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

Acquisition Time for Resting-State HbO/Hb Coupling Measured by Functional Near-Infrared Spectroscopy in Assessing Autism

Functional near-infrared spectroscopy was used to record spontaneous hemodynamic fluctuations form the bilateral temporal lobes in 25 children with autism spectrum disorder (ASD) and 22 typically developing (TD) children. The coupling between oxygenated hemoglobin (HbO) and deoxygenated hemoglobin (Hb) was calculated by Pearson correlation coefficient, showing significant difference between ASD and TD, thus the coupling could be a characteristic feature for ASD. To evaluate the discrimination ability of the feature obtained in different acquisition times, the receiver operating characteristic curve (ROC) was constructed and the area under curve (AUC) was calculated. The results showed AUC > 0.8 when the time duration was longer than 1.5 min, but longer than 4 min, AUC value (~0.87) hardly varied, implying the maximal discrimination ability reached. This study demonstrated the coupling could be one of characteristic features for ASD even acquired in a short measurement time.

Determining Associations Between Intervention Amount and Outcomes for Young Autistic Children: A Meta-Analysis

Importance

Health professionals routinely recommend intensive interventions (ie, 20-40 hours per week) for autistic children. However, primary research backing this recommendation is sparse and plagued by methodological flaws.

Objective

To examine whether different metrics of intervention amount are associated with intervention effects on any developmental domain for young autistic children.

Data Sources

A large corpus of studies taken from a recent meta-analysis (with a search date of November 2021) of early interventions for autistic children.

Study Selection

Studies were eligible if they reported a quasi-experimental or randomized clinical trial testing the effects of a nonpharmacological intervention on any outcome in participant samples comprising more than 50% autistic children 8 years or younger.

Data Extraction and Synthesis

Data were independently extracted by multiple coders. Meta-regression models were constructed to determine whether each index of intervention amount was associated with effect sizes for each intervention type, while controlling for outcome domain, outcome proximity, age of participants, study design, and risk of detection bias. Data were analyzed from June 2023 to February 2024. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Main Outcomes and Measures

The primary predictor of interest was intervention amount, quantified using 3 different metrics (daily intensity, duration, and cumulative intensity). The primary outcomes of interest were gains in any developmental domain, quantified by Hedges g effect sizes.

Results

A total of 144 studies including 9038 children (mean [SD] age, 49.3 [17.2] months; mean [SD] percent males, 82.6% [12.7%]) were included in this analysis. None of the meta-regression models evidenced a significant, positive association between any index of intervention amount and intervention effect size when considered within intervention type.

Conclusions and Relevance

Findings of this meta-analysis do not support the assertion that intervention effects increase with increasing amounts of intervention. Health professionals recommending interventions should be advised that there is little robust evidence supporting the provision of intensive intervention.

Alliance for Scientific Autism Intervention: System Components and Outcome Data from High-Quality Service Delivery Organizations

Promoting excellence in autism intervention is arguably more urgent than ever for the field of applied behavior analysis. To fulfill this objective, autism agencies must operate from validated program systems and do so with fidelity. Program components include, but are not limited to, staff training and evaluation of clinical skills, functional personnel roles designed to promote positive outcomes for those served, and professional staff-communication-skill repertoires. Data on client outcomes must be tied to implementation of core program variables; and, contingencies between the data on client outcomes and staff performance must exist. Furthermore, these contingencies must be yoked across members of the organization to ensure a sustainable and effective program model. Finally, data on consumer satisfaction must be collected and used to evaluate program components and agency practices. Members of the Alliance for Scientific Autism Intervention have implemented key program-wide systems based upon the work of McClannahan and Krantz Journal of Applied Behavior Analysis, 26, 589-596 (1993) for decades and across various agency cultures. Data collected by six independent educational agencies on client outcomes, program implementation, and consumer feedback for a 10-year time span demonstrate the sustainability of the model and support the importance of key organizational systems and the relationship between implementation of the model and high-quality outcomes for individuals with autism.

Outcomes for children with autism spectrum disorder and their families after two years of school based early intensive behavioural intervention

The effectiveness of a school based Early Intensive Behavioural Intervention (EIBI) program was assessed over a two-year period for a cohort of 16 pre-school children with autism spectrum disorder (ASD) and their families. Children with a mean age of 40 months, were assessed prior to intervention, after 1 year of intervention, and again after 2 years. Significant improvements were observed on measures of adaptive behaviour, communication ability and challenging behaviour. Parents of children attending the program also reported increased familial quality of life, specifically improved emotional and physical well-being and increased parenting capacity over the duration of the program. The current study suggests that EIBI for young children with ASD can be effective in facilitating improvements in communication ability, reducing challenging behaviours and improving quality of life for families. Children's pre-intervention adaptive skills appeared to be the strongest predictor of post intervention gains as initial level of adaptive ability was positively related to improved post-intervention outcomes.

Behavior Analysts' Use of Treatments for Individuals with Autism: Trends within the Field

Previous surveys revealed the majority of certified behavior analysts reported using applied behavior analysis (ABA) as a treatment for individuals on the autism spectrum. However, some certificants have also reported using treatments without evidence (Schreck et al. Behavioral Interventions, 31(4), 355-376, 2016; Schreck & Mazur Behavioral Interventions: Theory & Practice in Residential & Community- Based Clinical Programs, 23(3), 201-212, 2008). The field of ABA has undergone many changes in the last five years. This survey evaluated trends in the use and variables influencing the use of autism treatments over that time. Results indicated that study participants (N = 921 BCBA-Ds, BCBAs, BCaBAs, and RBTs) were significantly less likely to report current use of ABA and some unestablished treatments (e.g., DIR Floortime, sensory integration therapy) than participants in 2016 (Schreck et al. Behavioral Interventions, 31(4), 355-376, 2016). Participants frequently cited persuasion by others as an influence for their treatment selections. Because behavior analysts' use of unestablished treatments may be detrimental to client outcomes and the reputation and success of the field of ABA, future research is needed to identify methods for increasing behavior analysts' use of empirically supported treatments.

Teaching Requesting to Individuals with Rett Syndrome Using Alternative Augmentative Communication (AAC) Through Caregiver Coaching via Telehealth

Rett syndrome is a severe neurodevelopmental disorder that results in both motor and language skill regression with a wide range of severity in symptom presentation. Communication intervention may be particularly challenging for this population due to the decline in speech, motor skills, and motor planning difficulties that characterize the disorder (Townend et al., 2020), often resulting in the need for augmentative and alternative communication (AAC) technology. Very limited research has evaluated communication interventions for individuals with Rett syndrome and even fewer have targeted expressive communication, an important skill required for improved autonomy and quality of life (Sigafoos et al., 2009; Townend et al., 2020). The current study sought to systematically replicate the Simacek et al. (2017) mand training procedures to teach three girls with Rett Syndrome to use AAC to make requests through caregiver coaching by researchers via telehealth. Results suggest that mand training was successful in increasing AAC use for all three participants. Barriers to intervention for this population and implications of results for future research and clinical practice are discussed.

Autism Spectrum Disorder: When There is no Cure, There are Countless of Treatments

We investigated parent reports of use of special education and support services, use of evidence-based practices (EBPs), use of past and current complementary and alternative medicine (CAM) treatments, non-use of CAM treatments, willingness, and unwillingness to use CAM treatments, reasons for use and non-use of CAM treatments, and perceptions of EBPs and CAM treatments in their children's functioning. We collected data from a total of 166 parents of children with autism spectrum disorder (ASD) through a web-based survey. 94% of the parents reported lifetime use of at least one CAM treatment. Parents weighed on a wide variety of factors in decision-making. CAM treatments use was positively associated with parental educational level, length of time since ASD diagnosis, and child's ASD severity.

A Pilot Feasibility Study Assessing the Combined Effects of Early Behavioral Intervention and Propranolol on Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD), a neurodevelopmental disorder typified by differences in social communication as well as restricted and repetitive behaviors, is often responsive to early behavioral intervention. However, there is limited information on whether such intervention can be augmented with pharmacological approaches. We conducted a double-blinded, placebo-controlled feasibility trial to examine the effects of the β-adrenergic antagonist propranolol combined with early intensive behavioral intervention (EIBI) for children with ASD. Nine participants with ASD, ages three to ten, undergoing EIBI were enrolled and randomized to a 12-week course of propranolol or placebo. Blinded assessments were conducted at baseline, 6 weeks, and 12 weeks. The primary outcome measures focusing on social interaction were the General Social Outcome Measure-2 (GSOM-2) and Social Responsiveness Scale-Second Edition (SRS-2). Five participants completed the 12-week visit. The sample size was insufficient to evaluate the treatment efficacy. However, side effects were infrequent, and participants were largely able to fully participate in the procedures. Conducting a larger clinical trial to investigate propranolol's effects on core ASD features within the context of behavioral therapy will be beneficial, as this will advance and individualize combined therapeutic approaches to ASD intervention. This initial study helps to understand feasibility constraints on performing such a study.

A Comparison Controlled Study Examining Outcome for Children With Autism Receiving Intensive Behavioral Intervention (IBI)

This study evaluated the effects of a center-based Intensive Behavioral Intervention (IBI) model for preschool aged children with autism. Outcomes of 25 children receiving IBI was compared to the outcomes of 14 children receiving autism specific, eclectic, special education. Both provisions were described as appropriate treatment options by the professional agency who diagnosed the children, and the decision of where to enroll the child was made by the parents after consultations with the specialists. After 14 months of treatment, children from the IBI group improved significantly on standard scores in intellectual functioning and adaptive behavior and had a significant reduction in autism severity compared to the children in the autism specific, eclectic, special education group. Results suggest that preschool aged children with autism may make large gains in intellectual and adaptive functioning and improvement in autism severity with IBI, and that effects of IBI may be similar to that of EIBI. These findings must be interpreted with caution due to the limitations inherent in the present comparison-controlled design.

ICT Framework for Supporting Applied Behavior Analysis in the Social Inclusion of Children with Neurodevelopmental Disorders

The applied behavior analysis (ABA) model emphasizes observable and measurable behaviors by carrying out decision making using experimental data (behavioral observation assessment strategies). In this framework, information and communication technology (ICT) becomes highly suitable for enhancing the efficiency and effectiveness of the methodology. This paper aims to delve into the potential of ICT in providing innovative solutions to support ABA applications. It focuses on how ICT can contribute to fostering social inclusion with respect to children with neurodevelopmental disorders. ICT offers advanced solutions for continuous and context-aware monitoring, as well as automatic real-time behavior assessments. Wireless sensor systems (wearable perceptual, biomedical, motion, location, and environmental sensors) facilitate real-time behavioral monitoring in various contexts, enabling the collection of behavior-related data that may not be readily evident in traditional observational studies. Moreover, the incorporation of artificial intelligence algorithms that are appropriately trained can further assist therapists throughout the different phases of ABA therapy. These algorithms can provide intervention guidelines and deliver an automatic behavioral analysis that is personalized to the child's unique profile. By leveraging the power of ICT, ABA practitioners can benefit from cutting-edge technological advancements to optimize their therapeutic interventions and outcomes for children with neurodevelopmental disorders, ultimately contributing to their social inclusion and overall wellbeing.

Geographic Access to Registered Behavior Technicians among Children with Autism Spectrum Disorder

Research has documented inequities in geographic access to board certified behavior analysts (BCBAs) among children with autism spectrum disorder (ASD). Unexplored is geographic access to registered behavior technicians (RBTs), the frontline ABA providers BCBAs supervise. In this study we examined county-level geographic access to RBTs in the United States, including change in their geographic distribution over time, the current distribution of RBTs related to the distribution of BCBAs, and the current distribution of RBTs as a function of children with ASD. The sample included all U.S. counties in all 50 states and the District of Columbia (N = 3,138). County-level ASD/RBT ratios indicate that the number of children with ASD far exceed RBTs, and the geographic accessibility of RBTs appears to be superior to that of BCBAs.

Clinical Outcomes of a Hybrid Model Approach to Applied Behavioral Analysis Treatment

Objective This study examines the implementation of a hybrid applied behavioral analysis (ABA) treatment model to determine its impact on autism spectrum disorder (ASD) patient outcomes.  Methods Retrospective data were collected for 25 pediatric patients to measure progress before and after the implementation of a hybrid ABA treatment model under which therapists consistently captured session notes electronically regarding goals and patient progress. ABA treatment was streamlined for consistent delivery, with improved software utilization for tracking scheduling and progress. Eleven goals within three domains (behavioral, social, and communication) were examined.  Results After the implementation of the hybrid model, the goal success rate improved by 9.7% compared to the baseline; 41.8% of goals showed improvement, 38.4% showed a flat trend, and 19.8% showed deterioration. Multiple goals trended upwards in 76% of the patients.  Conclusion This pilot study demonstrated that enhancing the consistency with which ABA treatment is monitored/delivered can improve patient outcomes as seen through improved attainment of goals.

Comprehensive ABA-based interventions in the treatment of children with autism spectrum disorder - a meta-analysis

BACKGROUND

Many studies display promising results for interventions that are based on Applied Behavior Analysis (ABA) in the treatment of autism spectrum disorder (ASD).

METHODS

This meta-analysis assessed the effects of such treatments on developmental outcomes in children with ASD and on parental stress based on 11 studies with 632 participants.

RESULTS

Compared to treatment as usual, minimal or no treatment, comprehensive ABA-based interventions showed medium effects for intellectual functioning (standardized mean difference SMD = 0.51, 95% CI [0.09; 0.92]) and adaptive behavior (SMD = 0.37, 95% CI [0.03; 0.70]). Language abilities, symptom severity or parental stress did not improve beyond the improvement in control groups. Moderator analyses indicate that language abilities at intake could influence the effect sizes and the influence of treatment intensity might decrease with older age.

CONCLUSIONS

Practical implications and limitations are discussed.

Resting-state coupling between HbO and Hb measured by fNIRS in autism spectrum disorder

To distinguish between children with autism spectrum disorder (ASD) and typically developing (TD) children, we have uncovered a new discriminative feature, hemoglobin coupling. Functional near-infrared spectroscopy (fNIRS) was used to record resting-state hemodynamic fluctuations in the bilateral temporal lobes in 25 children with ASD and 22 TD children, in which the coupling between low frequency oxygenated hemoglobin (HbO) and deoxygenated hemoglobin (Hb) fluctuations was evaluated by Pearson correlation coefficient. The results showed significantly weak coupling in children with ASD in both the left and right, and throughout the whole temporal cortex. To explain this observation, a simulation study was performed using a balloon model, in which we found four related parameters could impact the coupling. This study suggested that hemoglobin coupling might be applied as a new cerebral hemodynamic characteristic for ASD screening or diagnostics.

Parent Perceptions of the Effects of Early Intensive Behavioral Interventions for Children with Autism

The current study aimed to understand parents' perceptions of the effects of early intensive behavioral intervention (EIBI) based on the principles of applied behavioral analysis (ABA) and the lasting outcomes for their children with Autism spectrum disorder (ASD). In particular, this study sought to examine parent perceptions of the relationship between the intensity of ABA interventions and current autism symptom severity, adaptive functioning, and school placement. The current study employed a convergent parallel mixed-methods design, which consisted of collecting, analyzing, interpreting, and combining both quantitative and qualitative data. Overall, results suggested that the intensity of previous ABA interventions was a unique predictor of current school placement. Additionally, results suggested that the intensity of previous ABA interventions was a unique predictor of adaptive skills, which was supported by parent interviews. However, the intensity of previous ABA interventions was not a unique predictor of current autism severity. Parent responses to interview questions revealed the imperative nature of the interventions and their effect on service delivery for their children with ASD. Overall, this study provided an increased understanding of parents' perceptions of the effectiveness of EIBI, which in turn may be central to understanding service utilization.

A follow-up study of early intensive behavioral intervention program for children with Autism in Syria

We examined the sustained effects of early intensive behavioral intervention (EIBI) on 66 children with autism spectrum disorder who participated in the Future Center's EIBI program. Children were assessed using the childhood autism rating scale (CARS), autism behavior checklist (ABC), and adaptive behavior scale (ABS-Arabic) 3 years after leaving the program. Continued positive effects were observed in several areas, including adaptive behavior and autism symptoms. However, participants' social skills might have declined on the ABS-Arabic after service withdrawal. Additionally, a significant negative association (p < .001) was found between participants' performance on the CARS and the number of weekly trials. This is encouraging, given the lack of EIBI services and regional instability. Future research should increase the sample size and use a more rigorous design.

Addressing current barriers to autism diagnoses through a tiered diagnostic approach involving pediatric primary care providers

Formal autism diagnosis from a specialist trained in autism assessment is customary prior to a child accessing early, intensive autism-specific services. However, long wait lists for diagnostic evaluations and limited specialty workforce have created substantial delays. Additionally, lengthy multidisciplinary evaluations are costly to insurers, inconvenient to families, and disproportionally impact under-resourced families. Diagnostic delays can impede access to intervention services. These barriers, combined with evidence regarding the importance of receiving early, autism-specific treatment, demand new approaches enabling access to autism specific services before comprehensive evaluation. Pediatric primary care providers (PCPs) are often the only health care professionals with whom a family interacts during early childhood and can play a crucial role in helping children with autism symptoms access services. Many strategies for autism diagnosis in primary care are being developed and tested; however, they have yet to be broadly adopted by PCPs, primarily due to critical implementation barriers in primary care settings. There is also not enough evidence on the accuracy of PCPs' diagnostic impressions without extensive specialty support, resulting in PCP hesitancy in diagnosing ASD, as well as family and service provider hesitancy in accepting a PCP autism diagnosis. In this commentary, we explore the acute need for shortening waitlists for autism evaluations through a tiered diagnostic approach, in which PCPs can rule in or rule out autism in children, for whom diagnosis is clear, and refer more complex cases for specialist evaluations, and explore implementation challenges to this approach.

Early intervention for very young children with or at high likelihood for autism spectrum disorder: An overview of reviews

AIM

To identify which interventions are supported by evidence and the quality of that evidence in very young children with or at high likelihood for autism spectrum disorder (ASD) to improve child outcomes.

METHOD

We conducted an overview of reviews to synthesize early intervention literature for very young children with or at high likelihood for ASD. Cochrane guidance on how to perform overviews of reviews was followed. Comprehensive searches of databases were conducted for systematic reviews and meta-analyses between January 2009 and December 2020. Review data were extracted and summarized and methodological quality was assessed. Primary randomized controlled trial evidence was summarized and risk of bias assessed. This overview of reviews was not registered.

RESULTS

From 762 records, 78 full texts were reviewed and seven systematic reviews and meta-analyses with 63 unique studies were identified. Several interventional approaches (naturalistic developmental behavioral intervention, and developmental and behavioral interventions) improved child developmental outcomes. Heterogeneity in design, intervention and control group, dose, delivery agent, and measurement approach was noted. Inconsistent methodological quality and potential biases were identified.

INTERPRETATION

While many early interventional approaches have an impact on child outcomes, study heterogeneity and quality had an impact on our ability to draw firm conclusions regarding which treatments are most effective. Advances in trial methodology and design, and increasing attention to mitigating measurement bias, will advance the quality of the ASD early intervention evidence base.

WHAT THIS PAPER ADDS

Naturalistic developmental behavioral interventions, as well as developmental and behavioral interventions, improve child outcomes in autism spectrum disorder (ASD). If only randomized controlled trials are considered, guidelines for early intensive behavioral intervention in younger children should be revisited. The greatest intervention impacts were on proximal, intervention-specific outcomes. Inadequacies in the quality of the early ASD intervention evidence base were observed.

Applied Behavior Analysis in Children and Youth with Autism Spectrum Disorders: A Scoping Review

This manuscript provides a comprehensive overview of the impact of applied behavior analysis (ABA) on children and youth with autism spectrum disorders (ASD). Seven online databases and identified systematic reviews were searched for published, peer-reviewed, English-language studies examining the impact of ABA on health outcomes. Measured outcomes were classified into eight categories: cognitive, language, social/communication, problem behavior, adaptive behavior, emotional, autism symptoms, and quality of life (QoL) outcomes. Improvements were observed across seven of the eight outcome measures. There were no included studies that measured subject QoL. Moreover, of 770 included study records, only 32 (4%) assessed ABA impact, had a comparison to a control or other intervention, and did not rely on mastery of specific skills to mark improvement. Results reinforce the need for large-scale prospective studies that compare ABA with other non-ABA interventions and include measurements of subject QoL to provide policy makers with valuable information on the impacts of ABA and other existing and emerging interventions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-022-00338-x.

Concerns About ABA-Based Intervention: An Evaluation and Recommendations

For over 50 years, intervention methods informed by the principles of applied behavior analysis (ABA) have been empirically researched and clinically implemented for autistics/individuals diagnosed with autism spectrum disorder (ASD). Despite the plethora of evidence for the effectiveness of ABA-based interventions, some autism rights and neurodiversity activists have expressed concerns with ABA-based interventions. Concerns have included discontent with historical events and possible harm from the procedures and goals targeted. The purpose of this manuscript is to examine some expressed concerns about ABA-based intervention and suggest productive ways of moving forward to provide the best outcomes for autistics/individuals diagnosed with ASD. The authors represent stakeholders from multiple sectors including board certified behavior analysts, licensed psychologists, parents, and autistics/individuals diagnosed with ASD.

Assessing Parameters of Reinforcement on Efficiency of Acquisition: A Systematic Review

Discrete-trial training (DTT) is a common method of instruction used in early intervention amongindividuals with autism spectrum disorder and related neurodevelopmental disorders and is an effective method of teaching different skills such as tacting, listener responding, and matching. Delivery of effective reinforcers is a key component of DTT. Although general recommendations have been made for effective reinforcement delivery in DTT, no review has synthesized the available research on the efficiency of various reinforcer parameters on efficiency of acquisition. The current systematic review assessed the efficiency of various reinforcer parameters on acquisition in DTT. Results were idiosyncratic, and a general paucity of repeated measures examining specific reinforcer parameters within and across studies was observed. In general, (1) maintaining high levels of treatment integrity, (2) delivery of tangible (i.e. leisure items) or edible reinforcers in comparison with contingent praise as a reinforcer, and (3) delivery of edible reinforcers in comparison with other topographies of reinforcement were the most successful reinforcer parameter manipulations and always resulted in more efficient skill acquisition. The results of this review provide clinicians with information regarding what reinforcer parameter manipulations may be more or less likely to support efficient acquisition. The present review also provides considerations and makes recommendations for future research.

Standards for Interprofessional Collaboration in the Treatment of Individuals With Autism

Interprofessional collaboration has become an essential component in the treatment of individuals with autism spectrum disorder, as practitioners from a range of disciplines are often necessary to address the core features and co-occurring conditions. Theoretically, such cross-disciplinary collaboration results in superior client care and maximal outcomes by capitalizing on the unique expertise of each collaborating team member. However, conflict in collaborative practice is not uncommon given that the treatment providers come from varying educational backgrounds and may have opposing core values, fundamental goals, and overall approaches. Although the overarching interest of each of these professionals is to improve client outcomes and quality of life, they may be unequipped to effectively navigate the barriers to collaboration. This article reviews the potential benefits and misconceptions surrounding interprofessional collaboration and highlights common sources of conflict. As a proposed solution to many of the identified issues, we offer a set of standards for effective collaborative practice in the interprofessional treatment of autism spectrum disorder. These standards prioritize client care and value each discipline's education and unique contributions. They are intended to function as core standards for all treatment team members, promote unity, prevent conflict, and ultimately help practitioners achieve the most integrated collaborative practice among professionals of varying disciplines.

Collaboration between Behavior Analysts and Occupational Therapists in Autism Service Provision: Bridging the Gap

Interdisciplinary collaboration is challenging, but necessary, to meet the needs of individuals with autism spectrum disorder. Among the dyadic interactions in interdisciplinary teams, the relationships between occupational therapy practitioners and board certified behavior analysts are uniquely challenging. The disciplines define evidence-based practice differently and approach intervention from different angles. Furthermore, there are fundamental differences in worldview between the disciplines. Both disciplines offer necessary treatment, and successful collaboration between these disciplines is essential for maximizing outcomes. Hence, finding ways to help bridge the gap between these professions, in particular, is essential. Common barriers to developing collaborative alliances include misperceptions of the other discipline, differences in terminology, and unprofessional behavior. This article reviews the history and foundational concepts of both disciplines, and the common approaches associated with each. In addition, models of collaboration are discussed, with suggestions for enhancing interdisciplinary communication and treatment. Successful collaborative treatment is predicated on an understanding of the value and expertise offered by different disciplines, and requires mutual respect and professional dialogue.

Evidence-based use of scalable biomarkers to increase diagnostic efficiency and decrease the lifetime costs of autism

Challenges associated with the current screening and diagnostic process for autism spectrum disorder (ASD) in the US cause a significant delay in the initiation of evidence-based interventions at an early age when treatments are most effective. The present study shows how implementing a second-order diagnostic measure to high risk cases initially flagged positive from screening tools can further inform clinical judgment and substantially improve early identification. We use two example measures for the purposes of this demonstration; a saliva test and eye-tracking technology, both scalable and easy-to-implement biomarkers recently introduced in ASD research. Results of the current cost-savings analysis indicate that lifetime societal cost savings in special education, medical and residential care are estimated to be nearly $580,000 per ASD child, with annual cost savings in education exceeding $13.3 billion, and annual cost savings in medical and residential care exceeding $23.8 billion (of these, nearly $11.2 billion are attributable to Medicaid). These savings total more than $37 billion/year in societal savings in the US. Initiating appropriate interventions faster and reducing the number of unnecessary diagnostic evaluations can decrease the lifetime costs of ASD to society. We demonstrate the value of implementing a scalable highly accurate diagnostic in terms of cost savings to the US. LAY SUMMARY: This paper demonstrates how biomarkers with high accuracy for detecting autism spectrum disorder (ASD) could be used to increase the efficiency of early diagnosis. Results also show that, if more children with ASD are identified early and referred for early intervention services, the system would realize substantial costs savings across the lifespan.

Intensive behavioural interventions based on applied behaviour analysis for young children with autism: An international collaborative individual participant data meta-analysis

LAY ABSTRACT

Early intensive applied behaviour analysis-based interventions are designed to support young autistic children's learning and development. Unfortunately, the available evidence about the effectiveness of these interventions remains unclear. Several reviews have focused on the published findings rather than contacting the authors to collect and analyse data about the individual participants in the original studies. Also, most of the studies were carried out by groups involved in delivering the interventions leading to the potential bias in interpreting the results. Our research team (supported by an international advisory group) carried out an independent individual patient data review by collecting the original participant data from the authors of the studies, to examine the effectiveness of these interventions. The results suggested that early intensive applied behaviour analysis-based interventions might lead to some changes in children's cognitive ability (intelligence quotient) and everyday life skills after 2 years, compared with standard treatments. However, all the studies had problems with the way they were designed. Also, few of the studies looked at outcomes that have been described as most important to autistic people or followed children beyond 2 years. We think that further systematic reviews of the existing evidence are unlikely to add to the findings of our review. Furthermore, we recommend that future research should investigate which types of supports and interventions are most effective for children and families, prioritising outcomes measures that are meaningful for the autism community and include, wherever possible, longer-term follow-up.

A Longitudinal Study of Language Trajectories and Treatment Outcomes of Early Intensive Behavioral Intervention for Autism

The present study examined language trajectories and placement outcomes for children with autism spectrum disorder (ASD) receiving early intensive behavioral intervention (EIBI). Language measures were collected at baseline and 6, 12, 18, 24, and 36 months or until exit from EIBI in 131 children with ASD. Growth models estimated overall and subgroup language trajectories. Overall, children receiving EIBI showed substantial increases in language relative to normative expectations. Earlier age at EIBI start, higher baseline cognitive function, and lower baseline ASD severity predicted better language trajectories. Although there was significant variability in language trajectories and educational outcomes, most children showed significant increases in language scores, relative to normative expectations. Additional research, in more representative samples, is needed to understand this variability.

Autism, Therapy and COVID-19

While numerous treatments for ASD are available, intervention based on the principles and procedures of Applied Behavior Analysis (ABA) has garnered substantial scientific support. In this study we evaluated the effects of the lockdown during the COVID-19 pandemic outbreak, followed by quarantine provisions and during the three months after the resumption of activities. The study was conducted on a group of children taking part on a ABA-based intervention funded by the Local Health Authority (ASL) of the province of Caserta. In this study we considered a sample of 88 children who had been diagnosed with Autism Spectrum Disorder, aged between 18 and 30 months. The following inclusion criteria were observed: age at the time of diagnosis less than 30 months, absence of other neurological, genetic, or sensorineural pathologies, and severity level 1 measured by symptoms evaluation based on the ADOS 2 module T (used for diagnosis). During the lockdown children experienced improvements in communication, socialization, and personal autonomy. During the three months after the ABA treatment, the acquired skills were maintained but no significant improvement was demonstrated. In this study, we describe how parent training was significant in avoiding delays in the generalization of socially significant behaviors, following the drastic interruption of the treatment in this group of children.

An evaluation of a comprehensive training package for interventionists providing behavioral intervention for children with autism spectrum disorder

There has been rapid growth in the number of behavior analysts and interventionists in the world today. With this growth it is imperative to ensure that each behavior analyst and interventionist receives quality training. The training should be comprehensive (i.e. training multiple areas of behavior analysis) and should not conclude until the trainee is able to perform each behavior analytic procedure to a high degree of fidelity. The purpose of this study was to evaluate the effectiveness of a training package to train four participants how to implement multiple behavior analytic procedures. Using a multiple baseline design across participants the results indicate that each participant improved their implementation of behavioral intervention. Additionally, the participants maintained their skills over time.

A randomized clinical trial of a virtual-training program for teaching applied-behavior-analysis skills to parents of children with autism spectrum disorder

Parents play an important role in the treatment of their children's symptoms of autism spectrum disorder (ASD); thus, developing effective, efficient, socially acceptable, and accessible procedures for training parents to implement applied-behavior-analysis (ABA) interventions is critically important. One potential approach involves delivering training via a virtual private network (VPN) over the internet (Fisher et al., 2014). In this study, we conducted a randomized clinical trial to evaluate a virtual parent-training program with e-learning modules and scripted role-play via a VPN. We evaluated parent implementation of ABA skills using direct-observation measures in structured-work and play-based training contexts. Parents in the treatment group showed large, statistically significant improvements on all dependent measures; those in the waitlist-control group did not. Parents rated the training as highly socially acceptable. Results add to the growing literature on the efficacy and acceptability of virtually delivered training in ABA.

Interventions based on early intensive applied behaviour analysis for autistic children: a systematic review and cost-effectiveness analysis

BACKGROUND

Early intensive applied behaviour analysis-based interventions are intensive interventions for autistic children that are often delivered on a one-to-one basis for 20-50 hours per week.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of early intensive applied behaviour analysis-based interventions for autistic children, based on current evidence.

METHODS

A systematic review and individual participant data meta-analysis were conducted to evaluate the clinical effectiveness of an early intensive applied behaviour analysis-based intervention for autistic children. An economic analysis included a review of existing analyses and the development of a new model.

RESULTS

Twenty studies were included in the clinical review. Individual participant data were retrieved from 15 of these studies. Results favoured the interventions when assessing adaptive behaviour after 2 years compared with treatment as usual/eclectic interventions (mean difference 7.00, 95% confidence interval 1.95 to 12.06). In analyses of cognitive ability (intelligence quotient), results favoured the interventions by approximately 10 points after 1 year (mean difference 9.16, 95% confidence interval 4.38 to 13.93) and 2 years (mean difference 14.13, 95% confidence interval 9.16 to 19.10). Evidence for other outcomes was limited and meta-analyses were generally inconclusive. There was no evidence that the effect of the interventions varied with characteristics of the children, but data were limited. Adopting a £30,000 per quality-adjusted life-year threshold, the results of the cost-effectiveness analysis indicate that early intensive applied behaviour analysis-based interventions would need to generate larger benefits or cost savings to be cost-effective. Adopting a public sector perspective and making pessimistic assumptions about long-term effects, the incremental cost-effectiveness ratio for early intensive applied behaviour analysis-based therapy compared with treatment as usual is £189,122 per quality-adjusted life-year. When optimistic assumptions are made, the incremental cost-effectiveness ratio is £46,768 per quality-adjusted life-year. Scenario analyses indicated that these interventions can potentially be cost-effective if long-term improvements persist into adulthood, or if they have significant impact on educational placement. Care should be taken when interpreting these scenarios owing to the limited data.

LIMITATIONS

All included studies were at risk of bias, there was substantial heterogeneity and effects varied considerably across studies. The effect of intervention on autism symptom severity, language development and school placement remains uncertain because of the limited data. The long-term effects are unclear owing to a lack of follow-up data.

CONCLUSIONS

This review found limited evidence that early intensive applied behaviour analysis-based interventions may improve cognitive ability and adaptive behaviour, but the long-term impact of the interventions remains unknown. The economic analysis is constrained by the limited effectiveness evidence, but suggests that these interventions are unlikely to be cost-effective unless clear long-term benefits, or a substantial change in which schools children attend, can be identified.

FUTURE WORK

Further studies into the effectiveness of early intensive applied behaviour analysis-based interventions may be warranted if they include well-defined, alternative interventions as comparators and collect relevant outcomes. Consideration should be given to future studies that not only address whether or not early intensive applied behaviour analysis-based interventions are clinically effective, but also aim to identify which components of early intensive applied behaviour analysis-based interventions might drive effectiveness.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068303.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 35. See the NIHR Journals Library website for further project information.

Advances in Our Understanding of Behavioral Intervention: 1980 to 2020 for Individuals Diagnosed with Autism Spectrum Disorder

There are three branches of science of behavior analysis [i.e., experimental analysis of behavior, behavior analysis, and applied behavior analysis (ABA)]. ABA can be defined as a systematic approach to understanding behavior of social interest. For the past 40 plus years, researchers have evaluated ABA and ABA based procedures (e.g., behavioral intervention) as they relate to individuals diagnosed with autism spectrum disorder (ASD) and have implemented behavioral intervention in clinical settings for individuals diagnosed with ASD. In this paper, we discuss some of the pivotal contributions in the field of ABA in research and clinical practice. Additionally, we provide recommendations for the science and clinical practice of behavioral intervention in the next 40 years.

Exclusion Criteria Used in Early Behavioral Intervention Studies for Young Children with Autism Spectrum Disorder

This literature review evaluated early behavioral intervention studies of Autism Spectrum disorder (ASD) based on their participant exclusion criteria. The studies included were found through searching PsycINFO and PubMed databases, and discussed behavioral interventions for children up to 5 years of age with ASD and utilized a group research design. Studies reviewed were categorized into three groups: Restrictive exclusion criteria, loosely defined exclusion criteria, and exclusion criteria not defined. Results indicated that studies that used restrictive exclusion criteria demonstrated greater differences in terms of outcomes between experimental and control groups in comparison to studies that used loosely defined exclusion criteria and/or did not define any exclusion criteria. We discussed implications for the generalizability of the studies' outcomes in relationship to exclusion criteria.

Helping parents choose treatments for young children with autism: A comparison of applied behavior analysis and eclectic treatments

BACKGROUND

Nurse practitioners (NPs) increasingly meet with families of young children who have been recently diagnosed with autism spectrum disorder (ASD). These families face a bewildering variety of treatment options and can benefit from working with NPs who can help them better understand those options and the likely outcomes for their children.

PURPOSE

This study describes outcomes for young children with autism, who were treated with either applied behavior analysis (ABA) or eclectic treatment. Nurse practitioners can use this information to help families choose treatments for their children.

METHODS

Children diagnosed with autism received ABA (n = 50) or eclectic treatment (n = 32). Age-appropriate assessments in a variety of domains were made before and after up to 7 years of treatment.

RESULTS

Initial scores were below normal in every domain except motor skills. Sixty percent of children had normal cognitive scores after ABA, compared with only 25% of children after eclectic treatment. Other domains also showed better outcomes after ABA than eclectic treatment.

IMPLICATIONS FOR PRACTICE

Nurse practitioners should be prepared to help families understand treatment options and their likely outcomes. The present study suggests that young children diagnosed with ASD can achieve normal levels of functioning in a variety of domains. These outcomes are much more likely after ABA than eclectic treatment.

Treatment for whom? Towards a phenomenological resolution of controversy within autism treatment

Autism's mainstream, behavioural treatment has recently faced allegations from neurodiversity activists, who claim that behaviourism is methodologically faulted and in serious breach of patient consent and human rights. In the present paper, I delve into this mounting controversy to suggest, contra behaviourism, that people with autism diagnoses do not just display a divergent set of behaviours, but should be seen to operate in 'worlds' different to those in typical neurological conditions. To philosophically accommodate this difference in 'worlds' and to utilise it in thinking about treatment orientation, I use Edmund Husserl's concept of the life-world (lebenswelt). I proffer that the autistic life-worlds should be used as the basis of treatment evaluation. I suggest that phenomenological ways of approaching autism, currently understudied, should be further developed and that behavioural treatment should be accordingly 'filtered' to accommodate the autistic life-worlds, and with them certain criticisms from neurodiversity.

Multidisciplinary Teaming: Enhancing Collaboration through Increased Understanding

In an effort to provide clarity about the unique contributions of several professions within the context of multidisciplinary treatment, we reviewed the definitions, philosophical underpinnings, and national requirements pertaining to both scopes of practice (i.e., model licensing acts, legislation, and regulatory boards) and training (i.e., task lists, accreditation standards and course requirements, and exam blueprints) of 4 behavioral health professions. The professions we selected (behavior analysis, psychology, speech-language pathology, and occupational therapy) are likely to provide treatment alongside one another and often to the same clients. In a review of documents pertaining to scopes of practice and training for each profession, we found overlapping content. However, the similarities between professions diminished when we reviewed more specific guidelines such as learning objectives, educational requirements (i.e., coursework), supervised clinical experience (e.g., internships), and national examinations. This was especially true when considering each profession's underlying approach to treatment (i.e., philosophical underpinnings) and, hence, service activities. We discuss our findings in light of service overlap and make a call for greater collaboration between professions, as related to the separate content knowledge and expertise of professionals in each field and the impact on client outcomes.

Implementing Aided Augmentative Communication Systems With Persons Having Complex Communicative Needs

Augmentative and alternative communication (AAC) systems can support communication skills for people with significant developmental disabilities who experience complex communication needs (CCNs). There is a need to tailor best practices in AAC assessment and intervention to create individualized communication systems with this population. In this article, we outline the important components of AAC systems that can be implemented in authentic settings. However, given the limited evidence on AAC interventions specific to people with CCNs, we also identify some priority areas for future inquiry. Among these involve strategies to enhance decision making regarding (a) matching communication mode(s) to learner skills and contextual demands, (b) identifying communicative opportunities and obligations, (c) individualizing aided communication display features, (d) selection of vocabulary specificity, and (e) considering dosage parameters needed to acquire and maintain a communicative repertoire. In addition, we briefly discuss the use of telehealth to enhance intervention capability.

Child-rearing routines among Mexican-heritage children with autism spectrum disorder

This study examined the daily routines and activities of Mexican-heritage mothers and their children with autism spectrum disorder. Experienced sampling methods were used to capture families' current daily routines and activities, how parents valued those activities, and whether the activity was part of the child's autism spectrum disorder intervention. A total of 32 mothers were texted five times per day over five consecutive days for a total of 721 observations. Mothers frequently engaged in Self-Care (e.g. showering), General Caregiving (e.g. cooking), and House Chores (e.g. laundry). Children engaged in activities in which interventions could easily be integrated (e.g. Academics, Self-Care, and Playing with Others). Families spent less than one-third (26.1%) of their activities participating in interventions. Mothers and children jointly spent time in General Caregiving, Playing with Others, and Using Electronics. Practitioners should focus on integrating evidence-based interventions into daily joint routine activities.

The effect of implementation climate on program fidelity and student outcomes in autism support classrooms

OBJECTIVE

An organization's implementation climate, or the extent to which use of an intervention is expected, supported, and rewarded by colleagues and supervisors, has been identified as critical to successful intervention implementation and outcomes. The effect of implementation climate has not been well studied in special education settings. The present study examines the association between teachers' perceptions of implementation climate, teacher fidelity to a school-based program for students with autism, and student outcomes (measured as changes in IQ) over time.

METHOD

Participants included 158 students from 45 classrooms and their teachers. Teachers provided a measure of implementation climate at the beginning of the academic year; program fidelity was measured monthly throughout the year. The main and interaction effects of perceived implementation climate and fidelity on student outcomes were examined using longitudinal nested linear models with random effects for classroom and student, controlling for important covariates.

RESULTS

On average, IQ scores improved 2.2 points (SD = 8.7). There were no main effects of perceived implementation climate or fidelity on student outcomes; however, the interaction between perceived implementation climate and fidelity was associated with student outcomes (p < .05, d = 0.54). Among classrooms with a strong perceived implementation climate, higher fidelity was associated with better student outcomes.

CONCLUSIONS

While preliminary and requiring replication, these findings suggest that perceived implementation climate and program fidelity each may be important but not sufficient for optimizing outcomes for students with autism. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Instruments for augmentative and alternative communication for children with autism spectrum disorder: a systematic review

New technologies designed to improve the communication of autistic children can also help to promote interaction processes and cognitive and social development. The aim of this study was to analyze the instruments used to improve the communication skills of children with autism spectrum disorder. We searched the PubMed and Web of Science databases using the descriptors "autism", "Asperger", "education", "children" and "assistive technology" and selected articles that met the following inclusion criteria: (i) original research; (ii) written in English; (iii) based on participants with a primary diagnosis of autism spectrum disorder; and (iv) tested an instrument designed to promote communication in children with autism spectrum disorder. Our search retrieved 811 articles, of which 34 met the inclusion criteria. Data on 26 instruments were extracted, and the measurement properties of the instruments were combined with information about their outcomes and presentation. The most commonly used interventions were the Treatment and Education of Autistic and Related Communication Handicapped Children program and the Picture Exchange Communication System. The Treatment and Education of Autistic and Related Communication Handicapped Children program was shown to produce improvements in the communication skills, socialization and self-care skills of children with autism spectrum disorder. The Picture Exchange Communication System produced inconsistent results. The results of the identified studies confirm the significant importance of these instruments in improving the communicative process of autistic children.

Applied Behavior Analysis, Students With Autism, and the Requirement to Provide a Free Appropriate Public Education

The prevalence of autism has been steadily rising over the previous decades. The diverse ways in which the disorder manifests in students and the free and appropriate public education (FAPE) mandate of the Individuals With Disabilities Education Act (IDEA) requires that a student’s individualized education program (IEP) team tailor interventions to meet the unique educational needs of that student. Deciding on the most appropriate evidence-based intervention programs for students with autism can be complex. In fact, a frequent source of litigation is when families and school personnel disagree on the particular programming to be provided to students with autism. Often this litigation involves disagreement over the extent to which services should be based on the principles of applied behavior analysis (ABA). The purpose of this article is to review select case law to analyze how courts have ruled on whether schools must provide ABA services to meet FAPE requirement when families request those services, and to extrapolate implications for practice, including guidance to families and school personnel on how to work collaboratively to resolve conflicts surrounding ABA services.

Evaluating Kupferstein’s claims of the relationship of behavioral intervention to PTSS for individuals with autism

Purpose

Kupferstein (2018) surveyed 460 respondents and found that 46 percent of respondents met the diagnostic threshold for posttraumatic stress disorder after exposure to applied-behavior-analysis-based intervention. The purpose of this paper is to provide an evaluation a critical analysis of Kupferstein (2018) including the experimental methods and discussion of the results.

Design/methodology/approach

The authors evaluated the Kupferstein’s methodological rigor with respect to the use of hypothesis testing, use of indirect measures, selection of respondents, ambiguity in definitions, measurement system, and framing of the experimental question when conducting the correlational analysis in addition to Kupferstein’s analysis and discussion of the results.

Findings

Based upon the analysis, Kupferstein’s results should be viewed with extreme caution due to several methodological and conceptual flaws including, but not limited to, leading questions used within a non-validated survey, failure to confirm diagnosis, and incomplete description of interventions.

Originality/value

It is the authors’ hope that this analysis provides caregivers, clinicians, and service providers with a scientific lens which will useful in viewing the limitations and methodological flaws of Kupferstein.

Sensory features as predictors of adaptive behaviors: A comparative longitudinal study of children with autism spectrum disorder and other developmental disabilities

BACKGROUND

Children with autism spectrum disorder (ASD) and other developmental disabilities (DD) exhibit sensory features that differ from their typically developing peers. Prior cross-sectional research has demonstrated significant associations between elevated sensory features and lower adaptive behavior scores, yet there is limited prospective research examining longitudinal associations.

AIMS

To examine the longitudinal prediction of early sensory response patterns (i.e., hyperresponsiveness, hyporesponsiveness, and sensory interests, repetitions, and seeking behaviors) to later adaptive behavior outcomes in children with ASD and DD.

METHODS AND PROCEDURES

Children with ASD (n = 51) and DD (n = 30) were seen at two time points (Time 1: M(SD) = 5.6(2.5) years; Time 2: M(SD) = 9.0(2.2) years). We used a series of regression models with both observational and parent-report measures of sensory response patterns, and including group interactions.

OUTCOMES AND RESULTS

All three sensory response patterns significantly predicted aspects of adaptive behaviors, with some differences based on assessment format and diagnostic group. Across groups and sensory patterns, we found some evidence that elevated sensory features early in childhood predicted lower adaptive behavior skills later in childhood.

CONCLUSIONS AND IMPLICATIONS

Sensory features may interfere with development of adaptive behaviors, suggesting a need for effective interventions addressing sensory features early in development.