Eldevik, S., Titlestad, K.B., Aarlie, H., & Tønnesen, R. (2019). Community implementation of early behavioral intervention: Higher intensity gives better outcome. European Journal of Behavior Analysis, 1-19. https://doi.org/10.1080/15021149.2019.1629781
Reviewed by: Jacqueline Shinall, MS, and Robert H. LaRue, PhD, BCBA-D
Graduate School of Applied and Professional Psychology, Rutgers University
Why research this topic?
Early Intensive Behavioral Intervention (EIBI) is considered the most effective treatment for helping children diagnosed with autism spectrum disorder (ASD). EIBI is highly structured and based on the principles of applied behavior analysis (e.g., skills broken down into teachable units, use of reinforcement to build adaptive skill and reduce challenging behavior, data-based). While the Behavior Analyst Certification Board (BACB) defines comprehensive ABA treatment programs as those providing 30–40 hours a week, many community programs provide fewer than 20 hours of intensive intervention for individuals with ASD (The Behavior Analyst Certification Board, 2014). In the current investigation, the researchers collected data from two community intervention centers in Norway, which suggested that the average amount of specialized care (e.g., ABA, EIBI) has gradually decreased in the past decade from about 35 hours a week to 20 hours per week. To this point, not much is known about the efficacy of intervention when delivered in models of differing intensity (i.e., 20 hours or less per week). In the current study, researchers evaluated the outcomes of individuals receiving higher-intensity EIBI (18.2 hours/week), individuals receiving lower-intensity EIBI (13.1 hours/week), and individuals receiving eclectic special education (i.e., treatment as usual).
What did the researchers do?
The study included 74 (N=74) children split into three groups by the type or intensity of treatment. Children in the study were between the ages of two and seven years-old and were already receiving at least five hours of intervention per week. Treatment was delivered in preschools by trained staff supervised by either a BCBA on site or through consultation. The higher-intensity treatment group (n=36) received an average of about 18.2 hours/week of EIBI at a center in Bergen, Norway. The lower intensity group (n=27) received about 13.1 hours/week at a center in Oslo. The comparison group (n=17) received treatment as usual (TAU) which was an eclectic combination of interventions. Researchers noted that the higher-intensity treatment group would not be considered as “high intensity” EIBI by normal standards (30+ hours per week). Outcome measures in the study included the Vineland Adaptive Behavior Scale II (VABS-II) as a measure of adaptive functioning, the Bayley Scales of Infant Development, 3rd Edition (BSID-3) as a measure of IQ, and the Childhood Autism Rating Scale, 2nd Edition (CARS-2) as a measure of autism symptom severity. Outcome measurements (i.e., VABS, CARS-2, and IQ scores) were administered at baseline, at around three months and after one year of treatment.
What did the researchers find?
Researchers found that the higher intensity EIBI group had significantly larger gains on adaptive behavior composite scores of the VABS compared to both the lower-intensity EIBI and TAU groups. Seven of the 36 children (19.4%) in the high-intensity group had a reliable change from baseline. A reliable change refers to the extent that the effects at an individual level are meaningful and significant and cannot be accounted for by measurement error and/or sample variance with 95% confidence. In contrast, only one of the 19 children (5.3%) in the low intensity group had a reliable change, and none of the children in the TAU group met criterion for reliable change from baseline. The difference between groups for reliable changes on the VABS was statistically significant.
The authors were unable to obtain information regarding the intellectual functioning for individuals in the higher-intensity group. However, the IQ scores for individuals from the lower-intensity EIBI group were significantly improved relative to that of the TAU group.
The authors also noted that higher-intensity EIBI reduced autism severity scores (CARS-2) to a greater extent than that of lower-intensity EIBI. However, given a lack of CARS-2 scores for individuals in the low intensity EIBI group, this difference was not statistically significant. There were no CARS-2 scores for the TAU group, so comparisons to eclectic intervention were not possible.
What are the strengths and limitations?
This study demonstrated a novel look at early intensive behavioral intervention (EIBI) delivered through community implementation. While best practice may support 30+ hours of intensive intervention, children routinely receive less. A strength of the current investigation is that it evaluated the efficacy of less intensive EIBI (under 20 hours a week).
While the findings from this study are important, there were some limitations that should be considered. First, children in the study were not randomly assigned to different treatment groups. As such, pre-existing differences may have affected the results. The researchers did not control for other factors such as parental involvement in the treatment process, any prior treatment or exposure to EIBI, or delivery methods of the measures used for assessing adaptive functioning. Another potential limitation in the current study was that the raters were not blind to the conditions. Lastly, they were missing a large amount of outcome data that affected the interpretation of the results.
What do the results mean?
These researchers demonstrated that children who received more hours of EIBI through community implementation had better outcomes in ASD severity and adaptive functioning compared to those with fewer hours or treatment as usual. Furthermore, children can make significant gains with less than 20 hours, but those with more hours had significantly better outcomes demonstrating a dose-response relationship between the weekly hours of treatment and improvement in ASD severity and adaptive functioning.
References
The Behavior Analyst Certification Board. (2014). Applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers. Retrieved from https://www.bacb.com/?s=Guidelines
Citation for this article:
Shinall, J., & LaRue, R. H. (2019). Research synopsis: Community implementation of early behavioral intervention: Higher intensity gives better outcome. Science in Autism Treatment, 16(12).
