Review of the Research to Identify the Most Effective Models of Practice in Early Intervention for Children with Autism Spectrum Disorders



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The scope of the survey was limited by our brief to primarily survey stakeholders about their experience, together with the processes for determining eligibility or otherwise of early intervention providers in a defined section of the HCWA package.

Feedback from a representative sample of consumers (parents) or from people with autism was not obtained due to time and resource constraints.



A significant number of the interventions requiring rating had insufficient research evidence and/or available information to enable us to rate eligibility.

Appendices


Appendix A: Selected research evidence for treatments of children with ASD Error: Reference source not found

Appendix B: Classification system used to group and discuss interventions based on learning Error: Reference source not found

Appendix C: Planning Matrix Error: Reference source not found

Appendix D: Research strategy and scientific merit rating scale Error: Reference source not found

Appendix E: Scientific merit rating scale and outcome data Error: Reference source not found

Appendix F: Application of principles of good practice to interventions Error: Reference source not found

Appendix G: Copy of peak bodies’ letter and submission request Error: Reference source not found

Appendix H: Autism Advisor Survey Error: Reference source not found

Appendix A: Selected research evidence for treatments of children with ASD

M.K. Makrygianni, P. Reed / Research in Autism Spectrum Disorders 4 (2010) 577–593-589 Sys Review


Goals:


  • Comparing the baseline and follow-up assessment with one another

  • Comparing behavioural EIPs with those in any eclectic-control programs (the most commonly employed control condition)

  • Identify effectiveness of the EIPs on children’s age, intellectual abilities, language skills, and adaptive behaviour, and of the programs, such as: the intensity and the duration of the program, the staff number and training and the parental training.

Overall outcomes:

  1. Behavioural EIPs can improve children’s language comprehension, communication skills, and socialization. Also improve the intellectual abilities of the children.

  2. Behavioural programs are effective in improving behavioural EIPs and are much more effective than the eclectic (control) programs in improving the intellectual, language, and adaptive behaviour abilities of children with ASD.

  3. Factors that were found to be correlated with the effectiveness of the behavioural programs were the intensity and the duration of the programs, the parental training, as well as the age and the adaptive behaviour abilities of the children at intake.

Inclusion criteria:

  1. Only peer-reviewed journals, longitudinal studies (all published between 1984 and 2007). Studies confirmed with funnel plot to not be biased. Search engines not identified

  2. Assessed an ABA program or a program based on Young Autism Project or it was a replication of Lovaas study.

  3. Diagnosis of autism, ASD, AD, PDD-NOS, PDD.

  4. Young children (nursery school, or first classes of primary school)

  5. Only quantitative data

Study methodology assessed:

Published 11 item scale: randomisation, IO agreement over 0.80, precise description of independent variable (e.g., treatment) and dependent variable, comparison group, fidelity, independent raters, reported effect sizes, participant characteristics, link between research question and data analysis, and appropriate statistical analysis with adequate power (n > 10)



Studies > 9 criteria: High quality

Studies 6–8 criteria: Low



Outcomes assessed:

Intellectual

Language

Adaptive behaviour abilities (communication, daily living skills, and socialization)

Number of participants, the age of the children at intake.


Pre-post treatment Effect Sizes in relation to methodological quality:

>0.9 (high) for both low and high qual. grps

>0.9 (high) for both low and high qual. grps

0.4–0.5 (medium) for both low and high qual. grps

38 months (mean), mental age 53 months


Outcomes assessed:

Intellectual

Language

Adaptive behaviour abilities (communication, daily living skills, and socialization)

Number of participants, the age of the children at intake

Behavioural vs. Control group Effect Sizes in relation to methodological quality:

0.4–0.5 (medium) for both high and low qual. grps

Medium for high qual. grp; high for low qual. grp

High for high qual. grp; medium for low qual. grp

38 months (mean), mental age 53 months





Intensity and the duration of the EIP


25hrs/week: ES >0.7 (High) for all outcomes; >25hrs/week no further effect

<25hrs/week: ES variable

Intensity not correlated with progress in language ability.

Effectiveness of the program varies independently from the programs’ duration.


Parent training


10/20 programs implemented parent training so conclusions could not be drawn

Child’s age at intake

Children <53 months at intake: ES medium

Children >53 months at intake: ES variable

Effectiveness of program not dependent on child’s age at intake.


Child’s developmental ability

Effectiveness of program not dependent on child’s intellectual or language ability. Higher adaptive ability more effective the Behavioural EIP program vs eclectic program


Peters-Scheffer 2010 A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with ASD Research in ASD 5(1): 60-69

Inclusion criteria:

comprehensive search performed (Medline, PsychInfo, ERIC), manual search of journals and search of bibliographies

intervention to address all 3 core deficits in autism using ABA

studies with a pre-test post-test control group only

ASD (using DSM III, III-R, IV) or AD and PDD-NOS via ICD 10

children <10 yr at onset

standardized measures and quantitative outcomes, standardized mean differences compared.

published in English between 1980–2009.

11 studies included; one RCT; rest non-randomised with rep-test post-test control grp.

Two independent reviews selecting studies (IOA 100%).

Study quality (Downs and Black checklist, 1998), independent reviewers. Mean quality score 24.65/32 (sd= 1.29; range 23-27).

Overall Outcome:

EIBI group out performed control group on all dependent variables. Full scale on non-verbal IQ improved in EIBI grp 11.98 and 11.09 points more than control groups, respectively. In receptive and expressive language average increases were 1394 and 15.21 points more, respectively. EIBI surpassed control group on composite adaptive behaviour, comm., daily living skills and socialization subscales by 5.92, 10.44, 5.48, 4.96 points more, respectively. Effect sizes (ES) were medium for adaptive behaviour: daily living subscale (0.68) and high for IQ (2) , non-verbal IQ (0.98), adaptive behaviour (0.91), receptive (2.91) and expressive language (1.1), adaptive behaviour: communication subscale (1.32) and adaptive behaviour: socialization scale (1.49). These large effect sizes reflect clinical significance.

Interpret results cautiously as there was publication bias identified with the expressive language outcome studies and quite high statistical heterogeneity possibly due to differences in characteristics of the treatment (setting, amount of supervision), participants (age at Tx onset, IQ at Tx onset, diagnosis) and methodology (small sample sizes, non-randomised approaches, non-uniform assessment tools, quasi-experimental designs, lack of equivalent groups, lack of adequate fidelity, selection bias, comparison group differences).

Children’s age

Diagnosis

IQ at intake


33.56 to 65.68 months

ASD (47%), AD (12.8%); PDD-NOS (40%)

27.52 to 76.53




- Intervention duration

Exp grps: ~12.5–38.6 hrs/week of EIBI for 10months to more than 2 yrs

Control grps:



    • less intensive EIBI (<10hr/week)

    • eclectic grp (12.5–29.08 hrs/week)

    • parent-directed ABA

or Treatment as usual (public EI, nursery provision, Portage, school based intervention)

Virues-Ortega 2010: Applied Behavior analytic intervention for autism in early childhood: meta-analysis, meta-regression and dose response meta-analysis of multiple outcomes


non-peer reviewed studies

ABA not implement according to major features of approach (referenced)

Focus of intervention was specific rather than general

Intervention did not meet >10hours/wk and no less than 45 weeks duration

Not formally diagnosed according to ADIR, ADOS, DSM IV

Single subject design or intervention less than 5 subjects

study was epidemiological

reported non-standardised outcomes

no pre-test measurement

subject selection bias evident

mean and SD not available

Comprehensive lit search (Medline, PsychINfo, Cochrane Centre). Search strategy provided (1985-2009). References lists of reviews searched.


Exclusion criteria:

Independent screener of papers, IR agreement 90%. Twenty-two studies included.

Independent screening of methodological quality (Downs and Black 1989); IR agreement 95%.

Overall outcome: long-term, comprehensive ABA intervention leads to (positive) medium to large effects in terms of intellectual functioning, language development, and adaptive behaviour of individuals with autism. Although favourable effects were apparent across all outcomes, language-related outcomes (IQ, receptive and expressive language, communication) were distinctively superior to non-verbal IQ, social functioning and daily living skills, with effect sizes approaching 1.5 for receptive and expressive language and communication skills.

Participants:

age


diagnosis

Setting of intervention & duration

Type of study


323 participants

22.6 to 66.3 months

15 studies exclusively autism; 7 studies autism and PDD-NOS

13 UCLA model, 9 general ABA

18 school- or clinic-based (two of these home-based) & 48 to 407 weeks

4 parent managed programs & 12–45 weeks

8 studies within subject design and 13 studies had a control group


Outcomes:

IQ

ABA: ES 1.19 for 18 studies (113 subjects)

Clinic-based: ES 1.23

Parent-managed: ES 1.02

Studies with a control grp (10: 169 subjects)

ES: 1.31


- non-verbal IQ

ABA: ES 0.65 for 10 studies (146 subjects)

Clinic-based: ES 0.65

Parent-managed: ES 0.65

Studies with a control grp (8: 123 subjects)

ES 0.76


- receptive language

- expressive language



ABA: ES 1.48 for 11 studies (172 subjects)

Studies with a control grp (7: 116 subjects)

ES: 0.99

ABA: ES 1.47 for 10 studies (164 subjects)

Studies with a control grp (7: 116 subjects)

ES: 0.99


-adaptive behaviour domains:

- Communication

Daily living skills

Socialisation

Composite


ABA for 11 studies (170 subjects);

ES: 1.45


6 studies using UCLA model; ES = 1.73

4 studies using general ABA = 1.17; ES: 0.62

8 studies with a control grp; ES = 0.68

ES: 0.95

8 studies with a control grp; ES= 0.68

15 studies (232 subjects); ES=1.09

ES no different for clinic based vs parent managed programs or when limited to 10 studies with a control (165 subjects).

ES increased with intensity but not duration


All meta-analysis subject to statistical heterogeneity (I2 = 68-88%) and publication bias (p<0.02) .

Kagorah D. Is video-based instruction effective in the rehabilitation of children with

autism spectrum disorders? 2007. Developmental Neurorehabilitation 13(2):129-140.

Reviewed intervention studies on the use of video-based instruction for teaching adaptive behaviours to children with autism spectrum disorders (ASD).

Forty-four studies encompassing 49 experiments met the inclusion criteria. The studies targeted a range of adaptive behaviours and academic skills.


  1. Adequate search strategy searching four known databases, no year range specified and three manual search strategies employed as well

  2. Inclusion criteria appropriate though only needed one participant in study to have ASD for study to be included and included all children <18yrs.

  3. Some quality assessment performed in studies but not clear to what degree. No formal quality assessment process used.

Outcomes:

Difficult to draw conclusions due to only 1–3 participants in any one included study having ASD. Also mean age of included sample was 7.6 years although 55% were school age (6–12 years) and 30% (3–5 years).

Most studies reported positive results, but the certainty of evidence was not strong for all of the studies due to reliance on pre-experimental designs. Most studies assessed outcomes of social and communication skills, not adaptive behaviours. Most studies performed video based instruction in home or school settings, not community settings where instruction is required. A wide range of models were used for video instruction making it difficult to determine which model works best in which setting. Furthermore few studies looked at video-based instruction independent of additional strategies making it difficult to determine effects specific to video-based instruction.


Karkhaneh M. Social stories to improve social skills in children with autism spectrum disorder. Autism 14(6): 641-662.

Followed systematic reviews methods (Higgins 2006).

Comprehensive search strategy used (all key databases) plus hand searches of bibliographies

Two independent reviewers of search and for quality assessment with a validated scale (Jadad, 1996, Chalmers, 1981, Smith 2007).

Inclusion criteria:


Six Controlled trials (4 RCT, 2 CCT) published between 2006–2009

135 participants, median sample size 20

variable control groups

quality criteria (0 low, 5 high): 1 study 2/5, 2studies 1/5, 3 studies 0/5





Participants:

Age


Diagnosis

Treatment duration

Treatment intensity


10 years (4–14 years)

not clear if independently diagnosed in any studies

same day to 6 weeks

2 trials within a session to 10 readings in a day for 30 consecutive days



Majority of children in this review were >7yrs, therefore will exclude at this stage. The one study that had children with mean age 6 yrs (4–8) had a quality score of 0/5 and therefore will not offer any further information to this review.

Preston D. A Review of the Efficacy of the Picture Exchange Communication System Intervention. J Autism Dev Disord (2009) 39:1471–1486



Descriptive review; 27 studies

comprehensive lit search strategy using all databases and manual searching of bibliography references.


Inclusion criteria:


journal articles in English from 1992 to July 2007;

used PECS (Bondy & Frost 1994; Frost & Bondy 1994, 2002) as whole or part of an intervention strategy as indicated by reference to program documentation and description of implementation (Phases I–VI)

presented group or individual data on the results of the intervention.
Overall outcome based on RCT studies (3): nature and quantity of data arising from RCTs at this point in time is insufficient to draw firm conclusions regarding the PECS interventions.

Single subject designs:

14 single subject studies:

4 used alternating design

8 used multiple baseline across participants, settings, descriptors taught and activities.

2 ABAB design

2 within subject changing criteria design

poor quality for single subject designs (not discussed further)



Group experimental design:

Number


Diagnosis

Age


Quality

RCT: Howlin et al. 2007; Yoder and Stone 2006a, quasi-experimental: Carr and Felce 2007a, b.

161 subjects (35% of the total sample): 98 in PECS and 92 in control or other treatment groups.

Autism or PDD-NOS and little or no speech.

20 months to 11 years

IO reliability reported in <20% sessions (Howlin 2007); procedural fidelity only reported by Yoder 2006 in <20% of sessions)

Social validity reported by Yoder 2006



Outcomes for 3 RCT studies

Yoder and Stone (2006a):

36 children with autism, aged 21–54 months

randomly assigned to PECS (phases I–VI) or Responsive Education and Prelinguistic Milieu Teaching (RPMT) intervention groups

PECS group showed a significantly greater increase in frequency of speech (d = 0.63) and in number of different words used (d = 0.50) after 6 months of intervention, but by 6 months post-intervention the difference was no longer evident.

children who were low in initial object exploration benefited more from the RPMT intervention, while those who were higher benefited more from PECS, these effects being evident 6 months post-intervention.

Overall, a significant increase in non-imitative spoken acts over 1 year, though increase could be attributed to maturation.

Yoder and Stone (2006b):

36 children with autism, Aged 20–53 months

examined effect of the PECS vs RPMT on initiating joint attention, requesting, and turn-taking

all 3 functions increased significantly, but RPMT increased turn-taking more than PECS. Children who were higher in initiating joint attention before treatment had greater increases in both initiating joint attention and requesting following RPMT intervention, while those who were initially lower in initiating joint attention had greater increases following PECS intervention.

Howlin et al. (2007):

group RCT of 84 children with autism, aged 4–11 years

examined effectiveness of a consultancy model to deliver PECS (phases I-VI), rather than the efficacy of PECS per se.

rates of communicative initiations and PECS usage were significantly increased immediately following intervention, but that these effects were not maintained once the intervention ceased.

no significant increase in frequency of speech.

no increase in most ADOS-G ratings, with the exception of a decrease in the severity score for the Reciprocal Social Interaction domain at the 10 month follow- up. Unfortunately no data was provided on the fidelity of implementation of the PECS program, or indeed on the fidelity of the teacher training.


Wallace & Rogers, Intervening in infancy: implications for autism spectrum disorders. J Child Psychology & Psychiatry. 2010. 51(12): 1300-1320.


Comprehensive search strategy including search of PsychInfo and Pub Med databases, hand search of reviews

32 controlled, high-quality experimental studies.


Inclusion criteria:


article published in a peer-reviewed journal

article described a well-designed, controlled intervention efficacy study involving infants or toddlers with significant risk of prematurity, developmental delay including Down syndrome, risk of intellectual disability

study participants were in the age range of 0–3 years

paper reported sufficient data to calculate effect sizes.


Two independent reviewers of studies including rating of studies by level of evidence type 1-type 6 (Nathan and Gorman, 2002):


Type 1 Studies are randomized, prospectively designed clinical trials which use randomly assigned comparison groups and all critical design requirements.

Type 2 Studies are clinical trials using a comparison group to test an intervention. These have some significant flaws but not critical design flaws that would prevent one from using the data to answer a study question. This category also includes single-subject designs.


Overall outcome:

Most efficacious interventions routinely use a combination of four specific intervention procedures, include:
    1. parent involvement in intervention, including ongoing parent coaching that focused both on parental responsivity and sensitivity to child cues and on teaching families to provide the infant interventions


    2. individualization to each infant’s developmental profile

    3. focusing on a broad rather than a narrow range of learning targets

    4. temporal characteristics involving beginning as early as the risk is detected and providing greater intensity and duration of the intervention.

Study design

type 1 studies (6)

type 2 studies (26)

24 studies looking at prematurity; 6 type 1, 18 type 2

5 studies looking at Dev. Delay incl. Down syndrome; all type 2

3 studies looking at intellectual disability; all type 2

23/32 studies used randomization

3/32 partial randomisation


Premature group outcomes:

two randomized controlled studies demonstrated large effect sizes (0.7-0.8) in cognitive ability following intervention up to 36months and effect was sustained well into early childhood and beyond. Intervention started with parent training in hospital and at home from when child was an infant (study 1: long-lasting and intensive intervention carried out for 36 months and study 2: a very brief intervention lasting only 3 months and carried out by a visiting nurse. Common elements include an individualized develop- mental curriculum for children, a strong focus on parent training and parent delivery of the intervention, and emphasis on supporting parents.

overall ES for group was 0.44; key strategy involved parent training

Developmental delay group outcomes:


intervention involved teaching parents developmental activities to share with their children. Ix was broad-based and individualized, and provided in a mixed one-to-one and group setting. Families were provided with additional support in the form of parent groups and therapy.

overall ES for group was 0.44; key strategy parent training and continued support for parents over the long term



Intellectual disability group

key RCT: full-day intervention was delivered in specialized daycare centres beginning when the infants were 6–12 weeks of age and continued until age 5 years. The infant curriculum consisted of activities designed to stimulate language, motor, social, and cognitive skills and was delivered by the daycare staff. Families receive support throughout intervention. Intense (40hrs/wk for 60 months)

most of them delivered in high-quality child care settings

overall ES for group was 1.26


Communication interventions involving speech-generating devices for children with autism: A review of the literature. LJ van Der Meer. Developmental Neurorehabilitation, August 2010; 13(4): 294–306

Comprehensive search strategy using 6 different databases including CINAHL, MEDLINE, ERIC plus manual searches of reference lists. 23 studies identified between 1998–2009. Two Independent reviewers to identify included studies.



Inclusive criteria:

children (<18 years of age) with ASD (9.8%), autism, (66.7%), PDD-NOS (23.5%)

intervention involving SGDs defined as implementing one or more therapeutic/ teaching procedures for the purpose of trying to increase or improve the child’s communication skills or abilities through the use of a SGD. Examples could include teaching a child to use an SGD to (a) make requests, (b) spell words or (c) repair a communicative breakdown

quality assessment criteria not clear

51 children aged 3–16 years (mean 7.7 yrs)

Overall outcome:


Only 4 /23 studies had ‘conclusive’ single-subject study designs comprising a total of 13 children.



Trembath D., Balandin S., Togher L., Stancliffe R. Peer- mediated teaching and augmentative and alternative com- munication for preschool-aged children with autism. Journal of Intellectual and Developmental Disability 2009;34: 173–186.


To assess the effectiveness of peer-mediated naturalistic teaching, with and without an SGD (Talara-32; digitized) on the communicative behaviours of children with autism (3 boys aged 3–5 yrs)

Used multiple baseline design



Following the SGD intervention there were immediate increases in the communicative behaviours of all three children. Increases were statistically significant. Interactions generalized to mealtime activities, however, only one child maintained these increases

Olive M, de la Cruz B, Davis T, Chan J, Lang R, O’Reilly M, Dickson S. The effects of enhanced milieu teaching and a voice output communication aid on the requesting of three children with autism. Journal of Autism and Developmental Disorders 2007;37:1505–1513.

To evaluate the effects of enhanced milieu teaching combined with a SGD (Cheap Talk 4 Inline Direct; digitized) on the requesting skills of 3 boys aged 45–66 months

Used multiple probe across participants design


All participants demonstrated an increase in SGD use as well as an increase in total spontaneous independent requests



No RCTs have been performed in this area.


__________________________________________________________________________

Outcome of comprehensive psycho-educational interventions for young children with autism

Eikeseth. S. 2009. Research in Developmental Disabilities 30 (2009) 158–178.

Evaluated comprehensive psycho-educational research on early intervention for children with autism. Twenty-five outcome studies were identified.

Twenty studies evaluated behavioural treatment, 3 studies evaluated TEACCH and 2 studies evaluated the Colorado Health Sciences Project.

Looked at scientific merit (Highest 1, lowest 3) and magnitude of treatment (Highest 1; lowest 4)

Scientific merit: (only 1 study with scientific merit 1: Smith, 2000)

Studies relevant to current review see below: all scientific merit 2, criteria include:



    • diagnosis by independent diagnostician using DSM IV criteria plus standardised tools (ADOS, ADIR)

    • study design not random

    • dependent variable (standardized assessments of IQ and adaptive functioning and other assessments)

    • treatment fidelity (performed or if not, provided in a treatment manual)

Magnitude of treatment criteria:

    • significant differences between groups on IQ and adaptive functioning (IQ measure must be based on language/ communication skills in addition to visual spatial or performance skills) as a minimum

    • significant differences between groups on IQ or adaptive functioning as a minimum.

Study


Study outcomes

Scientific merit (SM)

Magnitude of Treatment (MT)

Magnitude of results

Eikeseth, S. 2007

Compared effects of ABA and eclectic treatment for children with autism. Mean intake age was 5.5 years. ABA group received 28/week of one-to-one ABA treatment during the first year of intervention with a gradual reduction of treatment hours over the next 2 years. Eclectic group received 29 h/ week of one-to-one eclectic treatment with a gradual reduction of treatment hours over the next 2 years.

SM =; MT = 1

Group assignment to either an ABA treatment group (n = 13) or to an eclectic treatment group (n = 12) was based on availability of ABA supervisors and performed by a person who was independent of the study


Follow-up assessment—~3 years after the treatment begun—ABA group scored significantly higher as compared to the eclectic treatment group on intelligence, language, adaptive functioning, maladaptive functioning and on two of the subscales on the socio-emotional assessment (social and aggression). The ABA treatment group gained an average of 25 IQ points, ES = 2.21; 12 points in adaptive functioning ES = 1.35. By comparison, the eclectic treatment group obtained

Average change of +7 points in IQ, +10 points in Adaptive Functioning. Seven of 13 children in the ABA group who scored within the range of mental retardation at intake scores within the average range (0.85) on both IQ and verbal IQ at follow-up, compared to 2 of 12 children in the eclectic treatment group.


Remington 2007

Compared effects of ABA with treatment as usual for children with autism. Mean intake age was 37 months.


ES = 2; MT = 2

Group assignment to either an ABA treatment group (n = 23) or to a treatment as usual group (n = 21) was based on parental choice. Participants in the ABA treatment group received 25.6 h per week of one-to-one ABA for 2 years. Participants in the comparison group received standard provision from the local education authorities. Hours not unspecified.



There were no significant differences at intake on any of the measures. Follow-up assessment showed that the ABA treatment group scored significantly higher as compared to the comparison group on intelligence, but not on language functioning or adaptive behaviour (ABA treatment group gained an average of 12 IQ points, ES = 0.72, whereas children in the comparison group lost, on average, two IQ points). Children in the ABA group showed an advantage over the comparison group in language functioning at follow-up, as more children in the ABA group reached basal on the Reynell comprehension and expression scales post treatment.

The ABA group showed significantly better score on responding to joint attention as compared to the comparison group, but not in initiating joint attention. No other significant changes were reported in child outcome.



Cohen 2006

Compared effects of ABA with special education provided at local public schools for children with autism or PDD-NOS. Participants’ mean age at diagnosis was 31.2 months (range 18–48) and all <48 months by the onset of treatment.



SM: 2; MT = 1

Group assignment to either an ABA treatment group (n = 21, 20 with autism and 1 with PDD-NOS) or to an eclectic treatment group (n = 21, 14 with autism and 7 with PDD-NOS) was based on parental preference.

ABA group received 35–40 h per week of one-to-one ABA treatment provided in a community setting. Participants in the comparison group received public community Services. The child/teacher ratios varied from 1:1 to 3:1. Classes 3–5 days/week, for up to 5 h per day.


At intake, ABA group had significantly more children with autism (less with PDD-NOS) as compared to the comparison group. Follow-up assessment ~3 years after the treatment begun –ABA group scored significantly higher as compared to the two comparison groups on IQ and adaptive functioning, though not on visual IQ and language (language comprehension was marginally significant with p = 0.06). The ABA group gained an average of 25 IQ points, ES = 1.52, 10 points in adaptive functioning, ES = 1.23. By comparison, the eclectic treatment group obtained average change of 4 points in IQ, ��3 points in Adaptive Functioning. Six of the 21 ABA treated children were fully included into regular education without assistance, and 11 others were included with support; in contrast, only 1 comparison child was placed primarily in regular education.

ABA treatment is demonstrated effective in enhancing global functioning in pre-school children with autism when treatment is intensive and carried out by trained therapists (one Level 1 study, four Level 2 studies, Cohen et al. 2006; Eikeseth et al. 2002, 2007; Howard et al. 2005; Remington et al. 2007; nine Level 3 studies, Andersen et al. 1987; Birnbrauer & Leach 1993; Eldevik et al. 2006; Lovaas 1987; and Sallows & Graupner 2005; Sheinkopf & Siegel 1998; Smith, Buch, & Gamby 2000; McEachin et al.1993; Magiati et al. 2007; Weiss 1999).


Odom 2010: Evaluation of comprehensive treatment models (CTMs) for individuals with ASD. J Autism Dev Disord 40(4):425-436.

CTMs:


identified by literature search (PsychInfo and EBSCO)

surveyed well known books and literature review

incorporated models from NAC report

experts in the field


Defined by 6 criteria:


model description published in a refereed journal article

a single procedural guide, manual to define model

clear theoretical or conceptual framework that is published

address multiple developmental or behavioural domains that represent core features of autism

model must be intensive (25hrs/week or more), extends for 9–10 months, and planned engagement consistent with mode.

implemented at least at one site in the US.


Evaluation

Four evaluators with extensive training and experience related to ASD. Standard telephone Ix to CTM director (30–90min) and summarised outcomes according to evaluation criteria. Used American Evaluation Association guidelines combined with guidelines from leaders in ASD Tx field. Polit testings of evaluation performed. Inter rater agreement 83%



Operationalisation: Interventions documented and published such that others can use them

Implementation measures: Fidelity implementation measure developed plus some evidence of reliability and validity.

Replication: Model adopted and replicated by others, provided with initial training but otherwise independent of CTM developer

Type of empirical evidence: Evidence of efficacy must appear in different venues, strongest being a peer-reviewed journal, then book chapters or reports from CTM developers


Quality of research methodology: SMRS system

Complementary evidence from studies of focused interventions: provide evidence from peer reviewed journals of focused interventions that are used as part of the models.

Scored 0 lowest to 5 highest



Program

Operation-

alisation

Fidelity

Replication

Outcome data

Quality

Additional studies

Denver

5

4

5

5

2

0

DIR

5

3

5

4

2

0

Douglass

5

3

0

5

3

5

Hanen

2

0

1

3

0

0

Case-Smith, J., & Arbesman, M. (2008). Evidence-based review of interventions for autism used in or of relevance to occupational therapy. American Journal of Occupational Therapy, 62, 416–429.


Inclusion criteria


  1. Performance area or intervention approach used in occupational therapy

  2. Included children and adolescents

  3. Peer reviewed

  4. Study design (Level 1: RCTs, sys reviews, meta-analysis); ( Level 2: nonrandomized controlled trials such as cohort studies; (Level 3: before-after one group designs)

  5. Searches (1986–2007) Medline, CINAHL, ERIC, PsycINFO, Social Sciences Abstracts, Sociological Abstracts, Linguistics and Language Behavior Abstracts, Rehab Data, Latin American and Caribbean Health Sciences Literature and EBSCO Host, Cochrane Database of Systematic Reviews, Campbell Collaboration.

Overall outcome

Overall this was a descriptive review of studies (Level I to III) that looked at a range of interventions which fall in the domain of occupational therapy. Majority of studies described were performed before 2005, outside this review’s study criteria. Also as no clear independent standardised quality assessment was performed on included studies, the level of scientific rigour is likely to vary among studies making it difficult to make comparisons or draw clear conclusions. Few studies were completed by occupational therapists, rather the author has attempted to interpret the outcomes and apply to occupational therapy practice.



Study design & methodology

Published criteria used for Law 2002


Reported: 49 studies

18 Level 1

17 level 2

14 level 3

(no clear evidence of assessment of study quality or which research design elements are assessed).


Outcomes:


Descriptive review, no objective measures examined.





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