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Rodgers M, Marshall D, Simmonds M, Le Couteur A, Biswas M, Wright K, Rai D, Palmer S, Stewart L, Hodgson R. Interventions based on early intensive applied behaviour analysis for autistic children: a systematic review and cost-effectiveness analysis. Health Technol Assess 2020; 24:1-306. [PMID: 32686642 PMCID: PMC7397479 DOI: 10.3310/hta24350] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
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.
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Affiliation(s)
- Mark Rodgers
- Centre for Reviews and Dissemination, University of York, York, UK
| | - David Marshall
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Mark Simmonds
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Ann Le Couteur
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Mousumi Biswas
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Dheeraj Rai
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
| | - Lesley Stewart
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, UK
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Murphy D, Glaser K, Hayward H, Eklund H, Cadman T, Findon J, Woodhouse E, Ashwood K, Beecham J, Bolton P, McEwen F, Wilson E, Ecker C, Wong I, Simonoff E, Russell A, McCarthy J, Chaplin E, Young S, Asherson P. Crossing the divide: a longitudinal study of effective treatments for people with autism and attention deficit hyperactivity disorder across the lifespan. PROGRAMME GRANTS FOR APPLIED RESEARCH 2018. [DOI: 10.3310/pgfar06020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BackgroundAutism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) frequently persist into adolescence and young adulthood. However, there are few clinical services that support those with these disorders through adulthood.ObjectiveOur aim was to determine if clinical services meet the needs of people with ASD and ADHD, who are ‘at transition’ from childhood to adulthood.DesignA longitudinal study of individuals with ASD and ADHD, the impact of services and treatments.MethodsOur research methods included (1) interviewing > 180 affected individuals (and their families) with a confirmed diagnosis of ASD and/or ADHD, (2) screening for ASD and ADHD in approximately 1600 patients and (3) surveying general practitioner prescribing to 5651 ASD individuals across the UK. In addition, we tested the effectiveness of (1) new ASD diagnostic interview measures in 169 twins, 145 familes and 150 non-twins, (2) a magnetic resonance imaging-based diagnostic aid in 40 ASD individuals, (3) psychological treatments in 46 ASD individuals and (4) the feasability of e-learning in 28 clinicians.SettingNHS clinical services and prisons.ParticipantsFocus – young people with ASD and ADHD as they ‘transition’ from childhood and adolescence into early adulthood.InterventionsTesting the utility of diagnostic measures and services, web-based learning interventions, pharmacological prescribing and cognitive–behavioural treatments.Main outcome measuresSymptom severity, service provision and met/unmet need.ResultsPeople with ASD and ADHD have very significant unmet needs as they transition through adolescence and young adulthood. A major contributor to this is the presence of associated mental health symptoms. However, these are mostly undiagnosed (and untreated) by clinical services. Furthermore, the largest determinant of service provision was age and not severity of symptoms. We provide new tools to help diagnose both the core disorders and their associated symptoms. We also provide proof of concept for the effectiveness of simple psychological interventions to treat obsessional symptoms, the potential to run treatment trials in prisons and training interventions.LimitationsOur findings only apply to clinical service settings.ConclusionsAs individuals ‘transition’ their contact with treatment and support services reduces significantly. Needs-led services are required, which can both identify individuals with the ‘core symptoms’ of ASD and ADHD and treat their residual symptoms and associated conditions.Future workTo test our new diagnostic measures and treatment approaches in larger controlled trials.Trial registrationCurrent Controlled Trials ISRCTN87114880.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Declan Murphy
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Karen Glaser
- Institute of Gerontology, King’s College London, London, UK
| | - Hannah Hayward
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Hanna Eklund
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Tim Cadman
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - James Findon
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Emma Woodhouse
- Medical Research Council Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK
| | - Karen Ashwood
- Medical Research Council Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK
| | | | - Patrick Bolton
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King’s College London, London, UK
| | - Fiona McEwen
- Medical Research Council Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King’s College London, London, UK
| | - Ellie Wilson
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Christine Ecker
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Ian Wong
- Department of Pharmacology and Pharmacy, University of Hong Kong, PokFuLam, Hong Kong
| | - Emily Simonoff
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King’s College London, London, UK
| | - Ailsa Russell
- Department of Psychology, University of Bath, Bath, UK
| | | | - Eddie Chaplin
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Susan Young
- Sackler Institute for Translational Neurodevelopment and Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, London, UK
| | - Philip Asherson
- Medical Research Council Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK
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Cost Offset Associated With Early Start Denver Model for Children With Autism. J Am Acad Child Adolesc Psychiatry 2017; 56:777-783. [PMID: 28838582 PMCID: PMC7007927 DOI: 10.1016/j.jaac.2017.06.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/23/2017] [Accepted: 06/28/2017] [Indexed: 12/27/2022]
Abstract
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.
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Lai JKY, Weiss JA. Priority service needs and receipt across the lifespan for individuals with autism spectrum disorder. Autism Res 2017; 10:1436-1447. [PMID: 28383156 PMCID: PMC5573942 DOI: 10.1002/aur.1786] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 02/07/2017] [Accepted: 03/03/2017] [Indexed: 01/13/2023]
Abstract
Individuals with Autism Spectrum Disorder (ASD) have a range of health, community, and social support needs across the lifespan that create age‐specific challenges in navigating service sectors. In this study, we set out to identify the priority needs of individuals with ASD across the lifespan, and the factors that predict receiving priority services. Participants included 3,317 individuals with ASD from a Canada‐wide online caregiver survey, stratified into five age groups (preschool, elementary school age, adolescence, emerging adulthood, adulthood). Priority receipt was calculated as a ratio of current services that corresponded to individualized priority need. Age‐stratified Poisson regression analyses were used to identify the sociodemographic, clinical and systemic predictors of priority receipt. Results indicate that the distribution of priority need varied by age, except for social skills programming, which was a high across all groups. The number of high and moderate priority needs diversified with age. Overall, 30% of individuals had none of their priority needs met and priority receipt decreased with age. Systemic factors were most consistently related to priority receipt across the lifespan. Understanding patterns and correlates of priority needs and use that currently exist in different age groups can inform policies to improve service access. Autism Res2017, 10: 1436–1447. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.
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Staff Training in Autism: The One-Eyed Wo/Man…. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13070716. [PMID: 27438846 PMCID: PMC4962257 DOI: 10.3390/ijerph13070716] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 11/17/2022]
Abstract
Having well-trained staff is key to ensuring good quality autism services, especially since people affected with autism generally tend to have higher support needs than other populations in terms of daily living, as well as their mental and physical health. Poorly-trained staff can have detrimental effects on service provision and staff morale and can lead to staff burn-out, as well as increased service user anxiety and stress. This paper reports on a survey with health, social care, and education staff who work within the statutory autism services sector in the UK that explored their knowledge and training with regards to autism. Interview data obtained from staff and service users offer qualitative illustrations of survey findings. Overall, the findings expose an acute lack of autism-specific training that has detrimental impacts. At best, this training was based on brief and very basic awareness raising rather than on in-depth understanding of issues related to autism or skills for evidence-based practice. Service users were concerned with the effects that the lack of staff training had on the services they received. The paper concludes with a discussion of policy routes to achieving quality staff training based on international best practice. The focus is on improving the quality of life and mental health for services users and staff, as well as making potentially significant cost-savings for governments.
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Veenstra-VanderWeele J, Warren Z. Intervention in the context of development: pathways toward new treatments. Neuropsychopharmacology 2015; 40:225-37. [PMID: 25182180 PMCID: PMC4262912 DOI: 10.1038/npp.2014.232] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/31/2014] [Accepted: 09/01/2014] [Indexed: 02/07/2023]
Abstract
Neuropsychiatric disorders vary substantially in age of onset but are best understood within the context of neurodevelopment. Here, we review opportunities for intervention at critical points in developmental trajectories. We begin by discussing potential opportunities to prevent neuropsychiatric disorders. Once symptoms begin to emerge, a number of interventions have been studied either before a diagnosis can be made or shortly after diagnosis. Although some of these interventions are helpful, few are based upon an understanding of pathophysiology, and most ameliorate rather than resolve symptoms. As such, in the next portion of the review, we turn our discussion to genetic syndromes that are rare phenocopies of common diagnoses such as autism spectrum disorder or schizophrenia. Cellular or animal models of these syndromes point to specific regulatory or signaling pathways. As examples, findings from the mouse models of Fragile X and Rett syndromes point to potential treatments now being tested in randomized clinical trials. Paralleling oncology, we can hope that our treatments will move from nonspecific, like chemotherapies thrown at a wide range of tumor types, to specific, like the protein kinase inhibitors that target molecularly defined tumors. Some of these targeted treatments later show benefit for a broader, yet specific, array of cancers. We can hope that medications developed within rare neurodevelopmental syndromes will similarly help subgroups of patients with disruptions in overlapping signaling pathways. The insights gleaned from treatment development in rare phenocopy syndromes may also teach us how to test treatments based upon emerging common genetic or environmental risk factors.
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Affiliation(s)
| | - Zachary Warren
- Departments of Psychiatry and Pediatrics, and Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, TN, USA
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Casenhiser DM, Shanker SG, Stieben J. Learning through interaction in children with autism: preliminary data from asocial-communication-based intervention. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2011; 17:220-41. [PMID: 21949005 DOI: 10.1177/1362361311422052] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The study evaluates a social-communication-based approach to autism intervention aimed at improving the social interaction skills of children with autism spectrum disorder. We report preliminary results from an ongoing randomized controlled trial of 51 children aged 2 years 0 months to 4 years 11 months. Participants were assigned to either a target treatment or community treatment group. Families in the target treatment group were given 2 hours of therapy and coaching each week in an intervention emphasizing social-interaction and the parent-child relationship. Children in the community treatment group received a variety of services averaging 3.9 hours per week. After 12 months, outcomes were measured to determine changes in the groups in social interaction and communication. In addition, a regression analysis was conducted to determine whether changes in social interaction skills were associated with language development. Results suggest that children in the treatment group made significantly greater gains in social interaction skills in comparison to the community treatment group, but no between-group differences were found for standard language assessments. Initiation of joint attention, involvement, and severity of language delay were found to be significantly associated with improvement of language skills in children with autism. Finally caregiver skills targeted by the intervention were found to be significantly associated with changes in children's interaction skills.
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Affiliation(s)
- Devin M Casenhiser
- Department of Audiology and Speech Pathology, University of Tennessee,Knoxville, TN 37996, USA.
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