Research in Autism Spectrum Disorders 8 (2014) 138–142

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

Jo u rn al h om ep ag e: h t tp : / /ees .e lsev ier . co m /RASD/d efau l t .as p

Early Intensive Behavioral Interventions: Selecting behaviors

for treatment and assessing treatment effectiveness

Johnny L. Matson, Rachel L. Goldin *

Louisiana State University, USA

A R T I C L E I N F O

Article history:

Received 4 November 2013

Accepted 21 November 2013

Keywords:

Autism

Early Intensive Behavioral Intervention

Target behaviors

Treatment outcome

A B S T R A C T

Early Intensive Behavioral Interventions (EIBI) is well established as the most effective

treatment for young children with Autism Spectrum Disorders (ASD). A hallmark of this

intervention model is the bundling of multiple behaviors simultaneously for intervention.

With the addition of various comorbid problems such as challenging behaviors and

psychopathology, it becomes incumbent on clinicians to prioritize behaviors for

intervention. Based on the studies conducted to date, little has been done in this regard.

Additionally, general measures of ASD, adaptive behavior and cognitive functioning are

primarily used to assess outcomes, many of these measures were not designed to assess

treatment effects, and little evidence is available to link intervention to specific items on

these scales.

� 2013 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Results and discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Introduction

The study of Autism Spectrum Disorders (ASD) has become very popular in the mental health field. This trend may be dueto several factors. For example, once considered to be rare, ASD is now believed to be frequent and chronic (Li, Chenm, Song,Du, & Zheng, 2011; Matson & Kozlowski, 2011). Additionally, the problems these children exhibit are broad, including coresymptoms such as communication, social skills, and stereotypies and rituals (Fodstad, Matson, Hess, & Neal, 2009;Machalicek, O’Reilly, Beretvas, Sigafoos, & Lancioni, 2007; Matson & Wilkins, 2007; Matson, Matson, & Rivet, 2007; Matson,Dempsey, & Fodstad, 2009; Smith & Matson, 2010a). Further, a number of comorbid problems also accompany these corefeatures. Challenging behaviors such as aggression, self-injury, and feeding problems are routinely reported (Farmer &Aman, 2011; Kuhn & Matson, 2004; LoVullo & Matson, 2009; Matson & Kuhn, 2001; Matson & Rivet, 2008; Matson, Mayvilleet al., 2005; Smith & Matson, 2010b; Smith & Matson, 2010c). These findings are critical in treatment planning. Knowing thescope and specific deficits are critical in selecting specific targets for treatment and selecting the interventions that are best

* Corresponding author at: Department of Psychology, LSU Baton Rouge, LA 70803, USA. Tel.: +1 225 578 1494.

E-mail address: rgoldi3@lsu.edu (R.L. Goldin).

1750-9467/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.rasd.2013.11.005

J.L. Matson, R.L. Goldin / Research in Autism Spectrum Disorders 8 (2014) 138–142 139

suited to treat them (Machalicek et al., 2007; Matson & LoVullo, 2008; Matson & Wilkins, 2008; Matson, Dixon, & Matson,2005). Finally, this recognition of multiple comorbidities with ASD is in large part the reason why such a large number ofskills are packaged together in Early Intensive Behavioral Interventions (EIBI).

As noted, a variety of problems occur simultaneously among persons with ASD (Matson, Hamiltion, et al., 1997; Matson,Kiely, & Bamburg, 1997b; Paclawskyj, Matson, Bamburg, & Baglio, 1997). While not prescribed for core symptoms of ASD,pharmacology in the form of psychotropic drugs has become a common approach to the treatment of ASD and relateddevelopmental disorders (Holloway & Aman, 2011; Scheifes et al., 2013). However, for the treatment of very young children,such interventions are not advisable due to potential side effects (Matson et al., 1998). Rather, EIBI based or applied behavioranalysis has become the intervention of choice (Gould, Dixon, Najdouski, Smith, & Tarbox, 2011; Kuppens & Onghena, 2012;Matson, Boisjoli, Hess, & Wilkins, 2010; Matson, Wilkins, & Gonzalez, 2008).

It is becoming increasingly evident that a variety of problems tend to occur at high rates among young children with ASD.Intellectual disabilities are particularly common and complicate a positive prognosis for persons with ASD to a considerabledegree (Matson, Smiroldo, Hamiltion, & Baglio, 1997c). Thus, as this awareness of additional comorbid conditions grows, it isbecoming more apparent that all the problems these children display cannot realistically be treated simultaneously. Thus, acritical aspect of EIBI programs is how do researchers select and prioritize the behaviors to be trained. The purpose of thispaper was to look at existing trends in the selection of target behaviors and to recommend possible additional strategies tofurther systematize this process. The types of methods to determine treatment effectiveness are also discussed.

Method

A literature search was conducted using SCOPUS. Search terms included autism and Early Intensive BehavioralIntervention. Once these articles were identified, the reference section of each article was then searched to identifyadditional papers. Using these procedures, 32 papers were identified. Thus, a representative number of EIBI studies wereevaluated. The method section of each paper was then reviewed. Factors addressed included whether the authors describedmethods and procedures for prioritizing the skills that would be treated and in what order. Additionally, target behaviorswere defined as specific observable behaviors not included in standardized tests. Finally, the specific standardized tests usedat pretest and posttest were determined.

Results and discussion

When treating young children with ASD, a large number of core behaviors and collateral problems need to be treated.Additionally, persons with ASD can range from profoundly intellectually disabled to intellectually gifted. Severe motorproblems such as cerebral palsy and epilepsy may also be present. This extremely heterogeneous group of individualstherefore insures that a broad range of skills must be assessed. A good deal of overlap in target skills across individuals willoccur. However, there will also be many skills that do not match across children. Thus, a good deal of tailoring of skills andinterventions is required. In clinical practice it is therefore necessary to rank order what will be treated. It is impossible todeal with all the skills that are clinically indicated for a given individual. Additionally, many of these skills are sequential. Forexample, the clinician cannot work on complex verbal and nonverbal interaction skills until the child has been taught toattend and make eye contact. The outcome measure reported and often the descriptions of the treatment procedures do notreflect this reality.

It is certainly possible that informal or formal methods were used to prioritize target behaviors. In fact, it would not bepossible to do otherwise. However, none of the studies reviewed described how this process was executed. Systematicmethods and procedures should be developed and used. For example, precursor skills such as in seat attention, followingdirections, and elimination of challenging behaviors would be the first priority. A second tier of skills could be based onseverity of core symptoms of ASD and adaptive skills. Obviously, some skills will be stronger and some weaker. Thus,strength of the skills should be considered, typically applying treatment to the most problematic behaviors first. Anotherfactor to consider involves behaviors that are closely related to one another and which may generalize from one skill to thenext. This factor is also worth considering when prioritizing skills for treatment. The child will be able to acquire some skillsfaster than others. Variables of this sort should also be taken into account. Past history and a few brief sessions can be used tobetter define this factor. The general point however, is that a number of issues can be used to systematically establishtreatment priorities.

Target behaviors were found in 13 of the 32 papers (41%). The methods used however were highly variable. Methodsemployed included treatment plans, progress notes, in vivo observations, recording data from videotaped observations,frequency counts of tantrums and other challenging behaviors, toileting problems, a checklist of core ASD symptoms,communication objectives, and pre-established behavioral objectives. The most commonly recorded target behaviors werechallenging behaviors followed by social and communication behaviors.

Unquestionably, the most common method used to evaluate treatment effectiveness has been standardized scales. Thesetools allow for the assessment of a broad range of behaviors. However, these methods are not tailored to the individual norare they as treatment sensitive as target behaviors. A broad range of scales were used including the Vineland Adaptive

Behavior Scales (21 of 32 studies; 66%), standardized IQ tests (13 of 32 studies; 41%), and the Bayley Scales of Infant

Development (6 of 32; 19%). There were many other measures used as well. All of these methods were employed infrequently.

Table 1

EIBI studies.

Author(s) Prioritized

behaviors

Target behavior(s) Tests and other methods

Klintwall and Eikeseth (2012) No None Vineland Adaptive Behavior Scales (VABS),

Social Mediated and Automatic Reinforcer

Questionnaire

Butter, Mulick, and Metz (2006) No None VABS, standardized IQ test

Turner-Brown, Baranek,

Reznick, Watson, and Crais

(2013)

No None First Year Inventory, Social Responsiveness

Scale-Preschool, Developmental Concerns

Questionnaire

Solomon, Necheles, Ferch, and

Bruckman (2007)

No None Functional Emotion Assessment Scale

Stahmer and Ingersoll (2004) No Family services plan (e.g., treatment plan),

progress notes, in vivo observations,

videotaped observations

Bayley Scale of Infant Development (BSID),

VABS, Brigance Diagnostic Inventor of Early

Development

Mudford, Martin, Eikeseth, and

Bibby (2001)

No None Standardized IQ test, VABS, BSID

Smith, Eikeseth, Klevstrand,

and Lovaas (1997)

No Checklist of observable behaviors for core

symptoms of ASD; tantrums; toileting skills

BSID

Eikeseth, Smith, Jahr, and

Eldevik (2007)

No None VABS, Standardized IQ test

Zachor, Ben-Itzchak, and

Rabinovich (2007)

No None BSID, Standardized IQ test, Autism Diagnostic

Interview (ADI), Autism Diagnostic Observation

Schedule (ASDO)

Koegel, Koegel, Shoshan, and

McNerney (1999)

No Videotape of social language, nonecholalic

utterances, spontaneous initiations

Report cards (for academic perforamce), VABS

Green, Brennan, and Fein

(2002)

No Multiple social and adaptive skills VABS, Standardized IQ test

Lovaas (1987) No None School placement, Standardized IQ test

Eikeseth, Smith, Jahr, and

Eldevik (2002)

No Goals in treatment plan Standardized IQ test, Reynell Developmental

Language Scales, VABS

Strauss et al. (2012) No Rate of correct responding, frequency or

challenging behaviors

Autism Spectrum Disorders- Behavior

Problems for Children (ASD-BPC)

Bibby, Eikeseth, Martin,

Mudford, and Reeves (2002)

No Speech, behavior excesses and deficits,

challenging behaviors

BSID, VABS, Standardized IQ test, Reynell

Developmental Language Scales

Sheinkopf and Siegel (1998) No None Standardized IQ test, DSM-III-TR symptoms

Sallows and Graupner (2005) No None BSID, Standardized IQ test, Child Behavior

Checklist (CBCL), classroom placement,

Woodcock-Johnson Test of Achievement, Early

Learning Measure

Graff, Green, and Libby (1998) No Multiple challenging behaviors VABS

Koegel, Koegel, Shoshan, and

McNerney (1999)

No Social interactions VABS

Salt et al. (2002) No None BSID, British Picture Vocabulary Test, VABS,

Pre-verbal Communication Schedule,

MacArthur Communication Development

Inventory, Symbolic Play Test, Early Social

Communication Scales, Parenting Stress Index

(PSI)

Smith, Groen, and Wynn (2000) No Direct observation of instructions on receptive

language, nonverbal imitation expressive

language

Wechsler Individualized Achievement Test,

Class placement, Standardized IQ test, Reynell

Language Developmental Scale, VABS, CBCL

Reed, Osborne, and Corness

(2007)

No None VABS, Gilliam Autism Rating Scale,

Psychoeducational Profile-Revised, British

Abilities Scale

Granpeesheh, Dixon, Tarbox,

Kaplan, and Wilke (2009)

No Behavioral objectives None

Eikeseth, Klintwall, Jahr, and

Karlsson (2011)

No None VABS, Childhood Autism Rating Scale (CARS)

Magiati, Moss, Charman, and

Howlin (2011)

No None BSID, Standardized IQ test, VABS, British

Vocabulary Scales, ADI-R

Stock, Mirenda, and Smith

(2013)

No None Preschool Language Scale, Merrill Palmer

Scales, VABS, CBCL, PSI-Short Form

Zachor and Ben-Itzchak (2010) No None ADI-R, ADOS, VABS, Mullen Scales of Early

Learning

McGarrell, Healy, Leader,

O’Connor, and Kenny (2009)

No Curriculum objectives None

Fava et al. (2011) No None ADOS, Questions About Behavior Function,

ASD-BPC, VABS, PSI-Short Form

Fernell et al. (2011) No None VABS, Standardized IQ test, Diagnosis of Social

Communication Disorder

J.L. Matson, R.L. Goldin / Research in Autism Spectrum Disorders 8 (2014) 138–142140

Table 1 (Continued )

Author(s) Prioritized

behaviors

Target behavior(s) Tests and other methods

Green et al. (2010) No Communication skills ADOS, VABS, Preschool Language Scales,

MacArthur Communicative Development

Inventory, Communication and Symbolic

Behavior Scales Development Profile

Perry et al. (2011) No None CARS, VABS

J.L. Matson, R.L. Goldin / Research in Autism Spectrum Disorders 8 (2014) 138–142 141

The measures used included the Social Mediated and Automatic Reinforcer Questionnaire, the First Year Inventory, the Social

Responsiveness Scale-Preschool, the Developmental Concerns Questionnaire, the Questionnaire About Behavior Function, and theBritish Picture Vocabulary Test to name a few. A complete list of all 35 measures is presented in Table 1.

Thus, only three measures were used frequently while 35 measures were used infrequently. These infrequently usedinstruments covered core measures of ASD, methods to assess academic achievement, instruments to assess challengingbehaviors and comorbid psychopathology, and instruments to address parental concerns.

This list of infrequently used outcome measure clearly shows that no consensus exists about which tests should be used.Additionally, the three frequently used methods to measure treatment outcome are cognitive developmental andindependent living skills. Of course, these are not measure of core symptoms of ASD. Just as important, these instrumentswould be fine for children likely to have below normal IQ as second tier measures of improvement (after measures of coreASD symptoms). Similarly, these instruments would be instructive when highly debilitating conditions such as cerebralpalsy are also present. However, a child with ASD who also has normal or above average IQ and typical physical developmentwould benefit very little from such measure. Children who fall in this latter group therefore would show little improvementon these instruments. This profile could occur at the same time that marked improvements were occurring in core symptomsof ASD, challenging behaviors, or comorbid psychopathology. Failure to assess behavior in this latter measure would greatlyunderestimate overall EIBI treatment effectiveness.

A much more systematic way of determining what methods are used to evaluate treatment efficacy in EIBI studies isneeded. The same tests do not need to be used. However, specific topics need to be addressed. How skills are prioritized fortreatment, and what methods are used to assess progress needs to be spelled out. Second, specific target behavior should beincluded. Third, tests covering core symptoms of ASD, challenging behaviors, and psychopathology should be part of theassessment. Adaptive behaviors and measure of general childhood development should be included, and a measure ofbehavior function for challenging behaviors should be used in all cases. A great deal of improvement in these areas is needed.These issues cannot be neglected since intervention effectiveness is defined within the parameters of what is assessed.

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