Recommendations for research
- 1 A key worker approach for autistic children and young people and their families
- 2 Managing behaviour that challenges in autistic children and young people
- 3 Treating comorbid anxiety in autistic children and young people
- 4 Teacher-, parent- and peer-mediated psychosocial interventions in pre‑school autistic children
What is the value of a key worker approach (defined by protocol and delivered in addition to usual care) for autistic children and young people in terms of parental satisfaction, functioning and stress and child psychopathology?
Autism is well characterised as a chronic disorder with lifelong disability in some individuals, yet the current health management structure is usually organised around single episodes of care. The theory and practice of management of chronic illness, as well as widely expressed service-user opinion, indicate that a chronic care model for the organisation of autism services could be appropriate and cost effective.
A key worker approach for autistic children and young people and their families should be formally evaluated in a randomised controlled trial (RCT) reporting short- and medium-term outcomes (including cost-effectiveness) with a follow‑up of at least 6 months and again at 12 months. The outcomes (parental satisfaction, functioning and stress and child psychopathology) should be assessed by structured clinical interviews, parent- and self-reports using validated questionnaires and objective measures of behaviour. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators (in particular the child or young person's age) should be investigated.
Is a group-based parent training intervention for parents or carers of autistic children and young people clinically and cost effective in reducing early and emerging behaviour that challenges in the short- and medium-term compared with treatment as usual?
Behaviour that challenges is common in autistic children and young people but many are referred only when the behaviour has become severely impairing, they pose a threat to themselves or others, or everyday life has broken down. By this time, behavioural interventions may be difficult or impossible and antipsychotic medication is used despite it being symptomatic in its benefits, having long-term adverse effects and behavioural problems typically recurring after use.
A group-based parent training intervention (such as educating parents to identify triggers and patterns of reinforcement) should be evaluated using an RCT. Primary outcomes should be short- and medium-term reduction in behaviour that challenges. Secondary outcomes should include parental and sibling stress, quality of life and the child or young person's adaptive function. The medium-term use of medication should also be assessed. Cost effectiveness should encompass a wide range of services, such as additional educational support and social services, and health service use by families.
What is the comparative clinical and cost effectiveness of pharmacological and psychosocial interventions for anxiety disorders in autistic children and young people?
Early trials of CBT for anxiety in autistic children and young people have been promising but have methodological shortcomings. Furthermore, the common pharmacological approaches have not been evaluated in this population.
A parallel-arm RCT should compare pharmacological and psychosocial interventions with placebo in autistic children and young people and an anxiety disorder. Pharmacological treatment should be with a selective serotonin reuptake inhibitor (SSRI) and dosing should follow research in typically developing children but with the option of evaluating outcomes at lower doses. The SSRI should be blinded with an identical placebo and an 'attention' or other psychosocial control group. The psychosocial intervention should be manualised and based on cognitive behavioural approaches shown to be effective in previous trials. The sample should cover the full age and intellectual range of children and young people and the size powered to deliver precise effect size estimates for both active arms.
Primary outcome measures should be reduction in anxiety symptoms by parent report. Secondary outcomes may include self- and teacher-report, blinded measures such as heart rate and skin conductance, patient satisfaction, changes in adaptive function, quality of life and disruptive behaviour. Adverse effects should be evaluated and an economic evaluation included.