Parents of children with autism can be effectively trained with telehealth support to increase functional communication and reduce challenging behaviors.

Background: Children with ASD are at higher risk for problem behaviors such as self-injury, aggression, verbal outbursts, property destruction, and severe noncompliance, which can significantly disrupt social and learning interactions. Studies have identified several evidence-based approaches for treating these behaviors, including therapy, parent education, and medication. However, among the most researched and utilized treatment approaches is an applied behavior analysis (ABA) method called functional communication training (FCT). FCT has been shown to successfully increase functional communication and reduce challenging behaviors across different populations and settings.

Methods & Findings: Access to FCT can be limited by geography, provider availability, and cost. To overcome these barriers to an effective treatment for challenging behaviors, this randomized controlled study sought to examine its effectiveness in a telehealth setting. The researchers compared the effectiveness of FCT to treatment as usual in 38 young children (age 21 to 85 months) with autism. The children were randomly placed in either a group that immediately received FCT for 12 weeks or a waitlist control group that received treatment as usual for 12 weeks followed by delayed FCT for 12 weeks. FCT was administered by parents using real-time support from a telehealth behavioral consultant. The researchers measured the reductions in frequency of challenging behaviors, increases in appropriate requests, and the durability of these effects six months after treatment. Although both groups showed significantly improved behavior after completing FCT, the group of children who received immediate FCT had slightly more behavioral improvement than the group of children who received FCT 12 weeks later. Parents rated the telehealth FCT treatment generally positive, indicating it as highly acceptable.

Implications: The results of this study demonstrate that parents can be effectively trained to apply FCT with live telehealth support. FCT intervention resulted in a 98% reduction (on average) of challenging behaviors and significant increases in functional communication. FCT training delivered remotely to parents can increase access to an evidence-based approach for increasing functional communication and reducing challenging behaviors—improving not only social and learning outcomes, but potentially increasing the benefit of other ASD services.

While 15-25 hours of high-quality early behavioral/social skills intervention has been shown to have benefits for children on the autism spectrum, there is little evidence that more than 25 hours per week of early intervention leads to better outcomes.

Background: The evidence for early intervention to improve outcomes in young children with ASD is wellestablished. However, different studies use different intervention styles and levels of intensity, with some studies using a treatment design that is so time-intensive that it would be impractical in a real-life setting. Further, there has not previously been a rigorous effort to compare outcomes across the differing intervention styles and intensities, resulting in a lack of guidance for caregivers and practitioners on optimal delivery.

Methods & Findings: This study conducted a rigorous assessment of two commonly used early intervention styles: the Early Intensive Behavioral Intervention (EIBI), a one-on-one discrete trial training, and the Early Start Denver Model (ESDM), a one-on-one naturalistic developmental behavioral intervention. The researchers evaluated both interventions across two levels of intensity: 15 hours or 25 hours per week, across 12 months. The researchers enrolled 87 children aged 12 to 30 months who met ASD criteria. The children were randomized to four conditions: EIBI for 15 hours a week, EIBI for 25 hours a week, ESDM for 15 hours a week, or ESDM for 25 hours a week. Additionally, all families received two 90-minute coaching sessions each month on the use of their assigned intervention. The researchers found that all interventions improved outcomes over time. There was no difference in outcomes across the EIBI or ESDM and no evidence that initial severity of developmental delay and autism characteristics impacted outcomes from either treatment style. Across most study sites, the researchers found no difference in outcomes across either 15 or 25 hour a week of intervention and no evidence that initial severity of developmental delay and autism characteristics impacted any of the other outcomes from the intensity of either intervention delivered. However, at one study site, they found evidence that initial severity predicted a greater effect from higher intensity intervention (25 hours a week) in improving one outcome: core autism characteristics.

Implications: This study provided some guidance for clinicians in their recommendations for early intervention for ASD. First, the quality and characteristics of early intervention may be more important than its "brand name." A high-quality early intervention should include a specific, evidence-based approach that provides regular developmental and behavioral intervention integrated with everyday activities. There is evidence that 25 hours of intervention a week may be more effective than 15 hours in improving core autism characteristics for some children, but additional study is needed to support this finding. The researchers reiterated that there is no high-quality evidence for intervention intensity longer than 25 hours.

An analysis of research describing seven types of early interventions for children with autism summarizes their benefits and limitations and provides recommendations for more research.

Background: There has been an abundance of research on ASD interventions targeted to young children. In a broad effort to evaluate the effectiveness of early nonpharmacological interventions for ASD, the researchers of this study conducted a comprehensive meta-analysis of seven different intervention types—behavioral approaches, developmental approaches, naturalistic developmental behavioral interventions (NDBIs), Treatment and Education of Autistic and related Communication-Handicapped Children (TEACCH), sensory-based interventions, animalassisted interventions, and technology-based interventions. A meta-analysis is a type of study that systematically gathers data from previous studies and analyzes the outcomes of these studies as a whole.

Methods & Findings: Researchers identified 140 peer-reviewed articles and ten dissertations that met a more rigorous set of criteria than is generally used to evaluate the quality of evidence in ASD interventions. The research team assigned a quality rating to each study according to each intervention type. The research team also assessed whether the outcomes were directly aligned to the intervention (i.e., specific skills that could be observed in the context of the intervention) or not. They then extracted data from all studies to determine how much of a difference the intervention had (i.e., effect size) across each type of outcome within each type of intervention. Of all the intervention types, NDBIs emerged as having strong evidence for the development of social communication, language, and play skills. NDBIs were the most likely to have been conducted in a scientifically rigorous manner to prevent bias and incorporate comparison groups, and they were the least likely to rely on parent or caregiver report.

Implications: Behavioral interventions were the most common intervention studied, which is likely the result of their common use due to the availability of insurance coverage. Of all behavioral interventions, only Early Intensive Behavioral Interventions (EIBI) showed some evidence of effectiveness for cognition and language, but most studies did not meet high standards for quality evidence. The trend towards positive results in behavioral interventions indicate that future studies could improve the confidence of these approaches through use of more scientifically rigorous study designs, such as randomized controlled trials. All other interventions showed little evidence of effectiveness. The researchers of this study suggested that NDBIs and developmental approaches be included in insurance mandates and other policies. Importantly, the results of this meta-analysis suggest that future ASD intervention studies should move toward randomized controlled trials and rely less on parent and teacher reports as outcomes.

Cognitive behavioral therapy helps reduce anxiety in children and youth with autism, especially when the therapy is specifically adapted for autism.

Background: Anxiety is common among school-aged youth with ASD. Youth with ASD who experience anxiety commonly react to their fear using coping mechanisms such as meltdowns, aggression, self-harm, or avoidance. These behaviors can significantly interfere with social and learning environments, create family conflict, and result in increased isolation and depression. Several small randomized controlled studies suggest that cognitive behavioral therapy (CBT) may be effective for school-aged youth with ASD and anxiety, but their study designs have not been robust enough to establish evidence. Other studies of CBT that has been adapted to the characteristics of ASD have also shown promise, but these efforts have also been too limited to establish evidence for their effectiveness. It has also been unknown if CBT adapted for youth with ASD differs from standard CBT.

Methods & Findings: This study aimed to evaluate the effectiveness of both standard and adapted CBT for anxiety in children with ASD. The researchers evaluated 145 children aged 7 to 13 years with ASD and anxiety. The children were randomized across three groups: standard CBT, adapted CBT, and treatment as usual. Standard CBT consisted of 16 weekly one-hour sessions targeted for identifying anxiety triggers and developing a plan for appropriate coping strategies. Adapted CBT consisted of 16 weekly 90-minute sessions that included higher levels of parent engagement, personalized strategies to incorporate the child’s special interests, a focus on self-regulation and social engagement skills, and increased reappraisal and reinforcement. Treatment as usual included 16 weeks of usual services and no other no specific treatment. Both standard and adapted CBT resulted in positive effects as compared to treatment as usual. However, the adapted CBT was significantly more effective than standard CBT in reducing anxiety and interfering behaviors. Additionally, adapted CBT was shown to further improve emotional dysregulation, social-communication, and adaptive functioning.

Implications: This study provided robust evidence that a CBT protocol adapted for children with ASD was effective for reducing anxiety and coping behaviors and improving social, emotional, and adaptive functioning. The researchers recommended that adapted CBT become available in all clinical settings where children with ASD receive services, suggesting that the protocol can be provided by therapists without specific ASD expertise with modest training and guidance.