ReviewA meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with Autism Spectrum Disorders
Introduction
Autism Spectrum Disorder (ASD) is characterized by severe and sustained impairment in communication and social interaction and restricted patterns of ritualistic and stereotyped behaviors manifested prior to age 3 years (APA, 1994). In approximately 26–40% of young children with ASD intellectual disability (ID) is also present (Baird et al., 2000, Chakrabarti and Fombonne, 2001). A range of behavior problems are also common, including self-injury, anxiety, compulsions, withdrawal, uncooperative behavior, aggression, and destruction of property (Gadow et al., 2004, Lecavalier, 2006, McClintock et al., 2003). There are many intervention approaches including applied behavior analysis (ABA), diets and vitamins, floor time, holding, medication, options, Picture Exchange Communication System, sensory integration, speech and music therapy, special education and visual schedules (Green et al., 2006, Hess et al., 2008); however, there is little empirical evidence for the effectiveness of many of these approaches and available evidence shows mixed results (Foxx, 2008, Howlin, 1997, Schechtman, 2007, Smith, 1999).
Building on research from the 1960s, Early Intensive Behavioral Intervention (EIBI) is the most often studied type of intervention for children with ASD (Matson & Smith, 2008). It is based on principles of operant learning and focuses on remediation of deficient language, imitation, pre-academics, self-help and social interaction skills (Sturmey & Fitzer, 2007) which are broken down into discrete components and taught on a one-to-one basis in school and/or at home, typically using discrete trial teaching (with subsequent planned generalization), reinforcement, backward chaining, shaping, extinction, prompting and prompt fading (Duker, Didden, & Sigafoos, 2004). Parental participation is considered essential to achieve generalization and maintenance. EIBI is effective when it is both intensive (i.e. approximately 40 h per week) and extensive – minimally 2 years (Lovaas, 2003, Matson and Smith, 2008).
Studies have reported mixed outcomes (Eikeseth, 2009). Several descriptive reviews have concluded that, although EIBI generally has meaningful benefits for young children with ASD, there were large individual differences in treatment response and most children continued to require specialized services (Eikeseth, 2009, Howlin et al., 2009, Matson and Smith, 2008, Rogers and Vismara, 2008, Shea, 2004, Smith, 1999). Two meta-analyses (Eldevik et al., 2009, Reichow and Wolery, 2009) found an average medium to large effect size for IQ change despite using different effect sizes (standardized mean change effect size versus a standardized mean difference effect size) and differences in study selection criteria. Eldevik et al. (2009) also found a medium effect size on change of the adaptive behavior composite. Several studies have also reported supplementary measures of adaptive behavior; however, meta-analyses have not systematically analyzed full scale, verbal and performance IQ and measures of adaptive behavior. Thus, it is unclear if the effects of EIBI are robust across all these measures. Therefore, this meta-analysis synthesized the outcomes of comprehensive EIBI programs in which data were collected in group designs using full scale, verbal and performance IQs and measures of adaptive behavior.
Section snippets
Search methods and selection of studies
There were three search strategies. First, computerised literature searches of MedLine, Psychinfo and Eric were conducted using the keywords “behavioral treatment” or “behavioral intervention” in combination with “autism”, “autism spectrum disorder” or “pervasive developmental disorder”. Second, a manual search of the following journals was performed: American Journal on Mental Retardation/American Journal on Intellectual and Developmental Disabilities, Autism, Behavioral Interventions,
Study characteristics
Participants’ average age ranged from 33.56 (Magiati, Charman, & Howlin, 2007) to 65.68 months (Eikeseth et al., 2002). Reported gender was 65.70% male, 10.47% female; 23.84% was not reported. All had an Autism Spectrum Disorder (47.09% autistic disorder; 12.79% PDD-NOS; 40.12% not specified) and average IQ ranged from 27.52 (Smith, Eikeseth, Klevstrand, & Lovaas, 1997) to 76.53 (Magiati et al., 2007).
Experimental groups received on average 12.5 (Eldevik, Eikeseth, Jahr, & Smith, 2006) to 38.6 h
Discussion
Children with ASD participating in EIBI generally outperformed children receiving other treatments or treatment as usual on both IQ and adaptive behavior measures. This confirms findings from other studies on EIBI (Eikeseth, 2009, Howlin et al., 2009) and two other recent meta-analyses (Eldevik et al., 2009, Reichow and Wolery, 2009). The average differences of 11.09 to 15.21 standardized points in scores between the experimental and control groups on IQ, non-verbal IQ and receptive and
Acknowledgments
This study was funded by Stichting De Driestroom, Elst, The Netherlands.
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