COMMENTARY

Implementing and Evaluating Early Intervention for Children with

Autism: Where Are the Gaps and What Should We Do?
Giacomo Vivanti , Connie Kasari, Jonathan Green, David Mandell, Melissa Maye, and Kristelle Hudry

Despite recent advances, the evidence base supporting early intervention for young children with autism spectrum disor-
der (ASD) remains relatively sparse. The International Society for Autism Research (INSAR) recently sponsored a Special
Interest Group (SIG) on Implementing and Evaluating Community-Based Early Intervention. Across three meetings, in 2015,
2016, and 2017, conveners of this SIG engaged >200 members to identify knowledge gaps and research priorities for
moving the field forward. Here, we summarize the perspectives that emerged from group discussion at the SIG meetings
as represented by scholars working actively in the field. Despite encouraging progress, critical gaps and research priorities
were identified across all the stages of intervention development and testing from conceptualization to community
implementation. Key issues include the need for (a) formal theories to guide early intervention development, evaluation,
and implementation; and alignment of intervention goals with scientific knowledge and societal changes that have
occurred in the decades since interventions were originally developed; (b) increased focus on feasibility of treatment pro-
cedures and alignment with stakeholder values during pilot evaluations; (c) use of research designs that allow for compar-
isons of different interventions and formats, analyses of active ingredients of treatment, and identification of moderators
and mediators of outcome; (d) use of community-partnered participatory research to guide adaptation of intervention
models to community settings; (e) inclusion of constructs related to implementation processes and outcomes in
treatment trials and; (f) an iterative approach to the progression of knowledge from intervention development to imple-
mentation. Autism Res 2018, 11: 16–23. V C 2017 International Society for Autism Research, Wiley Periodicals, Inc.

Lay Summary: In this article, we summarize the themes discussed at the INSAR Special Interest Group (SIG) on
Implementing and Evaluating Community-Based Early Intervention. Priorities for moving the field forward identified in
the SIG included the need for (a) formal theories to guide the development and evaluation of interventions, (b) pilot
evaluations that investigate feasibility and acceptability of interventions, (c) methodologies that allow us to deter-
mine for whom different interventions bring most benefit and why this is so, (d) strategies to include community
members and other stakeholders in the process of developing and evaluating interventions, and (e) understanding of
factors that make interventions more likely to be adopted and successfully implemented in the real world.

Keywords: early intervention; autism; feasibility; efficacy; effectiveness; implementation; randomized controlled trials

While the past decade has witnessed steady growth in In the subsequent SIG meetings in 2016 and 2017,
autism spectrum disorder (ASD) early intervention scholars in the field were invited to identify research
research, further research efforts are needed to ensure priorities to address such gaps through open debate and
practitioners and policy-makers have robust data on collaborative problem solving. The present report is
intervention effectiveness and implementation to based on the transcripts of discussions at each SIG,
secure optimal outcomes for children with ASD. To this summarized by the SIG co-chairs and scholars in the
end, the International Society for Autism Research field who presented at the 2016 SIG.
sponsored a Special Interest Group (SIG) on Implement- A scarcity of randomized controlled trials (RCTs) has
ing and Evaluating Community-Based Early Intervention, historically been identified as the key barrier to progress
aimed at stimulating discussion among groups working in ASD early intervention [e.g., National Research
on this topic around the world. The first SIG meeting, Council, 2001; Smith et al., 2007]. However, discussion
held in 2015, initiated discussion and identified knowl- among SIG members highlighted that knowledge gaps
edge gaps in early intervention research and practice. exist at every stage along the pathway from theoretical

From the A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA (G.V.); Center for Autism Research and Treatment, UCLA, Los Angeles,
CA (C.K.); University of Manchester, Manchester, UK (J.G.); Center for Mental Health Policy and Services Research, University of Pennsylvania,
Philadelphia, PA (D.M.); University of Massachusetts, Boston, MA (M.M.); Victorian Autism Specific Early Learning and Care Centre, and Olga
Tennison Autism Research Centre, La Trobe University, Melbourne, Australia (K.H.)
Received June 06, 2017; accepted for publication November 14, 2017
Address for correspondence and reprints: Giacomo Vivanti, A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA.
E-mail: giacomo.vivanti@drexel.edu
Published online 05 December 2017 in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/aur.1900
C 2017 International Society for Autism Research, Wiley Periodicals, Inc.
V

16 Autism Research 11: 16–23, 2018 INSAR

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Box 1. Stages and processes in developing, evaluating and implementing interventions
Traditionally, the path from intervention development to implementation is articulated in a series of hierarchical steps. The first involves
the development of a treatment theory which underscores and clearly articulates the rationale for a given approach. Thereafter, evaluat-
ing an intervention typically begins with proof-of-concept work to ascertain preliminary evidence in support of the approach, including
evidence of feasible delivery and safety/acceptability to key stakeholders. With initial support for a model, evaluation typically proceeds to
pilot testing with larger numbers of participants, and then to full-scale test of efficacy with a sufficiently-sized sample to yield a
well-powered evaluation of whether or not the intervention can achieve its aims with the target population. Efficacious interventions are
then subject to tests of effectiveness, evaluating the extent to which putative benefits are maintained when delivery is within normative
contexts (rather than artificial settings, such as highly resourced University labs). Finally, implementation science addresses how to
ensure the successful adoption and implementation of a target program within relevant community settings.
Early intervention science may benefit from a more iterative approach, with various stages addressed in parallel and multidirectional
knowledge exchange between different levels [Stahmer, Aranbarri, Drahota, & Rieth, 2017]. For example, both careful theorizing and con-
sideration of resources and stakeholders’ beliefs should inform the development and evaluation of interventions, and moving directly from
treatment theory to community-based effectiveness trials might accelerate the pace of treatment development and testing.

conceptualization to community implementation of and parsimony to the field. To this aim, proponents of
early intervention. A framework for this pathway is new models should articulate the rationale dictating
detailed in Box 1. Here, we follow this framework to treatment procedures and clarify the theoretical distinc-
summarize the discussion points raised at the SIG, tiveness of the new approach relative to existing ones,
highlighting gaps and priorities for furthering the thus providing a road-map for hypothesis-driven evalu-
knowledge base around effective intervention for chil- ation. A test of these hypotheses should then be
dren with ASD. Importantly, none of the research prior- reflected in a pre-specified analytic plan which is final-
ities discussed at the SIG was free from debate, and the ized before unblinding and analysis. Importantly, inter-
framework presented here might not be unanimously ventions might work for reasons that differ from those
endorsed in the ASD research community. In the inter- theorized by their developers, raising the question of
est of parsimony, the current report focuses on the ‘why bother’ with intervention theories if the treatment
areas where consensus was reached among the article’s is beneficial anyway. However, as even the most prom-
authors. ising interventions produce different levels of success
across individuals [Schreibman, 2000] and contexts
Key Gaps and Research Priorities in [Mandell et al., 2013], theory-driven efforts to under-
Implementation and Evaluation of ASD Early stand how interventions work are critical to our capac-
Intervention ity to adapt, optimize, and customize interventions
Gaps in Intervention Theory without diluting their active ingredients [Onken et al.,
2014].
Formal theories elucidating the hypothesized factors Additionally, many intervention models in current use
leading to the problem being targeted and the hypothe- were originally conceptualized decades ago. Therefore, a
sized processes of treatment change are critical to guide key priority for the field is to evaluate whether contempo-
intervention development and evaluation [Kazdin, rary knowledge about ASD can be accommodated within
1999; Rapport, 2001]. However, in the field of ASD early existing early intervention theories, or requires that treat-
intervention research, theory lags behind practice ment concepts and protocols be updated or reformulated.
[Vivanti, 2017]. Therefore, a key priority in the field is Early intervention approaches for ASD are designed to
the formulation and/or refinement of formal theories to facilitate the acquisition of novel skills—thus, interven-
guide hypothesis-driven examinations of all aspects of tions should evolve as our knowledge advances on how
how interventions work: the utility and usability of par- children with ASD learn. There are encouraging efforts in
ticular models; the mechanisms underlying their effec- this direction. For example, neuroscience research on the
tiveness; and how these interact with particular social reward system and abnormal cortical connectivity
characteristics of the child, implementation context, in ASD is beginning to inform teaching practices and
and other interventions the child is receiving concur- hypothesized mechanisms of action in some early inter-
rently. Additionally, as new early interventions for ASD vention models [Dawson, 2008; Odom, 2016; Sullivan,
are introduced with growing frequency, and limited Stone, & Dawson, 2014]. However, historical difficulties
information is offered about their differences and over- with cross-disciplinary dialogue and insufficient transla-
lap with existing approaches, a precise delineation of tional efforts to bridge basic science, theory and applied
the unique and shared theoretical underpinnings knowledge in the field are significant barriers to the
informing intervention models is critical to bring clarity agenda of aligning treatment theories to current

INSAR Vivanti et al./Gaps and priorities for intervention research 17

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knowledge [Critchfield, Doepke, & Campbell, 2015; the potential benefits of a specific manualized interven-
Kohls, Chevallier, Troiani, & Schultz, 2012; Smith, 2012]. tion and to explore additional factors, such as for
Similar considerations apply with respect to the socie- whom the intervention is beneficial, and how/why this
tal changes that have occurred in the decades since is the case. The need for more RCT-based evidence as a
intervention programs were originally developed, key research priority in ASD has been discussed in the
including the growing emphasis on social models of field for decades [Kasari, 2002; Rogers, 1996] and in
disability focused on removing barriers to self- recent years, significant gains have been made in
determination, and inclusion [United Nations, 2006]. scaling-up intervention studies from pilot- to full-scale
Formalized treatment theories would create the oppor- trials. For example, while Diggle and McConachie
tunity to explicitly clarify the relevance of intervention [2002] found only two very small RCTs (n < 40) in a sys-
rationales and treatment targets (e.g., changes in cogni- tematic review of parent-mediated early interventions
tive functioning) to the core concepts of empowerment for ASD conducted 15 years ago, Oono, Honey, and
and social participation that underlie contemporary McConachie [2013] more recently identified 17 such
societal views on disability and priorities of advocacy studies, at least 5 of which were fully powered to detect
movements. their anticipated effects. Despite such an encouraging
Gaps in Proof-of-Concept and Pilot Evaluation Studies trend, RCT evidence in the field of ASD treatment con-
tinues to be meager compared to that for other mental
Once the theoretical rationale for an intervention is health diagnoses [McGrew, Ruble, & Smith, 2016], pos-
established, proof-of-concept work using small scale sibly reflecting practical barriers (e.g., logistical chal-
studies (e.g., single-subject designs, case series, and pilot lenges with carrying out RCTs on resource intensive
controlled trials) should be conducted to ascertain pre- interventions), and cultural ones [e.g., historical skepti-
liminary evidence in support of the feasibility and cism on the appropriateness of RCTs in the context of
potential utility of the new treatment, in particular for the multifaceted and comprehensive nature of interven-
trials that require many resources or comprise novel tion programs for individuals with ASD, e.g., Mesibov &
approaches. Although there is no shortage of proof-of- Shea, 2011; Keenan & Dillenburger, 2011].
concept and pilot evaluations in ASD early interven- RCT studies allow us to understand the average effect
tion, guidelines on what can be learned from such stud- of a particular intervention model or format for a par-
ies [e.g., Craig et al., 2008; Kratochwill et al., 2010] are ticular target population, and can provide information
not utilized consistently. In particular, pilot studies in on how/why such approaches confer benefit for young
this field often focus on drawing inference regarding children with ASD [if powered to permit tests of media-
evidence for the treatment benefits (even though the tion; Gulsrud, Hellemann, Shire, & Kasari, 2015; Pickles
study was not designed or adequately powered to pro- et al., 2015], and factors that predict greater versus
vide this information), and neglect critical information more limited gains from intervention, including charac-
on treatment feasibility, and social validity/acceptabil- teristics of individuals for whom an approach may be
ity to key stakeholders (a critical step for moving particularly well suited [tests of moderation; Kaale,
towards tests of effectiveness). This might reflect the Fagerland, Martinsen, & Smith, 2014]. Such informa-
historical emphasis on demonstrating intervention suc- tion is critical in the ASD field, as the etiological and
cess over documenting the relevance of treatment goals clinical heterogeneity of this population might result in
to stakeholders in the ASD field [Dingfelder & Mandell, different sub-groups of children responding differently
2011]. However, ASD intervention research would bene- to different treatments [Stahmer, Suhrheinrich, & Man-
fit from an increased appreciation of the scope of proof- dell, 2016].
of-concept studies and pilot evaluations. This should We have yet to fully exploit the potential of RCT
include indication of feasibility and acceptability of designs to thoroughly test the comparative efficacy of
treatment procedures and alignment with stakeholder interventions, active therapeutic ingredients, and sub-
values, as well as preliminary indication—but not con- group variation in treatment response. Further progress
clusive claims—of whether any signal of effect presents in this area requires increasing sophistication in trial
in the anticipated direction, thereby providing justifica- methodology (e.g., factorial designs, comparative effi-
tion for moving toward a fully-powered clinical trial cacy trials) and adaptive treatment designs to provide
[see e.g., Bearss, Johnson, Handen, Smith, & Scahill, information on how and when to introduce adapta-
2013; Brookman-Frazee, Drahota, & Stadnick, 2012]. tions in response to the child’s treatment progress over
the course of the intervention [see Almirall & Chronis-
Gaps in the Evaluation of Efficacy
Tuscano, 2016; and Lei et al., 2012 for an overview on
Well-powered clinical trials are the gold-standard for adaptive designs, and Kasari et al., 2014, for an applica-
evaluating treatment efficacy, allowing us to estimate tion in ASD early intervention].

18 Vivanti et al./Gaps and priorities for intervention research INSAR

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Gaps in the Evaluation of Effectiveness gain a sophisticated understanding of the context in
which the implementation is taking place through basic
Research on effectiveness evaluates the extent to which descriptive research and thoughtful piloting, and to cre-
benefits documented in efficacy trials are maintained
ate imaginative adaptations of intervention procedures
when early intervention is implemented in “the real
so as to preserve effectiveness in the novel (and often
world”. Such research is critical in the field of ASD, as
complex) setting [Smith, Iadarola, Mandell, Harwood,
community practitioners often question the utility of
& Kasari, 2017].
recommended evidence-based interventions in the con-
text of the complex needs of this heterogeneous client Gaps at the Level of Implementation
group, the large caseload and the low resources avail-
When early intervention models for children with ASD
able in community settings [Stahmer, Suhrheinrich,
are implemented in the community, a number of chal-
Reed, & Schreibman, 2012]. As we learn more about
lenges arise, including issues with organizational leader-
implementation challenges, we can hone intervention
ship, infrastructure and resources, lack of motivation/
strategies to fit the context within which they need to
commitment from staff, or commitment in the control
be delivered, and work towards sustainability. By way
group that results in their learning the intervention on
of illustration, Preschool Autism Communication Ther-
their own, thereby contaminating the results. While a
apy (PACT), a parent-mediated approach originally
full description of implementation science is beyond
developed and tested in the UK [Green et al., 2010;
the scope of this commentary [see Eccles et al., 2009;
Pickles et al., 2016], was recently adapted for delivery in
Green, 2012, for an overview], a critical focus of this
rural communities in South Asia [Divan et al., 2015].
discipline concerns the features of organizations (e.g.,
The original efficacy trial was designed in a way that
preschool settings, early intervention programs) that
made it possible to identify the therapeutic mechanism
[Pickles et al., 2015], so as to preserve ‘active ingre- influence the adoption and successful deployment of
dients’ while adapting procedures and concepts to the efficacious interventions. Through the lens of imple-
specific parenting cultures, resources, and other contex- mentation science, factors such as organizational sys-
tual factors in rural South India and Pakistan. The adap- tems, processes and cultures, and the ‘buy-in’ of
tation process was based on focus groups and professionals involved in the intervention, are not
workshops conducted with local stakeholders, which merely ‘noise’ inherent in the evaluation of a carefully
resulted in an adapted, manualized treatment proce- controlled trial, but rather are critical factors of interest
dures and, in turn, provided the foundation for an RCT that deserve evaluation in their own right. Ultimately,
that replicated key findings from the original UK effi- it is incumbent upon the ASD research community to
cacy trial [Rahman et al., 2016]. understand not just whether a particular intervention is
Despite the recent growth of ASD intervention studies effective, but how to make that intervention viable
using community-based participatory research [e.g., within a particular context.
Mandell et al., 2013], there remains a paucity of studies To achieve this aim, studies should include measure-
based on a community-partnered participatory research ment of ‘implementation outcomes,’ such as (a) adop-
(CPPR) approach [Jones & Wells, 2007], which empha- tion, the commitment from individuals and
sizes community-academic collaborations where organizations to using a particular intervention; (b) fea-
researchers and community stakeholders are equal part- sibility, whether community workers have the necessary
ners in the development of research aims, design, skills/training and desire/intention to do what an inter-
implementation, and outputs. Using CPPR as a comple- vention approach stipulates; and (c) penetration, the
mentary effort to large scale effectiveness trials, recent extent to which an approach is implemented with all
studies have introduced adaptations for teachers work- children vs. selectively implemented with some but not
ing with children in preschool settings in the context others, for reasons which may be logical for the individ-
of randomized controlled hybrid implementation ual in question but not otherwise apparent. Another
designs, where teacher implementation and child out- important implementation construct is fidelity, or
comes are both considered [Chang, Shire, Shih, Gel- adherence to the treatment protocol. While interven-
fand, & Kasari, 2016; Shire et al., 2017]. tion fidelity has received more research attention com-
Challenges associated with CPPR include identifying pared to other implementation constructs, in a solid
the trade-off between adaptations to improve treatment evaluation of effectiveness, fidelity should be allowed to
usability (e.g., making the treatment shorter) and pres- vary as it would in usual community practice, as it is
ervation of elements that promote effectiveness (e.g., important to understand the reasons for and conse-
treatment intensity), as well as negotiating and relin- quences of sub-threshold implementation, as well as
quishing power on research methods and products. effects on subsequent child outcomes. Investigation of
Addressing this challenge requires clinical scientists to factors such as interventionists’ attitudes (whether they

INSAR Vivanti et al./Gaps and priorities for intervention research 19

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think that using the intervention is good or bad thing change on factors important to stakeholders). In turn,
to do), norms (the extent with which interventionists the result of a trial will inform both theory of treatment
feel they are expected to use the intervention, or change and the relevance of treatment outcomes to
believe that their peers are using it) and self-efficacy stakeholders’ goals. Such iterative approach might
(the extent to which they think that, if they wanted to, accelerate the pace of treatment development and test-
they could deliver the intervention), are critical to iden- ing in ASD.
tifying markers of whether an intervention will be
implemented, and to what degree of fidelity [see for
Conclusions
example Dingfelder & Mandell, 2011; Locke et al.,
2015, 2016]. Several “calls to action” have been made to improve
Implementation science is characterized by many
ASD intervention development research [Lord et al.,
constructs, but few formal theories. Therefore, the study 2005; Maglione et al., 2012; Smith et al., 2007; Stahmer
of these factors borrows from theories of motivation, et al., 2016]. The key priorities that emerged from the
leadership, organizational dynamics, supply and INSAR SIG on Implementing and Evaluating Community-
demand that arise from other disciplines, such as eco- Based Early Intervention expanded on the previously
nomics, and social and organizational psychology. identified scarcity of efficacy and effectiveness trials and
Crossing disciplinary boundaries to engage other fields need for characterizing ASD intervention by indicating
in collaboration is challenging, and requires measuring the presence of gaps and priorities at each stage of the
and making predictions on factors and constructs process from intervention theory development to
which traditionally sit outside of ASD intervention implementation, and highlighting the way in which an
research. Nevertheless, considering implementation iterative approach—involving both top-down and
outcomes is critical from the initial stages of interven- bottom-up dynamics of knowledge exchange between
tion development. Just like a software developer will different stages—might accelerate the pace of work in
never create a program without the end-user in mind, this field. Gaps and research priorities included the
intervention developers must consider the caregivers, need for formal theories on mechanisms of treatment
teachers, and clinicians who will deliver the interven- change and adoption of interventions by individuals
tion with children with ASD, and ensure they will be and organizations to guide implementation and evalua-
able and willing to implement it as intended, or a tion. On a related point, intervention theories should
highly promising approach might be destined for be aligned with current knowledge and societal views
failure. on ASD, which differ considerably from those held at
Need for an Iterative Approach in Intervention Development the time when many interventions were originally
and Evaluation developed. Second, pilot evaluations of interventions
should devote greater attention to indicators of feasibil-
The path from constructing treatment rationales to ity and acceptability of treatment goals and alignment
implementing interventions in the ‘real world’ involves with stakeholder values. Third, efficacy trials should use
a sequence of hierarchically organized stages, with research designs that allow comparison of the benefits
knowledge gained in each step providing a foundation of different approaches, analyze mechanisms of effect,
for the following step. However, the process should not and identify prerequisites for interventions to benefit
be limited to a unidirectional linear progression, but particular children, given the substantial heterogeneity
also include multidirectional exchange between differ- evident in this condition. Fourth, community-
ent levels, where knowledge generated at each stage partnered participatory research is needed to guide the
informs both the following and the preceding stages adaptation of existing approaches and to develop new
[Kazdin, 2001; Stahmer et al., 2017]. For example, models with a focus on targets and procedures relevant
knowledge generated in an efficacy RCT study might to end-users. Fifth, intervention trials should include
indicate the appropriateness of moving toward effec- constructs related to implementation processes and out-
tiveness trials and implementation studies, while also comes. Importantly, numerous barriers to this research
indicating the need for adjustments in the conceptuali- agenda exist, reflecting the heterogeneity of strengths
zation of treatment rationale (e.g., if the treatment and needs within the ASD population, conflicting views
appears to be beneficial but mechanisms and domains on intervention research goals and priorities among dif-
of change differ from those hypothesized). Similarly, ferent stakeholders [including self-advocacy groups; Pel-
both the hypothesized mechanisms of treatment licano, Dinsmore, & Charman, 2014], and the logistical
change, and stakeholders’ goals related to the treatment challenges associated with flexible and rigorous imple-
should inform the evaluation of interventions (e.g., mentation of early interventions for ASD. However,
choice of outcome measures that reflect meaningful efforts towards these goals have the potential to

20 Vivanti et al./Gaps and priorities for intervention research INSAR

 19393806, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.1900 by Drexel University, Wiley Online Library on [24/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
generate a wealth of ‘usable’ knowledge to improve out- Diggle, T.T., & McConachie, H.H. (2002). Parent-mediated
comes for children with ASD in community settings early intervention for young children with autism spectrum
globally. disorder. The Cochrane Library, 1, CD009774.
Divan, G., Hamdani, S.U., Vajartkar, V., Minhas, A., Taylor, C.,
Acknowledgments Aldred, C., . . . Patel, V. (2015). Adapting an evidence-based
intervention for autism spectrum disorder for scaling up in
We would like to thank Cathy Bent, Heather Nuske, the resource-constrained settings: The development of the PASS
INSAR SIG Committee Co-Chairs Mayada Elsabbagh intervention in South Asia. Global Health Action, 3, 272–278.
and Laura Anthony, and the SIG attendees. A special Dingfelder, H.E., & Mandell, D.S. (2011). Bridging the
thank also to the invited speakers in the 2017 SIG research-to-practice gap in autism intervention: An applica-
panel, Evdokia Anagnostou, Bhismadev Chakrabarti, tion of diffusion of innovation theory. Journal of Autism
Isabel Smith, Aubyn Stahmer, Fred Volkmar, and those and Developmental Disorders, 41, 597–609.
Eccles, M.P., Armstrong, D., Baker, R., Cleary, K., Davies, H.,
who participated in the 2015 SIG forum, Alice Carter,
Davies, S., . . . Logan, S. (2009). An implementation research
Ya-Chih Chang, Blythe Corbett, Annette Estes, Marie-
agenda. Implementation Science, 4, 18.
Maude Geoffray, Victoria Grahame, Anders Nordahl-
Green, J., Charman, T., McConachie, H., Aldred, C., Slonims, V.,
Hansen, Suzannah Iadarola, Lisa Iban ~ ez, and Brian
Howlin, P., . . . Barrett, B. (2010). Parent-mediated
Reichow. communication-focused treatment in children with autism
(PACT): A randomised controlled trial. Lancet, 375, 2152–2160.
Green, J. (2012). Editorial: Science, implementation, and
Conflict of Interest
implementation science. Journal of Child Psychology and
Psychiatry, 53, 333–336.
The authors declare no conflict of interest. Gulsrud, A.C., Hellemann, G., Shire, S., & Kasari, C. (2015).
Isolating active ingredients in a parent-mediated social
communication intervention for toddlers with autism spec-
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