There has been a striking increase in the number of children and adolescents diagnosed with autism spectrum disorder (ASD) in the past two decades in the United States (Fombonne, 2009). From 2000 to 2014, the prevalence estimates of ASD in 8-year-old children increased from 6.7 to 16.8 per 1,000 children, suggesting an increase of approximately 150% (Baio et al., 2018). This increase in diagnosis of ASD, coupled with emerging evidence of favorable outcomes associated with psychosocial interventions, highlights the importance of recognizing and addressing the deficits in social interactions, communication, and language development for children with ASD.
The development and implementation of these interventions are limited by the financial implications for caregivers of children with ASD and the health care system at large. Many children with ASD living in community settings may have limited access to these interventions due in part to the shortage of specialists and health care providers to deliver these interventions (Naveed et al., 2018). Caring for individuals with ASD presents direct and indirect costs ranging from medical expenses, special education costs, and lost productivity; the estimated lifetime cost of ASD is $1.4 to $2.4 million per person, amounting to a total of $11.5 to $60.9 billion nationally depending on his/her needs (Buescher, Cidav, Knapp, & Mandell, 2014). Moreover, mixed evidence for effectiveness of these interventions on different outcome measures has led to parents' dissatisfaction and unmet needs of children with ASD (Naveed et al., 2018).
For these reasons, it is important to develop and implement cost-effective strategies that provide an opportunity for active collaboration with parents and integration of their perspectives for effective translation of the interventions into community settings (Stahmer, Brookman-Frazee, Lee, Searcy, & Reed, 2011). In the context of low resource settings, non-specialist mediated interventions have been found to be beneficial and effective (Rahman et al., 2016). Finally, yet importantly, these interventions are provided in the natural environment of children and adolescents, which is critical considering the social limitation of these individuals. This recent focus on task-shifting approaches includes brief training sessions for parents, teachers, caregivers, and peers. Nonspecialist mediated interventions result in an increased exposure of the child to the number of intervention hours; reduced financial burden; and improvement in social skills, pragmatic language, behavioral problems, and sensory issues (Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015). This approach has been found to be cost-effective; the PLAY Project Home Consultation program, for example, costs $3,500 to $4,500 per child annually compared to $40,000 to $80,000 for interventions delivered by mental health professionals (Solomon, Van Egeren, Mahoney, Quon Huber, & Zimmerman, 2014). The current article reviews evidence-based non-specialist interventions for children and adolescents with ASD.
Review of Non-Specialist Mediated Interventions for Autism Spectrum Disorder
A number of non-specialist mediated interventions have been developed for children with ASD. The programs differ in their therapeutic strategies, focus on different symptoms, and are designed for settings such as home or school. Several non-specialist mediated interventions for individuals with ASD are highlighted below.
Parent-Mediated Cognitive-Behavioral Therapy (CBT)
Cook, Donovan, and Garnett (2019) investigated the effects of parent-mediated CBT on young children with ASD. These children were high-functioning individuals. In this intervention, parents were educated about CBT-based strategies and skills for regulating challenging thoughts and emotions, which in turn, they taught to their children. This intervention comprised psychoeducation, training on exposure hierarchy creation, graded exposure, affective education, and emotional regulation skills training. The intervention also focused on activities to address anxiety symptoms, internalizing and externalizing behaviors, and enhancing emotional awareness.
Social Emotional NeuroScience Endocrinology (SENSE) Theatre
SENSE Theatre (Corbett et al., 2016) used theatrical techniques and games, role-play exercises, extemporization, and character development through play. This peer-mediated intervention was delivered by peers who serve as role models in terms of verbal and nonverbal communication, socio-emotional perception and expression, as well as behavioral and affective control. The intervention also focused on improving reciprocal social interactions in a protected and affectionate environment. Participants were provided access to videos of target behaviors, role-plays, and songs performed by neurotypical peers and were advised to practice these behaviors.
Preschool Autism Communication Trial (PACT)
PACT is a parent-mediated intervention targeting social communication in children with ASD (Green et al., 2010). In the child's presence, PACT uses face-to-face sessions between the parent and therapist targeting the synchronization of parental response with the child's communication and minimizing untimely responses. Therapists also monitor the parent–child interaction using a video feedback system. The child's communication is further encouraged using different approaches such as action routines, familiar repetitive language, and pauses.
ImPACT Online, a telehealth parent-mediated intervention, is a program that targets social communication using a naturalistic, developmental– behavioral intervention (Ingersoll, Wainer, Berger, Pickard, & Bonter, 2016). The website has 12 self-directed lessons including slide shows, self-check questions, exercises, and video clips. Parents are encouraged to complete the interventions with their children to improve their communication skills. In this intervention, there was an opportunity to participate in a self-directed group or therapist-assisted group. Although the therapist-assisted group made greater gains in outcomes, the self-directed group also made sufficient gains to maintain parental engagement with these interventions.
Joint Attention, Symbolic Play, Engagement & Regulation (JASPER)
The JASPER approach was developed by Dr. Connie Kasari at the Center for Autism Research and Treatment. This technique is based on the incorporation of developmental and behavioral principles. The basic framework of the intervention revolves around realistic strategies to target the foundations of social communication in terms of joint attention, imitation, and play (Kasari et al., 2015). In this intervention, parents and teachers promote generalization across environments and activities while maintaining progress over time. JASPER has multiple strategies including modeling, promoting hierarchies, imitating and expanding joint attention, language, and play acts; adjustments are made to match the child's language abilities, and themes of play are based on the interests of the child.
Peer-Mediated (PEER) Intervention
The PEER intervention involves pairing typically developing children with children with ASD (Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2012). The goal is to encourage social communication in children with ASD by teaching skills to increase suitable and meaningful interaction with peers. Peers are given training through direct instruction, modeling, role-playing, and rehearsal to assist children who have difficulties in social interactions. Peers are also taught how to identify appropriate and inappropriate behaviors on the playground, strategies for encouraging positive social interactions, initiate play interactions, and facilitate engagement in games and strategies for conflict resolution.
Parent-Mediated Intervention for Autism Spectrum Disorder (PASS)
Similar to the PACT intervention, PASS is a naturalistic approach to encouraging and developing communication skills in children with ASD (Rahman et al., 2016). In contrast, PASS includes other family members in addition to parents to deliver interventions; provides simplification of the language and preparation of scripts for non-specialist delivery; and provides more structured guidance for delivery of strategies. PASS also includes a shortened intervention, focusing on the initial 6 months, which is when the maximum therapeutic gains were noted in the PACT intervention.
Joint Attention Mediated Learning (JAML)
JAML is a parent-led intervention for toddlers with ASD exclusively designed to encourage joint attention and targets preverbal communication (Schertz, Odom, Baggett, & Sideris, 2013). JAML fosters developmentally appropriate approaches, family-centered principles, social-based learning, and cognitive development. In the Focusing on Faces phase, the child is helped to look freely and often to the parent's face. In Turn-Taking, the child engages with the parent in reciprocal repetitive play that acknowledges the other's shared interest by accommodating the parent's turn. Finally, triadic engagement is promoted using toys in the Joint Attention phase.
Qigong Sensory Treatment (QST)
QST is a whole-body massage to stimulate social and self-regulatory activity, increase circulation to the skin, and normalize the child's perception of touch (Silva et al., 2015). The improvement in social skills and self-regulatory development is critical in the context of care and feeding of children with ASD. These children observe a change in their tactile responses from being hyposensitive to hypersensitive to normosensitive. During the course of the intervention, therapists observe participants during high-risk periods and provide ongoing support and training.
Play and Language for Autistic Youngsters (PLAY) Project
The PLAY Project is an evidence-based intervention for ASD developed by Richard Solomon, MD (Solomon et al., 2014). It is a parent-mediated intervention focused on social reciprocity. The PLAY Project involves a structured approach through coaching, modeling, and video feedback. During coaching, consultants help parents identify their child's subtle and hard to detect cues, respond promptly to the child's intentions, and effectively engage the child in reciprocal exchanges. During modeling, consultants play for 15 to 30 minutes with the child to demonstrate PLAY methods and techniques. During video feedback, the home consultant obtains a 10-minute representative sample of parent play, and the parent obtains a 5-minute representative sample of the home consultant modeling.
Learning Experiences and Alternative Program for Preschoolers and Their Parents (LEAP)
LEAP is a comprehensive, multi-component, educational program in which small groups of children with ASD are taught alongside a small number of typically developing children (Strain & Bovey, 2011). LEAP is based on the idea that children with ASD will learn better in integrated settings alongside their typically developing peers. Peers are trained on how to communicate and interact with children with ASD. LEAP aims to help children reach their full potential, so they are best able to benefit from mainstream education. The LEAP curriculum is designed to concentrate on the development of functional skills, independent play, social interactions, pre-academics, language skills, and adaptive behaviors. Independent play skills are learned from other typically developing children and reinforced using strategies such as age-appropriate rewards and praise for demonstrating correct actions and behaviors.
The Peer-Mediated Intervention was designed to improve the social interactions of children with pervasive developmental disorder (PDD) by providing them an opportunity to play with peers without PDD (Roeyers, 1996). These children were placed in a dyad of normal developing peers and children with PDD. Play sessions occurred in a naturalistic environment with adult supervision. The playroom was equipped with different play items such as balls, bowling pins, puppets, cars, and puzzles. This intervention resulted in favorable outcomes, suggesting that children with PDD can develop social relationships within an appropriate social environment.
Focused Playtime Intervention (FPI)
FPI is a parent education program that targets language gains in children with ASD with the help of their parents (Siller, Hutman, & Sigman, 2013). This intervention has two phases. In the first phase, the interventionist and parents interact with children by taking turns. Parents and children then play together for 15 minutes. In the second phase, parents are taught strategies through video feedback, conventional teaching, and a review of homework assignments.
Hanen's “More than Words” (HMTW)
HMTW is a parent-centered training program to improve communication in children with ASD by increasing playful parent–child interaction (Girolametto, Sussman, & Weitzman, 2007). This intervention is delivered in a developmentally sensitive manner to encourage children to initiate or respond to communication. Increased parental response in the form of attention and communication is observed to have favorable outcomes for language development. Parents also learned to be responsive to their children in this intervention.
The current article highlights the characteristics and goals of different non-specialist mediated interventions in children and adolescents with ASD. A meta-analysis of 24 studies assessed the effectiveness of these non-specialist mediated interventions compared to treatment as usual among children with ASD (Naveed et al., 2018). The analysis demonstrated that the non-specialist mediated interventions have favorable outcomes pertaining to social skills, motor skills, communication, and paralinguistic gains in this population. In addition to these developmental gains, these interventions improve parent–child interactions and reduce parental stress (Naveed et al., 2018). These interventions provide non-specialist treatment options to reduce the gap in treatment for children with ASD, especially in rural communities or low-resource countries.
There are several barriers in accessing treatments delivered by mental health professionals specializing in ASD services; professional interventions are resource intensive and bear high economic costs. Task-shifting interventions that are mediated by parents, teachers, and peers are clinically effective in reducing the severity of symptoms among children with ASD, for a small fraction of the clinical treatment cost.
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