Interventions for children on the autism spectrum: A synthesis of research evidence

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Whitehouse, Andrew
Varcin, Kandice
Waddington, Hannah
Sulek, Rhylee
Bent, Cathy
Ashburner, Jill
Eapen, Valsamma
Goodall, Emma
Hudry, Kristelle
Roberts, Jacqueline
Silove, Natalie
Trembath, David
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Having access to effective intervention during childhood is an important element of the clinical pathway for children on the autism spectrum, providing an opportunity to support early development and promote longer-term quality of life. There are a large number of interventions available within clinical practice, which vary in their theoretical orientation and practical application. The current report had two broad aims: (1) to provide an overview of non-pharmacological interventions that have been developed for children on the autism spectrum, and the training pathways in Australia for clinical practitioners who provide these interventions; and (2) to review the scientific evidence for the therapeutic (and other) effects of interventions for children on the autism spectrum.

The first aim was addressed through a narrative review, which provided a rationale for clinical intervention, including a description of the medical, social, biopsychosocial, and neurodiversity models/perspectives of clinical intervention for children on the autism spectrum. A method for classifying clinical intervention practices was then discussed, categorising intervention practices into behavioural interventions, developmental interventions, naturalistic developmental and behavioural interventions (NDBIs), sensory-based interventions, technology-based interventions, animal-assisted interventions, cognitive behavioural therapy (CBT), Treatment and Education of Autistic and related Communication-handicapped CHildren (TEACCH), and interventions that do not readily fit within these categories (‘other’ interventions). The theoretical premise for each of these intervention categories was described, as well as the principles that underpin the use of these interventions in clinical practice. The narrative review concludes by outlining the training pathways that are typically undertaken by clinical practitioners in Australia that ensure the effective and ethical delivery of these interventions.

The second aim was addressed through an umbrella review of the empirical evidence base examining interventions for children on the autism spectrum, focusing on those designed for use with children aged 0-12 years. The umbrella review used reproducible methods to identify, collate, and summarise existing systematic reviews (including meta-analyses) of the intervention research literature, with a focus on group study designs that included a comparison group. A total of 58 systematic reviews were identified, which drew on data from 1,787 unique studies. From the data reviewed, a matrix was created that presented the evidence for the effect of different interventions on a wide range of child and family outcomes. When examined at a category level, there was evidence for positive effects for behavioural interventions, developmental interventions, NDBI, technology-based interventions and CBT on a range of child and family outcomes. Within these categories, the intervention effect on outcomes was variable (null, positive) between intervention practices. Positive intervention effects for sensory-based interventions were reported for certain intervention practices only, and in those cases, positive effects were limited to select child and family outcomes. A mix of inconsistent and null intervention effects on child and family outcomes were reported for both TEACCH and animal-assisted interventions. Among ‘other’ intervention practices, only social skills training had evidence for a positive effect on child outcomes. Adverse effects were rarely discussed by systematic reviews, and so it was not possible to provide a comprehensive analysis of this information.

Among the studies reviewed, there was a wide range in the amount of intervention children were reported to have received. There was evidence that, for certain behavioural intervention practices, a greater amount of intervention related to greater intervention effects. However, this finding was inconsistent across child outcomes, and null effects were also reported, suggesting that this was not a clear relationship. For interventions within the NDBI category, the amount of intervention a child received did not influence the effect of intervention on most child outcomes. The influence of the amount of intervention was not reported by systematic reviews examining the remaining categories and practices. There was evidence that both parent-mediated (also called caregiver-mediated intervention) and peer-mediated interventions have a positive effect on a range of child and family outcomes. Active caregiver involvement in intervention was reported to have a similar, and at times greater, intervention effect on child outcomes compared to interventions delivered by clinical practitioners or educators alone. Minimal information was reported that directly compared the effect of interventions delivered in different settings (e.g., clinic, school, home), in different formats (i.e., individual, group), or via different modes (e.g., face-to-face, telepractice). Similarly, minimal information was reported on the influence of child characteristics on the effects of interventions. Where this information was available, such as for child age, inconsistent or null findings were reported.

This report is a comprehensive review of the evidence underpinning non-pharmacological interventions for children on the autism spectrum. The findings provide key insights into which interventions have research evidence for producing a positive effect on which child and family outcomes. This information is critical in guiding clinical and policy decisions regarding interventions that may be most appropriate for an individual child and their family. This information will also serve an important role in helping caregivers to make informed decisions regarding how best to support their child’s learning and participation. The variability in the effects of interventions on child and family outcomes reinforces the need for clinical decision making to take place within an evidence-based practice framework, which also draws on evidence from clinical experience and accounts for each child’s and family’s preferences and priorities. The near complete absence of evidence regarding the effects of intervention practices on quality of life outcomes highlights an urgent research priority. Understanding and measuring the desired outcomes of an intervention, as defined by individuals on the spectrum and their families, will advance the key research goal of how intervention practices can best be tailored the strengths and support needs of children and their families. The information presented in this review will change as further scientific evidence emerges, and so it is recommended that this report becomes the basis for a living guideline that is continually updated.

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Whitehouse, A; Varcin, K; Waddington, H; Sulek, R; Bent, C; Ashburner, J; Eapen, V; Goodall, E; Hudry, K; Roberts, J; Silove, N; Trembath, D, Interventions for children on the autism spectrum: A synthesis of research evidence, 2020