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Research in Developmental Disabilities 30 (2009) 158–178

Outcome of comprehensive psycho-educational

interventions for young children with autism
Svein Eikeseth
Akershus University College, P.O. Box 423, N-2001 Lillestrom, Norway
Received 9 January 2008; accepted 15 February 2008

Abstract
This paper evaluates comprehensive psycho-educational research on early intervention for children with
autism. Twenty-five outcome studies were identified. Twenty studies evaluated behavioral treatment, 3
studies evaluated TEACCH and 2 studies evaluated the Colorado Health Sciences Project. Outcome studies
are graded according to their scientific value, and subsequently graded according to the magnitude of results
documented in the studies. Based on the available evidence, treatment recommendations are made and
practice parameters are suggested.
# 2008 Elsevier Ltd. All rights reserved.

Keywords: Autism; Early intervention; Treatment; Outcome

Autism is a Pervasive Developmental Disorder characterized by severe impairment in social

interaction and communication along with high rates of ritualistic and stereotyped behavior
(DSM-IV; APA, 1994). It is one of the most common developmental disorders. The prevalence
rate for all forms of Pervasive Developmental Disorder is estimated to be around 3–11 per 1000,
and childhood autism is estimated to have a prevalence of approximately 1–4 per 1000 (Baird
et al., 2006; Fombonne, 2003). Researchers have shown that 50–80% of children with autism
have mental retardation (Baird et al., 2006; Fombonne, 1999), and that the majority will require
professional care throughout their lives (Billstedt, Gillberg, & Gillberg, 2005).
Although specific causes of the condition have not yet been identified, researchers have
suggested that genetic, epigenetic and/or environmental factors are involved (Bailey et al., 1995;
Freitag, 2007; Muller, 2007; Volkmar, Lord, Bailey, Schultz, & Klin, 2004). Currently,
researchers are searching for medical and biomedical treatments that are effective, safe, and
generally accepted (c.f., Pangborn & Baker, 2005). However, the only drug approved for autism

E-mail address: [email protected].

0891-4222/$ – see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2008.02.003
 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178 159

by the U.S. Food and Drug Administration (FDA) is risperidone (FDA, October 6, 2006).
Risperidone may be used to treat aggression, self-injury, and temper tantrums, but it does not
address the core deficits of the autistic disorder, that is, the deficits in social interaction,
communication and stereotyped behaviors. Hence, medical treatments are not a substitute for
psycho-educational interventions, which currently is the benchmark intervention for autism
(Filipek, Steinberg-Epstein, & Book, 2006; Howlin, 2005).
A wide variety of psycho-educational interventions for children with autism have been
proposed, and many proponents have claimed beneficial effects (Dawson & Osterling, 1997;
Howlin, 2005; Smith, 1999). In 1999, the National Research Council (NRC) commissioned a
systematic review of psycho-educational interventions for children with autism. The committee
concluded that there is a great need for more knowledge about which interventions are most
effective (Lord et al., 2002, p. 349). Subsequently, a working group supported by the National
Institute of Mental Health (NIMH) was formed to develop guidelines for designing research
studies for psycho-educational interventions for individuals with autism (Lord et al., 2005; Smith
et al., 2007). Building on the recommendations made by the NRC and the NIMH working groups,
the present paper provides a systematic evaluation of comprehensive psycho-educational
programs for children with autism.
In addition to building on the recommendations made by the NRC and the NIMH working
groups, the current review includes recent studies not previously reviewed, it includes a more
systematic approach to evaluating outcome studies than those suggested by the NRC and the
NIMH groups, and it evaluates treatment effect. Finally, based on the available evidence,
treatment recommendations are made and practice parameters are suggested.

1. Method

1.1. Search methods

Three different search methods were used to identify all relevant outcome studies. First,
electronic searches on Medline (U.S. National Library on Medicine), ERIC (U.S. Department on
Education), and PsycLit (American Psychological Association) were conducted. Second, recent
publications (e.g., Smith, 1999; Suozzi, 2004; Volkmar et al., 2004) were inspected to confirm that
the computer search identified all relevant studies. Finally, researchers known to be involved in
outcome research were contacted by e-mail and asked to provide references on outcome studies
recently published or in press. This search method produced a large number of studies, many which
were not appropriate for the current review. To be included in the current review, the following
criteria had to be met: (a) study was published in a peer-reviewed journal; (b) children had a mean
age of 6 years or less at intake; (c) participants received comprehensive psycho-educational
interventions; (d) studies contained outcome data. Comprehensive psycho-educational interven-
tions were defined as interventions addressing all three-core deficits in autism. That is, the
interventions addressing social behaviors, communication and ritualistic/stereotyped behaviors.

1.2. Criteria for assigning scientific merit

Outcome studies were graded according to their scientific value and according to the
magnitude of results documented in the studies. Scientific Merit was evaluated based on: (a)
diagnosis, (b) study design, (c) dependent variables and (d) treatment fidelity. Four levels were
used to describe scientific merit: Level 1 represented the highest possible rating; Level 2
160 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

represented a moderate scientific merit; Level 3 represented a low scientific merit, and finally,
Insufficient Scientific Value (ISV) was assigned to studies where the evidentiary support was so
low that outcome data gave insufficient scientific meaning.
The criteria for Scientific Merit were as follows.

1.2.1. Level 1
1.2.1.1. Diagnosis. To obtain Level 1 status, the participants must have been diagnosed
according to current international standards, that is, either according to the ICD-10 or DSM-IV
criteria (or DSM-III criteria for studies conducted prior to the publication of DSM-IV). Further to
ensure objectiveness of the diagnosis, the diagnosis must have been set by clinicians who were
independent of the study or the diagnosis must have been based on well-researched diagnostic
instruments including ADI-R (Lord, Rutter, & LeCouteur, 1994), ADOS-G (Lord et al., 2000), or
CARS (Schopler, Reichler, & Rennner, 1988).

1.2.1.2. Design. In addition, Level 1 status required a randomized study design, that is, the
participants must have been assigned randomly to two or more study groups.

1.2.1.3. Dependent measures. Level 1 rating also requires that the intake and outcome
measures assessed both intellectual and adaptive functioning. The instruments used to assess
these skills must be normed and standardized. The IQ score must be derived from both language/
communication skills as well as visual spatial or performance skills (e.g., including Wechsler
tests, Bayley Scales of Infant Development, Stanford–Binnet; excluding Merrill–Palmer and
Leiter International Performance Scales). In addition, to ensure objectiveness of the assessments,
blind or independent assessors must have conducted the assessments.

1.2.1.4. Treatment fidelity. Finally, assessment of treatment fidelity was required to obtain
Level 1 status, or if not directly assessed, treatment must be described in treatment manuals.

1.2.2. Level 2
Criteria for achieving Level 2 Scientific Merit were identical to that of Level 1 except that the
study design was not random. That is, each participant did not have an equal chance of entering either
of the study groups. Group assignment based on, for example, participants’ geographical location,
parental choice or availability of treatment personnel is examples of non-random group designs.

1.2.3. Level 3
Criteria for achieving Level 3 status were as follows.

1.2.3.1. Diagnosis. Diagnosis (based on the ICD-10 or DSM-IV criteria) was not blind or
independent; or diagnosis was not based on diagnostic instruments (i.e., ADI-R, ADOS-G, or
CARS); or diagnosis was independent or blind but not based on ICD-10 or DSM-IV (or DSM-III
for older studies); or study failed to specify which diagnostic system was used.

1.2.3.2. Design. Retrospective (archival) studies with comparison group, or single-case

experimental studies where outcome measures were assessed pre and post.

1.2.3.3. Dependent measures. Intake and outcome measures did not assess both intellectual and
adaptive functioning, or measures were not normed and standardized.
 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178 161

1.2.3.4. Treatment fidelity. Insufficient assessment of treatment fidelity or treatment not based
on treatment manuals. Level 3 classification was given when one or more of the above criteria is
met.

1.3. Insufficient scientific value (ISV)

Studies classified as ISV with pre–post designs without a comparison group, retrospective
(archival) studies without comparison group, or pre–post designs without single-case control.

1.4. Criteria for deciding magnitude of results

In this section, criteria for evaluating magnitude of treatment effect are described. Treatment
effect is graded into four levels, where Level 1 represents the highest possible rating and Level 4
represents the lowest rating.

1.4.1. Level 1
To obtain Level 1 status regarding magnitude of results, significant group differences on IQ and
Adaptive Functioning (deviation or ratio scores) must be reported. This was considered a minimum
criterion. A better and more complete assessment battery would include measures of empathy,
personality, school performance, friendship, and information regarding diagnostic changes.

1.4.2. Level 2
Level 2 status required significant group differences on either IQ or adaptive functioning
(deviation or ratio scores). For both Level 1 and 2, the IQ measure must be based on language/
communication skills in addition to visual spatial or performance skills (e.g., including Wechsler
tests, Bayley Scales of Infant Development, Stanford–Binet; excluding the Merrill–Palmer Scale
of Mental Tests and the Leiter International Performance Scales).

1.4.3. Level 3
Level 3 status required significant group differences on developmental (or mental) age, or
significant group differences (or significant group differences on improvement) on assessment
instruments that are not normed and standardized.

1.4.4. Level 4
Studies reporting significant pre-post improvements.
In this review, only Levels 1–3 scientific evidence studies are evaluated according to magnitude
of treatment effect. Studies classified with Insufficient Scientific Value are excluded because for
methodological reasons they did not allow reliable conclusions regarding outcome to be drawn.

2. Classification of studies based on scientific merit and magnitude of results

The search criteria described above identified 25 outcome studies. Twenty studies evaluated
interventions based on Applied Behavior Analysis (ABA) treatment, 3 studies evaluated Project
TEACCH and 2 studies evaluated the Colorado Health Sciences Model. These treatment
approaches are described in Table 1. Table 2 describes each of the studies and their ratings
according to scientific merit and magnitude of results.
162 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

Table 1
Description of psycho-educational programs subjected to outcome research
TEACCH TEACCH (Treatment and Education of Autistic and Communication
Handicapped Children) was founded at the University of North
Carolina in 1966 by Eric Schopler (Schopler & Reichler, 1971).
Several hundred research studies have been conducted by or in
collaboration with Division TEACCH. Today, it is the most
influential special education program for children with autism, and
is used world wide. It aims at addressing multiple problems such as
communication, cognition, perception, imitation and motor skills.
The program emphasizes teaching in multiple settings with the
involvement of several teachers.
TEACCH was traditionally used in segregated self-contained classrooms
for children with autism, but recently, focus has been shifted towards
exposing children with autism to inclusive settings with typically
developing children (Lord & Schopler, 1994). In addition, emphasis has
been placed on home programming using parents as co-therapists (Ozonoff &
Cathcart, 1998). The TEACCH approach has been described in numerous
manuals and books (cf., Mesibov, Shea, & Schopler, 2005; Schopler &
Mesibov, 1995), and typically contains the following five components:
1. Focus on structural teaching. Typically, a teacher and a teacher assistant
have the responsibility of teaching five children with autism. Focus is placed
on teaching children independent work skills.
2. Strategies to enhance visual processing are emphasized including (a)
the physical (ecological) structure of the classroom, (b) the use of visual
activity schedule to help children anticipate future events (c) a visual
organization of the work materials to teach the learning tasks and their
sequences, and (d) a visual system to teach complicated skills such
as language and imitation.
3. Program involves the teaching of a communication system based on
gesture, pictures, signs, or printed words.
4. Program involves teaching pre-academic skills (colors, numbers, shapes,
drawing, writing, and assembly).
5. Parents are encouraged to work as co-therapists with their child in the
home using the same techniques and materials as employed during the
TEACCH clinic sessions.
The Denver Model The Denver Model was developed by Sally Rogers and colleagues in the
1980s (Rogers et al., 2006; Rogers, Hall, Osaki, Reaven, & Herbison, 2001).
The program provides more than 20 h per week of systematic instruction to
children from ages 2 to 5 years. The program is a developmental play-based
approach, based on Piaget’s theory of cognitive development. Piaget focused
on how children explore their environments to construct schemas about how
the world works and how to reason about it. In addition to Piaget, the
Colorado Health Science Program also used Mahler’s psychoanalytic
theory of child development. Mahler’s theories centered on how
children establish a sense of identity and an understanding of others
through interactions with caregivers. The Colorado Health Science
Program also utilizes the INREAL pragmatic based communication
program (Weiss, 1981), which aims to enhance functional
communication in the context of naturally occurring activities.
Finally, the program use behavior analytic techniques for example
to reduce aberrant behaviors. The Denver Model is offered as a
comprehensive, eclectic ‘‘best practice’’ approach with a broad
theoretical underpinning.
 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178 163
Table 1 (Continued )
Applied–Behavior–Analytic Interventions based on ABA was pioneered by Ivar Lovaas and colleagues
Interventions (ABA) in the 1960s (Ferster & DeMyer, 1961; Lovaas & Simmons, 1969; Wolf,
Risley, & Mees, 1964), and rests on several hundred clinical studies
published in peer-reviewed journals (Matson, Benavidez, Compton, Paclawskyj,
& Baglio, 1996; Newsom & Rincover, 1989; Suozzi, 2004). Building on
this body of knowledge several empirically supported treatment manuals
has been published to guide the practitioners in designing effective programs
for children with autism (Leaf & McEachin, 1999; Lovaas, 1977, 2003;
Lovaas et al., 1981; Maurice, 1996; Maurice, Green, & Foxx, 2001).
ABA focuses on remediating the children’s delays in communication, social
and emotional skills and place great focus on integrating the children with
typical peers in typical settings. ABA programs are based on principles derived
from laboratory and applied research on learning psychology (Catania, 1998;
Cooper, Heron, Heward, 1987). One working hypothesis is that children with
autism have a biological based learning/developmental deficit, and that
principles derived from learning psychology may facilitate acquisition of
adaptive skills and a facilitate reduction of aberrant behaviors. Moreover,
it is argued that some children may overcome their learning deficit,
enabling them to acquire behaviors exhibited by typical children and
eventually to learn from typical (non-behavioral) education (Lovaas, 2003).
Important components include:
1. Early intervention. Treatment onset as early as possible in the child’s life,
preferably before the child is 3.5-years-old, though treatment of older children
has also been documented effective.
2. Parent involvement. Parents are trained to be co-therapists and parents to
facilitate generalization and maintenance of new skills.
3. Mainstreaming children with typically developing children.
4. Intensive one-to-one teaching. Research has shown that 30–40 h per week
of one-to-one intervention for at least 2 years may be required to produce
maximum effect.
5. Comprehensiveness of program. The program target and teach skills within
all areas of functioning such as language and communication, play, social skills,
leisure activities, pre-academic and academic skills, self-help skills, and
social–emotional skills. In addition, the program focuses on reducing aberrant
behaviors such as aggressive behaviors, attention deficits, and stereotyped
behaviors and ritualistic behaviors.
6. Individualized programming. Based on an assessment of each individual
child, existing strengths of children are accommodated and efforts are made to
remediate weaknesses.

2.1. Level 1 scientific merit

As can be seen in Table 2, only one Level 1 study was identified. The study was conducted by
Smith, Groen and Wynn (2000) and was designed to evaluate ABA treatment. Results showed
that the ABA treatment group scored significantly higher as compared to the parent training
control group on intelligence, visual–spatial skills, language and academics, though not adaptive
functioning. Because the study did not show significant group differences on adaptive
functioning, the study received Level 2 magnitude-of-results rating. Though the Smith et al.
study is the best designed outcome study conducted to date, the study has limitations, such as a
relatively small sample size (n = 28). Also, the participants received less intensive intervention
than is considered optimal (c.f., Eledevik, Eikeseth, Jahr, & Smith, 2006; Lovaas, 1987), and this
may have affected the results.
 164
Table 2
Evaluation of scientific merit and treatment effect
Reference Description Scientific Treatment
merit effect
Smith, Groen, Examined effects of ABA treatment for children with autism and children with PDD-NOS. Mean intake age 1 2
and Wynn was 36 months. The diagnosis was set by an independent agency and based on the DSM-III criteria. Participants
(2000) were matched on pre-treatment IQ and randomly assigned by an independent statistician to either an ABA

S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

treatment (n = 15) group or to a parent training group (n = 13). Participants in ABA group (seven with autism,
eight with PDD-NOS) received a mean of 24.5 h per week of one-to-one ABA treatment during the first year
of intervention with a gradual reduction of treatment hours over the next 2 years. Participants in the control
group (seven with autism, six with PDD-NOS) received 3–9 months of parent training for several hours per week.
Measures included IQ, visual–spatial IQ, language functioning, adaptive functioning, socio-emotional functioning,
academic achievement, class placement progress in treatment, and parent evaluation. Tests were carried out by
independent assessors. There were no significant differences at intake on any of the measures. At follow-up the
ABA treatment group scored significantly higher as compared to the parent training group on IQ, visual–spatial
skills, language (assessed the by score combining comprehension and expression), school placement and
academics, though not adaptive functioning and socio-emotional functioning. The ABA treatment group gained
an average of 16 IQ points ES = 1.43. By comparison, the parent training group lost one IQ point. Children with
PDD-NOS gained more than those with autism. Twenty-seven percent of the children in the ABA group achieved
average post-treatment scores and were succeeding in regular education classrooms.
Eikeseth et al. Compared effects of ABA and eclectic treatment for children with autism. Mean intake age was 5.5 years. The 2 1
(2002, 2007) diagnosis was set by an independent agency and based on the ICD-10 criteria, and confirmed by the ADI-R.
Group assignment to either an ABA treatment group (n = 13) or to an eclectic treatment group (n = 12) was
based on availability of ABA supervisors and performed by a person who was independent of the study.
Participants in the ABA treatment group received 28 h per week of one-to-one ABA treatment during the
first year of intervention with a gradual reduction of treatment hours over the next 2 years. Participants in
the eclectic group received 29 h per week of one-to-one eclectic treatment with a gradual reduction of
treatment hours over the next 2 years. Measures included IQ, language functioning, adaptive functioning,
maladaptive behavior and socio-emotional functioning. Tests were carried out by independent assessors. There
were no significant differences at intake on any of the measures. Follow-up assessment—conducted approximately
3 years after the treatment begun—showed that the ABA treatment group scored significantly higher as compared
to the eclectic treatment group on intelligence, language, adaptive functioning, maladaptive functioning and on two
of the subscales on the socio-emotional assessment (social and aggression). The ABA treatment group gained an
average of 25 IQ points, ES = 2.21; 12 points in adaptive functioning ES = 1.35. By comparison, the eclectic treatment
group obtained average change of +7 points in IQ, 10 points in Adaptive Functioning. Seven of 13 children in the
ABA group who scored within the range of mental retardation at intake scores within the average range ( 85) on
both IQ and verbal IQ at follow-up, compared to 2 of 12 children in the eclectic treatment group.
Howard et al. Compared effects of three treatment approaches on children with autism or PDD-NOS. Twenty-nine children received 2 1
(2005) 25–40 h per week one-to-one ABA treatment. A comparison group (n = 16) received 30 h per week of one-to-one or
two-to-one eclectic intervention in public special education classrooms. A second comparison group (n = 16)
received 15 h per week public early intervention in small groups. Mean intake CA = 36 months. The diagnosis was
set by an independent agency and based on the DSM-IV criteria. Measures included IQ, language functioning, and
adaptive functioning. Tests were carried out by independent assessors. There were no significant differences at
intake on any of the measures. Follow-up assessment – conducted approximately 14 months after the treatment
begun – showed that the ABA treatment group scored significantly higher scores as compared to the two comparison

S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

groups on all measures. There were no statistically significant differences between the mean scores of the two
comparison groups. The ABA treatment group gained an average of 31 IQ points, ES = 1.73, 11 points in adaptive
functioning, ES = 0.94. The comparison groups obtained average change of +9 points in IQ, 2 points in
Adaptive Functioning. Learning rates at follow-up were also substantially higher for children in the ABA group
than for participants in either of the other two comparison groups.
Cohen et al. Compared effects of ABA treatment with special education provided at local public schools for children with autism 2 1
(2006) or PDD-NOS. Participants’ mean age when the treatment begun was unspecified, but the mean age at diagnosis was
31.2 months (range 18–48 months) and all participants were less than 48 months by the onset of treatment. The
diagnosis was set by an independent agency, based on the DSM-IV criteria and confirmed by the ADI-R. Group
assignment to either an ABA treatment group (n = 21, 20 with autism and 1 with PDD-NOS) or to an eclectic
treatment group (n = 21, 14 with autism and 7 with PDD-NOS) was based on parental preference. Participants
in the ABA treatment group received 35–40 h per week of one-to-one ABA treatment provided in a community
setting. Participants in the comparison group received public community Services. The child/teacher ratios varied
from one-to-one to three-to-one. Classes operated for 3–5 days per week, for up to 5 h per day. Speech, occupational,
and behavioral therapy varied from 0 to 5 h per week. Three of the children spent brief sessions (up to 45 min per day)
mainstreamed in regular education. Measures included IQ, visual IQ, language functioning, and adaptive functioning.
Assessments were carried out by independent assessors. There were no significant differences at intake on any
of the measures, though the groups differed on some of the demographic variables. Most notably, the ABA group had
significantly more children with autism (and less with PDD-NOS) as compared to the comparison group. Follow-up
assessment – conducted approximately 3 years after the treatment begun – showed that the ABA treatment group
scored significantly higher as compared to the two comparison groups on IQ and adaptive functioning, though not
on visual IQ and language (language comprehension was marginally significant with p = 0.06). The ABA treatment
group gained an average of 25 IQ points, ES = 1.52, 10 points in adaptive functioning, ES = 1.23. By comparison,
the eclectic treatment group obtained average change of 4 points in IQ, 3 points in Adaptive Functioning.
Six of the 21 ABA treated children were fully included into regular education without assistance, and 11 others
were included with support; in contrast, only 1 comparison child was placed primarily in regular education.

165
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Table 2 (Continued )
Reference Description Scientific Treatment
merit effect
Remington Compared effects of ABA with treatment as usual for children with autism. Mean intake age was 37 months. The 2 2

S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

et al. (2007) diagnosis was set by an independent agency and based on the ICD-10 criteria, and confirmed by the ADI-R. Group
assignment to either an ABA treatment group (n = 23) or to a treatment as usual group (n = 21) was based on parental
choice. Participants in the ABA treatment group received 25.6 h per week of one-to-one ABA for 2 years. Participants
in the comparison group received standard provision from the local education authorities. Number of one-to-one
treatment hours in the treatment as usual group was unspecified. Measures included IQ, language functioning, adaptive
functioning, rating scales and observation measures for child behavior, and self-report measure of parent well being.
Tests were carried out by one of the authors of the study, but the assessor was not informed regarding which group the
participants belonged to. There were no significant differences at intake on any of the measures. Follow-up assessment
showed that the ABA treatment group scored significantly higher as compared to the comparison group on intelligence,
but not on language functioning or adaptive behavior (as measured by standard scores). The ABA treatment group
gained an average of 12 IQ points, ES = 0.72, whereas children in the comparison group lost, on average, two IQ points.
Children in the ABA group showed an advantage over the comparison group in language functioning at follow-up, as
more children in the ABA group reached basal on the Reynell comprehension and expression scales post treatment.
The ABA group showed significantly better score on responding to joint attention as compared to the comparison
group, but not in initiating joint attention. No other significant changes were reported in child outcome. On parental
outcome, no significant group differences were found except that fathers of children in the ABA group showed
higher degree of depression at follow-up.
Lovaas (1987) The seminal outcome study examining effects of ABA treatment for children with autism. Nineteen children received 3 2
and McEachin 40 h per week of one-to-one ABA treatment for a minimum of 2 years. A comparison group (n = 19) received 10 h or
et al. (1993) less per week one-to-one ABA treatment. Mean intake was CA = 33.3 months. A second comparison group (n = 21) came
from the same agency that diagnosed the majority of the other participants and had received services generally available
for children with autism in the area. The diagnosis for all percipients was set by an independent agency and based on the
most current DSM system available at the time of the study. Intake measures included IQ and behavioral observations.
Follow-up measures included IQ, adaptive behavior, personality and school placement. Assessment of best outcome
participants was carried out by independent and blind assessors. There were no significant between group differences at
intake on any of the measures. Follow-up assessment – conducted when the children averaged 11.5 years of age – showed
that the ABA treatment group scored significantly higher as compared to the comparison groups on IQ, adaptive
functioning and school placement, but not on the personality measures. The ABA treatment group gained an average
of 31 IQ points, 11 points in adaptive functioning. The comparison groups obtained average change of +9 points in IQ,
2 points in Adaptive Functioning. Forty seven percent of the children in the ABA group achieved average post-treatment
scores and was succeeding in regular education classrooms.
Magiati et al. Compared outcome of parent managed ABA treatment to autism-specific nursery provision for pre-school children with 3 3
(2007) autism spectrum disorders. In the parent managed program, the families located and recruited consultants and therapists and
managed the child’s program. The parent managed program is different to the clinic based or school programs described above.
Mean intake age was 40 months. The diagnosis of autism or autistic spectrum disorders was set by an independent agency.
Diagnostic system not specified, but diagnosis was confirmed by the ADI-R in the majority of the cases. Measures included IQ
(as measured in many cases by the Merrill–Palmer Scale of Mental Tests), language, play, adaptive behavior and severity of
autism. Both groups showed improvements in age equivalent scores but not on standard scores. At follow-up, there were no
significant group differences in cognitive ability, language, play or severity of autism.

S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

Mukaddes Examined effects of TEACCH provided to children with autism as compared to children with reactive attachment 3 3
et al. (2004) disorder. Mean intake age was 43.2 months for the children with autism and 48.4 months for the children with reactive
attachment disorder. The diagnosis was based on DSM-IV and performed by two independent clinicians. Ten boys
with autism and 11 children with reactive attachment disorder (nine boys and two girls) were included in the study.
Group assignment was based on the participant’s diagnosis. The measure was the Ankara Developmental Screening
Inventory, which assesses parental reports of children’s social, language/cognitive, social/self-care, fine motor and gross
motor functioning. There was no information regarding whether or not the assessment was conducted independently
or blindly. At intake, there were no significant differences between the two groups on raw scores on any of the four
subscales or the total score of the measure. Following 14, 45-min sessions of psycho-educational treatment the
children with reactive attachment disorder showed greater improvement than the autism group in their total
development score, on the language–cognitive subscale, and in social/self-care abilities, but not on the fine
or gross motor subscales. Both groups showed significant improvements in raw scores on all subscales and on
the total developmental score following the intervention.
Ozonoff and Examined effects of a TEACCH based home program for children with autism. Mean intake age was 53.4 months. 3 3
Cathcart Participants were diagnosed with autism, but no information was provided regarding diagnostic system, whether
(1998) or not the diagnosis was set independently, or whether any diagnostic instruments were used. The first 11 participants
volunteering for the study were assigned to the intervention group and the latter 11 participants endured the comparison
group. Participants were matched on age, pretest PEP-R scores, severity of autism, and time to follow-up. Averages of
10 hands-on training sessions over a period of 4 months were provided to the child and the family by trained graduate
students. Parents were encouraged to work with the child between sessions, but number of such one-to-one teaching sessions
provided by the parents was unspecified. Participants in both groups attended a day-care treatment program. Measure was
PEP-R, but assessment was not blind or independent. Children in the treatment group improved significantly more
(as measured by months) than those in the control group on the PEP-R subtests of imitation, fine motor, gross motor, and
nonverbal conceptual skills, as well as in overall PEP-R scores, but not on the other subtests.

167
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Table 2 (Continued )
Reference Description Scientific Treatment
merit effect
Eldevik Compared effects of low intensity ABA and low intensity eclectic treatment for children with autism. Mean intake age 3 2
et al. (2006) was 51 months. The diagnosis was based on the ICD-10 criteria. Study design was retrospective. An examination of each
child’s treatment record and a questionnaire completed by case supervisors determined group assignment. Children who had

S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

received treatment based only on ABA constituted the ABA group (n = 13). Children who had received a combination of
two or more types of treatment comprised an eclectic group (n = 15). Group assignment was blind. Participants in the ABA
treatment group received 12.5 h per week of one-to-one ABA treatment for 20 months. Participants in the eclectic group
received 12 h per week of one-to-one eclectic treatment for 21 months. Measures included IQ, nonverbal intelligence,
language functioning, adaptive functioning, psychopathology (no words, affectionate, toy play, peer play, stereotypes,
temper tantrums, toilet trained, sum pathology). Diagnosis and assessment was not provided independently, but may be
considered blind since the study was archival and hence not planned at the time of diagnosis and assessment. There were
no significant differences at intake on any of the measures. Follow-up assessment showed that the ABA treatment group
scored significantly higher as compared to the eclectic treatment group on intelligence, language, but not on adaptive
functioning. On the pathology scale, the ABA group scored higher than the eclectic group on, affectionate, toy play, peer
play, toilet trained, and sum pathology, but not on no words, temper tantrums, or stereotypes. The ABA treatment
group gained an average of 8.2 IQ points, ES = 0.54. By comparison, the eclectic treatment group lost and average
of 2.9 IQ points. The degree of mental retardation was reduced for 38% of the children in the ABA group, as compared
to 7% in the eclectic group. Gains were more modest than those reported with children receiving more intensive
behavioral treatment, and it is unclear whether they were clinically significant.
Sallows and Examined effects of ABA treatment and parent managed ABA treatment for children with autism. Mean intake age 3 1
Graupner was 36 months. The diagnosis was set by an independent agency, based on the DSM-IV criteria and confirmed by
(2005) the ADI-R. Participants were matched on pre-treatment IQ and randomly assigned by an independent statistician
to either an ABA treatment (n = 13) group or to parent managed ABA treatment (n = 10). Participants in ABA group
received a mean of 37.6 h per week of one-to-one treatment for 2 years. Participants in the parent managed ABA
control group received a mean of 31.3 h per week of one-to-one treatment for 2 years. It is unclear whether this
difference in treatment intensity is statistically significant. Number of one-to-one hours decreased over the next
2 years as the children entered school. Measures included measures of IQ, visual–spatial IQ, language functioning,
adaptive functioning, socio-emotional functioning and autism symptoms (ADI-R). Pretests were carried out by
the second author prior to group assignment. Posttests were conducted independently. There were no significant
differences at intake on any of the measures. At follow-up there were no significant differences between groups
at pre- or posttest. Combining children in both groups, pretest to posttest gains were significant for IQ, language
comprehension and ADI-R Social Skills and ADI-R Communication, but not on visual–spatial IQ, expressive
language, adaptive behavior, socio-emotional functioning, and ADI-R Rituals. All children in both groups gained
an average of 25 IQ points, ES = 2.56. Forty-eight-percentage of all children in both groups showed rapid learning,
achieved average post treatment scores and were succeeding in regular education classrooms.
Smith, Buch, Examined effects of parent managed ABA intervention for children with autism or PDD-NOS. Mean intake age was 36 months. 3 4
and Gamby The diagnosis was set by an independent agency and based on the DSM-III criteria. Six boys (four with autism) participated in
(2000) the study. A multiple-baseline design across participants was used to assess children’s progress in treatment. Participants were
randomly assigned to a baseline condition lasting 1, 3 or 5 months. Participants and therapists received six 1-day workshops
over a 5-month period, with additional consultations over the next 2–3 years. During the first 3 months of treatment,
participants received a mean of 26.2 h of one-to-one treatment per week. Measures included IQ, language, adaptive
functioning, and progress in treatment. Five of six children rapidly acquired skills when treatment begun, but only
two of six children improved on standardized tests conducted 2–3 years into treatment.

S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

Weiss (1999) Examined effects of 2 years of 1:1 ABA treatment for children with autism (n = 20). Initial acquisition of 3 3
skills was correlated with later learning rates, severity of autism symptomatology and adaptive behavior
profiles 2 years into treatment.
Birnbrauer and Examined effects of 18 h per week of 1:1ABA treatment for 2 years for children with autism (n = 9). Comparison with 3 3
Leach (1993) children not qualifying for study (n = 5). Mean intake age was 39 months. The diagnosis was set by an independent agency
and based on the DSM criteria. Fourteen children participated in the study. A one-group pretest–posttest design was used.
In addition a multiple-baseline design across behaviors was used to help demonstrate relationship between treatment
effect and program intervention. Participants received a mean of 18 h per week of one-to-one ABA treatment for a
period of 2 years. Measures included IQ, language functioning, and adaptive functioning, school placement and
parent’s skills in behavioral techniques. Assessments of IQ, language functioning, and adaptive functioning was
carried out independently. Results indicate significant change between intake and follow-up in mental age,
developmental language functioning, and developmental adaptive functioning. In addition integrated school placement
increased, and parents improved their skills in using behavioral techniques.
Sheinkopf and Examined effects of ABA treatment for children with autism and children with PDD-NOS. Mean intake age was 34 months. 3 3
Siegel (1998) The diagnosis was made by consensus from two or more independent clinic staff and was based on the DSM-III criteria. Study
design was retrospective. Participants were matched on pre-treatment CA, mental age, interval between pre- and
post-assessments, diagnosis and sex. Eleven children (10 with autism) received ABA treatment and 11 children (10 with autism)
received services available in the child’s local community. Participants in ABA group received a mean of 19.5 h per week of
one-to-one ABA treatment for an average of 15.7 months. Measures included IQ and autism symptoms. Assessments
may be considered blind since the study was archival and hence not planned at the time of diagnosis and assessment.
There were no significant differences at intake on any of the measures. At follow-up the ABA treatment group scored
significantly higher as compared to the comparison group on both measure. The ABA treatment group gained
an average of 26.9 IQ points. By comparison the comparison group gained two IQ points.
Andersen Examined effects of ABA treatment for children with autism. Mean intake age was 43 months. The diagnosis was set 3 3
et al. (1987) by an independent agency and based on the DSM (1980) criteria. Fourteen children participated in the study. A one-group
pretest–posttest design was used. In addition a multiple-baseline design across behaviors was used to help demonstrate
relationship between treatment effect and program intervention. Participants received a mean of 20 h per week of one-to-one
ABA treatment for a period of 2 years. Measures included IQ, language functioning, and adaptive functioning, school
placement and parent’s skills in behavioral techniques. Assessments of IQ, language functioning, and adaptive functioning
was carried out independently. Results indicate significant change between intake and follow-up in mental age,
developmental language functioning, and developmental adaptive functioning. In addition integrated school

169
placement increased, and parents improved their skills in using behavioral techniques.
 170
Table 2 (Continued )
Reference Description Scientific Treatment
merit effect

S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

Lord and TEACCH for unspecified number of hours and for unspecified time (n = 72.3-year-old and n = 70.4-year-old). ISV Na
Schopler (1989) Pre–post design without single-case control.
Rogers Colorado Health Science Program for 22.5 h per week (n = 13) for 5 months. Pre–post design without ISV Na
et al. (1986) single-case control.
Rogers and Colorado Health Science Program for 22.5 h per week (n = 49) for 6.4 months. Pre–post design without ISV Na
DiLalla (1991) single-case control.
Bibby Parent managed ABA intervention for unspecified number or hours per week of 1:1 treatment for at ISV Na
et al. (2002) 2 years and 6 months. Pre–post design without single-case control.
Handleman ABA. Children working in self-contained (n = unspecified) or integrated classrooms (n = unspecified) ISV Na
et al. (1991) for 11 months.
Harris ABA. Children working in self-contained (n = unspecified) or integrated classrooms (n = unspecified) ISV Na
et al. (1990) for 11 months. Pre–post design without single-case control.
Harris ABA. Children working in self-contained (n = unspecified) or integrated classrooms (n = unspecified) ISV Na
et al. (1991) for 11 months. Pre–post design without single-case control.
Hoyson ABA. 15 h per week of intervention in class of typically developing children (n = 6) for 9 months. ISV Na
et al. (1984) Some 1:1 treatment. Pre–post design without single-case control.
Luiselli ABA for 14 h per week of 1:1 for 9 months (n = 16). Pre–post design without single-case control. ISV Na
et al. (2000)

Level 1 Scientific Merit represents the highest possible rating; Level 2 represents a moderate scientific merit; Level 3 represents a low scientific merit. ISV describes scientific merit
so low that outcome data gives insufficient scientific meaning. Levels 1–3 Scientific Merit studies were evaluated for Treatment Effects. Level 1 Treatment Effect represents the
highest possible rating; Level 2 represents a moderate treatment effect; Level 3 represents a low treatment effect, and Level 4 represents the lowest treatment effect.
 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178 171

2.2. Level 2 scientific merit

Four Level 2 studies were identified (Cohen, Amerine-Dickens, & Smith, 2006; Eikeseth,
Smith, Jahr, & Eledevik, 2002, 2007; Howard, Sparkman, Cohen, Green, Stanislaw, 2005;
Remington et al., 2007). All four studies evaluated ABA treatment. Three of the studies showed
that the participants in the ABA treatment groups scored significantly higher on intelligence,
language and adaptive functioning as compared to comparison group children (Cohen et al.,
2006; Eikeseth et al., 2002, 2007; Howard et al., 2005). Consequently these three studies received
Level 1 magnitude-of-results rating. The Remington et al. study found that children in that ABA
treatment group scored significantly higher as compared to children in the comparison group on
intelligence, but not on adaptive functioning and language (as measured by standard scores).
Hence this study received Level 2 magnitude-of-results rating. All four studies gained Level 2
Scientific Merit classification because they lacked a randomized study design: Three studies
(Cohen et al., Howard et al., Remington et al.) based group assignment on parental preference.
This because treatment was funded by public agencies required to offer free and appropriate
services to all children. Unfortunately, group assignment based on parental preference may
results in study groups that differ on important variables (e.g., parental involvement), and this
may, in turn, affect outcome. Eikeseth et al. based group assignment on availability of ABA
supervisors as judged by a director of the habilitation service who was independent of the study.
Hence, group assignment was not based on any child or family characteristics. Yet, group
assignment was still not random.
In the Cohen et al. (2006), Eikeseth et al. (2002, 2007) and Howard et al. (2005), and
Remington et al. (2007) studies pre-treatment test scores reviled no significant group differences
on any of the outcome variables suggesting that the groups were similar at intake measures. In the
Cohen et al. study, the groups differed on other pre-treatment variables potentially influencing
outcome: The ABA group had more children with autism and fewer with PDD-NOS than did the
comparison group, a difference which may have favored the comparison group (Smith, Groen, &
Wynn, 2000). Also, the ABA group had more two-parent families than the comparison group,
which may have favored the experimental group. However, when statistically controlling for
family variables, results continued to show improved outcomes in the ABA group as compared to
the comparison group.
A shortcoming of the Eikeseth et al. study was that the teachers in the ABA group received
more intensive supervision (up to 10 h per week) as compared to the teachers in the eclectic
treatment group (2 h per week). However, the ABA teachers had no prior knowledge of ABA
treatment before entering the study. Because of this, they required intensive supervision and
training so they could provide proper behavioral treatment. The teachers in the eclectic group, in
contrast, had prior training in special education methods, and hence might have required less
intensive supervision.

2.3. Level 3 scientific merit

Eleven outcome studies received Level 3 evidence support. Two studies evaluated TEACCH
(Mukaddes, Kaynak, Kinali, Besikci, & Issever, 2004; Ozonoff & Cathcart, 1998), and both
studies received Level 3 magnitude-of-results rating. Ozonoff and Cathcart did not specify which
diagnostic system the children’s diagnosis was based on, whether or not the diagnosis was set
independently, or whether any diagnostic instruments was used. Also, number of one-to-one
teaching sessions provided by the parents was unspecified. The first 11 participants volunteering
172 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

for the study were assigned to the intervention group and the latter 11 participants were assigned
to the comparison group. Hence, group assignment was not random. The measure was not
performed blind or independently and did not include adaptive functioning. Children in the
treatment group improved significantly more, as measured by months, than those in the control
group on the PEP-R subtests of imitation, fine motor, gross motor, and nonverbal conceptual
skills, as well as in overall PEP-R scores, but not on the other subtests. Mukaddes et al. based
group assignment on the participant’s diagnosis (reactive attachment disorder vs. autism). The
measure was the Ankara Developmental Screening Inventory, which assesses parental reports of
children’s social, language/cognitive, social/self-care, fine motor and gross motor functioning.
There was no information regarding whether or not the assessment was conducted independently
or blindly. At intake, there were no significant differences between the two groups on raw scores
on any of the four subscales or the total score of the measure. At follow-up, children with reactive
attachment disorder showed greater improvement than the autism group in their total
development score, on the language–cognitive subscale, and in social/self-care abilities, but not
on the fine or gross motor subscales. Both groups showed significant improvements in raw scores
on all subscales and on the total developmental score following the intervention.
The remaining nine studies evaluated ABA treatments (Andersen, Avery, DiPietro, Edwards,
& Christian, 1987; Birnbrauer & Leach, 1993; Eldevik et al., 2006; Lovaas, 1987; McEachin,
Smith, & Lovaas, 1993; Magiati, Charman, & Howlin, 2007; Sallows & Graupner, 2005;
Sheinkopf & Siegel, 1998; Smith, Buch, & Gamby, 2000; Weiss, 1999).
The Lovaas (1987) and McEachin et al. (1993) studies received Level 3 scientific merit
because intake measures did not include Adaptive functioning. Andersen et al., Birnbrauer and
Leach, and Sheinkopf and Siegel lacked assessment of Adaptive functioning. Sheinkopf and
Siegel and Eldevik et al. used archival design. Sallows and Graupner (2005) was designed as a
randomized study comparing clinic-directed ABA treatment to intensive parent-directed ABA
treatment. In addition they employed a multiple-baseline design across participants. Children in
both treatment groups made significant improvements on cognitive, language, adaptive, social,
and academic measures between intake and follow-up. However, differences between the two
treatment groups at follow-up were nonsignificant. Because of these nonsignificant group
differences, the study is more appropriately described as a pre–post design with single-case
control (multiple-baseline design across participants) rather than a randomized study.
Magiati et al. (2007) examined effects of a parent managed ABA program compared to an
autism-specific nursery provision. In the parent managed program, the families located and
recruited a consultant to provide overall directions of the child’s program. In addition they hired
therapists to provide the one-to-one teaching of the child. This type of program has been
described by Bibby, Eikeseth, Martin, Mudford, and Reeves (2002) and is different from the
clinic based or school based programs described above. Measures included IQ, language, play,
adaptive behavior and severity of autism. Neither groups improved on standard scores on any of
the measures (though improvement was observed on in age equivalent scores for participants in
both groups). Moreover, there were no significant group differences in cognitive ability,
language, play or severity of autism at follow-up. Neither the parent managed ABA program nor
the autism-specific nursery provision was effective. Thus, a high number of one-to-one treatment
(32.4 h of one-to-one per week, on average, for the parent managed ABA group) is by itself not
sufficient to produce significant and meaningful gains. A reason for this may be that the therapists
received too little supervision, which in the Magiati study ranged from monthly to six-monthly as
compared to, for example, up to 10 h per week in the Eikeseth et al. (2002) study. This study
received Level 3 scientific merit because IQ was assessed for many of the participants using the
 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178 173

Merrill–Palmer Scale of Mental Tests. This test emphasize almost entirely visual–spatial. A
shortcoming of the Magiati et al. study was that the groups differed at intake on IQ, adaptive
functioning and parental education. Moreover, treatment was not monitored by the investigators
and there was no quality control measures on treatment.

2.4. Insufficient scientific value

Nine outcome studies were classified as having insufficient scientific value. Six studies
evaluated ABA programs (Bibby et al., 2002; Handelman, Harris, Celbiberti, Lilleheht, &
Tomchek, 1991; Harris, Handleman, Gordon, Kristoff, & Fuentes, 1991, Harris, Handleman,
Kristoff, Bass, & Gordon, 1990; Hoyson, Jamieson, Strain, 1984; Luiselli, Cannon, Ellis, Sisson,
2000), one evaluated TEACCH (Lord & Schopler, 1989), two evaluated the Colorado Health
Science Program (Rogers & Dilalla, 1991; Rogers, Herbison, Lewis, Pantone, & Reiss, 1986).
All studies used a pre–post design without single-case control or comparison group.

3. Discussion

This paper evaluates comprehensive psycho-educational research on early intervention for

children with autism and examines to what extent treatment effect has been documented in
outcome studies. Twenty-five outcome studies were identified. As shown in Table 2, 20 studies
evaluated ABA treatment, 3 studies evaluated TEACCH and 2 studies evaluated the Colorado
Health Sciences Project. Interestingly, no other psycho-educational approaches have been
subjected to outcome research according to the above criteria. Outcome studies identified in the
present report were graded according to their scientific value, and according to the magnitude of
results documented in the studies. For scientific merit, studies were graded into four levels. One
study received Level 1 scientific merit (the highest possible rating) and four studies received
Level 2 scientific merits. All these studies evaluated ABA treatment. Eleven outcome studies
received Level 3 evidence support. Nine of the 11 studies evaluated ABA treatments and 2 studies
evaluated TEACCH. Finally, nine outcome studies were classified as having insufficient
scientific value. One evaluated TEACCH, two evaluated the Colorado Health Science Program,
and six evaluated ABA.
Evaluating magnitude of treatment effects, four ABA studies received Level 1 rating
demonstrating that children receiving ABA made significantly more gains than control group
children on standardized measures of IQ, language and adaptive functioning (Cohen et al.,
2006; Eikeseth et al., 2002, 2007; Howard et al., 2005; Sallows & Graupner, 2005). Several
studies also included data on maladaptive behavior, personality, school performance and
changes in diagnosis. Three studies received Level 2 rating (Eldevik et al., 2006; Lovaas,
1987; Smith, Groen, & Wynn, 2000), demonstrating that ABA treated children made
significantly more gains than the comparison group on one standardized measures of IQ or
Adaptive Functioning. Finally, five ABA studies and two TEACCH studies received Level 3
rating.
Note that other randomized control studies examining ‘‘non-comprehensive’’ interventions
have been published. For example, Drew et al. (2002) and Aldred, Green, and Adams (2004)
examined effects of parent-delivered pragmatic language interventions for children with autism
and Jocelyn, Casiro, Beattie, Bow, and Kneisz (1998) examined effects of a intervention
consisting of lectures and on-site consultations to day-care centers. Because these studies fail to
meet the definition of comprehensive interventions they are not include in this review.
174 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

This present review has several limitations, and one is based on the limitations that are
inherent in the current method for classification based on scientific merits. Other variables could
be included and emphasized such as statistical alpha and beta errors. Yet another way of
evaluating outcome studies is to apply the criteria for ‘‘well-established’’ or ‘‘probably
efficacious’’ psychosocial interventions described by Chambliss et al. (1996) and Chambliss and
Hollon (1998), which are as follows:

1. ‘‘Well-established’’ requires treatment manuals, and clearly specified subject groups, and
either: (a) two independent well-designed group studies showing the treatment to be better
than placebo or alternative treatment or equivalent to an established effective treatment; (b) or
nine or more single subject design studies using strong designs and comparison to an
alternative treatment.
2. ‘‘Probably efficacious’’ requires clearly specified subject groups (treatment manual preferable
but not required), and: (c) either two studies showing better outcomes than a no-treatment
control group; (d) or two strong group studies by the same investigator showing the treatment
to be better than placebo or alternative treatment or equivalent to an established treatment; (e)
or three or more single subject design studies that have a strong design and compare the
intervention to another intervention.

Based on these guidelines interventions based on ABA will be considered ‘‘Well Established’’.
TEACCH and Colorado Health Science model will be considered neither ‘‘Well Established’’
nor ‘‘Probably efficacious’’.
Other limitations with the current review are those inherent in the classification of magnitude
of results (Matson, 2007). In this review, gains in ratio or deviation scores based on IQ and
adaptive functioning was used. A more comprehensive assessment battery would include
measures of empathy, personality, school performance, friendship, and information regarding
diagnostic changes. Nevertheless, emphasis on different classification aspects would not change
the main conclusions of the present report, but it could alter the classification status on some
studies.

3.1. Future directions

Future research could consider the following:

1. There is a need for additional outcome research. The fact that only three psycho-educational
approaches have been subjected to outcome research illustrates this issue’s urgency. Study
designs should meet Level 1 standards. In cases where it is unethical to conduct randomized
studies, for example, because progress is measured several years into treatment, Level 2
standards should be met (cf., Lord et al., 2005). A solution to this ethical dilemma may be to
conduct short term randomized studies comparing benchmark ABA treatment to other
treatment approaches. A trial period of 6–8 months may well be ethical. After completion of
such a relatively brief trial period, the participants who had received the less effective
intervention could get immediate access the intervention that was demonstrated more
effective.
2. Whenever an approach is documented effective, there is a need to identify effective treatment
parameters and mechanisms responsible for change (Kazdin & Nock, 2003). Such studies
should be a priority for ABA researchers.
 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178 175

3. There is a need to identify characteristics that interact with outcome. Variables interacting with
outcome could be social (e.g., family variables, socio-economic status) behavioral (e.g., level
of functioning or severity of ‘‘autistic symptoms’’) and/or medical/biological/toxicological
(e.g., genetics, immune system, infection, porphyrin status).
4. There is a need to improve treatment for those children who respond less favorable.
5. Research could examine the efficacy of biomedical treatments in combination with
psychosocial treatments.
6. Research could examine the generalizability and transportability of interventions shown to be
efficacious in controlled research settings to applied settings.
7. Research could be conducted to examine the efficacy of psycho-educational treatments with
older children and adults.
8. Research could develop criteria for discontinuing or changing treatment approach.
9. Research could be conducted to examine the cost-effectiveness and cost–benefits of the
interventions.

4. Conclusions and practice parameters

Practice parameters are graded into recommended parameters and guideline parameters,
adapted from Eddy (1992). To achieve status as a recommended practice parameter, a Level 1
evidence study addressing the specific question, or overwhelming Level 2 evidence is required. A
recommended practice parameter is a therapeutic strategy that reflects a high degree of clinical
certainty.
To be considered a guideline, a therapeutic strategy that reflects a moderate degree of clinical
certainty, implies the existence of Level 2 evidence or consensus of Level 3 evidence.

4.1. Recommended practice parameter

1. ABA treatment is demonstrated effective in enhancing global functioning in pre-school

children with autism when treatment is intensive and carried out by trained therapists
(one Level 1 study, four Level 2 studies, Cohen et al., 2006; Eikeseth et al., 2002, 2007;
Howard et al., 2005; Remington et al., 2007; nine Level 3 studies, Andersen et al., 1987;
Birnbrauer & Leach, 1993; Eldevik et al., 2006; Lovaas, 1987; and Sallows & Graupner, 2005;
Sheinkopf & Siegel, 1998; Smith, Buch, & Gamby, 2000; McEachin et al.,1993; Magiati et al.,
2007; Weiss, 1999).
2. ABA treatment is demonstrated effective in enhancing global functioning in children with
PDD-NOS (one Level 1 study; Smith, Groen, & Wynn, 2000).
4.2. Guideline practice parameter

1. ABA can be effective for children who are up to 7 years-of-age at intake (one Level 2 study;
Eikeseth et al., 2002, 2007).

Acknowledgements

This research was supported by a Grant from The Norwegian Directorate of Health and Social
Services. The manuscript is based on an invited lecture presented at the World Congress of
Behavioral and Cognitive Therapies, Kobe, Japan, July 2004. I thank Drs. Tristram Smith and
Frank Hoover for helpful comments.
176 S. Eikeseth / Research in Developmental Disabilities 30 (2009) 158–178

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