New Autism Guidelines Address Nonmedical Interventions

Pam Harrison

November 05, 2012

Nonmedical interventions that address cognitive function and core deficits in children with autism spectrum disorders (ASDs) have been evaluated and consensus guidelines have been developed in an effort to improve access to services.

Margaret Maglione, MPP, RAND Corporation, Santa Monica, California, and other members of the Technical Expert Panel (TEP) agreed that certain behavioral and developmental programs and interventions have demonstrated efficacy in the treatment of cognitive function and core deficits in children with ASD.

They also agreed that children with ASD should have access to at least 25 hours per week of a comprehensive intervention that addresses social communication, language, play skills, and maladaptive behavior.

"The strength of evidence of efficacy of interventions designed to address the core deficits of autism varies among approaches," TEP members state.

"However, we feel that the level of evidence of effectiveness of these programs is sufficient to make availability a worthy goal."

The guidelines are published in the November issue of Pediatrics.

Higher Intensity, Longer Duration

Members of TEP, including practitioners, researchers, and parents, narrowed their evaluation down to an analysis of 33 systematic reviews and 68 intervention studies not already included in the reviews.

They then assessed the overall strength of evidence for the effectiveness of the intervention using guidance suggested by the US Agency for Healthcare Research and Quality.

Only guideline statements that had 100% approval from all members of the panel were included in the published guidelines.

In evaluating comprehensive programs that target multiple core deficits, TEP found moderate evidence of effectiveness for behavioral programs based on Lovaas/applied behavioral analysis (ABA) in the areas of language, adaptive skills, and IQ.

They also found moderate evidence supporting the effectiveness of a dose-response relationship for intensive behavioral interventions on both language and adaptive skills outcomes.

"Higher intensity (hours per week) and higher duration (in months or years) led to better outcomes," they add.

For individual programs, they found moderate evidence supporting the Early Start Denver Model program for gains in cognitive ability and other core deficits in preschool-aged children.

In contrast, evidence supporting the Scottish Autism Center comprehensive program along with other programs including STAR (Students Teachers Achieving Results Program), the Walden Toddler Program, and ABA combined with TEACCH (Treatment and Education of Autistic and Communication Handicapped Children) was low.

TEP also found moderate evidence supporting social skills programs designed for higher-functioning children and adolescents but could not determine which approaches are best for which children.

They also found that effective social skills interventions took place in both individual and group settings.

For children with no or limited language, TEP found moderate evidence supporting the Picture Exchange Communication System but felt there was insufficient evidence to support augmentative and alternative communication devices.

They also rated evidence for auditory integration training as "moderate for ineffectiveness."

Comprehensive, Timely Treatment

"Comprehensive programs have the potential for remediating multiple core deficits simultaneously and allow for potential synergistic effects of intervention components," the authors write.

"Timely treatment can [also] help maximize the impact of interventions on young children's development and prevent further developmental delays or deterioration of functioning in older individuals.

"Thus, individuals with ASDs should receive comprehensive services within a reasonable time frame following identification [of ASD]".

As TEP also observe, none of the evidence reviewed for the new guidelines reached a high level of strength and more large, well-designed controlled trials are needed.

Few head-to-head trials have been done in ASD interventions, so TEP could not determine whether any specific programs were superior to others.

Studies have typically been underpowered, and few studies provided long-term follow-up or evaluated interventions for preverbal or nonverbal children.

These limitations were taken into consideration when formulating priorities for future research, the authors note.

The authors have disclosed no relevant financial relationships.

Pediatrics. 2012;130(suppl2):S169-S178. Full article

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