Clinical Corner: What matters the most in early intervention?

Answered by
Stephen R. Anderson, PhD, BCBA, LBA
The Summit Center

What matters the most in early autism intervention

Photographed by Pavel Danilyuk (pexels.com)

While most children seem to acquire foundational social and cognitive skills effortlessly through everyday experiences, many children with autism face significant challenges in developing these same abilities. Most children enter the world with natural abilities that provide the foundation for healthy social and intellectual development. Daily life experiences provide each child with an active and engaging world that stimulates the senses, interacts with individual biology, and shapes language, social and cognitive development. It is surprising how quickly children learn to talk and socialize. There seems to be an inherent desire to engage with others and to show one’s independence. Children quickly demonstrate the ability to observe the behavior of others and imitate their actions. At a very young age, children recognize their parents’ emotional expressions (e.g., pleasure, anger) and imitate a world of non-verbal and verbal behavior. And, once they begin to observe other children, learning goes into high gear. The key prerequisite building blocks to learning include attention to people and things, imitation, and a desire to engage with others.

Autism Spectrum Disorders

For a child with autism spectrum disorders (ASD), learning is not so simple. As most people know, ASD is diagnosed more frequently than ever before (prevalence is now 1 in 31) (Shaw et. al., 2025). Core features of ASD include impairments in social interactions and communication as well as rigid and repetitive mannerisms (American Psychiatric Association, 2022). Some children with ASD have average or above average intelligence, while others exhibit severe intellectual disabilities. For this discussion, I am going to address the needs of young children (under age 5 years) with ASD and profound intellectual disabilities.

Most autistic children with severe intellectual disabilities appear to observe the world around them differently. It is not that they are not observing; they just seem to have different interests. For example, a child with ASD may be interested in the moving parts of a fan in the room but show little interest in the people standing near the fan. The concern is that a child cannot learn very much by observing a fan. But he or she might learn a lot by observing and interacting with adults or other children. In short, the child with ASD may not be observing the things that matter the most toward the development of communication and social relationships.

Neurotypical children often observe their parents pouring juice from a large bottle, and they want to do it themselves, even before they are able to do so. They also point to objects in their environment and vocalize to pull others into social interactions. Again, the key elements in both examples are attention to things that matter, imitation, and a desire to engage others. However, these are the foundational skills often missing for children with autism. Without these skills, typical parenting and early intervention that rely primarily on experiential learning alone do not result in much progress. The assumption is that by creating natural situations with toys and materials, the autistic child will engage spontaneously, generating hundreds of instructional opportunities. With foundational skills absent or impaired, spontaneous engagement often does not occur. Although this creates a challenge, there are ways to help children with ASD acquire foundational skills and once established, skills may be taught successfully in more natural environments.

Limitations of Traditional Teaching Methods

If foundational skills are not developing naturally, then they must be explicitly taught. Teaching these foundational skills is not easy and what is needed seems contrary to everything we know about engaging young children in learning. A common approach in early intervention is to display toys and materials and deploy enthusiastic and attentive staff to engage with them. Within this context, children will naturally play with the toys and materials, and there will be hundreds of moments for the adults to teach. But this approach, while seemingly perfect for neurotypical children, is unlikely to work for children with ASD (at least initially). Again, most of the critical prerequisite building blocks (attention, imitation, and desire for engagement) are absent or impaired. Those missing foundational skills reduce the opportunities for learning and change how adults and peers interact with them. Consciously or unconsciously, we interact less with individuals who are often unresponsive to our social overtures. Fortunately, there are strategies shown to help children learn and apply foundational skills.

The Learning Environment

It is common for early intervention to begin at home with the parent’s active involvement. Successful programs start by establishing a learning environment that helps to overcome the significant impairments in attention. The environment minimizes distractions but is engaging

and fun. The job of the adult is to support and praise the child for attending, engaging with people and things, making requests, and following simple instructions. Initially, activities should be brief but increase as thechild appears more comfortable. Introduce things that the child can already do or that are emerging. For young children (under 3-yrs), the best approach is to start within the context of play on the floor. By 3 years, most children begin to play and learn while sitting on a chair at a table.

The Curriculum

Many basic skills are important for learning other things. These skills include attending to other people and materials and responding to simple instructions. Imitation is a pivotal skill that can be used to accelerate the learning of social and communication skills. A variety of cognitive tasks, like matching and sorting objects, are helpful to learn foundational skills (e.g., classifying food groups). These activities help the brain to develop and form the required skills to succeed in kindergarten. There are many receptive and expressive communication skills required for learning other things most efficiently (e.g., identifying common objects). In addition, developmentally appropriate self-help skills should be addressed for eating, toileting, hygiene, and dressing.

Instruction

Effective programs start by considering expectations for the child based on their chronological age. As mentioned above, for a child under 3-years that may mean an interaction on the floor with a variety of toys and materials observed to be of interest to the child. The initial job of the adult is to build rapport with the child, show enthusiasm to help keep the child engaged, and begin to shape small improvements in behavior (e.g., manipulating toys and materials, responding to name, remaining in the defined area). Initially, the lessons should be very short (1 – 5 minutes), but as success is achieved the time is lengthened. The early lessons may involve following the child’s lead (i.e., their presumed interests), while periodically encouraging attention to less preferred materials and activities. The early days focus on building the child’s acceptance or tolerance for structure. Eventually, the child begins to look forward to the people and activities as lessons feed into autistic children’s desire for sameness and consistency.

Over time, instruction becomes more systematic and structured. Systematic, in that each lesson has established goals for learning and an organized approach to instruction. Structured, in that the adult leads the lesson content while slowly raising expectations. For example, in the beginning, the adult may imitate the child’s behavior (e.g., lining up cars). Eventually, the adult gets the child’s attention, claps their hands, while simultaneously instructing the child to imitate the model (“Do this”). Any approximation to the model is rewarded with praise. If praise alone is not yet rewarding to the child, a previously identified reward can be paired with praise (a preferred toy or high five). These rewards are eventually faded. As the child acquires skills, the adult will embed instructional opportunities into natural routines with natural consequences. For example, a child’s vocalization or sign approximating the request “more” results in the adult bouncing the child on their knee.

There are many other methods to help children with ASD learn, including breaking complex skills into smaller parts for learning, and mixing easy and hard tasks so the child is immediately more successful. The use of picture-symbol systems or manual signing can also help facilitate the acquisition of communication skills. Adults can enhance motivation by rewarding the child’s attempts to respond and offering a choice of preferred activities and materials as rewards. And, of course, the adult must ensure that the skills are developmentally appropriate, and prerequisites have been met.

Moving from Highly Structured to Natural Situations

Systematic and highly structured situations are usually the beginning, not the end point. Like any instructional situation, structure is both a strength and a weakness. Most adults have learned things in school that they are now unable to apply in their daily lives. Some things were never meant to be permanent (e.g., memorizing facts). The goal was to stimulate the brain and develop foundational skills. We did not maintain some skills because they were not particularly functional for our daily lives and we never practiced them beyond the classroom (e.g., reciting the capitals of all U.S. states and territories). The same is true for children with ASD.

The other complicating factor for children with ASD is that they sometimes do not attend to the right things within a given context. They are likely to focus on a particular instructional phrase, a specific set of materials, and/or a setting and not be able to perform the skills outside of that instructional context. For example, the child with ASD may learn to imitate several common actions (e.g., touch head, clap hands, say “ah”) but not learn the rule “Watch and do the same thing I am doing.” The ability to follow a set of common actions is helpful, but learning the rule could open the door to rapid and sustained development. Attention to this instructional challenge is important. Adults must ensure that skills, when acquired, are used across a variety of situations including settings, people, objects, and materials. To achieve this, adults must actively plan and execute to ensure that skills are repeated in novel conditions.

Practice Makes Progress

One of the most important things to consider is the number of opportunities the child must practice before a skill is learned. It is common for a child with ASD to require hundreds of opportunities to learn a new skill. A mistake that adults often make is to only practice an emerging skill a couple times a week and hope it will be learned. If it were that simple, most children with ASD would learn many skills through simple trial and error, but they don’t. Adults must expect that acquisition of skills will take a long time with hundreds of practice opportunities. And even longer to ensure that the skills are performed fluently. For example, a child may be able to express some words, but if unable to perform fluidly, he/she is not likely to be understood.

Learning in Groups

Individual instruction makes sense when the child has limited attention, requires physical prompting, and lack basic group readiness skills. However, the potential benefits of group instruction are clear: (a) it prepares the child for kindergarten, (b) it creates the potential for observational learning, and (c) it provides opportunities for social and language interactions with other children. It can be difficult to determine when it is best to introduce group instruction. Introduce it too early and the child may not be able to attend well enough. Introduce it too late, the child may be unprepared for larger group settings at school and in community.

A cautionary note about group instruction is to make sure the child is getting enough learning opportunities. Spreading the opportunities across many children could mean that the child with autism is not getting enough practice specific skill targets. An intermediary step is to provide one-to-one instruction within a group context. Flexible models that allow fluid change from one context to another and movement between individual and group instruction are most likely to be successful.

As the child with autism progresses, opportunities to integrate with children with no developmental disabilities should occur. Neurotypical children model age-appropriate social, language, and symbolic

play behavior for the child with ASD. However, for many autistic children integration must be structured to ensure that there is mutual engagement. Adults will need to establish activities to foster interactions and may need to encourage the neurotypical children to connect. Simple exposure often is not enough to ensure that relationships develop.

Summary

There are two key points to take from this description: (a) every child with autism can learn and acquire skills and behaviors leading to greater independence; and (b) learning is unlikely to occur without a systematic and structured approach. Recently, some advocates and professionals have suggested that autism is not a disability. They argue that we need a more accepting and inclusive society, not intervention. It’s important to consider that

without addressing the core symptoms of autism, individuals may face greater challenges in developing confidence and self-sufficiency. In the end, individuals with autism will have fewer choices and potentially a more socially isolated life. Parents and professionals would not simply accept the social and academic deficits of their non-autistic children without first trying to make a difference.

While behavioral symptoms of autism often emerge at 15 – 18 months, many children still do not get critical intervention until much later, if at all. An argument to not intervene could exacerbate the situation and lead to a compounding of deficits over time. Research indicates that the results of early intervention can produce substantial gains in communication, socialization, and cognition. This is particularly true for those with severe intellectual delays and profound impairments in socialization and communication.

The field of early intervention and its allied professions (e.g., education, psychology, applied behavior analysis), need to continuously focus on finding the best methods (behavioral and medical) to address skill deficits that may prevent full participation in the community. The evolution of successful intervention is a process that unfolds over years and decades. As a comparison, examine how medical interventions for treating disease have changed. Less than a century ago, vaccines that eliminated many infectious diseases in children were unknown. Most of the pharmacologic agents that are widely used today in clinical practice such as antibiotics did not exist. Significant cancer treatments have been identified in just the last 20 years. The comparison is not perfect, autism is not a disease, but the example illustrates the need for carefully controlled research to identify proven methods for helping children with autism to be successful. This does not obviate the need for a more accepting society that values individual differences. Two things can be true at the same time.

This paper is an attempt to explain the strategies for autism intervention free of professional jargon and based on my best understanding of the science at this point. Some elements are based on experience, common sense, and a compassionate approach to intervention. Others have a strong base of scientific support.

1. Build a relationship with the child.
2. Ensure that lessons are fun and engaging.
3. Be planful and systematic.
4. Start where the child is functioning.
5. Focus on developing foundational learning-to-learn skills.
6. Over time, be more direct and systematic.
7. Ensure lots of practice.
8. Deploy instructional methods shown to be effective.
9. Use a variety of ways to motivate the child to participate.
10. Gradually move from structured to less structured environments.

There are many proven methods (#8) for teaching including breaking complex skills into smaller steps for learning (a task analysis), recognizing small improvements in responding (shaping), and using rewards to motivate the child (principles of reinforcement). There are differences among professionals in the proportion, sequencing, and timing of strategies. For example, child vs. teacher-initiated activities, structured vs. unstructured lessons, use of contingent reinforcement, individual vs. group instruction, self-contained vs. socially-integrated settings, and instruction in the natural vs. contrived settings. All these strategies are important and should be continuously assessed and modified based on individual child needs.

It may be fair to say that no area within intellectual and developmental disabilities (IDD’s) generates more tension and debate than autism intervention. My hope is that professionals, parents, and advocates continue to engage in open and respectful dialogue to understand the range of perspectives involved. While I have intentionally avoided technical language in this paper, the approach described—including systematic teaching, breaking complex tasks into manageable steps, using reinforcement, and shaping behavior—are hallmark principles of Applied Behavior Analysis (ABA). Over the past several decades, ABA has evolved significantly, with increasing attention to compassionate, child-centered, and developmentally appropriate practices. Unfortunately, the field has also been subject to frequent mischaracterizations. But the core principles—when implemented thoughtfully and responsively—have helped thousands of children with autism build meaningful skills, improve communication, and participate more fully in their families and communities. Like all behavioral and medical treatments, ABA has evolved, and will continue to evolve, as a science.

References

American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Publishing.

Shaw, K. A., Williams S., Patrick, M. E., Valencia-Prado, M., Durkin, M. S., Howerton, E. M., Ladd-Acosta, C. M., Pas, E. T., Bakian, A. V., Bartholomew, P., Nieves-Muñoz, N., Sidwell, K. Alford, A., Bilder, D. A., DiRienzo, M., Fitzgerald, R. T., Furnier, S. M., Hudson A. E., Pokoski, O.M., Shea, L., … Maenner, M. J. (2025). Prevalence and early identification of autism spectrum disorder among children aged 4 and 8 years—Autism and Developmental Disabilities Monitoring Network, 16 sites, United States, 2022. Morbidity and Mortality Weekly Report: Surveillance Summaries, 74(2), 1–22.

Reference for this article:

Anderson, S. (2025). Clinical Corner: Early childhood development and Autism Spectrum Disorders. What matters the most? Science in Autism Treatment, 21(12).

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Early Childhood Development and Autism Spectrum Disorders: What Matters the Most?