Implementation evaluation of early intensive behavioral intervention programs for children with autism spectrum disorders: A systematic review of studies in the last decade

Family-Centric Applied Behavior Analysis Promotes Sustained Treatment Utilization and Attainment of Patient Goals

BACKGROUND/OBJECTIVES

 Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social communication difficulties and restricted repetitive behaviors or interests. Applied behavior analysis (ABA) has been shown to significantly improve outcomes for individuals on the autism spectrum. However, challenges regarding access, cost, and provider shortages remain obstacles to treatment delivery. To this end, parents were trained as parent behavior technicians (pBTs), improving access to ABA, and empowering parents to provide ABA treatment in their own homes. We hypothesized that patients diagnosed with severe ASD would achieve the largest gains in overall success rates toward skill acquisition in comparison to patients diagnosed with mild or moderate ASD. Our secondary hypothesis was that patients with comprehensive treatment plans (>25-40 hours/week) would show greater gains in skill acquisition than those with focused treatment plans (less than or equal to 25 hours/week).  Methods: This longitudinal, retrospective chart review evaluated data from 243 patients aged two to 18 years who received at least three months of ABA within our pBT treatment delivery model. Patients were stratified by utilization of prescribed ABA treatment, age, ASD severity (per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), and treatment plan type (comprehensive vs. focused). Patient outcomes were assessed by examining success rates in acquiring skills, both overall and in specific focus areas (communication, emotional regulation, executive functioning, and social skills).

RESULTS

Patients receiving treatment within the pBT model demonstrated significant progress in skill acquisition both overall and within specific focus areas, regardless of cohort stratification. Patients with severe ASD showed greater overall skill acquisition gains than those with mild or moderate ASD. In addition, patients with comprehensive treatment plans showed significantly greater gains than those with focused treatment plans.

CONCLUSION

The pBT model achieved both sustained levels of high treatment utilization and progress toward patient goals. Patients showed significant gains in success rates of skill acquisition both overall and in specific focus areas, regardless of their level of treatment utilization. This study reveals that our pBT model of ABA treatment delivery leads to consistent improvements in communication, emotional regulation, executive functioning, and social skills across patients on the autism spectrum, particularly for those with more severe symptoms and those following comprehensive treatment plans.

Vowel distinctiveness as a concurrent predictor of expressive language function in autistic children

Speech ability may limit spoken language development in some minimally verbal autistic children. In this study, we aimed to determine whether an acoustic measure of speech production, vowel distinctiveness, is concurrently related to expressive language (EL) for autistic children. Syllables containing the vowels [i] and [a] were recorded remotely from 27 autistic children (4;1-7;11) with a range of spoken language abilities. Vowel distinctiveness was calculated using automatic formant tracking software. Robust hierarchical regressions were conducted with receptive language (RL) and vowel distinctiveness as predictors of EL. Hierarchical regressions were also conducted within a High EL and a Low EL subgroup. Vowel distinctiveness accounted for 29% of the variance in EL for the entire group, RL for 38%. For the Low EL group, only vowel distinctiveness was significant, accounting for 38% of variance in EL. Conversely, in the High EL group, only RL was significant and accounted for 26% of variance in EL. Replicating previous results, speech production and RL significantly predicted concurrent EL in autistic children, with speech production being the sole significant predictor for the Low EL group and RL the sole significant predictor for the High EL group. Further work is needed to determine whether vowel distinctiveness longitudinally, as well as concurrently, predicts EL. Findings have important implications for the early identification of language impairment and in developing language interventions for autistic children.

Behavioral Interventions for Autism Spectrum Disorder: A Brief Review and Guidelines With a Specific Focus on Applied Behavior Analysis

We conducted a comprehensive review of behavioral and educational interventions for individuals with autism spectrum disorder (ASD). The most prominent type of intervention, Comprehensive Early Intervention, often referred to as Early Intensive Behavioral Intervention (EIBI), has been found to be particularly effective in improving intelligence and adaptive behaviors. The naturalistic developmental behavioral intervention, designed to enhance social and communication abilities, showed effectiveness in improving language, cognitive function, and social initiation. However, more studies are needed to examine its effectiveness. Intensive individualized intervention, which provides a tailored intervention for a specific target behavior, was effective in improving social skills and communication, as well as reducing sleep, eating, and toileting problems. Cognitive behavioral therapy (CBT) is the most effective method for dealing with emotional difficulties, but it has not been widely used because of the shortage of trained experts. Parent-mediated intervention (PMI) involves parents acquiring knowledge and specific skills to improve their child's functioning or reduce challenging behaviors. Speech and language therapy, sensory integration, Treatment and Education of Autistic and related Communications Handicapped Children, developmental approaches, and social stories are frequently used interventions. However, evidence of their effectiveness has yet to be well established. Based on these findings, intervention recommendations for autism include EIBI, Early Start Denver Model, intensive individualized intervention, CBT, and PMI. The choice of intervention should be tailored to the individual's needs and delivered by qualified professionals with expertise in the specific intervention.

Non-pharmacological interventions for autism spectrum disorder in children: an overview of systematic reviews

OBJECTIVE

To assess the effectiveness of non-pharmacological interventions for the treatment of autism spectrum disorder (ASD) in children.

DESIGN

Overview of systematic reviews (SRs).

PARTICIPANTS

Children aged 12 years and under with ASD.

SEARCH METHODS

In October 2021, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and Epistemonikos placing no restrictions on language or date of publication.

INTERVENTIONS

17 non-pharmacological interventions compared with placebo, no-treatment (including waiting list) or other interventions (ie, usual care, as defined by the authors of each study).

DATA COLLECTION AND ANALYSIS

We rated the methodological quality of the included SRs using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). We reported the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty of the evidence (CoE) according to the analysis conducted by the authors of the included SRs.

MAIN OUTCOME MEASURES

A multidisciplinary group of experts agreed on analysing nine critical outcomes evolving core and non-core ASD symptoms.

PUBLIC AND PATIENT INVOLVEMENT STATEMENT

Organisations of parents of children with ASD participated in external revision of the final version of the report.

RESULTS

We identified 52 reports that were within our scope, of which 48 were excluded for various reasons. After excluding less reliable SRs, we included four SRs. Non-pharmacological interventions (ie, Early Intensive Behavioural Intervention, Applied Behaviour Analysis, Picture Exchange Communication System and Naturalistic Developmental Behavioural Interventions) may have favourable effects on some core outcomes including language, social and functioning, play or daily living skills in children with ASD (with either no GRADE assessment, very low or low CoE). In addition, we identified a lack of report for other key outcomes in the included SRs (ie, restricted, repetitive behaviour; play and sensory processing).

CONCLUSIONS

Synthesised evidence regarding the efficacy of non-pharmacological interventions for children with ASD is scarce. High-quality SRs addressing the variety of both non-pharmacological interventions and relevant outcomes are needed.

PROSPERO REGISTRATION NUMBER

CRD42020206535.

Treatment of Preschool Children With Autism Spectrum Disorder: A Trial to Evaluate a Learning Style Profile Intervention Program in China

OBJECTIVE

To investigate whether the provision of learning style profile (LSP) training improves development in preschool children with autism spectrum disorder (ASD) in China and to describe the characteristics of children who benefit from the intervention.

METHODS

Eighty-one children aged 36 to 72 months who were diagnosed with ASD for the first time were recruited for the intervention group. All of them received 24 weeks of LSP training, consisting of hospital- and home-based training. Twenty-one children with ASD of the same age in the control group had never received any intervention after diagnosis but underwent an assessment. Assessments were conducted at baseline and 24 weeks later. Differences in the developmental level and severity of ASD symptoms over time and between groups were analyzed by repeated standardized measures. Secondary analyses examined age effects among the 36- 48-, 48- 60-, and 60-72-month age groups.

RESULTS

Within-group comparison of the intervention group revealed significant treatment effects after the intervention, according to: language, social and adaptive developmental quotients (DQs) of the China Developmental Scale; total Childhood Autism Rating Scale (CARS) score; and hyperactivity, peer problems, total difficulties, and prosocial behavior scores of the Strengths and Difficulties Questionnaire (SDQ). Similar gains were observed in gross and fine motor DQs of the China Developmental Scale and emotional symptoms and conduct problems scores of the SDQ; however, the differences between these pre- and postintervention scores did not reach statistical significance. Comparisons among the three age groups in the intervention groups demonstrated a significant age effect on adaptive DQs of the China Developmental Scale; total CARS score; hyperactivity, peer problems and total difficulties scores of the SDQ. Comparison between the intervention and control groups revealed significant treatment effects on language, social and adaptive DQs of the China Developmental Scale; total CARS score; and emotional symptoms, conduct problems, hyperactivity, peer problems, total difficulties, and prosocial behavior scores of the SDQ after the intervention. Similar gains were observed in gross and fine motor DQs of the China Developmental Scale, although differences between the two groups did not reach statistical significance.

CONCLUSION

Our findings suggest that LSP training can effectively improve social behavior and reduce the severity of ASD symptoms in children with ASD. Our data also highlight the importance of early intervention.

Comparing the Impact of Differing Preschool Autism Interventions on Parents in Two Canadian Provinces

Early Intensive Behavioural Intervention (EIBI) is effective for preschoolers with autism spectrum disorder (ASD). Parental measures are rarely included in EIBI effectiveness studies, yet parental distress and lower self-efficacy are associated with poorer child outcomes. Parents of preschoolers with ASD (N = 485) were surveyed at baseline (T1), one-year post-intervention (T2), and school entry (T3) about family distress/crisis, parental self-efficacy, and satisfaction with services in two Canadian provinces. Family distress/crisis decreased and parental self-efficacy increased from T1 to T2. Increases in self-efficacy were largely maintained at T3. Parents were highly satisfied with services. Greater satisfaction for those residing in the province utilizing a parent-coaching model suggests that parent involvement is associated with positive parent outcomes.

Spending on Young Children With Autism Spectrum Disorder in Employer-Sponsored Plans, 2011-2017

OBJECTIVE

Rapid increases in the prevalence of autism spectrum disorder (ASD) and increased access to intensive behavioral interventions have likely increased health care spending. This study estimated recent changes in spending among privately insured children with and without current ASD.

METHODS

A repeated cross-sections analysis of 2011-2017 claims data from large-employer-sponsored health plans assessed changes in annual expenditures by service type for children ages 3-7 enrolled for ≥1 year and with two or more claims with ASD billing codes within a calendar year and for all other children.

RESULTS

Mean spending per child with a current-year ASD diagnosis increased by 51% in 2017 U.S. dollars, from roughly $13,000 in 2011 to $20,000 in 2017. Among children who did not meet the current-year ASD case definition, per-child spending increased by 8%. Spending on children with ASD accounted for 41% of spending growth for children ages 3-7 during 2011-2017. Outpatient behavioral intervention-related spending per child with ASD increased by 376%, from $1,746 in 2011 to $8,317 in 2017; spending on all other services increased by 2%. Their share of behavioral intervention-related spending increased from 13.2% in 2011 to 41.7% in 2017. In 2011, 2.5% of children with current-year ASD diagnoses incurred ≥$20,000 in outpatient behavioral intervention-related spending, which increased to 14.4% in 2017.

CONCLUSIONS

During 2011-2017, spending increased six times as much for privately insured children ages 3-7 with current-year ASD as for children without ASD, largely from increased behavioral intervention-related spending. One in seven children received at least $20,000 in services in 2017.

Linking risk factors and outcomes in autism spectrum disorder: is there evidence for resilience?

Autism spectrum disorder (referred to here as autism) is one of several overlapping neurodevelopmental conditions that have variable impacts on different individuals. This variability results from dynamic interactions between biological and non-biological risk factors, which result in increasing differentiation between individuals over time. Although this differentiation continues well into adulthood, the infancy period is when the brain and behavior develop rapidly, and when the first signs and symptoms of autism emerge. This review discusses advances in our understanding of the causal pathways leading to autism and overlapping neurodevelopmental conditions. Research is also mapping trajectories of brain and behavioral development for some risk groups, namely later born siblings of children with autism and/or infants referred because of developmental concerns. This knowledge has been useful in improving early identification and establishing the feasibility of targeted interventions for infant risk groups before symptoms arise. However, key knowledge gaps remain, such as the discovery of protective factors (biological or environmental) that may mitigate the impact of risk. Also, the dynamic mechanisms that underlie the associations between risk factors and outcomes need further research. These include the processes of resilience, which may explain why some individuals at risk for autism achieve better than expected outcomes. Bridging these knowledge gaps would help to provide tools for early identification and intervention that reflect dynamic developmental pathways from risk to outcomes.

The Implementation of Functional Family Therapy (FFT) as an Intervention for Youth Probationers in Singapore

Family functioning is predictive of youth recidivism in Singapore. However, there is a lack of family based interventions for youth offenders on community probation. Evidence-based family interventions developed in Western populations, such as Functional Family Therapy (FFT), have been found to be effective in mitigating subsequent youth criminal behavior. However, no study has examined whether such interventions can be implemented and adapted for use in Eastern cultures. Thus, this paper sought to detail the implementation of FFT in Singapore. Rationale for the adoption of FFT is discussed, and key activities undertaken during the first 18 months of implementation are described. Preliminary data suggest that initial implementation efforts were successful. Challenges encountered, and implications in relation to the broader literature are discussed.

Early results from a combined low-intensive psychoeducational intervention for preschoolers with autism spectrum disorder

Purpose: Early and Intensive Behavioral Treatments are considered to be evidence-based interventions for children with Autism Spectrum Disorder (ASD). Nevertheless, children with ASD might not always have the opportunity to benefit from intensive treatment; new, more accessible and alternative treatment options need to be tested. The aim of this study was to evaluate the effectiveness of the Combined Low-intensive Psychoeducational Intervention (CLI-PEI) delivered to preschoolers with ASD at the end of the pre-primary school day.Methods: A quasi-experimental design study, namely a pretest-posttest alternative-treatment comparison groups design, was used. Treatment sessions were carried out over a period of 12 months. Forty-three individuals with autism were included in the study: 24 received the CLI-PEI and 19 were administered the Treatment As Usual. A pre- and posttreatment assessment was carried out using the Psychoeducational Profile-Third edition and the Vineland Adaptive Behavior Scale.Results: The children who received the CLI-PEI showed better gains in both developmental and maladaptive behaviors; furthermore, increased skills were found in all adaptive domains.Conclusions: The CLI-PEI might seems to be a viable treatment option for children with ASD, when intensive behavioral treatments are not accessible.Implication for rehabilitationChildren with ASD might not always have the opportunity to benefit from intensive treatment.The identification of more accessible, less intensive and less expensive evidence-based psychoeducational interventions might represent an appealing challenge for rehabilitation therapists.Less intensive and less expensive evidence-based interventions might also represent a viable option for children and their families, especially in communities with limited resources for autism.A pragmatic approach including components from evidence-based treatments might guarantee flexibility and the possibility to implement an intervention well-tailored to the specific child needs.CLI-PEI for preschoolers with ASD seems to be a promising pragmatic approach, promoting improvements in developmental, adaptive and maladaptive domains.