We break down three main autism intervention approaches, and provide you with information that will help you improve on your abilities to recognize which particular autism intervention might be best for a specific patient.
Published On: 10/25/2021
Duration: 19 minutes, 24 seconds
Related Article: “Approaches to Autism Intervention” The Carlat Child Psychiatry Report, April 2021
Joshua Feder, MD, and Mara Gover, LCSW, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Sandbank M et al, Psychol Bull 2020;146(1):1-29.
Rogers SJ et al, J Am Acad Child Adolesc Psychiatry 2021;60(6):710-722.
For more information on ABA and NDBI: www.bacb.com.
For more information on DRBI: www.icdl.com and www.profectum.org.
Dr. Feder: As clinicians we are often faced with questions from families about the “best” program for autism intervention. While autistic children may receive a range of services including speech and language therapy, occupational therapy, and social skills help, some in the community, the anchor to most programs is some form of behavioral health treatment. The latest issue of The Carlat Child Psychiatry Report includes a clinical update describing the three main approaches to autism intervention. In this podcast, Mara and I will break down three main autism intervention approaches, and provide you with information that will help you improve on your abilities to recognize which particular autism intervention might be best for a specific patient.
Welcome to The Carlat Psychiatry Podcast.
This is a special episode from the child psychiatry team.
I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice.
Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice.
In the past couple of decades, the field of autism intervention has evolved into three main evidence-based approaches, traditional Applied Behavioral Analysis (ABA), Developmental Relationship-Based Intervention (DRBI), and Naturalistic Developmental-Behavioral Intervention (NDBI).
Dr. Feder: Before we do a deep dive into each intervention, let’s briefly describe them.
Mara: ABA is the best-known type of intervention. It is based on operant learning theory, meaning that behavior is learned based on what happens before the behavior (antecedent) and what happens after it (reward). Since the groundbreaking 1987 study by Dr. Lovaas which indicated a positive relationship between individual behavior modification and ‘normal intellectual and educational functioning’, there have been many additional studies.
Dr. Feder: Some drawbacks of the ABA approach include poor maintenance of skills, poor generalization of learning to new situations, and reliance on adults to tell the child what to do (prompt dependency).
In contrast to behavioral intervention, DRBI is a parent mediated intervention (PMI) where the primary focus is on training parents and other caregivers to build and use warm, meaningful interactions to help the child to function better in communicating, learning, and problem solving.
Mara: An adult takes a child’s interest and builds on it, while making the activity an emotionally meaningful experience. These fun reciprocal interactions help the child extend their capacities for creating and working with ideas, communicating, and social connection.
Dr. Feder: In an effort to address some of the drawbacks of traditional ABA, NDBI incorporates more choices for children to gain their buy-in to the treatment. The learning is carried out in natural situations such as play or daily routines and involves parents, and the rewards given are related to the child’s interest. For example if a child performs the desired behavior, they get the toy they want, rather than a sticker or other reward that may be preferred by other children.
Mara: For example, if a child performs the desired behavior, they get the toy they want, rather than a sticker or other reward that may be preferred by other children. Some goals in NDBIs are chosen based on developmental abilities, such as pointing to share interest (also known as joint attention), eye contact, and having the child imitate an adult, rather than a specific behavior, such as increasing vocabulary.
Dr. Feder: When deciding which intervention might be best for a particular child, the time investment of each intervention must be considered. In addition, the amount of time that the parents of your patients can commit to their child's treatment is also a critical factor in determining which intervention is most optimal.
Mara: While mostly focused on younger children, ABA and DRBI approaches are used for children for all ages and abilities and any behavioral challenge. NDBI is more narrowly focused on children 12 and younger.
Dr. Feder: The recommendation of 40 hours of ABA therapy per week is not uncommon. Which is a huge time commitment for any child. And it can potentially lead to parents becoming discouraged if their child does not progress as rapidly as they may have expected they would from a 40 hour/week commitment.
Mara: Direct DRBI is usually provided for fewer hours per week than ABA, with parents implementing the model throughout the week, which naturally extends the child’s engagement in the therapeutic process.
Dr. Feder: While DRBI may also employ some additional hours with an interventionist to expand the range of people and experiences for the child, on balance DRBI requires less time and cost in most cases.
Mara: So if 40 hours per week of ABA is commonly recommended, then it must be the most effective autism intervention approach, right?
Dr. Feder: Well, not exactly. The most recent edition of The National Clearinghouse on Autism Evidence supports specific practices that fall within all three of these main branches of autism intervention. And the American Academy of Pediatrics also endorsed all three interventions in their recent guidelines.
Mara: Okay. Are there any particular interventions that standout from the rest in terms of their quality of evidence?
Dr. Feder: The world of autism research is vast, and it can be difficult to find studies with quality evidence. Luckily, the quality of autism research has been steadily increasing over the years. Nevertheless, there are high quality studies that we can confidently use to inform our clinical care.
Mara: Like Dr. Sandbank’s 2019 Project AIM study?
Dr. Feder: Yes, exactly! In this study, Dr. Sandbank and her colleagues performed a comprehensive systematic review and meta-analysis of autism interventions for young children, ages 0-8 years old. They gathered 1,615 effect sizes from 130 independent participant samples. Their total sample size included 6,240 participants.
Mara: What makes this an excellent study is that they were able to restrict effect sizes from included studies that did not meet prespecified study quality indicators. Meaning, they were able to evaluate whether the effect sizes from a certain study were reliable. In other words, they did a quality check of each study, and they ultimately only included studies that were of high quality.
Dr. Feder: That’s right! And here’s what’s interesting. When they did not include the study quality indicators in their analysis, they found significant positive effects for all three autism intervention approaches, including behavioral, developmental, and NDBI intervention types. But when they limited their analysis to effect sizes only from RCTs and took the quality indicators into account, they found evidence of positive summary effects for only the developmental and NDBI intervention types, and these interventions had moderate effects. And this is huge because as we previously mentioned ABA is the most commonly recommended intervention, yet Dr. Sandbank’s study reveals that there isn’t enough quality evidence from RCTs to even compare the effect sizes of ABA interventions to the other autism approaches.
Mara: There just isn’t enough quality evidence for ABA interventions to compare them to the other approaches. This doesn’t mean that they necessarily lack efficacy.
Dr. Feder: And that’s not all Mara. When Dr. Sandbank and his team limited their effect size analysis to only RCTs with outcomes that did not have any risk of detection bias, NONE of the three main approaches to autism intervention showed significant effects on any outcome.
As a side note, detection bias is a systematic error which affects the internal validity of a study through the inaccurate recording of outcomes. It occurs when the assessor knows whether the subject is in the treatment or control group, also known as the unblinding of the outcome assessor. This can lead to an overestimation of the treatment benefit for the experimental group and an underestimation of the placebo effect or benefit from a specific control treatment for the control group on the measured outcomes in a study.
Mara: Wow! We really do need more high quality research in the field of autism.
So where does this whole 40 hour per week recommendation come from? If we can’t say with 100% certainty how effective ABA interventions are, how can responsible clinicians recommend that a child must undergo 40 hours a week of ABA treatment?
Dr. Feder: Well, we can’t. And we shouldn’t just casually recommend 40 hours of ABA to all of our patients. Or even just recommend ABA because the guidelines say to do so. Each child needs their own personalized treatment plan, and this was made clear in a recent RCT by Dr. Rogers and colleagues.
In their 2020 study, they compared 2 categories of independent variables: treatment intensity and intervention approach.
Mara: 87 autistic children, with a mean age of 23.4 months, were randomized to one of two treatment arms within each independent variable category. So children were randomized to either NDBI or ABA interventions and to receive either 15 or 25 hours of intervention per week. The interventions were administered for 12 months by trained research professionals.
At four different time points, the four dependent variables were assessed. These included nonverbal ability, expressive communication, receptive language, and autism symptom severity.
Dr. Feder: And surprisingly, the type of intervention, NDBI or ABA interventions, and the amount of intervention given, 15 vs 25 hours per week, had no effect on any of the four dependent variables. In other words, they did not find any association between the type and/or amount of intervention administered with improvement on any of the four outcomes.
Mara: In addition, there was no correlation between initial autism symptom severity and greater improvement with one of the two intervention modalities. And they found very limited evidence supporting that initial symptom severity can be utilized to predict a better response to a certain intensity of treatment, or the amount of hours a particular intervention should be administered per week.
So how do we know which treatment option is best for each of our patients?
Dr. Feder: Each patient is different from one another and unique in their own way, which is why their treatment should be as personalized as possible. Also, the amount of time our patient’s parents can commit to their child’s treatment and the amount of involvement in the treatment that the parents can give needs to be incorporated into our recommendation.
Parents may be baffled by the autism treatment options and the various opinions that they hear. Review the basics of the three types of treatments and help them decide what fits their own family style and values.
Mara: For instance, a family that prioritizes learning specific facts and following directions may do better with traditional ABA, and a family that is more free flowing in their interactions may do better with DRBI.
Dr. Feder: We should explain to families how each of these different programs work.
Behavioral programs are more structured, and the interventionist will work directly with the child to teach them specific skills. They may also teach parents how to use some of these strategies. Developmental programs use natural interactions such as play and focus on parents’ relationships with their child and to build better communication and learning.
Mara: With the plethora of online information surrounding which treatment is best for different children, it can be hard for families to know which information they can trust and what information should be incorporated into their decision.
It’s important to acknowledge that there are many opinions about what is the ‘right’ treatment for kids with autism. Emphasize the need to figure out what might work best for each family. They can try it out and see how it works. Families often try different styles as their needs change.
Dr. Feder: Many families may wonder if they can do different types of interventions concurrently. And the answer is yes, they can.
Many children receive some ABA services at school, and developmental services, such as Floortime® after school, or other combinations of services. This can be successful if there are clear distinctions about the developmental areas to be addressed. For example, behavioral intervention can be focused on specific language or cognitive skills, activities of daily living, or other routines. Floortime could focus on play skills, parent and peer interactions. However, confusion can arise if both developmental and behavioral approaches address the same activity, such as feeding, sleep or behavioral issues. If a child is receiving both types of intervention, you can facilitate providers to coordinate their efforts and avoid conflict.
Mara: But Dr. Feder won’t it be extremely expensive for families to do non-ABA interventions? Since the Affordable Care Act mandates that all commercial insurance companies and Medicaid must provide ‘Behavioral Health Treatment’ for autism.
Dr. Feder: Actually, this is a common misunderstanding. Many insurance companies interpret this to mean ABA, however all evidence-based treatments are included. Although you should direct families to go to their insurance company and ask for the treatment they desire, it is important to keep in mind that the choice of intervention approach may be dictated by the available funding source and options available in their community, rather than the best fit for the child and family. Traditional ABA has been easier to obtain with insurance, however developmental options are becoming more available, and good informed consent includes helping the family to advocate for the choice they feel is best for their child.
Mara: For more information on ABA and NDBI, a good resource is www.bacb.com. For DRBI, good resources include: www.icdl.com and www.profectum.org.
And if you’re interested in reading the research studies by Dr. Sandbank and Dr. Rogers, feel free to click the links attached to this webpage.
Dr. Feder: Overall, the choice of autism intervention is not a one-time decision. It’s an on-going process of monitoring and evaluation. Any program may be more or less effective depending on the skills of the particular interventionist as well as the match to the family and the developing child. Together, you can guide families in navigating these complex decisions.
Dr. Feder: The clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust.
Mara: As always, thanks for listening and have a great day!
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