When a child is diagnosed with an autism spectrum disorder (ASD), health professionals often recommend intensive interventions – which can be as much as 20-40 hours per week – to support their development. However, more is not always better and a new study has found that there is no conclusive evidence that higher intensity interventions provide additional benefits for young children with autism.
The researchers, led by Michael Sandbank, assistant professor in the Department of Health Sciences at the UNC School of Medicine, conducted a comprehensive systematic analysis of data from 144 early intervention studies, including 9,038 children from between 0 and 8 years, and conducted a meta-analysis to determine whether higher-intensity interventions provided additional benefits compared to less-intensive ones.
They found that the results of the interventions did not improve with increasing intensity. “We found no rigorous evidence to support the idea that increasing the amount of intervention produces better outcomes,” Sandbank said. “We recommend that professionals consider what amount of intervention would be developmentally appropriate for the child and beneficial for the family.” Her findings have been published in JAMA Pediatrics.
In November 2023, Sandbank noted that many low-quality studies are dominating this field and that few studies have adequately examined whether interventions can have adverse or harmful effects. Indeed, interventions that require young children to be away from home for long periods of time can deprive them of rest and opportunities to socialise with their family, among other things.
Balance between intervention and other needs of the child with ASD
Many different types of interventions can be offered to young children with autism spectrum disorders. Behavioral interventions systematically teach functional and cognitive skills through direct one-on-one instruction and tend to be very intensive. Developmental interventions focus on improving a child’s social interaction and engagement through play with caregivers and are typically provided for only a few hours per week. Naturalistic developmental behavioral interventions combine behavioral and developmental approaches. All of these interventions may look very similar or different in their implementation, depending on the provider.
To further investigate the impact of intervention quantity, the researchers measured it in three ways. They defined “intensity” as the amount of intervention provided in a given time frame (such as hours per day), “duration” as the total amount of time (in days) that the intervention is provided, and “cumulative intensity” as an overall metric describing the total intervention provided over the total duration.
Using these three metrics, the researchers explored whether intensity, duration, or cumulative intensity were associated with developmental benefits for autistic children. At the same time, they wanted to determine whether the strength of the relationship between the metrics and developmental improvement differed depending on the type of intervention provided.
There is no amount of intervention that is appropriate for all children and a balance must be found between the demands of the intervention and other needs of the child to ensure their well-being.
Their final sample for the meta-analysis included 144 separate studies with a total of 9,038 participants. Knowing that neuroplasticity – or the brain’s ability to adapt – is at its peak during this developmental period and can affect intervention success, the researchers controlled for participants’ age. They also accounted for the quality of the included studies and the type of intervention with the help of meta-regression models.
Taking all these factors into account, the researchers found no evidence that higher-intensity interventions provide additional benefits for autistic children. The evidence contrasts with the results of quasi-experimental studies and some meta-analyses suggesting that high-intensity behavioral interventions are associated with greater cognitive gains in young children on the autism spectrum.
“There is probably a minimum amount of intervention needed to provide some benefit, and an optimal amount that depends on the child,” Sandbank said. “Unfortunately, at this time, we do not have clear evidence of what that amount should be.”
This research suggests that clinicians should avoid providing a specific amount of intervention as a default recommendation. Instead, they should inform families that there is no amount of intervention that is appropriate for all children, and that a careful balance must be found to meet the demands of the intervention with the child’s other needs to ensure their well-being.
