Evidence-based comprehensive treatments for early autism

Moving Beyond the Intensive Behavior Treatment Versus Eclectic Dichotomy

Professionals serving students with autism spectrum disorders (ASD) in inclusive classroom settings face the challenge of selecting and successfully implementing evidence-based intervention strategies. Many propose that Intensive Behavioral Treatment (IBT) is the most efficacious approach for learners with ASD. Evidence for this approach is often established by comparing the IBT model to a condition described as “eclectic”. In this paper, authors examine the IBT vs. eclectic literature, acknowledge the potential efficacy of the IBT model with preschool-aged children, suggest concerns about efficacy studies that have compared IBT and eclectic programs, point out that most of the studies were restricted in the age range of their participants, and note that few were implemented in inclusive settings. The authors propose that a technical eclectic approach can be beneficial for children and youth with ASD if it is conceptually grounded, incorporates evidence-based focused intervention practices, and is well implemented. A detailed example of such a technical eclectic program model is provided and the practicality of such an approach in inclusive settings for children and youth with ASD and their families is discussed.

Oxidative stress-related biomarkers in autism: systematic review and meta-analyses

Autism spectrum disorders (ASDs) are rarely diagnosed in children younger than 2 years, because diagnosis is based entirely on behavioral tests. Oxidative damage may play a central role in this pathogenesis, together with the interconnected transmethylation cycle and transsulfuration pathway. In an attempt to clarify and quantify the relationship between oxidative stress-related blood biomarkers and ASDs, a systematic literature review was carried out. For each identified study, mean biomarker levels were compared in cases and controls providing a point estimate, the mean ratio, for each biomarker. After meta-analysis, the ASD patients showed decreased blood levels of reduced glutathione (27%), glutathione peroxidase (18%), methionine (13%), and cysteine (14%) and increased concentrations of oxidized glutathione (45%) relative to controls, whereas superoxide dismutase, homocysteine, and cystathionine showed no association with ASDs. For the C677T allele in the methylene tetrahydrofolate reductase gene (MTHFR), homozygous mutant subjects (TT) showed a meta-OR of 2.26 (95% CI 1.30-3.91) of being affected by ASD with respect to the homozygous nonmutant (CC). Case-control studies on blood levels of vitamins suggest a lack of association (folic acid and vitamin B12) or rare association (vitamins A, B6, C, D, E). Sparse results were available for other biomarkers (ceruloplasmin, catalase, cysteinylglycine, thiobarbituric acid-reactive substances, nitric oxide) and for polymorphisms in other genes. Existing evidence is heterogeneous and many studies are limited by small sample size and effects. In conclusion, existing evidence suggests a role for glutathione metabolism, the transmethylation cycle, and the transsulfuration pathway, although these findings should be interpreted with caution, and larger, more standardized studies are warranted.

Outcomes of a behavioral education model for children with autism in a mainstream school setting

The authors report 1-year outcomes for 11 children (3-7 years) with autism who attended an "Applied Behavior Analysis (ABA) classroom" educational intervention in a mainstream school setting. The children learned new skills by the end of 1 year and learned additional skills during a 2nd year. Group analysis of standardized test outcomes (IQ and adaptive behavior) showed moderate to large effect size changes over 1 year, with further changes during a 2nd year. Standardized test outcomes for nine children after 2 years were also analyzed against a comparison group (n = 18) of children with autism receiving "education as usual." These controlled comparisons were associated with statistically significant large effects in favor of the ABA group for adaptive skills. Exploratory analysis also showed that increases in language and learning skills in the ABA class group were generally associated with positive changes in standardized test scores. A comprehensive behavioral intervention model can be successfully implemented in a mainstream school setting.

Autism spectrum disorders in Hispanics and non-Hispanics

OBJECTIVES

To compare differences in autism between Hispanic and non-Hispanics. We also examined the relationship between multiple language exposure and language function and scores of children.

METHODS

The Childhood Autism Risks from Genetics and the Environment (CHARGE) study is an ongoing population-based case-control study with children sampled (n=1061) from three strata: those with autism (AU) or autism spectrum disorder (ASD); developmental delay (DD); or the general population (GP).

RESULTS

Non-Hispanic cases demonstrated higher cognitive composite scores for the Mullen Scales of Early Learning (MSEL). There were significant associations between multiple language exposure and MSEL subscales for receptive language and expressive language, in both cases (AU/ASD) and TD controls, but not DD controls. Results of multivariate regression analyses suggest several predictors to be associated with lower Mullen expressive language scores including: diagnosis of ASD/AU, speaking to the child in a second language 25-50% of the time and Hispanic ethnicity; while maternal college education was associated with higher scores.

CONCLUSION

Overall, the CHARGE Hispanic group displayed more similarities than differences compared to non-Hispanics in terms of autistic phenotypes and maladaptive & adaptive scores for cases. The relationship between multiple language use and cognitive scores warrants a closer look.

Office screening and early identification of children with autism

Autism spectrum disorders (ASDs), also called pervasive developmental disorders in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revised), constitute a group of neurodevelopmental disorders that coalesce around a common theme of impairments in social functioning, communication abilities, and repetitive or rigid behaviors. The ASDs considered here include autism/autistic disorder, Asperger disorder/Asperger syndrome (AS), and pervasive developmental disorder not otherwise specified. This article focuses on autism/autistic disorder screening and its early identification, with a brief mention for AS screening, as there are limited tools and no recommendation for universal screening for AS.

Behavioral interventions for children with autism spectrum disorders

Early intensive behavioral intervention is the only well-established treatment for young children with autism spectrum disorders (ASDs). Less intensive behavioral interventions are also effective for targeted concerns with older children and adolescents. This article describes the core features of behavioral treatments, summarizes the evidence base for effectiveness, and provides recommendations to facilitate family understanding of these interventions and identification of qualified providers. Recommendations are also provided for collaboration between pediatric providers and behavior analysts who are serving families of individuals with ASDs.

Outcomes of behavioral intervention for children with autism in mainstream pre-school settings

We evaluated outcomes for 31 children with autism (2-6 years of age at intake) who received behavioral intervention in mainstream pre-school settings and a comparison group of 12 children receiving treatment as usual. After 2 years, children receiving behavioral intervention had higher IQ scores (Hedges g = 1.03 (95% CI = .34, 1.72) and adaptive behavior composite scores (Hedges g = .73 (95% CI = .05, 1.36). Despite probably fewer intervention hours, these group level outcomes were comparable to studies providing more intensive intervention. Individual child data also showed positive results with 19.4% achieving change at a reliable level for IQ; but a lower percentage than found in recent meta-analysis research. Strengths and weaknesses of the mainstream pre-school delivery model are discussed.

Improvement in symptoms versus functioning: how do our best treatments measure up?

We examined the effects of redefining standards of evidence for treatments targeting childhood mental health problems by expanding outcomes beyond symptom reduction to include functioning. Over 750 treatment protocols from 435 randomized controlled trials were rated based on empirical evidence. Nearly two-thirds (63.9%) demonstrated at least a minimum level of evidence for reducing symptoms; however, only 18.8% of treatments demonstrated evidence for reducing functional impairment. Of those treatments with empirical support for symptom reduction, the majority did not demonstrate empirical support for improvement in functioning because measures of functioning were not included in the studies in which these treatments were tested. However, even when measures of functioning were included, it was much more difficult for treatments to achieve improvement. Among treatments that achieved improvement in functioning, the most notable were Collaborative Problem Solving for disruptive behavior and Cognitive Behavioral Therapy plus Medication for traumatic stress because they demonstrated no support for symptom reduction but good support for improvement in functioning. Results are discussed within the context of evaluating the standards of evidence for treatments and the opportunity to move towards a multidimensional framework whose utility has the potential to exceed the sum of its parts.

Effects of a father-based in-home intervention on perceived stress and family dynamics in parents of children with autism

Parents of children with autism report high rates of stress. Parental differences in stress are inconsistent, with most research indicating that mothers report higher levels of stress than fathers. We explored parental differences before and after an in-home training program. Fathers were taught an intervention designed to improve their child's social reciprocity and communication; they then trained mothers. Stress was assessed with the Parenting Stress Index-Short Form, and family dynamics was assessed with the Family Adaptability and Cohesion Evaluation Scales II. Both mothers and fathers reported high preintervention levels of stress. After intervention, fathers' stress was reduced, but not significantly, possibly because of the variability in fathers' scores; mothers' stress scores were significantly reduced. Parenting styles were significantly different before and after intervention. Interdisciplinary teams, including occupational therapists, nurses, and special educators, can work.together to have a positive impact on the lives of families of children with autism.

Web-based training in early autism screening: results from a pilot study

BACKGROUND

Lack of familiarity with early signs of autism by community service providers has resulted in significant delays in children receiving early intervention services necessary to improve long-term outcomes. The Screening Tool for Autism in Toddlers and Young Children (STAT) was specifically developed to identify early behavioral features of autism. Although STAT training has been available for years, access is limited because of few STAT trainers and geographic concerns. This study evaluated the efficacy and acceptability of Web-based training of the STAT as a means of increasing accessibility to this training.

MATERIALS AND METHODS

Thirty professionals from three geographic areas participated. Roughly 1 of 3 had little or no training on autism assessment. The tutorial contains a general overview, administration and scoring conventions, and item-specific content and concepts. Participants completed a pretest and then completed the STAT tutorial at their own pace, followed by a post-test and a user satisfaction questionnaire.

RESULTS

Mean scores on STAT concepts significantly improved after taking the tutorial (p<0.001). At pretest, only 1 person (3%) obtained correct scores on at least 80% of the items (a priori cutoff for a "pass"), compared with 22 (73%) at post-test (p<0.001). The majority of trainees enjoyed taking the tutorial, thought it was well organized, relevant, interesting, and useful, and felt it was easy to understand and operate.

DISCUSSION

Results support Web-based training as a promising method for promoting early identification of autism and may help overcome problems associated with the critical shortage of autism-screening professionals.

Modified checklist for autism in toddlers: cross-cultural adaptation and validation in Spain

Early detection and treatment have been shown to be effective in reducing disability severity caused by Autistic Spectrum Disorders (ASDs). As Spanish pediatricians have no detection tool, the Modified Checklist for Autism in Toddlers (M-CHAT) was first translated into and culturally adapted to Spanish. Validity and reliability studies were carried out in two different geographical areas of Spain, where M-CHAT was administered to two different samples, namely: 2,480 high- and low-risk children; and 2,055 low-risk children. The results obtained were similar to those yielded by the original M-CHAT studies. Differences were found in positive predictive value, due to the low ASD frequency observed in this study. M-CHAT is still being studied in a large population-based screening program in Spain.

A systematic review with meta-analysis of comprehensive interventions for preschool children with autism spectrum disorder (ASD): study protocol

INTRODUCTION

The aims of this study are to (1) conduct a systematic review of the intervention literature in preschool children with autism spectrum disorder (ASD), including types of interventions that are tested and the classification of outcome measures used and (2) to undertake a meta-analysis of the studies, allowing for the first time the comparison of different approaches to intervention using comparative outcomes. There are a number of alternative modalities of intervention for preschool children with ASD in use with different theoretical background and orientation, each of which tend to use different trial designs and outcome measures. There is at this time an urgent need for comprehensive systematic review and meta-analyses of intervention studies for preschool children with ASD, covering studies of adequate quality across different intervention types and measurement methods, with a view to identifying the best current evidence for preschool interventions in the disorder.

METHODS AND ANALYSIS

The authors will perform a systematic review of randomised controlled trials for preschool children with ASD aged 0-6 years, along with a meta-analysis of qualifying studies across intervention modality. The authors will classify the interventions for preschool children with ASD under three models: behaviour, multimodal developmental and communication focused. First, the authors will perform a systematic review. Then, the authors will conduct a meta-analysis by comparing the three models with various outcomes using an inverse variance method in a random effect model. The authors will synthesise each outcome of the studies for the three models using standardised mean differences.

DISSEMINATION AND ETHICS

This study will identify each intervention's strengths and weaknesses. This study may also suggest what kinds of elements future intervention programmes for children with ASD should have. The authors strongly believe those findings will be able to translated into the clinical practices and patients and their family benefits. Review registration: PROSPERO CRD42011001349.

Pleasure, Throwing Breaches, and Embodied Metaphors: Tracing Transformations-in-Participation for a Child with Autism to a Sensory Integration—Based Therapy Session

In occupational therapy practice, the rich interweaving of procedural and narrative reasoning results in healing transformations. However, a lack of research focus on transformational processes perpetuates a focus on observable and measurable behaviors. In line with the movement toward evidence-based implementation research, this article focuses on a case study drawn from an ethnography of therapist—child—family interactions in a sensory integration—based clinic to provide a thick description of the moments leading up to and following changes in bodily and social engagement for a child with autism. Using theoretical resources on acted narratives and aesthetics, this article provides a developing method and language to show how an occupational therapist and a child with autism throw breaches to jointly create embodied metaphors of what matters to the child in his or her everyday life. A microanalysis of therapist—child bodily and sensing interactions also reveals how narrative and procedural reasoning converge in moments of pleasure that ultimately lead to outcomes in participation outside the clinic and confound characterizations of autistic aloneness. Implications for research on sensory integration approaches in general and social interventions for children with autism are discussed.

A web-based tutorial for parents of young children with autism: results from a pilot study

OBJECTIVE

Early intervention can significantly improve long-term outcomes for children with autism. Unfortunately, many children do not receive early intervention services due to a critical shortage of trained professionals in this area. To bridge this gap, we evaluated a Web-based parent training tutorial (Enhancing Interactions), based on evidence-based practices and utilizing the Web-based platform to maximize learning.

METHODS

Twenty-three parents with a child between 18 months and 6 years with an autism spectrum disorder participated. Pre- and posttest scores of parents' knowledge were used to evaluate tutorial effectiveness. The system usability scale (SUS) evaluated technical user-friendliness and the user satisfaction questionnaire (USQ), gauged satisfaction with content.

RESULTS

The mean number of correct items on the posttest significantly increased, from 12.6 to 20.4, p<0.001. The mean SUS score was 85 (standard deviation=17), corresponding to a score of "excellent." All participants found the tutorial user friendly, well integrated, and 96% (all but one participant) thought it was easy to use, felt confident using the technical features, and would use a tutorial like this again. On the USQ, all participants found that the tutorial was well organized, clearly presented, and easy to understand; that it increased their knowledge about communicating with their child; and that they felt capable of applying these techniques with their child.

CONCLUSIONS

The tutorial appears effective in increasing parents' knowledge with high user satisfaction.

Recurrence risk for autism spectrum disorders: a Baby Siblings Research Consortium study

OBJECTIVE

The recurrence risk of autism spectrum disorders (ASD) is estimated to be between 3% and 10%, but previous research was limited by small sample sizes and biases related to ascertainment, reporting, and stoppage factors. This study used prospective methods to obtain an updated estimate of sibling recurrence risk for ASD.

METHODS

A prospective longitudinal study of infants at risk for ASD was conducted by a multisite international network, the Baby Siblings Research Consortium. Infants (n = 664) with an older biological sibling with ASD were followed from early in life to 36 months, when they were classified as having or not having ASD. An ASD classification required surpassing the cutoff of the Autism Diagnostic Observation Schedule and receiving a clinical diagnosis from an expert clinician.

RESULTS

A total of 18.7% of the infants developed ASD. Infant gender and the presence of >1 older affected sibling were significant predictors of ASD outcome, and there was an almost threefold increase in risk for male subjects and an additional twofold increase in risk if there was >1 older affected sibling. The age of the infant at study enrollment, the gender and functioning level of the infant's older sibling, and other demographic factors did not predict ASD outcome.

CONCLUSIONS

The sibling recurrence rate of ASD is higher than suggested by previous estimates. The size of the current sample and prospective nature of data collection minimized many limitations of previous studies of sibling recurrence. Clinical implications, including genetic counseling, are discussed.

Bridging the research-to-practice gap in autism intervention: an application of diffusion of innovation theory

There is growing evidence that efficacious interventions for autism are rarely adopted or successfully implemented in public mental health and education systems. We propose applying diffusion of innovation theory to further our understanding of why this is the case. We pose a practical set of questions that administrators face as they decide about the use of interventions. Using literature from autism intervention and dissemination science, we describe reasons why efficacious interventions for autism are rarely adopted, implemented, and maintained in community settings, all revolving around the perceived fit between the intervention and the needs and capacities of the setting. Finally, we suggest strategies for intervention development that may increase the probability that these interventions will be used in real-world settings.

Autism spectrum disorders--a genetics review

Autism is an etiologically and clinically heterogeneous group of disorders, diagnosed solely by the complex behavioral phenotype. On the basis of the high-heritability index, geneticists are confident that autism will be the first behavioral disorder for which the genetic basis can be well established. Although it was initially assumed that major genome-wide and candidate gene association studies would lead most directly to common autism genes, progress has been slow. Rather, most discoveries have come from studies of known genetic disorders associated with the behavioral phenotype. New technology, especially array chromosomal genomic hybridization, has both increased the identification of putative autism genes and raised to approximately 25%, the percentage of children for whom an autism-related genetic change can be identified. Incorporating clinical geneticists into the diagnostic and autism research arenas is vital to the field. Interpreting this new technology and deciphering autism's genetic montage require the skill set of the clinical geneticist including knowing how to acquire and interpret family pedigrees, how to analyze complex morphologic, neurologic, and medical phenotypes, sorting out heterogeneity, developing rational genetic models, and designing studies. The current emphasis on deciphering autism spectrum disorders has accelerated the field of neuroscience and demonstrated the necessity of multidisciplinary research that must include clinical geneticists both in the clinics and in the design and implementation of basic, clinical, and translational research.

Developmental surveillance of infants and toddlers by maternal and child health nurses in an Australian community-based setting: promoting the early identification of autism spectrum disorders

Although signs of autism spectrum disorders (ASDs) are evident during the first year of life, few children are diagnosed prior to 3 years. The objective in this article is to highlight the role that primary health care professionals can play in the early identification of ASDs by briefly outlining the successful implementation of The Social Attention and Communication Study. Maternal and child health nurses were trained on the early signs of ASDs, which enabled them to identify these children prior to 2 years. The training procedure used will be outlined, and the early signs that were monitored will be explained in detail. It is recommended that routine monitoring for ASDs in infancy and toddlerhood become standard practice among all primary health care professionals.

Factors affecting the age at diagnosis of autism spectrum disorders in Nova Scotia, Canada

While early diagnosis of autism spectrum disorders (ASD) is essential for ensuring timely access to early intervention services, there is limited existing literature investigating factors that delay this diagnosis. This population-based cohort study explored the age at which children in Nova Scotia, Canada, are diagnosed with ASDs and the factors associated with this age. Children diagnosed with an ASD between January 1992 and December 2005 were identified from a cohort of live births in the province between 1990 and 2002. Demographic and clinical variables were extracted from population-based perinatal and administrative health databases and evaluated as predictors of age at ASD diagnosis. Of 122,759 live births, 884 cases of ASDs were identified during the study period. The median age at diagnosis within the cohort was 4.6 years. In adjusted linear regression analysis, a one year increase in maternal age at delivery was associated with a 0.06 decrease in age at ASD diagnosis (p= .0007). Children who were residents of Halifax County received their diagnoses 0.52 years later than residents of other counties (p= .0054). A diagnosis of attention-deficit/hyperactivity disorder (ADHD) was associated with a 1.29-year increase in age at diagnosis (p< .0001). These results suggest that potential exists for improving early detection of ASDs in the province. Future research in this field has the potential to contribute to our understanding of the causal pathways linking the demographic and clinical variables we have identified and the age at diagnosis of ASDs.

Early indicators of autism spectrum disorders at 12 and 24 months of age: A prospective, longitudinal comparative study

Prospective questionnaire data from a longitudinal population sample on children with autism spectrum disorders (ASD), developmental delay, specific language impairment, or typical development (TD), were collected at ages eight, 12 and 24 months, via the Communication and Symbolic Behavior Scale Developmental Profile (CSBS) – Infant Toddler Checklist, and the Actions and Gesture section of the MacArthur-Bates Communicative Development Inventory (CDI):Words and Gestures. The four groups were compared at four years of age to identify whether any early behaviours differentiated the groups. While children with ASD differed from TD children on most social communicative measures by 12 months of age, the only social communication characteristic which could differentiate the children with ASD from the other groups were gesture scores on the CDI at 12 months and the CSBS at 24 months. Significant markers of ASD were identifiable in this community sample at an early age, although discrimination between clinical groups was rarely evident.

Early autism detection: are we ready for routine screening?

BACKGROUND. Autism is a serious neurodevelopmental disorder that has a reportedly rising prevalence rate. The American Academy of Pediatrics recommends that screening for autism be incorporated into routine practice. It is important to consider the pros and cons of conducting autism screening as part of routine practice and its implications on the community. We have explored this question in the context of screening from a scientific point of view.

METHOD

A literature search was conducted to assess the effectiveness of community screening programs for autism.

RESULTS

Judged against critical questions about autism, screening programs failed to fulfill most criteria. Good screening tools and efficacious treatment are lacking, and there is no evidence yet that such a program would do more good than harm.

CONCLUSIONS

On the basis of the available research, we believe that we do not have enough sound evidence to support the implementation of a routine population-based screening program for autism. Ongoing research in this field is certainly needed, including the development of excellent screening instruments and demonstrating with clinical trials that such programs work and do more good than harm.

Early diagnoses of autism spectrum disorders in Massachusetts birth cohorts, 2001-2005

OBJECTIVE

We examined trends in autism spectrum disorder diagnoses by age 36 months (early diagnoses) and identified characteristics associated with early diagnoses.

METHODS

Massachusetts birth certificate and early-intervention program data were linked to identify infants born between 2001 and 2005 who were enrolled in early intervention and receiving autism-related services before age 36 months (through December 31, 2008). Trends in early autism spectrum disorders were examined using Cochran-Armitage trend tests. χ² Statistics were used to compare distributions of selected characteristics for children with and without autism spectrum disorders. Multivariate logistic regression analyses were conducted to identify independent predictors of early diagnoses.

RESULTS

A total of 3013 children (77.5 per 10,000 study population births) were enrolled in early intervention for autism spectrum disorder by age 36 months. Autism spectrum disorder incidence increased from 56 per 10,000 infants among the 2001 birth cohort to 93 per 10,000 infants in 2005. Infants of mothers younger than 24 years of age, whose primary language was not English or who were foreign-born had lower odds of an early autism spectrum disorder diagnosis. Maternal age older than 30 years was associated with increased odds of an early autism spectrum disorder diagnosis. Odds of early autism spectrum disorders were 4.5 (95% confidence interval: 4.1-5.0) times higher for boys than girls.

CONCLUSIONS

Early autism spectrum disorder diagnoses are increasing in Massachusetts, reflecting the national trend observed among older children. Linkage of early-intervention program data with population-based vital statistics is valuable for monitoring autism spectrum disorder trends and planning developmental and educational service needs.

Preliminary Investigation of the Sources of Self-Efficacy Among Teachers of Students with Autism

Teacher self-efficacy refers to the beliefs teachers hold regarding their capability to bring about desired instructional outcomes and may be helpful for understanding and addressing critical issues such as teacher attrition and teacher use of research-supported practices. Educating students with autism likely presents teachers with some of the most significant instructional challenges. The self-efficacy of 35 special education teachers of students with autism between the ages of 3 to 9 years was evaluated. Teachers completed rating scales that represented self-efficacy and aspects of the following 3 of Bandura's 4 sources of self-efficacy: (1) sense of mastery, (2) social persuasions, and (3) physiological/affective states. Significant associations were observed between physiological/affective states and self-efficacy, but no associations were observed for the other sources.

Two-Year Outcomes for Children With Autism After the Cessation of Early Intensive Behavioral Intervention

Evidence from recent meta-analytic and narrative review suggests that early intensive behavioral intervention (EIBI) may improve life chances of preschool children with autism. Unfortunately, there are few data indicating whether early gains are maintained after intervention ceases. The purpose of the present study was to establish the 2-year follow-up outcome for children with autism ( N = 41) who had participated in an earlier 2-year controlled comparison of EIBI. Twenty-three children in the intervention group (100% of original sample) and 18 in the treatment-as-usual comparison group (86% of original sample) were located and retested. Group differences favoring intervention substantially diluted in this period but varied significantly between subgroups who had received university-supervised and parent-commissioned interventions, favoring the latter. These groups differed in terms of their baseline characteristics and intensity of intervention. Results strongly suggest a need for better characterization of those children who would benefit from more active maintenance programs.

Credible knowledge: a pilot evaluation of a modified GRADE method using parent-implemented interventions for children with autism

BACKGROUND

Decision-making in child and youth mental health (CYMH) care requires recommendations that are developed through an efficient and effective method and are based on credible knowledge. Credible knowledge is informed by two sources: scientific evidence, and practice-based evidence, that reflects the "real world" experience of service providers. Current approaches to developing these recommendations in relation to CYMH will typically include evidence from one source or the other but do not have an objective method to combine the two. To this end, a modified version of the Grading Recommendations Assessment, Development and Evaluation (GRADE) approach was pilot-tested, a novel method for the CYMH field.

METHODS

GRADE has an explicit methodology that relies on input from scientific evidence as well as a panel of experts. The panel established the quality of evidence and derived detailed recommendations regarding the organization and delivery of mental health care for children and youth or their caregivers. In this study a modified GRADE method was used to provide precise recommendations based on a specific CYMH question (i.e. What is the current credible knowledge concerning the effects of parent-implemented, early intervention with their autistic children?).

RESULTS

Overall, it appeared that early, parent-implemented interventions for autism result in positive effects that outweigh any undesirable effects. However, as opposed to overall recommendations, the heterogeneity of the evidence required that recommendations be specific to particular interventions, based on the questions of whether the benefits of a particular intervention outweighs its harms.

CONCLUSIONS

This pilot project provided evidence that a modified GRADE method may be an effective and practical approach to making recommendations in CYMH, based on credible knowledge. Key strengths of the process included separating the assessments of the quality of the evidence and the strength of recommendations, transparency in decision-making, and the objectivity of the methods. Most importantly, this method combined the evidence and clinical experience in a more timely, explicit and simple process as compared to previous approaches. The strengths, limitations and modifications of the approach as they pertain to CYMH, are discussed.

Telepractice in the assessment and treatment of individuals with autism spectrum disorders: A systematic review

OBJECTIVE

Studies involving the use of telepractice in the delivery of services to individuals with autism spectrum disorders (ASD) were reviewed with the intent to inform practice and identify areas for future research.

METHODS

Systematic searches of electronic databases, reference lists and journals identified eight studies that met pre-determined inclusion criteria. These studies were analysed and summarized in terms of the: (a) characteristics of the participants, (b) technology utilized, (c) services delivered via telepractice, (d) research methodology and (e) results of the study.

RESULTS

Telepractice was used by university-based researchers, behaviour analysts, psychiatrists and psychologists to assist caretakers and educators in the delivery of services to 46 participants with ASD. The services delivered included behavioural and diagnostic assessments, educational consulting, guidance and supervision of behavioural interventions and coaching/training in the implementation of a comprehensive early intervention programme.

CONCLUSIONS

Results suggests telepractice is a promising service delivery approach in the treatment of individuals with ASD that warrants additional research. Guidelines for practitioners and potential directions for future research are discussed.

Is the Autism Treatment Evaluation Checklist a useful tool for monitoring progress in children with autism spectrum disorders?

BACKGROUND

There are few well validated brief measures that can be used to assess the general progress of young children with autism spectrum disorders (ASD) over time. In the present study, the Autism Treatment Evaluation Checklist (ATEC) was used as part of a comprehensive assessment battery to monitor the progress of 22 school-aged children with ASD who had previously taken part in intensive home- or school-based intervention programmes in their pre-school years.

METHODS

Parents completed the ATEC when the children were on average 5.5 years and then again 5-6 years later (mean age 10.4 years). Standardised measures were also used to assess cognitive, language and adaptive behaviour skills and severity of autism symptoms over the same period.

RESULTS

The ATEC had high internal consistency at both time points. ATEC total and sub-scale scores remained relatively stable over time and were highly and significantly correlated with cognitive, language and adaptive behaviour skills and severity of autism symptoms at both assessment points. Initial ATEC total scores predicted 64% of the variance in scores at the subsequent follow-up. However, there was also considerable variation in the patterns of scores shown by individual children over time.

CONCLUSIONS

This study provides some preliminary evidence of the ATEC's potential value for monitoring progress of children with ASD over time. Its advantages and limitations are discussed in the context of the need systematically to monitor the progress of children with ASD over time or in response to intervention.

Randomized controlled trial of the focus parent training for toddlers with autism: 1-year outcome

This randomized controlled trial compared results obtained after 12 months of nonintensive parent training plus care-as-usual and care-as-usual alone. The training focused on stimulating joint attention and language skills and was based on the intervention described by Drew et al. (Eur Child Adolesc Psychiatr 11:266–272, 2002). Seventy-five toddlers with autism spectrum disorder (65 autism, 10 PDD-NOS, mean age = 34.4 months, SD = 6.2) were enrolled. Analyses were conducted on a final sample of 67 children (lost to follow-up = 8). No significant intervention effects were found for any of the primary (language), secondary (global clinical improvement), or mediating (child engagement, early precursors of social communication, or parental skills) outcome variables, suggesting that the ‘Focus parent training’ was not of additional value to the more general care-as-usual.

Point-counter-point: psychotherapy in the age of pharmacology

The long-held view that medicine or therapy is an "art" is quickly becoming obsolete. To procure referrals and reimbursement, clinicians are being forced to be accountable (ie, use empirically supported, effective, reproducible, and efficient treatment interventions) by insurance companies, professional credentialing bodies, and their consumers. This article focuses on reviews of treatment interventions by scholars, researchers, clinicians, and study groups who have examined multiple databases of published studies and ongoing treatment protocols. Behavioral and cognitive-behavioral therapies were most often identified as well-established treatments for specific mental and behavioral health disorders in children and adolescents. Psychotherapy alone or in conjunction with pharmacotherapy can be powerful tools in helping youth manage or eliminate negative outcomes of mental and behavioral disorders.

Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: a randomized controlled trial

BACKGROUND

Social and communication impairments are core deficits and prognostic indicators of autism. We evaluated the impact of supplementing a comprehensive intervention with a curriculum targeting socially synchronous behavior on social outcomes of toddlers with autism spectrum disorders (ASD).

METHODS

Fifty toddlers with ASD, ages 21 to 33 months, were randomized to one of two six-month interventions: Interpersonal Synchrony or Non-Interpersonal Synchrony. The interventions provided identical intensity (10 hours per week in classroom), student-to-teacher ratio, schedule, home-based parent training (1.5 hours per month), parent education (38 hours), and instructional strategies, except the Interpersonal Synchrony condition provided a supplementary curriculum targeting socially engaged imitation, joint attention, and affect sharing; measures of these were primary outcomes. Assessments were conducted pre-intervention, immediately post-intervention, and, to assess maintenance, at six-month follow-up. Random effects models were used to examine differences between groups over time. Secondary analyses examined gains in expressive language and nonverbal cognition, and time effects during the intervention and follow-up periods.

RESULTS

A significant treatment effect was found for socially engaged imitation (p = .02), with more than doubling (17% to 42%) of imitated acts paired with eye contact in the Interpersonal Synchrony group after the intervention. This skill was generalized to unfamiliar contexts and maintained through follow-up. Similar gains were observed for initiation of joint attention and shared positive affect, but between-group differences did not reach statistical significance. A significant time effect was found for all outcomes (p < .001); greatest change occurred during the intervention period, particularly in the Interpersonal Synchrony group.

CONCLUSIONS

This is the first ASD randomized trial involving toddlers to identify an active ingredient for enhancing socially engaged imitation. Adding social engagement targets to intervention improves short-term outcome at no additional cost to the intervention. The social, language, and cognitive gains in our participants provide evidence for plasticity of these developmental systems in toddlers with ASD. http://www.clinicaltrials.gov/ct2/show/NCT00106210?term = landa&rank = 3.

Dynamic Eye gaze and its Potential in Virtual Reality Based Applications for Children with Autism Spectrum Disorders

Children with Autism Spectrum Disorder are often characterized by deficits in social communication skills. While evidence suggests that intensive individualized interventions can improve aspects of core deficits in Autism Spectrum Disorder, at present numerous potent barriers exist related to accessing and implementing such interventions. Researchers are increasingly employing technology to develop more accessible, quantifiable, and individualized intervention tools to address core vulnerabilities related to autism. The present study describes the development and preliminary application of a Virtual Reality technology aimed at facilitating improvements in social communication skills for adolescents with autism. We present preliminary data from the usability study of this technological application for six adolescents with autism and discuss potential future development and application of adaptive Virtual Reality technology within an intervention framework.

Brief parent training in pivotal response treatment for preschoolers with autism

BACKGROUND

Evidence of improved outcomes with early behavioural intervention has placed the early treatment of autism as a health priority. However, long waiting lists for treatment often preclude timely access, raising the question of whether parents could be trained in the interim. Parent training in pivotal response treatment (PRT) has been shown to enhance the communication skills of children with autism. This is typically provided within a 25-hour programme, although less intensive parent training may also be effective. The main objective of the present study was to evaluate the efficacy of brief training in PRT for parents of preschoolers with autism, who were awaiting, or unable to access, more comprehensive treatment.

METHOD

Eight preschoolers with autism and their parents participated in the study. A non-concurrent multiple (across-participants) baseline design was used, in which parents were seen individually for three 2-hour training sessions on PRT. Child and parent outcomes were assessed before, immediately after, and 2 to 4 months following training using standardised tests, questionnaires and behaviour coded directly from video recordings.

RESULTS

Overall, children's communication skills, namely functional utterances, increased following training. Parents' fidelity in implementing PRT techniques also improved after training, and generally these changes were maintained at follow-up. A moderate to strong relationship was found between parents' increased ability to implement PRT techniques and improvement in the children's communication skills.

CONCLUSION

Our findings suggest that brief parent training in PRT promises to provide an immediate, cost-effective intervention that could be adopted widely.

Intervening in infancy: implications for autism spectrum disorders

There is a scarcity of empirically validated treatments for infants and toddlers under age 3 years with autism spectrum disorders (ASD), as well as a scarcity of empirical investigation into successful intervention characteristics for this population. Yet early screening efforts are focused on identifying autism risk in children under age 3 years. In order to build ASD interventions for infants and toddlers upon a foundation of evidence-based characteristics, the current paper presents the results of a systematic literature search and effect size analysis of efficacious interventions for infants and toddlers with other developmental disorders: those who were born prematurely, have developmental impairments, or are at high risk for developmental impairments due to the presence of a biological or familial condition associated with developmental impairments. A review of 32 controlled, high-quality experimental studies revealed that the most efficacious interventions routinely used a combination of four specific intervention procedures, including (1) parent involvement in intervention, including ongoing parent coaching that focused both on parental responsivity and sensitivity to child cues and on teaching families to provide the infant interventions, (2) individualization to each infant's developmental profile, (3) focusing on a broad rather than a narrow range of learning targets, and (4) temporal characteristics involving beginning as early as the risk is detected and providing greater intensity and duration of the intervention. These four characteristics of efficacious interventions for infants and toddlers with other developmental challenges likely represent a solid foundation from which researchers and clinicians can build efficacious interventions for infants and toddlers at risk for or affected by ASD.

Age of diagnosis among Medicaid-enrolled children with autism, 2001-2004

OBJECTIVE

This study examined child- and county-level factors associated with age of diagnosis of autism among Medicaid-enrolled children and the change in age of diagnosis over time.

METHODS

National Medicaid claims from 2002 to 2004 were used to identify age of diagnosis and characteristics of children younger than ten years old with a diagnosis of autism (ICD-9 codes 299, 299.0x, or 299.8x). These data were linked to county-level education and health care variables. Linear regression with random effects for state and county was used to examine associations between these variables and age of diagnosis.

RESULTS

A total of 28,722 Medicaid-enrolled children newly diagnosed with an autism spectrum disorder were identified. Their average age of diagnosis was 64.9 months. Adjusted average age of diagnosis dropped 5.0 months for autistic disorder and 1.8 months for other spectrum disorders during the study period. Asian children were diagnosed earlier than children in other racial or ethnic groups, although these differences were much more pronounced for other spectrum disorders than for autistic disorder. Children eligible for Medicaid through the poverty category were diagnosed earlier, on average, than children who were eligible through disability, foster care, or other reasons, although this difference decreased over time. Children in large urban or rural counties were diagnosed later than children in small urban or suburban counties.

CONCLUSIONS

Findings showed that diagnosis of autism occurs much later than it should among Medicaid-enrolled children, although timeliness is improving over time. Analyses suggest that most of the observed variation is accounted for by child-level variables, rather than county-level resources or state policies.

Effectiveness of a novel community-based early intervention model for children with autistic spectrum disorder

The Nova Scotia early intensive behavior intervention model -NS EIBI ( Bryson et al., 2007 ) for children with autistic spectrum disorders was designed to be feasible and sustainable in community settings. It combines parent training and naturalistic one-to-one behavior intervention employing Pivotal Response Treatment - PRT (R. Koegel & Koegel, 2006 ). We followed 45 children (33 males, mean baseline age  =  50 months) for 12months. Mean gains of 14.9 and 19.5 months were observed on expressive and receptive language measures, respectively, for children with an IQ of 50 or more at baseline versus 6.1 and 8.4 months for children with IQs less than 50. Behavior problems decreased significantly over the 1-year treatment for both groups, but autism symptoms decreased only for those with an IQ of 50 or more.

Low intensity behavioral treatment supplementing preschool services for young children with autism spectrum disorders and severe to mild intellectual disability

This study evaluated the effectiveness of low intensity behavioral treatment (on average 6.5h per week) supplementing preschool services in 3-6-year-old children with autism spectrum disorder and severe to mild intellectual disability. Treatment was implemented in preschools (i.e., daycare centers) and a discrete trial teaching approach was used. Twelve children in the treatment group were compared to 22 children receiving regular intervention. At pre-treatment, both groups did not differ on chronological age, developmental age, diagnosis and level of adaptive skills. Eight months into treatment, children receiving behavioral treatment displayed significantly higher developmental ages and made more gains in adaptive skills than children from the control group. No significant differences between groups were found on autistic symptom severity and emotional and behavioral problems.

Age of diagnosis for autism: individual and community factors across 10 birth cohorts

BACKGROUND

The incidence of autism rose dramatically between 1992 and 2001, while the age at which children were first diagnosed declined. During this period the size and composition of the autism caseload has changed, but little is known about whether the factors associated with the timing of diagnosis may also have shifted. Using a multilevel analysis strategy, the individual and community-level factors associated with age of diagnosis were modelled across 10 birth cohorts of California children.

METHODS

Linked birth and administrative records on 17,185 children with diagnoses of autistic disorder born in California between 1992 and 2001 and enrolled with the California Department of Developmental Services (DDS) were analysed. Information on cases, their parents and their residential location were extracted from birth and DDS records. Zip codes of residence were matched to census data to create community-level measures. Multilevel linear models were estimated for each birth cohort, with individual-level effects for sex, race, parental characteristics, poverty status, birth order and symptom expression. At the community level measures of educational and economic composition, local autism prevalence and the presence of a child psychiatrist were included.

RESULTS

Children with highly educated parents are diagnosed earlier, and this effect has strengthened over time. There is a persistent gap in the age of diagnosis between high and low socioeconomic status (SES) children that has shrunk but not disappeared over time.

CONCLUSION

Routine screening for autism in early childhood for all children, particularly those of low SES, is necessary to eliminate disparities in early intervention.

Screening accuracy of Level 2 autism spectrum disorder rating scales. A review of selected instruments

The goal of this review was to examine the state of Level 2, caregiver-completed rating scales for the screening of Autism Spectrum Disorders (ASDs) in individuals above the age of three years. We focused on screening accuracy and paid particular attention to comparison groups. Inclusion criteria required that scales be developed post ICD-10, be ASD-specific, and have published evidence of diagnostic validity in peer-reviewed journals. The five scales reviewed were: the Social Communication Questionnaire (SCQ), Gilliam Autism Rating Scale/Gilliam Autism Rating Scale-Second Edition (GARS/GARS-2), Social Responsiveness Scale (SRS), Autism Spectrum Screening Questionnaire (ASSQ), and Asperger Syndrome Diagnostic Scale (ASDS). Twenty total studies were located, most examining the SCQ. Research on the other scales was limited. Comparisons between scales were few and available evidence of diagnostic validity is scarce for certain subpopulations (e.g., lower functioning individuals, PDDNOS). Overall, the SCQ performed well, the SRS and ASSQ showed promise, and the GARS/GARS-2 and ASDS demonstrated poor sensitivity. This review indicates that Level 2 ASD caregiver-completed rating scales are in need of much more scientific scrutiny.

Social peers rescue autism-relevant sociability deficits in adolescent mice

Behavioral therapies are currently the most effective interventions for treating the diagnostic symptoms of autism. We employed a mouse model of autism to evaluate components of behavioral interventions that improve sociability in mice. BTBR T+tf/J (BTBR) is an inbred mouse strain that exhibits prominent behavioral phenotypes with face validity to all three diagnostic symptom categories of autism, including robust and well-replicated deficits in social approach and reciprocal social interactions. To investigate the role of peer interactions in the development of sociability, BTBR juvenile mice were reared in the same home cage with juvenile mice of a highly social inbred strain, C57BL/6J (B6). Subject mice were tested as young adults for sociability and repetitive behaviors. B6 controls reared with B6 showed their strain-typical high sociability. BTBR controls reared with BTBR showed their strain-typical lack of sociability. In contrast, BTBR reared with B6 as juveniles showed significant sociability as young adults. A 20-day intervention was as effective as a 40-day intervention for improving social approach behavior. High levels of repetitive self-grooming in BTBR were not rescued by peer-rearing with B6, indicating specificity of the intervention to the social domain. These results from a robust mouse model of autism support the interpretation that social enrichment with juvenile peers is a beneficial intervention for improving adult outcome in the social domain. This novel paradigm may prove useful for discovering factors that are essential for effective behavioral treatments, and biological mechanisms underlying effective behavioral interventions.

Characterizing community-based mental health services for children with autism spectrum disorders and disruptive behavior problems

This study describes the characteristics of children with autism spectrum disorders (ASD) with disruptive behavior problems served in community-based mental health clinics, characterizes psychotherapy process and outcome, and examines differences between children with ASD and a non-ASD comparison group. Results indicate that children with ASD served in this setting are high functioning and diagnostically complex. Certain research-based behavioral and cognitive behavioral psychotherapeutic strategies were observed frequently, while parent training strategies and active teaching strategies were observed less frequently. The intensity or thoroughness with which strategies were pursued was relatively low. Outcome analyses indicate improvement in child symptoms and family functioning. Treatment delivery and outcome were similar for children with and without ASD. These findings represent the first detailed observational data characterizing community-based mental health services for children with ASD.

What Happens Next? Follow-Up From the Children's Toddler School Program

This study was a follow-up of a group of 29 children diagnosed with autism spectrum disorders at age 2 who attended an inclusive toddler program until age 3. Children ranged in age from 4 to 12 years at the time of the parent survey and follow-up testing. The majority of children were placed in a special education (noninclusive) preschool class, but among the children who were in elementary school at the time of follow-up, 63% were in general education classroom placement. Diagnoses of autism spectrum disorders remained stable, socialization skills remained a weakness, and child-related parental stress remained high despite average cognitive and language skills in the majority of children. Social skill development and support remained a service need.

Evidence-based practices and autism

Interventions for autism are increasing being held to standards such as 'evidence-based practice' in psychology and 'scientifically-based research' in education. When these concepts emerged in the context of adult psychotherapy and regular education, they caused considerable controversy. Application of the concepts to autism treatments and special education has raised additional concerns. An analysis of the benefits and limitations of current approaches to empiricism in autism interventions is presented, and suggestions for future research are made.