Rethinking Autism Interventions: Quality Over Quantity

When a child is diagnosed with autism, health care professionals often recommend intensive interventions, which can amount to 20-40 hours per week, to support their development. These recommendations are typically grounded in a belief that higher amounts of intervention can lead to better outcomes for children on the spectrum. However, recent research has begun to challenge this long-held assumption.

A new study led by Micheal Sandbank, Ph.D., assistant professor in the Department of Health Sciences at the UNC School of Medicine, along with researchers from across the United States, has found that more does not necessarily equate to better. By conducting a meta-analysis on data from 144 early childhood intervention studies, which involved 9,038 children aged 0 to 8, the researchers sought to determine whether increased intensity of interventions led to greater benefits for young autistic children compared to those who received less intensive interventions. Surprisingly, they found that intervention outcomes did not improve as intervention intensity increased. The findings of this significant research were published in JAMA Pediatrics.

“We concluded that there was not rigorous evidence supporting the notion that increasing the amount of intervention produces better intervention outcomes,” said Sandbank, the study’s first author. “Instead, we recommend that practitioners consider what amount of intervention would be developmentally appropriate for the child and supportive to the family.”

Traditionally, the most commonly recommended approach for autistic children in the United States has been Early Intensive Behavioral Intervention, or EIBI. This strategy was influenced by a landmark study conducted in 1987, which concluded that autistic children receiving 40 hours of behavioral intervention weekly exhibited greater cognitive improvements than those who received only 10 hours per week. However, many subsequent studies have yielded mixed results and have often lacked the necessary quality to inform clinical practices.

Notably, many studies have confused the amount of intervention with the approach taken, leading to inconsistent findings. In November 2023, Sandbank highlighted the dominance of low-quality studies in the field, noting that few studies have thoroughly examined whether interventions can have adverse effects. For instance, interventions requiring young children to be away from home for extended periods can deprive them of essential rest and family socialization, potentially counteracting any benefits gained from intensive intervention.

“In order to determine what amount of intervention is most effective, while also being minimally interruptive, we need more high-quality primary studies,” Sandbank emphasized. “Few high-quality studies systematically compare the same intervention offered at different amounts.”

Researchers have identified several different types of interventions available for young children on the autism spectrum. Behavioral interventions aim to systematically teach functional and cognitive skills through direct one-on-one teaching, typically requiring a more intensive commitment. Conversely, developmental interventions concentrate on enhancing children’s engagement and social interaction through play with their caregivers, often provided for just a few hours each week. Additionally, naturalistic developmental behavioral interventions blend both behavioral and developmental approaches, and their implementation can vary significantly based on the provider.

To thoroughly investigate the relationship between intervention amount and effectiveness, researchers assessed it in three distinct ways: defining “intensity” as the amount of intervention within a specific time frame (such as hours per day), “duration” as the total time (in days) that intervention is delivered, and “cumulative intensity” as an overall measure of total intervention over the total duration.

By using these three metrics, the researchers examined whether intensity, duration, or cumulative intensity correlated with developmental benefits in young autistic children. They also sought to determine if the relationship strength between these metrics and developmental improvement differed based on the type of intervention provided.

The final sample for the meta-analysis included 144 separate studies, encompassing a total of 9,038 participants. Recognizing the importance of neuroplasticity—the brain’s ability to adapt during this critical developmental period—researchers controlled for participant age and assessed the quality of included studies and intervention types through meta-regression models.

Ultimately, after accounting for these factors, the researchers found no evidence that higher intensity interventions produced increased benefits for young autistic children. These findings stand in contrast to the results of some quasi-experimental studies and earlier meta-analyses, which suggested that high-intensity behavioral interventions lead to greater cognitive gains in young children on the autism spectrum.

“There’s probably a minimum amount of intervention needed to provide any benefit at all, and an optimal amount that is dependent on the child,” said Sandbank. “Unfortunately, right now, we don’t have clear evidence as to what that amount should be.”

This research implies that clinicians should refrain from prescribing a specific amount of intervention as a standard recommendation. Instead, they should communicate to families that there is no one-size-fits-all approach to intervention; a careful balance must be struck between meeting intervention demands and addressing the child’s other needs to ensure their overall well-being and development.