Cost Comparison of Early Intensive Behavioral Intervention and Special Education for Children with Autism

The financial implications of the increased prevalence of autism, though rarely discussed, will be extremely important to society. We compared the costs associated with 18 years of special education to the costs associated with the implementation of an average of 3 years of Discrete Trial Training as an Early Intensive Behavioral Intervention (EIBI) in an effort to minimize the need for special education. Our results indicate that the state of Texas would save $208,500 per child across eighteen years of education with EIBI. When applied to the conservative estimate of 10,000 children with autism in Texas, the State would save a total of $2.09 billion with EIBI. Implications for taxpayers, policymakers, and treatment are discussed.     

Cost–benefit estimates for early intensive behavioral intervention for young children with autism—general model and single state case

Clinical research and public policy reviews that have emerged in the past several years now make it possible to estimate the cost–benefits of early intervention for infants, toddlers, and preschoolers with autism or pervasive development disorder—not otherwise specified (PDD—NOS). Research indicates that with early, intensive intervention based on the principles of applied behavior analysis, substantial numbers of children with autism or PDD—NOS can attain intellectual, academic, communication, social, and daily living skills within the normal range. Representative costs from Pennsylvania, including costs for educational and adult developmental disability services, are applied in a cost–benefit model, assuming average participation in early intensive behavioral intervention (EIBI) for three years between the age of 2 years and school entry. The model applied assumes a range of EIBI effects, with some children ultimately participating in regular education without supports, some in special education, and some in intensive special education. At varying rates of effectiveness and in constant dollars, this model estimates that cost savings range from $187,000 to $203,000 per child for ages 3–22 years, and from $656,000 to $1,082,000 per child for ages 3–55 years. Differences in initial costs of $33,000 and $50,000 per year for EIBI have a modest impact on cost–benefit balance, but are greatly outweighed by estimated savings. The analysis indicates that significant cost-aversion or cost-avoidance may be possible with EIBI. © 1998 John Wiley & Sons, Ltd.     

Videoconference to supervise early intensive behavioral intervention: A preliminary evaluation of acceptability

At present, early intensive behavioral intervention (EIBI) for children with autism spectrum disorders is the intervention that has the strongest empirical support. EIBI requires frequent supervision by qualified professionals. Norway, like many other countries, has a shortage of qualified supervisors, particularly in rural regions. This study used a reversal design to investigate how supervisors and supervisees perceive the quality of EIBI supervision and the local team's preparedness when supervision was provided either on-site or via videoconference. Calculations were made on how much time could be saved on travel when part of the supervision was provided via videoconference. There were no significant differences in the supervisors' and supervisees' ratings of on-site and videoconference supervision. Moreover, the supervisors found the local EIBI teams to be better prepared when supervision was provided via videoconference, and the videoconference supervision meetings were shorter. The study discusses the implications of these findings for the accessibility of EIBI and case capacity and proposes some areas for further research.     

Teaching behavior analysts in an early intensive behavioral intervention setting to conduct a structured mealtime protocol

Children with autism spectrum disorder often display feeding problems, such as consumption of a limited variety of foods. It is also common for these children to be enrolled in early intensive behavioral intervention (EIBI) services for comprehensive treatment. Combined, these factors make it possible that behavior analysts will have a role in a child's clinical care related to feeding. However, given that the etiology of pediatric feeding disorders is complex and multifactorial, clinicians should ensure they have sufficient training and a setting that is appropriate for assessment and treatment. Therefore, we evaluated the effects of behavioral skills training in an EIBI setting to conduct a structured mealtime protocol. Training resulted in increases in procedural integrity, and we replicated these effects for all participants.     

Intercontinental telehealth coaching of therapists to improve verbalizations by children with autism

This study examined the effects of intercontinental telehealth coaching on the mastery of therapists’ skills and improvements in verbalizations by children with autism, testing whether telehealth can be a solution for underserved communities in developing countries such as Georgia‐Sakartvelo in Eastern Europe. Three therapists delivering and three children with autism receiving early‐intervention services from the nongovernmental organization Children of Georgia in Tbilisi participated. Experimenters provided coaching from Virginia, USA to therapists in Georgia‐Sakartvelo. Observers in Georgia‐Sakartvelo and in Virginia conducted the behavioral observations. We used inexpensive communications technology to provide the coaching and a multiple‐baseline design across participants to evaluate the effects of the intervention. Therapists demonstrated improvements in two classes of behaviors: correct command sequences and positive consequences. The children demonstrated improvements with echoics and mands. The study demonstrated that telehealth can be a good model for delivering early‐intervention services to children with autism in underserved and distant regions of the world.     

Children with autism can track others' beliefs in a competitive game

Theory of mind (ToM) development, assessed via ‘litmus’ false belief tests, is severely delayed in autism, but the standard testing procedure may underestimate these children's genuine understanding. To explore this, we developed a novel test involving competition to win a reward as the motive for tracking other players' beliefs (the ‘Dot‐Midge task’). Ninety‐six children, including 23 with autism (mean age: 10.36 years), 50 typically developing 4‐year‐olds (mean age: 4.40) and 23 typically developing 3‐year‐olds (mean age: 3.59) took a standard ‘Sally‐Ann’ false belief test, the Dot‐Midge task (which was closely matched to the Sally‐Ann task procedure) and a norm‐referenced verbal ability test. Results revealed that, of the children with autism, 74% passed the Dot‐Midge task, yet only 13% passed the standard Sally‐Ann procedure. A similar pattern of performance was observed in the older, but not the younger, typically developing control groups. This finding demonstrates that many children with autism who fail motivationally barren standard false belief tests can spontaneously use ToM to track their social partners’ beliefs in the context of a competitive game.     

Assessment of social communication skills in preschoolers

This paper orients the reader to social communication assessment and reviews methods for assessing social communication behavior in children from toddlerhood through the preschool years. Most standardized, normed tests of language in this age range focus on morpho-syntactic and semantic comprehension and production abilities. While social communication is perhaps one of the most important skills for peer acceptance, these skills are often overlooked in language evaluation with children. However, there are a number of caregiver questionnaires, interviews, or direct social-communication sampling methods that are available to assist clinicians or researchers in documenting social-communication skills or behaviors. Since assessment of social communication is essential in clinical work with children with an autism spectrum disorder, some of the tools described below are outgrowths of autism research or provide autism-related scores. While many children receiving social communication assessments do not have autism, the need to assess social communication skills in children with language impairment is highlighted by the growing literature documenting social and pragmatic difficulties in this population (Bishop 2000 Causes, Characteristics, Intervention, and Outcome. Hove, UK: Psychology press). Regardless of whether the measures presented herein were initially designed for children with autism or not, they will provide insights into the social communicative behaviors or tendencies in young children.     

A review of recommendations for sequencing receptive and expressive language instruction

We review recommendations for sequencing instruction in receptive and expressive language objectives in early and intensive behavioral intervention (EIBI) programs. Several books recommend completing receptive protocols before introducing corresponding expressive protocols. However, this recommendation has little empirical support, and some evidence exists that the reverse sequence may be more efficient. Alternative recommendations include teaching receptive and expressive skills simultaneously (M. L. Sundberg & Partington, 1998) and building learning histories that lead to acquisition of receptive and expressive skills without direct instruction (Greer & Ross, 2008). Empirical support for these recommendations also is limited. Future research should assess the relative efficiency of receptive-before-expressive, expressive-before-receptive, and simultaneous training with children who have diagnoses of autism spectrum disorders. In addition, further evaluation is needed of the potential benefits of multiple-exemplar training and other variables that may influence the efficiency of receptive and expressive instruction.     

Behavioral Variability in the Play of Children With Autism and Their Typically Developing Peers

Invariable or repetitive behavior is a defining feature of autism and can limit a child's exposure to varying consequences and subsequent learning opportunities. We compared the variability in play material selection between 30 children with autism and 30 typically developing children, aged 2‐8 years, across three different activities: selecting paper outfits to dress dolls, selecting beads to place on a string, and choosing marker colors for coloring shapes. Selections of materials could be varied or identical to previous selections within the session. Although there was some overlap between the two groups, children with autism were more likely to respond invariably than typically developing children. Two‐year‐old children in both groups tended to display invariable play material selection, but variability increased across increasing age groups for typical children and remained relatively stable across increasing age groups for children with autism. Implications regarding the divergence in variable behavior across children with autism and typically developing children as a function of age are discussed. Copyright © 2015 John Wiley & Sons, Ltd.     

Atypical updating of face representations with experience in children with autism

Face identity aftereffects are significantly diminished in children with autism relative to typical children, which may reflect reduced perceptual updating with experience. Here, we investigated whether this atypicality also extends to non‐face stimulus categories, which might signal a pervasive visual processing difference in individuals with autism. We used a figural aftereffect task to measure directly perceptual updating following exposure to distorted upright faces, inverted faces and cars, in typical children and children with autism. A size‐change between study and test stimuli limited the likelihood that any processing atypicalities reflected group differences in adaptation to low‐level features of the stimuli. Results indicated that, relative to typical children, figural aftereffects for upright faces, but not inverted faces or cars, were significantly attenuated in children with autism. Moreover, the group difference was amplified when we isolated the ‘face‐selective’ component of the aftereffect, by partialling out the mid‐level shape adaptation common to upright and inverted face stimuli. Notably, the aftereffects of typical children were disproportionately larger for upright faces than for inverted faces and cars, but the magnitude of aftereffects of autistic children was not similarly modulated according to stimulus category. These findings are inconsistent with a pervasive adaptive coding atypicality relative to typical children, and suggest that reduced perceptual updating may constitute a high‐level, and possibly face‐selective, visual processing difference in children with autism.     

Effects of stimulus presentation order during auditory–visual conditional discrimination training for children with autism spectrum disorder

Children with autism spectrum disorder are typically taught conditional discriminations using a match‐to‐sample arrangement. Consideration should be given to the temporal order in which antecedent stimuli (the sample and comparison stimuli) are presented during match‐to‐sample trials, as various arrangements have been used in the extant literature. The purpose of the current study was to compare the effects of four stimulus presentation orders on the acquisition of auditory–visual conditional discriminations. The study included participants from a clinically relevant population (three children with autism spectrum disorder), employed clinically relevant teaching procedures, and included two presentation formats not included in previous comparison evaluations (simultaneous and sample‐first with re‐presentation conditions). Results were found to be learner‐specific; that is, a different stimulus presentation format was most efficient for each participant. We provide suggestions to evaluate stimulus control topographies and enhance experimental control in match‐to‐sample arrangements.     

A replication of the response‐restriction preference assessment

We replicated the response‐restriction (RR) preference assessment and compared results in terms of preference hierarchies to those from free‐operant and multiple stimulus without replacement (MSWO) formats with six children with autism spectrum disorders (ASDs). We also assessed social validity of each format with teachers and clinicians who work with children with ASDs. Complete hierarchies were produced in four of 18 assessments and with MSWO and RR formats only. Results of the social validity assessment varied across raters, with each preference assessment format receiving the highest rating from at least one rater. Results are discussed in terms of practical recommendations and relative to the preference assessment literature as a whole.     

Behavioral Telehealth Consultation with Families of Children with Autism Spectrum Disorder

In this study, desktop video teleconferencing was used to facilitate behavioral consultation at a distance with three parents of school‐age children with autism spectrum disorders. Parents were supported via desktop video teleconferencing as they conducted functional analyses and learned to implement an antecedent manipulation strategy, functional communication training, and a consequence‐based strategy. Parents then conducted a brief multi‐element treatment comparison to evaluate the preliminary effectiveness of each intervention strategy on their child's challenging behavior. The results of this study provide additional support to previous research suggesting that a telehealth model of behavioral consultation may be an effective way to assist parents of children with autism spectrum disorders address challenging behavior that disrupts family routines. Suggestions for future research are discussed. Copyright © 2016 John Wiley & Sons, Ltd.     

Anticipatory concern: a study in autism

There has been substantial research on children's empathic responsiveness towards distressed people, and on the limited responsiveness of children with autism. To date, however, there have not been experimental studies to test how far children show concern towards someone who might be expected to feel badly, when that person has not (yet) expressed any negative feelings. We tested matched groups of children with autism and learning disability, and typically developing children of similar verbal mental age (approximately 6 years), with a novel procedure in which participants witnessed one person (E1) tearing the drawing of another (E2). In a comparison condition, a blank card was torn. In the torn‐drawing condition, as predicted, fewer participants with autism orientated towards E2 with an immediate look, and as a group, they were rated as showing less concern for, and fewer concerned looks towards, E2. We discuss possible implications for theoretical perspectives on the early development of empathy in typically as well as atypically developing children.     

Sensory Integration as a Treatment for Automatically Maintained Stereotypy

According to sensory integration (SI) theory, many symptoms of autism are caused by an inability to integrate and adaptively respond to sensory input. Despite little evidence supporting SI, this form of therapy is a popular treatment for children with autism. Should these treatments work, they should be most effective for behavior maintained by sensory consequences (automatically maintained). SI activities may make these sensory consequences less reinforcing. The purpose of this study was to determine whether SI treatments could reduce automatically‐maintained stereotypy. Five individuals with autism participated. An occupational therapist prescribed sensory activities that competed with stereotypy for SI treatments. Two types of SI treatments were tested: sensory diets and brushing with deep‐pressure therapy. The effect of these treatments on stereotypy was evaluated in an ABAB design. Neither the sensory diet alone, brushing and deep pressure alone, nor both treatments combined were effective interventions for stereotypy. These results do not support the use of SI as a treatment for stereotypy. Copyright © 2015 John Wiley & Sons, Ltd.     

Comparison of Video Prompting with and Without Voice‐Over Narration: A Replication with Young Children with Autism

We compared the effects of video prompting (VP) with and without voice‐over narration on the play skills of two young children with autism spectrum disorder using an adapted alternating treatment design. The results showed increases in play skills when using VP with and without voice‐over narration for both participants. These results suggest that the difference in effectiveness between VP with and without voice‐over narration may be negligible for some children with autism. Implications for the use of VP without additional teaching strategies and the need for additional component analyses are discussed. Copyright © 2016 John Wiley & Sons, Ltd.     

The relation between social engagement and pretend play in autism

The focus of this study is the nature and concomitants of pretend play among young children with autism. Age‐ and language‐matched children with autism (n= 27), autism spectrum disorder (n= 14), and developmental disorders without autism (n= 16) were administered the Test of Pretend Play (ToPP; Lewis & Boucher, 1997 ), with an additional rating of ‘playful pretence’. As predicted, children with autism showed less playful pretend than participants with developmental disorders who did not have autism. Across the groups, playful pretence was correlated with individual differences in communication and social interaction, even when scores on the ToPP were taken into account. Limitations in creative, playful pretend among children with autism relate to their restricted interpersonal communication and engagement.     

The effects of token reinforcement on attending in a young child with autism

The benefits of token economies have been widely established, however there are very few empirical studies on the effects of token reinforcement on the behavior of young children with autism. The establishment of conditioned reinforcers such as tokens may be important in interventions for children with autism. Token reinforcement was used to increase the attending behavior of a young child with autism during discrete trials instruction for academic and communication skills. A reversal design showed that token reinforcement sustained attending only when the back‐up reinforcer was available and was accessed immediately. The results extend and corroborate findings on token reinforcement reported in other applied settings and are also consistent with findings from basic research on conditioned reinforcement. Copyright © 2006 John Wiley & Sons, Ltd.