Behavioral and other psychological interventions for people with autism spectrum disorder (ASD) may be divided into two main groups: (1) behavioral and developmental approaches that aim at improving overall functioning, and (2) interventions that address specific difficulties associated with ASD, such as communication, social skills, and sensory difficulties.
Behavioral interventions are designed to teach new skills, support families, and reduce inappropriate behaviors. Applied Behavior Analysis (ABA) and Discrete Trial Training (DTT) are the two main therapies used in most behavioral intervention programs.
Applied Behavior Analysis
ABA involves assessment of behavior and implementation of instructional modifications and systematic reinforcement to produce improvements in behavior. ABA can be provided in different settings (eg, specialized center, home and schools) by trained therapists.
Discrete Trial Training
DTT is a highly structured technique that involves breaking down the desired behaviors into small, achievable tasks that are then taught in a structured manner. The DTT approach is useful in teaching foundation skills such as attention, compliance, imitation, and discrimination learning.
Early Intensive Behavioral Intervention
Early Intensive Behavioral Intervention (EIBI), one of the most established treatments of ASD, is a behavioral approach based on the principles of ABA that is delivered early (before age 5 years) and intensively (20 to 40 hours per week), usually over a period of 2 to 3 years. A recent Cochrane review noted gains in adaptive behavior, IQ, communication, socialization, and daily living skills.1 The largest gain was in IQ and the smallest was is social skills. One review did not find adequate evidence that EIBI is more effective than standard care in the four studies included in their meta-analysis.2
Child-specific predictors to ABA treatment response. There is conflicting evidence on the optimal age for early intervention. In some studies, younger age at intake predicted better outcome and gains in cognitive and language abilities,3,4 whereas other studies found the absence of such influence.5,6 Makrygianni and Reed7 found a correlation between age and language abilities in which the younger the children were at intake the greater the impact of the EIBI was on their language abilities.
One study has shown that children with higher pretreatment IQ, language abilities, and adaptive skills have greater developmental gains after intervention.8 These results are not consistent with other studies that concluded EIBIs are equally effective for children with low to medium intellectual abilities as well as for both verbal and nonverbal children.7
Treatment-specific predictors to ABA treatment response. Despite difficulty in obtaining clear estimates of treatment intensity in many studies, research7,9,10 indicates that the intensity of the interventions affected outcome. This effect was strongest on adaptive behaviors but was also evident on intellectual and language abilities. EIBI has been found to be effective when provided for 25 hours per week, although increases in the program intensity above 25 hours did not produce better outcomes.7 Studies have reported that long-term and intensive ABA interventions produce large, positive effects on numerous domains in children with ASD;3,11 however, the current literature does not specify the optimal duration for these gains to be achieved.
Long-term effect of EIBI. Although there is evidence to show that EIBI is effective in improving developmental and cognitive gains, good robust studies on long-term effect of EIBI are sparse and gains are also not universal, as some children make only modest progress whereas others show little or no change. At present, we do not have enough research data to understand why outcomes vary so dramatically across different children, and the studies to identify groups of children for whom EIBI will be most and least effective are still pending.12
Parent-mediated early interventions have positive effects on both the child and the parent. Child-related improvements are mostly in the child's language comprehension, communicative behavior, and reduction in autism severity. Benefits for parents include increased parental knowledge of autism, enhanced parental communication style, and reduced parental depression. Improved parent–child interaction is also reported.13
Developmental interventions are designed to address the core deficits of ASD by enhancing the child's self- awareness and emotional development. These programs involve systematic approaches that use the child's interests to gradually build engagement, interaction, communication, affection, and cognitive skills.
The Developmental, Individual Difference, Relationship-Based Model
The Developmental, Individual Difference, Relationship-Based model (DIR), also known as DIR Floortime, is a play-based method in which the adult and child engage in tailored play sessions for 2 to 5 hours per day. These sessions are usually delivered by parents and facilitated by a DIR specialist, who develops and oversees the child's individualized program. The DIR method can help reduce ASD symptom severity and has potential to improve the child's emotional functioning, communication, and daily living skills as well as parent–child interactions.14
Early Start Denver Model
Because of the highly structured nature of behavioral methods, spontaneity and generalization of learned behaviors in different settings may be difficult for a child with ASD. Traditional ABA techniques have been modified to include incidental teaching and learning in real-life settings. The Early Start Denver Model (ESDM) is an intensive (20 hours per week) play-based intervention for infants and toddlers (age 12-48 months) with ASD that integrates behavioral and developmental principles targeting the core deficits of autism, such as joint attention, imitation, and play. Research has shown that toddlers and children who receive ESDM intervention show significant improvements in IQ, language, social skills, adaptive behaviors, and reduction in autism severity.15
Teaching and Education of Autistic and Communication Handicapped Children
The Teaching and Education of Autistic and Communication Handicapped Children (TEACCH) autism program is an educational approach for children with autism that was developed for classroom education but can be modified to be used by parents or therapists at home. TEACCH is a structured approach that takes into account the strengths of the children, including their cognitive abilities. It also caters to their need for order and their reluctance to sudden changes by allowing the child to have his or her own well-organized workspace and classroom support. TEACCH promotes student's flexibility and encourages participation in social activities to facilitate acquisition of social skills and social reciprocity.
One study has noted small effects on cognitive skills and activities of daily living, and moderate to large effects on social and maladaptive behaviors.16
Language and Communication Skills Interventions
Delay in speech and language is usually the first concern that brings the child to the specialist's attention. Communication difficulties in ASD cannot be seen in isolation as they both reflect and cause problems in other areas. Lack of interest in social interactions further reduces the need and motivation to communicate.
At the time of diagnosis, children may be at different stages of language development (Table 1). Alongside behavioral and developmental interventions, there are numerous programs to enhance language and communication skills in ASD.
Evidence-Based Treatments of Autism Spectrum Disorders
Alternative Augmentative Communication
Alternative augmentative communication (AAC) refers to any therapeutic intervention aimed at improving communication by means other than just verbal language. These interventions can be aided or unaided. Aided interventions involve the use of pen and paper, picture cards, and special electronic devices commonly called speech-generating devices (SGD). Unaided interventions do not rely on any type of physical items or equipment but instead use gestures, facial expressions, or sign language to encourage basic communication skills.
Picture Exchange Communication System
The Picture Exchange Communication System (PECS) is an augmentative communication approach developed by Bondy and Frost17 and is mostly used with nonverbal children or those with limited speech. It is based on the use of picture cards to be exchanged for objects or specific needs, such as food or drink. PECS has the advantage that it can be used with children with or without intellectual disability. Its main goal is to improve functional communication, but it has the added benefit of encouraging social interaction.
Children initially are taught to obtain something they want by handing the therapist a relevant picture. This progresses to learning how to differentiate between pictures and how to use several pictures to construct a sentence. The program progresses through numerous phases until its completion. The efficacy of PECS in children with ASD is well established in research studies;18 it provides significant increases in functional communication over relatively short periods of time (6 to 14 months). In another study, improvements in speech were consistent across different ages and degree of disability.19
Technology-Based Treatments: Speech-Generating Devices
The past 10 years have seen growth in the use of SGDs for children with ASD. The natural interest that most children appear to have in electronic devices helps to stimulate their interest in these programs.
There are numerous SGDs, so choosing the most appropriate one for any person should be left to an expert clinician. It is important to take into consideration the child's cognitive and motor abilities, communication needs, and literacy ability. These devices, known as voice output communication aids, can be expensive, which limit their accessibility. At present, highly sophisticated computer programs in the form of apps can be downloaded onto handheld devices, which are less costly. These apps include Quick Talk (Digital Scribbler, Silicon Valley, CA), Go Talk (Attainment Company, Verona, WI), the Activity Trainer and Emotion Trainer (Accelerations Educational Software, Columbia, SC), and Proloquo2Go (AssistiveWare, Amsterdam, The Netherlands).
A large part of the research literature in this area consists of comparison studies between PECS and other AAC systems, mainly SGDs. A systematic review by Lorah et al.20 looked at 17 studies comparing different types of computerized SGDs and concluded that children who were able to use these devices acquired a range of new vocabulary quicker than those using PECS. On the contrary, two articles comparing the use of PECS and other AAC methods concluded that both systems improved social communication, with only minimal evidence that PECS achieved its targets quicker than SGDs.21,22
Facilitated Communication and Auditory Integration Therapy
Two other commonly mentioned treatments for language development in children with ASD are Facilitated Communication (FC) and Auditory Integration Training (AIT).
FC is a form of augmented communication in which a “communication partner” or “facilitator” physically supports the ASD child to point to a picture or words on the computer or the book. FC is based on the theory that many children with autism possesses a normal level of intelligence and that the difficulties of ASD children are because of a movement disorder that prevents children from expressing themselves.23 At present, there is no evidence to consistently support the use of FC as a treatment for ASD.
A well-conducted Cochrane review analyzed seven small studies of AIT and concluded that outcomes were inconclusive, with three of these reporting no long-term benefits.24
Social Skills Intervention
Social skills interventions break down complex social behaviors into more feasible steps as determined by the needs of the child. A range of interventions, including video modeling, role play, social stories, and peer-mediated interventions can be used. Delivering interventions in a group setting is preferred. The age of participant does not correlate with effect size,25 which means that children of all ages should be offered these interventions.
Video modeling includes the use of video footage to teach a variety of skills, from social interactions and communication to play activities and activities of daily living.26
Social Skills Groups
Social skills are usually practiced in small groups in which children not only practice social skills among themselves but also with their neurotypical peers. A review of 66 studies by Reichow and Volkmar25 concluded that social skills groups and video modeling are the best evidenced-based interventions to improve social behavior for people with autism.
Social Stories are written stories to help children with ASD navigate specific situations in their lives. They were first proposed by Gray and Garand27 in 1993 and have been widely used since then.
Sensory Integration Therapy
Differences in sensory response to normal stimuli are one of the most prevalent symptoms of ASD, and greater sensory dysfunction is considered to be associated with autism severity.28 Sensory integration therapy (SIT) is based on sensory integration theory that was initially presented by Ayres.29 The goal of SIT is to remediate deficits in processing of sensory stimuli to allow for appropriate and productive interaction with the environment. These interventions are typically provided in clinic settings by trained occupational therapists. Interventions usually consist of using a combination of weighted vest, brushing and rubbing the skin, bouncing on balls, swinging, and application of pressure. Research in this area is sparse, and studies have concluded that there is insufficient high-quality evidence to support the use of SIT in children with ASD.30
There is a vast range of interventional approaches that aim at reducing overall autism symptoms and improving functioning, as well as targeted interventions that address specific difficulties associated with ASD such as communication, social skills, and sensory difficulties. At present, we do not have enough research data to understand why outcomes vary so dramatically, or to identify groups of children for whom a specific intervention will be most or least effective. Clinicians should be aware of the evidence of these interventions to provide the best clinical care.
- Reichow B, Hume K, Barton EE, Boyd BA. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2018;5:CD009260. doi:10.1002/14651858.CD009260.pub3 [CrossRef].
- Spreckley M, Boyd R. Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language, and adaptive behavior: a systematic review and meta-analysis. J Pediatr. 2009;154(3):338–344. doi:. doi:10.1016/j.jpeds.2008.09.012 [CrossRef]
- Granpeesheh D, Dixon DR, Tarbox J, Kaplan AM, Wilke AE. The effects of age and treatment intensity on behavioral intervention outcomes for children with autism spectrum disorders. Res Autism Spectr Disord.2009;3(4):1014–1022. doi:10.1016/j.rasd.2009.06.007 [CrossRef]
- Harris SL, Handleman JS. Age and IQ at intake as predictors of placement for young children with autism: a four-to six-year follow-up. J Autism Dev Disord. 2000;30(2):137–142. doi:10.1023/A:1005459606120 [CrossRef]
- Magiati I, Charman T, Howlin P. A two-year prospective follow-up study of community-based early intensive behavioural intervention and specialist nursery provision for children with autism spectrum disorders. J Child Psychol Psychiatry.2007;48(8):803–812. doi:. doi:10.1111/j.1469-7610.2007.01756.x [CrossRef]
- Eikeseth S, Smith T, Jahr E, Eldevik S. Outcome for children with autism who began intensive behavioral treatment between ages 4 and 7: a comparison controlled study. Behav Modif. 2007;31(3):264–278. doi:. doi:10.1177/0145445506291396 [CrossRef]
- Makrygianni MK, Reed P. A meta-analytic review of the effectiveness of behavioural early intervention programs for children with autistic spectrum disorders. Res Autism Spectr Disord.2010;4(4):577–593. doi:. doi:10.1016/j.rasd.2010.01.014 [CrossRef]
- Remington B, Hastings RP, Kovshoff H, et al. Early intensive behavioral intervention: outcomes for children with autism and their parents after two years. Am J Ment Retard. 2007;112(6):418–438. doi:. doi:10.1352/0895-8017(2007)112[418:EIBIOF]2.0.CO;2 [CrossRef]
- Strauss K, Mancini F, Fava LSPC Group. Parent inclusion in early intensive behavior interventions for young children with ASD: a synthesis of meta-analyses from 2009 to 2011. Res Dev Disabil. 2013;34(9):2967–2985. doi:. doi:10.1016/j.ridd.2013.06.007 [CrossRef]
- Virues-Ortega J. Applied behavior analytic intervention for autism in early childhood: meta-analysis, meta-regression and dose-response meta-analysis of multiple outcomes. Clin Psychol Rev. 2010;30(4):387–399. doi:. doi:10.1016/j.cpr.2010.01.008 [CrossRef]
- Linstead E, Dixon DR, Hong E, et al. An evaluation of the effects of intensity and duration on outcomes across treatment domains for children with autism spectrum disorder. Transl Psychiatry. 2017;7(9):e1234. doi:. doi:10.1038/tp.2017.207 [CrossRef]
- Howlin P, Magiati I, Charman T. Systematic review of early intensive behavioral interventions for children with autism. Am J Intellect Dev Disabil. 2009;114(1):23–41. doi:. doi:10.1352/2009.114:23-41 [CrossRef]
- McConachie H, Diggle T. Parent implemented early intervention for young children with autism spectrum disorders: a systematic review. J Eval Clin Pract. 2007;13(1):120–129. doi:. doi:10.1111/j.1365-2753.2006.00674.x [CrossRef]
- Mercer J. Examining DIR/Floortime as a treatment for children with autism spectrum disorders: a review of research and theory. Res Social Work Pract. 2017;27(5):625–635. doi:. doi:10.1177/1049731515583062 [CrossRef]
- Ryberg KH. Evidence for the implementation of the Early Start Denver Model for young children with autism spectrum disorder. J Am Psychiatr Nurses Assoc. 2015;21(5):327–337. doi:. doi:10.1177/1078390315608165 [CrossRef]
- D'Elia L, Valeri G, Sonnino F, Fontana I, Mammone A, Vicari S. A longitudinal study of the TEACCH program in different settings: the potential benefits of low intensity intervention in preschool children with autism spectrum disorder. J Autism Dev Disord. 2014;44(3):615–626. doi:. doi:10.1007/s10803-013-1911-y [CrossRef]
- Bondy AS, Frost LA. The picture exchange communication system. Focus Autistic Behav. 1994;9(3):1–19. doi:10.1177/108835769400900301 [CrossRef]
- Flippin M, Reszka S, Watson LR. Effectiveness of the picture exchange communication system (PECS) on communication and speech for children with autism spectrum disorders: a meta-analysis. Am J Speech Language Pathol. 2010;19(2):178–195. doi:. doi:10.1044/1058-0360(2010/09-0022) [CrossRef]
- Ganz JB, Davis JL, Lund EM, Goodwyn FD, Simpson RL. Meta-analysis of PECS with individuals with ASD: investigation of targeted versus non-targeted outcomes, participant characteristics, and implementation phase. Res Dev Disabil.2012;33(2):406–418. doi:. doi:10.1016/j.ridd.2011.09.023 [CrossRef]
- Lorah ER, Parnell A, Whitby PS, Hantula D. A systematic review of tablet computers and portable media players as speech generating devices for individuals with autism spectrum disorder. J Autism Dev Disord.2015;45(12):3792–3804. doi:. doi:10.1007/s10803-014-2314-4 [CrossRef]
- Boesch MC, Wendt O, Subramanian A, Hsu N. Comparative efficacy of the picture exchange communication system (PECS) versus a speech-generating device: effects on social-communicative skills and speech development. Augment Altern Commun. 2013;29(3):197–209. doi:. doi:10.3109/07434618.2013.818059 [CrossRef]
- Mahoney B, Johnson A, McCarthy M, White C. Systematic review: comparative efficacy of the picture exchange communication system (PECS) to other augmentative communication systems in increasing social communication skills in children with autism spectrum disorder. https://scholarworks.uvm.edu/csdms/4/. Accessed February 4, 2019.
- Jacobson JW, Mulick JA, Schwartz AA. A history of facilitated communication: science, pseudoscience, and antiscience science working group on facilitated communication. Am Psychologist. 1995;50(9):750. doi:10.1037/0003-066X.50.9.750 [CrossRef]
- Sinha Y, Silove N, Hayen A, Williams K. Auditory integration training and other sound therapies for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011;(12):CD003681. doi:10.1002/14651858.CD003681.pub3 [CrossRef].
- Reichow B, Volkmar FR. Social skills interventions for individuals with autism: evaluation for evidence-based practices within a best evidence synthesis framework. J Autism Dev Disord. 2010;40(2):149–166. doi:. doi:10.1007/s10803-009-0842-0 [CrossRef]
- Radley KC, O'Handley RD, Ness EJ, et al. Promoting social skill use and generalization in children with autism spectrum disorder. Res Autism Spectr Disord. 2014;8(6):669–680. doi:10.1016/j.rasd.2014.03.012 [CrossRef]
- Gray CA, Garand JD. Social stories: improving responses of students with autism with accurate social information. Focus Autistic Behav. 1993;8(1):1–10. doi:10.1177/108835769300800101 [CrossRef]
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- Ayres AJ. Sensory Integration and Learning Disorders. 1st ed. Los Angeles, CA: Western Psychological Services; 1973.
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Evidence-Based Treatments of Autism Spectrum Disorders
||Children have no spontaneous or echolalic speech at all. Some children may use a range of vocalizations or jargon as if speaking to themselves while playing. They tend to use adults as tools to obtain what they want, by pushing or pulling them to the desired object
||Children are able to use clear speech to recite dialogues from their favorite cartoons or sing whole nursery rhymes, but they will not use even single words to ask for what they want
|Some communicative speech but delayed for age
||Children may use words or small sentences, both to request needs and to make comments, the latter usually not addressed to anyone in particular. The gap between their actual language and what would be expected for their age may vary from mild to severe
|Normal language development but difficulty in social communication
||Children may be quite articulate, but have difficulty participating in normal conversation. More often they will talk at length about their favorite subjects with no awareness that they may be boring the other person. They will not use greetings and other speech niceties expected in social conversation. These are deficits in pragmatic language, which includes all communicative aspects of language such as social and emotional behavior