To explore the effect of play-based communication and behavior intervention (PCBI) on internalizing and externalizing behaviors in children with autism spectrum disorder (ASD).

From November 2018 to November 2021, 90 ASD children aged 8-30 months who registered in the Child Mental Health Research Center of the Affiliated Brain Hospital of Nanjing Medical University for PCBI ultra-early intervention training were selected and randomly assigned to the intervention group(n=60) and the waiting group(n=30) according to the ratio of 2∶1.Behavioral videos of free play between children and caregivers were collected before and after the 12-week intervention and the behavioral observation and analysis system (Observer XT) was used to code the parent-child interaction status and children's internalizing and externalizing behaviors.SPSS 23.0 statistical software were used and the data were analyzed by t-test, chi-square test, Pearson correlation analysis and multiple linear stepwise regression analysis.

After the intervention, the children in the intervention group had improved internalizing and externalizing behaviors (2.43±2.22, 1.88±1.91) compared with those before the intervention (4.82±3.37, 3.68±5.68), and the difference was statistically significant (t=4.66, 2.60, both P<0.05). The children in the waiting group had no significant difference in internalizing and externalizing behaviors before (4.23±2.47, 4.00±2.18) and after intervention (4.37±2.57, 4.67±3.72) (t=-0.23, -0.83, both P>0.05). After intervention, the children in the intervention group had fewer internalizing and externalizing behaviors than those in the waiting group, and the difference was statistically significant (t=-3.70, -4.71, both P<0.05). The differences in internalizing behaviors (2.38±3.96, 1.80±5.37) and externalizing behaviors (1.80±5.37, -0.67±4.38) between the two groups before and after the intervention were statistically significant (t=3.03, 2.18, both P<0.05). The results of multiple linear stepwise regression showed that the negative interaction of caregivers (β=0.29, P<0.01) was a risk factor for internalizing behaviors.The negative interaction of children (β=0.45, P<0.01) was a risk factor for externalizing behaviors, and the child's object status (β=-0.30, P<0.01) and binary interaction (β=-0.39, P<0.01) were protective factors for externalizing behaviors.In the intervention group, active child interaction, active caregiver interaction, and binary interaction increased after the intervention (t=-6.77, -4.58, -7.72, all P<0.05), while the child's object status and the caregiver's negative interaction decreased (t=3.37, 4.30, both P<0.05).

The PCBI ultra-early intervention can effectively improve the internalizing and externalizing behaviors of ASD children.Improvements in internalizing behaviors may work by reducing negative caregiver interactions, and improvements in externalizing behaviors may work by increasing parent-child binary interactions.

Autism spectrum disorder; Play-based communication and behavior intervention; Ultra-early intervention; Internalizing behaviors; Externalizing behaviors; Parent-child interaction