Evidence lacking to support intensive intervention for autism
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Key takeaways:
- Researchers expected that higher amounts of autism intervention would produce more effects.
- Effects from all studied interventions were not statistically significant from zero.
There is insignificant evidence to support recommendations that children with autism will benefit from intensive interventions, according to the results of a meta-analysis published in JAMA Pediatrics.
One of the study’s authors told Healio that in reviewing standard intervention recommendations for autism in children, she found that one recommended that children receive at least 20 hours or up to 40 hours of intensive intervention per week.
“This recommendation originated initially from a quasi-experimental study conducted in the ’80s that, although remarkable for the time, was flawed,” Micheal P. Sandbank, PhD, director of The Brain and Language Lab at the University of Texas at Austin, told Healio. “There have been additional studies since then, but most were quasi-experimental and compared intensive intervention with different uncontrolled supports, failing to isolate the effect of intensity specifically from the effect of providing a systematic and comprehensive intervention approach.”
Sandbank said only a handful of randomized controlled trials have since been conducted that could allow for the effect of intensity to be explored, and their results have been mixed.
“Because we had a very large and recent data set from our meta-analysis of all controlled group intervention studies published before November 2021, I knew that meta-analysis offered another tool for investigating this question, in a way that goes beyond primary studies,” Sandbank said.
Sandbank said that the researchers began by examining 289 reports from 252 separate studies, and extracted the effect size of the interventions they described. They also extracted three metrics of intervention where possible: daily intensity, or the amount of intervention per day; duration, or the total amount of days that the intervention was provided over the course of the study; and cumulative intensity, the total number of intervention hours provided over the course of a study.
“In theory, if intervention amount is a key driver of intervention effects, we expect that we might see evidence of this when we look across effects from many different studies in which many different intervention amounts were provided,” Sandbank said. “We would expect that studies in which higher amounts of intervention were provided would have larger effects.”
The researchers also restricted the intervention types included in their analysis to behavioral interventions, developmental interventions and naturalistic developmental behavioral interventions, which Sandbank said are “types of intervention approaches commonly offered to autistic children in the U.S.,” and technology-based interventions, or intervention mediated entirely through technology, which Sandbank noted are not common but are frequently studied.
The exclusions left the authors with 144 studies that included 175 reports and 9,038 children (mean age, 49.3 months; 82.6% boys).
“Not all of these intervention types have an underpinning theory that intervention amount drives effectiveness, so it was important that our analyses controlled for intervention type,” Sandbank said.
Intervention duration could be derived for almost all included studies (97%), but daily intensity and cumulative intensity could be determined for fewer than two-thirds of studies, including approximately three-quarters of included outcomes.
Sandbank and colleagues also found that technology-based interventions evidenced the largest positive association (B = 0.1; standard error = 0.09; 95% CI, 0.09 to 0.29), but this was not statistically distinguishable from zero, a result it shared with the other interventions.
Sandbank cautioned that nuance can be lost in brief guidelines, and that “high amounts of intervention compete with other important childhood activities, like rest, recreation and participation in daily family and community routines.”
“My goal here is to make it evident to providers that the evidence supporting high amounts of intervention for young autistic children is not as robust as it might seem in guidelines, and that this recommendation should not be their default,” Sandbank said. “Many parents will have heard about intensive intervention and believe that only sufficiently intensive intervention will be helpful to their child. Providers need to be ready to inform families that evidence does not support that any one intervention amount is helpful for all children.”
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