Therapies for Children With Autism Spectrum Disorders

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Preface The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to organize knowledge and make it available to inform decisions about health care. As part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Congress directed AHRQ to conduct and support research on the comparative outcomes, clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services to meet the needs of Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). AHRQ has an established network of Evidence-based Practice Centers (EPCs) that produce Evidence Reports/Technology Assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care. The EPCs now lend their expertise to the Effective Health Care Program by conducting Comparative Effectiveness Reviews (CERs) of medications, devices, and other relevant interventions, including strategies for how these items and services can best be organized, managed, and delivered. Systematic reviews are the building blocks underlying evidence-based practice; they focus attention on the strengths and limits of evidence from research studies about the effectiveness and safety of a clinical intervention. In the context of developing recommendations for practice, systematic reviews are useful because they define the strengths and limits of the evidence, clarifying whether assertions about the value of the intervention are based on strong evidence from clinical studies. For more information about systematic reviews, see http://effectivehealthcare.ahrq.gov/reference/purpose.cfm. AHRQ expects that CERs will be helpful to health plans, providers, purchasers, government programs, and the health care system as a whole. In addition, AHRQ is committed to presenting information in different formats so that consumers who make decisions about their own and their family’s health can benefit from the evidence. Transparency and stakeholder input are essential to the Effective Health Care Program. Please visit the Web site (www.effectivehealthcare.ahrq.gov) to see draft research questions and reports or to join an e-mail list to learn about new program products and opportunities for input. Comparative Effectiveness Reviews will be updated regularly. Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H. Director Director, Center for Outcomes and Evidence Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality Stephanie Chang, M.D., M.P.H. CAPT. Karen L. Siegel, P.T., M.A. Director Task Order Officer Evidence-based Practice Center Program Center for Outcomes and Evidence Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality iii
Acknowledgments We are indebted to a tireless group of colleagues who made this report possible. Each step of systematic reviews draws on the skills and attention of an entire team. Ms. Rachel Bazan and Mr. Michael Tranchina were our energetic student workers. They spent hours helping to track and file documents, and were always positive and always ready to ensure that the project investigators had what they needed to do their work. Ms. Ellen Davis and Ms. Cheena Clermont provided invaluable research assistance on this report. Ms. Kathy Lee and Mr. Jeff Seroogy checked tables, formatted tables, and located citations. Dr. Mark Hartmann brought his extraordinary attention to detail—and his commitment to perfection—to completion of the evidence tables. He spent many, many hours checking and rechecking tables both for formatting and for content. His ability to point out inconsistencies and enhance uniformity was key to ensuring smooth development of the evidence tables. Ms. Nikki McKoy provided invaluable advice and assistance with formatting and logistics. Ms. Rachel Walden and Ms. Pauline Alexander are key members of the library science staff. Their support of Ms. Jerome, including their detailed approach to literature searching and data abstraction, was invaluable. Their thoughtful attention to detail in reviewing abstracts and articles for inclusion in the review was a generous gift to the project and to the EPC as a whole. Technical Expert Panel Robin Dea, M.D. Regional Director, Autism Spectrum Disorder Services Kaiser Permanente Redwood City, CA Bryan King, M.D. Professor, Psychiatry and Behavioral Sciences University of Washington Seattle, WA Susan Levy, M.D. Medical Director, Regional Autism Center The Children’s Hospital of Philadelphia Philadelphia, PA Catherine Lord, Ph.D. Director, Autism and Communication Disorders Center University of MichiganAnn Arbor, MI Doris Lotz, M.D., M.P.H. Medicaid Medical Director New Hampshire Department of Health and Human Services iv
Page 1 and 2: Comparative Effectiveness Review Nu
Page 3: This report is based on research co
Page 7 and 8: Therapies for Children With Autism
Page 9 and 10: Dietary and Other Medical Intervent
Page 11 and 12: Figures Figure A. Analytic framewor
Page 13 and 14: Table A. Description of interventio
Page 15 and 16: Analytic Framework Figure A. Analyt
Page 17 and 18: Strength of evidence. The degree of
Page 19 and 20: epetitive behavior showed improveme
Page 21 and 22: subgroups of children, although the
Page 23 and 24: We encourage investigators to provi
Page 25 and 26: 9. Remington B, Hastings RP, Kovsho
Page 27 and 28: 46. Green J, Charman T, McConachie
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Page 31 and 32: 120. Masi G, Cosenza A, Mucci M, et
Page 33 and 34: 157. Evangeliou A, Vlachonikolis I,
Page 35 and 36: Introduction Need for Evidence for
Page 37 and 38: Interventions intended primarily to
Page 39 and 40: Table 1. Description of behavioral
Page 41 and 42: Serotonin reuptake inhibitors. Sero
Page 43 and 44: Table 3. Description of medical and
Page 45 and 46: Table 4. Description of allied heal
Page 47 and 48: Key Questions and Analytic Framewor
Page 49 and 50: Chapter 4 discusses the results in
Page 51 and 52: Methods This chapter documents proc
Page 53 and 54: • Did not present aggregated resu
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Additional behavioral interventions
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1. Did the study employ a group des
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Scoring: Studies minimally had to h
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These ratings of applicability do n
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Figure 2. Disposition of articles a
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• ABA-based approaches including
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education, children in the intensiv
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abilities. This finding is further
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Table 10. Outcomes of early intensi
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forecast behavior; perspective taki
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interaction with peers; outcome mea
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hyperactivity, inattention, challen
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Table 12. Outcomes of RCTs assessin
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Schedule for Affective Disorders an
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SCAS-P=Spence Child Anxiety Scale-P
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Summary of the literature. Jarusiew
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Table 14. Overview of educational s
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on the Ankara Developmental Screeni
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Checklist scores decreased by 8.4 f
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Table 15. Outcomes of studies asses
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evaluated the effects of risperidon
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that this somnolence improved over
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Table 17. Outcomes of RCTs of antip
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Serotonin Reuptake Inhibitors SRIs
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One prospective case series of esci
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Most participants were recruited fr
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Dietary and Other Medical Intervent
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Summary of the literature-other int
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withdrew after the first six weeks;
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therefore described separately belo
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addressed, 85 typically involves on
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In the second paper, 89 treatment s
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Table 25. Overview of CAM studies a
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Teacher and Parent Scales, behavior
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Because of the potentially increase
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Educational Interventions Child cha
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showed diminished response to escit
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oom as the other assessments, so it
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contrast group (n=18) on three meas
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and are based on consideration of f
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Few studies directly comparing the
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Strength of evidence. The strength
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While individual studies of CBT and
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Table 32. Summary of results of edu
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Table 33. Summary of results of med
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strength of this reviewed literatur
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Table 36. Intervention, strength of
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Table 37. Interventions/outcomes wi
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gains. 104 Other studies have seen
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percent of behavioral studies repor
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limited followup, lack of comparati
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individual intervention is warrante
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selecting participants for their st
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studies lacked an arm that consider
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23. Kanner L. Autistic Disturbances
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62. Dosman CF, Drmic IE, Brian JA,
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104. Ben-Itzchak E and Zachor DA. T
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142. Tyminski RF and Moore PJ. The
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177. Aman MG, McDougle CJ, Scahill
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214. Correia CT, Almeida JP, Santos
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252. Akhondzadeh S, Tajdar H, Moham
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290. Dawson G, Rogers S, Munson J,
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Acronyms/Abbreviations ABA Applied
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Appendix A. Exact Search Strings an
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Table A2. PsycINFO search strategie
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Therapies for Children with Autism
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Therapies for Children with ASD Sys
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Appendix C. Evidence Tables Tables
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Evidence Table. Therapies for child
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Country: US Practice setting: Clini
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Dunn-Geier et al., 2000 (continued)
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Evidence Table: Therapies for Child
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Appendix D. List of Excluded Studie
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31. Aarsland D, Cummings JL and Lar
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59. Ahearn WH, Clark KM, Gardenier
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89. Allison DB, Basile VC and MacDo
Page 615 and 616:
118. Ando H, Yoshimura I and Wakaba
Page 617 and 618:
146. Atkinson RP, Jenson WR, Rovner
Page 619 and 620:
177. Bakare MO, Agomoh AO, Ebigbo P
Page 621 and 622:
204. Baron-Cohen S, Scott FJ, Allis
Page 623 and 624:
233. Bebko JM, Perry A and Bryson S
Page 625 and 626:
262. Bergmann F, Stepp H, Metzger R
Page 627 and 628:
291. Birkan B, McClannahan LE and K
Page 629 and 630:
319. Boddy F, Rowan EN, Lett D, et
Page 631 and 632:
348. Bouma R and Schweitzer R. The
Page 633 and 634:
376. Broadstock M, Doughty C and Eg
Page 635 and 636:
404. Brudnak MA. Application of gen
Page 637 and 638:
432. Buitelaar JK. Why have drug tr
Page 639 and 640:
460. Butler DE, Nordin IC, L’Ital
Page 641 and 642:
489. Campbell M, Locascio JJ, Choro
Page 643 and 644:
517. Caronna EB, Augustyn M and Zuc
Page 645 and 646:
546. Case-Smith J and Miller H. Occ
Page 647 and 648:
574. Charlop MH, Burgio LD, Iwata B
Page 649 and 650:
602. Cheng CW, Cho SH, Taylor M, et
Page 651 and 652:
631. Cicero FR and Pfadt A. Investi
Page 653 and 654:
662. Collier D and Reid G. A compar
Page 655 and 656:
691. Coskun M, Karakoc S, Kircelli
Page 657 and 658:
718. Cullen LA, Barlow JH and Cushw
Page 659 and 660:
748. Davidovitch M, Holtzman G and
Page 661 and 662:
777. DeLeon IG, Fisher WW and Marhe
Page 663 and 664:
805. Devlin SD, Harber MM. Collabor
Page 665 and 666:
834. Doherty K, Fitzgerald M and Ma
Page 667 and 668:
863. Dudley LL, Johnson C and Barne
Page 669 and 670:
893. Dybvik AC. Autism and the Incl
Page 671 and 672:
924. Elder JH. In-home communicatio
Page 673 and 674:
953. Erickson CA, Posey DJ, Stigler
Page 675 and 676:
979. Faja S, Aylward E, Bernier R,
Page 677 and 678:
1008. Ferri R, Elia M, Agarwal N, e
Page 679 and 680:
1037. Fisher W, Kerbeshian J and Bu
Page 681 and 682:
1066. Fragala-Pinkham M, Haley SM a
Page 683 and 684:
1095. Furneaux B. Keeping the balan
Page 685 and 686:
1124. Garcaa-Villamisar D, Wehman P
Page 687 and 688:
1152. Ghezzi PM. Discrete Trials Te
Page 689 and 690:
1180. Goin-Kochel RP, Myers BJ and
Page 691 and 692:
1210. Gordon R, Handleman JS and Ha
Page 693 and 694:
1239. Grimaldi BL. The central role
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1268. Guptill JT, Booker AB, Gibbs
Page 697 and 698:
1296. Hamdan-Allen G. Brief report:
Page 699 and 700:
1324. Hare DJ, Jones JPR and Paine
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1356. Harrison S and Berry L. Valui
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1386. Heilbrun AB, Jr., Blum N and
Page 705 and 706:
1414. Hetzroni OE and Shalem U. Fro
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1443. Holburn CS. Counter the mistr
Page 709 and 710:
1473. Horner RH, Carr EG, Strain PS
Page 711 and 712:
1504. Hughes C, Soares-Boucaud I, H
Page 713 and 714:
1533. Ijichi S and Ijichi N. Beyond
Page 715 and 716:
1562. James SJ, Cutler P, Melnyk S,
Page 717 and 718:
1591. Johnson CR, Butter EM, Handen
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1619. Joyce PR. The medical model-w
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1647. Karmali I, Greer RD, Nuzzolo-
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1673. Kelly AB, Garnett MS, Attwood
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1702. Kielinen M, Linna SL and Moil
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1731. Klin A, Lin DJ, Gorrindo P, e
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1761. Koegel RL and Frea WD. Treatm
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1790. Kolmen BK, Feldman HM, Handen
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1819. Kratochvil CJ, Findling RL, M
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1846. Lam MK and Rao N. Developing
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1874. Lattimore LP, Parsons MB and
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1903. Lee PC. Verification of a sim
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1932. Lerman DC, Vorndran C, Addiso
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1960. Licciardello CC, Harchik AE a
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1989. Liptak GS, Orlando M, Yinglin
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2015. Lorimer PA, Simpson RL, Myles
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2043. Luiselli JK, Kane A, Treml T,
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2071. MacFarlane JR and Kanaya T. W
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2099. Malone RP, Maislin G, Choudhu
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2127. Marin FZ. CAM versus nucleopl
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2157. Martineau J, Roux S, Adrien J
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2185. Matson JL and Lo Vullo SV. A
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2213. McCabe H. The Importance of P
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2240. McDougle CJ, Holmes JP, Carls
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2267. McHale SM, Olley JG, Marcus L
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2296. Merlo LJ, Lehmkuhl HD, Geffke
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2325. Minderaa RB, Anderson GM, Vol
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2354. Montgomery JM, Duncan CR and
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2385. Morrison RS, Sainato DM, Benc
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2413. Munesue T, Ono Y, Mutoh K, et
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2445. Napolitano DA, Tessing JL, Mc
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2474. Niederhofer H and Pittschiele
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2501. Nwora AJ and Gee BM. A case s
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2530. Olive ML, Lang RB and Davis T
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2559. Owens JA, Rosen CL and Mindel
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2589. Pansegrouw I and Alant E. Com
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2618. Paul C, Williams KE, Riegel K
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2646. Perry R, Nobler MS and Campbe
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2675. Piazza CC, Hagopian LP, Hughe
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2704. Poon L, Partika N and Bolman
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2734. Prizant BM. Speech-language p
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2764. Rapp JT, Vollmer TR, St. Pete
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2792. Reed P, Broomfield L, McHugh
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2819. Remington G, Sloman L, Konsta
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2849. Ringdahl JE, Kitsukawa K, And
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2877. Rogers SJ. Interventions that
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2908. Rossignol DA. Novel and emerg
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2939. Rutter M, Kreppner J, Croft C
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2967. Sandt D. Social Stories for S
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2994. Scanlon K. Art therapy with a
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3023. Schneider CK, Melmed RD, Bars
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3054. Schwartz IS, Sandall SR, Garf
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3085. Shafer MS, Egel AL and Neef N
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3115. Shipley-Benamou R, Lutzker JR
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3143. Siller M and Sigman M. The be
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3173. Smith C, Felce D, Jones E, et
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3202. Snyder A, Bossomaier T and Mi
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3230. Spero MH. The emancipation of
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3259. Stephens CE. Spontaneous imit
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3289. Strambi M, Longini M, Hayek J
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3318. Suzumura K. How an autistic b
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3346. Tager-Flusberg H and Calkins
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3376. Taylor I, O’Reilly M and La
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3407. Thunberg G, Ahlsen E and Sand
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3435. Trembath D, Balandin S, Toghe
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3464. Turner-Brown LM, Perry TD, Di
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3492. Van Der Putt R, Dineen C, Jan
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3522. Vitiello B. Recent NIMH clini
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3553. Walenski M, Mostofsky SH, Gid
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3581. Weber RC and Thorpe J. Teachi
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3610. Wheeler JJ, Baggett BA, Fox J
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3637. Williams B. Mental handicap n
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3669. Wimpory D, Chadwick P and Nas
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3698. Worth S and Reynolds S. The A
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3728. Young JM, Krantz PJ, McClanna
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3759. Zuddas A, Di Martino A, Mugli
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Appendix F. Approach to Categorizin
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APPENDIX G. Discussion of Recent Sy
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one a casein free regime. Diets wer
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outcome data as Type 6, defined as
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Yes—no disclosures to make G7 Bai
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Table G1. Characteristics of recent
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Random assignment Appropriate compa
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Study Group design Random assignmen
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APPENDIX I. Applicability Summary T
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Social skills (continued) Domain De
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Therapies for Children With Autism Spectrum Disorders

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