Early and Intensive Behavioral Intervention: Addressing Behavior Excesses and Deficits in Young Children with ASD

What Defines Early and Intensive Behavioral Intervention?

A working hypothesis in contemporary EIBI is that children with autism have a learning deficit that is biologically based and is responsible for the behavioral deficits and excesses exhibited by these children. Moreover, it is argued that EIBI may help children overcome this learning deficit, enabling them to acquire behaviors demonstrated by typical children and eventually allowing some children to learn in a typical (non-behavioral) educational environment.

Intervention Methods

There are several key elements to an effective EIBI program. These elements must be included to have the best benefit for the child.

Parental Involvement

Parents are trained to become co-teachers for the child. They also learn how to manage the child’s challenging behaviors, and how to make the child use the skills he or she has learned during therapy sessions in everyday life. Parents are also taught how they can maintain a good family environment and how to care for siblings.

Teaching Methods

Discrete trial teaching is used to teach a wide variety of skills, such as language and communication, play, social skills, self-help skills and academic skills (Lovaas, 2003). Discrete trial teaching is carried out by presenting the child with the appropriate instruction and teaching material for the target behavior, prompting the target behavior if necessary and rewarding the child for emitting the target response.

In contrast to discrete trial teaching, natural environment teaching teaches skills in the situation they naturally occur. For example, during a mealtime, the child is rewarded for sitting nicely or is taught how to eat with a knife and fork. Many skills, such as learning to speak or tie shoelaces, may be difficult to learn from natural environment teaching because either the skill is complex and/or too few learning opportunities occur over the course of the day. Consequently, natural environment teaching is often combined with discrete trial teaching, where a particular skill (e.g., language) can be broken down into smaller components and practiced repeatedly until mastered.

Curriculum

The early curriculum addresses social initiations, joint attention, requesting, responding to social stimuli, responding to simple instructions such as “come here” and “wave bye-bye,” matching identical objects, imitating gross motor actions or actions with objects, mimicking sounds and words, identifying and naming objects, playing independently with toys, and basic interactive skills such as turn taking.

The intermediate curriculum includes parallel play; observational learning; turn-taking games with peers; commenting, describing and asking questions; simple reciprocation; further language training such as identification and naming of abstract concepts including colors, prepositions, pronouns and emotions; repeating sentences; early academic skills such as identifying letters and numbers; drawing imitation and tracing; and self-help skills such as dressing and undressing, toilet training, drinking from an open cup, and increasing the types of food and drink taken.

The advanced curriculum is designed to enhance cooperative play, pretend play, social language such as conversation and asking social questions, social-emotional skills such as theory of mind, developing peer relationships, general knowledge and interest in a wider range of topics, appropriate leisure activities, advanced academic skills, and learning in the classroom environment.

Reducing Aberrant Behaviors

Functional behavior assessment is used to investigate causal relationships between aberrant behavior and specific environmental events so that effective interventions can be designed. Functional behavior assessment involves, for example, observing specific incidences of the aberrant behavior and its antecedent and consequent events.

Sometimes, rewards are used to reduce inappropriate behaviors. For example, a reward may be delivered if inappropriate behavior does not occur during a defined time interval (e.g., a highly desired toy is given to the child if he/she does not throw objects during a two-minute interval). At other times, a behavior that is incompatible with the inappropriate behavior may be rewarded. For example, a child is rewarded for drawing pictures instead of biting his/her fingernails. In other situations it is desirable to reward a behavior that serves as an alternative to the inappropriate behavior. For example, a child is prompted to name a desired toy instead of tantruming to obtain it. Finally, sometimes it is most appropriate to present rewards noncontingent on behaviors to reduce inappropriate behaviors. For example, the reward is delivered contingent on time elapsed, not on absence of undesired behavior or presence of desired behavior.

Starting Early Intervention

Another important element of EIBI is that intervention is started as early as possible in the child’s life. Preferably, intervention should start before the child is 3 1/2 years old. However, research has shown that EIBI can be effective even for children who are between 4 and 7 years old at intake.

Individualized Programing

Another important defining characteristic of EIBI is that the intervention is individually tailored to meet each child’s individual needs. The curriculum must be based on an assessment of the individual child, where existing strengths of the particular child are accommodated and efforts are made to remediate behavioral deficits.

Intensity and Length of EIBI

Together with the treatment method, this is perhaps the most important element of EIBI. Research has shown that 30–40 hours per week of one-to-one intervention is required to produce optimal gains. Moreover, intervention should last for a minimum of two years. For many children, treatment continues for several additional years as an integrated part of the child’s education. As the child enters school, the focus shifts gradually to adjusting to classroom routines and learning from the classroom setting. In the classroom, the therapist becomes a shadow by helping the child to attend and learn, rewarding appropriate behaviors and minimizing aberrant behavior. Whether the child is in the class part time or full time depends on his/her needs. Fulltime integration requires that the child is able to learn from group instruction. While not in class, the child typically receives one-to-one discrete trial teaching in the school.

Supervision

Research suggests that there is relation between intensity of supervision and outcome in EIBI programs (Eikeseth, Hayward, Gale, Gitlesen, & Eldevik, in press). Ideally, supervisors should come from a research-based organization that has demonstrated through outcome research that they posit the necessary competency in EIBI. A supervisor is required to have knowledge of advanced learning principles. This expertise may be assessed through the Behavior Analysis Certification Board examination. In addition, extensive clinical experience is required, including experience with beginning, intermediate and advanced curriculums; different types of learners (e.g., auditory and visual learners, those with attention deficits and severe problem behaviors); and managing rituals and stereotypical behavior. What constitutes the optimal level of supervision may vary from child to child, and depend on child characteristics and the competency of the teachers.

What is the Evidence for EIBI?

EIBI has been more thoroughly researched compared to other comprehensive interventions for children with autism (Eikeseth, in press). To date, more than 20 outcome studies have evaluated EIBI. Four outcome studies have shown that children receiving EIBI made significantly more gains on standardized measures of IQ, language and adaptive functioning compared to control-group children receiving other interventions (Cohen, Amerine-Dickens, & Smith, 2006; Eikeseth et al., 2002, 2007; Howard et al., 2005; Sallows & Graupner, 2005). Some of those studies have also included data on maladaptive behavior, personality, school performance and changes in diagnosis, and reported favorable outcomes with EIBI. An additional four studies have shown that children receiving EIBI made significantly more gains than the comparison group on standardized measures of IQ or Adaptive Functioning (Eikeseth, in press). The remaining studies have used less rigorous research designs, but support the notion of the effectiveness of EIBI. Currently, there is an increasing consensus that EIBI is effective for many children with autism (Filipek, Steinberg-Epstein, & Book, 2006; Rogers &Vismara, 2008).

There is a great variability in treatment outcome across children, however. While some children may acquire behaviors exhibited by typical children, succeed in regular schools and develop friendships with typical peers, more limited gains are achieved with others. Some children may develop language, play and social skills, but require support in school and need assisted living as they grow older. Other children may show little or no gains in IQ scores, but may establish some level of functional communication and show a reduction in challenging behaviors.

What Makes EIBI Programs Maximally Effective?

Despite the evidence for the effectiveness of EIBI, research has also indicated that not all EIBI programs are equally effective (Bibby et al., 2001; Magiati, Charman, & Howlin, 2007). One reason for this may be that the treatment is not sufficiently intensive. Indeed, a high-quality EIBI program is not sufficient to produce maximum gains if the intensity of the program is too low or the intervention period too brief. Another reason for an ineffective EIBI program may be that it does not meet the standard in terms of program quality. Highly intensive teaching and supervision will not produce optimal gains if teachers and/or supervisors do not have the necessary qualifications. Whether lack of progress is related to child characteristics rather than system variables (i.e., program quality and/or quantity) can be determined only when the system variables are optimal.

Conclusions

Historically, there are numerous examples of interventions proposed as effective in treating children with autism. Unfortunately, often such claims have turned out to be false. EIBI is a well-researched treatment alternative, and as research continues to make advances, it may become even more effective. With time, other successful treatments may also become available. In particular, it is likely that medical interventions will become more beneficial as the neuro-biological basis for the condition becomes better understood. It is likely that behavioral and neuro-biological interventions may complement each other, and this could be a priority for future research. In the meantime, it is important that effective EIBI programs are made available to the families and professionals who seek them.

References

Bibby, P., Eikeseth, S., Martin, N.T., Mudford, O., & Reeves, D. (2001). Progress and outcomes for children with autism receiving parent-managed intensive intervention. Research in Developmental Disabilities, 22, 425-447.

Cohen, H., Amerine-Dickens, M., & Smith, T. (2006). Early intensive behavioral treatment: Replication of the UCLA model in a community setting. Developmental and Behavioral Paediatrics, 27, 145-155. Eikeseth, S. (in press). Outcome of comprehensive psycho-educational interventions for young children with autism. Research in Developmental Disabilities.

Eikeseth, S., Hayward, D., Gale, C., Gitlesen, J-P., & Eldevik, S. (in press). Intensity of supervision and outcome for preschool-aged children receiving early and intensive behavioral interventions: A preliminary study. Research in Autism Spectrum Disorders.

Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7-year-old children with autism: A 1-year comparison controlled study. Behavior Modification, 26, 49-68.

Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2007). A comparison controlled study of intensive behavioral treatment for four- to seven-year-old children with autism. Follow-up at age 8. Behavior Modification, 31, 264-278.

Filipek, P.A., Steinberg-Epstein, R., & Book, T.M. (2006). Intervention for autistic spectrum disorders. NeuroRx, 3, 207-216.

Howard, J.S., Sparkman, C.R., Cohen, H.G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatment for young children with autism. Research in Developmental Disabilities, 26, 359-383.