ARTICLE IN PRESS
Evidenced-Based Interventions
for Children With Autism
Spectrum Disorder
D1X XMeredith N. WillD2X X, D3X XKristn CurransD4X X, D5X XJennifer SmithD6X X, D7X XStephanie WeberD8X X, D9X XAmie DuncanD10X X,
D1X XJenny BurtonD12X X, D13X XKimberly Kroeger-GeoppingerD14X X, D15X XValerie MillerD16X X, D17X XMegan StoneD18X X,
D19X XLindsay MaysD20X X, D21X XAshley LuebrechtD2X X, D23X XAnna HeemanD24X X, D25X XCraig EricksonD26X X and D27X XJulia AnixtD28X X*
This paper reviews evidenced-based interventions for children
with autism spectrum disorders (ASD) across the disciplines of
psychology, speech-language pathology, occupational ther-
apy, and developmental pediatrics. Background: rates of ASD
diagnoses have been steadily rising over the past 2 decades.
There are a wide range of therapies and interventions, of vary-
ing levels of evidence, across disciplines that are now available
to treat children with ASD. The field has moved toward a
greater emphasis on the identification and utilization of evi-
denced-based treatments. Methods: a review and summary of
recent literature was conducted by professionals in an
Introduction
utism spectrum disorder (ASD) is a neurode-
A velopmental condition characterized by per-
vasive deficits in social interaction and
communication, as well as the presence of rigid and/
or repetitive behaviors or sensory concerns that impact
the individual’s functioning and development. Indi-
viduals with this disorder may experience symptoms
with or without intellectual or language impairment.
The term “spectrum” is used to capture the wide array
of symptomology seen across age and developmental
levels.1 According to the Center for Disease Control
and Prevention’s 2018 published data, approximately
1 in 59 children in the United States are diagnosed
with ASD, with reported prevalence in all racial, eth-
nic, and socioeconomic groups. ASD is about 4 times
more common among males (26.6 per 1000) than
From the The Kelly O’Leary Center for Autism Spectrum Disorders, Cin-
cinnati Children’s Hospital Medical Center, University of Cincinnati Col-
lege of Medicine, 3333 Burnet Avenue MLC 4002, Cincinnati, OH 45229,
United States.
*Corresponding author. Julia Anixt
E-mail: julia.anixt@cchmc.org
Curr Probl Pediatr Adolesc Health Care 000;000:1 17
1538-5442/$ -see front matter
Ó 2018 Published by Elsevier Inc.
https://doi.org/10.1016/j.cppeds.2018.08.014
Curr Probl Pediatr Adolesc Health Care, & &&&&
interdisciplinary autism center. An emphasis was placed on
results of the National Autism Center's National Standards Proj-
ect. Results and Conclusions: within each discipline, interven-
tions exist that vary in level of evidenced-based support.
Although disciplines may differ in their definitions of evidence-
based treatments, it is important for each discipline to strive to
offer and promote practices with the best evidenced-based sup-
port according to each field's standards.
Curr Probl Pediatr Adolesc Health Care 2018; 000:1 17
among females (6.6 per 1000).2 The documented rise
in the prevalence of ASD is a much-debated topic,
and may be linked to improvement in diagnostic tools,
increasing awareness of the disorder, and/or an
increase in incidence over time.
The manifestation and severity of symptoms of ASD
vary widely, with treatment typically focusing on the
core features of ASD such as: deficits in social com-
munication or social interactions, restricted behaviors,
sensory concerns, or on co-occurring challenging
behaviors that impact the development of functional
skills and independence. Symptom presentation and
treatment may be further complicated by medical con-
cerns such as: epilepsy, sleep problems, and gastroin-
testinal problems, as well as intellectual/cognitive
impairment, and, in some children, the presence of
challenging maladaptive behaviors such as hyperac-
tivity, anxiety, irritability, self-injury, and aggression.3
Effective treatment for children with ASD involves an
interdisciplinary approach. It includes a combination
of educational interventions, psychological/behavioral
therapies, speech-language therapy, occupational/
physical therapy, and medical treatments (e.g., psy-
chopharmacology). The focus of this paper is on the
non-pharmacologic treatments and therapies that sup-
port optimal outcomes for children and adolescents
with ASD.
1
 ARTICLE IN PRESS

What is meant by evidence-based to address the need for evidence-based practice guide-
practice? lines in ASD.6 This effort focuses on educational and
behavioral interventions that improve core symptoms of
There is a wide range of possible interventions avail-
children and adolescents with ASD less than 22 years of
able to treat core symptoms of ASD and co-occurring age.6 In this systematic review, an interdisciplinary
conditions. The cause of ASD is unknown and team of experts critically evaluated 775 research studies
believed to be multi-factorial, including a combination published between 1957 and late 2007. A Scientific
of predisposing genetic factors and environmental Merit Rating Scale (SMRS) was developed to evaluate
exposures.4 There is no single cause for ASD, and the methods used in each study. This scale included five
there is no single best treatment option. Given the het-domains: (1) research design, (2) measurement of the
erogeneity of ASD symptoms and severity across the dependent variable, (3) measurement of the independent
spectrum, ASD is generally not a condition that can variable or procedural fidelity, (4) participant ascertain-
be “cured.” The primary goal of treatment is to opti- ment, and (5) generalization.6 Based on scores from the
mize functional outcomes, including: communication SMRS, interventions were categorized into four classifi-
skills, social skills, quality of life, and independent liv-
cations called the Strength of Evidence Classification
ing, while reducing or eliminating maladaptive behav- System: (1) Established, (2) Emerging, (3) Unestab-
iors. Without a cure, families may be easily persuaded lished, and (4) Ineffective/Harmful. No interventions
to try a range of complementary and alternative medi- reviewed were classified into the Ineffective/Harmful
cal (CAM) treatments, with little-to-no rigorous category. Interventions in each of the other classifica-
empirical research to support effectiveness. In addi- tions are listed in Table 1.
tion, many well-established medical/behavioral treat- In 2015, a second iteration of this work, the National
ments used in traditional practice may also lack a Standards Project, Phase 2 (NSP2) was released and
rigorous research base. Given the multitude of treat- included research published between the end of 2007
ment options available, with varying levels of research and early 2012. These results are also shown in
support, it is imperative that the field reliably evaluate
Table 1. The NSP2 focused on updating findings from
interventions and that clinicians follow evidence- the original report for individuals in the target age
based practices. Evidence-based practice consists of range as NSP1 (< 22 years of age), while also analyz-
three elements: (1) consideration of the best available ing studies published from 1987 to 2012 for interven-
research evidence, (2) applied in the context of an tions used with individuals with ASD ages 22 years
individual patient’s profile / characteristics, (3) based
and older.7 NSP2 included analysis of an additional
on the judgement/professional expertise of the 361 studies for the former age range (<22 years) and
clinician.5 28 studies for the latter (22 years). Other groups
Faced with a multitude of potential interventions andhave also conducted systematic reviews of ASD
no single obvious best choice that works for all individ-
treatments.8 10 However, the combination of NSP1
uals with ASD, families often explore treatments that and NSP2 encompasses the largest review of its type
may have long-standing scien- in the field of ASD.
tific support, as well as those
with limited or no research sup- To aid families in selecting evi- Developmental
port. To aid families in selecting dence-based interventions, clini- screening and
evidence-based interventions, cians must be mindful of the monitoring
clinicians must be mindful of the breadth of interventions that
breadth of interventions that Following guidelines of the
parents/caregivers consider, the
parents/caregivers consider, American Academy of Pediat-
associated evidence to support the associated evidence to sup- rics (AAP), primary care clini-
use of each intervention, the port use of each intervention, cians who provide well child
likelihood of benefit, and poten- the likelihood of benefit, and care for children are expected
tial associated harms or risk. to conduct routine developmen-
The National Autism Center
potential associated harms or tal surveillance at all well child
launched the National Standards risk. visits and structured develop-
Project (NSP) in 2005 in order mental screening at 9, 18, and

2 Curr Probl Pediatr Adolesc Health Care, & &&&&

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TABLE 1. Evidenced-based interventions as identified by the National Standards Project (Phases 1 and 2).6,7

Established
 Antecedent Package*  Schedules
 Behavioral Package*  Self-management
 Comprehensive Behavioral Treatment for Young Children  Story-based Intervention Package
 Joint Attention Intervention Behavioral Interventions*
 Modeling Cognitive Behavioral Intervention Package
 Naturalistic Teaching Strategies Language Training (Production)
 Peer Training Package Parent Training
 Pivotal Response Treatment Scripting
Social Skills Package

Emerging
 Augmentative and Alternative Communication Device  Music Therapy
 Cognitive Behavioral Intervention Package  Peer-mediated Instructional Arrangement
 Developmental Relationship-based Treatment  Picture Exchange Communication System
 Exercise  Reductive Package
 Exposure Package  Scripting
 Imitation-based Interaction  Sign Instruction
 Initiation Training  Social Communication Intervention
 Language Training (Production)  Social Skills Package
 Language Training (Production and Understanding)  Structured Teaching
 Massage/Touch Therapy  Technology-based Treatment
 Multi-component Package  Theory of Mind Training
Functional Communication Training

Unestablished
 Academic Interventions Movement-based Intervention
 Auditory Integration Training SENSE Theatre Intervention
 Facilitated Communication Sensory Intervention Package
 Gluten-free/Casein-free diet Shock Therapy
 Sensory Integrative Package Social Behavioral Learning Strategy
Animal-assisted Therapy Social Cognition Intervention
Concept Mapping Social Thinking Intervention
DIR/Floor Time
+Bulleted items include interventions listed in NSP and NSP2.
++Italics indicate NSP2 categorization only.
++Bold and italics indicates movement from Emerging to Established.
*In NSP2, Antecedent Package and Behavioral Package were combined into Behavioral Interventions.

30-months, including the use of ASD-specific screen-
ing tools at ages 18 and 24-months.11 Despite the
AAP’s 2006 recommendations for developmental
screening, a 2014 report from the Centers for Disease
Control and Prevention (CDC) demonstrated that
reported use of screening tools for young children is
mixed.12 Less than half of pediatricians in a 2011
study reported consistently using a standardized
developmental screening tool.13 Parents/caregivers
report low rates of engagement with healthcare clini-
cians in their child’s developmental screening pro-
cess.14 To assist clinicians who engage with families
in the developmental surveillance and screening of
children, the CDC launched the “Learn the Signs. Act
Early.” public health initiative. This initiative includes
free, caregiver-tested online and print materials
designed to support caregivers, clinicians and profes-
sionals in early childhood settings to recognize devel-
opmental red flags.15
When a child “fails” a developmental screening,
he or she should be referred to a developmental-
behavioral or neurodevelopmental pediatrician,
child neurologist, child psychiatrist, psychologist,
or other developmental specialist for additional
evaluation, diagnosis, and treatment. In an interdis-
ciplinary center, the developmental pediatrician, or
other consulting developmental expert, oversees the
care of the patient by (1) establishing a diagnosis of
ASD (often with the support of a team of psycholo-
gists and other allied health professionals such as

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speech-language pathologists), (2) evaluating, mon- is strong evidence that EI programs that employ an
itoring, and treating medical and mental health con- Applied Behavior Analysis (ABA) approach yield opti-
ditions potentially related to the disorder (e.g., mal outcomes for the child, his or her family, and com-
irritability), (3) supporting parents/caregivers in munity (e.g.18 21).
making educational and other treatment decisions, Early intensive behavioral intervention (EIBI)
and (4) coordinating care over time, including refer- programs, which are EI programs that follow an
rals to specialists in psychology, speech-language ABA model of treatment, are characterized by the
pathology, or occupational therapy for treatment as following attributes: (1) an individualized and com-
indicated. prehensive curriculum that targets multiple devel-
opmental domains; (2) employs a wide variety of
behavior analytic strategies to increase and decrease
Treatment interventions target behaviors; (3) is supervised, at minimum, by
The goal of this paper is to provide an overview of a professional with advanced training in ABA and
evidence-based therapeutic interventions that clini- ASD; (4) use of neuro-typical development sequen-
cians in the fields of primary care and developmental ces to identify behaviors to modify; (5) parents and/
pediatrics should consider for treatment of children or other caregivers are trained as co-therapists and
and adolescents with ASD. This includes a review of monitored by the supervising ABA professional; (6)
the evidence-based therapies (non-pharmacologic intervention that is both one-on-one and group
treatments) across disciplines including the fields of: delivered; (7) intervention that is home-based, cen-
psychology, speech-language pathology, and occupa- ter-based, and generalizes to other treatment and/or
tional therapy. It is important to note that the scope of educational placements; (8) continuous treatment
many treatments overlaps among disciplines. There- with a minimum of 20 30 structured hours per
fore, in some content areas, to reduce redundancy, the week; and (9) intervention that begins prior to or
reader may be referred to other sections of the paper during the preschool years and continues for no less
for additional information. than two years (e.g.18,22). EIBI programs utilizing
ABA yield positive outcomes with 20 50% of par-
ticipant children (as young as 2-years old) achieving
Early intervention and early intensive average IQ and placement in general education set-
behavioral intervention programs tings upon the conclusion of treatment.22-24 An
Early intervention (EI) includes treatments that additional 20 40% of participant children make
begin before the age of 5 years, or prior to entry into moderate gains (but still require additional aca-
formalized schooling, and aims to increase skills in demic and/or social assistance upon the conclusion
the core deficits of ASD, such as communication and of treatment), and 10% of children make modest
socialization, while decreasing excessive maladaptive gains and require ongoing support.23 25 Children
symptoms, such as stereotypies and self-injurious who participate in EIBI according to the criteria
behaviors. Initiation of EI as young as possible is cru- listed above will be more likely to make and main-
cial to improve long-term outcomes for children diag- tain significant gains in intelligence/cognitive func-
16
nosed with ASD. Establishing an ASD diagnosis as tioning, language and communication, daily living
early and efficiently as possible and independent self-help
is important for intervention skills, and social functioning
services to begin during this crit- Establishing an ASD diagnosis compared to children who par-
ical early window of develop- as early and efficiently as possi- ticipate in alternative inter-
ment.17 While there is general ble is important for intervention vention 26
or no intervention at
consensus that EI is helpful for all. Participation in early
services to begin during this criti- intervention is therefore the
reducing ASD core symptoms,
there is less agreement about the cal early window of standard for evidence-based
17
type and quantity of services or development. intervention during this devel-
which curriculum is best. There opmental period.16

4 Curr Probl Pediatr Adolesc Health Care, & &&&&

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Treating behavior challenges in ASD to an item, gain the attention of others, engage in a
pleasurable activity (e.g., rocking back and forth), or
Applied behavior analysis (ABA) and escape a demand. With this information, the treating
functional behavior assessment (FBA) clinician is able to select an appropriate behavioral
Individuals with ASD often present with co-occur- intervention to either increase the frequency of an
ring challenging behaviors that include: disruptive adaptive behavior or decrease the frequency of a mal-
behaviors, aggression, and self-injury and these adaptive behavior. While analyzing the function/pur-
behaviors may affect the safety of the child with ASD pose of a behavior, it is important to keep in mind
and others. Developmental disabilities associated with potential medical conditions that could be a trigger for
ASD such as impaired cogni- disruptive behaviors and would
tive functioning, decreased require a different treatment
adaptive behaviors, and com- Behavioral interventions, includ- approach. For example, an indi-
munication delays may also ing antecedent (e.g., prompting, vidual may present to clinic
increase the potential for mal- environmental modifications) with a challenging behavior of
adaptive behaviors in children and consequent (e.g., reinforce- hitting himself in the head with
with ASD.27 Behavior chal- his fist. If the “function” of the
lenges, if left untreated, have
ment, extinction) strategies, is hitting behavior is to avoid the
the potential to negatively the largest category of Estab- pain of a severe sinus infection,
impact social-emotional func- lished Interventions for individu- medical treatment is the first
tioning, educational and voca- als under age 22 years and the priority.
tional opportunities, and the Once clinicians have identi-
development of independent
only category of Established fied the function of challenging
living skills.28 ABA incorpo- Interventions for those age behaviors, they can work to
rates behavioral learning theory 22 years and older as reported prevent the behavior from
into real-world settings and is in the NSP2.7 occurring or limit occurrence
not a single strategy or inter- in the future. Behavioral inter-
vention. Rather, Baer et al ventions, including antecedent
define ABA as “the process of systematically applying (e.g., prompting, environmental modifications) and
interventions based upon the principles of learning consequent (e.g., reinforcement, extinction) strate-
theory to improve socially significant behaviors to a gies, is the largest category of Established Interven-
meaningful degree,”29. Based on scientific inquiry, tions for individuals under age 22 years and the only
ABA requires ongoing measurement of target out- category of Established Interventions for those age
comes and analysis of collected data to determine 22 years and older as reported in the NSP2.7
effectiveness of interventions.29 For over 70 years, Whereas antecedent strategies described above are
research has supported the effectiveness of ABA to more proactive or preventative in nature, consequent
improve pro-social behaviors.30,31 strategies are more reactive and involve responding
It is essential to note that each challenging behavior following a challenging behavior. These antecedent
serves a purpose for an individual in their environ- or preventative approaches involve altering an indi-
mental context. An imperative first step in any effec- vidual’s environment to decrease the probability of
tive behavioral intervention plan is to complete a challenging behavior.
Functional Behavioral Assessment (FBA). An FBA
involves examining what happens before (i.e., ante- Antecedent strategies to prevent disruptive
cedent) and after (i.e., consequence) a maladaptive behaviors
behavior. Data from a FBA are used to determine Effective strategies for preventing or reducing prob-
which function(s) motivate and/or maintain maladap- lem behaviors in individuals with ASD include visual
tive behaviors32,33 to determine how best to respond supports, such as schedules or story-based interven-
to the behaviors to disrupt their maintenance. Individ- tions, and modeling. Picture or written schedules ori-
uals behave in ways that enable them to either: (1) get ent the individual to the order of daily activities and
something or (2) escape something. The function story-based interventions, such as Social StoriesTM,
behind a challenging behavior may be to obtain access establish explicit expectations for behaviors across

Curr Probl Pediatr Adolesc Health Care, & &&&& 5

 ARTICLE IN PRESS
various situations with a combination of text and pic-
tures to explain expected behaviors in a targeted situa-
tion.7,34 Modeling is also a highly effective approach
to teach an individual an expected behavior. Although
individuals with ASD may have a deficit in imitation
skills, research has demonstrated that both live and
video modeling (e.g., showing an individual a pre-
recording of behavioral expectations in a situation)
are effective strategies in teaching individuals with
ASD.7
Consequent strategies in response to disruptive
behaviors
Despite using preventive strategies, challenging
behaviors commonly occur in individuals with ASD.
Consequent strategies can impact behavior in two
ways. They can result in the behavior happening
either: (1) more frequently in the future or (2) less fre-
quently in the future. ABA focuses on improving
socially significant behaviors in a meaningful way and
is based on learning theory, which includes the princi-
ples of reinforcement and punishment. Following con-
sequences, reinforced behaviors are more likely to
occur in the future, and punished behavior are less
likely to occur. Positive reinforcement designates the
increase in a target behavior following the addition of
a stimulus (e.g., a child sits nicely and receives an edi-
ble reward and praise for sitting). Negative reinforce-
ment has occurred when removal of a stimulus leads
to an increase in behavior (e.g., a child completes a
task after he leaves a noisy classroom). Alternatively,
when a behavior decreases following the addition of a
stimulus, the behavior has been positively punished (e.
g., a child stops screaming when she is reprimanded
for doing so). Behaviors that decrease after the
removal of a stimulus are negatively punished (e.g., a
child stops screaming after his favorite toy is
removed). Extinction is a procedure that involves
removing the reinforcement that was previously main-
taining maladaptive behavior.30
Although treatment relying on antecedent/conse-
quent strategies is effective, generalizability may be
limited by caregiver involvement in treatment and
practice of strategies in the natural environment. Care-
giver involvement in behavioral intervention is a cru-
cial component to generalizing treatment effects
going from therapeutic to real-world settings. Care-
giver involvement helps to increase adaptive behavior
and decrease maladaptive behavior. Caregivers are
encouraged to learn through modeling and coaching
6 Curr Probl Pediatr Adolesc Health Care, & &&&&
from their child’s treating clinicians on how to iden-
tify the functions of behavior, recognize the environ-
mental impact upon maladaptive behavior, and
implement an appropriate intervention plan.
Social skill interventions
Deficits in social skills are a core feature of ASD.
Difficulties in social functioning include challenges
in: initiating and maintaining eye contact, joint atten-
tion, engaging in reciprocal conversations, emotion
recognition, empathy, and recognizing/reading social
cues. Social skill deficits in children with ASD do not
tend to improve over time with developmental matura-
tion alone.35 Often, as individuals with ASD enter
later childhood and adolescence, social skill deficits
become more pronounced and have been associated
with academic problems, depressive symptoms, and
anxiety.36 Social skills deficits may be challenging to
treat as interactions with others are complex, some-
times unpredictable, and vary greatly depending on
the context of the situation. As such, few social skill
interventions have an established evidence base.
Although many social skills interventions exist, this
review focuses on the few interventions supported by
some level of evidence, including: (1) social skill
groups, (2) peer-mediated interventions, (3) video
modeling, and (4) social narratives.6,7,37 39
Social skill interventions within larger
comprehensive programs for young children
Many treatment programs for toddlers and young
children with ASD, include a focus on improving
social functioning (e.g., EIBI, Early Start Denver
Model, etc.). Joint attention is a particularly salient
skill to target at a young age, because it is one of the
earliest precursors for development of later social-
communication skills.40 Joint attention describes the
process of a child trying to share his or her experience
with another by visually referencing another person to
show them something of interest. Joint attention inter-
ventions will be further discussed below in the
“Speech and Language Interventions” section.
Social skill groups
Group-based interventions are one of the most
widely used treatment methods to teach social skills in
youth, and, therefore, are often readily available treat-
ments. Social skills groups include direct instruction
of basic concepts and role-playing or practice. Many
 ARTICLE IN PRESS
social skills groups require participants to have at least
low-average cognitive ability. A recent meta-analysis
of group-based social skills interventions for youth
with ASD indicated that such interventions yielded
large effects for self-report measures (of social-knowl-
edge), smaller effects for parent- and observer-
reported measures, and non-significant effects for
teacher reported measures.41 This study, which
included only randomized controlled trials, concluded
that group-based social skill interventions are
“modestly” effective for youth with ASD. This is due
to skills developed in the context of social skills
groups not necessarily generalizing to other settings,
such as school. The authors noted that the largest
effect, in self-report measures of social skills, was
attributable to an increase in social knowledge, but
not necessarily an increase in observable skills. Never-
theless, this research highlights the challenge of gener-
alizing skills from the clinic to everyday life.
A specific social skills group curriculum called the
Program for the Education and Enrichment of Rela-
tional Skills (PEERSÒ ) is an empirically supported
and evidenced-based program that teaches skills for
adolescents with high-functioning ASD.42 Please refer
to the section entitled, “Evidence-Based Practices and
Interventions for Adolescents with ASD” for addi-
tional information on PEERSÒ .
Peer-mediated interventions
Social skill group-based interventions are taught
using a variety of different formats. They are often
implemented by clinicians and include other partici-
pants with similar diagnoses. However, groups may
also include same-age peers who are considered
“typically developing.” Rather than adult-led groups,
peer-mediated interventions have shown promising
results and are considered an “Established Inter-
vention” in the National Standards Project.7 Peer-
mediated interventions focus on teaching neuro-typi-
cally developing peers how to initiate social interac-
tions with individuals with ASD to increase social
interactions in their daily life.
Modeling and video modeling
In-vivo modeling is an intervention technique in
which a teacher demonstrates a desired behavior that
the learner then imitates and eventually acquires.
Video modeling is a technique that involves watching
a video of someone (or oneself) demonstrating a target
behavior. Video modeling is hypothesized to be
Curr Probl Pediatr Adolesc Health Care, & &&&&
especially beneficial as it “taps into” the visual learn-
ing acuity of those with ASD.37 A meta-analysis of
social skill interventions for children with ASD found
that video modeling was the only intervention that
was evidenced-based and highly effective as an inter-
vention strategy.38 Video self-modeling, in particular,
is an effective element in teaching skills for those
with high-functioning ASD and video self-modeling
generalizes skills across settings.36
Story-based interventions/social narratives
Story-based interventions generally incorporate
written or visual descriptions of specific situations
under which certain behaviors are expected to occur.
Social narratives are typically written by clinicians,
teachers, parents, or other adults. The content of the
story depends on the learner’s cognitive ability, but in
general, such story-based interventions focus on the
“who, what, where, when, and why” questions
designed to improve perspective-taking and self-regu-
lation skills. Story-based interventions are categorized
as an “Established Intervention” by the National
Standards Project, and are considered evidenced-
based by the National Professional Development Cen-
ter.39,43 Despite this, other review studies do not pro-
vide support for the use of story-based
interventions.36,38 There have been mixed reviews
regarding the level of effectiveness of this interven-
tion; thus additional, research is needed to clarify the
efficacy of social narratives.
Interventions to address co-occurring mental
health conditions
The mental health concerns of individuals with ASD
have been historically overlooked for a variety of rea-
sons. A professional’s clinical perspective and ability
to recognize symptoms of mental health conditions in
context of a developmental disability such as ASD or
Intellectual Disability is complex. This bias of clini-
cians to attribute behaviors to the patient’s underlying
disability rather than a co-morbid condition (e.g.,
Attention Deficit/Hyperactivity Disorder, depression,
or anxiety) is known as diagnostic overshadowing.44
In addition to diagnostic overshadowing, there are
inherent challenges associated with diagnosing mental
health symptoms in individuals with ASD. Most
measures that assess mental health concerns, such as
anxiety and depression, rely on an individual to self-
report their symptoms. Individuals with ASD often
7
 ARTICLE IN PRESS
present with communication impairments that make
self-report of symptoms a significant challenge, as
well as social deficits that make identification and
understanding of emotional states difficult. In addi-
tion, it is often difficult for families and professionals
to differentiate between symptoms of a mental health
condition, such as anxiety or obsessive compulsive
disorder, and core features of ASD that may overlap,
such as rigid and repetitive behaviors.45,46
Fortunately, mental health challenges in individuals
with ASD have started to receive increased attention
within the past few decades. Anxiety and depression
will be the focus of the remaining section due to their
high prevalence in this population, as well as the num-
ber of studies that examine assessment and treatment
of these conditions. Individuals with ASD may be sus-
ceptible to symptoms of anxiety and depression due to
characteristics inherent to their diagnosis including
communication and social deficits, rigid thinking pat-
terns, sensory processing differences, and emotional
regulation difficulties.45,47
Anxiety
Symptoms of anxiety are extremely common in
individuals with ASD. The majority of studies report
a prevalence rate of anxiety disorders in children and
adolescents to be around 50%, with rates varying
from 42 to 79%.48 Specific phobias (e.g., anxiety
towards specific objects or situations) were the most
prevalent diagnosis in 8 of 12 studies reviewing anxi-
ety disorders in children and adolescents with ASD.48
Social anxiety disorder and generalized anxiety dis-
order are also common diagnoses among individuals
with ASD.49 Despite the high prevalence, the symp-
toms of anxiety may present differently in individu-
als with ASD compared to other populations. In
addition to physiological symptoms, individuals with
ASD may appear more irritable and engage in more
challenging behaviors such as aggression, self-injury,
and tantrums when they are anxious.47 Anxiety in
individuals with ASD may be triggered by different
events or experiences related to diagnostic features
of ASD compared to other children and adolescents.
Triggers may include changes to their routine, being
overstimulated by sensory experiences, and idiosyn-
cratic/highly specific fears.
Depression
It is now widely accepted that individuals with ASD
experience symptoms of depression and reported
8 Curr Probl Pediatr Adolesc Health Care, & &&&&
prevalence rates vary widely, ranging from 10 to
53%.50 Symptoms of depression in youth with ASD
are often under-recognized and under-treated due to
the challenges associated with making accurate diag-
noses and a reliance on self-report of symptoms. As a
result, observable behaviors reported by caregivers
become even more important.45 In addition to the tra-
ditional signs of depression (e.g., changes in sleep or
disinterest in preferred activities), the symptoms of
depression in children with ASD may include higher
rates of aggression, self-injurious behavior, hyperac-
tivity, compulsiveness, and stereotypic behavior as
well as regression in skills and decreased adaptive
functioning.45 Higher-functioning individuals with
ASD also have more symptoms of depression as
reported by their parents and have lower self-esteem
compared to their lower-functioning peers.51 Lower-
functioning individuals may demonstrate higher levels
of externalizing behaviors (e.g., increased aggression)
during periods of depression while higher-functioning
individuals may be able to report more of the internal-
izing symptoms of depression (e.g., depressed mood,
feelings of guilt, negativistic thinking, etc.).
Treatment approach for anxiety/depression
Cognitive Behavioral Therapy (CBT) is an empiri-
cally-supported treatment for typically developing
children with anxiety disorders.52 Moderate to large
effect sizes have been found across studies that have
evaluated the effectiveness of CBT for children and
adolescents with ASD.53 CBT for anxiety typically
addresses three areas: identification of emotions and
physiological arousal, reduction of avoidance behav-
iors, and restructuring distorted thoughts.54 Read et al.55
identified the following steps involved in CBT for anxi-
ety: psychoeducation about emotions and physiological
symptoms, relaxation training to reduce physiological
arousal, cognitive restructuring to target distorted
thoughts, problem solving, gradual exposure to feared
tasks, and booster sessions to prevent relapse. Adapta-
tions to CBT for individuals with ASD have included
the use of visual supports, more concrete language,
incorporation of special interests, additional repetition
and practice, and extra rewards for participation in thera-
peutic activities with effectiveness.55
Within the past decade, researchers and clinicians
have made considerable strides in the treatment of
anxiety in youth with ASD. Vasa et al.49 found the
moderate evidence for treatment of anxiety in youth
with ASD to be moderate in a systematic review of
 ARTICLE IN PRESS
eleven studies using CBT, with 38 to 71.4% of chil-
dren participating being diagnosis free after participat-
ing in treatment. Ung et al.56 conducted an updated
systematic review and meta-analysis that included
more recent studies and also found CBT (ranging
from 6 to 32 weeks in duration) to have a moderate
treatment effect size in youth with high-functioning
ASD.
All of the studies examined by systematic reviews
utilize structured treatments to deliver CBT. One
study57 used a modified version of a commercially
available, manualized cognitive-behavioral interven-
tion, the Coping Cat program,58,59 to accommodate
the learning styles of children with ASD. Other stud-
ies60 63; used a modular CBT program, Behavioral
Interventions for Anxiety in Children with Autism
(BIACA), but this program is not commercially avail-
able at this time. Manualized treatments designed to
address the specific needs of youth with ASD, includ-
ing the Facing Your Fears curriculum,64 are available
for purchase and dissemination.
Concerns have been raised that children with ASD
who have lower intellectual abilities are unable to par-
ticipate in the cognitive aspects of CBT. However,
this does not mean that such individuals can not bene-
fit from the behavioral aspects of CBT including grad-
ual exposure to a feared object or avoided situation.
Behavioral treatment has been identified as an evi-
dence-based treatment for “phobic avoidance” in indi-
viduals with intellectual disabilities.65 Graduated
exposure and positive reinforcement, two components
of CBT, are effective to reduce anxiety related to spe-
cific phobias in individuals with ASD (for a review,
see Hagopian et al.66).
Compared to the multitude of studies that examine
the efficacy of CBT with individuals with ASD who
have anxiety, studies that examine CBT for depressive
symptom is extremely limited. CBT is an effective
treatment for depression in typically developing chil-
dren53 and adolescents.67 More recent studies have
also shown promising results for CBT adapted for par-
ticipants with ASD in the reduction of depressive
symptoms.68 70
The assessment and treatment of depression in indi-
viduals with ASD remains an area that will require an
increase in the future collaboration among patients,
families, clinicians, and researchers. The number of
scientifically-sound research studies that have been
published recently on the assessment and evidence-
based treatment of anxiety in individuals with ASD is
Curr Probl Pediatr Adolesc Health Care, & &&&&
encouraging and reflects the existing mental health
challenges of this population. Clinicians who work
with individuals with ASD may need to modify man-
ualized CBT curriculum and provide extra supports to
meet the unique needs of these individuals. Primary
care clinicians can be confident that therapy should be
successful when they refer individuals with ASD to
CBT programs to address symptoms of anxiety.
Interventions to build skills and independence
for adolescents with ASD
The National Professional Development Center39,43
has identified a range of evidence-based practices that
are effective to improve skills in adolescents with
ASD (ages 15 22 years) across a range of domains
(e.g., social, communication, joint attention, behavior,
school-readiness, play, cognitive, motor, adaptive,
vocational, and academic). For example, evidence-
based practices that have been identified in the area of
vocational skills include modeling, prompting, rein-
forcing, self-management, technology aided instruc-
tion, and video modeling. It is important to note that
there are significantly fewer evidence-based practices
and interventions for adolescents with ASD compared
to preschool and school-aged children with ASD.
While many of the evidence-based practices discussed
above have been used to improve skills,71 adaptive
behavior,72 and technology-aided interventions and
instruction,73 this section focuses on specific interven-
tion packages that have been shown to be effective or
have shown promise to improve skills in adolescents
with ASD, in the following 3 domains: (1) social
skills, (2) daily living skills, and (3) employment. It is
important to note that anxiety is one of the most com-
mon co-morbid disorders in adolescents with ASD.42
The reader is referred to the section entitled, “Mental
Health Interventions in ASD” for additional informa-
tion on this topic.
Social skills in adolescence
The PEERSÒ program has been shown to be an
effective social skills intervention for high-function-
ing adolescents and young adults with ASD.42,74
PEERSÒ consists of 14 weekly, 90-min sessions that
are attended by parents and teens separately. Session
content includes engaging in back and forth conversa-
tion, developing and maintaining friendships, using
humor, handling bullying and teasing, and planning
get-togethers with friends. In adolescent sessions,
9
 ARTICLE IN PRESS

techniques such as teaching the rules of specific social communication skills, functional behavioral assess-
behaviors and then role-playing and receiving/provid- ments and intervention plans for problem behaviors,
ing feedback are used. In parent sessions, instruction and customized employment methods. The results of a
on how to help their teen overcome any social difficul- pilot RCT revealed that 74% of adolescents with ASD
ties through coaching and using weekly homework were competitively employed at the end of the inter-
assignments is provided. A pilot study demonstrated vention as compared to 6% of adolescents with ASD
that, after completing PEERSÒ , adolescents with ASD who just received supports through the high school
made significant gains in areas such as frequency of special education program. These results were main-
peer interactions and improved social responsiveness tained at a 1-year follow-up.79
and social skills knowledge.42 Laugeson and col-
leagues74 recently conducted a long term follow-up
study (1 5 years after completion of PEERSÒ ) and Evidence based practices to address
found that most social improvements were main-
communication (speech-language pathology)
tained.
Deficits in social-communication are a core feature
Daily living skills of ASD, though there is tremendous heterogeneity in
Adolescents with ASD often have daily living skills the presentation of speech/language concerns across
that fall far below their chronological age; this then the autism spectrum. According to the American
affects their ability to successfully transition to col- Speech-Language Hearing Association (ASHA), defi-
75,76
lege, work, and independent living. Duncan and cits in social communication are the result of disrupted
colleagues77 recently developed “Surviving and early social-cognitive behaviors including joint atten-
Thriving in the Real World”, which is a 12-week, 90- tion (e.g., directing another’s attention towards items
min intervention attended by adolescents with ASD of interest by pointing), social reciprocity (e.g., main-
and their parents. Adolescent sessions target the acqui- taining interactions by taking turns), language and rel-
sition of skills such as self-care, cooking, laundry, and ative cognitive skills (e.g., understanding and using
money management through direct instruction, peer nonverbal and verbal communication and symbolic
modeling, and video modeling. Parent sessions focus play), and emotional-behavioral regulation (e.g.,
on how to assist their adolescent in acquiring and mas- appropriately regulating one’s emotional state and
tering daily living skills in the home and community. behavior while engaging in social interaction).80 Dis-
Follow-up to this study indicated that adolescents rupted joint attention is one of the earliest signs of
with ASD made significant progress in all targeted ASD.81,82 Impairments in joint attention pose a serious
daily living skills, and gained 2 2.5 years of daily liv- problem by limiting the language promoting interac-
ing skills on a standardized measure of adaptive func- tions with parents and caregivers83 and the acquisition
tioning over the course of the 12 week intervention.77 of other developmental skills including play.84
Some children with ASD have strong verbal abilities
Employment and demonstrate average to above average use of
Project SEARCH78 is a 9-month job training pro- vocabulary and sentence structures. These children
gram for adolescents and young adults with develop- may struggle with pragmatic language, which includes
mental disabilities who are still enrolled in high using language appropriately in social interactions.85
school that focuses on building Many children with ASD dem-
employability skills through For children with ASD, sponta- onstrate impairments in their
didactic sessions while also ability to understand and use
completing several internships
neous use of expressive lan- age-appropriate vocabulary and
at local businesses (e.g., hospi- guage skills by the end of the sentences structures (e.g.,
tal, university, private sector preschool years has been asso- receptive and expressive lan-
companies). Wehman et al.79 ciated with positive outcomes in guage), in addition to pragmatic
recently modified the tradi- language deficits.86 Approxi-
tional Project SEARCH model
adulthood, including social and mately 30% of children with
by utilizing ABA techniques to vocational success. ASD fail to acquire meaningful
address behavioral and social- use of expressive language. The

10 Curr Probl Pediatr Adolesc Health Care, & &&&&

 ARTICLE IN PRESS
reason why this group remains essentially “nonverbal”
or acquires only minimal use of words and phrases is
not well understood.87
For children with ASD, spontaneous use of expres-
sive language skills by the end of the preschool years
has been associated with positive outcomes in adult-
hood, including social and vocational success. 88
Therefore, addressing social-communication deficits
as early as possible is a critical priority. Speech-lan-
guage pathologists (SLPs) provide assessment and
treatment services to children with impaired social-
communication skills and language impairment.
Research has shown that teaching foundational social-
communication skills such as joint attention, social
reciprocity, and play, facilitates later language acqui-
sition.89 Thus, an appropriate goal for treatment serv-
ices provided by SLPs is to address foundational
social-communication skills rather than addressing
language impairment in isolation. The social-commu-
nication deficits experienced by youth with ASD also
impact their communication partners. Family mem-
bers, peers, teachers, SLPs, and other professionals
who interact with children with ASD are faced with
the challenge of learning to respond to unusual styles
of communication, interpreting the function of prob-
lem behavior, and modifying the environment to foster
social engagement. Treatment by the SLP may be
delivered in a variety of settings (e.g., one-on-one,
classroom- or community-based models) and should
include education and training of family members,
teachers, peers, and other child health professionals.80
SLPs may use a variety of specific treatment
approaches or they may be involved in implementing
a comprehensive treatment program. Treatment
approaches may include adult-led to child-led strate-
gies to improve social-communication. Below we
briefly describe specific speech/language treatment
approaches.
Early comprehensive models
As previously described in the “Early Intervention”
section, principles of Applied Behavioral Analysis
(ABA) are used to teach communication skills to chil-
dren with ASD. One particular component of ABA is
discrete trial teaching (DTT) methodology, which has
been used to teach children expressive communica-
tion,90 verbal imitation,91,92 play,93 and joint atten-
tion.94 While children may acquire communication
skills using DTT, a criticism of this approach has been
that skills often fail to generalize to other
Curr Probl Pediatr Adolesc Health Care, & &&&&
environments.95 To improve the generalization of
skills, there is a growing trend toward using develop-
mental behavioral approaches in daily life as part of
speech-language treatment. These approaches are
child-led and focus on activities and routines that are
familiar and highly motivating for the child to elicit
and improve a variety of social-communication skills
deficits.96,97
Commonly used intervention strategies
A variety of language modeling strategies are used
by SLPs to encourage understanding and using lan-
guage in social interactions. Parents, family members,
and others involved in interactions with children with
ASD should also be trained to use these strategies in
the child’s daily environment to model appropriate
use of language. Such modeling strategies are also cat-
egorized as “Established” interventions in the
NSP2.6,7
Environmental arrangement or “communicative
temptations” involves setting up the environment so
that the child must initiate a communication bid such
as a gesture, word, or phrase toward the adult in order
to obtain a desired item or outcome. The use of envi-
ronmental arrangement strategies may include specific
strategies such as limiting access to high preferred
items, or more broadly, designing a treatment space to
provide visual clarity regarding the activity that occurs
in that space. Such environmental arrangements are
consistent with behavioral antecedent strategies,
which are considered to be “Established” intervention
strategies in the NSP.6
Schedules and written scripts are also considered
“Established” intervention strategies by the NSP2.7
Schedules are used to successfully promote engage-
ment and understand task completion for children
with ASD who range from being minimally verbal to
very verbal.98,99 Schedules may consist of words, pic-
tures, or a combination of both. They may include a
daily sequence of activities that need to be completed
(e.g., a daily schedule) or they may be used to illus-
trate a sequence of steps that need to be completed
within a single activity (e.g., circle time at preschool,
bed time routine at home). Written scripts, are used to
help readers with ASD initiate and engage in conver-
sational exchanges.7,100 The child may be provided
with cue cards with text or more extensive written
scripts and prompted as needed to read the appropriate
lines of text. As the child learns the scripts, cue cards
or written scripts are removed. Written scripts can be
11
 ARTICLE IN PRESS
created and adapted easily based on the child’s inter-
ests and implemented in a variety of social situations
Visual cues are considered an “Emerging” interven-
tion in the NSP6 and are also used to support children
with ASD in making choices. Visual cues may also be
used to support social initiation, including play with
peers, or the initiation of requests for a break or assis-
tance. The strategy of visual cues is well-aligned with
a common pattern of relative strengths for individuals
with ASD, including visuospatial skills, memory
recall, and comprehension of graphic symbols.101
Augmentative and alternative communication
systems
Since a significant minority of individuals with ASD
fail to acquire adequate use of expressive language,
SLPs may provide assessment and treatment for the
use of augmentative and alternative communication
(AAC) systems, currently considered an “Emerging”
intervention by the NSP2.6,7 A wide range of AAC
approaches may be used to improve the social-com-
munication skills of children with ASD. Unaided
AAC approaches include the use of gestures and sign
language. Aided AAC approaches may include the
use of pictures, graphic symbols, written cues, speech
generating devices, or mobile technologies with
AAC-specific apps. The Picture Exchange Communi-
cation System (PECS)102 combines both behavioral
principles and aided AAC to teach individuals with
ASD to initiate requests for highly preferred items.
The use of AAC may have positive effects on behav-
ior for children with ASD,103 such as improved social
interaction104 and receptive and expressive lan-
guage.105 A systematic review by Schlosser and
Wendt found that AAC does not impede and may
actually encourage the development of expressive lan-
guage.106 The current literature does not yet identify
specific forms of AAC that may be appropriate for
individuals with ASD.107 Clinical decisions about the
use of unaided and aided AAC techniques should be
made on an individual basis. Considerations should
include the individual’s learning strengths and weak-
nesses, his or her developmental level of social-com-
munication skills, and vision as well as motor skills.
The context in which the AAC system might be used
(e.g., home, school), communication partners, and the
individual’s and family’s preferences should also be
considered before AAC is implemented.
12
Addressing sensory processing and motor
skills: occupational-therapy based interventions
Children with ASD often have impairments in activ-
ities of daily living due to behavioral, motor, and/or
social deficits related to the diagnosis. Areas of func-
tion affected include basic activities of daily living,
play skills, productive occupations such as school,
socialization, and the ability to handle schedule and
routine changes.108 Occupational therapists (OTs) are
poised to address two common challenges in children
with ASD: decreased sensory processing abilities and
decreased motor skills.
According to Ayres,109 sensory integration is a
neurological process that determines how we make
sense of how our bodies interact with the environ-
ment. Sensory processing dysfunction occurs when
the neurological system does not interpret or react
to sensory information appropriately.110 These dif-
ficulties are hypothesized to cause disruptions to
daily living activities. They also impact how a
child with ASD engages with his or her environ-
ment. An OT trained in sensory integration will
identify and treat sensory processing difficulties
using sensory-based interventions, such as those
that follow Ayres’ Sensory Integration theory. The
ideal goal of sensory-based therapy is to provide a
“just right challenge” that will elicit what is termed
an adaptive response, “an appropriate action in
which the individual responds successfully to some
environmental demand”.109 An OT can work with
a family to gradually expose a child to a sensory
challenge and teach him or her strategies to cope
with it.
A limited number of research papers have evaluated
the effectiveness of sensory integration therapy. This
may be due to the wide variety of sensory differences
among children with ASD and differences in thera-
peutic approaches. Currently, sensory integration ther-
apy is considered an “Unestablished” intervention by
the NSP.6,7 Clinicians are encouraged to follow guide-
lines to ensure best-practice in sensory integration
therapy, such as the fidelity measure developed by
Parnham et al.111 based on Ayres’ Sensory Integration
theory.82 Watling and Hauer’s systematic review112
states that, when Parham’s fidelity measure is
applied111 in sensory integration therapy, there is
moderate evidence for the use of Ayres approach in
children with ASD.
Curr Probl Pediatr Adolesc Health Care, & &&&&
 ARTICLE IN PRESS
Motor coordination deficits, while not part of the diag-
nostic criteria for ASD, are a common concern in children
with ASD.113 115 ASD is associated with gross and fine
motor coordination problems including: clumsiness, pos-
tural instability, and poor performance on standardized
tests of motor functioning.113 Deficits in motor skills can
impact independence with activities of daily living as
well as socialization due to the gross-motor nature of
play, especially in younger children. OTs are skilled in
addressing fine motor concerns and motor planning
(praxis), and physical therapists (PT) are skilled in assess-
ment and intervention for children with gross motor defi-
cits. Using the basis of engagement in functional tasks in
natural environments, OTs facilitate children building
skills to improve their coordination and overall control of
motor movements.116 In addition, OTs can provide assis-
tive technology and adapted strategies to supplement
motor abilities in order to increase independence and
engagement in functional tasks and daily living skills.
Conclusion
There is a wide range of interventions available, with
varying levels of evidence to treat the core features of
ASD, which include communication and social deficits,
challenging behaviors, and sensory processing and motor
coordination difficulties. Since ASD is a pervasive disor-
der that affects multiple areas of functioning, it is impor-
tant for clinicians to be knowledgeable about the most
effective and evidenced-informed interventions across dis-
ciplines in order to provide clinical care that optimizes
outcomes for children with ASD. The treatment strategies
and interventions presented in this paper are interdisciplin-
ary. Clinicians should strive to provide children with ASD
an interdisciplinary, multi-modal approach that addresses
the individual patient’s deficits, while building on his or
her strengths, and prioritizes the patient’s and family’s
goals and priorities. While this may be a complicated
endeavor, the clinician may focus on evidenced-based
treatments as a guide for providing the best clinical care.
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