What is the recommended timing, sequence, and goals of sensory integration, speech‑language therapy, occupational therapy, behavioral therapy, and applied behavior analysis for a child with autism spectrum disorder?

Timing, Sequence, and Goals of Autism Spectrum Disorder Therapies

Start Immediately: Do Not Wait for Formal Diagnosis

Begin intensive interventions (20-30 hours per week) combining developmental and behavioral approaches as soon as ASD is suspected or confirmed, without waiting for complete diagnostic evaluation, as interventions started before age 3 have significantly greater impact than those begun after age 5. 1

Core Intervention Framework (Birth to Age 3)

Immediate Implementation

• Intensity: Deliver 20-30 hours per week of structured therapy through therapists, plus 5 hours per week of parent training 1, 2
• Setting: Can be home-based (parent-managed), center-based (clinic or school), or combination depending on resources 1
• Approach: Integrate both behavioral (ABA-based) and developmental strategies—the distinction is less important than the integration, as most effective programs blend both 1

Primary Targets in Sequential Order of Development

1. Joint attention skills (Weeks 1-8): Large effect sizes demonstrated after just 6-8 weeks of targeted therapy 1, 3
2. Social communication and emotional reciprocity (Ongoing from start): Core deficit requiring continuous focus 1
3. Language skills (Ongoing from start): Moderate effect sizes after 12 months for expressive language growth 1

Specific Therapy Types and Their Roles

Applied Behavior Analysis (ABA)

• Goal: Systematically change behavior using principles of antecedents and consequences 1
• Timing: Begin immediately as part of comprehensive intervention 1, 2
• Specific techniques: Forward or backward chaining with reinforcement for multi-step tasks, differential reinforcement strategies, functional communication training 2, 3, 4
• Evidence: Comprehensive models like Early Start Denver Model and UCLA/Lovaas model show significantly improved outcomes after 2-3 years 1

Speech-Language Therapy

• Goal: Develop functional communication, including alternative modalities for nonverbal children 2
• Timing: Integrate from the start, not as separate sequential step 1, 3
• For minimally verbal children: Implement augmentative and augmentative communication (AAC) systems immediately, with mean pooled effect size of 0.88 3, 5
• Specific approaches: Picture Exchange Communication System, sign language, voice output communication aids, speech-generating devices 2, 5
• Evidence: Children receiving JASPER (naturalistic developmental behavioral intervention) with speech-generating devices from the start show superior outcomes in spontaneous communicative utterances 5

Occupational Therapy

• Goal: Address sensory processing, adaptive behaviors, and daily living skills 1
• Timing: Begin as part of comprehensive intervention package, sustained even when difficulties appear improved 4
• Specific techniques: Sensory integration approaches including weighted items, fidget toys, environmental modifications for light/noise control 4
• Integration: Should be coordinated with other therapies, not delivered in isolation 3

Parent Training as Co-Therapists

• Goal: Increase intervention time, capitalize on teachable moments, facilitate skill generalization across environments 1
• Timing: Must begin simultaneously with professional therapy, not after 1
• Specific role: Parents help set goals, teach/reinforce core features, implement strategies during daily routines 1, 2
• Evidence: Active family involvement has positive impact on developmental outcomes and is cost-effective 1

Age-Specific Considerations

Under Age 3

• Programs more likely to use developmental approaches, more intensively involve parents, and target social communication 1
• Focus on infant/preschool level strategies: guided participation, careful selection of play materials, organized environment 2

Age 3 and Older

• Continue intensive intervention (20-30 hours per week) but may shift more to center-based/school settings 1, 3
• Add structured educational approaches with explicit teaching methods tailored to strengths and vulnerabilities 2
• Implement classroom adaptations of evidence-based models like TEACCH program 2, 3

Critical Sequencing Principles

Do Not Sequence These Therapies—Deliver Simultaneously

The evidence does not support sequential delivery (e.g., "first do ABA, then add speech therapy"). Instead, deliver integrated intervention addressing multiple core deficits simultaneously from the start 1

Reassess and Adjust Every 4-8 Weeks

• Monitor which specific deficits show improvement versus those requiring modified approaches 2
• Children who initiate joint attention more frequently or have higher receptive language at baseline make more progress with naturalistic developmental behavioral interventions 6
• Adjust intensity, focus, and strategies based on individual response 2

Common Pitfalls to Avoid

• Do not wait for formal diagnosis completion: Begin intervention as soon as ASD is seriously considered 1
• Do not deliver therapies in isolation: Speech therapy, OT, and behavioral therapy must be coordinated and integrated 3
• Do not assume one intervention addresses all deficits: Target specific areas (language, joint attention, emotional reciprocity) with specific techniques 1
• Do not exclude parents from therapy delivery: Parent involvement is essential, not optional 1
• Do not focus solely on behavior management without addressing underlying communication needs: This is a critical error that misses the core deficits 3

Measuring Progress

Expected Outcomes by Timeframe

• 6-8 weeks: Large effect sizes for joint attention skills 1
• 12 months: Moderate effect sizes for expressive language growth 1
• 2-3 years: Significant improvements in cognitive and adaptive skills with comprehensive programs 1
• General expectation: Children should make approximately 6 months gain in language development over 6 months of active intervention 6

Use Standardized Measures

• Verbal Behavior Milestones Assessment and Placement Program 4
• Assessment of Basic Language and Learning Skills-Revised 4
• Aberrant Behavior Checklist-Irritability subscale 4