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147
Scandinavian Journal of Child and Adolescent Psychiatry and Psychology
Vol. 3(3):147-168 (2015)
Review Open Access
A Systematic Review of Social Communication and Interaction
Interventions for Patients with Autism Spectrum Disorder
Tatja Hirvikoski1,2, Ulf Jonsson1, Linda Halldner1,3,4, Aiko Lundequist1, Elles de Schipper1,
Viviann Nordin1,5, Sven Bölte1,4
1Center of Neurodevelopmental Disorders (KIND), Pediatric Neuropsychiatry Unit,
Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden;
2Habilitation & Health, Stockholm County Council, Stockholm, Sweden;
3Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden;
4Center for Psychiatry Research, Child and Adolescent Psychiatry, Stockholm County Council,
Stockholm, Sweden;
5Sachs’ Children and Youth Hospital, Stockholm, Sweden
*Corresponding author: Sven.bolte@ki.se
Abstract
Background: Autism spectrum disorder (ASD) is currently not curable, but it may be malleable to varying degrees in response
to different interventions to improve outcomes.
Objective: We conducted a systematic review of interventions aimed at ameliorating social communication impairments in
patients with ASD. This study was registered in the International Prospective Register of Systematic Reviews (no.
CRD42013003780).
Methods: We focused on the ASD interventions that are frequently applied in Swedish clincial practice to address ASD. To
ensure stakeholder involvement, we also conducted two surveys with three major Swedish ASD interest organizations to
assess perceived research priorities for ASD treatment. With the use of this rationale for selection, Early Intensive Behavioral
Intervention [EIBI], Treatment and Education of Autistic and Related Communication Handicapped Children [TEACCH],
social skills training groups, and interventions that involved significant others were reviewed. A bibliographic search was
conducted via five databases: Medline, PubMed, PsycInfo, CINAHL, and ERIC. Identified articles were screened for
relevance by two independent reviewers, who also assessed the risk of bias in randomized controlled trials using systematic
checklists.
Results: A total of 7264 citations were identified as being published before February 2013, and 109 studies (18 of EIBI, 18
of social skills training, 4 of TEACCH, and 69 of interventions involving significant others) were included in the analysis. The
included studies provided some support for the positive effects of each of the interventions; this is especially true if the most
recently published research (March 2013 through August 2015) is considered, and a crude updated search for relevant
randomized controlled trials was performed. The interventions that involve the significant others of individuals with ASD
form a heterogenous area of treatment strategies that require subcategorization for future review.
Conclusions: These findings provide preliminary support for treatments that are commonly used in clinical practice for the
treatment of ASD in Sweden. However, larger and more rigorously designed and controlled studies are still needed before
definitive conclusions regarding their effects can be made.
Key words: Autism spectrum disorder; pervasive developmental disorder; treatment; intervention; therapy; review.
Introduction
Autism spectrum disorder (ASD) is a neuro-
developmental disorder that is defined in the
Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-V) as involving either current or
historical deficits in social communication and
Interventions in Autism Spectrum Disorders
148
interaction across multiple contexts; it also includes
restricted and repetitive patterns, interests, or
activities as manifested by at least two prototypically
inflexible behaviors. An internationally increasingly
accepted prevalence estimate for ASD among
school-aged children is approximately 1% (1),
although some more recent studies have reported
figures that are substantially higher (2), and the
percentage of diagnosed cases among adolescents
between the ages of 13 and 17 years in Stockholm
County, Sweden, reached 2.6% in 2011 (3). Males are
affected three to four times more often than females,
and comorbidity with other neurodevelopmental
disorders and other psychiatric or neurological
disorders is the rule rather than the exception (4).
ASD is a brain-based disorder of complex origin that
is currently not considered curable, although many
have claimed that certain developmental,
educational, psychological, pharmacological, and
complementary and alternative interventions have
resulted in improvements or even cured this
condition (5,6).
Recent systematic reviews of some behavioral
interventions for individuals with ASD have
demonstrated low to moderate evidence for the
improvement of ASD symptoms as well as cognitive
or adaptive functioning; these have included early
behavioral intervention and social skills and social
cognition training (7-11). Systematic reviews are
deemed the gold standard for evaluating evidence in
clinical science. The method summarizes the existing
scientific knowledge in terms of randomized
controlled trials (RCTs), which may serve as a basis
for the making of political decisions that affect future
clinical services development and prioritization.
Systematic reviews describe the availability of high-
quality studies for certain interventions, but they
should not be confused with immediate or absolute
recommendations by clinicians for the use (or
ceasing of use) of certain techniques in clinical
practice. They are not intended and are equally
unable to assess the actual quality of regional clinical
services, so their findings should therefore be
interpreted with prudence (12). In addition, many
systematic reviews of interventions for patients with
ASD have focused on efficacy rather than
effectiveness and directed relatively little attention
toward implementability (13).
The aim of this study was to conduct a systematic
review of ASD interventions that are aimed at
ameliorating social communication impairments. As
compared with earlier systematic reviews, this work
not only incorporates the current state of science but
also addresses health care practices as well as societal
and social network issues, which accounts for several
aspects of the generalizability and applicability of
intervention methods. In addition to providing an
update on intervention techniques covered by prior
studies—particularly Early Intensive Behavioral
Intervention (EIBI), Treatment and Education of
Autistic and Related Communication Handicapped
Children (TEACCH), and social skills training—this
article also covers interventions that involve
significant others, which are assessed here for the
first time. The choice of intervention techniques to
be reviewed was based on those commonly applied
during the clinical treatment of individuals with ASD
in Swedish child and adolescent psychiatry and
habilitation services. We also addressed those
interventions deemed important by stakeholders,
such as those that involve the relatives of the affected
individual. We will first briefly and generally describe
the different interventions reviewed as well as their
objectives, concepts, and target groups. This will be
followed by a discussion of the selection process and
then the actual systematic literature review for each
of the four study areas selected.
Reviewed social communication and interaction
interventions for autism spectrum disorder
Early Intensive Behavioral Intervention. EIBI is currently
one of the most widely used and accepted treatments
for infants and young children with ASD. It involves
several typical components: a 1:1 trainer-to-child
ratio, intense intervention of 20 to 40 hours per week
for up to 4 years, and discrete trial training in home
or preschool settings. Discrete trial training is a
teaching method in which learning units are
simplified and structured: a skill is not taught as a
whole but rather broken down and then conveyed
one step at a time. Normally, the method is carried
out or supervised by personnel who are certified in
applied behavior analysis (14). This type of analysis
seeks to develop appropriate behavior repertoires
and to decrease or reduce inappropriate behaviors by
employing the following methods: 1) positive
reinforcement, such as praise, a token, or a favorite
activity; 2) shaping, which involves reinforcing the
individual for exhibiting behavior that approaches
the target behavior or goal; 3) fading, which reduces
the individual’s dependence on the trainer for help;
4) prompting, which includes providing cues as to
the performance of an appropriate behavior; and 5)
maintenance strategies, which help to ensure the
generalization of the learned behavior and the
avoidance of inappropriate behaviors (e.g., analyzing
and manipulating the antecedents that trigger the
behavior, ignoring the behavior, providing undesired
or unpleasant consequences). Possible variables that
affect EIBI outcomes may be the treatment provider
(e.g., parent, clinician, teacher), the treatment
intensity and duration, the quality of the supervision
and the intervention settings, and the allegiance to
the method (15).
Interventions in Autism Spectrum Disorders
149
Treatment and Education of Autistic and Related
Communication Handicapped Children. TEACCH is an
educational program that was developed during the
1960s at the University of North Carolina (16). It is
broadly used by organizations that provide services
for individuals with ASD and their families to
improve the affected subject’s functioning at home
(or in a group home) and in the classroom. TEACCH
acknowledges that ASD is a disorder of neural
development that affects both cognitive and
emotional development, and it tries to identify ways
to facilitate everyday activities with the use of visual
information processing, visual clarity and frugality,
and the reduction of distractibility. The latter aims to
compensate for attention deficits; difficulty with
organizing ideas, materials, and activities; poor use
and understanding of verbal and non-verbal language
in social interactions; and difficulty with
generalization processes. TEACCH suggests that
individuals with ASD benefit from a highly
structured teaching approach that provides routine
and predictability (17). This so-called “structured
teaching” builds on several principles, such as the
individualized assessment of communication, self-
care, vocational, and leisure time skills. Specific
instruments such as the Psychoeducational Profile
(18) are used to identify the patient’s strengths and
interests to facilitate learning processes, and family
involvement is assessed to facilitate the generali-
zation of skills. Major components of structured
teaching include the organization of the physical
environment by visual cues (space is adapted for
specific activities [e.g., colored areas for play]), the
sequential organization of activities (visual schedules
show activities for the day), the introduction of
routines (increasing predictable events), and the
organization of tasks and materials (activity materials
are located in the places where activities are being
carried out).
Social skills training. This intervention approach
attempts to teach children with ASD the skills they
need to engage in social interaction and
communication to create opportunities for social
contact, to behave in socially expected ways, to build
social relationships, and to increase the likelihood
that they will experience social interaction as both
meaningful and enjoyable (19). Social skills training is
usually conducted in a group setting, and it typically
involves rather high-functioning individuals with
ASD in a structured lesson format. For young
children, the training may focus on simple acts such
as offering a greeting, joining a peer in playing with a
toy, or sharing a preferred object. For older
individuals, the training commonly involves the
acquisition of social rules, social cognition exercises,
perspective and turn taking, and the avoidance of and
coping with conflicts. Social skills training is generally
designed for individuals who are 6 years old and
older. Groups range in size to include up to eight
participants, with one to three trainers. Many
manualized training programs involve weekly
sessions of 60 to 90 minutes that occur over a period
of 12 weeks or more. Targeted skills are modeled in
different ways (e.g., role playing, group discussion),
and group members are welcome to suggest topics of
individual relevance.
Interventions involving significant others. These inter-
ventions included a range of partly different
interventions that are offered to parents and other
relatives. They all aim to support the relatives or to
improve the relatives’ capacities to better understand
and nurture their family members with ASD. These
interventions include everything from providing
information about the diagnosis and treatment
options to more complex education about certain
intervention techniques. This is surely an area that is
under development. Carrying out a classical
systematic review is compromised as a result of
heterogeneity of both the interventions and the
target groups (20,21).
Methods
Protocol and registration
This study was conducted on behalf of the National
Board of Health and Welfare, Sweden and registered
in the International Prospective Register of
SystematicReviews (crd.york.ac.uk/NIHR_PRO-
SPERO/; no. CRD42013003780).
The selection of target interventions was based on
three criteria: 1) the availability of scientific evidence;
2) current applicability to Swedish clinical practice
and recommendation by regional clinical guidelines;
and 3) the values, preferences, needs, and attitudes
put forth by interest organizations and stakeholders
in Sweden. We first selected three treatment methods
for systematic review on the basis of the first two
criteria: EIBI, TEACCH, and social skills group
training. In August 2012, before the current review
and database searches were conducted, we assessed
the viewpoints of stakeholders regarding the focus
and objectives of the project and the selection of
interventions to review. Three major Swedish
interest organizations participated in this survey: The
Autism and Asperger Association (Autism- and
Aspergerförbundet; www.autism.se); The Attention
National Association (Riksförbundet Attention;
www.attention-riks.se); and the Organized Aspies
(Organiserade Aspergare; www.aspergare.org). The
survey results indicated a strong preference for the
inclusion of interventions that involved significant
others.
Interventions in Autism Spectrum Disorders
150
Eligibility criteria
For studies of EIBI, TEACCH, and social skills group
training
Participants. Children and adolescents (≤18 years
old) diagnosed with autism, Asperger syndrome,
atypical autism, or pervasive developmental
disorders not otherwise specified according to DSM-
IV, DSM-IV-TR, or International Statistical Classification
of Diseases and Related Health Problems, 10th Revision,
criteria; studies of adult populations (>18 years old)
were excluded
Interventions. TEACCH, EIBI, and social skills
group training
Comparators. Any comparators
Outcome measures. Primary outcomes: Social com-
munication/interaction skills at the time point when
the study or treatment is terminated and long-term
follow up
Secondary outcomes: Adaptive behaviors; core
symptoms of ASD; symptoms of comorbid
conditions; cognitive development; quality of life;
caregiver burden; parental stress, parental knowledge
of ASD
Study design. RCTs and observational studies with
comparison groups; case studies were excluded
For studies of interventions involving significant others
Participants. Family members (i.e., parents,
grandparents, siblings, or caregivers in a home
setting) of individuals with any kind of ASD
diagnosis, as described previously
Interventions. Any interventions involving signi-
ficant others
Comparator. As described previously
Outcome measures. As described previously
Study design. RCTs and observational studies with
or without comparison groups; case studies were
excluded
Information sources
Electronic searches were conducted using Medical
Subject Headings (MeSH) and relevant text word
terms. Five databases (Medline, PubMed,
PsycINFO, CINAHL, and ERIC) were searched up
to February 15, 2013. The search was performed by
an information specialist at the University Library of
Karolinska Institutet. For studies published between
February 2013 and August 2015, we only added an
unsystematic crude update search that was
conducted via PubMed. These results are added at
the end of the Results section and discussed in the
Conclusion section.
Search strategy
We used search terms relevant for the study
interventions and population. Search results were
limited to original studies from 1990 or later and to
those written in English, Danish, Norwegian, or
Swedish. Animal studies and case studies were
excluded. For a detailed description of search terms,
see Appendix 1.
Study selection
For studies of EIBI, TEACCH, and social skills group
training
Two reviewers independently screened the titles and
abstracts identified by the search strategy. Studies of
potential relevance were grouped according to
intervention and then screened a second time by two
reviewers. If it was deemed necessary at this stage,
the full text of the article was obtained, and two
reviewers then independently assessed the text to
determine inclusion. Any disagreements were
resolved by discussions between the reviewers.
Reference lists and systematic reviews were screened
for additional studies of relevance.
For studies of interventions involving significant others
As a result of the heterogeneity of the identified
studies in this area and to enable a descriptive
synthesis, the search results for studies of
interventions involving significant others were
divided by two researchers (TH and AL) into two
major subcategories: interventions involving parents
and interventions involving significant others other
than parents. The interventions were then further
subclassified into several content-valid subcategories
on the basis of the target group/receiver of the
intervention (type of relative) and the primary focus
of the treatment: either the relative receives
treatment (e.g., parents learn how to cope with stress)
or the relative conducts treatment (e.g., parents
support their children in the development of social
skills).
Data collection process
From each included RCT with a moderate or low risk
of bias (as discussed later in this article), data were
extracted and inserted into a table by one reviewer. A
second reviewer then audited the data extraction.
Any disagreements were resolved by discussion.
Data items
Information about the following topics was extracted
from the included RCTs: 1) participants (e.g., age,
diagnosis); 2) treatment; 3) type of comparator; 4)
relevant outcome measures; and 5) adverse events or
deterioration.
Risk of bias in individual studies
Two reviewers independently assessed the risk of
bias of the selected RCTs with the use of checklists
developed by the Swedish Council on Health
Technology Assessment. The risk of bias is the
Interventions in Autism Spectrum Disorders
151
systematic tendency that any aspect of the study may
make the estimated treatment effect deviate from its
true value (i.e., the extent to which the results of an
included trial can be believed). The checklist for
RCTs is very similar to the Cochrane Collaboration’s
tool for assessing the risk of bias (22), and it includes
31 items to consider related to randomization
(methods and outcomes; 3 items); treatment
(blinding, compliance, therapists, and confounding
variables; 5 items); assessment (blinding, reliability,
validity, timing, and analysis; 9 items); dropout (size,
balance, covariates, and analysis; 5 items); reporting
bias (protocol, primary/secondary outcome, adverse
events, and assessment; 6 items); and conflicts of
interest (3 items). A rating of low, moderate, or high
risk of bias was given to each category of items and
then combined into a global rating for the trial. The
risk of bias was not assessed for observational or
quasi-experimental studies or for those studies
involving significant others.
Methods of analysis for social communication
interventions
Initially, a quantitative synthesis of RCTs (using
RevMan 5 software) related to each of the research
questions was planned. If quantitative synthesis was
not meaningful or possible, a descriptive synthesis
was performed. For observational or quasi-experi-
mental studies, only a descriptive synthesis was
planned. If systematic reviews of high quality were
available from previous studies of the areas
examined, they were used as resources for
consistency checks and cross-validation.
Results
Early Intensive Behavioral Intervention
A total of 161 studies of potential relevance for EIBI
were identified by the literature search; 18 studies
remained after screening by two reviewers (AL and
LH). There were 17 observational studies that
included control groups and 1 RCT, which was
conducted in the United States (23). The RCT
included 28 children, of which 15 were in the EIBI
group; the boys-to-girls ratio was 12:3 in the
intervention group and 11:2 in the control group.
The children in the EIBI group received a mean of
30 hours of treatment per week for two to three
years; the control group had supervised parental
training twice a week for a total of five hours per
week, training with parents for five hours per week,
and education in a special class for ten to 15 hours
per week for three to nine months. The outcome
measures are presented in Table 1. There were no
significant differences between groups before
treatment with regard to outcome variables. After
treatment, there were statistically significant
differences in intelligence as measured by the
Stanford-Binet Intelligence Scales, in visuospatial
abilities as measured by the Merrill-Palmer Scales of
Development, and in verbal ability according to the
Reynell Developmental Language Scales between the
EIBI group and the control group. However, there
was a certain risk for bias, because the groups were
not comparable with regard to the interval between
completed treatment and follow-up measurement.
Of the 17 non-randomized studies with control
groups that were identified, 4 were from the United
Kingdom (24-27), 4 were from the United States (28-
31), two were from Italy (32,33), two were from
Israel (34,35), one was from Canada (36), one was
from Sweden (37), one was from Norway (38), one
was from Norway and Sweden (39), and one was
from Norway and the United States (40). Two of the
non-randomized studies with control groups (25,27)
examined the same sample, with the later study being
a 2-year follow-up study of the intervention. One
more study with a control group from the United
Kingdom was identified, but the intervention
consisted of more than EIBI, and the control and
intervention groups differed only by the intensity of
the same treatment interventions (41), so it was not
further considered.
All non-randomized studies reported improve-
ments in different areas at the group level for both
children who underwent EIBI treatment and control
children. Of these, 13 studies showed superior
improvement for the EIBI groups in some outcome
measures as compared with the control groups (23-
30,32,36-38,40). Outcome measures varied among
studies, with most studies applying several outcome
measures. Results showed relative improvements in
intelligence quotient (10 studies), adaptive behavior
(10 studies), language and communication (7 studies),
symptom reduction (6 studies), and the need for
school assistance (1 study). Results also demon-
strated changes in diagnostic status (1 study) and
personality and other behaviors (2 studies). Many of
these studies had relatively small sample sizes.
One study with relatively large study groups
showed no difference in outcomes between the EIBI
group (n = 45) and the control group (n = 33) after
intervention (35). The control group in this trial
received “individualized eclectic treatment” of the
same magnitude as and parallel to the EIBI group. In
the other study that did not demonstrate better
outcomes after high-intensity EIBI treatment, the
control group received low-intensity EIBI treatment
(37). However, in this design, the study groups were
not comparable, the study lacked both the control of
what was actually administered and the quantity
(number of hours) of the treatment, and the health
care professionals were not comprehensively trained
in EIBI techniques.
Interventions in Autism Spectrum Disorders
152
During the two years of follow up by Kovshoff and
colleagues (29), the group differences that were
initially observed ultimately disappeared (27).
Alternatively, McEachin and colleagues (30), who
studied the long-term outcomes of a previous study
(42), found persistent effects in the intervention
group as compared with a non-randomized
comparison group.
Treatment and Education of Autistic and
Related Communication Handicapped Children
Thirty-six studies of potential relevance to TEACCH
were found in our literature search. After screening
(by AL and ES), four studies remained, whereas 32
studies were excluded: 11 studies with irrelevant
research questions, nine observational studies
without comparison groups, five reviews, three
studies with adult participants, one case study, and
one study of an intervention other than TEACCH.
There were two RCTs (43,44) (Table 2) and two
quasi-experimental studies with matched controls
(45,46): two of these studies were conducted in the
United States (44,45), one was performed in Italy
(46), and one took place in China (43). Each of the
four included studies was deemed to be of low quality
and to have a high risk for bias.
In the first RCT, Tsang and colleagues (43)
evaluated the usefulness of TEACCH for Chinese
preschool children between the ages of three and five
years with autism. The experimental group (n = 18)
received full-time center-based TEACCH training,
whereas the control group (n = 16) received types of
training other than TEACCH. The experimental
group demonstrated motor skills as rated by the
Psychoeducational Profile, Revised (PEP-R).
Alternatively, the control group showed more
progress than the experimental group in social
TABLE 1. Randomized controlled trials of EIBI (until 2/2013)
Publication
Risk of
bias
Participants
Intervention
Outcome measures
Main results
Mean post-treatment
(Standard deviation)
Name
Year
Country
Study
group
Comparison
group
Study
group
Comparison
group
Study group
Comparison
group
Smith, 2000
USA
High-
modera
te
n=15
Clinical
ASD
diagnosis
(n=8)
PDD-NOS
(n=7)
Age
36.07
(6.05)
months
Follow up
Age
94.07
(1.17)
months
n=13
Clinical ASD
diagnosis
(n=7)
PDD-NOS
(n=6)
Age
35.77 (5.37)
months
Follow up
Age
92.23(17.24)
months
EIBI 30
h/week
during 2-3
years
two
parental
training
sessions
5 h/week &
Special
education
10-15 h/
week
during 3-9
months
Stanford-Binet: IQ
Marill –Palmer: Visuo-
spatial
Reynell: Language
Vineland:
communication
DLS
Socialization
CBCL
Internalizing
- Parent
- Teacher
Somatic complaints
- Parent
- Teacher
Anxious/Depressed
- Parent
- Teacher
Social problem
- Parent
- Teacher
Thought problem
- Parent
- Teacher
Attention problem
- Parent
- Teacher
Rule-breaking
- Parent
- Teacher
Aggressive behav.
- Parent
- Teacher
66.5 (24.1)
64.3 (18.7)
87.4 (46.2)
67.87 (30.08)
62.3 (25.8)
66.3 (24.8)
59.3 (10.3)
61.9 (7.0)
56.1 (8.2)
52.3 (5.0)
52.2 (5.2)
54.2 (5.3)
60.1 (13.5)
59.8 (9.6)
67.1 (10.8)
64.7 (13.6)
64.8 (10.3)
64.9 (12.8)
54.7 (9.2)
53.4 (12.8)
56.1 (9.1)
60.0 (10.8)
49.7 (19.7)*
49.2 (21.4)*
61.3 (31.9)*
60.77 (17.26)
63.0 (17.0)
68.9 (16.9)
60.2 (7.8)
55.0 (4.4)
56.1 (8.2)
54.9 (8.5)
59.7 (11.6)
54.6 (4.1)
64.3 (11.4)
57.4 (8.0)
64.5 (12.7)
62.6 (7.6)
67.5 (4.2)
61.6 (9.3)
54.0 (5.1)
61.6 (9.3)
59.7 (10.4)
55.7 (5.6)
Note. DLS = Developmental Language Scales; CB CL = Child Behavior Checklist
Interventions in Autism Spectrum Disorders
153
TABLE 2. Randomized controlled trials of TEACCH (until 2/2013)
Publication
Risk of
bias
Participants
Intervention
Outcome
measures
Main results
Mean post-treatment
(Standard deviation)
Name
Year
Country
Study
group
Comparison
group
Study group
Comparison
group
Study group
Comparison
group
Tsang, Shek,
Lam, Tang &
Cheung
2007
China
High
Clinical
ASD-
diagnosis
according
to DSM-
IV;
Age: 3-5
yrs;
n=18
As in study
group;
n=16
Full time center-
based TEACCH
training: structured
physical set-up and
tasks organization
with use of schedule,
visual support and
Independent Work
System (IWS); 12
months, 7 h per day
Treatment as
usual; non-
TEACCH
classroom set-
up and teaching
mode
Tests:
Psycho
Educational
Profile-Revised
Chinese version;
Merril-Palmer
Scale of Mental
Tests; Hong
Kong Based
Adaptive
Behavioral
Scales (Chinese
adaptation of
Vineland
Adaptive
Behavior Scales)
Adjusted means
corrected for
pretest and
covariates
CPEP-R:
Perception 10.067
(SD .693)
Fine Motor
11.091 (SD .729)
Gross Motor
15.425 (SD .915)
Other subscales ns
HKBABS:
Daily Living Skills
54.951 (SD 2.309)
Sum of Domains
253.425 (SD 7.881)
Other subscales ns
Merril-Palmer:
48.106 (SD 2.233)
Adjusted means
corrected for
pretest and
covariates
CPEP-R:
Perception
7.300 (SD .740)
Fine Motor
8.522 (SD .778)
Gross Motor
11.522 (SD .978)
Other subscales
ns
HKBABS:
Daily Living Skills
69.680 (SD 2.473)
Sum of Domains
284.771 (SD
8.513)
Other subscales
ns
Merril-Palmer:
51.505 (SD 2.387)
Welterlin,
Turner-Brown,
Harris, Mesibov
& Delmolino
2012
USA
High
Clinical
autism-
diagnosis;
Age: 2-3
yrs;
n=10
As in study
group;
n=10
Home TEACCHing
Program: training
parents to work with
child on cognitive,
fine motor and
language skills; 12
weekly sessions of
1.5h
Wait-list
Tests:
Mullen Scales of
Early Learning;
Scales of
Independent
Behavior-
Revised;
Parent self-
report:
Parent Stress
Index-3rd
edition
MSEL:
63.7 (SD 17.4)
SIB-R – social
interaction:
18.4 (SD 7.3)
SIB-R – language
comprehension:
12.0 (SD 4.7)
SIB-R – language
expression:
16.2 (SD 7.1)
PSI:
242.4 (SD 41.5)
MSEL:
58.1 (SD 25.0)
SIB-R – social
interaction:
16.0 (SD 5.0)
SIB-R – language
comprehension:
10.9 (SD 4.8)
SIB-R – language
expression:
14.2 (SD 7.1)
PSI:
256.2 (SD 70.0)
Note. CPEP-R = Psycho Educational Profile- Revised Chinese version; HKBABS = Hong Kong Based Adaptive Behavior Scale (Chinese adaptation of Vineland
Adaptive Behavior Scales); MPSMT = Merrill-Pal mer Scale of Mental Tests; MSEL = Mullen Scales of Early Learning; SIB-R = Scales of Independent Behavior-
Revised; PSI = Parent Stress Index-3rd edition
social adaptive functioning as indicated by higher
scores on the Daily Living and Adaptive Behavior
Composite scales of the Hong Kong Based Adaptive
Behavior Scale (i.e., adjusted Vineland Adaptive
Behavior Scales). Cognitive functioning as measured
by the Merrill-Palmer Scales of Development did not
improve in either of the two groups.
In the other RCT, Welterlin and colleagues (44)
evaluated the effect of a TEACCH-based home
training program on children with ASD and their
parents. Parents were trained to support their
children in the areas of cognitive, fine motor, and
language skills. Twenty families were randomly
assigned to the treatment group or the waiting list
group. The results suggested that participation in the
home training program led to improvements in the
children’s independence and in the parents’ ability to
structure the children’s learning environment and to
effectively prompt their children in teaching
situations. However, group comparisons did not
reveal significant differences in child developmental
outcomes (Mullen Scales of Early Learning), adaptive
behavior (Scales of Independent Behavior, Revised),
or parent stress (Parenting Stress Index, Third
Edition).
In the non-randomized study with a control group
(45), parents were trained to implement TEACCH at
home in the treatment group; members of both the
treatment and the control groups were enrolled in a
regular day treatment program. Twenty-two children
between the ages of two and six years were assigned
non-randomly to the treatment or the control groups
(n = 11 in each group). The results demonstrated that
children in the treatment group improved
significantly more than those in the control group on
the PEP-R subscales of imitation, fine motor, gross
motor, and non-verbal conceptual skills as well as on
their overall PEP-R scores. Correlations between
Interventions in Autism Spectrum Disorders
154
pretreatment scores and total change scores indicated
that subjects with mild ASD and good language skills
benefited the most.
Panerai and colleagues (46) compared two
educational treatments in schools: the TEACCH
program and the integration program for individuals
with disabilities that is commonly used in Italian
schools. Two groups of children with ASD—an
experimental group (n = 8) and a control group (n =
8)—were matched by gender (all males) and
diagnosis (ASD and severe intellectual disability
combined). The mean chronological age was 9 years.
The authors found improvements on the PEP-R
scales (test items were scored as “passing,”
“emerging,” and “failing,” depending on specific
scoring criteria) for all “passing” categories except
that of fine motor skills, but this was not the case
with the “emerging” categories. The analysis of the
results from the Vineland Adaptive Behavior Scales
did not yield improvements in communication and
interpersonal relationships. The authors concluded
that the TEACCH program was more effective than
the treatment applied to the control group.
Social skills training
During the first screening of abstracts (by UJ and
VN), 204 unique citations of potential relevance for
social skills training were identified. A total of 186 of
these reports were excluded: 57 case studies; 30
observational studies without comparison groups; 76
studies with irrelevant research questions; eight
studies of other interventions; three studies with
adult participants; six study protocols; and 6 reviews.
The remaining reports—11 RCTs and seven non-
randomized studies with comparison groups—were
included. A recent systematic review of high quality
that included five of the 11 RCTs was identified (11).
The systematic review by Reichow and colleagues
searched the literature up to December 2011 and
included five RCTs of social skills training as
compared with a waitlisted control group. All five of
these trials were conducted in the United States. The
sample sizes of all included trials were relatively small
and ranged from 18 to 76 participants (Table 3). In
total, 196 participants were included in the studies.
The participants were children between the ages of 7
and 12 years, with the exception of one trial that
included adolescents between the ages of 13 and 17
years (47). To some extent, the outcome measures
differed between the trials: 4 trials measured social
competency (47-50), and 2 trials measured friendship
quality (48,51). The social skills groups improved in
overall social competence (effect size = 0.47; 95%
confidence interval, 0.16 to 0.78) and friendship
quality (effect size = 0.41; 95% confidence interval,
0.02 to 0.81), but there was no effect on emotional
recognition and understanding of idioms. Overall,
the quality of evidence was rated as low. Given the
nature of the intervention and the selected outcome
measures, the authors concluded that the risk of bias
was high.
Our search identified two additional trials of
comparable interventions (52,53), which were
published after the final search in the review by
Reichow and colleagues (11). In a trial from the
United States (52), a total of 35 children were
randomized to social skills group training or to being
waitlisted. The intervention consisted of group
sessions 5 days a week for 5 weeks. A number of
outcome measures were used to assess
improvements in social competency and social
communication, and the effects were comparable to
the effects observed in previous trials. DeRosier and
colleagues (53) compared a social skills training
intervention specifically designed to address multiple
social skill areas for children between the ages of 8
and 12 years with high-functioning ASD with a
similar intervention developed for typically
developing children; 55 children were included in the
study, and the results indicated that the specifically
designed intervention had better effects on social
skills. We have determined that these trials do not
change the conclusions drawn in the review by
Reichow and colleagues.
An additional four RCTs of social skills training
were identified, but the interventions differed
substantially from the ones included in the Cochrane
review. Beaumont and Sofronoff (54) tested a 7-week
program that included computer games, group
sessions, parent training, and information being
given to teachers. A total of 49 children were
randomized to either the intervention group or being
waitlisted. Parent and teacher ratings indicated that
children who received the intervention had more
improved social skills and that the effects were
maintained at a 5-month follow-up appointment.
The remaining 3 trials were assessed as having a high
risk of bias factors, such as a small sample size and
baseline differences between the intervention and
control groups. One of these trials evaluated a
training program for theory of mind (55), one
compared two forms of skills training programs (56),
and one studied the effect of a multimodal
intervention for social skills and anxiety (57).
A range of different outcome measures was used
in the trials. One questionnaire, the Social
Responsiveness Scale (58), was used in five studies.
another questionnaire, the Social Skills Rating system
for Parents (59), was used in three studies. in only
one of the 11 RCTs were both of these
questionnaires used. In addition, three of the studies
that used the Social Responsiveness Scales had
Interventions in Autism Spectrum Disorders
155
TABLE 3. Randomized controlled trials of social skills training (until 2/2013)
Publication
Risk of
bias
Participants
Intervention
Outcome
measures
Main results
Mean pre- and post-treatment
(Standard deviation)
Name
Year
Country
Study group
Comparison
group
Study group
Comparison
group
Study group
Comparison
group
Beaumont et
al.
2008
Australia
Moderate
Clinical ASD-
diagnosis
confirmed by
parent
questionnaires
IQ>85
Age: 7½-11 years;
n=26
Attrition: N/A
As in study
group;
n=23
Attrition: N/A
A multi-component
social skills
intervention;
computer game +
small group sessions
+ parent training
sessions + teacher
handouts;
introduction + 7
weekly sessions;
follow-up 6 weeks
and 5 months post-
treatment
Wait-list
Tests:
Emotion
recognition
measure; James
and the Maths
test; Dylan is
being teased
Parent
questionnaires:
SSQ-P, ERSSQ
Teacher
questionnaire:
SSQ-T
SSQ-P:
Pre 25.30
(7.43)
Post 38.8
(SD 9.84)
SSQ-P:
Pre 23.16
(SD 9.05)
Post 25.11
(SD 7.91)
Begeer et al.
2011
The
Netherlands
High
Clinical ASD-
diagnosis
confirmed by
parent
questionnarires
IQ>70;
Age: 8-13 years;
n=20;
Attrition: 1
As in study
group;
n=20;
Attrition: 3
“The Theory of Mind
training”; 16 weekly
group sessions +
parent program
Wait-list
Tests:
Theory of Mind
test; LEAS-C
Self-reported
empathy:
The index of
empathy for
children and
adolescents
Parent
questionnaire:
CSBQ
Theory of mind
test total score:
Pre 50.89
(SD 5.31)
Post 58.21
(SD 4.00)
Theory of mind
test total score:
Pre 54.00
(SD 5.93)
Post 58.00
(SD 5.78)
DeRosier et
al.
2011
USA
Moderate
Prior ASD-
diagnosis
confirmed by
parent
questionnaires
IQ>85;
Age: 8-12 years;
n=27;
Attrition: 3
As in study
group;
n=28;
Attrition: 2
”The Social Skills
Group Intervention –
High Functioning
Autism”
(development of
original program);
15 weekly group
sessions + parent
program
”The Social Skills
Group
Intervention”
(original
program for
children with
typical
development);
10 weekly group
sessions
Self-report:
Social
Dissatisfaction
Questionnaire
Parent
questionnaires:
SRS, ALQ
Parent and child
report:
Social Self-
efficacy Scale
SRS –
communication
(individual
change scores):
-0.38 (SD 1.07)
SRS –
communication
(individual
change scores):
0.50 (SD 0.78)
Frankel et al.
2010
USA
Moderate
ASD (according to
ADI-R + ADOS)+
verbal IQ>60 +
basic level of
communication
and play
Age: mean 103.2
months (SD 15.2)
n=40;
Attrition: 5
As in study
group;
Age: mean
101.5 months
(SD 15.0);
n=36;
Attrition: 3
”Parent-assisted
Children’s Friendship
Training”; 12 weekly
sessions for children
and parents
separately +
homework
assignment
Wait-list
Self-reports:
The Loneliness
Scale; PHS
Parent
questionnaires:
QPQ; SSRS-P
Teacher
questionnaire:
PEI
SSRS-P (Self-
control):
Pre 10.2
(SD=3.4)
Post 12.2
(SD 2.9)
SSRS-P (Self-
control):
Pre 9.0
(SD 3.9)
Post 10.1
(SD 3.7)
Koenig et al.
2010
USA
Moderate
Prior ASD-
diagnosis
confirmed by
ADOS parent
questionnaires
IQ>70;
Age: 8-11 years;
n=25;
Attrition: 2
As in study
group;
n=19;
Attrition: 1
Training based on
social learning and
behavior theory;
16 weekly group
sessions; peer tutors
included
Wait-list
Blinded rating:
CGI-I
Parent
questionnaire:
SCI
Post-treatment
much or very
much improved
on the CGI-I:
16/23
Post-treatment
much or very
much improved
on the CGI-I:
0/18
Laugeson et
al.
2009
USA
Moderate
Prior ASD-
diagnosis IQ>70;
Age: 13-17 years;
n=17;
Attrition: 3
As in study
group;
n=16;
Attrition: 0
”Program for the
Education and
Enrichment of
Relational Skills” (the
UCLA PEERS program
adapted for teens);
12 weekly group
sessions for teens
and parents
separately +
homework
assignment
Wait-list
Self-report:
TASSK; QPQ; FQS
Parent
questionnaires:
QPQ; SSRS-P
Teacher
questionnaire:
SSRS-T
SSRS-P:
Pre 80.2
(SD 8.8)
Post 89.7
(SD 12.1)
SSRS-P:
Pre 77.9
(SD 12.1)
Post 79.8
(SD 11.7)
Interventions in Autism Spectrum Disorders
156
Publication
Risk of
bias
Participants
Intervention
Outcome
measures
Main results
Mean pre- and post-treatment
(Standard deviation)
Lerner &
Mikami
2012
USA
High
Study group 1:
Prior diagnosis of
high-functioning
ASD confirmed by
parent
questionnaires
Age: mean 10.86
(SD 1.68);
n=7
Attrition: N/A
Study group
2:
As for group 1
Age: mean
11.33 (SD
1.63);
n=6
Attrition: N/A
Study group 1:
“Sociodramatic
Affective Relational
Intervention (SDARI)”
(use of games
targeting specific
social goals);
4 weekly sessions
Study group 2:
“Skill-streaming”
(training steps of
social
interaction);
4 weekly
sessions
Blinded
observation:
SIOS; Socio-
metrics
Parent
questionnaires:
SRS, SSRS-P
Teacher
questionnaire:
SSRS-T
SRS (parent):
Pre 76.57
(SD 10.74)
Post 75.57
(SD 13.05)
SRS (parent):
Pre 82.17
(SD 10.68)
Post 76.17
(SD 9.56)
Lopata et al.
2010
USA
Moderate
Prior diagnosis of
high-functioning
ASD + IQ>70;
Age: 7-12 years;
n=18
Attrition: N/A
As in study
group;
n=18
Attrition: N/A
Intervention
according to “Skill-
streaming“:
summer camp, 5
weeks, 5 days per
week + weekly parent
training
Wait-list
Tests:
SKA; DANVA-2
Child Faces; CASL,
Idiomatic
Language subtest
Parent
questionnaires:
SRS; ASC; BASC-2-
PRS – social skills
and withdrawal
Staff
questionnaires:
ASC, SRS; BASC-2
SRS (parent):
Pre 79.94
(SD 11.02)
Post 73.67
(SD 11.42)
SRS (parent):
Pre 81.12
(SD 13.78)
Post 82.53
(SD 13.77)
Solomon et al.
2004
USA
High
Prior ASD-
diagnosis
confirmed by ADI-
R and ADOS
IQ>75;
Age: 8-12 years;
n=9
Attrition: N/A
As in study
group;
n=9
Attrition: N/A
“The Social
Adjustment
Enhancement
Curriculum”;
20 weekly group
sessions +
psychoeducational
parent groups
Wait-list
Tests:
DANVA-2-AF;
DANVA-2-CF;
Strange Stories
Task; Faux Pas
Stories Task;
TOPS-Elementary
Revised
Self-report:
CDI
Parent
questionnaire:
BDI
DANVA-total
faces (expression
recognition)
Age 8-10:
Pre 23.8
(SD 1.3)
Post 26.6
(SD 1.5)
Age 10-12:
Pre 22.5
(SD 2.9)
Post 24.8
(SD 3.4)
DANVA-total
faces (expression
recognition)
Age 8-10:
Pre 24.8
(SD 3.1)
Post 24.0
(SD 2.3)
Age 10-12:
Pre 25.2
(SD 3.3)
Post 23.6
(SD 3.3)
Thomeer et
al.
2012
USA
Moderate
Prior ASD-
diagnosis
confirmed by ADI-
R
IQ>70;
Age: 7-12 years;
n=17
Attrition: N/A
As in study
group;
n=18;
Attrition: N/A
Intervention
according to “Skill-
streaming“:
summer camp, 5
weeks, 5 days per
week + weekly parent
training
Wait-list
Tests:
SKA; DANVA-2
CF; CASL,
Idiomatic
Language subtest
Parent
questionnaires:
ASC; SRS; BASC-2-
PRS
Teacher
questionnaire:
BASC-2-TRS
Staff
questionnaire:
ASC, SRS; BASC-2
SRS (parent):
Pre 83.24
(SD 17.27)
Post 75.24
(SD 13.54)
SRS (parent):
Pre 83.06
(SD 12.61)
Post 84.29
(SD 13.84)
White et al.
2013
USA
High
ASD-diagnosis
supported by
ADOS and ADI-R +
verbal IQ>70
Met criteria for
anxiety disorder
Age: 12-17 years;
n=15;
Attrition: 2
As in study
group;
n=15;
Attrition: 3
”Multimodal Anxiety
and Social Skill
Intervention
(MASSI)”;
14 weeks with group
social skills training +
individual therapy +
parent coaching
Wait-list
Blinded rating:
PARS; CGI-I; DD-
CGAS
Parent
questionnaires:
SRS; CASI-Anx
SRS (parent):
Pre 88.87
(SD 12.32)
Post 74.33
(SD 12.63)
SRS (parent):
Pre 85.73
(SD 14.14)
Post 84.80
(SD 12.18)
Note. ADI-R = The Autism Diagnostic Interview-Revised; ASC = Adapted Skill-streaming Checklist; ADOS = The Autism Diagnostic Observation Schedule; ALQ = Achieved
Learning Questionnaire; ASD = Autism Spectrum Disorders; BASC-2PRS = Behavior Asses sment For Children; BDI = Beck Depression Inventory; CASI-Anx = Child and
Adolescent Symptom Inventory-4 ASD Anxiety; CASL = Comprehensive Assessment of Spoken Language; CDI = The Children’s Depression Inventory; CGI-I = Clinical
Global Impressions - Improvement scale; CSBQ = The Ch ildren´s Social Behavior Questionnaire; DANVA -2 = Diagnostic Analysis of Nonverbal Accuracy-2; DD-CGAS =
Developmental Disabilities Children’s Global Assessment Scale; ERSSQ = Emotion Regulation and Social Skills Questionnaire; FQS = Friendship Qualities Scale IQ =
Intelligence quotient; LEAS-C = The levels of Emotional Awareness Scale for Children; n = Number of patients; N/A = No t applicable; PARS = Pediatric An xiety Rating
Scale; PEI: The Pupil Evaluation Inventory; PHS = Piers -Harris Self-Concept Scale; QPQ = The Quality of Play; SCI = Social Competence Inventory; SD = Standard
deviation; SIOS = Social Interaction Observation System; SKA = Skill-streaming Knowledge Assessment; SRS = Social Responsiveness Scale; SSQ -P = Social Skills
Questionnaire – Parent; SSQ-T = Social Skills Questionnaire – Teacher; SSRS-P = Social Skills Rating S ystem – Parent; SSRS-T = Social Skills Rating Syste m - Teacher;
TASSK = Test of Adolescent Social Skills Knowledge; TOPS = Test of Pro blem Solving
Interventions in Autism Spectrum Disorders
157
comparable participant groups but different training
programs.
The studies included few blinded or objective
measurements. The Diagnostic Analysis of
Nonverbal Accuracy (60), which measures an
individual’s ability to recognize facial expressions,
was used in two studies (50,51). In 2 other studies,
the improvement subscale of the Clinical Global
Impressions Scale (61) was used by blinded
investigators (49,57). Four of the trials were
determined to have a high risk of bias, mainly as a
result of uncertainties related to missing information
(51,55-57). For the remaining seven trials, the risk
was assessed as moderate.
We identified a total of seven non-randomized
studies with control groups that evaluated different
forms of social skills group training interventions. Of
these, 5 were conducted in the United States (62-66),
one took place in the United Kingdom (67), and one
occurred in Australia (68). Some of the studies
included children (62,63,67,68), whereas others
focused on adolescents (64-66).
A study by Kroeger and colleagues compared two
kinds of social skills groups for 4- to 6-year-old
children with ASD (62). A 3-year retrospective study
by Legoff and colleagues (63) compared the long-
term outcomes of children with ASD who
participated in Lego-based interactive playgroups
and a matched comparison group who had received
comparable non-Lego therapy. A study by Owen and
colleagues (67) evaluated Lego therapy as well as
another social skills intervention, the Social Use of
Language Program, for 6- to 11-year-old children
with high-functioning autism and Asperger syn-
drome. Participants were matched and randomly
assigned to one of the interventions and compared
with a control group that was not randomly assigned.
A pilot study by Castorina and Negri (68) compared
social skills training (alone or with a sibling) with
waitlisting for boys with Asperger syndrome who
were between the ages of 8 and 12 years.
A small study by Ozonoff and Miller (64) evaluated
the effectiveness of a social skills training program
for adolescent boys with high-functioning autism as
compared with a no-treatment control group.
Another study compared a parent-assisted social
skills group intervention for high-functioning
adolescents with ASD with a delayed-treatment
control group (65). Finally, another study examined
the effectiveness of an intervention that adapted
dramatic training activities to improve social skills
among adolescents with Asperger syndrome and
high-functioning ASD diagnoses (66).
The number of included participants was
exceptionally small in most studies, with between 5
and 14 participants in the intervention groups. The
only exception was the retrospective study of the
Lego-based interactive playgroups (63), which
included 60 participants in the intervention group.
Although all 7 studies reported beneficial effects of
the interventions, we assessed that the results should
be interpreted with caution due to the small sample
sizes and the non-randomized design.
Interventions involving significant others
A total of 441 studies of potential relevance were
identified. After screening (by AL and TH), 71
studies remained. We identified the following
subclasses of interventions that involved relatives: 1)
parent-mediated treatment of children with ASD
(excluding EIBI and TEACCH; these studies are
presented above); 2) support and education for the
parents of children with ASD (i.e., help for the
parents themselves); 3) support for parents while
their children are receiving professional treatment; 4)
education for parents with the aim of improving their
skills related to teaching others about ASD and their
children; 5) sibling-mediated intervention for the
individual with ASD; 6) support for siblings of
individuals with ASD (i.e., support for the siblings
themselves); and 7) interventions involving grand-
parents.
Parent-mediated treatment of children with ASD (excluding
EIBI)
In this category, the focus was on intervention that
aimed at the parent-mediated treatment of the child
with ASD rather than at support for the parents. The
parent-mediated, communication-focused treatment
of children with autism has been studied in a
multicenter RCT in the United Kingdom called the
Preschool Autism Communication Trial (PACT)
(89). Children were assigned to PACT (n = 77) or
treatment as usual (n = 75). The PACT intervention
did not reduce autism symptoms; however, there was
a clear benefit for parent-child dyadic social
communication. Sofronoff and colleagues (70,71)
evaluated an intervention program aimed at
improving parental self-efficacy for the management
of problem behaviors associated with Asperger
syndrome among children of primary school age. In
this research, 51 parents were randomly assigned to
different formats (i.e., a 1-day workshop or six
individual sessions) of the parental self-efficacy
program or to a waiting list. Parents in both
intervention groups reported fewer problem
behaviors in children and increased parental self-
efficacy after the interventions at both four weeks
and three months of follow up. In addition, 22
families participated in an accelerated parental
educational program for 12 weeks, and half of them
also participated in an additional weekly parent
education support group. Results indicated that the
addition of a parent support group may increase
Interventions in Autism Spectrum Disorders
158
parental mastery of teaching techniques as well as the
success of accelerated programming (72). In a study
by Keen and colleagues (73), families were assigned
to a professionally supported intervention that
included a workshop and 10 home visits (n = 17) or
to a self-directed video-based intervention (n = 22).
The professionally supported intervention resulted in
greater development in social communication and
adaptive behavior in children as well as more reduced
parenting stress and increased parenting self-efficacy
as compared with the self-directed intervention.
Other studies within this category were open
studies, most of which were small pilot studies (74-
92); others were randomized small pilot studies (93)
or the further analysis of previously published studies
(94,95).
Support and education for parents (i.e., help for parents
themselves)
Interventions with primary outcome measures that
reflected parental stress, mental health, or parenting
style (i.e., with the primary focus on parents) were
classified as belonging to this category. In one of the
RCTs (96), parents were allocated to either a 20-week
manual-based parent education and behavior
management intervention (n = 35) or a manual-based
parent education and counseling intervention (n =
35). Both programs provided improvements in
parental mental health and adjustment. In another
RCT (97), 59 families were randomized either to the
Stepping Stones Triple P program or to a waiting list.
The results indicated significant improvements in
parenting styles, parental satisfaction, and conflicts
related to parenting. Additional effects were
observed in parental reports of child behavior.
Other identified studies were small randomized
studies (n ≤ 31 in total) or non-randomized
controlled studies that indicated positive effects on
family interaction (98), decreased hopelessness and
improved coping (99), and perceived self-efficacy
regarding the care of autistic children (100). Internet-
based parent support group participation had no
effect on parental well-being, although participant
satisfaction was high (101).
No effects were observed in response to increased
counseling with a pediatric nurse practitioner in
conjunction with the diagnostic assessment (102) or
to parent support group participation on mental
health or quality of life (103); this was possibly related
to the small sample sizes.
Support and education for parents while their children are
receiving professional treatment
In an RCT (104), 35 preschool children were
randomized to an intervention group or a control
group. In the intervention group, the child’s parents
and child care workers received a 12-week
intervention that consisted of lectures and on-site
consultations with day care centers. In addition,
supportive work was undertaken with the children’s
families. Control subjects received day care alone.
The intervention was significantly superior to day
care alone with regard to its effects on caregivers’
knowledge of autism, the perception of control on
the part of mothers, and greater parental satisfaction.
In another RCT, children with ASD and serious
behavioral problems (n = 124) were randomized to
pharmacological treatment alone (risperidone) (105)
or pharmacological treatment in combination with a
parent training program. The combined treatment
showed modest additional benefit over
pharmacological treatment alone. In another RCT,
parents of preschoolers with ASD and minimal
speech received parent responsiveness training,
whereas the children were allocated to a discrete trial
or a naturalistic language treatment (106). However,
because the parents of all children received the same
intervention, it was not possible to distinguish the
specific effects of parent responsiveness training.
A trial of transition planning intervention included
training sessions for families in the transition process
as well as other components that were aimed at
facilitating the transition process of an adolescent
with ASD from high school to adult life (107). As
compared with waitlisted controls, the transition
intervention group showed improved student and
family expectations as well as higher levels of self-
determination and career decision-making ability.
Other studies within this area were open or non-
randomized studies with promising preliminary
effects on subjective stress and well-being after
participation in parallel parent support and education
programs when the children with ASD were being
treated by professionals (90,108-111).
Parents are educated with the aim of educating and informing
others in the networks of their children with ASD
A few open trials have reported positive outcomes in
response to educating parents, who in turn educate
other people in their children’s networks (112,113).
Sibling-mediated intervention for individuals with ASD
Both children with ASD and their typically
developing siblings were reported to benefit from
interventions that involved siblings to improve the
social skills of the children with ASD (68,114). Both
of the studies found were open pilot studies.
Support for siblings of individuals with ASD (i.e., support for
the siblings themselves)
Two pilot studies with an open study design
(115,116) described preliminary positive effects of
sibling support groups.
Interventions in Autism Spectrum Disorders
159
Interventions involving grandparents
A small pilot study with an open study design (117)
reported preliminary positive effects of involving
grandparents in the treatment of their grandchildren
with ASD through a joint activity.
Crude search update on randomized controlled
studies of all interventions from February 2013
through August 2015
Our crude search update on all examined
interventions that were aimed at ameliorating social
communication impairments in children and
adolescents with ASD yielded a notheworthy recent
increase in RCTs. We identified 2 additonal studies
of EIBI (118,119), one of TEACCH (120), four of
social skills training (121-124), and five of
interventions involving significant others related to
the parent-mediated treatment of children with ASD
(excluding EIBI) (125-129). All studies reported
findings that were in favor of the respective
intervention method evaluated, with small to large
effect sizes; however, study samples were mostly
small to medium large (i.e., N = 11 to N = 86).
Discussion
Early Intensive Behavioral Intervention
Results of the identified studies of EIBI mostly
showed improvements for both the EIBI group and
the control group, although the effect for the EIBI
group as compared with the control group ranged
from no difference to better effect. However, we
only found a single RCT that compared the EIBI
method with another (or no) intervention. Non-
randomized studies indicate a risk for systematic
differences between the compared groups (e.g., the
motivation for treatment). The interventions for the
control groups of the described studies varied
considerably, and most of the studies offered some
kind of active treatment to the control group. In
several studies, it was not clear exactly which form of
EIBI treatment was administered, and the treatment
fidelity was not assessed. Most of the studies
included higher proportions of boys than girls. The
male-to-female ratio also varied with respect to
known gender differences in ASD prevalence, and it
was not always reported. Thus, the impact of EIBI
on girls with ASD is probably even more uncertain
than the effects on boys. All of this can obviously
contribute to heterogeneous results from the
different studies. Furthermore, the study groups
were generally small, which may in fact have masked
smaller differences in outcome between the EIBI
groups and the control groups, considering the vast
interindividual differences and the fact that children
in general develop and make progress independently
of intervention.
A Cochrane report that evaluated the effects of
EIBI for children with ASD included four non-
randomized controlled studies (all included in this
report) as well as an RCT study (10). It concluded
that the quality of the evidence is low (as rated by the
Grading of Recommendations Assessment, Deve-
lopment and Evaluation system) when it comes to
judging the effects of the EIBI method.
Clearly, more sound scientific evidence is needed
to be able to draw definitive conclusions about the
effects of EIBI as a treatment method for ASD.
Criticism against the EIBI method has been put
forward from clinical researchers, which may also
complicate the clinical application of the method.
For example, the effect of EIBI on the core
symptoms of ASD has been questioned. The impact
of the baseline functioning of the children on the
intervention effects, the consequences for the
children and their families (e.g., distress), and the
possibility of implementing the method considering
its intensity and extensiveness have also been
discussed (23,27). In addition, questions have been
raised about the costs associated with the EIBI
method, although these may need to be weighed
against lowered future costs if the method is effective
(130).
Our survey of three Swedish interest organizations
showed inconsistent stakeholder viewpoints. While
one organization advocates the EIBI method as the
treatment method to offer all preschool children with
autism or ASD, another association views the EIBI
method as too directive and less desirable as a
treatment method. These differences in attitude
illustrate the importance of accurate information
regarding the purpose and contents of the
intervention as well as of actively involving all
concerned individuals in the making of decisions
about interventions.
Treatment and Education of Autistic and
Related Communication Handicapped Children
Few studies have evaluated the effectiveness of
TEACCH. All four of the studies identified in this
review (two RCTs and two quasi-experimental
studies with matched controls) reported positive
effects on outcome measures for children with ASD,
mainly with regard to cognitive, motor, and language
skills and, to a lesser extent, to social adaptive
functioning and communication skills. However,
these studies were of low quality and had a high risk
for bias as a result of their unclear and non-
randomized procedures for recruitment and
assignment to a treatment or control group. This
made it hard to determine whether the participants
were representative of the population. In addition,
neither the participants nor the researchers were
blind to the treatment condition, which may have
Interventions in Autism Spectrum Disorders
160
created a placebo effect in the participants and a bias
in the assessment of the treatment effect by the
researchers. These and other factors made it difficult
to draw any strong conclusions about the reliability
of the findings reported in these studies. More
controlled trials are necessary to scientifically
establish the effectiveness of TEACCH.
The promotion of a “culture of autism,” which is a
central concept in the TEACCH program and which
refers to the specific characteristics that are common
among individuals with ASD, has led to the criticism
that the TEACCH method does not facilitate
inclusion but rather creates a separation of autistic
and neurotypically developing individuals. According
to the creators of the TEACCH method, however,
the objective is to facilitate inclusion in addition to
respecting and promoting an individual’s specific
skills, interests, strengths, and needs. This is why
increasing the understanding of ASD is an important
part of the TEACCH method, which aims to create
an environment in which there is space for the
individual with ASD to function.
Other criticisms that are often heard are that the
TEACCH method is too structured, that it focuses
too much on task completion, and that it does not
leave room for spontaneous interaction and
communication. This criticism seems to be
supported by the findings of the present study, in
which effects on cognitive skills are clearer than
those on social and communication skills. Such
effects might make the method less suitable for
higher-functioning individuals with ASD.
Social skills training
A core deficit in individuals with ASD is difficulty
with social communication and functioning. Another
core feature involves repetitive patterns of behaviors.
This latter feature can contribute to social
impairment by restricting the child with ASD’s range
of interests as well as his or her opportunities to
collect social experiences. Children with ASD
without severe mental retardation will experience
more serious social difficulties as could be expected
from cognitive abilities. In this group of children,
loneliness and isolation may give rise to comorbid
psychiatric disorders (e.g., depression, anxiety
disorders). Continued isolation will result in more
obvious social exclusion as children with ASD grow
older. Group activities that involve both children
with ASD and typically developing children without
other simultaneous interventions have not been
shown to increase social interaction for children with
ASD (131). Therefore, training in social skills is a
logical step in the support of children with ASD,
both at schools and via health care services.
In summary, the RCTs included in this review
provide some scientific support for the positive
short-term effect of social skills training delivered in
a group format. We judge that our analysis of further
trials does not differ from the conclusions drawn by
Reichow and colleagues (11): the quality of evidence
is low. We also concur with the conclusion of those
researchers that there is limited generalizability from
the studies because they were mainly conducted in
the United States, they mainly focused on children
between the ages of 7 and 12 years, and they included
participants of average or above-average intelligence.
The broad range of social and communication
deficits that are common to individuals with ASD
requires a comprehensive approach. The training
programs include different amounts of such tactics
as direct instruction, modeling, role playing,
computer games, behavior feedback, and
reinforcement. Parent training and parent and
teacher handouts are used. It is not possible to
conclude if any program is better than any other.
Only one replication RCT has been published (52);
there are no RCTs of the long-term effects of any
program.
In the included RCTs, both study and comparison
samples were adequately matched on key variables.
The interventions were well described. A central
factor that confers a high risk of bias ratings for these
studies is the small sample sizes that were used. The
use of delayed treatment (i.e., placement on a waiting
list) was the usual method used for comparison. This
might lead to the confounding of results by
attention-related factors. Another risk factor for bias
is the dependence on parent questionnaires as
outcome measures. In many programs, the parents
are engaged as coworkers as well (e.g., helping with
exercises and activities of daily living). When asked,
parents reported high satisfaction with the program
(132). This is clearly a desirable element of a social
skills training program, but it also increases the risk
for biased assessment. For future studies, more
objective or blinded outcome measures should be
used.
Interventions involving significant others
Family-based interventions have been shown to be
effective for several mental disorders (133). The
involvement of significant others in assessment and
treatment has been found to be of importance for
patients with ASD as well (134-138), and this was
clearly endorsed by the involved interest
organizations in the current project. Increased
knowledge of ASD may improve significant others’
ability to participate in everyday family life with an
autistic relative (137). In this study, interest
organizations also stressed the importance of parallel
interventions for individuals with ASD and their
significant others as well as information about and
the involvement of individuals with ASD (adjusted
Interventions in Autism Spectrum Disorders
161
to their developmental phase) in interventions given
to significant others. Moreover, a lack of support for
parents who have adult offspring with ASD was
highlighted by the interest organizations. Parents of
adult offspring with ASD may experience high levels
of stress due to their own health problems in addition
to the burden of the lifelong care and support of their
affected children (139).
Interventions for the significant others of
individuals with ASD is a broad and heterogeneous
area that is currently under development, and there is
an urgent need for further studies that apply stringent
research methods (21), with well-defined
intervention targets and formats (20). Furthermore,
long-term follow up and generalizability to other
contexts should be further explored (140). Evidence-
based practice and clinical guidelines for these types
of interventions were also called for by the interest
organizations addressed in the current research. The
interest organizations further stressed the need for
different kinds of family interventions, depending on
the family dynamics and the affected individual’s
characteristics. Other future challenges include the
development of interventions that are targeted at
specific issues, such as sexuality in adolescents with
ASD (141), transitioning to adulthood (107), and the
use of new technological possibilities (e.g., internet-
delivered interventions) (142).
Conclusion
This systematic review examined the evidence related
to social communication interventions for the
treatment of ASD. The present results update and
largely confirm previous findings of low to moderate
scientific support for several commonly applied
techniques in Swedish clinical practice of ASD
treatment (e.g., EIBI, TEACCH, social skills
training), despite the need for more thorough and
large-scale research. Our crude update search found
an increased number of RCTs to have taken place in
the last two years, especially for social skills training
and parent-mediated training methods, thereby
indicating developments in the area of increasing
study quality and broadening the evidence base for
these techniques. Moreover, according to registered
trials at ClinicalTrials.gov and Controlled-Trials.com,
several large-sized RCTs are currently being
conducted (e.g., NCT01854346, ISRCTN94863788).
In this study—for the first time and based on the
recommendations of interest organizations and
stakeholders—we explored the interventions that
specifically involve the significant others of children
and adolescents with ASD. These interventions are
heterogeneous in terms of addressees and
procedures, thereby making scientific support hard
to judge and the need for more rigorous research
especially apparent. Although the current study
tackles some of the most frequently used
interventions, it covers only a small proportion of the
methods claimed by some to be effective or that are
used in international clinical practice (143). For many
of these interventions, systematic reviews will only
serve the purpose of showing that they have never
been evaluated in RCTs.
This review suffers from at least two limitations.
First, it may already be somewhat obsolete, because
only studies that occurred before the beginning of
2013 were included in the systematic review. For
studies that occurred from February 2013 through
August 2015, we only added a crude update search.
Second, we did not assess the non-randomized
studies for quality. There is a large risk of
confounding bias in the non-randomized studies, and
most of them must be viewed as being of low quality.
Moreover, even systematic reviews show some
limitations, thus hampering their use as a starting
point for the selection of scientifically supported
methods for evidence-based practice. Inevitably,
systematic reviews only summarize data from
primary research studies. Therefore, the results of
these reviews cannot be markedly more informative
than the information taken from the original studies
directly. Many of the primary studies, while reaching
sufficient internal validity, lack the characteristics
necessary for effectiveness or generalizability. For
instance, as compared with clinical reality, studies
almost never examine combined (“eclectic”)
interventions or those that are naturalistically
integrated into the flow of clinical routine. In
addition, studies and systematic reviews often focus
on changes in core ASD symptoms as defined in the
Diagnostic and Statistical Manual of Mental Disorders or
the International Statistical Classification of Diseases and
Related Health Problems, even though functional
adaptation, quality-of-life measures, changes in
comorbidity severity, or the perceived stress of the
affected individual and his or her relatives may be
equally important. It should also be noted that
adverse effects are rarely monitored and reported in
trials of psychological interventions, precluding risk-
benefit analyses (144). Moreover, the quality of the
delivery of the respective methods is rarely
controlled, although frequently in published trials
interventions are not administered by experienced
personnel. To somewhat comply with limitations in
external validity, in this study, we introduced a
bottom-up approach when selecting the methods to
be included in the review. We addressed the attitudes
of the interest organizations, and we also mapped the
clinical practices and opportunities in Sweden; both
of these were seen as important prerequisites for the
implementation of intervention techniques. This
strategy identified the significance of interventions
Interventions in Autism Spectrum Disorders
162
that involved significant others, which had not been
systematically evaluated previously.
We deem our bottom-up approach to be a strength
of this study as compared with previous systematic
reviews: it enhanced communication with
stakeholders and policy makers, who frequently feel
that scientific reviews are difficult to comprehend
and that they do not take into account anything other
than scientific views. We hope to encourage future
intervention research to increasingly include societal
perspectives and issues of implementation to
maximize patient gains and the impact of ASD
research on clinical practice.
Acknowledgements
This study was conducted on behalf of the National
Board of Health and Welfare, Sweden. Sven Bölte
was supported by the Swedish Research Council
(grant no. 523-2009-7054).
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Appendix 1. Search terms
Medline (OVID)
Early Intensive Behavioral Intervention (EIBI)
1. animals/ not humans/
2. autis*.tw.
3. exp child development disorders, pervasive/
4. asperger*.tw.
5. (PDD or PDDs).tw.
6. (ASD or ASDs).tw.
7. "pervasive develop*".tw.
8. 2 or 3 or 4 or 5 or 6 or 7
9. "eibi".tw.
10. "early intensive behavio*".tw.
11. exp behavior therapy/
12. Early Intervention/
13. Early Medical Intervention/
14. "early intervention*".tw.
15. (child* or infant* or baby or babies or toddler or girl*
or boy* or pre*school*).tw.
16. exp child/
17. exp infant/
18. adolescent/
19. 15 or 16 or 17 or 18
20. (behavio* adj1 (analys* or therap* or modification or
interven* or lovaas or lovas or communicat*)).tw.
21. ("applied behavio*" adj1 (intervention* or
analys*)).tw.
22. 9 or 10 or 14 or 20 or 21
23. 12 or 13
24. 11 and 23
25. 22 or 24
26. 8 and 19 and 25
27. 26 not 1
28. limit 27 to yr="1990 -Current"
29. limit 28 to ((danish or english or norwegian or
swedish) and (case reports or journal article))
Treatment and Education of Autistic and Related Communication
Handicapped Children (TEACCH)
1. autis*.tw.
2. exp child development disorders, pervasive/
3. asperger*.tw.
4. (PDD or PDDs).tw.
5. (ASD or ASDs).tw.
6. "pervasive develop*".tw.
7. 1 or 2 or 3 or 4 or 5 or 6
8. "Treatment and Education of Autistic".tw.
9. "TEACCH*".tw.
10. "university of north carolina".mp. [mp=title, abstract,
original title, name of substance word, subject heading
word, keyword heading word, protocol supplementary
concept, rare disease supplementary concept, unique
identifier]
11. 8 or 9 or 10
12. 7 and 11
13. 12 not (animals/ not humans/)
Social skills training
1. autis*.tw.
2. exp child development disorders, pervasive/
3. asperger*.tw.
4. (PDD or PDDs).tw.
5. (ASD or ASDs).tw.
6. "pervasive develop*".tw.
7. 1 or 2 or 3 or 4 or 5 or 6
8. animals/ not humans/
9. "communication skill*".tw.
10. "human relation*".tw.
11. exp communication disorders/
12. exp social behavior/
13. "train*".tw.
14. "treatment*".tw.
15. "intervention*".tw.
16. "therap*".tw.
17. "educat*".tw.
18. "program*".tw.
19. exp behavior therapy/
20. communication/
21. language/
22. exp verbal behavior/
23. 20 or 21 or 22
24. socialization/
25. interpersonal relations/
26. social participation/
27. (interpersonal adj1 (behavio* or communication* or
competenc* or relation* or skill*)).tw.
28. (social adj1 (behavio* or adjustment* or interaction*
or communication* or competenc* or relation* or
skill*)).tw.
29. 9 or 10 or 11 or 12 or 23 or 24 or 25 or 26 or 27 or
28
30. 13 or 14 or 15 or 16 or 17 or 18 or 19
31. 7 and 29 and 30
32. 31 not 8
33. 32
34. limit 33 to yr="1990 -Current"
35. limit 34 to ((danish or english or norwegian or
swedish) and (case reports or journal article))
Interventions involving significant others
1. animals/ not humans/
2. autis*.tw.
3. exp child development disorders, pervasive/
4. asperger*.tw.
5. (PDD or PDDs).tw.
6. (ASD or ASDs).tw.
7. "pervasive develop*".tw.
8. 2 or 3 or 4 or 5 or 6 or 7
9. exp child/
10. exp infant/
11. adolescent/
12. (child* or infant* or baby or babies or toddler or girl*
or boy* or pre*school* or adolescent* or teen*age* or
school*).tw.
13. 9 or 10 or 11 or 12
14. exp family/
15. caregivers/
16. (support* or educat* or training* or program* or
psychoeduca* or knowledge or intervention* or guidance
or supervis*or promot*).tw.
17. ((parent* or care*giver* or family or families or
mother* or father* or maternal* or paternal* or network*
or "significant other*" or sibling* or group*) adj3
(support* or educat* or training* or program* or
Interventions in Autism Spectrum Disorders
168
psychoeduca* or knowledge or intervention* or guidance
or supervis*or promot*)).tw.
18. 14 or 15
19. 16 and 18
20. 17 or 19
21. 8 and 13 and 20
22. 21 not 1
23. limit 22 to (yr="1990 -Current" and (danish or
english or norwegian or swedish) and (case reports or
journal article))
PsycInfo (OVID)
Early Intensive Behavioral Intervention (EIBI)
1. (autis* or asperger* or pdd or pdds or asd or asds or
"pervasive develop*").ab,ti.
2. exp Pervasive Developmental Disorders/
3. exp Early Intervention/
4. exp Behavior Therapy/
5. (eibi or "early intensive behavio*" or "Early
Intervention").ab,ti.
6. "early medical intervention".ab,ti.
7. (child* or infant* or baby or babies or toddler or girl*
or boy* or pre*school*).ab,ti.
8. (behavio* adj1 (analys* or therap* or modification or
interven* or lovaas or lovas or communicat*)).ab,ti.
9. ("applied behavio*" adj1 (intervention* or
analys*)).ab,ti.
10. 1 or 2
11. 3 or 4 or 5 or 6 or 8 or 9
12. 7 and 10 and 11
13. limit 12 to (journal article and (danish or english or
norwegian or swedish) and yr="1990 -Current")
Treatment and Education of Autistic and Related Communication
Handicapped Children (TEACCH)
1. TEACCH.mp. [mp=title, abstract, heading word, table
of contents, key concepts, original title, tests & measures]
2. "university of north carolina".mp. [mp=title, abstract,
heading word, table of contents, key concepts, original
title, tests & measures]
3. "Treatment and Education of Autistic".mp. [mp=title,
abstract, heading word, table of contents, key concepts,
original title, tests & measures]
4. 1 or 3
Social skills training
1. (autis* or asperger* or pdd or pdds or asd or asds or
"pervasive develop*").ab,ti.
2. exp Pervasive Developmental Disorders/
3. communication/ or communication skills/ or
communication skills training/ or exp communication
barriers/ or exp communication disorders/
4. ("communication skill*" or "human relation*").ab,ti.
5. exp Interpersonal Communication/ or exp
Interpersonal Relationships/ or exp Interpersonal
Interaction/
6. social behavior/ or social adjustment/ or exp social
interaction/ or exp social skills/
7. exp Socialization/
8. exp Intervention/
9. exp Treatment/
10. exp Training/
11. (train* or treatment* or intervention* or therap* or
educat* or program*).ab,ti.
12. exp Behavior Therapy/
13. "social participation* ".ab,ti.
14. (interpersonal adj1 (behavio*r* or communication* or
competenc* or relation* or skill*)).ab,ti.
15. (social adj1 (behavio*r* or adjustment* or
interaction* or communication* or competenc* or
relation* or skill*)).ab,ti.
16. 1 or 2
17. 3 or 4 or 5 or 6 or 7 or 13 or 14 or 15
18. 8 or 9 or 10 or 11 or 12
19. 16 and 17 and 18
Interventions involving significant others
1. (autis* or asperger* or pdd or pdds or asd or asds or
"pervasive develop*").ab,ti.
2. exp Pervasive Developmental Disorders/
3. (child* or infant* or baby or babies or toddler or girl*
or boy* or pre*school*).ab,ti.
4. (adolescent* or teen*age* or school*).ab,ti.
5. exp Family/
6. exp Caregivers/
7. ((parent* or care*giver* or family or families or
mother* or father* or maternal* or paternal* or network*
or "significant other*" or sibling* or group*) adj3
(support* or educat* or training* or program* or
psychoeduca* or knowledge or intervention* or guidance
or supervis*or promot*)).ab,ti.
8. 1 or 2
9. 3 or 4
10. 5 or 6 or 7
11. 8 and 9 and 10
12. limit 11 to (journal article and (danish or english or
norwegian or swedish) and yr="1990 -Current")
