DOI: 10.1542/peds.2012-0900O 2012;130;S169Pediatrics

Behavioral (AIR-B) Network−For the Technical Expert Panel, and HRSA Autism Intervention Research

Margaret A. Maglione, Daphna Gans, Lopamudra Das, Justin Timbie, Connie Kasari,and Further Research Needs

Nonmedical Interventions for Children With ASD: Recommended Guidelines  

  http://pediatrics.aappublications.org/content/130/Supplement_2/S169.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Nonmedical Interventions for Children With ASD:RecommendedGuidelines and Further ResearchNeeds

abstractOBJECTIVE: To use the findings of a systematic review of scientific ev-idence to develop consensus guidelines on nonmedical interventionsthat address cognitive function and core deficits in children with au-tism spectrum disorders (ASDs) and to recommend priorities for fu-ture research.

METHODS: The guidelines were developed by a Technical Expert Panel(TEP) consisting of practitioners, researchers, and parents. A system-atic overview of research findings was presented to the TEP; guidelinestatements were drafted, discussed, debated, edited, reassessed, andpresented for formal voting.

RESULTS: The strength of evidence of efficacy varied by interventiontype from insufficient to moderate. There was some evidence thatgreater intensity of treatment (hours per week) and greater duration(in months) led to better outcomes. The TEP agreed that children withASD should have access to at least 25 hours per week of comprehen-sive intervention to address social communication, language, playskills, and maladaptive behavior. They agreed that applied behavioralanalysis, integrated behavioral/developmental programs, the PictureExchange Communication System, and various social skills interven-tions have shown efficacy. Based on identified gaps, they recommendthat future research focus on assessment and monitoring of outcomes,addressing the needs of pre/nonverbal children and adolescents, andidentifying the most effective strategies, dose, and duration to improvespecific core deficits.

CONCLUSIONS: The creation of treatment guidelines and recommenda-tions for future research represents an effort by leading experts to im-prove access to services for children with ASDs while acknowledgingthat the research evidence has many gaps. Pediatrics 2012;130:S169–S178

AUTHORS: Margaret A. Maglione, MPP,a Daphna Gans,PhD,a Lopamudra Das, MPH,a Justin Timbie, PhD,a ConnieKasari, PhD,b and For the Technical Expert Panel, HRSAAutism Intervention Research – Behavioral (AIR-B)NetworkaRAND Corporation, Santa Monica, California; and bCenter forAutism Research & Training, University of California, Los AngelesSemel Institute, Los Angeles, California

KEY WORDSautism spectrum disorders, interventions, guidelines, standards

ABBREVIATIONSASD—autism spectrum disorderEPC—Evidence-based Practice CenterHRSA—Health Services Resources AdministrationPECS—Picture Exchange Communication SystemTEP—Technical Expert PanelUCLA—University of California, Los Angeles

This manuscript has been read and approved by all authors.This paper is unique and not under consideration by any otherpublication and has not been published elsewhere.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-0900O

doi:10.1542/peds.2012-0900O

Accepted for publication Aug 8, 2012

Address correspondence to Margaret Maglione, MPP, AssociateDirector, Southern California Evidence-based Practice Center,RAND Corporation, 1776 Main St, Mailstop 4W, Santa Monica, CA90407

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

PEDIATRICS Volume 130, Supplement 2, November 2012 S169

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Autism spectrum disorders (ASDs)have emerged as a major publichealth and community challenge;most estimates of the prevalence ofASDs in children range from 6.5 to 6.6per 1000.1–3 More recent studies sug-gest that ASD prevalence might behigher than previously estimated, with∼11 per 1000 children between theages of 3 and 17 years affected.4 Na-tionally, between 500 000 and 673 000children and adolescents are impactedby ASDs.1–4

ASD is a developmental disability char-acterized by early core deficits in socialinteraction and communication thatprofoundly influence development intoadulthood.5,6 Although autism is a neu-robiological disorder, its pathophysiol-ogy remains obscure, and psychologicaland educational interventions are cur-rently the primary treatments foradressing the core deficits in children.The interventions have various goals,including reducing detrimental behav-iors, increasing social skills and cog-nitive ability, and facilitating childdevelopment.7 Given the scope of theproblem, there is a pressing need toclarify effective practices and to high-light gaps for additional interventiondevelopment.

As mandated by the Combating AutismAct of 2006, the Maternal and ChildHealth Bureau of the US HealthResources and Services Administration(HRSA) funded 2 research centersaimed at investigating treatment ofASDs: one for physical aspects, based atMassachusetts General Hospital, andone for behavioral aspects, based atthe University of California, Los Ange-les (UCLA). UCLA contracted with theSouthern California Evidence-basedPractice Center (EPC), based at theRand Corporation, to conduct a system-atic review of the scientific evidenceon the efficacy of various interven-tions, assemble a report on the results,and develop evidence-based guidelines.

Because thescientific literaturealone isoften insufficient tomake these kinds ofclinically detailed judgments, we con-vened a multidisciplinary group ofexperts to develop the guidelines byusing the evidence from the systematicreview and their own individual back-grounds to make decisions. This doc-ument presents the final guidelinestatements.

METHODS

The guidelines were developed bya Technical Expert Panel (TEP), withassistance from the EPC and UCLA. TheTEP is a large, multidisciplinary groupconsisting of experts in psychology,developmental pediatrics, child psy-chiatry, and education as well asparents of children with autism. Themembers and their affiliations arepresented in Table 1.

Evaluation of Relevant Evidence

The process began with a thoroughsystematic review of the scientific evi-dence. Throughconference calls, the TEPadvised on the scope of the review, theintervention types and age groups toinclude, intervention characteristics toassess, and which outcomes were mostimportant in assessing core deficits aswell as cognitive function. Importantly,the panel expanded the project to in-clude some interventions that may notnecessarily be considered “psychoso-cial” but target the core deficits ofautism, such as augmentative com-munication systems and auditoryintegration therapy. Thus, our scopecovers comprehensive programs(behavioral, developmental, those in-tegrating behavioral and developmen-tal approaches, and environmentalsupport), social skills programs, com-munication interventions for non-verbal children, speech and languagetherapy, and sensory motor inter-ventions. A complete description of themethodology, including the literature

search strategy, is available in our fullreport.8 To be included in the project,studies had to meet the followingcriteria:

� Include data on children or adoles-cents.

� Include specific outcome data onparticipants with ASDs. For example,if a study included subjects with au-tism, mental retardation, and otherdevelopmental disorders, the studyhad to report separate outcomesfor individuals with autism.

� Report outcome data on cognitivefunction or core deficits, whichinclude communication, language,social skills, behavior, restrictedinterest, and adaptive skills.

TABLE 1 Technical Expert Panel (TEP)

Anshu Batra, MD, Parent, Founder - Our Special KidsPediatric Care

Tony Charman, PhD, Chair in Autism Education,Institute of Education (UK)

Janet Grillo, Parent, FilmmakerPatricia Howlin, PhD, Institute of Psychiatry (UK)Brooke Ingersoll, PhD, Dept of Psychology, MichiganState University

Portia Iversen, Parent, Cofounder - Cure AutismNowSusan Levy, MD, Director, Regional Autism Center,Childrens Hospital Philadelphia

Catherine Lord, PhD, Director, Autism andCommunication Disorders Center, University ofMichigan

Brian King, MD, Professor of Psychiatry, Universityof Washington

Marsha Mailick Seltzer, PhD, Director, WaismanCenter

Ann Neumeyer, MD, Medical Director, Lurie FamilyAutism Center

Ricki Robinson, MD, Descanso Medical Center forDevelopment & Learning

Lawrence Scahill, PhD, Child Study Center, YaleSchool of Nursing

Laura Schreibman, PhD, Dept of Psychology, UC SanDiego

Ilene Schwartz, PhD, Experimental Education Unit,University of Washington

Tristam Smith, PhD, Strong Center forDevelopmental Disabilities, University ofRochester

Aubyn Stahmer, PhD, Child & Adolescent ServicesResearch Center (CASRC) Rady ChildrensHospital

Wendy Stone, PhD, Director, University ofWashington Autism Center

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� Have a sample size of at least 10. Acontrol group was not necessary;observational studies were in-cluded. However, single-subject re-search was excluded. Editorials,nonsystematic reviews, and back-ground articles were excluded, al-though we searched their referencelists for any relevant studies.

Two researchers abstracted informationabout research design, search dates (forreviews/meta-analysis), population, in-tervention components, outcomes mea-suring cognitive function or core deficitareas, and any comparison groups fromeach study. We assessed each study’squality with the use of standard instru-ments.9–11 Data were summarized tocreate evidence tables for each inter-vention type.

We assessed the overall strength ofevidence for intervention effectivenessusing guidance suggested by the USAgency for Healthcare Research andQuality (AHRQ) for its Effective Health-care Program.12 This method is basedloosely on one developed by the GradeWorking Group13 and classifies thestrength of evidence according to thefollowing criteria:

High = High confidence that the ev-idence reflects the true effect. Fur-ther research is very unlikely tochange our confidence on the esti-mate of effect.

Moderate = Moderate confidencethat the evidence reflects the trueeffect. Further research may changeour confidence in the estimate of ef-fect and may change the estimate.

Low = Low confidence that the evi-dence reflects the true effect. Fur-ther research is likely to changeour confidence in the estimate ofeffect and is likely to change theestimate.

Insufficient = Evidence either isunavailable or does not permit aconclusion. We also used this clas-

sification if studies showed no evi-dence of effectiveness.

The strength of evidence is based on 4primary domains (required) and 4 op-tional domains. The required domainsarerisk of bias, consistency, directness,and precision; the additional domainsare dose-response, plausible con-founders that would decrease the ob-served effect, strength of association,and publication bias.

In April 2010, the TEP members receiveda copy of the draft evidence report8 forreview. To facilitate discussion anddrafting of guidelines, we held a 2-daymeeting on June 3 to 4, 2010. Althoughan effort was made to accommodateall members’ schedules, some expertswere unable to attend in person. Thus,aWeb-based conference line (both audioand visual) was arranged so TEP mem-bers could attend remotely and partici-pate in the discussion. Eighty percent ofthe TEP members attended in person,and the remaining 20% participatedover the Web. All TEP members, whetherattending in person or remotely, wereencouraged to actively participate. Allwere required to complete a form dis-closing any potential financial, business,or professional conflicts of interest be-fore participating.

Generation of ConsensusGuidelines Statements

Drafting Guidelines and ReachingConsensus

At the meeting, the TEP members dis-cussed the scientific evidence pre-sented in the report, examined thestrength of the evidence, and critiquedit in a series of open discussions ledby EPC staff and the UCLA AutismIntervention Research – BehavioralNetwork Principal Investigator. TEPmembers expressed their points ofview about the efficacy of the variousinterventions, relying upon both theevidence presented in the report and

their clinical or empirical knowledgeand expertise. Parents commented onthe findings in light of their personalexperience. The meeting goal was todraft a series of consensus statementspertaining to interventions and to de-velop recommendations for the 5 toppriority areas for future research. Theface to face process was led by PaulShekelle, MD, PhD, Director of the EPC.Guidelines statements were draftedindividually for each area of evidenceand discussed by the group. The panelspent as much time as was needed todiscuss the proposed statement, andamendments were made to addressvarious proposed concerns, issues,and suggestions.

Once the group reached a consensusthat the proposed statement was wellformulated, they voted electronicallyto determine the degree of agreementwith the proposed statement. TEPmembers were asked to state the de-gree to which they agreed witha statement on a Likert scale with thefollowing terms: “strongly disagree,”“disagree,” “neutral,” “agree,” or“strongly agree.” All voting partic-ipants in the room were provided withclickers that allowed them to anony-mously choose an answer. Remotevoting participants were assigneda proxy voter, who received commu-nication from them via e-mail or tele-phone and used a the clicker to voteon their behalf. The results werepooled by using a computerizedaudience-response system. Outcomeswere tallied and displayed in realtime. Based on the outcomes, state-ments were renegotiated, debated,and reassessed in an open forum. Thegoal of this process was to reacha unanimous agreement on guidelinestatements and achieve a high level ofenthusiastic agreement from all TEPmembers.

Because the body of evidence on manyof the interventions is not robust,

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because many of the findings aremixed, and because the various expertsin the room subscribed to differentphilosophical schools and use differingmethodological approaches (eg, single-study design versus controlled trials),some discussion was contentious. Asa result, several areas received in-sufficient attention and not all state-mentswere completed by the end of thesecond day.

To allow for continued progress, thepanel agreed to continue the processvia conference calls and electro-nic communication. Statements weredrafted andpresentedby using Internetmeeting technology. Because votingcould not take place during the calls,all proposed statements were writtenand presented for electronic polling.Respondents could vote and postcomments anonymously. This processallowed the EPC team to continue untila final set of guidelines statements wasagreed upon by the TEP members. Onlystatements that received unanimousvotes for “Strongly Agree” or “Agree”were included in the final set.

Final Vote on Degree of Strengthof Guideline Statements

In the final stage, a rating for eachapproved guideline statement wasdeveloped. In February 2011, TEPmembers were asked to vote whetherthey considered each recommenda-tion “weak” or “strong.” The percent-age of TEP members who felt theguideline statement should be“strong” was tallied. This figure ispresented after each guideline state-ment below and translated into a rat-ing of A (90%–100%), B (80%–89%), orC (,80%). Of note, the rating for eachguideline statement does not neces-sarily reflect the strength of evidencefor a particular intervention, becausethe members of the TEP used theirexpertise and personal experience toinform their votes.

RESULTS

Systematic Review of ScientificEvidence

Of 325 reports of research selected forretrieval, 314 (85reviews,229 individualstudies) were successfully retrievedand screened by our investigators.Thirty-three systematic reviews and 68intervention studies (not already in-cluded in those reviews) met our in-clusion criteria. In Table 2, we brieflysummarize those results which pertainto the intervention areas included inthe final guidelines. As stated above,only guideline statements with 100%TEP agreement are included. Therewere several intervention areas wherewe could not achieve consensus; sci-entific evidence for these areas isavailable in our report.8 These areasinclude sensory integration, deeppressure therapy, and exercise.

In sum,according tocommonlyacceptedstandards, the evidence that compre-hensive intervention programs, oftenreferred to as “intensive” interventions,are effective at improving core deficitsof ASD is moderate strength. Althoughcontrolled studies have been conducted,few have randomly selected their sub-jects or enrolled large samples. Severalmeta-analyses of programs based onapplied behavioral analysis or the Lov-aas method have been conducted to in-crease statistical power; they havefound promising results in the areas oflanguage, adaptive skills, and IQ. Evi-dence is insufficient to suggest the su-periority of one behavioral curriculumover others. There is moderate evidencethat greater intensity of treatment(hours per week) and greater duration(in months) lead to better outcomes.Regarding developmentally based in-tensive programs and environmentalprograms such as TEACCH, the strengthof evidence is lower. Overall, autono-mous social skills programs for high-functioning children and adolescentshave a moderate strength of evidence of

efficacy; however, our analyses couldnot determine which approaches, set-tings, and modalities were superior. Forchildren with little or no verbal lan-guage, the Picture Exchange Communi-cation System (PECS) has moderatestrength of evidence of efficacy, and nocontrolled trials or uncontrolled obser-vational studies of augmentative com-munication devices were identified.Auditory integration training was foundineffective in 4 of 5 trials. Further detailsabout our results are available in the fullreport.8

The Guideline Statements

The final guideline statements are pre-sented below. Although the primaryarea of focus is comprehensive in-tervention programs for children, thepanel also made recommendations forsocial skills and communication pro-gramsandsuggestedpriorities for futureintervention research. In presentingthese priorities, we first present theconsensus on the deficits that any com-prehensive program for children withASDsshouldaddress, followedbyspecificrecommendation statements. The ratio-nale behind each statement is presented,as is thepercentageof TEPmemberswhoagreed that the recommendation shouldbe considered “strong” rather than“weak.”

Comprehensive Interventions: TargetDeficits

A comprehensive intervention programshould address deficits in the area ofsocial communication, such as lack ofappropriate joint attention capabilities(eg, spontaneous seeking to share in-terest or enjoyment), inability to re-spond to stimuli such as calling one’sname, even when occupied in anothertask, lack of reciprocal communicationand failure to develop developmentallyappropriate peer relationships, andimpaired ability to use and compre-hend nonverbal cues.

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A comprehensive intervention programshould address deficits in the area oflanguage, such as complete or partiallack of or delay in the development of

functional language, echolalia or re-petitive use of language, significant pho-nologic decoding/articulation deficits,and difficulty in modulating vocal vol.

A comprehensive intervention programshould address deficits in the area ofplay skills, such as lack of spontaneousmake-believe play, lack of social imita-tion, and excessive interest in 1 type ofplay with a lack of interest in varieddevelopmentally appropriate types ofplay.

A comprehensive intervention programshould address deficits in the area ofmaladaptive function and maladaptivebehavior, such as excessive preoc-cupation with restricted patterns ofinterests that are abnormal in focus orintensity or with specific objects, rigidadherence to routines or rituals, diffi-culty adjusting to relatively minorchanges in schedules and routines,engagement in stereotypical motormannerisms (eg, hand or finger flap-ping or twisting body movements),uncooperative behavior or withdrawal,and, in severe cases, aggression toothers or toward property and self-injurious behavior.

Any comprehensive intervention pro-gram should offer an ongoing parenteducation component in the specificintervention technique used. Parentscan enhance the child’s acquisition ofskills and help transfer the newly ac-quired skills to home and communitysettings.

Comprehensive Interventions:Suggested Standards

Comprehensive programs have thepotential for remediating multiple coredeficits simultaneously and allow forpotential synergistic effects of in-tervention components. Timely treat-ment can help maximize the impact ofinterventions on young children’s de-velopment and prevent further de-velopmental delays or deterioration offunctioning in older individuals. Thus,individuals with ASDs should receivecomprehensive. services within a rea-sonable time frame following identifi-cation. The literature provides little

TABLE 2 Summary of Evidence

Findings Strength ofEvidence

Comprehensive programs targeting multiple core deficitsBehavioral programs based on Lovaas/ applied behavioral analysis (ABA)We found 16 previous systematic reviews and meta-analyses14–17,19,20,42–51; most

reported significant effects in the areas of language, adaptive skills, and IQ. Thesereviews included only 2 randomized controlled trials; the other studies wereeither nonrandomized trials or observational studies. There was not enoughevidence to suggest the superiority of 1 behavioral curriculum over others.

Moderate

A recent meta-analysis19 found a dose-response relationship for intensivebehavioral interventions on both language and adaptive skills outcomes. Higherintensity (hours per week) and higher duration (in months or years) led to betteroutcomes. Twenty hours per week was the minimum intensity of mostcomprehensive programs.

Moderate

DevelopmentalWe found one 10-month nonrandomized trial of the Scottish Autism Center

comprehensive program.52 Improvements in socialization, daily living skills, andmotor and adaptive behavior were reported.

Low

Integrative: Behavioral 1 DevelopmentalIn a high-quality randomized controlled trial53 and several observational studies,

the Early Start Denver Model has reported significant gains in cognitive abilityand other core deficits in preschool-aged children.

Moderate

Other programs such as STAR,54 the Walden Toddler Program,55 and ABA combinedwith TEACCH56 showed improvements in core deficits in 1 uncontrolledobservational study each.

Low

Environmental supportThere were 2 poor-quality nonrandomized controlled trials of TEACCH to nonspecific

educational programs.57,58 Improvements in cognitive function, social skills, andadaptive behavior were reported. Both small studies were conducted in Italy bythe same researchers. In both studies, TEACCH was conducted in a residentialsetting; 1 study also had a TEACCH arm in a “natural setting.”

Low

Social skills programs for higher-functioning children and adolescentsMany controlled trials21,23,24,29,59–65 and observational studies25,26,30,31,66–70 of social

skills programs have been conducted. We conducted several meta-analyses onsocial skills studies that used similar outcome measures. There was moderate,consistent evidence that social skills programs as a whole are effective for bothchildren and adolescents. Effect sizes tend to be significant and fairly large.However, our analyses could not determine which approaches are best for whichchildren. Effective interventions took place in both individual and group settings.

Moderate

Interventions for children with no or limited languagePicture Exchange Communication System (PECS)One previous systematic review32 reported on 2 randomized controlled trials, 1

nonrandomized controlled trial, and 3 uncontrolled observational studies.Results in communication/social skills were consistently positive in the shortterm but inconsistent in the long term. The outcome effect sizes varied acrossstudies.

Moderate

Augmentative and alternative communication devicesThere are no controlled trials or observational studies on the efficacy or

effectiveness of Augmentative and Alternative Communication (AAC)interventions8; only single-subject studies have been reported.

Insufficient

Auditory integration trainingA previous systematic review71 reported no significant improvements in sound

sensitivity in 3 controlled trials. None of these trials reported significantimprovement in core deficits. There were 2 trials published after the review. Onefound no improvements in core deficits35; the other found no improvement insound sensitivity, but did find improvements in language, intelligence, and socialskills.72

Moderate: for ineffectiveness

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information on the relative effective-ness of interventions delivered at dif-ferent intervals from the time ofidentification, although 1 review of be-havioral interventions suggests thattreatments are more effective duringthe first 12 months following initialassessment.14 Given the ability of in-terventions to address a wide range ofdeficits, there is no theoretical basisfor delaying treatment initiation. Guide-line: Individuals with ASDs shouldreceive comprehensive interventionwithin 60 days of identification. Rating:A (94%)

The needs of a very young child differfrom those of an adolescent or adult,and pre- or nonverbal individuals re-quire different types of interventionsfrom those with verbal skills. Pro-grams must be customized to theneeds of each individual to be suc-cessful and to avoid the fiscal andemotional costs of inappropriate ormisdirected intervention efforts. Fewinterventions found in the literaturedemonstrate benefits across all coredeficits, and some children experienceboth improvements and declines indifferent types of functioning followingcertain treatments.15–17 This inconsis-tency suggests that comprehensiveprogramsmust be carefully selected toaddress the unique strengths and coredeficits of each individual with ASDs.Little evidence exists to allow furthercustomization of programs accordingto other characteristics of children(such as age) or intervention charac-teristics (such as specific methods),suggesting that flexibility needs to bebuilt into comprehensive programs toallow for uncertainty in the effective-ness of interventions for children withdifferent needs. Guideline: A compre-hensive program must be individu-alized to the strengths and deficits ofthe person with ASD. Rating: A (100%)

Families play a key role in extendingtreatment programs into the home

setting, but are greatly impacted by thedemands of caring for individuals withASD.18 Families require tools and edu-cation to enhance the effectiveness oftreatments delivered at home. Theyalso need support to maintain emo-tional strength and reduce burnout.Family needs that are not addressedmay impede the progress of individualswith ASDs. The literature suggests thatparental, behavior-based training pro-grams can have significant benefitsfor children,18 although the evidencewas generally weak, inconsistent, andmainly limited to improvements inchildren’s communication skills. Guide-line: A comprehensive program mustaddress the concerns of the family andoffer opportunities for their activeparticipation. Rating: A (94%)

The need for intervention for ASDscontinues throughout an individual’slife span and will vary depending on anindividual’s chronological age and de-velopmental need. Interventions pub-lished in the literature reflect a widerange of intensities and duration,8 andfew studies systematically compare in-terventions with different intensities.8

One review demonstrated dose-responserelationships for language-based out-comes and psychosocial adaptive skills.19

In that review, improvements in adap-tive skills were most sensitive to theintensity of behavioral interventions,whereas language outcomes were mostsensitive to the duration of theseinterventions. The vastmajority of high-quality behavioral interventions foundin the literature required 20 to 40hours of treatment per week,14,19,20 andthe American Academy of Pediatricsrecommends a minimum of 25 hours perweek.7 Comprehensive programs maybe supplemented with additional pro-grams to reach this minimum. Guideline:Children with ASD should be activelyengaged in comprehensive interventionfor a minimum of 25 hours per weekthroughout the year. Rating: C (56%)

The appropriate program type, in-tensity, and duration for adults withASDs is not clear. Many of these indi-viduals will need ongoing supportthroughout their life span to live pro-ductively. The comprehensive inter-ventions we identified were targetedmainly to young children. These types ofbehavioral interventions, parent train-ing programs, environmental support,and developmental interventions rarelystudied adolescents8 and thus pro-vided limited information on the char-acteristics of effective programs foradolescents or adults. Guideline: Olderindividuals with ASD should also beactively engaged in comprehensiveinterventions, although more researchis needed to better define the appro-priate models of service delivery andnumber of hours per week. Rating: B(88%)

Programs That Address the SpecificDeficit of Social CommunicationFocusing on Social Skills

There is growing scientific evidence(from both controlled trials and ob-servational studies) that specificinterventions to improve social skills inchildren with autism (including SocialStories, video modeling, and peermodeling) are effective.21–26 No specificsetting or psychological approach hasbeen found superior to others. One-on-one approaches have been foundeffective for young children, whereasgroup programs, often involving typicalpeers, have been found effective forolder children.27,28 Theory of Mind andother cognitive behavioral approacheshave scientific evidence of effective-ness.29–31 All programs with scientificevidence of effectiveness used writtenprotocols or manuals.8 Where lengthof program was reported, programslasted at least 3 months.8 Guideline:Individuals with ASDs should be of-fered interventions specifically target-ing deficits in social communication

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with a focus on social skills. The pro-grams may be group or individuallyfocused and should be based on em-pirically supported methods describedin a protocol or manual. The recom-mended duration of the program is asneeded. Progress should be assessedat least monthly, and ongoing inter-ventions should be recommendedaccording to developmental needs.Rating: A(94%)

Programs for Individuals With Limitedor No Language

There is scientific evidence (from con-trolled trials and observational studies)of the effectiveness of the Picture Ex-change Communication System (PECS)in increasing child-to-adult initiatedcommunication, primarily requestingcommunication acts.32 Studies range inlength from 3months to 2 years. At leasthalf the studies did not report intensity;in the studies that did report intensity,intensity ranged from 20 minutes, 3times per week, to a total of 15 hoursper week.32 Guideline: Individuals withASDs who have limited verbal language,or those who do not respond tomultipleinterventions aimed at improving com-munication, should be offered the op-portunity to use the PECS. Monitoringand ongoing intervention are recom-mended to maintain gains in commu-nication. Rating: B(80%)

We identified no controlled trials orobservational studies on the efficacy oreffectiveness of Augmentative and Al-ternative Communication devices.8 Asmall number of single-subject studieshave been conducted, with mixedresults.33,34 Because nonverbal indi-viduals are an understudied and un-derserved population, well-designedstudies could shed light on whichdevices are best for which individuals.Guideline: Augmentative and Alterna-tive Communication interventions suchas computers or other devices shouldbe considered if PECS is unsuccessful

or if the individual is likely to benefitfrom the increased flexibility affordedby such devices. An interventionistshould provide training on how touse the device effectively. Monitoringand ongoing intervention are recom-mended to maintain gains in commu-nication. Rating: B (80%)

Small but well-designed controlled tri-als found auditory integration therapyineffective in addressing any of the coredeficits of autism.35 Guideline: Given thecurrent state of scientific evidence,auditory integration therapy cannot berecommended to address the coredeficits of ASD. Additional researchmay be necessary to identify the char-acteristics of a select group of individ-uals who respond to this intervention.Rating: C (69%)

An Additional Guideline Pertaining toAll Programs

Measurements of a child’s behavior,skills, and cognitive ability can be un-reliable or prone to bias.36–39 Guideline:Any treatment program must includea carefully designed assessment planthat includes a baseline assessmentand periodic follow-up assessmentsmeasuring change in core deficits. As-sessment should be done by usinginstruments with acceptable reliabilityand validity, as documented scientifi-cally. Rating: C (75%)

Top Five Research Priorities

The systematic review identified sig-nificant heterogeneity in outcome mea-sures used in trials of interventionsfor ASD.8 Many measures appeared tolack previous validation studies, andoutcome measures were occasionallyreported in nonstandardized ways,both of which limited the ability to poolresults across studies. Given the smallsample sizes of the studies, the in-ability to pool data significantly limitedthe authors’ability to draw meaningfulconclusions from the review. Expert

panels are often convened to recom-mend standard outcome measure setsto advance research in a particulararea; such an approach should beconsidered to enhance the measure-ment of program effectiveness forchildren with ASD. Research priority:Assessment and monitoring of out-comes. Rating: A (100%)

The needs of preverbal children maydiffer considerably from those of verbalchildren, but existing studies rarely fo-cus on preverbal children (or childrenwho areminimally verbal or nonverbal).In 1 trial we found that targeted thispopulation, children experienced im-provements in language acquisition fol-lowing the intervention.40 In another,41

children with the least language (,5words) benefited most from joint at-tention intervention. Although otherstudies may have enrolled preverbalchildren, results were not stratifiedaccordingly. Research priority: Un-derstanding and addressing the needsof pre- or nonverbal individuals withASDs. Rating: A (100%)

The appropriate intensity, duration, andtype of program for adolescents withASDs cannot be determined from thecurrent literature, because few studiesreport on the effectiveness of inter-ventions for this age group. Adolescentsmay have distinct needs, and inter-ventions may need to be tailored ap-propriately. Likewise, few studies havebeen conducted on interventions foradults. Research priority: Under-standing and addressing the needs ofadolescents and adults with ASDs. Rat-ing: A (100%)

Although some reviews found that ap-plied behavioral analysis is a highlyeffective componentofacomprehensiveintervention in addressing IQ and com-munication skills,19,42,43 it is unclearwhich other components affect whichspecific core deficits.8 Research prior-ity: Identifying the most effective strat-egies to impact the specific core deficits

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of ASDs (the “active ingredients”). Rat-ing: A (94%)

Comparative effectiveness studies ofdifferent intensitiesanddurationsofASDinterventions are relatively lacking fromthe existing literature, but are importantfor at least 2 reasons. First, if dose-response relationships exist for cer-tain interventions, then such studiescould identify the dose that maximizesthe effectiveness of each programwhilelimiting the demands on families andreducing the possibility of burnout.Second, findings could help define ap-propriate evaluation periods for spe-cific treatments, afterwhichapparentlyineffective ones should be consideredfor termination. Research priority:Identification of the most effectivedose and duration of interventions.Rating: A (94%)

DISCUSSION

An independent TEP developed guide-lines and priorities for future researchbased on a systematic review of scien-tificevidence. Thestrengthof evidenceofefficacy of interventions designed toaddress the core deficits of autismvaries among approaches. However,none of the evidence reaches the levelof high strength according to estab-lished standards. Additional large, well-designed controlled trials are needed;

at this point, the strength of evidence foreven themost-studied intervention typesand approach modalities is moderate.Few head-to-head trials have comparedthe effects of different interventionapproaches and components, so we canconclude little about the superiority ofspecific programs (other than pointingout that certainapproacheshave littleorno evidence of effectiveness). Fewstudies are powered to identify specificprogram components associated withefficacy, and few follow participantslong-term. In addition, few studies ofinterventions for pre- or nonverbalchildrenwere reported in the literature.These limitations of the body of scientificevidence were taken into considerationwhen formulating the priorities for fu-ture research.

We identified several previous system-atic reviews; most focused on 1 partic-ular intervention type, such as appliedbehavioral analysis for preschool-agedchildren or PECS for children withlimitedverbal language. Incontrast, ourreview had a broad focus: nonmedicalinterventions designed to address thecore deficits of ASDs (communication,social skills, adaptive behavior, orcognitive function). In thisway,we couldidentify the gaps in the overall scientificevidence to use as springboards tomake recommendations for key areasof future research. In addition, the

criteria for including a study in ourreview were more rigorous than inprevious reviews that included single-subject research designs. Such reviewshave been used to create “evidence-based” standards that in fact do notreflect accepted principles of evidence-based practice. Still, our own guidelinestatements are based largely on expertopinion, with the systematic reviewas a starting point. Thus, recommen-dations may be based on a low tomoderate level of evidence. To increaseexternal validity, we only kept state-ments that everyone agreed orstrongly agreed to. There were variousareas where the panel could not cometo agreement; these are discussedfurther in our full report.8

We realize that the recommendedguidelines have substantial fiscal im-plications. In the current economicclimate, resources to make compre-hensive programs available to all chil-dren in need appear to be lacking. Wealsoemphasize thatnotall childrenwhoattend these programs will make sig-nificant gains regarding core deficits;the scientific literature is not clear as towhich individual participant charac-teristics are associated with success ofvarious approaches. However, we feelthat the level of evidence of effective-ness of these programs is sufficient tomake availability a worthy goal.

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DOI: 10.1542/peds.2012-0900O 2012;130;S169Pediatrics

Behavioral (AIR-B) Network−For the Technical Expert Panel, and HRSA Autism Intervention Research

Margaret A. Maglione, Daphna Gans, Lopamudra Das, Justin Timbie, Connie Kasari,and Further Research Needs

Nonmedical Interventions for Children With ASD: Recommended Guidelines  

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