Understanding the Effects of Naturalistic Developmental Behavioral Interventions: A Project AIM Meta‐analysis

Abstract

We examined the quality of evidence supporting the effects of Naturalistic Developmental Behavioral Interventions (NBDIs) for facilitating change in young children with autism. We also investigated whether effects varied as a function of specific features of the intervention, samples, and outcomes measured. Twenty‐seven studies testing the effects of NDBIs were extracted from data collected for the Autism Intervention Meta‐analysis (Project AIM), a comprehensive meta‐analysis of group design, nonpharmacological intervention studies for children with autism aged 0–8 years. We extracted effect sizes for 454 outcomes from these studies for use in meta‐regression analyses testing associations between intervention effects and mean participant chronological age, language age, autism symptomatology, percentage of sample reported as male, cumulative intervention intensity, interventionist, outcome boundedness, outcome proximity, and risk of parent/teacher training correlated measurement error. The extant literature on NDBIs documents effects on social communication, language, play, and cognitive outcomes. However, our confidence in the positive and significant summary effects for these domains is somewhat limited by methodological concerns. Intervention effects were larger for context‐bound outcomes (relative to generalized), and for proximal outcomes (relative to distal). Our results indicate that NDBIs have promise as an approach for supporting development for some, but not all of the core and related features of autism in early childhood. Confidence in summary effect estimates is limited by study quality concerns, particularly an overreliance on measures subject to high detection bias. The results of this review support the use of proximity and boundedness as indicators of the limits of intervention effects. Lay summary Naturalistic Developmental Behavioral Interventions may increase language, social communication, play skills, and cognition in young children with autism, but these increases are largest for skills directly targeted by the intervention, and in contexts that are similar to that of the intervention. These conclusions are tempered by some concerns regarding research design across the studies that have been conducted to date. Autism Res 2021, 14: 817–834. © 2021 International Society for Autism Research and Wiley Periodicals LLC

The Lancet Commission on the future of care and clinical research in autism

“…Some, as shown in figure 7 (under naturalistic developmental behavioural interventions), have been supported by randomised controlled trials showing changes most commonly in the specific social communication behaviours taught, such as joint attention, synchrony, and social interactions. 138 General programmes of psychoeducation (eg, the More Than Words programme by Hanen) are often used as well, although evidence supporting them is more variable. 139 Direct treatments with similar approaches for very young children, usually involving a non-specialist (eg, a graduate student or a childcare worker), report a range of intensity from 1 h to 40 h a week.…”

Early intervention for very young children with or at high likelihood for autism spectrum disorder: An overview of reviews

“…With ongoing advances in intervention trial methodology and design, the quality challenges facing the early ASD intervention field will certainly decrease over time 113 . In addition, increasing attention toward mitigating measurement bias, in particular the challenges associated with outcome proximity and boundedness, will advance the quality of ASD early intervention evidence 35 . However, it is critical that calls for increasingly robust clinical trial methodologies are balanced with research strategies to bridge the community implementation gap in early ASD intervention, bearing in mind that there is tremendous disparity in who participates in and benefits from ASD intervention research globally.…”

Rethinking Autism Intervention Science: A Dynamic Perspective

“…However, methodological concerns such as small sample size, detection bias related to limited informant types and objective outcome measures, and restricted trial contexts, continue to limit the replicability and generalizability of these findings (1)(2)(3). Recent meta-analytic studies revealed empirical gaps in the prediction of differential treatment response and mechanisms through which treatments work, potentially due to limited statistical power and discrepancies in designs and reporting practices across studies (1,4).…”