J Autism Dev Disord
DOI 10.1007/s10803-014-2235-2
ORIGINAL PAPER
Feasibility and Effectiveness of Very Early Intervention
for Infants At-Risk for Autism Spectrum Disorder: A Systematic
Review
Jessica Bradshaw • Amanda Mossman Steiner •
Grace Gengoux • Lynn Kern Koegel
Ó Springer Science+Business Media New York 2014
Abstract Early detection methods for autism spectrum
disorder (ASD) in infancy are rapidly advancing, yet the
development of interventions for infants under two years
with or at-risk for ASD remains limited. In order to guide
research and practice, this paper systematically reviewed
studies investigating interventions for infants under
24 months with or at-risk for ASD. Nine studies were
identified and evaluated for: (a) participants, (b) interven-
tion approach (c) experimental design, and (d) outcomes.
Studies that collected parent measures reported positive
findings for parent acceptability, satisfaction, and
improvement in parent implementation of treatment. Infant
gains in social-communicative and developmental skills
were observed following intervention in most of the
reviewed studies, while comparisons with treatment-as-
usual control groups elucidate the need for further research.
These studies highlight the feasibility of very early inter-
vention and provide preliminary evidence that intervention
for at-risk infants may be beneficial for infants and parents.
Electronic supplementary material The online version of this
article (doi:10.1007/s10803-014-2235-2) contains supplementary
material, which is available to authorized users.
J. Bradshaw (&)
L. K. Koegel
Counseling, Clinical, and School Psychology Department,
Koegel Autism Center, Graduate School of Education,
University of California, Santa Barbara, CA, USA
e-mail: jbradshaw@education.ucsb.edu
A. M. Steiner
SIERRA Kids, Sacramento, CA, USA
G. Gengoux
Department of Psychiatry and Behavioral Sciences, Stanford
University School of Medicine, Stanford, CA, USA
Keywords Autism
Early intervention
Infancy
High-
risk infants
Treatment
Introduction
Research dedicated to advancing methods for early identifi-
cation of autism spectrum disorder (ASD) has resulted in
evidence of behavioral markers in the first year of life (Cha-
warska et al. 2013; Elsabbagh et al. 2012; Jones and Klin
2013; Maestro et al. 2002; Shic et al. 2014), the development
of clinical autism-specific screeners that begin as early as
12 months (Barbaro and Dissanayake 2013; Kleinman et al.
2008; Robins 2008), and a statement by the American Acad-
emy of Pediatrics recommending routine screenings for ASD
beginning at 18 months (Johnson and Myers 2007). Early
identification of ASD in clinical and research settings neces-
sitates parallel development and investigation of early inter-
ventions for infants and toddlers that mitigate, and possibly
prevent, impairments associated with ASD (Dawson 2008). In
light of empirical research documenting significantly
improved outcomes with early intervention for preschool and
school-aged children with ASD (Granpeesheh et al. 2009;
Rogers et al. 2012; Zachor et al. 2007), there is a critical need
for the development of effective early intervention techniques
during the first years of life.
Developmental and transactional models of ASD empha-
size interactive biological and environmental processes that
shape early development (Dawson 2008; Elsabbagh and
Johnson 2010; Mundy and Neal 2000). Evidence of neuro-
plasticity and critical periods of development in infancy lend
support for the investigation of very early interventions.
Effective interventions at the earliest age possible may be able
to modify early experiences-effectively altering cortical
organization, enhancing learning, and potentially improving
123

developmental trajectories (Fox et al. 2010; Johnson 2001;
Webb et al. 2014). As such, the present article seeks to review
current findings in the development and implementation of
treatment for infants with or at-risk for ASD in the first two
years of life.
Current Approaches to Intervention for Autism in Early
Childhood
Interventions for children with ASD encompass a wide
range of techniques that target an array of behaviors or
symptoms. Some of the most common therapies accessed
by parents of children with ASD include speech/language
therapy, applied behavior analysis (ABA), occupational
therapy and sensory integration, as well as medication
treatments and special diets (Green et al. 2006; Goin-Ko-
chel et al. 2009; Love et al. 2009). Many community-based
intervention services for toddlers first diagnosed with ASD
fall under the blanket term ‘‘Early Intervention’’ (e.g.,
IDEA, Part C, and Birth to Three programs). Early Inter-
vention may consist of a variety of services, some of which
are empirically validated while others carry minimal
empirical support (Stahmer et al. 2005). Despite the pop-
ular use of services with limited empirical support, several
evidence-based interventions have been established, eleven
of which are recognized as ‘Established Treatments’ by the
National Standards Project (National Autism Center 2009).
At the time of the National Standards Project, the majority
of the established treatments were associated with favor-
able outcomes for preschoolers, school-age children, and
middle-school aged children, with very few interventions
suggested for use with children under 2 years of age.
While some highly structured interventions based on
Applied Behavior Analysis have historically had the stron-
gest research support (Lovaas 1987; Reichow 2012), early
behavioral interventions for toddlers with ASD have evolved
to incorporate elements from developmental psychology in
addition to more ‘‘naturalistic’’ methods, in which the
intervention is more child-directed and occurs in the child’s
natural environment (Schreibman 2014). Some examples of
interventions that combine behavioral, naturalistic, and
developmental approaches (also termed Naturalistic Devel-
opmental Behavioral Interventions; NDBIs) are the Early
Start Denver Model (Rogers and Dawson 2010), Enhanced
Milieu Teaching (Kaiser and Hester 1994), and Pivotal
Response Treatment (PRT; Koegel and Koegel 2012).
Why Intervene So Early?
The first 2 years of infant development are marked by rapid
change and an explosion of cognitive, language, and social
abilities. Beginning at birth, early attentional preferences for
social stimuli (Johnson et al. 1991) foster the emergence of
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social communication. This developmental pathway is char-
acterized by mutual gaze and shared positive affect (Parlade
et al. 2009), social engagement and parental scaffolding
(Bakeman and Adamson 1984), and joint attention and gesture
use (Tomasello and Carpenter 2007), which emerge within the
first 12 months of life. The second year of life is characterized
by an exponential growth of verbal communication (Paul
2007). By the time children with ASD are identified and
enrolled in treatment programs between 3 and 5 years (Shat-
tuck et al. 2009), the gap between their abilities and those of
typically developing peers has often grown quite wide.
This early stage of development prior to age two also marks
a critical period with regard to accelerated brain growth and
connectivity (Courchesne et al. 2003; Wolff et al. 2012),
interactive specialization (Johnson 2001), language learning
(Kuhl et al. 2005), and potentially social perception and social
development (Dawson 2008; Schultz 2005). After 24 months,
neurosynapatic development, including cortical specializa-
tion and white matter growth, significantly attenuates, making
this age a critical period in development and possibly in the
pathogenesis of ASD (Wolff et al. 2012). It is hypothesized
that atypical development of social mechanisms, including
attention, communication, and reward processing, may persist
without intervention and could have consequential effects on
the subsequent development of social-communicative abili-
ties (Chevallier et al. 2012; Eyler et al. 2012; Schumann and
Amaral 2006). Capturing developmentally delayed behaviors
and providing enriched experiences and differential rein-
forcement in this sensitive period, when neural plasticity is
heightened, could have a long-term impact on development.
That is, if developmental trajectories for vulnerable infants
can be altered when the gap between infants with and without
delays is small, long-term outcomes could be significantly
improved.
Evidence for observable prodromal symptoms of ASD
in infancy is mounting, making implementation of inter-
vention in this critical period feasible (Barbaro and Dis-
sanayake 2009; Vismara and Rogers 2008). As mentioned
above, symptoms of ASD have been documented in the
first year of life (e.g. Chawarska et al. 2013; Elsabbagh
et al. 2012; Flanagan et al. 2012; Jones and Klin 2013).
Additionally, early screening strategies are being evaluated
to enable detection and referral in the first year of life
(Bryson et al. 2008) and before the second birthday (Dietz
et al. 2006; Reznick et al. 2007; Robins 2008; Wetherby
et al. 2008). Further, accumulating studies are documenting
that many children can be reliably diagnosed at 18 months
of age (Chawarska et al. 2007; Guthrie et al. 2012). This is
consistent with parent observations confirming concerning
behaviors before age two (Young et al. 2003). Clinical
assessments and early screeners can help to identify infants
and toddlers who are ‘‘at-risk’’ for ASD based on prodro-
mal behavioral features and might benefit from
J Autism Dev Disord
intervention and prevention strategies rather than waiting
for the emergence of full diagnostic features (Crais and
Watson 2014). In addition to infants who are identified as
‘‘at-risk’’ due to behavioral presentation and screening
measures, infant siblings of ASD are also identified as ‘‘at-
risk’’ due to genetic contributions to the disorder (Ozonoff
et al. 2011). Consequentially, pediatric practices are urged
to scrupulously monitor infants, especially at-risk infant
siblings, and immediately refer them for intervention upon
the observation of developmental red flags (Ozonoff et al.
2011).
While early detection techniques are being refined and
encouraged, empirically based interventions for infants in this
early period before 24 months remain limited. The majority of
the existing early intervention research focuses on children
with ASD in the preschool years, between 2 and 4 years of age
(see Boyd et al. 2010 for review). This is problematic con-
sidering that current recommendations suggest initiation of
intervention within 60 days following a diagnosis (Maglione
et al. 2012). In a comprehensive review of interventions for
toddlers with ASD under 36 months, Schertz et al. (2012)
identified a total of 20 research studies, with only five studies
targeting infants under 2 years of age and only one study of a
single infant focused on treatment implementation within the
first year of life. Given the unique developmental character-
istics of children in the first and second year of life, which may
warrant additional specialized modifications to intervention
focus and method of delivery even beyond those made for 2- to
3-year-olds, we elected to specifically focus on treatments
applied to these very young children for the present review.
We focus narrowly on the critical period of birth to 24 months
and the specific challenges associated with intervening at this
very early age, including developmental modifications nec-
essary for implementation of intervention in the prelinguistic
period, and evaluating parent outcomes following interven-
tion. For these very young children there is a clear need to
address parental concerns as they arise and provide guidelines
for delivery of empirically based interventions (Webb et al.
2014). Furthermore, the complexities of identifying infants
under 24 months with or at-risk for ASD are highlighted in
this review.
The present article reviews available research investi-
gating the feasibility and effectiveness of early interven-
tions for infants under 24 months, when routine ASD
screenings are recommended and when enriched experi-
ence may have a significant impact on development tra-
jectories. The following critical elements are explored
within the available infant intervention research: (a) par-
ticipant characteristics, (b) intervention approach,
(c) experimental design, and (d) infant and parent out-
comes. A synthesis of existing evidence is intended to
guide and inform practitioners as they develop very early
intervention programs for ASD and to stimulate research
efforts that may help to mitigate early signs of ASD in
infancy and to improve developmental trajectories for at-
risk infants.
Methods
This review involved a systematic analysis of studies that
focused on interventions for infants with or at-risk for ASD
under 24 months of age. In order to provide a compre-
hensive review of the current state of intervention research
for this population, each identified study that met prede-
termined inclusion criteria was analyzed and summarized
in terms of (a) participant characteristics, (b) intervention
approach, (c) experimental design, and (e) infant and par-
ent outcomes. More specifically, the summary of partici-
pant characteristics included the number of participants in
each study, the average age, and participants’ risk for ASD.
The intervention approach was evaluated with a synopsis
of the empirical and theoretical basis of intervention, par-
ent involvement, length and intensity of treatment, and
specific intervention goals and strategies. The summary of
outcome included reports on infant-specific developmental,
diagnostic, social, and communication outcomes as well as
parent measures such as satisfaction, feasibility, and
acceptability.
Search Procedures
A systematic search procedure was used to identify studies
for possible inclusion in this review. First, a literature search
of the following four electronic databases was conducted for
articles published from the beginning dates of the database
(1949 was the earliest resulting publication) up to June 2014:
PsychINFO, Education Resources Information Center
(ERIC), Academic Search Complete, and PubMED. The
search only included studies written in English that appeared
in peer-reviewed journals. The following combination of
search terms was entered into each database: autism or
autistic or ASD or PDD* or pervasive developmental dis-
order AND infant or toddler AND intervention or treatment.
Additionally, articles that were published online, ahead of
print, were searched for the same key terms from the fol-
lowing publishers: Elsevier, Springer, and Sage. This initial
search yielded a total of 2,353 articles across all databases
after duplications were removed. The articles were then
independently screened by the first (JB) and last (LK) authors
for the inclusion criteria, listed below.
Inclusion Criteria
Each study resulting from the initial search was evaluated
for the following pre-determined inclusion criteria:
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1. Research Design. The study involved systematic,
experimentally controlled investigation of a non-phar-
macological intervention. Example research designs
meeting inclusion criteria were randomized controlled
trials, quasi-experimental designs, and single-case
designs. Uncontrolled case studies (e.g., N = 1) were
excluded from this review. In order to ensure the study
was evaluating intervention effectiveness, at least one
dependent variable had to be a child outcome measure.
2. Autism Risk Status. All participants in the study were
diagnosed with ASD or labeled by the study’s authors as
at-risk for developing ASD. There were no restrictions
related to the study’s methodology for determining
diagnosis of ASD or determination of ‘‘at-risk’’ for ASD.
3. Average Age Less than 24 Months. The study focused
on children under 24 months of age. In order to
account for studies that included primarily, but not
exclusively, children less than 24 months, we included
studies where the mean age of participants was
\24.0 months at the start of intervention.
In order to ensure the accuracy of the systematic search,
the first and last authors both independently completed the
search and made an initial determination as to whether
each study met inclusion criteria. The articles identified by
each author were then compared for reliability. Reliability
was calculated using percent agreement on the studies each
author positively identified as meeting inclusion criteria.
This resulted in eight agreements and one disagreement,
yielding an overall agreement of 89 %. The one disagree-
ment was based on the Research Design criteria for a study
that utilized a quasi-experimental design. Through discus-
sion it was ultimately decided that a quasi-experimental
design with a post-test only control group was sufficient to
be included in this review. A final total of nine studies
met all the inclusion criteria.
Coding
After the list of included studies was agreed upon, the first
and last authors independently extracted information and
answered 10 questions related to the four broad categories
used to evaluate each study (see Appendix): (a) participant
characteristics, (b) intervention approach, (c) experimental
design (d) outcomes.
Participant characteristics
The number of total participants in each study, the age range,
and the mean age of participants were collected from each
study. The total number of participants was reported for sin-
gle-case designs and the number of participants in each group
was reported for group designs. The age range and mean age
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were reported across all participants for both single-case and
group design studies. The age range and mean age were
computed for single-case designs in which the age of each
participant was reported individually. Additionally, the
method in which each study classified its participants as either
‘‘at-risk’’ for ASD or diagnosed with ASD was summarized.
Intervention approach
Details regarding the intervention approach used by each
study included the empirical and theoretical basis, the
length and intensity, and goals and strategies. The name
and theoretical basis of each intervention was extracted
from the description of the intervention. For any studies
that did not thoroughly explain a theoretical basis, relevant
references cited in that article were reviewed to identify the
theoretical foundation. Additionally, it was determined
whether the intervention was primarily parent-mediated,
clinician-directed, or a combination of both. The length and
intensity of each intervention was reported in terms of
number of individual sessions over a set period of time.
Where possible, the length of each session was also
included. If the intervention included group sessions or
playgroups, this was indicated as well. The intervention
goal(s) of each study referred to how the authors described
the overall goal of their treatment. Intervention strategies
referred to specific strategies listed by the author that were
used or taught in order to meet the intervention goals.
Experimental design
The type of experimental design used to evaluate effec-
tiveness and/or feasibility of the intervention was reported.
Outcomes
Intervention outcomes for each study were collected for
both infants and parents. This included observed changes in
infant measures following the intervention as well as any
parent measures that were collected, such as fidelity of
implementation or satisfaction.
Reliability
Coding reliability was calculated for all nine studies in
order to ensure accuracy in the summary of studies and to
provide a measure of inter-rater agreement on data
extraction and analysis. There were 90 items on which
there could be agreement or disagreement (i.e., 9 studies
with 10 questions per study). Reliability was determined by
calculating percent agreement across all nine studies.
Agreement was obtained on 80 of the 90 possible items
yielding 80 % agreement. In the instances in which there
J Autism Dev Disord
was disagreement on any of the items, the items were
discussed until consensus was obtained. The final summary
was then checked by the co-authors for accuracy. The
results are presented in Tables 1 and 2 and the four broad
domains are further addressed below.
Results
Participant Characteristics
The nine studies included a total of 353 participants
between 4 and 30 months of age. This included 150 infants
in the experimental treatment condition and 203 control
infants who were either typically developing or received
‘‘treatment-as-usual’’ (TAU). Three studies investigated
intervention for participants in the first year of life,
between 4 and 12 months (Green et al. 2013; Koegel et al.
2013; Steiner et al. 2013), while six studies intervened with
infants primarily in the second year of life, (Carter et al.
2011; Dawson et al. 2010; Drew et al. 2002; Rogers et al.
2012; Schertz and Odom 2007; Wetherby and Woods
2006). The latter six studies that focused on infants with
mean age \24 months contributed the majority of treat-
ment participants (N = 137 in the treatment condition)
while the former three studies were relatively small and in
total reported treatment effects for 13 infants.
All studies required that participants be either at-risk for
ASD (‘‘at-risk’’ due to behavioral symptoms of ASD or
being a sibling of a child with ASD) or diagnosed with
ASD prior to participating in the intervention. Three gen-
eral approaches were used to determine eligibility based on
ASD diagnosis or risk status: (1) inclusion of any infant
sibling of a child with autism, regardless of behavioral
profile (Green et al. 2013; Steiner et al. 2013), (2) expert
clinical concern for ASD based on autism screeners or
behavioral assessments (Carter et al. 2011; Koegel et al.
2013; Rogers et al. 2012; Schertz and Odom 2007), and (3)
clinical or provisional clinical diagnosis of ASD (Dawson
et al. 2010; Drew et al. 2002; Wetherby and Woods 2006).
Assessment procedures were aimed at ascertaining early
symptoms of ASD, and often used multiple sources. These
assessments included systematic behavioral observation
(Drew et al. 2002; Koegel et al. 2013), Autism Diagnostic
Observation Schedule—Toddler Module (ADOS-T, Lord
et al. 2012; Rogers et al. 2012), Autism Diagnostic Inter-
view—Revised (ADI-R) and Toddler Autism Diagnostic
Interview (Dawson et al. 2010; Drew et al. 2002; Lord
et al. 1994), Childhood Autism Rating Scale (CARS;
Schertz and Odom 2007; Schopler et al. 1988), Infant
Social Communication Questionnaire (ISCQ; Schertz,
unpublished; Schertz and Odom 2007), Modified Checklist
for Autism in Toddlers (MCHAT; Robins et al. 2001;
Schertz and Odom 2007), Pervasive Developmental Dis-
orders Screening Test-II (PDD-ST-II; Schertz and Odom
2007; Siegel 2001), Systematic Observation of Red Flags
of ASD (SORF; Wetherby and Woods 2002, 2006), and the
Screening Tool for Autism in Two-Year Olds (STAT;
Stone et al. 2004; Carter et al. 2011), .
Intervention Approach
Empirical and Theoretical Basis
Most of the reviewed studies adapted intervention models
that had been previously applied for preschool-aged chil-
dren. Pivotal Response Treatment (Koegel et al. 2013;
Steiner et al. 2013), Early Start Denver Model (ESDM;
Dawson et al. 2010; Rogers et al. 2012), and Hanen’s More
Than Words (HMTW; Carter et al. 2011) have all been
researched for use with older children. All authors reported
that treatment procedures and targets were modified to be
developmentally appropriate for infants under the age of
two. The studies by Green et al. (2013), Drew et al. (2002),
Schertz and Odom (2007), and Wetherby and Woods (2006)
represent the first investigation of the experimental inter-
vention not previously studied with older populations. PRT
and ESDM were both reported to be founded in develop-
mental and behavioral theories, with social motivation being
emphasized in PRT while ESDM stressed a relationship-
based approach. The Early Social Interaction Project (ESI;
Wetherby and Woods 2006) and HMTW both described a
family centered and routine-based approach as key elements
to their intervention. The Social-pragmatic joint attention
parent-training program (Drew et al. 2002) utilizes both
developmental and behavioral approaches to teach joint
attention. Schertz and Odom (2007) described the Joint
Attention Mediated Learning (JAML) intervention as a
parent-mediated and family centered approach focusing on
the developmental foundations of joint attention. The
‘‘Intervention in BASIS’’ (iBASIS) program (Green et al.
2013) highlighted attachment theory and the importance of
parent-infant synchrony. Additionally, five out of the nine
reviewed studies reported using a manualized intervention
(Dawson et al. 2010; Green et al. 2013; Rogers et al. 2012;
Schertz and Odom 2007; Steiner et al. 2013).
Parent Involvement
Nearly all interventions used parent-mediated procedures.
That is, parents were taught specific intervention proce-
dures during treatment sessions and were expected to
implement them with their child during and outside of the
sessions. Methods in which parents were taught interven-
tion strategies involved didactic sessions about treatment
techniques in addition to a ‘‘practice-with-feedback’’
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Table 1 Description of reviewed studies

Study Participants Intervention approach Experimental
design
N and age Risk Empirical and Length and Intervention goals and strategies
determinants theoretical basis intensity
or diagnosis
of ASD

Carter N = 32 (intervention – Symptoms Hanen’s More 8 group and 3 Goal: Increase child communication Randomized
et al. group) and N = 30 of ASD Than Words individual using everyday routines controlled trial
2011 (control group); – Expert Program sessions over Strategies: Video feedback; responding with treatment-
15-24 months clinical (HMTW) 3.5 months to child’s communicative attempts; as-usual
(M = 20) judgment of – Social- following child’s lead; joint action control group
ASD interactionist routines; use of books to elicit and
theory reward communication; scaffolding
– Parent- peer play dates; visual supports
mediated
– Family-
centered
– Routine-based
Dawson N = 24 (intervention – Clinical Early Start 20-h/week over Goal: Improve developmental Randomized
et al. group) and N = 24 diagnosis of Denver Model 2 years outcomes controlled trial
2010 (control group); ASD or (ESDM) Strategies: Interpersonal exchange and with a
18-30 months PDD-NOS – Developmental positive affect; shared engagement; treatment-as-
(M = 23.1 and behavioral adult responsivity and sensitivity to usual control
intervention group; theory child cues; focus on verbal and group
M = 23.9 control – Relationship- nonverbal communication; behavioral
group) based principles (operant conditioning,
shaping and chaining); plan
– Therapist and
individualization
parent-
delivered
Drew N = 12 (intervention – Clinical Social-pragmatic One 3-h session Goal: Enhance communication skills Randomized
et al. group) and N = 12 diagnosis of joint attention every 6 weeks Strategies: Behavior management; joint controlled trial
2002 (control group); ASD focused parent over 12 months action routines; teaching joint with a
Under 24 months training attention behaviors (mirror games, treatment-as-
(M = 22.6) program pointing, following points, gaze usual control
– Developmental switching game); increase mutual group
and behavioral enjoyment; exaggerated prosody;
theory repetitive paraphrasing
– Parent-
mediated
Green N = 7 (case series – Sibling with Intervention in 12 sessions over Goal: Improve the quality of parent- Case series with
et al. group) and N = 70 ASD BASIS (i- 5 months infant interactions and increase a high-risk and
2013 (comparison BASIS) parent-infant synchrony low-risk
groups); – Developmental Strategies: Use of video aides; maternal control group
8–10 months (M = 8) and attachment sensitive and contingent responding;
theory affect matching; reciprocal
– Parent-infant vocalization
synchrony
Koegel N = 3; – Symptoms Pivotal Response 1 h/week for Goal: Increase motivation to engage in Multiple baseline
et al. 4–9 months (M = 6) of ASD Treatment 4-11 weeks social interaction design across
2013 – Expert (PRT) Strategies: Use of infant-preferred participants
clinical – Behavioral and activities; task variation; interspersal
concern for developmental of preferred and neutral activities;
ASD theory reinforcement
– Social
motivation
hypothesis

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Table 1 continued
Study Participants Intervention approach Experimental
design
N and age Risk Empirical and Length and Intervention goals and strategies
determinants theoretical basis intensity
or diagnosis
of ASD

Rogers N = 49 (intervention – Symptoms Parent- 1 h/week for Goal: Improve social, communicative, Randomized
et al. group) and N = 49 of ASD Implemented 12 weeks and developmental outcomes controlled trial
2012 (control group); – Expert Early Start Strategies: Increase child attention and with treatment-
12–24 Months clinical Denver Model motivation; use of sensory social as-usual
(M = 21) judgment of (P-ESDM) routines; joint activity routines; use of control group
ASD – Developmental antecedent-behavior-consequence
and behavioral relationships; use of prompting,
theory shaping, fading, and functional
– Relationship- behavior assessment
based
– Parent-
mediated
Schertz N = 3; – Symptoms Joint Attention 1-2 sessions/ Goal: Promote joint attention Multiple baseline
and 20–28 months of ASD Mediated week over Strategies: Engage in face-to-face design across
Odom (M = 23.7) – Positive Learning 9-26 weeks interactive games; turn-taking participants
2007 screen for (JAML) activities; respond to join attention;
ASD – Developmental initiating joint attention activities
theory
– Mediated
learning
– Family-
centered
– Parent-
mediated
Steiner N = 3; – Sibling with Pivotal Response Ten 1-h sessions Goal: Increase functional Multiple baseline
et al. 12 months (M = 12) ASD Treatment over 3 months communication and social motivation design across
2013 (PRT) Strategies: Following the child’s lead; participants
– Behavioral and providing clear prompts; interspersal
developmental of maintenance and acquisition tasks;
theory use of immediate, contingent, and
– Social natural reinforcement; reinforcement
motivation of attempts
hypothesis
Wetherby N = 17 (intervention – Provisional Early Social 2 individual Goal: Improve social communication in Quasi-
and group); clinical Interaction sessions/week the context of family routines experimental
Woods 12–24 months diagnosis of Project (ESI) and 9 Strategies: Goal individualization; design with a
2006 (M = 18) ASD – Developmental playgroup environmental arrangement; waiting; post-treatment
theory sessions over natural reinforcers; balanced turn- contrast group
N = 18 (3rd year 12 months
contrast group); – Parent- taking; modeling; contingent
mediated imitation; requesting imitation; time
25–36 months delay
(M = 31) – Family-
centered
– Routine-based

model in which parents and their infant practiced the
intervention while a clinician provided feedback about
implementation. Only one study was therapist-delivered,
but incorporated a parent-training component (Dawson
et al. 2010). Parent education took place primarily in the
natural environment (i.e., the home) for seven of the nine
studies (Carter, et al. 2011; Dawson et al. 2010; Drew et al.
2002; Green et al. 2013; Koegel et al. 2013; Schertz and
Odom 2007; Wetherby and Woods 2006). Intervention
occurred primarily in a university clinic setting for the two
remaining studies (Rogers et al. 2012; Steiner et al. 2013).
Length and Intensity
Length of treatment ranged from 4 weeks to 2 years and all
but one intervention were low-intensity, totaling no more

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Table 2 Infant and parent outcomes

Study Infant outcome Parent outcome

Carter et al. No main effects of treatment were observed for any child outcome Medium-to-large, but statistically insignificant,
2011 variables. A medium effect size for child social communication improvements in parent responsivity were observed
was found for both the HMTW and treatment-as-usual (TAU) following intervention
groups. Children in the HMTW group who exhibited less Child
Object Interest prior to intervention achieved greater gains in
initiating joint attention, initiating behavioral requests, intentional
communication, and parent-reported nonverbal communication
Dawson Improvement in nonverbal cognitive skills significantly greater No parent outcomes were reported
et al. 2010 than baseline assessment and the TAU group after 1 year of
intervention. After 2 years of intervention, the ESDM group
showed significantly greater improvements in receptive and
expressive language as well as parent-reported communication,
daily living skills, and motor skills. No significant group
differences in autism severity were observed, but toddlers in the
ESDM group were more likely to have improved diagnostic
status
Drew et al. Significantly more children in the Parent training group moved There were no group differences in parent-stress
2002 from being minimally verbal to having single word or phrase
speech than in the TAU group. The Parent training group had
marginally higher language comprehension than the TAU group.
There were no group differences in nonverbal IQ, words,
gestures, or symptom severity
Green et al. Preliminary results suggest improvement in infant liveliness for High session attendance and reports on parent satisfaction
2013 both treatment and control groups, but greater improvement in questionnaires suggest overall feasibility and
treatment group acceptability. Preliminary results show that all but one
mother who exhibited low synchrony behaviors, i.e. non-
directiveness and sensitive responsiveness, improved on
these measures following intervention
Koegel et al. Rapid increases in social engagement for all participants following All parents learned to correctly implement the intervention
2013 initiation of the intervention. Social engagement was defined as procedures and met the Fidelity of Implementation
increased happiness, interest, and response to name, as well as criterion during all intervention sessions
decreased eye contact avoidance during parent-infant
interactions. These gains were maintained at a two and six month
follow-up
Rogers Both groups (P-ESDM and TAU) made significant gains in rates of Parents in both P-ESDM and TAU groups showed
et al., 2012 acquisition of developmental skills and reduction of core significant improvement in their use of ESDM interaction
symptoms of ASD following the 12-week intervention. No group skills in the 12-week period. Although these groups did
differences on any primary child outcome variables were found. not significantly differ in their acquisition of the ESDM
Developmental and diagnostic improvements were associated treatment procedures, the P-ESDM group exhibited a
with more intervention hours and younger age at the start of larger effect size than the TAU group following
intervention. Children in the TAU group received a greater intervention. Further, parents in the P-ESDM group
number of intervention hours. reported a stronger working alliance with their therapist
Contrary to the authors’ hypothesis, social orienting and imitation than parents in the TAU group
did not moderate the child effects of P-ESDM.
Higher parent P-ESDM fidelity scores at the start of the study were
significantly related to milder ASD symptoms and higher
developmental scores
Schertz and All participants improved above baseline in focusing on the Parent satisfaction with their child’s progress following
Odom parents’ face, turn-taking, responding to parents’ joint attention intervention was high for two out of three parents and all
2007 overtures, and initiating joint attention encounters. One parents improved confidence in their ability to support
participant only slightly improved on the two joint attention child interactions. Parent participation was high for all
measures parents and fidelity of implementation was high for two
out of three parents
Steiner et al. All participants demonstrated rapid increases in frequency of Following intervention, all parents demonstrated
2013 communication with their parent following the start of independent, correct implementation of intervention
intervention. These gains maintained at post-treatment. Follow- procedures both with and without a clinician present.
up developmental testing at 36 months showed decreases in Additionally, all parents reported high overall satisfaction
autism symptomology with the intervention

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Table 2 continued
Study Infant outcome Parent outcome

Wetherby After one year of treatment, children in the intervention group None reported
and Woods exhibited significant improvements in all reported measures of
2006 social-communication, except for shared positive affect and
number of gaze shifts. The intervention group also exhibited
superior skills in social signals, rate of communicating,
communicative functions, and understanding compared to the
third year contrast group

than 2 h of intervention per week. All treatment programs
included the expectation that parents would frequently
implement the intervention strategies throughout the week
and integrate them into daily activities. Dawson et al.
(2010) was the only study to collect data on the amount of
time the intervention procedures were implemented by the
parents outside of the intervention sessions (an average of
16.3 h per week).
Intervention Goals and Strategies
Most of the reviewed studies discussed behavioral princi-
ples as a foundational element of intervention (Carter et al.
2011; Dawson et al. 2010; Drew et al. 2002; Koegel et al.
2013; Rogers et al. 2012; Steiner et al. 2013; Wetherby and
Woods 2006). Behavioral components that provided a
framework for intervention included: providing a learning
opportunity (antecedent), waiting for the child to respond
(behavior), and delivering appropriate reinforcement
(consequence). Further, all interventions used naturalistic
approaches such that the infant’s daily routines, natural
interests, or preferred activities were infused into treatment
procedures.
Goals for intervention fit generally under the broad
developmental area of social-communication, constituting
one of the two core areas of ASD in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5; American Psychiatric Association 2013). All
interventions embraced a developmental framework by
adapting treatment targets and intervention strategies to be
developmentally appropriate for the age of the sample. For
example, one of the treatment goals for 6-9-month-olds
was to increase social engagement, namely positive affect
and social interest (Koegel et al. 2013) while an interven-
tion program for 20-month-old toddlers targeted receptive
and expressive verbal communication (Carter et al. 2011).
For this reason, intervention procedures are summarized
below in two developmental stages: the first and second
years of life.
First Year: 4–12 Months Green et al. (2013) developed
the ‘Intervention in BASIS’ (iBASIS) program based on
autism-specific intervention strategies previously estab-
lished in the Preschool Autism Communication Trial
(PACT; Green et al. 2010). The primary aim of the inter-
vention was to increase parent-infant synchrony while also
addressing emerging symptoms of ASD in 8–10 month-old
infants. Improvements in parent-infant synchrony were
hypothesized to lead to improvements in child dyadic
communication and reductions in ASD symptoms. Koegel
et al. (2013) also provided an intervention designed to
modify parent-infant interactions for prelinguistic infants.
Using PRT (Koegel and Koegel 2012), this brief inter-
vention program aimed to increase infants’ motivation to
engage in social interaction. Specifically, goals were to
increase eye contact, happiness, and interest during parent-
infant interactions. Similarly, in an intervention program
for 12-month-old infants (Steiner et al. 2013), procedures
and target behaviors of PRT were modified for use with
infants. Traditionally, PRT has been studied with preschool
and school-aged children where the focus of intervention is
initially verbal communication (Koegel et al. 1999). These
treatment targets were adapted for 12-month-olds to
include verbal (vocalizations, word approximations), non-
verbal (gestures, pointing, giving, showing, and commu-
nicative reaching), and coordinated social communicative
behaviors (communication involving multiple verbal and/
or nonverbal behaviors).
Second Year: 13–30 Months Six of the reviewed research
studies investigated the effectiveness of interventions for
infants with a mean age between 13 and 24 months of age
(range 13–30 months). The ESDM (Dawson et al. 2010) is a
comprehensive developmental and behavioral treatment
model that focuses on the use of naturalistic methods for
supporting young child development. In addition to tradi-
tional ESDM, which focused on improving developmental
outcomes through an intensive therapist-delivered program,
parent-implemented ESDM (P-ESDM; Rogers et al. 2012)
focused on teaching parents strategies for engaging in child-
centered responsive interactions. Both intervention models
targeted the following child behaviors: attention, motivation,
social engagement in joint activity routines, verbal and
nonverbal communication, imitation, and joint attention.

123

The Early Social Interaction (ESI) Project (Wetherby and
Woods 2006) aimed to teach parents to increase social
communication in their toddler using strategies based on
behavioral principles that included natural reinforcement,
time delay, modeling, turn-taking, and imitation. Specific
target behaviors differed for each toddler based on individ-
ual goals and parental input, but broadly related to social
communication skills. The HMTW program (Carter et al.
2011) emphasized the use of everyday routines to target
improvements in social communication. The intervention
aimed to teach parents to increase their responsivity to child
communicative attempts, provide rewards, follow the child’s
lead, and build joint action routines. HMTW target behav-
iors included improving two-way interactions and increasing
expressive and receptive communicative abilities. Drew
et al. (2002) used a social-pragmatic joint attention focused
parent-training program to promote joint action routines and
teach children with ASD joint attention behaviors. Lan-
guage-learning was promoted through the use of exagger-
ated prosody and repetitive phrasing and behavioral
management strategies were also taught to parents. Schertz
and Odom (2007) also employed a joint attention focused
intervention, but rather than explicitly teaching joint atten-
tion using a behavioral framework, the JAML program
structures parent–child interactions in a way that promotes
joint attention.
Experimental Design
Overall, effects of intervention were measured using pre-
and post-treatment behavioral assessments. Four studies
(Carter et al. 2011; Dawson et al. 2010; Drew et al. 2002;
Rogers et al. 2012) employed randomized controlled trials
with a TAU control group. Wetherby and Woods (2006)
used a quasi-experimental design in which post-intervention
outcomes were compared to a TAU control group, however
the control group was not available for comparison at pre-
intervention. A case series design in which a small sample of
treatment participants was compared to both an at-risk non-
intervention control group as well as a low-risk non-inter-
vention control group was reported in Green et al. (2013).
Koegel et al. (2013), Schertz and Odom (2007), and Steiner
et al. (2013) used a multiple baseline design in which change
was measured through repeated observations prior to, dur-
ing, and after the intervention.
Intervention Outcome
Feasibility and Acceptability
Parent-perceived acceptability and feasibility are especially
important components for interventions with infants and
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J Autism Dev Disord
toddlers when the parent is the primary interventionist.
Most studies reported very high satisfaction with the
intervention on satisfaction questionnaires (Carter et al.
2011; Green et al. 2013; Schertz and Odom 2007; Steiner
et al. 2013), while Rogers et al. (2012) reported stronger
working alliances between parents and therapists in the
P-ESDM group over the comparison TAU group.
Additionally, most studies evaluated training fidelity for
parent performance in adhering to intervention procedures
and correctly implementing techniques. Results of fidelity
of implementation measures showed that parents improved
in their ability to implement the specific intervention
strategies taught during intervention (Koegel et al. 2013;
Rogers et al. 2012; Schertz and Odom 2007; Steiner et al.
2013). Additionally, some studies monitored treatment
integrity by collecting fidelity of implementation measures
for clinicians (Carter et al. 2011; Dawson et al. 2010;
Rogers et al. 2012; Wetherby and Woods 2006). These
methods included completing self-assessment checklists
and behavioral coding of videotaped intervention sessions.
However, one study that compared fidelity of imple-
mentation of parents in the active treatment condition to
parents in the control group found that parents in the TAU
group were equally as skilled at implementing the inter-
vention procedures despite never being taught the inter-
vention (Rogers et al. 2012).
Developmental Outcome
Assessments of behavioral functioning and developmental
ability were conducted pre- and post-treatment for five of
the nine studies (Dawson et al. 2010; Drew et al. 2002;
Green et al. 2013; Rogers et al. 2012; Steiner et al. 2013).
These measures included the Griffiths Scale of Infant
Development, MacArthur Communicative Development
Inventories, Mullen Scales of Early Learning, and Vine-
land Adaptive Behavior Scales. Three studies observed
within-group gains in cognitive abilities (Dawson et al.
2010; Rogers, et al. 2012; Steiner et al. 2013). Addition-
ally, Dawson et al. (2010) reported gains in cognitive skills
and adaptive behavior greater than that of the TAU control
group, while Rogers et al. (2012) did not observe signifi-
cant between-group differences in developmental outcome
following the brief 12-week intervention.
Diagnostic outcome
The effect of intervention on autism symptomology was
assessed through two autism-specific evaluations for
infants and toddlers, the ADOS-T and the Autism Obser-
vation Scale for Infants (AOSI; Bryson et al. 2008).
Although intervention for infants and toddlers with or at-
risk for ASD older than 12 months appeared to lessen
J Autism Dev Disord
autism symptom severity, again it was reported that these
improvements were not significantly different than
improvements of toddlers in the TAU control group
(Dawson et al. 2010; Drew et al. 2002; Rogers et al. 2012).
Furthermore, measurement of autism symptomology ear-
lier in life using the AOSI and a visual disengagement task
between 8 and 10 months of age revealed no obvious
effects of intervention (Green et al. 2013).
Social-Communication Outcome
Intervention effectiveness for the youngest group of infants
was measured primarily through change in infant social
engagement during parent-infant interactions. Intervention
for infants in the first year of life demonstrated improve-
ments in infant positive affect, eye contact, and response to
name (Koegel et al. 2013), as well as preliminary findings
indicating increases in infant liveliness (Green et al. 2013).
Additionally, gains in emerging communication were
captured with increase in the use of eye contact, vocal-
izations, and/or gestures during parent-infant interactions
(Steiner et al. 2013),
Infant functional communication was among the pri-
mary outcome measures for infants older than 12 months.
Observed gains included improved performance on the
expressive and receptive language (Dawson et al. 2010;
Drew et al. 2002; Rogers et al. 2012; Wetherby and Woods
2006), and an increase in behaviors related to joint atten-
tion (Carter et al. 2011; Schertz and Odom 2007; Wetherby
and Woods 2006). However, gains in social-communica-
tion were only greater than the TAU group for children
enrolled in 2 years of ESDM (Dawson et al. 2010).
Moderators of Outcome
Two studies included moderator variables to uncover the
effects of specific child and intervention characteristics on
child outcomes. Rogers et al. (2012) identified several
variables leading to improved outcome for all toddlers,
regardless of treatment condition. In particular, nonsocial
orienting prior to intervention predicted developmental
ability and lower ADOS Social Affect scores, while social
orienting was found to predict decreases in the ADOS
Restricted and Repetitive Behavior at outcome. This study
also revealed significant relationships between both age at
the start of treatment and the number of intervention hours.
That is, toddlers who were younger and received more
hours of intervention demonstrated enhanced develop-
mental gains and greater decreases in autism symptomol-
ogy. Finally, Carter et al. (2011) identified decreased object
interest as a moderator for facilitated growth in commu-
nication for the HMTW group.
Discussion
Treatments for infants with or at-risk for ASD in the first
2 years of life are still emerging and at the time of this
review, only nine identified studies have investigated the
feasibility and effectiveness of very early intervention.
Three studies examined intervention for infants in the first
year, and six studies focused on infants in the second year
of life. There was a mix of experimental designs including
four randomized controlled trials (RCTs), three multiple
baseline designs, and two quasi-experimental designs. The
multiple baseline designs demonstrated improvement in
infant social engagement and communication behaviors
following intervention (Koegel et al. 2013; Schertz and
Odom 2007; Steiner et al. 2013), while the RCTs had
mixed findings regarding enhanced effectiveness over the
TAU comparison group (Carter et al. 2011; Dawson et al.
2010; Drew et al., 2002; Rogers et al., 2012). The quasi-
experimental designs documented feasibility and provided
preliminary support for treatment effects on infant behav-
ior, including increased infant liveliness (Green et al. 2013)
and improved social communication (Wetherby and
Woods 2006). Overall, the studies reviewed provide a
foundation for the further development and investigation of
interventions for infants and toddlers under 2 years of age
who are at-risk for, or diagnosed with, ASD. These studies
also highlight several issues in need of continued explo-
ration, including effectiveness of intervention for reducing
symptoms of ASD in infancy, impact of intervention on
parent stress and fidelity of implementation, and reliable
strategies for identifying at-risk infants.
Treatment Effectiveness
Empirical evidence for the effects of intervention on infant
and toddler social and communicative development pre-
sented in this review is encouraging, but demonstrates the
need for further research. Most studies demonstrated some
improvement in verbal and nonverbal communication,
social engagement, and autism symptomology from pre- to
post-intervention, providing preliminary evidence sup-
porting the effectiveness of very early intervention. How-
ever, two out of the four studies employing an RCT with a
TAU control group found that the target interventions
(P-ESDM and HMTW) did not result in gains significantly
greater than the TAU comparison group. Notably, the only
study to successfully demonstrate efficacy of a specific
intervention (Dawson et al. 2010) was the most intensive
intervention and the only one to utilize both clinician-
delivered treatment methods and parent training. This
stresses the need for more rigorous investigation of the key
ingredients in intervention for this very young population.
Interestingly, Rogers et al. (2012) note that the TAU group
123

in fact received a greater number of intervention hours than
the P-ESDM group, and that the number of hours positively
predicted improvement on child outcome measures. The
authors also highlight the likelihood that the TAU group
received a parent education program that resembled many
aspects of their own P-ESDM program, calling to question
the true difference in service delivery between the two
groups. As a final note, the authors question the suitability
of some measures (e.g. ADOS, Vineland) in evaluating
short-term changes following a 12-week intervention.
These questions regarding validity of the TAU and selec-
tion of appropriate outcome measures are critical consid-
erations for accurately evaluating the effectiveness of early
interventions.
It would be prudent for future research to weigh the
benefits of conducting an RCT using a TAU control group
design against the challenges when limited information is
available about the nature of these community treatments.
For example, it may be more advantageous to directly
compare established treatments that can be delivered in a
standardized way at a specified intensity in order to
evaluate the unique contributions of each treatment
approach. This experimental design may be more effective
in understanding the effects of treatment. Multiple baseline
design studies begin to allow for analysis of treatment
effectiveness while controlling for maturation, an espe-
cially critical threat to validity in research with young
infants and toddlers. However, this approach is compli-
cated by the heterogeneity of typical development and the
documented trends of some high-risk siblings who resolve
developmental delays quickly and without the need for
intervention (Landa et al. 2007). Inherent weaknesses of
multiple baseline designs also include questions of gen-
eralizability and specific treatment efficacy without a
comparison group. Recommendations for optimal inter-
vention research designs include multisite RCTs that
control for several variables including intensity and length
of treatment, active ingredients of treatment, and both
short and long-term effects on child outcome (Kasari
2002).
Exploration of moderator variables associated with
outcome data can provide critical information about factors
influencing the effectiveness of intervention. For example,
HMTW was documented to be more effective with chil-
dren with less interest in objects, whereas children who had
a high interest in objects were less amenable to the treat-
ment program (Carter et al. 2011). Identifying behavioral
profiles that match particular intervention methods for
children with ASD has long been a topic of interest (e.g.
Sherer and Schreibman 2005; Stahmer et al. 2011), and
infant intervention research could benefit from identifying
subgroups that might differentially benefit from specific
treatment strategies.
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J Autism Dev Disord
Additional moderators for treatment identified in the
studies reviewed include the infant’s age and the intensity
of intervention. Younger children and those who received
more hours of intervention seemed to benefit more from
early intervention (Rogers et al. 2012). Intriguingly, no
studies reported moderating effects of cognitive ability or
verbal communication, despite other studies reporting these
factors in early childhood are predictors of positive out-
come later in life (e.g., Billstedt et al. 2007). These and
other potential moderators should continue to be explored
in future research. Most intervention programs for children
with ASD focus on increasing social-communication and
decreasing problem behaviors, assuming that poor social-
communicative abilities may have cascading long-term
effects on a variety of areas including academic success,
mental health, and independent living. Indeed, higher
cognitive ability and early-onset verbal communication in
childhood are among the best-known prognostic indicators
for improved outcome (Billstedt et al. 2007). For infants
with prodromal symptoms of ASD, however, pivotal
behaviors that will maximally improve outcomes are not
well understood. Long-term prognostic factors for infants
at-risk for ASD should be investigated with an emphasis on
improved functioning for the individual as well as the
family system. Recent research on long-term ASD outcome
has begun to scrutinize the meaning of ‘‘positive outcome’’
for the individuals and their families (e.g., Henninger and
Taylor 2013). Similar rigor should be applied in defining
positive outcome for infants, which will then directly
influence the identification of target behaviors. The current
studies have begun to tackle this issue by capitalizing on
family therapist collaborative decision-making processes
(e.g., Wetherby and Woods 2006) and pivotal areas, such
as motivation (e.g., Koegel et al. 2013), in goal
development.
Feasibility
Establishing feasibility was a key objective in all reviewed
studies. Feasibility is an important component of inter-
vention models as it provides preliminary support for wide-
scale dissemination and yields information about accept-
ability for clinicians and parents (Smith et al. 2007). Some
of the reviewed studies used measures of parent satisfac-
tion, parent involvement, and fidelity of implementation to
address issues of feasibility. Despite emphasis on parental
responsibility to implement the intervention throughout
daily routines, families reported very high satisfaction,
high involvement in treatment sessions, and enjoyment of
the intervention. In fact, Estes et al. (2013) reported in a
later study that P-ESDM parents (Rogers et al. 2012)
experienced significantly less stress than the TAU control
group, after controlling for autism social severity and
J Autism Dev Disord
baseline levels of stress. This finding is consistent with this
group also reporting stronger working alliances with ther-
apists. Furthermore, Schertz and Odom (2007) used qual-
itative methods to examine parent perspectives on the
intervention, revealing a relation between increased autism
severity, slower progress in treatment, and lower parent
fidelity of implementation.
Research suggests that generalization of learned
behaviors and maintenance of gains for children with ASD
largely depends on the persistent and consistent imple-
mentation of naturalistic behavioral procedures, making
fidelity of implementation an important measure of feasi-
bility, and possibly child outcome (Kashinath et al. 2006;
National Research Council 2001; Rocha et al. 2007). The
studies reviewed here demonstrated the effectiveness of
teaching parents to implement intervention techniques,
possibly suggesting that this type of dissemination model
may be appropriate and implementable by some parents of
at-risk infants. Interestingly, Rogers et al. (2012) reported
that the TAU control group met fidelity of implementation
to the same degree as the P-ESDM group. The authors
speculate that this was due to the community TAU parents
learning similar skills to the P-ESDM parents, and the
community TAU infants receiving significantly more hours
of intervention. Furthermore, fidelity of implementation
(FOI) scores were quite high prior to onset of intervention,
suggesting a sample bias that could contribute to the lack of
FOI difference between the groups. Participants were
highly educated, 80 % of parents had received at least
some college education, and half of the participants had an
older sibling with ASD or another developmental disabil-
ity. It is then possible that parents had a priori knowledge
of common intervention procedures and were already
integrating some techniques into routine interactions with
their at-risk infant. The challenge of gathering representa-
tive participant samples is not unique to this study and is
acknowledged as a limitation by the authors. There remains
an urgent need to recruit representative samples and iden-
tify the effects of such demographic variables on FOI and
child outcome. Future research investigating parent FOI
and child outcome will help to guide clinical practice.
It is also interesting to note that although our search
criteria included all delivery modes for intervention, all of
the studies that met our inclusion criteria were at least
partially parent-mediated. Eight of the nine intervention
studies used a parent-mediation model that was very low-
intensity, averaging 1–2 h per week. While this is in line
with several intervention studies for toddlers with ASD that
have demonstrated effectiveness of low-intensity inter-
ventions (e.g., Vismara et al. 2009), it is significantly less
than the Early Intensive Behavior Intervention (EIBI)
model in which 40 h per week of clinician-delivered
intervention is recommended (Lovaas 1987). Additionally,
research suggests that intensity of early interventions is
positively associated with improved child outcome (Reed
et al. 2007), a finding that was replicated by Rogers et al.
(2012). Despite the limited number of studies in this
review, the research presented here could suggest that a
more intensive intervention evaluated over a longer period
of time (Dawson et al. 2010) may result in greater gains
than 1 h per week of parent-mediated intervention. Future
research should consider the possibility that more hours of
intervention are needed in order to improve symptoms of
ASD in infancy.
Early Identification and Prevention
One of the greatest difficulties associated with designing
research studies to investigate the effectiveness of very
early intervention for infants at-risk for ASD is the issue of
accurate identification. The reviewed studies used three
primary methods to address this challenge. A firm clinical
diagnosis or provisional clinical diagnosis of ASD was
required for only three studies while four of the remaining
studies required participants to exhibit behavior that war-
ranted clinical concern for ASD based on quantifiable
behavioral assessment and/or an autism screener. The use
of both clinical judgment and behavioral assessment could
reflect the concern that currently available diagnostic tools
may lack the sensitivity and specificity to serve as the sole
determinant of risk for ASD in infancy. Alternatively, two
studies assumed a model of prevention and provided
intervention to all infants at increased genetic risk for ASD
(i.e., younger siblings of children with ASD). However, a
large proportion of these children would be expected to
have typical developmental trajectories even without any
intervention, making evaluation of intervention effects
challenging (Ozonoff et al. 2011).
These approaches to ascertaining risk for ASD in
infancy give rise to the question of whether or not a
diagnosis of ASD is necessary to provide intervention.
Public health models are increasingly adopting models of
preventative care, in which medical professionals note
prodromal features and, in an effort to avoid the manifes-
tation of full-scale symptomology, provide the indicated
treatment prior to diagnosis (American Academy of Pedi-
atrics 2006). The preliminary, but generally positive,
treatment results of the reviewed studies support the further
development of prevention models and warrant additional
experimentally controlled research designs to establish the
effectiveness of behavioral intervention for infants in the
first 2 years of life. The data presented here may suggest
that intervention beginning as early as 6 months of age
could lead to observable improvements in core areas of
ASD, at least in the short-term, and if continued research
supports these findings, the argument for identifying and
123

referring at-risk infants in the first 2 years of life, before
ASD is typically diagnosed, is even stronger.
Limitations
This review paper has several limitations. Due to the lim-
ited number of studies on this topic to date, conclusions
presented here are based upon a relatively small sample
size, especially regarding interventions for infants in the
first year of life. It was also necessary to analyze treatments
for infants with confirmed diagnosis of ASD along with
treatments for infants at-risk for ASD, which makes con-
clusions from this heterogeneous group more challenging
to interpret. It is possible that other relevant findings were
excluded based on criteria related to experimental design or
publication in English-language peer reviewed journals.
Though an effort was made to include studies where the
majority of children were under 24 months (mean age did
not exceed 24 months), the review did not include studies
where only a few participants fell in this age range. Finally,
the diverse methodological approaches and varied out-
comes measured across studies necessitate additional rep-
lication of results to confirm the initial findings for each of
these novel treatment applications. While it is premature to
make conclusions about differential effects of the treat-
ments reviewed, this review serves as a guide summarizing
research efforts to date.
Future Directions
Prevention and intervention efforts for infants at-risk for
ASD in the first 2 years of life are part of a burgeoning trend
in the field, with several studies documenting preliminary
positive findings. The evidence suggests that parent-medi-
ated treatment programs may improve short-term outcomes
for at-risk infants and toddlers, including social engagement
and communication, yet additional research is needed in this
area (National Autism Center 2009). The heterogeneity of
both typically developing infants and those with ASD calls
for both acute scientific rigor and careful evaluation and
description of presenting symptoms. Experimental design
issues, including the use of a TAU control group, potential
sample biases, and threats to internal and external validity,
must be thoughtfully considered in future research for this
population. Research exploring novel methodologies for
identifying infants and toddlers who are ‘‘at-risk’’ and for
determining appropriate targets for intervention is needed.
Family context and cultural variables should also be of
primary importance in designing individual treatment plans
and delivering parent education. Furthermore, intervention
studies should carefully consider moderator variables that
may influence differential treatment effectiveness for such a
heterogeneous population. Observed child gains and high
123
J Autism Dev Disord
levels of parent satisfaction following intervention are
encouraging and long-term outcome studies will enrich our
understanding of the effects of receiving intervention during
the first 2 years of life.
Acknowledgments This study was not directly funded, however
conceptualization for this article was aided by a predoctoral fellow-
ship awarded to the first author by the Autism Science Foundation
(11-1014). We would like to express our appreciation to all families
who continue to dedicate their time to autism research.
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