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

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.

A blocking and distance management staff training intervention for torso- and head-directed aggression

Although decades of behavior-analytic studies have focused on decreasing the aggressive behavior of clients, relatively little research has been conducted on preventing injuries for the staff members who implement treatment plans. In this study, three direct-care staff members working with clients presenting with aggressive behavior were taught targeted blocking and distance management techniques designed to keep the clients safe while preventing injuries to the participants. Findings indicated that all staff members acquired the target skills in simulations, after which the skills for two participants generalized to the natural work environment.

Cognitive, behavioral and socio-communication skills as predictors of response to Early Start Denver Model: a prospective study in 32 young children with Autism Spectrum Disorder

Introduction

The effectiveness of early interventions in young autistic children is well established, but there is great interindividual variability in treatment response. Predictors of response to naturalistic developmental behavioral interventions (NDBI), like the Early Start Denver Model (ESDM), are needed.

Methods

We conducted an exploratory study to prospectively seek predictors of response in 32 young children treated with ESDM after receiving an ASD diagnosis. All children were less than 39 months old (mean age: 29.7 mo), and received individualized ESDM for nine months. Tests were administered at the beginning, after 4 months, and at the end of treatment.

Results

Four children (12.5%) were "strong responders", 8 children (25.0%) were "moderate responders", and 20 children (62.5%) were "poor responders". A more favorable response to ESDM was significantly predicted by higher PEP-3 Expressive Language, Receptive Language, Cognitive Verbal/Preverbal, Visuo-Motor Imitation scores, higher GMDS-ER Personal/Social, and VABS-II Communication scores, by lower ADI-R C restricted/stereotypic behaviors, and by joint attention level.

Discussion

Most predictors showed a linear association with increasing response to ESDM, but GMDS-ER Personal-Social and joint attention level predicted strong response, while PEP-3 receptive language equally predicted moderate or strong response. Although larger samples will be necessary to reach definitive conclusions, in conjunction with prior reports our findings begin providing information able to assist clinicians in choosing the most appropriate treatment program for young autistic children.

Oral language interventions can improve language outcomes in children with neurodevelopmental disorders: A systematic review and meta-analysis

Background

Young people who fail to develop language as expected face significant challenges in all aspects of life. Unfortunately, language disorders are common, either as a distinct condition (e.g., Developmental Language Disorder) or as a part of another neurodevelopmental condition (e.g., autism). Finding ways to attenuate language problems through intervention has the potential to yield great benefits not only for the individual but also for society as a whole.

Objectives

This meta-analytic review examined the effect of oral language interventions for children with neurodevelopmental disorders.

Search Methods

The last electronic search was conducted in April 2022.

Selection Criteria

Intervention studies had to target language skills for children from 2 to 18 years of age with Developmental Language Disorder, autism, intellectual disability, Down syndrome, Fragile X syndrome, and Williams syndrome in randomised controlled trials or quasi-experimental designs. Control groups had to include business-as-usual, waiting list, passive or active conditions. However, we excluded studies in which the active control group received a different type, delivery, or dosage of another language intervention. Eligible interventions implemented explicit and structured activities (i.e., explicit instruction of vocabulary, narrative structure or grammatical rules) and/or implicit and broad activities (i.e., shared book reading, general language stimulation). The intervention studies had to assess language skills in receptive and/or expressive modalities.

Data Collection and Analysis

The search provided 8195 records after deduplication. Records were screened by title and abstract, leading to full-text examinations of 448 records. We performed Correlated and Hierarchical Effects models and ran a retrospective power analysis via simulation. Publication bias was assessed via p-curve and precision-effect estimate.

Main Results

We examined 38 studies, with 46 group comparisons and 108 effects comparing pre-/post-tests and eight studies, with 12 group comparisons and 21 effects at follow-up. The results showed a mean effect size of d = 0.27 at the post-test and d = 0.18 at follow-up. However, there was evidence of publication bias and overestimation of the mean effects. Effects from the meta-analysis were significantly related to these elements: (1) receptive vocabulary and omnibus receptive measures showed smaller effect sizes relative to expressive vocabulary, grammar, expressive and receptive discourse, and omnibus expressive tests; and (2) the length of the intervention, where longer sessions conducted over a longer period of time were more beneficial than brief sessions and short-term interventions. Neither moderators concerning participants' characteristics (children's diagnosis, diagnostic status, age, sex, and non-verbal cognitive ability and severity of language impairment), nor those regarding of the treatment components and implementation of the language interventions (intervention content, setting, delivery agent, session structure of the intervention or total number of sessions) reached significance. The same occurred to indicators of study quality. The risk of bias assessment showed that reporting quality for the studies examined in the review was poor.

Authors’ Conclusions

In sum, the current evidence base is promising but inconclusive. Pre-registration and replication of more robust and adequately powered trials, which include a wider range of diagnostic conditions, together with more long-term follow-up comparisons, are needed to drive evidence-based practice and policy.

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.

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.

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.

Differential Predictors of Response to Early Start Denver Model vs. Early Intensive Behavioral Intervention in Young Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

The effectiveness of early intensive interventions for Autism Spectrum Disorder (ASD) is now well-established, but there continues to be great interindividual variability in treatment response. The purpose of this systematic review is to identify putative predictors of response to two different approaches in behavioral treatment: Early Intensive Behavioral Interventions (EIBI) and the Early Start Denver Model (ESDM). Both are based upon the foundations of Applied Behavioral Analysis (ABA), but the former is more structured and therapist-driven, while the latter is more naturalistic and child-driven. Four databases (EmBase, PubMed, Scopus and WebOfScience) were systematically screened, and an additional search was conducted in the reference lists of relevant articles. Studies were selected if participants were children with ASD aged 12-48 months at intake, receiving either EIBI or ESDM treatment. For each putative predictor, p-values from different studies were combined using Fisher's method. Thirteen studies reporting on EIBI and eleven on ESDM met the inclusion criteria. A higher IQ at intake represents the strongest predictor of positive response to EIBI, while a set of social cognitive skills, including intention to communicate, receptive and expressive language, and attention to faces, most consistently predict response to ESDM. Although more research will be necessary to reach definitive conclusions, these findings begin to shed some light on patient characteristics that are predictive of preferential response to EIBI and ESDM, and may provide clinically useful information to begin personalizing treatment.

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.

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.

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.

Ethical Issues in ABA-based Service Provision for Autism in Limited-Resource Contexts: A Case Example of the People’s Republic of China

Recommendations for intervention for young children with autism spectrum disorders (ASD) focus on early, intensive, and often individual intervention based on methods of applied behavior analysis. In much of the world, there are few options for early intervention. This article examines this question: in a context where intensive and high staff-to-student ratio intervention is not possible, how can provision of high-quality evidence-based intervention be ensured? We consider the case of China, where intervention for young children with autism is provided at diverse educational organizations, and funding limitations impact teacher-to-student ratio. Due to challenges, rigorous use of evidence-based methods often lags behind best practices. This article presents an ethical analysis of the choices educators face and research-based recommendations consistent with the ethical analysis. Given the current context, we recommend a socially valid approach of systematically using group instruction based on ABA principles to increase the effectiveness and intensity of each aspect of intervention programs. While focused on the case of China, recommendations and analysis have implications for other settings with limited resources.

The impact of a telehealth platform on ABA-based parent training targeting social communication in children with autism spectrum disorder

Interventions based upon applied behaviour analysis (ABA) have been shown to be best practice for children with autism spectrum disorder. However, in many parts of the world there is a shortage of appropriately trained behaviour analysts. Telehealth is a potential solution to increasing access to ABA. Our study assessed the use of telehealth to provide parent training in naturalistic teaching strategies designed to increase child communication skills. Five parent child dyads took part in the training, utilising didactic training and synchronous coaching. Parents could be trained to a high level of fidelity and viewed the training favourably. Children showed variable gains in communication and improved positive affect. The project was cost effective in comparison with traditional training models.

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.

Educational Interventions for Children and Youth with Autism: A 40-Year Perspective

Commemorating the 40 th anniversary of the Diagnostic and Statistical Manual (DSM) III, the purpose of this commentary is to describe school-based and school-relevant interventions and instructional approaches for children and youth with autism that have been developed and employed during that time period. The commentary begins with a brief description of foundational research that provides an historical context. Research themes shaped by science, ethics, social policy, and the changes in the DSM provide an organization for describing the evolution of intervention and instructional practices over the four previous decades. The commentary concludes with a discussion of school-contextual variables that influence implementation and the promise of the "iSciences" for closing the research to practice gap in the future.

Improvement of Autism Symptoms After Comprehensive Intensive Early Interventions in Community Settings

BACKGROUND

Preschool children with autism in southern Sweden participated in a comprehensive Naturalistic Developmental Behavioral Intervention (NDBI) program.

AIMS

To evaluate the ongoing NDBI program by comparing the pre- and postintervention outcomes in terms of improved autism symptom severity.

METHOD

The improvement of Autism Diagnostic Observation Schedule (ADOS-R) test results between baseline and evaluation among children participating in the NDBI program (n = 67) was compared with the results among children receiving community treatment as usual (n = 27) using analysis of covariance.

RESULTS

The study showed that children in the NDBI group improved their ADOS-R total scores between baseline and evaluation (-0.8 scores per year; 95% CI [-1.2, -0.4]), whereas no improvement was detected in the comparison group (+0.1 scores per year; 95% CI [-0.7, +0.9]). The change in the NDBI group versus the change in the comparison group was statistically significant after adjusting for possible confounders as well. Children in the NDBI group also significantly improved their ADOS severity scores, but the scores were not significantly different from those of the comparison group.

CONCLUSIONS

The results from the current naturalistic study must be interpreted cautiously, but they do support earlier studies reporting on improvement of autism symptoms after early intensive interventions. Results from observational studies are difficult to interpret, but it is nevertheless of uttermost importance to evaluate costly autism intervention programs. The results do indicate that children with autism benefit from participating in early comprehensive intensive programs.

Internet of Things (IoT)-Enhanced Applied Behavior Analysis (ABA) for Special Education Needs

Applied behavior analysis (ABA) has become a popular behavioral therapy in the special education needs (SEN) community. ABA is used to manage SEN students’ behaviors by solving problems in socially important settings, and puts emphasis on having precise measurements on physical and observable events. In this work, we present how Internet of Things (IoT) technologies can be applied to enhance ABA therapy in normal SEN classroom settings. We measured (1) learning performance data, (2) learners’ physiological data, and (3) learning environment sensors’ data. Upon preliminary analysis, we have found that learners’ physiological data is highly diverse, while learner performance seems to be related to learners’ electrodermal activity. Our preliminary findings suggest the possibility of enhancing ABA for SEN with IoT technologies.

Unsupervised Machine Learning for Identifying Challenging Behavior Profiles to Explore Cluster-Based Treatment Efficacy in Children With Autism Spectrum Disorder: Retrospective Data Analysis Study

Background

Challenging behaviors are prevalent among individuals with autism spectrum disorder; however, research exploring the impact of challenging behaviors on treatment response is lacking.

Objective

The purpose of this study was to identify types of autism spectrum disorder based on engagement in different challenging behaviors and evaluate differences in treatment response between groups.

Methods

Retrospective data on challenging behaviors and treatment progress for 854 children with autism spectrum disorder were analyzed. Participants were clustered based on 8 observed challenging behaviors using k means, and multiple linear regression was performed to test interactions between skill mastery and treatment hours, cluster assignment, and gender.

Results

Seven clusters were identified, which demonstrated a single dominant challenging behavior. For some clusters, significant differences in treatment response were found. Specifically, a cluster characterized by low levels of stereotypy was found to have significantly higher levels of skill mastery than clusters characterized by self-injurious behavior and aggression (P<.003).

Conclusions

These findings have implications on the treatment of individuals with autism spectrum disorder. Self-injurious behavior and aggression were prevalent among participants with the worst treatment response, thus interventions targeting these challenging behaviors may be worth prioritizing. Furthermore, the use of unsupervised machine learning models to identify types of autism spectrum disorder shows promise.

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 Exploratory Study of Executive Function Development in Children with Autism, after Receiving Early Intensive Behavioral Training

Objective: To examine the development of executive functions, in preschool children with autism spectrum disorders (ASD), receiving early intensive behavioral training (EIBI). Method: Executive functions (EF) were assessed with The Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P), by parents and preschool teachers at the time of diagnostic assessment and after 15 months of EIBI intervention. Ten children with ASD (M = 2.9 years, nine males) participated in the study. Reliable Change Index scores were computed for each of the participants in order to investigate any significant change in BRIEF-P T-scores. Results: Three children showed a significant improvement in EF, based on parent ratings. Four children showed a significant improvement in EF based on preschool teacher ratings. Conclusion: Findings indicating a reliable improvement in one third of preschool children with ASD receiving EIBI are encouraging but need to be replicated in larger scale controlled studies.

The role of staffing and classroom characteristics on preschool teachers' use of one-to-one intervention with children with autism

LAY ABSTRACT

For preschool children with autism, individual (one-to-one) behavioral interventions are among the best-tested treatments. However, they are rarely used in special education preschools. We observed formally and informally delivered one-to-one behavioral interventions use by classroom staff (n = 51) in 12 classrooms across three special education preschools for children with autism, aged 3-6 years, in a major US city. We estimated the associations between one-to-one intervention use and classroom characteristics including staff-student ratio, professional role composition, and frequency of challenging child behaviors. As a whole, the factors we examined were considerably important for both formally and informally delivered one-to-one interventions. The number of individually assigned personal care aides in the classroom was negatively associated with the use of formally delivered one-to-one intervention. Classroom challenging behavior was positively associated with use of formally delivered one-to-one interventions. Interventionist's professional roles and the number of children in the class were most important for the use of informally delivered interventions. Staff training, clarifying professional roles, setting performance expectations for personal care aides and other classroom team members, and reducing class size may represent promising implementation targets. Findings suggest caution around task-shifting policies that transfer clinical functions from more highly trained to less highly trained staff.

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.

Intervention Effects on Language in Children With Autism: A Project AIM Meta-Analysis

Purpose This study synthesized effects of interventions on language outcomes of young children (ages 0-8 years) with autism and evaluated the extent to which summary effects varied by intervention, participant, and outcome characteristics. Method A subset of effect sizes gathered for a larger meta-analysis (the Autism Intervention Meta-analysis or Project AIM) examining the effects of interventions for young children with autism, which were specific to language outcomes, was analyzed. Robust variance estimation and metaregression were used to calculate summary and moderated effects while controlling for intercorrelation among outcomes within studies. Results A total of 221 outcomes were gathered from 60 studies. The summary effect of intervention on language outcomes was small but significant. Summary effects were larger for expressive and composite language outcomes compared to receptive language outcomes. Interventions implemented by clinicians, or by clinicians and caregivers together, had summary effects that were significantly larger than interventions implemented by caregivers alone. Participants' pretreatment language age equivalent scores positively and significantly moderated intervention effects, such that effects were significantly larger on average when samples of children had higher pretreatment language levels. Effects were not moderated by cumulative intervention intensity, intervention type, autism symptomatology, chronological age, or the proximity or boundedness of outcomes. Study quality concerns were apparent for a majority of included outcomes. Conclusions We found evidence that intervention can facilitate improvements in language outcomes for young children with autism. Effects were largest for expressive and composite language outcomes, for children with initially higher language abilities, and for interventions implemented by clinicians or by caregivers and clinicians combined. However, quality concerns of included studies and borderline significance of some results temper our conclusions regarding intervention effectiveness and corresponding moderators.

Efficacy of Interventions Based on Applied Behavior Analysis for Autism Spectrum Disorder: A Meta-Analysis

OBJECTIVE

To systematically evaluate evidence for the use of interventions based on appied behavior analysis (ABA) to manage various symptoms of children with autism spectrum disorder (ASD).

METHODS

Sensitivity analyses were conducted by removing any outlying studies and subgroup analyses were performed to compare the effectiveness of ABA and early start denver model (ESDM), picture exchange communication systems (PECS) and discrete trial training (DTT).

RESULTS

14 randomized control trials of 555 participants were included in this meta-analysis. The overall standardized mean difference was d=-0.36 (95% CI -1.31, 0.58; Z=0.75, p=0.45) for autism general symptoms, d=0.11 (95% CI -0.31, 0.54; Z=0.52, p=0.60) for socialization, d=0.30 (95% CI -0.02, 0.61; Z=1.84, p=0.07) for communication and d=-3.52 (95% CI -6.31, -0.72; Z=2.47, p=0.01) for expressive language, d=-0.04 (95% CI -0.44, 0.36; Z=0.20, p=0.84) for receptive language. Those results suggested outcomes of socialization, communication and expressive language may be promising targets for ABA-based interventions involving children with ASD. However, significant effects for the outcomes of autism general symptoms, receptive language, adaptive behavior, daily living skills, IQ, verbal IQ, nenverbal IQ, restricted and repetitive behavior, motor and cognition were not observed.

CONCLUSION

The small number of studies included in the present study limited the ability to make inferences when comparing ABA, ESDM, PECS and DTT interventions for children with ASD.

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.

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.

Cross-Cultural Content Validity of the Autism Program Environment Rating Scale in Sweden

Increasing rates of autism spectrum disorder (ASD) and younger age at diagnosis pose a challenge to preschool intervention systems. In Sweden, most young autistic children receive intervention service in community-based preschool programs, but no tool is yet available to assess the quality of the preschool learning environment. This study adapted the Autism Program Environment Rating Scale Preschool/Elementary to Swedish community context (APERS-P-SE). Following translation and a multistep modification process, independent experts rated the content validity of the adaptation. Findings indicate high cross-cultural validity of the adapted APERS-P-SE. The cultural adaption process of the APERS-P-SE highlights similarities and differences between the American and Swedish preschool systems and their impact on early ASD intervention.

Efeitos de Intervenção Comportamental Intensiva Realizada por Meio da Capacitação de Cuidadores de Crianças com Autismo

RESUMO O estudo avaliou os efeitos da Intervenção Comportamental Intensiva, realizada por meio da capacitação de cuidadores, no desenvolvimento de crianças com autismo. A pesquisa foi realizada a partir dos dados de crianças atendidas por um centro brasileiro especializado. Os participantes do Grupo 1 eram 22 crianças que finalizaram o primeiro ano de intervenção intensiva. Onze crianças que não fizeram a intervenção intensiva compuseram o Grupo 2, para fins de análise de dados. Os resultados indicaram ganhos significativos em todas as áreas do desenvolvimento das crianças com autismo que passaram pelo primeiro ano de Intervenção Comportamental Intensiva, enquanto as crianças do grupo controle apresentaram ganhos menos expressivos. Crianças mais novas, que falavam e que apresentavam sintomas mais brandos de autismo obtiveram melhores resultados.

Behavioral predictors of improved speech output in minimally verbal children with autism

We investigated the relationship between eight theoretically motivated behavioral variables and a spoken-language-related outcome measure, after 25 sessions of treatment for speech production in 38 minimally verbal children with autism. After removing potential predictors that were uncorrelated with the outcome variable, two remained. We used both complete-case and multiple-imputation analyses to address missing predictor data and performed linear regressions to identify significant predictors of change in percent syllables approximately correct after treatment. Baseline phonetic inventory (the number of English phonemes repeated correctly) was the most robust predictor of improvement. In the group of 17 participants with complete data, ADOS score also significantly predicted the outcome. In contrast to some earlier studies, nonverbal IQ, baseline levels of expressive language, and younger age did not significantly predict improvement. The present results are not only consistent with previous studies showing that verbal imitation and autism severity significantly predict spoken language outcomes in preschool-aged minimally verbal children with autism, but also extend these findings to older minimally verbal children with autism. Autism Res 2018, 11: 1356-1365. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We wished to understand what baseline factors predicted whether minimally verbal children with autism would improve after treatment for spoken language. The outcome measure was change in percentage (%) syllables approximately correct on a set of 30 two-syllable words or phrases. Fifteen were both practiced in treatment and tested; the remainder were not practiced in treatment, but only tested, to assess how well children were able to generalize their new skills to an untrained set of words. Potential predictors tested were sex, age, expressive language, phonetic inventory (the number of English speech sounds repeated correctly), autism severity, and nonverbal IQ. Phonetic inventory and (for some children) autism severity predicted children's posttreatment improvement. Nonverbal IQ and expressive language ability did not predict improvement, nor did younger age, suggesting that some older children with autism may be candidates for speech therapy.

Cognitive behavioral therapy for children with autism spectrum disorder: A prospective observational study

OBJECTIVE

To evaluate prospectively the effectiveness of cognitive behavioral therapy (CBT) in children with autism spectrum disorder (ASD).

METHODS

Drug-naïve children who met the DSM-V criteria for a diagnosis of ASD were recruited from a day care center, specialized in long-term treatment of children and adolescents with ASD. Symptom assessment was performed using the Aberrant Behavior Checklist (ABC) before (base-line) and after 12 months (follow-up) of CBT.

RESULTS

Nine boys with a mean age of 6 (±2.0) years were included. Compared to baseline, significant improvements of symptoms of irritability (p = 0.012), hyperactivity (p = 0.008) and lethargy (p = 0.008) were observed at follow-up.

CONCLUSION

Results indicate that CBT is an effective therapy for children with ASD. Larger studies are needed to give more details about which symptoms respond best in these patients.

Evaluating Efficacy and Preference for Prompt Type During Discrete-Trial Teaching

The components of discrete-trial teaching (DTT) may be individualized to each learner during instruction (e.g., the type of prompts used). However, there is limited research on the relative efficiency and effectiveness of these different prompt types. In addition, the learner's preference for how they are taught is not always considered. The present study compared relative effectiveness of three prompt types (i.e., a gesture, modeling, physical guidance) to a no-prompt control condition during a receptive identification task with three boys with autism. One participant met the mastery criterion first in the model prompt condition, and two participants in the physical prompt condition. All participants selected the physical prompt during a concurrent-chains preference assessment. In addition, all participants completed a chained task using the most effective prompt type.

Sustainability of Early Intensive Behavioral Intervention for Children With Autism Spectrum Disorder in a Community Setting

This study examined whether outcomes in early intensive behavioral intervention (EIBI) during a university-led multisite project could be replicated by the same community agency independently of the project. Participants, age 18 to 75 months at onset of intervention, were 48 children with autism spectrum disorder (ASD) enrolled in 35 hr per week of publicly funded, community-based EIBI for 3 years and 46 children who were matched on baseline characteristics and received early childhood services as usual (SAU) through local early childhood special education providers. Linear mixed models indicated that EIBI participants improved significantly more than SAU participants on standardized tests of IQ, nonverbal IQ, adaptive behavior, and academic achievement, administered by independent evaluators. Although limited by the use of a matched comparison group rather than random assignment, the study provides evidence for the sustainability of effective EIBI in community settings for children with ASD who start intervention at varying ages throughout early childhood.

Parent-reported early symptoms of autism spectrum disorder in children without intellectual disability who were diagnosed at school age

Despite efforts to detect autism spectrum disorder during toddlerhood, many children with autism spectrum disorder remain undiagnosed until school age. To identify characteristics of children whose autism spectrum disorder might not be diagnosed during toddlerhood, this study used archived Autism Diagnostic Interview-Revised records to examine the historical presentation of autism spectrum disorder symptoms in 48 school-age children with autism spectrum disorder. Children diagnosed after starting school (Late-Diagnosed; n = 24) were compared to age-matched children diagnosed before school age (Early-Diagnosed; n = 24). Symptom presentation was similar between groups, with the Late-Diagnosed group exhibiting only marginally fewer symptoms historically. The most commonly reported historical symptoms were negative symptoms, namely, deficits in social behaviors. Positive symptoms, such as unusual preoccupations, rituals, and mannerisms, were less commonly reported. These findings may aid earlier identification of autism spectrum disorder in children who would likely be diagnosed at school age.

Altered Behavior in Mice Socially Isolated During Adolescence Corresponds With Immature Dendritic Spine Morphology and Impaired Plasticity in the Prefrontal Cortex

Mice socially isolated during adolescence exhibit behaviors of anxiety, depression and impaired social interaction. Although these behaviors are well documented, very little is known about the associated neurobiological changes that accompany these behaviors. It has been hypothesized that social isolation during adolescence alters the development of the prefrontal cortex, based on similar behavioral abnormalities observed in isolated mice and those with disruption of this structure. To establish relationships between behavior and underlying neurobiological changes in the prefrontal cortex, Thy-1-GFP mice were isolated from weaning until adulthood and compared to group-housed littermates regarding behavior, electrophysiological activity and dendritic morphology. Results indicate an immaturity of dendritic spines in single housed animals, with dendritic spines appearing smaller and thinner. Single housed mice additionally show impaired plasticity through measures of long-term potentiation. Together these findings suggest an altered development and impairment of the prefrontal cortex of these animals underlying their behavioral characteristics.

Predictors of longitudinal ABA treatment outcomes for children with autism: A growth curve analysis

BACKGROUND

Autism spectrum disorder (ASD) is a developmental disorder that causes lifelong disability. Applied Behavior Analysis (ABA) is one of the most empirically studied and validated approaches for treating children diagnosed with ASD. Due to the heterogeneity of ASD, it is important to ascertain who will most benefit from treatment.

METHODS

In this study, 35 participants, with a mean entry age of 3 years, received ABA therapy. Children were assessed at intake and every 6 months thereafter using the Developmental Profile-3 (DP-3) to measure their communication, social-emotional, adaptive behavior, and physical development (2-6 measures per participant). Using a growth curve analysis, we investigated if age, diagnosis severity, cognitive functioning, treatment hours, gender, parent education level, or primary language spoken at home significantly predicted the growth trajectories of ABA treatment outcomes.

RESULTS

Our findings indicated that higher cognitive functioning significantly predicted faster growth across all four developmental domains, age at entry predicted initial status, and other variables only predicted growth rates in one or two domains.

IMPLICATIONS

Knowing the predictors of treatment outcome is important information for customizing treatment and this study demonstrated how longitudinal analyses can illuminate how participant characteristics affect the course of ABA therapy.

Outcome for Children Receiving the Early Start Denver Model Before and After 48 Months

The Early Start Denver Model (ESDM) is an intervention program recommended for pre-schoolers with autism ages 12-48 months. The rationale for this recommendation is the potential for intervention to affect developmental trajectories during early sensitive periods. We investigated outcomes of 32 children aged 18-48 months and 28 children aged 48-62 months receiving the ESDM for one year (approximately 20 h per week). Younger children achieved superior verbal DQ gains compared to their older counterparts. There were no group differences with respect to non-verbal DQ and adaptive behavior (with both age-groups undergoing significant change), or ASD severity (with neither age-group showing improvements on the ADOS). The association between verbal DQ gains and age at intake was moderated by baseline verbal level.

Communication Intervention for Young Children with Severe Neurodevelopmental Disabilities Via Telehealth

Young children with neurodevelopmental disorders such as autism spectrum disorders (ASD) and Rett syndrome often experience severe communication impairments. This study examined the efficacy of parent-implemented communication assessment and intervention with remote coaching via telehealth on the acquisition of early communication skills of three young children with ASD (2) and Rett syndrome (1). Efficacy of the intervention was evaluated using single-case experimental designs. First, functional assessment was used to identify idiosyncratic/potentially communicative responses and contexts for each child. Next, parents implemented functional communication training (FCT). All of the children acquired the targeted communication responses. The findings support the efficacy of telehealth as a service delivery model to coach parents on intervention strategies for their children's early communication skills.

An evaluation of the effects of intensity and duration on outcomes across treatment domains for children with autism spectrum disorder

Applied behavior analysis (ABA) is considered an effective treatment for individuals with autism spectrum disorder (ASD), and many researchers have further investigated factors associated with treatment outcomes. However, few studies have focused on whether treatment intensity and duration have differential influences on separate skills. The aim of the current study was to investigate how treatment intensity and duration impact learning across different treatment domains, including academic, adaptive, cognitive, executive function, language, motor, play, and social. Separate multiple linear regression analyses were used to evaluate these relationships. Participants included 1468 children with ASD, ages 18 months to 12 years old, M=7.57 years, s.d.=2.37, who were receiving individualized ABA services. The results indicated that treatment intensity and duration were both significant predictors of mastered learning objectives across all eight treatment domains. The academic and language domains showed the strongest response, with effect sizes of 1.68 and 1.85 for treatment intensity and 4.70 and 9.02 for treatment duration, respectively. These findings are consistent with previous research that total dosage of treatment positively influences outcomes. The current study also expands on extant literature by providing a better understanding of the differential impact that these treatment variables have across various treatment domains.