Moderate Effects of Low-Intensity Behavioral Intervention

Do Naturalistic Developmental Behavioral Interventions improve family quality of life? A systematic review and meta-analysis

LAY ABSTRACT

Naturalistic Developmental Behavioral Interventions have been described as culturally responsive and family-friendly interventions, with research demonstrating improvements in children's development following the receipt of these interventions. Given the child-directed nature of Naturalistic Developmental Behavioral Interventions and the intervention's integration within families' daily routines, many studies have examined the impact of Naturalistic Developmental Behavioral Interventions on family and family member quality of life. We conducted a systematic review and meta-analysis to explore the relationship between Naturalistic Developmental Behavioral Interventions and family quality of life. Results suggest that the provision of a Naturalistic Developmental Behavioral Intervention neither improved nor worsened family or family member quality of life. For those involved in delivering Naturalistic Developmental Behavioral Intervention services, there is an immediate need to convey to families that children's improvements will likely not translate into improvements in family quality of life.

Pilot Study of Personalized Transcranial Magnetic Stimulation with Spectral Electroencephalogram Analyses for Assessing and Treating Persons with Autism

Autism spectrum condition (ASC) is a neurodevelopmental condition that is only partly responsive to prevailing interventions. ASC manifests core challenges in social skills, communication, and sensory function and by repetitive stereotyped behaviors, along with imbalances in the brain's excitatory (E) and inhibitory (I) signaling. Repetitive transcranial magnetic stimulation (rTMS) has shown promise in ASC and may be a useful addition to applied behavioral analysis (ABA), a gold-standard psychotherapeutic intervention. We report an open-label clinical pilot (initial) study in which ABA-treated ASC persons (n = 123) received our personalized rTMS protocol (PrTMS). PrTMS uses low TMS pulse intensities and continuously updates multiple cortical stimulation locales and stimulation frequencies based on the spectral EEG and psychometrics. No adverse effects developed, and 44% of subjects had ASC scale scores reduced to below diagnostic cutoffs. Importantly, in PrTMS responders, the spectral EEG regression flattened, implying a more balanced E/I ratio. Moreover, with older participants, alpha peak frequency increased, a positive correlate of non-verbal cognition. PrTMS may be an effective ASC intervention, offering improved cognitive function and overall symptomatology. This warrants further research into PrTMS mechanisms and specific types of subjects who may benefit, along with validation of the present results and exploration of broader clinical applicability.

Adapting the preschool environment to the needs of children on the autism spectrum in Sweden: A quasi-experimental study

BACKGROUND

Children on the autism spectrum may receive Early Intensive Behavioural Intervention (EIBI) in Sweden to support development by providing learning opportunities. However, research suggests a need to improve the quality of their learning environment.

AIM

This pre-registered study (#NCT03634761) aimed to evaluate the Swedish Autism Program Environment Rating Scale (APERS-P-SE) as a means to promote the quality of the pre-school learning environment for children on the autism spectrum, along with outcomes for these children, and their pre-school staff.

MATERIAL AND METHODS

In a quasi-experimental study, pre-school staff (n = 35) conducted either EIBI supported by in-service training and on-site coaching based on APERS-P-SE assessment (at k = 9 preschools) or EIBI only (k = 8), during an 8-months period.

RESULTS

The quality of the immediate learning environment (primary outcome) increased significantly in the EIBI/APERS-P-SE preschools. However, changes in child and pre-school staff measures were not significant.

CONCLUSIONS AND SIGNIFICANCE

In-service training and on-site coaching based on APERS-P-SE assessments can increase the quality of the learning environment in Swedish pre-school. Studies of longer duration and larger sample size are required to determine if using the APERS-P-SE can also achieve desired behavioural change for children-, and impact pre-school staff applying EIBI.

Concordance between patient-centered and adaptive behavior outcome measures after applied behavior analysis for autism

BACKGROUND

Applied behavior analysis (ABA) is an evidence-based approach to autism spectrum disorder that has been shown in clinical trials to improve child functional status. There is substantial focus in ABA on setting and tracking individualized goals that are patient-centered, but limited research on how to measure progress on such patient-centered outcomes.

PURPOSE

The purpose of this investigation was to assess concordance between patient-centered and standard outcome measures of treatment progress in a real-world clinical sample of children receiving ABA for autism spectrum disorder.

METHODS

This observational study used a clinical sample of children ages 3 to 16 years (N = 154) who received 24 months of ABA from an integrated health system. Concordance between three outcome measures after ABA was assessed using a correlation matrix: (1) patient-centered measures of progress on individualized treatment goals, (2) caregiver-centered measure of progress on treatment participation goals, and (3) the Vineland Adaptive Behavior Scales adaptive behavior composite.

RESULTS

There was limited concordance among measures at both 12 and 24 months of ABA. None of the patient-centered measures showed significant positive correlation with adaptive behavior composite difference scores at either 12 or 24 months, nor did the caregiver measure. The percentage of children achieving clinically meaningful gain on patient-centered goal measures increased between 12 and 24 months of ABA, while the percentage of children achieving clinically meaningful gains in adaptive behavior declined during the same time period.

CONCLUSIONS

In a health system implementation of ABA, there was limited concordance between patient-centered and standard measures of clinically meaningful treatment progress for children with ASD. Clinicians should have ongoing dialogue with patients and parents/caregivers to ensure that interventions for ASD are resulting in progress towards outcomes that are meaningful to patients and families.

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.

Patient Outcomes After Applied Behavior Analysis for Autism Spectrum Disorder

OBJECTIVES

The purpose of this study was to examine patterns of service receipt and patient outcomes for children receiving applied behavior analysis (ABA) for autism spectrum disorder (ASD) in an integrated health care system in which commercially insured children were covered by a state autism mandate.

METHODS

This retrospective, observational study used a random sample of children with ASD (3-17 yrs) who were members of a large integrated health care system in Southern California and referred for ABA between January 2016 and November 2018. From the 4145 children referred, a random stratified sample of 334 was selected to extract data from clinical reports over 24 months of services. The primary outcome measures were time in ABA and child adaptive behavior.

RESULTS

Thirteen percent of the sample never received ABA after referral. Of those who were referred for ABA, 66% initiated ABA and remained in services for 12 months, whereas less than half (46%) remained in services for 24 months. Having a history of special education was associated with longer time spent in ABA, whereas having a single parent was associated with discontinuation of ABA. A minority of children received a full ABA dose (28%), but the lowest functioning children still experienced clinically significant adaptive behavior gains after 24 months of ABA (p = 0.02).

CONCLUSION

In a health system implementation of ABA for children with ASD, there were high rates of ABA discontinuation and low ABA dosing. These challenges may diminish the potential benefits of ABA, even in a context in which there is mandated commercial insurance coverage.

Barriers to Building More Effective Treatments: Negative Interactions Amongst Smoking Intervention Components

Meaningfully improved mental and behavioral health treatment is an unrealized dream. Across three factorial experiments, inferential tests in prior studies showed a pattern of negative interactions suggesting that better clinical outcomes are obtained when participants receive fewer rather than more intervention components. Further, relatively few significant main effects were found in these experiments. Modeling suggested that negative interactions amongst components may account for these patterns. This paper evaluates factors that may contribute to such declining benefit: increased attentional or effort burden; components that produce their effects via the same capacity limited mechanisms, making their effects subadditive; and a tipping point phenomenon in which those near a hypothesized "tipping point" for change will benefit markedly from weak intervention while those far from the tipping point will benefit little from even strong intervention. New research should explore factors that cause negative interactions amongst components and constrain the development of more effective treatments.

Can the Early Start Denver Model Be Considered ABA Practice?

The Early Start Denver Model (ESDM) is an evidence-based early intervention approach for young children with autism spectrum disorder. Although the ESDM is described by its authors as being rooted in applied behavior analysis (ABA), some states, agencies, and scholars consider the ESDM to qualify as ABA practice, whereas others do not. The purpose of this article is to examine the status of the ESDM in relation to the 7 dimensions established by Baer, Wolf, and Risley ("Some Current Dimensions of Applied Behavior Analysis," Journal of Applied Behavior Analysis, 1(1): 91-97, 1968) to define applied behavior-analytic research and intervention, as well as to discuss implications for the field.

Creating and Sharing Digital ABA Instructional Activities: A Practical Tutorial

Board Certified Behavior Analysts (BCBAs) may encounter situations, such as the current COVID-19 pandemic, that preclude them from providing traditional in-person applied behavior-analytic services to clients. When conditions prevent BCBAs and behavior technicians from working directly with clients, digital instructional activities designed by BCBAs and delivered via a computer or tablet may be a viable substitute. Google applications, including Google Slides, Google Forms, and Google Classroom, can be particularly useful for creating and sharing digital instructional activities. In the current article, we provide task analyses for utilizing basic Google Slides functions, developing independent instructional activities, developing caregiver-supported instructional activities, and sharing activities with clients and caregivers. We also provide practical recommendations for implementing digital instructional activities with clients and caregivers.

Inter-Rater Agreement for the Milestones and Barriers Assessments of the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP)

We determined inter-rater agreement for the VB-MAPP, an instrument sometimes used in planning educational goals and evaluating intervention effects for young people with autism. A pair of raters independently rated each of 32 children diagnosed with autism. Intraclass correlation coefficients for the total Milestones and Barrier scores were 0.876 and 0.629, respectively, indicating good and moderate reliability. There was variability in reliability in the different domains of the Milestones Assessment, with most indicating moderate reliability, and most of the individual Barriers Assessment domains indicating poor reliability. These are the first data relevant to the reliability of the VB-MAPP, they suggest that further evaluation of its reliability is merited and that a high reliability for individual domains should not be assumed.