**10. Controversies related to EIBI efficacy**

**8. Screening for ASD and EIBI provision**

586 Recent Advances in Autism Spectrum Disorders - Volume I

rate of typical development (Dawson, 2008).

in the long-term.

**9. The benefits of EIBI**

ly diagnosis and EIBI.

following:

It is accepted in the field of autism that there now exists enough evidence to recognise the disorder at a very early age (Feldman et al. 2012; Matson, Boisjoli, Rojahn, & Hess, 2009). While many screening instruments exist for the disorder, the most thoroughly ex‐ amined of these is the BISCUIT (Matson et al., 2009; Matson, Fodstad, & Mahan, 2009; Matson, Fodstad, Mahan, & Sevin, 2009; Matson, Wilkins, Sevin, et al., 2009; Matson, Wilkins, Sharp, et al., 2009). In addition to providing clinicians with a measure of the very early signs of autism symptomology, the BISCUIT also provides a measure of emo‐ tional/behavioural disorders and comorbid psychopathology. We believe that providing EIBI to young infants showing early signs of autism, before the condition is fully mani‐ fest, will target core skills by accelerating developmental sequences, halting deteriorating behavioural repertoires, and preventing additional secondary problems. Provision of EIBI at the time when symptoms are initially detected, may in tandem, alter the course of ear‐ ly behavioural and brain development increasing the likelihood that children attain a

We advocate for the need to screen children for this disorder during routine health and de‐ velopmental checks. Screening in Ireland is currently haphazard and often depends on a pa‐ rent showing concern for some area of their child's development. In particular, prevention entails detecting infants at risk before the full diagnostic criteria are present and it has been recognised that early signs may emerge as soon as 9 months in infants with siblings who have ASD (Ozonoff et al. 2010; Zwaigenbaum et al. 2005). Screening these biologically "at risk" children in early infancy should allow greater access to the effective methods demon‐ strated by EIBI. We strongly believe that the availability of both standardised screening techniques and EIBI provision to such children will impact on a more promising prognosis

There is no doubt that the cost of an intensive and accomplished EIBI program is expensive. For example, cost analysis studies revealed that the average annual cost of an EIBI program in North America to be \$33,000 per year with the average duration being three years (Jacob‐ son, Mulick & Green, 1998). However, further analysis of this cost-effectiveness and saving over time has also been provided. For instance, the Autism Society of America reported in 2008 that the cost of lifelong care could be reduced by up to as much as two thirds with ear‐

Dillenberger (2011) provides a synopsis of recent cost-benefit analyses showing the savings that can be achieved by implementation of EIBI in autism treatment. She puts forward the

**1.** in Ontario, Canada, an estimated annual CA\$ 45 million can be saved if EIBI is made

available to all children diagnosed with ASD (see Motiwala et al., 2006);

The published studies outlined in this chapter highlight the possible positive outcomes for young children diagnosed with autism. EIBI continues to be investigated internationally as a treatment intervention for this condition and as a result of these investigations attracts many critics and controversies. In the past, some authors have criticised a behavioural approach to autism intervention with regard to "robotic" teaching and behaviour patterns that lack gen‐ eralisation to naturalistic settings (Jordan, Jones & Murray, 1998; Shea, 2004) along with the use of negative consequences in acquisition teaching and behaviour reduction (Carr, Robin‐ son & Palumbo, 1990). Others have highlighted the concerns with regard to claims of "re‐ covery"or a "cure" for autism (Offit, 2008). However, the improvements shown over the last decade in EIBI refinement and provision, particularly with regard to training and regulatory protocols with its delivery (Behavior Analyst Certification Board®, 2012) has addressed many of these issues. Indeed, professional training in behaviour analysis and behavioural intervention has never been as well regulated as it is today.

No doubt there are still many issues that continue to require analysis in the EIBI and autism field of research. We would like to draw the reader's attention to a recent publication by Matson and Smith (2008) providing an analysis of the current status of intensive behavioural

intervention for young children with autism. We believe that this paper provides an excel‐ lent summary of the criticisms provided on EIBI and we will highlight these here. Firstly, many of the studies providing analysis of EIBI outcomes fail to report the severity of ASD across participants and groups. This makes it difficult to decipher which children will show greatest susceptibility to the intervention. Those with greater severity of symptoms may show slower progress or less gains. It has been reported that a milder degree of autism is related to better prognosis (e.g., Bartak & Rutter, 1976) and therefore it is essential that varia‐ bles at intervention onset include such a measure. Secondly, Matson and Smith (2008) high‐ light the fact that researchers often do not take into account the additional, co-morbid, problems that present with autism (e.g., ADHD symptoms or anxiety disorders). Psychopa‐ thological problems can co-occur with the condition and may exacerbate the challenges and deficits for many children. The impact this can have on treatment susceptibility is underre‐ ported and often not addressed in treatment research. For example, only two studies in our review provided outcome measures of co-morbid psychopathology (Birnbrauer & Leach, 1993; Fava, 2011). Matson and Smith (2008) provide a strong argument for the assessment of psychopathology before, during, and after EIBI, to determine ongoing changes in child pro‐ files or to address any required adjustments to the delivery of EIBI (e.g., increasing or de‐ creasing the duration of intervention, removing skills acquisition teaching from artificial environments, less emphasis on massed trial instruction etc.). Perhaps not enough attention has been given to these issues in EIBI research. The young age of onset of EIBI and the inten‐ sity of the intervention may have undesired side effects such as anxiety, stress, "burn out" or indeed refusal to participate. Other controversial issues involving EIBI include parent and sibling involvement which can often induce stress and family strain when highly intensive intervention is provided within the family home. The negative side effects of this kind of in‐ tensive intervention certainly warrant separate analysis.

group of young children who received "eclectic" intervention than those receiving EIBI. Fur‐ thermore, Fava et al. (2011) and Strauss et al. (2012) showed that both groups receiving EIBI and "eclectic" intervention showed significant gains in adaptive functioning. Two more re‐ cent studies by Eldevik et al.(2012) and Eikseth et al., (2012) reported the opposite findings to Eikseth et al. (2002) in relation to adaptive functioning when comparing both interven‐

Early Intensive Behavioural Intervention in Autism Spectrum Disorders

http://dx.doi.org/10.5772/54274

589

Another variable that has been increasingly analysed in early intervention autism research includes parental stress. Interestingly, two comparison studies (Fava et al., 2011; Strauss et al., 2012) showed significant reductions in parental stress for those parents whose children were receiving "eclectic" intervention. The same effect was not shown for parents of chil‐ dren receiving EIBI. This is another important area of analysis particularly in light of the de‐

EIBI as an approach to autism treatment is one of the most intensively analysed interven‐

Substantial objective evidence for EIBI has been demonstrated at an experimental, descrip‐ tive and meta-analytic level of analysis (Reichow, 2012). We support the contention of many authors in the field of autism treatment, that EIBI prevails by adhering to a principle of evi‐ dence-based practice, incorporating standardised objective measurement of outcomes along with implementation of robust experimental design. This robust demonstration of effective‐ ness is driving policy change on the international stage and some authors (e.g., Dawson, 2008) suggest that one of the most important goals of investigations in the domains of au‐ tism and behaviour analysis research, is to become more effective communicators of scientif‐ ic findings to the general public/government bodies/advocacy groups/related professionals, not only to harvest their support, but to ensure the dissemination of accurate and effective

[1] Alessandri, M., Thorp, D., Mundy, P., & Tuchman, R. F. (2005). Can we cure autism?

From outcome to intervention. *Revista de Neurologia, 40*, S131–S136.

tions.

**11. Conclusion**

**Author details**

**References**

mands that EIBI places on parents and family.

intervention to so many who require it.

National University of Ireland, Galway

Olive Healy and Sinéad Lydon

tions in paediatric clinical psychology (Matson & Smith, 2008).

Unfortunately, like any professional practice or therapeutic intervention, there will be those who claim to provide EIBI without adhering to the scientific demonstrations of what is, and is not, effective within an intervention protocol. We have heard of anecdotal accounts of the applications of behavioural interventions in autism treatment that are outdated and often lack individualisation. Treatment fidelity is often a major problem in the field and often au‐ thors fail to demonstrate or report adherence to effective and current practice in many of the published studies on EIBI. Such problems can lend support to a negative view of the use of EIBI with young children with autism diagnoses.

An analysis of changes in adaptive functioning of young children has become an added fo‐ cus of EIBI studies in more recent years. Traditionally, studies tended to focus on changes in intellectual and social functioning and language and communication abilities. Some authors have criticised EIBI for overly focusing on cognitive skills with 1:1 teacher/student ratios and a focus on desk-top instruction and intensive "drills" (e.g., Shea, 2004). Increasingly, EI‐ BI curricula and instructional protocols have grown to ensure inclusion of adaptive skills teaching and acquisition of novel skills in natural environments. Studies evaluating out‐ comes of EIBI have also focused more on adaptive functioning changes as a result of the in‐ tervention. In 2002, Eikseth et al. reported greater increases in adaptive functioning in a group of young children who received "eclectic" intervention than those receiving EIBI. Fur‐ thermore, Fava et al. (2011) and Strauss et al. (2012) showed that both groups receiving EIBI and "eclectic" intervention showed significant gains in adaptive functioning. Two more re‐ cent studies by Eldevik et al.(2012) and Eikseth et al., (2012) reported the opposite findings to Eikseth et al. (2002) in relation to adaptive functioning when comparing both interven‐ tions.

Another variable that has been increasingly analysed in early intervention autism research includes parental stress. Interestingly, two comparison studies (Fava et al., 2011; Strauss et al., 2012) showed significant reductions in parental stress for those parents whose children were receiving "eclectic" intervention. The same effect was not shown for parents of chil‐ dren receiving EIBI. This is another important area of analysis particularly in light of the de‐ mands that EIBI places on parents and family.
