Synthesis – senior seminar – behavioral intervention

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Read the following 3 articles and synthesize (Combine the ideas of all three sources into one overall point – DO NOT SUMMARIZE)  them into 1 and half page word document. Also, write a well elaborated question from each reading. Keep in mind the following points when working on this task:

*Questions must be original, thought and not easily found in the articles.

*Follow APA Rules

*Use proper citations

*Use  PAST TENSE when discussing the articles  (Research already took place)

*DO NOT USE the following words: Me, you, I, we.

*Refer to the articles by their AUTHORS (year of publication) 

*DO NOT USE the article name or words first, second, or third.

*DO NOT SUMMARIZE!!!

***MUST FOLLOW ATTACHED SAMPLE

OPINIONS & PERSPECTIVES

None of the As in ABA stand for autism: Dispelling the myths*

KAROLA DILLENBURGER
1

& MICKEY KEENAN
2

1
Queen’s University Belfast, Ireland and

2
University of Ulster at Coleraine, Ireland

Keywords: applied behaviour analysis (ABA), autism spectrum disorder (ASD), misunderstanding

Introduction

Interventions that are based on scientific principles

of applied behaviour analysis (ABA) are recognised

as effective treatments for children with autism

spectrum disorder (ASD) by many governments

and professionals (Office of the Surgeon General,

2000; Ontario IBI Initiative, 2002). However, many

still view ABA as one of many treatments for

autism and contend that it should be part of an

eclectic mix of interventions. This paper addresses

this issue by outlining what ABA is and how ABA is

related to the array of treatments for ASD. With

approximately 1 in 100 children diagnosed with

ASD, it is important for professionals to understand

ABA accurately.

Getting it right

ABA is not a ‘‘therapy for autism’’ (Chiesa, 2005);

instead, it is the science on which a wide range of

techniques are based that have been used to help

people with a variety of behaviours and diagnoses,

autism being one of them.

Like most other sciences, behaviour analysis

encapsulates three distinct but related fields:

(1) Philosophy of the science: behaviourism.

(2) Basic experimental research: Experimental

analysis of behaviour.

(3) Applied research: Applied behaviour analysis

(ABA).

(1) Behaviourism: The philosophy of the science of

behaviour

Behaviourism defines behaviour as anything a person

does. Behaviour can have one or more dimensions,

such as frequency, duration, and/or latency; can be

overt (public) or covert (private); can be observed

and recorded by one (self) or more persons; and is

lawful, in as much as it is influenced by environ-

mental events.

The key point of behaviourism is that what people do

can be understood. Traditionally, both the layperson

and psychologist have tried to understand behaviour by

seeing it as an outcome of what we think, what we feel,

what we want, what we calculate, and etcetera. But we

don’t have to think about behavior that way. We could

look upon it as a process that occurs in its own right and

has its own causes. And those causes are very often

found in the external environment. (Cooper, Heron, &

Heward, 2007, p. 15)

One of the main advantages of defining behaviour

as ‘‘anything a person does,’’ apart from being

inherently a holistic perspective, is the way that it

permits ‘‘private behaviour’’ (e.g., thinking and

cognitions, and feelings and emotions) to be

considered when developing explanations. A child

who behaves in certain ways (e.g., makes no social

contact, engages in repetitive, self-stimulatory beha-

viour) is typically said to have ASD, and ASD is

referred to then as the reason (i.e., cause or

*This manuscript was accepted under the Editorship of Roger J. Stancliffe.

Correspondence: Dr Karola Dillenburger, School of Education, Queen’s University Belfast, 69/71 University Street, Belfast, BT7 1HL, Ireland.

E-mail: [email protected]

Journal of Intellectual & Developmental Disability, June 2009; 34(2): 193–195

ISSN 1366-8250 print/ISSN 1469-9532 online ª 2009 Australasian Society for the Study of Intellectual Disability Inc.
DOI: 10.1080/13668250902845244

explanation) for the said behaviours; ‘‘he does this

because he has ASD.’’ In reality though, the term

ASD is merely a ‘‘summary label’’ (Grant & Evans,

1994) for the full range of the child’s behaviours, not

the cause of them.

The philosophical basis of modern behaviour

analysis stems from the early work of Skinner (e.g.,

Skinner, 1938) and sits in stark contrast to the earlier

methodological behaviourism, in which only publicly

observable behaviour was considered relevant to

psychology (Leigland, 1992). In contrast, today’s

behaviour analysts consider ‘‘everything a dead man

cannot do’’ as in the purview of analysis.

(2) Experimental analysis of behaviour

The laboratory-based experimental analysis of beha-

viour has evolved from over 100 years of research and

has lead to the discovery of many principles of

behaviour; for example, respondent (or classical)

conditioning, operant conditioning, derived rela-

tional responding, and so forth (Sidman, 1994).

(3) Applied behaviour analysis (ABA)

Applied Behaviour Analysis is the science in which

tactics derived from the principles of behaviour are

applied systematically to improve socially significant

behaviour and experimentation is used to identify the

variables responsible for behaviour change. (Cooper et al.,

2007, p. 20)

ABA brings improvements and change in socially

relevant behaviours within the context of the

individual’s social environment; is conducted within

the scientific framework; focuses on functional

relationships and replicable procedures; is concep-

tually systematic and reflective; achieves measurable

changes in relevant target behaviours that last across

time and environments; is accountable, public,

doable, empowering, optimistic; and is more effec-

tive than eclectic treatments. Aversive methods are

avoided in favour of interventions based on func-

tional assessment and functional analysis and posi-

tive reinforcement.

Dispelling the myths about ABA and autism

The effectiveness of ABA-based intervention in ASDs

has been well documented through 5 decades of

research by using single-subject methodology and in

controlled studies of comprehensive early inten-

sive behavioural intervention programs in univer-

sity and community settings. (Myers & Johnson, 2007,

p. 1164)

Many lay people as well as professionals equate the

pioneering work of Lovaas (1987) with ABA.

However, behaviour analysts at the Princeton Child

Development Institute demonstrated the effective-

ness of early, comprehensive, intensive ABA 2 years

prior to the publication of Lovaas’s study (Ferster &

DeMyer, 1961). Since then, more than 19,000

papers have been published using ABA within a

variety of areas, including well over 500 studies

concentrating on children with ASD (Anderson &

Romanczyk, 1999).

When ABA is mistakenly categorised as a therapy

for autism, rather than as a science, it is listed

alongside a range of techniques such as Discrete Trial

Training (DTT), Picture Exchange Communication

System (PECS), Verbal Behavior Analysis (VBA),

Precision Teaching, generalisation and skill main-

tenance training, Pivotal Response Training (PRT),

prompting and prompt fading, imitation and

instruction, Aggression Replacement Training (ART),

shaping, Intensive Behavioural Intervention (IBI),

chaining, differential reinforcement, incidental teach-

ing, extinction, and others (Green, 1996). However,

it is the knowledge base gathered from the science of

ABA that underpins all of these techniques. For

practitioners, this means that learning specific tech-

niques is not the same as learning the science.

Training and professional certification

The Behavior Analyst Certification Board (BACB,

2007) certifies and regulates ABA professionals.

There are two levels of certification. Board Certified

Behavior Analysts (BCBA) must have at least Masters

degree level training in behaviour analysis as well as

1,500 hours supervised independent fieldwork ex-

perience prior to taking a rigorous 4-hour exam. At

present there are nearly 3,500 BCBAs worldwide.

Board Certified Associate Behavior Analysts (BCABA),

who since January 2009 are now termed Board

Certified assistant Behavior Analysts (BCaBA), must

have at least Bachelor degree level training in

behaviour analysis and 1,000 hours supervised

independent fieldwork experience prior to taking

the exam, and must be supervised by a BCBA

afterwards.

Discussion

In this paper we made three important points to

dispel the myths of the relationship between ABA

and autism treatment:

(1) ABA is an applied science that has evolved

from more than 100 years of research.

194 K. Dillenburger & M. Keenan

(2) This scientific research has produced a

wealth of evidence-based intervention proce-

dures, which are in turn derived from or

related to several more basic behavioural

principles.

(3) These procedures have been applied with

considerable success in the treatment of

autism. However, readers should not equate

ABA with any particular application or

program (e.g., Discrete Trial Training).

The scientific method applied to the study of

individual’s behaviours was pioneered by ABA. It is

not autism specific, but it guides the development of

techniques that address any socially relevant beha-

viour. When applied to children who display autistic

behaviours, ABA is method driven only in the sense

that the scientific method guides decision making

with respect to data collected. By responding to the

specific needs of each individual within their social

context, ABA offers a holistic and comprehensive

alternative to an eclectic mixture of techniques

that are not anchored in a science of behaviour

(Howard, Sparkman, Cohen, Green, & Stanislaw,

2005; Zachor, Ben-Itzchak, Rabinovich, & Lahat,

2007).

References

Anderson, S. R., & Romanczyk, R. G. (1999). Early intervention

for young children with autism: Continuum-based behavioral

models. Journal of the Association for Persons with Severe

Handicaps, 24, 162–173.

Behavior Analyst Certification Board (BACB). (2007). Retrieved

10 October 2007 from http://www.bacb.com

Chiesa, M. (2005). ABA is not ‘a therapy for autism’. In M.

Keenan, M. Henderson, P.K. Kerr, & K. Dillenburger (Eds.),

Applied behaviour analysis and autism: Building a future together

(pp. 225–240). London: Jessica Kingsley.

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied

behavior analysis (2nd ed.). Upper Saddle River, NJ: Prentice

Hall.

Ferster, C. B., & DeMyer, M. K. (1961). The development of

performances in autistic children in an automatically con-

trolled environment. Journal of Chronic Disease, 13, 312–345.

Grant, L., & Evans, A. (1994). Principles of behavior analysis.

New York: HarperCollins.

Green, G. (1996). Early behavioral intervention for autism: What

does research tell us? In C. Maurice, G. Green, & S. C. Luce

(Eds.), Behavioral intervention for young children with autism: A

manual for parents and professionals (pp. 29–44). Austin, TX:

Pro-Ed.

Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., &

Stanislaw, H. (2005). A comparison of intensive behavior

analytic and eclectic treatments for young children with autism.

Research in Developmental Disabilities, 26, 359–383.

Leigland, S. (Ed.). (1992). Radical behaviorism: Willard Day on

psychology and philosophy. Reno, NV: Context Press.

Lovaas, O. I. (1987). Behavioral treatment and normal educa-

tional and intellectual functioning in young autistic children.

Journal of Consulting and Clinical Psychology, 55, 3–9.

Myers, S. M., & Johnson, C. P. (2007). Management of

children with Autism Spectrum Disorders. Pediatrics, 120,

1162–1182.

Ontario IBI Initiative. (2002). Retrieved 10 October 2008 from

http://www.bbbautism.com/ont_new_funding.htm

Sidman, M. (1994). Equivalence relations and behavior: A research

story. Boston: Authors Cooperative.

Skinner, B. F. (1938). Behavior of organisms: An experimental

analysis. New York: Appleton-Century.

Office of the Surgeon General (OSG). (2000). Mental health: A

report of the Surgeon General. Retrieved 10 December 2008 from

http://www.surgeongeneral.gov/library/mentalhealth

Zachor, D. A., Ben-Itzchak, E., Rabinovich, A.-L., & Lahat, E.

(2007). Change in autism core symptoms with intervention.

Research in Autism Spectrum Disorders, 1, 304–317.

Opinions & Perspectives: Applied behaviour analysis 195

ANRV407-CP06-18 ARI 22 February 2010 15:48

Behavioral Treatments in
Autism Spectrum Disorder:
What Do We Know?
Laurie A. Vismara and Sally J. Rogers
M.I.N.D. Institute, University of California, Davis, Sacramento, California 95817;
email: [email protected]

Annu. Rev. Clin. Psychol. 2010. 6:447–68

First published online as a Review in Advance on
January 4, 2010

The Annual Review of Clinical Psychology is online
at clinpsy.annualreviews.org

This article’s doi:
10.1146/annurev.clinpsy.121208.131151

Copyright c© 2010 by Annual Reviews.
All rights reserved

1548-5943/10/0427-0447$20.00

Key Words

applied behavior analysis, autism spectrum disorder, intervention,
discrete trial training, naturalistic behavioral teaching

Abstract
Although there are a large and growing number of scientifically ques-
tionable treatments available for children with autism spectrum disorder
(ASD), intervention programs applying the scientific teaching principles
of applied behavior analysis (ABA) have been identified as the treatment
of choice. The following article provides a selective review of ABA in-
tervention approaches, some of which are designed as comprehensive
programs that aim to address all developmental areas of need, whereas
others are skills based or directed toward a more circumscribed, specific
set of goals. However, both types of approaches have been shown to be
effective in improving communication, social skills, and management of
problem behavior for children with ASD. Implications of these findings
are discussed in relation to critical areas of research that have yet to be
fully explored.

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Autism spectrum
disorder (ASD):
a group of
neurobiological
disorders characterized
by impaired social
interaction and
communication and by
restricted and
repetitive behavior

Applied behavior
analysis (ABA):
an applied science
devoted to
understanding the laws
by which the
environment affects
behavior in order to
address socially
significant problems
for individuals with
disabilities

Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . 448
COMPREHENSIVE-BASED

ABA MODELS . . . . . . . . . . . . . . . . . . . . 449
SKILLS-BASED APPLIED

BEHAVIOR ANALYSIS MODELS 455
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . 459

INTRODUCTION

Autism spectrum disorder (ASD) is a group of
neurobiological disorders with long-term im-
plications for the individuals concerned, their
families, and for the provision of education and
habilitative services. In recent years, there has
been a dramatic increase in the number of in-
dividuals, of all ages and all levels of ability and
severity, seeking treatment services for autism
(Kogan et al. 2008). It is now widely acknowl-
edged that the forms of treatment with the most
empirical validation for effectiveness with indi-
viduals with ASD are those treatments based on
a behavioral model (Natl. Res. Counc. 2001).
A defining characteristic of these treatments
is their foundation in the experimental anal-
ysis of behavior, which is a science devoted
to understanding the laws by which environ-
mental events influence and change behavior.
The clinically applied field from this science is
known as applied behavior analysis (ABA), and
the development of the behavioral treatments
of autism is largely the result of this field of
science (Schreibman 2000).

ABA requires careful assessment of how
environmental events interact to influence an
individual’s behavior. The assessment consists
of contextual factors such as the setting in which
a behavior occurs; motivational variables such
as the need to attain something; antecedent
events leading to the occurrence of a behavior,
such as a request to do something or a question
from another person; and consequences or
events following the behavior that dictate
whether the behavior is likely to occur again.
A detailed assessment of how the environment

and the individual’s behavior interact is crucial
because the information resulting from this as-
sessment leads to the design, implementation,
and additional evaluation of environmental
interventions intended to change behaviors.
For individuals with ASD, these behaviors
typically include language and communication,
social and play skills, cognitive and academic
skills, motor skills, independent living skills,
and problem behavior (Smith et al. 2007).
Progress in achieving the desired behavior
change is typically determined by direct
observations that occur on multiple occasions
with the same individual over time. An equally
important measurement is the acceptability of
the interventions and outcomes to the treated
individual, as well as the impact on caregivers
and other family members (Wolf 1978).

Initial evidence of the effectiveness of ABA
treatment models appeared in the 1960s with
papers by Wolf, Risley, and Lovaas, who used
highly structured operant learning paradigms
to build behavioral repertoires and improve
maladaptive behaviors of children with autism
(e.g., Baer et al. 1968; Lovaas et al. 1966, 1967;
Risley 1968). These behavioral programs led to
increased language, social, play, and academic
skills and reduced some of the severe behavioral
problems often associated with the disorder.
These studies were seminal in that they were the
first to demonstrate empirically validated gains
in children with autism. However, in addition
to these promising results, data concerning
maintenance and generalization indicated
some limitations to their effectiveness (e.g.,
Lovaas et al. 1973). Subsequent research has
addressed these problems, leading to enhanced
effectiveness of ABA treatments for communi-
cation (Cohen et al. 2006, Sallows & Graupner
2005), social skills (McConnell 2002), and
management of problem behavior (Horner
et al. 2002). As demonstrated in these studies,
ABA approaches have evolved and broadened
to include comprehensive behavioral packages
designed to address all developmental areas
of need and applied across all (or an extended
part) of the child’s day, as well as behavioral
strategies that focus on a narrow response

448 Vismara · Rogers

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ANRV407-CP06-18 ARI 22 February 2010 15:48

pattern or set of skills; both of which result in
widespread and durable treatment outcomes.

COMPREHENSIVE-BASED
ABA MODELS

Perhaps the most well-known of the behavioral
approaches is discrete trial training (DTT; Lo-
vaas 1981), also referred to as early intensive be-
havioral intervention (EIBI) if delivered before
age 5 years. DTT involves breaking down com-
plex skills and teaching each subskill through a
series of highly adult-structured, massed teach-
ing trials. Each trial or learning opportunity
consists of a concise and consistent instruction
for a response, typically the imitation of the
therapist’s model or compliance with a verbal
request, and acquisition occurs through the use
of explicit prompting and shaping techniques
with systematic reinforcement contingent upon
the child’s production of the target response.
Teaching trials are typically delivered in blocks
over the course of 20–40 hours per week for two
or more years, with skill emphasis in communi-
cation, social skills, cognition, and preacademic
skills (e.g., letter and number concepts, match-
ing) (Leaf & McEachin 1999).

In the most well known study of this method,
Lovaas (1987) reported an average gain of 20
IQ points for 19 young children with autism
receiving 40 hours per week of EIBI for two
years or more. Initially, the treatment occurred
in children’s homes in order to provide highly
structured one-on-one teaching. As children
improved, instruction extended to facilitating
social interaction and transitioning to typical
preschools and other community settings. Re-
sults revealed that nine children from the EIBI
group (47%) achieved average intellectual func-
tioning (IQ over 75) and attended general ed-
ucation classrooms. The two other matched
control groups, in which one group received
only 10 hours of behavioral intervention and
the other group received other types of in-
tervention, showed virtually no changes in IQ
scores. In fact, only 1 child out of the 40 com-
parison children was reported to have intel-
lectual functioning in the normal range. In a

Discrete trial
training (DTT): an
intervention approach
that teaches behaviors
by breaking down
complex skills and
teaching each subskill
through a series of
highly adult-
structured, massed
teaching trials

EIBI: early intensive
behavioral
intervention

follow-up study, McEachin et al. (1993) found
that the intellectual and academic gains of the
original EIBI group remained consistent sev-
eral years after treatment, with an average of
up to 13 years of age. Additional studies have
attempted to replicate the original findings re-
ported by Lovaas (1987), including one study
using a randomized controlled design (Bibby
et al. 2002; Cohen et al. 2006; Eikeseth et al.
2002; Howard et al. 2005; Luiselli et al. 2000;
Sallows & Graupner 2005; Smith et al. 2000a,b;
Takeuchi et al. 2002).

In examining findings from studies of
Lovaas’s treatment approach, two important
points stand out. First, three groups—Cohen
et al. (2006), Howard et al. (2005), and Sallows
& Graupner (2005)—reported findings of best
outcome status in approximately half of their
groups of treated children, thus supporting
Lovaas’s (1987) original findings that “recov-
ery,” defined as IQs in the normal range and
educational placement in typical age-level class-
rooms without supports, may occur for a signif-
icant subgroup of children with autism treated
early enough and intensively enough. Second is
that DTT delivered to young children at a high
level of intensity and supervised by experienced
therapists with rigorous levels of training and
supervision results in marked group increases
in standardized test scores. Nonetheless, chil-
dren may continue to show significant deficits
in intellectual, language, social, and adaptive
functioning, and as many as 50% of the chil-
dren who receive DTT may show no substantial
change in symptoms or test scores after exten-
sive, intensive intervention. The few compara-
tive studies (Eikeseth et al. 2002, Howard et al.
2005) to examine effects of Lovaas’s approach
compared to eclectic approaches demonstrated
statistically significant differences in test scores
in favor of Lovaas’s treatment. Thus, intensity
of treatment without consistently applied ABA
strategies and techniques was not sufficient for
treatment effectiveness.

Although DTT has been successful for im-
parting important behaviors to children with
autism, it has been criticized for several rea-
sons. First, the adult-directed nature of the

www.annualreviews.org • Behavioral Treatments in Autism Spectrum Disorder 449

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PRT: pivotal response
training

instruction and strict stimulus control can
limit the spontaneous use of skills (Schreibman
1997a). Second, the highly structured teaching
environment (Lovaas 1977) and use of artifi-
cial or unrelated reinforcers (Koegel et al. 1987)
can prevent generalization to the natural envi-
ronment and lead to cue dependency and rote
responding (Horner et al. 1988, Schreibman
1997b). Concerns have also been noted in
some applied settings with respect to the level
of expertise and amount of staff time that
are required in order for correct implementa-
tion of the intensive teaching procedures in-
volved. Moreover, the use of punitive pro-
cedures following inaccurate responses may
contradict other teaching philosophies (i.e.,
positive behavior support) adopted by many
facilities.

In response to some of the difficulties asso-
ciated with DTT, new behavioral interventions
have been developed that include more natural-
istic, spontaneous types of learning situations
that embed the child’s interest into teaching op-
portunities. These include incidental teaching
(e.g., Hart & Risley 1980, McGee et al. 1991),
natural language paradigm or pivotal response
training (PRT; e.g., Koegel et al. 1987, Laski
et al. 1988, Schreibman & Koegel 1996), and
milieu teaching (Alpert & Kaiser 1992, Kaiser
& Hester 1996). These treatment approaches
share commonalities in terms of embedding
teaching opportunities within naturally oc-
curring events (e.g., play routines, mealtime,
dressing, bath time), following the child’s lead
in initiating learning events, explicit prompting,
reinforcing attempts, and natural reinforce-
ment. These approaches also draw from the
developmental literature, such as contingent
imitation and linguistic mapping (Warren et al.
1993). Research suggests that these naturalistic
approaches can address a variety of commu-
nicative functions, such as preverbal com-
munication (e.g., eye contact, joint attention)
(Hwang & Hughes 2000), spontaneous produc-
tions (Charlop & Walsh 1986), social amenities
(e.g., please, thank you, hello) (Matson et al.
1993), peer interactions (McGee et al. 1992),
answers to “Where is ?” (McGee et al.

1985), phoneme production (R.L. Koegel et al.
1998a), and increased talking (Laski et al. 1988).

However, there are mixed results on whether
naturalistic behavioral approaches are superior
to DTT for facilitating greater and sustain-
able child changes (Goldstein 2002). Naturalis-
tic teaching procedures can be more easily em-
bedded into everyday activities and reduce the
need to program for generalization. As a result,
a number of studies have found increased spon-
taneity and generalization of language gains
to natural contexts and for improving effi-
ciency in teaching acquisition and generaliza-
tion simultaneously (e.g., L.K. Koegel et al.
1998b, McGee et al. 1985, Schreibman 1997a,
Schreibman & Koegel 1996). In contrast to
DTT, naturalistic behavioral approaches have
also been reported as less aversive to children
with autism and their treatment providers (e.g.,
parents), as evidenced by higher levels of pos-
itive affect (Koegel & Egel 1979, Schreibman
et al. 1991). Children have been shown to emit
fewer disruptive behaviors and to make greater
improvements in verbal attempts, word approx-
imations, word production, and word combi-
nations during naturalistic teaching conditions
compared to the discrete trial format (R.L.
Koegel et al. 1992b).

An additional benefit of naturalistic inter-
ventions is the ease with which others can be
taught to embed the strategies into already ex-
isting activities across multiple settings, such
as the home, the classroom, and the commu-
nity. Schopler & Reichler (1971) highlighted
the importance of including parents of chil-
dren with autism as intervention agents, with-
out whom gains were unlikely to be maintained
(Lovaas et al. 1973). Although most ABA inter-
vention approaches include a parent education
program, naturalistic interventions programs
are specifically designed to fit into a family’s
lifestyle and routine so that teaching can oc-
cur on a regular, constant basis throughout the
day in natural settings. The importance of im-
parting skills and knowledge to parents cannot
be understated given the lack of preparation,
assistance, and support parents may experience
when caring for their child with autism (Koegel

450 Vismara · Rogers

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2000, Stahmer & Gist 2001). Research has
shown that parent education actually reduces
family stress (Koegel et al. 1996, Schreibman
et al. 1991) while resulting in improved child
nonverbal (Anderson & Romanczyk 1999) and
verbal communication (Charlop & Trasowech
1991, Laski et al. 1988, McGee et al. 1999,
Stahmer & Gist 2001), behavior management
(R.L. Koegel et al. 1992b, Lutzker & Steed
1998, Lutzker et al. 1998), play skills (Stahmer
1995, Stahmer & Schreibman 1992), joint at-
tention (Rocha et al. 2007, Vismara & Lyons
2007), imitation and social responsiveness
(Ingersoll & Schreibman 2006), and parent-
child engagement (R.L. Koegel et al. 1996b,
Mahoney & Perales 2003).

A model group program that applies
naturalistic behavioral teaching—incidental
teaching—in an inclusive group early child-
hood program to toddlers and preschoolers
with autism is the Walden Early Childhood
Program (McGee et al. 2001). The curricu-
lum has developed from the philosophy that
early childhood education for all young chil-
dren should emphasize language and social de-
velopment, that the appropriate social environ-
ment for young children with ASD is with their
typical peers, and that incidental teaching tech-
niques can provide all the support that young
children with ASD need for optimal develop-
ment. Hallmarks of the approach include teach-
ing in the course of children’s ongoing play
activities, the use of activity schedules and des-
ignated teaching zones (LeLaurin & Risley
1972, Risley & Favell 1979), arranging envi-
ronments with highly preferred materials and
activities to support peer engagement, and fam-
ily collaboration. At least 30 hours per week of
planned instruction is provided to children to
promote social responsivity to adults, social im-
itation and synchrony of play with peers, ver-
bal expressive language, and independence in
daily living skills, including dressing and toilet-
ing. Parent involvement is critical to teaching
these key behaviors as well as identifying family
priorities to develop as intervention goals.

McGee et al. (2001) described the outcome
of 34 Walden graduates who began in the

LEAP: Learning
Experiences: An
Alternative Program
for Preschoolers and
Parents

toddler program and continued on through
the preschool and prekindergarten programs.
Their data showed all 34 children acquiring
some functional words, with 30 of 34 devel-
oping meaningful verbal language (defined as
more than 10 words and functional unprompted
speech) and 12 of 34 exiting with verbalization
levels in terms of rates of production at typi-
cal ranges for kindergarten entry. Social out-
come data also revealed an increased response in
peer interactions, with 17 of 34 children receiv-
ing social bids from peers at levels within the
ranges of 5.5-year-old typical children (range
6% to 39%). Further, 79% of the children were
successfully included in regular kindergarten
classes at their local public schools as docu-
mented by parent-report measures of continued
social and language advancement and participa-
tion in typical extracurricular activities. The ev-
idence provided is descriptive rather than com-
parative and is thus at a level of open trials.
As such, it provides initial support for com-
bining incidental teaching procedures and so-
cial inclusion to facilitate social communicative
skills and promoting participation in school and
community activities for young children with
autism.

Other researchers have also focused on a
systematic integration of social interventions
within a comprehensive and long-term con-
text of high-quality intervention for all de-
velopmental needs (Hoyson et al. 1984). The
work of Strain, Hoyson, and other colleagues
has contributed to the literature on developing
specific social interaction interventions that oc-
cur throughout the classroom day. Their pro-
gram, Learning Experiences: An Alternative
Program for Preschoolers and Parents (LEAP;
Strain & Cordisco 1994), provides preschool
services in which children with ASD are in-
tegrated with typically developing peers. In-
terventions strongly emphasize (a) the use of
an individualized, rather than fixed, curriculum
to identify learning objectives and strategies to
meet each child’s idiosyncratic needs; (b) a data-
driven approach to making strategic decisions
about continuing, modifying, or terminating
specific teaching efforts; (c) skill generalization

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Developmental
intervention: an
intervention approach
in which children’s
learning needs are
derived from
assessments of their
developmental skills
and taught in the
sequence in which
typically developing
children learn and
acquire behaviors

ESDM: Early Start
Denver Model

with teaching across multiple exemplars, set-
tings, and social partners; (d ) maximizing
naturally occurring teaching opportunities;
(e) peer mediation to promote social initiations
and contact; and ( f ) extensive parent training.
Unfortunately, no controlled outcome study
has been published since 1986, when the ini-
tial, uncontrolled pilot study reported that six
children who entered LEAP between the ages
of 30 and 53 months maintained gains from
preschool to age 10, with 5 of the 6 chil-
dren enrolled in regular education classrooms
without special education services (Strain &
Hoyson 2000). Well-designed outcome studies
of LEAP would help fulfill the need for models
involving effective, inclusive group education
for preschoolers with ASD.

Other intervention models have adopted a
developmental framework for the assessment
and intervention process for young children
with ASD. Unlike approaches derived from
ABA, in which children’s teaching goals are
derived from assessment of children’s behav-
ioral deficits and excesses, a developmental
model derives teaching goals from assessments
of children’s developmental skills. Develop-
mental intervention models typically begin
by constructing each child’s developmental
profile across relevant areas of functioning.
In general, the assessment process includes
(a) clinical observation(s) of child-caregiver
and/or therapist-child interactions; (b) a
developmental history and review of current
functioning (typically of child, family, and
caregiver); (c) review of current interven-
tion programs and patterns of interaction;
(d ) consultation with specialists from other
disciplines (e.g., speech language patholo-
gists, occupational and physical therapists,
educators, mental health colleagues); and
(e) biomedical evaluation. This process leads
to an individualized developmental profile that
describes the child’s current cognitive, com-
municative, and social skills (and sometimes
additional domains such as motor, self-care,
and play), which is then used to create indi-
vidually tailored interventions in each of the
domains affected by ASD in that child.

The most rigorously assessed of these mod-
els is the Denver Model and its toddler version,
the Early Start Denver Model (ESDM; Dawson
et al. 2010). The Denver Model is another ex-
ample of a program that views ASD as a complex
disorder affecting virtually all areas of function-
ing and thus requires an interdisciplinary ap-
proach to address a wide range of challenges.
Teaching occurs inside typical family routines,
such as meals, bathing, playtime, chores, and
community outings, and targets all affected ar-
eas of development, with particular attention
to the child’s affect, attention, and arousal. Re-
sults in early studies using a prepost design con-
trolling for initial developmental rate included
significant developmental accelerations in mul-
tiple areas of development, including language
and social-emotional development (Rogers &
DiLalla 1991; Rogers et al. 1986, 1987; Rogers
& Lewis 1989). Subsequent research has ex-
panded the model to the infant-toddler range
(i.e., the Early Start Denver Model), with initial
findings of efficacy using single-subject design
research (e.g., Vismara et al. 2009, Vismara &
Rogers 2008).

The most recent outcome research is a
randomized controlled clinical trial of ESDM
funded by the National Institute of Mental
Health and carried out at the University of
Washington. Dawson and colleagues (2010) re-
cruited 48 toddlers with idiopathic autism be-
tween 18 and 30 months of age who were ran-
domly assigned to one of two groups: (a) an
ESDM intervention group whose members re-
ceived, on average, 15 hours of 1:1-delivered
ESDM weekly from trained home therapists
and 16 hours per week from parents for two
years; and (b) an assessment and monitor (AM)
group referred for standard community-based
treatments and evaluated annually. These two
groups did not differ at baseline in severity
of autism symptoms, gender, IQ, or socio-
economic status. There was no attrition in the
ESDM group. Two-year follow-up data were
obtained for 21 community-treated children
and 24 ESDM-treated children.

At two years after the baseline assess-
ment, the ESDM group showed significantly

452 Vismara · Rogers

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ANRV407-CP06-18 ARI 22 February 2010 15:48

improved Mullen Early Learning Composite
standard scores compared to the AM group.
On average, the ESDM group improved 17.6
points compared to 7.0 points in the AM group.
The bulk of this change appears to be due to
improvements in both receptive and expressive
language, which showed increases of 18.9 and
12.1 points, respectively, for the ESDM group,
whereas the AM group improved 10.2 and
4.0 points, respectively; all of these differences
were statistically significant. The ESDM group
also showed a statistically significant 10-point
advantage on the Vineland Adaptive Behavior
Composite standard scores relative to the AM
group due to stable scores for the ESDM group
and a decline of 11.2 points for the AM group,
with significant differences ranging from 6 to
13 points favoring the ESDM group on com-
munication, daily living, and motor skills.

All children in both groups continued to
have some type of ASD diagnosis at time 2,
when they were, on average, 52 months old.
In terms of diagnostic stability, 15 children
(71.4%) in the AM group received a diagno-
sis of autistic disorder both at baseline and at
time 2. In the ESDM group, 14 (62.5%) of the
24 children retained their diagnosis of autis-
tic disorder from baseline to the two-year out-
come. In terms of increasing symptoms, five
children (23.8%) in the AM group received a
PDD-NOS diagnosis at baseline and then re-
ceived a diagnosis of autistic disorder at time
2. This same pattern was observed in only two
children (8.3%) in the ESDM group. In terms
of decreasing symptoms, one child (4.8%) in
the AM group and seven children (29.2%) in the
ESDM group received a diagnosis that changed
from autistic disorder at baseline to pervasive
development disorder not otherwise specified
(PDD-NOS) at time 2, a statistically signifi-
cant difference in diagnostic change between
the groups.

Thus, in this rigorous two-year random-
ized controlled trial testing intensive delivery
of ESDM at home, we found significant IQ
and language differences between ESDM and
AM groups that compare favorably with those

DIR: Developmental
Individual-Difference,
Relationship-
Based/Floortime

published by Lovaas (1987) and that are larger
and more widespread and from fewer hours of
treatment than those from the randomized con-
trolled trial of Lovaas’s approach published by
Smith et al. (2000b). Although ESDM needs
to be independently replicated before it can be
considered to be an empirically supported treat-
ment for early ASD, these results are certainly
consistent with earlier positive findings from
Denver Model studies.

A second developmental relationship-based
approach that has demonstrated initial promis-
ing results is Responsive Teaching, developed
by Mahoney & Perales (2003, 2005). Re-
sponsive Teaching focuses on educating par-
ents to use responsive interaction strategies to
address their children’s individualized devel-
opmental needs. The program includes spe-
cific intervention objectives designed to address
four developmental domains—cognition, com-
munication, motivation, and social-emotional
functioning—that have been reported to be in-
fluenced by maternal responsiveness and de-
scribed as core processes for developmental
gains. The authors’ work indicates that par-
ents can be encouraged to engage in respon-
sive interactions to promote child gains in piv-
otal behaviors (i.e., communication, cognition,
and social-emotional functioning) as well as im-
proved engagement, cooperation, joint atten-
tion, and affect.

A third approach is the Developmental
Individual-Difference, Relationship-Based
(DIR) model (sometimes referred to as Floor-
time) that emphasizes three components:
(a) functional emotional developmental;
(b) individual differences in sensory modu-
lation, processing, and motor planning; and
(c) relationships and interactions (Greenspan
1992, Greenspan & Wieder 1998). Rather than
focusing on isolated behaviors or skills, the
DIR/Floortime approach integrates functional
emotional development and differences that
underlie particular symptoms or behaviors to
establish a relationship that creates interac-
tive, affective opportunities of engagement.
The goal is to enable children to develop a

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Comprehensive
intervention: an
intervention model
that addresses multiple
core deficits in autism
spectrum disorder,
including language,
social, cognition, and
play

sense of themselves as intentional interactive
individuals and to build cognitive, language,
and social capabilities from this sense of
intentionality. The approach often involves
three types of activities: playful, spontaneous,
and creative interactions initiated and led by
the child with support from the adult to both
follow and challenge the child; semistructured,
problem-solving interactions to introduce new
skills, concepts, and target academic goals (e.g.,
searching for a missing object, mastering spatial
concepts); and motor, sensory, and spatial play
to strengthen fundamental processing skills.

Research examining the efficacy of the
DIR/Floortime approach includes a case
review of 200 children, all of whom had started
the intervention between 2 and 4 years and had
received between 2 and 8 years of intervention,
follow-up consultation, or both (Greenspan &
Wieder 1997). The children were divided into
three groups based on their response to the
program. The good-to-outstanding outcome
group shifted into the nonautism range on
the Childhood Autism Rating Scale (CARS;
Schopler et al. 1988), advanced in various
social, cognitive, and motor-based tasks, and
used words and symbols communicatively
and purposefully. The second, or medium,
group demonstrated slower and more gradual
progress but still improved in their ability to
relate and communicate with gestures and
developed some degree of language. The third
group made very slow progress, and although
most learned to communicate with gestures or
simple words and phrases, they had continued
difficulties with attention, self-stimulation, and
perseveration.

Subsequent to this study, Wieder &
Greenspan (2005) conducted a 10- to 15-year
follow-up study of 16 male children between
the ages of 12 and 17 years who were in
the good-to-outstanding group of the original
200 children. The study reported maintained
gains in relating, communicating, and reflec-
tive thinking, with most performing at aver-
age to above average in academic areas. For
this subgroup of children, the core deficits and

symptoms of ASD were no longer observed 10
to 15 years after they initially presented. Ad-
ditional research has examined the impact of
parent coaching and community-based appli-
cation of the model to address children’s social,
cognitive, and language functioning (Solomon
et al. 2007). Rigorous controlled studies of DIR
are needed to confirm relationships between
the model’s teaching practices and children’s
progress.

Other comprehensive behaviorally based
programs have been developed for children
and adults with ASD and take place in special-
ized classrooms, residences, or occupational
settings. Unlike early intervention programs
that provide more intensive, individualized,
structured teaching, programs such as the
Eden Family of Services (Holmes 1997) and
the Adult Life-Skills Program as part of
the Princeton Child Development Institute
(McClannahan & Krantz 1997) aim to provide
a continuum of educational, residential, and
employment programs to supply the seamless
permanent support network that individuals
with autism and their families desperately
need. These programs facilitate participation
in group activities and promote the ability
to complete tasks independently, without
direct supervision. In addition to community
participation, the curriculum focuses on skills
in such areas as keyboard use, language devel-
opment, money management, recreation and
leisure, self-care, social interaction, and time
telling (McClannahan et al. 2002). Services are
delivered in multiple settings, including com-
munity workplaces, learners’ own homes, and
recreation and entertainment facilities where
trainers model target skills, provide supervised
practice opportunities, and deliver immediate
positive and corrective feedback (McClannahan
& Krantz 1985). Although it is evident that
individuals with ASD in these programs learn
many new skills, there is still insufficient
evidence on long-term outcomes, such as
whether participants in the programs continue
to progress afterward in less specialized or
supported settings (McClannahan et al. 2002).

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SKILLS-BASED APPLIED
BEHAVIOR ANALYSIS MODELS

We have thus far been discussing comprehen-
sive intervention models that address a great
many learning needs at once; however, a variety
of interventions for teaching specific skills have
been developed, empirically examined, and
published in the autism literature. These inter-
ventions differ from each other across multiple
factors, such as the age group of the people
with autism involved, the target behavior of the
intervention (e.g., social skills, communication,
adaptive behavior), the kind of social partner
involved (e.g., peer or adult), the intervention
strategy applied, and the characteristics of the
interventionist (e.g., adult or peer). However,
almost all the published interventions involve
a behavioral methodology, requiring a concise
definition of the target behaviors to be taught,
the inclusion of task analysis, careful measure-
ment of the acquisition of the behavior, main-
tenance of the behavior under more natural
reinforcement conditions, and generalization
to other settings, persons, and behaviors.

Picture Exchange Communication System.
One such intervention is the Picture Ex-
change Communication System (PECS; Bondy
& Frost 1994, 1998) developed for nonverbal
children with ASD. PECS aims to teach sponta-
neous social-communication skills through the
use of symbols or pictures, and teaching in-
volves behavioral strategies, particularly rein-
forcement techniques, for the child to learn to
use functional communicative behaviors to re-
quest desired items (Frost & Bondy 2002). Ini-
tially, the child is physically prompted to pick
up and exchange a symbol/picture for the de-
sired object (i.e., Phase I: Physical Exchange).
In Phase II: Expanding Spontaneity, children
are taught to exchange a symbol with a commu-
nicative partner who is not in proximity and to
persist until their response is met. Prompts are
then faded using backward chaining techniques.
Once a child is using symbols with some flexi-
bility, having learned to seek out a communica-
tive partner and generalize skills to other adults,

PECS: Picture
Exchange
Communication
System

Phase III: Picture Discrimination is begun, in
which the child learns to discriminate among
symbols to request preferred objects. In Phase
IV: Sentence Structure, the child is taught to
apply an “I want” symbol to a blank sentence
strip, combine it with the symbol of the desired
object, and to exchange the sentence strip with
the communication partner. Then, in Phase V:
Responding To “What Do You Want?”, the
child learns to respond to this direct question.
Finally, in Phase VI: Responsive and Sponta-
neous Commenting, additional skills are en-
couraged, such as responding to other questions
(e.g., “What do you hear?”).

Several studies have evaluated the effects
of PECS instructions and have been rated as
inconclusive; as such, the studies carry little
weight for the efficacy of this approach (Beck
et al. 2008, Buckley & Newchock 2005, Frea
et al. 2001, Ganz & Simpson 2004, Marckel
et al. 2006, Son et al. 2006, Yokoyama et al.
2006). Although carried out with smaller sam-
ples, other studies have found PECS to be fairly
effective in terms of requesting, commenting,
and language expansion (Kravits et al. 2002,
Tincani et al. 2006) and in improving eye con-
tact, joint attention, or play as well as requests
and initiations (Charlop-Christy et al. 2002).

Two group studies conducted by Yoder &
Stone (2006a,b) yielded more convincing evi-
dence. In a randomized controlled trial, they
compared PECS with Responsive Education
and Prelinguistic Milieu Teaching (RPMT) in
36 children with ASD. The first study exam-
ined speech production as its outcome measure
and found that PECS increased the rate of non-
imitative spoken communicative acts and the
number of different nonimitative words in non-
verbal children with ASD compared to RPMT.
An additional exploratory analysis showed a
faster progression rate of the number of differ-
ent nonimitative words with PECS than with
RPMT for children who exhibited more object
exploration prior to starting treatment. How-
ever, children with little object exploration skills
at preintervention responded better to RPMT
than to PECS. The second study involved the
same children and found that RPMT led to

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SGDs: speech-
generating devices

generalized turn-taking and generalized joint
attention initiations more than the PECS for
those children who began intervention with
some joint attention skills. In contrast, children
with very little joint attention skills responded
better to PECS than to RPMT.

In another randomized controlled trial,
Howlin et al. (2007) provided extensive PECS
training and consultation to teachers of non-
verbal children with ASD in specialist school
settings. Although expert guidance to teachers
led to increased PECS usage, the study did not
demonstrate increases in spoken language or
scores on language tests, and significant impair-
ments in the children’s communication skills
were maintained. A follow-up period of one
treatment group also revealed that treatment ef-
fects were not maintained once classroom con-
sultations ceased. Additional studies are needed
to examine the potential value of PECS for non-
speaking children with autism, and additional
intervention strategies may need to be devel-
oped to foster easier use of this approach across
children’s environments and greater incorpo-
ration of the approach into natural routines at
home and in the community.

Investigators have also compared PECS
training to manual signing in terms of acqui-
sition and use of language. Signs represent
another symbolic system for representing ob-
jects and actions that individuals with ASD
might be motivated to request, label, and com-
ment upon. In the past, manual signing has
been thought of as a viable option for chil-
dren with poor verbal imitation skills because
most children can imitate (or be taught to imi-
tate with physical prompting and fading proce-
dures) a few fine or gross motor movements
(Sundberg & Partington 1998). At the same
time, children using manual signs to unaware
or unskilled communicative partners will have
great difficulty being understood (Mirenda &
Erickson 2000). Tincani (2004) compared man-
ual signing with PECS in teaching request-
ing and speech production. Manual signing was
found to be fairly effective for two of the par-
ticipants in the case of requesting, but not as
effective as PECS. The remaining two partici-

pants showed increased vocalizations after man-
ual signing, yielding positive results over PECS.
Overall, the aggregated evidence suggests that
PECS is more efficient than manual signing
related to requesting; however, it remains un-
clear as to which approach is more effective for
targeting speech production. A rigorous review
by Schwartz & Nye (2006) confirmed the ef-
fectiveness of manual signing for children with
autism in sign production and speech produc-
tion, but this is qualified by the very small num-
ber of high-quality studies on teaching manual
signing to children with ASD (see Brady 2007
for additional information).

Speech-generating devices. Speech-
generating devices (SGDs) provide digitized
and/or synthetic speech when activated. In-
tervention studies have evaluated the effects
of SGDs as part of a treatment package or
examined speech production as an outcome
measure. Although some results have been
inconclusive (Dyches 1998, Sigafoos et al.
2003, Son et al. 2006), other studies found
that embedding SGDs within naturalistic
teaching strategies increased communicative
interactions and behaviors in children with
autism (Olive et al. 2007, Schepis et al. 1998,
Sigafoos et al. 2004). Another study compared
teaching requesting of preferred objects using
an SGD with the speech on versus the speech
off to five children with autism (Schlosser et al.
2007). The authors reported no significant
differences across conditions or children.
The results were unreliable, with only two
children showing some improvement in use of
vocalizations.

Self-management. Self-management is an-
other option for teaching individuals with
autism to increase independence and gener-
alization of newly acquired behaviors without
the need for constant supervision by a treat-
ment provider (Koegel et al. 1995, Pierce &
Schreibman 1997, Schreibman & Koegel
1996). Self-management typically involves self-
evaluation of performance, self-monitoring
(ideally in the absence of an adult), and

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self-delivery of reinforcement. The procedures
have been used with children of different ages
to target a variety of skill areas, such as aca-
demic performance (Shimabukuro et al. 1999),
conversational skills (L.K. Koegel et al. 1998a),
and disruptive and/or perseverative behavior
(Newman et al. 2000). Stahmer & Schreibman
(1992) used a self-management treatment pack-
age to increase levels of functional play in three
school-aged children with autism, who prior
to intervention typically engaged in inappro-
priate or self-stimulatory behavior when left
on their own. Self-management training taught
the children to play appropriately in the ab-
sence of a supervising adult, and skills gener-
alized to new settings and toys. Decreases in
self-stimulatory and disruptive behaviors were
maintained in the unsupervised settings, and
two of the three children maintained the play
skills at one-month follow-up. Newman et al.
(2000) extended the self-management research
by teaching children with autism to vary their
play responding, thereby reducing inappropri-
ate forms of play. Three preschool-aged chil-
dren showed increases in variability of play
after self-management training, with the be-
havior sustaining at a one-month follow-up.
Other studies have successfully employed self-
management to increase social initiations while
reducing challenging behaviors (L.K. Koegel
et al. 1992a), to increase independent interac-
tions with typical peers (Shearer et al. 1996),
and to improve untreated social communica-
tive behaviors and overall appropriateness of
the children’s social interactions (Koegel & Frea
1993).

Positive Behavior Support. Another skill-
based approach to empowering individuals
with ASD and building autonomy is through
Positive Behavior Support (PBS) strategies.
PBS appeared in the 1980s as an alternative to
aversive interventions for people with severe
disabilities. Since then, it has expanded to ad-
dress the behavioral support needs of a diverse
population of individuals with ASD. PBS is a
collaborative, assessment-based approach to
addressing problem behavior that integrates

the procedural tools of behavioral science
with person-centered values and a systems
perspective (Lucyshyn et al. 2002). PBS aims
to improve the behavior and quality of life of
people who engage in problem behavior and
to do so in ways that are effective, acceptable,
feasible, and durable when implemented by ed-
ucators, families, and other support providers
in typical home, school, and community
settings (Horner et al. 2000, R.L. Koegel
et al. 1996b). In addition, PBS embodies the
philosophy that people with developmental
disabilities should be included and integrated
in the same settings and provided with the
same opportunities as other people. To assist
with this ideal, service providers of PBS build
partnerships with families to develop a vision of
the individual’s inclusion in family and commu-
nity life and to develop goals and plans that fit
within the cultural and ecological framework of
the individual’s family and community (Albin
et al. 1996, Moes & Frea 2000, Vaughn et al.
1997). Thus, parent involvement and training
are strongly emphasized so that families are
supported to accurately implement behavior
support strategies, to facilitate lasting changes
in behavior and in quality of life, and to address
new or recurring behavior problems with little
or no professional involvement (Dunlap et al.
2000). The importance of enhancing mean-
ingful lifestyle outcomes for the individual
and family has also led to the development
of person-centered planning methods in PBS
(Fox et al. 1997, Harrower et al. 1999–2000).
Person-centered planning is a collaborative
process to develop a vision of an inclusive
lifestyle for the individual and an action plan to
achieve those steps leading toward the vision.
The behavior support plan offers the strategies
and tools necessary to help the individual,
family, and team accomplish the goals. PBS ad-
vocates that in addition to evaluating treatment
strategies on their efficacy, equally important
is how the strategies enhance choice-making
opportunities, respect, and the personal dignity
of the individual for which they are used.

The fact that PBS aims to prevent prob-
lem behavior rather than utilize consequential

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FCT: Functional
Communication
Training

methods following the behavior has led to
a strong understanding of the variables that
influence behavior, particularly the impact
of ecological variables (i.e., setting events)
and immediate antecedent events on behav-
ior (Horner et al. 1996, Luiselli & Cameron
1998, Smith & Iwata 1997). In turn, a wide
range of antecedent-based techniques have
been adopted, such as building activity pat-
terns, offering choices, and using visual sched-
ules to promote predictability of routines (Repp
& Horner 1999, Scotti & Meyer 1999). A sec-
ond development is the use of functional as-
sessment for understanding problem behavior
and for designing effective interventions that
integrate proactive and educational strategies
and reinforcement-based procedures to facil-
itate lifestyle improvements (Horner & Carr
1997, Iwata et al. 1994, O’Neill et al. 1997).
This process involves identifying the events that
reliably predict and maintain problem behav-
iors so that changes relating to behavioral im-
provements can be introduced to those events
(O’Neill et al. 1997). Thus, the goal is to create
effective environments in which positive behav-
ior is more functional than problem behavior.

Functional Communication Training. A
strong relationship exists between the ability to
communicate and the prevalence of problem
behavior in individuals with ASD. When in-
dividuals with ASD are taught communication
skills that serve efficiently and effectively as
alternative behaviors, reductions in problem
behaviors result (Bird et al. 1989; Carr &
Durand 1985; Durand & Carr 1987, 1992;
Horner & Budd 1985). PBS encompasses
Functional Communication Training (FCT)
to teach individuals to emit an appropriate
alternative communicative behavior to obtain
the same reinforcer determined to maintain the
problem behavior while the problem behavior
is placed on extinction, or ignored so that the
reinforcing consequence is removed (Durand
1990). Different communication modes such as
real object or tangible symbols, photographs,
written word cards, speech, simple gestures,
manual signs, and even voice output communi-

cation aids may be used to teach the individual
to communicate in a way that matches the
function of the behavior. For example, a child
who throws objects or toys to protest or to
escape a nonpreferred activity could be taught
to verbalize “no” or to sign “done” in order to
appropriately refuse or end the task. A teenager
who engages in embarrassing, disruptive behav-
ior to escape loud noises whenever taken into
the community could learn to ask for a break
with the use of a card when noises become too
overwhelming. FCT has been demonstrated
to be an effective treatment for individuals
with developmental disabilities, including
ASD, who exhibit severe behavior problems
(e.g., Bailey et al. 2002; Carr & Durand 1985;
Fisher et al. 1993, 2000; Hagopian et al. 1998,
2005). Broader generalization and greater
maintenance of effects are also associated with
FCT when a variety of natural contexts are
included (Durand & Carr 1992, Horner &
Budd 1985). More recently, Bopp et al. (2004)
identified 16 FCT studies and Mancil (2006)
covered 8 FCT studies that used intervention
procedures that included extinction, ignoring,
and/or redirection combined with communi-
cation techniques of various kinds (e.g., manual
signing, picture symbols, printed words,
SGDs). Although both reviews arrived at the
decision that FCT was effective for eliciting
the new communicative behaviors and reduc-
ing the frequency of challenging behaviors,
Schlosser & Sigafoos (2008) warned readers to
interpret the findings with caution owing to
methodological limitations (e.g., incomplete
inclusion/exclusion criteria, lack of inter-rater
agreement, incomprehensive search).

Reciprocal imitation training. In addition to
promoting verbal language skills, intervention
programs have focused on teaching earlier-
emerging nonverbal social-communication
skills to children with ASD (Drew et al. 2002,
Mahoney & Perales 2003). Imitation is a
nonverbal social-communication skill that is
significantly impaired in children with ASD
(Charman et al. 1997, Rogers et al. 2003,
Smith & Bryson 1994), yet emerges early in

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development and plays a crucial role in the
development of more complex cognitive and
social skills (Stern 1985, Uzgiris 1981). Prior
research has shown imitation ability in children
with ASD to be associated with language (Stone
& Yoder 2001), play (Stone et al. 1997), and
joint attention (Carpenter et al. 2002). As such,
researchers have suggested that teaching young
children with ASD to imitate may improve
their social-communicative development more
broadly (Carpenter et al. 2002, Rogers 1999,
Rogers & Bennetto 2000).

Reciprocal imitation training (RIT; Inger-
soll 2008) is a naturalistic intervention designed
to teach the spontaneous social use of imita-
tion to young children with ASD during ongo-
ing play interactions. RIT employs naturalistic
intervention strategies similar to PRT (Koegel
et al. 1987, 1989), incidental teaching (Hart &
Risley 1968, McGee et al. 1983), and milieu
teaching (Alpert & Kaiser 1992, Kaiser et al.
1992), including following the child’s lead, ex-
plicit prompting, reinforcing attempts, and nat-
ural reinforcement in addition to techniques
from the developmental literature (e.g., con-
tingent imitation, linguistic mapping) (Warren
et al. 1993). Previous research has demonstrated
that RIT is effective for teaching both ob-
ject (Ingersoll & Schreibman 2006) and gesture
imitation (Ingersoll et al. 2007); in addition,
it leads to collateral changes in other social-
communication skills, including language, pre-
tend play, and joint attention (Ingersoll &
Schreibman 2006). It has also been demon-
strated as an appropriate parent training inter-
vention for promoting spontaneous imitation
with maintained and generalized skill use and
has received positive parent satisfaction ratings
for ease of use and effectiveness (Ingersoll &
Gergans 2007).

SUMMARY

In closing, intervention for children with ASD
is a politically heated and scientifically mul-
tifaceted topic. As discussed throughout this
review, a multitude of research articles docu-
ment the effectiveness of many different ABA

RIT: reciprocal
imitation training

Naturalistic
intervention
strategies: an
intervention approach
that applies the
behavioral teaching
principles of applied
behavior analysis
within the child’s
natural environment

comprehensive and skill-based methods for
teaching a variety of skills in communicat-
ing, interacting with adults and peers, playing
and engaging in activities, performing self-
help skills and tasks, and regulating prob-
lem behavior. Efforts in research continue to
refine these methods, including the need to
(a) determine which areas of development when
targeted will lead to a greater amount of
change in children’s learning rates over time
and in long-term outcome measures of skill;
(b) differentiate manualized, empirically sup-
ported teaching practices from general eclec-
tic approaches that mix a variety of approaches
(some of which have no scientific evidence)
to teach children; (c) conduct more com-
parative studies to identify the most effec-
tive combinations of curricular sequences and
teaching practices for specific outcomes; and
(d ) develop empirically supported treatments
for infants at risk for ASD, given the current
emphasis for earlier detection (Filipek et al.
1999).

In particular, the push for early detection
and more effective interventions has led
researchers to examine whether the prevention
of ASD is plausible by altering the course
of early behavioral and brain development
(Dawson 2008). Dawson and colleagues (e.g.,
Dawson & Faja 2008, Dawson et al. 2009)
have proposed a model outlining the genetic,
environmental, and phenotypic risk indices
that early intervention will need to address
in order to alter the abnormal developmental
trajectory that young children with ASD face.
Specifically, the authors posit that early genetic
and environmental risk factors contribute to
an atypical trajectory of brain and behavioral
development, which is then manifest in the
child’s lack of ability to actively engage in social
interaction. An important consequence to this
compromised neural-behavioral network is
the missed opportunities for normal social and
linguistic input (typically involved in social
exchanges) that promotes the development of
social and linguistic brain circuitry during early
critical growth periods. Early intervention that
facilitates reciprocal social interactions and

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engagement with a partner may guide brain
circuitry—its acquisition, organization, and
function—in addition to behavior development
back toward a normal pathway. Current efforts
are under way in the field of infant-toddler
autism intervention to examine the impact
of earlier intervention for reducing and pre-
venting ASD symptoms (Chandler et al. 2002,
Drew et al. 2002, Green et al. 2002, Mahoney &
Perales 2003, McGee et al. 1999). As described
above, one of the first randomized studies of
infant-toddler intervention has been reported
by Dawson and colleagues (2010); in this study,
noteworthy gains are reported in cognitive, lan-
guage, and social abilities and ASD symptoms.
However, the next step for intervention and

prevention studies is to demonstrate that earlier
efforts can result in more normal patterns of
brain function and organization. Incorporating
brain-based measures of outcome into studies
will provide insight into the effects of early
intervention on brain functioning in ASD.

Further research into these areas will pro-
vide information on the variables that mediate
and moderate treatment effects and the kinds
of intervention that are most efficacious, as well
as the degree of both short-term and long-term
improvements that can be expected in affected
individuals. By pursuing these areas of research,
it is hoped that the quality of lives for children
with ASD and their families will be substantially
improved.

SUMMARY POINTS

1. ABA is an educational-behavioral intervention for children with ASD that has generated
the most extensive research and thus has been identified as the treatment of choice to
address learning deficits.

2. ABA is an applied science integrated in diverse educational settings and aimed at under-
standing the functional relations between environmental events and behavior in order to
produce socially significant changes.

3. The most favorable outcomes are suggested to occur when ABA programs are started
early in life (before age 5 years) and implemented intensively (20 hours or more per week
for two or more years). Early intensive ABA intervention programs are intended to be
comprehensive, targeting all areas of development, and may result in accelerated gains,
including increased scores in IQ and other standardized tests; enhanced communication,
cognition, and socioemotional functioning; and mainstreamed school placements.

4. Comprehensive ABA programs in classrooms and residential settings have also been
developed for older children and adults with ASD. In addition, programs exist that target
a more circumscribed and specific set of skills and behaviors; these programs may include
training of parents, teachers, peers, or others to implement interventions.

5. Research suggests that both comprehensive and skills-based programs produce positive
short-term benefits, but additional evidence on long-term effects is needed.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.

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young children with developmental delay. J. Speech Hear. Res. 36:83–97

Wieder S, Greenspan S. 2005. Can children with autism master the core deficits and become empathetic,
creative, and reflective? A ten- to fifteen-year follow-up of a subgroup of children with autism spectrum
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(DIR) approach. J. Dev. Learn. Disord. 9:39–61

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finding its heart. J. Appl. Behav. Anal. 11(2):203–14

Yoder P, Stone WL. 2006a. A randomized comparison of the effect of two prelinguistic communication
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RELATED RESOURCES

Rogers SJ, Vismara LA. 2008. Evidence-based comprehensive treatments for early autism. J.
Clin. Child Adolesc. Psychol. 37:8–38. A detailed literature review of the science behind early
intervention programs for children with autism spectrum disorder.

Schreibman L. 2005. The Science and Fiction of Autism. Cambridge, MA: Harvard Univ. Press.
A wealth of information regarding scientifically valid versus ineffective interventions for
children with ASD.

Smith T, Mozingo D, Mruzek DW, Zarcone JR. 2007. Applied behavior analysis in the treatment
of autism. In Clinical Manual for the Treatment of Autism, ed. E Hollander, E Anagnostou,
pp. 153–77. Arlington, VA: Am. Psychiatr. Publ. The chapter evaluates various ABA psy-
chosocial treatments for treating children with ASD. Their explanation of current research
contributes to the literature on efficacious intervention approaches to help advance the care
that children with ASD should receive.

Weiss MJ, Fiske K, Ferraioli S. 2008. Evidence-based practice for autism spectrum disorder. In
Clinical Assessment and Intervention for Autism Spectrum Disorder, ed. J Matson, pp. 33–65.
Burlington, MA: Elsevier. A literature review of effective programs and methods for children
with ASD as well as recommendations for professionals and families navigating intervention
decisions.

468 Vismara · Rogers

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AR407-FM ARI 6 March 2010 12:23

Annual Review of
Clinical Psychology

Volume 6, 2010 Contents

Personality Assessment from the Nineteenth to Early Twenty-First
Century: Past Achievements and Contemporary Challenges
James N. Butcher � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

Prescriptive Authority for Psychologists
Robert E. McGrath � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �21

The Admissibility of Behavioral Science Evidence in the Courtroom:
The Translation of Legal to Scientific Concepts and Back
David Faust, Paul W. Grimm, David C. Ahern, and Mark Sokolik � � � � � � � � � � � � � � � � � � � � � �49

Advances in Analysis of Longitudinal Data
Robert D. Gibbons, Donald Hedeker, and Stephen DuToit � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �79

Group-Based Trajectory Modeling in Clinical Research
Daniel S. Nagin and Candice L. Odgers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 109

Measurement of Functional Capacity: A New Approach to
Understanding Functional Differences and Real-World Behavioral
Adaptation in Those with Mental Illness
Thomas L. Patterson and Brent T. Mausbach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 139

The Diagnosis of Mental Disorders: The Problem of Reification
Steven E. Hyman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 155

Prevention of Major Depression
Ricardo F. Muñoz, Pim Cuijpers, Filip Smit, Alinne Z. Barrera, and Yan Leykin � � � � � � 181

Issues and Challenges in the Design of Culturally Adapted
Evidence-Based Interventions
Felipe González Castro, Manuel Barrera Jr., and Lori K. Holleran Steiker � � � � � � � � � � � � 213

Treatment of Panic
Norman B. Schmidt and Meghan E. Keough � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 241

Psychological Approaches to Origins and Treatments of Somatoform
Disorders
Michael Witthöft and Wolfgang Hiller � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 257

vi

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AR407-FM ARI 6 March 2010 12:23

Cognition and Depression: Current Status and Future Directions
Ian H. Gotlib and Jutta Joorman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 285

The Genetics of Mood Disorders
Jennifer Y.F. Lau and Thalia C. Eley � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 313

Self-Injury
Matthew K. Nock � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 339

Substance Use in Adolescence and Psychosis: Clarifying the
Relationship
Emma Barkus and Robin M. Murray � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 365

Systematic Reviews of Categorical Versus Continuum Models in
Psychosis: Evidence for Discontinuous Subpopulations Underlying
a Psychometric Continuum. Implications for DSM-V, DSM-VI,
and DSM-VII
Richard J. Linscott and Jim van Os � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 391

Pathological Narcissism and Narcissistic Personality Disorder
Aaron L. Pincus and Mark R. Lukowitsky � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 421

Behavioral Treatments in Autism Spectrum Disorder:
What Do We Know?
Laurie A. Vismara and Sally J. Rogers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 447

Clinical Implications of Traumatic Stress from Birth to Age Five
Ann T. Chu and Alicia F. Lieberman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 469

Emotion-Related Self-Regulation and Its Relation to Children’s
Maladjustment
Nancy Eisenberg, Tracy L. Spinrad, and Natalie D. Eggum � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 495

Successful Aging: Focus on Cognitive and Emotional Health
Colin Depp, Ipsit V. Vahia, and Dilip Jeste � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 527

Implicit Cognition and Addiction: A Tool for Explaining Paradoxical
Behavior
Alan W. Stacy and Reineout W. Wiers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 551

Substance Use Disorders: Realizing the Promise of Pharmacogenomics
and Personalized Medicine
Kent E. Hutchison � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 577

Update on Harm-Reduction Policy and Intervention Research
G. Alan Marlatt and Katie Witkiewitz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 591

Violence and Women’s Mental Health: The Impact of Physical, Sexual,
and Psychological Aggression
Carol E. Jordan, Rebecca Campbell, and Diane Follingstad � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 607

Contents vii

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  • All Articles in the Annual Review of Clinical Psychology, Vol. 6
    • Personality Assessment from the Nineteenth to Early Twenty-First Century: Past Achievements and Contemporary Challenges
    • Prescriptive Authority for Psychologists
    • The Admissibility of Behavioral Science Evidence in the Courtroom:The Translation of Legal to Scientific Concepts and Back
    • Advances in Analysis of Longitudinal Data
    • Group-Based Trajectory Modeling in Clinical Research
    • Measurement of Functional Capacity: A New Approach to Understanding Functional Differences and Real-World Behavioral Adaptation in Those with Mental Illness
    • The Diagnosis of Mental Disorders: The Problem of Reification
    • Prevention of Major Depression
    • Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions
    • Treatment of Panic
    • Psychological Approaches to Origins and Treatments of Somatoform Disorders
    • Cognition and Depression: Current Status and Future Directions
    • The Genetics of Mood Disorders
    • Self-Injury
    • Substance Use in Adolescence and Psychosis: Clarifying the Relationship
    • Systematic Reviews of Categorical Versus Continuum Models in Psychosis: Evidence for Discontinuous Subpopulations Underlying a Psychometric Continuum. Implications for DSM-V, DSM-VI,and DSM-VII
    • Pathological Narcissism and Narcissistic Personality Disorder
    • Behavioral Treatments in Autism Spectrum Disorder: What Do We Know?
    • Clinical Implications of Traumatic Stress from Birth to Age Five
    • Emotion-Related Self-Regulation and Its Relation to Children’s Maladjustment
    • Successful Aging: Focus on Cognitive and Emotional Health
    • Implicit Cognition and Addiction: A Tool for Explaining Paradoxical Behavior
    • Substance Use Disorders: Realizing the Promise of Pharmacogenomics and Personalized Medicine
    • Update on Harm-Reduction Policy and Intervention Research
    • Violence and Women’s Mental Health: The Impact of Physical, Sexual,and Psychological Aggression
  1. ar:
    1. logo:

O R I G I N A L P A P E R

Overview of Meta-Analyses on Early Intensive Behavioral
Intervention for Young Children with Autism Spectrum Disorders

Brian Reichow

Published online: 15 March 2011

� Springer Science+Business Media, LLC 2011

Abstract This paper presents an overview of 5 meta-

analyses of early intensive behavioral intervention (EIBI)

for young children with autism spectrum disorders (ASDs)

published in 2009 and 2010. There were many differences

between meta-analyses, leading to different estimates of

effect and overall conclusions. The weighted mean effect

sizes across meta-analyses for IQ and adaptive behavior

ranged from g = .38–1.19 and g = .30–1.09, respectively.

Four of five meta-analyses concluded EIBI was an effec-

tive intervention strategy for many children with ASDs. A

discussion highlighting potential confounds and limitations

of the meta-analyses leading to these discrepancies and

conclusions about the efficacy of EIBI as an intervention

for young children with ASDs are provided.

Keywords Early intensive behavioral intervention � EIBI
� Early intervention � Autism spectrum disorders � Meta-
analysis

Early intensive behavioral intervention (EIBI; sometimes

referred to as intensive behavioral intervention, early

behavioral treatment, Lovaas therapy, etc.) was one of the

first comprehensive treatment programs for young children

with autism spectrum disorders (ASDs; Lovaas 1981). EIBI

is based on the principles and technologies of applied

behavior analysis and is typically an intensive home-based

program (e.g., intervention lasting 2? years involving

comprehensive programming for upwards of 40 h per week

with an initial emphasis on discrete trial training using

1-to-1 adult-to-child ratios). According to surveys of par-

ents and service providers (Green et al. 2006; Stahmer et al.

2005), EIBI is one of the most common, popular, and

requested treatment approaches for young children with

ASDs.

The first empirical results of the effects of EIBI were

published in 1987 (Lovaas 1987), and were very encour-

aging; 47% of the children with autism receiving EIBI

achieved best outcome (i.e., post-treatment IQ [ 85 and
unassisted placement in a general education classroom or

successful completion of first grade in a general education

classroom). A follow-up report (McEachin et al. 1993)

suggested much of the gains the children with best outcome

achieved during intervention were maintained for 6 years.

However, the report also revealed some individuals

receiving greater than 7 years of EIBI did not make good

progress. The initial report and subsequent follow-up report

stirred much debate (e.g., Foxx 1993; Gresham and Mac-

Millan 1998; Mesibov 1993; Mundy 1993; Schopler et al.

1989), and many replications ensued (e.g., Birnbrauer and

Leach 1993; Anderson et al. 1987; Cohen et al. 2006;

Sallows and Graupner 2005; Smith et al. 2000). Due much

in part to the strong effects shown in the initial study and

the surrounding debate on the effectiveness of the inter-

vention, EIBI has become the most studied comprehensive

treatment model for young children with ASDs.

Given the large amount of resources invested in EIBI,

precise estimates of the effects of EIBI should be a priority.

Since 2009, five meta-analyses of EIBI for young children

with ASDs have been published in peer-reviewed journals

(Eldevik et al. 2009; Makrygianni and Reed 2010; Reichow

and Wolery 2009; Spreckley and Boyd 2009; Virués-Ort-

ega 2010). The results and key methodological character-

istics of these five meta-analyses are shown in Table 1. The

basic findings of these meta-analyses varied from strong

B. Reichow (&)
Yale Child Study Center, 230 South Frontage Road, New Haven,

CT 06519, USA

e-mail: [email protected]

123

J Autism Dev Disord (2012) 42:512–520

DOI 10.1007/s10803-011-1218-9

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J Autism Dev Disord (2012) 42:512–520 513

123

support of EIBI to a conclusion that EIBI was not superior

to standard care. Four of five meta-analyses (Eldevik et al.

2009; Makrygianni and Reed 2010; Reichow and Wolery

2009; Virués-Ortega 2010) concluded EIBI was an effec-

tive intervention strategy for many children with ASDs.

For these four meta-analyses, the weighted mean effect

sizes for IQ had a range of g = .57–1.19 and the range of

weighted mean effect sizes for adaptive behavior was

g = .42–1.09, respectively. The one meta-analysis

(Spreckley and Boyd 2009) concluding EIBI was not

superior to standard care reported weighted mean effect

sizes of g = .38 and g = .30 for IQ and adaptive behavior,

respectively.

Although it is evident that much effort was employed by

the research teams conducting the meta-analyses included

in this overview, all meta-analyses had at least one meth-

odological limitation including calculation of effect sizes

based on small samples (sometimes without reference to a

control group), inclusion of non-randomized studies, over

inclusion of participant data, and lack of standardized

comparison or control groups. This paper provides an

overview of the five meta-analyses on EIBI for young

children with ASDs and an examination of key differences

and potential confounds that might have led to the dis-

crepant findings.

Overview of Meta-Analyses

Inclusion Criteria of Meta-Analyses

One striking difference across meta-analyses is the varia-

tion in inclusion criteria. Although all meta-analyses syn-

thesized comprehensive treatment programs for young

children with ASDs based on applied behavior analysis, the

specific definitions of the intervention varied from restric-

tion to EIBI based on the manuals of Lovaas (e.g., Lovaas

1981, 2003; inclusion criterion of Reichow and Wolery

2009) to broader definitions of EIBI leading to the inclu-

sion of programs such as Pivotal Response Treatment and

Group Intensive Family Training (studies by Baker-Ericzen

et al. 2007 and Anan et al. 2008, respectively; inclusion

criterion of Virués-Ortega 2010), which have significant

differences from the treatment described in the Lovaas

manuals and many conceptualizations of EIBI. Care must

be taken when conducting meta-analyses not to combine

studies evaluating different independent variables (fre-

quently referred to in meta-analysis as the apples and

oranges problem; Borenstein et al. 2009), which appears to

be a possible confound that cannot be ruled out of all meta-

analyses included in this overview. An additional limitation

of each meta-analysis is that all of the studies on EIBI had

at least one methodological shortcoming including use of

quasi-experimental designs, small sample sizes, non-ran-

dom assignment to groups, inadequate participant charac-

terization, narrow and inadequate outcome measures, lack

of fidelity data, and lack of standardized treatment methods

for control and/or comparison groups.

The different definitions of EIBI was largely responsible

for the differences in which studies were included in each

meta-analysis, which resulted in large differences in the

total number of studies within each meta-analysis (from 4

studies with a total of 41participants in the Spreckley and

Boyd (2009) meta-analysis to 22 studies with a total of 323

participants in the Virués-Ortega (2010) meta-analysis).

Table 2 provides characteristics of each study included

across meta-analyses. As shown in Table 2, most studies

were included in two, three, or four meta-analyses, except

for one study that was included in all five meta-analyses

(Smith et al. 2000) and eight studies that were included in

only one meta-analysis apiece (Anan et al. 2008; Baker-

Ericzen et al. 2007; Ben-Itzchak et al. 2008; Harris et al.

1991; Harris and Handleman 2000; Boyd and Corley 2001,

Matos and Mustaca 2005, and Reed et al. 2007b).

The other inclusion criterion likely to have had a sig-

nificant effect on the conclusions of each meta-analysis is

the research design. In the evaluation of EIBI, studies

using multiple research designs (e.g., randomized clinical

trials, retrospective pre/post comparisons, multiple-arm

trials) with many different types of comparison groups

(e.g., standardized nursery school, treatment as usual,

eclectic models) have been conducted. No meta-analysis

restricted inclusion to randomized control trials, which is

a common recommendation in meta-analysis (Reeves

et al. 2008). All meta-analyses restricted inclusion to

group research design studies. Eldevik et al. (2009) and

Spreckley and Boyd (2009) further restricted the criteria

to comparative group research designs, which limited the

number of studies meeting eligibility criteria. Given the

lack of a standardized comparison group, both strategies

seem justifiable, however, the inclusion of non-random-

ized studies is a potential confound and should be con-

sidered a limitation of all meta-analyses included in this

overview. The lack of standardized conditions for com-

parison groups creates a situation in which drawing strong

conclusions about the effectiveness of EIBI is difficult and

should be considered a limitation that needs to be care-

fully addressed in future meta-analyses. Furthermore, the

lack of a standardized comparison group across studies

evaluating EIBI also created a situation in which the

research teams conducting meta-analysis had to make

decisions on how to interpret different comparison groups,

which had significant consequences on the outcome of

each meta-analysis.

514 J Autism Dev Disord (2012) 42:512–520

123

Differences in the Interpretation of Comparison Groups

Misinterpretation of Sallows and Graupner Parent-

Directed EIBI Group

The interpretation of a comparison group had a significant

impact on the outcome of the Spreckley and Boyd (2009)

meta-analysis, which interpreted the parent-directed EIBI

group of the Sallows and Graupner (2005) study as a

control group. In the Sallows and Graupner study, partic-

ipants in the parent-directed EIBI group received greater

than 30 h of EIBI per week using the same curriculum

(Lovaas 1981; Maurice et al. 1996) delivered from thera-

pists hired from the same agency as the clinic-directed

EIBI group, which also received greater than 30 h of EIBI

per week. The treatment received by the participants in the

parent-directed EIBI group was not equivalent to standard

care or a traditional no-treatment control group and should

not be considered as such (see Smith et al. 2009 for further

explanation). In fact, the results showed that, on average,

both the parent-directed EIBI group and the clinic-directed

EIBI group made significant gains on the standardized

assessments between pre-treatment and post-treatment but

there were not statistically significant differences between

the two EIBI groups. The interpretation of the Sallows and

Graupner parent-directed EIBI group as a control group

likely led to the smaller effect sizes found in the Spreckley

and Boyd meta-analysis and their subsequent conclusion

that EIBI was not superior to standard care.

It is noteworthy that the Spreckley and Boyd (2009)

meta-analysis was the only meta-analysis included in this

overview to calculate an effect size for the Sallows and

Graupner (2005) study with the parent-directed EIBI group

treated as a control group. Eldevik et al. (2009) excluded

the Sallows and Graupner study because they concluded

the study did not have a control or comparison group. The

other three meta-analyses included in this overview

(Makrygianni and Reed 2010; Reichow and Wolery 2009;

Virués-Ortega 2010) calculated the standardized mean

change effect size for the Sallows and Graupner study,

which is calculated with respect to change scores and not

post-treatment differences between groups. Although the

Sallows and Graupner parent-directed EIBI group was

treated as a control group in only one of five meta-analyses

included in this overview, it has occurred elsewhere with

similar consequences. Multiple health insurance agencies

(e.g., Aetna 2010; Blue Cross and Blue Shield 2009; Cigna

2009) have either made a similar misinterpretation or used

the Spreckely and Boyd results to conclude the effective-

ness of EIBI has not been well established, leading to

policy decisions denying coverage of the treatment. The

misinterpretation of the parent-directed EIBI group of the

Sallows and Graupner study as a control group (and lim-

itation to randomized clinical trials) also likely led to

erroneous conclusions in the recent What Works Clear-

inghouse Intervention Report: Lovaas Method of Applied

Behavior Analysis (What Works Clearinghouse 2010). The

significance of the misinterpretation of the Sallows and

Graupner parent-directed EIBI group cannot be under-

stated and future reviews should take great care to ensure

this mistake is not made.

Multiple-arm Studies

Multiple-arm studies compare one group of participants

receiving a treatment (e.g., EIBI) to at least two other

groups not receiving that treatment (e.g., TAU and no

treatment control). Three studies included in one or more

meta-analyses were conducted using multiple-arm meth-

odology (Howard et al. 2005; Lovaas 1987; Reed et al.

2007b). When a multi-arm trial is included in a meta-

analysis, recommended practice suggests using only one

comparison either by selecting the comparison that is the

closest to other comparisons in the meta-analysis or by

creating a comparison that averages the results of all pair-

wise comparisons between the treatment and comparison

groups (Borenstein et al. 2009; Higgins et al. 2008). It

appears that most meta-analyses including multiple-arm

trials (Makrygianni and Reed 2010; Reichow and Wolery

2009; Virués-Ortega 2010) followed these conventions.

However, the Eldevik et al. (2009) meta-analysis has

multiple effect size estimates for the treatment group of the

Howard et al. (2005) study, creating a situation in which

the results of the participants of the treatment group

counted twice. Given the large effect size estimates of both

comparisons from the Howard et al. study, it is possible

that the inclusion of multiple comparisons inflated the

weighted mean effect sizes and should therefore be con-

sidered a limitation.

Effect Size Calculations

Because studies with and without comparison groups were

included across meta-analyses, two different types of effect

size estimates were used. The standardized mean difference

effect size with Hedges and Olkin’s (1985) small sample

correction, which compares post-treatment scores for the

treatment and comparison groups, could be calculated for

studies comparing one group receiving EIBI with another

group not receiving EIBI. For studies without a comparison

group, the standardized mean change effect size with

Hedges and Olkin’s small sample correction, which com-

pares pre-treatment and post-treatment scores of one group,

had to be used. Across meta-analyses calculations based on

J Autism Dev Disord (2012) 42:512–520 515

123

Table 2 Characteristics of studies included in reviews

Study Year Included in Pretreatment participant characteristics by group Treatment characteristics

Group n Age M,F IQ VABS EL RL Model hr/wk Mo of Tx

Lovaas 1987 E, R, V, M TX 19 34.6 – 62.7 – – – UCLA 40 24?

C 19 40.9 – 57.0 – – – UCLA 10 24?

C 21 42 – 60.0 – – – TAU – 24?

Anderson et al. 1987 R, V, M TX 14 42.8 – 57.3 50.7 UCLA 15–25 12–24

Harris et al. 1991 V TX 9 50.1 8,1 67.6 – – – EIBI 35–45 11.4

Birnbrauer and Leach 1993 E, R, V TX 9 38.1 5,4 51.3 46.1 – – UCLA 18.7 21.6

C 5 33.2 5,0 54.5 51.5 – – – – 24

Smith et al. 1997 E, R, V, M TX 11 36 11,0 28 50.3 – – UCLA 30 35

C 10 38 8,2 27 – – – UCLA 10 26

Sheinkopf and Siegel 1998 R, V TX 11 33.8 – 62.8 – – – UCLA 27.0 15.7

C 11 35.3 – 61.7 – – – TAU 11.1 18

Weiss 1999 V, M TX 20 41.5 19,1 – 49.9 – – EIBI 40 24

Harris and Handleman 2000 V TX 27 49.0 – 59.3 – – – EIBI 35–40 93

Smith et al. 2000 E, R, S, V, M TX 15 36.1 12,3 50.5 63.4 41.9 37.3 UCLA 24.5 33.4

C 13 35.8 11,2 50.7 65.2 45.6 38.3 UCLA 15–20 24

Bibby et al. 2002 R, V TX 66 45.0 55,11 50.8 54.5 – – UCLA 30.3 32.8

Boyd and Corley 2001 R TX 22 41.3 16,6 – – – – UCLA 20–30 23

Eikeseth et al. 2002 E, S, V TX 13 66.3 8,5 61.9 55.8 45.1 49.0 UCLA 28.0 12.2

C 12 65.0 11,1 65.2 60.0 51.2 50.4 Eclectic 29.1 13.6

Howard et al. 2005 E, V, M TX 29 30.9 25,4 58.5 70.5 51.9 52.2 EIBI 25–40 14.2

C 16 37.4 13,3 53.7 69.8 43.9 45.4 Eclectic 25–30 13.3

C 16 34.6 16,0 59.9 71.6 48.8 49.0 Eclectic 15 14.8

Matos and Mustaca 2005 V TX 9 48 8,1 31 21 – 32 UCLA 30 9–12

Sallows and Graupner 2005 R, S, V, M TX 13 35.0 11,2 50.9 59.5 47.9 38.9 UCLA 37.6 48

TX 10 37.1 8,2 52.1 60.9 48.4 38.8 UCLA 31.3 48

Cohen et al. 2006 E, R, V, M TX 21 30.2 18,3 61.6 69.8 52.9 51.7 UCLA 35–40 36

C 21 33.2 17,4 59.4 70.6 52.8 52.7 Eclectic – –

Eldevik et al. 2006 E, R, V, M TX 13 53.0 10,3 41.0 52.5 33.8 37.3 UCLA 12.5 20.3

C 15 49.0 14,1 47.2 52.5 41.6 33.2 Eclectic 12.0 21.4

Baker-Ericzen et al. 2007 V TX 158 49.4 128,28 – – – – PRT – 12

Ben-Itzchak and Zachor 2007 V, M TX 25 26.6 23,2 70.7 – – – EIBI 35 12

Eikeseth et al. 2007 R, S TX 13 66.3 8,5 61.9 55.8 45.1 49.0 UCLA 28.0 31.4

C 12 65.0 11,1 65.2 60.0 51.2 50.4 Eclectic 29.1 33.3

Magiati et al. 2007 R, V, M TX 28 38.0 27,1 83.0 59.6 2.2
r

4.9
r

UCLA 32.4 25.5

C 16 42.5 12,4 65.2 55.4 1.7
r

2.9
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Eclectic 25.6 26.0

Reed et al. 2007a V, M TX 12 40 11,1 56.8 58.2 – – EIBI 30.4 9

C 20 43 18,2 57.8 53.0 – – Eclectic 12.7 9

C 16 38 – 53.4 58.6 – – Portage 8.5 9

Reed et al. 2007b M TX 14 42.9 14,0 60.1 59.3 – – EIBI 30.4 9–10

C 13 40.8 13,0 56.6 56.5 – – EIBI 12.6 9–10

Remington et al. 2007 E, V, M TX 23 38.4 – 61.4 114.8
r

– – EIBI 25.6 24

C 21 35.7 – 62.3 113.6
r

– – TAU 15.3 24

Anan et al. 2008 V TX 72 44 61,11 51.7 53.11 – – EIBI 15 2.8

Ben-Itzchak et al. 2008 V TX 44 27.3 43,1 74.8 – – – EIBI 45 12

C 37 24.2 23,14 71.0 – – – TAU – 12

Key: Age average age by group in months, M male, F female, IQ intelligence quotient, VABS vineland adaptive behavior scales (Sparrow et al. 1984) composite
standardized score, EL expressive language, RL receptive language, hr/wk average number of hours per week of treatment, mo of tx average number of months of
treatment, E Eldevik et al., 2009, R Reichow and Wolery 2009, V Virués-Ortega 2010, M Makrygianni and Reed 2010, S Spreckley and Boyd 2009, TX treatment
group, C control/comparison group,—not reported UCLA University of California at Los Angeles, TAU treatment as usual, EIBI early intensive behavioral
intervention, PRT pivotal response treatment, r raw score

516 J Autism Dev Disord (2012) 42:512–520

123

the different effect sizes led to very large differences (e.g.,

[g = 1.50) in effect size estimates for individual studies A
sensitivity analysis from one meta-analysis (Virués-Ortega

2010) including both effect sizes suggested that studies

with control groups had a larger weighted mean effect size

for IQ but a smaller weighted mean effect size for adaptive

behavior than studies that did not contain control groups.

Because the standardized mean change effect size does not

account for maturation, the use of this effect size in meta-

analysis should be considered a potential confound and

limitation of the meta-analyses using this estimate.

Moderator Analyses

Three reviews (Makrygianni and Reed 2010; Reichow and

Wolery 2009; Virués-Ortega 2010) concluded their meta-

analysis showed enough between group differences to con-

duct moderator analyses. Makrygianni and Reed used partial

correlations controlling for methodological quality to

examine seven treatment and pre-intervention child char-

acteristics (treatment intensity, treatment duration, parental

training, chronological age, IQ, language, and adaptive

behavior). They found large relations suggesting (a) higher

treatment intensity was related to larger changes and greater

between group differences in IQ and adaptive behavior,

(b) greater treatment duration was related to greater between

group differences in adaptive behavior, (c) inclusion of

parent training was related to greater between group differ-

ences in adaptive behavior, and (d) better pre-treatment

adaptive behavior was related to larger changes in language

and greater between group differences in adaptive behavior.

No statistically significant relations were found for pre-

intervention chronological age, IQ, or language ability.

Reichow and Wolery (2009) used analysis of variance

methods to examine methodological rigor and method of

group assignment, both of which did not have a statistically

significant relation to changes in IQ. Weighted multiple

regression was used to examine six additional variables

(model of supervisor training, treatment density [intensity],

treatment duration, total hours of treatment, pre-intervention

chronological age, and pre-intervention IQ). Only one vari-

able had a significant relation; studies in which supervisors

were trained using the UCLA procedures had greater

increases in IQ scores.

Finally, Virués-Ortega (2010) used random-effects

meta-regression models and dose–response meta-analysis

to examine relations between effect sizes for IQ, language

composite, and adaptive behavior and intervention (dura-

tion and intensity) and child (pre-intervention age and pre-

intervention IQ) characteristics. The meta-regression

showed longer treatment duration was related to larger

differences in language composite scores. The dose–

response meta-analysis suggested longer treatment duration

was related to higher expressive and receptive language

scores and greater treatment intensity was related to higher

adaptive behavior scores.

Publication and Selection Bias

Publication bias should be considered a potential confound

in all of the meta-analyses. All meta-analyses included in

this overview only included studies published in peer-

reviewed journals, which increases the threat of publication

bias. Publication bias was assessed in four meta-analyses;

two analyses found evidence of publication bias (Reichow

and Wolery 2009; Virués-Ortega 2010) and two did not

(Eldevik et al. 2009; Makrygianni and Reed 2010).

Therefore, it is unclear what, if any, effect publication bias

might have had on the results of these meta-analyses;

future meta-analyses should consider more inclusive

inclusion criteria. A related risk is selection bias. Three of

five meta-analyses (i.e., Eldevik et al. 2009; Makrygianni

and Reed 2010; Spreckley and Boyd 2009) included in this

review were conducted by a research team that included at

least one individual previously involved in studying EIBI.

Furthermore, the author of this overview was involved in

one of the meta-analyses included in this review (Reichow

and Wolery 2009). Although peer-review might help limit

the threat of selection bias, it cannot be ruled out.

Conclusions and Future Recommendations

This paper presents an overview of five meta-analyses on

EIBI for young children with ASDs. By synthesizing the

results across multiple studies, meta-analysis can be a

powerful tool for estimating the average effects of an

intervention; thus, the collective and accumulating evi-

dence supporting EIBI from meta-analytic studies cannot

be dismissed. On average, EIBI can be a powerful inter-

vention capable of producing large gains in IQ and/or

adaptive behavior for many young children with ASDs.

Despite their differences, most (4 of 5) meta-analyses

(Eldevik et al. 2009; Makrygianni and Reed 2010; Reichow

and Wolery 2009; Virués-Ortega 2010) reached the con-

clusion that EIBI is an effective intervention. It should be

noted that the four meta-analyses reaching this conclusion

are also the four meta-analyses that properly interpreted the

Sallows and Graupner (2005) parent-directed EIBI group.

Stated differently, all meta-analyses correctly interpreting

the Sallows and Graupner parent-directed EIBI group

concluded EIBI is an effective intervention. The conclusion

that EIBI can be an effective intervention for many chil-

dren with autism is also supported by multiple descriptive

reviews (e.g., Granpeesheh et al. 2009; Eikeseth 2009;

Matson and Smith 2008; Rogers and Vismara 2008) and in

J Autism Dev Disord (2012) 42:512–520 517

123

a recent ‘‘mega-analysis’’ of 309 individual participant data

(Eldevik et al. 2010). Furthermore, the current evidence on

the effectiveness of EIBI meets the threshold and criteria

for the highest levels of evidence-based treatments across

definitions (e.g., Kratochwill and Stoiber 2002; National

Autism Center 2009; Odom et al. 2005; Reichow 2011;

Silverman and Hinshaw 2008). Collectively, EIBI is the

comprehensive treatment model for individuals with ASDs

with the greatest amount of empirical support and should

be given strong consideration when deciding treatment

options for young children with ASDs.

Although the average effects of EIBI appear to be strong

and robust, no treatment, including EIBI, has been effective

for all children with ASDs. Therefore, data providing

information on the child characteristics that are most likely

to be associated with best outcomes are needed. Because of

the discrepant findings across moderator analyses, the

meta-analyses included in this review shed little light on

this issue. To continue to move the field forward and

increase the knowledge on effective treatments for children

with ASDs, it is imperative that thorough pre-treatment

participant characterization and collection of outcome data

across a broad range of measures be collected.

Discrepancies across moderator analyses were also seen

with respect to treatment characteristics, suggesting the

specific treatment components with the greatest effects

remain unclear. Recent survey data suggest that while EIBI

programs often use a similar conceptual foundation (e.g.,

intensive intervention based on applied behavior analysis).

specific program characteristics vary across and within

programs (Love et al. 2009). To fully realize the potential

benefits of EIBI, additional knowledge on the characteris-

tics of EIBI programs outside of treatment studies (i.e.,

how EIBI is used in real world settings) is needed.

Guidelines focusing on the intensity, duration, level of

treatment fidelity, and therapist experience and/or training

necessary to achieve optimal outcomes should also be more

closely measured and reported in future research.

Finally, in addition to the greater specificity needed for

treatment components, better knowledge about treatment

outcomes are needed. Based on the meta-analyses reviewed

for this overview, most young children with ASDs

receiving EIBI can expect, on average, large increases in

IQ and lesser (but still significant) increases in adaptive

behavior. Although some studies have shown large gains

on standardized measures of language (e.g., Cohen et al.

2006; Smith et al. 2000), it has been less frequently

reported in studies of EIBI and was not synthesized in all of

the meta-analyses. A better understanding of the effects of

EIBI on language abilities is needed. Moreover, although

measuring social competence is difficult, it is a defining

feature of ASDs (Kanner 1943) and determining the effects

of this intervention, if any, on this core feature of the

disorder should be given careful consideration in future

studies. Finally, the differences in measurement instru-

ments across studies for psychopathology have likely led to

no synthesis of these measures. Better measurement and

reporting of psychopathology and in turn, a better under-

standing of the effects of EIBI on the core symptomotology

of children receiving the treatment should be a priority.

Data reflecting typical changes on standard outcomes such

as IQ, adaptive behavior, language abilities, and psycho-

pathology due to treatment in real life settings should also

be collected. Once data on optimal child characteristics,

necessary treatment components, and likely outcomes are

collected, parents and clinicians will be able to make more

informed choices when selecting EIBI as a treatment for

young children with ASDs.

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  • Overview of Meta-Analyses on Early Intensive Behavioral Intervention for Young Children with Autism Spectrum Disorders
    • Abstract
    • Overview of Meta-Analyses
      • Inclusion Criteria of Meta-Analyses
      • Differences in the Interpretation of Comparison Groups
        • Misinterpretation of Sallows and Graupner Parent-Directed EIBI Group
        • Multiple-arm Studies
      • Effect Size Calculations
      • Moderator Analyses
      • Publication and Selection Bias
    • Conclusions and Future Recommendations
    • References

Two Factor Model of ASD Symptoms

One of the key factors in determining whether an individual has Autism Spectrum Disorder (ASD) is in their social and communication skills. Individuals who are diagnosed with ASD have delayed joint attention, eye gazing, and other social interactions such as pointing (Swain et al., 2014).

Joint attention is an important social skill to master because it is a building block for developing theory of mind which, helps us to understand other’s perspectives. Korhonen et al. (2014) found that individuals with autism have impaired joint attention. However, some did not show impairment in joint attention, which lead to evidence that suggests there are different trajectories for joint attention. One suggestion as to why Korhonen et al. (2014) found mixed results, is that there is evidence that joint attention may not be directly linked to individuals with ASD since they were unable to find a difference in joint attention between ASD and developmentally delayed (DD) individuals. Another suggestion for the mixed results, is individual interest in the task vary. Research has found that while individualized studies are beneficial in detecting personal potential and abilities, it would be difficult to generalize the study in order to further research to ASD as a whole (Korhonen et al., 2014). In addition to joint attention, atypical gaze shifts is a distinguishing factor in individuals with ASD. Swain et al. (2014) found the main difference between typically developing (TD) and ASD individuals in the first 12 months of life is in gaze shifts. Individuals that were diagnosed with ASD earlier had lower scores on positive affect, joint attention, and gaze shifts, however those diagnosed later differed from typically developing (TD) only in gaze shifts. It is not until 24 months that later onset ASD individuals significantly differ from their TD peers, by displaying lower positive affect and gestures (Swain et al., 2014). These findings may lead to other ASD trajectories.

Another defining characteristic of ASD is the excess of restrictive patterns of interest and repetitive motor movements. These patterns and movements often impaired the individual from completing daily tasks. Like joint attention and gaze shifts, these repetitive movements and patterns of interest have different trajectories (Joseph et al., 2013). Joseph et al. (2013) found that individuals with high cognitive functioning ASD engage in more distinct and specific interests and less in repetitive motor movements than individuals with lower cognitive functioning ASD. Another finding showed that at the age of two, repetitive motor and play patterns were more common than compulsion. By the age of four all these behaviors increased however, repetitive use of specific objects was found to be less frequent in older children than younger children. This finding suggests that the ritualistic behaviors and motor movements may present themselves differently based on the age of the individual (Joseph et al., 2013).

Joseph et al. (2013), Korhornen et al. (2014), and Swain et al. (2014) all defined key characteristics of an ASD individual and explains the different trajectories of each characteristic. The difficulty with the trajectories is that it is specific to each individual, some symptoms may worsen while others remain stable. It is also difficult to generalize finding with small sample sizes (Joseph et al., 2013).

Discussion Questions:

1. Korhonen et al. (2014) did not use preference-based stimuli to look for joint attention and did not separate high- from low-functioning ASD individuals. Do you think that there could be a difference in level of motivation from each group? If so, how do you think this could change the results?

2. Swain et al. (2014) found that early and late onset of ASD did not differ in their social skills scores at the age of 12 months. If we know that their social skills do not differ then, is there another factor that would allow diagnosis of late onset ASD to be diagnosed at an earlier point in development?

3. Joseph et al. (2013) explains that it is difficult to assess the trajectories of ASD with a small sample size however, how do you think that their findings still help advance the research on ASD?

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