Behavioral Interventions for Children with Autism Spectrum Disorders

Early intensive behavioral intervention is the only well-established treatment for young children with autism spectrum disorders (ASDs). Less intensive behavioral interventions are also effective for targeted concerns with older children and adolescents. This article describes the core features of behavioral treatments, summarizes the evidence base for effectiveness, and provides recommendations to facilitate family understanding of these interventions and identification of qualified providers. Recommendations are also provided for collaboration between pediatric providers and behavior analysts who are serving families of individuals with ASDs.

Pediatricians are now equipped with excellent tools and guidelines for screening young children for autism spectrum disorders (ASDs) as part of standard pediatric care (see the article by Patel and Pratt elsewhere in this issue). When those screenings suggest that a referral for a comprehensive evaluation is warranted, clinicians have psychometrically sound tools to assist with diagnosing a growing number of children with ASDs at early ages (see the article by Huerta and Lord elsewhere in this issue). Early identification is critically important to ensure that families have the opportunity to reap the many unique benefits that may arise from early intervention efforts. For example, intervention efforts that occur early during a child’s development may have the advantage of increased brain plasticity, which may enhance outcomes. Intervention efforts that are designed to have both sustained and developmental trajectory-altering impacts have the greatest likelihood of eliminating developmental delays when they occur earlier in the developmental course. In addition, earlier intervention and family supports decrease the likelihood of the development of severe problem behaviors that often arise and negatively affect family functioning.

As the primary care provider, pediatricians are the first and best source of guidance for families who are seeking treatment services after the initial diagnosis of an ASD and as new problems arise throughout childhood and adolescence. Although excellent resources and practice guidelines have been disseminated to facilitate surveillance and screening of ASDs, fewer comprehensive resources exist to guide treatment selection. The currently available treatments for ASDs vary greatly with respect to the degree of dissemination and the degree to which their effectiveness is supported by well-controlled research. The only psychoeducational treatment that meets the criteria as a well-established and efficacious intervention for ASD is behavioral treatment, which is often referred to as applied behavior analysis (ABA). In the National Autism Center guidelines, virtually all of the 11 interventions identified as established treatments are components of applied behavior analysis. However, families may be unaware of the existence of ABA services, unsure how to find a qualified provider to access the services, or may mistakenly think that there is only 1 version of ABA services (early intensive behavioral intervention [EIBI]) when other forms of behavioral treatment have proved effective for concerns across the lifespan and at lower intensities.

Families are likely to turn to their pediatrician for guidance about what sources are useful and trustworthy and what information should guide their selection of treatments and providers. This article provides information to guide recommendations to families in seeking behavioral treatment. The appendices are useful resources for pediatricians and are appropriate for distribution to families. Information is provided about the different models of behavioral intervention along with a review of the evidence for their effectiveness, including information about dosage effects and predictors of response to intervention, where available. In addition, this article provides information about what families should look for when seeking a provider of behavioral treatment services (ie, qualifications and credentials, indicators of quality programming), and recommendations about the types of collaboration and assistance pediatricians might expect from a behavior analyst who is serving one of their patients.

Behavioral treatment

There are at least 3 critical features of all behavioral treatments. First, the procedures are derived directly from behavioral theory and research. Second, there is an emphasis on frequent measurement of observable indicators of progress. Third, all aspects of the child’s functioning (eg, skills, deficits, problem behavior) are considered products of the interaction between children and influential aspects of their environments. After a careful examination of the interplay between the child and the environment (eg, people, events) reveals important interaction patterns, problematic interactions can be directly targeted using behavioral treatment procedures. Sometimes the interaction pattern is changed by teaching the child important new functional skills (ie, requests) and sometimes the interaction pattern is changed by altering some aspect of the environment (eg, availability of certain interactions, adult responses to problem behaviors). However, substantial differences exist in behavioral treatments related to the scope and goals of the therapy, the venue for delivering the services, and unique client characteristics (eg, age, clinical presentation). For example, a recently diagnosed 2.5-year-old with limited language, social, and cognitive skills may be a prime candidate for intensive instructional services. In contrast, an 8-year-old who attends general educational classes in school but has substantial anxiety and social skills deficits might benefit from behavioral consultation and less intensive outpatient services.

The terms commonly used for these different varieties of behavioral treatment are often foreign to families. For example, Ivar Lovaas coined the phrase discrete trial training (DTT) to refer to the first brand of intensive behavioral intervention for ASD, and that version of behavioral treatment is sometimes referred to as DTT, Lovaas therapy, or UCLA (University of California, Los Angeles) model behavioral treatment. Other terms for this specific application of ABA might be used depending on regional influences and provider preferences. Appendix 1 provides a list of common terms and definitions that a pediatrician might find useful or that could be directly disseminated to parents as they prepare to seek treatment services.

EIBI

The purpose of EIBI is to increase intellectual (ie, communication, cognitive, academic) skills and adaptive functioning (ie, social skills, self-care skills, safety) to prepare children with ASD to learn from, and succeed in, typical home and school environments with the fewest possible supports. These goals are achieved by creating a precise and sophisticated instructional environment for as many of the child’s waking hours as possible, at the youngest age possible, to alter the developmental trajectory in all areas of functioning. Perhaps the most critical repertoires targeted are the learning-to-learn skills (eg, imitation, following instructions, initiating interactions) that allow children to learn from more typical environments in ways that are similar to their peers. Large and sustained improvements in specific skills and in overall functioning increase the likelihood that a child will continue to be able to succeed throughout life with less intensive behavioral supports.

EIBI has several characteristic features that are critical to producing successful outcomes regardless of whether the services are provided in the family home or in a center-based clinic program. Families should be encouraged to evaluate their potential service options to determine the extent to which these characteristics are readily evident. First, the intervention model should focus on teaching small units of learning systematically and the targeted skills should be arranged in a carefully constructed behavior analytical curriculum. Children with ASDs do not readily learn complex skills from typical environments; thus, EIBI is designed to establish all of the component skills that evolve into complex skills. Any EIBI program should be using a well-established behavior analytical curriculum to guide programming, and several excellent ones have been published. Some provider agencies develop their own excellent proprietary curricula rather than using one that is commercially available; however, the agency should be willing and prepared to show that curriculum to a family that is considering their services. Second, the teaching procedures should be specified in great detail with respect to precise behavioral instructional procedures (ie, prompting strategies along with powerful rewards for every success). Third, the learning opportunities are repeated many times and in many environments until the child can perform all the skills independently across all natural settings (ie, generalized skills with all people, in all places, and in play contexts). Fourth, data are collected on performance during virtually all learning opportunities to examine progress in each area so that instruction can be modified as quickly as possible to ensure rapid progress. Furthermore, parents should expect a quality behavioral provider to collect data, to show them graphs of performance frequently, and to teach them how to collect data.

In addition to the characteristics of EIBI listed earlier, effective programs always include a substantial component of parent support and training designed to assist families in crafting a home environment that promotes optimal functioning for their child and minimize the likelihood of development of severe problem behavior. Providers teach parents how to play with their children in ways that feel natural, but are likely to promote better social interactions and more meaningful and appropriate play. They also learn how to prevent problem behavior or how to change their interactions with the child if problem behavior emerges, and how to teach daily living skills, communication, and social skills using behavioral instructional procedures.

Since the publication of the findings of the American Psychological Association’s task force on empirically supported treatments for children and adolescents, the Chambliss Criteria have been used to evaluate the degree of published empirical support for psychosocial interventions. The category with the most stringent criteria and greatest evidence is Well-established and Efficacious, which requires multiple controlled trials of the intervention compared with various reasonable controls. Other categories include Probably Efficacious, Promising, and Not Supported, based on less rigorous evaluations, fewer evaluations, or lack of evidence of demonstrated effectiveness. Based on multiple meta-analyses and systematic reviews, EIBI is the only intervention for ASD that meets the criteria for the category Well-established and Efficacious.

The initial demonstration of the effectiveness of comprehensive EIBI indicated that about 40 hours per week of intervention at very young ages resulted in 47% of participants achieving best outcome, as opposed to 2% of participants in a treatment-as-usual control group. Best outcome was defined as an intelligence quotient (IQ) in the normal range and a full-inclusion first grade placement with ameliorated symptoms of ASD such that these children were indistinguishable from their peers. Although the common vernacular of recovered or recovery has been used with regard to this outcome, we do not recommended using this term with families because ASD is a lifelong neurobiological disorder rather than a fluctuating disease state. These individuals typically continue to experience some characteristic features of the ASD although their functioning is substantially improved, they are able to participate more fully in society, and they may be indistinguishable from their nonaffected peers. Families that view ASD as a lifelong serious condition tend to have better adjustment outcomes and are more likely to pursue scientifically validated treatments than families who view it as having an unpredictable timeline or course. Encourage families to view the goal of EIBI as producing the best possible functionality and happiness in life for their children with ASD, exactly as they would hope for any of their children who do not have ASD.

Using this best outcome standard, the effectiveness of EIBI for young children with ASD has been shown in several replications and extensions in the past decade. Recent research has identified important parameters of EIBI, including the level of intensity and duration of services, the age for which EIBI is most effective, and the qualifications of the most effective providers. The most positive child outcomes have been documented when EIBI is consistently delivered at a high dosage or intensity (ie, at least 25–40 hours per week and for a duration of 2–3 years). However, it is critical that the high volume of services consist of EIBI because, compared with equally intensive traditional or eclectic model special education services, EIBI consistently produces better outcomes. In addition, when the intensity of EIBI decreases to approximately 12 to 20 hours per week, children with ASDs show only modest gains in functioning, although these outcomes are better than those achieved with the other types of treatment discussed earlier.

Common to most replication studies is the young age at which children with ASDs receive EIBI: compared with children who entered EIBI programs after the age of 5 years, younger children are more likely to experience greater positive outcomes (eg, public school classroom placement). Older children (ie, 7 years old) do respond positively to intensive behavioral interventions, although to a limited degree compared with younger children. Smith and colleagues reported that EIBI was not effective with 3 girls initially diagnosed with autism and later identified as having Rett disorder, even though the services were provided at a young age and intensively. Rett disorder is slated to be removed from the category that will be referred to as ASD in the new diagnostic classification system, and these girls should not be considered exceptional candidates for EIBI as children with ASD are. Based on the available literature, children should begin EIBI programs before the age of 5 years, preferably before the age of 3 years ; however, this will only occur if ASD screening occurs at recommended well-child visits.

In addition to starting an EIBI program at the youngest possible age, it is also important to have the services provided and supervised by quality behavior analytical professionals. In replication studies on the effects of EIBI, the training model and credentials of the supervisors was one of the few variables that predicted differential outcomes (ie, supervisors with higher credentials and certification produced better outcomes). One UK study found significantly poorer outcomes for children served in home-based EIBI programs coordinated by their parents and supervised intermittently by providers with varying degrees of training, compared with the published studies in which programming was coordinated and supervised by certified providers.

The international credentialing body for certifying behavior analysts is the Behavior Analyst Certification Board, which was established at the international level in 1998 and evolved from a previously established credentialing program in Florida. The Behavior Analyst Certification Board (BACB) is accredited by the National Council for Certifying Agencies and is endorsed by the national and international professional organizations of behavior analysis in the United States and Europe. This certification requires a passing score on an international content examination, documentation of supervised practical training, required coursework in behavior analysis, and ongoing continuing education in behavior analysis.

The BACB certifies 3 levels of providers and maintains an online directory of all currently certified behavior analysts by state and country. The highest level of credential, the Board Certified Behavior Analyst-Doctoral (BCBA-D) requires a doctorate degree. The most common credential for direct providers and EIBI program supervisors is the Board Certified Behavior Analyst (BCBA) credential, which requires a minimum of a Master’s degree. The Board Certified Assistant Behavior Analyst (BCaBA) is the credential for individuals with a Bachelor’s degree and this credential requires ongoing supervision by a BCBA or BCBA-D during practice. Certification is considered the practice credential for individuals practicing behavior analysis, similar to the medical license for a physician. In addition to certification, some qualified providers have credentials pertinent to their degree specialization (eg, licensed psychologist, licensed social worker, certified teacher, certified speech-language pathologist) or for specific models of EIBI intervention programming (eg, UCLA model certification) in addition to the broader discipline of behavior analysis. Families seeking EIBI services should seek a provider with the BCBA practice credential because this is the basic standard for behavior analysis. Families are also encouraged to check the BACB Web site ( www.bacb.com ), which provides information for consumers about the guidelines for professional conduct for the field and about any prior or outstanding complaints and sanctions against credentialed providers. In addition, most states or regions have an organization or association for behavior analysis that may be a good source of information about potential providers and statewide intervention resources.

As a family seeks EIBI services, they need to identify a qualified provider and determine how to manage the finances associated with pursuing this intervention. The costs of EIBI can be substantial over the course of 2 to 3 years of treatment, although the savings accrued by avoiding 16 to 18 years of special education costs and adult support services costs are substantial. In spite of the potential savings to government agencies, not all states have legislated funding mechanisms to cover these costs. In some states and Canadian provinces, the costs of EIBI services are covered by governmental entities or are mandated as part of health insurance coverage up to a certain dollar amount. In other states, no such legislation and funding streams exist and families may encounter tens of thousands of dollars of out-of-pocket expenses per year. The advocacy organization, Autism Speaks, maintains an up-to-date accounting of the states that have mandated insurance coverage, which increased from 1 state to more than 25 states in just 5 years (see www.autismspeaks.org for current information).

In summary, EIBI is the treatment of choice for young children identified with ASDs. This form of behavioral treatment involves a highly structured curriculum and precise teaching methodologies to target skills that allow children to learn more effectively from typical environments. Multiple studies show the robust effects of EIBI for children with ASDs, particularly when services are provided at young ages, at a substantial level of intensity, and by highly qualified providers. Meta-analyses of these findings have confirmed that approximately 30% to 50% of children who receive EIBI achieve outcomes such as improved global functioning (eg, cognitive or intellectual functioning, adaptive behaviors, language) along with placement in regular education classrooms. The remaining children typically experience moderate to substantial increases in functioning compared with before treatment, but may not achieve typical intellectual functioning and full integration in subsequent schooling. Appendix 2 includes common questions of parents about behavioral treatment services and answers that could be directly distributed to families. Appendix 2 also includes a list of recommended books and Web site resources that could be distributed directly to families.