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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2.6 Other Interventions

This category can potentially include a range of interventions; however, the only studies to emerge from the current literature review were evaluations of the effects of music therapy and physiotherapy.

Results of individual studies and systematic reviews are presented in Table 4.



Table 4: Review of recent (2005–May 2011) research literature on other interventions and autism

Studies evaluated for this review

New research




Author/s

Quality and outcomes

Lim, H.A. (2010). Effect of ‘Developmental Speech and Language Training Through Music’ on speech production in children with Autism Spectrum Disorders. Journal of Music Therapy, 47(1), 2–26.

Good quality study (3.975) comparing music training, speech training and control using appropriate videos over 3 days. Music and speech groups both increased verbal production compared with controls (significant differences, large effect size); low functioning participants showed greater improvement with music training than with speech training.

Summary of systematic reviews of treatments

Petrus, C., Adamson, S.R., Block, L., Einarson, S.J., Sharifnejad, M. & Harris, S.R. (2008). Effects of exercise interventions on stereotypic behaviours in children with autism spectrum disorder. Physiotherapy Canada, 60 (1), 134–145.


Overall outcome: This review incorporated 7 studies, 4 single subject design with weak methodology, 1 case study with weak methodology and two group design studies assessed to have moderate quality. The two group studies included one repeated measures study (no control group) with only 5 children aged 14–15 years. The other study was a case series with 5 children aged 9–11 years. Both these studies fall outside this review’s criteria. The method for identifying children with ASD was based on a statement only rather than using standardized tools. Based on the weakness in study design and method to identify children with ASD, along with the small sample sizes and broad sage groups of children being assessed, no strong conclusions can be drawn from this review.

2.6.1 Summary of current research evidence for other interventions


This review identified one study regarding music therapy that involved videos rather than more traditional, interaction based music therapy. A positive outcome was found (increased verbal production) but it is unlikely that this particular intervention is representative of music therapy more broadly. The Comparative Effectiveness Review (2011) identified two studies that described some positive results regarding music therapy but described the quality of both as ‘poor’.

One review study of physiotherapy and autism was identified which looked at the effect of exercise on stereotypical mannerisms often seen in autism. Some short-term reductions were observed in some children; however the studies included were generally of low quality with a small number of children and a wide age range.

2.7 Summary of Named Interventions

Table 5 provides a summary of named interventions in terms of direct evidence and indirect evidence or principles of good practice for known treatments with some direct evidence. An evaluation of compliance with principles of good practice is shown if sufficient information was available about an intervention to enable an assessment to be completed. For an explanation of the principles of good practice see Appendix F.

Table 5: Summary of named interventions




Interventions

Type 1 direct evidence (current review, National Autism Centre, Roberts and Prior 2006)

Type 2 indirect research evidence about autism &/or rationale (principles of good practice)

Comment




Known treatments for ASD with some evidence




Developmental Social-Pragmatic (DSP) model:

Single subject design, n = 3. Variable outcomes measured using observation, no levels of significance reported (Ingersoll et al 2005).


See Roberts & Prior (2006) for discussion.

See Raising Children Network <http://raisingchildren.net.au/> for summary.



Model of engaging parent and child using a developmental approach, well grounded in child development theory and in relation to autism.

Limited direct evidence but strong theoretical basis.






DIR/Floortime approach


Limited direct evidence; single study low quality (Solomon et al. 2007; cited in Comparative Effectiveness Review, 2011) used a DIR/Floortime approach in a parent training model.

See Roberts & Prior (2006) for discussion. Based on developmental theory, focuses on individual strengths and needs, takes into account sensory needs, follows child’s lead, developing reciprocal relationships. Emphasis on parent training to allow for high intensity program in the natural setting.

Limited direct evidence, addresses core features of autism utilising a developmental approach.




The PLAY Project®


Limited direct evidence; single study low quality (Solomon et al. 2007; cited in Comparative Effectiveness Review, 2011)

As above

Uses DIR/Floortime theoretical approach, home based, parent training to play with children

Limited direct evidence, addresses core features of autism utilising a developmental approach.




Preschoolers with Autism


Manualised parent training program. One study, RCT, high quality (4.85). Compared program with counselling program and no treatment. Better outcomes for parents compared with no treatment, similar outcomes for parents in counselling intervention. Greater outcomes for parents with pre-existing mental health difficulties.

Program focuses on key areas of autism, including features of autism, communication and behaviour support.

Developed at Monash University by Tonge & Brereton (2005). Parent training researched with good outcomes for parents. No measures reported for child outcomes. Addresses core features of autism.




Social, Communication, Emotional Regulation Transactional Support (SCERTS)


No research based direct evaluation found

Program focuses on key areas of autism – social communication, emotional regulation and providing transactional supports (including visual supports and other communication aides).

Very strong basis in research for all components of the model.



SCERTS is a model of service provision, rather than a specific program. No research regarding the effectiveness as a whole but all components are grounded in well-established research.





TEACCH

See Roberts & Prior (2006) for discussion of early research. Comparative Effectiveness review identified 4 newer studies, 2 of reasonable quality, 1 of these with young children (3–5 years) (Tsang 2007). Significant improvements in motor and cognitive domains, control group also made gains.


Components of program strongly based in established understanding of autism, utilising:

autism specific curriculum

structured teaching

routines and organisation

communication support

use of visual supports

strengths based content and teaching

individualisation




Involves structured teaching and a ‘whole of life’ approach to support and education. Strong use of organisation and visual supports to structure learning.




Triple P – Stepping Stones adaptation


Good quality (3.95) study (see literature table) with significant reductions in child behaviour, improvement in parenting styles, greater parental efficacy at follow up.

Program specifically adapted for parents of children with a developmental disability. Targets associated features of autism (specifically challenging behaviour) and aims to reduce parent stress. Functional approach to challenging behaviour.

Parenting program modified for parents of children with a developmental disability. Some good quality research evidence and good practice principals (single component address a specific area of need to be used within a comprehensive program.




Building Blocks

One good quality study (3.65) comparing Building Blocks® home based program with the Building Blocks® centre based program and a waiting list control group. Mixed outcomes, centre based outcomes generally slightly better than home-based but the need for range of programs to suit different families/children noted.


Comprehensive approach including:

naturalistic play-based intervention

behavioural and developmental theory

structured teaching

functional communication skills

positive behaviour support

assessment of sensory processing issues

use of visual supports



Good quality research though with mixed outcomes, the need to provide centre-based and/or home-based programs depend on family and child characteristics is recognised. Approach meets good practice guidelines and key effective elements.




Speech generating devices/ high tech Augmentative and Alternative Communication (AAC) devices


No large scale RCT of speech generating devices but some single subject design suggesting efficacy.


Speech generating devices address core feature of autism (communication and social interaction) as part of comprehensive program. Matches some learning style features of ASD including visual skills.

Assessment and provision of high tech communication devices. Relevant to autism as one part of a comprehensive intervention plan.




Known interventions with limited or no evidence base




Miller Method

From Roberts & Prior (2006):

Jordan, Jones, and Murray (1998) conducted a review of research evidence for the effectiveness of the Miller Method

one study of outcomes of the program, which failed to evaluate the direct effects of the independent variable (i.e. the treatment program)

further research is required…the program must be considered pre-experimental in nature.


From Roberts & Prior (2006):

based on ‘Cognitive-developmental systems theory’, assumes that typical development depends on the ability of the children to form systems and organised ‘chunks’ of behaviour

claims to transform the child's ‘aberrant systems (lining up blocks, driven reactions to stimuli, etc.) into functional behaviours’

strategies employed include narrating the children's actions while they are a metre above the ground on an 'Elevated Square'

From website:

focus on sign AAC while narrating elevated activities, philosophy mentions social interaction, communication and behaviour but it is unclear how these are addressed.



Very limited research evidence (type 1)

Limited type 2 evidence

Limited evidence for ‘elevated platform’ rationale

Unknown best practice elements, including predictability and routine, autism specific curriculum, intensity and transition support






Multi-sensory Environment

(Snoezelen room)

Also known as Snoezelen rooms, provides sensory stimuli across the range of sensory modalities within a specially built room. Initially designed for institutionalised patients. Also used with elderly population with dementia.

Total 6 studies (autism + Snoezelen, autism + multisensory environment)

one study of 3 adults with autism found no effect on challenging behaviour

one study of children 5–17, 2 with ASD, no stats, not quality reviewed

no studies found with children under 5

no studies found with children with autism


Limited evidence for rationale, limited evidence of any good practice principles or elements of effective interventions (ASD content, teaching, generalisation, functional approach to challenging behaviours).


Limited Type 1 evidence

Limited evidence for rationale

Does not meet best practice criteria as a stand-alone intervention





Sensory Integration Therapy (SIT)

Sensory Diet 

Weighted Vests

Wilbarger Brushing Protocols




Roberts & Prior (2006) found no supporting evidence for SIT

Comparative Effectiveness Review (2011) indicated that studies of SI were of poor quality.

Rodger et al. (2010) describe “no robust evidence supporting its efficacy in achieving functional outcomes by correcting underlying sensory integrative dysfunction” (p.2).


Sensory processing differences are widely reported in autism but no quality evidence that SI changes sensory responses in ASD.

Studies have not shown evidence of impact of weighted vests (Stephenson & Carter, 2009).

Very limited published research on effectiveness of sensory diets or brushing protocols.


Children with autism may have marked responses to sensory information; however there is currently no evidence that SIT, sensory diets, brushing programs or weighted vests can correct underlying sensory problems.


Auditory Integration Therapy


Limited evidence of effectiveness (see Roberts & Prior 2006 for review). Comparative Effectiveness Review (2011) described two fair quality studies with no effect of treatment.

Sound sensitivities often reported but limited evidence of physiological differences (Stiegler & Davis 2010). No evidence that AIT changes physiological level or behavioural response.


Also known as ‘Tomatis therapy’, listening therapy and therapeutic listening. No research evidence of effectiveness. Not currently listed by FaHCSIA as an eligible therapy.




Alert Program for Self-Regulation


Program evaluated for students with ‘emotional disturbances’ in mainstream schools and a modified program for school aged children with foetal alcohol spectrum disorder.

No other empirical research found.



Based on theories of self-regulation and self-management use of sensory strategies to manage self-regulation issues.

Aims to teach children (and/or their parents) to identify their state of arousal (high, low, alert) and to use appropriate cognitive and or sensory strategies to self-regulate.





Cognitive Behaviour Therapy

Some direct evidence of effectiveness for school aged children with high-functioning autism or Asperger syndrome (ages 7+). No apparent evidence for early intervention population.


Anxiety can be associated with autism but unclear whether principles and practice of CBT would match the language and cognitive level of young children with an ASD.

CBT is an established treatment for anxiety disorders (which can be associated with ASDs) but even adapted CBT relies on adequate language and cognitive skills. Unlikely to be appropriate for the EI population.




Single element components addressing one aspect of ASDs




PALS Social Skills Program (Playing and Learning to Socialise)

www.palsprogram.com.au


One RCT found, good quality study (2.85) though not specific to autism.


Based on rationale that children with an ASD have difficulties learning and using social skills. Program targets skills:

greeting others

taking turns: talking and listening

taking turns at play

sharing

asking for help

identifying feelings

empathy


overcoming fear and anxiety

managing frustration

calming down and speaking up.

Uses video modelling, puppets, role play, songs to teach skills.


Well established program for typically developing, some use in autism, though no empirical research. Rationale, teaching methods and program elements suggest appropriate for some children.

Single element addressing one aspect of ASDs. For use combined with other ASD specific elements only.



Sleepwise©: Positive Sleeping Practices for Young Children with Developmental Delay

One empirical study found (O’Connell & Vannan 2008), 23 families, mixed diagnoses, all developmental disability ages 1–7 years.

Treatments varied according to child characteristics and parental preferences

General gains, though outcomes and level of success were determined according to individual goals


Increased prevalence of sleep disturbance in children with developmental delay that requires professional intervention (cited in O’Connell & Vannan, 2008)

High rates of sleep problems reported in children with autism (Richdale 1999)

Sleepwise© is used by therapists to help families/carers of young children (under six) with developmental delay in supporting children's sleep, including individual sleep plans and family support

Techniques include social stories, visual supports, positive behaviour supports, sensory supports, appropriate for children with an ASD

Family based, working with parents


Sleep is a particular issue for children with autism. Sleepwise© has some Type 1 evidence and the rationale is consistent with current understanding of autism and best practice intervention to address a particular issue.

Single element addressing one aspect of ASDs. For use combined with other ASD specific elements.



SoSAFE!

No direct evidence found.


Based on addressing social skills issues, relevant to autism but applicable to older age group regarding relationships, sexuality and protective behaviours.

So Safe pages on www.shfpact.org.au/index.php?option=com_content&view=article&id=141:sosafe-user-training&catid=25:for-disability-workers&Itemid=128

Sexuality program for adults – no evidence of efficacy for children.



Toilet Time©: Toilet Training for Young Children with Developmental Delay

One small study on the effects of traditional toilet training (operant conditioning) plus video modelling. Some impact of training plus video modelling compared with training alone. Carers reported that support was important (Keen et al. 2007.)

Evidence that toilet training can be delayed in children with an ASD.

Limits opportunities for integration (e.g. preschool).

Parent training and support, use of visual supports, use of video modelling, behaviour analysis techniques are consistent with needs of children with autism.

Addresses an issue for children with autism documented in the research, likely difficulties attributable to intellectual disability/delay, communication and socialisation difficulties, differences in sensory processing.

Program is consistent with autism learning needs, one small research study providing some supporting evidence.

Single element addressing one aspect of ASDs. For use combined with other ASD specific elements.


‘Social Eyes’ 

No reference in the literature

Rationale based on social interaction difficulties seen in people with an ASD.

Developed for adults.



Developed by NAS but for adults www.autism.org.uk/socialeyes.aspx

Need to look at whether any modifications have been made for young children.

Current format would suggest that it is unsuitable.


Pragmatic Language Group / Pragmatics for Prep

Service based; no direct evidence.

Pragmatics is an area of communication that is particularly affected by autism. Relevant to higher functioning young children with autism. Will need to check that good practice principles are met.


Service based; no direct evidence but matches particular area of need for some children with autism.

Single element addressing one aspect of ASDs. For use combined with other ASD specific elements.



Music Therapy

Good quality study (Lim, 2010; SMRS score of 3.975) comparing music training, speech training and control using appropriate videos over 3 days. Music and speech groups both increased verbal production compared with controls (significant differences, large effect size); low functioning participants showed greater improvement with music training than speech training.

2 low quality studies identified in Comparative Effectiveness Review (2011) describing outcomes for joint attention and communication skills.


Aims to address core autism features of social interaction and communication. Would need to be used in conjunction with other treatments, rather than as a stand-alone intervention.

Some limited research evidence of effectiveness for communication. Would need to be used in conjunction with other treatments, rather than as a stand-alone intervention. Would need to meet best practice guidelines.

Service based and/or not specific to ASDs

‘Super-nanny’ – whole family support provided by a mental health nurse in the family home using a DSP approach

No direct evidence for or against ‘super-nanny’ approach.

DSP is an approach supported by some limited evidence; however, it would need to be operationalised appropriately to meet key effective elements and principles of good practice.



Unclear whether any core features of autism are addressed.

Not multi-disciplinary, appears to be delivered by nurse, rather than psychologist.



Limited information about components. No information about how good practice principles or key effective elements are addressed. Not multidisciplinary. Query whether this service is specific to autism.

Phonological Awareness Groups, Literacy groups

Phonological awareness relates to development of literacy skills. No evidence that children with high functioning autism (i.e. those with good verbal language skills) have literacy difficulties greater than the typical population.


Not addressing core features of autism or established associated features.

Limited relevant rationale, not related to functional language and/or communication development. Need to question whether groups were run by a speech pathologist, teacher, OT or psychologist, rather than a therapy aide (unqualified).

Aquatic OT 10 Week Program

One small survey regarding clinicians’ perceptions of the benefits of aquatic therapy, though within a Sensory Integration (SI) framework (Vonder Hulls et al. 2006).

One conference abstract (Daniels & Mahmic 2006) relating to this specific intervention, aim of the program to foster interaction and communication between child and parent in a natural setting rather than swimming, sensory or motor skills.

Children made gains in goals, parents were able to identify many areas of benefit for both their children and themselves.

Very limited study.



Limited evidence that general aquatic interventions are relevant to the core features of autism.

In this service, however, the weekly pool sessions focused on developing: movement in the water; play skills; communication; independence and consistent routines, parent interaction and education, various communication aides.

Potential to meet some good practice/effective elements guidelines, would need to be part of a more comprehensive service and thoroughly checked for effective elements

Abstract of Aquatic Therapy Program www.icms.com.au/apc2005/abstract/36.htm

Limited direct or indirect evidence for rationale, however, in this service, the focus on communication, routines and interaction mean that it may be part of an overall comprehensive program.





Aquatic OT School Holiday Intensive Program

As above

As above

As above




Fast ForWord Program

Computer based, intensive

Designed to improve oral language and literacy


Strong et al. (2011) meta-analysis, PRISMA protocol. Included only RCT, had to include standardised measures of language, oral or written. All included studies were school aged. Not specific to autism. Conclusion: There is no evidence from this review that the program is effective as a treatment for children’s reading or expressive or receptive vocabulary weaknesses.

Russo et al. (2010) – study of ASD children and FFW, n=5, mean age 9 years, there is a control but it is non-randomised, biological outcome measures but no measure of language, behaviour, adaptive functioning or school performance. There is no verification of diagnosis, a variety of diagnoses (autism, Asperger’s and ASD) and restrictive inclusion criteria (normal IQ and language abilities). Not relatable to an EI population.

SMRS score 1.51 (SMRS scores of 0 or 1 indicate that insufficient scientific rigor has been applied to the population of individuals with ASD. There is insufficient evidence to even suggest whether a treatment may or may not have beneficial, ineffective, or harmful effects.)

Intensive computer program designed to improve literacy and oral language. No relationships to good practice principles for young children with autism (i.e. not autism specific, does not address the core features of autism, not multidisciplinary, not functional approach to challenging behaviours, limited family involvement etc.)



The best available meta-analysis of randomised controlled trials suggests there is no evidence that Fast ForWord (FFW) is an effective treatment for typically developing children with language or literacy difficulties

The only study found of ASD and FFW is of poor quality with no measures of functioning

There is no Type II evidence or rationale that would suggest that FFW would match the learning strengths/deficits of children with ASD

FFW does not match the best practice guidelines set out in Prior & Roberts (2006)






PROMPT

PROMPTs for Restructuring Oral Muscular Phonetic Targets



One study of PROMPT with children with autism (Rogers et al. 2006). Study design single subject design (5 participants), meaning that each child acted as their own control, scattered results (1 child showed improvement on formal assessment, 2 of 5 increased their spoken words, 1 child regressed).

PROMPT is a treatment designed to impact on motor aspects of speech production, originally designed for children with significant motor speech disorders (e.g. childhood apraxia of speech).

Limited evidence of efficacy with children with motor speech disorders

Limited evidence that childhood apraxia of speech is prevalent within the autism population (Shriberg et al. 2011)


Limited evidence for rationale for use.




Parent and family support


Early Bird Advanced training


Parental needs for emotional support, education and training are well established (see Roberts & Prior, 2006 for discussion). Family involvement is one of the key effective elements of early intervention and appropriate consideration of family needs is a component of good practice. Current research indicates that there is preliminary empirical support for parent training on child outcomes:

From the Comparative Effectiveness Review (2011)

“Less intensive interventions focusing on providing parent training for bolstering social communication skills and managing challenging behaviours have been associated in individual studies with short-term gains in social communication and language use. The current evidence base for such treatment remains” insufficient, with current research lacking consistency in interventions and outcomes assessed (p.ES-7).

Any training provided for parents by approved service providers must adhere to the key elements of effective early intervention identified in Roberts & Prior (2006) and the current review, particularly with regard to:

autism specific curriculum, addressing the core features of ASDs and/or associated features

functional approach to challenging behaviours

predictability and routine

visual supports

multidisciplinary team involvement wherever appropriate





Individual Parent Counselling




Family Camp




ABA Parent Training




Individual Family Psychological Therapy




Intensive Family Support – Family Therapists




Parent/Family Workshops and Sibling Workshops










Teacher/centre support




Parent/teacher training

Teacher training is not an approved service under the current guidelines.

Consideration should be given to funding services that allow for collaborative planning (e.g. Individual Education Program (IEP) meetings) and individual visits to children’s everyday settings (such as preschools and childcare) to facilitate generalisation of skills, appropriate behaviour support, use of visual supports and transition, as per the established principles of good practice.






Advanced Behaviour Management
teacher training




Coaching for preschool / childcare staff




Educational Services. Training for teachers




Let's Link: Mainstream child care setting support for staff




Other




Physiotherapy / motor skills

Limited research evidence regarding physiotherapy in autism. Consideration may be given to children with Rett’s syndrome.





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