Parent inclusion in Early Intensive Behavioral Intervention: the influence of parental stress, parent treatment fidelity and parent-mediated generalization of behavior targets on child outcomes

Effect of community interventions on social-communicative abilities of preschoolers with autism spectrum disorder

PURPOSE

To evaluate the effect that different intervention methods have on the social-communicative abilities of children with autism spectrum disorder (ASD) in community settings.

METHODS

Intervention based on applied behaviour analysis was compared with a more specific intervention programme targeting imitation and joint attention (JA) and with treatment as usual in a sample of 85 children with ASD. Objective measures for imitation, JA, pretend play, language, autism severity and parent report measures were used to assess the effect of six months of intervention.

RESULTS

Results revealed no differences between the intervention methods. There was, however, great individual variability in outcome within each treatment method.

CONCLUSION

These results suggest that it is important to focus on "What works for whom" instead of trying to find a one-size-fits-all-treatment for children with ASD.

Systematic review of tools to measure outcomes for young children with autism spectrum disorder

BACKGROUND

The needs of children with autism spectrum disorder (ASD) are complex and this is reflected in the number and diversity of outcomes assessed and measurement tools used to collect evidence about children's progress. Relevant outcomes include improvement in core ASD impairments, such as communication, social awareness, sensory sensitivities and repetitiveness; skills such as social functioning and play; participation outcomes such as social inclusion; and parent and family impact.

OBJECTIVES

To examine the measurement properties of tools used to measure progress and outcomes in children with ASD up to the age of 6 years. To identify outcome areas regarded as important by people with ASD and parents.

METHODS

The MeASURe (Measurement in Autism Spectrum disorder Under Review) research collaboration included ASD experts and review methodologists. We undertook systematic review of tools used in ASD early intervention and observational studies from 1992 to 2013; systematic review, using the COSMIN checklist (Consensus-based Standards for the selection of health Measurement Instruments) of papers addressing the measurement properties of identified tools in children with ASD; and synthesis of evidence and gaps. The review design and process was informed throughout by consultation with stakeholders including parents, young people with ASD, clinicians and researchers.

RESULTS

The conceptual framework developed for the review was drawn from the International Classification of Functioning, Disability and Health, including the domains 'Impairments', 'Activity Level Indicators', 'Participation', and 'Family Measures'. In review 1, 10,154 papers were sifted - 3091 by full text - and data extracted from 184; in total, 131 tools were identified, excluding observational coding, study-specific measures and those not in English. In review 2, 2665 papers were sifted and data concerning measurement properties of 57 (43%) tools were extracted from 128 papers. Evidence for the measurement properties of the reviewed tools was combined with information about their accessibility and presentation. Twelve tools were identified as having the strongest supporting evidence, the majority measuring autism characteristics and problem behaviour. The patchy evidence and limited scope of outcomes measured mean these tools do not constitute a 'recommended battery' for use. In particular, there is little evidence that the identified tools would be good at detecting change in intervention studies. The obvious gaps in available outcome measurement include well-being and participation outcomes for children, and family quality-of-life outcomes, domains particularly valued by our informants (young people with ASD and parents).

CONCLUSIONS

This is the first systematic review of the quality and appropriateness of tools designed to monitor progress and outcomes of young children with ASD. Although it was not possible to recommend fully robust tools at this stage, the review consolidates what is known about the field and will act as a benchmark for future developments. With input from parents and other stakeholders, recommendations are made about priority targets for research.

FUTURE WORK

Priorities include development of a tool to measure child quality of life in ASD, and validation of a potential primary outcome tool for trials of early social communication intervention.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002223.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities

BACKGROUND

Outwardly-directed aggressive behaviour is a significant part of problem behaviours presented by people with intellectual disabilities. Prevalence rates of up to 50% have been reported in the literature, depending on the population sampled. Such behaviours often run a long-term course and are a major cause of social exclusion. This is an update of a previously published systematic review (see Hassiotis 2004; Hassiotis 2008).

OBJECTIVES

To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly-directed aggressive behaviour in people with intellectual disabilities when compared to standard intervention or wait-list controls.

SEARCH METHODS

In April 2014 we searched CENTRAL, Ovid MEDLINE, Embase, and eight other databases. We also searched two trials registers, checked reference lists, and handsearched relevant journals to identify any additional trials.

SELECTION CRITERIA

We included studies if more than four participants (children or adults) were allocated by random or quasi-random methods to either intervention, standard treatment, or wait-list control groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies and extracted and assessed the quality of the data.

MAIN RESULTS

We deemed six studies (309 participants), based on adult populations with intellectual disabilities, suitable for inclusion in the current version of this review. These studies examined a range of cognitive-behavioural therapy (CBT) approaches: anger management (three studies (n = 235); one individual therapy and two group-based); relaxation (one study; n = 12), mindfulness based on meditation (one study; n = 34), problem solving and assertiveness training (one study; n = 28). We were unable to include any studies using behavioural interventions. There were no studies of children.Only one study reported moderate quality of evidence for outcomes of interest as assessed by the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We judged the evidence for the remaining studies to be of very low to low quality. Most studies were at risk of bias in two or more domains: one study did not randomly allocate participants and in two studies the process of randomisation was unclear; in one study there was no allocation concealment and in three studies this was unclear; blinding of assessors did not occur in three studies; incomplete outcome data were presented in one study and unclear in two studies; there was selective reporting in one study; and other biases were present in one study and unclear in four studies.Three of the six studies showed some benefit of the intervention on improving anger ratings. We did not conduct a meta-analysis, as we considered the studies too heterogeneous to combine (e.g. due to differences in the types of participants, sample size interventions, and outcome measures).Follow-up data for anger ratings for both the treatment and control groups were available for two studies. Only one of these studies (n = 161) had adequate long-term data (10 months), which found some benefit of treatment at follow-up (continued improvement in anger coping skills as rated by key workers; moderate-quality evidence).Two studies (n = 192) reported some evidence that the intervention reduces the number of incidents of aggression and one study (n = 28) reported evidence that the intervention improved mental health symptoms.One study investigated the effects of the intervention on quality of life and cost of health and social care utilisation. This study provided moderate-quality evidence, which suggests that compared to no treatment, behavioural or cognitive-behavioural interventions do not improve quality of life at 16 weeks (n = 129) or at 10 months follow-up (n = 140), or reduce the cost of health service utilisation (n = 133).Only one study (n = 28) assessed adaptive functioning. It reported evidence that assertiveness and problem-solving training improved adaptive behaviour.No studies reported data on adverse events.

AUTHORS' CONCLUSIONS

The existing evidence on the effectiveness of behavioural and cognitive-behavioural interventions on outwardly-directed aggression in children and adults with intellectual disabilities is limited. There is a paucity of methodologically sound clinical trials and a lack of long-term follow-up data. Given the impact of such behaviours on the individual and his or her support workers, effective interventions are essential. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes that include reduction in outward-directed aggressive behaviour, improvement in quality of life, and cost effectiveness.

Building capacity for rigorous controlled trials in autism: the importance of measuring treatment adherence

Research groups across Europe have been networking to share information and ideas about research on preschool children with autism. The paper describes preliminary work to develop capacity for future multi-site randomized controlled trials of early intervention, with a specific focus on the need to measure treatment adherence where parents deliver therapy. The paper includes a review of randomized and controlled studies of parent-mediated early intervention from two sources, a recent Cochrane Collaboration review and a mapping of European early intervention studies in autism published since 2002. The data extracted focused on methods for describing parent adherence, that is, how and to what extent parents carry out the strategies taught them by therapists. Less than half of the 32 studies reviewed included any measure of parent adherence. Only seven included a direct assessment method. The challenges of developing pan-European early intervention evaluation studies are discussed, including choice of intervention model and of important outcomes, the need for translation of measurement tools and achievement of joint training to reliability of assessors. Measurement of parent-child interaction style and of adherence to strategies taught need further study.

Promoting Shared Decision Making to strengthen outcome of young children with Autism Spectrum Disorders: the role of staff competence

Little is known on how the conceptual description of Shared Decision Making (SDM) accomplishes clinical practice in the context of lifetime disabilities as in particular Autism Spectrum Disorders (ASD), when intervention is long-lasting and requires constant family involvement. This study aimed mainly to investigate to what extent the staff's competence in SDM contributes to positive child and parent improvement when involving parents in Early Intensive Behavior Interventions (EIBI). It was also geared to verify whether SDM staff competence contributes to a child's treatment responsiveness. A total of 25 young children with ASD (23 male, 3 female, age range 34-92 months, mean age 51.4±13.6) were included in the study. Of these, nine children were allocated to a Parent Involvement condition accompanied by SDM Staff Training (PI-SDM), and eight children to a Parent Inclusion in Treatment Delivery Only condition without SDM Staff Training (PI-DO). Nine months treatment outcomes of severity, developmental and adaptive measures were compared to Treatment As Usual (n=8). PI-SDM was associated with improvement of autistic symptoms (p≤.05), adaptive functioning (p≤.01) and developmental outcome (p≤.01), as well as parent (p≤.05) and staff competence (p≤.001). The magnitude of outcome was inferior in the PI-PO and TAU group. A Reliable Change was identified in more than 40% of children included in PI-SDM, while PI-PO (>20%) and TAU (>12%) let to little Reliable Change and partially skill deterioration. Staff's SDM skill competence predicts reduced parental stress (β=-.500, p≤.05) and contributes significantly to a positive treatment responder trajectory (p≤.01), besides lower severity (p≤.05), higher adaptive (p≤.01) and communication skills (p≤.05). The study indicates that parent inclusion should be conceptualized as a collaborative partnership model rather than as adherence in treatment provision, based on a target SDM staff training that may constitute an external contributor to treatment responsiveness and positive child as well as parent outcome.

Effects of parent management training programs on disruptive behavior for children with a developmental disability: a meta-analysis

This meta-analysis determined the effects of parent management training (PMT) on disruptive behaviors in children with a developmental disability. Parent management training programs, based on behavioral theories of psychology, are commonly used in addressing disruptive behavior in children. Eleven studies met inclusion criteria with a total of 540 participants, with 275 in experimental groups and 265 in control groups. The effect of PMT on the disruptive behavior in children with a developmental disability was significant (g=0.39). The moderator effects of type of PMT, delivery type and setting, and administrator level of education were also significant. The moderator effects of child age, and session number and duration were not significant in this meta-analysis.

Determinants of stress in parents of children with autism spectrum disorders

Parents of children with autism spectrum disorder are known to experience more stress than parents of children with any other conditions. The current study describes the parental stress of 118 fathers and 118 mothers at the onset of their children's Early Intensive Behavioral Intervention program. The objectives of the study were to compare and analyze each parent's stress and to identify factors that might predict their stress. Results indicated that fathers reported higher levels of stress than mothers. Correlations indicated that the stress levels of both parents were associated with their child's age, intellectual quotient, severity of autistic symptoms, and adaptive behaviors. Paternal stress, but not maternal stress, was predicted by severity of autistic symptoms and child's gender. Results are discussed in terms of their implications for services and early interventions.

Familia, estrés y atención temprana || Family, stress and early care attention

El presente trabajo tiene por objeto analizar la influencia del nivel de estrés de los padres y sus concepciones acerca de la educación de sus hijos con trastornos del desarrollo, sobre los resultados que se obtienen en la recuperación de las dificultades o trastornos en un Servicio de Atención Temprana. Para ello 23 familias (padre y madre) contestaron la versión reducida del CIP (Palacios, 1988) y la versión reducida del Parenting Stress Index (Solis y Abidin, 1995). Además, estos datos se relacionaron con los referentes a seguimiento de las pautas de intervención, nivel de estudios de los padres, temporalización en la consecución de los objetivos del programa de atención temprana, el etiquetado y la severidad del trastorno. Los resultados muestran que la recuperación de los trastornos de los hijos se relaciona en mayor medida con niveles de respuesta defensiva más bajos por parte de los padres en relación al nivel de estrés percibido, así como con concepciones modernas sobre el desarrollo de sus hijos.

A review of evidence-based early intervention for behavioural problems in children with autism spectrum disorder: the core components of effective programs, child-focused interventions and comprehensive treatment models

PURPOSE OF REVIEW

This article reviews recent evidence and other earlier relevant articles regarding early intervention studies for children with autism spectrum disorder (ASD).

RECENT FINDINGS

There is a well-established body of empirical evidence for the effectiveness of Early Intensive Behavioural Intervention (EIBI) with young children with ASD. The importance of parent skills training, education and positive behaviour support is also a key factor in influencing outcomes. Drug treatment is of short-term benefit for disruptive behaviour but long-term outcome and metabolic side-effects have not been studied.

SUMMARY

Few studies have measured the long-term value and effectiveness of early intervention treatments, and currently there are no articles published on effects into adulthood of such treatments. Such research would indicate whether early intervention results in reduced reliance on health services into adulthood.

Exploratory study describing 6 month outcomes for young children with autism who receive treatment as usual in Italy

BACKGROUND

In the last few years, the results of different studies have confirmed, in different ways, the importance of early intervention for autism. This study aims to evaluate the role of early "as usual" interventions in the outcome of toddlers diagnosed with autism spectrum disorder (ASD).

METHOD

Seventy children with ASD aged between 24 and 48 months were recruited at different centers in Italy. They were evaluated by blind researchers at baseline and after 6 months of using Autism Diagnostic Observation Schedule-Generic (ADOS-G), Griffiths Mental Developmental Scales, and Vineland Adaptive Behavior scales. Parents filled out the MacArthur Inventory, Social Communication Questionnaire, and Child Behavior Check List. All children were referred to community providers for available interventions.

RESULTS

At the endpoint, most of the children were still classified as having an ADOS-G classification of ASD. However, 21 (34.2%) passed from autism to autism spectrum, and 3 (4.2%) passed from autism spectrum to no spectrum. Treatment effects were obtained for cognitive functioning, language, adaptive behavior, and child behavior without differences between development-oriented and behavior-oriented interventions. Parent involvement was a mediator for the best clinical outcome. Baseline low impairments of communication, language comprehension, and gesture were predictors of positive outcome.

CONCLUSION

Treatment as usual, composed of individual therapy plus school-supported inclusion, may be an effective intervention in ASD. Better initial levels of communication in child and parent involvement during treatment have an important role for a positive outcome.

The relationship of early communication concerns to developmental delay and symptoms of autism spectrum disorders

OBJECTIVE

Parental concerns related to communication are an oft-cited reason that children present to early intervention clinics. We examine the relationship between early communication first concerns (FCs) and symptoms of ASD.

METHODS

The present study included 3173 toddlers at risk for developmental delay. The Battelle Developmental Inventory, 2nd edition and the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) were used to examine developmental quotient scores and autism symptoms.

RESULTS

Significant results were observed with respect to FC group and gender. A significant effect of FC-Communication group was observed with respect to developmental quotient overall and subscale scores, as well as autism symptom scores.

CONCLUSION

Those with communication disorders are a heterogeneous population and do not account for all children who will meet criteria for a diagnosis of an ASD.

Child Behavior Check List 1½-5 as a tool to identify toddlers with autism spectrum disorders: a case-control study

Tools to identify toddlers with autism in clinical settings have been recently developed. This study evaluated the sensitivity and specificity of the Child Behavior Check List 1½-5 (CBCL 1½-5) in the detection of toddlers subsequently diagnosed with an Autism Spectrum Disorder (ASD), ages 18-36 months. The CBCL of 47 children with ASD were compared to the CBCL of 47 toddlers with Other Psychiatric Disorders (OPD) as well as the CBCL of 47 toddlers with Typical Development (TD) in a case control study. One-way analysis of variance (ANOVA) and logistic regression with odds ratio (OR) analyses were performed. In order to establish the optimal threshold able to discriminate children with ASD from children with OPD and TD, Receiver Operating Characteristic (ROC) analyses were performed. One-way ANOVA revealed significant differences between the three groups. Logistic regression analysis showed that the Withdrawn and the Pervasive Developmental Problems (PDP) subscales can recognize toddlers subsequently identified as ASD from both children with TD (p<0.001) and OPD (p<0.001). ROC analyses showed very high sensitivity and specificity for the PDP (0.98 and 0.91) and Withdrawn (0.92 and 0.97) subscales when ASD was compared to TD. Sensitivity and specificity of Withdrawn (0.90 and 0.83) and PDP (0.85 and 0.83) remained high when comparing ASD versus OPD. In conclusion, the CBCL 1½-5 seemed to be able to identify toddlers subsequently diagnosed with ASD from children with TD and OPD. Its high sensitivity and specificity, coupled with its efficiency in terms of time and cost, suggest this broadband tool should be tested in a pilot screening survey of toddlers in the general population.

Stressful life events and daily stressors affect awakening cortisol level in midlife mothers of individuals with autism spectrum disorders

OBJECTIVES

The current study examines the awakening cortisol level in midlife mothers (M = 51.4 years old, SD = 8.4) of individuals (M = 22.1 years old, SD = 7.1) with autism spectrum disorders (ASD) under stressful conditions that are not specific to their son or daughter's ASD symptoms.

METHODS

In addition to completing a set of questionnaires and in-home interviews, 82 mothers from the Adolescents and Adults with Autism Study (AAA) participated in a Daily Diary Study.

RESULTS

Findings from the multilevel models indicated that mothers who previously were exposed to no negative life events in the previous period had an increased awakening cortisol level on days following a greater number and more severe stressors, a normative stress response. In contrast, we observed a flatter cortisol level of daily stressors in mothers who experienced a greater number of negative life events in the previous period.

CONCLUSION

These findings highlight the sustained toll that global and everyday stressors have on awakening cortisol level of midlife and aging mothers of individuals with ASD.