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

Implementing a Uniform Outcome Measurement Approach for Early Interventions of Autism Spectrum Disorders

OBJECTIVE

Naturalistic developmental behavioral interventions for children with autism spectrum disorder show evidence for effectiveness for specific social communication targets such as joint attention or engagement. However, combining evidence from different studies and comparing intervention effects across those studies have not been feasible due to lack of a standardized outcome measure of broader social communication skills that can be applied uniformly across trials. This investigation examined the usefulness of the Brief Observation of Social Communication Change (BOSCC) as a common outcome measure of general social communication skills based on secondary analyses of data obtained from previously conducted randomized controlled trials of 3 intervention models, Early Social Intervention (ESI), Early Start Denver Model (ESDM) and Joint Attention Symbolic Play Engagement and Regulation (JASPER).

METHOD

The subset of datasets from the 3 randomized controlled trials was created to examine differences in the BOSCC scores between intervention and control groups over the course of the interventions.

RESULTS

Based on 582 videos from 207 caregiver-child dyads, the BOSCC noted significant differences between intervention vs control groups in broad social communication skills within 2 of the 3 intervention models, which were longer in duration and focused on a broad range of developmental skills.

CONCLUSION

The BOSCC offers the potential to take a uniform measurement approach across different intervention models to capture the effect of intervention on general social communication skills but may not pick up the effects of some brief interventions targeting proximal outcomes.

CLINICAL TRIAL REGISTRATION INFORMATION

Comparing Parent-Implemented Interventions for Toddlers With Autism Spectrum Disorders; https://www.

CLINICALTRIALS

gov/; NCT00760812. Intensive Intervention for Toddlers With Autism (EARLY STEPS); https://www.

CLINICALTRIALS

gov/; NCT00698997. Social and Communication Outcomes for Young Children With Autism; https://www.

CLINICALTRIALS

gov/; NCT00953095.

EEG findings and clinical severity and quality of life in non-epileptic patients with autism spectrum disorders

Electroencephalogram (EEG) abnormalities could be seen in up to 60% of non-epileptic children with autism spectrum disorder (ASD). They have been used as biomarkers of ASD severity. The objective of our study is to identify EEG abnormalities in children with different degrees of ASD severity based on the Autism Treatment Evaluation Checklist (ATEC). We also want to assess the quality of life for children with ASD. All of the children underwent at least one hour of sleep-deprived EEG. Forty-five children were enrolled, of whom 42 were male. EEG abnormalities were found in 10 (22.2%) children, predominantly in the bilateral frontal areas. There were no differences in EEG findings among the mild, moderate, and severe ASD groups. The severity of ASD was associated with female sex (p-value = 0.013), ASD with attention deficit hyperactivity disorder (ADHD) (p-value = 0.032), ASD children taking medications (p-value = 0.048), and a lower Pediatric Quality of Life Inventory (PedsQL) (p-value <0.001). Social and emotional domains were the most problematic for health-related quality of life in ASD children, according to parent reports of PedsQL. Further studies with a larger sample size will help to clarify the potential associations between EEG abnormalities and the severity of ASD, as well as the impact on quality of life.

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.

Mediation of 6-year mid-childhood follow-up outcomes after pre-school social communication (PACT) therapy for autistic children: randomised controlled trial

BACKGROUND

There are very few mechanistic studies of the long-term impact of psychosocial interventions in childhood. The parent-mediated Paediatric Autism Communication Therapy (PACT) RCT showed sustained effects on autistic child outcomes from pre-school to mid-childhood. We investigated the mechanism by which the PACT intervention achieved these effects.

METHODS

Of 152 children randomised to receive PACT or treatment as usual between 2 and 5 years of age, 121 (79.6%) were followed 5-6 years after the endpoint at a mean age of 10.5 years. Assessors, blind to the intervention group, measured Autism Diagnostic Observation Scale Calibrated Severity Score (ADOS CSS) for child autistic behaviours and Teacher Vineland (TVABS) for adaptive behaviour in school. Hypothesised mediators were child communication initiations with caregivers in a standard play observation (Dyadic Communication Measure for Autism, DCMA). Hypothesised moderators of mediation were baseline child non-verbal age equivalent scores (AE), communication and symbolic development (CSBS) and 'insistence on sameness' (IS). Structural equation modelling was used in a repeated measures mediation design.

RESULTS

Good model fits were obtained. The treatment effect on child dyadic initiation with the caregiver was sustained through the follow-up period. Increased child initiation at treatment midpoint mediated the majority (73%) of the treatment effect on follow-up ADOS CSS. A combination of partial mediation from midpoint child initiations and the direct effect of treatment also contributed to a near-significant total effect on follow-up TVABS. No moderation of this mediation was found for AE, CSBS or IS.

CONCLUSIONS

Early sustained increase in an autistic child's communication initiation with their caregiver is largely responsible for the long-term effects from PACT therapy on autistic and adaptive behaviour outcomes. This supports the theoretical logic model of PACT therapy but also illuminates fundamental causal processes of social and adaptive development in autism over time: early social engagement in autism can be improved and this can have long-term generalised outcome effects.

Comprehension of irony in autistic children: The role of theory of mind and executive function

Although previous studies have examined irony comprehension in autistic children and potential impact factors, the relationship between theory of mind (ToM), executive function (EF), symptoms of autism, and comprehension of irony in this population remains largely unknown. This study explored irony comprehension in autistic children and examined the roles of ToM and EF in linking autism symptoms to deficits in irony comprehension. Twenty autistic children were compared with 25 typically developing (TD) children in an irony story picture task, ToM task, and EF task. The results showed that autistic children had impaired comprehension of irony compared with TD children, and performance on ironic stories showed a significant moderate discriminatory effect in predicting autistic children. A ToM deficit has also been proposed for autistic children. Comprehension of irony was significantly correlated with second-order ToM (2nd ToM) but was not significantly correlated with any components of EF. Moreover, 2nd ToM can predict the level of irony comprehension and mediate the relationship between symptoms of autism and irony comprehension. Taken together, these findings suggest that irony comprehension may offer a potential cognitive marker for quantifying syndrome manifestations in autistic children, and 2nd ToM may provide insight into the theoretical mechanism underlying the deficit in irony comprehension in this population.

Clinical utility of the standardized observation tool Autism Behavior Coding System for early intervention research in autism spectrum disorder

The Autism Behavior Coding System (ABCS) was developed to help evaluating the effectiveness of early intensive interventions in children with autism spectrum disorder (ASD). The video-based ABCS assesses eight core autistic behavioral variables during therapist-child interaction using standardized quantitative criteria, four behaviors according to their frequency of occurrence, four according to their duration. The present study focuses (1) on the correspondence of ABCS scores with scores on two standard clinical instruments (the ADOS-2 and an ASD-adaptation of the Children's Global Assessment Scale, DD-CGAS), (2) on the sensitivity to change of ABCS scores by the end of an intensive 18 days intervention period (EIP) and (c) on the predictability of short- and longer-term changes in social and repetitive behaviors from ABCS scores at baseline and EIP. Data from 51 children (42 M, 9 F; median age 45 months) followed over 1 year were available. There were significant correlations at baseline between several ABCS scores and ADOS-2 as well as DD-CGAS scores. Correlations at EIP between some ABCS and DD-CGAS scores were highly significant. Four ABCS scores reflected significant changes from baseline to EIP. Several baseline ABCS scores were predictive of DD-CGAS and ADOS-2 scores at EIP and Year 1. However, associations between ABCS score changes from baseline to EIP and the clinical scale changes by Year 1 were not significant. It is concluded that several ABCS scores have adequate clinical validity and sensitivity to change. The short-term changes in ABCS scores and their relationship to longer-term clinical changes need further study.

Examining Treatment Outcomes Across Contexts: How Do Child Baseline Characteristics Impact Measurement of Treatment Response?

The evaluation of the overlap between the ADOS BOSCC and Standard BOSCC as well as the exploration of child characteristics that may predict change are important steps in consolidating data-driven definitions of "improvement". Participants were seen between 2 and 5 times with Standard BOSCC and ADOS BOSCC observations over the course of early intervention trials (Grzadzinski et al. in J Autism Dev Disord 46:2464, 2016; Kim et al. in Autism 23:5, 2019). Results showed consistency between the Standard BOSCC and ADOS BOSCC, highlighting the utility of both as metrics of change and treatment outcome across contexts. Baseline characteristics may play a role in the tailoring of early intervention to maximize treatment outcome and may offer guidance when determining which outcome measures to use.

A Passing Problem: Evaluating Harm and Benefit in Autism Research

Autism research frequently seeks to evaluate interventions or inform their development. Unfortunately, researchers often assume that autism intervention should reduce autistic traits, effectively setting as a goal of treatment that autistic people attempt to "pass" as nonautistic. A growing body of evidence highlights serious potential harms from passing demands. We discuss why it is important for institutional review boards (IRBs) to scrutinize autism research for clinical passing demands, and we document the existence of such demands in outcome measures commonly employed in autism research. We propose an ethical framework for IRBs and others to make use of in evaluating the ethical appropriateness of particular treatment goals in autism intervention or intervention-adjacent research, emphasizing that treatment goals should be in pursuit of a beneficial nonpassing purpose and be the least burdensome means of accomplishing such a purpose. We also highlight potential promising practices for IRBs, investigators, and other stakeholders seeking to address these issues in autism research.

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.

Measuring Transactional Engagement Among Young Children with Elevated Likelihood for Later Autism Spectrum Disorder Diagnosis

This analytical study documented the presence of transactions in parent-child engagement within a sample of young children at an elevated likelihood for an eventual diagnosis of autism spectrum disorder (ASD). Specifically, the study examined the establishment of transactional engagement through reciprocal behaviors between parents and their young children at-risk for ASD. In the study sample, established transactional engagement occurred at a higher rate than other levels of engagement. Additionally, transactional engagement had a higher likelihood of being established when parents initiated. Post-hoc analyses revealed possible early markers of ASD within a certain behavior displayed in transactions. This study signifies the initial efforts in identifying transactions within parent-child engagement, and foremost, how transactional engagement is established.

Notes from an epicenter: navigating behavioral clinical trials on autism spectrum disorder amid the COVID-19 pandemic in the Bronx

BACKGROUND

The COVID-19 pandemic impacted nearly all facets of our daily lives, and clinical research was no exception. Here, we discuss the impact of the pandemic on our ongoing, three-arm randomized controlled trial (RCT) Sensory Integration Therapy (SIT) in Autism: Mechanisms and Effectiveness (NCT02536365), which investigates the immediate and sustained utility of SIT to strengthen functional daily-living skills and minimize the presence of maladaptive sensory behaviors in autistic children.

MAIN TEXT

In this text, we detail how we navigated the unique challenges that the pandemic brought forth between the years 2020 and 2021, including the need to rapidly adjust our study protocol, recruitment strategy, and in-person assessment battery to allow for virtual recruitment and data collection. We further detail how we triaged participants and allocated limited resources to best preserve our primary outcome measures while prioritizing the safety of our participants and study team. We specifically note the importance of open and consistent communication with all participating families throughout the pandemic in ensuring all our protocol adjustments were successfully implemented.

CONCLUSIONS

Though the COVID-19 pandemic resulted in an unprecedented interruption to in-person clinical research, clinical trials have always been and will continue to be at risk for unforeseen interruptions, whether from world events or participants' personal circumstances. By presenting our steps to preserving this RCT throughout the pandemic, we offer suggestions for successfully managing unexpected interruptions to research. Ideally, by taking these into account, future RCTs may be increasingly prepared to minimize the impact of these potential interruptions to research.

Efficacy and moderating factors of the Early Start Denver Model in Chinese toddlers with autism spectrum disorder: a longitudinal study

BACKGROUND

Several studies have shown the effectiveness of the Early Start Denver Model (ESDM), but few studies have explored the long-term efficacy of ESDM. This study aimed to explore the efficacy and moderating factors of ESDM in Chinese toddlers with autism spectrum disorder (ASD) in a longitudinal way.

METHODS

A total of 60 toddlers with ASD were recruited and randomly divided into two groups: ESDM group all received 24 weeks intervention; Control group were waiting for intervention. Baseline assessment (T0) was conducted before intervention, including Gesell Developmental Scale (GDS) and Psycho-educational Profile-3rd Edition (PEP-3). All toddlers with ASD were examined in the first assessment (T1) at 6 months and in the second assessment (T2) at 12 months.

RESULTS

In T1 assessment, the increments in speech and personal communication development quotient in GDS were significantly larger in the ESDM group than in the control group (P = 0.010, 0.047). In T2 assessment, the ESDM group had higher elevation in cognitive verbal/preverbal (CVP), social reciprocity and characteristic verbal behaviors assessed by PEP-3 (P = 0.021, 0.046, 0.014). In addition, the severity of stereotyped behavior was negatively associated with improvement in CVP. Family income was positively associated with improvement in speech and CVP (all P < 0.05).

CONCLUSIONS

ESDM can effectively improve speech and communication in toddlers with ASD after 24-week intervention. More importantly, ESDM can promote cognition and social interaction and can reduce stereotyped verbal behavior in toddlers with ASD in longitudinal observation. The severity of stereotyped behavior and family ecological factors may be considered as affecting the efficacy of ESDM.

Research-Based Intervention (RBI) for Autism Spectrum Disorder: Looking beyond Traditional Models and Outcome Measures for Clinical Trials

The rising prevalence of Autism Spectrum Disorders (ASD) has led to a quickly increasing need for effective interventions. Several criteria and measures have been developed to critically assess these interventions with particular focus on the evaluation of the efficacy. Given the huge diversity of ASD symptoms and the different levels of severity across individuals, identifying a one size fits all intervention approach is challenging, and the question What works and for whom? Remains still unanswered. Why do we seem to be dragging our feet on this fundamental issue? The main aim of this paper is to answer this question through four non-alternative points. First, there are a scarce number of studies with a solid methodology. Secondly, most trials on intervention efficacy for ASD are designed exclusively in terms of behavioral outcomes. Thirdly, there is a reduced use of biologically oriented outcome measures. Fourthly, in most clinical trials, appropriate practices emerging from research evidence are not systematically applied. A strong effort to improve the methodology of clinical trials is mandatory for the future of autism research. The development of a research-based intervention (RBI) perspective aimed at better integrating: (a) evidence-based approaches; (b) more sensitive behavioral outcome measures; and (c) biomarkers, with the aim of increasing a more detailed clustering of phenotypes, may strongly improve our approach to a precision medicine.