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SIGN Guideline 98: Assessment, diagnosis and clinical interventions for children and young people with autism spectrum disorders
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Parent mediated intervention programmes are used to both advance the development and communication of an affected child and to offer practical advice and support to parents (see section 7.2.2 for further details).114-117
A Cochrane review of parent mediated early intervention for young children (aged 1-6 years) with ASD was only able to identify a few small studies, which could not be directly compared. This review concluded that there are insufficient reliable studies from which to draw general conclusions.118 Evidence level 1++
A pilot randomised controlled trial (RCT) described an increase in reciprocal social interaction in young children but no effect on adaptive behaviour, when parent training was added to standard care.119 Evidence level 1+
A non-randomised controlled trial of a training course for parents of pre-school children with ASD using the Hannen more than words programme showed benefit in vocabulary development and parents’ use of facilitative strategies.120 Evidence level 3
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Parent mediated intervention programmes should be considered for children and young people of all ages who are affected by ASD, as they may help families interact with their child, promote development and increase parental satisfaction, empowerment and mental health.
Many children and young people with autism have little or no speech. Those who do have speech have difficulties in using language effectively (pragmatic language impairment). The manner in which this is manifest is influenced by the child’s acquisition of language. Many of the strategies implemented to support communication are designed and managed by speech and language therapists, working in combination with a wide range of professionals and in partnership with parents. Parent led interventions incorporate features such as working on joint attention and communicative intent (see section 5.1). Alternative/augmentative communication is employed in day to day educational support.113
Interventions which offer visual support to communication found increases in spontaneous imitation and social communicative behaviour suggesting a focus for future research.121, 122 The evidence for interventions supporting communication was heterogeneous with a small number of studies looking at different aspects, eg intelligibility,123 reading and writing as a visual support to communication.122, 124 Evidence level 3
An RCT showed that clinician mediated early intervention supported the development of joint attention and symbolic play.125 Evidence level 1++
A randomised comparison of two interventions for pre-school children with ASD provided preliminary evidence that the effects seen on initiating joint attention depended on the child’s existing level of ability.126 Evidence level 1+
D Interventions to support communication in ASD are indicated, such as the use of visual augmentation, eg in the form of pictures of objects.
Interventions to support communication in children and young people with ASD should be informed by effective assessment.
A number of studies were identified that assessed the efficacy of interventions to directly support social communication and interaction, eg visual timetabling, operationalising through short stories or the use of speech bubbles or cartoons. The number of participants in each study was very small and the study populations were heterogeneous, making it difficult to generalise from their findings.127-136 Evidence level 1-, 3
Although it is difficult to synthesise the evidence as it relates to many different facets, the interventions are linked to theories about underlying core deficits in ASD. They fall into a number of areas, eg offering additional support to verbal social initiations, eg tactile prompting, or visual reinforcement, to help children with autism acquire an alternative to a theory of mind. Studies also looked at peer training, to support the social interaction and communication of the child with ASD and “buddy” programmes that aim to elicit more appropriate social skills in students with autism, in comparison to a passive proximity approach.
The evidence does not clarify which of these approaches is the most effective but many of them are currently in everyday educational use for children with ASD.
D Interventions to support social communication should be considered for children and young people with ASD, with the most appropriate intervention being assessed on an individual basis.
Adapting the communicative, social and physical environments of children and young people with ASD may be of benefit (options include providing visual prompts, reducing requirements for complex social interactions, using routine, timetabling and prompting and minimising sensory irritations).
Most intensive behavioural programmes for ASD are based on the principles of behaviour modification using applied behavioural analysis (ABA). These programmes are intensive, usually involving 20 to 40 hours of intervention per week. Their focus is primarily on early intervention with pre-school children, and they are often parent mediated, with support from helpers and professional consultants. The best known of the intensive ABA interventions is the Lovaas programme. 137, 138
The Lovaas programme was the only intensive behavioural intervention examined by a systematic review.139 The review confined itself to the question of whether this intensive behavioural intervention for pre-school children with ASD could achieve normalisation (interpreted as the capacity to follow a normal academic curriculum in a mainstream school). All studies included in this review were marked by considerable methodological flaws and there was also a concern that many had enrolled high functioning children with autism, making it difficult to generalise from the conclusions. The review concluded that a causal relationship cannot be established between a particular programme of intensive behavioural intervention and the achievement of ‘normal functioning’. Evidence level 1++
A The Lovaas programme should not be presented as an intervention that will lead to normal functioning.
A comprehensive literature search, based on the terms in annex 3 did not find any good quality evidence for other intensive behavioural interventions.
The possibility that specific skills deficits or sensory problems are contributing to particular behaviour patterns should be investigated prior to initiating any interventions.
One systematic review examined 251 studies of focal treatments for children and young people with ASD. Although the studies varied considerably in their quality, the review concluded that focal behavioural interventions consistently result in positive behavioural outcomes across a wide range of target areas.140 These include aberrant behaviours (eg self-injury, aggression), language skills, daily living skills, community living skills (eg public transportation and shopping skills), academic skills and social skills. Evidence level 2++
B Behavioural interventions should be considered to address a wide range of specific behaviours in children and young people with ASD, both to reduce symptom frequency and severity and to increase the development of adaptive skills.
Healthcare professionals should be aware that some aberrant behaviours may be due to an underlying lack of skills and also may represent a child’s strategy for coping with their individual difficulties and circumstances.
Auditory integration training (AIT) is offered to children with ASD on the premise that they experience “discomfort” when listening to certain sound frequencies. In AIT the subject listens to modulated music tapes through headphones for specified time periods. Two systematic reviews of the intervention were identified.141, 142 Two thirds of the studies showed no benefit. An RCT showed no benefit conferred by AIT compared to listening to unmodulated music. 143 Evidence level 1++
A Auditory integration training is not recommended.
Two well conducted systematic reviews were identified.144,145 Due to the methodological limitations of the studies included in the systematic reviews, the limited number of studies and the lack of clinically relevant outcomes, there is insufficient evidence to make a recommendation about the use of music therapy in ASD. Evidence level 1++
By the age of one year most children are able to sleep through the night. If after this time a child is regularly unable to sleep, or has a period of good sleep which is disrupted, then this constitutes a sleep disorder. Sleep disturbance is reported to be a common problem for children and young people with ASD. The benefits of therapy to improve sleep problems have only been assessed in a small study of children with autism and fragile X syndrome, where it was shown to have a benefit.146
Behavioural therapy should be considered for children and young people with autism who experience sleep disturbance.
The available studies were insufficient to support an evidence based recommendation about occupational therapy for ASD, including the use of particular interventions such as sensory integration.
Children and young people affected by ASD may benefit from occupational therapy for generic indications, such as providing advice and support in adapting environments, activities and routines in daily life.
Facilitated communication is defined by the American Psychological Society as “a process by which a facilitator supports the hand or arm of a communicatively impaired individual while using a keyboard or typing device.”
Two systematic reviews of facilitated communication conclude that there is no evidence to validate claims that the person with autism is being helped to communicate, although there is extensive evidence of communications that are generated by the ‘facilitator’.147, 148 Given the ethical implications of these findings in relation to the integrity and dignity of children and young people with autism, the American Psychological Association has passed a resolution against the use of facilitated communication for people with ASD on ethical grounds. 149 Evidence level 1++
A Facilitated communication should not be used as a means to communicate with children and young people with ASD.
Research into biomedical interventions, including diets and nutritional supplements, has been identified as a key priority for members of the National Autistic Society.150 The list of potential biomedical interventions searched for in this guideline in given in annex 3.
A well conducted Cochrane systematic review was unable to identify an evidence base for or against casein and gluten exclusion diets.151 Results of a subsequent, preliminary double blind clinical trial suggest that exclusion diets appear to have no significant benefits for children with ASD, although the authors acknowledge limitations.152 There is insufficient evidence on the use of casein and gluten exclusion diets for children and young people with ASD and therefore no recommendation can be made. Evidence level 1++, 1+
As with all children and young people, nutritional interventions may be required for children and young people with ASD who also have significant food selectivity and dysfunctional feeding behaviour (see section 8.4.3 for details of how to contact the British Dietetic Association).
A Cochrane systematic review of combined vitamin B6 and magnesium treatment for children and young people with ASD found insufficiently robust studies to meet the criteria set for the review and therefore no recommendation can be made.153 Evidence level 1++
Gastrointestinal symptoms in children and young people with ASD should be managed in the same way as in children and young people without ASD.
Advice on diet and food intake should be sought for children and young people with ASD who display significant food selectivity and dysfunctional feeding behaviour, or who are on restricted diets that may be adversely impacting on growth, or producing physical symptoms of recognised nutritional deficiencies or intolerances.
There was little evidence to inform the question of whether or not any specific dietary/non-pharmaceutical interventions are more appropriate for children with specific forms of ASD, or particular types of comorbidity.
Cognitive behaviour therapy (CBT) has been shown to be feasible in children with ASD who have a verbal IQ of at least 69.154 However, this systematic review was unable to draw reliable conclusions about the effectiveness, or potential harm, of CBT in this group. Evidence level 1++
Professionals should be aware that some interventions require a level of verbal and cognitive development which precludes their employment with some groups of children and young people with ASD.
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Last modified
10/05/10
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