Version May 2024
INTRODUCTION — Autism spectrum disorder (ASD) is a biologically based neurodevelopmental disorder characterized by persistent deficits in social communication/interaction and restricted, repetitive patterns of behavior, interests, and activities.
This topic focuses on behavioral and educational interventions for children with ASD. Related topics are presented separately:
●(See "Autism spectrum disorder in children and adolescents: Clinical features".)
●(See "Autism spectrum disorder in children and adolescents: Evaluation and diagnosis".)
●(See "Autism spectrum disorder in children and adolescents: Overview of management".)
●(See "Autism spectrum disorder in children and adolescents: Pharmacologic interventions".)
●(See "Autism spectrum disorder in children and adolescents: Complementary and alternative therapies".)
OVERVIEW — Individuals with ASD have varying degrees of impairment in social and behavioral function (see "Autism spectrum disorder in children and adolescents: Evaluation and diagnosis", section on 'Diagnostic criteria'). Management of ASD is individualized according to age and specific needs [1]. It requires a multidisciplinary lifespan approach that makes use of the individual's strengths to address their challenges.
Behavioral, developmental, and educational interventions target the core symptoms of ASD with the objective of improving overall function. Intensive behavioral and educational interventions are the primary component of treatment programs for children and adolescents with ASD [2]. The interventions typically are carried out by special education personnel or trained therapists.
Adult advocates with autism have raised concerns that autism is conceptualized as a medical disorder rather than a form of neurodiversity. This underscores the importance of remaining sensitive to the way that language may impact individuals. The adult advocacy group favors using person-first versus identity-first language when discussing autism. Similarly, the term "treatment" when referring to autism may imply that autism is a disease that requires treatment rather than part of a person's general makeup and identity.
This topic alternates between person-first and identity-first language when summarizing the evidence-based interventions to date. This terminology may change over time, and providers should be sensitive to this when talking with their patients and families. Interventions discussed in this topic focus on therapies that aim to increase a child's or adolescent's overall functioning when they are experiencing challenges.
Goals of therapy — Although treatment programs for children and adolescents with ASD vary, they generally focus on similar objectives. The overarching goals of treatment are to:
●Maximize functioning
●Move the child toward independence
●Improve the quality of life for the child and family
Specific goals are to [1,3,4]:
●Improve social functioning and play skills
●Improve communication skills (both functional and spontaneous)
●Improve adaptive skills
●Decrease nonfunctional or negative behaviors
●Promote academic functioning and cognition
Effectiveness — Practical and ethical factors have made it challenging to evaluate intervention programs for ASD in randomized controlled trials [5]. Choosing an appropriate outcome measure is particularly challenging, given the heterogeneity of presentations with the autism spectrum. Instruments that are typically used for diagnosis may not demonstrate incremental improvements in core deficits. The strength of the literature on behavioral and educational interventions for ASD is mixed but stresses the importance of early intervention [2,6,7]. (See "Autism spectrum disorder in children and adolescents: Overview of management", section on 'Early intervention'.)
Systematic reviews of small randomized trials and nonrandomized controlled trials have found that certain behavioral and education treatment strategies are associated with improvements in the core symptoms of ASD (behavior, language skills, and peer interaction) and intelligence quotient (IQ; intelligence test scores) [6-22]. However, the methodologic limitations of the individual studies make it difficult to be certain about the effectiveness of particular programs [8,18,20]. Methodologic limitations include the lack of outcome measures that are sensitive to changes in autism symptomatology and the inability to measure or control pretreatment factors, such as environmental context, other treatments, comorbid conditions, etc [5]. Questions remain regarding the optimal age at initiation of treatment, language and cognitive skills necessary for certain treatment modalities, intensity of treatment (ie, number of hours per week), magnitude and type of benefit, and whether certain programs are better than others for certain children [6,18,23-27]. There is limited evidence regarding treatment programs for adolescents with ASD.
The National Research Council, one of the four agencies that make up the National Academies including the Institute of Medicine, recommends that educational services begin as soon as a child is suspected of having an ASD [6]. The services should include a minimum of 25 hours a week, 12 months per year, in which the child is engaged in systematically planned and developmentally appropriate educational activity toward identified objectives. (See 'Attributes of successful programs' below.)
Most research has focused on the treatment of preschool and school-aged children. There is emerging information about treatment of ASD in adolescents and children younger than two years [28]. (See 'Programs for toddlers' below and 'Programs for older children and adolescents' below.)
Attributes of successful programs — Despite the lack of evidence from randomized controlled trials, there is growing evidence from observational studies and systematic reviews and a general consensus in the professional community that children with ASD should participate in therapeutic programs as early as possible [1,2,6,7,29].
Core features of successful autism educational programs identified in observational studies and systematic reviews include [1,2,6,7,27]:
●A high staff-to-student ratio (1:1 or 1:2)
●Individualized programming for each child
●Family involvement
●Teachers with special expertise in working with children with autism
●A minimum of 25 hours per week of services
●Functional analysis of behavior problems
●Ongoing program evaluation and adjustment
●Close monitoring and modification as the child's needs change
●A curriculum emphasizing attention, imitation, communication, play, social interaction, regulation, and self-advocacy
●A highly supportive teaching environment
●Predictability and structure
●Transition planning
The components of the educational program for an individual child with ASD will vary depending upon the child's chronologic age, developmental level, specific strengths and weaknesses, and family needs [6]. However, minimal intensity (ie, 25 hours per week) is critical to effective intervention [1,6].
To better understand the child's learning environment and program, the pediatric health care provider can ask the following questions:
●How many days a week does the child attend and how much time does he or she spend in each setting?
●How many students and providers are in each setting?
●What therapies is the child receiving? For how long? Are the therapies provided individually or in group settings?
●Are there any home-based therapies?
●Who is providing the therapies? Who is overseeing the program? What are their qualifications?
●Is parent training included in the program to expand the impact of the intervention?
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. A tool for evaluating the quality of Individual Education Programs for children with ASD that incorporates the requirements of the Individuals with Disabilities Education Act and the National Research Council's recommendations for children with autism is available in the full text of reference [30].
Classroom environment — The classroom placement should be guided by the child's individualized goals and objectives and the supports that are necessary to achieve them [2]. Different schools may have different models. The goal is to promote independent functioning and, if appropriate, transition to a regular classroom with support.
Children who require a lot of support may be placed in a small classroom with a high teacher-to-student ratio and other children with similar behavioral profiles. They may receive all of their therapies in the classroom or be taken to a small therapy room. They may spend the entire day in the small classroom or part of the day in a classroom with more typically developing peers. If they spend part of the day with typically developing peers, they may require part- or full-time support from an aide or behavioral therapist in that setting.
INTERVENTIONAL MODELS — Children with ASD generally require a combination of therapies and interventions to address their individual constellation of symptoms. Approaches can be broadly categorized according to conceptual models; however, there is no uniformly agreed upon classification system. The availability of programs varies by region; access to interventions may affect the choice of programming.
Because most of the interventions use more than one treatment approach, it may be helpful to consider the various techniques as part of an intervention system that [31]:
●Has a variety of components, including:
•Behavioral (behavioral modification and shaping using behavioral therapy and principles)
•Structured teaching (modifying the environment to provide optimal outcome)
•Developmental/relationship-based (promoting reciprocal social interaction, joint attention, and shared emotion)
●Targets specific domains (eg, social, language, cognitive)
●May occur in various settings (eg, naturalistic versus structured)
●Involves the parents, particularly when interventions are provided in the home
A systematic review found insufficient evidence to suggest that any particular interventional model is superior to another [1]. However, there is moderate evidence that greater intensity (in hours per week) and greater duration (in months) of treatment lead to better outcomes. A 2014 systematic review found evidence that early behavioral, developmental/relationship-based interventions can improve outcomes in many areas in young children [32].
Some of the commonly used therapies in treatment programs for children with ASD are described below.
Intensive behavioral interventions — Intensive behavioral interventions seek to target the defining symptoms of ASD (ie, deficits in social communication/interaction and restricted, repetitive interests, behaviors, and activities) [2,14]. They are based upon the principles of behavior modification. One such intensive behavioral intervention, Applied Behavior Analysis (ABA), seeks to reinforce desirable behaviors and decrease undesirable behaviors [15]. The goals of ABA are to teach new skills and generalize learned skills by breaking them down into their simplest elements. The skills are taught through repeated reward-based trials.
To maximize success, intensive behavioral programs should have a low student-to-therapist ratio. They may be delivered in a variety of settings (eg, home, self-contained classroom, inclusive classroom, community) [14,33].
Examples of specific intensive behavior intervention programs include [14]:
●Discrete trial training (DTT), which is the most structured form of intensive behavior therapy; it was developed by Ivar Lovaas.
●Contemporary ABA programs, which occur in more naturalistic settings; they include pivotal response training (PRT), language paradigms, and incidental teaching (teaching as events occur in the context of the natural environment).
●Early intensive behavioral intervention (EIBI).
These intensive behavioral programs have some evidence of effectiveness in randomized and observational studies [3,34-36]. However, many other interventions use behavioral principles including identifying a target behavior, and using behavioral modification and shaping as part of the treatment.
●Effectiveness – Intensive behavioral intervention programs have a larger body of supportive evidence than other types of interventions [3,34]. One reason for this is that ABA methodology requires collection and analysis of detailed data about the child's response to therapy. When performed in the manner in which it was developed, ABA includes intensive data collection, which provides appropriate monitoring of efficacy of individual treatment programs and promotes change in programs and goals when needed. However, in practice, not all interventions are applied as initially intentioned, which may affect their effectiveness.
Intensive behavioral intervention programs for ASD have been evaluated in systematic reviews of randomized trials and cohort studies, most of which had methodologic limitations [1,9-16,18,20,32,35]. With evidence of benefit from several well-controlled studies, the National Autism Center's National Standards Report, Phases 1 and 2, systematic reviews of the peer-reviewed behavioral and educational literature (1957 to 2007 and 2007 to 2012) considers intensive behavioral intervention to be an "established" treatment [14]. The Phase 2 review added review of evidence for treatments of adults (1987 to 2012) [37].
Intensive behavior programs may improve core symptoms of ASD and maladaptive behaviors but should not be expected to lead to typical function [9,10,13-15,18,35,38]. The studies revealing the most gains for intensive behavior programs included a high level of intervention (eg, 30 to 40 hours per week of intensive one-on-one services for two or more years and starting before the age of five years) [9,39]. However, the evidence is insufficient to provide a general recommendation that all children with ASD require this level of intervention. The most significant improvements generally are seen within the first 12 months of treatment [11]. Pretreatment variables that are associated with improved outcomes include the presence of joint attention, functional play skills, higher cognitive abilities, and decreased severity of autism symptoms [40-42].
Although research is ongoing, it is unclear whether one type of intensive behavioral intervention is better than another, how to determine which children with ASD will respond maximally to intensive behavioral interventions, and whether intensive behavior programs should be recommended over other types of treatment programs [9,11,16,18].
●Compared with other interventions – Although ABA methods appear to be efficacious when compared with control interventions (eg, special education), it is not clear that ABA is superior to other behavioral therapy methods [9]. There are very few studies comparing ABA with other treatment models, and those studies have methodologic limitations. Those performed comparing ABA with a Developmental Individual Difference Relationship-based Model (Floortime) and Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) found no difference in efficacy [43,44]. (See 'TEACCH/Structured Teaching method' below and 'Developmental and relationship models' below.)
●ABA for older children – There is some controversy about the use of ABA for older children, and there are few studies to guide recommendations for this age group [2]. The studies tend to be smaller both in duration and in numbers [39]. Children requiring ABA at an older age may be more impaired than children who no longer require ABA. In such children, ABA may be used to target specific needs rather than broad deficits, limiting the generalizability of study results. A systematic review of the peer-reviewed behavioral and educational literature (2007 to 2012) found sufficient evidence to support ABA in adults to increase communication and self-regulation and decrease maladaptive behaviors [37].
TEACCH/Structured Teaching method — The TEACCH method uses Structured Teaching to help individuals overcome areas of weakness. The goal is to modify the environment and to improve skills.
The TEACCH method focuses on [36]:
●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
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 [9,45-47]. The 2011 Agency for Healthcare Research and Quality (AHRQ) systematic review of four studies of TEACCH published after 2000 found some evidence of benefit in cognitive and motor function, but that the body of evidence was insufficient to estimate the magnitude of the effect [48]. This conclusion is similar to that of earlier systematic reviews, although one categorized TEACCH as "likely to be beneficial," based upon consensus [12,14].
Developmental and relationship models — Developmental and relationship-based models focus on teaching skills that are essential to development (eg, social communication, emotional relationships, cognitive abilities) that were not learned adequately at the expected age. Some commonly used developmental models are described in the table (table 1). They include the Denver model; Developmental Individual Difference Relationship-based approach (DIR or Floortime); Relationship-Development Intervention (RDI); Reciprocal interaction; Incidental teaching; PRT; and Responsive Teaching (RT).
Developmental therapies often are used in clinical practice. However, the evidence is inconclusive [9,12,14]. The variety of approaches to developmental therapies makes it difficult to interpret, compare, and generalize results. A 2008 systemic review found evidence of benefit for some developmental approaches, as illustrated below [9]:
●Milieu therapy was associated with improvement in cognitive skills, overall course, and communication and play skills [49,50].
●Responsive teaching was associated with improvements in quality of social communication and expressive language [51].
●The More Than Words program was associated with positive outcomes in facilitative strategies and vocabulary but failed to show gains in other areas [52].
Integrative models — Many programs use an integrative approach that combines developmental and behavioral approaches in the natural environment. Joint Attention Symbolic Play Engagement and Regulation (JASPER) addresses development of joint attention and social communication [53-59].
Comprehensive integrative models address multiple domains of function. The Social Communication/Emotional Regulation/Transactional Support (SCERTS) program is an example, although it is sometimes classified as a relationship-based model. The SCERTS program provides individualized, collaborative programming that addresses social communication deficits and interfering behaviors to help the child increase his or her competence and independence using various strategies supported in the literature.
The Early Start Denver Model (ESDM) uses a combination of intensive ABA programming and developmental- and relationship-based approaches, and includes parents as therapists. A randomized trial comparing the ESDM program with interventions commonly available in the community demonstrated significant language, cognitive, and adaptive functioning gains in 48 toddlers over a two-year period [60]. These gains were sustained in the two years after the intervention was discontinued [61]. In addition, during the two-year follow-up period, core symptoms of ASD and adaptive behavior improved in the ESDM group compared with the community intervention group. Although this trial suggests that this particular combination of ABA and relationship-developmental model is efficacious in young children, it is not clear that the results can be generalized to other specific models or combinations of models [18]. A subsequent study demonstrated long-term improvements over two year follow-up for participants who received ESDM compared with community treatment for both core ASD symptoms and individual developmental domains including cognition, adaptive skills, and behavior [61].
Parental role — Parental and family involvement is an important aspect of the treatment program for children with ASD [14]. Some therapies may be provided in the home, especially for younger children, and parent training may be part of the intervention. Training parents in specific behavior management strategies may be more effective than providing parents with general education about ASD. In a 24-week randomized trial in which the parents of children with ASD were randomly assigned to receive specific behavior training for the management of maladaptive behaviors or general ASD education (eg, developmental changes in ASD, treatment options, advocacy, etc), more children in the parent-training group had a positive response on the Clinical Global Impression Improvement Scale, as assessed by a clinician blinded to the intervention (68.5 versus 39.6 percent) [62]. Disruptive and noncompliant behaviors improved in both groups immediately after the intervention, with slightly greater improvements in the parent-training groups (a difference of 3.9 points on the 45-point Aberrant Behavior Checklist-Irritability subscale and a difference of 0.7 points on the 9-point Home Situations Questionnaire-ASD). However, the clinical significance of these small improvements, assessed by parents who were not blind to the intervention, is unclear.
Parent-mediated interventions may help families interact with their child, promote development, and increase parental satisfaction, empowerment, and mental health [15,63-65]. However, which parental interventions maximize outcomes is unknown. Parent-mediated intervention programs must be individualized to the child and changes made based on the child's progress. (See 'Attributes of successful programs' above.)
A 2013 systematic review and meta-analysis of 17 randomized trials (919 children) of parent-mediated interventions compared with no treatment or treatment as usual found that parent-mediated interventions improved patterns of parent-child interactions, and suggested improvements in parent-reported language comprehension and severity of autism characteristics (child communication and social development) [64]. Six-year follow-up of approximately 80 percent of the participants in one of the included trials, which compared a 12-month parent-mediated social communication intervention with treatment as usual in 152 preschool-aged children with ASD [63], found sustained improvements in severity of autism symptoms, social communication, and restricted/repetitive behaviors in the treatment group [66]. However, the clinical significance of the modest reported changes in symptom severity is unclear. In addition, the changes in restricted and repetitive behaviors were based on unblinded parent report. These findings reinforce the importance of early intervention as well as the need for meaningful outcome measures.
Interventions for specific behaviors — Behavioral interventions may be used to target specific behaviors (eg, sleep disturbance, failure to initiate social contact with peers, self-injury) [14,15]. Before initiating a behavioral intervention for a specific behavior, the possibility that the behavior is related to a particular skill deficit or sensory problem should be evaluated [15].
A systematic review of 251 studies of targeted behavioral interventions found that focal behavioral interventions consistently result in positive behavioral outcomes across a wide range of targets, including aberrant behaviors (eg, self-injury, aggression), language skills, daily living skills, social skills, etc [38]. The National Autism Center's National Standards Reports consider targeted behavioral interventions to be an "established" treatment [14,37].
A 2014 systematic review of studies published after 2000 found several studies suggesting that cognitive behavioral therapy (CBT)-based interventions were effective in reducing anxiety symptoms in individuals with ASD and intelligence quotient (IQ) ≥70 [32]. The 2015 National Standards systematic review classifies CBT as an established intervention for children and adolescents [37]. The AHRQ systematic review also found a few studies suggesting the utility of parent training for improving behavioral outcomes in general and of adding parent training to medication interventions (risperidone) for children with challenging behaviors. However, the studies were small, relied on parent report, and used varying intervention models.
OTHER INTERVENTIONS
Communication interventions — Communication-, speech-, and language-based interventions seek to improve core deficits in social and functional communication skills. Interventions to promote communication skills are essential to improvement in overall functioning [15]. The specific goals of communication interventions vary depending upon the child's level of function but include increasing expressive, receptive, and pragmatic language.
Children with ASD benefit most from language interventions that span settings and are incorporated into their daily routines [15]. Many therapists in clinical practice use a total communication approach to promote verbal language skills and enhance overall communication skills. The communication program may include a variety of interventions, including:
●Traditional speech and language interventions
●Behaviorally 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)
There is insufficient evidence to support a specific methodology for improvement of communication skills in children with ASD [9,14]. Systematic reviews have found individual controlled trials of computer-assisted instruction [67-69] and sign language training [70,71] that suggested improvement in some areas, but could draw no overall conclusions [9,14].The 2015 National Standards systematic review classified language training (for speech production) as an established intervention. A number of other communication-focused interventions such as picture exchange are classified as emerging interventions.
The use of augmentative communication strategies for individuals who are nonverbal or have diminished language skills can be helpful in promoting communication and decreasing frustration related to communication deficits [72-74]. The use of a specific augmentative communication system called PECS, or Picture Exchange Communication System (a system through which an individual is taught to use pictures to communicate), is common in clinical practice. It can be helpful in improving communication initiation. Systematic reviews of the effectiveness of PECS have generally found it to be beneficial [1,12,14,48]. More flexible communication systems incorporating photographs, pictures, scene arrays, and video and voice output are now available through personal computers and mobile devices. These are used increasingly to promote communication in children with ASD.
Parents may be concerned that use of augmentative strategies inhibits the development of communication and language skills, but this is not the case [2]. There is some evidence to suggest that children with ASD may be more stimulated to learn speech if they already have an understanding of symbolic communication [74-76].
Social skills instruction — Deficits in social function are one of the core deficits of ASD, and social skills instruction is an important component of management.
Although additional studies are necessary, a 2012 meta-analysis of five randomized trials (196 participants) found some evidence that participation in social skills groups improved overall social competence and friendship quality in the short term [77]. The included studies did not report long-term outcomes.
The National Autism Center's National Standards Reports identified several therapies that directly target social skills for which there is evidence of benefit from well-controlled studies [14,37]. These include:
●Joint attention interventions (eg, pointing to objects, showing, etc)
●Modeling (both real-life and video-based modeling)
●Peer training package (including, but not limited to, peer networks, peer initiation training, and peer-mediated social interventions)
●Story-based intervention package (including the Socials Stories approach) [78]
●The social skills package (eg, social and pragmatic groups)
Comorbid emotional or behavioral problems may influence outcomes of social skills interventions. In an observational study, after a 10-week social skills training program, parent-reported social-skills improved among children with ASD and children with ASD and comorbid anxiety, but not among children with ASD and comorbid attention-deficit/hyperactivity disorder [79].
Occupational therapy
Traditional occupational therapy — Children with ASD commonly present with deficits in adaptive functioning 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 enhancing sensory processing, sensorimotor and social-behavioral performance, self-care (eg, dressing, hygiene), and participation in play [80]. In older children, the focus of occupational therapy may include social and behavioral performance and transition to work and independence in the community.
Sensory integration therapy — The theory of sensory integration disorder or dysfunction is based upon the hypothesis that various sensory experiences (eg, vestibular, proprioceptive, gravitational, tactile, visual, and auditory) help to guide development [81]. Within this hypothesis, aberrations in sensory integration are thought to result in disorganization of the central nervous system that manifests as developmental and behavioral abnormalities known as sensory integration dysfunction. As part of this theory, sensory integration dysfunction is treated through the introduction of intensive sensory inputs using specific equipment and techniques. Such treatment typically is provided by occupational therapists.
Sensory integration therapy is often used for children with ASD because many of their behaviors are thought to be related to deficiencies in the sensory system (hyperresponsiveness or hyporesponsiveness). However, the validity of the sensory integration model and sensory integration therapy are controversial, with strong supporters on both sides [81-85].
A 2017 systematic review of small randomized trials concluded that sensory integration therapy improves sensory-related and motor skills measures [86]. The evidence is limited by small sample size, short duration of follow-up, and inconsistent blinding, diagnostic criteria, treatment, and outcome measures.
There is little information about the potential harms of sensory integration therapy. However, many of the interventions that are used in sensory integration therapy also are used in traditional occupational therapy treatment without adverse effect [82].
The role of sensory integration therapy in ASD is not clear [14,81]. However, sensory integration therapy may be included as part of a comprehensive program to calm the child, reinforce desired behaviors, or help with transitions between activities [2,81]. Continued use of sensory integration should be based upon the treatment response in the individual child.
PROGRAMS FOR TODDLERS — As awareness of autism and ASD increases and the diagnosis is made in younger children, interventions for toddlers are essential. However, the most appropriate interventions for toddlers with ASD have not yet been determined. In addition, outside of the research setting, ASD-specific interventions for children younger than two years are not widely available. Evidence suggests that integrative developmental behavioral models are effective in younger children with ASD [31,57,60,61]. (See 'Integrative models' above.)
In the community setting, early intervention services, including speech and language interventions, are strongly recommended for toddlers with ASD [28].
Interventions for toddlers should focus on [28]:
●Natural learning environments – Stimulating learning in the context of everyday life and play activities
●Child initiative and sensory-motor exploration – Getting the child to initiate play and exploration
●Development of nonverbal intentional communicative acts – Helping with intentional nonverbal communication (eg, pointing to request)
●Reciprocal play with social partners
●Enriched language environments
●Environments that provide opportunities for the toddlers to have an active role in learning
PROGRAMS FOR OLDER CHILDREN AND ADOLESCENTS — There is little published research evaluating comprehensive educational programs for older children and adolescents on the autism spectrum. However, there is empirical support for the use of certain strategies, particularly those based on Applied Behavior Analysis or general behavioral principles, to increase and maintain desirable behaviors, reduce maladaptive behaviors, teach new skills, and generalize behaviors to new environments or situations [37,38,87,88].
Educational interventions for adolescents should continue to include the core attributes of successful programs (see 'Attributes of successful programs' above). The program should focus on achieving social competence, emotional and behavioral regulation, educational success, and the functional adaptive and vocational skills necessary for independence.
Transition planning — By age 16 years, the individualized education program for a child with ASD should include a plan for transition from child- to adult-oriented activities, but the process of transition planning should begin in early adolescence [2]. Comprehensive transition planning involves the student, parents, teachers, medical home, and community agencies. (See "Children and youth with special health care needs", section on 'Transition planning'.)
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".)
SUMMARY AND RECOMMENDATIONS
●Individuals with autism spectrum disorder (ASD) have varying degrees of impairment in social and behavioral function. Behavioral and educational interventions targeting core symptoms should be tailored to the child's specific needs. (See "Autism spectrum disorder in children and adolescents: Evaluation and diagnosis", section on 'Diagnostic criteria' and 'Overview' above.)
●The overarching goals of treatment 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, and promote academic functioning and cognition. (See 'Goals of therapy' above.)
●Practical and ethical factors have made it challenging to evaluate intervention programs for individuals with ASD in randomized controlled trials. Systematic reviews of behavioral and educational interventions for children with ASD suggest that earlier and more intensive therapies are associated with better outcomes. However, the evidence is insufficient to endorse any particular therapy. (See 'Effectiveness' above.)
●Expert reviews of treatment programs for ASD have identified the following core attributes of successful programs (see 'Attributes of successful programs' above):
•A high staff-to-student ratio (1:1 or 1:2)
•Individualized programming for each child
•Family involvement
•Teachers with special expertise in working with children with autism
•A minimum of 25 hours per week of services
•Functional analysis of behavior problems
•Ongoing program evaluation and adjustment
•Close monitoring and modification as the child's needs change
•A curriculum emphasizing attention, imitation, communication, play, social interaction, regulation, and self-advocacy
•A highly supportive teaching environment
•Predictability and structure
•Transition planning
●Interventional models for treatment may include a variety of techniques. Behavioral-based interventions and developmental models have support for efficacy, especially when provided early and intensively. However, it is important to monitor response to interventions and have clearly targeted symptoms. (See 'Interventional models' above.)
●The addition of parent-mediated interventions to other types of intervention may help families interact with their child, promote development, and increase parental satisfaction, empowerment, and mental health. However, which parental interventions maximize outcomes is unknown. In addition to providing direct interventions, general parental involvement in the treatment program is essential and should include parent training and collaboration. (See 'Parental role' above.)
●Children with ASD benefit most from language interventions that span settings and are incorporated into their daily routines. There is insufficient evidence to support a specific methodology (eg, traditional speech and language interventions, behaviorally based strategies, augmentative communication strategies, visual support), and a variety of methods may be used. (See 'Communication interventions' above.)
●Interventions that address social skills deficits that have evidence of benefit from well-controlled studies include interventions that address joint attention, modeling, peer training, and story-based interventions; the long-term outcomes of these interventions is unclear. There is less evidence to support social and pragmatic groups, although these are used in clinical practice with success. (See 'Social skills instruction' above.)
●Traditional occupational therapy is often used to address deficits in adaptive functioning and fine motor skills. (See 'Traditional occupational therapy' above.)
●Low quality evidence suggests that sensory integration therapy may improve sensory challenges and motor skills, but long-term benefits are uncertain. Sensory integration therapy may be warranted for specific indications (eg, to calm the child, reinforce desired behaviors, or help with transitions) within a comprehensive behavioral and educational program. (See 'Sensory integration therapy' above.)
●Some of the strategies that are used to address the deficits in autism in preschool children may not be appropriate for toddlers or children with significant cognitive impairment, but early intensive therapy is recommended. (See 'Programs for toddlers' above.)
●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. They should continue to include the core attributes of successful programs, including a plan for transition to adulthood. (See 'Programs for older children and adolescents' above and 'Attributes of successful programs' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Carolyn Bridgemohan, MD (deceased), who contributed to an earlier version of this topic review.
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