Early behavioral interventions (BI) such as applied behavior analysis (ABA) and early intensive behavioral intervention (EIBI) are the main established therapeutic interventions for autism spectrum disorders (ASD). The current study examined the effect of early BI when delivered in routine clinical care.
We included studies that examined the effectiveness of empirically supported early BI treatment programs for children with ASD, delivered by practicing clinicians in routine clinical care, to patients referred for treatment through usual clinical routes. We were interested in answering three main questions: First, what is the effectiveness of evidence-based early BIs for ASD in young children (i.e., age below 5 years)? That is, do these programs work in reducing the child’s challenges? Second, what is the methodological quality of the effectiveness studies, and are there potential moderators of treatment outcome? That is, factors beyond the treatment that influence how well the treatment works? Third, how do the treatments delivered in routine clinical care fare in comparison to efficacy studies (i.e., studies conducted in specialized research settings?
We found 29 studies that met out inclusion criteria. We found that BI for ASD were as effective in the real world setting as in specialized research settings. The interventions led to improvements in adaptive behavior, cognition, communication, and socialization, with medium to large within-group effect sizes (ES). The mean ES was large both at post-treatment and at follow-up (Hedges’s g = 0.94 and g = 1.08, respectively), indicating that the effect remains over time. Attrition was low overall. Larger effects were seen in interventions that were of higher intensity and that were carried out at the participants’ homes. Large improvements across domains were seen in both open studies and in randomized control studies (RCT).
Overall, the findings indicate that delivering BI to preschool children with ASD carries large potential for improved daily functioning also in routine clinical care, and that the improvement was maintained over time, as the mean follow-up time was more than four years. The meta-analysis also highlighted areas of improvements and opportunities including a more detailed classification of the programs used based on the core components, and a common standard of outcome measures for assessing the effectiveness of interventions. Although the meta-analysis included early BI, there were no published studies of BI in school-age children, indicating an urgent need for intervention research in older children with ASD.
Discussion Questions
- What barriers may exist for implementing behavioral interventions in routine clinical care?
- How can we ensure that children with ASD and their families receive evidence-based services?
- In view of the good effect for young children, the lack of evidence for ABA in school children is striking, how to proceed from here?
- How can researchers and clinicians in the field reach a consensus on methods for the assessment of ASD that can be used in routine clinical care?
About the Authors
Gro Janne Wergeland, M.D, Ph.D., is a child and adolescent psychiatrist, and an associate professor at the Department of Clinical Medicine, University of Bergen, Norway. Her research interests are focused on anxiety disorders in children and adolescents, cognitive behavior therapy, and evaluation of treatment outcome in routine clinical care.
Maj-Britt Posserud, M.D, Ph.D., is a child and adolescent psychiatrist, and professor at the Department of Clinical Medicine, University of Bergen, Norway. Her research interests are focused on autism and other neuropsychiatric disorders, epidemiology, translational and intervention research.
Urdur Njardvik, Ph.D., is a professor of clinical child psychology in the Department of Psychology at the University of Iceland. Her research interests include disruptive behavior problems, ADHD and ASD, especially regarding comorbidity, emotion regulation and treatment outcome.
Krister Fjermestad, Ph.D. is a professor of clinical child psychology in the Department of Psychology at the University of Oslo, Norway. His research interests include neurodevelopmental disorders and their impact on parents and siblings.
Lars-Göran Öst, Ph.D., D.Med.Sci., is professor emeritus of clinical psychology, Department of Psychology, Stockholm University, Sweden. He has done CBT research for more than 50 years and has developed three behavioral treatments which are evidence-based with strong research support. His research has mainly been focused on anxiety disorders, both for children and adults.