Early Intervention Found Cost Effective Through School Years
The Early Start Denver Model (ESDM), a comprehensive behavioral early intervention program that is appropriate for children with autism spectrum disorder (ASD) as young as 12 months, has been found to reduce the need for ASD therapies and special education services through the school years following their early intervention. These findings were presented by David S. Mandell, Sc.D., Associate Professor, Director, Center for Mental Health Policy & Services Research, University of Pennsylvania Perelman School of Medicine, today at the Autism Speaks Toddler Treatment Network meeting held in San Sebastian, Spain concurrent with the start of the International Meeting for Autism Research.
The investigation evaluated cost of the early intervention, both ESDM and typically available “community” early intervention services, both in combination with traditional autism-specific related services including other forms of ABA, speech therapy, occupational therapy and physical therapy.
After the clinical trial comparing ESDM to community interventions was completed, all children were referred back to the community and parents were free to seek services for their child. During this post-intervention period, children in the ESDM group were found to receive fewer hours of service per month than the children who received early intervention services typically-available in the community (168 vs. 257). This difference is spread across many different services, but is concentrated in the use of special education services and individual therapies, including speech and language therapy, physical therapy and occupational therapy. On the other hand, the ESDM group received many more hours in typical education settings than the group of children who previously received typically available early intervention services.
ESDM is the first early intervention for toddlers with ASD to undergo controlled clinical study of intensive early intervention and has demonstrated both improvement of social skills and brain responses to social stimuli. These optimal outcomes include increased IQ, increased adaptive and social behaviors as well as promoting the normal development of the brain and behavior that optimizes a child’s potential to participate meaningfully in the community into their adult years.
“It is very promising to see that children who received two years of ESDM intervention required fewer hours of therapy and special education services through the remainder of their preschool years,” said Geraldine Dawson, Ph.D., Autism Speaks chief science officer. “Not only do the young children who receive ESDM benefit in the short term with respect to improved IQ and social skills, and brain functioning, we see that through their remaining preschool years these children require fewer special education supports.”
CDC estimates 1 in 88 children (11.3 per 1,000) has been identified with an autism spectrum disorder (ASD).
This marks a 23% increase since our last report in 2009. And, a 78% increase since our first report in 2007. Some of the increase is due to the way children are identified, diagnosed and served in their local communities, although exactly how much is due to these factors in unknown.
The number of children identified with ASDs varied widely across the 14 ADDM Network sites, from 1 in 47 (21.2 per 1,000) to 1 in 210 (4.8 per 1,000).
ASDs are almost 5 times more common among boys (1 in 54) than among girls (1 in 252).
The largest increases over time were among Hispanic children (110%) and black children (91%). We suspect that some of this increase is due to greater awareness and better identification among these groups. However, this finding explains only part of the increase over time, as more children are being identified in all groups.
There were increases over time among children without intellectual disability (those having IQ scores above 70), although there were also increases in the estimated prevalence of ASDs at all levels of intellectual ability.
More children are being diagnosed at earlier ages - a growing number of them by age 3. Still, most children are not diagnosed until after they reach age 4, even though early identification and intervention can help a child access services and learn new skills. This is why CDC’s Learn the Signs. Act Early. program is essential. Through this program, CDC provides free tools to help parents track their child’s development and free resources for doctors and educators. CDC is also working with states and communities to improve early identification.
CDC also provided leadership in establishing Healthy People 2020 objectives and supporting the American Academy of Pediatrics recommendation that all children be screened by age 2, because early screening and diagnosis improve access to services during a child’s most critical developmental period.
This findings compare 21 children who underwent ESDM to 18 children who received community early intervention during the two years they received these early intervention services and then for four years as they were followed by Principal Investigator Annette Mercer Estes, Ph.D., Research Associate Professor of Speech and Hearing Sciences and Research Affiliate, in the Center on Human Development and Disability at University of Washington. Dr. Estes compiled all of the services the children continued to receive post intervention. Dr. Mandell then converted them to 9 categories of therapy and calculated the cost of each category by multiplying the number of hours of each type of service received by the common cost units based on public reimbursement models in U.S. and U.K.
While ESDM frontloads costs and is more expensive to deliver in those first two years of early intervention, the end of elementary schools by the time children entered high school, ESDM showed a positive return on investment ,by the time children will enter high school” explained Dr. Mandell. “Based on the data we had available, the cost effectiveness of ESDM over a relatively short period of time is clear, even when only examining this narrow group of services. Given what we know about service use as children with autism age, it is quite likely that the long-term cost savings will be even greater,” he continued.
WHAT ARE AUTISM SPECTRUM DISORDERS?
Autism spectrum disorders (ASDs) are a group of developmental disabilities that often are diagnosed during early
childhood and can cause significant social, communication, and behavioral challenges over a lifetime. People with ASDs
have a different way of understanding and reacting to people and events in their world. These differences are caused by
the way their brain processes information.
This group of developmental disabilities is considered a “spectrum” of disorders. This means ASDs affect each person
in different ways, and symptoms can range from mild to severe. People with ASDs share some similar symptoms, such
as problems with social interaction, problems with communication, and highly focused interests or repetitive activities.
But, there are differences in when the symptoms begin or are first noticed and in ho w the symptoms affect a person’s
functioning.
There are three main subtypes of autism spectrum disorders
• Autistic disorder
• Asperger disorder
• Pervasive developmental disorder-not otherwise specified (PDD-NOS)
Diagnosis
At this time, there is no medical test, such as a blood test or brain scan, to diagnose ASDs. Instead, they are diagnosed
by qualified professionals who conduct comprehensive psychological and behavioral evaluations. These evaluations can
include clinical observation, parental reports of developmental and health histories, psychological testing, speech and
language assessments, and possibly the use of one or more questionnaires developed specifically for people with ASDs.
Also, neurologic and genetic testing can be used to rule out other disorders.
WHY DO WE NEED TO KNOW HOW MANY CHILDREN HAVE ASDS?
We need to know how many children have ASDs, so that realistic plans can be made to support these children and their
families. Some of the resources that are needed include therapies, trained teachers, diagnosticians, health care providers,
and related service professionals. Understanding the characteristics and number of children who have ASDs is key to
promoting awareness of the condition, helping educators and providers to plan and coordinate service delivery, and
identifying important clues for further research.
During the two years of delivery, ESDM, including all related services, had an average monthly cost of approximately $10,000/child. The average monthly cost of ESDM alone is $5,560/child. Children in the control group, who were receiving standard community-based early intervention, had an average monthly cost of about $5,200/child.
In the four years post early intervention, during which these children were tracked, the ESDM cohort required on average approximately $4,450 in related services – speech therapy, physical therapy, occupational therapy and ABA. The community intervention children, on average, required approximately $5,550 in related services.
Dr. Mandell believes this is provocative research. “We used a very narrow definition of cost for this study, including only autism-specific services, such as physical, occupational and speech therapies as well as ABA,” he explained, “I believe the cost efficiencies would become even more pronounced if there had been an evaluation on health costs and overall family economics such as the ability of both parents to continue to work and earn income while their child received services.”
ESDM, which combines applied behavioral analysis (ABA) teaching methods with developmental ‘relationship-based’ approaches, was previously demonstrated to achieve significant gains in cognitive, language and daily living skills compared to children with ASD who received commonly available community interventions. On average, the preschoolers receiving ESDM for two years improved 17.5 points in IQ compared with 7.0 points in the community intervention comparison group.
“This work creates an important framework, such that validated treatments and interventions should be assessed over the long term,” concluded Dr. Mandell. “These metrics, the number of functional services and hours of services of support an individual continues to receive, are important measures to demonstrate efficacy.”
About Autism
Autism is a general term used to describe a group of complex developmental brain disorders – autism spectrum disorders – caused by a combination of genes and environmental influences. These disorders are characterized, in varying degrees, by communication difficulties, social and behavioral challenges, as well as repetitive behaviors. An estimated one in 88 children in the U.S. is on the autism spectrum – a 78 percent increase in six years that is only partly explained by improved diagnosis.
About Autism Speaks
Autism Speaks is the world’s leading autism science and advocacy organization. It is dedicated to funding research into the causes, prevention, treatments and a cure for autism; increasing awareness of autism spectrum disorders; and advocating for the needs of individuals with autism and their families. Autism Speaks was founded in February 2005 by Suzanne and Bob Wright, the grandparents of a child with autism. Mr. Wright is the former vice chairman of General Electric and chief executive officer of NBC and NBC Universal. Since its inception, Autism Speaks has committed more than $195 million to research and developing innovative resources for families. Each year Walk Now for Autism Speaks events are held in more than 100 cities across North America. On the global front, Autism Speaks has established partnerships and related activities in more than 40 countries on five continents to foster international research, services and awareness.
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Autism Speaks