Early interventions for young children with ASD are often recommended to build a comprehensive treatment model ( Early Intervention Program for Infants and Toddlers with Disabilities, 2004; Reichow, 2012; Sandall et al., 2005) that aims to promote overall developmental growth through interventions across various domains ( Hyman et al., 2020; McConachie & Diggle, 2007; Solomon et al., 2007). Nevertheless, a thorough review of the existing literature indicates a scarcity of interventional studies, specifically targeting toddlers and preschool-aged children diagnosed with ASD ( Vismara & Rogers, 2008). Furthermore, only a few of these studies have implemented a comprehensive treatment model that holistically addresses many aspects of the disorder. Behavioral models, such as applied behavioral analysis (ABA) ( Lovaas, 1987), and naturalistic developmental models, such as the Early Start Denver Model (ESDM) ( Dawson et al., 2010), are, thus far, the most extensively researched approaches for treating ASD ( Baril & Humphreys, 2017; MacDonald et al., 2014; Tiura et al., 2017; Velazquez & Nye, 2011; Vivanti & Dissanayake, 2016). However, both methods have been criticized for their limitations ( Xu et al., 2018). On the one hand, the structured nature of ABA has faced criticism for its perceived limitations in promoting spontaneity and potential overreliance on prompts ( Bradshaw et al., 2015; Schreibman et al., 2015). On the other hand, the widespread adoption of ESDM has been hindered by substantial qualification and training requirements, resulting in increased community costs ( Boyd et al., 2010; Dawson et al., 2010).

Further, most early intervention studies have noticeably focused on samples comprising individuals who identify as white and monolingual English speakers ( DuBay et al., 2018). Additionally, interventionists with the necessary qualifications are predominantly certified in Western countries. The lack of acknowledgment of cultural diversity when providing early intervention services may hinder the implementation and efficacy of treatment, as research ( Buzhardt et al., 2016; Parra Cardona et al., 2012) has shown that the same interventions may not have similar efficacy across different populations. Moreover, interventions incongruent with a family’s culture, values, and expectations often lead to conflicts ( Hwa-Froelich & Vigil, 2004), strained therapeutic relationships ( Garcia et al., 2012), and higher rates of service discontinuation ( Long et al., 2015).

This phenomenon reflects the current situation in Malaysia. The exorbitant costs associated with obtaining the necessary training to become a proficient practitioner in administering early interventions can result in high treatment fees. According to published articles ( Kamaralzaman et al., 2018; Md Jani et al., 2022), the estimated annual financial costs associated with intensive comprehensive treatment (10–40 hours per week) could range between RM36,000 and RM42,472. Consequently, a notable obstacle to the availability of therapy emerges, leading to a tendency toward more affordable options that may lack a foundation for empirical evidence ( Ong, 2019; Yaacob et al., 2021). For instance, most alternative intervention strategies available in Malaysia, such as dietary supplements, hot-spring therapy, and religious practices, have not been tested empirically ( Ong, 2019). Moreover, parents of children with ASD have reported facing difficulties in facilitating therapy at home, which often leads to strained adult-child relationships ( Wetherby et al., 2014). Furthermore, vast differences in treatment approaches and outcomes pose difficulties in reaching a consensus as to which treatment strategies are the most effective ( Strain et al., 2011; Warren et al., 2011).

In summary, based on several literature reviews, the current limitations of early intervention programs are as follows: (1) limited published studies ( Vismara & Rogers, 2008); (2) not acknowledging cultural diversity ( DuBay et al., 2018); (3) being overly time-consuming ( Kasari et al., 2015); (4) poor transfer of acquired skills to daily life ( Prizant et al., 2000); (5) extensive requirements for qualification or training ( Boyd et al., 2010; Dawson et al., 2010).

Moreover, with the emerging literature suggesting no relationship between the intensity or style of treatment and treatment outcomes ( Rogers et al., 2021), as well as a significant effect of cultural values in early interventions ( DuBay et al., 2018; Fong & Lee, 2017), there is an urgent need to develop interventions for young children with ASD specific to the targeted populations. As such, early interventions for young children should be comprehensive and low-intensity and implemented in community settings ( Brian et al., 2015).

The primary objective of this current randomized controlled study is to assess the effectiveness of the CEITA program as an early intervention program for children in Malaysia who have been diagnosed with ASD and are aged four years and below. The efficacy of the CEITA program was assessed by examining its impact on developmental domains and the existence of ASD symptoms in the participants. This program is designed to provide a comprehensive intervention, and it has been designed with a rigorous empirical foundation, aiming to optimize the intervention’s impact by employing low-intensity and culturally relevant delivery modalities. This approach was tailored to meet the requirements of a cost-effective yet highly successful intervention for a specific target demographic.

In this study, 16 Malaysian children aged 18–48 months had been diagnosed with ASD were recruited and randomly assigned to either the intervention or control groups. Children in the intervention group who participated in the CEITA program showed a statistically significant decrease in autism-related symptoms. The M-CHAT-R/F scores substantially declined immediately after the completion of the CEITA program. Furthermore, these scores decreased further even after six weeks post-intervention. Conversely, children in the control group did not demonstrate any noteworthy variations during the designated timeline. With the non-significant baseline scores between the intervention and control groups, the huge decrease in scores and significant difference between the groups further suggested the high efficacy of the CEITA program. Indeed, the average initial M-CHAT-R/F scores for both groups fell within the high-risk category. However, following the intervention, the children in the intervention group achieved significantly lower scores (M=6.13) and were classified as falling within the medium-risk range. Contrarily, children in the control group exhibited a consistent pattern of M-CHAT-R scores that fell within the high-risk category. The M-CHAT-R scores for children in the intervention group continued to decrease at even after six weeks post-intervention, further supporting the efficacy and validity of the CEITA program and its possible long-term benefits.

The findings of this study also showed a significant increase in almost all developmental domains among children in the intervention group immediately after the CEITA program completion. The growth scores exhibited a sustained and significant increase across all domains during the post-intervention and at the six-week follow-up, indicating that the effects of the intervention were substantial and enduring. In fact, the strong correlation observed in the post-intervention stage provides clear evidence of the interconnectedness and inter-relatedness of all developmental areas. Further, except for the physical domains, all other domains, such as adaptive behaviors, social-emotional, cognition, and communications, showed a large intervention effect (p<0.001) at post-intervention and follow-up. The consistent increase in growth scores across the measured timeline within the intervention group further validates the intervention effect of the CEITA program in this study. Compared to other intervention studies with control groups ( Estes et al., 2015; Vivanti & Dissanayake, 2016) that did not show significant group difference immediately after the intervention, this research evidently presented a substantial intervention effect post-intervention. The immediate group differences observed in this study could be explained by several factors.

Compared to intervention programs and studies conducted in Western countries, the current research highlights the inclusion of cultural values and traditions. Some of the cultural considerations were as follows: (a) the choice of language used in sessions was congruent with the family; (b) the choice of activities or reinforcements given were culturally appropriate; (c) cultural celebrations or events included were relevant to the local community; (d) the materials used were closely related to the local community. The integration of cultural values and traditions in the CEITA program may be one of the prominent factors in its succession. The importance of cultural differences and the need for adaptation to early intervention have also been documented in recent research ( Xu et al., 2018), which found a significant intervention effect immediately after treatment. In their study, the authors also claimed that the cultural adaptation steps were necessary to ensure successful implementation of the intervention. Therefore, the findings of this study further support the importance of acknowledging cultural diversity among populations. In line with the widespread use of screening tools globally ( Han et al., 2023b; Soto et al., 2015), future studies should explore the potential of modifying efficacious interventions to cater to diverse populations with varying cultural backgrounds.

Apart from the cultural factors, the use of appropriate measures could also have contributed to the success of this study. As noted in previous studies ( Fulton et al., 2014; Vivanti & Dissanayake, 2016), different instruments and methodologies have been used to measure intervention efficacy. Although a consensus is reached that the efficacy of an ASD intervention is reflected in the decreased autism symptoms, the data obtained from different instruments may not accurately reflect the severity of symptoms, given the highly complex nature of the disorders. Additionally, young children diagnosed with ASD often exhibit impairments beyond communication and behavioral deficits ( Brian et al., 2015). Hence, This study assessed the effectiveness of the intervention by documenting the alterations in symptoms associated with autism and examining the changes in growth scores across various developmental domains. Specifically, the high correlation between developmental domains and autism symptoms further supports the inter-relatedness of the domains. This finding provides additional support for the fundamental theoretical underpinnings of the CEITA program, which is designed to prioritize comprehensive developmental growth rather than solely address the symptoms associated with ASD. Nonetheless, predictive analysis could not be performed in this study because the sample size of the intervention group was small. Future research could gather more data to analyze which developmental domains could be significant predictors of a reduction in ASD symptoms.

Overall, the findings of this study provide preliminary evidence that the CEITA program may be an effective early intervention for young children with ASD. The development-based approach in this model analytically assesses a child’s functioning level across many developmental domains, enabling therapists and parents to establish goals that are more attainable and aligned with the child’s current ability level. Therefore, the implementation and utilization of the CEITA program in this study align with the concept of early intervention for young children ( Dunst, 2000), which refers to the provision of assistance and services to young children and their families regardless of whether the child has a diagnosed disability or is at risk of developing a disability. In fact, the current findings provide initial support for further studies on evidence-based early intervention to enhance overall developmental growth as a primary method for mitigating symptoms related to ASD. Consequently, the stigmatization linked to ASD could be alleviated, and the effectiveness of treatments could be conveyed in a more optimistic and encouraging manner to parents. From a practical standpoint, the adoption of the CEITA program is anticipated to be more cost-effective and less time-consuming because of its delivery in low-intensity and brief sessions.

However, this study has several limitations. First, despite the significant intervention effects observed across measures, significant predictors among the developmental domains of autism symptoms could not be pinpointed, as the number of participants was too small for regression analysis. Second, although the CEITA program noted the importance of parental involvement, the analysis or findings on how parental involvement moderated the findings were not discussed. Third, as this study was designed to be quantitative, the qualitative nature that offers insights into other possible key explanations for the efficacy of the CEITA program might have been missed. Therefore, the current research findings are preliminary and should be interpreted cautiously.

In summary, this study makes a significant contribution to the field of early intervention services for young children with ASD, particularly considering the limited number of existing comparable papers. Furthermore, the CEITA program examined in this study was designed to recognize the significance of cultural diversity. This study’s findings suggest that the inclusion of cultural values in early interventions may have a beneficial moderating effect on their efficacy. Furthermore, the CEITA program’s design and methodology were emphasized as being of significant relevance. The developmental trajectory of a child with ASD is highlighted as comparable to that of a neurotypical child, in which the growth of all developmental domains is interwoven during the early years ( Hyman et al., 2020). These results emphasize the importance of complete and holistic early interventions.