Early Intensive Intervention

Comprehensive Curriculum

• Addresses all major developmental domains, not just isolated skills.
• Programming is individualized based on assessment results (VB-MAPP, ABLLS-R, or equivalent).
• Curriculum is sequenced developmentally and adjusted based on ongoing data.

Individualized Programming

• Every child's program is different based on their assessment profile, learning style, and family priorities.
• Programs are not "one size fits all" packages—cookie-cutter approaches violate the individualization principle.
• Data-driven decision making adjusts programs weekly or more frequently.

1:1 or Small Group Delivery

• Begin with 1:1 instruction to establish foundational learning skills.
• Transition to small group (1:2, 1:3) as the child develops group readiness skills (attending, waiting, responding in turn).
• Group instruction builds social skills and prepares for less intensive settings (preschool, kindergarten).

Historical Context

Lovaas (1987) Study

• Landmark study: 19 children receiving 40 hours/week of intensive ABA for 2+ years.
• 47% achieved "normal functioning" (IQ in normal range, placed in regular education).
• Control groups receiving <10 hours or no treatment showed significantly less improvement.
• Criticized for methodological limitations (non-random assignment, IQ as primary outcome) but catalyzed the field.

Evolution Since Lovaas

• Modern EIBI incorporates naturalistic teaching strategies (NET), verbal behavior approaches, and social skills programming alongside DTT.
• Increased emphasis on family involvement and quality of life outcomes beyond IQ.
• Recognition that not all children respond equally—predictors of response include pre-treatment skills, rate of learning, and treatment integrity.

Curriculum Domains

Language and Communication

• Manding (requesting): Foundational skill—teaches the child that communication produces outcomes.
• Tacting (labeling): Naming objects, actions, properties in the environment.
• Intraverbal: Conversational responses, answering questions, fill-in-the-blank.
• Echoic: Vocal imitation—a prerequisite for vocal language development.
• Listener responding: Following instructions, receptive identification.
• AAC: Augmentative and alternative communication for pre-vocal or minimally vocal learners (PECS, SGD).

Social Skills

• Joint attention: following and initiating shared focus.
• Social referencing: looking to others for information.
• Turn-taking and sharing.
• Cooperative play.
• Peer interaction: initiating, responding, maintaining.
• Emotion recognition and expression.

Adaptive and Self-Help Skills

• Toilet training.
• Self-feeding: utensil use, cup drinking, food tolerance.
• Dressing: putting on/removing clothing, fasteners.
• Hygiene: handwashing, teeth brushing, bathing.
• Safety skills: responding to name, stopping, danger awareness.

Academic Readiness

• Pre-academic skills: matching, sorting, sequencing.
• Pre-literacy: letter recognition, phonemic awareness, name writing.
• Pre-math: counting, number recognition, one-to-one correspondence.
• Attending to group instruction: sitting in a group, following group directions.

Play Skills

• Independent play: engaging with toys functionally and for sustained periods.
• Symbolic/pretend play: using objects representatively, creating narratives.
• Cooperative play with peers.
• Leisure skills: activities the child can engage in independently for recreation.

Behavior Reduction

• Functional behavior assessment to identify the function of problem behaviors.
• Function-based interventions: FCT, DRA, antecedent interventions.
• Replacement behaviors that serve the same function as the problem behavior.
• Proactive strategies to prevent problem behavior from occurring.

Evidence Base

Meta-Analyses

Long-Term Outcomes

• Some children who receive EIBI achieve typical educational placement and independence.
• Others make significant but not normalizing gains—improvements in adaptive functioning, communication, and quality of life are valuable in their own right.
• Predictors of stronger response: higher pre-treatment skills (especially language), faster initial learning rate, earlier start, and higher treatment integrity.

Determining Recommended Hours

Factors to Consider

• Severity of skill deficits: More severe deficits generally warrant more hours.
• Number of treatment targets: More targets require more programming time.
• Learning rate: Children who acquire skills more slowly may benefit from more hours to reach the same goals.
• Family resources and schedule: Practical constraints affect what is feasible.
• Research base: Evidence supports 25–40 hours for comprehensive EIBI, but individualization is key.
• Payer guidelines: Insurance companies may have hour caps; clinical documentation should support the requested hours.

Dose-Response Relationship

• Linstead et al. (2017) found a positive dose-response relationship: more hours of ABA were associated with greater gains in all domains.
• Diminishing returns may occur at the highest intensities for some children.
• Hours should be adjusted over time based on the child's progress—not set at one level permanently.

Transition Planning

From EIBI to Less Intensive Services

Transition occurs when:

• The child has mastered foundational skills and is ready for a less intensive model.
• The child is entering a school setting that provides appropriate support.
• Data show maintenance of skills at reduced service levels.

Transition Process

1. Assess readiness: Does the child have the prerequisite skills for the receiving environment (group instruction, independence, safety)?
2. Gradual reduction: Decrease hours incrementally while monitoring data.
3. Environmental preparation: Visit the new setting, meet teachers, adapt materials.
4. Overlap period: Maintain some ABA support during the initial transition period.
5. Consultation: BCBA consults with the school team to ensure skill maintenance.
6. Follow-up: Scheduled check-ins and maintenance probes after transition.

School Readiness Skills

Skills that support successful school transition:

• Sitting in a group for 15+ minutes.
• Following group instructions.
• Raising hand and waiting to be called on.
• Transitioning between activities independently.
• Toileting independently.
• Communicating needs to unfamiliar adults.
• Tolerating peer proximity and noise.

Parent Involvement in EIBI

• Parents are essential team members, not passive recipients of services.
• Parent training (97156) should occur weekly or biweekly at minimum.
• Parents implement strategies during natural routines: mealtimes, bath time, play, errands.
• Parent-implemented intervention extends the treatment dose beyond direct therapy hours.
• Assess and support parent well-being—EIBI is demanding for families.

Quality Indicators for an EIBI Program

• Individualized assessment-driven curriculum (not a pre-packaged one-size program).
• Data collected on every target, every session.
• Regular BCBA supervision (minimum 10–15% of direct hours).
• Ongoing staff training with treatment integrity monitoring.
• Active caregiver training component.
• Regular program review with data-based modifications.
• Generalization and maintenance programming embedded throughout.
• Transition planning from the beginning of treatment.

Key References

• Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3–9.
• Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross, S. (2009). Meta-analysis of early intensive behavioral intervention for children with autism. Journal of Clinical Child & Adolescent Psychology, 38, 439–450.
• Howard, J. S., Stanislaw, H., Green, G., Sparkman, C. R., & Cohen, H. G. (2014). Comparison of behavior analytic and eclectic early interventions for young children with autism after three years. Research in Developmental Disabilities, 35, 3326–3344.
• Linstead, E., et al. (2017). An evaluation of the effects of intensity and duration on outcomes across treatment domains for children with autism spectrum disorder. Translational Psychiatry, 7, e1234.
• Virués-Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood: Meta-analysis, meta-regression, and dose-response meta-analysis. Clinical Psychology Review, 30, 387–399.