Guidelines for evaluating intervention programs for children with autism

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.

Pivotal Response Intervention II: Preliminary Long-Term Outcome Data

The literature and our observations suggest that self-initiations may be an especially important part of intervention for children with autism. Therefore, the purpose of this study was to conduct preliminary assessments as to whether self-initiations might be associated with highly favorable postintervention outcomes. In the first phase of this study, archival data were analyzed for 6 children. At intake, according to traditional variables, they appeared to have especially good prognoses for reducing symptoms of autism, but had extremely different outcomes (either exceptionally good or exceptionally poor) after years of intensive intervention. Results of Phase 1 indicated that the children who had highly favorable outcomes exhibited more spontaneous self-initiations at preintervention. Given these results, Phase 2 of the study assessed whether a series of self-initiations could be taught to children with autism who demonstrated few or no spontaneous self-initiations at preintervention, and whether this intervention would result in highly favorable postintervention outcomes. Results indicated that these children learned a variety of self-initiations and had extremely favorable outcomes. The results of this exploratory study are encouraging in terms of assessment of key pivotal target behaviors that may be identified as prognostic indicators, and that may be important during intervention for children with autism.

Services for Children With Autism Spectrum Disorders

Recommendations for improving school and community-based services for children with autism spectrum disorders (ASD) in the state of Virginia were investigated. Participants consisted of 783 parents of children birth to age 22 with a medical diagnosis of ASD. Data obtained through an open-ended survey question were analyzed both quantitatively and qualitatively. Parents recommended improving the quality, quantity, accessibility, and availability of services; educating and training individuals to work effectively with children with ASD; increasing funding for services; and creating appropriate school placements and educational programs. The findings from this study suggest the need for increased individualization of and accessibility to services. Future state-level research must examine the variables that affect parent recommendations and evaluate the quality of existing services for children with ASD.

Mothers' attributions following their child's diagnosis of autistic spectrum disorder

Although the impact of autism spectrum disorders (ASDs) on the family is well recognized, the way mothers attempt to make sense of the diagnosis is largely unexplored. However, in other disabilities, attributions have been shown to predict a variety of outcomes including maternal wellbeing and engagement in treatment. Using Weiner's (1985) three-dimensional model, 16 mothers were interviewed to examine the nature and impact of their beliefs about their child's ASD using semi-structured interviews and measures of depression, parenting stress and expectations for their child's future. The findings suggested that mothers made a diverse and complex range of attributions that were consistent with Weiner's dimensions of locus of cause, stability and controllability. The nature of their attributions reflected particular difficulties associated with ASDs, such as uncertainties regarding cause and prognosis. Taking account of mothers' search for meaning will better enable professionals to support families following diagnosis.

Evaluating Practice

This article seeks to examine some of the issues involved in the evaluation of practice by practitioners themselves. Five questions are posed which represent five different kinds of design suitable for the different purposes of evaluation in each case. For each question, an analysis is made of the problem that the question is addressing, an example is given of the design needed to answer that question, and a further analysis is made of the possible outcomes of the evaluation, suggesting how they may be interpreted. Finally, there is a brief discussion of the issues involved in controlled studies, the ethical issues that arise in research and how participants with autism spectrum disorders may themselves by involved in evaluation. The article makes the point that research should not be an activity carried out by others, using natural settings merely as sources of data, but a process that all practitioners are engaged in at some level. In this way, progress can be made in improving services and the quality of life for people with autism spectrum disorders.

Improving question-asking initiations in young children with autism using pivotal response treatment

Social initiations make up a core deficit for children with autism spectrum disorder (ASD). In particular, initiated questions during social interactions are often minimal or absent in this population. In the context of a multiple baseline design, the efficacy of using the motivational procedures of Pivotal Response Treatment to increase social question-asking for three young children with autism was assessed. Results indicated that participants initiated a greater number of targeted questions following intervention. Additionally, all children exhibited increases in initiation of untargeted questions during social interaction in novel settings. Furthermore, post intervention data revealed collateral gains in communication and adaptive behavior. Theoretical implications of incorporating motivational strategies into intervention to improve social initiations in young children with ASD are discussed.

Cost comparison of early intensive behavioral intervention and treatment as usual for children with autism spectrum disorder in The Netherlands

Early intensive behavioral intervention (EIBI) may result in improved cognitive, adaptive and social functioning and reductions in autism severity and behavioral problems in children with Autism Spectrum Disorder (ASD). For a subset of children, normal functioning may be the result. However, due to the intensity (20-40 h per week for 3 years with a low child staff ratio) implementation costs are high and can be controversial. Estimated costs for education, (supported) work and (sheltered) living for individuals with ASD in The Netherlands are applied in a cost-offset model. A compelling argument for the provision of EIBI is long term savings which are approximately € 1,103,067 from age 3 to 65 years per individual with ASD. Extending these costs to the whole Dutch ASD population, cost savings of € 109.2-€ 182 billion have been estimated, excluding costs associated with inflation.

Issues, Policies, and Recommendations for Improving the Education of Learners With Autism Spectrum Disorders

Children and youth with autism spectrum disorders (ASD) create significant challenges to educators and the educational system not only based on their ever-increasing numbers but also because of the questions and debates surrounding how best to provide them an appropriate and effective education. These issues include the skills, knowledge, and professional credentials of educators who teach learners with ASD, which settings are best suited for their educational experiences, and what and how children and youth with ASD should be taught. In this article the authors address these three core elements that underpin the education of pupils with ASD and offer recommendations for improving the present system.

Behavioural intervention practices for stereotypic and repetitive behaviour in individuals with autism spectrum disorder: a systematic review

AIM

The purpose of this systematic review was to examine the quality of conduct of experimental studies contributing to our empirical understanding of function-based behavioural interventions for stereotypic and repetitive behaviours (SRBs) in individuals with autism spectrum disorders (ASDs).

METHOD

Systematic review methodology was used to identify relevant articles, to rate the level of evidence and quality of conduct of the studies, and to extract data systematically.

RESULTS

Ten single case studies examining 17 participants (14 males, 3 females; age 2y 11mo-26y) diagnosed with various ASDs were included. Overall, studies reported decreases in SRBs using behavioural interventions and some collateral increase in desirable behaviours.

INTERPRETATION

Only a small number of intervention studies for SRBs explicitly state the function of the behaviour; therefore, relatively little is known about the efficacy of SRB interventions in relation to the range of possible behavioural functions. Evidence supporting SRB interventions is preliminary in nature, and caution should be used in choosing and implementing SRB intervention practices for individuals with ASDs.

Autism, "recovery (to normalcy)", and the politics of hope

This article draws on the traditions of critical discourse analysis (N. Fairclough, 1995, 2001; M. Foucault, 1972, 1980; J. P. Gee, 1999) in critically examining the discursive formation of "recovery" from autism in applied behavioral analysis (ABA) discourse and its relationship to constructs of hope. Constituted principally in the work of O. I. Lovaas (1987) and C. Maurice (1993), and central to ABA discourse on recovery, has been the construction of a particular vision of hope that has at least 2 integral conceptual elements: (a) Hope for recovery within ABA discourse is constructed in binary opposition to hopelessness, and (b) recovery within ABA discourse is discursively constructed as "recovery (to normalcy)." The author analyzes these 2 pivotal ABA texts within the context of an analysis of other uses of the term recovery in broader bodies of literature: (a) within prior autism-related literature, particularly autobiography, and (b) within literature emanating from the psychiatric survivors' movement. If, indeed, visions of hope inform educational policy and decision making, this analysis addresses S. Danforth's (1997) cogent query, "On what basis hope?", and asserts that moral and political commitments should be central sources of visions of hope and, therefore, inform educational policy and decision making for young children with labels of autism.

Social interaction and repetitive motor behaviors

Students with autism have difficulty initiating social interactions and may exhibit repetitive motor behavior (e.g., body rocking, hand flapping). Increasing social interaction by teaching new skills may lead to reductions in problem behavior, such as motor stereotypies. Additionally, self-monitoring strategies can increase the maintenance of skills. A multiple baseline design was used to examine whether multi-component social skills intervention (including peer training, social initiation instruction, and self-monitoring) led to a decrease in repetitive motor behavior. Social initiations for all participants increased when taught to initiate, and social interactions continued when self-monitoring was introduced. Additionally, participants' repetitive motor behavior was reduced. Changes in social behavior and in repetitive motor behavior maintained more than one month after the intervention ended.

Department for Education and Skills/Department of Health Good Practice Guidance on the education of children with autistic spectrum disorder

Currently, it is held by many that educational interventions are those most likely to make a significant difference to the prognosis and well-being of a child with an autistic spectrum disorder (ASD). Yet, decision making about educational interventions and provision in ASD is often based on beliefs, tradition and assumptions, rather than on empirical evidence. This can lead to inappropriate or ineffective provision and can cause confusion and conflict between and within professional groups and parents. Little rigorous research evidence exists to guide decisions for children with ASD. This is true for educational practice generally, and for children with other special educational needs. Practitioners and parents alike are keen for good information on how best to educate children with ASD. It was against this background that the Department for Education and Skills (DfES) and Department of Health (DoH) convened a working group of experienced practitioners and parents to produce the 'Good Practice Guidance on ASDs'. This paper explores the need for the DfES/DoH Guidance, describes its structure and content and then suggests why research evidence is sparse and how future research might be enhanced to inform practice.

Interaction and imitation deficits from infancy to 4 years of age in children with autism: a pilot study based on videotapes

The present study investigated the influence of developmental level on interaction and imitation in infants and young children with autism on the basis of family videos and filmed consultation. The sample comprised 18 children with autism divided into groups according to their developmental quotient (DQ>50 and DQ<50). A quantitative evaluation was performed on video observations at four periods (10-12 months, 16-18 months, 24-26 months, after 4 years) using scales appropriate for the evaluation of interaction and imitation impairments. The findings showed that, at a very early age, infants later diagnosed as having autistic disorder show different intensities of interaction and imitation deficits according to developmental level.

Treating the core features of autism: are we there yet?

A wide variety of nonestablished treatments have been proposed as "cures" for the core features of autism and are used frequently despite having largely escaped scientific scrutiny. In contrast, a growing body of empirical evidence supports the use of a few forms of theory-based and empirically validated treatment for some aspects of the core features of autism. These include behavioral/psychoeducational interventions and specific forms of medication treatment, which can produce significant improvements in communication, social interaction, and problem behaviors that both maintain over time and generalize across settings. While there is no doubt that treatment and educational services for persons with autism have improved over the past 6 decades, it also appears that significant issues remain with respect to (1) the routine application of validated treatments for the majority of cases with autism, (2) the resistance to even validated forms of treatment for a substantial minority of cases with autism, and (3) the extent to which validated treatments effectively treat the specific core features of autism that are most disabling for persons with autism and their families.

Communicating a diagnosis of developmental disability to parents: multiprofessional negotiation frameworks

It is a hard task for professionals to give and parents to receive the bad news about a child's developmental disability. This study describes how findings about four preschool children, with difficulties suspected to lie within the autistic spectrum, were negotiated with parents by two multiprofessional groups, one in a Medical (Site M) and one in an Education setting (Site E). Each assessment was undertaken over half a day, the professionals jointly interacting with the child and family. All assessment discussions were audiotaped and each participant was interviewed after the assessment. Conversation analysis showed the activation of three major social-interaction frameworks: professionals at both sites applied a parent-friendly frame, but this was complemented by a hopeful-diagnostic-formulation frame at Site M, and a defocusing-of-bad-news frame at Site E.

The Scottish Centre for Autism preschool treatment programme. I: A developmental approach to early intervention

Early intervention is an area of intense current interest for parents and professionals. This article describes a mainstream National Health Service (NHS) approach to early intervention, developed at the Scottish Centre for Autism. The aims of treatment are to improve the child's early social communication and social interaction skills, leading to the potential development of play and flexibility of behaviour. This is achieved by 1:1 intensive treatment by trained therapists, and a schedule of parent training. The treatment protocol incorporates a child led approach; the use of imitation as a therapeutic strategy; using language contingent on activities; and the introduction of flexibility into play and social exchanges.