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 Non-Pharmacological Treatments in Autism Spectrum Disorders Current Clinical Pharmacology, 2014 , Vol. 9, No. 1 2

improved significantly in comprehension and expressive

language.

In the Aldred study [59], 28 preschoolers ere randomly

assigned to to groups receiving speech therapy, !"A##$

treatment and social s%ills training. In the experimental

group, parents also received a manual guide for the

implementation of five s%ills& '( dyadic activities) 2( child

sensitivity and responsiveness to signals) *( communicative

 +ehaviors) ( communicative interactions and 5( development

of the child-s s%ills repertoire. !his group shoed significant

improvements compared ith the control group regarding

severity of autism, expressive voca+ulary, communication

and parental responsiveness during parentchild interactions.

/allos and 0raupner [1] examined the outcomes of 2*

children ith autism 3mean age& *5 months( randomly

assigned to a more or less intensive individuali4ed ovaas

 plus 67! treatment. 6arents of +oth groups ere invited to

 participate in ee%ly meetings ith a team specialist here

they ere encouraged to practice the techniues of treatment

ith their children at home. !he supervision at home as

found to +e higher in the experimental group 31' hours  per 

ee% vs. 1 hours per month(. All children ere evaluated

 periodically until the age of :8 years and the results 3relatedto I;, level of language, adaptive +ehavior, socialemotional

functioning and school functioning( shoed an overall

improvement +ut no significant differences ere evidenced

 +eteen the to groups.

7ic%ards [1'] conducted 7#! to determine hether an

extra home+ased program provided over a year may lead to

sustained improvement in development and +ehavior. In

comparison to the control group, improvement in cognitive

development as higher in children ho received the extra

home

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22 Current Clinical Pharmacology, 2014 , Vol. 9, No. 1 Narisi et a

a similar trend of the I; increase in time. Although the

increases in I; are not negligi+le, their long term small si4e

suggests that the main impact of the intervention occurs

during the first year of treatment. In some studies researchers

have used the ADF/0 to monitor changes in autism

severity over time [59, 2*, 2]. In an 7#! study +y Aldred

[59], the active treatment group shoed significant

improvement compared ith control group on the  primary

outcome measure Autism Diagnostic F+servation /chedule

3ADF/( total score particularly in reciprocal socialinteraction. /uggestive +ut nonsignificant results ere

found also in ADF/ stereotyped and restricted  +ehavior 

domain. In Dason study [2*] on "arly /tart Denver =odel,

diagnostic shifts ithin the autism spectrum ere reported in*K of children +ut they ere not associated ith clinically

significant improvements on ADF/ severity scores. 0reen

[2] pointed out that at folloup, most children ere still

classified as having an ADF/0 diagnosis of core autism. In

 particular, in the group assigned to 6reschool Autism

#ommunication !rial 36A#!(, *K had changed to autism

spectrum disorder and 5K to nonspectrum) moreover in the

control group assigned to treatment as usual, 2K changed to

autism spectrum disorder and K to nonspectrum disorder.

0reen underlines that after '* months of treatment, ADF/scores improved in +oth groups ith a small estimated group

difference in favour of the 6A#! intervention. $oever,

effect of the intervention on ADF/ scores in relation to

diagnostic thresholds as small.

In studies on interventions centred on nuclear aspects of 

autism such as communication, the outcome varia+les are

more directly related to social and communicative s%ills [59,

8, *5]. Eor example, 0reenspan and >ieder [] have

used scores on socioemotional development as a measure

for treatment. !his retrospective study involved 2 children

ith autism +eteen 22 months and years folloed for a

 period of 2 years ith the DI7:Eloor !ime model and 58K

of the cases shoed a favoura+le outcome on socioaffectivescores.

Einally, fe studies have evaluated the outcomes in terms

of the impact of autism on family uality of life. 6arental

coping s%ills, family relations and parental stress have not

 +een systematically studied despite the inclusion of these

outcome varia+les representing a necessary step in the

assessment of effectiveness and efficacy of treatments.

Methodological Quality of Outcoe Studie!

Futcome studies can +e classified on the +asis of 

scientific merit [1, 5] hich is assessed in the presence of&

['] accurate diagnosis, [2] research design, [*] type of 

varia+les and [] fidelity to treatment. Cased on these

criteria, the studies are classified in four levels ranging from

evel ', hich represents the highest score, to evel . In

evel ', the diagnosis is performed +y an independent

clinician according to the international standards 3I#D' or 

D/=I( and confirmed +y gold standard instruments such

as ADF/0 and ADI7) the research design provides a

randomi4ed assignment ith to or more treatment groups)

outcome measures are comprehensive of the evaluation of 

intellectual and adaptive functioning) standardi4ed instruments

are administered +y examiners external to treatment) the

treatment is manuali4ed. Ceside the scientific merit, th

impact of the results can +e descri+ed also in four level

[1]. !o get an impact of evel ', significant difference

 +eteen the groups on +oth I; and adaptive functionin

must +e reported. evel 2 impact reuires significan

differences on I; or adaptive functioning. evel * accept

the evaluation of significant differences +ased on no

standardi4ed measures. evel impact is related to thos

studies that sho significant general improvements. !her

are only a fe evel ' studies in the field of autism

treatments 3see !a+le 1(.

Eirst, the or% of /mith [58] is a randomi4ed study i

hich preschoolers ere assigned to an intensive ACA

treatment 325 hours per ee%( or to a group of  paren

training. At folloup, the receiving intensive ACA treatmen

o+tained higher scores on I;, visualspatial a+ilities, language

socioemotional functioning and school  performance

$oever, the lac% of significant differences on adaptiv

functioning led to a classification of evel 2.

/econd, DasonLs study [2*] evaluated the efficacy o

the "arly /tart Denver =odel 3"/D=( in 8 children 3age

 +eteen '8 and * months( randomly assigned to "/D=

group or to the usual treatment availa+le in the territory. !h

"/D= treatment consists of '5 hours ith a therapist and '

hours of parent training using "/D= strategies and 5 hour

of other therapies 3i.e. speech therapy( for to years. !h

control group performed an individual treatment of 9 hour

and a group therapy for the same period. #hildren ho ha

received "/D= treatment shoed higher scores in cognitiv

and adaptive functioning. DasonLs or% is the first stud

that demonstrates the effectiveness of an integrated treatmen

model +ased on the principles of developmental an

 +ehavioral theory according to high methodological ualit

criteria.

!hird, in 0reen [2] study, the preschoolers it

core autism ere randomly assigned to a  parentmediatecommunicationfocused 36reschool Autism #ommunicatio

!rial6A#!( intervention or treatment as usual. !hos

assigned to 6A#! ere also given treatment as usua

/everity of autism symptoms as o+served as primary outcom

after '* months. #omplementary secondary outcomes er

o+served as measures of parentchild interaction, chil

language and adaptive functioning at school. !reatmen

effect as positive for parental synchronous response t

child, child initiations ith parent and for  parentchil

shared attention. "ffects on directly assessed language

adaptive functioning at school and ADF/0 ere small.

A recent revie [1] has identified four studies of eve

2 ithout randomi4ation [19]. All four contri+utions refeto the ACA model. /ome of these studies reach evel

impact +ecause they have shon that the ACA grou

o+tained significantly higher scores in I;, language an

adaptive +ehavior. In 7emington study ['], children in th

ACA group o+tained overall scores higher than those in th

control group except I;, adaptive functioning and languag

so the study has received a evel 2 regarding the impact o

the results.

"leven studies have achieved a evel * merit. !"A##$

method as applied in the to studies [, 8] and the