Clinical Predictors of Discontinuation of Adapted Intensive Applied Behavior Analysis in Children with Autism: A 10 Year Retrospective Study
-
Hamidreza Pouretemad
,
Saeid Sadeghi
,
Sima Saniee
,
Elnaz Veisi
,
Fatemeh Farshchi
,
Katayoun Khoshabi
,
Serg Brand
Abstract
Objective: Applied Behavior Analysis (ABA) is an evidence-based intervention for autism spectrum disorder (ASD), but treatment discontinuation remains common. Adapted Intensive Applied Behavior Analysis (AIABA) is a culturally modified version of ABA developed for Iranian families, that integrates cultural and family values into daily routines. This study examined clinical and contextual predictors of AIABA discontinuation.
Method: We reviewed clinical files of 529 children with ASD (mean age = 41.7 months, SD = 13.8) who received AIABA at the Tehran Autism Center (2011 2021). Predictors included parental engagement, programming mode (in person vs. semi online), medication use, age at diagnosis, comorbidity, motor development, additional therapies, and symptom severity. Logistic regression identified predictors of discontinuation.
Results: Discontinuation occurred in 66.7% of children. Mean treatment duration was shorter in the discontinuation group (11.4 months) than the planned termination group (19.1 months). Significant predictors included lower parental engagement (OR = 0.03, 95% CI [0.01 0.07]), concurrent medication use (OR = 3.22, 95% CI [1.89 5.49]), semi online supervision (OR = 3.01, 95% CI [1.61 5.63]), higher pre cessation symptom severity (OR = 1.04, 95% CI [1.01 1.06]), and younger age at diagnosis (OR = 0.97, 95% CI [0.95 0.98]). The model explained 38.8% 53.9% of variance and correctly classified 83.4% of cases.
Conclusion: Lower parental engagement, concurrent medication use, semi online supervision, higher pre cessation symptom severity, and younger age at diagnosis significantly predicted AIABA discontinuation. Targeting parental engagement, monitoring intensity, and coordinated care may reduce dropout risk. Given the retrospective, single center design and reliance on record-based measures, results require cautious interpretation. Prospective multi-site studies are needed to translate these predictors into retention focused planning.
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7. Baer DM, Wolf MM, Risley TR. Some current dimensions of applied behavior analysis. J Appl Behav Anal. 1968;1(1):91-7.
8. Lovaas OI. Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol. 1987;55(1):3-9.
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17. علیرضا ما, احمد ع, نسرین بن. فراتحلیل اثربخشی روش تحلیل رفتار کاربردی (ABA) بر مشکلات کودکان مبتلا به اختلال طیف اوتیسم در ایران، 92-1384. 2015.
18. Virués-Ortega J. Applied behavior analytic intervention for autism in early childhood: meta-analysis, meta-regression and dose-response meta-analysis of multiple outcomes. Clin Psychol Rev. 2010;30(4):387-99.
19. Collins IM, Halter F, Schächinger Tenés LT, Lieb R, Meyer AH. A meta-analysis of applied behavior analysis-based interventions to improve communication, adaptive, and cognitive skills in children on the autism spectrum. Rev J Autism Dev Disord. 2025:1-21.
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21. Asta L, Persico AM. Differential Predictors of Response to Early Start Denver Model vs. Early Intensive Behavioral Intervention in Young Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis. Brain Sci. 2022;12(11).
22. Sandbank M, Bottema-Beutel K, Crowley LaPoint S, Feldman JI, Barrett DJ, Caldwell N, et al. Autism intervention meta-analysis of early childhood studies (Project AIM): updated systematic review and secondary analysis. Bmj. 2023;383:e076733.
23. Reichow B, Wolery M. Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA young autism project model. J Autism Dev Disord. 2009;39(1):23-41.
24. Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;10:Cd009260.
25. Spreckley M, Boyd R. Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language, and adaptive behavior: a systematic review and meta-analysis. J Pediatr. 2009;154(3):338-44.
26. Trembath D, Vivanti G. Problematic but predictive: individual differences in children with autism spectrum disorders. Int J Speech Lang Pathol. 2014;16(1):57-60.
27. Tiura M, Kim J, Detmers D, Baldi H. Predictors of longitudinal ABA treatment outcomes for children with autism: A growth curve analysis. Res Dev Disabil. 2017;70:185-97.
28. Stahmer AC, Schreibman L, Cunningham AB. Toward a technology of treatment individualization for young children with autism spectrum disorders. Brain Res. 2011;1380:229-39.
29. Granpeesheh D, Dixon DR, Tarbox J, Kaplan AM, Wilke AE. The effects of age and treatment intensity on behavioral intervention outcomes for children with autism spectrum disorders. Res Autism Spectr Disord. 2009;3(4):1014-22.
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31. Ben-Itzchak E, Zachor DA. The effects of intellectual functioning and autism severity on outcome of early behavioral intervention for children with autism. Res Dev Disabil. 2007;28(3):287-303.
32. Zarafshan H, Mohammadi MR, Abolhassani F, Motevalian SA, Sepasi N, Sharifi V. Current Status of Health and Social Services for Children with Autism in Iran: Parents' Perspectives. Iran J Psychiatry. 2019;14(1):76-83.
33. Baekeland F, Lundwall L. Dropping out of treatment: a critical review. Psychol Bull. 1975;82(5):738-83.
34. Armbruster P, Schwab-Stone ME. Sociodemographic characteristics of dropouts from a child guidance clinic. Hosp Community Psychiatry. 1994;45(8):804-8.
35. Cottrell D, Hill P, Walk D, Dearnaley J, Ierotheou A. Factors influencing non-attendance at child psychiatry out-patient appointments. Br J Psychiatry. 1988;152:201-4.
36. Gould MS, Shaffer D, Kaplan D. The characteristics of dropouts from a child psychiatry clinic. J Am Acad Child Psychiatry. 1985;24(3):316-28.
37. Grover S, Mallnaik S, Chakrabarti S, Mehra A. Factors associated with dropout from treatment: An exploratory study. Indian J Psychiatry. 2021;63(1):41-51.
38. Choi KR, Bhakta B, Knight EA, Becerra-Culqui TA, Gahre TL, Zima B, et al. Patient Outcomes After Applied Behavior Analysis for Autism Spectrum Disorder. J Dev Behav Pediatr. 2022;43(1):9-16.
39. American Psychiatric Association D, American Psychiatric Association D. Diagnostic and statistical manual of mental disorders: DSM-5: American psychiatric association Washington, DC; 2013.
40. Bandyopadhyay Prasanta S, Forster Malcolm R, Oxford E, Barkow Jerome H, Leda C, John T, et al. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Dsm-5, Washington, DC, American Psychiatric Publishing, 2013. Ananth Mahesh, In defense of an evolutionary concept of health nature, norms, and human biology, Aldershot, England, Ashgate. Philosophy. 2014;39(6):683-724.
41. Lord C, Rutter M, Le Couteur A. Autism Diagnostic Interview-Revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. J Autism Dev Disord. 1994;24(5):659-85.
42. Bell CC. DSM-IV: diagnostic and statistical manual of mental disorders. Jama. 1994;272(10):828-9.
43. Organization WH. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines: World Health Organization; 1992.
44. Pouretemad HR, Khoshabi K. Application of Lovaas-based Structured Behavioral Therapy for Children with Autistic Disorders. National Research Centre of Medical Sciences, Ministry of Health and Medical Education of Iran; 2001.
45. Grant proposal [in Persian]. South M, Williams BJ, McMahon WM, Owley T, Filipek PA, Shernoff E, et al. Utility of the Gilliam Autism Rating Scale in research and clinical populations. J Autism Dev Disord. 2002;32(6):593-9.
46. Ahmadi S, Safari T, Hemmatian M, Khalili Z. Exploring the criterion of diagnosing autism (GARS). Journal of Researchers of Cognitive and Behavioral Sciences. 2012;1(1):87-104.
47. Baharian N, Raji P, AlizadehZarei M, Baghestani AR. Effectiveness of a Sensory Play Activity Program with Parent Engagement for Children with Autism Spectrum Disorder: A Randomized Control Trial. Iranian Journal of Psychiatry & Behavioral Sciences/Progress in Psychiatry & Behavioral Sciences. 2023;17(4).
48. Althoff CE, Dammann CP, Hope SJ, Ausderau KK. Parent-Mediated Interventions for Children With Autism Spectrum Disorder: A Systematic Review. Am J Occup Ther. 2019;73(3):7303205010p1-p13.
49. Odonnell K. Critical Review of Applied Behavioral Analysis and Parental Involvement for Autism Spectrum Disorder. 2017.
50. Shiri E, Pouretemad H, Fathabadi J, Narimani M. A pilot study of family-based management of behavioral excesses in young Iranian children with autism spectrum disorder. Asian J Psychiatr. 2020;47:101845.
51. Sneed L, Samelson D. Effectiveness of parent-led applied behavior analysis at improving outcomes for parents of autistic children. Journal of Social, Behavioral, and Health Sciences. 2022;16(1):160-76.
52. Aqdassi L, Pouretemad HR, Fathabadi J, Sadeghi S. Family-based tele-intervention of SPARK program on motor proficiency and severity of autism symptoms in children with high functioning autism spectrum disorder: A pilot study. Razi Journal of Medical Sciences. 2019;25(11):61-71.
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| Section | Original Article(s) | |
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| Autism Spectrum Disorder (ASD) Applied Behavior Analysis Family Iran Retrospective Studies Patient Non-Compliance | ||
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How to Cite
1.
Pouretemad H, Sadeghi S, Saniee S, Veisi E, Farshchi F, Khoshabi K, Brand S. Clinical Predictors of Discontinuation of Adapted Intensive Applied Behavior Analysis in Children with Autism: A 10 Year Retrospective Study. Iran J Psychiatry. 2026;:1-13.
