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

Development and Preliminary Validation of the Patient Outcome Planning Calculator (POP-C): A Tool for Determining Treatment Dosage in Applied Behavior Analysis

Board certified behavior analysts (BCBA) are responsible for determining the medically necessary treatment dosage for patients (i.e., the number of hours of therapy a patient should receive per week to optimize progress) during applied behavior analysis (ABA) therapy. However, because there is currently no standard method for making these determinations, BCBAs must rely on their own clinical judgment. Given that clinical judgment may be underdeveloped in some BCBAs, particularly those who are newly certified, more formal strategies are needed to guide decision making as it relates to medical necessity and treatment dosage. In this article we describe the development of the Patient Outcome Planning Calculator (POP-C), a standardized decision-making tool designed to assist novice practitioners in determining the medically necessary ABA treatment intensity and appropriate treatment setting for individuals with autism spectrum disorder (ASD). We present preliminary reliability data as well as construct validity data indicating statistically significant correlations between the POP-C and several norm-referenced and criterion-referenced assessments commonly used to estimate skill level and the corresponding degree of support needed within the ASD population to inform the ABA treatment model and goals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00861-6.

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

BACKGROUND/OBJECTIVES

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

RESULTS

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

CONCLUSION

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

A Non-parametric Analysis of Gender Differences With the Impacts of Applied Behavior Analysis on Autistic Individuals

Introduction Considering the scarcity of research that directly investigates the differences between genders in their response to applied behavior analysis (ABA) therapy for individuals diagnosed with autism spectrum disorder (ASD), the objective of this study is twofold. First, it aims to reinforce the male-to-female ratio reported in existing scientific literature, thereby contributing to a broader understanding of gender distribution in ABA therapy for ASD. Second, it seeks to identify gender-based differences in aggregate target behaviors at various time intervals using three distinct datasets. The goal is to determine if gender influences the effectiveness of ABA therapy for ASD, which could inform future therapeutic strategies. Ultimately, this study strives to enhance our understanding of gender disparities in ABA therapy response among ASD individuals and hopes to improve therapeutic outcomes for all, regardless of gender. Materials and methods Three to five behavioral technicians per child collected daily general target mastery data for 263 individuals with autism. This data was gathered using a large N design through retrospective chart reviews within the "Catalyst" tracking software (DataFinch Technologies, Atlanta, USA). Three separate datasets were collected from June 7, 2023 to January 7, 2024. Behavior analysts employed a mixed model of discrete trial training, mass trials, and naturalistic environment treatment over seven months. General target mastery data was assembled for 259 children and four adults, with seven data instances missing. Descriptive statistics encompassed central tendency and dispersion measures, including the data distribution's mean, standard deviation, median, and range. Non-parametric inferential analysis was performed with the Mann-Whitney U test. Results Mann-Whitney U computations resulted in non-significant gender differences on all gender comparisons for the three datasets covering the seven-month timeframe. Dataset #1: Time 1-(U=727.5, p=0.846, ή2=0.0002, Time 2-(U=736, p=0.910, ή2=0.00005), Time 3-(U=687.5, p=0.569, ή2=0.001) Dataset #2: Time 1-(U=781, p=0.383, ή2=0.003), Time 2-(U=819.5, p=0.585, ή2=0.001), Time 3-(U=825, p=0.618, ή2=0.001) Dataset #3: Time 1-(U=395, p=0.198, ή2=0.007), Time 2-(U=373.5, p=0.365, ή2 =0.003), Time 3-(U=363, p=0.471, ή2=0.002), Time 4-(U=366.5, p=0.436, ή2 =0.003), Time 5-(U=371, p=0.391, ή2=0.003), Time 6-(U=394, p=0.208, ή2=0.007), Time 7-(U=373, p=0.373, ή2=0.003), Time 8-(U=371.5, p=0.387, ή2=0.003), Time 9-(U=464.5, p=0.512, ή2=0.002), Time 10-(U=356.5, p=0.546, ή2=0.002), Time 11-(U=357.5, p=0.535, ή2=0.002), Time 12-(U=350.5, p=0.346, ή2=0.004) Conclusions This study suggests no significant gender differences in response to ABA therapy among individuals with autism, indicating its potential effectiveness for both genders. However, these findings should be interpreted cautiously due to statistical uncertainties reflected in the broad confidence intervals as they hint at possible substantial gender differences. Further research, including an extension study, must confirm these results and understand potential gender nuances in ABA therapy response. This could help tailor more effective, personalized therapeutic strategies for individuals with autism.

Comparative Effects of Applied Behavior Analysis on Male and Female Individuals With Autism Spectrum Disorder

Introduction Current evidence-based treatments for autism spectrum disorder (ASD) are based on applied behavior analysis (ABA). However, research on gender differences in ABA therapy response is limited. This study seeks to (1) confirm the 4:1 male-to-female ratio reported in the literature and (2) identify any possible gender differences in target behaviors over seven timepoints measured every two weeks. Materials and methods  For three months, from March 19, 2023, to June 11, 2023, a team of 3-5 behavioral technicians per individual collected daily data on general target mastery for 100 individuals with ASD treated with ABA. Data was collected at seven timepoints every two weeks. Descriptive demographics were computed. Two independent sample t-tests were performed to determine significant or nonsignificant gender differences with the seven timepoint variables.  Results Nonstatistically significant gender differences (p > .05) were found on all seven cumulative target behavior timepoints measured at two-week intervals. For targets mastered Time 1, baseline between males and females, there was no significant difference in the means for males (M = 1.0571, SD = 1.9196) and females (M = 2.0455, SD = 3.9457) (t(90) = -1.591, p = 0.115, confidence interval (CI) = -2.2223, 0.2456, d = -0.389). For targets mastered Time 2, two weeks between males and females, there was no significant difference in the means for males (M = 3.7132; SD = 4.5065) and females (M = 4.0682, SD = 5.1508) (t(88) = -0.310, p = 0.757, CI = -2.6305, 1.92056, d = -0.076). For targets mastered Time 3, four weeks between males and females, there was no significant difference in the means for males (M = 7.0956; SD = 8.7781) and females (M = 8.6136; SD = 11.2799) (t(88) = -0.656, p = 0.514, CI = -6.1173, 3.0811, d = -0.161). For targets mastered Time 4, six weeks between males and females, there was no significant difference in the means for males (M = 13.1728, SD = 16.2003) and females (M = 13.0682, SD = 16.9272) (t(88) = 0.026, p = 0.979, CI = -7.8779, 8.0871, d = 0.006). For targets mastered Time 5, eight weeks between males and females, there was no significant difference in the means for males (M = 17.2096; SD = 18.8546) and females (M = 17.4286, SD = 22.1683) (t(87) = -0.045, p = 0.965, CI = -9.9773, 9.5393, d = -0.011). For targets mastered Time 6, 10 weeks between males and females, there was no significant difference in the means for males (M = 21.0074, SD = 21.3329) and females (M = 20.6818, SD = 26.1231) (t(88) = 0.059, p = 0.953, CI = -10.6752, 11.3262, d = 0.014). For targets mastered Time 7, 12 weeks between males and females, there was no significant difference in the means for males (M = 26.1196, SD = 24.2235) and females (M = 29.6364, SD = 33.7406) (t(89) = -0.536, p = 0.593, CI = -16.5431, 9.5094, d = -0.131). Conclusions The study indicates that ABA treatments may be equally beneficial for both genders with ASD, showing no significant gender differences. However, the broad CIs in this study imply a level of statistical uncertainty, indicating potential gender differences, suggesting the results may not be uniform across genders. These findings challenge assumptions on gender-specific treatment responses, implying that ABA treatments shouldn't be recommended based on gender. Instead, individual needs should guide treatment recommendations. Future research could consider other response moderators like age, ASD severity, or coexisting mental health conditions.

Landscape of NRXN1 Gene Variants in Phenotypic Manifestations of Autism Spectrum Disorder: A Systematic Review

Background: Autism spectrum disorder (ASD) is a complex neurodevelopmental condition characterized by social communication challenges and repetitive behaviors. Recent research has increasingly focused on the genetic underpinnings of ASD, with the Neurexin 1 (NRXN1) gene emerging as a key player. This comprehensive systematic review elucidates the contribution of NRXN1 gene variants in the pathophysiology of ASD. Methods: The protocol for this systematic review was designed a priori and was registered in the PROSPERO database (CRD42023450418). A risk of bias analysis was conducted using the Joanna Briggs Institute (JBI) critical appraisal tool. We examined various studies that link NRXN1 gene disruptions with ASD, discussing both the genotypic variability and the resulting phenotypic expressions. Results: Within this review, there was marked heterogeneity observed in ASD genotypic and phenotypic manifestations among individuals with NRXN1 mutations. The presence of NRXN1 mutations in this population emphasizes the gene's role in synaptic function and neural connectivity. Conclusion: This review not only highlights the role of NRXN1 in the pathophysiology of ASD but also highlights the need for further research to unravel the complex genetic underpinnings of the disorder. A better knowledge about the multifaceted role of NRXN1 in ASD can provide crucial insights into the neurobiological foundations of autism and pave the way for novel therapeutic strategies.

Naturalistic Developmental Behavioral Interventions for Developmental Language Disorder

PURPOSE

Naturalistic-developmental-behavioral interventions (NDBIs) are a widely accepted and validated approach for treating language-related symptoms in autism spectrum disorder, including deficits in vocabulary, social skills, and grammar. The purpose of this article is to define the elements naturalistic, developmental, and behavioral as applied to children with developmental language disorder (DLD) and to provide an example of how this type of intervention can be implemented to teach vocabulary and test cross-modal generalization between expressive and receptive modalities.

METHOD

A vocabulary intervention using hybrid NDBI methods (storybook reading and conversational recast interaction) was provided to three participants with DLD using a single-case design.

RESULTS

The results indicated that all participants successfully learned receptive and expressive vocabulary targets with extensive cross-modal generalization. However, generalization was limited in some of the participants.

CONCLUSIONS

This article provided definitions of key elements of NDBI (naturalistic, developmental, and behavioral) including a rationale for extending NDBI procedures to language intervention for children with DLD. In addition, a single-case design demonstrated that NDBI can be implemented in DLD and that broadly defined naturalistic-developmental applied behavior analysis techniques are applicable to language interventions for children with language disorders. Moreover, diverse naturalistic and developmental procedures meet the highest standards for evidence-based practice to treat DLD.

Replicative Study of the Impacts of Applied Behavior Analysis on Target Behaviors in Individuals With Autism Using Repeated Measures

Background  The effectiveness of interventions based on applied behavior analysis (ABA) for individuals with autism has been well documented in numerous meta-analyses, systematic reviews, and cost-benefit analyses. However, an observed 'efficacy-effectiveness gap' exists, which can be attributed to various factors. This third replication study, therefore, has significant implications for the field. By assessing the impact of ABA treatment, specifically involving discrete trial training and mass trials, within a naturalistic environment, the study provides valuable insights that can inform and improve the delivery of ABA treatments in real-world settings. Methods  The study was conducted using a repeated measures research design. Retrospective chart review data were collected from 62 individuals with autism, age (M=8.65, SD=4.53), all of whom were level two autistic and required moderate support in communication, socialization, and daily life. These individuals received ABA treatment over five months. The study measured cumulative target behaviors using a repeated measures design, which allowed for the identification of statistically significant differences across 12 time points. This robust methodology ensures the validity and reliability of the study's findings. Results  Mixed repeated measures analysis of variance (ANOVA) indicated statistical significance (sphericity assumed), F(11,495) = 55.432, p < 0.001 (time). Multiple comparisons using bootstrapped paired t-tests showed p < 0.05 on time points 1-8 and non-significance (p > 0.05) on time points 9-12. There was a significant interaction effect (sphericity assumed) with time x (age category), F(44,495) = 2.338, p < 0.001. Interaction contrasts indicated statistically significant differences over time, mainly within the one-year to four-year-old, five to eight-year-old, and most in the nine to 12-year-old age groups. There was some significance within the 13- to 16-year-old age group and no significance within the 17- to 26-year-old age group. Conclusions  Over five months, individuals with autism who underwent ABA treatments demonstrated a statistically significant enhancement in general target behaviors. This finding is crucial as it underscores the effectiveness of ABA treatments in a naturalistic environment. Moreover, the study's discovery of a significant interaction between time and age in these behaviors provides valuable insights into the impact of age on treatment outcomes. Extensive large-N studies of general ABA broad effectiveness and repeated measures designs are lacking and can lead to further research to improve quality and outcomes. These findings contribute to the body of empirical evidence and emphasize the importance of replicative efficacy studies in ensuring the reliability of research findings.

Social media shaping autism perception and identity

LAY ABSTRACT

This study suggested that social media can provide important information about autism to autistic people. We interviewed 12 autistic adults (aged 18-49 years) and talked to them about the use of social media to find both general information and content specifically about autism, autism identity and online autistic communities. There is little research exploring how autistic people find information about autism on social media and how that makes them feel. Therefore, it is important to ask autistic people about their experiences with using social media to obtain content about autism. The 12 participants explained that when they searched for information about autism on the official health pages, they often felt that the information they found was insufficient and could not answer their questions. In addition, they searched on social media platforms for information about autism despite that they perceived social media as an unreliable source. On the social media platforms, many found content that was positive in relation to their autistic identities. The participants also found comfort in some of the forums and social media groups and received helpful advice. Nevertheless, some of the discussions were aggressive and the participants felt alienated, which did not provide a sense of community online. The findings from the study may advice on what is missing in the official pages about autism, and highlight the need to involve the autistic community in writing the content on such platforms.

Exploring the Acquisition of Social Communication Skills in Children with Autism: Preliminary Findings from Applied Behavior Analysis (ABA), Parent Training, and Video Modeling

Social communication skills, especially eye contact and joint attention, are frequently impaired in autism spectrum disorder (ASD) and predict functional outcomes. Applied behavior analysis is one of the most common evidence-based treatments for ASD, but it is not accessible to most families in low- and middle-income countries (LMICs) as it is an expensive and intensive treatment and needs to be delivered by highly specialized professionals. Parental training has emerged as an effective alternative. This is an exploratory study to assess a parental intervention group via video modeling to acquire eye contact and joint attention. Four graded measures of eye contact and joint attention (full physical prompt, partial physical prompt, gestural prompt, and independent) were assessed in 34 children with ASD and intellectual disability (ID). There was a progressive reduction in the level of prompting required over time to acquire eye contact and joint attention, as well as a positive correlation between the time of exposure to the intervention and the acquisition of abilities. This kind of parent training using video modeling to teach eye contact and joint attention skills to children with ASD and ID is a low-cost intervention that can be applied in low-resource settings.

Strategies for addressing the needs of children with or at risk of developmental disabilities in early childhood by 2030: a systematic umbrella review

BACKGROUND

There are over 53million children worldwide under five with developmental disabilities who require effective interventions to support their health and well-being. However, challenges in delivering interventions persist due to various barriers, particularly in low-income and middle-income countries.

METHODS

We conducted a global systematic umbrella review to assess the evidence on prevention, early detection and rehabilitation interventions for child functioning outcomes related to developmental disabilities in children under 5 years. We focused on prevalent disabilities worldwide and identified evidence-based interventions. We searched Medline, Embase, PsychINFO, and Cochrane Library for relevant literature from 1st January 2013 to 14th April 2023. A narrative synthesis approach was used to summarise the findings of the included meta-analyses. The results were presented descriptively, including study characteristics, interventions assessed, and outcomes reported. Further, as part of a secondary analysis, we presented the global prevalence of each disability in 2019 from the Global Burden of Disease study, identified the regions with the highest burden and the top ten affected countries. This study is registered with PROSPERO, number CRD42023420099.

RESULTS

We included 18 reviews from 883 citations, which included 1,273,444 children under five with or at risk of developmental disabilities from 251 studies across 30 countries. The conditions with adequate data were cerebral palsy, hearing loss, cognitive impairment, autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder. ASD was the most prevalent target disability (n = 8 reviews, 44%). Most reviews (n = 12, 67%) evaluated early interventions to support behavioural functioning and motor impairment. Only 33% (n = 10/30) of studies in the reviews were from middle-income countries, with no studies from low-income countries. Regarding quality, half of reviews were scored as high confidence (n = 9/18, 50%), seven as moderate (39%) and two (11%) as low.

CONCLUSIONS

We identified geographical and disability-related inequities. There is a lack of evidence from outside high-income settings. The study underscores gaps in evidence concerning prevention, identification and intervention, revealing a stark mismatch between the available evidence base and the regions experiencing the highest prevalence rates of developmental disabilities.

Health supervision for children and adolescents with 16p11.2 deletion syndrome

Rare genetic conditions are challenging for the primary care provider to manage without proper guidelines. This clinical review is designed to assist the pediatrician, family physician, or internist in the primary care setting to manage the complexities of 16p11.2 deletion syndrome. A multidisciplinary medical home with the primary care provider leading the care and armed with up-to-date guidelines will prove most helpful to the rare genetic patient population. A special focus on technology to fill gaps in deficits, review of case studies on novel medical treatments, and involvement with the educational system for advocacy with an emphasis on celebrating diversity will serve the rare genetic syndrome population well.

Avoidant-restrictive food intake disorder and autism: epidemiology, etiology, complications, treatment, and outcome

PURPOSE OF REVIEW

There is considerable overlap between the features of avoidant-restrictive food intake disorder (ARFID) and autism. The purpose of this scoping review is to provide an overview of studies published on ARFID and autism in 2022 and the first half of 2023.

RECENT FINDINGS

ARFID and autism are highly heritable conditions that often co-occur. In a large autism cohort, 21% of participants and 17% of their parents presented with avoidant-restrictive features. Of children diagnosed with ARFID, 8.2-54.8% are autistic. More than half of individuals with ARFID also have other neurodevelopmental, psychiatric, or somatic diagnoses. Anxiety, depression, sleep disorders, and learning difficulties are particularly common co-occurring issues. Various strategies have been developed to support autistic children with feeding difficulties. It appears that their feeding difficulties, particularly sensory sensitivities, food preferences, and mealtime rituals and routines frequently persist into adolescence and adulthood, but research on optimal support for adults and adolescents is still scarce. Untreated ARFID in autistic individuals may lead to serious complications.

SUMMARY

Individuals seeking specialist care for autism, eating disorders, or gender dysphoria should be screened for ARFID. More research is needed on how to support autistic adolescents and adults with features of ARFID.