Empirically-Derived Effect Size Distributions of Interventions for Young Children on the Autism Spectrum

Treatment mechanism of the WHO caregiver skills training intervention for autism delivered in community settings

This study examined the mechanism of effect of the WHO Caregiver Skills Training (CST) through secondary analysis of a pilot RCT conducted in community settings. Participants were 86 caregivers (77% mothers) of children with ASD (78% male, mean age: 44.8 months) randomized to CST (n = 43) or treatment as usual (n = 43). The primary outcomes, measured at baseline (t1), immediately post-intervention (t2), and 3 months post-intervention (t3), were derived from the coding of caregiver-child free play interactions with the Brief Observation of Social-Communication Change (BOSCC) and the Joint Engagement Rating Inventory scale (JERI). At t3 positive treatment main effects had been observed for caregiver skills supportive of the interaction and for flow of the interaction (JERI), albeit only non-significant changes in the expected direction for child outcomes: autism phenotypic behaviors (BOSCC), joint engagement and availability to interact (JERI). This study tested the theory of change of CST, hypothesizing that the intervention would lead to an improvement on all child and dyad outcomes through an increase in the caregiver skills supportive of the interaction. Serial mediation analyses revealed that the effect of the intervention was significantly influenced by change in caregiver skills. Participation in the intervention led to notable increases in caregiver skills at t2 and t3, which subsequently contributed to improvements at t3 in flow of the interaction, autism phenotypic behavior, joint engagement, and availability to interact. We confirmed our a priori hypothesis showing that change in caregiver skills significantly mediated the effect of treatment on the dyad primary outcome, as well as on the other child outcomes that had shown non-significant changes in the expected direction. Implications for intervention design and policy making in the context of public health services are discussed.

Nature-Based Interventions for Autistic Children: A Systematic Review and Meta-Analysis

Importance

There is a gap in the evidence regarding nature-based interventions (NBIs) for children with autism spectrum disorder (ASD).

Objective

To systematically review and meta-analyze available evidence on the health-related outcomes in NBIs for children with ASD.

Data Sources

The Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase, Emcare, Education Resources Information Center, Global Health, MEDLINE, PsycInfo, SPORTDiscus, and Web of Science were searched from inception until May 2023. Google Scholar and references from included studies were searched for additional studies.

Study Selection

Included studies were randomized clinical trials (RCTs), controlled studies, and single-group before-and-after studies that reported health-related outcomes.

Data Extraction and Synthesis

This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Random-effects meta-analyses were used to synthesize the data. The findings of studies that were ineligible for meta-analysis were summarized according to the Synthesis Without Meta-analysis (SWIM) reporting guidelines.

Main Outcomes and Measures

The outcomes of interest were health-related outcomes (ie, social functioning, behavioral functioning, emotional functioning, sensory functioning) and the self-reported well-being of children with ASD.

Results

A total of 24 studies with 717 participants (mean age range, 5.3 to 17.8 years; 141 [21.9%] female) were included. A meta-analysis from 13 studies indicated a significant negative moderate association between NBIs and social communication (standardized mean difference [SMD], -0.59; 95% CI, -0.85 to -0.34). For behavioral functioning outcomes, NBIs showed a significant moderate association with reduced hyperactivity (SMD, -0.56; 95% CI, -0.86 to -0.26) and a small to moderate association with reduced irritability (SMD, -0.49; 95% CI, -0.79 to -0.19). For sensory functioning, NBIs were significantly associated with improved inattention and distractibility (SMD, 1.13; 95% CI, 0.67 to 1.60). Significant moderate associations were observed in sensory seeking (SMD, 0.77; 95% CI, 0.33 to 1.22; P < .001; I2 = 0%) and sensory sensitivity (SMD, 0.56; 95% CI, 0.12 to 1.00; P = .01; I2 = 0%). Heterogeneity of the intervention effects was not high, and I2 ranged from 0% to 67%.

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggested an association of NBIs in group-based recreational therapy with experiential learning with positive short-term outcomes on sensory, social, and behavioral functioning for children with ASD. Future evidence using robust study design to aid the health and functional trajectories of children with ASD is recommended.

Long-Term Effects of Early Communication Interventions: A Systematic Review and Meta-Analysis

PURPOSE

Early language and communication interventions for children with language impairments have been shown to be effective in assessments administered immediately after treatment. The purpose of the current systematic review and meta-analysis was to assess the overall durability of those effects over time and whether durability was related to outcome type, etiology of child language impairments, implementer of intervention, magnitude of posttest effects, time between intervention and follow-up, and study risk of bias.

METHOD

We conducted a systematic search of online databases and reference lists to identify experimental and quasi-experimental group design studies. All studies tested the effects of early communication interventions at least 3 months post-intervention. Participants were children 0-5 years old with language impairments. Coders identified study features and rated methodological quality indicators for all studies. Effect sizes at long-term timepoints and associations with potential moderators were estimated using multilevel meta-analysis with robust variance estimation.

RESULTS

Twenty studies with 129 long-term outcome effect sizes met inclusion criteria. Studies included children with developmental language disorders or language impairment associated with autism. The overall average effect size was small and significant (g = .22, p = .002). Effect size estimates were larger for prelinguistic outcomes (g = .36, p < .001) than for linguistic outcomes (g = .14, p = .101). Significant factors were the posttest effect sizes, the risk of bias for randomized trials, and etiology of language impairment for linguistic outcomes. Time post-intervention did not significantly predict long-term effect sizes.

CONCLUSIONS

Outcomes of early language and communication interventions appear to persist for at least several months post-intervention. More research is needed with collection and evaluation of long-term outcomes, a focus on measurement, and consistency of primary study reporting.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23589648.