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

A randomized, controlled trial of a home-based intervention program for children with autism and developmental delay

OBJECTIVE

This study aimed to (1) investigate whether provision of a home-based program in addition to a center-based program improves development in young children with disabilities and coping abilities of their families and (2) describe the characteristics of children and families who benefit most from the intervention.

METHODS

Fifty-nine children, aged 3-5 years, with no cerebral palsy, participated in the study. Half of the group was randomized to receive an additional program in their homes. A special education teacher provided 40 visits over 12 months working with the families to help generalize skills to the home environment and assist with their concerns. All children were assessed before and after the intervention, and families completed questionnaires assessing family stress, support, and empowerment on both occasions. Differences in change over time and between the intervention and control group were analyzed by repeated measures and the association between characteristics of children and families with improved outcome by multivariate analysis of variance.

RESULTS

Change in cognitive development and behavior (in the centers) over time favored the children who received the extra intervention (p = .007 and p = .007, respectively). The groups did not differ on any of the family measures of change. Multivariate analysis of variance revealed more improvement for children in the intervention group from higher than lower stressed families.

CONCLUSIONS

Results suggest the need for daily reinforcement of skills learned at the center-based program and the importance of involving families, especially those with few resources and relatively high stress.

A two-year prospective follow-up study of community-based early intensive behavioural intervention and specialist nursery provision for children with autism spectrum disorders

BACKGROUND

This prospective study compared outcome for pre-school children with autism spectrum disorders (ASD) receiving autism-specific nursery provision or home-based Early Intensive Behavioural Interventions (EIBI) in a community setting.

METHODS

Forty-four 23- to 53-month-old children with ASD participated (28 in EIBI home-based programmes; 16 in autism-specific nurseries). Cognitive, language, play, adaptive behaviour skills and severity of autism were assessed at intake and 2 years later.

RESULTS

Both groups showed improvements in age equivalent scores but standard scores changed little over time. At follow-up, there were no significant group differences in cognitive ability, language, play or severity of autism. The only difference approaching significance (p = .06), in favour of the EIBI group, was for Vineland Daily Living Skills standard scores. However, there were large individual differences in progress, with intake IQ and language level best predicting overall progress.

CONCLUSIONS

Home-based EIBI, as implemented in the community, and autism-specific nursery provision produced comparable outcomes after two years of intervention.

Outcome for children with autism who began intensive behavioral treatment between ages 4 and 7: a comparison controlled study

This study extends findings on the effects of intensive applied behavior analytic treatment for children with autism who began treatment at a mean age of 5.5 years. The behavioral treatment group (n = 13, 8 boys) was compared to an eclectic treatment group (n = 12, 11 boys). Assignment to groups was made independently based on the availability of qualified supervisors. Both behavioral and eclectic treatment took place in public kindergartens and elementary schools for typically developing children. At a mean age of 8 years, 2 months, the behavioral treatment group showed larger increases in IQ and adaptive functioning than did the eclectic group. The behavioral treatment group also displayed fewer aberrant behaviors and social problems at follow-up. Results suggest that behavioral treatment was effective for children with autism in the study.

Brief report: the effects of Tomatis sound therapy on language in children with autism

Due to the myriad of problems associated with autism, parents often consider alternative treatments. The investigation was undertaken to determine the effects of the Tomatis Method on language skills in children with autism utilizing a randomized, double-blind, placebo-controlled, crossover design. The results indicated that although the majority of the children demonstrated general improvement in language over the course of the study, it did not appear to be related to the treatment condition. The percent change for Group 1 (Placebo/Treatment) for treatment was 17.41%, and placebo was 24.84%. Group 2 (Treatment/Placebo) showed -3.98% change for treatment and 14.15% change for placebo. The results reflect a lack of improvement in language using the Tomatis Method for children with autism.

Estimating the Burden of Disease for Autism Spectrum Disorders in Spain in 2003

Autism Spectrum Disorders (ASD) are lifelong neurodevelopmental disabilities. Burden of Disease is an indicator that provides important information on health status and outcomes such as premature mortality and disability. In order to estimate the burden of disease of ASD in the Spanish population during 2003, we followed the procedures used in the WHO Global Burden of Disease Study. ASD generated 43,928 Disability Adjusted Life Years (DALY) in Spain in 2003, from which 33,797 were attributable to Autistic Disorder and 10,131 were caused by Asperger's Disorder and Pervasive Developmental Disorder-Not Otherwise Specified. DALY could be a useful tool for health policy makers for setting health service priorities, allocating available resources effectively and providing a comparable measure of output for early intervention.

The effects of intellectual functioning and autism severity on outcome of early behavioral intervention for children with autism

This study assessed the relation between pre-intervention variables (cognition, socialization and communication) to outcome in young children with autism.

METHOD

Twenty five children with autism (20-32 months) were enrolled in intensive behavior intervention. The children were divided into groups based on their IQ scores and on the severity of their social interaction and communication deficits [per autism diagnostic observation schedule (ADOS) scores]. Six developmental-behavioral domains including, imitation, receptive language, expressive language, nonverbal communication skills, play skills and stereotyped behaviors were assessed at pre- and post-1 year of intervention times.

RESULTS

Significant progress was noted in all the six developmental-behavioral domains after 1 year of intervention. Children with higher initial cognitive levels and children with fewer measured early social interaction deficits showed better acquisition of skills in three developmental areas, receptive language, expressive language and play skills. Both groups showed better progress in Receptive language skills. Better progress in expressive language was associated with the child's social abilities, while more significant progress in play skills was related to pre-intervention cognitive level.

CONCLUSIONS

These findings emphasize the importance of early intensive intervention in autism and the value of pre-intervention cognitive and social interaction levels for predicting outcome.

Early communication development and intervention for children with autism

Autism is a neurodevelopmental disorder defined by impairments in social and communication development, accompanied by stereotyped patterns of behavior and interest. The focus of this paper is on the early development of communication in autism, and early intervention for impairments in communication associated with this disorder. An overview of components of communication is provided. Communication characteristics that are diagnostic of autism are summarized, with consideration of the overlap between social and communication impairment, particularly for children with autism functioning at the prelinguistic level. Early communication development and predictors of communication functioning in autism are examined, based on a review of prospective and retrospective studies. The focus of the discussion then turns to intervention. Consideration is given to the rationale for beginning intervention as early in life as possible for children with autism. Implications of motor, imitation, and play deficits for communication-based intervention are examined. Finally, issues related to the design and delivery of intervention for young children with autism are presented, along with a review of the major early intervention approaches for autism.

Developmental disabilities modification of the Children's Global Assessment Scale

BACKGROUND

Interventions for pervasive developmental disorders (PDD) aim to alleviate symptoms and improve functioning. To measure global functioning in treatment studies, the Children's Global Assessment Scale was modified and psychometric properties of the revised version (DD-CGAS) were assessed in children with PDD.

METHODS

Developmental disabilities-relevant descriptors were developed for the DD-CGAS, and administration procedures were established to enhance rater consistency. Ratings of clinical case vignettes were used to assess inter-rater reliability and temporal stability. Validity was assessed by correlating the DD-CGAS with measures of functioning and symptoms in 83 youngsters with PDD. Sensitivity to change was assessed by comparing change from baseline to post-treatment with change on the Aberrant Behavior Checklist-Irritability and Clinical Global Impressions-Improvement subscale scores in a subset of 14 children.

RESULTS

Inter-rater reliability (intraclass correlation coefficient [ICC] = .79) and temporal stability (average ICC = .86) were excellent. The DD-CGAS scores correlated with measures of functioning and symptoms with moderate to large effect sizes. Changes on the DD-CGAS correlated with changes on the Aberrant Behavior Checklist-I (r = -.71) and Global Impressions Scale-I (r = -.52). The pre-post DD-CGAS change had an effect size of .72.

CONCLUSIONS

The DD-CGAS is a reliable instrument with apparent convergent validity for measuring global functioning of children with PDD in treatment studies.

Predictors of expressive vocabulary growth in children with autism

PURPOSE

The purpose of this exploratory study was to examine the variability and predictors of expressive vocabulary development in children with autism and very delayed language.

METHOD

This study involved 35 children with autism whose initial chronological ages were between 20 and 71 months and whose initial expressive vocabularies were less than 60 words. Their expressive vocabularies were measured at baseline and at 6, 12, and 24 months following the start of intervention using the MacArthur-Bates Communicative Developmental Inventory (L. Fenson et al., 1993).

RESULTS

A cluster analysis revealed 4 distinct patterns of expressive vocabulary development over 2 years. The number of words said, the presence of verbal imitation skills and pretend play skills with objects, and the number of gestures to initiate joint attention at baseline were all associated with the cluster of children who demonstrated the most rapid expressive vocabulary growth over time. The 2 clusters of children who demonstrated the least vocabulary growth had the most significant developmental delays and autism severity at 6 months, but not at baseline.

CONCLUSIONS

This study confirms the heterogeneity in language development in young children with autism and, consistent with other reports, confirms that specific prelinguistic skills are predictive of development.

Differential treatment intensity research: A missing link to creating optimally effective communication interventions

Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. Yet virtually no systematic research has been conducted on the effects of different treatment intensities. We review how intervention intensity has been defined in the literature and propose a set of terms borrowed from medicine that are intended to capture the dynamic aspects of this concept as an aid to further investigation. On the basis of this approach, we propose four types of knowledge that can be generated through the systematic study of treatment intensity and discuss appropriate methods for investigating the effects of differential treatment intensities. We conclude with three recommendations for the field.

Frankfurter Gruppentraining sozialer Fertigkeiten für Kinder und Jugendliche mit autistischen Störungen

Zusammenfassung: Fragestellung: Trotz des hohen Bedarfs an gruppentherapeutischen Interventionen bei Kindern und Jugendlichen mit autistischen Störungen stehen bisher kaum spezifische deutschsprachige Therapieprogramme zur Verfügung. Seit 2003 wird an unserer Klinik ein strukturiertes Gruppentraining sozialer Fertigkeiten primär für Kinder und Jugendliche mit High-Functioning-Autismus und Asperger-Syndrom entwickelt und durchgeführt. Das Training adressiert die Hauptproblembereiche dieser Störungsbilder, Hauptziele sind die Verbesserung der sozialen Kommunikations- und Interaktionsfertigkeiten. Methodik: Die Teilnehmer sind Kinder und Jugendliche mit ausreichenden kognitiven Fähigkeiten und funktionaler Sprache. Prinzipien der Intervention sind die Strukturierung der Abläufe, Kombination von theoretischen und praktischen Elementen, verbindliche Gruppenregeln, Berücksichtigung individueller Problembereiche, schrittweises Vorgehen und sukzessive Steigerung des Schwierigkeitsgrades der Therapiebausteine. Die Therapiebausteine umfassen strukturierte Gruppenspiele, Training der Emotionserkennung, gemeinsame Gruppenaktivitäten, Rollenspiele, Gruppendiskussionen, Feedback und Hausaufgaben. Verwendet wird ein an unserer Klinik entwickeltes Gruppentrainingsprogramm sozialer Fertigkeiten in Form eines strukturierten Trainingsmanuals. Das Training umfasst aktuell drei Gruppen (5-7 Teilnehmer) unterschiedlicher Altersbereiche (Kinder und Jugendliche) und findet wöchentlich/14-tägig für 1-1,5 Stunden außerhalb der Schulferien statt. Jeweils zwei Gruppenleiter leiten die Trainingsstunden und wechseln sich im Verlauf des Programms ab. Es finden in regelmäßigen Abständen Gruppengesprächsrunden mit den Eltern zum gegenseitigen Erfahrungsaustausch und zur Information über Einzelheiten des Programms statt. Ergebnisse: Sowohl die Akzeptanz und Zufriedenheit mit dem Training als auch die Toleranz für die jeweiligen individuellen Probleme sind unter den Teilnehmern hoch. Rückmeldung der Eltern und die klinischen Beobachtungen der Gruppenleiter weisen auf eine klare Verbesserung der Verbalisations- und Kontaktfähigkeit hin. Die Teilnehmer scheinen dabei insbesondere von den Rollenspielen zu profitieren. Schlussfolgerungen: Qualitative Daten (Angaben der Teilnehmer, Eltern und der Gruppenleiter zu Veränderungen der sozialen Fertigkeiten) legen verbesserte Interaktions-, Kommunikations- und Problemlösefertigkeiten im Verlauf des Gruppentrainings nahe. Eine laufende Pilotevaluation des Gruppentrainings beinhaltet auch die Erfassung von Effekten in Alltagssituationen. In Abhängigkeit der Ergebnisse könnte das Training nachfolgend in gemischten Gruppen mit anderen psychiatrischen Störungsbildern angewendet und überprüft werden.

Follow-up of children diagnosed with pervasive developmental disorders: stability and change during the preschool years

Forty-one children with pervasive developmental disorders (PDDs) receiving eclectic services were assessed twice during their preschool years. Measures were compared over time for the whole group and for diagnostic subgroups: Childhood autism (CA group) and Other PDDs group. The mean intelligence quotient/developmental quotient (IQ/DQ) of the whole group was stable (P = 0.209) and scores on the Childhood Autism Rating Scale (CARS) decreased (P = 0.001). At time 2, the CA group was more impaired than the other PDDs group: autistic symptoms were more severe (P = 0.01), adaptive behavior scores were lower (P = 0.014), and a trend for lower IQ/DQs (P = 0.06). Children in this study seemed to fare better than reported in previous follow-up studies on children with autism.

Effects of low-intensity behavioral treatment for children with autism and mental retardation

We retrospectively compared 2 groups of children receiving either behavioral treatment (n = 13) or eclectic treatment (n = 15) for an average of 12 hours per week. Children were assessed on intelligence, language, adaptive functioning and maladaptive behavior at pretreatment and 2 years into treatment. The groups did not differ significantly at pretreatment. After 2 years of treatment, the behavioral group made larger gains than the eclectic group in most areas. However, gains were more modest than those reported in previous studies with children receiving more intensive behavioral treatment, and it is questionable whether they were clinically significant.

Screening for infants with developmental deficits and/or autism: a Swedish pilot study

The purpose of this study was to develop an instrument (SEEK) for the early detection of developmental deficits and/or autistic spectrum disorders among children by the age of 8 months at eight child health care centers in southern Sweden. Health visitors, trained by the research team, screened 312 infants. SEEK captured 5 infants with several points. Twenty-one percent of the infants obtained at least one SEEK point. At the 18-month follow-up, 5 children still showed more obvious signs of developmental problems. The health visitors found SEEK to be very satisfactory and easy and quick to use and its items and questions to be easy to administer. The results have indicated a new systematic methodology to examine infants, which is to be further developed.

Neurobiological correlates of autism: a review of recent research

This review paper integrates recent structural and functional imaging, postmortem, animal lesion, and neurochemical research about the pathophysiology of autism. An understanding of the neurobiological correlates of autism is becoming increasingly important as more children are diagnosed with the condition and funding for well-targeted interventions increases. Converging evidence suggests that autism involves abnormalities in brain volume, neurotransmitter systems, and neuronal growth. In addition, evidence firmly links autism with abnormalities in the cerebellum, the medial temporal lobe, and the frontal lobe. Potential implications of these findings and suggestions for future research are reviewed.

Challenges in evaluating psychosocial interventions for Autistic Spectrum Disorders

In 2002, the National Institutes of Health sponsored a meeting concerning methodological challenges of research in psychosocial interventions in Autism Spectrum Disorders. This paper provides a summary of the presentations and the discussions that occurred during this meeting. Recommendations to federal and private agencies included the need for randomized clinical trials of comprehensive interventions for autism as the highest, but not the sole priority. Ongoing working groups were proposed to address psychosocial interventions with a focus on relevant statistics, standardized documentation and methods of diagnosis, development of outcome measures, establishment of standards in research; and the need for innovative treatment designs, including application of designs from other research areas to the study of interventions in ASD.

Risperidone and adaptive behavior in children with autism

OBJECTIVE

To evaluate the impact of risperidone on adaptive behavior in children with autistic disorder who have serious behavior problems and to examine different methods of scoring the Vineland Adaptive Behavior Scales to measure change.

METHOD

Forty-eight children (5 years to 16 years, 5 months) who showed behavioral improvement during acute treatment with risperidone were followed for 6 months and assessed with the Vineland Scales.

RESULTS

Raw scores, age-equivalents, and special norm percentile scores all showed significant increases in adaptive behavior in the areas of communication, daily living skills, and socialization (p <.01). During a period of 6 to 8 months, children gained an average of 7.8 age-equivalent months in the area of socialization, a > 6% improvement beyond what would be expected based on baseline growth rates.

CONCLUSIONS

Although limited by the absence of a control group, these results suggest that risperidone may improve adaptive skills in children with autistic disorder accompanied by serious behavioral problems. Vineland age-equivalent scores appear to be most useful in assessing change with treatment over time.

Individual behavioral profiles and predictors of treatment effectiveness for children with autism

Differential responsiveness to intervention programs suggests the inadequacy of a single treatment approach for all children with autism. One method for reducing outcome variability is to identify participant characteristics associated with different outcomes for a specific intervention. In this investigation, an analysis of archival data yielded 2 distinct behavioral profiles for responders and nonresponders to a widely used behavioral intervention, pivotal response training (PRT). In a prospective study, these profiles were used to select 6 children (3 predicted responders and 3 predicted nonresponders) who received PRT. Children with pretreatment responder profiles evidenced positive changes on a range of outcome variables. Children with pretreatment nonresponder profiles did not exhibit improvements. These results offer promise for the development of individualized treatment protocols for children with autism.

Evaluating the effectiveness of teacher training in Applied Behaviour Analysis

Interventions for children with autism based upon Applied Behaviour Analysis (ABA) has been repeatedly shown to be related both to educational gains and to reductions in challenging behaviours. However, to date, comprehensive training in ABA for teachers and others have been limited. Over 7 months, 11 teachers undertook 90 hours of classroom instruction and supervision in ABA. Each teacher conducted a comprehensive functional assessment and designed a behaviour support plan targeting one behaviour for one child with an autistic disorder. Target behaviours included aggression, non-compliance and specific educational skills. Teachers recorded observational data for the target behaviour for both baseline and intervention sessions. Support plans produced an average 80 percent change in frequency of occurrence of target behaviours. Questionnaires completed by parents and teachers at the end of the course indicated a beneficial effect for the children and the educational environment. The potential benefits of teacher implemented behavioural intervention are discussed.

A comparison of intensive behavior analytic and eclectic treatments for young children with autism

We compared the effects of three treatment approaches on preschool-age children with autism spectrum disorders. Twenty-nine children received intensive behavior analytic intervention (IBT; 1:1 adult:child ratio, 25-40 h per week). A comparison group (n=16) received intensive "eclectic" intervention (a combination of methods, 1:1 or 1:2 ratio, 30 h per week) in public special education classrooms (designated the AP group). A second comparison group (GP) comprised 16 children in non-intensive public early intervention programs (a combination of methods, small groups, 15 h per week). Independent examiners administered standardized tests of cognitive, language, and adaptive skills to children in all three groups at intake and about 14 months after treatment began. The groups were similar on key variables at intake. At follow-up, the IBT group had higher mean standard scores in all skill domains than the AP and GP groups. The differences were statistically significant for all domains except motor skills. There were no statistically significant differences between the mean scores of the AP and GP groups. Learning rates at follow-up were also substantially higher for children in the IBT group than for either of the other two groups. These findings are consistent with other research showing that IBT is considerably more efficacious than "eclectic" intervention.

Autism in infancy and early childhood

Although initially described as an inborn disorder of affective contact, information on autism as it exists in infants has been limited. Delays in diagnosis, lack of information about the condition, and reliance on retrospective research strategies have been problematic. An awareness of the increased risk for siblings is now allowing the development of new, prospective approaches. Consistent with Kanner's original hypothesis, the available information strongly suggests a fundamental difficulty in the earliest social processes, which, in turn, impacts many other areas of development. New approaches to screening have lowered the age of initial diagnosis; this presents new challenges for early intervention. Directions for future research are highlighted.

Who should pay for intensive behavioural intervention in autism? A parent's view

The evidence that early intensive behavioural intervention (IBI) is effective for young children with autism has persuaded parents worldwide to finance and advocate for IBI. Intensive behavioural intervention uses applied behavioural analysis to address the deficits of autism with an individualized and systematic approach. Communication, social, cognitive and adaptive gains are seen in the majority of children; a sizeable minority can catch up to near normal functioning, under ideal conditions. However there is not universal acceptance amongst professionals that IBI is the most proven intervention. What level of evidence is required for Australian states to provide adequate public funds for IBI?

Does routine child health surveillance contribute to the early detection of children with pervasive developmental disorders? An epidemiological study in Kent, U.K

Background

Recently changed guidelines for child health surveillance in the United Kingdom (U.K.) suggest targeted checks only, instead of the previously conducted routine or universal screening at 2 years and 3.5 years. There are concerns that these changes could lead to a delay in the detection of children with autism and other pervasive developmental disorders (PDD). Recent U.K. studies have suggested that the prevalence of PDD is much higher than previously estimated. This study establishes to which extent the routine checks contributed to the early detection and assessment of cases of PDD. Simultaneously we have evaluated the process involved and estimate the prevalence of PDD in our district.

Methods

Retrospective study design utilising community medical files. Headteachers of schools (n = 75) within Maidstone district (Kent) were asked to report all children with an established diagnosis of autism or PDD attending year 4 (born '91 and '92 / n = 2536) in October 2000 based on educational records.

Results

59 schools (78.7%) took part in the study. A total of 33 children were reported. 21 fulfilled the inclusion criteria (12 falsely reported). The prevalences were (per 10,000): PDD 82.8 (male to female ratio 6:1), childhood autism 23.7, Asperger's syndrome 11.8 and autistic spectrum disorder 47.3. Co-existing medical conditions were noted in 14.3%; 52.4% were attending mainstream schools. In 63.2% of cases concerns – mainly in the area of speech and language development (SLD) – had been documented at the 2 year check. At the 3.5 year check concerns were noted in 94.1% – the main area was again SLD (76.5%), although behavioural abnormalities were becoming more frequent (47.1%). A total of 13 children (68.4%) were referred for further assessment as a direct result of the checks.

Conclusions

The prevalences for different types of PDD were similar to figures published recently, but much higher than reported a few years ago. Analysis of our data suggests that routine surveillance is a valuable contributing factor for the early detection of PDD and thereby facilitates early intervention. Thus, if routine surveillance ceases, then an alternative method of early detection should be put in place.

Autism and pervasive developmental disorders

The quantity and quality of research into autism and related conditions have increased dramatically in recent years. Consequently we selectively review key accomplishments and highlight directions for future research. More consistent approaches to diagnosis and more rigorous assessment methods have significantly advanced research, although the boundaries of the 'broader phenotype' remain to be defined and the validity of Asperger's disorder as a discrete syndrome remains controversial. Recent epidemiological studies have shown that Autism Spectrum Disorders are common, but there continues to be debate about the causes of the increase in the frequency with which autism is diagnosed. Psychological research has helped to develop new developmental models for the disorder and there have also been significant advances in the molecular genetics of autism and understanding of the underlying neurobiological processes. Areas important for future research include the study of autism as it first develops, i.e., in infants and very young children, and of specific processes (psychological and neurobiological) which underlie the disorder. Significant challenges lie ahead in evaluating the growing number of treatments for autism and in integrating the results of research into treatment and educational settings.

Early intervention critical to autism treatment

It is still not universally accepted within the scientific community that the habilitation of autistic children is possible, or that their ability to function without supports in regular education by third, fourth, or fifth grade happens as a direct result of EIBI. However, using the outcome studies that have been reported, the rate of children reaching a best-outcome status appears to be between about 10% and 47%. There is a more global way to look at the effects of EIBI or behavioral intervention. Even if the child retains many characteristics of autism, the usual outcome of treatment is that the child learns useful skills. Behavioral intervention results in effective and efficient learning, which is precisely what it aims to accomplish and what behavioral techniques have been developed to do. Children and families have been able to achieve much more than many would ever have believed before EIBI became a realistic possibility.

Autism spectrum disorders: early detection, intervention, education, and psychopharmacological management

Our understanding and treatment of children with autism have changed dramatically since Leo Kanner first formally documented the disorder in 1943. With reference to the historical context, this paper reviews recent research addressing 4 major issues: early detection, intervention, education, and psychopharmacological management of children with autism and related (autistic) spectrum disorders (hereafter, "autism"). We conclude from our review of the evidence that, in the absence of additional, more compelling data, the clinical usefulness of existing screening instruments remains questionable. However, the potential importance of such research is underscored by the clear benefits of early behavioural intervention: despite differences in orientation, outcomes for children with autism can be significantly enhanced with early intensive intervention. Although many questions remain (notably, What are the critical therapeutic components? For whom? For what domains of development? For what level of intensity and duration?), interventions shown to be effective are all carefully planned, engineered, monitored, and designed to target specific skill domains. Including children with autism in regular classes within the public school system poses several challenges, the most pressing of which is the large number of school personnel who need to be trained in evidence-based teaching and behavioural management practices. Finally, psychotropic drugs may help to reduce some symptoms, but they are neither curative nor a substitute for other forms of support and intervention.