Early Intensive Behavioral Intervention Program for Children With Autism in Syria

Abstract

In this study, we evaluated the effect of the Future Center Early Intensive Behavioral Intervention program on children’s skills longitudinally by sex, age, and diagnoses as dependent variables. Sixty-seven children ages 1–6 years and diagnosed with autism spectrum disorder were followed up for 2 years in Syria. They were assessed twice across the 2-year program: at their first visit and at the end of the program. Assessments included the Autism Behavior Checklist, Childhood Autism Rating Scale, and Adaptive Behavioral Scale–Arabic version. Results showed that the changes in participants’ scores from pre- to post-test were statistically significant, and the treatment group showed significantly larger gains on all scales. No significant differences were found by sex and age between the pre- and post-test on all scales, while there were significant differences regarding diagnoses. The limitations of this study and suggestions for future research are described.

Usually emerging in early childhood, Autism Spectrum Disorder (ASD) is defined by experiencing difficulties with reciprocal social communication and stereotyped interests or behaviors (American Psychiatric Association, 2013). Approximately one third of the children with ASD have delays in cognitive development and experience difficulties regarding the performance of daily living skills (Autism and Developmental Disabilities Monitoring Network Surveillance Year 2010 Principal Investigators & Centers for Disease Control and Prevention, 2014). Co-occurring behavior problems (e.g., tantrums, self-injury) and medical conditions (e.g., seizure disorders) are also common in those with ASD. Although ASD usually persists across the lifespan, early interventions can alleviate symptoms (Rogers & Vismara, 2008).

Specifically, some conditions contribute to the effectiveness of early intensive behavioral intervention (EIBI) programs for children, including: training based on the principles of applied behavior analysis (ABA), an intensity of 25–40 hr per week, early intervention, a minimum duration of 12 months, supervision of the intervention, a child-caseworker ratio of 1:1, parental training, and parental participation (Fava & Strauss, 2014; Hepburn, 2013; Makrygianni & Reed, 2010). In EIBI, two treatment models have emerged, focused and comprehensive (Council of Autism Service Providers, 2020; Eikeseth & Klintwall, 2013; Odom, Boyd, et al., 2010). In addition, several interventions and teaching methods are considered to be a part of EIBI (e.g., antecedent-based interventions, discrete trial teaching, reinforcement, prompting, visual supports, and modeling) (Steinbrenner et al., 2020). In children with ASD, these interventions have been used to increase adaptive functioning and language skills and reduce stereotypy and problem behaviors (e.g., Akers et al., 2019; Eikeseth et al., 2012; S. L. Harris & Handleman, 2000; S. L. Harris et al., 1991; Lovaas, 1987; McEachin et al., 1993; Myers et al., 2007; Odom, Boyd, et al., 2010; Sallows & Graupner, 2005; Weiss, 1999; Wong et al., 2015).

In summary, EIBI refers to a set of effective procedures for teaching young children with ASD (e.g., Eikeseth, 2009; Eikeseth et al., 2002, 2012; Eldevik et al., 2009; Huffman et al., 2011; Reichow, 2012; Virués-Ortega, 2010). Remington et al. (2007) reported, after 2 years of EIBI, robust results on measures of intelligence, language, daily living skills, and positive social behavior. Dawson (2013), after conducting a randomized controlled trial (RCT) and four non-RCTs with 203 participants, showed positive effects in favor of the EIBI treatment group in all outcome measures. Although there have been major advances in EIBI, a gap remains between the scientific knowledge behind this program and the services provided in several educational areas, particularly those intended for children with ASD (Cook & Odom, 2013; Odom, Collet-Klingenberg, et al., 2010). Therefore, the effectiveness of the implementation of EIBI is not always guaranteed, and the centers that choose it may not always have the capacity to ensure that EIBI best practices are followed in the interventions (Cook & Odom, 2013).

Intervention programs based on the ABA have presented well-evaluated short-term effects on children with ASD (Matson et al., 2012; Steinhausen et al., 2016; Velazquez & Nye, 2011; Virués-Ortega, 2010). Nonetheless, the longitudinal maintenance of these short-term effects has yet to be empirically shown, a task that is difficult to accomplish. Smith and Iadarola (2015) reviewed quasi-experimental and RCT studies on EIBI published since 1998, identifying both strengths and limitations in this literature. Specifically, they noted that numerous quasi-experimental studies have shown positive effects similar to those found in RCTs, albeit a lack of methodological rigor was often found across them (e.g., poor subject characterization and data collectors; assessors not blinded to treatment conditions; etc.). Caron et al. (2017) reported that while most studies provided relatively good descriptions regarding intervention dosage and protocol, they also did not report on intervention participation, differentiation, or quality. Furthermore, Velazquez and Nye (2011) demonstrated that although EIBI had a moderate to large effect on the IQ and adaptive behavior in young children with ASD, its impact on adaptive behavior was smaller. These authors, nonetheless, reported that their results should be interpreted cautiously, considering that most studies presented in their review exhibited methodological issues that limited finding generalizability (e.g., sample size, study design, participant heterogeneity). They also remarked that such methodological problems must be addressed in future research.

Behavioral research is largely based on data from Western, educated, industrialized, and democratic countries. Thus, some research that has been interpreted as universal may, instead, be specific to a given culture (Muthukrishna et al., 2020). The ABA field has emphasized the importance of working toward social justice, developing sensitivity to and humility for other cultures (Sugai et al., 2012). However, these aspects have not always been considered in practice (Miller et al., 2019). This brings up a question: If ABA-based interventions are conducted outside of these Western countries (e.g., in Syria), would intervention values, objectives, approaches, and outcomes shift? In the Arab region, the number of individuals diagnosed with ASD continues to rise, leading prior research to highlight the need for more research, educational opportunities, and clinical services aimed at this population (Hussein et al., 2011). Despite this need in Arab countries, most experience a severe deficit in local professionals trained in ABA, indicating that the provision of ABA-based interventions is significantly restricted (Kelly et al., 2016).

EIBI in Syria

In Syria, the Ministry of Social Affairs provides rehabilitation services across 31 centers to individuals with disabilities, including visual, hearing, and vocal impairments, as well as cerebral palsy (Office of the High Commissioner for Human Rights, 2013). In addition, there are 65 nongovernmental organizations (NGOs) in Syria, with some providing services to children with disabilities; however, none provide services to children with ASD. Furthermore, there is a lack of precise service guidelines (Office of the High Commissioner for Human Rights, 2013). Thus, identifying determinants of the successful implementation of EIBIs in Syria can lead to fruitful outcomes; these may include increased knowledge of the implementation process and a broader impact of EIBI. Despite such potential, there is a paucity of literature regarding how EIBIs are typically implemented within community-based settings, implying a lack of data regarding whether these interventions can be characterized as being evidence-based and whether they have high fidelity to the original sources (Drahota et al., 2021; Stahmer & Aarons, 2009; Stahmer et al., 2019).

Despite these limitations, NGOs and special centers can provide EIBI in Syria. One organization, the Future Center, was the first center licensed to serve individuals with ASD in Syria; it is currently operating an EIBI program, FC-EIBI, aimed at children ages 1–10 years diagnosed with ASD in two Syrian cities. In this center, most children begin EIBI between 2 and 4 years of age. The FC-EIBI program was designed to teach parents to serve as active co-therapists for their children and help the latter to be successful at school, home, and in the community. This program aims at making a difference in the lives of individuals with ASD in Syria by building knowledge, awareness, securing treatment and habilitation, and pursuing an integrated approach. The FC-EIBI began with 24 therapists, all of whom were qualified special education teachers.

Study Aim

In this study, we aimed to conduct an evaluation of the FC-EIBI program; here, we provide a description of its critical elements and examine the benefits and barriers of delivering EIBI to children with ASD in Syria. Specifically, we evaluated the following questions: (a) After the 2-year FC-EIBI program, were there changes in participants’ scores for the Autism Behavior Checklist (ABC; Volkmar et al., 1988), Childhood Autism Rating Scale (CARS; Al-Shammari & Al-Sartawi, 2002; Schopler et al., 1980), and the Adaptive Behavioral Scale-Arabic (ABS-Arabic; Al-Kilani & Al-Batesh, 1981)? (b) Are there differences by sex and pharmaceutical use regarding these program outcomes? (c) Is there a statistically significant relationship between participants’ scores for the ABS-Arabic and those for the ABC and CARS?

Method

Participants

This study took place 2008–2010 in Syria. Participants were recruited from the surrounding communities in Damascus and As-Suwayda, Syria, through referrals from professionals (e.g., medical doctors) or organizations (e.g., Red Crescent). The sample was derived from those who had convenient access to Future Center. The inclusion criteria were: (a) having never been in a behavioral program, (b) being 1–6 years old, (c) diagnosed with ASD, (d) both parents had to provide consent to participate in the study, and (e) parents had to commit to enroll in the FC-EIBI program for 2 years.

To avoid the methodological errors described by Smith and Iadarola (2015), we confirmed whether the children had no history of ABA treatment and were not receiving other treatments. During the initial procedures, participants’ parents provided their demographic information (i.e., address, education level, family health history) and their child’s developmental history (i.e., prenatal, birth, neonatal, education, speech, psychomotor).

Initially, 138 individuals were referred to the center, but only 67 participated in the study. The 67 participants were either diagnosed solely with ASD or diagnosed with ASD and an accompanying intellectual disability (see online supplemental material, Table 1). Among participants, 37% (n = 25) ranged from 1 to 3 years old, 28% (n = 19) were 3–5 years old, and 34% (n = 23) were 5 years or older.

The center’s psychologist confirmed the diagnosis and IQ scores of study participants by using the Wechsler Intelligence Scale for Children-IV IQ-test and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2013) (DSM V was not available at the time). The mean IQ of participants was 59 (range: 37–81), and they were not receiving other support services (e.g., speech, language, or occupational therapy) while enrolled in the FC-EIBI program. Moreover, 46% of the participants were prescribed medication (e.g., risperidone, atomoxetine, and depakine). In this study, we did not attempt to control pharmaceutical treatments.

Setting

In the center, each classroom was 4 m × 5 m in size and equipped with six child-sized tables and six chairs. To create a more physically structured setting for students, participants were assigned a small cubby to store their personal effects, their own table, and a small wardrobe. The six child-sized tables were divided into two clusters of three, and together they formed a flower shape; they were placed on the opposite side of the room, with the staff’s chair in front of each one. In one wall of the classroom there was a whiteboard, and in another there was a filing cabinet, leaving students with only one way in and out of their own area. Participants were provided with chairs and desks of the same size, and they were designed to ensure that the children sit with their feet flat on the floor, their knees bent at a 90° angle, and their elbows resting on the desktop or beside it. In each intervention, there were six children and two adults in the room at the same time. The rooms were equipped with ceiling-mounted surveillance cameras, allowing parents and staff to monitor the teaching sessions.

Instruments

We chose the ABC, CARS, and ABS-Arabic scales for this study because they were available in Arabic and were the most appropriate and valid measures available for use. Participants were pretested in 2008 and post-tested in 2010. Prior to program onset, the researcher pretested each child for 2 days. Parents were the ones who answered to the ABC, CARS, and ABS-Arabic, which were administered by the researcher in a room other than the training rooms. The total testing time ranged from 27 to 75 min (M = 42 min) across both days. The same raters participated in 2008 and 2010 and responded to the ABC, CARS, and ABS-Arabic.

ABC

To assess ABC, we used an Arabic version developed by Ghazal (2007). The ABC is designed to be completed independently by a parent or a teacher familiar with the child for at least 3–6 weeks. It should take from 10 to 20 min to complete. ABC consists of 5 subscales and 57 items: Sensory (9 items), Relating (12 items), Body and Object use (13 items), Language (12 items), and Social and Self-help skills (11 items). Each item was scored from 1 to 4 and the total score is obtained by adding the weight of the different areas. In prior research, scores greater than 67 points indicated ASD (Volkmar et al., 1988); we used this score as the threshold value for ASD diagnosis. Scores were calculated by adding the scores for each item. Higher scores indicated greater clinical competency. The Cronbach’s alpha of the original tool was .86 (Ghazal, 2007).

CARS

To identify children with ASD, we used the CARS. It assesses behavior across 14 domains that are severely affected by problems related to ASD, and it also contains a general category of impressions of ASD. The 15 items in the scale were: relating to people, imitative behavior, emotional response, body use, object use, adaptation to change, visual response, listening response, perceptive response, fear or anxiety, verbal communication, nonverbal communication, activity level, level and consistency of intellectual relations, and general impressions.

The examiners were the ones who assessed impressions of autism regarding the child, and they assigned a score of 1–4 for each item (1 = age-appropriate behavior; 4 = severe deviance from age-appropriate behavior). The scores for each item were added to obtain a final score. A score below 30 indicates that the child does not have ASD, ranging from 30 to 37 indicates mild to moderate ASD, and above 37 indicates severe ASD (CARS; Al-Shammari & Al-Sartawi, 2002). In our study, we used a score of 30 or higher as the threshold value for diagnosing ASD. The Arabic version based on prior studies of the scale showed acceptable internal consistency coefficients (α = .79, and through the midterm split which is the sum of two factors and product equal to last term = .93).

ABS-Arabic

The ABS-Arabic was designed for the Arabic culture. To assess with the ABS-Arabic, we used a guide developed by Al-Kilani and Al-Batesh (1981). ABS-Arabic is to be completed independently by a parent or a teacher familiar with the child for at least 6 weeks. This self-reported tool contains 6 subscales and 96 items: social interaction (16 items), communication and language (16 items), self-care (16 items), gross and fine motor skills (16 items), cognitive skills (16 items), and personal and emotional adaptation (16 items). Each domain has two subdomains, each of which has eight items. Each item was scored on a scale that ranged from 1 (age-appropriate behavior) to 4 (severe deviance from age-appropriate behavior). Scores were calculated by adding the scores in each item. Higher scores indicated greater clinical competency. The Cronbach’s alpha of the original tool was .93 (Al-Kilani & Al-Batesh, 1981).

ABC, CARS, and ABS-Arabic reliability

Because of translation and to assess the internal consistency and test–retest reliability of the ABC, CARS, and ABS-Arabic, we randomly selected 14 children from the center; these children were not part of the evaluation we conducted. We employed the same raters for the test–retest validation process. Each child was assessed using the three scales; after 10 days, they were re-assessed. The Cronbach’s alpha results indicated a high level of internal consistency across the scales (α_ABC=.95; α_CARS = .98; α_ABS=.87). The Pearson correlation coefficients indicated high test–retest reliability across the scales (r_ABC =.96, r_CARS =.91, r_ABS = .87, p<.001).

FC-EIBI Program

The FC-EIBI program consists of the following processes: (a) theoretical education, (b) workshops and practice, (c) documentation and assessment, (d) communication and feedback, and (e) implementation.

Theoretical education

During theoretical education, which occurred prior to the intervention conducted at the center, staff received 10 advanced training sessions across 25 h, while parents received 10 h of training. The training content included the following: (a) three lectures about ASD; (b) three lectures about the principles and procedures of behavioral interventions, functional assessments, positive and negative reinforcements, punishment, prompting, fading, chaining, and shaping; (c) Individualized Education Program (IEP) and instruction educational plan (IIP); (d) augmentative and alternative communication (AAC) for children with ASD; (e) communication with families; and (f) treatment documentation.

Workshops and practice

Staff also participated in six workshops; in them, they worked in small groups to practice strategies to be used in the intervention, such as functional assessment, task analysis, IEP, IIP, weekly communication with families, and documentation. During the two years of the FC-EIBI, we observed no staff turnover.

Documentation and assessment

The FC-EIBI staff used two assessment tools to identify child-specific skills; these data served for them to produce targeted interventions. First, they employed the Child Performance Monitoring List, an assessment developed by the center, to assess the typical development of the child in (a) communication (i.e., impression and expression language skills); (b) social skills; (c) self-care (e.g., showering and toileting); (d) interaction; (e) imitation; (f) play and leisure; (g) motor skills; and (h) learning (i.e., perception, cognitive, pre-academic and academic skills). Second, they employed a functional behavior assessment to identify the function of participants’ challenging behaviors (e.g., stereotypy).

Using both tools, the staff developed program books (i.e., IIPs) for each child; these IIPs outlined the specific goals and behavioral intervention plans that were to be conducted in order to address participants’ specific challenging behaviors. Moreover, the staff measured the children’s skill acquisition and behavior on a daily basis. These data were reviewed daily and weekly using the IIPs. In the weekly review, the researcher assessed whether the data collection procedure was accurate. The general proficiency criterion for students was 8 out of 10 trials.

Communication and feedback

For center staff to communicate with families, the first sent to the latter’s homes the participants’ training book every Monday and Wednesday. The book included information on the current targets and written instructions on how to conduct trials; the latter included instructions on prompting procedures, putative reinforcers, and skill targets for parents to work on with their children at home.

Moreover, there were four meetings across a 6-month span; two among staff and families and two among parents, therapists, and researchers. The staff scheduled two meetings with families every 6 months. At the meetings, which served as a form of social support provision for the families, parents had the opportunity to share their experiences and concerns with the staff. In addition, two parent–therapist–researcher meetings were scheduled every 6 months; these served to review the child’s progress and address parents’ questions and concerns. Once a year, each child’s therapist and the researcher visited the parents at home. Furthermore, parents were allowed to visit the center at any time to observe their child’s work using a closed-circuit video.

Implementation

Once the IEP and IIP were developed, participants were initially provided with EIBI with a one-to-one design. Then, gradually, they were transitioned to a small group with no more than three children and one therapist; thereafter, when possible, they were transitioned to a group with six children and two therapists. Finally, when possible, and with the aim of preparing the children for primary school, they were transitioned to a large group; it contained a maximum of nine children and one therapist. The teaching strategies aimed at increasing target behaviors and reducing interfering behaviors, and they were based on ABA principles. The staff used positive and negative reinforcement based on each child’s reinforcement checklist (e.g., naturalistic reinforcers, toy, food), differential reinforcement of alternative behavior, differential reinforcement of other behavior, extinction, prompting (e.g., most to least physical, visual, and gestural depending on child progress; the assistance could be removed more easily as the skill was acquired; “fading”), discrete-trial teaching, incidental teaching, activity-embedded trials, task analysis, stimulus control, chaining, and shaping. At the beginning of each trial, children were allowed to choose what they would work on.

In the program, the most targeted skills were social interaction, communication and language, self-care, gross and fine motor skills, and cognitive and pre-academic skills; all these were taught daily. Trials to identify children’s proficiency in each skill varied depending on their individual skill acquisition rates (M = 1 week). Each skill was reduced into small, discrete steps, with the staff teaching each step, from simple (e.g., imitating single sounds) to more complex (e.g., carrying on a conversation) levels. In each session, to collect data on the children’s progress through these small, discrete steps toward a given target, both staff and parents used paper and pen annotations. At the center, participants received 25 h of EIBI per week, arriving daily at the center at 8:30 a.m. and departing at 1:30 p.m. There were 10 lessons per day, each lasting 30 min, during which the targeted skills were taught. The mean number of skills in which children became proficient (i.e., goal reached) per child was 52/year, and the mean number of trials was 39 trials/week (range 36–45) per child (see online supplemental material, Table 1).

Each day started with a morning group session; in it, participants imitated therapist movements with simple songs (e.g., clapping your hands). At least once per month, parents served as co-therapists for their children. To promote skill generalization, skills were taught in settings other than the center (e.g., home settings). When parents served as co-therapists, they implemented the procedures with their children outside the center. Staff encouraged the parents to train their children daily, and the parents were asked to report how many home training programs they implemented. The researcher monitored the therapists’ correct implementation by reviewing video recordings.

To assist in the participants’ communication, we used a picture exchange communication system, which served to provide children with access to functional communication (Bondy & Frost, 2011). Then, to develop stimuli for picture schedules that could be included in children’s daily routines (e.g., the participants were taught to remove the completed activity card and put it in the completed box when the lesson ended), we created visual icons with Boardmaker (Paul, 2012).

Data Analysis

We analyzed descriptive statistics using means, standard deviations, or medians. We used Kolmogorov–Smirnov and Shapiro–Wilk tests to verify data normality. Upon observing a non-normal distribution, we used the Wilcoxon signed-rank test, a nonparametric statistical test, to evaluate pre–posttest differences. Moreover, we employed the Mann–Whitney and Kruskal–Wallis H tests for comparing continuous variables. Effect sizes were calculated using r=Z/√n. In addition, we employed Spearman’s rank correlation coefficient to assess the relationships between two variables.

Social Validity

To evaluate parental acceptance of the FC-EIBI program, we also administered a social validity questionnaire to the participants’ parents (N = 67 parents). We asked questions regarding whether: (a) the parents felt that the program was socially acceptable; (b) the program produced socially important outcomes; (c) the program fit well with the FC-EIBI instructional style; (d) the intervention was effective; and (e) they were satisfied with the results (see online supplemental material, Table 2). These questions were developed specifically for this study, and the parents responded to them using a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree).

Design

We evaluated the effects of the FC-EIBI program on the 67 participants using a pre-test design, assessing changes in participants’ scores for the ABC, CARS, and ABS-Arabic from 2008 to 2010. We did not design a control group.

Results

To verify whether the study sample had a normal distribution, we used the Kolmogorov–Smirnov and Shapiro–Wilk tests. Both tests yielded statistically significant results, and they were not normally distributed (W_CARS [67] = .95, p < .001; W_ABC [67] = .95, p < .001; W_ABS [67] = .95, p < .001).

We compared the scores for the CARS, ABC, and ABS-Arabic pre- and post-test. On average, children performed worse before (median: Mdn_CARS = 36; Mdn_ABC = 129; Mdn_ABS = 70) than after the intervention (Mdn_CARS = 32; Mdn_ABC = 98; Mdn_ABS = 233). Owing to the non-normal distribution, we conducted the Wilcoxon signed-rank test, which indicated that these differences were statistically significant for all three scales (T_CARS = 2,278, Z = −7.230, p < .001, r = .89; T_ABC = 2,278, Z = −7.116, p < .001, r = .88; T_ABS = 2,278, Z = −7.115, p < .001, r =.87). We calculated the effect sizes based on the following equation: ( $r=\frac{Z}{\sqrt{n}}$ ); it served to demonstrate the differences between the pre- and post-test outcomes across all scales. The effect sizes are shown in the online supplemental material, Figures 1, 2, 3, and Table 3.

We conducted the Mann–Whitney U test to explore sex differences (i.e., boys and girls) regarding scores for the CARS, ABC, and ABS-Arabic. We found no statistically significant differences by sex across all scales: U_CARS (N_Boys = 39, N_girls = 28) = 498, Z = −.618, p = .53; U_ABC (N_Boys = 39, N_girls = 28) = 494, Z = −.662, p = .51. U_ABS (N_Boys = 39, N_girls = 28) = 534, Z = −.149, p = .88.

We also found no statistically significant differences by pharmaceutical use (i.e., with and without): U_CARS (N_with = 31, N_without = 36) = 403, Z = −1.96, p = .49; U_ABC (N_with = 31, N_without = 36) = 379, Z = −2.24, p = .25; U_ABS (N_with = 31, N_without = 36) = 469, Z = −1.14, p = .26.

Using the Kruskal–Wallis H test, we analyzed the scores by age groups (1–3 years, 3–5 years, and 5–6 years old; see online supplemental material, Table 4); we found no statistically significant results by age group across the scales: H_CARS (2) = 3.59, p = .16; H_ABC (2) = .40, p = .82; H_ABS (2) = 6.25, p = .44.

We also compared participants’ scores by diagnoses (see online supplemental material, Table 5), finding statistically significant differences between the diagnosis groups (i.e., Pervasive Developmental Disorder-Not Otherwise Specified, high function autism, autism with mild intellectual disorder, autism with middle intellectual disorder, and autism with severe intellectual disorder) in both the pre-test and post-test: H_CARS (4) = 56, p < .001; H_ABC (4) = .40, p < .001; H_ABS (4) = 6.25, p < .001. Namely, the groups by diagnosis already showed score differences at pre-test and at post-test; then, we conducted the Mann–Whitney U to analyze the specific differences between groups and find out which groups showed higher or lower scores what favored these differences. We found that the differences existed among all five groups.

Then, we used Spearman’s rank correlation coefficient to assess the relationship between the number of weekly trials (<39 trials/week; exactly 39 trials/week; and more than 39 trials/week) and participants’ scores for the CARS, ABC, and ABS-Arabic. There was a strong significant negative correlation between the number of weekly trials and participants’ scores for the CARS and ABC: r_sCARS = .79, 95% constructs bias-corrected and accelerated confidence intervals: BCa CI [−.865, −.676], p < .001, N=67; r_sABC = .80, 95% BCa CI [−.870, −.693], p <.001, N=67. In addition, there was a strong significant positive correlation between the number of weekly trials and participants’ scores for the ABS-Arabic: r_sABS =.81, 95% BCa CI [.686, .871], p <.001, N=67.

Upon analyzing the social validity outcomes, we found that parents and staff responded favorably toward the FC-EIBI (see online supplemental material, Figure 1 and Table 2). When parents were asked whether they would enroll in FC-EIBI again, all answered yes.

Discussion

The FC-EIBI program was devised to provide ABA-based interventions to children with ASD living in Syria. This program contained several components aimed at improving therapy, which were operationalized by teaching staff about the foundational components of ASD, ABA, program planning, communication, and data collection. Overall, based on our pre–post-test comparisons, we observed notable progress in most children who attended the program.

Specifically, the program reduced some characteristic behaviors of ASD and increased desirable behaviors for social interaction, communication and language, self-care, gross and fine motor skills, and cognitive and pre-academic skills. We also found that progress occurred regardless of sex or age, as well as a strong association between reductions in ASD-related symptoms and the accumulation of proficiency in adaptive goals. Together, our findings imply that it is possible to decrease ASD-related symptoms in those diagnosed with ASD when they make progress using individualized intervention plans. Finally, parents in our sample reportedly showed satisfaction with the FC-EIBI program.

Smith and Iadarola’s (2015) indicated that one of the limitations in current literature is that, at the time they assessed the efficacy of the ABA-based programs, the child samples in most studies were concomitantly involved with treatments other than the ABA-based one. To address this gap, we confirmed that our participants were not receiving other treatments in our program evaluation; this served to reduce potential confounding factors. Meanwhile, although we examined pharmaceutical use effects, we did not analyze whether children’s prescriptions changed longitudinally; considering that our sample consisted of 31 children who took the prescribed medication and that our program stretched through a 2-year span, we deem it highly unlikely that none of their prescriptions changed over time. This exposes a clear study limitation. Therefore, future research should ensure that this confounding factor is addressed.

Moreover, we observed a small statistically significant difference between sexes, a finding that we deem promising regarding its potential outcomes; this implies that the FC-EIBI program can benefit both sexes. We also found that our participants benefited from the program regardless of ASD severity and age group. This means that the program was generally effective across different demographic characteristics. This is an encouraging finding for the study context, given that it may be difficult for providers in Syria to differentiate their programs across different demographic strata; these findings denote that providers can follow the parameters of EIBI for individualizing the program and ensuring its therapeutic outcomes.

Some researchers have found that the long-term outcomes of ABA-based programs in some individuals with ASD are poor (e.g., Steinhausen et al., 2016). However, our findings are similar to those of Ben-Itzchak and Zachor (2007), who found promising progress in all six developmental behavioral domains on the Autism Diagnostic Observation Schedule (Lord et al., 1999) after 1 year of intervention in children with ASD. Our study results also concur with past research showing that short-term behavioral treatment improves the adaptive functioning of children with ASD: Eikeseth et al. (2002) found that children in the behavioral treatment group had significantly larger gains on standardized tests than did children in the eclectic treatment group. Specifically, their results suggested that some 4- to 7-year-olds may present large gains by undergoing intensive behavioral treatment and that such treatment can be successfully implemented in school settings. Moreover, this cited study showed that the behavioral treatment groups had larger gains in IQ scores and adaptive functioning than the eclectic treatment groups. Similarly, Eikeseth et al. (2012), Remington et al. (2007), and Dawson (2013) found that, after 1 year of treatment, children in the EIBI group showed significant improvements in adaptive behaviors, maladaptive behaviors, and autism symptoms; these improvements continued across the second year of treatment, albeit to a lesser degree.

Green (1996) contended that to achieve the best possible outcomes related to the EIBI, children with ASD should begin the program as early as possible, preferably before the age of 4 years. However, in our preliminary analyses, we did not find statistically significant differences between children ages 5–6 years and those ages 1–3 years. In addition, Lovaas and Smith (1988) found no relationship between age at treatment onset and outcome; however, our findings are not conclusive, and considering these mixed discussions about the topic of age and EIBI, we believe that future research should continue to examine these variables.

In our program evaluation, we also ensured that the participants were assessed in their native language (Arabic) by tools appropriate to the Arabic culture. On the topic, B. Harris et al. (2014, p. 1286) contended that, when assessing individuals with ASD, “The properties of the assessments being used, such as the normative sample and the cultural and linguistic relevance, must be taken into consideration [. . .].” We believe that the use of culturally appropriate tools may have ensured that our findings provide a more direct measure of the improvements related to the FC-EIBI program.

In addition, we believe that the results of our study might be reasonably generalized in Syria to similar children groups across organizations that resemble the participating center. We also believe that governmental stakeholders could use our findings to support the implementation of EIBI in government-funded kindergartens. In addition, we deem possible to replicate this model to other Syrian regions that may lack these resources (e.g., educated staff, specialized centers). We recommend for future researchers and practitioners to keep on endeavoring to increase the quality of the services in FC-EIBI and to engage with community partners to develop national standards for EIBI practices. Moreover, we see space for improvements regarding data collection and the reporting systems of the FC-EIBI, which will allow for us to have a more comprehensive understanding of who is accessing the EIBI and the gaps in the current service delivery model.

Implications

Our program evaluation provided further evidence for the efficacy of EIBI. The participants in our study resided in Syria, and to date, there is no research on the effectiveness of EIBI on children in a country rife with civil war. Generally, our evidence depicts that, despite several barriers to treatment (e.g., lack of funding, intense geopolitical issues), children can still learn and their parents can still effectively assist them in their learning.

Our study also suggests that the training staff and parents may influence the success of the program and that stakeholders need to consider culture upon evaluating the results of the EIBI. We suggest for future researchers to replicate this program and determine the potential impact of EIBI on the services provided by some organizations in Syria (e.g., NGOs).

Our study also provides behavior analysts with additional information for designing and implementing an EIBI program in communities that face service barriers. It also provides researchers interested in developing EIBI within war-torn countries, and we deem the introduction of this model across Syria as a critical endeavor owing to the general lack of resources in the country. Furthermore, our evidence may provide a theoretical basis and practical guidance for adjusting interventions for habilitation and teaching in children with ASD.

Limitations

Our sample size was limited (i.e., 67 children from the Future Center); we used a quasi-random study design; our pre–post-test design lacked a control group; and we evaluated FC-EIBI implemented in Syria under a specific environment that had scarce support regarding ASD. Therefore, future studies should include larger samples and present more rigorous designs.

Moreover, our evaluations were conducted between 2008 and 2010; since then, some of the tools we used were updated (e.g., CARS to CARS-2). Nonetheless, at that time, the instrumentation was applicable for the program evaluation, and the results demonstrated relevant improvements in participants’ scores for all scales. In addition, we deem this program evaluation as novel because it was implemented with Arabic speakers, included parents, and was conducted in an environment that was less than ideal for the education of individuals with ASD.

Strengths

This study had the following strengths: (a) we used blinded examiners for conducting the comprehensive and uniformized assessment protocols; (b) the personnel that conducted the treatment were experienced in the field; (c) the EIBI we used was standardized based on ABA research; and (d) it underpins the hard work required for establishing services for children with ASD in countries lacking support, funding, and infrastructure for such interventions. The situation in Syria is not an easy one, be it for the families involved or for the researchers and practitioners attempting to conduct their work. Thus, the results provide evidence that children with ASD ages 1–6 years old may experience gains of fundamental importance by undergoing EIBI.

Supplemental Material

sj-docx-1-foa-10.1177_10883576211073686 – Supplemental material for Early Intensive Behavioral Intervention Program for Children With Autism in Syria

Supplemental material, sj-docx-1-foa-10.1177_10883576211073686 for Early Intensive Behavioral Intervention Program for Children With Autism in Syria by Wissam Mounzer and Donald M. Stenhoff in Focus on Autism and Other Developmental Disabilities

Supplemental Material

sj-docx-2-foa-10.1177_10883576211073686 – Supplemental material for Early Intensive Behavioral Intervention Program for Children With Autism in Syria

Supplemental material, sj-docx-2-foa-10.1177_10883576211073686 for Early Intensive Behavioral Intervention Program for Children With Autism in Syria by Wissam Mounzer and Donald M. Stenhoff in Focus on Autism and Other Developmental Disabilities