between intake and follow-up, children in both groups improved significantly on IQ, visual-spatial IQ, language comprehension, expressive language, social skills, motor skills and adaptive behaviour. There were no significant differences between the two groups on any of the measures at follow-up. Mean IQ for participants in both groups increased by 16 points between intake and follow-up. These findings are consistent with previous studies demonstrating the benefits of ABA treatment.

Meta-analysis of Early Intensive Behavioral Intervention for children with autism

A systematic literature search for studies reporting effects of Early Intensive Behavioral Intervention identified 34 studies, 9 of which were controlled designs having either a comparison or a control group. We completed a meta-analysis yielding a standardized mean difference effect size for two available outcome measures: change in full-scale intelligence and/or adaptive behavior composite. Effect sizes were computed using Hedges's g. The average effect size was 1.10 for change in full-scale intelligence (95% confidence interval = .87, 1.34) and .66 (95% confidence interval = .41, .90) for change in adaptive behavior composite. These effect sizes are generally considered to be large and moderate, respectively. Our results support the clinical implication that at present, and in the absence of other interventions with established efficacy, Early Intensive Behavioral Intervention should be an intervention of choice for children with autism.

Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language, and adaptive behavior: a systematic review and meta-analysis

OBJECTIVE

To review the effectiveness of applied behavior intervention (ABI) programs for preschool children with autism spectrum disorder (ASD) in their cognitive, adaptive behavior, and language development.

STUDY DESIGN

Systematic reviews, randomized or quasirandomized controlled trials (RCT) of ABI delivered to preschool children with ASD were reviewed. Quantitative data on cognitive, language, and behavior outcomes were extracted and pooled for meta-analysis (RevMan 4.2).

RESULTS

Thirteen studies met the inclusion criteria. Six of these were randomized comparison trials with adequate methodologic quality (PEDro >or= 6). Meta-analysis of 4 studies concluded that, compared with standard care, ABI programs did not significantly improve the cognitive outcomes of children in the experimental group who scored a standardized mean difference (SMD) of 0.38 (95%CI -0.09 to 0.84; P = .1). There was no additional benefit over standard care for expressive language; SMD of 0.37 (95%CI -0.09 to 0.84; P = .11), for receptive language; SMD of 0.29 (95%CI -0.17 to 0.74; P = .22) or adaptive behavior; SMD of 0.30 (95%CI -0.16 to 0.77; P = .20).

CONCLUSIONS

Currently there is inadequate evidence that ABI has better outcomes than standard care for children with autism. Appropriately powered clinical trials with broader outcomes are required.

A case study in the misrepresentation of applied behavior analysis in autism: the gernsbacher lectures

I know that most men, including those at ease with problems of the greatest complexity, can seldom accept the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have proudly taught to others, and which they have woven, thread by thread, into the fabrics of their life. (Tolstoy, 1894)This article presents a case study in the misrepresentation of applied behavior analysis for autism based on Morton Ann Gernsbacher's presentation of a lecture titled "The Science of Autism: Beyond the Myths and Misconceptions." Her misrepresentations involve the characterization of applied behavior analysis, descriptions of practice guidelines, reviews of the treatment literature, presentations of the clinical trials research, and conclusions about those trials (e.g., children's improvements are due to development, not applied behavior analysis). The article also reviews applied behavior analysis' professional endorsements and research support, and addresses issues in professional conduct. It ends by noting the deleterious effects that misrepresenting any research on autism (e.g., biological, developmental, behavioral) have on our understanding and treating it in a transdisciplinary context.

Recent advances in autism spectrum disorders

OBJECTIVE

This review article provides an overview of the most recent developments in the literature regarding autism spectrum disorders including epidemiology, etiology, assessment, and management/treatment.

METHOD

A review of the recent literature was conducted using Medline and the search term "Autism Spectrum Disorders."

RESULTS

Autism Spectrum Disorders are more common than previously believed (1 in 166), and etiology appears to be multifaceted including both heritable and non-heritable factors. State of the art treatment includes comprehensive medical monitoring as well as behavioral intervention.

CONCLUSIONS

Current and anticipated federal funding, policy changes, and large scale research projects provide promise for increasing knowledge about Autism Spectrum Disorders.

Behavioural and developmental interventions for autism spectrum disorder: a clinical systematic review

BACKGROUND

Much controversy exists regarding the clinical efficacy of behavioural and developmental interventions for improving the core symptoms of autism spectrum disorders (ASD). We conducted a systematic review to summarize the evidence on the effectiveness of behavioural and developmental interventions for ASD.

METHODS AND FINDINGS

Comprehensive searches were conducted in 22 electronic databases through May 2007. Further information was obtained through hand searching journals, searching reference lists, databases of theses and dissertations, and contacting experts in the field. Experimental and observational analytic studies were included if they were written in English and reported the efficacy of any behavioural or developmental intervention for individuals with ASD. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively and, where possible, meta-analyses of the study results were conducted. One-hundred-and-one studies at predominantly high risk of bias that reported inconsistent results across various interventions were included in the review. Meta-analyses of three controlled clinical trials showed that Lovaas treatment was superior to special education on measures of adaptive behaviour, communication and interaction, comprehensive language, daily living skills, expressive language, overall intellectual functioning and socialization. High-intensity Lovaas was superior to low-intensity Lovaas on measures of intellectual functioning in two retrospective cohort studies. Pooling the results of two randomized controlled trials favoured developmental approaches based on initiative interaction compared to contingency interaction in the amount of time spent in stereotyped behaviours and distal social behaviour, but the effect sizes were not clinically significant. No statistically significant differences were found for: Lovaas versus special education for non-verbal intellectual functioning; Lovaas versus Developmental Individual-difference relationship-based intervention for communication skills; computer assisted instruction versus no treatment for facial expression recognition; and TEACCH versus standard care for imitation skills and eye-hand integration.

CONCLUSIONS

While this review suggests that Lovaas may improve some core symptoms of ASD compared to special education, these findings are based on pooling of a few, methodologically weak studies with few participants and relatively short-term follow-up. As no definitive behavioural or developmental intervention improves all symptoms for all individuals with ASD, it is recommended that clinical management be guided by individual needs and availability of resources.

Applied behavior analysis treatment of autism: the state of the art

The treatment of individuals with autism is associated with fad, controversial, unsupported, disproven, and unvalidated treatments. Eclecticism is not the best approach for treating and educating children and adolescents who have autism. Applied behavior analysis (ABA) uses methods derived from scientifically established principles of behavior and incorporates all of the factors identified by the US National Research Council as characteristic of effective interventions in educational and treatment programs for children who have autism. ABA is a primary method of treating aberrant behavior in individuals who have autism. The only interventions that have been shown to produce comprehensive, lasting results in autism have been based on the principles of ABA.

What clinical characteristics of children with autism influence their inclusion in regular classrooms?

BACKGROUND

This study took place in the context of recent legislation enacted in several countries--including France--and aimed at promoting inclusion of children with intellectual disabilities. It focuses on young children with autism and examines the links between the children's characteristics and their weekly hours of regular-classroom inclusion and intervention in specialised setting.

METHOD

Standardised clinical and sociodemographic data were collected for 77 children with autism, along with data about their interventional programmes.

RESULTS

The study showed that the number of hours of inclusion at school was influenced by the children's behavioural and adaptive characteristics, as well as by the socioprofessional category of their parents, although these factors did not affect the number of hours spent in specialised setting. Moreover, the total amount of time per week spent in interventional services of any kind was very small for some of the children.

CONCLUSION

The time spent in special-intervention services and regular classrooms combined did not add up to an adequate number of weekly hours for these children, particularly those exhibiting at least one of the following characteristics: low adaptation level, major behavioural problems or low socioprofessional category of parents.

Evidence-based comprehensive treatments for early autism

Early intervention for children with autism is currently a politically and scientifically complex topic. Randomized controlled trials have demonstrated positive effects in both short-term and longer term studies. The evidence suggests that early intervention programs are indeed beneficial for children with autism, often improving developmental functioning and decreasing maladaptive behaviors and symptom severity at the level of group analysis. Whether such changes lead to significant improvements in terms of greater independence and vocational and social functioning in adulthood is also unknown. Given the few randomized controlled treatment trials that have been carried out, the few models that have been tested, and the large differences in interventions that are being published, it is clear that the field is still very early in the process of determining (a) what kinds of interventions are most efficacious in early autism, (b) what variables moderate and mediate treatment gains and improved outcomes following intervention, and (c) the degree of both short-term and long-term improvements that can reasonably be expected. To examine these current research needs, the empirical studies of comprehensive treatments for young children with autism published since 1998 were reviewed. Lovaas's treatment meet Chambless and colleague's (Chambless et al., 1998; Chambless et al., 1996) criteria for "well-established" and no treatment meets the "probably efficacious" criteria, though three treatments meet criteria for "possibly efficacious" (Chambless & Hollon, 1998). Most studies were either Type 2 or 3 in terms of their methodological rigor based on Nathan and Gorman's (2002) criteria. Implications of these findings are also discussed in relation to practice guidelines as well as critical areas of research that have yet to be answered.

Cognitive, behavior and intervention outcome in young children with autism

The relations between cognition and autism severity, head size and intervention outcome, were examined. Change in cognitive level with intervention was measured in children with autism and compared to children with developmental disabilities (DD). Eighty-one children (mean age 25.9 months) with autism (n=44) and DD (n=37) were assessed at pre- and post 1 year of intervention. Cognitive abilities and autism severity were measured by standardized tests. Three pre-intervention cognitive level groups: normal (IQ>90), borderline (70<IQ<89) and impaired (50<IQ<69) were examined. The impaired group had more severe autism symptoms than the borderline and the normal cognitive groups. However, following intervention the groups did not differ in the change in core autism symptoms. IQ scores increased significantly more in the autism group than in the DD group. IQ improvements correlated significantly with reduction in autism symptoms and mostly in stereotyped behaviors.

CONCLUSIONS

Cognitive ability in autism is associated with autism severity. Two distinct subtypes based on cognitive level are identified. However, baseline cognitive level cannot predict the progress rate in autism symptoms with intervention. Improvement of social-communicative behaviors and the intensive intervention are related to significant cognitive increments in autism.

Genetic and Environmental Influences on Symptom Domains in Twins and Siblings with Autism

Clarifying the sources of variation among autism symptom domains is important to the identification of homogenous subgroups for molecular genetic studies. This study explored the genetic and environmental bases of nonverbal communication and social interaction, two symptom domains that have also been related to treatment response, in 1294 child and adolescent twins and siblings with pervasive developmental disorders (PDDs) from the Autism Genetic Resource Exchange under the age of 18. Twin/sibling resemblance was assessed through correlations and behavior genetic modeling of Autism Diagnostic Interview (ADI) nonverbal communication and social scores. Variation in these phenotypes was explained by additive genetic, dominant genetic, and unique environmental factors with no evidence for shared environmental factors. Broad heritability estimates were higher for nonverbal communication (45%) than social interaction (28%). Nonverbal communication and social scores were partially accounted for by the same underlying genetic and environmental factors. Gender differences were not supported. These results add to information on familial resemblance of these symptom domains based on correlational methods, and this study is one of the first to apply behavioral genetic modeling to a PDD population. The results have implications for molecular genetics as well as treatment.

Diagnosis of autism spectrum disorders in the first 3 years of life

Autism spectrum disorders (ASDs) are a class of neurodevelopmental disorders defined by qualitative impairments in social functioning and communication, often accompanied by repetitive and stereotyped patterns of behavior and interests. The term 'ASD' encompasses autism, pervasive developmental disorder not otherwise specified, and Asperger's syndrome. ASDs show etiologic heterogeneity, and there is no definitive medical test or cure for these conditions. Around 1 in 150 children have an ASD, with males being affected three to four times more frequently than females. The age at diagnosis of ASD ranges from 3 to 6 years, but there is increasing evidence that diagnosis in the second year of life is possible in some children. Early diagnosis will lead to earlier behavior-based intervention, which is associated with improvements in core areas, such as social functioning and communication. Early detection of-and intervention to treat-ASD is crucial because it is likely to lead to an improved outcome.

Atypical antipsychotics in children with pervasive developmental disorders

The treatment of pervasive developmental disorders (PDDs) is a challenging task, which should include behavioral therapy modifications as well as pharmacologic therapy. There has been a lack of data on using medications in children with PDDs until recent years. Within the last 10 years, an increase in clinical research has attempted to provide efficacy and safety data to support the use of medications in children with PDDs. Double-blinded and open-label research of atypical antipsychotics has been of particular focus. Evidence shows that atypical antipsychotics (AAs) may be useful in treating certain symptoms associated with PDDs, such as aggression, irritability, and self-injurious behavior. This article reviews the literature regarding the use of AAs in children with PDDs. Of the AAs, risperidone has the largest amount of evidence with five published double-blinded, placebo-controlled trials and nine open-label trials. These risperidone trials have consistently shown improvements in aggression, irritability, self-injurious behavior, temper tantrums, and quickly changing moods associated with autistic disorder and other PDDs. Data for the other AAs are limited, but ziprasidone and aripiprazole appear to be promising treatment options. Based on clinical trials, olanzapine and quetiapine have shown minimal clinical benefit and a high incidence of weight gain and sedation. It should be noted that all AAs do have a risk of metabolic syndrome, and patients should be monitored appropriately while receiving these medications. Overall, AAs can be beneficial in alleviating behavioral symptoms, and should be considered an appropriate therapeutic option, as part of a comprehensive treatment strategy, for children with PDD.

Autism spectrum disorders in early childhood: an overview for practicing physicians

Autism spectrum disorders (ASDs) affect approximately 1 in 166 children in the United States, making it likely for the average physician to encounter patients with ASDs in his or her practice. In particular, pediatricians and developmental neurologists play a critical role in early identification, resource referrals, and management of a variety of comorbid physical and medical concerns. This article reviews the current literature on ASDs and provides recommendations for practice in areas critical to the provision of medical services.

Management of children with autism spectrum disorders

Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child's ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed.

Level of functioning in autism spectrum disorders: phenotypic congruence among affected siblings

Little evidence supports that siblings with autism exhibit the same behaviors; however, some findings suggest that level of functioning shows familial aggregation. We tested this notion among multiplex families participating with the Autism Genetic Resource Exchange (AGRE) Consortium, using scores on the Peabody Picture Vocabulary Test-Third Edition (N = 204 families), the Ravens Colored Progressive Matrices (N = 226 families), and the Vineland Adaptive Behavior Scales (N = 348 families). Intraclass Correlation Coefficients revealed that siblings with autism/autism spectrum disorders (ASD) were more similar on measures of verbal and nonverbal IQ and adaptive functioning than were unrelated children with autism/ASD. Preliminary twin correlations indicated strong genetic effects for some skill domains and the influence of shared environmental factors for others.