Intensive behavioral treatment for a toddler at high risk for autism

The Ethics of Actually Helping People: Targeting Skill Acquisition Goals That Promote Meaningful Outcomes for Individuals with Autism Spectrum Disorder

As a field that predominately supports individuals with autism spectrum disorder (ASD), we have an ethical duty as behavior analysts to ensure that the goals we write and interventions we prescribe promote best outcomes across the lifespan. This is critical, given that as it stands now, outcomes in adulthood for individuals with ASD are poor in every area assessed. The Ethics Code for Behavior Analysts can be interpreted to provide support for teaching the right goals, the right way, with respect to inherent rights of those we serve, in order to help affect positive changes in these outcomes. The present article highlights ethical themes that are relevant in order to affect these changes that are supported by the Code, as well as actionable steps to take next. The aim is to provide a resource for practitioners to use in clinical practice and in making ethical decisions that will help to improve outcomes for individuals with autism in adulthood. In addition, recommendations are made about integrating these values and approaches in terms of training, supervision, advocacy, and research.

Psychometric properties of the Persian version of social responsiveness scale-second edition (SRS-2)

Purpose

To quantitatively measure the subtle and general symptoms of autism spectrum disorder (ASD), one of the instruments that have been designed and used is the social responsiveness scale (SRS). The purpose of this study is to translate the second edition of the SRS into Persian and to examine its psychometric properties in school and preschool children with ASD.

Design/methodology/approach

The present study is a methodological study of the psychometric type; the study population consisted of school and preschool children from 3 to 12 years of age with ASD and an intelligence quotient of approximately 70. In total, 10 professors and occupational therapists with research and clinical experience in the field of children, were selected for the translation and content validation stages by expert sampling. To determine the validity of the instrument, the content validity index (CVI) and the content validity ratio (CVR) were used; in addition, to determine the reliability, the internal consistency determination method with Cronbach’s alpha number report and inter-rater reliability method within-class correlation coefficient report were used.

Findings

The calculated CVI and CVR of the instrument for all instrument items were 0.82 and 0.86, respectively. The intra-class correlation coefficient performed by different raters was 0.80 and Cronbach’s alpha for all items was 0.93.

Originality/value

The reliability and validity of the Persian version of the social responsiveness scale-second edition are appropriate and acceptable so that this instrument can be used to assess the social performance skills of 3–12-years-old children with ASD for research and clinical study.

Study of the effectiveness of comprehensive, timely, and family-oriented interventions in reducing the symptoms of autism in children

BACKGROUND AND OBJECTIVES

The onset of rehabilitation interventions in children with autism spectrum disorder below 5 years old has been associated with the reduction of autism symptoms in all developmental domains. The present study aimed to illustrate the importance of early family-oriented interventions in the reduction of the problems and symptoms of children with autism spectrum disorder.

METHODOLOGY

This study was a pretest-posttest clinical trial without a control group. Fifty patients were selected using a convenience sampling method, of which forty patients were male and 10 females with a mean age of 3.2 ± 1.4. The efficacy assessment was evaluated using the Autism Behavior Checklist (ABC) and the Autism Treatment Evaluation Checklist (ATEC) as pretest and posttest. Data were analyzed by independent T-test using SPSS software.

RESULTS

The difference between pretest and posttest was significant in all aspects of the ATEC test (communication, health, sensory and cognitive awareness, socialization) at the level of P < 0.001. Moreover, the difference between pretest and posttest was significant at P < 0.001 for the aspects of speech, social and communication, and general performance, and at P < 0.002 for the sensory processing.

CONCLUSION

Timely interventions under 6 years old with an emphasis on family-oriented and growth aspects over one year can help autistic children in the aspects of speech, social and communication, sensory processing, and sensory and cognitive awareness.

Cortical and subcortical alterations associated with precision visuomotor behavior in individuals with autism spectrum disorder

In addition to core deficits in social-communication abilities and repetitive behaviors and interests, many patients with autism spectrum disorder (ASD) experience developmental comorbidities, including sensorimotor issues. Sensorimotor issues are common in ASD and associated with more severe clinical symptoms. Importantly, sensorimotor behaviors are precisely quantifiable and highly translational, offering promising targets for neurophysiological studies of ASD. We used functional MRI to identify brain regions associated with sensorimotor behavior using a visually guided precision gripping task in individuals with ASD (n = 20) and age-, IQ-, and handedness-matched controls (n = 18). During visuomotor behavior, individuals with ASD showed greater force variability than controls. The blood oxygen level-dependent signal for multiple cortical and subcortical regions was associated with force variability, including motor and premotor cortex, posterior parietal cortex, extrastriate cortex, putamen, and cerebellum. Activation in the right premotor cortex scaled with sensorimotor variability in controls but not in ASD. Individuals with ASD showed greater activation than controls in left putamen and left cerebellar lobule VIIb, and activation in these regions was associated with more severe clinically rated symptoms of ASD. Together, these results suggest that greater sensorimotor variability in ASD is associated with altered cortical-striatal processes supporting action selection and cortical-cerebellar circuits involved in feedback-guided reactive adjustments of motor output. Our findings also indicate that atypical organization of visuomotor cortical circuits may result in heightened reliance on subcortical circuits typically dedicated to motor skill acquisition. Overall, these results provide new evidence that sensorimotor alterations in ASD involve aberrant cortical and subcortical organization that may contribute to key clinical issues in patients.NEW & NOTEWORTHY This is the first known study to examine functional brain activation during precision visuomotor behavior in autism spectrum disorder (ASD). We replicate previous findings of elevated force variability in ASD and find these deficits are associated with atypical function of ventral premotor cortex, putamen, and posterolateral cerebellum, indicating cortical-striatal processes supporting action selection and cortical-cerebellar circuits involved in feedback-guided reactive adjustments of motor output may be key targets for understanding the neurobiology of ASD.

A Pilot Study of a Behavioral Parent Training in the Republic of Macedonia

Parenting children with autism in countries with limited professional and financial resources can be overwhelming. Parent training led by non-governmental organizations may help alleviate some of these burdens. The present pilot study was conducted in the Republic of Macedonia, a country located in Southeastern Europe. The purpose of the study was to evaluate a parent training model for disseminating evidence-based practices through didactic and pyramidal training strategies. Results indicated that children improved on a number of different behaviors and results provide some evidence that parenting confidence and distress improved.

Early Detection and Intervention of ASD: A European Overview

Over the last several years there has been an increasing focus on early detection of Autism Spectrum Disorder (ASD), not only from the scientific field but also from professional associations and public health systems all across Europe. Not surprisingly, in order to offer better services and quality of life for both children with ASD and their families, different screening procedures and tools have been developed for early assessment and intervention. However, current evidence is needed for healthcare providers and policy makers to be able to implement specific measures and increase autism awareness in European communities. The general aim of this review is to address the latest and most relevant issues related to early detection and treatments. The specific objectives are (1) analyse the impact, describing advantages and drawbacks, of screening procedures based on standardized tests, surveillance programmes, or other observational measures; and (2) provide a European framework of early intervention programmes and practices and what has been learnt from implementing them in public or private settings. This analysis is then discussed and best practices are suggested to help professionals, health systems and policy makers to improve their local procedures or to develop new proposals for early detection and intervention programmes.

Cost Offset Associated With Early Start Denver Model for Children With Autism

OBJECTIVE

To determine the effect of the Early Start Denver Model (ESDM) for treatment of young children with autism on health care service use and costs.

METHOD

We used data from a randomized trial that tested the efficacy of the ESDM, which is based on developmental and applied behavioral analytic principles and delivered by trained therapists and parents, for 2 years. Parents were interviewed about their children's service use every 6 months from the onset of the intervention to follow-up (age 6 years). The sample for this study consisted of 39 children with autism who participated in the original randomized trial at age 18 to 30 months, and were also assessed at age 6 years. Of this sample, 21 children were in the ESDM group, and 18 children were in the community care (COM) group. Reported services were categorized and costed by applying unit hourly costs. Annualized service use and costs during the intervention and post intervention for the two study arms were compared.

RESULTS

During the intervention, children who received the ESDM had average annualized total health-related costs that were higher by about $14,000 than those of children who received community-based treatment. The higher cost of ESDM was partially offset during the intervention period because children in the ESDM group used less applied behavior analysis (ABA)/early intensive behavioral intervention (EIBI) and speech therapy services than children in the comparison group. In the postintervention period, compared with children who had earlier received treatment as usual in community settings, children in the ESDM group used less ABA/EIBI, occupational/physical therapy, and speech therapy services, resulting in significant cost savings in the amount of about $19,000 per year per child.

CONCLUSION

Costs associated with ESDM treatment were fully offset within a few years after the intervention because of reductions in other service use and associated costs.

CLINICAL TRIAL REGISTRATION INFORMATION

Early Characteristics of Autism; http://clinicaltrials.gov/; NCT0009415.

Initial Development of the Early Intensive Behavioral Intervention Parental Self-Efficacy Scale: A Pilot Study

Early Intensive Behavioral Intervention (EIBI) is an effective treatment for children with autism. However, it is known that some parents struggle to fully implement the program, and providers are not always able to identify the specifics of each family's individualized challenges. The purpose of this pilot study was to begin the process of developing a new instrument, the EIBI Parental Self-Efficacy (EPSE) Scale, to help providers better assess and assist parents in regard to EIBI implementation. The methodology included four phases: scale construction, expert review, pretest administration, and a large sample pilot study (N = 192). The final 29-item EPSE Scale contained strong reliability properties (Cronbach's alpha = .900). Factor analysis established five subscales: Family Well-Being, Preparing for Successful Sessions, Team Participation, Not Giving Up, and Working with your Child. Following this pilot study, future research is recommended to refine and validate the EPSE Scale as a useful clinical tool for EIBI providers.

Investigating the validation of the Chinese Mandarin version of the Social Responsiveness Scale in a Mainland China child population

BACKGROUND

Researchers from several different countries have found the Social Responsiveness Scale (SRS) to have good psychometric properties. However, to our knowledge, no studies on this subject have been reported in Mainland China. In this study, we investigated the psychometric properties of the Chinese Mandarin version of the SRS when used in Mainland China.

METHODS

The reliability and validity of the parent-report SRS in a sample of 749 children of 4- to 14-year-olds: 411 typically developing and 338 clinical participants (202 with autism spectrum disorder (ASD)) were examined.

RESULTS

Internal consistency for total scale (0.871-0.922), test-retest reliability (0.81-0.94), and convergent validity with the Autism Behavior Checklist (ABC) (0.302-0.647) were satisfactory. The SRS total score discriminated between the ASD and other developmental disorders. Receiver operating characteristic (ROC) analyses revealed that the SRS was predicted to accurately classify 69.2-97.2% of youth ASD. Exploratory factor analysis (EFA) supported a single-factor solution for the ASD subsample. Confirmatory factor analysis (CFA) did not confirm the theoretical construct of five factors model with inadequate fit in the ASD subsample.

CONCLUSIONS

Overall, our findings supported the reliability and validity of the parent-report SRS as one ASD screening instrument. In addition, we also suggest that the use of separate cut-offs for screening purposes (optimizing sensitivity) vs. clinical confirmation (optimizing specificity) should be considered.

Implementation of early intensive behavioural intervention for children with autism in Switzerland

BACKGROUND

There is a major gap between the US and most European countries regarding the implementation of early intensive behavioural intervention (EIBI) for children with autism. The present paper reports on the current status of EIBI in Switzerland and on the effectiveness of EIBI under clinical conditions in a Swiss pilot project.

METHODS

The paper combines a narrative report of the care system for children with autism in Switzerland and an initial evaluation of EIBI as implemented in the Department of Child and Adolescent Psychiatry, University of Zurich.

RESULTS

The current situation of the implementation of EIBI for children with autism in Switzerland is characterized by marked deficits in its acceptance. Major reasons include insufficient governmental approval and lacking legal and financial support. In addition, ignorance among health care providers and educational professionals has contributed to this situation precluding that children with autism receive the most beneficial assistance. The authors have initiated and been working in an intervention centre offering EIBI for a decade and report on their experience with the implementation of EIBI. Based on their clinical practice, they document that EIBI also works efficiently under ordinary mental health service conditions.

CONCLUSIONS

EIBI needs to be implemented more intensively in Switzerland. Although the effects of EIBI as implemented in Zurich are promising, the results are not as pronounced as under controlled research conditions.

The Clinical Application of Applied Behavior Analysis in a Child With Partial Fetal Alcohol Syndrome

The current case study describes the longitudinal assessment of a young child diagnosed with Partial Fetal Alcohol Syndrome and pervasive developmental disorder–not otherwise specified. The patient participated in an applied behavior analysis (ABA)–based Verbal Behavior treatment program to target communication impairments and functional skill deficits. Because ABA-based interventions have demonstrated efficacy in improving levels of functioning across various developmental disabilities, it was reasonable to assess the clinical utility of these same strategies when applied to a patient presenting with fetal alcohol spectrum disorder and associated developmental delays. The current study relied on quasi-experimental single-subject design methods to measure treatment outcomes and to inform clinical decision making. Dependent measures in the study included standardized, norm-referenced assessments of cognitive and adaptive functioning, as well as behavioral data collected throughout treatment to measure gains across skill areas. Outcomes included rapid skill acquisition across several areas of functioning (e.g., expressive and receptive language, visual-performance, and adaptive emotional/behavioral functioning). The impact of treatment on global areas of functioning will be reported.

Feedforward and feedback motor control abnormalities implicate cerebellar dysfunctions in autism spectrum disorder

Sensorimotor abnormalities are common in autism spectrum disorder (ASD) and among the earliest manifestations of the disorder. They have been studied far less than the social-communication and cognitive deficits that define ASD, but a mechanistic understanding of sensorimotor abnormalities in ASD may provide key insights into the neural underpinnings of the disorder. In this human study, we examined rapid, precision grip force contractions to determine whether feedforward mechanisms supporting initial motor output before sensory feedback can be processed are disrupted in ASD. Sustained force contractions also were examined to determine whether reactive adjustments to ongoing motor behavior based on visual feedback are altered. Sustained force was studied across multiple force levels and visual gains to assess motor and visuomotor mechanisms, respectively. Primary force contractions of individuals with ASD showed greater peak rate of force increases and large transient overshoots. Individuals with ASD also showed increased sustained force variability that scaled with force level and was more severe when visual gain was highly amplified or highly degraded. When sustaining a constant force level, their reactive adjustments were more periodic than controls, and they showed increased reliance on slower feedback mechanisms. Feedforward and feedback mechanism alterations each were associated with more severe social-communication impairments in ASD. These findings implicate anterior cerebellar circuits involved in feedforward motor control and posterior cerebellar circuits involved in transforming visual feedback into precise motor adjustments in ASD.

Comparison of behavior analytic and eclectic early interventions for young children with autism after three years

In a previous study, we compared the effects of just over one year of intensive behavior analytic intervention (IBT) provided to 29 young children diagnosed with autism with two eclectic (i.e., mixed-method) interventions (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005). One eclectic intervention (autism programming; AP) was designed specifically for children with autism and was intensive in that it was delivered for an average of 25-30 h per week (n = 16). The other eclectic intervention (generic programming; GP) was delivered to 16 children with a variety of diagnoses and needs for an average of 15-17 h per week. This paper reports outcomes for children in all three groups after two additional years of intervention. With few exceptions, the benefits of IBT documented in our first study were sustained throughout Years 2 and 3. At their final assessment, children who received IBT were more than twice as likely to score in the normal range on measures of cognitive, language, and adaptive functioning than were children who received either form of eclectic intervention. Significantly more children in the IBT group than in the other two groups had IQ, language, and adaptive behavior test scores that increased by at least one standard deviation from intake to final assessment. Although the largest improvements for children in the IBT group generally occurred during Year 1, many children in that group whose scores were below the normal range after the first year of intervention attained scores in the normal range of functioning with one or two years of additional intervention. In contrast, children in the two eclectic treatment groups were unlikely to attain scores in the normal range after the first year of intervention, and many of those who had scores in the normal range in the first year fell out of the normal range in subsequent years. There were no consistent differences in outcomes at Years 2 and 3 between the two groups who received eclectic interventions. These results provide further evidence that intensive behavior analytic intervention delivered at an early age is more likely to produce substantial improvements in young children with autism than common eclectic interventions, even when the latter are intensive.

Assessing progress and outcome of early intensive behavioral intervention for toddlers with autism

Intensive behavioral intervention for young children diagnosed with autism can produce large gains in social, cognitive, and language development. Although several studies have identified behaviors that are possible indicators of best outcome, changes in performance are typically measured using norm-referenced standardized scores referencing overall functioning level rather than via repeated observational measures of autism-specific deficits (i.e., social behavior). In the current study, 83 children with autism (CWA), aged 1, 2 and 3 years, and 58 same-aged typically developing children (TDC) were directly observed in the areas of cognitive skills, joint attention (JA), play, and stereotypic behavior using a measure called the Early Skills Assessment Tool (ESAT; MacDonald et al., 2006). CWA were assessed at entry into an EIBI program and again after 1 year of treatment. Changes in performance were compared pre- and post-treatment as well as to the normative data by age. Results indicate significant gains on the ESAT across all age groups with the greatest gains seen in the children who entered treatment prior to their second birthday. Increases were seen on direct measures of JA, play, imitation and language while decreases were seen in stereotypy regardless of level of performance at entry into EIBI. The ESAT, a direct measurement tool, served as a sensitive tool to measure changes in autism symptomatology following EIBI treatment.

Non-specialist psychosocial interventions for children and adolescents with intellectual disability or lower-functioning autism spectrum disorders: a systematic review

BACKGROUND

The development of effective treatments for use by non-specialists is listed among the top research priorities for improving the lives of people with mental illness worldwide. The purpose of this review is to appraise which interventions for children with intellectual disabilities or lower-functioning autism spectrum disorders delivered by non-specialist care providers in community settings produce benefits when compared to either a no-treatment control group or treatment-as-usual comparator.

METHODS AND FINDINGS

We systematically searched electronic databases through 24 June 2013 to locate prospective controlled studies of psychosocial interventions delivered by non-specialist providers to children with intellectual disabilities or lower-functioning autism spectrum disorders. We screened 234 full papers, of which 34 articles describing 29 studies involving 1,305 participants were included. A majority of the studies included children exclusively with a diagnosis of lower-functioning autism spectrum disorders (15 of 29, 52%). Fifteen of twenty-nine studies (52%) were randomized controlled trials and just under half of all effect sizes (29 of 59, 49%) were greater than 0.50, of which 18 (62%) were statistically significant. For behavior analytic interventions, the best outcomes were shown for development and daily skills; cognitive rehabilitation, training, and support interventions were found to be most effective for improving developmental outcomes, and parent training interventions to be most effective for improving developmental, behavioral, and family outcomes. We also conducted additional subgroup analyses using harvest plots. Limitations include the studies' potential for performance bias and that few were conducted in lower- and middle-income countries.

CONCLUSIONS

The findings of this review support the delivery of psychosocial interventions by non-specialist providers to children who have intellectual disabilities or lower-functioning autism spectrum disorders. Given the scarcity of specialists in many low-resource settings, including many lower- and middle-income countries, these findings may provide guidance for scale-up efforts for improving outcomes for children with developmental disorders or lower-functioning autism spectrum disorders.

PROTOCOL REGISTRATION

PROSPERO CRD42012002641

Narrowing the gap: effects of intervention on developmental trajectories in autism

Although still a matter of some debate, there is a growing body of research supporting Early and Intensive Behavioral Intervention as the intervention of choice for children with autism. Learning rate is an alternative to change in standard scores as an outcome measure in studies of early intervention. Learning rates can be displayed graphically as developmental trajectories, which are easy to understand and avoid some of the counter-intuitive properties of changes in standard scores. The data used in this analysis were from 453 children with autism, previously described by Eldevik et al. Children receiving Early and Intensive Behavioral Intervention exhibited significantly steeper developmental trajectories than children in the control group, in both intelligence and adaptive behaviors. However, there was a considerable variability in individual learning rates within the group receiving Early and Intensive Behavioral Intervention. This variability could partly be explained by the intensity of the treatment, partly by children's intake intelligence quotient age-equivalents. Age at intake did not co-vary with learning rate.

Parent inclusion in early intensive behavior interventions for young children with ASD: a synthesis of meta-analyses from 2009 to 2011

This paper presents a comprehensive synthesis of six meta-analyses of early intensive behavioral interventions (EIBI) for young children with autism spectrum disorders published from 2009 to 2011. Analysis was conducted in three steps to account for different formats of treatment delivery and the extent to which parents took part in treatment. The three components of the synthesis were (a) descriptive analysis, (b) effect size analysis, and (c) mediator analysis via partial correlation and linear regressions. We completed the analysis by obtaining standardized mean difference effect sizes for 13 comparative studies ordered by comparison study type and 22 mean change effect sizes ordered by treatment delivery type. Results suggest that EIBI leads generally to positive medium-to-large effects for three available outcome measures: intellectual functioning, language skills and adaptive behaviors. Although favorable effects were apparent across comparative studies, analysis by type of delivery format revealed that EIBI programs that include parents in treatment provision are more effective. Mediator analyses suggest that treatment variables and child characteristics impact program effectiveness when accounting for the extent of parent inclusion. Clinical implications toward individualized treatment tailoring 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.

An analysis of autism as a contingency-shaped disorder of verbal behavior

This paper analyzes autism as a contingency-shaped disorder of verbal behavior. Contingencies of reinforcement in effect during the first to third year of a child's life may operate to establish and maintain those behaviors that later result in a diagnosis of autism. While neurobiological variables may, in some cases, predispose some children to be more or less responsive to environmental variables than others, our analysis suggests that reliance on neurobiological variables as causal factors in autism is unnecessary. We present six paradigms that may play critical etiologic roles in the development of behaviors labeled as autistic. Recognizing these contingencies and their resulting behaviors during the first two years of a child's life may contribute substantially to earlier identification, more effective treatment and, quite possibly, to the development of Applied Behavior Analysis programs for the prevention of autism that could be implemented immediately. Conceptualizing autism as a contingency-shaped disorder of verbal behavior may provide a new and potentially more effective paradigm for behavioral research and treatment in autism.

BUILDING A RESEARCH-COMMUNITY COLLABORATIVE TO IMPROVE COMMUNITY CARE FOR INFANTS AND TODDLERS AT-RISK FOR AUTISM SPECTRUM DISORDERS

This article describes the formation and initial outcomes of a research-community collaborative group that was developed based on community-based participatory research principles. The group includes a transdisciplinary team of practitioners, funding agency representatives, researchers, and families of children with autism spectrum disorders, who partnered to improve community-based care for infants and toddlers at risk for autism through the implementation of evidence-based practices. Data from this group provide support for the feasibility of developing and sustaining a highly synergistic and productive research-community collaborative group who shares common goals to improve community care.

Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders

This paper presents an overview of 5 meta-analyses of early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASDs) published in 2009 and 2010. There were many differences between meta-analyses, leading to different estimates of effect and overall conclusions. The weighted mean effect sizes across meta-analyses for IQ and adaptive behavior ranged from g = .38-1.19 and g = .30-1.09, respectively. Four of five meta-analyses concluded EIBI was an effective intervention strategy for many children with ASDs. A discussion highlighting potential confounds and limitations of the meta-analyses leading to these discrepancies and conclusions about the efficacy of EIBI as an intervention for young children with ASDs are provided.

Outcomes of a behavioral education model for children with autism in a mainstream school setting

The authors report 1-year outcomes for 11 children (3-7 years) with autism who attended an "Applied Behavior Analysis (ABA) classroom" educational intervention in a mainstream school setting. The children learned new skills by the end of 1 year and learned additional skills during a 2nd year. Group analysis of standardized test outcomes (IQ and adaptive behavior) showed moderate to large effect size changes over 1 year, with further changes during a 2nd year. Standardized test outcomes for nine children after 2 years were also analyzed against a comparison group (n = 18) of children with autism receiving "education as usual." These controlled comparisons were associated with statistically significant large effects in favor of the ABA group for adaptive skills. Exploratory analysis also showed that increases in language and learning skills in the ABA class group were generally associated with positive changes in standardized test scores. A comprehensive behavioral intervention model can be successfully implemented in a mainstream school setting.

Two-Year Outcomes for Children With Autism After the Cessation of Early Intensive Behavioral Intervention

Evidence from recent meta-analytic and narrative review suggests that early intensive behavioral intervention (EIBI) may improve life chances of preschool children with autism. Unfortunately, there are few data indicating whether early gains are maintained after intervention ceases. The purpose of the present study was to establish the 2-year follow-up outcome for children with autism ( N = 41) who had participated in an earlier 2-year controlled comparison of EIBI. Twenty-three children in the intervention group (100% of original sample) and 18 in the treatment-as-usual comparison group (86% of original sample) were located and retested. Group differences favoring intervention substantially diluted in this period but varied significantly between subgroups who had received university-supervised and parent-commissioned interventions, favoring the latter. These groups differed in terms of their baseline characteristics and intensity of intervention. Results strongly suggest a need for better characterization of those children who would benefit from more active maintenance programs.

Low intensity behavioral treatment supplementing preschool services for young children with autism spectrum disorders and severe to mild intellectual disability

This study evaluated the effectiveness of low intensity behavioral treatment (on average 6.5h per week) supplementing preschool services in 3-6-year-old children with autism spectrum disorder and severe to mild intellectual disability. Treatment was implemented in preschools (i.e., daycare centers) and a discrete trial teaching approach was used. Twelve children in the treatment group were compared to 22 children receiving regular intervention. At pre-treatment, both groups did not differ on chronological age, developmental age, diagnosis and level of adaptive skills. Eight months into treatment, children receiving behavioral treatment displayed significantly higher developmental ages and made more gains in adaptive skills than children from the control group. No significant differences between groups were found on autistic symptom severity and emotional and behavioral problems.

Using participant data to extend the evidence base for intensive behavioral intervention for children with autism

We gathered individual participant data from 16 group design studies on behavioral intervention for children with autism. In these studies, 309 children received behavioral intervention, 39 received comparison interventions, and 105 were in a control group. More children who underwent behavioral intervention achieved reliable change in IQ (29.8%) compared with 2.6% and 8.7% for comparison and control groups, respectively, and reliable change in adaptive behavior was achieved for 20.6% versus 5.7% and 5.1%, respectively. These results equated to a number needed to treat of 5 for IQ and 7 for adaptive behavior and absolute risk reduction of 23% and 16%, respectively. Within the behavioral intervention sample, IQ and adaptive behavior at intake predicted gains in adaptive behavior. Intensity of intervention predicted gains in both IQ and adaptive behavior.

The clinical utility of the Social Responsiveness Scale and Social Communication Questionnaire in tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is often associated with epilepsy, mental retardation, and autism spectrum disorders (ASDs). Thus, screening for ASDs is important when evaluating these individuals. We examined the utility of the Social Responsiveness Scale (SRS) and Social Communication Questionnaire (SCQ), two measures for screening for ASDs, in a TSC population. Twenty-one children were evaluated, with 52.4% classified as having ASDs on the SRS and 42.9% classified as such on the SCQ. Number of antiepileptic drugs significantly correlated with SRS Total score, as did level of intellectual functioning. Evidence for convergent validity was obtained between the SRS and SCQ Total scores (r=0.605). Moreover, all SRS subscales correlated with SCQ Total score (r>0.400). All SCQ subscales except for Communication correlated with SRS total. Overall, the results demonstrate that these questionnaires appear to be effective screens for ASDs in a TSC population and are measuring similar constructs.

Behavioral treatments in autism spectrum disorder: what do we know?

Although there are a large and growing number of scientifically questionable treatments available for children with autism spectrum disorder (ASD), intervention programs applying the scientific teaching principles of applied behavior analysis (ABA) have been identified as the treatment of choice. The following article provides a selective review of ABA intervention approaches, some of which are designed as comprehensive programs that aim to address all developmental areas of need, whereas others are skills based or directed toward a more circumscribed, specific set of goals. However, both types of approaches have been shown to be effective in improving communication, social skills, and management of problem behavior for children with ASD. Implications of these findings are discussed in relation to critical areas of research that have yet to be fully explored.

Autism spectrum disorders in infancy and toddlerhood: a review of the evidence on early signs, early identification tools, and early diagnosis

To date, the biological basis of autism spectrum disorders (ASDs) remains unknown. Thus, identification and diagnosis are reliant on behavioral presentation and developmental history. There have been significant advances in our knowledge of the early signs of ASD through the use of retrospective videotape analysis, parental report, screening studies, and more recently, studies on high-risk infant siblings. Despite behavioral markers being identified within the first year of life, the current average age of diagnosis for ASD remains at approximately 3 years or older. Consequently, these children are not receiving intervention in their early years, which is increasingly recognized as an important time to begin intervention. There remains little research on the prospective identification of these children in a community-based sample before 18 months. It is recommended that future prospective studies monitor behavior repeatedly over time, thereby increasing the opportunity to identify early manifestations of ASD and facilitating the charting of subtle behavioral changes that occur in the development of infants and toddlers with ASD.

Meta-analysis of Early Intensive Behavioral Intervention for children with autism

A systematic literature search for studies reporting effects of Early Intensive Behavioral Intervention identified 34 studies, 9 of which were controlled designs having either a comparison or a control group. We completed a meta-analysis yielding a standardized mean difference effect size for two available outcome measures: change in full-scale intelligence and/or adaptive behavior composite. Effect sizes were computed using Hedges's g. The average effect size was 1.10 for change in full-scale intelligence (95% confidence interval = .87, 1.34) and .66 (95% confidence interval = .41, .90) for change in adaptive behavior composite. These effect sizes are generally considered to be large and moderate, respectively. Our results support the clinical implication that at present, and in the absence of other interventions with established efficacy, Early Intensive Behavioral Intervention should be an intervention of choice for children with autism.

Clinical assessment and management of toddlers with suspected autism spectrum disorder: insights from studies of high-risk infants

With increased public awareness of the early signs and recent American Academy of Pediatrics recommendations that all 18- and 24-month-olds be screened for autism spectrum disorders, there is an increasing need for diagnostic assessment of very young children. However, unique challenges exist in applying current diagnostic guidelines for autism spectrum disorders to children under the age of 2 years. In this article, we address challenges related to early detection, diagnosis, and treatment of autism spectrum disorders in this age group. We provide a comprehensive review of findings from recent studies on the early development of children with autism spectrum disorders, summarizing current knowledge on early signs of autism spectrum disorders, the screening properties of early detection tools, and current best practice for diagnostic assessment of autism spectrum disorders before 2 years of age. We also outline principles of effective intervention for children under the age of 2 with suspected/confirmed autism spectrum disorders. It is hoped that ongoing studies will provide an even stronger foundation for evidence-based diagnostic and intervention approaches for this critically important age group.

Early Identification of Autism: Early Characteristics, Onset of Symptoms, and Diagnostic Stability

In the first year of life, infants who later go on to develop autistic spectrum disorders (ASD) may exhibit subtle disruptions in social interest and attention, communication, temperament, and head circumference growth that occur prior to the onset of clinical symptoms. These disruptions may reflect the early course of ASD development and may also contribute to the later development of clinical symptoms through alterations in the child's experience of his or her environment. By age 2, developmental precursors of autism symptoms can be used to diagnose children reliably, and by age 3, the diagnosis is thought to be relatively stable. The downward extension of the autism diagnosis poses important questions for therapists in designing interventions that are applicable for infants who demonstrate early risk factors. We review current knowledge of the early signs of ASD in the infancy period (0-12 months) and the manifestation of symptoms in toddlerhood (12- 36 months), noting the importance of considering the variability in onset and trajectory of ASD. Finally, we consider the implications of this emerging research for those who work or interact with young children, including the importance of early monitoring and the development and evaluation of age-appropriate interventions.

Can one hour per week of therapy lead to lasting changes in young children with autism?

Deficits in attention, communication, imitation, and play skills reduce opportunities for children with autism to learn from natural interactive experiences that occur throughout the day. These developmental delays are already present by the time these children reach the toddler period. The current study provided a brief 12 week, 1 hour per week, individualized parent-child education program to eight toddlers newly diagnosed with autism. Parents learned to implement naturalistic therapeutic techniques from the Early Start Denver Model, which fuses developmental- and relationship-based approaches with Applied Behavior Analysis into their ongoing family routines and parent-child play activities. Results demonstrated that parents acquired the strategies by the fifth to sixth hour and children demonstrated sustained change and growth in social communication behaviors. Findings are discussed in relation to providing parents with the necessary tools to engage, communicate with, and teach their young children with autism beginning immediately after the diagnosis.

A case study in the misrepresentation of applied behavior analysis in autism: the gernsbacher lectures

I know that most men, including those at ease with problems of the greatest complexity, can seldom accept the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have proudly taught to others, and which they have woven, thread by thread, into the fabrics of their life. (Tolstoy, 1894)This article presents a case study in the misrepresentation of applied behavior analysis for autism based on Morton Ann Gernsbacher's presentation of a lecture titled "The Science of Autism: Beyond the Myths and Misconceptions." Her misrepresentations involve the characterization of applied behavior analysis, descriptions of practice guidelines, reviews of the treatment literature, presentations of the clinical trials research, and conclusions about those trials (e.g., children's improvements are due to development, not applied behavior analysis). The article also reviews applied behavior analysis' professional endorsements and research support, and addresses issues in professional conduct. It ends by noting the deleterious effects that misrepresenting any research on autism (e.g., biological, developmental, behavioral) have on our understanding and treating it in a transdisciplinary context.

Recommendations for reporting independent variables in outcome studies of early and intensive behavioral intervention for autism

Early and intensive behavioral intervention (EIBI) has been established as an effective treatment for autism. However, the complexity and intensity of EIBI programs make it difficult to fully report all critical aspects of the independent variable. Consequently, scientific reports of EIBI outcomes have been criticized for providing less than comprehensive treatment descriptions. In an effort to address this problem, the present article provides a template to aid outcome researchers in (a) clearly reporting each participant's curricular targets and (b) describing critical aspects of treatment.

Evidence-based comprehensive treatments for early autism

Early intervention for children with autism is currently a politically and scientifically complex topic. Randomized controlled trials have demonstrated positive effects in both short-term and longer term studies. The evidence suggests that early intervention programs are indeed beneficial for children with autism, often improving developmental functioning and decreasing maladaptive behaviors and symptom severity at the level of group analysis. Whether such changes lead to significant improvements in terms of greater independence and vocational and social functioning in adulthood is also unknown. Given the few randomized controlled treatment trials that have been carried out, the few models that have been tested, and the large differences in interventions that are being published, it is clear that the field is still very early in the process of determining (a) what kinds of interventions are most efficacious in early autism, (b) what variables moderate and mediate treatment gains and improved outcomes following intervention, and (c) the degree of both short-term and long-term improvements that can reasonably be expected. To examine these current research needs, the empirical studies of comprehensive treatments for young children with autism published since 1998 were reviewed. Lovaas's treatment meet Chambless and colleague's (Chambless et al., 1998; Chambless et al., 1996) criteria for "well-established" and no treatment meets the "probably efficacious" criteria, though three treatments meet criteria for "possibly efficacious" (Chambless & Hollon, 1998). Most studies were either Type 2 or 3 in terms of their methodological rigor based on Nathan and Gorman's (2002) criteria. Implications of these findings are also discussed in relation to practice guidelines as well as critical areas of research that have yet to be answered.

Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder

Advances in the fields of cognitive and affective developmental neuroscience, developmental psychopathology, neurobiology, genetics, and applied behavior analysis have contributed to a more optimistic outcome for individuals with autism spectrum disorder (ASD). These advances have led to new methods for early detection and more effective treatments. For the first time, prevention of ASD is plausible. Prevention will entail detecting infants at risk before the full syndrome is present and implementing treatments designed to alter the course of early behavioral and brain development. This article describes a developmental model of risk, risk processes, symptom emergence, and adaptation in ASD that offers a framework for understanding early brain plasticity in ASD and its role in prevention of the disorder.

Early intensive behavioral intervention for children with autism: therapists' perspectives on achieving procedural fidelity

The variability in outcomes observed in home-based early intensive behavioral intervention for children with autism is likely in part to be the result of the quality of therapist performance. Therapist behavior in this context, however, is poorly understood. To achieve such an understanding, it will be necessary to specify how factors such as therapist, child and intervention program characteristics, as well as supervision and training provision, influence therapists' interactions with children. This study identified facilitating factors and barriers that therapists considered to influence their capacity to deliver early intensive behavioral intervention to young children with autism. Nineteen therapists associated with various service providers in the South of England were interviewed. In general, responses represented opposite poles of the same construct. For example, child factors such as compliance and competence were considered to facilitate instruction, whereas challenging behavior and lack of progress were perceived to hinder it. These issues are considered in the light of previous research on staff behavior in related contexts. The factors identified suggest specific avenues for questionnaire and experimental research to validate these findings, have implications for routine service provision and may help improve the outcomes of children receiving early intensive behavioral intervention.

A comparison of intensive behavior analytic and eclectic treatments for young children with autism

We compared the effects of three treatment approaches on preschool-age children with autism spectrum disorders. Twenty-nine children received intensive behavior analytic intervention (IBT; 1:1 adult:child ratio, 25-40 h per week). A comparison group (n=16) received intensive "eclectic" intervention (a combination of methods, 1:1 or 1:2 ratio, 30 h per week) in public special education classrooms (designated the AP group). A second comparison group (GP) comprised 16 children in non-intensive public early intervention programs (a combination of methods, small groups, 15 h per week). Independent examiners administered standardized tests of cognitive, language, and adaptive skills to children in all three groups at intake and about 14 months after treatment began. The groups were similar on key variables at intake. At follow-up, the IBT group had higher mean standard scores in all skill domains than the AP and GP groups. The differences were statistically significant for all domains except motor skills. There were no statistically significant differences between the mean scores of the AP and GP groups. Learning rates at follow-up were also substantially higher for children in the IBT group than for either of the other two groups. These findings are consistent with other research showing that IBT is considerably more efficacious than "eclectic" intervention.

Brain overgrowth in autism during a critical time in development: implications for frontal pyramidal neuron and interneuron development and connectivity

While abnormalities in head circumference in autism have been observed for decades, it is only recently that scientists have begun to focus in on the developmental origins of such a phenomenon. In this article we review past and present literature on abnormalities in head circumference, as well as recent developmental MRI studies of brain growth in this disorder. We hypothesize that brain growth abnormalities are greatest in frontal lobes, particularly affecting large neurons such as pyramidal cells, and speculate how this abnormality might affect neurofunctional circuitry in autism. The relationship to clinical characteristics and other disorders of macrencephaly are discussed.