A comprehensive evaluation of language for early behavioral intervention programs: The reliability of the SKILLS Language Index

Early intensive behavioral intervention (EIBI) is a well-established treatment for children with autism spectrum disorders (ASD) and is thus widely recommended. However, the content of EIBI programs presumably varies considerably and may not always be tailored to the individual strengths and deficits of each child. Few assessment tools exist (and none have been psychometrically evaluated) which attempt to identify appropriate targets for treatment in EIBI programs. The current study evaluated the reliability of the subscales of the SKILLS Language Index, an assessment tool for EIBI programs. Results demonstrated excellent internal consistency, inter-rater, and test-retest reliability.     

A person-centered perspective on differential efficacy of early behavioral intervention in children with autism: A latent profile analysis

BackgroundIndividuals with autism spectrum disorder (ASD) present heterogeneous symptom manifestations and responses to intervention. Despite being well-established, early intensive behavioral intervention (EIBI) has produced inconsistent responding across studies. Investigating individual differences and identifying more homogenous subgroups in samples may lead to a better understanding of symptom heterogeneity in ASD and response to EIBI.MethodAdopting a person-centered perspective, we conducted latent profile analyses (LPA) to explore the presence of homogenous subgroups in our sample of 233 preschoolers with ASD receiving early behavioral intervention services. We investigated predictors of group membership using logistic multinomial regressions and outcomes of membership with the BCH approach available in Mplus.ResultsWe found four latent profiles in our sample: a mild impairment profile, a severe impairment profile, and two intermediate profiles with combinations of mild to moderate autistic symptoms, adaptive functioning, and intellectual functioning. Only the annual family income predicted profile membership. All profiles made progress during the intervention period, with varying magnitudes of change. During the follow-up period, the moderate impairment and the severe impairment profiles showed stability or improvement in adaptive functioning, while the two mild impairment profiles showed a slight decrease.ConclusionsOur study contributes to the literature by suggesting the presence of distinct profiles with differences in their response to EIBI. The profiles associated with better short-term outcomes were different than the profiles who maintain their gains more consistently over time. This finding may guide both practitioners and researchers assessing the effects of intervention.     

Symptom severity and challenging behavior in children with ASD

The prevalence of challenging behaviors in the autism spectrum disorders (ASD) population is often assumed to be high but relatively little research has actually been published on it. Furthermore, challenging behaviors are likely to impede progress in evidence-based treatment programs, such as early intensive behavioral intervention (EIBI). Little or no previous research has evaluated the prevalence of various topographies of challenging behavior in a population of children with ASD receiving EIBI services, nor evaluated the relationship between such behaviors and the severity of ASD symptoms. Using data from the ASD–DC and the ASD–BPC in 84 children with autism receiving EIBI services, the current study conducted a regression analysis of relations between endorsement of challenging behaviors and ASD symptom severity. Results indicated that 94% of the sample reported the presence of challenging behavior, stereotypical behaviors were the most commonly reported, and that the presence of challenging behavior was predicted by ASD severity.     

Effectiveness of early behavioral intervention in public and mainstream settings: The case of preschool-age children with autism spectrum disorders

Despite the demonstrated positive outcomes of early intensive behavioral intervention (EIBI) among children with autism spectrum disorders (ASD), several challenges to its implementation on a large scale and in community settings remain. In order to maximize the accessibility and cost-effectiveness of its services, a regional public agency serving children with ASD implemented two consecutive programs: a 1 year pre-program for parents (intensive sessions followed by 1 hour per week of individual coaching) and an early behavioral intervention (EBI) program with less than optimal weekly intensity (16–20 hours) delivered in mainstream day care settings. The outcomes of these programs were assessed among 93 children. Their IQ, adaptive behavior, and socioaffective competencies were found to have improved after 12 months in the EBI program. Their autism symptoms had also decreased marginally. Although the pre-program did not have observable effects on children's outcomes, their parents reported positive impact on their well-being and family life. These results demonstrate the feasibility and sustainability of offering EBI to large, unselected populations. However, the pre-program may need to be offered more intensively in order to yield positive outcomes for children. Delivering EBI services in mainstream settings may foster the development of skills linked to social integration.     

A Cost of Illness Study of Children with High-Functioning Autism Spectrum Disorders and Comorbid Anxiety Disorders as Compared to Clinically Anxious and Typically Developing Children

The study’s aim was to estimate the societal costs of children with high-functioning ASD and comorbid anxiety disorder(s) (ASD + AD-group; n = 73), and to compare these costs to children with anxiety disorders (AD-group; n = 34), and typically developing children (controls; n = 87). Mean total costs for the ASD + AD-group amounted €17,380 per year. Societal costs were estimated at almost 142 million euro per year. Costs in the ASD + AD-group were four times higher compared to the AD-group, and 27 times higher compared to controls. ASD-related costs were higher in the ASD + AD-group; anxiety-related costs did not differ between the ASD + AD- and AD-group; costs due to physical or other reasons did not differ across groups. The findings suggest that costs can be decreased if effective treatment options for treating anxiety in ASD are established, however, the remaining costs associated with ASD would still be large. A limitation of the study is that a group of children with ASD without anxiety disorders is lacking.     

A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with Autism Spectrum Disorders

Excitement and controversy have surrounded the effectiveness of Early Intensive Behavioral Intervention (EIBI) for young children with autism. The purpose of this meta-analysis was to investigate the effectiveness of EIBI based on applied behavior analysis in young children with Autism Spectrum Disorders (ASD). There were 11 studies with 344 children with ASD. Quality of studies was assessed using the Downs and Black Checklist. Experimental groups who received EIBI outperformed the control groups on IQ, non-verbal IQ, expressive and receptive language and adaptive behavior. Differences between the experimental and control groups were 4.96–15.21 points on standardized tests. These results strongly support the effectiveness of EIBI.     

Assessing progress and outcome of early intensive behavioral intervention for toddlers with autism

Intensive behavioral intervention for young children diagnosed with autism can produce large gains in social, cognitive, and language development. Although several studies have identified behaviors that are possible indicators of best outcome, changes in performance are typically measured using norm-referenced standardized scores referencing overall functioning level rather than via repeated observational measures of autism-specific deficits (i.e., social behavior). In the current study, 83 children with autism (CWA), aged 1, 2 and 3 years, and 58 same-aged typically developing children (TDC) were directly observed in the areas of cognitive skills, joint attention (JA), play, and stereotypic behavior using a measure called the Early Skills Assessment Tool (ESAT; MacDonald et al., 2006). CWA were assessed at entry into an EIBI program and again after 1 year of treatment. Changes in performance were compared pre- and post-treatment as well as to the normative data by age. Results indicate significant gains on the ESAT across all age groups with the greatest gains seen in the children who entered treatment prior to their second birthday. Increases were seen on direct measures of JA, play, imitation and language while decreases were seen in stereotypy regardless of level of performance at entry into EIBI. The ESAT, a direct measurement tool, served as a sensitive tool to measure changes in autism symptomatology following EIBI treatment.     

Associations between domains of health-related quality of life and co-occurring emotional and behavioral problems in youth with autism spectrum disorder

BackgroundHealth-related quality of life (HRQoL) can be used as a measure of the impact of a particular disorder on one’s daily functioning. Previous studies have found that comorbid psychiatric disorders in children and adolescents with autism spectrum disorder (ASD) are associated with poorer HRQoL than ASD alone. Less is known about potential associations between specific symptoms of co-occurring psychopathology (i.e., emotional and behavioral problems) and domains of functioning or HRQoL in youth with ASD.MethodParticipants were 470 children with ASD 2–14 years old recruited from one of three sites. Hierarchical multiple regressions were conducted with Pediatric Quality of Life Inventory 4.0 (PedsQL; Varni, Seid, & Kurtin, 2001) HRQoL domains of physical functioning, emotional functioning, school functioning, and social functioning as the dependent variables. Covariates were entered at step 1, followed by the independent variables of interest at step 2: irritability, social withdrawal, stereotypic behavior, hyperactivity/noncompliance, and inappropriate speech.ResultsThe study found that increased irritability was associated with poorer emotional and physical functioning and that greater social withdrawal was associated with worse social functioning. Furthermore, findings showed that more hyperactivity/noncompliance was associated with worse school functioning.ConclusionsResults demonstrated that certain emotional and behavioral symptoms are differentially associated with domains of HRQoL. This indicates that emotional and behavioral problems should be considered when measuring HRQoL in children with ASD. It also suggests that treating co-occurring emotional/behavioral problems could improve HRQoL and functioning in certain domains for this population.     

Characterizing Community-Based Mental Health Services for Children with Autism Spectrum Disorders and Disruptive Behavior Problems

This study describes the characteristics of children with autism spectrum disorders (ASD) with disruptive behavior problems served in community-based mental health clinics, characterizes psychotherapy process and outcome, and examines differences between children with ASD and a non-ASD comparison group. Results indicate that children with ASD served in this setting are high functioning and diagnostically complex. Certain research-based behavioral and cognitive behavioral psychotherapeutic strategies were observed frequently, while parent training strategies and active teaching strategies were observed less frequently. The intensity or thoroughness with which strategies were pursued was relatively low. Outcome analyses indicate improvement in child symptoms and family functioning. Treatment delivery and outcome were similar for children with and without ASD. These findings represent the first detailed observational data characterizing community-based mental health services for children with ASD.     

Early Intensive Behavioral Interventions: Selecting behaviors for treatment and assessing treatment effectiveness

Early Intensive Behavioral Interventions (EIBI) is well established as the most effective treatment for young children with Autism Spectrum Disorders (ASD). A hallmark of this intervention model is the bundling of multiple behaviors simultaneously for intervention. With the addition of various comorbid problems such as challenging behaviors and psychopathology, it becomes incumbent on clinicians to prioritize behaviors for intervention. Based on the studies conducted to date, little has been done in this regard. Additionally, general measures of ASD, adaptive behavior and cognitive functioning are primarily used to assess outcomes, many of these measures were not designed to assess treatment effects, and little evidence is available to link intervention to specific items on these scales.     

Concurrent Validity of Social Subtype and IQ after Early Intensive Behavioral Intervention in Children with Autism: A Preliminary Investigation

Three subtypes of autism based on social style have been proposed by Wing: active-but-odd, passive, or aloof. Previous research has shown evidence of an association between IQ and Wing subtype in untreated children and adults. Because IQ changes can accompany behavioral treatment, but often only for a subset of children, social subtype may be related to treatment responsiveness. We administered a social subtyping measure, the Wing Subgroups Questionnaire (WSQ), at various points in treatment to younger children than previously studied with autism in early, intensive behavioral intervention (EIBI). Thirty-seven children in EIBI (aged 39–71 months, amount of EIBI 0–44 months) were assessed to determine whether Wing’s three proposed subtypes were found in this sample and whether subtypes were associated with current IQ and change in IQ after a period of EIBI. Results confirmed that all three subtypes were present and correlated with IQ after a period of intervention, as well as with change in IQ. Participants classified as aloof had significantly lower IQ scores and changes in IQ after EIBI than other children. Future studies should extend these findings by examining whether social subtype at pretreatment predicts EIBI outcome.     

Cost-effectiveness of treating first-episode psychosis: five-year follow-up results from an Italian early intervention programme

Aim: Early intervention programmes are expected to result in the reduction of illness severity in patients with schizophrenia, and contain health‐care costs by reducing hospital admissions and improving the social functioning of patients. This study aimed to investigate the cost‐effectiveness of treatment in an early intervention programme in comparison to standard care. Methods: Retrospective analysis of data prospectively recorded in an urban area (Milan, Italy). Twenty‐three patients from an early intervention programme and 23 patients from standard care with first‐episode psychosis were evaluated on their use of services over a 5‐year period. The Health of the Nation Outcome Scale was used to measure clinical status. Results: Significant changes with respect to initial assessment were recorded on the Health of the Nation Outcome Scale, with larger effect sizes in the early intervention programme than in the standard care group. Consequently, the cost‐effectiveness ratio per reduced score of severity was lower in the early intervention programme than in standard care (€ 4802 vs. € 9871), with an incremental cost‐effectiveness ratio, or net saving of €−1204 for every incremental reduced score of severity. Over time, greater recourse to hospital and residential facilities to obtain comparable improvement in symptoms resulted in a steady cost increase for the patients in standard care. Conclusions: Allocation of funds to specialized early intervention programmes is the best alternative, as it can save costs by reducing the use of hospitals and residential facilities, and may produce net savings of costs in the long term.     

Parent-managed behavioral treatment for preschool children with autism: some characteristics of UK programs

Early intensive behavioral intervention for autism has attracted controversy since Lovaas (1987) reported that 47% of his experimental group attained normal functioning. We summarize child and program data from 75 children receiving EIBI in the UK. The majority of children (57%) started treatment later than in Lovaas (1987), and 16% did not exceed his minimum IQ criterion. Children experienced fewer hours of treatment (mean of 32 hours vs. 40 hours per week), and their programs received relatively infrequent supervision. 21% of programs received supervision from individuals currently accredited as competent to provide Lovaas's treatment. No child started early enough, and received 40 hours per week, and had accredited supervision. Due to these variations from his model, Lovaas (1987) findings are unlikely to be replicated for this sample of children.     

Sleep in children with autistic spectrum disorder

Children and adolescents with autistic spectrum disorders (ASD) suffer from sleep problems, particularly insomnia, at a higher rate than typically developing children, ranging from 40% to 80%. Sleep problems in ASD might occur as a result of complex interactions between biological, psychological, social/environmental, and family factors, including child rearing practices that are not conducive to good sleep. Interestingly, children with a history of developmental regression have a more disturbed sleep pattern than children without regression. Even though regulation of sleep in children with ASD is still poorly understood, circadian abnormalities in autism might be the result of genetic abnormalities related to melatonin synthesis and melatonin’s role in modulating synaptic transmission. Recently a bifurcation of the sleep/wake cycle with increased sensitivity to external noise and short sleep duration causing irregular sleep onset and wake up times has been suggested. Identifying and treating sleep disorders may result not only in improved sleep, but also impact favorably on daytime behavior and family functioning. Several studies have also demonstrated effectiveness of behavioral interventions for sleep onset and maintenance problems in these populations. When behavioral interventions are not effective or lead only to a partial response, pharmacological treatment options should be considered. Studies of melatonin use in children with ASD provide evidence for its effectiveness and safety in the long run. The clinician assessing a child with an ASD should screen carefully for sleep disorders and make referrals as indicated.     

Respiratory Sinus Arrhythmia Predicts Restricted Repetitive Behavior Severity

In addition to social communication deficits, restricted repetitive behaviors (RRBs) are a key diagnostic feature of autism spectrum disorder (ASD). Dysfunction of the autonomic nervous system (ANS) in ASD has been posited as a mechanism of RRBs; however, most studies investigating ANS activity in ASD have focused on its relation to social functioning. This study used respiratory sinus arrhythmia (RSA) patterns to measure ANS functioning and analyze its relation to RRBs in children with and without an ASD diagnosis. Baseline RSA and RSA reactivity predicted RRB severity and exploratory analyses revealed these measures may be associated with RRB subgroups. These results are discussed in regards to the behavioral literature on RRBs and the benefits of finding biomarkers for these behaviors.     

Healthcare use and costs associated with children’s behavior problems

The objective of the study was to investigate associations between severity of behavior problems, specific symptom domains with healthcare use and costs in school-aged children. A cross-sectional study using data from the 10-year follow-up of two population-based birth cohorts was conducted on four rural and urban communities in Germany. There were 3,579 participants [1,834 boys (51%), 1,745 girls (49%)] on average aged 10.4 years. The severity levels (normal, at risk, abnormal) and symptom domains of behavioral problems were assessed by parent-reported strengths and difficulties questionnaire (SDQ).The outcomes were medical use categories (physicians, therapists, hospital, and rehabilitation), medical costs categories and total direct medical use and costs (calculated from parent-reported utilization of healthcare services during the last 12 months). Total direct medical costs showed a graded relationship with severity level (adjusted p < 0.0001). Average annual cost difference in total direct medical costs between at risk and normal total difficulties was Euro (€) 271 (SD 858), and € 1,237 (SD 2,528) between abnormal and normal total difficulties. A significant increase in physician costs showed between children with normal and at risk total difficulties (1.30), and between normal and abnormal total difficulties (1.29; p < 0.0001). Between specific symptom domains, children with emotional symptoms showed highest costs for physicians, psychotherapist, and hospitalization as well as total direct medical costs. Children with hyperactivity/inattention showed highest costs for therapists and emergency room costs. Healthcare use and costs are related to the severity of child behavior problems. In general, children’s costs for psychotherapy treatments have been low relative to general medical treatments which may indicate that some children with behavioral problems did not get appropriate care. To some degree, medical conditions may be attributable to some of the high hospitalization costs found in children with emotional symptom.     

Emotional and Behavioral Adjustment in Typically Developing Siblings of Children with Autism Spectrum Disorders

Research findings describing the emotional and behavioral functioning of typically developing (TD) siblings of children with autism spectrum disorders (ASD) are contradictory. Methodological issues, such as small study sample sizes and reliance on parent report, may contribute to inconsistent findings. The purpose of this study was to use parent and teacher report to describe presence of internalizing and externalizing behaviors among a large sample (n = 486) of TD siblings of children with ASD. Results indicated that siblings did not exhibit a disproportionate prevalence of internalizing or externalizing symptoms in comparison to the standardization sample of the rating scale. The presence of a sibling with an ASD may not be considered a risk-factor for adjustment problems among TD siblings.