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The Importance of Early Intervention for Autism
Importance of Early Diagnosis
When it comes to treating children with autism, the universal feeling shared by physicians is the earlier, the better. Researchers are currently working on blood tests for autism, but currently there is no medical test that can accurately diagnose autism.1-2 The first signs of autism, some of which include not turning when a parent says a baby’s name, lack of back and forth babbling, late smiling, and failure to make eye contact,3 are typically first noticed by the parents. These signs should not be taken lightly and parents should have their child receive an evaluation from a licensed physician if their child fails to exhibit any developmental milestone at the proper time.2 A 2006 report from the American Academy of Pediatrics states that “screening tests [for developmental disorders] should be administered regularly at the 9- 18-, and 30-month visits.”4 According to the Centers for Disease Control and Prevention (CDC), an accurate diagnosis of ASD can be achieved at age two.5 However, while CDC figures show that a greater percentage of children are being diagnosed at a younger age, most children are still not diagnosed until after they reach the age of four.5 The CDC has created Developmental Milestones Checklists, which range from as young as 2 months to as old as 5 years, that are available in both English and Spanish to help inform parents of the different developmental milestones their child should reach by a certain age. Being able to diagnose children with autism at an earlier age allows for the quicker implementation of early intervention that has the potential for tremendous, life-long benefits. This article will examine the research that supports the implementation of early intervention for autism spectrum disorders (ASDs) as well as explore the financial benefits of investing in early intervention.
Early Diagnostic Research
Early Intensive Behavioral Intervention (EIBI) is defined as a treatment that consists of “20-40 hours per week of individualized instruction for children with autism who begin treatment at the age of four years or younger and who usually continue for 2-3 years.”6 Early intervention for autism spectrum disorders goes beyond the simple notion that the sooner an individual starts a treatment or intervention, the greater the chance of a favorable prognosis. Early intervention is currently the best course of action for re-mediating the symptoms of autism. A study published in 2011 in the Journal of the American Medical Association observed the post-mortem brains of 7 individuals with autism and 6 controls and found that “male children with autism had a mean 67% more prefrontal neurons than those in the control group.”7 Despite the small sample size, this study, which was co-funded by the Autism Tissue Program, found that the “evidence of excess neuron numbers in our autistic cases was statistically robust and occurred in cases with varying characteristics, such as with less severe and more severe autistic symptoms, and with and without intellectual disability.”7 The study’s findings suggest that the brains of individuals with autism have “profound differences in brain cell interconnections—both within the prefrontal cortex and between this brain region and other parts of the brain.”8 These findings and similar research has led to a further understanding of how the brains of individuals with autism have unique “wiring” compared to neurotypical controls.8-9
According to a 2012 study that randomly assigned 48 children with autism to undergo either the Early Start Denver Model (ESDM) or a community intervention, “early intervention designed to enhance social attention and social engagement served to alter a child’s brain development toward a more positive developmental trajectory.”10 Tom Insel, M.D., the director of the National Institute of Mental Health has claimed that this study “may be the first demonstration that a behavioral intervention for autism is associated with changes in brain function as well as positive changes in behavior.”10 Dr. Sally Rogers, a co-author of the study, has been quoted as stating the “findings on improved behavioral outcomes and the ability to normalize brain activity associated with social activities has tremendous potential for children with ASD.”10
The National Research Council recommends that preschool age children with autism spectrum disorders receive 25 hours a week of an individualized early intervention program.11 Researchers associated with the Infant Brain Imaging Study (IBIS) have developed tests that can detect the risk for autism as early as 6 months to enhance early identification of children affected by autism.12 Advancements in detecting those at risk for autism spectrum disorders are parallel to the developments observed in researchers’ ability to better diagnose the disorder. A recent study observed eye gaze patterns of infants as they watched a monitor which depicted moving geometric patterns on one half and children in high action (dancing or yoga) on the other half. The study found that “toddlers with ASD as young as 14 months spent significantly more time fixating on dynamic geometric images than other diagnostic groups. If a toddler spent more than 69% of his or her time fixating on geometric patterns, then the positive predictive value for accurately classifying that toddler as having an ASD was 100%.”13 Further research regarding eye gaze patterns must be conducted before this diagnostic tool can be applicable for the entire population. Researchers have prioritized the need for earlier detection and diagnosis in order to help children with autism through early intervention.
Research and Early Intervention
Throughout the years, researchers have reported encouraging findings relating to early intervention, but “the strongest empirical base have been associated with the principles of applied behavior analysis (ABA).”14 A popular type of early intensive behavioral intervention is known as the Lovaas method. The intervention works to build positive behaviors, such as language, and re-mediate unwanted behaviors such as repetitive or aggressive behaviors and, as Lovaas contends, has the greatest chance for success when implemented as early as possible.15 One of the most frequently cited studies in support of this method is a 1987 study, conducted by Lovaas himself, which followed 19 children with autism who underwent a 2-3 year, 40-hour per week program and found that the experimental group gained an average of 30 IQ points over the control group.16 Additionally, 47% of the children “successfully passed through normal first grade in a public school and obtained an average or above average score on IQ tests (M=107, range=94-120).”15 These results were maintained over a 7-year follow-up.15 Among the drawbacks of this study’s design are a lack of randomness concerning group assignment, a lack of comparison to another type of intervention, and follow-up measures were limited to IQ and classroom placement.15
A 2009 review of Early Intensive Behavioral Interventions based on Applied Behavior analysis cited a 2005 study published in the American Journal on Mental Retardation as offering some of the strongest evidence for the use of EIBI to improve functioning in children.17 The study included 24 children on the autism spectrum who were randomly assigned a clinic-directed group that replicated “the parameters of the early intensive behavioral treatment developed at UCLA, or to a parent-directed group that received intensive hours but less supervision by equally well-trained supervisors.”18 The results showed that there was a 25-point mean increase in IQ for the subjects and 48% achieved IQ scores <85.18 Eight of these children reached an IQ <85 after 1 year of treatment while 3 more reached this level after 3 to 4 years of treatment and, at the age of 7, were succeeding in regular education classrooms.18 The drawbacks of this particular study were its small sample size, different IQ assessments, which might have caused the increases in IQ and could ”have reflected the use of two different tests instead of treatment effects,” and most pre- and post-testing of moderate learners was done by the study’s second author, which may have introduced bias.18 However, the study demonstrated that because “some treatment effects were so large and have been found in other studies (e.g., that a subset of the children do well), the current results can be seen as supporting an existing body of research.”18
The implementation of early intervention may help children reduce or possibly eliminate the symptoms of autism, which can help to relieve the large financial burden that can be caused by raising a child with autism. Children on the autism spectrum may require multiple therapies and services throughout their lifetime to help relieve the symptoms of the disorder. Families have the potential to save hundreds of thousands of dollars by providing early intervention for children at an appropriate age. This is evident through recent estimates that show that the lifetime cost of raising a child with autism and an intellectual disability in the United States to be $2.3 million and $1.4 million if the child is without an intellectual disability.19 Additionally, mothers of children on the autism spectrum are less likely to work or work fewer hours, causing these mothers to “earn 56% ($14,755) less than mothers of children with another health limitation.”20
Perhaps the financial benefits of implementing early intervention services for children with autism can be best illustrated through the summation of a study that utilized a formula to compare the expected costs of 3 years of Discrete Trial Training as an EIBI and 18 years of special education costs during school years. The 2007 study utilized estimates concerning autism rates of Texas, special education costs in Texas, the efficacy of early intervention for integrating children into normal classroom environments, and the number of years required for each service to develop the formula, and found that “the state of Texas would save $208,500 per child across eighteen years of education with EIBI. When applied to the conservative estimate of 10,000 children with autism in Texas, the State would save a total of $2.09 billion with EIBI.”21 This is especially alarming when you consider that David Mandell, one of the lead authors of another autism and cost-related study funded by Autism Speaks, says that autism-related costs are the largest in adulthood.22 In addition to more programs aimed towards helping adults on the autism spectrum, Mandell believes that “early intervention could also help reduce the overall costs.”22 According to the Autism Society, the implementation of early intervention can reduce the lifetime costs of raising a child with autism by two-thirds.23
The 1999 Mental Health report of the U.S. Surgeon General reached the conclusion that “[t]hirty years of research demonstrated the efficacy of applied behavior methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior.”24 Additionally, the American Academy of Pediatrics and the National Research Council have reported that “behavior and communication approaches that help children with ASDs are those that provide structure, direction, and organization for the child in addition to family participation.”25 The Lovaas Institute has published an article which demonstrates that ABA has been solidified as an evidence-based treatment and “is no longer to be considered either an experimental or an investigative treatment.”26 The article also features over 300 studies related to intensive early intervention and serves as a great resource for further early intervention information.26