Early Intervention for Children With Autism …...Early Intervention for Children With Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research abstract

Early Intervention for Children With Autism SpectrumDisorder Under 3 Years of Age: Recommendations forPractice and Research

abstractThis article reviews current evidence for autism spectrum disorder(ASD) interventions for children aged ,3 years, based on peer-reviewed articles published up to December 2013. Several groupshave adapted treatments initially designed for older, preschool-agedchildren with ASD, integrating best practice in behavioral teachingmethods into a developmental framework based on current scientificunderstanding of how infants and toddlers learn. The central role ofparents has been emphasized, and interventions are designed to in-corporate learning opportunities into everyday activities, capitalize on“teachable moments,” and facilitate the generalization of skills be-yond the familiar home setting. Our review identified several compre-hensive and targeted treatment models with evidence of clearbenefits. Although some trials were limited to 8- to 12-week outcomedata, enhanced outcomes associated with some interventions wereevaluated over periods as long as 2 years. Based on this review,recommendations are proposed for clinical practice and future re-search. Pediatrics 2015;136:S60–S81

AUTHORS: Lonnie Zwaigenbaum, MD,a Margaret L.Bauman, MD,b Roula Choueiri, MD,c Connie Kasari, PhD,d

Alice Carter, PhD,e Doreen Granpeesheh, PhD, BCBA-D,f ZoeMailloux, OTD, OTR/L, FAOTA,g Susanne Smith Roley, OTD,OTR/L, FAOTA,h Sheldon Wagner, PhD,i Deborah Fein, PhD,j

Karen Pierce, PhD,k Timothy Buie, MD,l Patricia A. Davis,MD,m Craig Newschaffer, PhD,n Diana Robins, PhD,n AmyWetherby, PhD,o Wendy L. Stone, PhD,p Nurit Yirmiya, PhD,q

Annette Estes, PhD,r Robin L. Hansen, MD,s James C.McPartland, PhD,t and Marvin R. Natowicz, MD, PhDu

aDepartment of Pediatrics, University of Alberta, Edmonton,Alberta, Canada; bDepartment of Anatomy and Neurobiology,Boston University School of Medicine, Boston, Massachusetts;cDivision of Developmental and Behavioral Pediatrics, Universityof Massachusetts Memorial Children’s Medical Center, Worcester,Massachusetts; dGraduate School of Education & InformationStudies, University of California Los Angeles, Los Angeles,California; eDepartment of Psychology, University ofMassachusetts, Boston, Massachusetts; fCenter for Autism andRelated Disorders, Tarzana, California; gDepartment ofOccupational Therapy, Thomas Jefferson University, Philadelphia,Pennsylvania; hUSC Mrs T.H. Chan Division of OccupationalScience and Occupational Therapy, Los Angeles, California;iBehavioral Development & Educational Services, New Bedford,Massachusetts; jDepartment of Psychology, University ofConnecticut, Storrs, Connecticut; kDepartment of Neurosciences,University of California San Diego, La Jolla, California; lHarvardMedical School and Massachusetts General Hospital for Children,Boston, Massachusetts; mIntegrated Center for ChildDevelopment, Newton, Massachusetts; nA.J. Drexel AutismInstitute, Drexel University, Philadelphia, Pennsylvania;oDepartment of Clinical Sciences, Florida State University Collegeof Medicine, Tallahassee, Florida; pDepartments of Psychology,and rSpeech and Hearing Sciences, University of Washington,Seattle, Washington; qDepartment of Psychology, HebrewUniversity of Jerusalem Mount Scopus, Jerusalem, Israel;sDepartment of Pediatrics, University of California Davis MINDInstitute, Sacramento, California; tYale Child Study Center, NewHaven, Connecticut; and uGenomic Medicine Institute, ClevelandClinic, Cleveland, Ohio

ABBREVIATIONSABA—applied behavior analysisASD—autism spectrum disorderESDM—Early Start Denver ModelGRADE—Grading of Recommendations Assessment, Development,and Evaluation

(Continued on last page)

S60 ZWAIGENBAUM et al by guest on March 4, 2020www.aappublications.org/newsDownloaded from

The ultimate goal of early detection andscreening is to ensure that childrenwith autism spectrum disorder (ASD)can access evidence-based inter-ventions toprovide thebestopportunityfor optimal development and out-comes.1 With the advances reviewed byZwaigenbaum et al2,3 in this specialissue of Pediatrics, and the growingevidence that ASD can be diagnosedaccurately before 2 years of age,4,5 theneed for ASD treatment programsspecifically designed for this age grouphas never been greater. Some authorshave also argued that the second yearof life is a particularly critical de-velopmental period for children withASD, for various reasons. First, thesecond year is a dynamic period ofbrain growth, during which increasesin brain volume and atypical connec-tivity associated with ASD first emerge6,7

but also a time of substantial neuralplasticity providing greater potentialto alter developmental course.8 Sec-ond, a proportion of children with ASDreportedly regress in the second year.Recent research has indicated onlymodest agreement between retroac-tively reported regression and analysisof behavioral change as observed onserial home videos9 and that acute skillloss may exist along a continuum ofgradually declining trajectories of so-cial and communicative behavior.10,11

However, interventions during this pe-riod may counter the developmentalcascade that contributes to pro-gressive symptom development andultimately prevent ASD-related impair-ments before they fully manifest.8

Intervention approaches for childrenaged ,2 to 3 years need to be de-velopmentally appropriate. We cannotassume that findings from treatmentresearch involving older children withASD will generalize to infants and tod-dlers, who differ with respect to thenature of their social relationships aswell as their cognitive and communi-

cative processes. Infants depend onexperiential learning within their nat-ural environments and on interactionsrooted in social play that occur withinthe context of everyday caregivingactivities.1 Fortunately, over the pastseveral years, a growing number ofstudies have evaluated interventionsspecifically designed for children aged,2 to 3 years. An updated review ofthese interventions may provide neededdirection and guidelines to cliniciansand policy makers.

METHODS

Theworkinggroupconductedasearchofthe literature published online between2000 and 2012 related to interventionprograms provided to children with ASDaged ,3 years. The working groupsummarized published research oninterventions developed for use in chil-dren aged#36 months, even if the agerange of samples of children beingevaluated extended beyond age 3 years(Table 1). A PubMed search was con-ducted on June 30, 2010, for articlespublished since January 1, 2000, byusing the search terms (“child de-velopmental disorders, pervasive” or“autistic disorder/” or “autism [tw]” or“autistic [tw]”) and (“Early Intervention/”or “intervention [tw]”), with an agefilter (“infant, birth-23 months” or “Pre-school child, 2-5 years”) and limited toEnglish-language articles. This searchyielded 419 references, which werereviewed by Drs Zwaigenbaum andBauman, who selected articles focus-ing on clinical trials of developmental/behavioral interventions (ie, not medi-cations or trials of other biomedicaltherapies) that included children aged,36 months. Search results werecomplemented by additional pub-lications identified by working groupmembers. Hence, although the searchstrategy was comprehensive, selectionof articles was not systematic, which isan important limitation. A scoping ap-

proach, with some discretion of themultidisciplinary expert working group,was used instead to select articles ofhighest relevance.

Each selected study was assessed, andworking group members were asked toarrive at a consensus evaluation on eacharticle after a detailed discussion. Thesearch was updated by using the samestrategy to add articles published toDecember 31, 2013, which yielded anadditional 323 references; selectionwas again limited to clinical trials ofdevelopmental/behavioral interventionsthat included children aged,36months.The working group reviewed and ap-proved the final wording of the summaryand recommendations.

We recognize that in addition to com-prehensive early intervention programs,themanagement and treatment of youngchildren with ASD often involves speechand language and occupational andphysical therapies, as well as manage-ment of comorbid conditions such asassociated medical disorders (eg, sleep,gastrointestinal),12 anxiety, and chal-lenging and maladaptive behaviors.However, a review of these targetedinterventions was beyond the scope ofthe current initiative.

LITERATURE REVIEW

Table 1 summarizes the key featuresand outcomes of 24 randomized con-trolled, quasi-experimental, and open-label studies involving children withASD aged ,3 years reviewed by theworking group.13–38 Because few stud-ies focused exclusively on this agegroup, studies in which participantsincluded some children aged.3 yearswere assessed as long as there wassufficient information to draw infer-ences about younger children. Thegroup reviewed additional reports,which have not been listed in Table 1,including single-subject studies,39–44

other relevant studies,16,45–50 meta-analyses,51,52 and reviews.53–56

SUPPLEMENT ARTICLE

PEDIATRICS Volume 136, Supplement 1, October 2015 S61 by guest on March 4, 2020www.aappublications.org/newsDownloaded from

TABLE1

Selected

InterventionStudiesInvolvingChildrenAged

,3Years(2000–2013)

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Rogers

etal,14

2012

N=98

with

ASD

(screen-positiveon

theITCandESATand

diagnosisby

using

ADOS-Tandclinical

judgment)

RCT

1hparent

training

perw

eek312wk,

plus

self-

instruction

manualfor

parent

toreview

Comprehensive

ESDM

(see

Dawson

etal,17

below),

adaptedas

briefer

parent

training

model

Nomaintreatm

ent

effectson

parent

acquisition

ofESDM

interventionskills

norimprovem

entin

child

developm

ent

orASDsymptom

s

Implem

entedby

parents

Both

groups

show

edimprovem

entin

child

outcom

es,

relatedtohoursof

interventionand

olderchild

ageat

baseline

Moderate/high

Weak

Aged

12–24

mo(m

ean:

21.0mo);76boys

Stronger

working

alliancewith

primary

therapistinESDM

groupcompared

with

community

interventioncontrols

Carter etal,15

2011

N=62

with

ASD

symptom

soratrisk

(STAT)

RCT

1groupsessionwith

parentsperweek

38wk,plus

3at-

home

individualized

sessions

for

parent

andchild

Targeted

Hanen

recommendations:

parent

training

insm

allgroupsplus

1:1a

Nomaintreatmenteffects

onparentresponsivity

orchild

communication

outcom

esimmediately

or5moafter

treatment(although

moderatetolarge

effectsizes

forparent

responsivitygains)

Implem

entedby

parents

Missing

data

precludedITT

analysis

Moderate/high

Weak

Aged

15–25

mo(m

ean:

20.3mo);51boys

Allsessions

completed

by3.5mo

Inchildrenwith

low

baselinelevelsof

objectinterest,↑

gainsinchild

communication

5moposttreatm

ent

Internalstudyvalidity

questionedby

authors

“Businessas

usual”b

Inthosewith

high

baselineobject

interest,attenuated

grow

thin

communication

Size

ofparent

groups

smallerthan

Hanen

recommendations

Landa

etal,16

2011

N=48

with

ASD

RCT

10h/week3

6mo

Targeted

Socialcurriculum

(5:3,aDTT,routines-

basedinteractions)

addedto

comprehensive

classroom-based

intervention(AEPS)

Significant

(P=.02)

between-group

differencefor

sociallyengaged

imitation

(moderateeffect

size

at6mo,large

effectsizeat12

mo)

Implem

entedby

interventionists

Controlgroup

without

socialcurriculum

nevertheless

received

some

imitationandJA

intervention

Moderate/high

Weak

Butthere

was

home-

basedparent

training

(1.5h/mo

36mo)andparent

educationclasses

(38h)


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Aged

21–33

mo(m

ean:

28.6,28.8mo);40

boys

AEPS

curriculum

(developmental

approach)without

addedintervention

NSbetween-group

differences

inIJA

andshared

positive

affect(m

oderateor

largeeffectsizesat

6and12

mo)

NSbetween-group

differences

inexpressive

language

ornonverbalcognition

(moderateeffect

sizesat6and12mo)

Dawson

etal,17

2010

N=48

with

ASD

RCT

20h/week3

2y

(therapists)

plus

$5h/wk3

2y

(parents)

Comprehensive

ESDM

:1:1,ahome-

based,ABAand

developm

ental

approaches;plus

otheravailable

therapiesc

Significant

between-

groupdifferencesin

IQandadaptive

behavior

after2y

Delivered

bytherapists

andparents

Groupdifferences

larger

than

thosein

studiesof

comparable

developm

ental

behavioral

approaches

ofshorterduration

andfewer

hoursof

deliveryperweek

Moderate/high

Strong

Aged

18–30

mo(m

ean:

23.9,23.1mo);

male-to-female

ratio

3.5:1

Actualmean:15.2h/wk

(therapists)

plus

16.3h/wk

(parents)

Mean:9.1h/wk

individual

therapyplus

9.3h/wkgroup

Assess

andmonitor:

referralsby

community-based

providers

ESDM

group

maintainedrateof

adaptivebehavior

grow

thcompared

with

norm

ative

sampleofTD

children,andthe

comparisongroup

show

edfurtherlag

Green

etal,18

2010

N=152with

ADRCT

4h/month

36mo,

then

2h/month

36mo

Targeted

PACT:interventionto

increase

parent

sensitivityand

responsiveness;

1:1a

with

child

present;plus

treatm

entasusuald

NSbetween-group

differenceinchild

autismsymptom

severity,language

measures,or

adaptive

functioning

inschoolat13

mo

Parent

mediated

ADOS-G,usedas

primaryoutcom

e,maynotbesensitive

measure

ofchange

Moderate/high

Strong (per

parent

report)

SUPPLEMENT ARTICLE


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Aged

24–60

mo(M

:45);

138boys

Treatm

entasusual

(localservices)d

Largeeffectsize

for

parent

synchronous

response

tochild;

smalleffectsizes

forotherparent–

child

interaction

measures(child

initiations

with

parent,parent-child

shared

attention)

Weak(per

child

measures)

Ingersoll,19

2010

N=21

with

ADRCT

3h/week3

10wk

Targeted

Behavioral

intervention(RIT):

laboratory

setting,

naturalistic

techniques

Significantlymore

gainsinelicited

(P,

.05)

and

spontaneous(P

,.02)

imitation,in

both

object(P

,.05),and

gesture

(P,

.01)

imitation

comparedwith

controls

Implem

entedby

therapists

Groups

notmatched

pretreatment

(betterimitationin

RITgroup)

Moderate/high

Strong

Aged

27–47

mo(m

ean:

41.4,37.2mo);18

boys

“Treatmentas

usual”

incommunity

Kasari

etal,20

2010

N=38

with

ADRCT

2h/wk(three

40-min

sessions)3

8wk

Targeted

ImmediateJA

intervention:

instructing

caregiver–child

dyad

during

play

routines;com

bined

developm

entaland

ABAapproach;

laboratory

setting

At8wk,significant

(P,

.05)

between-

groupdifferences

inlevelofjoint

engagement,child

responsiveness

toJA,and

diversity

offunctionalplayacts

(generallylarge

effectsizes)

Caregivermediated

Concurrent

early

intervention(9–40

h/wk)

received

byboth

groups

(no

differences

indose

ortype)e

Moderate/high

Strong

At1-yfollow-up,

treatm

entgains

weremaintainedor

improved

Aged

21–36

mo(m

ean:

30.8);29

boys

DelayedJA

intervention(wait-

listedgroup)

Quality

ofcaregiver

involvem

ent,butnot

treatm

entfidelity,

predictedchild

outcom

e


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Oosterling

etal,21

2010

N=75

with

ASD

RCT

Year

1:Group

sessions

2h/wk

34wk,then

homevisits3h/wk

every6wk

Targeted

Parent

training

bypsychologistsor

sociotherapists

(nonintensive,

home-based,called

“focus

parent

training”)plus

care

asusualf

After12

mo:

Parentsas

everyday

therapists

Modeled

onthe

interventionof

Drew

etal,37

2002

(see

below)

Moderatetolow/

very

low

Weak

Flaw

edrandom

ization

offirst26

participants

Aged

12–24

mo(m

ean:

34.4mo);52boys

Year

2:Homevisits

every3moplus

plenarysessions

every6mo

Care

asusualf

Nobetween-group

differences

inlanguage

developm

ent,

globalclinical

developm

ent,or

mediating

outcom

es(ie,child

engagement,early

precursorsofsocial

communication,

parentalskills)

Treatm

entintegritynot

form

allyverified

Zachor

and

Ben-Itzchak,22

2010

N=78

with

ASD

Quasi-experimental

20h/wk3

1y

Comprehensive

ABA-based

intervention:1:1,a

child-centered;part

ofcommunity

center–basedASD-

specificpreschool

program(40h/wk)

NSbetween-group

differences

inchange

inASD

diagnostic

classification,

cognitive

abilities,

oradaptiveskills

Stronger

parent

involvem

entin

eclecticgroup

Groups

notrandom

lyassigned

Moderate

Weak

Aged

15–35

mo(m

ean:

25.4);71

boys

19h/wk3

1y

ED:m

ixof

developm

ental,DIR,

andTEACCH;7:5a ;

partofsame

preschoolprogram

(40h/wk)

Insubgroup

with

less

severebaselineASD

symptom

s,eclectic

.ABAinadaptive

skills

Ben-Itzchak

and

Zachor,23

2009

N=68

with

ADOpen

35h/wk3

1y

Comprehensive

ABA-basedearly

interventionas

part

ofcenter-based

autism-specific

preschool;1:1a

NSeffectoftype

ofinterventionon

change

inautism

severity(∼

20%in

each

group

changeddiagnostic

classificationat1y)

Implem

entedby

therapistsand

specialeducation

teachers

Moderate

Strong

SUPPLEMENT ARTICLE


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Aged

18–35

mo(m

ean:

25.4mo);62boys

Eclecticas

partof

center-based

autism-specific

preschool;mixof

treatm

ent

approaches,small

groups

Comparedwith

childrenwith

unchangedstatus

(n=53),thosewith

improved

classification

(n=15)gained

significantlymore

incognitive

abilities

(P,

.01),adaptive

skills(P

,.05for

communication

scores),and

stereotyped

behaviors(P

,.05)

Butp

arenttrainingis

partofeclectic

programs

Eikeseth

etal,24

2009

N=20

with

ADOpen

Rangeofsupervision

intensity:2.9–7.8

h/month

(M:5.2)

Comprehensive

EIBI(UCLA/Lovaas

model):home-

based,1:1a;m

ean:

34.2h/wk3

50wk,

parent-managed

service

Intensity

ofsupervision

significantly

(P,

.05)correlated

with

changesinIQ

andvisual-spatialIQ

after14

mo

Implem

entedby

tutors

3childrenexcluded

from

data

analysis

(2withdrew

from

study;1required

increased

supervision)

Very

low/low

Weak

Aged

28–42

mo(m

ean:

34.9mo)

NScorrelationwith

adaptive

functioning

Butp

arenttrainingon

ABAmethods

Studydesigned

tofind

onlyassociation

between

supervision

intensity

and

outcom

eOf

23who

entered

study,17

boys

Ben-Itzchak

and

Zachor,25

2007

N=25

with

ADOpen

$35

h/wk3

1y

Comprehensive

IntensiveABA-

intervention:

center-based,1:1,a

addressing

developm

entaland

behavioralareas

Significant(P

,.001)

improvem

entsafter

1yinimitation,

receptive/expressive

language,nonverbal

communication,play

skills,and

stereotyped

behaviors

Implem

entedby

therapists

Nocontrolgroup

Low/m

oderate

Weak

Aged

20–32

mo(m

ean:

26.6mo);23boys

Childrenwith

higher

IQor

fewer

social

interactiondeficits

before

treatm

ent

show

edbetter

acquisition

ofreceptive/

expressive

language

andplay

skills

Parenttraining

onhow

tousebehavioral

methods

athome


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Goin-Kochel

etal,26

2007

N=29

with

ASD

Open

$30

h/wk3

12–18

mo

Comprehensive

EIBI:ASD-specific

preschoolprogram

inprivateschool

setting;ABA-based

(ABLLS

g )curriculum

;1:1a

plus

smallgroups

Significant

group

progress

over

time

across

multiple

skills(P

,.001

for

allABLLS

domains

g )

Parents“required”

toprovideEIBIat

home,10

h/wk,to

supplementschool-

basedintervention

Nocontrolgroup

Low

Weak

Aged

29.6–61.4mo

(mean:45.7mo);27

boys

BaselineABLLSg

score

andrateoflearning

during

first6mo

bestpredicted

outcom

e

Access

toarchival

schooldata

only

(notknow

nwhether

otherinterventions

werereceived)

9/16

discharged

toinclusive

kindergarten

orfirstgradewith

assistance

ofaide;

allneededspecial

educationservices

Magiati

etal,27

2007

N=44

with

ASD

Quasi-experimental

18–40

h/wk3

2y

(M,33.2atendof

2y)

Comprehensive

EIBIincommunity

setting:home

based;1:1a;DTTand,

in2families,verbal

behavior

NSgroupdifferencesin

cognitive

ability,

language,play

skills,or

ASD

severityat2y

In23

of28

families,1

parent

trainedas

atherapist

Groups

notrandom

lyassigned

Low/m

oderate

Weak

Aged

23–54

mo(m

ean:

38.0,42.5);39boys

Moderatetolarge

effectsizesfor

adaptivebehaviors;

moderateeffectsize

forASDseverity

Treatm

entfidelitynot

assessed

directly

15–30

h/wk3

2y

(M,27.4atendof

2y)

ED(including

PECS,

SPELL,andTEACCH)

inautism-specific

nurseries:1:1to

3.3:1a

BaselineIQand

language

levelbest

predictedoverall

progress

Nurseryprograms

emphasized

“close

liaison

with

parents”

Reed et

al,28

2007

N=27

with

ASD

Quasi-experimental

20–40

h/wk(M

,30.4)

39–10

mo

Comprehensive

Home-based,high-

intensity

ABA

programs,mostly

1:1a

andinnatural

settings:

Significant

(P,

.01)

between-group

differences

ineducational

functioning

Someinvolvem

entby

family

mem

bers

Groups

notrandom

lyassigned

Low/m

oderate

Weak

Aged

31–48

mo(m

ean:

42.9,40.8mo);all

boys

UCLA/Lovaasmodel

NSbetween-group

differences

inintellectual

functioning,

adaptivebehavior,

andASDseverity

Withinthehigh-

intensity

groups,↑

temporalinput

(h/

wk)

was

not

associated

with

↑gains

SUPPLEMENT ARTICLE


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

CABAS:em

phasizing

teacher–student

interactionas

unit

ofanalysis

Largeeffectsizesforhigh-

intensity

groupin

intellectualand

educational

functioning;moderate

effectsizesforlow-

intensity

group

Verbalbehavior:focusing

ondeveloping

verbal

responses

Smalleffectsizesforall

groups

inadaptive

behavior

11–20

h/wk(m

ean:

12.6)3

9–10

mo

Home-based,low-

intensity,generic

ABAprogram

Of3high-intensity

programs,CABAS

hadbesteffectsizes

Remington

etal,29

2007

N=44

with

ADQuasi-experimental

18.4–34.0h/wk

(mean:25.6)3

2y

Comprehensive

EIBI:ABA-based;hom

esetting;delivered

bymultipleservice

providers;plus

“usual”

treatm

entsh

Significantmaineffects

ofgroupforIQ,daily

livingskills,and

motor

skills;

significant

differences

inlanguageabilitiesat1

and2yfavoring

EIBI

EIBIdelivered

bytherapistsand

parents

Groups

notrandom

lyassigned

Moderate

Strong

Aged

30–42

mo(m

ean:

35.7,38.4mo)

Effectsizesat2y:large

forIQ,m

oderatefor

adaptivebehaviors

Potentialexaminer

bias

“Treatmentas

usual”:

nointensiveor

predom

inantly

1:1a

interventionh;

publiclyfunded

educationprovision

At2y,morechildrenin

EIBIgroupattended

mainstream

schools(17/23

comparedwith

10/21)

Investigatorscouldnot

controlpractical

aspectsof

interventions

Response

toEIBI

predictedby

higher

baselineintellectual

functioning,m

ore

baselineproblem

behaviors,m

ore

severeASDsymptom

sZachor

etal,30

2007

N=39

with

ASD

Quasi-experimental

35h/wk3

1y

Comprehensive

ABA-basedearly

intensive

intervention:

center-based,1:1,a

DTT,naturalistic

techniques

ABA.

EDin

improvem

entsin

language

and

communication

(P,

.01)

and

reciprocalsocial

interaction

(P=.07):onlyABA

show

edsignificant

improvem

entin

form

erdomain;ABA

hadlarger

effect

size

inlatter

Implem

entedby

therapists

ADOS

used

tomeasure

changesinASDcore

symptom

s

Low

Weak


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Aged

22–34

mo(m

ean:

27.7,28.8mo);37

boys

35h/wk3

1y

EDapproach:center-

based,mixof

methods

i ;focused

onteaching

imitationand

awarenessofsocial

interactions;1:1a

plus

smallgroups

ABA.ED

inchangesin

diagnostic

classification

(P,

.05)

Cohen

etal,31

2006

N=42

with

ASD

Quasi-experimental

35–40

h/wk3

47wk/y3

3yj

Comprehensive

EIBI(UCLA/Lovaas

model):community

based,1:1a

home

instruction,DTT;

plus

classroom-

basedregular

education

preschool

Significant

differences

inIQ(P

=.03)

and

adaptivebehavior

(P=.01)

favoring

EIBI

Implem

entedby

tutors

Groups

notrandom

lyassigned

Very

low/low

Weak

Aged

20–41

mo(m

ean:

30.2,33.2mo);35

boys

IQandadaptive

behavior

gainsin

EIBIgrouptended

toplateauafter1y

EIBI:parenttraining;

parents

encouraged

toparticipateactively

inintervention(no

setnum

berofhours

required)

Significantly(P

,.05)

morechildrenwith

ADinEIBIgroup

NSbetween-group

differencein

language

comprehension

ornonverbalskills

Treatm

entfidelitynot

assessablein

comparisongroup

#15–25

h/wk3

3y

(for

17of21

children)

Specialeducation

classesatlocal

publicschools

(mixed

approaches;

1:1to3:1a)

Atyear

3,17

of21

EIBI

childreninregular

education(6

withoutsupport)vs

1of21

incomparisongroup

Atyear

3,EIBIchildren

trainedinadvanced

socialskills

Kasari

etal,32

2006

N=58

with

ADRCT

2.5h/wk3

5–6wk

Targeted

JAintervention:child-

centered

ABAand

milieu

teaching

strategies

addedto

EIP;laboratory

setting

After6wk:

Childrendirectly

taught

bytrained

interventionists

After5–6wk,children

transitionedoffEIP

tocommunity

services

withoutJA

orSP

intervention

Moderate/high

Strong

Kasari

etal,33

2008

Aged

3–4y(m

ean:43.2,

42.7,41.9mo);46

boys

2.5h/wk3

5–6wk

SPinterventionusing

samestrategies,

addedtosameEIP;

laboratory

setting

↑JA

skillsinJA

group

and↑diversity

and

sophisticationof

play

inSP

group

comparedwith

controls(large

effectsizes)

Controlgroup

then

received

more

hoursof

intervention

services

than

form

erJA

(P,

.05)

andSP

(P,

.01)

groups

SUPPLEMENT ARTICLE


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

EIP:30

h/wk3

5–6

wk

Controlgroup:Sam

eEIPwithoutJAor

SPintervention:

hospitalday-

treatm

entprogram

forchildrenwith

developm

ental

disabilitiesand/or

behavioral

disorders;1:1or

1:2

ABA-based

techniques;adult-

centered,response-

oriented

approach

toteaching

Acquired

skills

generalized

toplay

with

mothers(large

effectsizesforJA

andSP)

Somegeneraleffectsof

therapy(JA,

functionalplay

skills)

inJA

andSP

groups

At12-mofollow-up:

Significantly(P

,.01)

greatergrow

thin

expressive

language

forJA

and

SP(m

oderateeffect

sizesforJA

andSP

versus

control)

Childrenwith

lowest

language

levels

pretreatmenthad

significantly(P

,.001)better

language

outcom

eswith

JAthan

with

SPor

EIP(m

oderate

tolargeeffectsizes

forJA)

JAandSP

groups

continuedto

show

grow

thand

generalizationin

skillsand

outperform

control

group


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Wetherby

and

Woods,34

2006

N=17

with

ASD

Quasi-experimental

2homevisits/wk3

1y

Targeted

ESI:family

training

tofollowchild’sfocus

ofattentionand

build

child’sskillsin

daily

routines

(developmental

approach,natural

environm

ent)

Significant

improvem

entsfrom

baselineforESI

groupin11

of13

social

communication

measures(large

effectsizesfor12

CSBS

DPbehavioral

samplemeasures,

moderateeffectsize

for13th

measure)

Implem

entedby

parents

Notknow

nwhether

groups

were

matched

atbaseline

(age

2y)

Very

low/low

Weak

Aged

12–24

mo(m

ean:

18.2mo);15boys

Plus

1supervised

parent–child

play

group(including

TDchildren)

per

week39wk31y

Atage3y,ESI.

contrastgroupin

social

communication

(large

effectsizefor

8of13

CSBS

DPmeasures)

Actualintervention

intensity

not

documented

n=18

with

ASD

No-treatm

entcontrast

groupat

thirdyear

Aged

25–36

mo(m

ean:

31.6mo);14boys

Yoderand

Stone,35

2006

N=36

with

ASD

RCT

1h/wk(three

20-min

sessions)3

6mo

Targeted

Universityclinic–

basedPECS:6

instructional

phases

conducted

byspeech-language

pathologists

RPMT.

PECS

infacilitating

frequencyof

generalized

IJA(in

childrenwith

some

pretreatmentIJA)

andgeneralized

turn

taking

(large

andmoderately

largeeffectsizes,

respectively)

Parent

training

(upto

15h)

tosupport

interventionuse

outsideclinic

Exam

inersconducting

pre/post

assessmentsnot

blindedto

treatm

entstatus

Moderate/high

Weak

Aged

18–60

mo;31

boys

Universityclinic–

basedRPMT:1:1a;

canadvanceto

Milieu

Language

Teaching;Hanen

curriculum

for

parent

support

Inchildrenwith

little

pretreatmentIJA,

PECS

.RPMTin

facilitating

generalized

requests(large

effectsize)

Howard

etal,36

2005

N=61

with

ASD

Quasi-experimental

25–40

h/wk3

14mo

Comprehensive

EIBI:1:1a ;home,school,

orcommunity

setting

EIBI.

AP:significantly

higher

groupmean

scores

forIQ,

nonverbal,

language,overall

communication,

andsocialskills

Delivered

bytrained

tutors

Groups

notrandom

lyassigned

Very

low/

moderate

Weak

SUPPLEMENT ARTICLE


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Aged

,48

mo(m

ean:

30.9,37.4,34.6mo);

54boys

25–30

h/wk3

14mo

Intensive,eclectic,

autism-specific

educational

programming(AP):

1:1or

2:1a;public

schoolclassroom-

based;including

DTT,PECS,and

TEACCH

NSdifferencesingroup

meanscores

betweenAP

andGP

Parentstoimplem

ent

programsoutside

ofscheduled

interventionhours

Nodirectgroup

comparison;

statisticalanalysis

ofgroupmean

scores

15h/wk3

14mo

Nonintensive

generic

educational

programming(GP):

6:1a;com

munity

based;mixof

methods

↑Learning

ratesat

14mo(P

#.05)

for

EIBIversus

other

2groups

inall

domains

except

motor

skills

(normalor

above-

norm

alrates,

especiallyin

acquisition

oflanguage

skills)

Manytechniques

not

operationally

defined

Drew et

al,37

2002

N=24

with

ADRCT

3h/wkevery6wk3

12mo

Targeted

Parenttraining

(hom

e-based)thatfocused

onjointattention

skills;plus

available

community

services


child

language

developm

entafter

12mo

Parent

mediated

Groups

notm

atched

onbaselinenonverbal

IQ

Very

low/low

/moderatel

Weak/moderate

Aged

,24

mo(m

ean:

22.5mo);19boys


nonverbalIQand

symptom

severity

after12

mo

Parentstouselearned

techniques

during

dailyroutinesandin

set-aside

jointp

lay

sessions

(30–60

min/d)

Nodata

onparent

training

implem

entation

Language

abilityin

both

groups

still

severely

comprom

ised

at12

mo

Totalintervention

hourshigher

(P=.07)

incontrol

group

Availablecommunity

services

onlyk

Sometimes

entirely

delivered

bytherapists,

sometimes

parent

involvem

ent

Relianceon

parent

reportforlanguage

outcom

es


TABLE1

Continued

Reference

N,Chronological

Age,Gender

Design

Dose

Treatm

ent

Outcom

esDegree

ofParental

Involvem

ent

Comments

GRADEQuality

ofEvidence

13GR

ADE

Recom-

mendation1

3Content

Approach

Smith etal,38

2000

N=28

with

ASD

RCT

30h/wk3

2–3y

(decreasingin

lateryearswith

progress

bychild)

Comprehensive

EIBI(UCLA/

Lovaas

model):home-

based1:1,athen

shiftingto

classroomsetting;

ABA-based

Significant

(P,

.05)

between-group

differences

atage

7–8yinIQ,visual

spatialskills,and

language

developm

ent

favoring

EIBI

Intensivetreatm

ent

implem

entedby

therapists

Lacked

standardized

diagnostic

instrument

Moderate/high

Strong

Aged

18–42

mo(m

ean:

35.8,36.1mo);23

boys

5h/wkparent

training

33–9

moplus

10–15

h/wkofspecial

educationfor

children

Parenttraining

insame

treatm

ent

approaches;plus

specialeducation

classesforchildren

Nodifferences

inadaptive

functioning

orbehavior

problems

Inbothgroups,parents

askedtoprovide

5h/wkof

intervention

Skew

eddistributionof

scores

precluded

somestatistical

analyses

Improved

school

placem

entin

intensivetreatm

ent

group

ABLLS,AssessmentofBasicLanguage

andLearning

Skills;AD,autistic

disorder;ADO

S,AutismDiagnosticObservationSchedule;ADO

S-G,AutismDiagnosticObservationSchedule–Generic;ADOS-T,AutismDiagnosticObservationSchedule–ToddlerModule;

AEPS,Assessm

ent,Evaluation,andProgrammingSystem

forInfantsandChildren;AP,intensive

eclecticautism-specificeducationalprogram

ming;CABAS,CompleteApplicationofBehavior

AnalysistoSchoolsapproach;CSBSDP,Com

municationand

Symbolic

Behavior

Scales

Developm

entalProfile;DIR,Developmental,IndividualDifference,Relationship;DTT,discretetrialtraining;ED,eclectic-developmental;EIBI,earlyintensivebehavioralintervention;EIP,EarlyInterventionProgram;ESAT,Early

ScreeningofAutistic

Traitsquestionnaire;ESI,EarlySocialInteractionProject;GP,non-intensivegenericeducationalprogram

ming;GRADE,GradingofRecommendations

Assessment,Developm

ent,andEvaluation;IJA,initiatingjointattention;ITC,Infant/

ToddlerChecklist;ITT,intention-to-treat;JA,jointattention;PACT,PreschoolAutismCommunicationTrial;PECS,PictureExchange

CommunicationSystem

;RCT,randomized

controlledtrial;RIT,reciprocalimitationtraining;RJA,respondingtojointattention;

RPMT,Responsive

EducationandPrelinguistic

Milieu

Teaching;SP,symbolic

play;SPELL,Structure,Positive

(approachesandexpectations),Em

pathy,Low(arousal),andLinksfram

ework;STAT,Screening

ToolforAutisminTwo-Year-Olds;TD,typically

developing;TEACCH,Treatm

entandEducationofAutistic

andRelatedCommunicationHandicappedChildren;UCLA,University

ofCalifornia,LosAngeles.

aChild-to-teacherratio.

bCarter

etal,15

2011:“Business

asusual”interventions

notspecified

inpublication.

cDawsonetal,17

2010:Including

speech,developmentalpreschool.

dGreenetal,18

2010:Treatmentasusualincludedgroup-basedautismpsychoeducation,communication-focusedintervention,Portagetherapy,speech

andlanguage

therapy,and(for

1child

each

inPACT

group)

home-basedEIBIandSon-Rise

therapy.

eKasarietal,20

2010:Concurrentearlyinterventions

involved

mostly

ABA/educationalservicesandspeech

andoccupationaltherapy;study

investigatorsdidnotcoordinatewith

providersoftheseservices.

fOosterlingetal,21

2010:Careas

usual,includingspeech

andlanguage

therapy,motor

therapy,musictherapy,play

therapy,andparentalcounseling.

gGoin-Kocheletal,262007:ABLLS

isacurriculum

guideforchildrenwith

language

delays

andacomprehensive

behavioralassessment;ABLLSdomains,language,social/play,academ

ics,self-help,m

otor.

hRemington

etal,29

2007:Treatment-as-usualinterventions

inboth

groups

included

PECS,TEACCH,speech

therapy,dietaryintervention,andprescriptionmedications.

iZachor

etal,30

2007:EDapproach

included

speech

andlanguage,occupational,andmusictherapies,plus

structured

cognitive

teaching

(DIR,TEACCH,andABAtechniques).

jCohenetal,31

2006:35to40

hoursperweekforchildrenaged

.3years;20

to30

hoursperweekforchildrenaged

,3years.

kDrew

etal,37

2002:Childrenincontrolgroup

received

mixofspeech

andlanguage

therapy,occupationaltherapy,and

preschoolservices.Within3moofinitialassessment,3childrenincontrolgroup

startedon

intensive,home-basedABAinterventions

(UCLA/Lovaas

model,1:1,m

eanof32.9h/weekfor12

months).

lDrew

etal,37

2002:Reflectsdifferent

assessmentsof3review

ers.

SUPPLEMENT ARTICLE


Comparedwith early interventionmodelsevaluated for preschool-aged children(aged 3–5 years), programs for childrenaged ,3 years were more likely to usedevelopmental approaches, more in-tensively involve parents, and target so-cial communication. These studies variedin sample size and severity of diagnosis,dose (level of intensity/frequency of ser-vice delivery), duration, agent (parent,therapist, or a combination), and for-mat of delivery (parent-managed/home-based and/or center-based in a clinic orschool) of the intervention. Some inter-ventionswere comprehensive, defined asaddressing multiple core ASD deficits,while others targeted specific areas offunctioning. A word of caution is war-ranted when interpreting any 1 inter-ventional study or model. In some cases,elements of a particular programmaticapproach varied from study to study (eg,the addition of training in advanced so-cial skills in 1 early intensive behavioralintervention program).31 Furthermore,reported group differences may not re-flect the range of individual responses inany 1 study, and participants who dem-onstrated gains in some end points mayhave continued to show impairment inothers.

Six randomized controlled trials wereconsidered to produce strong recom-mendations and an assessment that thedesirable effects of an interventionclearly outweighed the undesirableeffects. Only 2 studies focused solely onchildren aged,3 years; 1was related toa comprehensive treatment approach,17

and 1 was a targeted intervention pro-gram.20 The remaining 4 studies in-cluded preschool-aged children as wellas some children aged ,3 years or fo-cused on developmental tasks of infancy.Two of these studies evaluated the samesample of children aged 3 or 4 years atthe beginning of treatment.32,33

To briefly summarize these 6 stud-ies17–20,32,33,38: both of the comprehen-sive intervention programs (Early Start

Denver Model [ESDM] and the UCLA/Lovaas model) and the 4 targetedinterventions (focusing on social com-munication or imitation skills) exhibitedsignificantly improved outcomes rela-tive to comparison groups after thera-peutic durations of 8 weeks to 2 to 3years. Several of the 6 studies reportedeffect sizes: large effect sizes after 6 and8 weeks of therapy for increases in jointattention skills,20,32 a moderate effectsize after 12 months for expressive lan-guage growth,33 and small effect sizesafter 13 months for parent–child in-teraction measures.18 It is notable thattargeted interventions generally fo-cused on outcomes related to ASD-specific characteristics, whereas thecomprehensive models included teach-ing to the core deficits but often did notmeasure changes in these core deficits(or obtained nonsignificant findings);they instead focused on gains in generalfunctioning (eg, cognitive and/or adap-tive skills). Two nonrandomized con-trolled studies were rated as producingstrong recommendations: comprehen-sive applied behavior analysis (ABA)-type interventions were associatedwith significantly improved outcomesrelative to the comparison group after2 years (compared with publicly fundededucational services)29 and with signifi-cantly improved outcomes in a subsetof participants after 1 year (comparedwith an eclectic mix of treatments).23

Although other studies included in thepresent review exhibited less thanmoderate quality of evidence and/orproduced weak recommendations, itwas agreed that the findings in thesestudies might nevertheless informtreatment options as well as future re-search. Specifically, there were studiesrated as having a strong quality of evi-dence but equivocal findings.16 For ex-ample, a recent trial evaluated the ESDMin a brief format: 1 hour per week ofparent training for 12 weeks, as op-posed to the original ESDM, which in-

volved 20 hours per week of therapistinvolvement plus additional parent-mediated intervention for 2 years.14

The study failed to detect improvementsin parental intervention skill acquisitionand child-related outcomes relative tocommunity intervention controls.

Based on expert opinion that arosefrom the review and discussion of theexisting evidence, members of theworking group agreed on several sum-mary statements intended to guideclinical practice and future research.Practice recommendations are high-lighted in statements 1 through 4;consensus regarding future researchdirections is highlighted in statements5 through 9. Statement 10 focuses onthe importance of considering the po-tential impact of medical comorbiditieson treatment and developmental out-comes.

SUMMARY STATEMENTS

Statement 1: Current bestpractices for interventions forchildren aged ,3 years withsuspected or confirmed ASDshould include a combination ofdevelopmental and behavioralapproaches and begin as early aspossible.

Based on current outcome data, theworking group supported the provisionof interventions targeted to the specificdeficits of ASD (eg, language skills, jointattention, emotional reciprocity) (Ta-ble 1) for children aged,3 years thatintegrate both behavioral and de-velopmental approaches. Behavioralinterventions are techniques based onbehavioral analysis of antecedents andconsequences of specific behaviors,and they use principles derived fromexperimental psychology research tosystematically change behavior. De-velopmental models of interventionuse developmental theory to designapproaches to target ASD deficits.57

Developmental approaches often


underlie community services, such aspublic school programs implementedby special education specialists andspeech and language pathologists.56

However, the distinction between be-havioral and developmental strategiesmay not be very helpful, as many in-tervention programs blend features ofboth approaches. The curricula ofa behavioral intervention may be de-velopmentally informed and based ondevelopmental sequences, whereasa developmental program could usebehavioral techniques to teach a cur-riculum.

Our analysis supports the effectivenessof integrated developmental and be-havioral interventions, outside of thelaboratory setting, in improving de-velopmental quotients, adaptive func-tioning, and language skills.17,29

In line with the American Academy ofPediatrics, the working group recom-mended initiating interventionsas soonas a diagnosis of ASD is seriouslyconsidered or determined.57 Dataavailable since 2001 support the factthat early intensive education andtherapies can yield significantly im-proved developmental outcomes. Inaddition, it has been suggested thatinterventions initiated before 3 years ofage may have a greater positive impactthan those begun after the age of5 years.58–60

Statement 2: Current bestpractices for children aged ,3years with suspected or confirmedASD should have active involvementof families and/or caregivers aspart of the intervention.

There is a consensus that effective earlyintervention includes a family and/orcaregiver component.57 For many in-tervention programs, this approachwould mean parental involvement asa co-therapist, with appropriate su-pervision, training, and monitoring aspart of the intervention. Specifically,

parents should help set goals and pri-orities for their child’s treatment,identify and locate needed support forthemselves, and teach or reinforcetheir child’s new skills at home and inthe community.60

Active family involvement can havea positive impact on developmentaloutcomes. Parental or caregiver in-volvement increases the amount of in-tervention time delivered to the childinasmuch as children in this age rangeare likely to spend more time withtheir parents in their home andneighborhoods than in other settings.Furthermore, parents and caregiverscan capitalize on teachable momentsas they occur, provide learning oppor-tunities during daily routines, and fa-cilitate the generalization of learnedskills across environments.15 Familyinvolvement is also likely to be cost-effective and increases the sense ofempowerment on the part of parentsand caregivers. In the 2 comprehensivedevelopmental/behavioral programsfor which we have moderate or highevidence of effectiveness,17,29 parentswere supported in complementingeducators and therapists in the de-livery of the interventions because ofthe importance of, and challenges in-herent in, carrying over services andgeneralizing skills across multiple set-tings. Importantly, the concept of pa-rental involvement is consistent withthe recommended broader best prac-tices that support working with youngchildren in natural environments. Sev-eral parent-mediated interventionshave shown positive parent and/orchild outcomes. However, the extentto which these interventions are aseffective as therapist-mediated inter-ventions or are more effective whenadded into comprehensive child ser-vices, or with the combination oftherapist plus parent mediated inter-ventions, requires further study.18,20

Statement 3: Interventions shouldenhance developmental progressand improve functioning related toboth the core and associatedfeatures of ASD, including socialcommunication, emotional/behavioral regulation, andadaptive behaviors.

Many behavioral interventions for ASDfocus on cognitive, behavioral, andlanguage outcomes, but interventionsalso need to address social com-munication challenges central to thediagnosis. Sensory dysregulation,challenging behaviors, andmotor skillsare also common in children with ASDandshouldbe targetedby interventionswhen needed.

Despite an apparent lack of change onstandardized measures of social com-munication symptoms in 2 randomizedcontrolled trials,17,37 a growing bodyof research describes the beneficialeffects early intervention has on thedevelopment of communication andsocial functioning. (This lack of changemay reflect the utilization of symptommeasures such as the Autism Di-agnostic Observation Schedule, which,as a diagnostic tool, was designed to berelatively stable; measures specificallydesigned and validated as being sen-sitive to change are needed.) Specifi-cally, targeted interventions have beenassociated with gains in imitation,16,19

joint attention,16,20,32,34 social engage-ment,20,32,33 other social communica-tion measures,34 and functional andsymbolic play.20,32

Impaired effortful control (ie, a reducedability to regulate attention, emotions,andbehavior toachievegoals)hasbeenreported in children with ASD as earlyas at 24 months of age.61 Interventionsdealing with attention regulation inyoung children with ASD have not yetbeen reported, but in typically de-veloping children, short-term train-ing has improved attention controlmeasures associated with effortful

SUPPLEMENT ARTICLE


control.62 Comprehensive inter-ventions that blend developmental andbehavioral approaches have success-fully improved adaptive functioningin many studies.17,23,29,31 Thus, futureintervention studies should addressand assess various developmentaldomains as intervention and outcometargets.

Statement 4: Intervention servicesshould consider the socioculturalbeliefs of the family and familydynamics and supports, as well aseconomic capability, in terms ofboth the delivery and assessmentof factors that moderateoutcomes.

Socioeconomic status, family charac-teristics, and cultural factors maypresent barriers to service provision.Families with lower socioeconomicstatus are likely to have less access toservices. Because cultural values anddifferences can affect the goals andpriorities of the family andmay in somecases lead to misunderstandings,clinicians and other service providersshould aim to understand the values,beliefs, and accompanying practices offamilies of differing cultures and as-similate that knowledge into theirpractice parameters as it relates toautism occurring in ethnically diversepopulations. Culturally competent careextends beyondfluency in a non-Englishlanguage. As a minimum, culturallyappropriate programmaterials shouldbe developed for families. In addition,training programs should be createdthat can help service providers learnhow to promote culturally responsiveassessment and intervention ser-vices.56

Management of a child with ASD shouldfocus on the family as well as on thechild.57 Important considerations forthe clinician include the well-being ofeach person in the family, the comfortand support of each family member,

the lifestyle that has evolved aroundthe child with ASD, and the unmetneeds among family members orproblem areas that might otherwise gounaddressed.56 Service providers canbe of assistance by monitoring thephysical and mental health of thefamily as well as that of the child withASD. Finally, respect for the percep-tions, priorities, and preferences offamily members is an important“family-centered” tenet to bear in mindwhen working with children on theautism spectrum and their complexneeds.63

Statement 5: Intervention researchshould include socially andculturally diverse populations ofparticipants and evaluate familialfactors that may affectparticipation, acceptability, andoutcomes of therapeuticapproaches as well as willingnessto participate in investigativestudies.

Parents are expected to play a prom-inent role in supporting optimal de-velopment and thus interventionprogram delivery for their children,particularly at a very young age. Animportant focus of intervention re-search should therefore include fac-tors such as cultural background andother family characteristics that mayinfluence participation in treatmentprograms and interventional results.Due to attitudes concerning child-hoodrearing and independence, shameregarding developmental delays andASD, or other societal and culturalbeliefs, parents may be reluctant toenroll a child in a research study. Cu-mulatively, such decisions can diminishthe generalizability and clinical appli-cability of reported interventions. Inaddition, when there is participation,cultural differences and language bar-riers might influence and moderatetreatment effects.

In addition to any cultural issues, whenparents are expected to be the thera-peutic provider, assessment shouldfocus on more than just fidelity ofimplementation and adherence tointervention goals. The quality ofa parent’s involvement, considerationof a parent’s other responsibilities androles,20 and potential family stres-sors15 arising from fulfilling their rolein an intervention or from coping withcare for a child with ASD warrant ex-amination to determine whether mod-erators of treatment are present or areneeded. Apart from any possible re-luctance by families to participate inresearch, there is also a need forinvestigators to make a particular ef-fort to recruit as culturally diversea research sample as possible.

Statement 6: Future researchshould prioritize well-definedsampling strategies, rigorousinvestigative design, fidelity ofimplementation, and meaningfuloutcome measurements.

The methodologic rigor of interventiontrials in ASD is improving, but continuedattention to key aspects of researchdesign is needed to further develop theevidence base for toddlers.

Future directions include identifyingcharacteristics of children and familieswhowouldbenefitmost fromparticularinterventions to support a more in-dividualized approach, as well as sys-tematically varying components ofmultifaceted intervention programs toidentify critical ingredients. Thoroughcharacterization of research partic-ipants would help to define the subsetof children and families who moststrongly benefit from particular in-tervention approaches. In addition, toavoidsystematicbias fromconfoundingfactors, research participants shouldbe randomly allocated to the treatmentapproaches that are being com-pared, and each treatment (including


community-based “as-usual” treatment)should be thoroughly described. Al-though the optimal study design tominimize bias in treatment research isa randomized controlled trial, it is ac-knowledged that contexts occur inwhich other methods may be appropri-ate. For example, to determine whetheran intervention holds promise, it is im-portant that intervention proceduresare carefully tested for feasibility andacceptability. Moreover, single casedesigns, carefully implemented andwithattention to appropriate measurement,may also be informative.64 Attention toand systematic evaluation of fidelity ofimplementation and selection of well-validated measures of key constructs(eg, joint attention, imitation, otherindicators of age-appropriate social andcommunication skills and function) thatare responsive to change are also es-sential.

Statement 7: Research is needed todetermine the specific activecomponents of effectiveinterventions, including but notlimited to the type of treatmentprovided, the agent implementingthe intervention(s) (parent,therapist, teacher, orcombination), consistency ofservice provision acrossenvironments and betweenproviders, and duration oftreatment and hours per week.

Information is lacking regarding thefeatures of an intervention that drive itseffectiveness, but progress is beingmade on identifying these activeingredients or mechanisms of change.Without appropriate study designs tocarefully examine the effect of specificintervention strategies such as treat-ment type, dose, and agent, we may beunable to determine which of the po-tentially significant elements in an in-tervention model are responsible forchange and for which subgroups. With

such information, future interventionprograms can be refined.

Intensity of intervention

The National Research Council hasrecommended a minimum intensity of5 hours a day, 5 days a week, for inter-ventions.60 However, some recent studieshave suggested the possibility of positiveoutcomes with fewer hours of directtherapist involvement for young toddlerswith ASD, particularly when parents areactively engaged in the treatment pro-cess. For example, gains in some socialcommunication skills (eg, play, joint at-tention, imitation) were demonstrated insome studies when directly targeted ininterventions of relatively low intensity(based on hours per week or length oftreatment).16,18,20 Notably, the “real-life”intensity of the intervention may beinfluenced by the degree to whichparents are implementing the strategiesin natural routines throughout the day.The effectiveness of interventions is alsolikely to be influenced by whether train-ing and ongoing supports allow parentsto correctly implement the treatmentstrategies (ie, with fidelity to the treat-ment procedures as originally designed),as has been reported in the treatment ofpreschool-aged children with ASDs.65 Inaddition, other factors can affect the ex-tent to which such interventions are ef-fective, including age, degree ofimpairment, and the extent to whichthe child receives other services.

Treatment content

A recent study in toddlers with ASD hasattempted to determine the additivevalue of joint attention, imitation, andaffect on an intervention when appliedwithin 2 developmental/behavioraltoddler classroom environments.16

The investigators evaluated impact in 1study group, and another group re-ceived the same overall comprehen-sive intervention but without theingredient of interest. Few differences

emerged in this study except forthe apparent benefit of imitation in 1group. Nonetheless, this researchparadigm provides a possible modelthrough which intervention researchmay be implemented. Similarly, otherinvestigators have evaluated the addi-tive effects of joint attention or playskills into an ABA program that did notinclude a focus on these developmentalskills. Teaching these skills increasedtheir spontaneous occurrence in gen-eralized contexts and further predictedgreater language outcomes comparedwith the children in the ABA programwithout a focus on play and joint at-tention.33,59

Incorporating teaching targets of jointattention, play, and imitation are clearlyindicated for early intervention pro-grams for ASD. However, given theheterogeneity of the disorder, it will becritical to determine how treatmentstrategies can be most effectively tai-lored to the needs of subgroups ofchildren with ASD who have particularclinical profiles.

Statement 8: Adopting a commonset of research-validated coremeasures of ASD symptoms(including but not limited tocognitive function, communication,and adaptive behavior) that can beused across multiple sites willfacilitate comparisons acrossstudies of children with ASD aged,3 years.

The interpretation of study findings isoftenhamperedwhen investigatorsusedifferent variables, or measures, toreport outcomes. A consistent set ofcore measures relevant to the specificintervention goal(s) of interest shouldbe adopted for studies of toddlers withASD as well as for older children. Out-come measures do not need to beidentical across studies, but agreementon a subset of standardized instru-ments to use (which may assess

SUPPLEMENT ARTICLE


changes incognitive function,coreautismsymptoms, and adaptive and languagebehavior) would facilitate future com-parisons.Someearlydevelopmentalskillscould yield “early-read” measures thatare important to later developmentaloutcomes. These early-read measuresmay include joint attention, shared affect,and imitation skills, with the expectationthat these early developmental tasksmaypredict better functioning in later cogni-tion, language, and adaptive behavior.Early-read measures may provide im-portant information on the effectivenessof short-term interventions and may alsooffer information on active ingredientsessential to include in comprehensiveintervention programs. Additional meas-ures related to the impact that havinga child with ASD has on family life andparental stress would also be important.

Statement 9: Future researchshould examine biological andbehavioral heterogeneity asmoderators of individualresponses to interventions.

In any sample population, positive re-sponsestoaninterventioncanrangefromdramatic to extremely limited. Factorsthat underlie such heterogeneity—pos-siblemoderators of individual responses—can include age at onset of intervention,patient characteristics (eg, baselinestage of development of cognitive func-tion, language and preverbal skills,adaptive behavior, sociocultural char-acteristics), and symptom severity. Asimportant, however, is the increasingappreciation that ASD is a heterogeneousdisorder—etiologically, biologically, andclinically. Given this heterogeneity, it ishighly likely that specific subsets of indi-viduals with ASD may respond to specificinterventions more effectively than toothers, perhaps based on etiology andunderlying biological factors alone. Thus,there is a critical need to begin to identifysubtypes of individuals with ASD, to un-derstand the cause of their disorder as

well as the associated neurobiologicalmechanisms at work in each case, andto be able to offer more directedinterventions depending on the bi-ological subtype when available andpresent.

A number of genetic and neurobiolog-ical subgroups are already known to beassociated with ASD. The most well-known groups are children with frag-ile X syndrome, tuberous sclerosis, andduplication 15q. Other genetic dis-orders have been identified as beingassociated with ASD features, anda growing number of candidate genesare being explored. For example,Campbell et al66 reported that childrenwith ASD and MET gene mutations weremore likely to have gastrointestinaldisorders, raising the possibility thatmedical comorbidities in children withASD could index underlying geneticheterogeneity. It is thus important forfuture research to determine both bi-ological and clinical subtypes withinthe autism spectrum that may ulti-mately affect the effectiveness oftreatment and intervention.

Todate, fewstudieshavebeendesignedor powered for analysis of heteroge-neous effects.67 Treatment modifierswere recently identified in 2 studiesbased on appropriate study designand statistical analysis. In both stud-ies, a measure developed to index thelevel of initial object exploration de-termined the extent to which a childwould benefit more from 1 language-based intervention versus another35

or the extent to which children hadbetter communication outcomes froma parent-mediated intervention.15 Ob-ject exploration can reflect a child’sflexibility in play and play level, both ofwhich may influence later cognitiveand language outcomes.59 Furtherstudies like these are needed beforewe can make informed choices andpersonalize the treatment of each in-dividual child.

Statement 10: Interventionproviders should consider medicaldisorders that may affect a child’sclinical presentation (especiallybehavior) and response to anintervention and should refer toappropriate health care providersas indicated.

It has become increasingly evident in theASD population that changes in behaviormay be associated with an underlyingmedical condition.13 For example, clinicalexperience would suggest that a childwith ASD exhibiting behavioral changesmight be experiencing pain or discomfortowing to amedical problem such as otitismedia, a dental abscess, or constipation.Frequently encountered medical factorsin ASD include: seizures, particularly inchildren who also have severe intellect-ual disability, motor deficits, or a positivefamily history of epilepsy68,69; other gas-trointestinal symptoms57,70; and sleepdisturbances affecting daytime function-ing. The full effect of medical factors onthe clinical presentation of children aged,3 years with ASD is not known, nor hasthe association between medical factorsand maladaptive behaviors such as ag-gression and self-injury been well studiedin general in ASD. Nevertheless, bestpractices would indicate that a patientwith a potential medical comorbidity bereferred to a medical specialist for ap-propriate evaluation, diagnosis, andmanagement. It is important that futureresearch address these and other po-tential medical factors, how they may bemore reliably identified (especially innonverbal or hypo-verbal ASD individu-als), and what effect treatment of theseconditions may have on behavior, de-velopmental trajectory, and learning.

ACKNOWLEDGMENTSTheconferencechairsandworkinggroupsacknowledge the preconference contribu-tions of Tony Charman, PhD, and GaryMesibov, PhD, who were unable to attendthe conference. We also acknowledge the


efforts of Katherine F. Murray, BSN, RN,Massachusetts General Hospital for Chil-dren, incoordinating the forumandsubse-quentconferencereportprocess,andSiforNg in the conference report process.

Themeeting and consensus report weresponsored by the Autism Forum. An im-portant goal of the forum is to identifyearly indicators of ASDs that may leadto effective health care services. Autism

Forum programs are developed underthe guidance of its parent organization,the Northwest Autism Foundation. Forthis project, the Autism Research Insti-tute provided financial support.

REFERENCES

1. Zwaigenbaum L, Bryson S, Lord C, et al.Clinical assessment and management oftoddlers with suspected autism spectrumdisorder: insights from studies of high-riskinfants. Pediatrics. 2009;123(5):1383–1391

2. Zwaigenbaum L, Bauman ML, Stone WL,et al. Early identification of autism spec-trum disorder: recommendations forpractice and research. Pediatrics. 2015;136(suppl X):XXX–XXX

3. Zwaigenbaum L, Bauman ML, Fein D, et al.Early screening of autism spectrum disor-der: recommendations for practice andresearch. Pediatrics. 2015;136(suppl X):XXX–XXX

4. Guthrie W, Swineford LB, Nottke C,Wetherby AM. Early diagnosis of autismspectrum disorder: stability and change inclinical diagnosis and symptom pre-sentation. J Child Psychol Psychiatry. 2013;54(5):582–590

5. Chawarska K, Klin A, Paul R, Volkmar F.Autism spectrum disorder in the secondyear: stability and change in syndromeexpression. J Child Psychol Psychiatry.2007;48(2):128–138

6. Courchesne E, Campbell K, Solso S. Braingrowth across the life span in autism: age-specific changes in anatomical pathology.Brain Res. 2011;1380:138–145

7. Lewis JD, Evans AC, Pruett JR, et al. Net-work inefficiencies in autism spectrumdisorder at 24 months. Transl Psychiatry.2014;4:e388

8. Dawson G. Early behavioral intervention,brain plasticity, and the prevention of au-tism spectrum disorder. Dev Psychopathol.2008;20(3):775–803

9. Ozonoff S, Iosif AM, Young GS, et al. Onsetpatterns in autism: correspondence betweenhome video and parent report. J Am AcadChild Adolesc Psychiatry. 2011;50(8):796–806.e1

10. Landa RJ, Gross AL, Stuart EA, Faherty A.Developmental trajectories in children withand without autism spectrum disorders:the first 3 years. Child Dev. 2013;84(2):429–442

11. Ozonoff S, Iosif AM, Baguio F, et al. A pro-spective study of the emergence of earlybehavioral signs of autism. J Am Acad

Child Adolesc Psychiatry. 2010;49(3):256–66.e1, 2

12. Bauman ML. Medical comorbidities in au-tism: challenges to diagnosis and treat-ment. Neurotherapeutics. 2010;7(3):320–327

13. Guyatt GH, Oxman AD, Vist GE, et al; GRADEWorking Group. GRADE: an emerging con-sensus on rating quality of evidence andstrength of recommendations. BMJ. 2008;336(7650):924–926

14. Rogers SJ, Estes A, Lord C, et al. Effects ofa brief Early Start Denver model (ESDM)-based parent intervention on toddlers atrisk for autism spectrum disorders: a ran-domized controlled trial. J Am Acad ChildAdolesc Psychiatry. 2012;51(10):1052–1065

15. Carter AS, Messinger DS, Stone WL, CelimliS, Nahmias AS, Yoder P. A randomizedcontrolled trial of Hanen’s ‘More ThanWords’ in toddlers with early autismsymptoms. J Child Psychol Psychiatry. 2011;52(7):741–752

16. Landa RJ, Holman KC, O’Neill AH, Stuart EA.Intervention targeting development of so-cially synchronous engagement in toddlerswith autism spectrum disorder: a random-ized controlled trial. J Child Psychol Psy-chiatry. 2011;52(1):13–21

17. Dawson G, Rogers S, Munson J, et al. Ran-domized, controlled trial of an intervention fortoddlers with autism: the Early Start DenverModel. Pediatrics. 2010;125(1). Available at:www.pediatrics.org/cgi/content/full/125/1/e17

18. Green J, Charman T, McConachie H, et al;PACT Consor t ium. Parent-mediatedcommunication-focused treatment in chil-dren with autism (PACT): a randomisedcontrolled trial. Lancet. 2010;375(9732):2152–2160

19. Ingersoll B. Pilot randomized controlledtrial of reciprocal imitation training forteaching elicited and spontaneous imita-tion to children with autism. J Autism DevDisord. 2010;40(9):1154–1160

20. Kasari C, Gulsrud AC, Wong C, Kwon S, LockeJ. Randomized controlled caregiver medi-ated joint engagement intervention fortoddlers with autism. J Autism Dev Disord.2010;40(9):1045–1056

21. Oosterling I, Visser J, Swinkels S, et al.Randomized controlled trial of the focusparent training for toddlers with autism: 1-year outcome. J Autism Dev Disord. 2010;40(12):1447–1458

22. Zachor DA, Ben-Itzchak E. Treatment ap-proach, autism severity and interventionoutcomes in young children. Res AutismSpectr Disord. 2010;4(3):425–432

23. Ben-Itzchak E, Zachor DA. Change in autismclassification with early intervention: pre-dictors and outcomes. Res Autism SpectrDisord. 2009;3(4):967–976

24. Eikeseth S, Hayward D, Gale C, Gitlesen JP,Eldevik S. Intensity of supervision and out-come for preschool aged children receivingearly and intensive behavioral inter-ventions: a preliminary study. Res AutismSpectr Disord. 2009;3(1):67–73

25. Ben-Itzchak E, Zachor DA. The effects of in-tellectual functioning and autism severityon outcome of early behavioral in-tervention for children with autism. ResDev Disabil. 2007;28(3):287–303

26. Goin-Kochel RP, Myers BJ, Hendricks DR,Carr SE, Wiley SB. Early responsiveness tointensive behavioral intervention predictsoutcomes among preschool children withautism. Int J Disabil Dev Educ. 2007;54(2):151–175

27. Magiati I, Charman T, Howlin P. A two-yearprospective follow-up study of community-based early intensive behavioural in-tervention and specialist nursery provisionfor children with autism spectrum dis-orders. J Child Psychol Psychiatry. 2007;48(8):803–812

28. Reed P, Osborne LA, Corness M. Brief re-port: relative effectiveness of differenthome-based behavioral approaches toearly teaching intervention. J Autism DevDisord. 2007;37(9):1815–1821

29. Remington B, Hastings RP, Kovshoff H, et al.Early intensive behavioral intervention:outcomes for children with autism andtheir parents after two years. Am J MentRetard. 2007;112(6):418–438

30. Zachor DA, Ben Itzchak E, Rabinovitch AL,Lahat E. Change in autism core symptomswith intervention. Res Autism Spectr Dis-ord. 2007;1(4):304–317

SUPPLEMENT ARTICLE


http://www.pediatrics.org/cgi/content/full/125/1/e17

31. Cohen H, Amerine-Dickens M, Smith T. Earlyintensive behavioral treatment: replicationof the UCLA model in a community setting.J Dev Behav Pediatr. 2006;27(suppl 2):S145–S155

32. Kasari C, Freeman S, Paparella T. Joint at-tention and symbolic play in young childrenwith autism: a randomized controlled in-tervention study. J Child Psychol Psychiatry.2006;47(6):611–620

33. Kasari C, Paparella T, Freeman S, JahromiLB. Language outcome in autism: random-ized comparison of joint attention and playinterventions. J Consult Clin Psychol. 2008;76(1):125–137

34. Wetherby AM, Woods JJ. Early Social In-teraction Project for children with autismspectrum disorders beginning in thesecond year of life: a preliminary study.Top Early Child Spec Educ. 2006;26(2):67–82

35. Yoder P, Stone WL. Randomized comparisonof two communication interventions forpreschoolers with autism spectrum dis-orders. J Consult Clin Psychol. 2006;74(3):426–435

36. Howard JS, Sparkman CR, Cohen HG, GreenG, Stanislaw H. A comparison of intensivebehavior analytic and eclectic treatmentsfor young children with autism. Res DevDisabil. 2005;26(4):359–383

37. Drew A, Baird G, Baron-Cohen S, et al. Apilot randomised control trial of a par-ent training intervention for pre-schoolchildren with autism. Preliminary find-ings and methodological challenges. EurChild Adolesc Psychiatry. 2002;11(6):266–272

38. Smith T, Groen AD, Wynn JW. Randomizedtrial of intensive early intervention forchildren with pervasive developmentaldisorder. Am J Ment Retard. 2000;105(4):269–285

39. Green J, Wan MW, Guiraud J, et al; BASISTeam. Intervention for infants at riskof developing autism: a case series.J Autism Dev Disord. 2013;43(11):2502–2514

40. Leew SV, Stein NG, Gibbard WB. Weightedvests’ effect on social attention for toddlerswith autism spectrum disorders. Can JOccup Ther. 2010;77(2):113–124

41. Rocha ML, Schreibman L, Stahmer AC. Ef-fectiveness of training parents to teachjoint attention in children with autism.J Early Interv. 2007;29(2):154–172

42. Schertz HH, Odom SL. Promoting joint attentionin toddlers with autism: a parent-mediateddevelopmental model. J Autism Dev Dis-ord. 2007;37(8):1562–1575

43. Steiner AM, Gengoux GW, Klin A, ChawarskaK. Pivotal response treatment for infants at-risk for autism spectrum disorders: a pilotstudy. J Autism Dev Disord. 2013;43(1):91–102

44. Vismara LA, Colombi C, Rogers SJ. Can onehour per week of therapy lead to lastingchanges in young children with autism?Autism. 2009;13(1):93–115

45. Anderson DK, Oti RS, Lord C, Welch K. Pat-terns of growth in adaptive social abilitiesamong children with autism spectrumdisorders. J Abnorm Child Psychol. 2009;37(7):1019–1034

46. Hume K, Bellini S, Pratt C. The usage andperceived outcomes of early interventionand early childhood programs for youngchildren with autism spectrum disorder.Top Early Child Spec Educ. 2005;25(4):195–207

47. McGovern CW, Sigman M. Continuity andchange from early childhood to adoles-cence in autism. J Child Psychol Psychiatry.2005;46(4):401–408

48. Osborne LA, McHugh L, Saunders J, Reed P.Parenting stress reduces the effectivenessof early teaching interventions for autisticspectrum disorders. J Autism Dev Disord.2008;38(6):1092–1103

49. Paul R, Chawarska K, Cicchetti D, Volk-mar F. Language outcomes of toddlerswith autism spectrum disorders: a twoyear follow-up. Autism Res. 2008;1(2):97–107

50. Sallows GO, Graupner TD. Intensive behav-ioral treatment for children with autism:four-year outcome and predictors. Am JMent Retard. 2005;110(6):417–438

51. Eldevik S, Hastings RP, Hughes JC, Jahr E,Eikeseth S, Cross S. Meta-analysis of earlyintensive behavioral intervention for chil-dren with autism. J Clin Child AdolescPsychol. 2009;38(3):439–450

52. Virués-Ortega J. Applied behavior analyticintervention for autism in early childhood:meta-analysis, meta-regression and dose-response meta-analysis of multiple out-comes. Clin Psychol Rev. 2010;30(4):387–399

53. Warren Z, McPheeters ML, Sathe N, Foss-Feig JH, Glasser A, Veenstra-VanderweeleJ. A systematic review of early intensiveintervention for autism spectrum dis-orders. Pediatrics. 2011;127(5). Availableat: www.pediatrics.org/cgi/content/full/127/5/e1303

54. Reichow B, Wolery M. Comprehensive syn-thesis of early intensive behavioral inter-ventions for young children with autismbased on the UCLA young autism project

model. J Autism Dev Disord. 2009;39(1):23–41

55. Perry A, Cummings A, Dunn Geier J, et al.Effectiveness of intensive behavioral in-tervention in a large, community-basedprogram. Res Autism Spectr Disord. 2008;2(4):621–642

56. Rogers SJ, Vismara LA. Evidence-basedcomprehensive treatments for early au-tism. J Clin Child Adolesc Psychol. 2008;37(1):8–38

57. Myers SM, Johnson CP; American Academyof Pediatrics Council on Children With Dis-abilities. Management of children with au-tism spectrum disorders. Pediatrics. 2007;120(5):1162–1182

58. Harris SL, Handleman JS. Age and IQ atintake as predictors of placement foryoung children with autism: a four- to six-year follow-up. J Autism Dev Disord. 2000;30(2):137–142

59. Kasari C, Gulsrud A, Freeman S, Paparella T,Hellemann G. Longitudinal follow-up ofchildren with autism receiving targetedinterventions on joint attention and play.J Am Acad Child Adolesc Psychiatry. 2012;51(5):487–495

60. National Research Council. Committee onEducational Interventions for Children withAutism, Division of Behavioral and SocialSciences and Education. In: Lord C, McGeeJP, eds. Educating Children With Autism.Washington, DC: National Academy Press;2001

61. Garon N, Bryson SE, Zwaigenbaum L, et al.Temperament and its relationship to au-tistic symptoms in a high-risk infant sibcohort. J Abnorm Child Psychol. 2009;37(1):59–78

62. Posner MI, Rothbart MK. Research on at-tention networks as a model for the in-tegration of psychological science. AnnuRev Psychol. 2007;58:1–23

63. Woods JJ, Wetherby AM. Early identificationof and intervention for infants and toddlerswho are at risk for autism spectrum dis-order. Lang Speech Hear Serv Sch. 2003;34(3):180–193

64. Smith T, Scahill L, Dawson G, et al. De-signing research studies on psychosocialinterventions in autism. J Autism Dev Dis-ord. 2007;37(2):354–366

65. Coolican J, Smith IM, Bryson SE. Briefparent training in pivotal responsetreatment for preschoolers with autism.J Child Psychol Psychiatry. 2010;51(12):1321–1330

66. Campbell DB, Buie TM, Winter H, et al. Dis-tinct genetic risk based on association ofMET in families with co-occurring autism




and gastrointestinal conditions. Pediatrics.2009;123(3):1018–1024

67. Warren Z, Veenstra-VanderWeele J, StoneW, et al. Therapies for children with au-tism spectrum disorders. Comparativeeffectiveness review no. 26. (Prepared bythe Vanderbilt Evidence-based PracticeCenter under Contract No. 290-2007-10065-I.) AHRQ publication no. 11-EHC029-

EF. Rockville, MD: Agency for HealthcareResearch and Quality; April 2011. Avail-able at: www.effectivehealthcare.ahrq.gov/reports/final.cfm. Accessed June 13,2011

68. Pavone P, Incorpora G, Fiumara A, Parano E,Trifiletti RR, Ruggieri M. Epilepsy is nota prominent feature of primary autism.Neuropediatrics. 2004;35(4):207–210

69. Tuchman RF, Rapin I, Shinnar S. Autistic anddysphasic children. II: epilepsy. Pediatrics.1991;88(6):1219–1225

70. Buie T, Campbell DB, Fuchs GJ III, et al.Evaluation, diagnosis, and treatmentof gastrointestinal disorders in indi-v iduals with ASDss : a consensusreport. Pediatrics . 2010;125(suppl 1):S1–S18

(Continued from first page)

Drs Zwaigenbaum and Bauman initiated a literature review, co-chaired the meeting that generated the consensus recommendations outlined in this article, anddrafted the initial manuscript; Drs Choueiri and Kasari co-chaired the working group that conducted the detailed literature review, generated initial recommen-dations that were discussed at the consensus meeting, and provided critical input to subsequent drafts of the manuscript; Drs Carter, Granpeesheh, Mailloux, SmithRoley, and Wagner were members of the working group that reviewed selected publications, contributed to initial recommendations that were reviewed at theconsensus meeting, and critically reviewed the manuscript; Drs Fein, Pierce, Buie, Davis, Newschaffer, Robins, Wetherby, Stone, Yirmiya, Estes, Hansen, McPartland,and Natowicz contributed to the consensus meeting that formed the basis for the manuscript and critically reviewed the manuscript; and all authors approved thefinal manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3667E

doi:10.1542/peds.2014-3667E

Accepted for publication Aug 3, 2015

Address correspondence to Lonnie Zwaigenbaum, MD, Autism Research Center, Glenrose Rehabilitation Hospital, Room E209, 10230 111 Ave, Edmonton, AB, CanadaT5G 0B7. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Zwaigenbaum was the site Principal Investigator of a study sponsored by SynapDx (he received operating funds but no honoraria).Drs Fein and Robins are co-owners of M-CHAT, LLC, which licenses use of the Modified Checklist for Autism in Toddlers in electronic products. Dr Stone is theauthor of the Screening Tool for Autism in Two-Year-Olds and receives a share of royalties from sales of this instrument. The authors received an honorariumas well as travel expenses from Autism Forum for contributing to the expert panels.

FUNDING: Sponsored by the Autism Forum under the guidance of the Northwest Autism Foundation and with the support of the Autism Research Institute.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

SUPPLEMENT ARTICLE


http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

mailto:[email protected]

DOI: 10.1542/peds.2014-3667E2015;136;S60Pediatrics

L. Hansen, James C. McPartland and Marvin R. NatowiczDiana Robins, Amy Wetherby, Wendy L. Stone, Nurit Yirmiya, Annette Estes, Robin

Deborah Fein, Karen Pierce, Timothy Buie, Patricia A. Davis, Craig Newschaffer,Carter, Doreen Granpeesheh, Zoe Mailloux, Susanne Smith Roley, Sheldon Wagner, Lonnie Zwaigenbaum, Margaret L. Bauman, Roula Choueiri, Connie Kasari, Alice

of Age: Recommendations for Practice and ResearchEarly Intervention for Children With Autism Spectrum Disorder Under 3 Years

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/136/Supplement_1/S60including high resolution figures, can be found at:

References

BIBLhttp://pediatrics.aappublications.org/content/136/Supplement_1/S60#This article cites 66 articles, 8 of which you can access for free at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on March 4, 2020www.aappublications.org/newsDownloaded from

http://http://pediatrics.aappublications.org/content/136/Supplement_1/S60

http://pediatrics.aappublications.org/content/136/Supplement_1/S60#BIBL

http://pediatrics.aappublications.org/content/136/Supplement_1/S60#BIBL

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.2014-3667E2015;136;S60Pediatrics

L. Hansen, James C. McPartland and Marvin R. NatowiczDiana Robins, Amy Wetherby, Wendy L. Stone, Nurit Yirmiya, Annette Estes, Robin

Deborah Fein, Karen Pierce, Timothy Buie, Patricia A. Davis, Craig Newschaffer,Carter, Doreen Granpeesheh, Zoe Mailloux, Susanne Smith Roley, Sheldon Wagner, Lonnie Zwaigenbaum, Margaret L. Bauman, Roula Choueiri, Connie Kasari, Alice

of Age: Recommendations for Practice and ResearchEarly Intervention for Children With Autism Spectrum Disorder Under 3 Years

http://pediatrics.aappublications.org/content/136/Supplement_1/S60located on the World Wide Web at:

The online version of this article, along with updated information and services, is

ISSN: 1073-0397. 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on March 4, 2020www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/content/136/Supplement_1/S60

Early Intervention for Children With Autism …...Early Intervention for Children With Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research abstract

Documents