Therapy Intensity: How Much is Enough?

Parents often ask how much Intensive Early Behavior Therapy is enough for a preschooler with autism. In 1999, the State of New York issued a report of an expert panel recommending 20 hours per week on average for a preschool child. In 2001 the National Research Council committee on intervention for young children with autism recommended 25 hours per week based on a review of studies to that date. Many treatment programs throughout the US provide 30-40 hours per week for 2-5 year old children with ASD diagnoses, which is consistent with Lovaass original 1987 study and Sallows and Graupners 2005 replication study. However, there is some evidence of improvements with 15 hours per week of therapy for high functioning children with ASDs. What is not known from studies of less intensive treatment, is whether and how much additional benefit might have been gained over the first year had they received 20-30 therapy hours per week of structured therapy. However, there is no evidence 40-50 hours per week produces any greater or more lasting changes than 30-40 hours. More than 40 hours of intensive work with a preschooler may be excessively stressful for a young child, and be counter-productive. I work with the Minnesota Early Autism Project, which takes the position that hours of treatment depend on a childs age (24 month old toddlers tolerate fewer hours in the beginning, but more as the year progresses), his/her disability level (more disability requires more hours) and whether the child has already had 1 or more years of therapy by another provider (children with more therapy experience may make significant gains with 15-20 hours per week). It is important to bear in mind that 75% or more of the gains are made over the first 18-24 months of treatment among more rapidly learning children. The quality of therapy matters as much as the quantity. More hours of inadequately designed and implemented intervention not only doesnt compensate for inappropriate services, but it may backfire if carried out incorrectly. The child may become increasingly resistant and display worsening tantrums and attempt to escape from therapy. It is necessary to tailor-make intervention for the individual child, with higher functioning children profiting from more naturalistic incidental therapy approaches, while lower functioning children with limited attention skills may require more discrete trial strategies. In either case, periods of intensive practice interpolated with short periods of child-directed play usually works best. Eldevik S, Eikeseth S, Jahr E, Smith T (2006) Effects of low-intensity behavioral treatment for children with autism and mental retardaton. J Autism Dev 36:211-24. Lord, C., & McGee, J. (Eds.) (2001). Educating children with autism. Washington, DC: Commission on Behavioral and Social Sciences and Education of the National Academy of Sciences Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55:39. New York State Department of Health, Early Intervention Program. (1999, May). Clinical Practice Guidelines: Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children. Albany, N Sallows, G. O.,& Graupner, T. D. (2005). Intensive behavioral treatment for children with autism: Four-year outcome and predictors. American Journal of Mental Retardation, 110, 417-438. [Credit: Photo courtesy of the Wisconsin Early Autism Project, Madison, WI]