Project AIM: Autism intervention meta-analysis for studies of young children

One size does not fit all for parent-mediated autism interventions: A randomized clinical trial

LAY ABSTRACT

Parent-mediated interventions support parents' use of language facilitation strategies to improve their autistic child's communication and language development. To improve the effectiveness of parent-mediated interventions, it is important to individualize interventions. This article evaluates how different components of parent-mediated interventions and mothers' learning styles influence the effectiveness of the intervention. In a randomized clinical trial, mothers were taught to use one of two types of language facilitation strategies: responsive and directive. Mothers' learning styles were characterized by the Broad Autism Phenotype (BAP) and their natural tendency to use language facilitation strategies before intervention. Findings suggest that it was easier for all mothers (irrespective of learning style) to use responsive strategies compared to directive strategies. In addition, mothers with learning styles that were not consistent with the BAP were more likely to benefit from the intervention if they did not naturally use strategies before the intervention. In contrast, mothers with learning styles that were consistent with the BAP were more likely to benefit from the intervention if they did naturally use strategies before the intervention. Teaching mothers to use responsive strategies results in greater strategy use. Consideration of BAP and mothers' natural use of language facilitation strategies may inform intervention individualization.

Diagnosis and treatment of children and adolescents with autism and ADHD

Attention-deficit/hyperactivity disorder (ADHD) and autism are neurodevelopmental disorders that emerge in childhood. There is increasing recognition that ADHD and autism frequently co-occur. Yet, questions remain among clinicians regarding the best ways to evaluate and treat co-occurring autism and ADHD. This review outlines issues relevant to providing evidence-based practice to individuals and families who may be experiencing difficulties associated with co-occurring autism and ADHD. After describing the complexities of the co-occurrence of autism and ADHD, we present practical considerations for best practice assessment and treatment of co-occurring autism and ADHD. Regarding assessment, this includes considerations for interviewing parents/caregivers and youth, using validated parent and teacher rating scales, conducting cognitive assessments, and conducting behavior observations. Regarding treatment, consideration is given to behavioral management, school-based interventions, social skills development, and the use of medications. Throughout, we note the quality of evidence that supports a particular component of assessment or treatment, highlighting when evidence is most relevant to those with co-occurring autism and ADHD across stages of development. In light of the current evidence for assessment and treatment of co-occurring autism and ADHD, we conclude by outlining practical implications for clinical and educational practice.

Non-pharmacological interventions for autistic children: An umbrella review

LAY ABSTRACT

What is already known about the topic?The delivery of evidence-based interventions is an important part of the clinical pathway for many autistic children and their families. However, parents, practitioners, and policymakers face challenges making evidence informed decisions, due to the wide variety of interventions available and the large, and often inconsistent, body of evidence regarding their effectiveness.What this paper adds?This is a comprehensive umbrella review, also known as a 'review of reviews', which examined the range of interventions available, the evidence for their effectiveness, and whether effects were influenced by factors relating to individual children (e.g. chronological age, core autism characteristics, and related skills) or the ways interventions were delivered (by whom and in what setting, format, mode, and amount). There was evidence for positive therapeutic effects for some, but not all, interventions. No single intervention had a positive effect for all child and family outcomes of interest. The influence of child and delivery characteristics on effects was unclear.Implications for practice, research, and policyThe findings provide parents, practitioners, and policymakers with a synthesis of the research evidence to inform decision-making and highlight the importance of individualised approaches in the absence of clear and consistent evidence. The findings also highlight the need to improve consistency and completeness in reporting of research studies, so that the same questions may be answered more comprehensively in the future.

A Parental-Report Questionnaire for Language Abilities and Pragmatics in Children and Adolescents with Autism Spectrum Disorders

The aim of this study was to test and validate a parental-report questionnaire, which assesses language abilities and pragmatics, in children with Autism Spectrum Disorders (ASD). We report two experiments: The first served as the initial test and the second sought to provide the first assessment of convergent validity. In total, we recruited 230 parents, where approximately two-thirds had a child with ASD. Results of factor analyses showed a consistent factor structure within each subscale, and the internal consistency was excellent for both sub-scales (Cronbach's alpha >0.90). Convergent validity was assessed by correlating the results of the questionnaire with two sub-scales of the Autism Quotient questionnaire. The correlations were all greater than 0.60. The final version of the questionnaire (following exclusion of problematic items) contains 30 items (12 for language abilities and 18 for pragmatics). We conclude that the questionnaire is a concise and practical instrument for use in a variety of contexts for assessing language functioning and communication in children with ASD.

Teaching Caregivers to Support Social Communication: Results From a Randomized Clinical Trial of Autistic Toddlers

BACKGROUND

Studies of early caregiver-mediated interventions targeting social communication of young autistic children have yielded variable child outcomes. This study examined the effects of combining two caregiver-mediated interventions on caregiver strategy use and child social communication and language outcomes.

METHOD

This was a multisite parallel randomized controlled trial. Participants included 120 caregivers and their autistic children between 24 and 36 months of age. Dyads were randomly assigned to receive a hybrid intervention that combined Enhanced Milieu Teaching (EMT) and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) or to a behavior management control condition, each delivered over 6 months. Caregivers in the JASP-EMT group received twice-weekly, in-home, and hour-long sessions. Outcomes were measured at baseline, the end of intervention (T1), and 6 months later (T2) and included a naturalistic language sample procedure, standardized measures, and caregiver report measures. This trial was registered at clinicaltrials.gov (NCT02595697).

RESULTS

Child outcomes did not differ between conditions at T1 or T2 for child primary (social communication) or secondary (language, play, and autism symptoms) outcomes. Relative to control group caregivers, intervention group caregivers demonstrated significantly higher use of JASP-EMT strategies at T1 and T2, with the exception of two strategies (Responsiveness and Matched Responsiveness), which were used significantly more by control group caregivers. Neither autism severity nor baseline caregiver responsiveness moderated outcomes. Post hoc analyses revealed significant correlations between specific strategies and all child outcomes.

CONCLUSIONS

Twice-weekly caregiver-mediated intervention that taught caregivers of autistic children to use social communication support strategies did not yield significant child outcomes. Future studies should examine possible sources for the lack of main effects including unexpected differences in linguistic features of caregiver input, changes in control group caregiver behavior, and insufficient intervention dosage.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21714278.

Autism Spectrum Disorder: A Review

IMPORTANCE

Autism spectrum disorder (ASD), characterized by deficits in social communication and the presence of restricted, repetitive behaviors or interests, is a neurodevelopmental disorder affecting approximately 2.3% children aged 8 years in the US and approximately 2.2% of adults. This review summarizes evidence on the diagnosis and treatment of ASD.

OBSERVATIONS

The estimated prevalence of ASD has been increasing in the US, from 1.1% in 2008 to 2.3% in 2018, which is likely associated with changes in diagnostic criteria, improved performance of screening and diagnostic tools, and increased public awareness. No biomarkers specific to the diagnosis of ASD have been identified. Common early signs and symptoms of ASD in a child's first 2 years of life include no response to name when called, no or limited use of gestures in communication, and lack of imaginative play. The criterion standard for the diagnosis of ASD is a comprehensive evaluation with a multidisciplinary team of clinicians and is based on semistructured direct observation of the child's behavior and semistructured caregiver interview focused on the individual's development and behaviors using standardized measures, such as the Autism Diagnostic Observation Schedule-Second Edition and the Autism Diagnostic Interview. These diagnostic measures have sensitivity of 91% and 80% and specificity of 76% and 72%, respectively. Compared with people without ASD, individuals with ASD have higher rates of depression (20% vs 7%), anxiety (11% vs 5%), sleep difficulties (13% vs 5%), and epilepsy (21% with co-occurring intellectual disability vs 0.8%). Intensive behavioral interventions, such as the Early Start Denver Model, are beneficial in children 5 years or younger for improvement in language, play, and social communication (small to medium effect size based on standardized mean difference). Pharmacotherapy is indicated for co-occurring psychiatric conditions, such as emotion dysregulation or attention-deficit/hyperactivity disorder. Risperidone and aripiprazole can improve irritability and aggression (standardized mean difference of 1.1, consistent with a large effect size) compared with placebo. Psychostimulants are effective for attention-deficit/hyperactivity disorder (standardized mean difference of 0.6, consistent with a moderate effect size) compared with placebo. These medications are associated with adverse effects including, most commonly, changes in appetite, weight, and sleep.

CONCLUSIONS AND RELEVANCE

ASD affects approximately 2.3% of children aged 8 years and approximately 2.2% of adults in the US. First-line therapy consists of behavioral interventions, while co-occurring psychiatric conditions, such as anxiety or aggression, may be treated with specific behavioral therapy or medication.

Integrative treatment program for the treatment of children with autism spectrum disorder: A prospective observational case series

Background

In a situation where conventional treatments for autism spectrum disorder (ASD) are labor-intensive and there are concerns about the side effects of conventional medications, a 6-month integrative treatment program, including herbal medicine (HM), Floortime, and sensory enrichment therapy (SET) has been used on children with ASD in Korean medicine clinical settings.

Methods

We observed the treatment responses of 18 children with ASD (66.7% male, mean age 3.9 ± 0.9 years) to the integrative treatment program as part of a prospective, single-center, observational case series. Individualized HMs were administered according to the patient's symptoms, and parents were instructed to perform Floortime and SET with their children at home for 2 h and 20 min a day, 5 days a week, respectively. The Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC) were used to evaluate the core symptoms of ASD. A linear mixed model for repeated measures was used for analyzing the effect of the program over time, and logistic regression used to explore the predictors of treatment response.

Results

The CARS and ABC scores were significantly improved from 34.58 ± 6.27 and 69.28 ± 15.73 at baseline to 28.56 ± 6.05 and 39.67 ± 20.36 after 6 months (p < 0.0001, respectively). No serious adverse events (AEs) were reported, and compliance with HM, Floortime, and SET was high at >90%.

Conclusion

This 6-month integrative treatment program appears to be a potentially effective, safe, and feasible option for children with ASD. Low baseline CARS scores may be predictors of higher treatment response.

Effect of fecal microbiota transplantation in children with autism spectrum disorder: A systematic review

Background

Fecal microbiota transplantation (FMT) may be helpful in the treatment of autism spectrum disorder (ASD) as rebalancing the gut microbiome has been shown to potentially improve behavioral symptoms in children with ASD.

Methods

This systematic review was conducted to assess the effect of FMT for children with ASD. The Embase, PubMed, Web of Science, and Cochrane Library databases were searched for articles published from inception to October 6, 2022. Two reviewers independently screened the identified records and undertook data extraction.

Results

The search identified a total of five studies: two prospective open-label studies, two retrospective observational studies, and a case report; however, no randomized controlled trial was identified. All five studies reported a significant post-FMT-treatment improvement in neuropsychological assessment of ASD. The two prospective open-label studies suggested that the Autism Behavior Checklist (ABC) score, and the Social Responsiveness Scale (SRS) score at the posttreatment assessment decreased from the baseline (Wilcoxon signed-rank test; all p < 0.01]). The two retrospective observational studies suggested that FMT helped to improve the ASD symptoms. One observational study reported that the Childhood Autism Rating Scale (CARS) score and ABC score of the constipation group decreased from the baseline after the second course assessment (CARS [baseline: mean 35.25 ± standard deviation 4.36, second course: 32.5 ± 3.1, p = 0.015]; ABC [baseline: 56.21 ± 16.08, second course: 46.54 ± 16.54, p = 0.046]). Another observational study found that both ABC and CARS scores decreased as the number of FMT courses increased, and significant differences were found at the end of each course as compared with the baseline.

Conclusion

Compared with the baseline, FMT significantly improved symptoms of autism in children with ASD in observational studies. However, rigorously designed randomized controlled clinical trials are needed to establish the safety and efficacy of FMT as a treatment for ASD.

Measuring the association between behavioural services and outcomes in young children with autism spectrum disorder

BACKGROUND

Children with autism spectrum disorder (ASD) receive a wide range of services.

AIMS

To examine the association between behavioural services received by children with ASD between ages 2 and 5 years and outcomes during primary school years.

METHODS

A total of 414 preschool-aged children diagnosed with ASD were enrolled at five Canadian sites and were assessed within four months of diagnosis (T1), six months later (T2), 12 months later (T3), at school entry (T4), and then annually (T5-T8) to 11 years of age. The association between the receipt of behavioural services during T1 to T3 and T8 outcomes related to adaptive behaviour and behavioural problems was modelled using linear regressions adjusted for immigrant status, family income, child's age at diagnosis, site, sex assigned at birth, and baseline (T1) outcome.

RESULTS

Children who received behavioural services during at least one time period from T1 to T3 did not have significantly different outcomes at T8 than children who did not receive any behavioural services.

IMPLICATIONS

Pre-school use of behavioural services was not found to affect outcomes during later childhood. Numerous challenges accompany studies of the association between pre-school service use and later outcomes in a heterogeneous ASD sample. Recommendations for study design are provided.

Toward deeper understanding and wide-scale implementation of naturalistic developmental behavioral interventions

LAY ABSTRACT

Naturalistic Developmental Behavioral Interventions (NDBIs) are a group of early interventions that use a variety of strategies from applied behavioral and developmental sciences. Although Naturalistic Developmental Behavioral Interventions have been demonstrated effective, Naturalistic Developmental Behavioral Interventions are not implemented on a wide scale within early intervention programs for children on the autism spectrum. Potential reasons likely stem from differing theoretical orientations of developmental and behavioral sciences and practitioners' lack training, knowledge, and support for implementing Naturalistic Developmental Behavioral Interventions. In support of efforts to promote wide-scale implementation of Naturalistic Developmental Behavioral Interventions, we (1) clarify their common features, (2) discuss possible misconceptions, and (3) offer reasons why Naturalistic Developmental Behavioral Interventions should be widely implemented. We also provide recommendations to the autism service community, intervention developers, and researchers.

The Impact of Singing on Visual and Multisensory Speech Perception in Children on the Autism Spectrum

Autistic children show reduced multisensory integration of audiovisual speech stimuli in response to the McGurk illusion. Previously, it has been shown that adults can integrate sung McGurk tokens. These sung speech tokens offer more salient visual and auditory cues, in comparison to the spoken tokens, which may increase the identification and integration of visual speech cues in autistic children. Forty participants (20 autism, 20 non-autistic peers) aged 7-14 completed the study. Participants were presented with speech tokens in four modalities: auditory-only, visual-only, congruent audiovisual, and incongruent audiovisual (i.e., McGurk; auditory 'ba' and visual 'ga'). Tokens were also presented in two formats: spoken and sung. Participants indicated what they perceived via a four-button response box (i.e., 'ba', 'ga', 'da', or 'tha'). Accuracies and perception of the McGurk illusion were calculated for each modality and format. Analysis of visual-only identification indicated a significant main effect of format, whereby participants were more accurate in sung versus spoken trials, but no significant main effect of group or interaction effect. Analysis of the McGurk trials indicated no significant main effect of format or group and no significant interaction effect. Sung speech tokens improved identification of visual speech cues, but did not boost the integration of visual cues with heard speech across groups. Additional work is needed to determine what properties of spoken speech contributed to the observed improvement in visual accuracy and to evaluate whether more prolonged exposure to sung speech may yield effects on multisensory integration.

Intrapersonal synchrony analysis reveals a weaker temporal coherence between gaze and gestures in adults with autism spectrum disorder

The temporal encoding of nonverbal signals within individuals, referred to as intrapersonal synchrony (IaPS), is an implicit process and essential feature of human communication. Based on existing evidence, IaPS is thought to be a marker of nonverbal behavior characteristics in autism spectrum disorders (ASD), but there is a lack of empirical evidence. The aim of this study was to quantify IaPS in adults during an experimentally controlled real-life interaction task. A sample of adults with a confirmed ASD diagnosis and a matched sample of typically-developed adults were tested (N = 48). Participants were required to indicate the appearance of a target invisible to their interaction partner nonverbally through gaze and pointing gestures. Special eye-tracking software allowed automated extraction of temporal delays between nonverbal signals and their intrapersonal variability with millisecond temporal resolution as indices for IaPS. Likelihood ratio tests of multilevel models showed enlarged delays between nonverbal signals in ASD. Larger delays were associated with greater intrapersonal variability in delays. The results provide a quantitative constraint on nonverbal temporality in typically-developed adults and suggest weaker temporal coherence between nonverbal signals in adults with ASD. The results provide a potential diagnostic marker and inspire predictive coding theories about the role of IaPS in interpersonal synchronization processes.

Measuring Change During Intervention Using Norm-Referenced, Standardized Measures: A Comparison of Raw Scores, Standard Scores, Age Equivalents, and Growth Scale Values From the Preschool Language Scales-Fifth Edition

PURPOSE

Norm-referenced, standardized measures are tools designed to characterize a child's abilities relative to their same-age peers, but they also have been used to measure changes in skills during intervention. This study compared the psychometric properties of four types of available scores from one commonly used standardized measure, the Preschool Language Scales-Fifth Edition (PLS-5), to detect changes in children's language skills during and after a language intervention.

METHOD

This study included data from 110 autistic children aged 18-48 months whose mother participated in an 8-week parent-mediated language intervention. Children's language skills were measured at 3 time points using the PLS-5. Changes in children's expressive and receptive language skills were calculated using raw scores, standard scores, age equivalents, and growth scale values (GSVs).

RESULTS

Analysis of raw scores, age equivalents, and GSVs indicated significant improvement in the scores of autistic children in both receptive and expressive language throughout the study (i.e., during the intervention period and in the 3-month period after the intervention). Standard scores suggested improvement only in the receptive language scale during the intervention period. Standard scores showed a floor effect for children who scored at -3 SD below the mean.

CONCLUSIONS

Findings suggested that GSVs were not only psychometrically sound but also the most sensitive measure of direct changes in skills compared to raw, standard, and age-equivalent scores. Floor effects may limit the sensitivity of standard scores to detect changes in children's skills. Strengths, limitations, and interpretations of each of the scoring approaches in measuring changes in skills during intervention were discussed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21498522.

Virtual and Augmented Reality in Social Skills Interventions for Individuals with Autism Spectrum Disorder: A Scoping Review

In the last decade, there has been an increase in publications on technology-based interventions for autism spectrum disorder (ASD). Virtual reality based assessments and intervention tools are promising and have shown to be acceptable amongst individuals with ASD. This scoping review reports on 49 studies utilizing virtual reality and augmented reality technology in social skills interventions for individuals with ASD. The included studies mostly targeted children and adolescents, but few targeted very young children or adults. Our findings show that the mode number of participants with ASD is low, and that female participants are underrepresented. Our review suggests that there is need for studies that apply virtual and augmented realty with more rigorous designs involving established and evidenced-based intervention strategies.

The developing brain: Challenges and opportunities to promote school readiness in young children at risk of neurodevelopmental disorders in low- and middle-income countries

This paper discusses possibilities for early detection and early intervention in infants with or at increased risk of neurodevelopmental disorders in low- and middle-income countries (LMICs). The brain's high rate of developmental activity in the early years post-term challenges early detection. It also offers opportunities for early intervention and facilitation of school readiness. The paper proposes that in the first year post-term two early detection options are feasible for LMICs: (a) caregiver screening questionnaires that carry little costs but predict neurodevelopmental disorders only moderately well; (b) the Hammersmith Infant Neurological Examination and Standardized Infant NeuroDevelopmental Assessment (SINDA) which are easy tools that predict neurodisability well but require assessment by health professionals. The young brain's neuroplasticity offers great opportunities for early intervention. Ample evidence indicates that families play a critical role in early intervention of infants at increased risk of neurodevelopmental disorders. Other interventional key elements are responsive parenting and stimulation of infant development. The intervention's composition and delivery mode depend on the infant's risk profile. For instance, in infants with moderately increased risk (e.g., preterm infants) lay community health workers may provide major parts of intervention, whereas in children with neurodisability (e.g., cerebral palsy) health professionals play a larger role.

Interventions for Sensory Over-Responsivity in Individuals with Autism Spectrum Disorder: A Narrative Review

Individuals with autism spectrum disorder (ASD) often exhibit sensory over-responsivity (SOR), which is characterized by an overwhelmingly negative reaction to or avoidance of sensory stimulation. Despite the detrimental effects of SOR on people’s personal and social lives, the knowledge of and interventions for the issue remain limited. This paper collates and reviews studies on SOR and information on the potential for effective interventions for people with ASD. This review reveals evidence that SOR has a close relationship with anxiety, depression, insomnia, and family life impairment and an underlying mechanism related to SOR. Four interventions and their theoretical bases in sensory-motor processing are discussed in this paper, namely, physical activity (PA), sensory integration therapy (SIT), mindfulness-based cognitive therapy (MBCT), and cognitive behavioral therapy (CBT). These interventions focus on establishing coping strategies for regulating the emotional response to sensory information, and they have been found to be effective and to have the potential to help children with ASD reduce their SOR behaviors. This paper provides guidance for selecting appropriate interventions and for further investigation of more effective interventions in the future.

Are early social communication skills a harbinger for language development in infants later diagnosed autistic?-A longitudinal study using a standardized social communication assessment

The early emergence of social communication challenges and their impact on language in infants later diagnosed with autism has sparked many early intervention programs that target social communication skills. While research has consistently shown lower scores on social communication assessments in the first year of life, there is limited research at 12-months exploring associations between different dimensions of social communication and later language. Understanding associations between early social communication skills and language would enhance our ability to choose high priority intervention goals that will impact downstream language skills. The current study used a standardized assessment to profile social communication skills across 516 infants with a high (HL) or low likelihood (LL-Neg) for autism (84% White, 60% Male), based on the presence of a sibling with autism in the family. The primary aim of the study was to profile social communication skill development in the second year of life and to evaluate associations between social communication skills and later language. HL infants who met criteria for autism (HL-ASD, N = 81) demonstrated widespread reductions in social communication skills at 12-months compared to HL infants who did not meet criteria for autism (HL-Neg, N = 277) and LL-Neg (N = 158) infants. Across all infants in the study, those with better social communication skills at 12-months had better language at 24-months. However, within group analyses indicated that infants who met criteria for autism did not show this developmental coupling until 24-months-of-age at which point social communication was positively associated with downstream language skills. The cascading pattern of reduced social communication skills as well as overall significant positive associations with later language provide further evidence for the need to support developing social communication skills prior to formal autism diagnosis, a goal that could possibly be reached through pre-emptive interventions.

Migration is associated with baseline severity and progress over time in autism spectrum disorder: Evidence from a French prospective longitudinal study

Background

The prevalence of autism-spectrum disorder (ASD) has been shown to be higher in migrant families, but it is also a challenge for health care professionals to offer adequate services to families that face multiple challenges. In the context of the EPIGRAM study (a French prospective, multisite, longitudinal observational study implementing integrative care practices (ICPs) for children with ASD), we aimed to assess the impact of migration on children with ASD.

Method and findings

89 children with ASD aged 3 to 6 years old (92% males) were recruited and followed up for 12 months. The children were clinically assessed using several instruments. At baseline, children had severe autism on average on the Children Autism Rating Scale (CARS, mean = 44; SD = 6.51) and moderate autism on the PsychoEducational profile-3-R (PEP-3-R) maladaptive behavior category (mean = 30; SD = 29.89). Thirty percent of the families had a low socio-economic status, and 56% were first-generation immigrants. For all clinical variables, children of immigrant parents had more severe autism and developmental delays at baseline. A linear mixed model established an improvement in all clinical characteristics over the 12 months of the study. This trend may be attributed to ICPs or any naturally occurring event during that period. Families shared this positive view over time. However, the improvements were slower for two clinical dimensions of the PEP-3-R in children from migrant families. For the inappropriate behavior category, the time effect diminished by an average of 0.83 percentile/month for children whose parents were migrants vs. children whose parents were non-migrants. Similarly, for verbal behavior characteristics, the time effect diminished by an average of 1.32 percentile/month for children whose parents were migrants vs. children whose parents were non-migrants.

Conclusion

Despite an overall positive improvement, we found that migration is associated baseline severity and progress over time in children with ASD. There is an urgent need to target the migrant population with specific research and understand the avenues that carry such higher severity.

Clinical trial registration

Study registration on clinicaltrials.gov under the number NCT02154828.

An evaluation of intervention research for transition-age autistic youth

LAY ABSTRACT

In this study, we assess the quality of intervention research that focuses on autistic youth who are 14-22 years old. We found 193 different studies on this topic, and carefully reviewed them. Most of these studies tested strategies that were behavioral. This means that they used procedures like prompting and rewards to change participants' behavior. We found that the majority of studies had problems that make it hard to determine whether or not the intervention worked. The problems related to how researchers designed their studies, and how they measured the study outcomes. We also found that researchers rarely tried to find out if the strategies they studied had unintended negative effects for participants. Because of these issues, we make suggestions for how researchers might design better studies that will let people know how well the strategies worked.

Neurodiversity and Autism Intervention: Reconciling Perspectives Through a Naturalistic Developmental Behavioral Intervention Framework

Proponents of autism intervention and those of the neurodiversity movement often appear at odds, the former advocating for intensive treatments and the latter arguing that autism must be accepted as a form of diversity. The history of behavioral intervention has understandably outraged many in the Autistic community, though many still value supports focused on quality of life. This commentary argues that Naturalistic Developmental Behavioral Interventions (NDBIs) hold promise for bridging the gap between early intervention and the neurodiversity movement. However, we recognize NDBIs have much room to grow and suggest multiple strategies for improvement. We believe these updates are not only feasible for clinicians and researchers to implement but will ultimately lead to improved quality of life for Autistic individuals.

Pathways to adaptive functioning in autism from early childhood to adolescence

Adaptive functioning is lower in many autistic individuals to a greater extent than would be expected based on IQ. However, the clinical features associated with these difficulties are less well understood. This study examines longitudinal and contemporaneous associations of adaptive functioning in autistic youth across a wide ability range. Parent-reported autism symptoms, co-occurring emotional, behavioral and attention deficit hyperactivity disorder (ADHD) symptoms, and IQ were assessed in early childhood (M age 7 years; T1) and 6 years later in adolescence (M age 13 years; T2) in 179 autistic youth. Adaptive functioning was assessed at T2. Structural equation modeling estimated pathways to adaptive functioning from autism, and psychiatric symptoms at T1 and T2, testing whether associations were driven by continuity of behaviors from T1 to T2 or their contemporaneous effect at T2, or both, controlling for T1 IQ. Lower adaptive functioning at T2 was associated with higher T1 and T2 ADHD symptoms (β = -0.14, and β = -0.21) but not behavioral nor emotional symptoms at either timepoint. Lower adaptive functioning at T2 was also associated with lower T1 IQ (β = 0.43) and higher social communication symptoms (β = -0.37) at T2 but not T1, but the relationship with ADHD symptoms remained. Paths were not moderated by sex or IQ. Increased symptoms of ADHD, both in early childhood and contemporaneously, were associated with reduced adaptive functioning in adolescence. Co-occurring ADHD may be a modifiable risk factor for adaptive function impairments and should be routinely assessed and when present evidence-based treatments initiated which may benefit adaptive functioning outcomes. LAY SUMMARY: Adaptive functioning is lower in many autistic individuals to a greater extent than would be expected based on IQ. However, the clinical features associated with these difficulties are less well understood. In a community sample higher attention deficit/hyperactivity disorder (ADHD) symptoms, but not emotional or behavioral symptoms, in both early childhood and contemporaneously were associated with lower adaptive functioning in autistic adolescents. Co-occurring ADHD may be a modifiable risk factor for adaptive function difficulties in autism.

Revisiting the simplification of adult language input in the context of naturalistic developmental behavioral interventions: A commentary

Naturalistic developmental behavioral interventions (NDBI) are an evidence-based class of early interventions for improving language and social communication skills in autistic children. However, relatively little is known about how individual elements of NDBI support child development. This commentary focuses on one common element across NDBI models: the simplification of adult language input. Advances in developmental science focusing on the length and complexity of adult spoken utterances suggests that natural, grammatical utterances facilitate comprehension and expressive language development in autistic and nonautistic children. Yet, NDBI tend to recommend shorter and simpler adult utterances. We close by describing directions for future research which would inform recommendations around adult language input in NDBI to optimally support child language and communication development.

Impact of Three Kinds of Early Interventions on Developmental Profile in Toddlers with Autism Spectrum Disorder

Autism spectrum disorder is a neurodevelopmental disorder with a rising prevalence disorder. This high-cost/high-burden condition needs evidence-based behavioral treatments that are able to reduce the impact of symptoms on children’s functioning. This retrospective chart review study compared the impact of different types of early interventions on toddlers diagnosed with an autism spectrum disorder developmental profile. Analyses were conducted on 90 subjects (mean = 27.76 months, range 18−44 months; M:F = 4.29:1), of which 36 children underwent the usual treatment, 13 children underwent an intervention based on early intensive behavioral intervention (EIBI) and 41 children received the Early Start Denver Model, for one year, with the same weekly frequency of about 6 h a week. A significant decrease in the severity of autism symptoms was observed for all children when looking at the Ados-2 severity score (average difference = 3.05, SD = 0.71, p = < 0.001) and the Ados-2 social subscale (average difference = 2.87, SD = 0.59, p < 0.001). Otherwise, for most of the Griffiths subscales, we found a significant improvement only for those children who underwent the Early Start Denver Model intervention (General Quotient average difference = 14.47, SD = 3.22, corrected p < 0.001). Analyzing the influence of age on the investigated scores, we found a significant association with the Eye−hand Coordination Quotient (p = 0.003), Performance Quotient (p = 0.042) and General Quotient (p = 0.006). In all these domains, a mild negative correlation with age was observed, as measured by the Pearson’s correlation coefficient (r = −0.32, p = 0.002; r = −0.21, p = 0.044; r = −0.25, p = 0.019, respectively), suggesting less severe developmental skills at the start of treatment for older children. Our results are consistent with the literature that underlines the importance of early intervention, since prompt diagnosis can reduce the severity of autism symptoms; nevertheless, in toddlers, our study demonstrated that an intervention model based on naturalistic developmental behavioral principles such as the Early Start Denver Model is more effective on children’s developmental profile. Further studies are required to assess the extent of effectiveness of different early intervention models in community settings.

Barriers and facilitators for obtaining support services among underserved families with an autistic child: A systematic qualitative review

LAY ABSTRACT

Families from underrepresented ethnic or racial groups and those with limited financial resources could experience more difficulty in accessing support services for their autistic child due to certain types of barriers. We searched academic journals, websites, and other sources for studies which looked at what barriers might be present for such families and what might help families access support services for their autistic child. The search found 18 studies. Results from each study were examined and coded into themes. Parents reported that accessibility, diversity of support services, and stigma influenced their experiences with support services. We discuss what these findings might mean for future research and for service delivery.

What does it mean for an autism intervention to be evidence-based?

Although there is consensus in the field that individuals on the autism spectrum should receive interventions that are evidence-based, the concept of "evidence-based" is multifaceted and subject to ongoing development and debate. In this commentary, we review historical developments, methodological approaches, as well as areas of controversies and research directions in the establishment of an evidence base for autism intervention. LAY SUMMARY: What does it mean for an autism intervention to be evidence-based? In this commentary, we address this complex issue by examining historical developments, methodological approaches, as well as areas of ongoing debate in the establishment of evidence-based interventions for autism.

Early intervention for very young children with or at high likelihood for autism spectrum disorder: An overview of reviews

AIM

To identify which interventions are supported by evidence and the quality of that evidence in very young children with or at high likelihood for autism spectrum disorder (ASD) to improve child outcomes.

METHOD

We conducted an overview of reviews to synthesize early intervention literature for very young children with or at high likelihood for ASD. Cochrane guidance on how to perform overviews of reviews was followed. Comprehensive searches of databases were conducted for systematic reviews and meta-analyses between January 2009 and December 2020. Review data were extracted and summarized and methodological quality was assessed. Primary randomized controlled trial evidence was summarized and risk of bias assessed. This overview of reviews was not registered.

RESULTS

From 762 records, 78 full texts were reviewed and seven systematic reviews and meta-analyses with 63 unique studies were identified. Several interventional approaches (naturalistic developmental behavioral intervention, and developmental and behavioral interventions) improved child developmental outcomes. Heterogeneity in design, intervention and control group, dose, delivery agent, and measurement approach was noted. Inconsistent methodological quality and potential biases were identified.

INTERPRETATION

While many early interventional approaches have an impact on child outcomes, study heterogeneity and quality had an impact on our ability to draw firm conclusions regarding which treatments are most effective. Advances in trial methodology and design, and increasing attention to mitigating measurement bias, will advance the quality of the ASD early intervention evidence base.

WHAT THIS PAPER ADDS

Naturalistic developmental behavioral interventions, as well as developmental and behavioral interventions, improve child outcomes in autism spectrum disorder (ASD). If only randomized controlled trials are considered, guidelines for early intensive behavioral intervention in younger children should be revisited. The greatest intervention impacts were on proximal, intervention-specific outcomes. Inadequacies in the quality of the early ASD intervention evidence base were observed.

Applied Behavior Analysis in Children and Youth with Autism Spectrum Disorders: A Scoping Review

This manuscript provides a comprehensive overview of the impact of applied behavior analysis (ABA) on children and youth with autism spectrum disorders (ASD). Seven online databases and identified systematic reviews were searched for published, peer-reviewed, English-language studies examining the impact of ABA on health outcomes. Measured outcomes were classified into eight categories: cognitive, language, social/communication, problem behavior, adaptive behavior, emotional, autism symptoms, and quality of life (QoL) outcomes. Improvements were observed across seven of the eight outcome measures. There were no included studies that measured subject QoL. Moreover, of 770 included study records, only 32 (4%) assessed ABA impact, had a comparison to a control or other intervention, and did not rely on mastery of specific skills to mark improvement. Results reinforce the need for large-scale prospective studies that compare ABA with other non-ABA interventions and include measurements of subject QoL to provide policy makers with valuable information on the impacts of ABA and other existing and emerging interventions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-022-00338-x.

The Efficacy of Early Interventions for Children with Autism Spectrum Disorders: A Systematic Review and Meta-Analysis

The superiority of early interventions for children with autism spectrum disorders (ASDs) compared to treatment as usual (TAU) has recently been questioned. This study was aimed to investigate the efficacy of early interventions in improving the cognitive ability, language, and adaptive behavior of pre-school children with ASDs through a systematic review of randomized controlled trials (RCTs). In total, 33 RCTs were included in the meta-analysis using the random effects model. The total sample consisted of 2581 children (age range: 12-132 months). Early interventions led to positive outcomes for cognitive ability (g = 0.32; 95% CI: 0.05, 0.58; p = 0.02), daily living skills (g = 0.35; 95% CI: 0.08, 0.63; p = 0.01), and motor skills (g = 0.39; 95% CI: 0.16, 0.62; p = 0.001), while no positive outcomes were found for the remaining variables. However, when studies without the blinding of outcome assessment were excluded, positive outcomes of early interventions only remained for daily living skills (g = 0.28; 95% CI: 0.04, 0.52; p = 0.02) and motor skills (g = 0.40; 95% CI: 0.11, 0.69; p = 0.007). Although early intervention might not have positive impacts on children with ASDs for several outcomes compared to controls, these results should be interpreted with caution considering the great variability in participant and intervention characteristics.

Implementing the WHO caregivers skills training program with caregivers of autistic children via telehealth in rural communities

Background

For families with autistic children living in rural areas, limited access to services partly results from a shortage of providers and extensive travel time. Telehealth brings the possibility of implementing alternative delivery modalities of Parent Mediated Interventions (PMIs) with the potential to decrease barriers to accessing services. This study aimed to evaluate the feasibility and acceptability of implementing the World Health Organization-Caregivers Skills Training program (WHO-CST) via an online, synchronous group format in rural Missouri.

Methods

We used a mixed methods design to collect qualitative and quantitative data from caregivers and program facilitators at baseline and the end of the program, following the last home visit. Caregivers of 14 autistic children (3-7 years), residents of rural Missouri, completed nine virtual sessions and four virtual home visits.

Results

Four main themes emerged from the focus groups: changes resulting from the WHO-CST, beneficial aspects of the program, advantages and disadvantages of the online format, and challenges to implementing the WHO-CST via telehealth. The most liked activity was the demonstration (36%), and the least liked was the practice with other caregivers. From baseline to week 12, communication skills improved in both frequency (p < 0.05) and impact (p < 0.01), while atypical behaviors decreased (p < 0.01). For caregivers' outcomes, only confidence in skills (p < 0.05) and parental sense of competence (p < 0.05) showed a positive change.

Conclusion

Our results support the feasibility of implementing the WHO-CST program via telehealth in a US rural setting. Caregivers found strategies easy to follow, incorporated the program into their family routines, and valued the group meetings that allowed them to connect with other families. A PMI such as the WHO-CST, with cultural and linguistic adaptations and greater accessibility via telehealth-plays an essential role in closing the treatment gap and empowering caregivers of autistic children.

Short-term low-intensity Early Start Denver Model program implemented in regional hospitals in Northern Taiwan

LAY ABSTRACT

The Early Start Denver Model is an evidence-based early intervention program for young and very young children with autism. This interdisciplinary model is used by many types of professionals, such as psychologists, occupational therapists, speech pathologists, early child special educators, and paraprofessionals, as well as by parents. Most previous studies on the Early Start Denver Model were conducted in the West, and there are scarce studies on the topics of generalization in culture and countries outside the Western world. In this study, we evaluated the effect of the Early Start Denver Model with some adaptations, including a lower intensity, shorter duration, and delivery in regional general hospitals in Northern Taiwan. In total, 45 young children with autism, aged 2-4 years, were divided into the Early Start Denver Model and community-based control groups. The children in the Early Start Denver Model group received one-on-one intervention for approximately 8-9 h per week for 6 months. The results revealed that compared with the control group, the Early Start Denver Model group showed greater gains in overall development ability and nonverbal development ability from pre- to post-intervention. However, these differences did not sustain at the 6-month follow-up after the completion of the intervention. Being mindful of some caveats in trial designs, this study provides preliminary evidence to support the effectiveness of the Early Start Denver Model intervention in the regional general hospital settings in the context of Han-Chinese-mainly culture. Our findings can provide helpful information to stakeholders and policymakers of early intervention service systems for children with autism in Taiwan, as well as in Asian countries.

Caregiver-Implemented Communication Interventions for Children Identified as Having Language Impairment 0 Through 48 Months of Age: A Scoping Review

PURPOSE

Caregiver-implemented interventions are frequently used to support the early communication of young children with language impairment. Although there are numerous studies and meta-analyses supporting their use, there is a need to better understand the intervention approaches and identify potential gaps in the research base. With that premise, we conducted a scoping review to synthesize existing data with an end goal of informing future research directions.

METHOD

We identified relevant studies by comprehensively searching four databases. After deduplication, we screened 5,703 studies. We required included studies (N = 59) to evaluate caregiver-implemented communication interventions and include at least one caregiver communication outcome measure. We extracted information related to the (a) study, child, and caregiver characteristics; (b) intervention components (e.g., strategies taught, delivery method and format, and dosage); and (c) caregiver and child outcome measures (e.g., type, quality, and level of evidence).

RESULTS

We synthesized results by age group of the child participants. There were no studies with children in the prenatal through 11-month-old age range identified in our review that yielded a caregiver language outcome measure with promising or compelling evidence. For the 12- through 23-month group, there were seven studies, which included eight communication intervention groups; for the 24- through 35-month group, there were 21 studies, which included 26 intervention groups; and for the 36- through 48-month group, there were 21 studies, which included 23 intervention groups. Across studies and age groups, there was considerable variability in the reporting of study characteristics, intervention approaches, and outcome measures.

CONCLUSION

Our scoping review highlights important research gaps and inconsistencies in study reporting that should be addressed in future investigations.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20289195.

Playing to Pretend or "Pretending" to Play: Play in Children with Autism Spectrum Disorder

Children diagnosed with autism spectrum disorder (ASD) exhibit early delays and deficits in play. In infancy, they engage in unusual exploratory behaviors with toys. As toddlers, they are slow to develop functional play, and in preschool some children with ASD fail to develop symbolic play despite having the necessary cognitive and language skills. Furthermore, when children with ASD are engaged in play, they demonstrate less playfulness. This article reviews the literature on the characteristics of exploratory, functional, and symbolic/pretend play in children with ASD and possible reasons for their unusual patterns of play development. Increased quantity and quality of play are frequent therapeutic goals for children with ASD. If play interventions are to be successful, it is critical that speech-language pathologists have an adequate assessment of children's play skills. Several frameworks and tools appropriate for assessing play in typical children and children with ASD are described.

Factors associated with resilience among children and youths with disability during the COVID-19 pandemic

There is evidence of negative impact of social distancing and confinement measures to manage the COVID-19 pandemic on children, including increased anxiety and depression and behaviour difficulties. Paradoxically, positive impacts like increased support and more self-care activities have also been documented. Little is known about the impact of the COVID-19 pandemic on the children with disability and the potential role of familial, environmental, and biological factors on mitigating this impact. The aims of the study were 1) identifying profiles of functioning across multiple domains during the COVID-19 pandemic and 2) examining the extent to which parenting self-efficacy, support in accessing schooling, and type of diagnosis predict the likelihood of resilience among children with disability, after controlling for household income and single-parent status. An online survey developed from COVID-19 guidance recommendations, was available from June 11- July 21, 2020, and resulted in a convenience sample of caregivers across Canada (n = 883) of children with disability (mean age of 9.4 years old, SDage = 5.7, 58% male). We conducted latent class analysis to examine the number of latent profiles on caregiver-reported changes of 12 functioning domains, as either 'worsening', 'no change', or 'improving'. Most participants belonged to 'stable' or 'worsening' profiles. However, we identified a small subgroup with improvements in child functioning, a pattern indicative of a 'resilient' profile. Using a multinomial logistic regression, we found that diagnosis type, parenting self-efficacy and support in accessing schooling were associated with membership in the Resilient or Stable profiles compared to the Worsening profile, after controlling for single-parent status and income. Taken together, our findings identified variability in responses to adversity that is dependent on the child's diagnosis type, parenting self-efficacy, and support in accessing schooling. By identifying potentially modifiable predictors of resilience, namely parenting self-efficacy and support in accessing schooling, we signal the potential for tailored supports for different diagnoses, through interventions that enhance caregiver empowerment, access to schooling, access to health and social services, and/or mitigate disparities resulting from social disadvantage.

REACH-ASD: a UK randomised controlled trial of a new post-diagnostic psycho-education and acceptance and commitment therapy programme against treatment-as-usual for improving the mental health and adjustment of caregivers of children recently diagnosed with autism spectrum disorder

BACKGROUND

Autism is a neurodevelopmental disability affecting over 1% of UK children. The period following a child's autism diagnosis can present real challenges in adaptation for families. Twenty to 50% of caregivers show clinically significant levels of mental health need within the post-diagnostic period and on an ongoing basis. Best practice guidelines recommend timely post-diagnostic family support. Current provision is patchy, largely unevidenced, and a source of dissatisfaction for both families and professionals. There is a pressing need for an evidenced programme of post-diagnostic support focusing on caregiver mental health and adjustment, alongside autism psycho-education. This trial tests the clinical and cost-effectiveness of a new brief manualised psychosocial intervention designed to address this gap.

METHODS

This is a multi-centre two-parallel-group single (researcher)-blinded randomised controlled trial of the Empower-Autism programme plus treatment-as-usual versus usual local post-diagnostic offer plus treatment-as-usual. Caregivers of children aged 2-15 years with a recent autism diagnosis will be recruited from North West England NHS or local authority centres. Randomisation is individually by child, with one "index" caregiver per child, stratified by centre, using 2:1 randomisation ratio to assist recruitment and timely intervention. Empower-Autism is a group-based, manualised, post-diagnostic programme that combines autism psycho-education and psychotherapeutic components based on Acceptance and Commitment Therapy to support caregiver mental health, stress management and adjustment to their child's diagnosis. The comparator is any usual local group-based post-diagnostic psycho-education offer. Receipt of services will be specified through health economic data.

PRIMARY OUTCOME

caregiver mental health (General Health Questionnaire-30) at 52-week follow-up.

SECONDARY OUTCOMES

key caregiver measures (wellbeing, self-efficacy, adjustment, autism knowledge) at 12-, 26- and 52-week follow-up and family and child outcomes (wellbeing and functioning) at 52-week endpoint.

SAMPLE

N=380 (approximately 253 intervention/127 treatment-as-usual). Primary analysis will follow intention-to-treat principles using linear mixed models with random intercepts for group membership and repeated measures. Cost-effectiveness acceptability analyses will be over 52 weeks, with decision modelling to extrapolate to longer time periods.

DISCUSSION

If effective, this new approach will fill a key gap in the provision of evidence-based care pathways for autistic children and their families.

TRIAL REGISTRATION

ISRCTN 45412843 . Prospectively registered on 11 September 2019.

Effectiveness of the SCERTS Model-Based Interventions for Autistic Children: A Systematic Review

PURPOSE

This systematic review aimed to examine the effectiveness of the Social Communication, Emotional Regulation, and Transactional Support (SCERTS) Model-based interventions in supporting developmental skills of children who were diagnosed with or at increased likelihood of autism.

METHOD

We searched six electronic databases, in addition to Google Scholar and the reference lists, using terms related to SCERTS, the Early Social Interaction project, and autism spectrum disorder. Of the 70 articles, six published between 2014 and 2021 (a total of 455 children) were eligible for inclusion and were analyzed in terms of study design, type of publication, participant characteristics, intervention procedures, and major findings.

RESULTS

Most reviewed studies that were relatively less vulnerable to the given risk of bias suggested that SCERTS may be an effective approach for promoting children's social communication skills, and implementers were able to achieve an adequate level of intervention fidelity through training. Further implications could not be drawn concerning children's language, reduction in restricted repetitive behaviors, emotional regulation, adaptive behavior, play, cognitive skills, academic competence, and motor skills due to contradicting findings within limited evidence.

CONCLUSIONS

Although SCERTS is a promising intervention with emerging evidence, more methodologically rigorous studies are needed to progress the research base of SCERTS and draw firm conclusions about its effectiveness in improving a wide range of skills for children and implementers. Several areas for future research are discussed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20151842.

Association Between High-Need Education-Based Funding and School Suspension Rates for Autistic Students in New Zealand

IMPORTANCE

Autistic students often experience poor educational outcomes that have implications for later life, including unemployment, interactions with the criminal justice system, increased risk for substance abuse, and low socioeconomic status. Improving educational outcomes is critical for ensuring that autistic young people can reach their potential.

OBJECTIVE

To quantify differences in suspension rates between autistic and nonautistic students and to assess whether high-need education-based funding for autistic students is associated with reduced rates of school suspension.

DESIGN, SETTING, AND PARTICIPANTS

This national cohort study used linked health and education data from New Zealand's Integrated Data Infrastructure. Data were obtained for students aged 5 to 16 years from January 1 to December 31, 2018, and analyzed July 7, 2021, to January 1, 2022. A novel case identification method was used to identify autistic students.

EXPOSURES

High-need education-based funding (Ongoing Resourcing Scheme [ORS]) obtained before 2019.

MAIN OUTCOMES AND MEASURES

Rates of suspension from school. Crude and adjusted analyses of the association between suspension rates and autism among the full population with adjustment made for sociodemographic characteristics (sex, age, ethnicity, deprivation, and urban or rural profile of residence) were conducted using complete-case, 2-level random intercept logistic multivariable regressions. To assess the association between ORS funding and suspension, analysis was restricted to autistic students.

RESULTS

Of the 736 911 students in the study population, 9741 (1.3%) were identified as autistic (median [SD] age, 10 [3.2] years; 7710 [79.1%] boys), and 727 170 (98.7%) as nonautistic (median [SD] age, 10 [3.4] years; 369 777 [50.9%] boys). School suspension was experienced by 504 autistic students (5.2%) and 13 845 nonautistic students (1.9%). After adjustment for demographic characteristics, autistic students had significantly higher odds of suspension than their nonautistic peers (adjusted odds ratio, 2.81; 95% CI, 2.55-3.11). Of the 9741 autistic students, 2895 (29.7%) received high-need education-based (ORS) funding. Suspensions were experienced by 57 autistic students (2.0%) with high-need funding and 447 autistic students (6.5%) without high-need funding. After adjustment for demographic characteristics, co-occurring conditions, and level of disability support need, autistic students with high-need funding had significantly lower odds of suspension than autistic students without high-need funding (adjusted odds ratio, 0.29; 95% CI, 0.21-0.40).

CONCLUSIONS AND RELEVANCE

In this cohort study, the findings of disparities in suspension rates between autistic and nonautistic students underscore the challenges faced in providing inclusive education for all young people, regardless of disability status. This study found that high-need funding was associated with reduced suspension rates among autistic students, suggesting that if appropriate supports are afforded to autistic students, a more inclusive education can be provided.

Gesture Development in Chinese-Speaking Preschool Children With Autism and the Roles of Parental Input and Child-Based Factors

PURPOSE

Children with autism are found to have delayed and heterogeneous gesture abilities. It is important to understand the growth of gesture abilities and the underlying factors affecting its growth. Addressing these issues can help to design effective intervention programs.

METHOD

Thirty-five Chinese-speaking preschoolers with autism spectrum disorder (M _age = 4.89 years, SD = 0.91; four girls) participated in four play sessions with their parents over 9 months. Their child-based factors including autism severity, intellectual functioning, and expressive language abilities were assessed. The gestures (deictic, iconic, and conventional) of the children and their parents were coded. Growth curve analyses were conducted to examine individual growth trajectories and the roles of child-based factors and parental input in shaping the children's gesture development.

RESULTS

Child-based factors and parental input predicted gesture development differently. Parents' gestures positively predicted their children's gestures of the same type. Autism severity negatively predicted iconic and conventional gestures. Overall growth was found in deictic rather than iconic and conventional gestures. Subgroup variation was also found. Specifically, children with better expressive language ability showed a decrease in deictic gestures. An increase in iconic and conventional gestures was found in children with more severe autism and those with poorer expressive language ability and intellectual functioning, respectively.

CONCLUSIONS

Different types of gestures may have different growth trajectories and be predicted by different child-based factors. Particular attention should be given to children who never produced iconic gestures, which is more challenging and may not develop over a short period, and hence require direct instruction.

Developing Gene-Based Personalised Interventions in Autism Spectrum Disorders

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with onset in early childhood [...]

The future of care and clinical research in autism - recommendations from the 2021 Lancet Commission

At least 78 million people worldwide are affected by autism, a neurodevelopmental disorder characterized by deficits in social interactions, and repetitive behaviors and/or interests. Autism typically manifests in early childhood, and affects social communications and behaviors throughout the lifespan of the individual. Under the umbrella of autism spectrum disorder, it is a highly heterogeneous disorder, with some individuals profoundly affected and needing care every day, while others can live highly independent lives, with some adjustments. The past 60 years has seen a major influx of interest in autism, and significant advances in many areas. However, a large gap remains between current scientific knowledge and the help and support that people with autism and their families need. To address these concerns, the Lancet commissioned a report on the "future of care and clinical research in autism". The Commission calls for government coordination between health-care, education and social sectors, as well as active participation from people with autism and their families. The Commission proposes personalized, evidence-based assessments and intervention, that is accessible and affordable to all, and call for increased appreciation of neurodiversity and prioritization of research that can improve the lives of people with autism and their families. How to support each and every autistic individual and their families is highly challenging. The 64-page Lancet Commission Report, published on December 2021, was written jointly by 32 authors from 6 continents and 13 disciplines, including clinicians, other health-care providers, researchers, advocates, autistic individuals and their parents.

Evaluating a Two-Tiered Parent Coaching Intervention for Young Autistic Children Using the Early Start Denver Model

OBJECTIVES

Early intervention can improve the outcomes of young autistic children, and parents may be well placed to deliver these interventions. The Early Start Denver Model (ESDM) is a naturalistic developmental behavioral intervention that can be implemented by parents with their own children (P-ESDM). This study evaluated a two-tiered P-ESDM intervention that used a group parent coaching program, and a 1:1 parent coaching program. We evaluated changes in parent use of the ESDM and parent stress, as well as child engagement, communication, and imitation.

METHODS

Seven autistic or probably autistic children (< 60 months old) and their parents participated. A multiple-baseline design was used to compare individual changes between Baseline 1, Group Coaching (Tier 1), Baseline 2, and 1:1 Coaching (Tier 2). Parent and child behaviors were analyzed from weekly videos and graphed. Parenting stress was measured.

RESULTS

All parents improved in their use of ESDM strategies after the Tier 1 intervention. Changes in parent fidelity during Tier 2 were mixed, but all parents maintained higher than baseline levels of fidelity. Six parents demonstrated above 75% ESDM fidelity in at least one session. There were positive changes in parent stress levels pre- post-intervention. Positive results were found for most children's levels of engagement, imitation, and communication. There were significant positive relationships between parent fidelity and both child engagement and child functional utterances.

CONCLUSIONS

Group P-ESDM is a promising approach for improving parent fidelity and some child outcomes. Future randomized and controlled studies of group P-ESDM, using standardized outcome measures, are warranted.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s41252-022-00264-8.

"Going Mobile"-increasing the reach of parent-mediated intervention for toddlers with ASD via group-based and virtual delivery

Evidence supports early intervention for toddlers with ASD, but barriers to access remain, including system costs, workforce constraints, and a range of family socio-demographic factors. An urgent need exists for innovative models that maximize resource efficiency and promote widespread timely access. We examined uptake and outcomes from 82 families participating in a parent-mediated intervention comprising group-based learning and individual coaching, delivered either in-person (n = 45) or virtually (n = 37). Parents from diverse linguistic, ethnic, and educational backgrounds gained intervention skills and toddlers evidenced significant social-communication gains. Few differences emerged across socio-demographic factors or delivery conditions. Findings highlight the feasibility, acceptability, and promise of group-based learning when combined with individual coaching, with added potential to increase program reach via virtual delivery.

Caregiver Satisfaction with Delivery of Telehealth Autism Services

OBJECTIVE

The purpose of this study was to assess satisfaction with telehealth interventions for a large nonprofit organization that transitioned interventions for individuals with autism spectrum disorder (ASD) to telehealth during a pandemic. Services provided via telehealth included applied behavior analysis (ABA), speech and language, and occupational therapies. A secondary survey evaluated reasons for declining telehealth services.

METHODS

A survey was administered to 10,567 families who were receiving autism interventions. A total of 440 respondents answered all the questions on the survey, and their results were included in this study. A secondary survey was administered to 223 individuals who declined to have telehealth autism interventions.

RESULTS

There was not a clinically meaningful difference in satisfaction across service types. Although all ratings were in the high range, caregivers ranked speech therapists as more dependable than ABA therapists, and this difference was statistically significant. The findings suggested that the majority of caregivers were generally satisfied with services provided in a telehealth format. For those who declined services, the majority indicated a discomfort with the use of technology.

CONCLUSIONS

The participants of telehealth autism interventions reported high general satisfaction and indicated an improvement in their quality of life. Results provide suggestive evidence that increased satisfaction of telehealth services may allow for further acceptability and access for participants. Future research should evaluate participant and clinician satisfaction with telehealth versus in-person interventions.

An integrated early care pathway for autism

In this Viewpoint, we argue for the need to reconceptualise an integrated early-care provision for autistic children in the light of their enduring support needs and relevant new findings from developmental and intervention research. This model goes beyond short-term reactive care to outline an early proactive, evidenced, developmentally phased, and scalable programme of support for autistic children and their families from the earliest opportunity, with timely access to later step-up care when needed. We also integrate this model with emerging opportunities from data science and digital health technologies as a potential facilitator of such a pathway. Building on this work, we argue that the best current autism intervention evidence can be integrated with concepts and evidence gained in the management of other enduring health conditions to support an autistic child and their family through their early development. The aim is to improve those children's social communication abilities, expand their range and flexibility of interests, and mitigate any negative impacts of sensory difficulties and restricted, repetitive behaviours on the child and their family wellbeing. The pathway solutions described could also be adapted for older adolescents and adults and could be used within the health systems of different countries, including within low-income and middle-income contexts.

Interventions for Transition-Age Youth With Disabilities: A Meta-Analysis of Group Design Studies

This meta-analytic review investigated interventions for transition-age youth diagnosed with autism, intellectual disability, or extensive support needs. Nineteen group design studies with 215 effect sizes met inclusion criteria. A robust variance estimation procedure that accounts for the clustering effect sizes within studies was used to synthesize effect sizes within each intervention and outcome type. Occupational Therapy/Physical Therapy interventions have significant and positive effects on gross motor outcomes (g = 0.73, p < 0.01). All remaining interventions and outcomes could not be synthesized due to a limited number of studies, but are further described in a narrative manner. Recommendations for future research include improving the methodological quality of intervention studies and further analyzing the effects of interventions for transition-age youth.