Beyond intervention into daily life: A systematic review of generalisation following social communication interventions for young children with autism

Rehabilitation and intervention of developmental and acquired prosopagnosia: A systematic review

Prosopagnosia is a neurological disorder; characterized by an impairment in facial recognition. It can occur from acquired prosopagnosia (occurring in approximately 5.6% of the population), or from developmental prosopagnosia (occurring in approximately 2% of the population). Despite the relatively high prevalence of prosopagnosia, there has been limited research into intervention for this condition. The current systematic review aimed to review the evidence base to aid the development of practice guidelines for clinicians working with impacted individuals. A systemic search identified 14 studies, 10 of which involved participants with developmental prosopagnosia, while the remaining studies involved participants with acquired prosopagnosia. Overall, the findings identified two strategies which produced significant improvement in face recognition in prosopagnosics. The first strategy involved a perceptual learning strategy (a restorative approach). While this strategy improved face processing abilities, the intervention was time-consuming and relied on specific software. The second strategy involved learned association of distinguishable facial features (a compensatory approach). This intervention produced improvements in face recognition and was quick to administer, however, the gains made were not generalisable to untrained faces. The current review identified a number of limitations in the existing literature, such as the lack of single-case experimental designs and randomized controlled trials, limited control for practice effects, and no consensus with regard to the assessment and diagnosis of prosopagnosia. This review highlighted the need for further research to inform practice guidelines.

A pilot randomised controlled trial of a telehealth-delivered brief 'Sleeping Sound Autism' intervention for autistic children

BACKGROUND

Access to behavioural sleep intervention is beneficial for autistic children, yet many families face barriers to access associated with location and time. Preliminary evidence supports telehealth-delivered sleep intervention. However, no studies have evaluated brief telehealth sleep intervention. To address this, we evaluated telehealth delivery of the brief behavioural Sleeping Sound Autism intervention, using a two-armed, parallel-group, non-blinded, pilot randomised controlled trial (RCT) design (trial registration: ANZCTR12620001276943).

METHOD

Sixty-one families of autistic children without intellectual disability (5-12 years, 46% female) with caregiver-reported moderate-severe behavioural sleep problems participated Australia-wide, randomised to an intervention (n = 30) or treatment as usual control group (n = 31). Intervention group participants were invited to attend two video-conference telehealth sessions and one follow-up phone call with a trained clinician. Survey data was collected from caregivers at baseline and three- and six-months post-randomisation, to evaluate feasibility, acceptability, and efficacy. Ten intervention group caregivers participated in end-of-study semi-structured interviews to explore their experiences.

RESULTS

Forty-nine caregivers completed surveys. At baseline, 87% felt positive and 84% felt confident about participating via telehealth, and 75% believed the program would improve child sleep. At three-months, intervention group caregivers (n = 24) reported the usefulness (100%) of and preference for (71%) telehealth, and 95.8% would recommend this sleep program to other families. A significant group by time difference was observed in child sleep (Children's Sleep Habits Questionnaire) with large effect sizes (d = 0.87-1.05), emotion and behaviour (Developmental Behavior Checklist 2) with moderate effect sizes (d = 0.40-0.57), and caregiver mental health (Kessler 10) with small to moderate effect sizes (d = 0.60-0.28), favouring the intervention group (n = 23). There were no significant group differences in child (Child Health Utility instrument) or caregiver (Assessment of Quality of Life) quality of life. However, there were individual differences in the clinical significance of improved child sleep. Qualitative data showed that whilst telehealth was convenient for caregivers, without attenuating the benefits of most key intervention features, not all children were able to engage effectively with the clinician via telehealth.

CONCLUSIONS

This first pilot RCT of a brief telehealth behavioural sleep intervention for primary-school-aged autistic children suggests that telehealth delivery is acceptable, feasible and likely efficacious in improving sleep in the short-term. Providing families with ongoing choice of mode of delivery (telehealth/in-person) and examining the person-environment fit of telehealth for autistic children is important.

The translatability of communication interventions in paediatric autism: A scoping review

PURPOSE

Translation of research is requisite for speech-language pathologists; however, barriers have been reported. This review aimed to identify the extant literature published on communication for autistic children, and examine the replicability and translatability of communication interventions for speech-language pathologists providing services to children with autism.

METHOD

A scoping review was conducted using a six-stage protocol. Following initial database searching and screening, data were extracted from included studies for demographic characteristics and Template for Intervention Description and Replication (TIDieR) checklist elements. Stakeholder consultation interviews with 13 speech-language pathologists who work with autistic children were also undertaken.

RESULT

The database search revealed 4719 studies on the topic of communication in autistic children, of which 762 were communication intervention studies. Of these included intervention studies, 30% were considered replicable according to the TIDieR checklist. Stakeholder consultation revealed that poorly described intervention studies hindered translation efforts.

CONCLUSION

The vast amount of autism communication intervention literature and the variable quality of intervention description reporting are barriers to accessing high quality literature for translation to practice. Improved reporting of intervention descriptions in autism communication intervention studies would support research translation into clinical settings.

Using the ADDIE Model of Instructional Design to Create Programming for Comprehensive ABA Treatment

ABA research abounds with articles on increasing or decreasing a small set of behaviors. These articles fit nicely within the framework of Focused ABA Treatment in which the goal of treatment centers on only a few behaviors. However, many behavioral practitioners spend most of their time developing Comprehensive ABA Treatment in which a large number of behaviors are systematically changed across multiple developmental domains. Few resources are available to help in designing and implementing such programming. This article presents a model from the field of instructional design for the development of comprehensive programming. Applying the ADDIE model-Analyze, Design, Develop, Implement, Evaluate-the article identifies a consistent process to follow, critical actions to take, and helpful resources to use when developing comprehensive programming for individuals with autism.

Generalisation of Social Communication Skills by Autistic Children During Play-Based Assessments Across Home, School and an Unfamiliar Research Setting

We investigated autistic children's generalisation of social communication over time across three settings during a play-based assessment with different adults and explore the potential moderating effects on generalisation of age, nonverbal IQ and level of restricted and repetitive behaviours. The social communication abilities of 248 autistic children (2-11 years, 21% female, 22% single parent, 60% white) from three UK sites were assessed from 1984 video interactions in three contexts with three different interaction partners (parent/home, teaching assistant/school, researcher/clinic) at baseline, midpoint (+ 7m) and endpoint (+ 12m) within the Paediatric Autism Communication Trial-Generalised (PACT-G), a parent-mediated social communication intervention. Children's midpoint social communication at home generalised to school at midpoint and to clinic at endpoint. Generalisation was stronger from home to school and clinic than school to home and clinic. Generalisation was not moderated by age, nonverbal IQ or restricted and repetitive behaviour. Broader child development did not explain the pattern of results. The current study is the largest study to date to explore generalisation with autistic children and provides novel insight into their generalisation of social communication skills. Further research is needed to gain a more comprehensive understanding of facilitators of generalisation across settings and interaction partners in order to develop targeted strategies for interventions to enhance outcomes for young autistic children.

Social skills interventions for Thai adolescents with Autism Spectrum Disorder (ASD): a qualitative study of the perceptions and experiences of Thai adolescents, their caregivers and healthcare professionals

BACKGROUND

Social skills interventions (SSIs) are effective for enhancing social skills and decreasing mental health problems in adolescents with autism spectrum disorder (ASD). However, these interventions have been designed and their effectiveness has been established in Western countries. Lack of culturally acceptable SSIs for Asian nations is a possible barrier to implementing effective and tailored interventions that address the unique requirements of ASD individuals across countries and cultures. This study aims to explore the needs and preferences of adolescents with ASD, their caregivers, and healthcare professionals (HPs) in Thailand regarding the components, delivery formats, and cultural adaptation required for an outpatient-based social skills intervention.

METHODS

Qualitative data was collected via three focus groups of HPs (n = 20) and 24 paired interviews with adolescents with ASD and their caregivers from a child psychiatric hospital in Thailand. Purposive sampling was employed, and thematic analysis was used to analyse the data.

RESULTS

Nine themes emerged from the data generated by HPs, and seven from adolescents with ASD and their caregivers. SSIs for Thai adolescents with ASD and their caregivers should emphasise specific social skills training and assess the abilities of adolescents as required. Incorporating various learning strategies is important. Parental involvement is essential and provides knowledge of an adolescent's symptoms and coaching skills, which are best used to support their adolescents. Cultural considerations include the need for social knowledge of Thai culture, promoting assertiveness and praising parents' abilities, implementing a programme in time to not interrupt academic achievement, and renaming a programme from social skills intervention to social communication intervention. Barriers to implementing a programme included HPs' need for specialised training and education and decreased workload. Also, the caregivers' and adolescents' stigma reduced attendance in a programme. Increased extra compensation and relocation days off are provided as policy support for staff who deliver the intervention.

CONCLUSION

The results suggest that SSIs for Thai adolescents with ASD should be tailored to meet the needs for specific knowledge, skills, and parental collaboration as coaches for their adolescents. Additionally, it should incorporate Thai culture. It is necessary to consider staff knowledge, workload, and stigma in order to reduce barriers to implementation in practice.

Elucidating multifinal and equifinal pathways to developmental disorders by constructing real-world neurorobotic models

Vigorous research has been conducted to accumulate biological and theoretical knowledge about neurodevelopmental disorders, including molecular, neural, computational, and behavioral characteristics; however, these findings remain fragmentary and do not elucidate integrated mechanisms. An obstacle is the heterogeneity of developmental pathways causing clinical phenotypes. Additionally, in symptom formations, the primary causes and consequences of developmental learning processes are often indistinguishable. Herein, we review developmental neurorobotic experiments tackling problems related to the dynamic and complex properties of neurodevelopmental disorders. Specifically, we focus on neurorobotic models under predictive processing lens for the study of developmental disorders. By constructing neurorobotic models with predictive processing mechanisms of learning, perception, and action, we can simulate formations of integrated causal relationships among neurodynamical, computational, and behavioral characteristics in the robot agents while considering developmental learning processes. This framework has the potential to bind neurobiological hypotheses (excitation-inhibition imbalance and functional disconnection), computational accounts (unusual encoding of uncertainty), and clinical symptoms. Developmental neurorobotic approaches may serve as a complementary research framework for integrating fragmented knowledge and overcoming the heterogeneity of neurodevelopmental disorders.

Friendship interventions for children with neurodevelopmental needs: A systematic review and meta-analysis

RATIONALE

Children with neurodevelopmental disorders such as attention-deficit hyperactivity disorder (ADHD), autism, developmental language disorder (DLD), intellectual disability (ID), and social (pragmatic) communication disorder (SPCD) experience difficulties with social functioning due to differences in their social, emotional and cognitive skills. Previous systematic reviews have focussed on specific aspects of social functioning rather than broader peer functioning and friendships.

OBJECTIVE

To systematically review and methodologically appraise the quality and effectiveness of existing intervention studies that measured friendship outcomes for children with ADHD, autism, DLD, ID, and SPCD.

METHOD

Following PRISMA guidelines, we searched five electronic databases: CINAHL, Embase, Eric, PsycINFO, and PubMed. Two independent researchers screened all abstracts and disagreements were discussed with a third researcher to reach consensus. The methodological quality of studies was assessed using the Cochrane Risk of Bias Tool for Randomised Trials.

RESULTS

Twelve studies involving 15 interventions were included. Studies included 683 children with a neurodevelopmental disorder and 190 typically-developing children and diagnosed with either autism or ADHD. Within-group meta-analysis showed that the pooled intervention effects for friendship across all interventions were small to moderate (z = 2.761, p = 0.006, g = 0.485). The pooled intervention effect between intervention and comparison groups was not significant (z = 1.206, p = 0.400, g = 0.215).

CONCLUSION

Findings provide evidence that some individual interventions are effective in improving social functioning and fostering more meaningful friendships between children with neurodevelopmental disorders and their peers. Effective interventions involved educators, targeted child characteristics known to moderate peer functioning, actively involved peers, and incorporated techniques to facilitate positive peer perceptions and strategies to support peers. Future research should evaluate the effectiveness of friendship interventions for children with DLD, ID and SPCD, more comprehensively assess peer functioning, include child self-report measures of friendship, and longitudinally evaluate downstream effects on friendship.

Research Reviews: Advances in methods for evaluating child and adolescent mental health interventions

BACKROUND

The evidence base for interventions for child mental health and neurodevelopment is weak and the current capacity for rigorous evaluation limited. We describe some of the challenges that make this field particularly difficult and expensive for evaluation studies.

METHODS

We describe and review the use of novel study designs and analysis methodology for their potential to improve this situation.

RESULTS

While several novel designs appeared ill-suited to our field, systematic review found others that offered potential but had yet to be widely adopted, some not at all.

CONCLUSIONS

While funding is inevitably a constraint, we argue that improvements in the evidence base of both current and new treatments will only be achieved by the adoption of a number of these new technologies and study designs, the consistent application of rigorous constructive but demanding standards, and the engagement of the public, patients, clinical and research services to build a design, recruitment, and analysis infrastructure.

Generalization of the modulatory effect of social interaction on personal space

Introduction

Personal space (PS) is a safe area around an individual's body that affects spatial distance when socially interacting with others. Previous studies have shown that social interaction may modulate PS. However, these findings are often confounded by the effects of familiarization. Furthermore, whether the potential regulatory effects of social interaction on PS can be generalized from interacting confederates to strangers remains unclear.

Methods

To answer these questions, we enrolled 115 participants in a carefully designed experiment.

Results

We found that prosocial interaction in the form of a cooperative task effectively reduced PS, and this regulatory effect could be generalized from interacting confederates to non-interacting confederates.

Discussion

These findings deepen our understanding of PS regulation and may be aid in the diagnosis and rehabilitation of dysfunctional social behaviors.

Efficacy of very early interventions on neurodevelopmental outcomes for infants and toddlers at increased likelihood of or diagnosed with autism: A systematic review and meta-analysis

The aim of this systematic review was to determine the efficacy of very early interventions for infants and toddlers at increased likelihood of or diagnosed with autism for autism symptomatology, developmental outcomes and/or neurocognitive markers. Eight databases were searched (14 April 2022) with inclusion criteria: (i) RCTs with care as usual (CAU) comparison group, (ii) participants at increased likelihood of or diagnosed with autism and aged <24 months corrected age (CA), (iii) parent-mediated and/or clinician directed interventions, and (iv) outcome measures were autism symptomatology, cognition, language, adaptive skills, or neurocognitive assessments (EEG and eye tracking). Quality was assessed using Risk of Bias 2 and GRADE. Nineteen publications from 12 studies reported on 715 infants and toddlers. There was low to moderate certainty evidence that clinician-assessed outcomes did not show significant treatment effects for: autism symptomatology (ADOS CSS: MD -0.08, 95% CI -0.61, 0.44, p = 0.75), cognitive outcome (Mullen Scales of Early Learning-Early Learning Composite (MSEL-ELC): SMD 0.05, 95% CI -0.19, 0.29, p = 0.67), receptive language (MSEL-Receptive Language: SMD 0.04, 95% CI -0.21, 0.3, p = 0.74) or expressive language (MSEL-Expressive Language: SMD 0.06, 95% CI -0.1, 0.23, p = 0.45). Neurocognitive outcomes (EEG and eye tracking) were heterogeneous, with inconsistent findings. There is low to moderate certainty evidence that very early interventions have limited impact on neurodevelopmental outcomes by age 3 years.

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.

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.

Experiences of equine assisted therapy for females with autism spectrum disorders

Purpose

This research indicates females with autism spectrum disorders (ASDs) have a diverse clinical presentation compared to males. Furthermore, females with ASD are often diagnosed later and typically experience greater levels of mental health difficulties. Evidence suggests that clinic-based verbal interventions for ASD have limited efficacy; therefore, alternative therapies, such as equine-assisted therapies (EATs), are gaining recognition. The purpose of this study was to directly explore the experiences of females with an ASD who have undertaken EAT.

Design/methodology/approach

Five female participants with a diagnosis of ASD were recruited from two equine therapy centres. Participants were aged between 15 and 30 years and undertook semi-structured interviews, which were analysed using interpretative phenomenological analysis.

Findings

Three superordinate themes emerged: the difficult experience of the social world, the process of EAT and the emotional impact of horses.

Originality/value

Directly exploring the experiences of females with ASD highlights benefits from engaging therapeutically with horses, building confidence and independence to transferring this into more effective social communication with other people. Offering emotion-focused therapeutic complementary interventions for females with ASD should be forefronted to help remediate the impact of difficult and sometimes traumatic earlier experiences in the social world. This requires increased funding for EAT, combined with larger-scale research projects to evaluate this.

Daily living skills of autistic adolescents and young adults: A scoping review

INTRODUCTION

Daily living skills (DLS) are essential for an increased quality of life and autonomous living. DLS are a focus of occupational therapy practice; however, there has been no identified review of DLS acquisition in autistic adolescents or adults. A scoping review was undertaken of which the objective was to evaluate and synthesise the extent, range, and nature of research activity, and to identify research gaps in the existing literature as they relate to DLS acquisition and autistic adolescents and adults.

METHODS

A structured search of the literature was conducted. Studies published in English between 2011 and 2021 that included a focus on the acquisition of DLS in autistic adolescents and young adults were included. The titles and abstracts of 103 records were screened, and the full text of 53 records was reviewed. These reference lists were hand searched. Following this process, 25 papers were found to meet the inclusion criteria.

RESULTS

Findings indicate inconsistencies throughout the literature, with a lack of consensus on best practice methods, mediums, and/or tools to support optimal outcomes in terms of DLS acquisition for the autistic population. Themes related to (1) Generalisation of Skills Across Contexts, (2) Skill Maintenance, (3) Technology as a Teaching Method, (4) Participant and Family Perspectives, and (5) The Balance of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) focus in research were extracted from the reviewed literature. There is a strong consensus in the findings of the identified papers that autistic adolescents and young adults experience poorer outcomes in terms of DLS acquisition than non-autistic peers, and peers with other developmental or intellectual disabilities.

CONCLUSION

Future research is needed to fill these identified gaps and provide a clearer understanding on interventions to support optimal outcomes for autistic individuals.

What is the concordance between parent- and education professional-reported adaptive functioning in autistic children using the VABS-II?

Adaptive functioning of autistic children is traditionally measured through informant-report, often from parents. Behaviour varies across settings though, and context-specific reports should be considered. Limited and inconsistent results show low parent-education professional concordance, but no research has yet explored item level response variation. We investigated Vineland Adaptive Behaviour Scales-II concordance using 233 lower ability autistic children from the PACT-G sample. Domain and item level agreement was low, but better on objectively measured behaviours. Higher child nonverbal ability improved concordance. Where disagreements occurred, education professionals identified emergent skills more and parents were more likely to rate present/absent. Parents and education professionals view the adaptive abilities of autistic children differently and both should be considered when developing personalised interventions and support.

Combined social communication therapy at home and in education for young autistic children in England (PACT-G): a parallel, single-blind, randomised controlled trial

BACKGROUND

Autistic children can have difficulty generalising treatment effects beyond the immediate treatment context. Paediatric Autism Communication Therapy (PACT) has been successful when delivered in the clinic. Here we tested the Paediatric Autism Communication Therapy-Generalised (PACT-G) intervention combined between home and education settings for its overall effect and mechanistic transmission of effect across contexts.

METHODS

In this parallel, single-blind, randomised, controlled trial, we recruited autistic children aged 2-11 years in urban or semi-urban areas in Manchester, Newcastle, and London, England. Children needed to meet core autism criteria on Autism Diagnostic Observation Schedule-second edition (ADOS-2) and parent-rated Social Communication Questionnaire (SCQ-lifetime), and children older than 5 years were included if they had intentional communication but expressive language equivalent of age 4 years or younger. Eligible children were randomly assigned (1:1), using block randomisation (random block sizes of 2 and 4) and stratified for site, age (2-4 years vs 5-11 years), and gender, to either PACT-G plus treatment as usual or treatment as usual alone. Research assessors were masked to treatment allocation. The PACT-G intervention was delivered by a therapist in parallel to the child's parents at home and to learning-support assistants (LSA) at their place of education, using both in-person and remote sessions over a 6 month period, to optimise adult-child social interaction. Treatment as usual included any health support or intervention from education or local community services. The primary outcome was autism symptom severity using the ADOS-2, as measured by researchers, at 12 months versus baseline. Secondary outcomes were Brief Observation of Social Communication Change (BOSCC) and dyadic social interaction between child and adult across contexts, both at 12 months. Other secondary outcome measures were assessed using the following composites: language, anxiety, repetitive behaviour, adaptive behaviour, parental wellbeing, child health-related quality of life, and disruptive behaviour. Assessments were done at baseline, 7 months, and 12 months. We used an intention-to-treat (ITT) analysis of covariance for the efficacy outcome measures. Adverse events were assessed by researchers for all trial families at each contact and by therapists in the PACT-G group at each visit. This study is registered with the ISRCTN Registry, ISRCTN 25378536.

FINDINGS

Between Jan 18, 2017, and April 19, 2018, 555 children were referred and 249 were eligible, agreed to participate, and were randomly assigned to either PACT-G (n=122) or treatment as usual (n=127). One child in the PACT-G group withdrew and requested their data be removed from the study, giving an ITT population of 248 children. 51 (21%) of 248 children were female, 197 (79%) were male, 149 (60%) were White, and the mean age was 4·0 years (SD 0·6). The groups were well balanced for demographic and clinical characteristics. In the PACT-G group, parents of children received a median of 10 (IQR 8-12) home sessions and LSAs received a median of 8 (IQR 5-10) education sessions over 6 months. We found no treatment effect on the ADOS-2 primary outcome compared with treatment as usual (effect size 0·04 [95% CI -0·19 to 0·26]; p=0·74), or researcher-assessed BOSCC (0·03 [-0·25 to 0·31]), language composite (-0·03 [-0·15 to 0·10]), repetitive behaviour composite (0·00 [-0·35 to 0·35]), adaptive behaviour composite (0·01 [-0·15 to 0·18]), or child wellbeing (0·09 [-0·15 to 0·34]). PACT-G treatment improved synchronous response in both parent (0·50 [0·36 to 0·65]) and LSA (0·33 [0·16 to 0·50]), mediating increased child communication with parent (0·26 [0·12 to 0·40]) and LSA (0·20 [0·06 to 0·34]). Child dyadic communication change mediated outcome symptom alteration on BOSCC at home (indirect effect -0·78 [SE 0·34; 95% CI -1·44 to -0·11]; p=0·022) although not in education (indirect effect -0·67 [SE 0·37; 95% CI -1·40 to 0·06]; p=0·073); such an effect was not seen on ADOS-2. Treatment with PACT-G also improved the parental wellbeing composite (0·44 [0·08 to 0·79]) and the child disruptive behaviour composite in home and education (0·29 [0·01 to 0·57]). Adverse events on child behaviour and wellbeing were recorded in 13 (10%) of 127 children in the treatment as usual group (of whom four [31%] were girls) and 11 (9%) of 122 in the PACT-G group (of whom three [33%] were girls). One serious adverse event on parental mental health was recorded in the PACT-G group and was possibly study related.

INTERPRETATION

Although we found no effect on the primary outcome compared with treatment as usual, adaptation of the 12-month PACT intervention into briefer multicomponent delivery across home and education preserved the positive proximal outcomes, although smaller in effect size, and the original pattern of treatment mediation seen in clinic-delivered therapy, as well as improving parental wellbeing and child disruptive behaviours across home and school. Reasons for this reduced efficacy might be the reduced dose of each component, the effect of remote delivery, and the challenges of the delivery contexts. Caution is needed in assuming that changing delivery methods and context will preserve an original intervention efficacy for autistic children.

FUNDING

National Institute for Health Research and Medical Research Council Efficacy and Mechanism Evaluation Award.

Non-pharmacological interventions for autism spectrum disorder in children: an overview of systematic reviews

OBJECTIVE

To assess the effectiveness of non-pharmacological interventions for the treatment of autism spectrum disorder (ASD) in children.

DESIGN

Overview of systematic reviews (SRs).

PARTICIPANTS

Children aged 12 years and under with ASD.

SEARCH METHODS

In October 2021, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and Epistemonikos placing no restrictions on language or date of publication.

INTERVENTIONS

17 non-pharmacological interventions compared with placebo, no-treatment (including waiting list) or other interventions (ie, usual care, as defined by the authors of each study).

DATA COLLECTION AND ANALYSIS

We rated the methodological quality of the included SRs using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). We reported the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty of the evidence (CoE) according to the analysis conducted by the authors of the included SRs.

MAIN OUTCOME MEASURES

A multidisciplinary group of experts agreed on analysing nine critical outcomes evolving core and non-core ASD symptoms.

PUBLIC AND PATIENT INVOLVEMENT STATEMENT

Organisations of parents of children with ASD participated in external revision of the final version of the report.

RESULTS

We identified 52 reports that were within our scope, of which 48 were excluded for various reasons. After excluding less reliable SRs, we included four SRs. Non-pharmacological interventions (ie, Early Intensive Behavioural Intervention, Applied Behaviour Analysis, Picture Exchange Communication System and Naturalistic Developmental Behavioural Interventions) may have favourable effects on some core outcomes including language, social and functioning, play or daily living skills in children with ASD (with either no GRADE assessment, very low or low CoE). In addition, we identified a lack of report for other key outcomes in the included SRs (ie, restricted, repetitive behaviour; play and sensory processing).

CONCLUSIONS

Synthesised evidence regarding the efficacy of non-pharmacological interventions for children with ASD is scarce. High-quality SRs addressing the variety of both non-pharmacological interventions and relevant outcomes are needed.

PROSPERO REGISTRATION NUMBER

CRD42020206535.

Inclusivity for children with autism spectrum disorders: Parents' reflections of the school learning environment versus home learning during COVID-19

Whilst attendance in mainstream school helps encourage inclusivity, these environments are recognised as being particularly challenging for young people with an autism spectrum disorder (ASD). The COVID-19 pandemic brought a novel transition as young people moved from school to home-learning. This study compared the experiences of parents of children with ASD and co-occurring health difficulties of school-learning environments with their home-learning environments during COVID-19 lockdown. An interpretative phenomenological analysis was conducted on semi-structured interviews from six parents of children (aged 8-15 years old) with ASD. Four superordinate themes were generated: Interactions between Health, ASD and Learning Environments; School Support and Managing Health Needs; Seeking Solutions; and Learning from COVID-19 Lockdown. The study highlighted the impact of ASD and co-occurring health difficulties on learning where parents found ways to provide positive home-learning environments which could be used and/or transferred back into school environments. These results hold real-world implications where educators could treat sensory and ASD friendly environments as standard and include genuine adjustments for children with ASD and additional needs. A flexible home-learning approach using parental knowledge around environmental adjustments that support learning, wellbeing and a sense of inclusion should be prioritised for children's overall development and wellbeing in these unprecedented times, and beyond.

A Systematic Review of Play-Based Interventions Targeting the Social Communication Skills of Children with Autism Spectrum Disorder in Educational Contexts

Children with autism spectrum disorder (ASD) experience social communication difficulties which can be compounded by increased social demands and expectations of the school environment. Play offers a unique context for social communication development in educational settings. This systematic review aimed to synthesize play-based interventions for the social communication skills of children with ASD in educational contexts and identified nine studies. Overall, studies in this review provided a promising evidence base for supporting social communication skills through play in education for children with ASD. The review also highlighted gaps in research on play-based interventions for the social communication skills of children with ASD within naturalistic educational settings.

Evaluating evidence-based practice in light of the boundedness and proximity of outcomes: Capturing the scope of change

Evidence-based practice (EBP) reviews abound in early childhood autism intervention research. These reviews seek to describe and evaluate the evidence supporting the use of specific educational and clinical practices, but give little attention to evaluating intervention outcomes in terms of the extent to which they reflect change that extends beyond the exact targets and contexts of intervention. We urge consideration of these outcome characteristics, which we refer to as "proximity" and "boundedness," as key criteria in evaluating and describing the scope of change effected by EBPs, and provide an overview and illustration of these concepts as they relate to early childhood autism intervention research. We hope this guidance will assist future researchers in selecting and evaluating intervention outcomes, as well as in making important summative determinations of the evidence base for this population. LAY SUMMARY: Recent reviews have come to somewhat different conclusions regarding the evidence base for interventions geared toward autistic children, perhaps because such reviews vary in the degree to which they consider the types of outcome measures used in past studies testing the effects of treatments. Here, we provide guidance regarding characteristics of outcome measures that research suggests are particularly important to consider when evaluating the extent to which an intervention constitutes "evidence-based practice."

Could You Give Me the Blue Brick? LEGO®-Based Therapy as a Social Development Program for Children with Autism Spectrum Disorder: A Systematic Review

LEGO®-based therapy is a social skills development program aimed at children with autism spectrum disorder (ASD). A systematic review of the literature was conducted using PRISMA guidelines. PubMed, Scopus and Web of Science bibliographic databases were searched from their date of inception to August 2020. The review included 19 studies. Studies were classified according to experimental designs (e.g., Randomized Control Trial, Non-Randomized Studies of Interventions and case report and series) and a narrative synthesis of each was provided, along with a critical discussion of the strengths and weaknesses of the available literature on the topic. Although LEGO®-based therapy appears a promising treatment for social interaction in ASD, the findings of LEGO®-based therapy studies should be interpreted and generalized with caution, due to the low quality of the studies and the small sample sizes.

Virtual reality and naturalistic developmental behavioral interventions for children with autism spectrum disorder

BACKGROUND

Naturalistic Developmental Behavioral Interventions (NDBI) have been evaluated as the most promising interventions for children with autism spectrum disorder. In recent years, a growing body of literature suggests that technological advancements such as Virtual Reality (VR) are promising intervention tools. However, to the best of our knowledge no studies have combined evidence-based practice with such tools.

AIM

This article aims to review the current literature combining NDBI and VR, and provide suggestions on merging NDBI-approaches with VR.

METHODS

This article is divided into two parts, where we first conduct a review mapping the research applying NDBI-approaches in VR. In the second part we argue how to apply the common features of NDBI into VR-technology.

RESULTS

Our findings show that no VR-studies explicitly rely on NDBI-approaches, but some utilize elements in their interventions that are considered to be common features to NDBI.

CONCLUSIONS AND IMPLICATIONS

As the results show, to date, no VR-based studies have utilized NDBI in their intervention. We therefore, in the second part of this article, suggests ways to merge VR and NDBI and introduce the term Virtual Naturalistic Developmental Behavioral Interventions (VNDBI). VNDBI is an innovative way of implementing NDBI which will contribute in making interventions more accessible in central as well as remote locations, while reducing unwanted variation between service sites. VNDBI will advance the possibilities of individually tailoring and widen the area of interventions. In addition, VNDBI can provide the field with new knowledge on effective components enhancing the accuracy in the intervention packages and thus move forward the research field and clinical practice.

The behavioral effects of cooperative and competitive board games in preschoolers

Traditional board games are a common social activity for many children, but little is known about the behavioral effects of this type of game. The current study aims to explore the behavioral effects of cooperative and competitive board games in four‐to‐six‐year‐old children (N = 65). Repeatedly during 6 weeks, children in groups of four played either cooperative or competitive board games in a between‐subject design, and shortly after each game conducted a task in which children’s cooperative, prosocial, competitive, and antisocial behavior were observed. The type of board game did not have an effect on cooperative, prosocial or antisocial behavior. Cooperative and competitive board games elicited equal amounts of cooperative and prosocial behavior, which suggest that board games, regardless of type, could have positive effects on preschoolers’ social behavior. Our results suggest that children may compete more after playing competitive board games; but the measure of competitive behavior in particular was unreliable. Preschoolers enjoyed playing cooperative board games more than competitive board games, which may be one reason to prefer their use.

Utility of the Autism Diagnostic Observation Schedule and the Brief Observation of Social and Communication Change for Measuring Outcomes for a Parent-Mediated Early Autism Intervention

Measuring outcomes for autistic children following social communication interventions is an ongoing challenge given the heterogeneous changes, which can be subtle. We tested and compared the overall and item-level intervention effects of the Brief Observation of Social Communication Change (BOSCC), Autism Diagnostic Observation Schedule (ADOS-2) algorithm, and ADOS-2 Calibrated Severity Scores (CSS) with autistic children aged 2-5 years from the Preschool Autism Communication Trial (PACT). The BOSCC was applied to Module 1 ADOS assessments (ADOS-BOSCC). Among the 117 children using single or no words (Module 1), the ADOS-BOSCC, ADOS algorithm, and ADOS CSS each detected small non-significant intervention effects. However, on the ADOS algorithm, there was a medium significant intervention effect for children with "few to no words" at baseline, while children with "some words" showed little intervention effect. For the full PACT sample (including ADOS Module 2, total n=152), ADOS metrics evidenced significant small (CSS) and medium (algorithm) overall intervention effects. None of the Module 1 item-level intervention effects reached significance, with largest changes observed for Gesture (ADOS-BOSCC and ADOS), Facial Expressions (ADOS), and Intonation (ADOS). Significant ADOS Module 2 item-level effects were observed for Mannerisms and Repetitive Interests and Stereotyped Behaviors. Despite strong psychometric properties, the ADOS-BOSCC was not more sensitive to behavioral changes than the ADOS among Module 1 children. Our results suggest the ADOS can be a sensitive outcome measure. Item-level intervention effect plots have the potential to indicate intervention "signatures of change," a concept that may be useful in future trials and systematic reviews. LAY SUMMARY: This study compares two outcome measures in a parent-mediated therapy. Neither was clearly better or worse than the other; however, the Autism Diagnostic Observation Schedule produced somewhat clearer evidence than the Brief Observation of Social Communication Change of improvement among children who had use of "few to no" words at the start. We explore which particular behaviors are associated with greater improvement. These findings can inform researchers when they consider how best to explore the impact of their intervention.