Review article
Parent inclusion in early intensive behavior interventions for young children with ASD: A synthesis of meta-analyses from 2009 to 2011

https://doi.org/10.1016/j.ridd.2013.06.007Get rights and content

Highlights

  • Reviewed six meta-analyses on EIBI in children with autism including 21 studies.

  • Significant moderate to large effect sizes for EIBI over control group.

  • Parent inclusion in skill generalization favors increase in EIBI effectiveness.

  • Treatment variables impact staff-provided EIBI.

  • Child characteristics at intake affect parent-mediated EIBI.

Abstract

This paper presents a comprehensive synthesis of six meta-analyses of early intensive behavioral interventions (EIBI) for young children with autism spectrum disorders published from 2009 to 2011. Analysis was conducted in three steps to account for different formats of treatment delivery and the extent to which parents took part in treatment. The three components of the synthesis were (a) descriptive analysis, (b) effect size analysis, and (c) mediator analysis via partial correlation and linear regressions. We completed the analysis by obtaining standardized mean difference effect sizes for 13 comparative studies ordered by comparison study type and 22 mean change effect sizes ordered by treatment delivery type. Results suggest that EIBI leads generally to positive medium-to-large effects for three available outcome measures: intellectual functioning, language skills and adaptive behaviors. Although favorable effects were apparent across comparative studies, analysis by type of delivery format revealed that EIBI programs that include parents in treatment provision are more effective. Mediator analyses suggest that treatment variables and child characteristics impact program effectiveness when accounting for the extent of parent inclusion. Clinical implications toward individualized treatment tailoring are discussed.

Introduction

Autism is a neurodevelopmental disability specifically identified as an autistic disorder and is one of the five categories of pervasive developmental disorders (PDDs) classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). Autism is characterized by qualitative deficits in social interaction and communication and restricted, repetitive and stereotyped behaviors, interests and activities. Children with an autistic disorder have more profound difficulties, and are more likely to have associated speech and intellectual disability than those with other diagnoses within the PDDs (Volkmar, Lord, Bailey, Schultz, & Klin, 2004). Over the past two decades, there has been increasing interest in developing effective interventions for young children with autism spectrum disorder. Researchers have generally accepted that early intensive behavioral interventions (EIBI) are effective (Eikeseth, 2009, Makrygianni and Reed, 2010, Peters-Scheffer et al., 2011, Peters-Scheffer et al., 2012, Viruès-Ortega, 2010). Although EIBI programs vary slightly in their approaches, all programs are characterized by the following essential features (Peters-Scheffer et al., 2012): (1) based on ABA principles, (2) comprehensiveness, (3) systematic skill-building with transition to natural environments, (4) individualized treatment planning, (5) scientific evaluation of effectiveness, (6) beginning treatment early, (7) a low child–staff ratio, and (8) caregiver involvement and training.

There is a growing body of empirical evidence that EIBI treatment is effective for both the deficit features of autism and the expressed behavioral features (Lord et al., 2005, Makrygianni and Reed, 2010, Matson and Smith, 2008, Rogers and Vismara, 2008, Spreckley and Boyd, 2009, Zachor et al., 2007). In particular, intervention outcome studies found EIBI to be superior to an eclectic treatment approach in improving cognitive abilities, language skills and adaptive behaviors (Eikeseth et al., 2002, Eikeseth et al., 2007, Eldevik et al., 2006, Perry et al., 2008, Reed et al., 2007a, Smith et al., 2000b), and in lessening autism severity (Zachor and Ben-Itzchak, 2010, Zachor et al., 2007).

However, since the first empirical results of the effects of EIBI (Lovaas, 1987) and its various replications (Anderson et al., 1987, Birnbrauer and Leach, 1993, Cohen et al., 2006, McEachin et al., 1993, Sallows and Graupner, 2005, Smith et al., 2000a, Smith et al., 2000b) raised a debate on the great variability in outcome within and between studies. Gains were not universal, with some children making rapid progress, while others made only modest progress or showed little or no change (Eikeseth, 2009, Peters-Scheffer et al., 2011, Reichow and Wolery, 2009).

In his overview on meta-analyses existing on EIBI interventions for young children with autism spectrum disorders (ADSs), Reichow (2011) analyzed five meta-analyses that have been published between 2009 and 2010 in peer-reviewed journals (Eldevik et al., 2009, Makrygianni and Reed, 2010, Reichow and Wolery, 2009, Spreckley and Boyd, 2009, Viruès-Ortega, 2010), and highlighted key differences and potential confounds —ranging from effect size calculations, small sample sizes, lack of reference to control groups, randomization issues, participant versus professional data, and standardized group comparison methodology—that might have led to discrepant findings across these meta-analyses,. The crucial question in EIBI research has since shifted from general effectiveness toward understanding why outcomes vary across different children and for which children is EIBI most and least effective. Following this, many studies are now analyzing the different factors, to see which enhance or detract from treatment effectiveness. It has been established that mainly child factors (e.g., age at treatment intake; autism symptom severity; pretreatment IQ, language and adaptive functioning; co-morbid conditions) and treatment characteristics (e.g., treatment intensity; treatment duration; treatment quality; staff training; supervision) contribute to these differences in outcome (Ben-Itzchak and Zachor, 2007, Davis et al., 2002, Eldevik et al., 2006, Granpeesheh et al., 2009Lovaas, 1987, Peters-Scheffer et al., 2010, Smith et al., 2000b). Unfortunately, because studies focus on the analysis of group differences, existing research provides only limited information on the outcome for individual children and few data on moderators or mediators of therapy (Lord et al., 2005, Kasari, 2002). It is also difficult to draw reliable conclusions about possible child, family, or environmental variables associated with outcome because most studies involve relatively small numbers of participants. One way to approach this issue is to accumulate sample size in meta-analyses. Three of the five meta-analyses included in the Reichow overview (2011) achieved enough statistical power to conduct such moderator analyses (Makrygianni and Reed, 2010, Reichow and Wolery, 2009, Viruès-Ortega, 2010). In brief, Makrygianni and Reed (2010) found large relations based on partial correlations suggesting larger gains (a) in IQ and adaptive behaviors by higher treatment intensity, (b) in adaptive behaviors by greater treatment duration, (c) in adaptive behaviors by inclusion of parent training, and (d) in adaptive behaviors and language by better pretreatment adaptive behavior. No statistically significant relations were found for pre-intervention chronological age, IQ, or language ability. Reichow and Wolery (2009) did not find significant relation to change in IQ by applying analysis of variance methods. Weighted multiple regression revealed that supervisor training using UCLA procedures led to greater increases in IQ, whereas treatment density, duration, total hours of treatment, pre-intervention chronological age, and pre-intervention IQ did not interact with outcome. Finally, Viruès-Ortega (2010) found larger differences in language scores by treatment duration by using meta-regression and higher adaptive behaviors scores by treatment intensity by using dose–response meta-analysis methods. No effects were found for child (pre-intervention age and pre-intervention IQ) characteristics on post-intervention IQ, language, and adaptive behavior outcomes.

Kasari (2002) claims that one cannot be certain that the moderator effects found would hold if more rigorous scientific designs were applied. A relatively simple example is the treatment intensity debate that sprang from the original Lovaas study (1987)—in which the experimental group received 40 h a week of therapy and the control group 10 h a week—and which claims that the outcome may be due to intensity of treatment rather than any specific feature of the intervention itself (Gresham & MacMillan, 1998). In the majority of successive intervention studies, the alternative intervention has generally been of lower intensity than the EIBI program with which it is compared. In addition, the failure to control for time in intervention means that in some studies the fact that EIBI appears to be more effective than the comparison condition could be due simply to differences in treatment intensity, not quality. Moreover, differences in therapeutic intensity, and in intake and outcome measures, have led to considerable disagreement and controversy among researchers and professionals. Clearer evidence concerning both the optimal duration of therapy and the age at which it should begin could result in the development of better targeted, more cost-effective programs that could then be made more widely accessible to families. Such studies should shed light on which children benefit most from which interventions and the intensity and length of treatment necessary to effect a change. Kasari (2002, pp. 457–458) recommends:

  • (1)

    Comparing one treatment package with another will likely require multisite studies so that adequate numbers of subjects can be randomly assigned to different treatments (…).

  • (2)

    Given both similarities and differences among treatment packages (…), we should carefully examine the components of treatments that are most beneficial (…)—such as intensity of treatment, mode of therapy, different skill targets (…).

  • (3)

    Examining the relationship between pretreatment characteristics, response to intervention, and outcome will provide information on which children benefit most from which interventions (…).

However, given the variability of available data, it is likely that such an analysis at the present time could assess the role of only a very limited number of variables. For such studies to be informative, Howlin, Magiati, and Charman (2009) required from future research the following minimum reporting: (a) baseline data, (b) when treatment begins, treatment duration and intensity, when follow-up occurs, (c), intervention and comparison conditions in both (a) and (b), (d) standard scores, age equivalent scores, and raw scores for all measures of functioning and challenging behaviors, (e) change in autistic symptomatology over time, and (f) measures of family functioning.

Section snippets

Aim of the re-evaluation of existing meta-analysis distinguishing treatment delivery formats

Although it is evident that much effort was employed by the research teams conducting the meta-analyses to recover sample size in order to extend simple effectiveness results and to calculate mediator effects of treatment outcome, all meta-analyses have estimated mediator variables mainly based on best outcome studies by applying a clinical UCLA or Lovaas replication treatment model. It is unlikely that in community-based or parent-mediated programs children obtain the same outcome as in the

Study and sample characteristics

The most frequent type of study conducted across all twenty-one samples was a quasi-experimental group comparison, followed by quasi-experimental single group pre/post designs. A true experimental design was employed only twice. In studies with an experimental design (Sallows and Graupner, 2005, Smith et al., 2000a, Smith et al., 2000b), a random assignment to groups was employed which claimed group equivalence across outcome variables although such cannot be ensured with small sample sizes,

Limitations and discussion

This report represents a re-analysis of existing meta-analyses on the effectiveness of EIBI for children with ASD. The aim of the analysis was to account for differences in effectiveness by considering the extent of parent inclusion in different treatment delivery formats. Therefore, we analyzed study-control outcomes as well as pre–post treatment performances of single study samples. The impact of possible moderator variables on these outcomes was estimated.

Results suggest that comprehensive

Clinical and research implications

Despite the range of limitations—some inherent to the field of EIBI research, some conditioned by the approach of our report—it is possible to come to conclusions concerning future research. It is apparent that methodological issues should be examined and standards regarding group assignment, assessment protocols, type of comparison condition, and selection as well as publication bias should be reevaluated. Kasari (2002) gives a comprehensive overview and a wide range of indications on how to

Role of funding source

The authors are affiliated with the Association “Una Breccia nel Muro” under the sponsorship of the Foundation BNL and the partnership of the Foundation Vodafone Italy.

The sponsors and partners did not have any role in the collection, analysis, and interpretation of data; in writing the report, or in the decision to submit the paper for publication.

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    1

    See the SPC Group members in Appendix.

    2

    References marked with an asterisk indicate studies included in the meta-analysis.

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