Early intensive behavioral intervention (EIBI), which involves 20 or more hours per week of individualized instruction based on applied behavior analysis (ABA), is often considered the standard of care for toddlers and preschoolers with autism spectrum disorder (ASD). However, EIBI is expensive and takes up a lot of time and effort from children, families, and professionals.

Researchers have recently found that less intensive ABA interventions can effectively target specific core and associated features of ASD. We believe that an individualized approach to adapting and combining targeted interventions could be at least as effective as EIBI, yet substantially reduce expenditures of time and resources. We call this approach “adaptive” ABA.

All children who participate in the proposed study will receive either the current standard of care (EIBI as it is usually delivered in the community) or the intervention that we hypothesize is at least as effective (adaptive ABA). Both interventions will be 6 months in duration. The study addresses four key questions about ABA interventions. First, do children improve more in 20 or more hours per week of EIBI or in an adaptive ABA intervention that begins with 5 hours per week of instruction on core features of ASD and adds other components as needed? Second, what is the impact of EIBI and adaptive ABA on families? Third, what factors predict whether children and families will benefit more from EIBI or from adaptive ABA? Fourth, what factors would help or hinder agencies from continuing to implement EIBI or adaptive ABA in the future?

To examine these questions, we will enroll 130 children with ASD, ages 1 year and 6 months to 4 years and 11 months. All children will be eligible for ABA services through TRICARE insurance. We will randomly assign 65 children to EIBI as usual and 65 children to adaptive ABA. There will be five sites: the May Institute (Randolph, MA, with satellite clinics in GA, NC, and VA); Vanderbilt University (Nashville, TN); Nationwide Hospital (Columbus, OH); the University of Florida, partnered with the Florida Autism Center (Gainesville, Orlando, and Jacksonville, FL); and Trumpet Behavioral Health (Lakewood, CO). Outcomes of children and families will be assessed at the end of the 6-month intervention, at a follow-up 6 months later, and at age 5 years.

This work offers potential benefits for young children with ASD and their families who participate. All children will receive ABA interventions that have been found to be effective in prior research. All children and families will receive a very thorough evaluation free of charge; this evaluation should be useful to them. All children and families will be followed up after the study intervention ends in order to see whether improvements last. Because all participating children and families will be insured through TRICARE, the results will be particularly relevant to TRICARE beneficiaries. This is important because TRICARE families often differ from families that have participated in prior research on ABA interventions. On average, TRICARE parents are about 10 years younger, are less likely to have completed a 4-year college degree, relocate much more often, live further away from extended family, and experience more stressors, such as long separations related to military duty. Thus, it is vital to find out whether children with ASD and their families in TRICARE improve with ABA interventions.

Beyond the potential benefits to participating children and families, as well as to TRICARE beneficiaries, this work will benefit the larger community of young children with ASD and their families in several ways. First, knowing how EIBI compares to adaptive ABA gives families a basis for choosing an intervention approach with confidence. Second, knowing that ABA interventions work well in children who are covered by TRICARE justifies insurance funding for these interventions. Third, if we could know in advance whether EIBI or adaptive ABA is likely to be more effective, families could more easily select an ABA intervention for their child. Fourth, if the adaptive intervention is found to be as effective as EIBI for many children with ASD, it may be possible to lower costs and increase access to effective services. Fifth, knowing what helps or hinders agencies from implementing EIBI and adaptive ABA could guide future efforts to make these interventions more available to children with ASD and their families.