Reichow B, Hume K, Barton EE, et al.
BACKGROUND: The rising prevalence of autism
spectrum disorders (ASD) increases the need for evidence-based behavioral
treatments to lessen the impact of symptoms on children's functioning. At
present, there are no curative or psychopharmacological therapies to
effectively treat all symptoms of the disorders. Early intensive behavioral
intervention (EIBI) is a treatment based on the principles of applied behavior
analysis. Delivered for multiple years at an intensity of 20 to 40 hours per
week, it is one of the more well-established treatments for ASD. This is an
update of a Cochrane review last published in 2012.
OBJECTIVES: To systematically review the
evidence for the effectiveness of EIBI in increasing functional behaviors and
skills, decreasing autism severity, and improving intelligence and
communication skills for young children with ASD.
SEARCH METHODS: We searched CENTRAL, MEDLINE,
Embase, 12 additional electronic databases and two trials registers in August
2017. We also checked references and contacted study authors to identify
additional studies.
SELECTION CRITERIA: Randomized control trials
(RCTs), quasi-RCTs, and controlled clinical trials (CCTs) in which EIBI was
compared to a no-treatment or treatment-as-usual control condition.
Participants must have been less than six years of age at treatment onset and
assigned to their study condition prior to commencing treatment.
DATA COLLECTION AND ANALYSIS: We used standard
methodological procedures expected by Cochrane.We synthesized the results of the
five studies using a random-effects model of meta-analysis, with a mean
difference (MD) effect size for outcomes assessed on identical scales, and a
standardized mean difference (SMD) effect size (Hedges' g) with small sample
correction for outcomes measured on different scales. We rated the quality of
the evidence using the GRADE approach.
MAIN RESULTS: We included five studies (one
RCT and four CCTs) with a total of 219 children: 116 children in the EIBI
groups and 103 children in the generic, special education services groups. The
age of the children ranged between 30.2 months and 42.5 months. Three of the
five studies were conducted in the USA and two in the UK, with a treatment
duration of 24 months to 36 months. All studies used a treatment-as-usual
comparison group.Primary outcomesThere is low quality-evidence at
post-treatment that EIBI improves adaptive behaviour (MD 9.58 (assessed using
Vineland Adaptive Behavior Scale (VABS) Composite; normative mean = 100,
normative SD = 15), 95% confidence interval (CI) 5.57 to 13.60, P < 0.0001;
5 studies, 202 participants), and reduces autism symptom severity (SMD -0.34,
95% CI -0.79 to 0.11, P = 0.14; 2 studies, 81 participants; lower values
indicate positive effects) compared to treatment as usual.No adverse effects
were reported across studies.Secondary outcomesThere is low-quality evidence at
post-treatment that EIBI improves IQ (MD 15.44 (assessed using standardized IQ
tests; scale 0 to 100, normative SD = 15), 95% CI 9.29 to 21.59, P < 0.001;
5 studies, 202 participants); expressive (SMD 0.51, 95% CI 0.12 to 0.90, P =
0.01; 4 studies, 165 participants) and receptive (SMD 0.55, 95% CI 0.23 to
0.87, P = 0.001; 4 studies, 164 participants) language skills; and problem
behaviour (SMD -0.58, 95% CI -1.24 to 0.07, P = 0.08; 2 studies, 67
participants) compared to treatment as usual.
AUTHORS' CONCLUSIONS: There is weak evidence
that EIBI may be an effective behavioral treatment for some children with ASD;
the strength of the evidence in this review is limited because it mostly comes
from small studies that are not of the optimum design. Due to the inclusion of
non-randomized studies, there is a high risk of bias and we rated the overall
quality of evidence as 'low' or 'very low' using the GRADE system, meaning further
research is very likely to have an important impact on our confidence in the
estimate of effect and is likely to change the estimate.It is important that
providers of EIBI are aware of the current evidence and use clinical
decision-making guidelines, such as seeking the family's input and drawing upon
prior clinical experience, when making recommendations to clients on the use
EIBI. Additional studies using rigorous research designs are needed to make
stronger conclusions about the effects of EIBI for children with ASD.
