An early social engagement intervention for young children with autism and their parents

Effects of a Contingent Responses Intervention on the Quantity and Quality of Vocalizations of Preschool Children with Autism Spectrum Disorder

Multiple contemporary theories emphasize the quantity and quality of child vocalizations for promoting spoken language acquisition. Yet, empirical evidence for facilitating vocal development is strikingly lacking including for children with autism spectrum disorder (ASD) who have difficulty developing language. We evaluate use of contingent responses and vocal enhancement strategies to increase the quantity and quality of child vocalizations to which adults can respond with language-facilitating input for children with ASD. Three preschool children with ASD and minimal verbal skills participated. Using an alternating treatments design embedded within a multiple probe across participants design, we compared using contingent responses with and without vocal enhancement strategies versus a non-contingent control condition. Based on visual analysis and effect sizes, all participants showed a functional relation between both active intervention conditions and quantity of vocalizations, as predicted. For quality of vocalizations, changes under the active intervention conditions were less pronounced than those observed for quantity. Two participants showed a functional relation between at least one quality variable and the active interventions. Our hypothesis that vocal enhancement strategies would exhibit a value-added effect was partially supported for quantity and quality. Findings support using contingent responses to improve the quantity and to some degree the quality of vocalizations in young children with ASD and minimal verbal skills. Support for the added value of vocal enhancement strategies was mixed. Refining the intervention strategies is warranted to meet the needs of the understudied population of children with ASD and minimal verbal skills.

A Pilot Randomized Controlled Trial of Motivation-Based Social Skills Group Treatment with Parent Training

Despite the popularity of social skills groups, there remains a need for empirical investigation of treatment effects, especially when targeting pivotal aspects of social functioning such as initiations to peers. The goal of the present study was to conduct a randomized controlled trial of a 12-week social intervention (SUCCESS), which combined an inclusive social group with a parent education program. Twenty-five 4- to 6-year-olds with Autism Spectrum Disorder (ASD) were randomized to SUCCESS (N = 11) or to treatment as usual (N = 14). Combining a peer group model with a parent training program, the SUCCESS intervention used naturalistic behavioral techniques (e.g., environmental arrangement, natural reinforcement) to increase social initiations to peers. After 12 weeks, children participating in the SUCCESS program made more frequent initiations to peers than children in the treatment-as-usual group, including more prompted and unprompted initiations to request. Additional gains in clinician-rated social functioning were observed in children randomized to SUCCESS, while differential treatment effects were not detected in parent-rated measures. However, lower baseline social motivation was associated with greater parent-reported initiation improvement. This study provides preliminary support for the efficacy of a naturalistic, behavioral social skills intervention to improve peer initiations for children with ASD. The findings suggest that using a motivation-based social skills group was effective in increasing both prompted and spontaneous initiations to peers, and highlights the need for further research into the role of baseline social motivation in predicting social skills treatment response.

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

Socialization, Education, and Learning for the Internet (SELFI): A Pilot RCT of a Social Media Skills Group Program for Autistic Adults

Many autistic adults report preference for computer-mediated communication and social media use. Despite many benefits to online socialization, there are many challenges including anxiety and cyber-victimization. To date, support is limited related to helping autistic adults with safe and effective internet use. The purpose of this study was to evaluate the feasibility, acceptability, and preliminary efficacy of the novel SELFI program. This pilot study utilized a randomized controlled trial design. A total of 25 autistic adults enrolled in the study and were randomized to the nine-week SELFI program or a waitlist control condition. Feasibility assessed enrollment, attrition, and fidelity of delivery. Acceptability examined attendance and feedback from participants and peer mentors. Efficacy evaluated change in Facebook activity, social media utility/anxiety, and individualized goals. Regarding feasibility, the recruitment goal was met within one month, there was limited attrition, and therapists delivered the program with high fidelity. Participants attended a majority of scheduled sessions and feedback from participants reflected high levels of agreement with several facets of the program. Compared to the control group, more participants assigned to the SELFI condition were perceived by autistic and non-autistic raters as having improved Facebook activity. SELFI participants also reported reduced difficulty meeting their individualized goal. Findings support the piloted SELFI program as feasible and acceptable with signals of preliminary efficacy. This study establishes an exciting foundation regarding an innovative social media skills program, however more research is necessary.

A Scoping Review of Behavioral Interventions for Promoting Social Gaze in Individuals with Autism Spectrum Disorder and Other Developmental Disabilities

Background

Individuals diagnosed with autism spectrum disorder (ASD) commonly experience difficulties maintaining social gaze with others during interactions. Although behavioral interventions targeted to promote social gaze in ASD are evident in the literature, to our knowledge, no review of the literature has been conducted to summarize and evaluate the evidence for these interventions.

Methods

We reviewed and summarized behavioral intervention studies designed to promote social gaze in individuals diagnosed with ASD and other developmental disabilities published in English between 1977 and January 2022 using PsychINFO and PubMed databases.

Results

41 studies met the inclusion criteria describing interventions conducted on 608 individuals. A variety of intervention strategies were employed to promote social gaze in these individuals including discrete trial instruction, prompting, modeling, and imitation. Most studies employed single-case research designs and reported successful outcomes, but limited data were available concerning the generalization, maintenance and social validity of these interventions. An increasing number of studies utilized technology-based procedures including computer application gameplay, gaze-contingent eye tracking devices and humanoid robots.

Conclusions

The present review indicates that behavioral interventions can be successfully employed to promote social gaze in individuals with ASD and other developmental disabilities. However, future research is needed to establish the generalization, maintenance and social validity of these interventions. There are also important ethical issues to be addressed given the increasing divide between treatment advocates and proponents of the neurodiversity movement.

How Might Indices of Happiness Inform Early Intervention Research and Decision Making?

OBJECTIVES

The child-caregiver relationship is the foundation for which intervention occurs. Therefore, the acceptability of the intervention should be considered for both parties. Indices of happiness (IOH) have shown to be effective in assessing social validity and providing insight to improving interventions to promote better quality of life. However, to date, there is limited attention to the integration of IOH in very early caregiver-led intervention. The purpose of this study is to explore how researchers and clinicians might collect direct data on IOH to assess the acceptability of an intervention.

METHODS

Participants in this study included 4 children, ages 19-26 months old, identified as "at-risk" for autism, and their caregivers. Caregiver-led intervention focused on pairing, play, and following the child's lead. IOH data was collected on both child and caregiver using 10 s partial-interval recording. Data analysis from the intervention is presented using three different approaches: pre/post-analysis on an individual level, pre/post-analysis on a dyad level, and during intervention as a primary dependent variable.

RESULTS

Variations were seen in levels of happiness, both on an individual level and dyad level. IOH for caregivers increased in relation as their fidelity increased but child IOH decreased as they acquired the targeted skill.

CONCLUSIONS

Direct observation of happiness data is likely to provide valuable insight into participants perception of an intervention. And retrospective analysis may be a valuable tool for reflection and guidance and planning of future interventions.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s41252-022-00288-0.

Feasibility and Acceptability of Delivering Pivotal Response Treatment for Autism Spectrum Disorder via Telehealth: Pilot Pre-Post Study

BACKGROUND

Pivotal response treatment (PRT), an evidence-based and parent-delivered intervention, is designed to improve social communication in autistic individuals.

OBJECTIVE

The aim of this study was to assess the feasibility, acceptability, and clinical effects of an online model of PRT delivered via MindNest Health, a telehealth platform that aims to provide self-directed and engaging online modules, real-time coaching and feedback, and accessible stepped-care to large populations of parents seeking resources for their autistic children.

METHODS

Male and female autistic children, aged 2-7 years with single-word to phrase-level speech, and their parents were eligible to participate in the study. Families were randomized to the online parent training condition or control condition. The online component of the intervention consisted of eight 20-minute online courses of content describing parent training principles in PRT. Four 1-hour videoconferences were held after course 1, course 3, course 5, and course 8. Parents were given 1-2 weeks to complete each course. Parents completed the Client Credibility Questionnaire (CCQ) at week 2 and at the study endpoint, as well as the Behavioral Intervention Rating Scale (BIRS) at the study endpoint to assess parental expectancies, and treatment acceptability and effectiveness.

RESULTS

Nine of 14 participants completed the study curriculum in the online parent training condition, and 6 of 12 participants completed the control condition. Thus, a total of 58% (15/26) participants across both groups completed the study curriculum by study closure. Within the online parent training condition, there was a significant increase in mean CCQ total scores, from 25.38 (SD 3.25) at baseline to 27.5 (SD 3.74) at study endpoint (P=.04); mean CCQ confidence scores, from 6.0 (SD 1.07) at baseline to 6.75 (SD 0.89) at study endpoint (P=.02); and mean CCQ other improvement scores, from 5.25 (SD 0.89) at baseline to 6.25 (SD 1.28) at study endpoint (P=.009). Within the control condition, a modest increase in mean CCQ scores was noted (Confidence, difference=+0.25; Recommend, difference=+0.25; Total Score, difference=+0.50), but the differences were not statistically significant (Confidence P=.38, Recommend P=.36, Total Score P=.43). Among the 11 parents who completed the BIRS at the study endpoint, 82% (n=9) endorsed that they slightly agree or agree with over 93% of the Acceptability factor items on the BIRS.

CONCLUSIONS

The feasibility of this online treatment is endorsed by the high rate of online module completion and attendance to videoconferences within the online parent training group. Acceptability of treatment is supported by strong ratings on the CCQ and significant improvements in scores, as well as strong ratings on the BIRS. This study's small sample size limits the conclusions that can be drawn; however, the PRT MindNest Health platform holds promise to support parents of autistic children who are unable to access traditional, in-person parent-mediated interventions for their child.

Digital and remote behavioral therapies for treating tic disorders: Recent advances and next steps

The rapid expansion of access to and engagement with digital technology over the past 15 years has transformed the potential for remote delivery of evidence-based digital health interventions (DHIs). Digital and remote behavioral interventions have the potential to address current gaps in the provision of evidence-based therapies in healthcare services. As the lack of access to behavioral treatments for people with tic disorders is a pressing issue across the world, there is great potential for DHIs to close this treatment gap. Here, we present a critical synthesis of the recent key advances in the field of digitally delivered, remote therapy for tics, outlining the research evidence for the clinical and cost-effectiveness and acceptability of digital or remotely delivered therapy. We found five trials aimed at reducing tic severity in children and young people and one trial for adults. The evidence supports the clinical utility of DHIs to deliver tic therapies, which shows promise in being clinically efficacious compared to an active control. Furthermore, DHIs in trials show good adherence and engagement and are acceptable to patients. The role of human support (including therapists and parents for young people) is likely to be important to encourage adherence. DHIs, where the main therapeutic content is delivered via web-based chapters, are likely to reduce clinical time, and maintain intervention fidelity, but further research is required to understand cost-effectiveness. Despite utilizing randomized controlled trials, only two trials were sufficiently powered to address efficacy and only one trial explored contextual factors that may influence engagement. Moreover, only one trial followed patients for >12 months, thus further long-term follow-ups are required. Specifically, we note that despite an emerging evidence base, DHIs for tics are yet to be routinely implemented in healthcare provision in any country. Drawing on the existing evidence, we conclude by proposing a stepped care model, in which digital therapy is implemented as a widely accessible first-line treatment using a purely online or therapist-supported approach.

Effectiveness of Responsivity Intervention Strategies on Prelinguistic and Language Outcomes for Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis of Group and Single Case Studies

We conducted a systematic review to identify randomized controlled trials (RCTs) and single case research design (SCRD) studies of children with autism spectrum disorder that evaluate the effectiveness of responsivity intervention techniques for improving prelinguistic and/or language outcomes. Mean effect sizes were moderate and large for RCTs (33 studies; g = 0.36, 95% CI [0.21, 0.51]) and SCRD (34 studies; between-case standardized mean difference = 1.20, 95% CI [0.87, 1.54]) studies, respectively. Visual analysis (37 studies) revealed strong evidence of a functional relation for 45% of the opportunities and no evidence for 53%. Analyses of moderator effects and study quality are presented. Findings provide support for responsivity intervention strategies with more robust support for context-bound outcomes than more generalized outcomes.

The mediating role of parental playfulness on parent–child relationship and competence among parents of children with ASD

Purpose

The difficulties of a child diagnosed with autism spectrum disorder (ASD) can lead to behaviours that are quite challenging for parents to understand and address. Most of the parental studies of ASD focus on the challenges faced by the parents. This study aims to adopt a strength-based model that investigates the mediating role of parental playfulness in the association between parent–child relationship and parental competence.

Design/methodology/approach

This study is a quantitative study that adopts a correlational research design. The mediation analysis explores the role of parental playfulness as a mediator in the association between parent–child relationship and parental competence. The sample consisted of 120 parents of children diagnosed with ASD from India, selected using a purposive sampling technique.

Findings

The mediation analysis results indicate that playfulness among parents of children with ASD was found to function as a partial mediator in the relationship between parent–child relationship and parental competence. This could suggest that more playful parents have better parent–child relationships and are competent in parenting.

Research limitations/implications

These findings have importance in understanding the role of playful interaction on parent–child relationships and parenting competence, having implications for further research. Enabling playfulness in parenting will enhance children and parents to promote their relationship and thus feel competent to bring positive light in their lives.

Practical implications

Most often, the clinicians are concerned with addressing only the autistic symptoms; it is also essential to look into parental well-being. Practical playful interaction training should help parents establish a rapport, understand, adjust and adapt with their child.

Social implications

Practical intervention and training plans can be suggested to all family members to improve the condition of the child and the family’s general well-being. As the study focused on the clinical population, the findings could provide useful inputs for mental health professionals and counsellors.

Originality/value

There are some theoretical and empirical evidence that support positive outcomes of playfulness on personal well-being (Atzaba Poria, in press; Yue et al., 2016; Proyer, 2014). Although there has been some interest in the impact of children’s playfulness on their development (Bundy, 1997), little is known about the influence of parental playfulness on parents and children. Therefore, addressing these gaps, this empirical study focusses on investigating the role of parental playfulness in parent–child relationship and parental competence, rather than considering external challenges of parents based on the ASD child’s behavioural challenges and autistic features.

Fidelity of Delivery and Contextual Factors Influencing Children's Level of Engagement: Process Evaluation of the Online Remote Behavioral Intervention for Tics Trial

Background

The Online Remote Behavioral Intervention for Tics (ORBIT) study was a multicenter randomized controlled trial of a complex intervention that consisted of a web-based behavioral intervention for children and young people with tic disorders. In the first part of a two-stage process evaluation, we conducted a mixed methods study exploring the reach, dose, and fidelity of the intervention and contextual factors influencing engagement.

Objective

This study aims to explore the fidelity of delivery and contextual factors underpinning the ORBIT trial.

Methods

Baseline study data and intervention usage metrics from participants in the intervention arm were used as quantitative implementation data (N=112). The experiences of being in the intervention were explored through semistructured interviews with children (n=20) and parent participants (n=20), therapists (n=4), and referring clinicians (n=6). A principal component analysis was used to create a comprehensive, composite measure of children and young people’s engagement with the intervention. Engagement factor scores reflected relative uptake as assessed by a range of usage indices, including chapters accessed, number of pages visited, and number of log-ins. The engagement factor score was used as the dependent variable in a multiple linear regression analysis with various contextual variables as independent variables to assess if there were any significant predictors of engagement.

Results

The intervention was implemented with high fidelity, and participants deemed the intervention acceptable and satisfactory. The engagement was high, with child participants completing an average of 7.5 of 10 (SD 2.7) chapters, and 88.4% (99/112) of participants completed the minimum of the first four chapters—the predefined threshold effective dose. Compared with the total population of children with tic disorders, participants in the sample tended to have more educated parents and lived in more economically advantaged areas; however, socioeconomic factors were not related to engagement factor scores. Factors associated with higher engagement factor scores included participants enrolled at the London site versus the Nottingham site (P=.01), self-referred versus clinic referred (P=.04), higher parental engagement as evidenced by the number of parental chapters completed (n=111; ρ=0.73; P<.001), and more therapist time for parents (n=111; ρ=0.46; P<.001). A multiple linear regression indicated that parents’ chapter completion (β=.69; t₁₁₀=10.18; P<.001) and therapist time for parents (β=.19; t₁₁₀=2.95; P=.004) were the only significant independent predictors of child engagement factor scores.

Conclusions

Overall, the intervention had high fidelity of delivery and was evaluated positively by participants, although reach may have been constrained by the nature of the randomized controlled trial. Parental engagement and therapist time for parents were strong predictors of intervention implementation, which has important implications for designing and implementing digital therapeutic interventions in child and adolescent mental health services.

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-019-3974-3

Using tripartite group area as a measure of social interactions in pre-school children: A pilot study

This study aimed to measure tripartite group area using motion capture systems and investigated whether group area could be used as a measure of pre-school children’s social interactions. In Experiment 1, two typically developing girls and an adult staff member engaged in free play. In Experiment 2, two typically developing boys and two adult staff members played balloon volleyball. Both experiments had three types of measures: subjective evaluation of whether participants played together, social behaviours (e.g. eye contact for Experiment 1 and balloon tosses for Experiment 2) and group area. Results showed that group area was significantly and negatively related to subjective evaluation in Experiment 2, whereas we observed no relationship between subjective evaluation and group area in Experiment 1. Overall, however, only a low correlation was observed between subjective evaluation and group area in Experiment 2. Furthermore, there were strong sequential associations between subjective evaluation and social behaviour, rather than between subjective evaluation and group area. Although group area as an index of social interactions is less accurate than behavioural data directly observed by humans, it may be worth using as a low-cost preliminary measure, since it can be automatically calculated using motion capture systems.

A Systematic Review of Family-Mediated Social Communication Interventions for Young Children with Autism

Social communication deficits are a core symptom of autism spectrum disorder (ASD). The present paper reviews 54 studies evaluating social communication interventions delivered by parents and siblings to children with ASD under 6 years old. Fifty studies evaluated parent-mediated intervention, and four studies evaluated sibling-mediated intervention. Fourteen studies evaluated interventions using telehealth. Treatment effects and research strength were variable across studies. Treatment modality, setting, and dosage had inconclusive impact on treatment effect. Parent-implemented intervention packages, Pivotal Response Treatment (PRT), Early Start Denver Model (ESDM), and Joint Attention, Symbolic Play, Engagement & Regulation (JASPER), qualified as established evidence-based practice for this population. Most studies reported successful generalization of skills for some, but not all, children. Telehealth and sibling-mediated intervention are promising areas of further research and clinical practice.

Enhancing Social Initiations Using Naturalistic Behavioral Intervention: Outcomes from a Randomized Controlled Trial for Children with Autism

Deficits in social skills are common in children with Autism Spectrum Disorder (ASD), and there is an urgent need for effective social skills interventions, especially for improving interactions with typically developing peers. This study examined the effects of a naturalistic behavioral social skills intervention in improving social initiations to peers through a randomized controlled trial. Analyses of multimethod, multi-informant measures indicated that children in the active group (SIMI) demonstrated greater improvement in the types of initiations which were systematically prompted and reinforced during treatment (i.e., behavior regulation). Generalization to joint attention and social interaction initiation types, as well as collateral gains in broader social functioning on clinician- and parent-rated standardized measures were also observed.

Play-based interventions to support social and communication development in autistic children aged 2-8 years: A scoping review

BACKGROUND AND AIMS

Play is used by practitioners from across disciplinary backgrounds as a natural and enjoyable context for providing intervention and support in early childhood. In the case of autism interventions, many therapies are based on the association between social play and the development of social skills, language development, and communication skills, as these are often particular areas of challenge for autistic children. However, play is a wide-ranging concept and the extant literature on play-based interventions is large and heterogeneous. This means it is challenging for practitioners and families to navigate the evidence base and make choices about differing intervention strategies. This review aims to provide a comprehensive map of the research on this topic and to develop a conceptual framework to inform clinical decision-making.

METHODS

An initial stakeholder consultation confirmed the relevance of the topic to practitioners and autistic people. A scoping review methodology (preregistered) was used to identify relevant literature. We systematically searched seven databases to find peer-reviewed primary intervention studies of play-based approaches targeting language, social and communication outcomes for autistic children aged 2-8 years. We then summarised the literature using narrative synthesis and Evidence Gap Maps (EGMs). The literature was summarised according to a range of characteristics, including study design, population characteristics, agent of intervention and outcomes measured, among others. These summaries were then used to develop a framework for some key considerations for practitioners appraising play-based approaches.

RESULTS

388 studies met inclusion criteria. Approximately 21% of studies were RCTs, and over 50% had ≤10 participants. Over 45% of studies reported multiple relevant outcomes, with social play skills being the most common single intervention target. Girls and minority background groups are under-represented. A range of intervention types were identified, and some high-level categorisations are proposed.Main contribution: On the basis of the evidence synthesis we suggest important dimensions for appraisal of play-based interventions, including the role of play within an intervention (as a context, a key developmental mechanism, or a component of a larger approach), the underpinning philosophy (e.g. behaviourist or developmental), and the role of the practitioner (providing parent feedback, 1:1 intervention, group facilitation).

CONCLUSIONS

The wide range of approaches uncovered by this review is a testament to the wonderful diversity inherent to both play and autism. However, research could usefully focus on consolidating the evidence base for existing approaches, rather than aiming for further diversification. Implications: The conceptual framework proposed in this review can help practitioners appraise the literature and aid their advice to families when making shared intervention decisions.

Brief Report: A Pilot Online Pivotal Response Treatment Training Program for Parents of Toddlers with Autism Spectrum Disorder

Despite advances in evidence-based treatment for autism spectrum disorder (ASD), disparities in service access remain a serious concern. Current treatment models may not be feasible for families who live in remote geographical regions or have limited resources. To address this, studies have begun to explore parent-implemented interventions via an online format. The current study examined a new online course designed to help parents implement Pivotal Response Treatment (PRT) for their toddler with ASD. Parents submitted videos of parent-child interactions which were coded for fidelity of implementation (FOI) and social communicative behaviors. The data indicate that PRT fidelity and child behaviors significantly improved following course participation. This suggests that an online intervention may be a feasible approach to disseminating PRT strategies.

Acceptability of the Transitional Wearable Companion "+me" in Children With Autism Spectrum Disorder: A Comparative Pilot Study

+me is an experimental interactive soft toy, looking like a panda, developed for young children. When touched on the paws or head (inputs), the toy can emit attractive responses such as colored lights and amusing sounds (outputs). +me is wirelessly connected to a control tablet through which an adult caregiver can modify its input-output contingencies so as to produce different, rewarding response patterns using the same device. Given these features, we propose +me as a potential novel tool to support the therapy of Autism Spectrum Disorder (ASD). The allure of the device could be exploited to capture the attention and encourage the social interaction of toddlers during play activities with therapists. In this pilot study, +me was tested on two small groups of children aged 30–48 months, one group diagnosed with ASD and the second with Communication Disorder, a condition that often presents—especially at an early age—overlapping symptoms with ASD. The proposed play activities aimed to foster simple imitative behaviors and stimulate the engagement of the children. The results were compared with those of a previous test run on Typically Developed children. Preliminary observations, based on the analysis of video recordings, suggest that, on average, +me is able to encourage a positive engagement and that different groups tend to manifest some different behaviors.

A Systematic Review of Linguistic and Verbal Behavior Outcomes of Pivotal Response Treatment

Pivotal Response Treatment (PRT) is a popular intervention for improving targeted and untargeted communication skills for learners with autism. We systematically reviewed communication outcomes reported in experimental research to determine linguistic forms and verbal behavior functions associated with PRT. We found most researchers aggregated results or did not report sufficient detail to determine linguistic forms and/or verbal behavior functions. Generalization of communication skills to untargeted people, settings, materials, and/or activities was evident. However, only one study clearly indicated untargeted linguistic forms emerged following PRT, and no researchers described results that indicated improved generalized and collateral verbal behavior functions. We suggest PRT researchers more clearly define and report primary, generalized, and collateral communication-specific outcomes in order to advance research and practice.

Biographical disruption or cohesion?: How parents deal with their child's autism diagnosis

Currently, we are witnessing a precipitous rise in autism diagnoses among children, and several bodies of sociological research are attempting to explain this development. However, the experiences within parental contexts have been inadequately examined; that is, how parents feel about and act upon the awareness of their child's autism diagnosis. Drawing upon a qualitative study among Danish parents of 20 children recently diagnosed with autism, this paper contributes with situated insights into parents' experiences. We identify a spectrum of feelings towards the autism diagnosis, including both relief and grief. In the absence of theoretical notions drawing attention to how a child's diagnosis influences parents' self-conceptions and understandings of their child, we develop the concept of 'parent-biographical disruption': the parents' rethinking of themselves and their child that might be caused by a chronic condition such as autism. Based on the variety of findings, we discuss what we call 'parent-biographical cohesion' as a counterpart to 'disruption'. By 'cohesion' we refer to the diagnostic awareness potentially creating clarification for parents about the past, present and future parenting of their child instead of disrupting their self-understandings as parents. In this way, through the notion of a parental-biographical spectrum of disruption and cohesion, we emphasize the diversity in how parents deal with a child's autism diagnosis and the variety of needs for rethinking parental biographies in the wake of a diagnosis.

A Pilot Randomized Clinical Trial of an Enhanced Pivotal Response Treatment Approach for Young Children with Autism: The PRISM Model

The symptoms of autism spectrum disorder are conceptualized to alter the quality of parent-children interactions, exposure to social learning exchanges, and ultimately the course of child development. There is evidence that modifying the procedures of Pivotal Response Treatment (PRT) to explicitly target social motivation enhances child engagement and parent-child synchrony in moment-by-moment exchanges. However, it is unclear if these within session improvements ultimately yield favorable developmental outcomes over time. The current investigation presents feasibility, utility, and preliminary efficacy data of a pilot randomized clinical trial (RCT) of a Pivotal Response Intervention for Social Motivation (PRISM) model. Data on participant factors, treatment protocol acceptability, and outcome variance and effect size are highly favorable and support the pursuit of a future, large scale RCT.

The Use of Eye Tracking as a Biomarker of Treatment Outcome in a Pilot Randomized Clinical Trial for Young Children with Autism

There is a pressing need for objective, quantifiable outcome measures in intervention trials for children with autism spectrum disorder (ASD). The current study investigated the use of eye tracking as a biomarker of treatment response in the context of a pilot randomized clinical trial of treatment for young children with ASD. Participants included 28 children with ASD, aged 18-48 months, who were randomized to one of two conditions: Pivotal Response Intervention for Social Motivation (PRISM) or community treatment as usual (TAU). Eye-tracking and behavioral assessment of developmental functioning were administered at Time 1 (prior to randomization) and at Time 2 (after 6 months of intervention). Two well-established eye-tracking paradigms were used to measure social attention: social preference and face scanning. As a context for understanding relationships between social attention and developmental ability, we first examined how scanning patterns at Time 1 were associated with concurrent developmental functioning and compared to those of 23 age-matched typically developing (TD) children. Changes in scanning patterns from Time 1 to Time 2 were then compared between PRISM and TAU groups and associated with behavioral change over time. Results showed that the social preference paradigm differentiated children with ASD from TD children. In addition, attention during face scanning was associated with language and adaptive communication skills at Time 1 and change in language skills from Time 1 to Time 2. These findings highlight the importance of examining targeted biomarkers that measure unique aspects of child functioning and that are well-matched to proposed mechanisms of change. Autism Research 2019, 12: 779-793. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Biomarkers have the potential to provide important information about how and why early interventions effect positive change for young children with ASD. The current study suggests that eye-tracking measures of social attention can be used to track change in specific areas of development, such as language, and points to the need for targeted eye-tracking paradigms designed to measure specific behavioral changes. Such biomarkers could inform the development of optimal, individualized, and adaptive interventions for young children with ASD.

Acceptability of the Transitional Wearable Companion "+me" in Typical Children: A Pilot Study

This work presents the results of the first experimentation of +me-the first prototype of Transitional Wearable Companion-run on 15 typically developed (TD) children with ages between 8 and 34 months. +me is an interactive device that looks like a teddy bear that can be worn around the neck, has touch sensors, can emit appealing lights and sounds, and has input-output contingencies that can be regulated with a tablet via Bluetooth. The participants were engaged in social play activities involving both the device and an adult experimenter. +me was designed with the objective of exploiting its intrinsic allure as an attractive toy to stimulate social interactions (e.g., eye contact, turn taking, imitation, social smiles), an aspect potentially helpful in the therapy of Autism Spectrum Disorders (ASD) and other Pervasive Developmental Disorders (PDD). The main purpose of this preliminary study is to evaluate the general acceptability of the toy by TD children, observing the elicited behaviors in preparation for future experiments involving children with ASD and other PDD. First observations, based on video recording and scoring, show that +me stimulates good social engagement in TD children, especially when their age is higher than 24 months.

Play, Playfulness, and Self-Efficacy: Parental Experiences with Children on the Autism Spectrum

Background

Play serves as an essential medium for parent-child interaction; however, engaging children with ASD through play can be a challenge for parents.

Purpose

The purpose of this phenomenological study was to explore the perspectives of parents with children on the autism spectrum regarding play experiences and self-efficacy during play encounters.

Method

Semistructured interviews were administered to 8 parents of children 3–7 years of age with ASD. The analysis was guided by the constant comparison method.

Findings

Parental narratives denoted playful experiences reflecting components of Skard and Bundy's model of playfulness. The facilitation of framing and suspension of reality were generally more challenging than facilitating intrinsic motivation and internal control. Participants associated self-efficacy during play with their perceived ability to interact with their child and with positive emotions experienced during play. Fathers generally derived a greater sense of self-efficacy from play encounters than mothers, and this was explained by differences in fathers' and mothers' motivations for playing. Mothers were motivated to play for outcome-oriented reasons (e.g., promote the child's progress) whereas fathers' motivations depicted greater emotional emphasis, reflecting a better match between motivation and perceived indicators of efficacy during play.

Conclusion

The results suggest that a good match between motivation for playing and perceived indicators of efficacy during play is important for a parental sense of self-efficacy. Occupational therapists should utilize coaching strategies to increase parents' understanding of play and playfulness and how they can affect a sense of parental self-efficacy.

FaceLooks: A Smart Headband for Signaling Face-to-Face Behavior

Eye-to-eye contact and facial expressions are key communicators, yet there has been little done to evaluate the basic properties of face-to-face; mutual head orientation behaviors. This may be because there is no practical device available to measure the behavior. This paper presents a novel headband-type wearable device called FaceLooks, used for measuring the time of the face-to-face state with identity of the partner, using an infrared emitter and receiver. It can also be used for behavioral healthcare applications, such as for children with developmental disorders who exhibit difficulties with the behavior, by providing awareness through the visual feedback from the partner’s device. Two laboratory experiments showed the device’s detection range and response time, tested with a pair of dummy heads. Another laboratory experiment was done with human participants with gaze trackers and showed the device’s substantial agreement with a human observer. We then conducted two field studies involving children with intellectual disabilities and/or autism spectrum disorders. The first study showed that the devices could be used in the school setting, observing the children did not remove the devices. The second study showed that the durations of children’s face-to-face behavior could be increased under a visual feedback condition. The device shows its potential to be used in therapy and experimental fields because of its wearability and its ability to quantify and shape face-to-face behavior.

Use of a Level System with Flexible Shaping to Improve Synchronous Engagement

Level systems have been described as a framework which can be used to shape behavior through the systematic application of behavioral principles. Within level systems, an individual moves up and down through various levels contingent upon specific behaviors. Although level systems are commonly used within schools and other settings, they have a limited empirical literature base, and there is debate over the efficacy and overall acceptance of level systems. More especially, there is scant empirical literature on the use level systems to improve socially significant behaviors (e.g., synchronous engagement) with individuals diagnosed with autism spectrum disorder (ASD). The purpose of this study was to evaluate the effectiveness of a level system with a structured, yet flexible approach to movement on improving synchronous engagement with two dyads of children diagnosed with ASD. The results of an ABAB reversal design indicated that the level system was effective at improving synchronous engagement for both dyads. The results are discussed in relation to potential future research difficulties and clinical implications.

The effect of caregiver-delivered social-communication interventions on skill generalization and maintenance in ASD

BACKGROUND

Although caregiver-delivered social communication interventions have been considered scientifically proven practices for individuals with autism spectrum disorders, it is not well examined if these types of intervention modes are truly effective in promoting skill generalization and maintenance within those individuals with autism spectrum disorders.

AIMS

The purpose of this meta-analysis was to evaluate the status of the extant literature regarding the measures on generalization and/or maintenance of effects of caregiver-delivered communication interventions for children with autism spectrum disorders.

METHODS AND PROCEDURES

This systematic literature review and meta-analysis evaluated peer-reviewed research regarding the effects of caregiver-implemented interventions on the maintenance and generalization of the social-communication skills for children with autism spectrum disorders. A total of 34 articles were included following a systematic search. Articles were summarized according to the following categories: (a) generalization dimension, (b) generalization assessment design, (c) maintenance assessment design, (d) generalization/maintenance teaching strategy, and (e) latency to maintenance probes. After application of design standards, aggregate Tau-U and non-overlap of pairs effect sizes were calculated with a total of 67 separate contrasts across seven studies.

OUTCOMES AND RESULTS

Overall, effect size scores ranged from small to large effects across all comparisons. On average, most of the baseline to maintenance and generalization comparisons produced moderate to large effects. Whereas, small to moderate or even deteriorate effects were found in most of the intervention to maintenance and generalization comparisons.

CONCLUSIONS AND IMPLICATIONS

The findings in this review suggest that caregiver-delivered social-communication interventions are likely to result in mixed effects on skill generalization and maintenance within children with autism spectrum disorders. Implications for future research and practice are discussed.

Child's Sensory Profile and Adult Playfulness as Predictors of Parental Self-Efficacy

Parents of children with autism spectrum disorder (ASD) may have difficulty engaging their children through play, thus affecting the parent-child relationship and parental self-efficacy. This study intended to examine children's sensory profile and adults' playfulness as predictors of parental self-efficacy. A total of 136 parents of children ages 3-7 yr completed the Short Sensory Profile, the Playfulness Scale for Adults, and the Tool to Measure Parenting Self-Efficacy. For the parental couples of children with ASD, the most relevant predictor of general parental self-efficacy was the child's sensory profile. However, adult playfulness resulted in the most relevant predictor of emotional parental self-efficacy. Findings suggest the importance of considering play as a relevant co-occupation that must be acknowledged when intervening with families of children with ASD and considering the child's sensory modulation abilities, as well as parents' playfulness and sense of self-efficacy, as potential outcomes when designing and evaluating treatment programs.

Mechanisms of Diminished Attention to Eyes in Autism

OBJECTIVE

Two hypotheses, gaze aversion and gaze indifference, are commonly cited to explain a diagnostic hallmark of autism: reduced attention to others' eyes. The two posit different areas of atypical brain function, different pathogenic models of disability, and different possible treatments. Evidence for and against each hypothesis is mixed but has thus far focused on older children and adults. The authors evaluated both mechanistic hypotheses in two sets of experiments at the time of initial diagnosis.

METHOD

Eye-tracking data were collected in 86 2-year-olds: 26 with autism, tested at initial diagnosis; 38 matched typically developing children; and 22 matched developmentally delayed children. In two experiments, the authors measured response to direct and implicit cueing to look at the eyes.

RESULTS

When directly cued to look at the eyes, 2-year-olds with autism did not look away faster than did typically developing children; their latency varied neither categorically nor dimensionally by degree of eye cueing. Moreover, direct cueing had a stronger sustained effect on their amount of eye-looking than on that of typically developing children. When presented with implicit social cues for eye-looking, 2-year-olds with autism neither shifted their gaze away nor more subtly averted their gaze to peripheral locations.

CONCLUSIONS

The results falsify the gaze aversion hypothesis; instead, at the time of initial diagnosis, diminished eye-looking in autism is consistent with passive insensitivity to the social signals in others' eyes.

Are Children with Autism Spectrum Disorder Initially Attuned to Object Function Rather Than Shape for Word Learning?

We investigate the function bias—generalising words to objects with the same function—in typically developing (TD) children, children with autism spectrum disorder (ASD) and children with other developmental disorders. Across four trials, a novel object was named and its function was described and demonstrated. Children then selected the other referent from a shape match (same shape, different function) and function match (same function, different shape) object. TD children and children with ASD were ‘function biased’, although further investigation established that having a higher VMA facilitated function bias understanding in TD children, but having a lower VMA facilitated function bias understanding in children with ASD. This suggests that children with ASD are initially attuned to object function, not shape.

A comparison of the effects of rhythm and robotic interventions on repetitive behaviors and affective states of children with Autism Spectrum Disorder (ASD)

Repetitive behaviors and poor affect regulation are commonly seen in children with Autism Spectrum Disorder (ASD). We compared the effects of two novel interventions - rhythm and robotic therapies, with those of a standard-of-care intervention, on the repetitive behaviors and affective states of 36 children with ASD between 5 and 12 years using a randomized controlled trial design. We coded for frequencies of sensory, negative, and stereotyped behaviors and the duration of positive, negative, and interested affective states in children during early, mid, and late training sessions. In terms of repetitive behaviors, in the early session, the rhythm and robot groups engaged in greater negative behaviors, whereas the comparison group engaged in greater sensory behaviors. With training, the rhythm group reduced negative behaviors whereas there were no training-related changes in the other groups. In terms of affective states, the rhythm and robot groups showed greater negative affect, whereas the comparison group demonstrated greater interested affect across all sessions. With training, the rhythm group showed a reduction in negative affect and an increase in interested affect whereas the robot group showed a reduction in positive affect. Overall, it appears that rhythm-based interventions are socially engaging treatment tools to target core impairments in autism.

Improvements in social and adaptive functioning following short-duration PRT program: a clinical replication

Pivotal Response Treatment (PRT) is an empirically validated behavioral treatment for individuals with autism spectrum disorders (ASD). The purpose of the current study was to assess the efficacy of PRT for ten cognitively-able preschool-aged children with ASD in the context of a short-duration (4-month) treatment model. Most research on PRT used individual behavioral goals as outcome measures, but the current study utilized standardized assessments of broader-based social communication and adaptive skills. The children made substantial gains; however, magnitude and consistency of response across measures were variable. The results provide additional support for the efficacy of PRT as well as evidence for improvements in higher-order social communication and adaptive skill development within the context of a short-duration PRT model.

Fostering a social child with autism: a moment-by-moment sequential analysis of an early social engagement intervention

Young children with autism often experience limited social motivation and responsiveness that restricts establishment of crucial social momentum. These characteristics can lead to decreased opportunities for parental engagement and the social learning associated with these moments. Early social interventions that capitalize on pre-existing interests may be able to re-establish this developmentally critical feedback loop, in which both child and parent social behaviors simultaneously increase and influence one another. This investigation examined the moment-by-moment, micro-transactional relationship between parent and child social behavior gains observed in an early intervention study. Time-window sequential analyses revealed the presence of clinically and statistically significant sequential associations between parent and child social behaviors during an embedded social interaction intervention, but not in a comparable motivational intervention that utilized highly preferred toys and objects. Specifically, the onset of parent eye contact, directed positive affect, or offer of a reinforcing incentive predicted the immediate occurrence of child eye contact and positive affect in the experimental social intervention condition. Additionally, child verbal initiations, positive affect, and eye contact immediately predicted the onset of parent positive affect during this social intervention paradigm. Theoretical implications for the social developmental trajectory of autism are discussed.

Psychosocial treatments for individuals with autism spectrum disorder across the lifespan: new developments and underlying mechanisms

Researchers have studied many interventions to address the core impairment in social interactions in autism spectrum disorder. We reviewed the social skills intervention literature over the past two years (2012-2014). Social skills intervention studies have increased by 35% over our previous review of 2010-2012. Nearly equal numbers of studies reported results using single subject research designs (n = 29) and group designs (n = 25). Consistent with our previous review, many studies focused on joint attention/joint engagement for young children and interventions addressing peer interactions for older children. Advancements in this review period included more replications of intervention models, longitudinal outcomes, and a focus on minimally verbal children. Notably absent are social interventions for adults, and interventions addressing school-based inclusion. In addition to these target areas, future studies should isolate active ingredients of social interventions, include broader participant representation, and further examine the relation between neural development and behavioral outcomes.

The psychologist as an interlocutor in autism spectrum disorder assessment: insights from a study of spontaneous prosody

PURPOSE

The purpose of this study was to examine relationships between prosodic speech cues and autism spectrum disorder (ASD) severity, hypothesizing a mutually interactive relationship between the speech characteristics of the psychologist and the child. The authors objectively quantified acoustic-prosodic cues of the psychologist and of the child with ASD during spontaneous interaction, establishing a methodology for future large-sample analysis.

METHOD

Speech acoustic-prosodic features were semiautomatically derived from segments of semistructured interviews (Autism Diagnostic Observation Schedule, ADOS; Lord, Rutter, DiLavore, & Risi, 1999; Lord et al., 2012) with 28 children who had previously been diagnosed with ASD. Prosody was quantified in terms of intonation, volume, rate, and voice quality. Research hypotheses were tested via correlation as well as hierarchical and predictive regression between ADOS severity and prosodic cues.

RESULTS

Automatically extracted speech features demonstrated prosodic characteristics of dyadic interactions. As rated ASD severity increased, both the psychologist and the child demonstrated effects for turn-end pitch slope, and both spoke with atypical voice quality. The psychologist's acoustic cues predicted the child's symptom severity better than did the child's acoustic cues.

CONCLUSION

The psychologist, acting as evaluator and interlocutor, was shown to adjust his or her behavior in predictable ways based on the child's social-communicative impairments. The results support future study of speech prosody of both interaction partners during spontaneous conversation, while using automatic computational methods that allow for scalable analysis on much larger corpora.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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