Randomized trial of intensive early intervention for children with

Seventeen studies were case series; 2 were randomized controlled trials. We rated 1 study as good quality, 10 as fair quality, and 23 as poor quality. The strength of the evidence overall ranged from insufficient to low. Specific parent-training approaches yielded gains in short-term language function and some challenging behaviors. Both groups increased standardized intellectual ability scores over the follow-up period, with the COM group increasing Thus, the lack of statistically significant group differences was due to variability i.

The observed developmental gains in intellectual ability for both groups and decreased symptom severity for the ESDM group occurred in the context of community intervention and educational services. During the follow-up period, we assessed the number of hours of intervention that parents spontaneously sought for their children after completion of the RCT. Parents of children in the ESDM group reported a reduction in one-on-one intervention hours from Parents of children in the COM group reported one-on-one intervention hours were reduced from 9.

The ESDM group increased their performance during a period of substantially reduced one-on-one services, suggesting that they may have increased their ability to learn from less restrictive, more naturalistic environments as a result of early intervention. It is important to consider characteristics of this study that may limit the generalizability of these findings. Although this was a strength of the study in terms of making valid group comparisons, it may suggest that the COM group had greater access to intervention than is typical.

One effect of enrollment was that each family received early diagnosis and referrals to community services by a team of expert clinicians. In addition, this sample was recruited from a geographically constrained area, 30 minutes from an urban university. This was necessary in order for the university-based intervention team to be able to carry out high-intensity, in-home services without incurring extraordinary transportation expenses.

But this meant that families from the COM group lived in close proximity to a number of excellent private intervention providers.

Families that participated in this longitudinal study may differ from other families who did not participate in terms of ability and motivation to obtain high levels of early behavioral intervention for their children.

We also observed high numbers of intervention hours in the comparison group from an RCT of a low-intensity, parent coaching intervention that we conducted with a different sample. But in a very short time, by the end of the twelve-week intervention period, there was a significant difference in the number of treatment hours children aged 12—24 months were receiving weekly, with the comparison group receiving more intervention P-ESDM 1.

It is possible that families who enroll in an RCT and are randomized to the control group might make even more effort to obtain intervention when they are not assigned to the intervention group. Thus, participating families, even those who are randomized to community intervention, may receive more and earlier intervention than other families in the same community. However, there is a critical need to evaluate the effectiveness of this and other early autism intervention programs in culturally diverse populations, less-educated families, and lower resource, rural, or military communities.

Measurement issues may also constrain the types of observations we are able to make. For example, our measure of symptom severity, the ADOS, has four different modules based on the verbal ability of the participant, ranging from Module 1 for non-verbal individuals to Module 4 for highly verbal adults.

These modules contain a number of different activities and reflect qualitative differences in the expectations for a non-verbal individual as compared with individuals with more advanced communication abilities. Thus, individuals who have better verbal abilities have to meet higher expectations for social interaction. Thus, differences in symptom severity as measured by the ADOS should be interpreted cautiously. Attrition during the follow-up period was minimal and balanced across groups 3 in each , but should be noted.

An inherent weakness in the community intervention-as-usual study design is the impossibility of adequately describing and quantifying the intervention received in community settings. This difficulty is amplified in the follow-up study period when children in both groups receive non-randomly assigned intervention of differing types and intensities.

Although we carefully assessed the hours of intervention and general categories of intervention received, we were not able to create a single metric to directly compare community-delivered interventions due to unmeasured differences in implementation and practices.

Thus, the impact of intervention received after the study period is unknown. However, we can observe that the comparison group in the present study appeared to have more positive outcomes than the comparison group in the only other long-term follow-up study of a comprehensive, intensive intervention. We suspect that services for individuals with autism have greatly improved across many communities in the 20 years since the first long-term follow-up study 7 was conducted.

Future studies are needed to replicate these findings in independent samples, extend these findings to older ages, and investigate other styles and approaches to intervention. These results demonstrate that significant, longer-term gains are possible with early, comprehensive, intensive intervention, and that these gains are evident not only in intellectual ability, language, and social behavior, but also in reductions in ASD symptoms.

This study replicates the results of McEachin et al. A recent cost-comparison study of early intensive behavioral intervention in the Netherlands suggests that lifetime cost savings could be over one million Euros per individual. Early intensive behavioral intervention has been found efficacious in improving developmental outcomes for young children with autism spectrum disorder.

Children were able to maintain the developmental gains they made in early, intensive, in-home intervention over a two-year follow-up period. These children did not exhibit developmental regression or lose skills, even after substantial reductions in services. Intellectual, language, and adaptive functioning gains made as a result of early intervention may generalize to new domains of functioning, such as reduced ASD symptom severity, two years later.

Research is needed to extend these results to a more diverse range of families and communities to assess the effectiveness of early autism intervention. The authors wish to thank the children and parents who participated in this study and Lena Tsui, MS, of the University of Washington Autism Center, for her devotion to keeping in touch with these children and parents. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication.

As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Disclosure: Drs. Munson, Greenson, and Winter report no biomedical financial interests or potential conflicts of interest. Sally J. Rogers, University of California, Davis. National Center for Biotechnology Information , U.

Author manuscript; available in PMC Jul 1. Find articles by Annette Estes. Find articles by Jeffrey Munson. Rogers University of California, Davis. Find articles by Sally J. Find articles by Jessica Greenson.

Find articles by Jamie Winter. Find articles by Geraldine Dawson. Author information Copyright and License information Disclaimer.

Copyright notice. See other articles in PMC that cite the published article. Abstract Objective We prospectively examine evidence for the sustained effects of early intervention based on a follow-up study of 39 children with ASD who began participation in a randomized clinical trial testing the effectiveness of the Early Start Denver Model ESDM at age 18—30 months.

Results The ESDM group, on average, maintained gains made in early intervention during the 2-year follow-up period in overall intellectual ability, adaptive behavior, symptom severity, and challenging behavior. Conclusion These results provide evidence that gains from early intensive intervention are maintained 2 years later.

Families were given resource manuals and reading materials at baseline and twice yearly throughout the study. In the greater Seattle area, there are a number of Birth to Three centers that provide interventions, speech and language therapy, and occupational therapy. Developmental preschool programs vary but typically include special education and related services.

There are a number of private ABA providers in the community. The effect of ESDM intervention was assessed by using repeated-measures analysis of variance, with a priori contrasts that compared baseline scores with 1- and 2-year outcome scores. No serious adverse effects related to the intervention were reported during the 2-year period. Table 2 displays statistics for 1- and 2-year outcomes, change scores relative to baseline, and group comparisons for primary and secondary measures.

Significant intervention effects were found for cognitive ability after 1 year on the MSEL composite standard scores. The visual reception subscale was the only individual subscale on the MSEL on which the groups significantly differed at the 1-year outcome. The ESDM group gained 5. The ESDM group improved As a whole, children gained raw score points in the daily living skills subscale of the VABS; however, progress was much slower in relation to the VABS normative sample between baseline and 1 year.

Two years after the baseline assessment, the ESDM group showed significantly improved cognitive ability, measured by MSEL composite standard scores, which increased The bulk of this change seems to have been a result of receptive and expressive language, which showed increases of At the 2-year outcome, 15 Recommendations by the American Academy of Pediatrics 9 that all children be screened for autism at 18 months of age oblige the development of interventions that are appropriate for toddlers with ASD.

To our knowledge, this study is the first to demonstrate the efficacy of an intensive intervention designed for toddlers with ASD as young as 12 months of age. After 2 years of intervention, children provided with the ESDM 19 showed significant improvements in IQ, adaptive behavior, and diagnostic status compared with children who received community interventions.

Consistent evidence of improvement in communicative abilities in the ESDM group was found, as demonstrated by gains in receptive and expressive language scores on the MSEL subscales and the VABS communication subscale.

Significant improvement for the ESDM group was found for overall adaptive behavior, communication, daily living skills, and motor skills. Specifically, the ESDM group, although still significantly delayed in adaptive behavior, was able to keep pace with the rate of change of the VABS normative sample, whereas the community-based intervention group continued to fall farther behind in adaptive behavior.

Given the importance of adaptive behavior for everyday functioning at home and school, the fact that the ESDM group did not continue to fall farther behind is likely to affect ability to function in less-restrictive environments. This demonstrates that the ESDM intervention accelerates overall development and is generalizing to everyday life. These diagnostic assessments were conducted by experienced clinicians who were naive with respect to intervention-group status.

However, this change in diagnostic severity was not reflected in significant differences in the ADOS severity scores. However, other behaviors, including parental report, also contribute to overall clinical diagnosis.

The repetitive-behavior scores also did not change over time in either group. The group differences reported from our study are larger than those produced by other comparative trials of developmental behavioral approaches, which were conducted for briefer periods of time and with fewer hours of delivery per week.

The results of this study suggest that the ESDM model, 19 an intervention approach that uses teaching strategies of ABA that are delivered within an affectively rich, relationship-focused context, can be effective for improving outcomes of young children with autism. Previous studies on the efficacy of early behavioral intervention for improving outcomes for preschool-aged children with autism have yielded promising results. However, no randomized clinical trials of early developmental behavioral intervention designed for toddlers with autism have been conducted to date.

This study assessed the efficacy of the Early Start Denver Model, a comprehensive developmental behavioral intervention, for improving outcomes of toddlers with ASD. We acknowledge the contributions of the parents and children who took part in this study and the support and effort of numerous undergraduate and graduate students and staff who are part of the University of Washington Autism Center.

This trial has been registered at www. National Center for Biotechnology Information , U. Author manuscript; available in PMC Jul Author information Copyright and License information Disclaimer. Copyright notice. The publisher's final edited version of this article is available at Pediatrics. See other articles in PMC that cite the published article.

METHODS Forty-eight children diagnosed with ASD between 18 and 30 months of age were randomly assigned to 1 of 2 groups: 1 ESDM intervention, which is based on developmental and applied behavioral analytic principles and delivered by trained therapists and parents for 2 years; or 2 referral to community providers for intervention commonly available in the community.

Keywords: autism, behavioral intervention, cognitive function, developmental outcomes, early intervention. Participants Participants were recruited through pediatric practices, Birth to Three centers, preschools, hospitals, and state and local autism organizations.

Open in a separate window. Measures Autism Diagnostic Interview—Revised The toddler version of the Autism Diagnostic Interview—Revised 13 is a semi-structured parent interview that assesses autism symptoms across 3 domains: social relatedness; communication; and repetitive, restricted behaviors.