Early Intervention for Children With Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Interventions for children with ASD under 3 years are designed to incorporate learning opportunities into everyday activities, capitalize on "teachable moments," and facilitate the generalization of skills beyond the familiar home setting.

“interventions are designed to incorporate learning opportunities into everyday activities, capitalize on “teachable moments,” and facilitate the generalization of skills beyond the familiar home setting.”

Probably not a substantial claim: may not pass S4 (based).

Over the past several years, a growing number of studies have evaluated interventions specifically designed for children aged <2 to 3 years.

“Fortunately, over the past several years, a growing number of studies have evaluated interventions specifically designed for children aged <2 to 3 years.”

May combine two claims.

Several of the 6 studies reported effect sizes: large effect sizes after 6 and 8 weeks of therapy for increases in joint attention skills, a moderate effect size after 12 months for expressive language growth, and small effect sizes after 13 months for parent-child interaction measures.

“Several of the 6 studies reported effect sizes: large effect sizes after 6 and 8 weeks of therapy for increases in joint attention skills, 20 , 32 a moderate effect size after 12 months for expressive language growth, 33 and small effect sizes after 13 months for parent–child interaction measures. 18”

• cites [20] Kasari, 2010, Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism., J Autism Dev Disord sourceNot checked yet

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• cites [32] Kasari, 2006, Joint attention and symbolic play in young children with autism: a randomized controlled intervention study., J Child Psychol Psychiatry sourceNot checked yet

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• cites [33] Kasari, 2008, Language outcome in autism: randomized comparison of joint attention and play interventions., J Consult Clin Psychol sourceNot checked yet

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• cites [18] Green, 2010, Parent-mediated communication-focused treatment in children with autism (PACT): a randomised controlled trial., Lancet sourceNot checked yet

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May combine two claims.

Both of the comprehensive intervention programs (Early Start Denver Model and UCLA/Lovaas model) and the 4 targeted interventions (focusing on social communication or imitation skills) exhibited significantly improved outcomes relative to comparison groups after therapeutic durations of 8 weeks to 2 to 3 years.

“both of the comprehensive intervention programs (Early Start Denver Model [ESDM] and the UCLA/Lovaas model) and the 4 targeted interventions (focusing on social communication or imitation skills) exhibited significantly improved outcomes relative to comparison groups after therapeutic durations of 8 weeks to 2 to 3 years.”

• cites [17] Dawson, 2010, Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model., Pediatrics sourceNot checked yet

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• cites [18] Green, 2010, Parent-mediated communication-focused treatment in children with autism (PACT): a randomised controlled trial., Lancet sourceNot checked yet

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• cites [19] Ingersoll, 2010, Pilot randomized controlled trial of reciprocal imitation training for teaching elicited and spontaneous imitation to children with autism., J Autism Dev Disord sourceNot checked yet

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• cites [20] Kasari, 2010, Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism., J Autism Dev Disord sourceNot checked yet

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• cites [32] Kasari, 2006, Joint attention and symbolic play in young children with autism: a randomized controlled intervention study., J Child Psychol Psychiatry sourceNot checked yet

  Not checked in the free run.

• cites [33] Kasari, 2008, Language outcome in autism: randomized comparison of joint attention and play interventions., J Consult Clin Psychol sourceNot checked yet

  Not checked in the free run.

• cites [38] Smith, 2000, Randomized trial of intensive early intervention for children with pervasive developmental disorder., Am J Ment Retard sourceNot checked yet

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May combine two claims.

Compared with early intervention models evaluated for preschool-aged children (aged 3-5 years), programs for children aged <3 years were more likely to use developmental approaches, more intensively involve parents, and target social communication.

“Compared with early intervention models evaluated for preschool-aged children (aged 3–5 years), programs for children aged <3 years were more likely to use developmental approaches, more intensively involve parents, and target social communication.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Some trials were limited to 8- to 12-week outcome data.

“Although some trials were limited to 8- to 12-week outcome data”

Classified as probably not a substantial claim. May combine two claims.

Six randomized controlled trials were considered to produce strong recommendations and an assessment that the desirable effects of an intervention clearly outweighed the undesirable effects.

“Six randomized controlled trials were considered to produce strong recommendations and an assessment that the desirable effects of an intervention clearly outweighed the undesirable effects.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The central role of parents has been emphasized in interventions for children with ASD under 3 years.

“The central role of parents has been emphasized”

May combine two claims.

Only 2 studies focused solely on children aged <3 years; 1 was related to a comprehensive treatment approach, and 1 was a targeted intervention program.

“Only 2 studies focused solely on children aged <3 years; 1 was related to a comprehensive treatment approach, 17 and 1 was a targeted intervention program. 20”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Several groups have adapted treatments initially designed for older, preschool-aged children with ASD, integrating best practice in behavioral teaching methods into a developmental framework based on current scientific understanding of how infants and toddlers learn.

“Several groups have adapted treatments initially designed for older, preschool-aged children with ASD, integrating best practice in behavioral teaching methods into a developmental framework based on current scientific understanding of how infants and toddlers learn.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

The methodologic rigor of intervention trials in ASD is improving, but continued attention to key aspects of research design is needed to further develop the evidence base for toddlers.

“The methodologic rigor of intervention trials in ASD is improving, but continued attention to key aspects of research design is needed to further develop the evidence base for toddlers.”

May combine two claims.

Two nonrandomized controlled studies were rated as producing strong recommendations: comprehensive applied behavior analysis (ABA)-type interventions were associated with significantly improved outcomes relative to the comparison group after 2 years (compared with publicly funded educational services) and with significantly improved outcomes in a subset of participants after 1 year (compared with,

“Two nonrandomized controlled studies were rated as producing strong recommendations: comprehensive applied behavior analysis (ABA)-type interventions were associated with significantly improved outcomes relative to the comparison group after 2 years (compared with publicly funded educational services) 29 and with significantly improved outcomes in a subset of participants after 1 year (compared”

• cites [29] Remington, 2007, Early intensive behavioral intervention: outcomes for children with autism and their parents after two years., Am J Ment Retard sourceNot checked yet

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• cites [23] Ben-Itzchak, 2009, Change in autism classification with early intervention: predictors and outcomes., Res Autism Spectr Disord sourceNot checked yet

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May combine two claims.

A recent trial evaluated the ESDM in a brief format (1 hour per week of parent training for 12 weeks) and failed to detect improvements in parental intervention skill acquisition and child-related outcomes relative to community intervention controls.

“For example, a recent trial evaluated the ESDM in a brief format: 1 hour per week of parent training for 12 weeks, as opposed to the original ESDM, which involved 20 hours per week of therapist involvement plus additional parent-mediated intervention for 2 years. 14 The study failed to detect improvements in parental intervention skill acquisition and child-related outcomes relative to community”

• cites [14] Rogers, 2012, Effects of a brief Early Start Denver model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: a randomized controlled trial., J Am Acad Child Adolesc Psychiatry sourceNot checked yet

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May combine two claims.

Despite an apparent lack of change on standardized measures of social communication symptoms in 2 randomized controlled trials, a growing body of research describes the beneficial effects early intervention has on the development of communication and social functioning.

“Despite an apparent lack of change on standardized measures of social communication symptoms in 2 randomized controlled trials, 17 , 37 a growing body of research describes the beneficial effects early intervention has on the development of communication and social functioning.”

• cites [17] Dawson, 2010, Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model., Pediatrics sourceNot checked yet

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• cites [37] Drew, 2002, A pilot randomised control trial of a parent training intervention for pre-school children with autism. Preliminary findings and methodological challenges., Eur Child Adolesc Psychiatry sourceNot checked yet

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May combine two claims.

Targeted interventions generally focused on outcomes related to ASD-specific characteristics, whereas the comprehensive models included teaching to the core deficits but often did not measure changes in these core deficits (or obtained nonsignificant findings); they instead focused on gains in general functioning (eg, cognitive and/or adaptive skills).

“It is notable that targeted interventions generally focused on outcomes related to ASD-specific characteristics, whereas the comprehensive models included teaching to the core deficits but often did not measure changes in these core deficits (or obtained nonsignificant findings); they instead focused on gains in general functioning (eg, cognitive and/or adaptive skills).”

May combine two claims.

Our analysis supports the effectiveness of integrated developmental and behavioral interventions, outside of the laboratory setting, in improving developmental quotients, adaptive functioning, and language skills.

“Our analysis supports the effectiveness of integrated developmental and behavioral interventions, outside of the laboratory setting, in improving developmental quotients, adaptive functioning, and language skills. 17 , 29”

• cites [17] Dawson, 2010, Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model., Pediatrics sourceNot checked yet

  Not checked in the free run.

• cites [29] Remington, 2007, Early intensive behavioral intervention: outcomes for children with autism and their parents after two years., Am J Ment Retard sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Targeted interventions have been associated with gains in imitation, joint attention, social engagement, other social communication measures, and functional and symbolic play.

“Specifically, targeted interventions have been associated with gains in imitation, 16 , 19 joint attention, 16 , 20 , 32 , 34 social engagement, 20 , 32 , 33 other social communication measures, 34 and functional and symbolic play. 20 , 32”

May combine two claims.

The second year of life is a dynamic period of brain growth, during which increases in brain volume and atypical connectivity associated with ASD first emerge.

“First, the second year is a dynamic period of brain growth, during which increases in brain volume and atypical connectivity associated with ASD first emerge 6 , 7”

• cites [6] Courchesne, 2011, Brain growth across the life span in autism: age-specific changes in anatomical pathology., Brain Res sourceNot checked yet

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• cites [7] Lewis, 2014, Network inefficiencies in autism spectrum disorder at 24 months., Transl Psychiatry sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The search strategy was comprehensive.

“although the search strategy was comprehensive”

May combine two claims.

Selection of articles for the review was not systematic, which is an important limitation.

“selection of articles was not systematic, which is an important limitation.”

May combine two claims.

Infants depend on experiential learning within their natural environments and on interactions rooted in social play that occur within the context of everyday caregiving activities.

“Infants depend on experiential learning within their natural environments and on interactions rooted in social play that occur within the context of everyday caregiving activities. 1”

• cites [1] Zwaigenbaum, 2009, Clinical assessment and management of toddlers with suspected autism spectrum disorder: insights from studies of high-risk infants., Pediatrics sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Cultural values and differences can affect the goals and priorities of the family and may in some cases lead to misunderstandings.

“Because cultural values and differences can affect the goals and priorities of the family and may in some cases lead to misunderstandings, clinicians and other service providers should aim to understand the values, beliefs, and accompanying practices of families of differing cultures”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

Cumulatively, such decisions can diminish the generalizability and clinical applicability of reported interventions.

“Cumulatively, such decisions can diminish the generalizability and clinical applicability of reported interventions.”

Probably not a substantial claim: may not pass S4 (based).

Due to attitudes concerning childhood rearing and independence, shame regarding developmental delays and ASD, or other societal and cultural beliefs, parents may be reluctant to enroll a child in a research study.

“Due to attitudes concerning childhood rearing and independence, shame regarding developmental delays and ASD, or other societal and cultural beliefs, parents may be reluctant to enroll a child in a research study.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Parents are expected to play a prominent role in supporting optimal development and thus intervention program delivery for their children, particularly at a very young age.

“Parents are expected to play a prominent role in supporting optimal development and thus intervention program delivery for their children, particularly at a very young age.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

When there is participation, cultural differences and language barriers might influence and moderate treatment effects.

“In addition, when there is participation, cultural differences and language barriers might influence and moderate treatment effects.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The search was updated by using the same strategy to add articles published to December 31, 2013, which yielded an additional 323 references; selection was again limited to clinical trials of developmental/behavioral interventions that included children aged <36 months.

“The search was updated by using the same strategy to add articles published to December 31, 2013, which yielded an additional 323 references; selection was again limited to clinical trials of developmental/behavioral interventions that included children aged <36 months.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Family involvement is also likely to be cost-effective and increases the sense of empowerment on the part of parents and caregivers.

“Family involvement is also likely to be cost-effective and increases the sense of empowerment on the part of parents and caregivers.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Although the optimal study design to minimize bias in treatment research is a randomized controlled trial, it is acknowledged that contexts occur in which other methods may be appropriate.

“Although the optimal study design to minimize bias in treatment research is a randomized controlled trial, it is acknowledged that contexts occur in which other methods may be appropriate.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Each selected study was assessed, and working group members were asked to arrive at a consensus evaluation on each article after a detailed discussion.

“Each selected study was assessed, and working group members were asked to arrive at a consensus evaluation on each article after a detailed discussion.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Families with lower socioeconomic status are likely to have less access to services.

“Families with lower socioeconomic status are likely to have less access to services.”

May combine two claims.

Interventions dealing with attention regulation in young children with ASD have not yet been reported, but in typically developing children, short-term training has improved attention control measures associated with effortful control.

“Interventions dealing with attention regulation in young children with ASD have not yet been reported, but in typically developing children, short-term training has improved attention control measures associated with effortful control. 62”

• cites [62] Posner, 2007, Research on attention networks as a model for the integration of psychological science., Annu Rev Psychol sourceNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

Because few studies focused exclusively on this age group, studies in which participants included some children aged >3 years were assessed as long as there was sufficient information to draw inferences about younger children.

“Because few studies focused exclusively on this age group, studies in which participants included some children aged >3 years were assessed as long as there was sufficient information to draw inferences about younger children.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Socioeconomic status, family characteristics, and cultural factors may present barriers to service provision.

“Socioeconomic status, family characteristics, and cultural factors may present barriers to service provision.”

May combine two claims.

Frequently encountered medical factors in ASD include seizures (particularly in children with severe intellectual disability, motor deficits, or a positive family history of epilepsy), other gastrointestinal symptoms, and sleep disturbances affecting daytime functioning.

“Frequently encountered medical factors in ASD include: seizures, particularly in children who also have severe intellectual disability, motor deficits, or a positive family history of epilepsy 68 , 69 ; other gastrointestinal symptoms 57 , 70 ; and sleep disturbances affecting daytime functioning.”

• cites [68] Pavone, 2004, Epilepsy is not a prominent feature of primary autism., Neuropediatrics sourceNot checked yet

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• cites [69] Tuchman, 1991, Autistic and dysphasic children. II: epilepsy., Pediatrics sourceNot checked yet

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• cites [57] Myers, 2007, Management of children with autism spectrum disorders., Pediatrics sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

It is highly likely that specific subsets of individuals with ASD may respond to specific interventions more effectively than to others, perhaps based on etiology and underlying biological factors alone.

“Given this heterogeneity, it is highly likely that specific subsets of individuals with ASD may respond to specific interventions more effectively than to others, perhaps based on etiology and underlying biological factors alone.”

• AssumptionRests on an assumption: ASD is a heterogeneous disorder—etiologically, biologically, and clinically.

May combine two claims.

In two studies, a measure of initial object exploration determined the extent to which a child would benefit more from one language-based intervention versus another, or the extent to which children had better communication outcomes from a parent-mediated intervention.

“In both studies, a measure developed to index the level of initial object exploration determined the extent to which a child would benefit more from 1 language-based intervention versus another 35 or the extent to which children had better communication outcomes from a parent-mediated intervention. 15”

• cites [35] Yoder, 2006, Randomized comparison of two communication interventions for preschoolers with autism spectrum disorders., J Consult Clin Psychol sourceNot checked yet

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• cites [15] Carter, 2011, A randomized controlled trial of Hanen’s ‘More Than Words’ in toddlers with early autism symptoms., J Child Psychol Psychiatry sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based).

Some early developmental skills could yield early-read measures that may predict better functioning in later cognition, language, and adaptive behavior.

“Some early developmental skills could yield “early-read” measures that are important to later developmental outcomes. These early-read measures may include joint attention, shared affect, and imitation skills, with the expectation that these early developmental tasks may predict better functioning in later cognition, language, and adaptive behavior.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Children with ASD and MET gene mutations were more likely to have gastrointestinal disorders.

“Campbell et al 66 reported that children with ASD and MET gene mutations were more likely to have gastrointestinal disorders, raising the possibility that medical comorbidities in children with ASD could index underlying genetic heterogeneity.”

• cites [66] Campbell, 2009, Distinct genetic risk based on association of MET in families with co-occurring autism and gastrointestinal conditions., Pediatrics sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Without appropriate study designs to carefully examine the effect of specific intervention strategies such as treatment type, dose, and agent, we may be unable to determine which of the potentially significant elements in an intervention model are responsible for change and for which subgroups.

“Without appropriate study designs to carefully examine the effect of specific intervention strategies such as treatment type, dose, and agent, we may be unable to determine which of the potentially significant elements in an intervention model are responsible for change and for which subgroups.”

May combine two claims.

Teaching joint attention or play skills within an ABA program increased their spontaneous occurrence in generalized contexts and predicted greater language outcomes compared with children in an ABA program without a focus on play and joint attention.

“Teaching these skills increased their spontaneous occurrence in generalized contexts and further predicted greater language outcomes compared with the children in the ABA program without a focus on play and joint attention. 33 , 59”

• cites [33] Kasari, 2008, Language outcome in autism: randomized comparison of joint attention and play interventions., J Consult Clin Psychol sourceNot checked yet

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• cites [59] Kasari, 2012, Longitudinal follow-up of children with autism receiving targeted interventions on joint attention and play., J Am Acad Child Adolesc Psychiatry sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A recent study in toddlers with ASD found few differences between a comprehensive intervention and the same intervention without a specific ingredient, except for an apparent benefit of imitation in one group.

“Few differences emerged in this study except for the apparent benefit of imitation in 1 group.”

• cites [16] Landa, 2011, Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: a randomized controlled trial., J Child Psychol Psychiatry sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Object exploration can reflect a child's flexibility in play and play level, both of which may influence later cognitive and language outcomes.

“Object exploration can reflect a child’s flexibility in play and play level, both of which may influence later cognitive and language outcomes. 59”

• cites [59] Kasari, 2012, Longitudinal follow-up of children with autism receiving targeted interventions on joint attention and play., J Am Acad Child Adolesc Psychiatry sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The real-life intensity of an intervention may be influenced by the degree to which parents implement strategies in natural routines throughout the day.

“Notably, the “real-life” intensity of the intervention may be influenced by the degree to which parents are implementing the strategies in natural routines throughout the day.”