Application of intervention strategies for behavior management in autism spectrum disorder in childhood and adolescence. a systematic review

. Introduction and objectives: autism spectrum disorder (ASD) is a neurodevelopmental disorder, which exhibits symptoms such as early-onset impairment of interaction and social communication, as well as repetitive and restricted sensory and motor behavior. This study aims to carry out a systematic review regarding the application of intervention strategies for behavior management in autism spectrum disorder in childhood and adolescence. Methods: A systematic search of Randomized Controlled Clinical Trials conducted between January 2016 and June 2021 found in PubMed, Scient direct y Scopus was performed. Keywords used were “Psychomotor, disorder, autism, behavior, intervention”. Results: 2 845 records were found, and, after further analysis, 45 articles were obtained for the final analysis, with a number of participants (n=3 439), age range: 8-17 years of age, confirmed diagnosis of autism spectrum disorder. As a result, we found The use of technological resources is associated with a significant reduction in clinical severity of ASD, functioning global assessment, and social manifestations of anxiety. Conclusions: the authors to conclude that there are several strategies used for behavior management in autism spectrum disorder, the use of technological tools stands as a promising option as they are highly beneficial and contribute to achieve behavioral therapeutic objectives.


Introduction
According to Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013) and, International Classification of Diseases (ICD-11, 2018), Autism spectrum disorder (ASD) is a neurodevelopmental disorder, which exhibits symptoms such as early-onset impairment of interaction and social communication, as well as repetitive and restricted sensory and motor behaviors (Lord et al., 2018) Prevalence of ASD is increasing, due to recent changes in diagnostic criteria and optimization of assessment instruments, which are specific for this population (Mariño et al., 2021).
Considering the severity levels of ASD clinical symptoms, efforts are currently focused on research into intervention strategies that make it possible to mitigate the severity of symptoms and difficulties associated with diagnosis (Zwaigenbaum et al., 2015;Lai et al., 2020). There is evidence based on studies that evaluate the effectiveness of interventions ranging from conventional (Murza et al., 2016) to the use of virtual reality-based intervention modalities, application of alternative methods and the inclu-sion of parental involvement in treatment, (Gerow et al., 2018) all of these, designed with the purpose of reducing behavioral problems and stimulating the development of social, communicative, sensory, and motor skills (Marave et al., 2021).
This study aims to carry out a systematic review regarding the application of intervention strategies for behavior management in autism spectrum disorder in childhood and adolescence. A systematic search of Randomized Controlled Clinical Trials conducted between January 2016 and June 2021 found in PubMed, Scient direct y Scopus was performed following PRISMA systematic review and meta-analysis recommendations.

Inclusion criteria
Review of randomized controlled clinical trials conducted between January 2016 to June 2021, without language limits, related to intervention strategies for behavior management in autism spectrum disorder during childhood and adolescence, following PRISMA systematic re-

Analysis and data extraction
The manuscripts included were analyzed for: 1) characteristics of studied population: number of participants, diagnosis and age; 2) characteristics of interventions: design, frequency, duration, co-intervention and control group (Table 2). 3) characteristics of outcome measures of primary and secondary variables ( Table 3). The aforementioned data were obtained by using the CONSORT statement for RCT (Schulz, et al., 2010) whenever possible.
.  SI 1 1 0 0 0 0 1 1 1 1 6 1B A The selection criteria were specified. 2. Subjects were randomly assigned to groups (in a crossover study, subjects were randomized as they received treatments). 3. Allocation was concealed. 4. The groups were similar at the beginning in relation to the indicators of most important forecast. 5 All subjects were blinded 6. All therapists who administered the therapy were blinded. 7. All raters who measured at least one key outcome were blinded. 8. Measures of at least one of the key outcomes were obtained from more than 85% of the subjects initially assigned to the groups. 9. Results were presented for all subjects who received treatment or were allocated to the control group, or where this could not be, data for at least one key outcome were analyzed by "intention to treat" 10. Results of statistical comparisons between groups were reported for at least one key outcome. 11. The study provides point and variability measures for at least one key outcome.
-204 -Retos, número 47, 2023 (1º trimestre) Ability to recognize facial expressions and emotions in children with and without ASD.  . N= 24 (TEA) 10 individual therapy sessions attended by therapist, child, and primary caregiver with early therapeutic alliance N= 24 (TEA) 10 individual therapy sessions attended by therapist, child, and primary caregiver with late therapeutic alliance N= 31 (TEA) Classroom located in the hospital unit, consisted of two to four participants, followed a sequence with 5 minutes of play. followed by a social skills group with an average duration of 17 minutes.
N= 36 (TEA) Classroom located in the hospital unit, consisted of two to four participants, followed a sequence with 5 minutes of play. followed by a social skills group with an average duration of 17 minutes. Parsons et al. (2019) Improving visual motor, imitation, language, and social skills in young children with ASD 60 children. Age range: 2-6 years old. Diagnosed with ASD according to the Manual (DSM-V) N=30. They practiced 20 minutes on the TOBY app daily for 3 months using an iPad. Participants were then reassessed at 3 and 6 months.
N= 30 the control group received the TOBY app for 3 months.
To determine the feasibility and efficacy of home sensory interventions in children with autism spectrum disorder (ASD) 40 children.
Motor learning cognitive and motor skills IQ, CARS The regression analysis did not show any significance. This result means that IQ and CARS scores did not have an influence on the improvement in performance P = 0.096, r 2 = 0.38). Sarabzadeh et al.
Balance and coordination Learning acquisition, retention and transfer, proprioception, physical activity, body awareness, manual dexterity and ball skills.

M-ABC-2
Results showed a significant difference in the subscales of ball skills and balance performance (P < 0.05) and no significant difference in the manual agility scale (P > 0.05) between the two groups.
Kashefimehr et al. (2018) Occupational performance Emotional reactions, social responses, auditory processing and motor skills.

SCOPE
The intervention group showed significantly greater improvement in all the SCOPE domains, as well as in all the SP domains, except for the "emotional reactions" and "emotional/social responses" domains, (p < .05). ElGarhy & Liu (2016) motor skills and body awareness Psychomotor concepts (time, space and corporality) lista de verificación de Mann-WhitneyUtest onPIP Psychomotor intervention (PIP) improves motor skills and body awareness That is, 100% of students in the experi-mental group improved between 29% and 51%in body awareness, 17% and 57% in body con-cepts, 21% and 54% in space concepts, and 16%and 50% in overall psychomotor concepts (P= 0,16). Pan et al. (2017) Competence in motor skills and executive function Expression and emotion recognition FEET, (AR), (NEPSY-II) There was a significant group difference of medium effect in participants' ability to identify emotions, based on the NEPSY AR test (P= .04). Hill et al. (2020) Behavior in the task, level of satisfaction or not COPM Scores, videos Goal-directed occupational therapy leads to positive outcomes for children with ASD with or without the inclusion of the dog. (p < 0.01; 95%).6), indicating excellent inter-rater reliability of the on-task behaviour checklist. Tse et al. (2020) Emotional regulation behavioral functioning (ERC-ER), T-score y medida The intervention group demonstrated significant improvement in emotion regulation and reduction in behavioral problems (p<.05).

Rabeyron (2020)
Symptoms and clinical characteristics of autism CGI, CARS, ABC. Music therapy is more efficient when used as a complement to health care programs for ASDs, with great significance for stereotypy and lethargy. In the groups as reflected by a meaningful effect of time (P= < .001) IC 95%. The results indicate that adolescents with ASD can learn these aspects of social cognition implicitly in everyday acts, without being subjected to a structured teaching process. improvements in emotion recognition in low-intensity faces ( P < .001), improvements in emotion recognition on the DANVA-2 Face (P > .015) Retos, número 47, 2023 (1º trimestre) The affectation of the motor pattern of walking could be related to the planning of movements within the associative phases of motor learning with Movement Time (MT) and Percent Time-to-Peak Velocity (% TPV) p < 0,05.
Voss et al., Socialization VABS-II Children receiving the intervention showed significant improvements on the Vineland Adaptive Behaviors Scale socialization subscale compared with treatment as usual controls P = 0.005 Maskey et al.
Behavior, anxiety (SCAS-P), (SCAS-C), (FSSC-R), (CAPE) 1/3 of the group showed improvements in their specific phobia in real contexts; were able to manage everyday activities and situations that they did not previously.The treatment group showed a statistically significant greater improvement on Target Behaviour ratings compared with the control group, for both baseline to two weeks post treatment (p=0.021) Wang et al. Interventions of 8 to 12 weeks of individual music intervention can improve social communication and functional brain connectivity.Communication scores were higher in the music group post-intervention (difference score P = .01).Associated post-intervention resting-state brain functional connectivity was greater in music vs. nonmusic groups between auditory and subcortical regions (P < .0001) and auditory and fronto-motor regions (P < .0001). The findings support the effectiveness of the classroom intervention implemented by the teacher to improve participation, adaptive communication, social skills and executive functioning. Children in both groups experienced reduced solitary engagement (p<.001) and increased joint engagement (p<.001). Chang et al. (2018) Game skills, Receptive and expressive language skills (ADOS), (PPVT-4), (TCX) Improved participation in symbolic play was associated with increases in expressive language skills. There was a significant interaction (site by treatment by time) that was observed for the pre-symbolic play types p = 0.0421) Weiss et al. (2018) Emotional regulation in sadness, anger, worry, inhibition, and coping, emotional behavior, behavior adaptation skills and anxiety The children demonstrated significant improvements in measures of emotion regulation and aspects of psychopathology. Children with at least one disruptive disorder, and with both an anxiety and disruptive disorder, had greater levels of parent-reported child emotional lability/negativity at baseline compared to those without disruptive disorders p = 0.03 Yu et al. (2018) Physical Fitness (throwing, running, jumping and grip strength), non-verbal reasoning, language and visual attention.
Language, sociability, cognitive awareness, health and physical behavior.

ATEC
The results showed that there were differences in the two groups in all subscores (p=0.001).
Yun et al. (2017) Social behaviors, eye contact (ADOS). For facial emotion recognition, the percentages of correct answers were increased in similar patterns in both groups compared to baseline (P > 0.05). The subjects' ability to play, general behavioral and emotional symptoms were significantly diminished after treatment (p < 0.05). Conaughton et al. (2017) General level of functioning, behavior, anxiety (CGAS), (CBCL), (SCAS-C) The BRAVE-ONLINE program may be helpful in reducing anxiety symptoms in children with HFASD, although the effects are less strong than those found in neurotypical children. P=(p<.001). Touzet et al. (2017) Autism symptoms, behavioral adjustment, language level, sensory profile, and parental quality of life. Social comunication, social functioning, self-esteem, depression and family functioning.

(SSIS)
There was no significant difference for the child SSIS at week 13 p = 0.19) or however, for participants aged 13 and over in the intervention group, the child SSIS communication was significantly improved p = 0.07

Characteristics of participants and interventions
Based on findings retrieved from the 45 articles for final analysis, results related to the characteristics of the population were: number of participants (n=3 439), age range: 8-17 years of age, confirmed diagnosis of autism spectrum disorder with a profile in the levels of severity, which ranged from those with greater involvement to those with highest functionality, prior diagnosis of ASD using Diagnostic and Statistical Manual of Mental Disorders (DSM -IV, and V), Childhood Autism Rating Scale (CARS, secondary outcome), Aberrant Behavior Checklist (ABC, secondary outcome), Clinical Global Impression (CGI-I) and Pediatric Anxiety Rating Scale (PARS).
Regarding characteristics of the interventions, evidence was found on: Alternative therapies (tai-chi -mixed martial arts, acupuncture and yoga), sensory integration, psychomotor intervention, physical activity, physical exercise, animal-assisted therapy, music therapy, transcranial direct current stimulation, hydrotherapy, social skills training, cognitive -behavioral therapy, somatosensory therapy, virtual reality therapy, robot-based therapy, Early Start Denver Model and horse riding. According to the aforementioned information, it was found that six studies compared the effectiveness of virtual reality with different strategies to improve communication, interaction among children, facial expression, visual and motor skills in sensory processing, as well as behavioral work for anxiety in children with autism spectrum disorder. (McKinney, et al., 2020;de Moraes, et al., 2020;Wieckowski, et al., 2019;Parsons, et al., 2019;Sotoodeh, et al., 2017;Conaughton, et al., 2017).
Six studies compared physical activity and exercise versus conventional interventions, with duration of treatments between 12 to 48 weeks aiming to master motor skills, executive functions, emotional regulation, coordination, cognition, metabolism, sleep quality and reduction of stereotyped behaviors in children with autism spectrum disorder (ASD). Andy, 2020;Corral, et al., 2020;Tse, et al., 2019;Clare, et al., 2018;Toscano, et al., 2018).
Four studies evaluated the effectiveness of alternative therapies such as tai-chi for motor function, aromatherapy for regulation in anxiety processes, mixed martial arts for executive functions and yoga for communication processes. ( Sarabzadeh, et al., 2019;Hawkns, et al 2019;Phung & Goldberg, 2019;Nowell, et al., 2019).
Three studies showed the effectiveness of interventions with animals for social interaction and affective relationships such as therapeutic horse riding, behavior during task execution and social behavior during hospitalization using canines. (Hill, et al., 2020., Germone, et al., 2019Petty, et al., 2017).
Two studies demonstrated the effectiveness of somatosensory therapy versus other types of intervention for emotional reactions and responses in occupational performance. (Riquelme, et al., 2018;Padmanabha, et al., 2019) One study investigated the effectiveness of the use of the Early Start Denver Model versus other interventions (Touzet, et al., 2017). One study assessed the effectiveness of robotic training in a controlled clinical environment (Nowell, et al., 2019). Another study analyzed gestural production training . One study evaluated transcranial direct current stimulation (TDCS) (Hadoush, et al., 2020). Hydrotherapy (Mills, et al., 2020), symbolic play (Chang, et al., 2018), Coaching (Locke, et al., 2019) and effectiveness of sand play therapy were evaluated as well.
These findings demonstrated heterogeneity of doses between studies, where the average time of each intervention was 45min ± 16.08 minutes (range: 10-90 minutes), the average number of sessions per week was 15.8 ± 1.2 (range: 1-48 sessions per week); the mean number of weeks was 8.5 ± 3.6 (range: 1-16 week).

Assessment of methodological quality
For methodological quality assessment of studies included, the PEDRo scale was used (Table 1). Most studies obtained a high score, highlighting those published (Hawkins, et al., 2019) and (Chang, et al., 2018) that achieved a rating of 10.
In interventions related to motor functions, the greatest challenge was focused on the low frustration tolerance of patients, the control of group sessions and adherence to therapeutic process, particularly in studies with large populations (McKinney, et al., 2020). From this perspective, activities that include the development of sequences approached through symbolic letters, puzzles and categorizing games may be indicated as prerequisites to achieve skills that can support communicative development. These findings are consistent with other studies that demonstrated that physical activity such as Tai Chi Chuan, after six weeks of practice, might have a positive effect on balance, manual skills, but is also useful for regulation of speech skills, sensory regulation and stereotyped behavior (Phung & Goldberg, 2019).
However, due to variability in functioning profiles by levels of severity of ASD, it is likely that interventions need to be tailored to of everyone's symptoms. Likewise, it has been considered that cumulative effectiveness in behavior can be maintained over time, while physical activity programs (García & Gonzalez, 2021) are included accompanying other therapies that address the communication directly, aspects that should be evaluated in future longitudinal studies and meta-analyses (Andy, 2020). Regarding conductive-behavioral therapeutic approaches, the use of technological resources is associated with a significant reduction in clinical severity of ASD, functioning global assessment, and social manifestations of anxiety. In this regard, previous studies conclude that online interventions such as BRAVE-ONLINE (Conaughton, et al., 2017) are highly beneficial, as they allow maintenance of obtained results, after three months of follow-up. In addition to the therapeutic use of these digital tools, there are other elements of positive weighting, such as the level of satisfaction of parents and patients, who are highly pleased with these methodologies that can be applied at home, and whose functional objectives can be transfer to daily contexts (Wieckowski, et al., 2019). These results are related to findings from other studies which demonstrated statistically significant improvements in receptive language, pragmatic and social skills using tablets as mediators of the communicative process (Parsons, et al., 2019).
These data are useful for multidisciplinary rehabilitation teams to include in their interventions the use of information and communication technologies (ICT) to achieve social skills, that motivate children with ASD and their caregivers (Bravous et al., 2022).
It is important to acknowledge that, in recent years, strategies have diversified to respond to behavioral needs of children with ASD. In this way, music therapy has been used to manage lethargy and stereotypies. These results are usually obtained from 8-month duration structured programs, a dose of 25 sessions could induce the achievement of vestibular-origin motor skills that contribute to adaptation of participants and reduction of symptoms. Since this is a chronic condition, it is important to highlight that a sufficient number of sessions are required to notice the clinical improvements and to ensure its stability over time. To complement these statements, other studies have reinforced the utility of music therapy which demonstrated that, based on nervous system structural phenomena, it increased functional connectivity between the primary auditory cortex, subcortical and motor regions, which is often reduced in children with ASD; indicating a connection between changes of sensorimotor networks, and improvements in behavior. Since early motor difficulties are predictive of communication impairments, it is estimated that musical training programs aimed at motor skills may have a later impact on social behavior (Porter, et al., 2017).
Another emerging intervention in alternative therapies is aromatherapy, which based its use on reduction of anxi-ety responses in daily scenarios such as medical offices. According to its theories, a substance enters the body through an olfactory stimulus and reaches the limbic system, amygdala and hypothalamus to impact emotions and memory. Based on this action mechanism, once the aroma is captured and combined with a pleasant experience, the memory would be able to generate an association between the smell and the feeling of security.
Although contributions in this field are still emerging, the use of bergamot oil has shown to be of great utility for manage these behaviors in populations with neurotypical development. However, its application in studies performed with children with ASD has not provided positive results; on the contrary, it has been noticed that it may increase subjective feelings of insecurity in spaces of social interaction and high confluence as are found in medical centers (Hawkins, et al., 2019).
Concerning the inclusion of animals as support in therapeutic processes, interaction with dogs in lowfunctioning hospitalized children contributed significantly to verbal communication. However, during observation periods of interventions, no significant modifications were identified in prosocial behaviors such as getting involved in help situations or achieving physical contact with peers. It is important to highlight that these studies did not consider these conditions or opportunities; therefore, these findings cannot be assumed as being conclusive (Wieckowski, et al., 2019;Germone, et al., 2019).
Regarding the use of horses, after a period of 10 weeks of treatment, participants exhibited significant improvements interacting in solidarity at home with their families and expressing affection to pets, as reported by the caregivers. Nevertheless, authors have recognized some weaknesses in these studies in relation to sample size, and validity of the instruments for measuring results; so findings could be biased toward overestimation due to a ceiling effect of pre-and post-intervention measurements.
In accordance to the aforementioned, it is projected for future evaluation in research exercises, how humananimal interaction can affect family functioning; it could also be useful to acknowledge how the animal-induced behavior modification of children with ASD could benefit relationships at home (Petty, et al., 2017).
This study provides relevant information for teams that work with this type of populations, since management options can be applied by health and rehabilitation professionals from inter and trans-disciplinary approaches and, can lead to the development of new randomized control trials or studies that address complementary issues associated with prosocial behaviors specifically, for which sufficient evidence has not yet been reported.
Concerning the limitations of this review, the difficulty in blinding the participants by the type of population approached, do not allow to define conclusively which would be the best strategy for behavior modification within the autism spectrum. In this regard, it is considered that prescription of intervention processes from integrative approaches that include family, educators, and health staff, as well as the adaptation of strategies according to the characteristics, needs and, that are motivating for patients, could be useful recommendations, until better evidence is available.

Conclusion
The analysis of studies included in this systematic review allow the authors to conclude that there are several strategies used for behavior management in autism spectrum disorder, the use of technological tools stands as a promising option as they are highly beneficial and contribute to achieve behavioral objectives, that can be applied in daily life scenarios and that can be maintained over time in an estimated average of three months. However, it should be noted that there is no consensus regarding the prescription of intervention activities, since there are no defined protocols that respond to the functional diversity described in this disorder, and most of the studies that reported significant changes had subjects with higher levels of cognitive development and adaptive capacity.