Department of Dermatology, Traditional Chinese and Western Medicine Hospital of Wuhan, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, Hubei, China.
Department of Dermatology, Wuhan No.1 Hospital, Wuhan, Hubei, China.
BMJ. 2024 Jan 12;384:e076773. doi: 10.1136/bmj-2023-076773.
To summarize the breadth and quality of evidence supporting commonly recommended early childhood autism interventions and their estimated effects on developmental outcomes.
Updated systematic review and meta-analysis (autism intervention meta-analysis; Project AIM).
A search was conducted in November 2021 (updating a search done in November 2017) of the following databases and registers: Academic Search Complete, CINAHL Plus with full text, Education Source, Educational Administration Abstracts, ERIC, Medline, ProQuest Dissertations and Theses, PsycINFO, Psychology and Behavioral Sciences Collection, and SocINDEX with full text, , and ClinicalTrials.gov.
Any controlled group study testing the effects of any non-pharmacological intervention on any outcome in young autistic children younger than 8 years.
Newly identified studies were integrated into the previous dataset and were coded for participant, intervention, and outcome characteristics. Interventions were categorized by type of approach (such as behavioral, developmental, naturalistic developmental behavioral intervention, and technology based), and outcomes were categorized by domain (such as social communication, adaptive behavior, play, and language). Risks of bias were evaluated following guidance from Cochrane. Effects were estimated for all intervention and outcome types with sufficient contributing data, stratified by risk of bias, using robust variance estimation to account for intercorrelation of effects within studies and subgroups.
The search yielded 289 reports of 252 studies, representing 13 304 participants and effects for 3291 outcomes. When contributing effects were restricted to those from randomized controlled trials, significant summary effects were estimated for behavioral interventions on social emotional or challenging behavior outcomes (Hedges’ g=0.58, 95% confidence interval 0.11 to 1.06; P=0.02), developmental interventions on social communication (0.28, 0.12 to 0.44; P=0.003); naturalistic developmental behavioral interventions on adaptive behavior (0.23, 0.02 to 0.43; P=0.03), language (0.16, 0.01 to 0.31; P=0.04), play (0.19, 0.02 to 0.36; P=0.03), social communication (0.35, 0.23 to 0.47; P<0.001), and measures of diagnostic characteristics of autism (0.38, 0.17 to 0.59; P=0.002); and technology based interventions on social communication (0.33, 0.02 to 0.64; P=0.04) and social emotional or challenging behavior outcomes (0.57, 0.04 to 1.09; P=0.04). When effects were further restricted to exclude caregiver or teacher report outcomes, significant effects were estimated only for developmental interventions on social communication (0.31, 0.13 to 0.49; P=0.003) and naturalistic developmental behavioral interventions on social communication (0.36, 0.23 to 0.49; P<0.001) and measures of diagnostic characteristics of autism (0.44, 0.20 to 0.68; P=0.002). When effects were then restricted to exclude those at high risk of detection bias, only one significant summary effect was estimated—naturalistic developmental behavioral interventions on measures of diagnostic characteristics of autism (0.30, 0.03 to 0.57; P=0.03). Adverse events were poorly monitored, but possibly common.
The available evidence on interventions to support young autistic children has approximately doubled in four years. Some evidence from randomized controlled trials shows that behavioral interventions improve caregiver perception of challenging behavior and child social emotional functioning, and that technology based interventions support proximal improvements in specific social communication and social emotional skills. Evidence also shows that developmental interventions improve social communication in interactions with caregivers, and naturalistic developmental behavioral interventions improve core challenges associated with autism, particularly difficulties with social communication. However, potential benefits of these interventions cannot be weighed against the potential for adverse effects owing to inadequate monitoring and reporting.
总结支持常见推荐的幼儿自闭症干预措施的证据广度和质量，以及它们对发育结果的估计影响。
更新的系统评价和荟萃分析（自闭症干预荟萃分析；项目 AIM）。
2021 年 11 月（更新了 2017 年 11 月的搜索）对以下数据库和注册处进行了搜索：学术搜索完整、包含全文的 CINAHL Plus、教育来源、教育管理摘要、ERIC、Medline、ProQuest 论文和学位、PsycINFO、心理学和行为科学收藏，以及全文的 SocINDEX 、和 ClinicalTrials.gov。
任何非药物干预对 8 岁以下年轻自闭症儿童任何结果的影响的对照组研究。
新发现的研究被纳入先前的数据集，并对参与者、干预和结果特征进行编码。干预措施按方法类型进行分类（如行为、发育、自然发育行为干预和基于技术的干预），结果按领域进行分类（如社会交流、适应行为、游戏和语言）。根据 Cochrane 的指导，评估了偏倚风险。使用稳健方差估计，对具有足够贡献数据的所有干预和结果类型进行估计，按偏倚风险分层，以考虑研究内和亚组内效应的相关性。
搜索产生了 252 项研究的 289 份报告，代表了 13304 名参与者和 3291 项结果。当将有贡献的效应限制在随机对照试验中时，在社会情感或挑战性行为结果方面，行为干预的显著综合效应被估计为（Hedges' g=0.58，95%置信区间 0.11 至 1.06；P=0.02），发育干预在社会交流方面（0.28，0.12 至 0.44；P=0.003）；自然发育行为干预在适应行为方面（0.23，0.02 至 0.43；P=0.03）、语言方面（0.16，0.01 至 0.31；P=0.04）、游戏方面（0.19，0.02 至 0.36；P=0.03）、社会交流方面（0.35，0.23 至 0.47；P<0.001）和自闭症诊断特征的测量方面（0.38，0.17 至 0.59；P=0.002）；以及基于技术的干预在社会交流方面（0.33，0.02 至 0.64；P=0.04）和社会情感或挑战性行为结果方面（0.57，0.04 至 1.09；P=0.04）。当进一步将效应限制排除护理人员或教师报告的结果时，仅在发育干预对社会交流方面（0.31，0.13 至 0.49；P=0.003）和自然发育行为干预对社会交流方面（0.36，0.23 至 0.49；P<0.001）和自闭症诊断特征的测量方面（0.44，0.20 至 0.68；P=0.002）估计了显著的综合效应。当进一步将效应限制排除高检测偏倚风险的结果时，仅估计了一个显著的综合效应——自然发育行为干预对自闭症诊断特征的测量方面（0.30，0.03 至 0.57；P=0.03）。不良事件监测较差，但可能很常见。
支持幼儿自闭症的干预措施的现有证据在四年内翻了一番。一些来自随机对照试验的证据表明，行为干预措施改善了护理人员对挑战性行为和儿童社会情感功能的感知，而基于技术的干预措施支持特定社会交流和社会情感技能的直接改善。证据还表明，发育干预措施改善了与护理人员的互动中的社会交流，自然发育行为干预措施改善了与自闭症相关的核心挑战，特别是社会交流方面的困难。然而，由于监测和报告不足，不能权衡这些干预措施的潜在益处与潜在的不利影响。
