By Doreen Samelson, Ed.D., MSCP and Lindsey Sneed, Ph.D., BCBA-D
If a little bit is good for you, more must be even better. Patients frequently take this approach to health treatments, sometimes to their detriment.
In our specialty, care services for autistic children, some healthcare providers hold a similar view. Many professionals believe the “gold standard” for intervention is high-hour treatment—up to 40 hours a week—including for children under 5 years old. A recent meta-analysis in JAMA Pediatrics challenges this assumption head-on, with findings that could significantly alter how we approach crucial early interventions for autistic children.
The Study in Context
The JAMA Pediatrics study looked at the relationship between the amount of intervention provided (hours per day, duration, and cumulative intensity) and the outcomes for young autistic children. Researchers analyzed data from 144 studies involving more than 9,000 children, making it one of the most comprehensive analyses of its kind.
Contrary to what many have long believed, the study found no significant association between the amount of intervention and improved developmental outcomes. As the authors write, “health professionals recommending interventions should be advised that there is little robust evidence supporting the provision of intensive intervention.”
The authors of the meta-analysis looked at studies of any nonpharmacological intervention for autistic children, but their findings will likely have the greatest impact on interventions based in applied behavior analysis (ABA). The most common intervention utilized with autistic children, ABA uses the principles of operant conditioning (changing behavior through reinforcement or consequences) in real-world settings. The practice became widespread after the publication of a paper by clinical psychologist O. Ivar Lovaas in 1987. That and other publications helped establish the long-held view that high-hour intervention is the best approach for autistic children and their families.
The JAMA Pediatrics research directly challenges this view.
What This Means in Practice
The implications of this meta-analysis are profound. Instead of defaulting to high-hour interventions, this research suggests families and practitioners should utilize this approach sparingly. A better approach may be to start with lower hours and titrate up, if needed. Other personalized treatment options that practitioners and caregivers may consider (that do not require high intervention hours) include speech therapy, psychotherapy (for issues such as anxiety and depression), and caregiver-mediated interventions (including those based on ABA principles).
The authors included studies of caregiver-mediated interventions in their research—but found they were unable to include many of these studies because they often did not report daily data on the intensity of treatment (as needed for the meta-analysis). The researchers also noted the potential complexity of comparing clinician-mediated interventions with caregiver-mediated interventions. They write that caregiver-mediated interventions “even when they are delivered with relatively high intensity, may be less likely to interrupt child participation in everyday family activities and instead simply alter the nature of their participation. Our methods did not allow us to differentially examine the impact of clinician-delivered vs. caregiver-delivered intervention hours, but future investigations should more closely examine this question.”
Broader Impact: Access and Cost
Another consideration is the potential impact on access to care. As autism diagnoses continue to rise—1 in 36 children is now identified as having autism—the demand for intensive interventions places a significant burden on both families and healthcare systems. High-hour treatments are an expensive and resource-intensive approach in a field that is already struggling to keep up.
Anecdotally, we often encounter families who have waited many months or even years to begin treatment. Research suggests the problem is getting worse. In 2016-2017, the proportion of autistic children receiving treatment by age 4 was 60 percent. In 2020-2021, the most recent available data, that figure fell to 48 percent.
By allowing providers to work with more families, lower-hour interventions could help expand access, mitigate workforce shortages, and reduce wait times.
Risks of High-Hour Treatment
High-hour autism interventions may also impose significant burdens on the people they are supposed to benefit. The study authors write, “very intensive interventions could perceivably cause harm by depriving children of time to engage in other activities, such as rest, recreation, and time with family and community members.”
Additionally, for siblings, parents, and other caregivers, having a provider in the home for extended periods can be disruptive. Frequent travel to providers’ offices may also impose a burden.
How Many Hours?
The JAMA Pediatrics study does not offer families or providers guidance on the ideal number of hours. The authors write, “It is likely that there is a minimum amount needed for intervention to have any benefit at all and, potentially, an optimal amount of intervention that is dependent on the child. Unfortunately, current evidence does not offer clear values or ranges for those amounts.”
For families currently receiving high-hour interventions, the suggestion that their child’s hours of treatment should be cut may be cause for concern. The same is likely true for the professionals who provide that care. We hope the findings of this research will reassure both groups that there appears to be little risk that children’s outcomes will be negatively affected by lower-hour treatments.
We encourage providers and families to try alternatives to high-hour interventions—keeping a careful eye on the well-being of the child and the family as a whole—while staying ready to recalibrate if needed.
Lindsey Sneed, Ph.D., BCBA-D, is vice president of clinical excellence at the nonprofit Catalight, which provides access to innovative, individualized care and clinical research. She is also an adjunct faculty member at the University of San Francisco. She conducts applied research evaluating the efficacy of different models of care for children with developmental disabilities and contributes to the development of new care models.
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