Version July 2025
INTRODUCTION —
The primary interventions for autism spectrum disorder (ASD) are behavioral, educational, and developmental therapies. These interventions address the core symptoms of ASD as well as specific developmental and comorbid conditions. They are based on the needs of the individual and aim to improve overall functioning and quality of life.
Adult advocates with ASD view autism as a personal characteristic that is a life-long part of an individual's identity and prefer identity-first (eg, "autistic individual") rather than person-first (eg, "individual with autism") language. This has prompted conversations regarding the appropriateness of using the terms "autism spectrum disorder (ASD)" and "treatment." We respect these viewpoints. In this topic, we use the terms ASD, intervention, and person-first language, in agreement with the diagnostic terminology and common style used in medical journals. However, clinicians should be sensitive to changes in terminology and inquire about individual preferences in discussions with their patients.
The behavioral, educational, and developmental interventions for ASD will be reviewed here, focusing on interventions and practice models that are evidence-based, more frequently used, more widely available, and more likely to be covered by medical insurance in the United States.
Other related issues are discussed separately.
●(See "Autism spectrum disorder in children and adolescents: Pharmacologic interventions".)
●(See "Autism spectrum disorder in children and adolescents: Overview of management and prognosis".)
●(See "Autism spectrum disorder in children and adolescents: Evaluation and diagnosis".)
GOALS OF INTERVENTION —
Intervention programs for children and adolescents with ASD generally focus on the following objectives, although some variation exists among programs [1-3].
Broad goals are to:
●Maximize the ability of the individual to function in their environment
●Move the individual toward independence
●Improve the quality of life for the individual and their family
Specific goals are to:
●Improve social functioning and play skills
●Improve communication skills (both functional and spontaneous)
●Improve adaptive skills
●Decrease nonfunctional, negative, or aggressive behaviors
●Promote cognition and academic functioning
●Address co-occurring psychiatric disorders
OVERVIEW OF INTERVENTION PROGRAMS
Conceptual models — Therapeutic approaches can be broadly categorized according to conceptual models; however, there is no universal standard for categorizing these models. We have utilized a framework that aligns with more recent reviews and the most up to date information from the National Clearing House on Autism Evidence and Practice and the National Autism Center's National Standards Project [4-8].
The National Clearing House on Autism Evidence and Practice review of evidence-based interventions for individuals with ASD and co-occurring psychiatric disorders is based on studies published between 2012 to 2017 on the impact of behavioral, educational, clinical, and developmental practices [4-6,8]. The National Standards Project is a United States based research initiative that was developed by the National Autism Center and provides information on best practices for ASD [7]. Phase 1 and 2 of the project were completed in 2009 and 2015, respectively, and include an analysis of interventions for ASD based on research conducted from 2007 to 2012. Phase 3 of the project has not been completed yet and will include updated literature on ASD practices through 2018.
Available evidence supports the importance of early intervention and individualizing interventions based on the heterogeneity of the child's ASD presentation but does not clearly support the superiority of one intervention model over another [4,6,9]. Systematic reviews and meta-analyses have found that some behavioral and educational interventions are associated with improvements in the core symptoms of ASD (eg, social communication skills and repetitive/restrictive behaviors), challenging behaviors, adaptive functioning, intelligence quotient, and co-occurring diagnoses (eg, anxiety) [7,10-14]. In particular, early intensive behavioral, developmental and relationship-based interventions in young children appear to improve outcomes in many areas [15-19]. Although greater intensity and duration (eg, at least 10 to 20 hours per week for several years) of intervention have been reported to lead to better outcomes, questions remain regarding the benefits of more intensive (eg, 40 hours per week) intervention and whether certain programs are better than others for specific children [10,12,20,21]. (See 'Behavioral interventions' below and 'Age-based considerations' below.)
Practical and ethical factors have made it challenging to conduct randomized trials to evaluate intervention programs for ASD [22]. Choosing an appropriate outcome measure is particularly challenging, given the heterogeneity of ASD presentations. The appropriate assessment tool is also unclear. For example, instruments that are typically used for diagnosis may not be appropriate for evaluating incremental improvements in core deficits. Measures that have better sensitivity to assess changes in core symptoms and improve baseline measures of co-occurring internalizing and externalizing ASD behaviors are needed. One such measure, the Brief Observation of Social Communication Change (BOSCC), is under development [23-25].
General principles of effective intervention — Management of ASD requires a multidisciplinary lifespan approach that uses the individual's strengths to address weaknesses and thereby improve functioning and quality of life. Early intervention by trained therapists and special education personnel is important. Some interventions seek to target the core symptoms of ASD with the objective of improving overall function, while others focus on ancillary or comorbid symptomatology. The choice of interventions may be affected by access to programs, as the availability of programs varies by region [26]. Referrals for interventions can be initiated by the clinician or parent/caregiver, and this process also may vary by region.
Children with ASD generally require a combination of therapies to address their individual constellation of symptoms and needs. For example, social and behavioral function varies among children with ASD, and comorbid neurodevelopmental or psychiatric disorders (eg, intellectual impairment, language impairment, anxiety) may be present. Although the evidence does not support one specific type of intervention to address the core symptoms of ASD, these interventions should target specific domains to address needs (eg, social, language, cognitive), apply learned skills broadly (eg, to new environments, people, and situations), and involve the parents/caregivers and teachers.
A comprehensive intervention plan that is individualized based on the needs of the child with ASD includes the following components:
●An education program specific to the needs of the student (table 1) (see 'Educational programming' below)
●Direct interventions that utilize behavioral modification to target core symptoms and address co-occurring delays in language, motor, or cognitive development (table 2) (see 'Interventions for core symptoms' below)
●Ancillary therapies (eg, speech therapy, occupational therapy) (see 'Communication interventions' below and 'Occupational therapy' below)
●Targeted interventions for co-morbid conditions (see 'Interventions for comorbid psychiatric conditions' below)
●Age-related considerations (see 'Age-based considerations' below)
●A plan for generalization (ie, application of learned skills to new environments, people, and situations) (see 'Educational programming' below and 'Interventions for core symptoms' below and 'Age-based considerations' below)
●A parent/caregiver training component (see 'Educational programming' below and 'Interventions for core symptoms' below and 'Age-based considerations' below)
Interventions are often funded from multiple sources, including the individual's medical insurance and the school system.
Educational programming
Early educational intervention — Special education programming is a key part of an effective and comprehensive intervention plan for many children with ASD. In the United States, for children with ASD who are under three years of age (in some states five years of age), both educational and direct interventions (eg, behavioral and other therapies) are provided by government-funded early education programs. Examples of such programs include Early Intervention, Birth to Three, Early On, and Child Developmental Services. Early education programs are available in all states, but the services and names of programs vary by state.
When a child graduates from these programs, it is the role of the public school to provide interventions and services for individuals with ASD as part of an Individual Educational Program (IEP). This varies based on the age and needs of the child:
●For school-aged children (ie, kindergarten and beyond) who require minor accommodations within the classroom environment and do not require school-funded interventions, a "504 plan" may be developed in lieu of an IEP.
●For school-aged children and adolescents who require an IEP, interventions funded by the public school system are typically provided in the school environment. Rarely, they are provided outside of the school setting (eg, home or a center). Most children will require additional interventions that are covered by the child or family's medical insurance.
In addition to public schools, there are private or specialized schools with specific expertise in educating and supporting individuals with ASD. Students typically access services through private means when there is a lack of sufficient services in the public school setting. In some instances, these services may be funded by the child's local public school system; however, this may require the assistance of a special education attorney.
In the United States, recommendations for educational programs are based upon those by the National Research Council, which incorporates mandates from the Individuals with Disabilities Education Act (IDEA) [10,27]. The Council recommends that educational services should begin as soon as the individual is suspected of having ASD [10]. Services are received as part of a formal Individualized Educational Program (IEP) and should include a minimum of 25 hours a week for 12 months per year, in which the individual is engaged in systematically planned and developmentally appropriate educational activity toward identified objectives. The program should focus on achieving social competence, emotional and behavioral regulation, educational success, and the functional, adaptive, and vocational skills necessary for independence. (See 'Classroom environment' below and 'Attributes of successful educational programs' below.)
Details regarding IDEA and how a child can meet eligibility criteria for services under this mandate is discussed separately. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States", section on 'Individuals with Disabilities Education Act'.)
Classroom environment — Classroom placement for the child and adolescent should be guided by individualized goals and the supports that are necessary to achieve them [28]. Different schools may use different models. The goal is to promote independent functioning and, if appropriate, transition to a general education classroom with support.
Children and adolescents with ASD may spend most of the school day in a general education classroom with interventions occurring in the same setting, in a classroom separate from the general education setting, or a combination of the two. Some children may receive all interventions in a smaller classroom with a higher teacher-to-student ratio, more specialized educators, and peers who have similar developmental and behavioral profiles. Although placement in the general education setting might be optimal for some students, they may require part- or full-time support from an aide or professional who provides behavioral support (eg, a behavioral therapist) in that setting. Placement in a smaller classroom may be necessary for individuals who require more extensive support.
Attributes of successful educational programs — The attributes of a successful educational program for an individual child with ASD will vary depending on the child's chronological age, developmental level, specific strengths and weaknesses, and family needs [10]. Effective educational programs provide a minimum of 25 hours per week of intervention services [1,10].
To better understand the child's learning environment and program, the clinician can ask a series of questions regarding the special education services and interventions being provided, as listed in the table (table 1). The responses to these questions, in conjunction with information about the child's functioning, can be used to help families determine if the program is appropriate. Core features of successful educational programs for individuals with ASD have been identified and are also listed in the table (table 1) [1,10,28-31].
Role of the clinician — The IEP should include measurable goals that are appropriate to students with ASD and related to their social, communication (eg, speech therapy), and physical (eg, occupational and physical therapy), development, and academic needs. Clinicians should evaluate whether the goals are appropriate and whether students are meeting their goals in a timely fashion. If they are not, the clinician needs to consider whether the intensity or quality of the intervention is appropriate. A tool for evaluating the quality of the IEP for children with ASD incorporates the requirements of the Individuals with Disabilities Education Act and the National Research Council's recommendations for children with ASD and is available in the following reference [27].
INTERVENTIONS FOR CORE SYMPTOMS
Behavioral interventions — Behavioral interventions refer to a diverse group of practices that seek to target all of the core symptoms of ASD (ie, social communication, social interaction, and restricted/ repetitive interests and behaviors ) [7,28]. They are based on the principles of behavioral analysis, which focuses on modification of observable behaviors and skills. Behavioral interventions are typically begun in early childhood but can also be used for school aged children and adolescents (table 2). (See 'Age-based considerations' below.)
Intensive behavioral intervention — Applied behavior analysis (ABA) is the most commonly available and widely used intensive behavioral intervention. It seeks to build skills that children are not developing naturally and decrease behaviors that interfere with a child's functioning [32]. ABA teaches new skills by setting incremental goals within a controlled environment and a one-to-one child-to-therapist ratio. Learned skills are then "generalized" by supporting the application or use of the skill in new environments (eg, home or school). The individual's response to the intervention is documented so that the intervention can be modified as needed.
Research and clinical classifications vary, and a universal intensive behavioral system does not exist. Examples of interventions that use the principles of ABA are included in the table (table 2). This is not an exhaustive list but includes those that are most common in the United States. The nomenclature for these and similar programs may vary based on the geographic region.
ABA can have a more structured approach when it is provided in the form of Discrete Trial Training (DTT) or can have a less structured approach when provided within the context of an individual's natural environment. The choice of more versus less structured intervention depends on the severity of symptoms, including associated cognitive and language delays. For example, children with more severe symptoms may require more structured teaching. Other factors to consider include the child's age, program availability, therapist's skill set, and parent's/caregiver's comfort with structured interventions (which may initially upset the child). (See 'Age-based considerations' below.)
To maximize success, intensive behavioral programs should be performed by therapists trained in the modality with a low student-to-therapist ratio and higher intensity (eg, at least 10 to 20 hours per week) [9,33]. The program may be delivered in a variety of settings (eg, home, self-contained classroom, inclusive classroom, community) [7,34].
●Efficacy – Intensive behavior programs, such as ABA, may improve core symptoms of ASD and maladaptive behaviors but do not result in complete resolution of symptoms and behaviors [7,9,12,16,32,35-37]. Pretreatment variables that are associated with improved outcomes include the presence of joint attention, functional play skills, higher cognitive abilities, decreased severity of ASD symptoms, and positive response to treatment in the first year [38-40].
In Phases 1 and 2 of the National Autism Center's National Standards Report, intensive behavioral intervention had favorable effects and was considered to be an "established" treatment [7]. The efficacy of ABA by age group is discussed below. (See 'Age-based considerations' below.)
Intensive behavioral interventions, generally have a larger body of supportive evidence than other types of interventions [2,36,41,42]. This may be because data collection about the child's response to therapy can provide information on the efficacy of individual intervention programs. However, there are limitations. For example, in practice, not all interventions are applied as intended, which may impact their effectiveness. In addition, systematic reviews of randomized trials and cohort studies evaluating these interventions have had methodologic limitations [1,7,9,12,15-19,32,35,36,43]. Although research is ongoing, it is unclear whether one type of intensive behavioral intervention is better than another and how to determine which children with ASD will respond maximally to intensive behavioral interventions based on baseline symptom presentation [9,12,17,18].
Targeted behavioral intervention — Targeted behavioral intervention is another established therapy that addresses specific behaviors associated with ASD such as sleep disturbance, excessive tantrums, highly restrictive eating, elopement (ie, wandering off or running away), aggression, and self-injurious behaviors [32,44]. Before initiating interventions for a specific behavior, the clinician should evaluate for other problems that can cause these behaviors, such as a specific developmental deficit, medical concern (eg, constipation, pain, other illness), or sensory problem [32]. (See "Autism spectrum disorder in children and adolescents: Overview of management and prognosis", section on 'Surveillance for comorbidities' and "Autism spectrum disorder in children and adolescents: Evaluation and diagnosis", section on 'Evaluation for associated conditions'.)
Targeted behavioral interventions often start with a Functional Behavioral Assessment (FBA), preferably completed by a therapist who is trained in behavioral interventions (eg, a Board Certified Behavioral Analyst [BCBA]). The goals of this assessment are to establish the baseline frequency and duration of a defined behavior and to gather information regarding the factors that trigger it and contribute to its continuation. This information is then used to develop a targeted behavioral intervention plan and monitor progress.
In a systematic review of 251 studies of targeted behavioral interventions, focal behavioral interventions consistently resulted in positive behavioral outcomes across a wide range of targets, including aberrant behaviors (eg, self-injury, aggression), language skills, daily living skills, social skills, and academic skills [37].
Behavioral parent training — Specialized parenting methods can help promote skills development and the adoption of daily living skills, prevent aggressive behaviors, and reduce the frequency of unsafe behaviors in the community such as elopement (ie, wandering off or running away). Behavioral parent training can be provided as part of a child's ABA program or as a separate, manualized (ie, curriculum based) intervention.
Evidence on the effectiveness of behavioral parent training is mixed:
●A meta-analysis of randomized trials including 653 children found that manualized behavior parent training programs had moderate effects in reducing disruptive behavior in children with ASD [45]. Specific programs such as The Research Units in Behavioral Intervention (RUBI) Autism Network Parent Training for Disruptive Behavior, Stepping Stones Tiple P, Triple P-Positive Parenting Program, and Functional Behavioral Skills Training demonstrated efficacy and feasibility. Further community-based studies on the effectiveness of these interventions are needed.
●An Agency for Healthcare Research and Quality (AHRQ) systematic review found a few studies that suggested the utility of parent training in improving behavioral outcomes generally and when used in addition to medication intervention (eg, risperidone) for children with challenging behaviors [46]. However, the studies were small, relied on parent report, and used varying intervention models.
Developmental and relational interventions — Developmental and relational (ie, relationship-based) intervention models focus on teaching the individual skills that are essential to development (eg, social communication, emotional relationships, cognitive abilities) that were not learned adequately at the expected age. Availability of these interventions can vary by region. In some areas, they are more accessible to families as an alternative or adjunct to intensive behavioral interventions.
Examples of commonly used developmental and relational models are provided in the table (table 2).
Evidence for the effectiveness of these interventions is inconclusive [7,9,43]. The variety of approaches to developmental therapies makes it difficult to interpret, compare, and generalize results. A systemic review found evidence of benefit for some developmental approaches [9]. For example, Responsive Teaching (RT) was associated with improvements in quality of social communication and expressive language [47].
Social skills instruction — Social skills instruction is an important component of ASD management since challenges in social function are one of the core features of ASD.
Increasing evidence has demonstrated that social skills group training (SSGT) has moderate positive effects on social behavior [5,8]. A meta-analysis of randomized trials found large positive treatment effects of SSGTs on social communication and restricted/repetitive behavior with moderate effects on improved social behavior [48]. Manualized (ie, curriculum based) SSGTs that define and operationalize the teaching of social behaviors through the use of didactics, video vignettes, live practice, and in-vivo coaching have shown a larger positive impact on the development of social behavior and social communication. There is less evidence to support social cognition-based SSGTs, although these interventions are routinely used in clinical practice by speech and language pathologists and similar professionals [49].
SSGT programs that have demonstrated efficacy include:
●Program for the Education and Enrichment of Relational Skills (PEERS) – In a randomized trial of 22 young adults with ASD (ages 18 to 24 years), participants in the PEERS program had both short and long term gains in social functioning, including improved social knowledge, increased social responsiveness, and greater frequency of initiating social interactions [48,50].
●Children's Friendship Training (CFT) – In a randomized trial of 76 children (second to fifth grade), 87 percent of CFT participants showed improved peer interaction skills (eg, enhanced conversation and peer entry, behavior during cooperative play) and increased independence in navigating teasing per parent reported outcomes [51]. These gains were maintained in 67 percent of participants at three-month follow-up. In a study of 40 children with ASD (ages 7 to 12 years), CFT participants showed improved social and play skills per parent report [52].
Although Social Thinking Curriculum (STC) is widely available in schools and other community-based social skill programs, there are no randomized trials and few studies on the effectiveness of the model.
OTHER INTERVENTIONS
Communication interventions — Interventions to promote communication skills are essential to improving overall functioning [32]. These interventions include speech- and language-based interventions and focus on social and functional communication skills. The specific goals of communication interventions vary depending on the child's level of function but include increasing expressive, receptive, and pragmatic language. These interventions are typically begun in early childhood, but older children and adolescents may also require such interventions. (See 'Age-based considerations' below.)
Communication intervention models and approaches vary. Some experts feel that overall communication intervention should be part of a comprehensive program addressing the core symptoms of ASD. Others feel that individuals with communication challenges require more targeted speech and language interventions.
Children with ASD benefit most from language interventions that span settings and are incorporated into their daily routines [32]. In clinical practice, many therapists use a total communication approach to promote verbal language skills and enhance overall communication skills. The communication program may include a variety of interventions such as:
●Traditional speech and language therapy
●Behavior-based strategies to encourage language
●Augmentative communication strategies (eg, picture exchange system, gestures, sign language, electronic communication systems)
●Visual supports (eg, visual schedules, choice boards)
Traditional speech and language therapy is an established intervention, but there is insufficient evidence to support other specific interventions [7,9]. The More Than Words program is a social communication intervention that is typically provided by trained and certified speech and language pathologists. Although it has been associated with positive outcomes in facilitative strategies and vocabulary, it has failed to show gains in other areas [53].
Augmentative communication strategies are emerging interventions and increasingly used to promote communication in children with ASD. They are based on evidence that children with ASD may be more stimulated to learn speech if they already have an understanding of symbolic communication [54-56]. More flexible communication systems incorporating photographs, pictures, scene arrays, and video and voice output are now available through personal computers and mobile devices.
Although parents/caregivers may be concerned that use of augmentative strategies inhibits the development of communication and language skills, this is not the case [28]. Augmentative communication interventions have demonstrated benefit:
●Reviews have found that use of augmentative communication strategies for individuals who are nonverbal or have diminished language skills helps promote communication and decrease frustration related to communication deficits [54,57,58].
●The use of a specific augmentative communication system called Picture Exchange Communication System or PECS (a system through which an individual is taught to use pictures to communicate) is common in clinical practice and can help improve communication initiation [1,7,43,46].
●Studies of computer-assisted instruction [59-61] and sign language training [62,63] have reported that these interventions may result in improvement in some areas, but systematic reviews did not result in clear conclusions [7,9].
Occupational therapy
●Traditional occupational therapy – Children with ASD commonly present with deficits in adaptive and fine motor skills that affect academic and everyday functioning. Occupational therapy is often used to address these deficits.
In young children with ASD, occupational therapy usually focuses on improving fine motor skills, visual-motor integration, sensory processing, sensorimotor and social-behavioral performance, self-care (eg, dressing, hygiene), and participation in play [64]. In older children, the focus of occupational therapy may include ongoing intervention for fine motor skills, visual-motor integration, and social-behavioral performance skills as well as transition to work and independence in the community.
●Unclear role for sensory integration therapy – The role of sensory integration in ASD therapy is not clear [7,65]. Specific occupational therapy interventions that target improvement in sensory functioning have not been validated, although sensory impairment is recognized as part of the diagnostic criteria for ASD according to the DSM, Fifth edition Text Revision (DSM-5-TR) [66]. They should not be used as a primary intervention for ASD; if initiated, continued use should be based on treatment response in the individual child, cost to the family, impact on access to other therapies, and lack of negative effects.
Ayres Sensory Integration therapy is provided by occupational therapists and is thought to address dysfunction of the sensory system (eg, hyperresponsiveness or hyporesponsiveness). The dysfunction is thought to result from aberrations in the integration of sensory experiences (eg, vestibular, proprioceptive, gravitational, tactile, visual, and auditory) that help to guide development [65]. Based on this theory, therapy involves using specific equipment and techniques (eg, Ayres listening therapy) to provide intensive sensory inputs.
Expert groups have concluded that sensory integration may be used as part of a comprehensive program to calm the child, reinforce desired behaviors, or help with transitions between activities; however, it should not replace other interventions [28,65]. Placebo controlled randomized trials do not support the efficacy of sensory integration therapy alone in improving symptoms of ASD [6,67]. Nevertheless, there remains strong support based on anecdotal improvements [65,68-71]. Although there is little information about its potential harms, many of the interventions that are used in sensory integration therapy are also used in traditional occupational therapy without adverse effects [68].
Interventions for comorbid psychiatric conditions — Individuals with ASD have a high incidence of psychiatric comorbidities, including disorders of attention, anxiety, and mood dysregulation [72]. Although cognitive behavioral therapy (CBT) has not been shown to be effective at improving the core symptoms of ASD [73], it is an established intervention in children and adolescents for managing co-occurring symptoms of anxiety and mood dysregulation [44,74-81]. CBT-based interventions should be tailored to the specific needs of the individual with ASD in order to have positive treatment effects similar to those seen in other populations [44,80]. Psychopharmacology is also helpful and is discussed separately. (See "Autism spectrum disorder in children and adolescents: Pharmacologic interventions".)
In a systematic review, CBT-based interventions were associated with a reduction in anxiety symptoms in individuals with ASD and intelligence quotient (IQ) ≥70 [15]. There is mounting evidence for the use of specific programs that utilize CBT specifically for individuals with ASD (eg, Facing Your Fears [82,83] to improve anxiety, Unstuck and on Target [84] to improve executive functioning, and the Stress and Anger Management Program [85] for improving mood). Commonly used CBT approaches such as Unified Protocol appear to be effective at addressing symptoms of anxiety and mood dysregulation (eg, depression) in individuals with ASD and are applicable across comorbid psychiatry conditions [86].
AGE-BASED CONSIDERATIONS —
The majority of research has focused on interventions that target preschool and school-aged children. There is emerging information about practices focused on ASD in adolescents and increased focus on research including children younger than two years [87].
Pretreatment factors such as significant cognitive and language delay in combination with more severe ASD symptoms may be associated with less robust improvement [88-92], but further studies are needed.
Toddlers and preschool-aged children
Intervention program components — As more young children are diagnosed with ASD, early intervention for toddlers (children under three years of age) and preschool-aged children (aged three to five years) is important. Although many of the principles and interventions described above can be used in younger children, several models have been specifically developed for toddlers. (See 'General principles of effective intervention' above and 'Intervention models' below.)
Components of successful programming for toddlers should include, but are not limited to:
●Intensive intervention, use of applied behavior analysis (ABA) principles with a more naturalistic approach (ie, using natural opportunities for learning such as play).
●Integrative model with related services (eg, speech, occupational therapy).
●Parent/caregiver involvement for the purpose of carryover into daily routines [87].
In addition, programs for toddlers should focus on developing [87]:
●Natural learning environments by stimulating learning in the context of everyday life and play activities.
●Child initiative and sensory-motor exploration by getting the child to initiate play and exploration.
●Development of nonverbal intentional communicative acts by helping with intentional nonverbal communication (eg, pointing to request).
●Reciprocal play with social partners by encouraging participation in partnered activities that are not language intensive (eg, peek-a-boo, throwing or kicking a ball).
●Enriched language environments by using language to interact, share a focus, take turns.
●Environments that provide opportunities for toddlers to have an active role in learning by creating spaces that invite communication, interaction, and active play.
Children who do not respond as favorably to interventions in natural learning environments should be provided with more heavily structured, one-to-one intervention (eg, Discrete Trial Training [DTT]). These and other interventions are discussed in more detail separately. (See 'Intensive behavioral intervention' above and 'Interventions for core symptoms' above and 'Other interventions' above.)
Intervention models — Intervention models specifically tailored to toddlers and other young children are effective in improving core deficits related to ASD (eg, joint attention, communication, imitation, social reciprocity) and are becoming more widely accessible in community-based settings. Although they have specific components targeting the needs of younger children, they are classified under the category of ABA. (See 'Intensive behavioral intervention' above.)
Examples of accessible intervention models with training methods for professionals who provide care to young children include the Early Start Denver Model (ESDM), Joint Attention Symbolic Play Regulation (JASPER), Project ImPACT, and Incidental Teaching. Availability may vary by region. These programs can be employed as stand-alone ABA-based behavioral interventions or integrated with more structured ABA intervention approaches (eg, DTT). For example, Incidental Teaching is a naturalistic approach for children with ASD starting at two years of age to address behavioral needs and delays in language and social skills [44]. Details regarding these and other intervention models are discussed below and elsewhere (table 2). (See 'Behavioral interventions' above.)
●Early Start Denver Model (ESDM) — ESDM is intended for children with ASD who are 12 to 48 months of age and focuses on behaviorally based goals within a developmental framework. It includes direct, one-on-one work with the child and parent/caregiver training on strategies to incorporate skills into the child's daily routine.
ESDM has demonstrated benefit in some children:
•In a meta-analysis of 12 randomized trials and comparative studies including a total of 644 children with ASD <6 years of age, those who participated in ESDM demonstrated gains in cognition and language but less robust improvements in core ASD symptoms and adaptive behavior [93].
•In a systematic review including two randomized and six nonrandomized studies of toddlers and preschool-aged children with ASD, those who participated in ESDM demonstrated improvement in cognition, language, and adaptive behavior [94].
In one of the randomized trials including 48 children with ASD between 18 and 30 months of age, those who participated in ESDM demonstrated significant gains in language, cognitive, and adaptive functioning over a two-year period compared with those participating in community-based intervention programs [95].
In a follow-up study of 39 children included in the above randomized trial, those who participated in ESDM demonstrated long-term improvements in both core ASD symptoms and individual developmental domains including cognition, adaptive skills, and behavior at age six years, which was two years after the intervention ended [96].
•A subsequent multisite randomized trial of 118 children with ASD between 14 and 24 months of age demonstrated replication of these treatment gains for the ESDM group at two sites but not at a third site [97].
•In a study of 13 children with ASD between 34 to 54 months of age, those who participated in ESDM demonstrated improvement in receptive language and reduction in parent-reported core ASD symptoms compared with those participating in intervention as usual [98].
●Joint Attention Symbolic Play Engagement Regulation (JASPER) — JASPER is a play-based approach intended for children with ASD aged 12 months to eight years and includes targeted behavioral interventions to address social communication skills [99,100].
In a systematic review of 19 randomized trials and comparative studies, children with ASD who received JASPER had significantly greater improvement in language, play skills, joint attention, and joint engagement in shared activities compared with those receiving treatment as usual [99].
●Project ImPACT — Project ImPACT is a parent/caregiver mediated intervention intended for children with ASD <8 years of age (language level up to 48 months). It follows a prescribed set of objectives to train parents/caregivers on how to facilitate the child's communication and social skills (eg, social engagement, language, imitation, and play) during daily routines and activities. These interventions in Project ImPACT are provided with lower frequency than those in other programs (approximately one to two hours of weekly parent/caregiver sessions for 12 to 24 weeks), which may help with program participation [101-103].
In pilot studies, Project ImPACT appears to improve language skills and parent-child interactions and may be appropriate to integrate in combination with other forms of intervention [104-106]. However, the evidence is limited as sample sizes have been small and age ranges highly variable. More research is needed in order to determine if Project ImPACT has efficacy in treating core challenges of ASD.
School-aged children and adolescents — For school-aged children and adolescents with ASD (eg, past five years of age), educational and behavioral interventions should also address core and targeted symptoms based on an individualized approach, as discussed above (see 'General principles of effective intervention' above). Intervention programs for older children and adolescents should focus on achieving social competence, emotional and behavioral regulation, and the functional adaptive and vocational skills necessary for independence. Individuals with a variety of ASD presentations may require targeted ABA programs to address deficits in skills or disruptive behavior at specific times in their lives [44]. Older children who have co-occurring cognitive, intellectual, and language impairments may require comprehensive ABA programs. Interventions are often provided across multiple settings, including special educational programming through an Individualized Education Program (IEP) and home- or center-based services through medical insurance. (See 'Interventions for core symptoms' above and 'Other interventions' above and 'Educational programming' above.)
The role and efficacy of ABA in older children and adults is less clear than in younger children. Although individuals who require ABA at an older age may be more impaired than individuals who received ABA at younger ages and no longer require ABA, a systematic review found sufficient evidence to support ABA in adults to increase communication and self-regulation and decrease maladaptive behaviors [44].
Research evaluating comprehensive educational programs specifically targeted for older children and adolescents with ASD is limited. However, empirical evidence supports the use of strategies based on ABA or general behavioral principles to increase and maintain adaptive behaviors, reduce maladaptive behaviors, teach new skills, and generalize behaviors to apply to new environments or situations [31,37,44,107].
Support across settings (TEACCH) — Several interventions and strategies can be used to support an individual in different environments. The TEACCH method uses Structured Teaching to help individuals overcome areas of weakness. The goal is to modify the environment (eg, home and/or school) and to improve skills.
The TEACCH method focuses on [42]:
●Using an individualized person and family-centered plan
●Organizing the physical environment
●A predictable sequence of activities
●Visual schedules
●Routines with flexibility
●Structured work/activity systems
●Visually structured activities
Evidence in support of TEACCH are mixed:
●In an Agency for Healthcare Research and Quality (AHRQ) systematic review, TEACCH appeared to improve cognitive and motor function, but the body of evidence was insufficient to estimate the magnitude of the effect [46]. Earlier systematic reviews reached similar conclusions, although one categorized TEACCH as "likely to be beneficial" [7,43].
●Nonrandomized studies comparing TEACCH with no intervention have noted improvements in fine motor skills, gross motor skills, cognitive functioning, social adaptive functioning, and communication skills [9,108-110].
Transition planning — Comprehensive transition planning includes a constellation of activities related to the needs of children with ASD and involves the student, parents/caregivers, teachers, medical home, and community agencies. We recommend starting to discuss planning with families as early as 14 years of age [111].
Individuals with ASD can face challenges with social functioning and employment as adults, thus it is important to incorporate interventions to mitigate these challenges in the transition plan. Transition resources are provided in the table (table 3).
Transition planning includes but is not limited to:
●High-school and age 18 to 22 education – By 16 years of age, the Individualized Education Program (IEP) for a child with ASD should include a plan for transition from child- to adult- oriented activities [28]. Depending on the state, all those with ASD and Intellectual Disability and some others with ASD are eligible to remain in the public school until age 21 or 22 years. However, programming is different from that provided up to grade 12 and may include college classes with supportive services, community work, and increased focus on development of life-skills.
●Postsecondary education and vocational needs – Transition planning for individuals with ASD also includes discussion of interventions after 22 years of age, such as vocational training, employment, or day programming. Day programming may be required for individuals who continue to require significant support beyond public school services between age 18 to 22 years. Families should start to investigate resources for students who seek postsecondary education early in the process and request reasonable accommodations as needed (eg, change in testing environment, extended time for tests, note taking support). Some postsecondary schools have programs specific to students with special needs, and traditional colleges and universities often provide resources for students. In addition, patients and families should consider the types of employment that may be available and if vocational support is needed for the individual.
●Transition to adult medical care – As a child with ASD nears 18 years of age, patients and families should have a discussion with their current care providers (eg, pediatrician, specialty providers) about the need to transition to an adult practitioner. The age at which this occurs can vary by practice.
●Legal issues – It is important to discuss the potential need for partial and full guardianship. Rules for states may differ; in some cases, a report from a medical provider or group of providers (eg, medical, psychological, social work) is needed to apply for guardianship. These reports require preparation time and should be discussed and planned for in advance. Discussion with an attorney who specializes in legal guardianship may be helpful for families who have children with complex needs.
●Adult services and housing needs – Families and patients should become familiar with state agencies that provide support for adults with ASD in their region, including program application deadlines. It is important to discuss long-term housing, financial, and other resource needs.
The above concepts and transition planning for children with special health care needs, intellectual disability, and primary care of adults with developmental disabilities are discussed in more detail separately.
●(See "Children and youth with special health care needs", section on 'Transition planning'.)
●(See "Primary care of the adult with intellectual and developmental disabilities".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Autism spectrum disorder".)
RESOURCES —
Resources for parents and clinicians on ASD interventions and other information is provided in the table (table 3).
SUMMARY AND RECOMMENDATIONS
●Goals of intervention – Individuals with ASD have varying presentations regarding social and behavioral function. The overarching goals of therapy are to maximize functioning, move the child toward independence, and improve the quality of life. Specific goals are to improve core symptoms and adaptive skills, decrease negative behaviors, reduce symptoms of co-occurring disorders, and promote academic functioning and cognition. (See 'Goals of intervention' above.)
●General approach – Behavioral and educational interventions targeting core and other symptoms may vary but should be tailored to the individual's specific needs. Earlier and more intensive therapies are associated with better outcomes. It is important to monitor response to therapy and emphasize the adaptation of intervention strategies into daily routines and different environments.
In the United States, for children with ASD who are under three years of age (in some states under five years of age), both educational and direct interventions are provided by government-funded early education programs. For school-aged children and adolescents, interventions can occur in the school environment or outside of school as part of a treatment covered by insurance or in combination. Clinicians can help families determine if the program is appropriate (table 1). (See 'Overview of intervention programs' above.)
●Interventions for core symptoms – Interventions targeting the core symptoms of ASD include applied behavior analysis (ABA), targeted behavioral interventions, developmental and relational interventions, parent/caregiver training, and social skills instruction (table 2). These interventions aim to reinforce desirable behaviors, decrease undesirable behaviors, and improve social and developmental skills. (See 'Interventions for core symptoms' above.)
●Other interventions
•Communication interventions – These interventions address social communication and language deficits and include traditional speech and language therapy, behaviorally based strategies, augmentative communication strategies, and visual supports. (See 'Communication interventions' above.)
•Occupational therapy – Traditional occupational therapy is often used to address deficits in adaptive functioning and fine motor skills. The role of sensory integration in ASD therapy is not clear. (See 'Occupational therapy' above.)
•Interventions for comorbid psychiatric conditions – Individuals with ASD have a high incidence of psychiatric comorbidities including disorders of mood and attention. Cognitive behavioral therapy (CBT) is an established intervention to manage these comorbidities and should be tailored to the individual's needs. (See 'Interventions for comorbid psychiatric conditions' above.)
●Age-based considerations
•Toddlers and preschool-aged children – Early intervention for toddlers (children under three years of age) and preschool-aged children (aged three to five years) is important. Although many of the interventions described above can be used in younger children, several models have been developed specifically for toddlers (children <3 years of age) (table 2). Interventions for younger children should focus on behavioral modification and improvement of social and communication skills within a natural environment and with parent/caregiver involvement. Some children may require more structured interventions. (See 'Toddlers and preschool-aged children' above.)
•School-aged children and adolescents – For school-aged children and adolescents with ASD (eg, past five years of age), educational and behavioral interventions should also address core and targeted symptoms based on an individualized approach, as described above. Intervention programs for older children and adolescents should focus on achieving social competence, emotional and behavioral regulation, and the functional adaptive and vocational skills necessary for independence. Interventions are often provided across multiple settings (table 1). (See 'School-aged children and adolescents' above and 'Support across settings (TEACCH)' above.)
•Transition planning – Transition planning from child- to adult- oriented activities should begin in early adolescence and be included in the IEP. Comprehensive transition planning involves the student, parents, teachers, medical home, and community agencies (table 3). (See 'Transition planning' above.)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Carolyn Bridgemohan, MD, who contributed to an earlier version of this topic review.
