Integrating Behavioral Strategies for Children with Autism

Background: Treatment studies indicate that substantial gains may be achieved by some children with autism spectrum disorders (ASD) when behavioral treatment is provided at an early age. However, heterogeneity of treatment response is common to all evidence-based approaches. Currently, no treatment completely ameliorates the symptoms of ASD and no specific treatment has emerged as the established standard of care. Investigators have hypothesized that customizing treatments based on individual child and family needs should increase the overall number of children that benefit from intervention. Improved understanding of how to match specific treatments (e.g., Discrete Trial Training, Pivotal Response Training) to children exhibiting different behavioral characteristics may enhance our ability to tailor interventions to individual children, thereby improving treatment effectiveness.

Objectives: (1) To evaluate the relative effectiveness of Discrete Trial Training (DTT) and Pivotal Response Training (PRT) for teaching children with autism under the age of 3 receptive and expressive language, play, and imitation skills, and (2) to identify variables influencing whether specific children are more likely to benefit from DTT or PRT in the tested domains.

Methods: A single-subject adapted alternating treatments design was used, whereby children received both DTT and PRT for 12 weeks. Language, play, and imitation targets were matched on developmental appropriateness and difficulty and then randomly assigned to treatment conditions. Potential predictor variables were collected at pre-treatment. Fidelity measures were collected on 33% of all procedures. Data are reported on rate of learning, spontaneous skill use, as well as skill acquisition and generalization during weekly probes, and maintenance of gains at 3-month follow-up.

Results: All participants learned target skills in both treatments and demonstrated some generalization, maintenance, and spontaneous use of skills acquired during DTT and PRT. However, each child benefited to differing degrees from intervention. PRT was more effective for some children, domains, and dimensions of behavior, whereas DTT was more effective for others. The results also suggested that a combination of PRT and DTT may be optimal in some cases. Pre-treatment adult avoidance and language skills may aid in prospective treatment planning efforts. Additionally, early rates of learning may be predictive of longer-term treatment response.

Conclusions: The results confirm the importance of treatment individualization and begin to suggest specific methods for tailoring treatment programs to individual child needs. The strengths and weakness of DTT and PRT may vary depending on child variables, as well as curriculum area focus.