Efficacy of Behavioral Interventions for Young Children ... · Efficacy of Behavioral Interventions...
Transcript of Efficacy of Behavioral Interventions for Young Children ... · Efficacy of Behavioral Interventions...
REVIEW PAPER
Efficacy of Behavioral Interventions for Young Childrenwith Autism Spectrum Disorders: Public Policy, the EvidenceBase, and Implementation Parameters
Raymond G. Romanczyk & Emily H. Callahan &
Laura B. Turner & Rachel N. S. Cavalari
Received: 22 May 2014 /Accepted: 23 May 2014 /Published online: 27 June 2014# Springer Science+Business Media New York 2014
Abstract The complex and extensive deficits associatedwith Autism Spectrum Disorders, in concert with thesubstantial increase in prevalence over the last threedecades, combine to present a challenge to individuals,families, communities, and government that has fewparallels. This challenge is complicated by debateamong service providers concerning appropriate treat-ment approaches and the evidence for efficacy. Withinthis backdrop, numerous healthcare reform initiativeshave inc luded coverage for Aut ism Spect rumDisorders, both enhancing and complicating the role ofpublic education in the mix of provision of appropriateservices. Basic principles of limited resources and ex-penditure accountability require that standards of careand evidence-based procedures be established andagreed upon. While this approach is common in healthinsurance policies and procedures, it is less so in public
education. The purpose of this review is to provideimpetus toward guidelines for comprehensive treatmentservices, as well as individual skill/behavior interven-tions, with respect to required service provider charac-teristics, setting, and “dosage” (number of hours perweek for a designated time period). Quantitative analy-sis will permit progress in review panel deliberation forboth insurance reimbursement and public services allo-cation by having appropriate comparisons with which toevaluate progress reported versus progress expected giv-en the specific intervention program being provided.
Keywords Autism spectrum disorder . ASD . Intervention .
Evidence based . Efficacy . Dosage . Public policy . School .
Insurance
The increasing prevalence of Autism Spectrum Disorders(ASD) over the last few decades has presented both a complexproblem with respect to the contributing factors for this increaseand a significant and growing challenge for currently inadequateservice delivery systems. Beginning in 1980 with the adoptionof DSM-III (Diagnostic and Statistical Manual of the AmericanPsychiatric Association) criteria for autism, with an estimatedprevalence 4.5 per 10,000, to the present with estimates of 1 in68 for children (Centers for Disease Control and Prevention[CDC] 2014), the magnitude of the increase has eluded defin-itive explanation. Public awareness and demand for informationand services has also increased. As one index, the coverage ofASD in the popular press, in this example Time Magazine, hasincreased from three articles in the 1980s, to 11 in the 1990s, to73 in the 2000s up to 2008. Such increased awareness has beenparalleled by attention from professional groups to detect andtreat ASD as early as possible. For example, the AmericanAcademy of Pediatrics recommends that children be screenedfor ASD twice by age three (Myers and Johnson 2007).
R. G. Romanczyk (*) : L. B. TurnerDepartment of Psychology, State University of N.Y. at Binghamton,Binghamton, NY 13902-6000, USAe-mail: [email protected]
L. B. Turnere-mail: [email protected]
E. H. CallahanVirginia Institute of Autism, 1414 Westwood Rd., Charlottesville,VA 22903, USAe-mail: [email protected]
R. N. S. CavalariInstitute for Child Development, State University of N.Y.at Binghamton, Binghamton, NY 13902-6000, USAe-mail: [email protected]
Present Address:L. B. TurnerUniversity of Saint Joseph, West Hartford, CT 06117, USA
Rev J Autism Dev Disord (2014) 1:276–326DOI 10.1007/s40489-014-0025-6
The goal of diagnosis and early identification, aside fromneeded basic research, is to permit the delivery of effectivetreatment and services. The timing of treatment and servicescan be a significant variable, but the most important variable isdelivering intervention that has been established as effectivethrough well-conducted, replicated outcome research. It is theevidence base that permits decision-making that reflects theneeds of individuals and families, as well as broader society,while balancing the harsh reality of fiscal constraints andservice accessibility restrictions.
Establishing the Evidence Base
The need for a systematized and objective process for estab-lishing treatment effectiveness has a long history (Romanczykand Gillis 2004; 2008) and only comparatively recently has atenuous consensus emerged as to the specific process. Noyes-Grosser et al. 2005 have outlined the specific methodologyappropriate to conducting reviews of the literature in order toestablish guidelines for clinical practice. This methodologyderives from the Agency for Health Care Policy and Research(AHCPR), established in 1997, and currently designated asthe Agency for Healthcare Research and Quality (AHRQ).The AHRQ is part of the US Department of Health andHuman Services. In turn, Evidence-based Practice Centers(EPCs) were established. These Centers “… develop evidencereports and technology assessments on topics relevant toclinical, social science/behavioral, economic, and other healthcare organization and delivery issues—specifically those thatare common, expensive, and/or significant.” (http://www.ahrq.gov/clinic/epc/)
The AHRQ clinical practice guideline methodology usesprinciples for developing practice guidelines recommended bythe US Institute of Medicine (Field and Lohr 1992) and isconsidered to be the standard for developing evidence-basedclinical practice guidelines (Eddy andHasselblad 1994; Holland1995; Schriger 1995;Woolf 1991; 1994). This methodology hasonly comparatively recently been applied to ASD, with the NewYork State Department of Health (NYSDOH) EarlyIntervention Program (EIP) the first to use this methodology todevelop a series of evidence-based clinical practice guidelines.
When examining review projects that use this type ofmethodology and are inclusive of the full range of publishedresearch using established research methodologies, the out-comes have been remarkably consistent: approaches withinthe broad family of behaviorally oriented interventions yieldsignificant and consistent results. Examples of such large-scale reviews include:
& New York State Department of Health, Early InterventionProgram (1999a, b). Clinical Practice Guideline:Guideline Technical Report. Autism/Pervasive
Developmental Disorders, Assessment and Interventionfor Young Children (Ages 0–3 Years), no. 4217, NYSDepartment of Health, Albany, NY.
& National Research Council (2001a, b). Educating Childrenwith Autism. Washington DC: National Academy Press.
& National Autism Center. (2009). National StandardsReport: National Standards Project—Addressing the needfor evidence-based practice guidelines for autism spectrumdisorders. Randolph, MA: National Autism Center, Inc.
& Missouri Department of Mental Health (2012). AutismSpectrum Disorders: Guide to Evidence-basedInterventions. http://www.autismguidelines.dmh.mo.gov/
Despite the extensive literature base and available guide-lines, there remains general disarray concerning interventionrecommendations and preferences in the broad field of ASD.Some of this disarray is attributable to changing diagnosticcriteria, poor diagnostic reliability, and the range of expressionof autism spectrum disorders, (Lord et al. 2011; Lord and Jones2012; Romanczyk and Callahan 2012), but is secondary to thetreatment literature base. Clearly, the presence of well-conducted research studies, academic literature reviews, andpractice guidelines has been insufficient to promote adoption,as hundreds of non-empirically based treatments continue to bepopular andwidely used (Romanczyk et al. 2014). Romanczykand Gillis (2008) present an analysis of over 400 purportedtreatments culled from a sample of web sites, and indicate thatless than 2 % have strong outcome research evidence.
The first practice guidelines specific to behavioral interven-tion for ASD in the context of health insurance coverage wererecently published (Behavior Analyst Certification Board[BACB] 2012). These guidelines provide an unprecedentedlevel of specificity regarding treatment program characteristicsand clinical service delivery, but primarily constitute a consen-sus document that makes reference to a selected bibliographyand does not address specific issues of procedure and “dosage”(number of hours per week for a designated time period).
The purpose of our review is to tie the published researchliterature to functional practice guidelines that address therelationship of specific clinical problems in individuals withASD to procedure, dosage, and outcome probabilities, allwithin the context of existing service delivery systems thatengage in resource allocation. This is done in two parts. Thefirst addresses service delivery system issues and the secondthe evidence base and analysis of cost-benefit.
Part 1—The Service Delivery System
Educational Requirement vs. Medically Necessary Treatment
In the context of providing federally mandated educationservices (FAPE—Free appropriate education) for all children,
Rev J Autism Dev Disord (2014) 1:276–326 277
and needed intervention for ASD as a specific disorder in theperspective of an evolving set of diagnostic criteria [DSM 5](2013, Diagnostic and Statistical Manual of the AmericanPsychiatric Association, Fifth Edition), confusion can resultwith respect to separating broad child education needs fromthe characteristics of this heterogeneous disorder. The currentdiverse process by which educational and medical services are“divided” among parties, such as caregivers, school district,and an insurance carrier, adds inconsistency to the provisionof services.
From the educational perspective, federal mandate forFAPE is of course within an education rather than clinicalcontext. Statements such as: “The Section 504 regulationrequires a school district to provide a “free appropriate publiceducation” (FAPE) to each qualified person with a disabilitywho is in the school district’s jurisdiction, regardless of thenature or severity of the person’s disability.”makes it clear thatseverity is not a delimiting characteristic. However, statementssuch as: “An appropriate education may comprise educationin regular classes, education in regular classes with the use ofrelated aids and services, or special education and relatedservices in separate classrooms for all or portions of the schoolday. Special educationmay include specially designed instruc-tion in classrooms, at home, or in private or public institutions,and may be accompanied by related services such as speechtherapy, occupational and physical therapy, psychologicalcounseling, and medical diagnostic services necessary to thechild’s education…” are complex and less clear (http://www2.ed.gov/about/offices/list/ocr/docs/edlite-FAPE504.html).While implying the role of medical services and specifyingservice providers who often fall under the umbrella term ofmedical provider with respect to insurance coverage, by notexplicitly including the generally accepted term “medicallynecessary” services, room for substantial interpretation exists.
It is important to note that in this context, “medicallynecessary” does not necessarily imply services delivered sole-ly by a physician, but rather may include services from a rangeof professionals, including behavior analysts, psychologists,speech-language pathologists, etc. The complexity increaseswhen discussing the needs of an individual with a pervasivedevelopmental disorder that affects many areas of functioning.Some of the arguably needed services, such as intervention fordebilitating stereotyped behavior, or learning play skills with asibling, or reducing excessive fear responses to environmentalstimuli, do not fall cleanly in some definitions of educationalnecessity vs. medical necessity. In some ways, what is con-sidered appropriate educational services and appropriate med-ical services has expanded, but gaps nevertheless remain. It isalso important to note that these distinctions are independentof the particular type of service provider. As an example, aclinical psychologist may provide services under the auspicesof a particular school district for a child’s “educational pro-gram” as defined in the Individualized Education Plan, but as
likely could provide the same services in a private practicesetting under the child’s health insurance coverage, dependingon the specific policies of the insurance carrier.
Thus, the distinction between educational needs and med-ical needs can blur in the case of ASD. Some examples areclear, such as a child with adequate eyesight who needs to betaught to read compared to a child with a severe visionproblem that requires medical intervention. One perspectivethat also can cause confusion is the philosophical position thateducation is provided to all children independent of whateverdisorder they may experience and the position that given thepresence of a medical disorder (as defined as being a recog-nized DSM disorder), all services needed to address the dis-order’s impact are medically necessary. Such “absolute” po-sitions do little to advance solutions to the complex problemof resource allocation and coordination of services.
We would argue that disorders do not define people andalso that choosing not to acknowledge the influence of adisorder does not diminish its impact on the individual. Theallocation of resources to address a need should be based onobjective criteria rather than fluctuating positions grounded inchanging philosophy or rigid, arbitrary definitions. However,a central problem is that resource allocation is often tied tospecific bureaucratic structures that have at times arbitraryand/or poorly defined distinctions imposed such as “medical”versus “educational”. Ideally, the focus should be on what istherapeutic and skill/knowledge enhancing for the individual.But given the entrenched structures that provide services, therequirement for such distinction between what are educationalservices and medical services will persist.
Within this context of existing structures and existing fed-eral law concerning the right to FAPE for all children, abroadly accepted definition of what are “educational services”and what are “medical services” for individuals with ASD isneeded. Adding to the complexity, individual state educationdepartments adopt regulatory definitions of educational clas-sifications, while the diagnostic process currently predomi-nantly uses the criteria in the DSM. Thus, a given stateeducation department may have a definition of autism as aneducational classificationwhich differs from the current DSM,and may or may not require a formal DSM diagnosis. Thesestate definitions are not consistent across states and states alsovary as to what classifications they utilize (http://ectacenter.org/partc/statepolicies.asp). For instance, New York utilizes13 educational classifications, Massachusetts 10, andColorado 14.
As examples, in New York the educational classification ofautism is defined as:
(1) Autism means a developmental disability signifi-cantly affecting verbal and nonverbal communicationand social interaction, generally evident before age 3,that adversely affects a student’s educational
278 Rev J Autism Dev Disord (2014) 1:276–326
performance. Other characteristics often associated withautism are engagement in repetitive activities and ste-reotyped movements, resistance to environmentalchange or change in daily routines, and unusual re-sponses to sensory experiences. The term does not applyif a student's educational performance is adverselyaffected primarily because the student has an emo-tional disturbance as defined in paragraph (4) ofthis subdivision. A student who manifests thecharacteristics of autism after age 3 could be di-agnosed as having autism if the criteria in thisparagraph are otherwise satisfied. (REGULA-TIONS OF THE COMMISSIONER OF EDUCA-TION, Pursuant to Sections 207, 3214, 4403, 4404 and4410 of the Education Law, PART 200 Students withDisabilities).
Whereas in California, the educational classification forautism is defined as:
56846.2 (a) For purposes of this chapter, a “pupil withautism” is a pupil who exhibits autistic-like behaviors,including, but not limited to, any of the following be-haviors, or any combination thereof:
(1) An inability to use oral language for appropriatecommunication.
(2) A history of extreme withdrawal or of relating to peopleinappropriately, and continued impairment in social in-teraction from infancy through early childhood.
(3) An obsession to maintain sameness.(4) Extreme preoccupation with objects, inappropriate use of
objects, or both.(5) Extreme resistance to controls.(6) A display of peculiar motoric mannerisms and motility
patterns.(7) Self-stimulating, ritualistic behavior.
California Education Code, TITLE 2. ELEMENTARYAND SECONDARY EDUCATION [33000–64100],DIVISION 4. INSTRUCTION AND SERVICES [46000–64100], PART 30. SPECIAL EDUCATION PROGRAMS[56000–56865], CHAPTER 7.5. Autism Training andInformation [56846–56847] (Chapter 7.5 added by Stats.2006, Ch. 783, Sec. 1.)
We then add to this mix the definition of special education,as that is the system through which many children with ASDreceive services. The federal government defines special edu-cation as:
TITLE I – AMENDMENTS TO THE INDIVID-UALS WITH DISABILITIES EDUCATION ACT.Regulations: Part 300/A/300.39
Special education.
(a) General.
(1) Special education means specially designed instruc-tion, at no cost to the parents, to meet the uniqueneeds of a child with a disability, including:
(i) Instruction conducted in the classroom, in thehome, in hospitals and institutions, and in othersettings; and
(ii) Instruction in physical education.(2) Special education includes each of the following, if
the services otherwise meet the requirements of par-agraph (a) (1) of this section:
(i) Speech-language pathology services, or anyother related service, if the service is consideredspecial education rather than a related serviceunder State standards;
(ii) Travel training; and(iii) Vocational education.
Such a broad definition offers little by way of specifics andmixes the terms “instruction”, “services”, “training”, and “ed-ucation”. Since states are obligated to follow federal educationregulations, the operational definition of special education iscontained in the Individualized Education Plan (IEP), as isalso required by federal regulation. However, since the spe-cific content and breadth of the IEP is not well defined by thefederal government, great variation exists from school districtto school district and also state-to-state. Not surprisingly, theIEP can become a focal point for disagreement between parentand school district. While precise estimates at a national levelare not available, an attempt to analyze impartial hearings (theprimary method of resolution in New York) is illustrative.McMahon (2011), through a Freedom of Information Lawrequest to the New York Impartial Hearing Reporting System(IHRS) for the period 2002–2003 to 2009–2010 school years,found that the top three reasons for requesting an impartialhearing was tuition reimbursement to parents for alternateplacement/services to public school, determination of appro-priate educational program (placement), and the specifics ofthe IEP/program.
The situation is similar for the term “medical necessity”. Asstated by the American Academy of Pediatrics “In particular, amuch used term—“medical necessity”— is, in fact, generallyill defined.” (Long 2013, p 398). Further, in the 906 pages ofthe 2010 Patient Protection and Affordable Care Act, PublicLaw 111–148 of the 111th Congress, the term “medicallynecessary” is not defined. The American Medical Associationdefines medical necessity as “Health care services or products
Rev J Autism Dev Disord (2014) 1:276–326 279
that a prudent physician would provide to a patient for thepurpose of preventing, diagnosing or treating an illness, injury,disease or its symptoms in a manner that is: (a) in accordancewith generally accepted standards of medical practice; (b)clinically appropriate in terms of type, frequency, extent, site,and duration; and (c) not primarily for the economic benefit ofthe health plans and purchasers or for the convenience of thepatient, treating physician, or other health care provider.”(Harmon 2011, p. 3). More recently, the American Academyof Pediatrics has offered the following definition of medicalnecessity for children: “Hence, the pediatric definition of med-ical necessity should be as follows: health care interventionsthat are evidence-based, evidence-informed, or based on con-sensus advisory opinion and that are recommended by recog-nized health care professionals, such as the AAP, to promoteoptimal growth and development in a child and to prevent,detect, diagnose, treat, ameliorate, or palliate the effects ofphysical, genetic, congenital, developmental, behavioral, ormental conditions, injuries, or disabilities.” (Long 2013, p400). This definition’s emphasis on “… promote optimalgrowth and development …” would appear to be complemen-tary to the concepts presented above concerning educationservices, in that it emphasizes preparing the child to benefitfrom the social, physical, and educational environment.
In the on-going debate about educational requirement vs.medical necessity, it often appears that intent to influencefunding decisions is conflated with definition. While the de-sire to facilitate funding of services is understandable, thisleads to ambiguity and confusion among important concepts.Overly broad definitions along the lines of “whatever is nec-essary” do not aid in resolving a complex societal issue. Wepropose that symptoms/problems that are contained in thediagnostic criteria be considered those that are medicallynecessary and specific knowledge/achievement/skill deficitsbe considered educationally necessary. Such a distinctionprovides clear, understandable boundaries consistent withthe general concept of what is medical and what is education-al. However, as in all complex issues, our definition has adegree of artificiality. As an example, insensitivity to socialmotivation can impede a child’s ability to learn simple addi-tion as taught by a teacher in school. One would rarely seek“medical” services to address the specific content of theclassroom lessons but may indeed seek such assistance toaddress poor social motivation. This distinction can blur fur-ther depending on the specific professional orientation of theservice provider. For example, a Board Certified BehaviorAnalyst trained specifically to provide services to individualswith ASD would typically have no conceptual difficulty ad-dressing both of these issues. This reflects their training andthe underlying intervention principles being utilized. But thisis a very different perspective than the one facing bureaucra-cies—how to determine which aspects of need do schools vs.medical insurance pay for and for how long?
Insurance Coverage and Reimbursement
A study by the Harvard School of Public Health (Ganz 2007)estimated lifetime care costs of $3.2 million for an individualwith autism. Total US costs were estimated at $35 billion eachyear at that time. Estimates vary, with total costs possiblyseveral times higher currently. But, because of the size andscope of the insurance programs in the US, according to theCouncil for Affordable Health Insurance, covering autismincreases the cost of health insurance by about only 1 %.Once again a caveat is needed as the federal regulations ofwhat must be covered are changing. For example, “habilita-tion services” is a category of services recognized by theDepartment of Health and Human Services. Effective 2014,states must specify what they will cover under this category.Clearly regulation and insurance industry policies are a workin progress.
At the time of this review, 36 states in the US andWashington, D.C., have enacted autism insurance reformlaws, eight states have bills under review, and one state ispursuing autism insurance reform (Autism Speaks 2014c).Given this, health insurance coverage across the country hasundergone revision regarding access to services and reim-bursement policies. Although a thorough review of the reim-bursement rates for the US would be ideal in determining a“recommended rate” for reimbursement of autism-related ser-vices, there are several factors that limit the ability to do so.First and foremost, the three major sources of health insurancecoverage (i.e., Medicaid, TRICARE, and private commercialinsurance companies) offer various plans that differ withrespect to access and coverage of services. Second, reimburse-ment rates typically vary state-to-state and differ substantiallybetween providers. Finally, institutions can negotiate uniquereimbursement rates for services rendered at their facility. Forexample, one hospital might receive a higher reimbursementrate than another hospital within the same city based solely onnegotiation with the providing insurance company. Therefore,an accurate universal analysis of reimbursement rates forautism-related services is not feasible. Instead, we presentavailable data representing maximum service coverage forchildren from birth through 5 years old for 34 states and thefederal district of Washington, DC with active autism insur-ance reform laws.
Autism Service Coverage in the US As of December 2013,four states (CA, IN, MA, MN) and Washington, DC providedunlimited coverage for applied behavior analysis (ABA) ser-vices throughout an individual’s lifetime (see Fig. 1). Alaskaand Vermont also provided unlimited coverage of costs forABA, but only to individuals under the age of 21 years old.Similarly, Texas provided unlimited coverage until the age of10 years old, with annual dollar caps ($36,000/year) appliedthereafter. Other states placed age and dollar caps on ABA
280 Rev J Autism Dev Disord (2014) 1:276–326
services. Virginia restricted service coverage to children be-tween the ages of 2–6 years old and placed a $35,000 annualdollar cap on ABA services, while Kentucky set the approvedage range between 1 and 21 years old, with dollar caps varyingby age ($50,000/year for individuals 0–7 years of age; $1,000/month for individuals 7–21 years of age). West Virginia pro-vided $30,000 in annual coverage for individuals between 3and 18 years old, but required that individuals have a diagnosisbefore the age of 8 years old to qualify. While Oregon did notspecify a dollar or age cap, individuals had to begin receivingservices before the age of 9 years old and there was an hour capof 25 h per week. With that said, 91 % of the states and federaldistricts represented in this analysis were providing coveragefor children from birth through 5 years.
Importantly, half of the states with active insurance reformlaws set a cap on annual service coverage at or below $36,000.Costs of evidence-based behavioral therapy for children withautism can exceed $40,000–$50,000 each year (Berr 2013;National Conference of State Legislatures 2012). Therefore,despite the enactment of autism insurance reform laws,instatement of full coverage for evidence-based services wasonly available for 30 % of the nation. To provide examples ofthe substantial differences that existed, we present in detaildata from New York and Virginia as two case examples ofservice reimbursement rate-setting for different regions of thecountry. Data from New York represent coverage of childrenfrom birth through age five with an annual dollar cap that fellwithin the estimated service cost range noted above. In con-trast, data from Virginia represent restricted coverage by age(i.e. 2–6 years old), with an annual dollar cap that fell belowthe estimated service cost range.
New York State Autism Insurance Reform New York enactedautism insurance reform in November 2011, with provisionseffective for state-regulated health plans issued or renewed onor after November 2012. Coverage includes screening,
diagnosis, and treatment of autism spectrum disorder, specify-ing behavioral health treatment such as ABA (Autism Speaks2013). Effective January 2013, New York State issued anemergency rule (11 NYCRR 440, Entitled InsuranceRegulation 201, Provider Requirements for InsuranceReimbursement of Applied Behavior Analysis) to establishstandards of professionalism, supervision, and experience forthose who provide ABA to individuals with ASD under thenew insurance law. According to the text of the rule, ABAservices were only reimbursable if provided by a licensedprofessional who was also a Board Certified BehaviorAnalyst (BCBA) or an aide who met specific education orexperience requirements and was supervised by a licensedprofessional who is a BCBA. In July 2013, the NY StateDepartment of Financial Services redacted the requirement thata license was necessary to provide ABA services, but main-tained the requirement that a licensed provider be responsiblefor developing the treatment plan.
New York State Early Intervention (EI) Services Rates ofservice reimbursement for children ages 0–2 years, 11 monthsare set by the New York State Department of Health EarlyIntervention Program (NYSEIP). These service rates are usedfor both Medicaid and private commercial insurance reim-bursement. Services are typically reimbursed on an hour perday service delivery schedule, per type of service. However,extended and enhanced service rates are available in cases inwhich the need for more intensive or extended duration ofservices is evident. Individual service rates are provided forhome/community and facility-based services, while grouprates are provided for parent-child, basic and enhanced devel-opmental, and family/caregiver support groups. There are alsohigher rates for services requiring a 1:1 Aide. Additionally,although rarely used by agencies at the present time, theNYSEIP has provided an hourly rate of reimbursement forABA Aide services. Notably, reimbursement rates are set at
0
25
50
75
CA IN
MA
MN
AK
VT
TX
Wash
, D
C
SC
AZ
MT
CT
WI
KY
AR
MI
NY
MO
LA
FL
PA IL
NM
NV NJ
ME
KS
NH IA DE
VA
CO RI
WV
Do
lla
rs i
n T
ho
usa
nd
sStates with Autism Insurance Reform Laws
Fig. 1 State-regulated InsuranceDollar Caps for ABA Services byState for Children Ages 0–5.Adapted from a larger analysis ofinsurance coverage for ages 0–23;used with permission of LorriUnumb, Autism Speaks.Excludes Oregon due to weeklyhour caps as opposed to dollarcaps. All bars that reach 75,000represent unlimited coverage(marked as ceiling by source) forchildren from birth through age 5.Gray bars indicate age caps thatrestrict coverage to certain ageswithin the range of birth to age 5
Rev J Autism Dev Disord (2014) 1:276–326 281
the county level, so there is significant variation across thestate in terms of cost per intervention. The present range andaverage early intervention service reimbursement rates for 58of the 62 counties in New York State, as posted on theNYSEIP website, are displayed in Fig. 2.
Services provided within the categories displayed in Fig. 3,with the exception of ABA Aide, include special educationinstruction, related services (speech, occupational, physical ther-apy), and family training and support. Services can only beprovided by licensed, certified, or registered individuals ap-proved by New York State. Hourly direct individual servicereimbursement rates range between $38 and $75/h, with extend-ed services falling between $85 and 105/h. Direct group servicesare reimbursed at rates between $35 and $71/h, with addition ofa 1:1 Aide increasing rates to $79 and $123/h. Direct services tothe parent and child for the purposes of training and interventionare reimbursed at rates between $42 and $57/h. Notably, ABAAide hourly services represent the lowest reimbursed rates($24–$38/h), which are parallel only with Family/CaregiverSupport group services that serve as indirect support of thetargeted child by supporting parents, caregivers, or siblings.
New York State Preschool Special Education Services Childrenbetween the ages of 3 and 5 years old fall under the serviceumbrella of preschool services, with reimbursement rates setby the NewYork State Education Department (NYSED) Rate-Setting Unit in collaboration with the New York StateDepartment of Health. Services are typically reimbursed ona half-hour per day service delivery schedule, per type ofservice. Similar to NYSEIP, reimbursement rates are set atthe county level and there is significant variation across the
state in terms of cost per intervention. In contrast, the type ofservices reimbursed may vary across counties and there is noservice designation that specifies applied behavior analysis asa reimbursable service. Although there are a wide variety oftypes of reimbursement, we will limit our review to theservices typically approved for children with an ASD.Common service types include occupational therapy, physicaltherapy, speech therapy, parent counseling and training,counseling services, and psychological services. Similar to EI,NYSED approves preschool programs and related service pro-viders based on criteria related to licensing and certificationwithin the designated professions. Services can also include
$0.00
$10.00
$20.00
$30.00
$40.00
$50.00
$60.00
$70.00
$80.00
$90.00
$100.00
$110.00
$120.00
$130.00
Basic
Home a
nd C
ommun
ity In
dividu
al
Extend
ed H
ome a
nd C
ommun
ity In
dividu
al
Facili
ty Bas
ed In
dividu
al
Parent
Child G
roup
Rate
Basic
Group
Dev
elopm
ental
Basic
Group
Dev
elopm
ental
With
1:1 A
ide
Enhan
ced G
roup
Dev
elopm
ental
Enhan
ced G
roup
Dev
elopm
ental
With
1:1 A
ide
Family
/ Care
giver
Suppo
rt Gro
up
ABA Aide
Hou
rly R
ate
Hou
rly
Rat
e
Fig. 2 Mean Hourly Rates for EIService Reimbursement—NewYork State. Range ofreimbursement rate acrosscounties depicted by error bars.Data retrieved from http://www.health.ny.gov/community/infants_children/early_intervention/service_rates.htm
0
25
50
75
SEIT Individual Related Service
Group Related Service
30-M
inut
e R
ate
Service Type
Fig. 3 Mean Half-Hour Rates for Preschool Service Reimbursement—New York State. Range of reimbursement rate across counties depictedby error bars. Data retrieved from http://www.oms.nysed.gov/rsu/Rates_Methodology/Rates/NonRSURates/CountyRS201213_000.html andhttp://www.oms.nysed.gov/rsu/Rates_Methodology/MethodLetters/CurrentYear/1213metholttr.html
282 Rev J Autism Dev Disord (2014) 1:276–326
1:1 aides in 49 of the counties, but reimbursement rates aresignificantly more variable ($4–$25, M=$11.35 per half hour)than other related service rates across counties.
The present ranges and average preschool special educa-tion service reimbursement rates for counties in New YorkState, as posted on the New York State Education Departmentwebsite, are displayed in Fig. 3.
Data are presented separately for special education itinerantservices (SEIT), individual related services, and group relatedservices. Values presented for SEIT and individual relatedservices represent 58 of the 62 counties in New York State.Group related service values were generated from 43 counties,since only this subset lists reimbursement for group services.Data are presented as rates per half hour of service (i.e., standardtime unit for preschool special education service reimburse-ment). For counties with differential rates for each relatedservice type, an average rate was computed for individual andgroup services within that county in order to calculate theoverall average maximum reimbursement for individual andgroup services. As shown in Fig. 3, the range for SEITservices is between $30 and $47/half hour. Individualrelated services vary between $31 and $74/half hour and
group related services between $22 and $74/half hour.To compare these values to EI reimbursement rates,doubling the average service delivery rate (i.e., full hourservice duration) results in $66 for SEIT, $106 for individualrelated services, and $74 for group related services per hour.
Virginia Autism Insurance Reform The Commonwealth ofVirginia became the 26th state to enact autism insurance reformon May 6, 2011 for plans issued or renewed on or after January1, 2012 (Virginia House Bill No. 2467 (2011), Amendment inthe Nature of a Substitute). The law requires state-regulatedlarge group health plans and the state employee health plan toprovide coverage for the diagnosis and treatment of ASD forindividuals between the ages of 2 and 6 years. Health insurancecompanies are required to provide coverage for diagnostic as-sessments (including neuropsychological evaluations and genet-ic testing), behavioral health treatments (including ABA), phar-macy care, psychiatric care, psychological care, and therapeuticcare (i.e., speech, occupational, and physical therapies as well asclinical social work). Coverage for ABA is subject to an annualmaximum of $35,000 and ABA services must be supervised bya BCBA who is licensed by the Virginia Board of Medicine.
Table 1 Virginia Early Intervention Reimbursement Rates. Range of service and reimbursement rates for Part C services in the Commonwealth ofVirginia. Data retrieved from: http://infantva.org/documents/ovw-st-ProvBillingReimbursInfoSheet.pdf
Service Location Provider Rate (per 15 min unit)
Initial Assessment for Service Planning Natural environment or center Reimbursement category 1 providers $37.50/unit
Reimbursement category2 providers + dietitians
$27.50/unit
Audiologists $150/assessment
Physicians Negotiated individuallyat local level
Initial or Annual IFSP Meeting Natural environment or center RC 1 + audiologists $37.50/unit
RC 2 + dietitians $27.50/unit
Team Treatment activities (morethan one professional providingservices during same session)
Natural environment RC 1 + audiologists $37.50/unit
RC 2 + dietitians $27.50/unit
Team meetings (child or family present) Natural environment RC 1 + audiologists $37.50/unit
RC 2 + dietitians $27.50/unit
Assessments that are done after theinitial Assessment for Service Planning
Natural environment RC 1 $37.50/unit
RC 2 + dietitians $27.50/unit
Audiologists $150/assessment
Physicians Negotiated individuallyat local level
Group (congregate) earlyintervention services
Natural environment RC 1 + audiologists $25.13/unit
RC 2 + dietitians $18.43/unit
Individual early intervention services Natural environment RC 1 + audiologists $37.50/unit
RC 2 + dietitians $27.50/unit
Center-based group (congregate) services Center RC 1 + audiologists $7.43/unit
RC 2 + dietitians $5.44/unit
Center-based individual services Center RC 1 + audiologists $22.50/unit
RC 2 + dietitians $16.49/unit
Rev J Autism Dev Disord (2014) 1:276–326 283
Services must be prescribed, provided, or ordered by a licensedphysician or psychologist who deems the interventions to bemedically necessary. The law does not affect the provision ofservices to an individual under an individualized family serviceplan (IFSP), an IEP, or an individualized services plan (ISP).
Virginia Early Intervention Services In the Commonwealth ofVirginia, early intervention (EI) services are overseen by thelead state agency, Infant and Toddler Connection. EI servicereimbursement rates are set by Infant and Toddler Connectionand Medicaid. A range of service providers are reimbursedthrough the program including physical therapists, occupa-tional therapists, speech therapists, therapeutic recreation spe-cialists, family therapists, music therapists, medical profes-sionals (e.g., nurses and physicians, educators and psycholo-gists). Rates for reimbursement are dependent upon the typeof service being provided and the individual providingthe service. Reimbursement rates range from $21.76 to$150/h.
Table 1 presents a summary of the services covered and thereimbursement rates. ABA services are not listed as a servicecovered through EI in Virginia. In fact, the practice manual forEI providers in Virginia states that ABA is not an entitled earlyintervention service, rather it is a treatment modality and thatonly entitled services are listed on an IFSP. While an EIprovider may be trained in behavior analysis, those serviceswould not be listed as ABA on an IFSP and would not bereimbursed under a separate rate.
Reimbursement category 1 (RC 1) providers are physicaltherapists, occupational therapists, speech-language patholo-gists, nurses (registered nurses or nurse practitioners), physicaltherapy assistants, and occupational therapy assistants.Reimbursement category 2 (RC 2) providers are certifiedtherapeutic recreation specialists, counselors, educators, fam-ily and consumer science professionals, family therapists,music therapists, orientation and mobility specialists, psychol-ogists, social workers, early intervention assistants, certifiednurse aides, and licensed practical nurses.
While ABA services are not reimbursed through the VirginiaEI program, individuals and families can gain access to ABAservices through another Medicaid program, the Early PeriodicScreening Diagnosis and Treatment (EPSDT) program.Individuals under the age of 21 years, who are enrolled inMedicaid (through a waiver or due financial status), are eligibleto receive services through the EPSDT program. The programcovers a range of “medically necessary” services (as determinedby physician recommendation and file review) including hear-ing aids, assistive technology, personal care, nutrition, andbehavioral therapy. ABA services provided through theEPSDT program must be supervised by a BCBA or a licensedmental health professional (LMHP). Services must focus onincreasing adaptive behaviors and communication and teachingparents and caregivers to implement behavioral techniques.
Interventions that focus on educational skills are excluded fromcoverage through this program. All EPSDTBehavioral Therapyservices are reimbursed at a rate of $60/h and cover directservice, parent training, case management, and supervision.Group and center-based services are not covered through theEPSDT program. Services are generally authorized for a dura-tion of 6months, at which point the service provider would needto send a request to continue services including an updatedtreatment plan and progress summary. While the EPSDT pro-gram allows a number of families to access ABA services,gaining access to them is often difficult. Getting an individualonto aMedicaid waiver can be a long and arduous process. Andonce an individual is on a waiver, finding a provider with theexpertise and license to provide the services can be difficult.
The Affordable Care Act Based on generally acceptedresearch-based estimate of the number of hours identified asnecessary for significant clinical impact (addressed later in thisreview), the approved service duration and reimbursement ratesdetailed above are clearly not sufficient to meet evidence-basedservice requirements. Further, only a third of the country hadautism insurance reform laws that provided coverage for ABAservices within the estimated range for annual service coststhrough 2013. The Patient Protection and Affordable CareAct (PPACA), signed into law in March 2010, set January2014 as a major turning point in healthcare reform for childrenwith autism and their families. While some variability is de-pendent upon a family’s circumstances, there are several pro-visions that have changed the definition of covered services.First and foremost, Autism Spectrum Disorder, often classifiedas a pre-existing condition, can no longer be grounds forexclusion or denial of coverage for treatment (Autism Speaks2014b). Coverage for young children with autism and theirfamilies now also includes a set of “essential health benefits,”including behavioral health treatment, habilitative services,prescription medication, and pediatric services (AutismSpeaks 2014a). Additionally, coverage now has no lifetime orannual dollar caps, there are annual limits on out-of-pocketcosts for families, and preventive services, including earlychildhood screening, are now covered without copays or de-ductibles (Autism Speaks 2014a). However, there are now visitcaps on services (Autism Speaks 2014a). Given the evolvingnature of healthcare and importance of addressing the signifi-cant public health burden of ASD, specific definitions of ap-propriate services are necessary to provide insurance compa-nies, service agencies, individual practitioners, and communitystakeholders with a starting point for establishing criteria forcoverage. Central to this effort is the need to establish theboundaries of evidence-based services that warrant coveragedue to demonstrated impact through controlled research. Asindicated earlier in this manuscript, thus far, data overwhelm-ingly support the use of behaviorally oriented treatments inestablishing best outcomes for individuals with ASD.
284 Rev J Autism Dev Disord (2014) 1:276–326
Part 2—The Evidence Base and Cost-Benefit
Basic Principles of Behavioral Interventions
Before discussing the data collection procedures and analysis,it is important to establish a definition of what behavioralinterventions are. “Behavioral” refers to an approach to ther-apy and education that draw upon core scientific principles ofhow people learn and adapt. These interventions are derivedfrom research on basic principles of learning, retention, andgeneralization of learned skills. Behavioral interventions drawupon extensive research on learning principles that emphasizethe antecedents and precursors of behavior, the topography ofbehavior, and its adaptability to the social and physical envi-ronment. The social and physical environment in turn pro-vides simple and complex stimuli and simple and complexreactions to behavior. Additionally, behavioral interventionsfocus on the function of behavior in order to understand how itis acquired, maintained, and sometimes lost. Further, theteaching of new skills typically involves an analysis of themany component parts of complex behaviors involving com-munication, emotional development, social development, in-dependence, physical status, and knowledge.
Within the family of behavioral interventions, termsdescribing specific, well-established disciplines includeABA, behavioral medicine, behavior therapy, and cog-nitive behavior therapy. The emphasis in these areasrests upon an evidence-based approach and focus on:
& An understanding of the individual’s skill assets and defi-cits, as well as their physical/developmental/medical status
& Teaching skills that promote independence& An emphasis on developing adaptive behavior and skills& Sensitivity to the social and physical environment of the
individual& Thorough assessment prior to intervention to identify the
relationship between a behavior and the environment inwhich it occurs
& An individualized treatment plan that is linked to theresults of the assessment
& Clear identification of treatment goals& Objective quantification of outcomes
Behavioral interventions are highly individualized and in-corporate developmental, medical, and situational factors, andalso caregiver (and when appropriate, client) perspectives andneeds in goal selection and treatment planning.
Data Collection Procedures
For this review, articles describing the use of behavioralinterventions with individuals with ASD under the age of fivethat were published between January 2000 and June 2013
were selected. Similar to the process employed by the NewYork State Department of Health in 1999, the collection andreview of articles was a three-step process involving an ex-tensive literature search, a screening, and an in-depth review.Figure 4 presents a schematic of the process.
Literature Search
A search strategy was developed to identify relevantscientific research on behavioral interventions for chil-dren with ASD. For the purposes of this review, ASDwas def ined as Aut i s t i c Di so rde r, Pe rvas iveDevelopmental Disorder—Not Otherwise Specified(PDD-NOS) and Asperger ’s Disorder. Electronicsearches were conducted using relevant computer bib-liographic databases, which included MEDLINE (a da-tabase containing most of the medical literature andmuch of the psychological literature), PsycINFO (a databasecovering psychology and social science literature), and ERIC(a database of literature on education). These were the sameelectronic databases used to collect literature for the ClinicalPractice Guideline published in 1999 by the NYSDOH. Thefollowing search terms and search criteria were used inobtaining the articles:
& Search Terms: Autism, ASD, PDD-NOS, BehavioralIntervention, Behavior Modification, Behavior Therapy,Applied Behavior Analysis
& Date Range: January 2000–June 2013& Publication Type: Peer-reviewed journal& Publication Language: English& Age: Infancy to 5 years
Additionally, references lists of articles and reportsreviewing the efficacy of behavioral interventions for
Literature SearchReview of abstracts obtained through electronic and manual searches
(n > 3,000)
Systematic ScreeningSystematic screening of full article using scoring worksheet
(n > 500)
In-Depth ReviewIn-Depth review of full article
(n=144)
Fig. 4 The three-step process used in the current literature review
Rev J Autism Dev Disord (2014) 1:276–326 285
individuals with ASD (AHRQ 2011; Eikeseth 2008; Eldeviket al. 2009; Howlin et al. 2009; NAC 2009) were manually
searched in an attempt to identify studies that might have beenmissed in the electronic search.
Table 2 Definitions of research focus categories
Research focus definitionsResearch focus Definition Source(s)
Academic Interventions focusing on teaching or improving performanceon tasks that are precursors or required for success with school activities.Dependent variables associated with these tasks include but are notrestricted to preschool activities (e.g., sequencing, color, letter, numberidentification, etc.), fluency, latency, reading, writing, mathematics, science,history, or skills required to study or to improve performance on
NAC Standards Report (pg. 34)
Behavior reduction Assessments and intervention strategies designed to decrease inappropriatebehaviors. This may include functional analyses to determine the functionof the behaviors, the use of differential reinforcement of appropriate behaviorsand/or punishment of inappropriate behaviors.
DOH Technical GuidelinesReport (pg. IV-35)
Cognitive Interventions focusing on improving tasks that require complex problem-solvingskills outside of the social domain. Dependent variables associatedwith these tasks include but are not limited to critical thinking, IQ, problemsolving, working memory, executive functions, organizational skills, andtheory of mind tasks.
NAC Standards Report (pg. 36)
Communication Interventions focusing on the functional use of language (such as the use oflanguage in context, including implicit and explicit communicative intent;nonverbal communication such as intonation, communicative gestures,and facial expressions; and social aspects of communication such asturn-taking). The systematic means of communication may involve theuse of sounds, symbols, signs, or a combination of the three. Dependentvariables associated with these tasks include but are not restricted to requesting,labeling, receptive, conversation, greetings, nonverbal, expressive, syntax,speech, articulation, discourse, vocabulary, and pragmatics.
DOH Technical GuidelineReport(pg. IV-41) NAC StandardsReport (pg. 36)
Comprehensive Comprehensive programs involve a combination of applied behavior analytic procedures(e.g., discrete trial, incidental teaching, etc.). These interventions may be delivered in avariety of settings (e.g., home, self-contained classroom, inclusive classroom, community)and involve a low student-to-teacher ratio (e.g., 1:1). These treatments generally havethe following characteristics {a} target the defining symptoms of ASD {b} have treatmentmanuals, {c} providing treatment with a high degree of intensity, and {d} measure theoverall effectiveness of the program.
NAC Standards Report (pg. 46)
Daily living Interventions focusing on tasks that involve teaching or improving performance onactivities that are embedded in everyday routines. Dependent variables associated with thesetasks include but are not restricted to dressing, cleaning, family and/or community activities,health and fitness, phone skills, time and money management, and self-advocacy.
NAC Standard Report (pg. 37)
Feeding Interventions focusing on teaching skills associated with appropriate food intake. Dependentvariables associated with feeding interventions include but are not limited to appropriateuse of utensils, acceptance and ingestion of food, and expansion of variety of foods ingested.
Play Play tasks involve non-academic and non-work related activities that do not involveself-stimulatory behavior or require interaction with other persons. Dependent variablesassociated with these tasks may include but are not limited to functional independent play(i.e., manipulation of toys to determine how the “work” or appropriate use of toys, games).Whenever social play was targeted (independently or in conjunction with make-believe play),it should be included in the “social” category.
NAC Standards Report (pg. 37)
Sleep Interventions focusing on improving difficulties associated with sleep including disorderedsleep patterns, night waking, and difficulty falling asleep common among children withASDs. Behavioral interventions include sleep workshops which may provide training toparents in dealing with difficult sleep behaviors and establishing sleep routines.
Vanderbilt Report (pg. 5)
Social Interventions focusing on improving interactions between two or more individuals. Dependentvariables associated with these tasks include but are not limited to joint attention, friendship,social and pretend play, social skills, social engagement, social problem solving, andappropriate participation in group activities.
NAC Standards Report (pg. 36)
Toileting Interventions targeting improving skills associated with toilet training. Dependent variablesassociated with these interventions include but are not limited to indicating need to use thebathroom, keeping dry underwear, using the toilet to urinate, using the toilet to defecate,and wiping.
286 Rev J Autism Dev Disord (2014) 1:276–326
Over 3,000 articles were found through the electronic andmanual searches. Abstracts for all articles were reviewed onthe following criteria:
& Focused on a behavioral intervention& Primary participants have an ASD& Primary participants 5 years of age or younger
If an article met the above criteria it was obtained andincluded for screening. If it was unclear whether an articlemet criteria for screening based on the abstract, it was obtainedand included for screening. Of the articles reviewed, over 500met criteria for formal screening.
Systematic Screening
The articles identified during the literature search were sys-tematically screened to determine if they met criteria for in-depth review. Aworksheet outlining the inclusion criteria forin-depth review was completed for each article. Thisworksheet and the in-depth review criteria were based on thecriteria used for the 1999 NYSDOH Clinical PracticeGuidelines.
During the screening process, articles were also catego-rized by “Focus” to evaluate the types of skills the interventionbeing used in the studies were targeting. A list of the focuscategories and their definitions are presented in Table 2.
Articles were divided among three independent raters, withprofessional training and education in psychology and ASD,for screening. Training on the operational definitions for eachof the screening questions and focus categories was conductedand reliability was established prior to the start of screening. Inaddition, reliability checks were completed for 10 % of all ofthe articles that were screened in order to maintain calibrationbetween raters.
Following screening, 144 articles met criteria for in-depthreview. Table 3 provides a breakdown of those articles bystudy design and focus category.
In-Depth Review
The 144 articles identified during the screening process werereviewed further to obtain information about the specificinterventions being conducted and the outcomes for partici-pants. Aworksheet outlining all of the variables being collect-ed for in-depth review was completed for each article. Thevariables collected during in-depth review were based on thecriteria used for the 1999 NYSDOH Clinical PracticeGuidelines and other published reports on evidence-basedpractices for individuals with ASD (NAC 2009; AHRQ2011; Reichow 2011). Sixty-five variables were recordedand were divided into two categories, article level and grouplevel. Article level variables were those that pertained to the
article as a whole (e.g., design, group assignment method).Group level variables were specific to the focal treatmentgroup1 (e.g., number of hours of intervention per week, num-ber of participants per group, outcome). Definitions for thevariables were based on the 1999 NYSDOH Clinical PracticeGuidelines and other published reports on evidence-basedpractices for individuals with ASD (NAC 2009; AHRQ2011; Reichow 2011). Additional variables included the qual-ifications of the individuals providing direct intervention, thequalifications of the individuals providing either direct super-vision or functioning as a “lead” or consulting supervisor, andthe length and frequency of the supervision provided.
Outcome strengths were determined by the percentage ofchildren reaching statistical or positive clinical levels ofchange relative to each study’s design methodology. For com-prehensive behavioral interventions, meaningful positive clin-ical changes resulted from, for example, inclusion in a regulareducation setting, increases in at least a standard deviation onstandardized assessments, normative learning rates, or a re-duction in ASD symptoms. If data were not available at anindividual level, outcome strengths were based on the size ofthe change relative to reported effect sizes or the quality of theexperimental design.
Articles were divided among four independent raters, withprofessional training in education and psychology and ASD,for review. Training on the operational definitions for each ofthe in-depth review variables was conducted and reliabilitywas established prior to the start of the review. In addition,
1 To provide consistency in reporting results, for studies using groupmethodology, only the primary treatment group of interest was reported.That is, control groups or comparison groups were not reported in thefollowing summary tables.
Table 3 Articles meeting criteria for in-depth review by focus categoryand design
Intervention focus Group Single subject
Communication 8 36
Social 3 32
Behavior reduction 0 21
Academic 0 9
Daily living 0 4
Play 0 4
Feeding 0 3
Toileting 0 3
Comprehensive 17 2
Sleep 0 2
Anxiety 0 0
Cognitive 0 0
Total articles by research design 28 116
Grand total of articles for in-depth review 144
Rev J Autism Dev Disord (2014) 1:276–326 287
reliability checks were completed for 15% of all of the articlesthat were reviewed in order to maintain calibration betweenraters.
Each of the 144 reviewed studies was evaluated withrespect to more than 70 variables of interest. A subset ispresented for this review. They are:
1. Hours of intervention received per participant2. Impact of intervention3. Efficiency of intervention4. Type of intervention5. Intervention setting6. Type of direct intervention staff7. Type of supervisor staff8. Type of lead supervisor staff9. Group size for intervention sessions
10. Age range of participants11. Duration (in months) of intervention12. Intensity of intervention (hours per week)13. Number of study participants receiving behavioral
intervention
The studies are grouped under research design methodolo-gy, group design or single-subject methodology design, andthen by the specific focus of intervention, comprehensive orspecific skill/behavior.
Two variables require further description. Impact was firstevaluated by reviewing each study as to the degree to whichbehavior change occurred as a result of intervention. This wasthen refined to include an estimation of the clinical impact thatwould accrue to the participants—that is, the significance ofthe behavior change as it would affect their overall functioningin concert with the proportion of participants whoachieved success. Explicitly, this was a high bar toset, required significant clinical judgment of the impre-cise and differing data reporting methods across studies,but was necessary in the context of this review. Thus, itis important to note that a low impact score does notimply a lack of significant or meaningful findings froma research perspective, but rather simply that impact wasjudged low for the purposes of this specific review. Impactwas segmented into ranges. This was an estimate as to thepercent of participants that received clinical impact using thefollowing scale:
& Excellent 90 % and above& Very High 80 to 89 %& High 70 to 79 %& Medium 60 to 69 %& Fair 50 to 59 %& Poor 40to 49 %& Very Poor 30 to 39 %& Unacceptable less than 30 %
This variable, Impact, and intervention session group sizewas in turn used to calculate Efficiency for intervention usingthe same scale. This variable was intended to capture anelement of “cost-benefit”, in that while meaningful clinicalchange for an individual is the most important outcome var-iable, doing so with relatively fewer resources per individualoutcome is highly valued. Thus, group size during interven-tion session was factored in with a group size greater than 1receiving a one step higher tier ranking than if based onImpact alone with 1:1 session group size, and in turn a groupsize of greater than 3 receiving a two step higher ranking. Thesame categories as for Impact were used. Ideally, the factor ofaverage total hours of intervention per participant per studywould have been utilized in this formulation. However, therewas too much inconsistency in reporting to allow this calcu-lation across all studies.
Section 1—Comprehensive Intervention
There is much support for the effectiveness of comprehensivebehavioral interventions for childrenwith ASD (Eikeseth et al.2002, 2007; Howard et al. 2005; Lovaas 1987; Remingtonet al. 2007; Sallows and Graupner 2005; Sheinkopf and Siegel1998). In comparison to skill-based behavioral interventions,the essential elements of a comprehensive behavioral inter-vention include a wide range of individualized treatmenttarget behaviors across multiple developmental domains andspecific areas of deficit (BACB 2012; Howlin et al. 2009).Comprehensive behavioral interventions involve a combina-tion of specific intervention procedures that may be deliveredin a variety of settings (e.g., home, self-contained classroom,inclusive classroom, community) and involve a low child-to-service provider ratio (e.g., 1:1). All of the studies falling intothis category met the strict criteria of (a) targeting the definingsymptoms of ASD, (b) having treatment manuals, (c) provid-ing treatment with a high degree of intensity, and (d) measur-ing the overall effectiveness of the intervention program.
There are also many different treatment providers andsupervisory models, intervention contexts, and interventionintensities utilized when delivering comprehensive behavioralinterventions to children with ASD. As indicated by the recentBACB Guidelines for Health Plan Coverage of ABATreatment for ASD (BACB 2012), a key variable in theeffective delivery of comprehensive behavioral interventionsis the intensity and duration of the intervention. In general,research has suggested that high intensity (e.g., at least 30 hper week) interventions are more beneficial than low-intensityinterventions (approximately 10 h per week) (Eldevik et al.2006). Another key variable is the amount and frequency ofindividual case supervision as well as the qualifications andexperiences of the supervisor. Research has indicated that theintensity of supervision in comprehensive behavioral
288 Rev J Autism Dev Disord (2014) 1:276–326
interventions is positively correlated with improvement inchildren’s IQ scores (Eldevik et al. 2009). Comprehensivebehavioral programs typically function within a tiered servicedelivery and supervisory model, with differential insurancereimbursement rates for various service providers. It is there-fore important to assess the supervisory resources needed toachieve positive outcomes.
Combining these variables, as well as others such as inter-vention context and parent involvement, make the large-scaleanalysis of the effectiveness of comprehensive behavioralinterventions very complex. As such, the purpose of thissection is to provide a systematic analysis of these variablesin relation to impact. Such analysis is essential for the gener-ation of intervention guidelines for comprehensive behavioralintervention with respect to key variables such as serviceprovider characteristics, dosage, and cost-benefit.
Results—Comprehensive Studies Nineteen comprehensivestudies met inclusion criteria for this review. Studies weregrouped by the type of behavioral intervention provided, andincluded the Lovaas model (63 %, n=12), Early Start DenverModel (5 %; n=1), and the TEACCH model (11 %; n=2).Twenty-one percent (n=4) of authors identified their behav-ioral interventions as “comprehensive”. Seventeen of the 19studies utilized group designs, and two studies utilized single-subject designs to determine intervention effectiveness. Theaverage number of participants in the group comparison stud-ies was 21.4 (range 12–45), while the single-subject designstudies had six participants each. Children ranged in age from17 to 81 months. Notably, studies in which children beganreceiving comprehensive behavioral intervention prior to agefive were included in this review, even if children were olderthan age five at the time of the outcome assessment.Forty-two percent (n=8) of studies were conductedacross multiple settings. Services were primarily deliv-ered in school settings (68 %; n=13) and/or children’s homes(63 %; n=12). Additional settings included university-basedcenters (5 %; n=1), the community (5 %; n=1), and privateagencies (5 %; n=1).
Table 4 presents the 13 review variables for the 19 studies.Of note is the very high variability of hours of intervention andthe clinical impact factor. Inspection of these two variablesindicates no significant relationship. Perhaps more striking isthat only 2 of the 19 could be classified as having excellentclinical impact. Interestingly, both these studies demonstrateda very high efficiency as well.
Group Size A 1:1 child-to-provider ratio was implemented forat least some proportion of the intervention for nearly allstudies, consistent with the recent review by Matson andJang (2014). In one study, behavioral intervention was pro-vided to children in large groups only and, notably, one studydid not indicate group size. However, as can be seen in
Table 4, it is clearly the case that a 1:1 child-to-provider ratiois the standard in the reviewed literature.
Duration and Dosage The duration of services averaged21 months, with a range from 3 to 52 months. The intensityof services averaged 24 h/week with a range from 1.5 to 39 h/week. Such a range precludes simple summary statementsusing mean values.
Direct Service Delivery Sixty-three percent (n=12) of studiesincluded more than one type of direct service provider. Themajority of direct intervention hours were provided by para-professionals (68%; n=13) and/or parents (68 %; n=13), withsome direct intervention provided by teachers/educators(11 %; n=2), and university students (16 %; n=3). Twostudies did not provide details on the individuals providingdirect intervention.
Supervision Specific information regarding the professionalqualifications of supervisors was reported in 79 % (n=15) ofthe comprehensive studies. Most comprehensive studies uti-lized a hierarchical supervision model in which there was a“direct” and “lead” supervisor. The direct supervisor providedfrequent supervision to those directly providing behavioralintervention and was supervised by, or consulted with,the lead supervisor. Figure 5 displays the professionalqualifications of both direct and lead supervisors.Between both the direct and lead supervisors, the mostfrequent professional qualification of the supervisors was aBCBA (21 %; n=8), followed by Psychologists (18 %; n=7),other Master’s level professionals (16 %; n=6), and teachers/educators (16 %; n=6). Doctoral level BCBA (BCBA-D)were reported to provide supervision in 8 % (n=3) of com-prehensive studies.
Figure 6 displays the professional qualifications of directsupervisors only. BCBAs, teachers/educators, and other mas-ters level professionals (24 % each; n=4 each) provided themost frequent direct supervision, closely followed by graduatestudents (18 %; n=3).
Psychologists were only reported as direct supervisors inone comprehensive study (6 %); however, psychologists werethe most likely type of professional to provide lead supervi-sion (29 %; n=6; see Fig. 7). BCBAs (19 %; n=4) andBCBA-Ds (14 %; n=3) were the next most likely type of leadsupervisor.
Although method sections often included informationabout who was providing the supervision, information regard-ing the amount of supervision was not consistently included.Only 42 % reported the amount of supervision provided bydirect supervisors, and 26 % reported the amount of supervi-sion provided by lead supervisors. Utilizing the informationfrom these studies, on average, direct supervisors provided6.25 h/week of supervision (range 1–20 h/week) and lead
Rev J Autism Dev Disord (2014) 1:276–326 289
Tab
le4
The
19studiesthatmetcriteriaforclassificatio
nas
comprehensive
interventio
n
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Single-subjectd
esignmethodology
Com
prehensive
(2)
Smith
,T.,Buch,G.A
.,&
Gam
by,T
.E.
(2000).P
arentdirected,intensiveearly
interventio
nforchild
renwith
pervasive
developm
entald
isorder.Researchin
DevelopmentalD
isabilities,21
(4),297–309.
3772
Verypoor
Poor
Lovaas
Hom
eStudent,parent
Graduate
student
Not
specified
135..0.45
3626.2
6
Welterlin,A
.,Turner-Brown,L.M
.,Harris,
S.,M
esibov,G
.,&
Delmolino,L.(2012).
The
homeTEACCHingprogram
fortoddlers
with
autism.Journalof
Autism
and
DevelopmentalD
isorders,42(9),1827–1835.
18Unacceptable
Verypoor
TEACCH
Hom
eParent
Not
specified
Not
specified
124..0.39
31.5
6
Group
design
methodology
Com
prehensive
(17)
Cohen,H
.,Amerine-Dickens,M
.,&
Smith
,T.
(2006).E
arly
intensivebehavioraltreatm
ent:
Replicationof
theUCLAmodelin
acommunity
setting.Journalof
Developmentaland
BehavioralP
ediatrics,27
(2),145–155.
5400
Veryhigh
Medium
Lovaas
Hom
e,school
Paraprofessional,
parent
Masterslevel
professional,
graduate
student
BCBA,
masterslevel
professional
118..0.42
3637.5
21
Daw
son,G.,Rogers,S.,M
unson,J.,S
mith
,M.,
Winter,J.,G
reenson,J.,…
&Varley,J.(2010).
Randomized,controlledtrialo
fan
interventio
nfortoddlerswith
autism:T
heEarly
Start
DenverModel.P
ediatrics,125,17–23.
1459
Verypoor
Poor
Early
Start
Denver
Model
(ESD
M)
Hom
eParaprofessional,
parent
Graduatestudent
Psychologist,
SLP,
physician
119..0.28
2415.2
24
Eikeseth,S.,K
lintwall,L.,Jahr,E
.,&
Karlsson,
P.(2012).O
utcomeforchild
renwith
autism
receivingearlyandintensivebehavioral
interventio
nin
mainstream
preschooland
kindergarten
settings.Researchin
Autism
Spectrum
Disorders,6,829–835.
4784
Unacceptable
Unacceptable
Lovaas
Hom
e,school
Paraprofessional,
parent
BCBA,
masterslevel
professional
Psychologist
125..0.76
5223
35
Eikeseth,S.,S
mith
,T.,Jahr,E
.,&
Eldevik,S
.(2002).Intensive
behavioraltreatm
entatschool
for4-
to7-year-old
child
renwith
autism:
A1-year
comparisoncontrolledstudy.
BehaviorModification,26
(1),49–68
1368
Fair
Fair
Lovaas
School
Paraprofessional,
teacher/educator,
parent
Student
Psychologist
155..0.77
1228.52
13
Eldevik,S
.,Eikeseth,S.,Jahr,E.,&
Smith
,T.
(2006).E
ffectsof
low-intensity
behavioral
treatm
entfor
child
renwith
autism
andmental
retardation.Journalo
fAutism
andDevelopmental
Disorders,36(2),211–224.
812
Unacceptable
Verypoor
Lovaas
School
Paraprofessional,
parent
Teacher/
educator
Psychologist
136..0.68
2010.0.15
13
Eldevik,S
.,Hastings,R
.,Jahr,E
.,&
Hughes,
J.C.(2012).Outcomes
ofbehavioralinterventio
nforchildrenwith
autism
inmainstream
pre-school
settings.Journalo
fAutism
andDevelopmental
Disabilities,42,2
10–220.
1365
Unacceptable
Verypoor
Lovaas
School
Paraprofessional
Bachelorlevel
BCBA-D
126..0.70
25.1
13.6
31
Fava,L.,Strauss,K
.,ValeriG
.,D’Elia,L
.,Arima,
S.,&
Vicari,S.
(2011).T
heeffectivenessof
a624
High
Veryhigh
Com
prehensive
Hom
e,university-
Paraprofessional,
parent
Not
specified
Not
specified
1,4
26..0.81
626
12
290 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le4
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
cross-setting
complem
entary
staff-and
parent-m
ediatedearlyintensivebehavioral
interventio
nforyoungchildrenwith
ASD
.Researchin
Autism
Spectrum
Disorders,5
,1479–1492
based
center
Hayward,D.,Eikeseth,S.,G
ale,C.,&
Morgan,S.
(2009).A
ssessing
progress
during
treatm
ent
foryoungchild
renwith
autism
receivingintensive
behaviouralinterventions.A
utism,13(6),613–633.
1651
Fair
Fair
Lovaas
Hom
eParaprofessional
Teacher/
educator
Not
specified
130..0.42
1234..0.41
23
How
ard,J.S.,S
parkman,C
.R.,Cohen,H
.G.,Green,
G.,&
Stanislaw,H
.(2005).Acomparisonof
intensivebehavior
analyticandeclectictreatm
ents
foryoungchild
renwith
autism.R
esearchin
DevelopmentalD
isabilities,26
(4),359–383.
1422
Medium
Fair
Com
prehensive
Hom
e,school,
community
Student,parent
Masterslevel
professional
Psychologist/
BCB
A-D
,SLP
130..0.45
1425.0.40
29
Magiati,
I.,C
harm
an,T
.,&
How
lin,P.(2007).
Atwo-year
prospectivefollowup
studyof
community
-based
earlyintensivebehavioural
interventio
nandspecialistn
ursery
provision
forchildrenwith
autism
spectrum
disorders.
Journalo
fChild
Psychology
andPsychiatry,
48(8),803–812.
3110
Unacceptable
Verypoor
Lovaas
Hom
e,school
Not
specified,
parent
Not
specified
None
123..0.54
2432.4
28
Peters-Scheffer,N
.,Didden,R.,Mulders,M
.,&Korziliu
s,H.(2010).Low
intensity
behavioral
treatm
entsupplem
entin
gpreschoolservices
foryoungchild
renwith
autism
spectrum
disordersandsevere
tomild
intellectual
disability.Researchin
Developmental
Disabilities,31,1
678–1684.
163
Fair
Fair
Lovaas
School
Teacher/educator,
paraprofessional,
parent
Teacher/
educator,
psychologist
Teacher/
educator,
psychologist
142..0.62
85..0.10
12
Reed,P.,O
sbourne,L.A
.,&
Corness,M
.(2007).T
herealworld
effectivenessof
earlyteaching
interventio
nsforchildren
with
autism
spectrum
disorder.
Exceptio
nalC
hildren,73
(4),417–433.
1216
Fair
Fair
Lovaas
Hom
e,school
Paraprofessional
BCBA,
masterslevel
professional
BCBA,
masterslevel
professional
132..0.47
1030.4
12
Sallows,G.O
.,&
Graupner,T.
D.(2005).
Intensivebehavioraltreatm
entfor
child
ren
with
autism:F
our-year
outcom
eandpredictors.
American
Journalo
fMentalR
etardatio
n,110(6),417–438.
7488
Poor
Poor
Lovaas
Hom
e,school
Paraprofessional
Teacher/educator
BCBA-D
129..0.37
4839
13
Smith
,T.,Groen,A
.D.,&
Wynn,J.W.(2000).
Randomized
trialo
fintensiveearlyinterventio
nforchildrenwith
pervasivedevelopm
ental
disorder.A
merican
Journalo
fMentalR
etardatio
n,105(4),269–285.
2416
Poor
Poor
Lovaas
Hom
e,school
Student,parent
Not
specified
Doctorallevel
professional
130..0.42
3318..0.31
15
Tsang,S.K
.,Shek,D.T
.,Lam
,L.L
.,Tang,F.L
.,&
Cheung,P.M.(2006).Brief
report:A
pplication
oftheTEACCHprogram
onChinese
preschool
child
renwith
autism—does
cultu
remake
1680
Fair
High
TEACCH
Private
interventio
nagency
Not
specified
Not
specified
Not
specified
736..0.60
1235
18
Rev J Autism Dev Disord (2014) 1:276–326 291
supervisors provided 1.6 h/week of supervision (range 1–3 h/week).
Section 2—Skill-Based Interventions
While comprehensive behavioral interventions have shown tobe the most impactful for improving skills and addressing coresymptoms of ASD, the large majority of published researchhas addressed the development of individual skills or skillsets. The information gleaned from such research is critical toidentifying the components and intervention strategies thatshould be included as a part of a comprehensive interventionprogram. Within this large body of available research, studieswere categorized into primary areas of skill development formore directed evaluation. For the purposes of this review,skill-based interventions (i.e., not comprehensive treatments)were grouped into the categories shown in Table 2.
As was done for the comprehensive studies included in thisreview, information about dosage, intensity, duration, groupsize, setting, qualifications of interventionists, and qualifica-tions of supervisors was obtained. This section provides ananalysis of the information obtained from the skill-basedstudies and will assist in developing recommendations forintervention guidelines. In addition, these analyses will pro-vide guidance for researchers on key variables to include inwritten communication about their research methods.
Results—Skill-Based Interventions A total of 125 skill-basedstudies met the inclusion criteria for this review. The use ofsingle-case methodology dominated the skill-based interven-tion research. Ninety-one percent of the studies (n=114) uti-lized a single-case design, and 9 % (n=11) used a groupdesign to evaluate intervention effectiveness. The averagenumber of participants in the single-subject studies was 3.2(range 1–8). For the group designs, the average number ofparticipants receiving skill-based interventions was 24.5(range 10–56). Participants ranged in age from 10 months to144 months. Twenty-eight percent (n=36) were conductedacross multiple settings. The majority of the studies had atleast some portion of the intervention delivered in a schoolsetting (58 %; n=72). At least a third of the studies also had acomponent of the intervention that took place in the homeenvironment (34 %; n=43). Additional service settings in-cluded hospitals (2 %; n=3), research labs (10 %; n=13),outpatient clinics (6 %; n=7), university-based centers(13 %; n=16), and the community (4 %; n=5); see Fig. 8.As shown in Table 3, communication (29 %; n=36), socialskills (26 %; n=32), and behavior reduction (17 %; n=21)were the focus areas with the highest number of publishedarticles meeting the review criteria. Given that these are thethree core areas in which many individuals with autism spec-trum disorders experience deficits, this result is not surprising.T
able4
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
adifference?Journalo
fAutism
and
DevelopmentalD
isorders,37(2),390–396.
Zachor,D.A
.,Ben-Itzchak,E
.,Rabinovich,A.L
.,&
Lahat,E
.(2007).Changein
autism
core
symptom
swith
interventio
n.Researchin
Autism
Spectrum
Disorders,I,3
04–317.
1680
Poor
Poor
Com
prehensive
Private
interventio
nagency
Paraprofessional
BCBA
Teacher/
educator,
BCBA
122..0.34
1235
20
Zachor,D.,&
Izchak,E
.(2010).Treatment
approach,autism
severity
andinterventio
noutcom
esin
youngchild
ren.Researchin
Autism
Spectrum
Disorders,4,425–432.
960
Unacceptable
Unacceptable
Com
prehensive
Com
munity
-based
preschool
programsfor
child
ren
with
autism.
Paraprofessional,
parent
BCBA
BCBA
117..0.35
1220
45
292 Rev J Autism Dev Disord (2014) 1:276–326
Group Size A 1:1 child-to-provider ratio was implemented forthe majority of the skill-based studies reviewed (92 %; n=115). Of the studies not utilizing a 1:1 ratio, the child-to-provider ratio ranged from 2:1 to 6:1. These results are con-sistent with the results from the comprehensive studies includ-ed in this review.
Duration and Dosage The duration of treatment and intensity(sessions per week) were not consistently specified. The du-ration of treatment was not reported for 46 % (n=57) and theintensity of treatment was not reported for 38% (n=47), of thearticles reviewed. Of the studies that reported duration oftreatment, the average was 2.3 months with a range of lessthan a week to 12.5 months. For treatment intensity, theaverage was 2.5 h/week with a range of less than 15 min to27.5 h/week.
Direct Service Delivery In 35 % (n=44) of articles reviewed,the individual providing the treatment was not identified by
professional role or attained credentials. Instead, generic termslike “experimenter” and “instructor” were frequently used.When more specific information was provided, 27 %(n=34) of the studies included more than one type ofdirect service provider. Teachers/educators (18 %; n=23), parents (22 %; n=28) and paraprofessionals(20 %; n=25) were most likely to be implementing interven-tion procedures.
Supervision Specific information about regarding the profes-sional qualifications of supervisors was only provided in 22%(n=28) of the skills-based articles meeting review criteria. Ofthe articles that did provide information about supervision,doctoral level professionals (11 %; n=14), teachers/educators(7.2 %; n=9), and master’s level professionals (6.4 %; n=8)were most often reported to be providing supervision over theimplementation of treatment. Of note and quite puzzling, thelowest frequency of reported supervisors is for BCBA’s (seeFig. 9). Even less often than identifying who was providing
0
1
2
3
4
5
6
7
8
9
Fre
qu
ency
Type of Direct and Lead SupervisorsFig. 5 Frequency of direct andlead supervisors reported incomprehensive behavioralintervention studies
0
1
2
3
4
5
6
7
8
9
Freq
uenc
y
Type of Direct SupervisorsFig. 6 Frequency of directsupervisors reported incomprehensive behavioralintervention studies
Rev J Autism Dev Disord (2014) 1:276–326 293
supervision was any information provided about the amountof supervision that occurred. Only five articles of the 125reviewed provided any information about the duration andfrequency of supervision.
Section 3—Evaluation of Impact and Efficiency
Table 5 presents the studies that were rated as having“Excellent” Impact and “Excellent”, “Very High”, or “High”Efficiency. Of note, only 1 of the 51 studies was rated as“Excellent” Impact and “Excellent” Efficiency, with 4 rated“Very High”, and the remaining 46 rated “High” Efficiency.Given this “high bar” for impact and efficiency, the results areimpressive. It is unfortunate, however, that due to lack ofdetailed reporting in individual studies, total interventionhours per participant could only be estimated for 18 of the51 studies.
In this select group of 18 studies that allowed estimation oftotal intervention hours per participant, presented in Table 6,the range was from 1 to 1,366 h. Of particular note is that thisvery large range was seen for both single-subject methodolo-gy as well as group designmethodology studies. But, with justone exception, the very high number of hours per participantwas associated with comprehensive intervention studies, in-dependent of design methodology.
Even given the limitations because of inconsistent infor-mation reporting in published research studies, Table 6 doesillustrate the point that with proper development of standardsof reporting, compilation of specific intervention proceduresthat can be evaluated for impact as well as cost-benefit can beachieved. This will allow for more and more fine-grainedanalyses that incorporate child characteristics, proceduralcomponents, level of training/expertise of service provider,and specific levels of impact.
0
1
2
3
4
5
6
7
8
9
Freq
uenc
y
Type of Lead SupervisorsFig. 7 Frequency of leadsupervisors reported incomprehensive behavioralintervention studies
0
10
20
30
40
50
60
70
80
Fre
qu
ency
Setting for Skill-Based InterventionsFig. 8 Frequency of interventionsetting for skill-basedinterventions
294 Rev J Autism Dev Disord (2014) 1:276–326
Summary
Limitations of Published Research
It is clear from both our review and a more general reading ofthe literature that there is no consensus as to what participantcharacteristics or intervention parameters should be specified.A previous review and critique of the extant outcome researchliterature formed the impetus for the current review(Romanczyk 2011). Because of this lack of consensus, re-views, such as the present attempt, must of necessity be“creative” in culling information from research that comesfrom diverse investigators, intervention approaches, andpublication journals, in order to approximate estimates ofimpact and efficiency. This serious limitation of lack ofconsensus for reporting variables in the field represents anenormous waste of resources because of inefficiency inaggregating research studies, and in turn squanders valuabletime in understanding important variables in effective andefficient intervention. The result of this lack of consensus isthat specific and focused analyses across studies are highlylimited. Thus, progress in comprehensive analysis acrossresearch studies is being made in a slow and disjointedfashion. There are two noteworthy studies, however, thatexemplify the approach we propose. Eldevik et al. (2006),(2012), in addition to reporting group outcomes, presenteddata on the proportion of children making significant vs.clinical gains. This type of data presentation, over time, willenable additional analyses of the impact of behavioralinterventions.
The use of generic, or in contrast sub-field idiosyncraticdescriptors, in publications is problematic in several ways.
Vague descriptors for treatment providers, such as “experi-menter” or “instructor,” and use of split descriptors such as“undergraduates/paraprofessionals” limit using the evidencebase to establish a level of experience or credential necessaryfor effective treatment delivery. Additionally, descriptors suchas “sessions” or “trials” provide minimal treatment parametersdue to the absence of quantitative time duration informationregarding intensity and treatment duration. Specifying provid-er credentials and duration specification are central to further-ing research to understand appropriate choice of interventionparameters in applied settings, and would greatly serve thedebate as to school districts’ and insurance providers’ deter-mination of covered services, including the methodology,providers, and dosage required for meaningful impact.
Research has also indicated that certain child characteris-tics, such as IQ and language level, may be the best predictorof outcome (e.g., Magiati et al. 2007). Unfortunately, giventhe breadth of the content area, the disappointing lack ofstandardization, and general low rate of reporting detailedchild characteristics, meaningful analyses of such child char-acteristics in relation to behavioral intervention outcomescould not be conducted in the present review.
Impact Versus Efficiency
As is apparent in Table 7, the complete listing of all 144studies, by a very substantial margin, even within comprehen-sive intervention articles, the most common group size report-ed is a 1:1 child-to-provider ratio. This places severe con-straints on efficiency as defined by utilizing an interventionprocedure that does not rely on a 1:1 ratio. This pattern ofresults would seem to confirm the general clinical opinion that
0
10
20
30
40
50
60
70
80
90
100
Fre
qu
ency
Type of Supervisor for Skill-Based InterventionsFig. 9 Frequency of supervisortype for skill-based interventionstudies
Rev J Autism Dev Disord (2014) 1:276–326 295
Tab
le5
The
51studiesthatmetthecriteriaof
having
“Excellent”Im
pactandalso
“High”
andaboveEfficiency
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Single-subjectdesign
methodology
Academic(1)
Pelio
s,L.V
.,MacDuff,G.S
.,&
Axelrod,S
.(2003).The
effects
ofatreatm
entp
ackage
inestablishing
independentacademicworkskills
inchild
renwith
autism.E
ducatio
n&
Treatmento
fChildren,26
(1),1–21.
14Excellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
160..0.60
1.425
2.5
1
BehaviorReductio
n(14)
Ahearn,W.H
.,Clark,K
.M.,MacDonald,
R.P.F.,&
Chung,B
.I.(2007).
Assessing
andtreatingvocalstereotypy
inchild
renwith
autism.Journal
ofAppliedBehaviorAnalysis,40,
263–275.
ccExcellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
136..0.36
NI
NI
1
Ahrens,E.N
.,Lerman,D
.C.,Kodak,
T.,W
orsdell,A.S
.,&
Keegan,C.(2011).
Furtherevaluationof
response
interruptionandredirectionas
treatm
ent
forstereotypy.Journalof
Applied
BehaviorAnalysis,44
(1),95–108.
ccExcellent
High
Behavioral
component
Day
treatm
ent
center,
outpatient
clinic
Paraprofessional
Not
specified
Not
specified
148..0.60
NI
53
Boyd,B.A
.,McD
onough,S
.G.,Rupp,
B.,Khan,F.,&
Bodfish,J.W
.(2011).
Effectsof
afamily-implem
entedtreatm
ent
ontherepetitivebehaviorsof
children
with
autism.Journalof
Autism
and
DevelopmentalD
isorders,41(10),
1330–1341.
14Excellent
High
Behavioral
component
Outpatient
clinic
Parent
Not
specified
Not
specified
139..0.65
31..0.2
5
Brown,K.A
.,Wacker,D.P.,Derby,K
.M.,
Peck,S
.M.,Richm
an,D
.M.,Sasso,
G.M
.,…&
Harding,J.W
.(2000).
Evaluatingtheeffectsof
functional
communicationtraining
inthepresence
andabsenceof
establishing
operations.
Journalo
fAppliedBehaviorAnalysis,
33(1),53–71.
ccExcellent
High
Behavioral
component
Hom
e,outpatient
clinic,inpatient
unit
Parent
Not
specified
Not
specified
160..0.60
NI
NI
1
Cale,S.,C
arr,E.,Blakeley-Sm
ith,A
.,Owen-D
eSchyver,J.(2009).Context-based
assessmentand
interventionforproblem
behavior
inchildrenwith
autism
spectrum
disorder.B
ehaviorModification,33
(6),
707–742.
ccExcellent
High
Other
School
Paraprofessional
Not
specified
Not
specified
160..0.96
NI
NI
7
Donaldson,J.M
.,&
Vollm
er,T
.R.(2011).
Anevaluationandcomparisonof
time-out
procedures
with
andwith
outrelease
contingencies.Journalo
fAppliedBehavior
Analysis,44
(4),693–705.
ccExcellent
High
Behavioral
component
Hom
e,school,
community
Paraprofessional
Not
specified
Not
specified
136..0.48
NI
0.83
4
Ducharm
e,J.M.,Sanjuan,E.,&
Frain,T
.(2007).E
rrorless
compliancetraining:
Success-focusedbehavioraltreatm
ento
f
ccExcellent
High
Parenttraining
Workshop
setting,
home
Parent
Not
specified
Not
specified
148..0.72
NI
NI
2
296 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le5
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
child
renwith
asperger
syndrome.Behavior
Modification,31
(3),329–344.
Hagopian,L.,Crockett,J.,van
Stone,M
.,Deleon,I.,&
Bow
man,L
.(2000).Effects
ofnon-contingent
reinforcem
ento
nproblem
behavior
andstim
ulus
engagement:
The
roleof
satiation,extinction,
and
alternativereinforcem
ent.Journalo
fApplied
BehaviorAnalysis,33
(4),443–449.
ccExcellent
High
Behavioral
component
Hospital
Paraprofessional
Not
specified
Not
specified
148..0.48
NI
NI
1
Koegel,R.L
.,Openden,D
.,&
Koegel,L.K
.(2004).A
system
aticdesensitizationparadigm
totreath
ypersensitivity
toauditory
stim
uli
inchild
renwith
autism
infamily
contexts.
ResearchandPracticeforPersonswith
Severe
Disabilities,29
(2),122–134.
ccExcellent
High
Behavioral
component
Hom
e,school,
university-
basedcenter
Not
specified,
teacher/educator,
parent
Not
specified
Not
specified
130..0.43
0.75
NI
3
Kuoch,H
.,&
Mirenda,P.(2003).So
cialstory
interventions
foryoungchild
renwith
autism
spectrum
disorders.Fo
cuson
Autism
and
Other
DevelopmentalD
isabilities,18
(4),
219–227.
ccExcellent
High
Behavioral
component
School,home,
community
Paraprofessional,parent
Masterslevel
professional
Not
specified
146..0.76
NI
NI
3
Mancil,G.,Conroy,M.(2
009).E
ffectsof
amodifiedmilieu
therapyintervention
onthesocialcommunicaitonbehaviors
ofyoungchildrenwith
autism
spectrum
disorders.Journalo
fAutism
and
DevelopmentalD
isorders,39,149–163.
ccExcellent
High
Other
Hom
e,school
Parent
Masterslevel
professional
Not
specified
149..0.95
10.2
3
Moes,D.R
.,&
Frea,W
.D.(2002).
Contextualized
behavioralsupportin
earlyinterventionforchildrenwith
autism
andtheirfamilies.Journalof
Autism
and
DevelopmentalD
isorders,32(6),519–533.
ccExcellent
High
Behavioral
component
Hom
eParent
Not
specified
Doctorallevel
professional
139..0.43
NI
NI
3
Plavnick,J.B
.,&
Ferreri,S.
J.(2012).
Collateraleffectsof
mandtraining
for
childrenwith
autism.R
esearchin
Autism
Spectrum
Disorders,6
(4),1366–1376.
3Excellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
153..0.60
0.4
1.875
2
Schreibm
an,L
.,Whalen,C.,&
Stahmer,A
.C.
(2000).T
heuseof
videoprim
ingto
reduce
disruptivetransitionbehavior
inchildren
with
autism.Journalof
PositiveBehavior
Interventio
ns,2
(1),3–11.
2Excellent
High
Other
Settingin
which
problem
behavior
occurred;differed
byparticipant
Experim
enter
Doctorallevel
professional
Doctorallevel
professional
139..0.41
10.5
2
Com
munication(13)
Charlop-Christy,M
.H.,Carpenter,M
.,Le,L.,
LeB
lanc,L
.A.,&
Kellet,K.(2002).Using
thepictureexchange
communicationsystem
(PECS)with
childrenwith
autism:A
ssessm
ent
ofPE
CSacquisition,speech,socialcommunicative
behavior,and
problem
behavior.Journalof
AppliedBehaviorAnalysis,35
(3),213–231.
18Excellent
High
Other
Researchlab,
Com
munity,
Hospital
Paraprofessional
Not
specified
Not
specified
144..0.144
4..0.6
13
Finn,H
.E.,Miguel,C.F.,&
Ahearn,W.H
.(2012).
The
emergenceof
untrainedmands
andtactsin
11Excellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
146..0.66
2.15
1.3
3
Rev J Autism Dev Disord (2014) 1:276–326 297
Tab
le5
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
childrenwith
autism.Journalof
Applied
BehaviorAnalysis,45
(2),265–280.
Fragale,C.L
.,O'Reilly,M
.F.,Aguilar,J.,P
ierce,N.,
Lang,R.,Sigafoos,J.,&
Lancioni,G.(2012).
The
influenceof
motivatingoperations
ongeneralizationprobes
ofspecificmands
bychildrenwith
autism.Journalof
AppliedBehavior
Analysis,45
(3),565–577.
ccExcellent
High
Behavioral
component
School
Graduatestudent
Graduatestudent
Not
specified
148..0.48
NI
2.5
2
Grindle,C
.F.,&
Rem
ington,B
.(2002).Discrete-trial
training
forautistic
childrenwhenrewardis
delayed:
Acomparisonof
conditioned
cuevalue
andresponse
marking.Journalof
AppliedBehavior
Analysis,35
(2),187–190.
ccExcellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
148..0.60
NI
2.5
2
Grow,L
.L.,Carr,J.E.,Kodak,T
.M.,Jostad,C
.M.,
&Kisam
ore,A.N
.(2011).Acomparisonof
methods
forteaching
receptivelabelin
gto
child
renwith
autism
spectrum
disorders.Journalo
fAppliedBehavior
Analysis,44
(3),475–498.
ccExcellent
High
Behavioral
component
Hom
e,outpatient
clinic
Experim
enter
Not
specified
Not
specified
148..0.48
NI
NI
2
Ingvarsson,E
.T.,&
Hollobaugh,T.
(2011).A
comparison
ofprom
ptingtacticsto
establishintraverbalsin
childrenwith
autism.Journalof
AppliedBehavior
Analysis,44
(3),659–664.
ccExcellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
148..0.48
0.33
NI
3
Jahr,E
.(2001).Teaching
child
renwith
autism
toansw
ernovelw
h-questions
byutilizing
amultip
leexem
plar
strategy.R
esearchin
DevelopmentalD
isabilities,
22(5),407–423.
ccExcellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Not
specified
Not
specified
147..0.67
NI
3.75
3
Jones,C.D
.,&
Schw
artz,I.S
.(2004).Siblings,peers,and
adults:d
ifferentialeffectsof
modelsforchildrenwith
autism.T
opicsin
Early
Childhood
SpecialE
ducatio
n,24
(4),187–198.
1Excellent
Veryhigh
Behavioral
component
School
Experim
enter,
teacher/
educator
Not
specified
Not
specified
245..0.62
0.25
1.25
3
Naoi,N.,Yokoyam
a,K.,&
Yam
amoto,J.(2007).
Interventio
nfortactas
reportingin
childrenwith
autism.R
esearchin
Autism
Spectrum
Disorders,
1,174–184.
ccExcellent
High
Behavioral
component
Researchlab
Experim
enter
Not
specified
Not
specified
151..0.51
NI
NI
1
Ostryn,C.,&
Wolfe,P.S
.(2011).Teaching
preschool
childrenwith
autism
spectrum
disordersto
expressively
discriminatebetween“w
hat’s
that?”
and“w
here
isit?”.Fo
cuson
Autism
andOther
DevelopmentalD
isabilities,26
(4),195–205.
ccExcellent
High
Behavioral
component
School
Experim
enter,
paraprofessional
Not
specified
Not
specified
141..0.59
NI
NI
3
Ross,D.E
.,&
Greer,R
.D.(2003).Generalized
imitationandthemand:
Inducing
firstinstances
ofspeech
inyoungchild
renwith
autism.
Researchin
DevelopmentalD
isabilities,
24(1),58–74.
1Excellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
165..0.65
0.14
2.5
1
Wert,B.Y
.,&
Neisw
orth,J.T
.(2003).Effectsof
video
selfmodelingon
spontaneousrequestingin
children
with
autism.Journalof
PositiveBehaviorInterventions,
5(1),30–34.
ccExcellent
High
Behavioral
component
Hom
e,school
Paraprofessional
Not
specified
Not
specified
136..0.72
0.5
0.4
4
Williams,G.,Perez-Gonzalez,L.A
.,&
Vogt,K.(2003).
The
roleof
specificconsequences
inthemaintenance
ccExcellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
133..0.53
NI
2.5
2
298 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le5
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
ofthreetypesof
questions.Journalof
AppliedBehavior
Analysis,36
(3),285–296.
Daily
Living(2)
Reeve,S
.A.,Reeve,K
.F.,To
wnsend,D.B
.,&
Poulson,C.L
.(2007).E
stablishing
ageneralized
repertoire
ofhelping
behavior
inchildrenwith
autism.Journalof
Applied
BehaviorAnalysis,40
(1),123–136.
ccExcellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
160..0.72
NI
NI
4
Shipley-Benam
ou,R
.,Lutzker,J.R
.,&
Taubman,M
.(2002).
Teaching
daily
livingskillsto
child
renwith
autism
throughinstructionalv
ideo
modeling.Journalo
fPo
sitiv
eBehaviorInterventions,4
(3),165–175.
2Excellent
High
Behavioral
component
Hom
e,research
lab
Experim
enter
Not
specified
Not
specified
161..0.65
0.5
13
Feeding(1)
Seiverling,L.,Williams,K.,Sturmey,P.,&
Hart,S.(2012).
Effectsof
behavioralskillstraining
onparental
treatm
ento
fchild
ren'sfood
selectivity.Journalof
AppliedBehaviorAnalysis,45
(1),197–203.
ccExcellent
High
Behavioral
component
Hom
eParent,
experimenter
Not
specified
Not
specified
136..0.96
1.5
NI
3
Play
(1)
Jahr,E
.,Eldevik,S
.,&
Eikeseth,S.
(2000).T
eaching
childrenwith
autism
toinitiateandsustain
cooperativeplay.R
esearchin
Developmental
Disabilities,21
(2),151–169.
ccExcellent
High
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
148..0.60
NI
52
Sleep(1)
Durand,V.M
.(2002).Treatingsleepterrorsin
childrenwith
autism.Journalof
Positive
BehaviorInterventions,4
(2),66-72.
ccExcellent
High
Behavioral
component
Hom
eParent
Doctorallevel
professional
Doctorallevel
professional
136..0.60
1.5
NI
2
Social(15)
Gena,A.(2006).The
effectsof
prom
ptingandsocial
reinforcem
ento
nestablishing
socialinteractions
with
peersduring
theinclusionof
four
children
with
autism
inpreschool.InternationalJournal
ofPsychology,41(6),541–554.
1000
Excellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Not
specified
Not
specified
148..0.53
12.5
204
Gena,A.,Couloura,S.,&
Kym
issis,E.(2005).Modifying
theaffectivebehavior
ofpreschoolerswith
autism
usingin-vivoor
videomodelingandreinforcem
ent
contingencies.Journalo
fAutism
andDevelopmental
Disorders,35(5),545–556.
ccExcellent
High
Behavioral
component
Hom
eDoctorallevel
professional,
graduatestudent
Not
specified
Not
specified
147..0.67
1.94
0.09
3
Hwang,B.,&
Hughes,C.(2000).Increasing
early
socialcommunicativeskillsof
preverbalp
reschool
childrenwith
autism
throughsocialinteractive
training.Journalof
theAssociationforPersons
with
Severe
Handicaps,25,18–28.
8Excellent
High
Behavioral
component
University-
basedcenter
Graduatestudent,
teacher/educator
Not
specified
Not
specified
132..0.43
4.3
0.5
3
Johnston,S
.,Nelson,C.,Evans,J.,&
Palazolo,K
.(2003).
The
useof
visualsupportsin
teaching
youngchild
ren
with
autism
spectrum
disorder
toinitiateinteractions.
AAC:A
ugmentativeandAlternativeCom
munication,
19(2),86–103.
ccExcellent
High
Behavioral
component
School
Teacher/educator
Teacher/
educator
Not
specified
151..0.63
NI
NI
3
Jung,S
.,Sainato,D.,Davis,C
.(2008).Using
high-probability
requestsequences
toincrease
socialinteractions
inyoungchildrenwith
autism.Journalof
Early
Interventio
n,30
(3),163–187.
ccExcellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
463..0.77
NI
2.5
3
Rev J Autism Dev Disord (2014) 1:276–326 299
Tab
le5
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Koegel,R.L.,Vernon,T.W.,Koegel,L.K.(2009).
Improvingsocialinitiations
inyoungchildren
with
autism
usingreinforcerswith
embedded
socialinteractions.Journalof
Autism
and
DevelopmentalD
isorders,39,1240–1251.
ccExcellent
High
Behavioral
component
Hom
eStudent,parent
Graduatestudent
Not
specified
138..0.41
NI
23
Kohler,F.W.,Anthony,L
.J.,Steighner,S.
A.,&
Hoyson,M.(2001).Teaching
social
interactionskillsin
theintegrated
preschool:
Anexam
inationof
naturalistic
tactics.To
pics
inEarly
Childhood
SpecialE
ducation,21,93–103.
5Excellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Teacher/educator
Teacher/educator
149..0.55
2.5
0.5
4
Martins,M.P.,&
Harris,S.
L.(2006).Teaching
childrenwith
autism
torespondto
joint
attentioninitiations.C
hild
&Family
BehaviorTherapy,28(1),51–68.
7Excellent
High
Behavioral
component
University-
basedcenter
Paraprofessional,
experimenter
Teacher/educator,
notspecified
Teacher/educator,
notspecified
144..0.58
2.61
0.75
3
McG
ee,G
.G.,&
Daly,T.
(2007).Incidental
teaching
ofageappropriatesocialphrasesto
childrenwith
autism.R
esearch&
Practice
forPersonswith
Severe
Disabilities,32
(2),
112–123.
3Excellent
Veryhigh
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
357..0.62
20.4
3
Pollard,J.S
.,Betz,A.M
.,&
Higbee,T.
S.(2012).
Script
fading
toprom
oteunscripted
bids
for
jointattentionin
child
renwith
autism.Journal
ofAppliedBehaviorAnalysis,45
(2),387–393.
ccExcellent
High
Behavioral
component
School
Not
specified
Not
specified
Not
specified
148..0.84
NI
NI
3
Reagon,K.,Higbee,T.(2009).P
arent-im
plem
ented
script
fading
toprom
oteplay-based
verbal
initiations
inchildrenwith
autism.Journal
ofAppliedBehaviorAnalysis,42
(3),659–664.
ccExcellent
High
Behavioral
component
Hom
eParent
Graduate
student
Not
specified
135..0.72
NI
1.75
3
Schrandt,J.,To
wnsend,D.,Poulson,C
.(2009).
Teaching
empathyskillsto
child
renwith
autism.Journalof
AppliedBehavior
Analysis,42
(1),17–32.
ccExcellent
High
Behavioral
component
School
Not
specified
Not
specified
Not
specified
153..0.105
NI
2.25
4
Taylor,B
.A.,DeQ
uinzio,J.A
.,&
Stine,J.(2012).
Increasing
observationallearningof
children
with
autism:A
prelim
inaryanalysis.Journal
ofAppliedBehaviorAnalysis,45
(4),815–820.
ccExcellent
Veryhigh
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
244..0.56
NI
NI
3
Taylor,B
.A.,Hoch,H.,Po
tter,B.,Rodriguez,A
.,Sp
innato,D
.,&
Kalaigian,M
.(2005).
Manipulatingestablishing
operations
toprom
ote
initiations
towardpeersin
childrenwith
autism.
Researchin
DevelopmentalD
isabilities,
26,385–392.
ccExcellent
Veryhigh
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
248..0.48
NI
NI
1
Vismara,L.,Colom
bi,C
.,Rogers,S.(2009).
Can
onehour
perweekof
therapylead
tolastingchangesin
youngchildrenwith
autism?Autism,13(1),93–115.
12Excellent
High
Early
Start
Denver
Model
University-
based
center
Parent
BCBA-D
,graduate
student,
psychologist
Not
specified
110..0.36
31
8
Group
design
methodology
Com
munication(2)
Yoder,P.,&
Stone,W.L
.(2006).Randomized
comparisonof
twocommunication
interventions
forpreschoolerswith
autism
spectrum
disorders.Journal
24Excellent
High
Other
Researchlab
Masterslevel
professional,
paraprofessional,
parent
Masterslevel
professional
Masterslevel
professional
128..0.46
61
19
300 Rev J Autism Dev Disord (2014) 1:276–326
intensive, effective intervention, even for specific skills, re-quires a strong one-to-one component as a significant aspectof the intervention program.
Given this, attention should perhaps focus on thedegree of consistent impact achieved relative to the costof the intervention program. This is the first comprehen-sive review we are aware of that attempted to calculatethe actual hours of intervention per participant. Ideally,this variable would be used in concert with child char-acteristic variables to determine potential cost-benefit patternsand factors that limit impact. As described above, unfortu-nately the inconsistency in reporting such characteristics se-verely restricts such analyses.
Perspective
As we have acknowledged, there are limitations to our attemptto bring clarity of definition and perspective to limited re-source allocation and to our review of intervention studies.Unlike generally accepted standards with respect to evaluatingtime-series experimental designs or the type of statisticalanalyses appropriate for various group designs, there are nogenerally accepted standards for the type of analyses weattempted in this review—the policies and costs of clinicallysignificant impact across various intervention foci. Critiquewill be welcomed if it can lead to a consensus on how toevaluate clinical impact as can be used in the context oflimited resource allocation.
The first part of this review examined the complex issuesinvolved in public policy and resource allocation. Given re-sources are constrained, it appears valuable to determine in-tervention procedures that result in substantial and consistentimpact for young childrenwith ASD and also to ascertain their“costs”. The unit of analysis we used, total hours of interven-tion per participant, was not our original goal. Had the articlesreviewed more consistently specified the characteristics of theindividuals implementing the intervention procedures, thencalculations could have been performed as to actual monetarycost using geographical average cost for various types ofservice providers (e.g., special education teacher vs. under-graduate student, vs. Ph. D. vs. BCBA, etc.).
However, even given the disappointing limitations in theextant literature, this review brings attention to importantissues of desired standardization in reporting interventionparameters and child characteristics. Further, it represents afirst step in aggregating information in a manner that allowsfor discussion between researchers, caregivers, policy makers,and those that are in the role of resource allocation. Referencesto statements such as “The XYZ approach yields the bestoutcomes” are simply too broad to be of continuing use inthe complex process of service delivery on a large scale andrefinement of efficiency in achieving meaningful clinical andeducational impact.T
able5
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
ofConsulting
andClinicalPsychology,
74(3),426–435.
Yoder,P.J.,Lieberm
an,R
.G.(2010).
Brief
Report:Randonm
ized
test
oftheeficacyof
pictureexchange
communicationsystem
onhighly
generalized
pictureexchangesin
childrenwith
ASD
.Journal
ofAutism
andDevelopmental
Disorders,40,629–632.
24Excellent
High
Other
University-
based
center
Not
specified
Not
specified
Not
specified
128..0.47
61
19
Social(1)
Kasari,C.,Freem
an,S
.,&
Paparella,T
.(2006).Jointattention
andsymbolic
play
inyoungchildren
with
autism:A
random
ized
controlled
interventionstudy.Journalo
fChild
Psychology
andPsychiatry,and
Allied
Disciplines,47(6),611–620.
13Excellent
High
Behavioral
component
School
Graduatestudent
Teacher/
educator
Doctorallevel
professional
136..0.50
1.375
2.5
58
Rev J Autism Dev Disord (2014) 1:276–326 301
Tab
le6
The
18studieshaving
“Excellent”Im
pactandalso
“High”
andaboveEfficiencyandallowed
estim
ates
oftotalinterventionhoursperparticipant
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Single-subjectd
esignmethodology
Academic(1)
Pelios,L.V
.,MacDuff,G.S
.,&
Axelrod,S
.(2003).The
effectsof
atreatm
entp
ackage
inestablishing
independent
academ
icworkskillsin
child
ren
with
autism.E
ducatio
n&
Treatmento
fChildren,26
(1),
1–21.
14Excellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
160..0.60
1.425
2.5
1
BehaviorReduction(3)
Boyd,B.A
.,McD
onough,S
.G.,
Rupp,B.,Khan,F.,&
Bodfish,
J.W.(2011).Effectsof
afamily
-im
plem
entedtreatm
ento
nthe
repetitivebehaviorsof
child
ren
with
autism.Journalof
Autism
andDevelopmentalD
isorders,
41(10),1330–1341.
14Excellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
139..0.65
31..0.2
5
Plavnick,J.B.,&
Ferreri,S.
J.(2012).
Collateraleffectsof
mandtraining
forchildrenwith
autism.R
esearch
inAutism
Spectrum
Disorders,
6(4),1366–1376.
3Excellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
153..0.60
0.4
1.875
2
Schreibman,L
.,Whalen,C.,
&Stahmer,A
.C.(2000).The
useof
videoprim
ingto
reduce
disruptiv
etransitio
nbehavior
inchild
renwith
autism.Journalof
Positiv
eBehaviorInterventio
ns,
2(1),3–11.
2Excellent
High
Other
Setting
inwhich
problem
behavior
occurred;d
iffered
byparticipant
Experim
enter
Doctorallevel
professional
Doctorallevel
professional
139..0.41
10.5
2
Com
munication(4)
Charlop-Christy,M
.H.,Carpenter,M
.,Le,L.,LeB
lanc,L
.A.,&
Kellet,K.
(2002).U
sing
thepictureexchange
communicationsystem
(PECS)
with
child
renwith
autism:A
ssessm
ent
ofPE
CSacquisition,speech,
socialcommunicativebehavior,and
problem
behavior.Journalof
Applied
BehaviorAnalysis,35
(3),213–231.
18Excellent
High
Other
Researchlab,
community,
hospital
Paraprofessional
Not
specified
Not
specified
144..0.144
4..0.6
13
Finn,H.E
.,Miguel,C.F.,&
Ahearn,
W.H
.(2012).The
emergenceof
untrainedmands
andtactsin
children
with
autism.Journalof
AppliedBehavior
Analysis,45
(2),265–280.
11Excellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
146..0.66
2.15
1.3
3
1Excellent
Veryhigh
School
Not
specified
Not
specified
245..0.62
0.25
1.25
3
302 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le6
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Jones,C.D
.,&
Schwartz,I.S
.(2004).
Siblings,peers,and
adults:d
ifferential
effectsof
modelsforchild
renwith
autism.
Topics
inEarly
Childhood
Special
Educatio
n,24
(4),187–198.
Behavioral
component
Experim
enter,
teacher/educator
Ross,D.E
.,&
Greer,R
.D.(2003).
Generalized
imitatio
nandthemand:
Inducing
firstinstances
ofspeech
inyoungchild
renwith
autism.R
esearch
inDevelopmentalD
isabilities,
24(1),58–74.
1Excellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
165..0.65
0.14
2.5
1
Daily
Living(1)
Shipley-Benam
ou,R
.,Lutzker,J.R
.,&
Taubman,M
.(2002).Teaching
daily
livingskillsto
child
renwith
autism
throughinstructionalv
ideo
modeling.
Journalo
fPo
sitiv
eBehavior
Interventio
ns,4
(3),165–175.
2Excellent
High
Behavioral
component
Hom
e,research
lab
Experim
enter
Not
specified
Not
specified
161..0.65
0.5
13
Social(6)
Gena,A.(2006).The
effectsof
prom
ptingandsocialreinforcem
ent
onestablishing
socialinteractions
with
peersduring
theinclusion
offour
child
renwith
autism
inpreschool.InternationalJournal
ofPsychology,41(6),541–554.
1000
Excellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Not
specified
Not
specified
148..0.53
12.5
204
Hwang,B.,&
Hughes,C.(2000).
Increasing
earlysocialcommunicative
skillsof
preverbalp
reschool
child
renwith
autism
through
socialinteractivetraining.Journalof
theAssociatio
nforPersonswith
Severe
Handicaps,25,18–28.
8Excellent
High
Behavioral
component
University
-basedcenter
Graduatestudent,
teacher/educator
Not
specified
Not
specified
132..0.43
4.3
0.5
3
Kohler,F.W.,Anthony,L
.J.,Steighner,
S.A.,&
Hoyson,M.(2001).
Teaching
socialinteractionskills
intheintegrated
preschool:An
exam
inationof
naturalistic
tactics.
Topics
inEarly
Childhood
Special
Educatio
n,21,93–103.
5Excellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Teacher/educator
Teacher/educator
149..0.55
2.5
0.5
4
Martin
s,M.P.,&
Harris,S.
L.(2006).
Teaching
child
renwith
autism
torespondto
jointattentioninitiations.
Child
&Family
BehaviorTherapy,
28(1),51–68.
7Excellent
High
Behavioral
component
University
-basedcenter
Paraprofessional,
experimenter
Teacher/educator,
notspecified
Teacher/educator,
notspecified
144..0.58
2.61
0.75
3
McG
ee,G
.G.,&
Daly,T.
(2007).
Incidentalteaching
ofageappropriate
socialphrasesto
childrenwith
autism.
3Excellent
Veryhigh
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
357..0.62
20.4
3
Rev J Autism Dev Disord (2014) 1:276–326 303
Tab
le6
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Research&
PracticeforPersonswith
Severe
Disabilities,32
(2),112–123.
Vismara,L.,Colom
bi,C
.,Rogers,S.(2009).
Can
onehour
perweekof
therapy
lead
tolastingchangesin
young
child
renwith
autism?Autism,
13(1),93–115.
12Excellent
High
Early
Start
DenverModel
(ESD
M)
University
-basedcenter
Parent
BCBA-D
,graduate
student,
psychologist
Not
specified
110..0.36
31
8
Group
design
methodology
Com
munication(2)
Yoder,P.,&
Stone,W.L
.(2006).
Randomized
comparisonof
two
communicationinterventions
for
preschoolerswith
autism
spectrum
disorders.Journalo
fConsulting
and
ClinicalPsychology,74(3),426–435.
24Excellent
High
Other
Researchlab
Masterslevel
professional,
paraprofessional,
parent
Masterslevel
professional
Masterslevel
professional
128..0.46
61
19
Yoder,P.J.,Lieberm
an,R
.G.(2010).
Brief
Report:Randonm
ized
test
oftheeficacyof
pictureexchange
communicationsystem
onhighly
generalized
pictureexchangesin
child
renwith
ASD
.Journalof
Autism
andDevelopmentalD
isorders,
40,629–632.
24Excellent
High
Other
University
-basedcenter
Not
specified
Not
specified
Not
specified
128..0.47
61
19
Social(1)
Kasari,C.,Freeman,S
.,&
Paparella,T
.(2006).Joint
attentionandsymbolic
play
inyoungchildrenwith
autism:
Arandom
ized
controlledinterventio
nstudy.Journalo
fChild
Psychology
andPsychiatry,and
Allied
Disciplines,
47(6),611–620.
13Excellent
High
Behavioral
component
School
Graduatestudent
Teacher/educator
Doctorallevel
professional
136..0.50
1.375
2.5
58
304 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
The
144studiesreceivingintensivereview
with
the13
variablesof
prim
aryinterest,presented
bydesign
methodology
type
andcategorizedby
interventio
nfocus
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Single-subjectdesign
methodology
Academic(9)
Anson,H
.,To
dd,J.,Cassaretto,
K.(2008).Replacing
overt
verbalandgesturalprom
pts
with
unobtrusivecoverttactile
prom
ptingforstudentswith
autism.B
ehaviorResearch
Methods,40(4),1106–1110.
2High
Fair
Behavioral
component
Hom
eStudent,
graduate
student
Not
specified
Not
specified
148..0.84
0.25
2.5
5
Carp,C.L
.,Peterson,S.
P.,A
rkel,
A.J.,Petursdottir,A.I.,&
Ingvarsson,E
.T.(2012).A
furtherevaluatio
nof
picture
prom
ptsduring
auditory-visual
conditionaldiscrimination
training.Journalof
Applied
BehaviorAnalysis,45
(4),
737–751.
25High
Fair
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
145..0.56
5.6
1.13
4
Carr,D.(2003).Effectsof
exem
plar
training
inexclusionresponding
onauditory-visuald
iscrim
ination
taskswith
childrenwith
autism.
Journalo
fAppliedBehavior
Analysis,36
(4),507–524.
ccVerypoor
Poor
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
145..0.63
1NI
5
Greer,R
.D.,Yaun,L.,&
Gautreaux,
G.(2005).Noveldictationand
intraverbalresponses
asa
functionof
amultipleexem
plar
instructionalh
istory.T
heAnalysisof
VerbalB
ehavior,
21,99–116.
ccVeryhigh
Medium
Behavioral
component
School
Teacher/educator,
paraprofessional
Not
specified
Not
specified
160..0.72
NI
7.5
8
Pelio
s,L.V
.,MacDuff,G.S
.,&
Axelrod,S
.(2003).The
effectsof
atreatm
entp
ackage
inestablishing
independent
academ
icworkskillsin
children
with
autism.E
ducatio
n&
Treatmento
fChildren,26
(1),
1–21.
14Excellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
160..0.60
1.425
2.5
1
Perez-Gonzalez,L.A
.,&
Williams,
G.(2002).Multicom
ponent
procedureto
teachconditional
discriminations
tochildren
with
autism.A
merican
Journal
ofMentalR
etardation:
AJM
R,
107(4),293–301.
ccUnacceptable
Unacceptable
Behavioral
component
Hom
e,school
Experim
enter,
notspecified
Not
specified
Not
specified
159..0.65
0.5
0.05..0.1.5
2
Reichow
,B.,&
Wolery,M.(2011).
Com
parisonof
progressive
prom
ptdelaywith
andwithout
instructivefeedback.Journal
ofAppliedBehaviorAnalysis,
44(2),327–340.
ccHigh
Medium
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
136..0.60
0.5
NI
4
Rev J Autism Dev Disord (2014) 1:276–326 305
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Schilling,D
.L.,&
Schw
artz,I.S
.(2004).A
lternativeseatingfor
youngchildrenwith
autism
spectrum
disorder:E
ffectson
classroom
behavior.Journal
ofAutism
andDevelopmental
Disorders,34(4),423–432.
1Fair
Fair
Behavioral
component
School,
university-
basedcenter
Teacher/
educator
Not
specified
Not
specified
147..0.50
0.5
0.75
4
Schneider,N.,Goldstein,H
.(2010).
Using
socialstoriesandvisual
schedulesto
improvesocially
appropriatebehaviorsin
children
with
autism.Journalof
Positive
BehaviorInterventio
ns,12(3),149–160.
ccVerypoor
Poor
Behavioral
component
School
SLP
SLP
Not
specified
162..0.123
NI
NI
3
BehaviorReductio
n(21)
Ahearn,W.H
.,Clark,K
.M.,
MacDonald,R.P.F.,&
Chung,B
.I.(2007).Assessing
andtreatingvocalstereotypyin
childrenwith
autism.Journal
ofAppliedBehaviorAnalysis,
40,263–275
ccExcellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
136..0.36
NI
NI
1
Ahrens,E.N
.,Lerman,D
.C.,Kodak,
T.,W
orsdell,A.S
.,&
Keegan,
C.(2011).Further
evaluation
ofresponse
interruptionand
redirectionas
treatm
entfor
stereotypy.Journalof
Applied
BehaviorAnalysis,44
(1),
95–108.
ccExcellent
High
Behavioral
component
Day
treatm
ent
center,
outpatient
clinic
Paraprofessional
Not
specified
Not
specified
148..0.60
NI
53
Boyd,B.A
.,McD
onough,S
.G.,
Rupp,B.,Khan,F.,&
Bodfish,
J.W.(2011).Effectsof
afamily-implem
entedtreatm
ent
ontherepetitivebehaviors
ofchildrenwith
autism.Journal
ofAutism
andDevelopmental
Disorders,41(10),1330–1341.
14Excellent
High
Behavioral
component
Outpatient
clinic
Parent
Not
specified
Not
specified
139..0.65
31..0.2
5
Brown,K.A
.,Wacker,D.P.,Derby,
K.M
.,Peck,S
.M.,Richm
an,
D.M
.,Sasso,G.M
.,…&
Harding,J.W
.(2000).Evaluating
theeffectsof
functional
communicationtraining
inthe
presence
andabsenceof
establishing
operations.Journalof
Applied
BehaviorAnalysis,33
(1),53–71.
ccExcellent
High
Behavioral
component
Hom
e,outpatient
clinic,inpatient
unit
Parent
Not
specified
Not
specified
160..0.60
NI
NI
1
Cale,S.,C
arr,E.,Blakeley-Sm
ith,A
.,Owen-D
eSchyver,J.(2009).
Context-based
assessmentand
interventionforproblem
behavior
inchild
renwith
autism
spectrum
disorder.B
ehaviorModification,
33(6),707–742.
ccExcellent
High
Other
School
Paraprofessional
Not
specified
Not
specified
160..0.96
NI
NI
7
306 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Donaldson,J.M
.,&
Vollm
er,T
.R.(2011).
Anevaluationandcomparison
oftim
e-outp
rocedureswith
and
withoutrelease
contingencies.
Journalo
fAppliedBehavior
Analysis,44
(4),693–705.
ccExcellent
High
Behavioral
component
Hom
e,school,
community
Paraprofessional
Not
specified
Not
specified
136..0.48
NI
0.83
4
Ducharm
e,J.M.,&
Drain,T
.L.(2004).
Errorless
academ
iccompliancetraining:
Improvinggeneralized
cooperationwith
parentalrequestsin
childrenwith
autism.
Journalo
ftheAmerican
Academyof
Child
andAdolescentP
sychiatry,
43(2),163–171.
ccMedium
Fair
Parent
training
Hom
eParent
Not
specified
Not
specified
142..0.52
NI
NI
2
Ducharm
e,J.M.,Sanjuan,E.,&
Frain,
T.(2007).E
rrorless
compliance
training:S
uccess-focused
behavioraltreatm
ento
fchildren
with
asperger
syndrome.Behavior
Modification,31
(3),329–344.
ccExcellent
High
Parent
training
Workshopsetting,
home
Parent
Not
specified
Not
specified
148..0.72
NI
NI
2
Hagopian,L.,Crockett,J.,van
Stone,
M.,Deleon,I.,&
Bow
man,L
.(2000).E
ffectsof
non-contingent
reinforcem
ento
nproblem
behavior
andstim
ulus
engagement:The
role
ofsatiation,extin
ction,and
alternativereinforcem
ent.Journal
ofAppliedBehaviorAnalysis,
33(4),443–449.
ccExcellent
High
Behavioral
component
Hospital
Paraprofessional
Not
specified
Not
specified
148..0.48
NI
NI
1
Karmali,I.,G
reer,R
.,Nuzzolo-G
omez,
R.,Ross,D.E
.,&
Rivera-Valdes,
C.(2005).Reducingpalilaliaby
presentingtactcorrections
toyoung
childrenwith
autism.A
nalysisof
VerbalB
ehavior,21,145–153.
2Medium
Fair
Behavioral
component
Hom
e,school
Experim
enter
Not
specified
Not
specified
136..0.48
0.4
1.67
5
Koegel,R.L
.,Openden,D
.,&
Koegel,
L.K
.(2004).Asystem
atic
desensitizationparadigm
totreat
hypersensitiv
ityto
auditory
stim
uli
inchild
renwith
autism
infamily
contexts.R
esearchandPractice
forPersonswith
Severe
Disabilities,
29(2),122–134.
ccExcellent
High
Behavioral
component
Hom
e,school,
university-
basedcenter
Not
specified,
teacher/
educator,parent
Not
specified
Not
specified
130..0.43
0.75
NI
3
Kuoch,H
.,&
Mirenda,P.(2003).
Socialstoryinterventions
for
youngchildrenwith
autism
spectrum
disorders.Fo
cuson
Autism
andOther
Developmental
Disabilities,18
(4),219–227.
ccExcellent
High
Behavioral
component
Hom
e,school,
community
Paraprofessional,
parent
Masterslevel
professional
Not
specified
146..0.76
NI
NI
3
Lang,R.,O'Reilly,M
.,Sigafoos,J.,
Machalicek,W
.,Rispoli,
M.,
Lancioni,G.,Aguilar,J.,
Fragale,C.(2010).The
effects
ofan
abolishing
operation
interventioncomponent
onplay
ccFair
Fair
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
148..0.84
NI
1.66
4
Rev J Autism Dev Disord (2014) 1:276–326 307
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
skills,challengingbehavior,
andstereotypy.B
ehavior
Modification,34
(4),267–289.
Mancil,G.,Conroy,M.(2
009).
Effectsof
amodifiedmilieu
therapyinterventionon
thesocial
communicaitonbehaviorsof
young
childrenwith
autism
spectrum
disorders.Journalo
fAutism
and
DevelopmentalD
isorders,39,149–163.
ccExcellent
High
Other
Hom
e,school
Parent
Masterslevel
professional
Not
specified
149..0.95
10.2
3
Moes,D.R
.,&
Frea,W
.D.(2002).
Contextualized
behavioralsupport
inearlyinterventionforchildren
with
autism
andtheirfamilies.
Journalo
fAutism
andDevelopmental
Disorders,32(6),519–533.
ccExcellent
High
Behavioral
component
Hom
eParent
Not
specified
Doctorallevel
professional
139..0.43
NI
NI
3
Nuzzolo-G
omez,R
.,Leonard,M
.A.,
Ortiz,E
.,Rivera,C.M
.,&
Greer,
R.D
.(2002).Teaching
children
with
autism
toprefer
booksor
toys
over
stereotypy
orpassivity.
Journalo
fPositive
Behavior
Interventio
ns,4
(2),80–87.
ccFair
Fair
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
136..0.48
NI
NI
2
Parry–Cruwys,D
.E.,Neal,C.M
.,Ahearn,W.H
.,Wheeler,E
.E.,
Prem
chander,R.,Loeb,M.B
.,&
Dube,W.V
.(2011).Resistance
todisruptionin
aclassroom
setting.
Journalo
fAppliedBehavior
Analysis,44
(2),363–367.
ccMedium
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
648..0.156
NI
NI
6
Plavnick,J.B
.,&
Ferreri,S.
J.(2012).
Collateraleffectsof
mandtraining
forchildrenwith
autism.R
esearch
inAutism
Spectrum
Disorders,6
(4),
1366–1376.
3Excellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
153..0.60
0.4
1.875
2
Schindler,H.R
.,&
Horner,R.H
.(2005).
Generalized
reductionof
problem
behavior
ofyoungchildrenwith
autism:
Buildingtrans-situationalinterventions.
American
Journalo
fMentalR
etardatio
n:AJM
R,110
(1),36–47.
3Medium
Fair
Behavioral
component
Hom
e,school
Paraprofessional,
parent
Not
specified
Not
specified
148..0.60
10.86
3
Schreibm
an,L
.,Whalen,C.,&
Stahmer,
A.C
.(2000).The
useof
videoprim
ing
toreduce
disruptivetransition
behavior
inchildrenwith
autism.
Journalo
fPositive
Behavior
Interventio
ns,2
(1),3–11.
2Excellent
High
Other
Setting
inwhich
problem
behavior
occurred;differed
byparticipant
Experim
enter
Doctorallevel
professional
Doctorallevel
professional
139..0.41
10.5
2
Volkert,V
.,Lerman,D
.,Call,N.,
Trosclair-Lasserre,N.(2009).An
evaluationof
resurgence
during
treatm
entw
ithfunctio
nal
communicationtraining.Journalof
AppliedBehaviorAnalysis,
42(1),145–160.
ccMedium
Fair
Behavioral
component
School
Graduatestudent
Not
specified
Not
specified
160..0.108
NI
5..0.8
3
308 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Com
munication(36)
Bernstein,H
.,Brown,B.,Sturmey,
P.(2009).T
heeffectsof
fixed
ratio
values
onconcurrent
mandandplay
responses.
BehaviorModification,33
(2),
199–206.
ccVerypoor
Poor
Behavioral
component
Hom
eExperim
enter
Not
specified
Not
specified
136..0.36
NI
NI
3
Betz,A.M
.,Higbee,T.
S.,K
elley,
K.N
.,Sellers,T
.P.,&
Pollard,
J.S.
(2011).Increasingresponse
variability
ofmandfram
eswith
script
training
andextinction.
Journalo
fAppliedBehavior
Analysis,44
(2),357–362.
ccMedium
Fair
Behavioral
component
Hom
e,school
Experim
enter
Not
specified
Not
specified
136..0.48
NI
1.5
3
Carter,C.M
.(2001).Using
choice
with
gameplay
toincrease
language
skillsandinteractive
behaviorsin
childrenwith
autism.
Journalo
fPositive
Behavior
Interventio
ns,3
(3),131–151.
16Unacceptable
Unacceptable
Behavioral
component
Hom
e,university-
basedcenter
Student,
graduate
student
Not
specified
Not
specified
164..0.66
2.5
1.67
2
Charlop-Christy,M
.H.,Carpenter,
M.,Le,L.,LeB
lanc,L
.A.,
&Kellet,K.(2002).Using
thepictureexchange
communication
system
(PECS)
with
childrenwith
autism:A
ssessm
ento
fPE
CSacquisition,
speech,socialcom
municativebehavior,
andproblem
behavior.Journalof
AppliedBehaviorAnalysis,
35(3),213–231.
18Excellent
High
Other
Researchlab,
community,
hospital
Paraprofessional
Not
specified
Not
specified
144..0.144
4..0.6
13
Christensen-Sandfort,R.J.,&
Whinnery,
S.B.(2013).Im
pactof
milieu
teaching
oncommunicationskills
ofyoungchildrenwith
autism
spectrum
disorder.T
opicsin
Early
Childhood
SpecialEducation,
32(4),211–222.
ccFair
Medium
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
359..0.66
NI
0.34
3
Egan,C.,Barnes-Holmes,D
.(2009).
Emergenceof
tactsfollowingmand
training
inyoungchildrenwith
autism.
Journalo
fAppliedBehaviorAnalysis,
42(3),691–696.
ccVerypoor
Poor
Behavioral
component
Not
reported
Masterslevel
professional
Psychologist
Not
specified
167..0.91
NI
NI
4
Endicott,K.,&
Higbee,T.
S.(2007).
Contrivingmotivatingoperations
toevokemands
forinform
ationin
preschoolerswith
autism.R
esearchin
Autism
Spectrum
Disorders,1,210–217.
ccHigh
Medium
Behavioral
component
School
Student,
graduate
student
Not
specified
Not
specified
136..0.60
NI
NI
4
Finn,H
.E.,Miguel,C.F.,&
Ahearn,
W.H
.(2012).The
emergence
ofuntrainedmands
andtactsin
childrenwith
autism.Journalof
AppliedBehaviorAnalysis,
45(2),265–280.
11Excellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
146..0.66
2.15
1.3
3
Rev J Autism Dev Disord (2014) 1:276–326 309
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Fragale,C.L
.,O'Reilly,M
.F.,Aguilar,
J.,P
ierce,N.,Lang,R.,Sigafoos,
J.,&
Lancioni,G.(2012).
The
influenceof
motivating
operations
ongeneralizationprobes
ofspecificmands
bychildren
with
autism.Journalof
Applied
BehaviorAnalysis,45
(3),565–577.
ccExcellent
High
Behavioral
component
School
Graduate
student
Graduate
student
Not
specified
148..0.48
NI
NI
2
Ganz,J.B.,Parker,R
.,Benson,J.(2009).
Impactof
thepictureexchange
communicationsystem
:effects
oncommunicationandcollateral
effectson
madadaptivebehaviors.
Augmentativ
eandAlternative
Com
muncation,25
(4),250–261.
ccMedium
Fair
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
138..0.72
NI
NI
3
Gillett,J.N.,&
LeB
lanc,L
.A.(2007).
Parent-implem
entednatural
language
paradigm
toincrease
language
andplay
inchildren
with
autism.R
esearchin
Autism
Spectrum
Disorders,1,247–255.
ccHigh
Medium
Parent
training
Hom
e,university-
basedcenter
Parent
Not
specified
Not
specified
148..0.60
NI
13
Goldsmith,T
.R.,LeB
lanc,L
.A.,
&Sautter,R.A
.(2007).Teaching
intraverbalb
ehaviorto
child
ren
with
autism.R
esearchin
Autism
Spectrum
Disorders,1
(1),1–13.
ccFair
Fair
Behavioral
component
Researchlab,
school,hom
eExperim
enter
Not
specified
Not
specified
148..0.60
NI
1.5
2
Grindle,C
.F.,&
Rem
ington,B
.(2002).
Discrete-trialtrainingforautistic
childrenwhenrewardisdelayed:
Acomparisonof
conditioned
cue
valueandresponse
marking.Journal
ofAppliedBehaviorAnalysis,
35(2),187–190.
ccExcellent
High
Behavioral
component
School
Teacher/
educator
Not
specified
Not
specified
148..0.60
NI
2.5
2
Grindle,C
.F.,&
Rem
ington,B
.(2005).
Teaching
child
renwith
autism
whenrewardisdelayed:
The
effects
oftwokindsof
marking
stim
uli.
Journalo
fAutism
andDevelopmental
Disorders,35(6),839–850.
ccUnacceptable
Unacceptable
Behavioral
component
School
Teacher/
educator
Not
specified
Not
specified
163..0.63
NI
3.75
1
Grow,L
.L.,Carr,J.E.,Kodak,T
.M.,
Jostad,C
.M.,&
Kisam
ore,A.N
.(2011).A
comparisonof
methods
forteaching
receptivelabelin
gto
childrenwith
autism
spectrum
disorders.
Journalo
fAppliedBehaviorAnalysis,
44(3),475–498.
ccExcellent
High
Behavioral
component
Hom
e,outpatient
clinic
Experim
enter
Not
specified
Not
specified
148..0.48
NI
NI
2
Hancock,T
.B.,&
Kaiser,A.P.(2002).
The
effectsof
trainerim
plem
ented
enhanced
milieu
teaching
onthesocial
communicationof
child
renwith
autism.
Topics
inEarly
Childhood
Special
Education,22
(1),29–54.
6High
Medium
Other
University-
basedcenter
Masterslevel
professional,
paraprofessional
Not
specified
Not
specified
135..0.54
30.5
4
Ingersoll,B.,Lalonde,K
.(2010).The
impactof
objectandgestureim
itation
30Fair
Fair
Behavioral
component
Masterslevel
professional,
Masterslevel
professional
Not
specified
135..0.41
2.5
34
310 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
training
onlanguage
usein
children
with
autism
spectrum
disorder.Journal
ofSp
eech,L
anguage,andHearing
Research,53,1040–1051.
Smalltreatment
room
,location
notstated.
graduate
student
Ingersoll,B.,Lew
is,E
.,&
Kroman,E
.(2007).T
eachingtheim
itatio
nand
spontaneoususeof
descriptive
gestures
inyoungchildrenwith
autism
usinganaturalistic
behavioralintervention.Journalo
fAutism
andDevelopmental
Disabilities,37,1446–1456.
6Medium
Fair
Behavioral
component
University-
basedcenter
Experim
enter,
student
Doctorallevel
professional
Doctorallevel
134..0.49
0.75
25
Ingvarsson,E
.T.,&
Hollobaugh,T.
(2011).A
comparisonof
prom
pting
tacticsto
establishintraverbalsin
childrenwith
autism.Journalof
AppliedBehaviorAnalysis,
44(3),659–664.
ccExcellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
148..0.48
0.33
NI
3
Ingvarsson,E
.,Hollobaugh,T.(2010).
Acquisitionof
intraverbalb
ehavior:
Teaching
child
renwith
autism
tomandforansw
ersto
questions.
Journalo
fAppliedBehaviorAnalysis,
43(1),1–17.
ccFair
Fair
Behavioral
component
University-
basedcenter
Experim
enter
Not
specified
Not
specified
148..0.120
NI
NI
4
Jahr,E
.(2001).Teaching
child
ren
with
autism
toansw
ernovel
wh-questio
nsby
utilizing
amultipleexem
plar
strategy.
Researchin
Developmental
Disabilities,22
(5),407–423.
ccExcellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Not
specified
Not
specified
147..0.67
NI
3.75
3
Jones,C.D
.,&
Schw
artz,I.S
.(2004).S
iblings,peers,and
adults:
differentialeffectsof
models
forchildrenwith
autism.T
opics
inEarly
Childhood
Special
Education,24
(4),187–198.
1Excellent
Veryhigh
Behavioral
component
School
Teacher/educator,
paraprofessional
Not
specified
Not
specified
245..0.62
0.25
1.25
3
Kashinath,S
.,Woods,J.,&
Goldstein,
H.(2006).Enhancing
generalized
teaching
strategy
usein
daily
routines
bycaregiversof
child
renwith
autism.
Journalo
fSpeech,Language,and
Hearing
Research,49,466–485.
55Medium
Fair
Behavioral
component
Hom
eParent,S
LP
SLP
SLP
133..0.65
5.5
2.5
5
Keen,D.,Sigafoos,J.,&
Woodyatt,G.
(2001).R
eplacing
prelinguistic
behaviorswith
functional
communication.Journalo
fAutism
andDevelopmental
Disorders,31(4),385–398.
ccVerypoor
Poor
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
143..0.53
NI
NI
3
Lerman,D
.C.,Kelley,M.E
.,Vorndran,
C.M
.,Kuhn,S.
A.C
.,&
LaR
ue,Jr.,
R.H
.(2007).Reinforcement
magnitude
andresponding
during
treatm
entw
ithdifferentialreinforcement.
24Unacceptable
Unacceptable
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
148..0.48
32
1
Rev J Autism Dev Disord (2014) 1:276–326 311
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Journalo
fAppliedBehaviorAnalysis,
35(1),29–48.
Marion,C.,Martin,G
.L.,Yu,C.T
.,Buhler,
C.,Kerr,D.,&
Claeys,A.(2012).
Teaching
child
renwith
autism
spectrum
disorder
tomandforinform
ationusing
“which?”.Journalof
AppliedBehavior
Analysis,45
(4),865–870.
ccMedium
Fair
Behavioral
component
Hom
eExperim
enter
Not
specified
Not
specified
160..0.72
0.5
NI
3
Miguel,C.F.,Carr,J.E.,&
Michael,J.
(2002).T
heeffectsof
astim
ulus-
stim
ulus
pairingprocedureon
the
vocalb
ehaviorof
childrendiagnosed
with
autism.T
heAnalysisof
Verbal
Behavior,18,3–13.
24Medium
Fair
Behavioral
component
Hom
e,school
Experim
enter
Not
specified
Not
specified
136..0.60
23
3
Naoi,N.,Yokoyam
a,K.,&
Yam
amoto,
J.(2007).Interventionfortactas
reportingin
child
renwith
autism.
Researchin
Autism
Spectrum
Disorders,1,174–184.
ccExcellent
High
Behavioral
component
Researchlab
Experim
enter
Not
specified
Not
specified
151..0.51
NI
NI
1
Ostryn,C.,&
Wolfe,P.S
.(2011).
Teaching
preschoolchildrenwith
autism
spectrum
disordersto
expressively
discriminatebetween
“what’s
that?”
and“w
here
isit?”.
Focuson
Autism
andOther
DevelopmentalD
isabilities,
26(4),195–205.
ccExcellent
High
Behavioral
component
School
Experim
enter,
paraprofessional
Not
specified
Not
specified
141..0.59
NI
NI
3
Plavnick,J.B
.,&
Ferreri,S.
J.(2011).E
stablishing
verbal
repertoiresin
childrenwith
autism
usingfunction-based
videomodeling.Journalo
fAppliedBehaviorAnalysis,
44(4),747–766.
ccHigh
Medium
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
154..0.78
NI
NI
4
Ross,D.E
.,&
Greer,R
.D.(2003).
Generalized
imitationandthe
mand:
Inducing
firstinstances
ofspeech
inyoungchild
ren
with
autism.R
esearchin
DevelopmentalD
isabilities,
24(1),58–74.
1Excellent
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
165..0.65
0.14
2.5
1
Sherer,M
.,Pierce,K
.L.,Paredes,
S.,K
isacky,K
.L.,Ingersoll,B.,
&Schreibman,L
.(2001).
Enhancing
conversationskills
inchild
renwith
autism
viavideo
technology.W
hich
isbetter,
“self”or
“other”as
amodel?
BehaviorModification,25
(1),
140–158.
ccFair
Fair
Behavioral
component
Hom
e,research
lab
Paraprofessional
Not
specified
Not
specified
147..0.70
NI
NI
2
Sigafoos,J.,Didden,R.,&
O’Reilly,
M.(2003).Effectsof
speech
output
onmaintenance
ofrequestingandfrequencyof
1Fair
Fair
Behavioral
component
Hom
e,school,
outpatient
clinic
Not
specified
Not
specified
Not
specified
136..0.48
0.40
0.84
2
312 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
vocalizations
inthreechildren
with
developm
entald
isabilities.
AAC:A
ugmentativeand
AlternativeCom
munication,
19(1),37–47.
Wert,B.Y
.,&
Neisw
orth,J.T
.(2003).E
ffectsof
videoselfmodeling
onspontaneousrequestingin
children
with
autism.Journalof
Positive
BehaviorInterventions,
5(1),30–34.
ccExcellent
High
Behavioral
component
Hom
e,school
Paraprofessional
Not
specified
Not
specified
136..0.72
0.5
0.4
4
Williams,G.,Perez-Gonzalez,
L.A
.,&
Vogt,K.(2003).
The
roleof
specificconsequences
inthemaintenance
ofthree
typesof
questions.Journal
ofAppliedBehaviorAnalysis,
36(3),285–296.
ccExcellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
133..0.53
NI
2.5
2
Yokoyam
a,K.,Naoi,N.,&
Yam
amoto,J.(2006).T
eaching
verbalbehavior
usingthepicture
exchange
communicationsystem
(PECS)with
childrenwith
autistic
spectrum
disorders.
Japanese
Journalo
fSpecial
Education,43
(6),485–503.
28Veryhigh
Medium
Behavioral
component
Hom
e,research
lab
Not
specified
Not
specified
Not
specified
160..0.95
71
3
Com
prehensive
(2)
Smith,T
.,Buch,G.A
.,&
Gam
by,
T.E.(2000).Parentdirected,
intensiveearlyintervention
forchildrenwith
pervasive
developm
entald
isorder.
Researchin
Developmental
Disabilities,21
(4),297–309.
3772
Verypoor
Poor
Lovaas
Hom
eStudent,parent
Graduatestudent
Not
specified
135..0.45
3626.2
6
Welterlin,A
.,Turner-Brown,
L.M
.,Harris,S.,M
esibov,
G.,&
Delmolino,L.(2012).
The
homeTEACCHingprogram
fortoddlerswith
autism.Journalof
Autism
andDevelopmentalD
isorders,
42(9),1827–1835.
18Unacceptable
Verypoor
TEACCH
Hom
eParent
Not
specified
Not
specified
124..0.39
31.5
6
Daily
Living(4)
Ivey,M
.L.,Heflin,L
.,&
Alberto,
P.(2004).T
heuseof
social
storiesto
prom
oteindependent
behaviorsin
noveleventsfor
childrenwith
PDD-N
OS.
Focuson
Autism
andOther
DevelopmentalD
isabilities,
19(3),164–176.
ccMedium
Fair
Behavioral
component
Hospital
SLP,parent
SLP
Not
specified
161..0.89
3NI
3
Reeve,S
.A.,Reeve,K
.F.,
Townsend,D.B
.,&
Poulson,
C.L
.(2007).Establishing
ccExcellent
High
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
160..0.72
NI
NI
4
Rev J Autism Dev Disord (2014) 1:276–326 313
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
ageneralized
repertoire
ofhelpingbehavior
inchildren
with
autism.Journalof
Applied
BehaviorAnalysis,40
(1),
123–136.
Shipley-Benam
ou,R
.,Lutzker,
J.R.,&
Taubman,M
.(2002).
Teaching
daily
livingskills
tochild
renwith
autism
throughinstructionalv
ideo
modeling.Journalo
fPo
sitive
BehaviorInterventions,
4(3),165–175.
2Excellent
High
Behavioral
component
Hom
e,research
lab
Experim
enter
Not
specified
Not
specified
161..0.65
0.5
13
West,E.A
.,&
Billingsley,F.
(2005).Improvingthesystem
ofleastp
rompts:Acomparison
ofproceduralvariations.E
ducation
andTrainingin
Developmental
Disabilities,40
(2),131–144.
10Fair
Fair
Behavioral
component
School
Not
specified
Not
specified
Not
specified
170..0.74
1.5
1.7
4
Feeding(3)
Gale,C.M
.,Eikeseth,S.,&
Rudrud,
E.(2011).Fu
nctionalassessm
ent
andbehaviouralintervention
foreatingdifficultiesin
children
with
autism:A
studyconducted
inthenaturalenvironmentu
sing
parentsandABAtutorsas
therapists.Journalof
Autism
andDevelopmentalD
isorders,
41(10),1383–1396.
ccMedium
Fair
Behavioral
component
Hom
eParent
Not
specified
Not
specified
130..0.52
NI
1.67
3
Levin,L
.,&
Carr,E.G
.(2001).
Food
selectivity
andproblem
behavior
inchildrenwith
developm
entald
isabilities.
Analysisandintervention.
BehaviorModification,25
(3),443–470.
ccMedium
Fair
Behavioral
component
School
Student
Not
specified
Not
specified
160..0.60
NI
NI
1
Seiverling,L.,Williams,K.,
Sturmey,P.,&
Hart,S.
(2012).E
ffectsof
behavioral
skillstraining
onparental
treatm
ento
fchild
ren'sfood
selectivity.Journalof
Applied
BehaviorAnalysis,45
(1),
197–203.
ccExcellent
High
Behavioral
component
Hom
eParent,
experimenter
Not
specified
Not
specified
136..0.96
1.5
NI
3
Play
(4)
Jahr,E
.,Eldevik,S
.,&
Eikeseth,
S.(2000).T
eachingchildren
with
autism
toinitiateandsustain
cooperativeplay.R
esearchin
DevelopmentalD
isabilities,
21(2),151–169.
ccExcellent
High
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
148..0.60
NI
52
ccMedium
Fair
Hom
eNot
specified
Not
specified
158..0.62
NI
0.67
2
314 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Lifter,K.,Ellis,J.,C
annon,B.,
&Anderson,S.
R.(2005).
Developmentalspecificity
intargetingandteaching
play
activities
tochildrenwith
pervasivedevelopm
ental
disorders.Journalo
fEarly
Interventio
n,27
(4),247–267.
Behavioral
component
Teacher/educator,
paraprofessional
Morrison,R.S
.,Sainato,D.M
.,Benchaaban,D.,&
Endo,S.
(2002).Increasingplay
skills
ofchildrenwith
autism
using
activity
schedulesand
correspondence
training.
Journalo
fEarly
Intervention,
25(1),58–72.
ccHigh
Medium
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
142..0.70
NI
NI
4
Reinhartsen,D
.B.,Garfinkle,A
.N.,
&Wolery,M.(2002).
Engagem
entw
ithtoys
intwo-year-old
child
renwith
autism:
Teacherselectionversus
child
choice.R
esearchandPractice
forPersonswith
Severe
Disabilities,27
(3),175–187.
1Medium
Fair
Behavioral
component
University-
basedcenter
Paraprofessional
Teacher/educator
Not
specified
127..0.33
0.5
0.83
3
Sleep(2)
Durand,V.M
.(2002).Treating
sleepterrorsin
childrenwith
autism.Journalof
Positive
BehaviorInterventions,
4(2),66–72.
ccExcellent
High
Behavioral
component
Hom
eParent
Doctorallevel
professional
Doctorallevel
professional
136..0.60
1.5
NI
2
Weiskop,S
.,Richdale,A.,&
Matthew
s,J.(2005).
Behaviouraltreatm
entto
reduce
sleepproblemsin
childrenwith
autism
orfragile
Xsyndrome.
DevelopmentalM
edicine
&Child
Neurology,
47,94–104.
ccMedium
Fair
Behavioral
component
Hom
eParent
Not
specified
Not
specified
141..0.77
1.75
NI
5
Social(32)
Baker,M
.J.(2000).Incorporating
thethem
aticritualistic
behaviorsof
childrenwith
autism
into
games:
Increasing
socialplay
interactions
with
siblings.
Journalo
fPositive
Behavior
Interventio
ns,2
(2),66–84.
8Fair
Fair
Behavioral
component
Hom
e,school,
university-
basedcenter
Student,
graduatestudent
Not
specified
Not
specified
165..0.68
1.625
1.33
2
Betz,A.,Higbee,T.S.,R
eagon,
K.A.(2008).Using
joint
activity
schedulesto
prom
ote
peer
engagementin
preschoolerswith
autism.
ccVeryhigh
High
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
248..0.60
NI
NI
6
Rev J Autism Dev Disord (2014) 1:276–326 315
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Journalo
fAppliedBehavior
Analysis,41
(2),237–241.
Ganz,J.B.F
lores,M.M
.(2008).
Effectsof
theuseof
visual
strategies
inplay
groups
for
childrenwith
autism
spectrum
disordersandtheirpeers.
Journalo
fAutism
and
DevelopmentalD
isorders,
38,926–940.
9Veryhigh
Medium
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
153..0.55
12..0.2.5
3
Gena,A.(2006).The
effectsof
prom
ptingand
socialreinforcem
ento
nestablishing
socialinteractions
with
peersduring
the
inclusionof
four
childrenwith
autism
inpreschool.
InternationalJournalof
Psychology,41(6),541–554.
1000
Excellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Not
specified
Not
specified
148..0.53
12.5
204
Gena,A.,Couloura,S.,
&Kym
issis,E.(2005).
Modifying
theaffective
behavior
ofpreschoolers
with
autism
usingin-vivo
orvideomodelingand
reinforcem
entcontingencies.
Journalo
fAutism
and
DevelopmentalD
isorders,
35(5),545–556.
ccExcellent
High
Behavioral
component
Hom
eDoctorallevel
professional,
graduatestudent
Not
specified
Not
specified
147..0.67
1.94
0.09
3
Hwang,B.,&
Hughes,C.
(2000).Increasingearly
socialcommunicativeskills
ofpreverbalp
reschool
children
with
autism
throughsocial
interactivetraining.Journal
oftheAssociationforPersons
with
Severe
Handicaps,
25,18–28.
8Excellent
High
Behavioral
component
University-
basedcenter
Graduatestudent,
teacher/educator
Not
specified
Not
specified
132..0.43
4.3
0.5
3
Ingersoll,B.,&
Gergans,S
.(2007).T
heeffectof
aparent
implem
entedim
itatio
ninterventionon
spontaneous
imitationskillsin
young
childrenwith
autism.R
esearch
inDevelopmentalD
isabilities,
28(2),163–175.
12Verypoor
Poor
Other
Researchlab,private
intervention
agency
Parent
Doctorallevel
professional
Doctorallevel
professional
131..0.42
2.5
1.2
3
Ingersoll,B.,&
Schreibm
an,L
.(2006).T
eachingreciprocal
imitationskillsto
young
childrenwith
autism
usinga
naturalistic
behavioralapproach:
Effectson
language,pretend
play,and
jointattention.Journal
8Po
orPo
orBehavioral
component
School
Student
Teacher/educator
Doctorallevel
professional
129..0.45
0.75
2.67
5
316 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
ofAutism
andDevelopmental
Disorders,36(4),487–505.
Ingersoll,B.,Meyer,K
.,Bonter,N.,
&Jelinek,S
.(2012).A
comparisonof
developm
ental
social-pragm
aticandnaturalistic
behavioralinterventions
onlanguage
useandsocial
engagementinchildrenwith
autism.Journalof
Speech,
LanguageandHearing
Research,
55(5),1301–1313.
6Medium
Fair
Behavioral
component
Researchlab
Graduatestudent,
student
Masterslevel
professional
Masterslevel
professional
136..0.66
0.75
25
Johnston,S
.,Nelson,C.,Evans,J.,
&Palazolo,K.(2003).The
useof
visualsupportsin
teaching
youngchildrenwith
autism
spectrum
disorder
toinitiate
interactions.A
AC:A
ugmentativ
eandAlternativeCom
munication,
19(2),86–103.
ccExcellent
High
Behavioral
component
School
Teacher/educator
Teacher/educator
Not
specified
151..0.63
NI
NI
3
Jones,E.A
.,Carr,E.G
.,&
Feeley,
K.M
.(2006).Multipleeffects
ofjointattentionintervention
forchildrenwith
autism.
BehaviorModification,
30(6),782–834.
ccVeryhigh
Medium
Behavioral
component
School
Teacher/educator,
paraprofessional,
parent
Not
specified
Not
specified
125..0.36
NI
NI
5
Jung,S
.,Sainato,D.,Davis,
C.(2008).Using
high-
probability
request
sequencesto
increase
socialinteractions
inyoungchildrenwith
autism.Journalof
Early
Interventio
n,30
(3),163–187.
ccExcellent
Excellent
Behavioral
component
School
Experim
enter
Not
specified
Not
specified
463..0.77
NI
2.5
3
Koegel,R.L.,Vernon,T.W.,Koegel,
L.K.(2009).Im
provingsocial
initiations
inyoungchildren
with
autism
usingreinforcers
with
embedded
social
interactions.Journalof
Autism
andDevelopmental
Disorders,39,1240–1251.
ccExcellent
High
Behavioral
component
Hom
eStudent,parent
Graduate
student
Not
specified
138..0.41
NI
23
Kohler,F.W.,Anthony,L
.J.,
Steighner,S.
A.,&
Hoyson,
M.(2001).Teaching
social
interactionskillsin
the
integrated
preschool:An
exam
inationof
naturalistic
tactics.To
pics
inEarly
Childhood
Special
Education,21,93–103.
5Excellent
High
Behavioral
component
School
Teacher/educator,
paraprofessional
Teacher/
educator
Teacher/educator
149..0.55
2.5
0.5
4
Leaf,J.B.,Oppenheim
–Leaf,
M.L
.,Call,N.A
.,Sh
eldon,
J.B.,Sh
erman,J.A
.,Taubman,
13Medium
Fair
Behavioral
component
Research
lab,home
Experim
enter,
notspecified,
peer
Not
specified
Not
specified
160..0.60
13.25
3
Rev J Autism Dev Disord (2014) 1:276–326 317
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
M.,…
&Leaf,R.(2012).
Com
paring
theteaching
interactionprocedureto
social
storiesforpeoplewith
Autism.
Journalo
fAppliedBehavior
Analysis,45
(2),281–298.
Martins,M.P.,&
Harris,S.
L.(2006).
Teaching
child
renwith
autism
torespondto
jointattention
initiations.C
hild
&Fam
ilyBehaviorTherapy,28(1),51–68.
7Excellent
High
Behavioral
component
University-
basedcenter
Paraprofessional,
experimenter
Teacher/educator,
notspecified
Teacher/
educator,not
specified
144..0.58
2.61
0.75
3
McG
ee,G
.G.,&
Daly,T.
(2007).
Incidentalteaching
ofage
appropriatesocialphrasesto
childrenwith
autism.R
esearch
&PracticeforPersonswith
Severe
Disabilities,32
(2),
112–123.
3Excellent
Veryhigh
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
357..0.62
20.4
3
Nelson,C.,McD
onnell,
A.P.,
Johnston,S
.S.,Crompton,
A.,&
Nelson,A.R
.(2007).
Keysto
play:A
strategy
toincrease
thesocialinteractions
ofyoungchildrenwith
autism
andtheirtypically
developing
peers.Educatio
nandTraining
inDevelopmentalD
isabilities,
42(2),165–181.
ccFair
Fair
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
145..0.53
NI
NI
4
New
man,B
.,Reinecke,D.R
.,&
Meinberg,D.L
.(2000).Self
managem
ento
fvaried
responding
inthreestudentswith
autism.
BehavioralInterventions,
15(2),145–151.
ccHigh
Fair
Behavioral
component
School,H
ome
Experim
enter
Not
specified
Not
specified
148..0.72
NI
NI
3
Ozdem
ir,S.(2
008).U
sing
multim
edia
socialstoriesto
increase
appropriatesocialengagement
inyoungchildrenwith
autism.
Turkish
OnlineJournalo
fEducationalT
echnology,
7(3),80–88.
ccMedium
Fair
Behavioral
component
School
Paraprofessional
Not
specified
Not
specified
166..0.76
NI
0.5
3
Pollard,J.S
.,Betz,A.M
.,&
Higbee,
T.S.
(2012).S
criptfading
toprom
oteunscripted
bids
for
jointattentionin
child
renwith
autism.Journalof
Applied
BehaviorAnalysis,45
(2),
387–393.
ccExcellent
High
Behavioral
component
School
Not
specified
Not
specified
Not
specified
148..0.84
NI
NI
3
Reagon,K.,Higbee,T.(2009).
Parent-implem
ented
script
fading
toprom
ote
play-based
verbalinitiations
inchild
renwith
autism.
ccExcellent
High
Behavioral
component
Hom
eParent
Graduate
student
Not
specified
135..0.72
NI
1.75
3
318 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Journalo
fAppliedBehavior
Analysis,42
(3),659–664.
Rocha,M
.L.,Schreibman,L
.,&
Stahm
er,A
.C.(2007).
Effectivenessof
training
parentsto
teachjointattention
inchild
renwith
autism.
Journalo
fEarly
Intervention,
29(2),154–172.
16Medium
Fair
Behavioral
component
University-
basedcenter
Parent
BCBA
Not
specified
126..0.43
1.5
2.8
3
Schrandt,J.,To
wnsend,D.,Poulson,
C.(2009).Teaching
empathy
skillsto
childrenwith
autism.
Journalo
fAppliedBehavior
Analysis,42
(1),17–32.
ccExcellent
High
Behavioral
component
School
Not
specified
Not
specified
Not
specified
153..0.105
NI
2.25
4
Simpson,A
.,Langone,J.,&
Ayres,
K.M
.(2004).Embedded
videoandcomputerbased
instructionto
improve
socialskillsforstudents
with
autism.E
ducatio
nandTrainingin
Developmental
Disabilities,39,240–252.
ccHigh
Veryhigh
Behavioral
component
School
Not
specified
Not
specified
Not
specified
460..0.72
NI
NI
4
Taylor,B
.A.,DeQ
uinzio,J.
A.,&
Stine,J.(2012).
Increasing
observational
learning
ofchildrenwith
autism:A
prelim
inary
analysis.Journalof
Applied
BehaviorAnalysis,45
(4),
815–820.
ccExcellent
Veryhigh
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
244..0.56
NI
NI
3
Taylor,B
.A.,Hoch,H.,Po
tter,B.,
Rodriguez,A
.,Sp
innato,D
.,&
Kalaigian,M
.(2005).
Manipulatingestablishing
operations
toprom
ote
initiations
towardpeersin
childrenwith
autism.R
esearch
inDevelopmentalD
isabilities,
26,385–392.
ccExcellent
Veryhigh
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
248..0.48
NI
NI
1
Tsao,L
.,&
Odom,S
.L.(2006).
Sibling-mediatedsocial
interactioninterventionfor
youngchildrenwith
autism.
Topics
inEarly
Childhood
SpecialE
ducation,26
(2),
106–123.
ccHigh
Medium
Peertraining
Hom
eGraduatestudent
Graduate
student
Not
specified
141..0.90
NI
0.33
4
Vernon,T.
W.,Koegel,R.L
.,Dauterm
an,H
.,&
Stolen,K
.(2012).A
nearlysocial
engagementintervention
foryoungchildrenwith
autism
andtheirparents.
Journalo
fAutism
and
20Medium
Fair
Behavioral
component
Hom
e,Com
munity
Parent
Not
specified
Not
specified
128..0.51
1.25
43
Rev J Autism Dev Disord (2014) 1:276–326 319
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
DevelopmentalD
isorders,
42(12),2702–2717.
Vismara,L.A
.,&
Lyons,G.L
.(2007).U
sing
perseverative
intereststo
elicitjointattention
behaviorsin
youngchildren
with
autism:T
heoreticaland
clinicalim
plications
for
understandingmotivation.Journal
ofPo
sitiveBehaviorInterventions,
9(4),214–228.
60Medium
Fair
Other
Hom
e,university-
basedcenter
Doctorallevel
professional,
Parent
Psychologist
Not
specified
126..0.38
35
3
Vismara,L.,Colom
bi,C
.,Rogers,S.(2009).
Can
onehour
perweekof
therapy
lead
tolastingchangesin
young
childrenwith
autism?Autism,
13(1),93–115.
12Excellent
High
Early
Start
DenverModel
(ESD
M)
University-
basedcenter
Parent
BCBA-D
,graduatestudent,
psychologist
Not
specified
110..0.36
31
8
Whalen,C.,&
Schreibm
an,L
.(2003).
Jointattentiontraining
forchildren
with
autism
usingbehavior
modificationprocedures.Journal
ofChild
Psychology
andPsychiatry,
andAllied
Disciplines,44(3),
456–468.
45Veryhigh
Medium
Other
Researchlab
Experim
enter
Not
specified
Doctorallevel
professional
148..0.52
2.5
4.5
5
Toileting(3)
Cicero,F.R.,&
Pfadt,A.(2002).
Investigationof
areinforcem
ent-
basedtoilettrainingprocedure
forchildrenwith
autism.R
esearch
inDevelopmentalD
isabilities,
23(5),319–331.
110
Medium
Fair
Behavioral
component
School
Teacher/educator
Not
specified
Not
specified
148..0.72
127.5
3
Keen,D.,Brannigan,K
.L.,&
Cuskelly,
M.(2007).To
ilettrainingfor
child
renwith
autism:T
heeffects
ofvideomodeling.Journalo
fDevelopmentaland
Physical
Disabilities,19,291–303.
50Unacceptable
Unacceptable
Behavioral
component
Hom
e,school
Teacher/
educator,parent
Not
specified
Not
specified
153..0.57
34.2
4
LeB
lanc,L
.A.,Carr,J.E.,Crossett,S.
E.,
Bennett,
C.M
.,&
Detweiler,D.D
.(2005).Intensive
outpatient
behavioral
treatm
ento
fprim
aryurinary
incontinence
ofchildrenwith
autism.
Focuson
Autism
andOther
DevelopmentalD
isabilities,20
(2),98–105.
ccMedium
Fair
Behavioral
component
Hom
e,school,
outpatient
clinic
Parent,parent,
notspecified
Not
specified
Not
specified
149..0.59
0.67
NI
3
Group
design
methodology
Com
munication(8)
Carr,D.,&
Felce,J.(2007).T
heeffects
ofPE
CSteaching
tophaseIIIon
thecommunicativeinteractions
betweenchildrenwith
autism
andtheirteachers.Journalof
Autism
andDevelopmental
Disorders,37(4),724–737.
17Medium
Fair
Other
School
Paraprofessional
Not
specified
Not
specified
136..0.84
1.25
3..0.4
24
320 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Heimann,M.,Laberg,K.E
.,&
Nordoen,B
.(2006).Im
itative
interactionincreasessocialinterest
andelicitedim
itationin
non-verbal
childrenwith
autism.Infantand
Child
Development,15
(3),
297–309.
1Fair
Fair
Behavioral
component
Researchlab
Experim
enter
Not
specified
Not
specified
155..0.120
10.4
10
How
lin,P.,Gordon,R.K
.,Pasco,G.,
Wade,A.,&
Charm
an,T
.(2007).
The
effectivenessof
picture
exchange
communicationsystem
(PECS)training
forteachersof
childrenwith
autism:A
pragmatic,
grouprandom
ized
controlledtrial.
Journalo
fChild
Psychology
and
Psychiatry,48(5),473–481.
ccUnacceptable
Poor
Other
School
Teacher/educator
Teacher/educator
Not
specified
247..0.106
5NI
28
Rogers,S.J.,Hayden,D.,Hepburn,S
.,Charlifue-Smith,R
.,Hall,T.,&
Hayes,A
.(2006).Teaching
young
nonverbalchildrenwith
autism
useful
speech:A
pilotstudy
ofthe
DenvermodelandPR
OMPT
interventions.Journalof
Autism
andDevelopmentalD
isorders,
36,1007–1024.
19High
Fair
Early
Start
DenverModel
(ESD
M)
Researchlab
SLP,Parent
Doctorallevel
professional
Doctorallevel
professional
120..0.65
31.62
10
Wetherby,A.M
.,&
Woods,J.J.(2006).
Early
socialinteractionprojectfor
childrenwith
autism
spectrum
disordersbeginningin
the
second
year
oflife:Aprelim
inary
study.To
pics
inEarly
Childhood
SpecialE
ducation,26
(2),67–82.
ccHigh
Fair
Other
Hom
e,Com
munity
Parent,S
LP,
paraprofessional
Not
specified
Not
specified
112..0.24
12NI
17
Yoder,P.,&
Stone,W.L
.(2006).
Arandom
ized
comparisonof
the
effectof
twoprelinguistic
communicationinterventions
ontheacquisition
ofspoken
communicationin
preschoolers
with
ASD
.Journalof
Speech
&Hearing
Research,49
(4),698–711.
24High
Medium
Other
University-
basedcenter
Paraprofessional
Masterslevel
professional
Not
specified
121..0.54
61
19
Yoder,P.,&
Stone,W.L
.(2006).
Randomized
comparisonof
two
communicationinterventions
for
preschoolerswith
autism
spectrum
disorders.Journalo
fConsulting
andClinicalPsychology,74(3),
426–435.
24Excellent
High
Other
Researchlab
Masterslevel
professional,
paraprofessional,
parent
Masterslevel
professional
Masterslevel
professional
128..0.46
61
19
Yoder,P.J.,Lieberm
an,R
.G.(2010).
Brief
Report:Randonm
ized
test
oftheeficacyof
pictureexchange
communicationsystem
onhighly
generalized
pictureexchangesin
childrenwith
ASD
.Journalof
24Excellent
High
Other
University
-basedcenter
Not
specified
Not
specified
Not
specified
128..0.47
61
19
Rev J Autism Dev Disord (2014) 1:276–326 321
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Autism
andDevelopmental
Disorders,40,629–632.
Com
prehensive
(17)
Cohen,H
.,Amerine-Dickens,M
.,&
Smith,T
.(2006).Early
intensive
behavioraltreatm
ent:Replication
oftheUCLAmodelin
acommunity
setting.Journalof
Developmentaland
Behavioral
Pediatrics,27(2),145–155.
5400
Veryhigh
Medium
Lovaas
Hom
e,school
Paraprofessional,
parent
Masterslevel
professional,
graduatestudent
BCBA,
masterslevel
professional
118..0.42
3637.5
21
Daw
son,G.,Rogers,S.,M
unson,
J.,S
mith,M
.,Winter,J.,G
reenson,
J.,…
&Varley,J.(2010).
Randomized,controlledtrialo
fan
interventionfortoddlerswith
autism:T
heEarly
StartDenver
Model.P
ediatrics,125,17–23.
1459
Verypoor
Poor
Early
Start
Denver
Model
(ESD
M)
Hom
eParaprofessional,
parent
Graduatestudent
Psychologist,
SLP,Ph
ysician
119..0.28
2415.2
24
Eikeseth,S.,K
lintwall,L.,Jahr,E
.,&
Karlsson,P.(2012).O
utcomefor
childrenwith
autism
receiving
earlyandintensivebehavioral
interventionin
mainstream
preschooland
kindergarten
settings.Researchin
Autism
Spectrum
Disorders,6,829–835.
4784
Unacceptable
Unacceptable
Lovaas
Hom
e,school
Paraprofessional,
parent
BCBA,
masterslevel
professional
Psychologist
125..0.76
5223
35
Eikeseth,S.,S
mith,T
.,Jahr,E
.,&
Eldevik,S
.(2002).Intensive
behavioraltreatm
entatschool
for4-
to7-year-old
child
ren
with
autism:A
1-year
comparison
controlledstudy.Behavior
Modification,26
(1),49–68.
1368
Fair
Fair
Lovaas
School
Paraprofessional,
teacher/educator,
parent
Student
Psychologist
155..0.77
1228.52
13
Eldevik,S
.,Eikeseth,S.,Jahr,E
.,&
Smith,T
.(2006).Effectsof
low-intensity
behavioraltreatm
ent
forchildrenwith
autism
and
mentalretardation.Journalo
fAutism
andDevelopmental
Disorders,36(2),211–224.
812
Unacceptable
Verypoor
Lovaas
School
Paraprofessional,
parent
Teacher/educator
Psychologist
136..0.68
2010.0.15
13
Eldevik,S
.,Hastings,R
.,Jahr,E
.,&
Hughes,J.C.(2012).Outcomes
ofbehavioralinterventio
nfor
childrenwith
autism
inmainstream
pre-school
settings.Journal
ofAutism
andDevelopmental
Disabilities,42,210–220.
1365
Unacceptable
Verypoor
Lovaas
School
Paraprofessional
Bachelorlevel
BCBA-D
126..0.70
25.1
13.6
31
Fava,L
.,Strauss,K.,ValeriG
.,D’Elia,
L.,Arima,S.,&
Vicari,S.
(2011).
The
effectivenessof
across-setting
complem
entary
staff-and
parent-m
ediatedearlyintensive
behavioralinterventionforyoung
child
renwith
ASD
.Researchin
624
High
Veryhigh
Com
prehensive
Hom
e,university-
basedcenter
Paraprofessional,
parent
Not
specified
Not
specified
1,4
26..0.81
626
12
322 Rev J Autism Dev Disord (2014) 1:276–326
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Autism
Spectrum
Disorders,
5,1479–1492
Hayward,D.,Eikeseth,S.,G
ale,C.,&
Morgan,S.(2009).A
ssessing
progress
during
treatm
entfor
youngchildrenwith
autism
receivingintensivebehavioural
interventions.A
utism,13(6),
613–633.
1651
Fair
Fair
Lovaas
Hom
eParaprofessional
Teacher/educator
Not
specified
130..0.42
1234..0.41
23
How
ard,J.S.,S
parkman,C
.R.,Cohen,
H.G
.,Green,G
.,&
Stanislaw,H
.(2005).A
comparisonof
intensive
behavior
analyticandeclectic
treatm
entsforyoungchildren
with
autism.R
esearchin
DevelopmentalD
isabilities,
26(4),359–383.
1422
Medium
Fair
Com
prehensive
Hom
e,school,
Student,parent
Masterslevel
professional
Psychologist/
BCBA-D
,SL
P
130..0.45
1425.0.40
29
Magiati,
I.,C
harm
an,T
.,&
How
lin,
P.(2007).A
two-year
prospective
followup
studyof
community-
basedearlyintensivebehavioural
interventio
nandspecialistn
ursery
provisionforchildrenwith
autism
spectrum
disorders.Journalo
fChild
Psychology
andPsychiatry,
48(8),803–812.
3110
Unaccep
Very
Lovaas
Hom
e,school
Not
specified,
parent
Not
specified
None
123..0.54
2432.4
28
Peters-Scheffer,N.,Didden,R.,Mulders,
M.,&
Korzilius,H.(2010).Low
intensity
behavioraltreatm
ent
supplementingpreschoolservices
foryoungchildrenwith
autism
spectrum
disordersandsevere
tomild
intellectuald
isability.
Researchin
Developmental
Disabilities,31,1678–1684.
163
Fair
Fair
Lovaas
School
Teacher/educator,
paraprofessional,
parent
Teacher/educator,
psychologist
Teacher/educator,
psychologist
142..0.62
85..0.10
12
Reed,P.,O
sbourne,L.A
.,&
Corness,
M.(2007).The
realworld
effectivenessof
earlyteaching
interventions
forchildrenwith
autism
spectrum
disorder.
ExceptionalC
hildren,73
(4),
417–433.
1216
Fair
Fair
Lovaas
Hom
e,school
Paraprofessional
BCBA,m
asters
levelprofessional
BCBA,
masterslevel
professional
132..0.47
1030.4
12
Sallo
ws,G.O
.,&
Graupner,T.
D.
(2005).Intensive
behavioral
treatm
entfor
childrenwith
autism:
Four-yearoutcom
eandpredictors.
American
Journalo
fMental
Retardation,110(6),417–438.
7488
Poor
Poor
Lovaas
Hom
e,school
Paraprofessional
Teacher/educator
BCBA-D
129..0.37
4839
13
Smith,T
.,Groen,A
.D.,&
Wynn,
J.W.(2000).Randomized
trial
ofintensiveearlyinterventio
nfor
child
renwith
pervasive
developm
entald
isorder.American
2416
Poor
Poor
Lovaas
Hom
e,school
Student,parent
Not
specified
Doctorallevel
professional
130..0.42
3318..0.31
15
Rev J Autism Dev Disord (2014) 1:276–326 323
Tab
le7
(contin
ued)
Hrs
Impact
Efficiency
Type
Setting
Direct
Super
Lead
Group
size
Age
range
Dur
Inten
#P
Journalo
fMentalR
etardation,
105(4),269–285.
Tsang,S.
K.,Shek,D.T
.,Lam
,L.L
.,Tang,F.L
.,&
Cheung,P.M.
(2006).B
rief
report:A
pplication
oftheTEACCHprogram
onChinese
preschoolchildren
with
autism—does
culture
make
adifference?Journalo
fAutism
andDevelopmentalD
isorders,
37(2),390–396.
1680
Fair
High
TEACCH
Private
intervention
agency
Not
specified
Not
specified
Not
specified
736..0.60
1235
18
Zachor,D.A
.,Ben-Itzchak,E
.,Rabinovich,A.L
.,&
Lahat,E
.(2007).C
hangein
autism
core
symptom
swith
intervention.
Researchin
Autism
Spectrum
Disorders,I,304–317.
1680
Poor
Poor
Com
prehensive
Private
interventio
nagency
Paraprofessional
BCBA
Teacher/educator,
BCBA
122..0.34
1235
20
Zachor,D.,&
Izchak,E
.(2010).
Treatmentapproach,autism
severity
andinterventionoutcom
esin
youngchild
ren.Researchin
Autism
Spectrum
Disorders,4,
425–432.
960
Unacceptable
Unacceptable
Com
prehensive
Com
munity-
basedpreschool
programsfor
child
renwith
autism.
Paraprofessional,
parent
BCBA
BCBA
117..0.35
1220
45
Social(3)
Kasari,C.,Freem
an,S
.,&
Paparella,T
.(2006).Joint
attentionandsymbolic
play
inyoungchildrenwith
autism:
Arandom
ized
controlled
interventionstudy.Journalo
fChild
Psychology
andPsychiatry,and
Allied
Disciplines,47(6),
611–620.
13Excellent
High
Behavioral
component
School
Graduate
student
Teacher/educator
Doctorallevel
professional
136..0.50
1.375
2.5
58
Kroeger,K
.A.,Schultz,J.R
.,&
New
som,
C.(2007).Acomparisonof
twogroupdelivered
socialskills
programsforyoungchildren
with
autism.Journalof
Autism
andDevelopmentalD
isorders,
37,808–817.
15Medium
High
Behavioral
component
Outpatient
clinic
Student,graduate
student
Not
specified
Not
specified
452..0.77
1.25
313
Wong,C.S
.,Kasari,C.,Freeman,S
.,&
Paparella,T
.(2007).The
acquisition
andgeneralization
ofjointattentionandsymbolic
play
skillsin
youngchildren
with
autism.R
esearch&
PracticeforPersons
with
Severe
Disabilities,
32(2),101–109.
2Fair
Fair
Behavioral
component
School
Not
specified
Not
specified
Not
specified
131..0.55
0.25
2.5
41
324 Rev J Autism Dev Disord (2014) 1:276–326
References
Agency for Healthcare Research and Quality, Effective Health CareProgram. (2011). Therapies for children with autism spectrum dis-orders. Retrieved from: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=651.
American Psychiatric Association. (1980). Diagnostic and statisticalmanual of mental disorders: DSM-III (3rd ed.). Washington:American Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and statisticalmanual of mental disorders: DSM-5 (5th ed.). Washington:American Psychiatric Association.
Autism Speaks (2013). [Tables and map to show autism insurance initia-tives across U.S.]. Autism Speaks 2013 State Initiative Map.Retrieved from http://www.autismspeaks.org/sites/default/files/docs/gr/states_6.24.2013.pdf
Autism Speaks (2014a). The ACA and the autism community. Retrievedfrom http://www.autismspeaks.org/advocacy/insurance/affordable-care-act/aca-and-autism-community.
Autism Speaks (2014b). The affordable care act and autism: pre-existingconditions. Retrieved from http://www.autismspeaks.org/sites/default/files/docs/gr/aca.pre-existing.pdf.
Autism Speaks (2014c). The affordable care act and autism: pre-existingconditions. Retrieved from http://www.autismspeaks.org/advocacy/advocacy-news/nebraska-becomes-36th-state-require-autism-coverage.
Behavior Analyst Certification Board (2012). Health plan coverage ofapplied behavior analysis treatment for autism spectrum disorder.Tallahassee, Fl.
Berr, J. (2013). How autism can cost families millions. MSN Money.Retrieved from http://money.msn.com/now/post.aspx?post=00d9751b-dad1-4d2a-b3ea-01287216ce21.
Centers for Disease Control and Prevention. Morbidity and MortalityWeekly Report, March 28th, 2014, 63(SS02);1–21.
Eddy, D. M., & Hasselblad, V. (1994). Analyzing evidence by theconfidence and profile method. In K. A. McCormick, S. R.Moore, & R. A. Siegel (Eds.), Clinical practice guideline develop-ment: methodology perspectives. Rockville: Agency for Health CarePolicy and Research, Public Health Service, US Department ofHealth and Human Services (AHCPR Publication No. 95–0009).
Eikeseth, S. (2008). Outcome of comprehensive psycho-educational in-terventions for young children with autism. Research inDevelopmental Disabilities, 30, 158–178.
Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioraltreatment at school for 4- to 7-year-old children with autism: a 1-yearcomparison controlled study. Behavior Modification, 26(1), 49–68.
Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2007). Outcome forchildren with autism who began intensive behavioral treatmentbetween ages 4 and 7. Behavior Modification, 31, 264–278.
Eldevik, S., Eikeseth, S., Jahr, E., & Smith, T. (2006). Effects of low-intensity behavioral treatment for children with autism and mentalretardation. Journal of Autism and Developmental Disorders, 36(2),211–224.
Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross,S. (2009). Meta-analysis of early intensive behavioral interventionfor children with autism. Journal of Clinical Child and AdolescentPsychology, 38, 439–450.
Eldevik, S., Hastings, R., Jahr, E., & Hughes, J. C. (2012). Outcomes ofbehavioral intervention for children with autism in mainstream pre-school settings. Journal of Autism and Developmental Disabilities,42, 210–220.
Field, M.J. & Lohr, K.N. (1992). Guidelines for clinical practice: fromdevelopment to use. Institute of Medicine, Washington, D.C.;National Academy Press.
Ganz, M. L. (2007). The lifetime distribution of the incremental societalcosts of autism. Archives of Pediatric and Adolescent Medicine,161(4), 343–349. doi:10.1001/archpedi.161.4.343.
Harmon, G. (2011). Statement of the American Medical Association tothe Institute ofMedicine’s Committee on Determination of EssentialHealth Benefits. Division of Legislative Counsel, 25 MassachusettsAvenue NW, Suite 600 Washington, DC.
Holland, J. P. (1995). Development of a clinical practice guidelinefor acute low back pain. Current Opinion in Orthopedics, 6,63–69.
Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., & Stanislaw, H.(2005). A comparison of intensive behavior analytic and eclectictreatments for young children with autism. Research inDevelopmental Disabilities, 26(4), 359–383.
Howlin, P., Magiati, I., & Charman, T. (2009). A systematic review ofearly intensive behavioural interventions (EIBI) for children withautism. American Journal on Intellectual and DevelopmentalDisabilities, 114, 23–41.
Long, T. F. (2013). Essential contractual language formedical necessity inchildren, committee on child health financing. Pediatrics, 132, 39.doi:10.1542/peds.2013-1637.
Lord, C., & Jones, R. M. (2012). Annual research review: re-thinking theclassification of autism spectrum disorders. The Journal of ChildPsychology and Psychiatry, 53(5), 490–509. doi:10.1111/j.1469-7610.2012.02547.x.
Lord, C., Petkova, E., Hus, V., Gan, W., Lu, F., Martin, D., et al.(2011). A multisite study of the clinical diagnosis of differentautism spectrum disorders. Archives of General Psychiatry,69(3), 306–313.
Lovaas, O. L. (1987). Behavioral treatment and normal educational andintellectual functioning in young autistic children. Journal ofConsulting and Clinical Psychology, 55, 3–9.
Magiati, I., Charman, T., and Howlin, P. (2007). A two-year prospectivefollow-up study of community-based early intensive behaviouralintervention and specialist nursery provision for children with au-tism spectrum disorders. Journal of Child Psychology andPsychiatry, 48(8), 803-812.
Matson, J. L., & Jang, J. (2014). The most commonly reported behavioranalytic methods in early intensive autism treatments. ReviewJournal of Autism and Developmental Disorders, 1(1), 80–86.
McMahon, G.K. (2011). NYS Special Education Impartial HearingOutcomes. Mahopac, New York: McMahon Advocacy Group.Retrieved from http://www.specialedlawadvocacy.com/NYS%20Special%20Education%20Impartial%20Hearing%20Outcomes.pdf.
Missouri Department of Mental Health (2012). Autism spectrum disor-ders: guide to evidence-based interventions. http://www.autismguidelines.dmh.mo.gov/.
Myers S., & Johnson, C.P. (2007). Management of children with autismspectrum disorders. Pediatrics, 120(5), 1162-1182.
National Autism Center. (2009). National standards report: nationalstandards project—addressing the need for evidence-based practiceguidelines for autism spectrum disorders. Randolph: NationalAutism Center, Inc.
National Conference of State Legislatures (2012, August).Insurance coverage for autism. Retrieved from http://www.ncsl.org/issues-research/health/autism-and-insurance-coverage-state-laws.aspx.
National Research Council. (2001). In C. Lord & J. P. McGee (Eds.),Educating Children with Autism. Washington: National AcademyPress.
New York State Department of Health, Early Intervention Program.(1999). Clinical practice guideline: guideline technical report.Autism/Pervasive Developmental Disorders, Assessment andIntervention for Young Children (Ages 0–3 Years), no. 4217.Albany: NYS Department of Health.
Rev J Autism Dev Disord (2014) 1:276–326 325
Noyes-Grosser, D. M., Holland, J. P., Lyons, D., Holland, C. L.,Romanczyk, R. G., & Gillis, J. M. (2005). Rationale and method-ology for developing guidelines for early intervention services foryoung children with developmental disabilities. Infants & YoungChildren, 18(2), 119–135.
Patient Protection and Affordable Care Act (2010). http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm.
Reichow, B. (2011). Development, procedures, and application of theevaluative method for determining evidence-based practices in au-tism. In B. Reichow et al. (Eds.), Evidence-based practices andtreatments for children with autism (pp. 25–39). New York: Springer.
Remington, B., Hastings, R. P., Kovshoff, H., degli Espinosa, F., Jahr, E.,Brown, T., et al. (2007). Early intensive behavioral intervention:Outcomes for children with autism and their parents after two years.American Journal on Mental Retardation, 112, 418–438.
Romanczyk, R. G. (2011). Keynote address. The current state of practiceand research in ABA intervention for autism spectrum disorders:context, status, and future directions. Association for ProfessionalBehavior Analysts Annual Conference, Boston, MA.
Romanczyk, R. G., & Callahan, E. H. (2012). Autism and PervasiveDevelopmental Disorders. In Vilanayur Ramachandran (Editor inChief), The Encyclopedia of Human Behavior. Waltham, MA:Academic Press.
Romanczyk, R. G., & Gillis, J. M. (2004). Treatment approaches forautism: evaluating options and making informed choices. In Z.Dianne (Ed.), Autism: identification, education and treatment (3rded.). Hillsdale: Erlbaum.
Romanczyk, R. G., & Gillis, J. M. (2008). Practice guidelines for autismeducation and intervention: historical perspective and recent devel-opments. In J. Luiselli, D. C. Russo, & W. P. Christian (Eds.),Effective practices for children with autism: educational and behav-ior support interventions that work. UK: Oxford University Press.
Romanczyk, R. G., Turner, L. B., Sevlever, M., & Gillis, J. (2014). Thestatus of treatment for autism spectrum disorders: the weak relation-ship of science to interventions. In Lilienfeld, Lohr, & Lynn (Eds.),Science and pseudoscience in contemporary clinical psychology.NY: Guilford.
Sallows, G. O., & Graupner, T. D. (2005). Intensive behavioraltreatment for children with autism: four-year outcome andpredictors. American Journal of Mental Retardation, 110(6),417–438.
Schriger, D. L. (1995). Training panels in methodology. In K. A.McCormick, S. R. Moore, & R. A. Siegel (Eds.), Clinical practiceguideline development: methodology perspectives. Rockville:Agency for Health Care Policy and Research, Public HealthService, US Department of Health and Human Services (AHCPRPublication No. 95–0009).
Sheinkopf, S. J., & Siegel, B. (1998). Home based behavioral treatment ofyoung children with autism. Journal of Autism and DevelopmentalDisorders, 28(1), 15–23.
Virginia House Bill No. 2467, Amendment in the Nature of a Substitute.(2011, May 6).
Woolf, S. H. (1991). AHCPR Interim manual for clinical practice guide-line development. Rockville: Agency for Health Care Policy andResearch, Public Health Service, US Department of Health andHuman Services. (AHCPR Publication No. 91–0018).
Woolf, S. H. (1994). An organized analytic framework for practiceguideline development: using the analytic logic as a guide forreviewing evidence, developing recommendations, and explainingthe rationale. In K. A. McCormick, S. R. Moore, & R. A. Siegel(Eds.), Clinical practice guideline development: methodologyperspectives. Rockville: Agency for Health Care Policy andResearch, Public Health Service, US Department of Health andHuman Services (AHCPR Publication No. 95–0009).
326 Rev J Autism Dev Disord (2014) 1:276–326