Applied behavior analysis treatment of autism: the state of the art

A novel multi-modal model to assist the diagnosis of autism spectrum disorder using eye-tracking data

Background and objective

Timely and accurate detection of Autism Spectrum Disorder (ASD) is essential for early intervention and improved patient outcomes. This study aims to harness the power of machine learning (ML) techniques to improve ASD detection by incorporating temporal eye-tracking data. We developed a novel ML model to leverage eye scan paths, sequences of distances of eye movement, and a sequence of fixation durations, enhancing the temporal aspect of the analysis for more effective ASD identification.

Methods

We utilized a dataset of eye-tracking data without augmentation to train our ML model, which consists of a CNN-GRU-ANN architecture. The model was trained using gaze maps, the sequences of distances between eye fixations, and durations of fixations and saccades. Additionally, we employed a validation dataset to assess the model's performance and compare it with other works.

Results

Our ML model demonstrated superior performance in ASD detection compared to the VGG-16 model. By incorporating temporal information from eye-tracking data, our model achieved higher accuracy, precision, and recall. The novel addition of sequence-based features allowed our model to effectively distinguish between ASD and typically developing individuals, achieving an impressive precision value of 93.10% on the validation dataset.

Conclusion

This study presents an ML-based approach to ASD detection by utilizing machine learning techniques and incorporating temporal eye-tracking data. Our findings highlight the potential of temporal analysis for improved ASD detection and provide a promising direction for further advancements in the field of eye-tracking-based diagnosis and intervention for neurodevelopmental disorders.

l -carnitine adjunct to risperidone for treatment of autism spectrum disorder-associated behaviors: a randomized, double-blind clinical trial

The present study was designed to evaluate the efficacy and safety of l-carnitine as an adjuvant agent to risperidone in the treatment of autism spectrum disorder (ASD)-associated behaviors. In this study, 68 children with confirmed ASD were randomly allocated to receive either l-carnitine (150 mg/day) or matched placebo in addition to risperidone. We utilized the Aberrant Behavior Checklist-Community Edition scale (ABC-C) and a checklist of potential adverse effects to assess changes in behavioral status and safety profile at weeks 0, 5 and 10 of the trial. The primary outcome was defined as a change in the irritability subscale score. Sixty patients with similar baseline characteristics completed the trial period. Although scores of ABC-C subscales significantly decreased in both groups over the trial period, the combination of l-carnitine and risperidone resulted in more reduction on the irritability and hyperactivity subscales compared to the combination of risperidone and placebo ( P  = 0.033 and P  < 0.001, respectively). However, changes in lethargy, stereotypic behavior and inappropriate speech subscales were similar between groups. In conclusion, l-carnitine adjuvant to risperidone could improve irritability and hyperactivity features in children with ASD. Results of this study should be considered preliminary and further clinical trials with larger sample sizes and longer follow-up periods are warranted.

The Effects of Discrete Trial and Natural Environment Teaching on Adaptive Behavior in Toddlers With Autism Spectrum Disorder

The literature has yet to review the differential effects of Natural Environment Teaching (NET) and Discrete Trial Teaching (DTT) on adaptive skills. A sample of 142 children diagnosed with ASD between the ages of 16 and 35 months received either DTT, NET, or both interventions (NET+ DTT). The Bayley Scales of Infant and Toddler Development (BSID) Adaptive Subscale and the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP) Barriers Assessment were used as baseline and posttest measures. Children who received NET and NET+DTT conditions showed significant improvements compared to the DTT condition indicating that the addition of NET leads to increased adaptive skills and decreased barrier behaviors in participants. DTT may also play a necessary foundational role for children with more significant delays. These results provide support for the use of a combination of teaching strategies in community-based early intervention and refine protocols for teaching adaptive skills to toddlers with ASD.

Family-Centric Applied Behavior Analysis Promotes Sustained Treatment Utilization and Attainment of Patient Goals

BACKGROUND/OBJECTIVES

 Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social communication difficulties and restricted repetitive behaviors or interests. Applied behavior analysis (ABA) has been shown to significantly improve outcomes for individuals on the autism spectrum. However, challenges regarding access, cost, and provider shortages remain obstacles to treatment delivery. To this end, parents were trained as parent behavior technicians (pBTs), improving access to ABA, and empowering parents to provide ABA treatment in their own homes. We hypothesized that patients diagnosed with severe ASD would achieve the largest gains in overall success rates toward skill acquisition in comparison to patients diagnosed with mild or moderate ASD. Our secondary hypothesis was that patients with comprehensive treatment plans (>25-40 hours/week) would show greater gains in skill acquisition than those with focused treatment plans (less than or equal to 25 hours/week).  Methods: This longitudinal, retrospective chart review evaluated data from 243 patients aged two to 18 years who received at least three months of ABA within our pBT treatment delivery model. Patients were stratified by utilization of prescribed ABA treatment, age, ASD severity (per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), and treatment plan type (comprehensive vs. focused). Patient outcomes were assessed by examining success rates in acquiring skills, both overall and in specific focus areas (communication, emotional regulation, executive functioning, and social skills).

RESULTS

Patients receiving treatment within the pBT model demonstrated significant progress in skill acquisition both overall and within specific focus areas, regardless of cohort stratification. Patients with severe ASD showed greater overall skill acquisition gains than those with mild or moderate ASD. In addition, patients with comprehensive treatment plans showed significantly greater gains than those with focused treatment plans.

CONCLUSION

The pBT model achieved both sustained levels of high treatment utilization and progress toward patient goals. Patients showed significant gains in success rates of skill acquisition both overall and in specific focus areas, regardless of their level of treatment utilization. This study reveals that our pBT model of ABA treatment delivery leads to consistent improvements in communication, emotional regulation, executive functioning, and social skills across patients on the autism spectrum, particularly for those with more severe symptoms and those following comprehensive treatment plans.

Effectiveness of IMPUTE ADT-1 mobile application in children with autism spectrum disorder: An interim analysis of an ongoing randomized controlled trial

Objectives

IMPUTE Inc., a software firm dedicated to healthcare technology, has developed a mobile medical application known as IMPUTE ADT-1 for children with autism spectrum disorder (ASD) based on the principle of applied behavior analysis.

Materials and Methods

The primary objective of this trial was to compare the efficacy of add-on treatment with IMPUTE ADT-1 in children with ASD aged two to six years as compared to standard care alone for 12 weeks (in terms of change in Autism Diagnostic Observation Schedule [ADOS-2] scores). The secondary objective of the study was to assess the compliance with IMPUTE ADT-1 among participants and also to evaluate the feedback of parents regarding IMPUTE ADT-1 at the end of 12 weeks. The application provides personalized programs tailored to each user's needs, and the program evolves based on the user's progress. It also utilizes face tracking, eye tracking, and body tracking to gather behavior-related information for each child and apply it in reinforcement learning employing artificial intelligence-based algorithms.

Results

Till the time of interim analysis, 37 and 33 children had completed 12-week follow-up in IMPUTE ADT-1 and control arm. At 12 weeks, as compared to baseline, change in social affect domain, repetitive ritualistic behavior domain, total ADOS-2 score, and ADOS-2 comparison score was better in the intervention group as compared to the control group (P < 0.001 for all). A total of 30 (81%), 28 (75%), and 29 (78%) caregivers in the IMPUTE ADT-1 group believed that the ADT-1 app improved their child's verbal skills, social skills, and reduced repetitive behavior, respectively.

Conclusion

IMPUTE ADT-1 mobile application has the efficacy to improve the severity of autism symptoms in children. Parents of these children also feel that the application is beneficial for improving the socialization and verbal communication of their children.

Impact of Applied Behavior Analysis on Autistic Children Target Behaviors: A Replication Using Repeated Measures

INTRODUCTION

Applied behavior analysis (ABA) is a primary evidence-based practice in treating autism spectrum disorder (ASD). Ongoing research is needed to report the results of ABA relative to attaining target behaviors. This study aims to replicate the results of previous research to determine the effectiveness of ABA of target behaviors in autistic children with a new timepoint sample of data.  Materials & methods: A repeated measures analysis tracked 98 autistic children, which included four adult participants, over three timepoints during a one-month snapshot period from 6/7/23 to 7/7/23. This study used a retrospective chart review to gather data on target behaviors to determine the effectiveness of ABA treatments across age categories. A mixed (between x within) analysis of variance (ANOVA) and subsequent post hoc and interaction contrasts were used to determine statistical significance.

RESULTS

Mixed (between x within) ANOVA indicated statistical significance (sphericity assumed), F(2,160) = 32.893, and p < 0.05, across time. Using bootstrapped paired t-tests, multiple comparisons indicated p < 0.001 on all three multiple comparisons, with Bonferroni corrected α = 0.017. There was also a non-significant interaction effect (sphericity assumed) with (time) x (age category), F(8,160) = 0.333, p = 0.952, likely due to sizeable within-group variation resulting in a lowered statistical power.  Conclusions: This replication found that autistic children receiving the ABA intervention demonstrated statistically significant improvement in target behaviors over the one-month snapshot period.

Examining the Impact of Group-Based Social Skills Intervention in Autistic Children Aged Eight to 15 Years

Introduction Autism spectrum disorder (ASD) is a neurological and developmental disorder, which poses challenges to social communication and behavior, particularly affecting social functioning. Individuals with ASD face significant social challenges, including difficulty understanding social cues and body language, limited ability to engage in reciprocal social interactions, and challenges with establishing empathy. A preference for routines and repetitive behaviors limits their ability to adapt to new or unexpected social situations. These problems tend to escalate during adolescence. These often cause distress to the individual as well as the caregivers. Group-based social skills interventions (GSSIs) are a widely used and effective modality for addressing core social impairments in children with autism. This study aims to assess the impact of GSSI on the broad age group of eight to 15 years, involving parents to enhance the transferability of children's social skills. Methods This was a single-arm interventional study where 30 verbal autistic children, aged eight to 15 years, with intelligence quotient (IQ) > 70 were enrolled after utilizing the Binet Kamat Test of Intelligence (BKT) to assess IQ and the Indian Scale for Assessment of Autism (ISAA) to grade severity of autism. The children received GSSI from interdisciplinary therapists for 12 sessions, on a weekly basis, lasting 90 minutes each for a period of three months. After each therapy session, parents received summaries of each session and were delegated reinforcing homework assignments to enable generalization and maintenance of the skills taught. Outcome measures were taken at three points in time by utilizing the Social Communication Questionnaire (SCQ) and the parent-rated Social Responsiveness Scale 2 (p-SRS-2): T1: pre-therapy at the time of enrolment; T2: immediately post-therapy at the end of three months of training; and T3: long-term follow-up, three months after the end of training. Results Mean SCQ scores were as follows: T1 = 21.87, T2 = 18.57, and T3 = 18.57 (p = 0.000). This progressive decline at T1, T2, and T3 indicated a decreasing trend in the severity of difficulties in the social communication domain. Mean p-SRS-2 scores were as follows: T1 = 73.00, T2 = 64.57, and T3 = 64.30 (p < 0.0001). This declining trend at T1, T2, and T3 suggested a statistically significant decrease in the severity of difficulties faced in various social aspects tested by the p-SRS-2, i.e., social awareness, social cognition, social communication, and social motivation, along with a reduction in restricted interests and repetitive behaviors (RRBs). Very strong correlation coefficients were obtained for SCQ scores (T1-T2 = 0.921, T1-T3 = 0.921, and T2-T3 = 1.000), as well as for p-SRS-2 scores (T1-T2 = 0.743, T1-T3 = 0.746, and T2-T3 = 0.989), which reinforced the statistical significance of the data. Conclusion GSSI is an effective parent-assisted intervention for adolescents with ASD, with effects lasting up to three months post-intervention.

The impact of ILF neurofeedback on inhibitory control in high-functioning adolescents with autism spectrum disorder: Preliminary evidence of a randomized controlled trial

BACKGROUND

Individuals with Autism Spectrum Disorder (ASD) often exhibit impairments in inhibitory control, which can impact their cognitive functioning. This study aimed to investigate the effectiveness of Infra-Low Frequency (ILF) neurofeedback in improving inhibitory control among high-functioning adolescents with ASD.

METHODS

A single-blind, two-armed randomized controlled trial was conducted with 24 adolescents with ASD randomly divided into two groups (active and sham; n = 12 per group). Both groups participated in 15 sessions of one-hour ILF neurofeedback, three times per week. The ILF neurofeedback protocol was applied to the active group, while the sham group received an inactive intervention. Outcomes were measured at the pretest, post-test, and follow-up stages.

RESULTS

ILF neurofeedback significantly improved inhibitory control in adolescents with ASD, as indicated by improvements in behavioral measures and absolute power analysis. The most significant differences were observed in alpha, theta, and gamma waves located in the central areas of the left gyrus. However, no significant effect was observed at the follow-up level on either behavioral measures or absolute power.

CONCLUSION

The results suggest that ILF neurofeedback is effective in improving inhibitory control in high-functioning adolescents with ASD. This non-invasive intervention has the potential to improve inhibitory control in this population. However, future research is needed to determine the long-term effects of ILF neurofeedback.

Gut microbiota signature in children with autism spectrum disorder who suffered from chronic gastrointestinal symptoms

BACKGROUND

Children diagnosed with autism spectrum disorder (ASD) frequently suffer from persistent gastrointestinal symptoms, such as constipation and diarrhea. Various studies have highlighted differences in gut microbiota composition between individuals with ASD and healthy controls of similar ages. However, it's essential to recognize that these disparities may be influenced by cultural practices, dietary habits, and environmental factors.

METHODS

In this study, we collected fecal samples from both children diagnosed with ASD (n = 42) and healthy individuals (n = 41) residing in the southeastern coastal region of China. Subsequently, 16 S rRNA gene sequencing and advanced bioinformatics analyses were conducted to investigate the distinctive features of gut microbial communities within each group.

RESULTS

The ASD group consisted of 28 males and 14 females, with a median age of 5.8 years, while the control group included 25 males and 16 females, with a median age of 6.8 years. Among the 83 sequenced fecal samples, a total of 1031 operational taxonomic units (OTUs) were identified. These included 122 unique OTUs specific to the control group and 285 unique OTUs specific to the ASD group. Analyses of α-diversity and β-diversity unveiled significant differences in the abundance and composition of gut microbiota between the two groups. It was found that the dominant bacterial taxa in healthy individuals were UBA1819, Flavonifractor, and Bradyrhizobium. In contrast, the ASD group exhibited a prevalence of Streptococcus, Ruminococcus, and Ruminiclostridium. Further analysis using Kyoto Encyclopedia of Genes and Genomes (KEGG) and Clusters of Orthologous Groups (COG) showed significant differences in the metabolic functionalities of the gut microbiota between the two groups. Notably, the metabolic pathway related to alpha-linolenic acid (ALA) in the gut microbiota of the ASD group was notably diminished compared to the control group. Conversely, the ASD group demonstrated significantly elevated levels of metabolic pathways involving uncharacterized conserved proteins, aminoglycoside phosphotransferase, and inorganic pyrophosphatase compared to the control group.

CONCLUSIONS

Overall, these results confirm that there are significant differences in the gut microbiota structure between children with ASD and healthy controls in the southeast coastal region of China. This underscores the critical significance of delving into clinical interventions capable of mitigating the gastrointestinal and psychological symptoms encountered by children with ASD. A particularly encouraging path for such interventions lies in the realm of fecal microbiota transplantation, a prospect that merits deeper inquiry.

Measuring Engagement in Robot-Assisted Therapy for Autistic Children

Children with autism face a range of challenges when it comes to verbal and nonverbal communication. It is essential that children participate in a variety of social, educational, and therapeutic activities to acquire knowledge that is essential for cognitive and social development. Recent studies have shown that children with autism may be interested in playing with an interactive robot. The robot can engage these children in ways that demonstrate and train essential aspects of human interaction, guiding them in therapeutic sessions to practice more complex forms of interaction found in social human-to-human interactions. This study sets out to investigate Robot-Assisted Autism Therapy (RAAT) and the use of artificial intelligence (AI) approaches for measuring the engagement of children during therapy sessions. The study population consisted of five native Arabic-speaking autistic children aged between 4 and 11 years old. The child-robot interaction was recorded by the robot camera and later used for analysis to detect engagement. The results show that the proposed system offers some accuracy in measuring the engagement of children with ASD. Our findings revealed that robot-assisted therapy is a promising field of application for intelligent social robots, especially to support autistic children in achieving their therapeutic and educational objectives.

Information and communication technologies-based interventions for children with autism spectrum conditions: a systematic review of randomized control trials from a positive technology perspective

Information and communication technologies (ICTs) have become more widely used in the past years to help people with autism spectrum conditions (ASC). Serious games embedded into computers or tablets, as well as social robots, are the most employed ICT-related tools that are appealing to and appropriate for autistic children. The goal of ICT applications is to enhance behavioral abnormalities associated with ASC while also creating an interactive link between one person and one computer. Comparatively, to human-based therapy, ICT tools aid to inspire autistic children by providing predictability and regularity of tasks. Regaining social skills is the primary behavioral goal for which ICT tools have been designed and implemented. In the past several years, many studies have been created to show how effective it is at improving targeted behaviors. However, only a small number of researchers have used an RCT approach to evaluate its effectiveness. In this systematic review, we only included RCT studies where ICT technologies were used to help children with ASC in improving their social skills. Only 14 RCT studies satisfied the criteria and 12 described significant improvements, showing how the use of technology in educational contexts produced better improvement in developing several social skill facets with respect to the traditional face-to-face approach. Some studies used interventions and outcome measures focused on the core ASC symptoms, but many others addressed neurocognitive functions directly, like social cognition or emotional regulation, while other more general functions such as language or adaptive behaviors. We propose a classification based on processes and outcome measures to foster future research in this specific area of research. The behavioral intervention mediated by technological tools such as computer-based, tablet, and social robotics, undoubtedly provides a comfortable environment that promotes constant learning for people with ASC. Evidence provided in this review highlights the translational potential of this field of study in primary care practice and educational settings.

A mixed-methods examination of clinicians' perceived barriers to telehealth delivered applied behavior analysis

Following the COVID-19 pandemic, clinicians relied on telehealth to ensure continuity of essential healthcare services, such as Applied Behavior Analysis (ABA). Identifying barriers and examining them in the context of other implementation outcomes is important to support appropriate adaptations and sustainability of telehealth-delivered ABA services. Convergent mixed methods design was utilized to identify barriers experienced by ABA clinicians (N = 388) when delivering ABA services over telehealth to autistic children and their families following the first six months of the COVID-19 pandemic. Additionally, barriers were examined in relation to telehealth implementation outcomes and intentions for continued adoption. Findings reveal that clinicians rated providing direct services (M = 3.52, SD = 1.14) as more difficult than conducting assessments (M = 3.29, SD = 1.06), and both as more difficult than providing parent-mediated interventions [(M = 2.47, SD = 1.11), F(2, 381) = 162.26, p < 0.001]. A principal components analysis indicated a 3-factor solution of barriers related to: (1) technology (α = 0.82), (2) administrative tasks (α = 0.88), and (3) client characteristics (α = 0.88). The most frequently endorsed barriers were related to client characteristics, including increased difficulty providing telehealth services to children who elope (M = 4.37, SD = 0.81), children who exhibit challenging behaviors (M = 4.31; SD = 0.83), and children who are in the preverbal stage or use nonverbal language to communicate (M = 4.07; SD = 1.00). Fewer barriers related to client characteristics uniquely predicted implementation variables including acceptability, appropriateness, and feasibility. Thematic analysis revealed challenges related to technology, caregiver involvement, child engagement, implementation of intervention strategies over telehealth, and administrative or logistical barriers. These findings highlight the need for targeted strategies that facilitate telehealth use to address specific client needs and support the implementation of telehealth services in usual care settings.

A Short Report on the Impact of Judo on Behaviors and Social Skills of Children With Autism Spectrum Disorder

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by communication difficulty and social deficits. The current treatment employs the use of psychosocial therapy and medication as well as alternative treatments. This is a pilot study that assessed whether participation in judo improved behavior and social skills in children with ASD.

METHODS

Twenty-four students from the Riverside Youth Judo Club were included in the study, after obtaining consent from their parents to participate. Inclusion criteria included participation in judo classes for more than one month and diagnosis of ASD and/or a developmental disability. Parent(s) of the children signed a consent form, filled out a study questionnaire and completed the Social Skills Improvement System Social-Emotional Learning Edition, Parent Form (SSIS-SEL). Parents also had the opportunity to volunteer their child's baseline SSIS-SEL assessment. SSIS-SEL data was taken for four participants and compared to the baseline.

RESULTS

In the study questionnaire, 62.5% of parents agreed that their children demonstrated improvement across all six categories. The category with the greatest improvement was 'Behavior at home', while the category with the least improvement was 'Eye contact'.

CONCLUSION

While the direct impact of judo on special needs children was difficult to assess due to variability in abilities and developmental milestones, we hope that improving awareness regarding the effectiveness of youth sports would impact the long-term quality of life for children with any developmental or mental disability and may help improve their social and behavioral skills in multiple environments.

Miniature Linguistic Systems for Individuals With Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

PURPOSE

Miniature linguistic systems (also known as matrix training) is a method of organizing learning targets to achieve generative learning or recombinative generalization. This systematic review is aimed at determining whether matrix training is effective for individuals with autism spectrum disorder (ASD) in terms of improving recombinative generalization for instruction-following, expressive language, play skills, and literacy skills.

METHOD

A systematic review methodology was employed to limit bias in the various review stages. A multifaceted search was conducted. Potential primary studies were imported into Covidence, a systematic review software, and inclusion criteria were applied. Data were extracted regarding (a) participant characteristics, (b) matrix designs, (c) intervention methods, and (d) dependent variable. A quality appraisal using the What Works Clearinghouse (WWC) Single-Case Design Standards (Version 1.0, Pilot) was carried out. In addition to the visual analysis of the data, an effect size estimate, non-overlap of all pairs (NAP), was generated for each participant. Independent t tests and between-subjects analyses of variance were conducted to identify moderators of effectiveness.

RESULTS

Twenty-six studies including 65 participants met criteria for inclusion. All included studies were single-case experimental designs. Eighteen studies received a rating of Meets Standards Without Reservations or Meets Standards With Reservations. The aggregated combined NAP scores for acquisition, recombinative generalization, and maintenance of a range of outcomes were in the high range.

CONCLUSIONS

Findings suggested that matrix training is an effective teaching method for individuals with ASD for acquisition, recombinative generalization, and maintenance of a range of outcomes. Statistical analyses to identify moderators of effectiveness were insignificant. Based on the WWC Single-Case Design Standards matrix training meets criteria to be considered an evidence-based practice for individuals with ASD.

How Are Autism Spectrum Disorder and Savant Skills Treated in Cinematographic Works? A Study Focusing on Korean Movies and TV Series

Numerous films and TV series worldwide have depicted characters with autism spectrum disorder (ASD) and savant skills. This study describes the portrayal of ASD and savant skills in Korean films and dramas. Starting with the 2005 film Marathon, characters with ASD have been featured in five films and four dramas. Most portrayals were based on the diagnostic criteria and pathogenesis of ASD, as outlined in the DSM-5. Of the 10 characters with ASD in these films and dramas, seven were male and three were female, with seven of them possessing savant skills. In the future, caution and guidance on the general characteristics of ASD from experts should be provided with the release of ASD-based films and TV dramas in Korea; in addition, critiques and social discourse pertinent to the reality of ASD should be provided by people with ASD, their families, and relevant experts.

Cilostazol as adjunctive therapy in treatment of children with autism spectrum disorders: a double-blind and placebo-controlled randomized trial

We aimed to evaluate cilostazol therapeutic effects on aberrant behaviors of autism spectrum disorder (ASD) children and its safety profile in a double-blind, randomized clinical trial. Sixty-six children with confirmed ASD were allocated to receive either daily 50-mg cilostazol (increased to 100 mg/day after 2 weeks) or matched placebo in addition to risperidone. The Aberrant Behavior Checklist-Community Edition (ABC-C) scale and a checklist of probable adverse effects were used to assess the behavioral outcomes and safety profile at weeks 0, 5, and 10 of the study. Sixty-one participants, with comparable baseline characteristics, completed the trial. Unlike other ABC-C subscales, repeated-measures analysis showed significant effect for time × treatment interaction in the hyperactivity subscale ( P = 0.047; partial eta squared = 0.06). We used the median value for the baseline score hyperactivity subscale [median (interquartile range) = 31 (24-37)] to stratify participants to higher hyperactivity and lower hyperactivity subgroups and found that only participants with higher hyperactivity benefit from cilostazol adjunctive therapy ( P = 0.028; partial eta squared = 0.14). Cilostazol could be considered as a safe agent with beneficial effects on hyperactivity in children with ASD and higher levels of hyperactivity.

Randomized controlled pilot study of an app-based intervention for improving social skills, face perception, and eye gaze among youth with autism spectrum disorder

Introduction

This pilot study aimed to examine the effectiveness of an app-based intervention (Yface) in 53 children with autism spectrum disorder. Yface is a combined program that improves social skills, facial perception, and eye gaze.

Methods

Children were randomly assigned to one of the two training groups or a waitlist control group. One of the training groups completed the Yface training program lasting for 66 days, while the other training group used a similar app called Ycog, which focuses on cognitive rehabilitation. Questionnaires, computerized tasks, and semi-structured interviews were administered to children and their parents at pre- and post-training sessions.

Results

The Yface group showed improvements in face perception and some social skills compared to waitlist controls, and in eye gaze compared to the Ycog group.

Discussion

Our results suggest that this app-based intervention is effective in improving targeted social skills and face perception, although their relative effectiveness differs across skill domains.

Addressing the Need for Training More School Psychologists to Serve Toddlers and Preschoolers with Autism Spectrum Disorders

The prevalence of autism spectrum disorder (ASD) has risen significantly in the past two decades. Unfortunately, there is a shortage of mental health providers who have specialized training in delivering evidenced-based services to this population. Early intensive behavioral intervention (EIBI) is an evidenced-based treatment recommended for toddlers with ASD, and school psychologists are uniquely positioned to help children with ASD receive it. However, many school psychologists do not receive adequate training in this subspecialty. This paper makes recommendations to school psychology training programs about how to add or improve training in this subspecialty based on the results of an Office of Special Education Programs grant-funded ASD training program which involved collaboration between a NASP-approved and APA-accredited school psychology training program and a community-based early intensive behavioral intervention (EIBI) clinic. The grant supported development of an interdisciplinary didactic and clinical training program to increase the ASD knowledge, skills, and competencies of school psychology graduate students, with the broader goals of developing a replicable training model and increasing the workforce of trained providers for this underserved population. Fifteen graduate students completed the training program. Outcomes related to trainee knowledge, skills, and competencies, trainee satisfaction, and lessons learned over time analyzed within a logic model that guided the project's development and execution can be informative for other school psychology programs undertaking training in this subspecialty.

A Systematic Review of Maintenance Measurement in Early Childhood Autism Spectrum Disorder Research

Single case research designs (SCRDs) are integral to identifying evidence-based practices (EBPs) for young children with autism spectrum disorder (ASD); however, the field lacks guidance on measuring response maintenance within SCRDs. We identified 103 studies in which researchers used SCRD to investigate the maintenance of behavioral intervention outcomes for children with ASD ages 0-5. Findings include: (a) maintenance conditions across most EBP categories, (b) limited within-case replication of maintenance assessment, (c) inconsistent use of maintenance terminology, (d) varying frequencies of maintenance assessment, and (e) wide range in latency to first and last maintenance probe. Results indicate a pressing need for the regular inclusion of maintenance conditions in behavioral research to increase our understanding of programming for and assessing maintenance.

Applications of operant demand to treatment selection I: Characterizing demand for evidence-based practices

Various treatment approaches have been determined efficacious for improving child behavior outcomes. Despite a variety of evidence-based options, consumers often disregard empirically supported treatments to pursue alternatives that lack empirical support, such as 'fad' therapies. The choice to pursue therapies lacking empirical support has been considered a 'gamble' on therapeutic outcomes and this form of risky choice has historically been explained using various cognitive heuristics and biases. This report translates quantitative analyses from the Operant Demand Framework to characterize how caregivers of children with behavioral issues consume treatment services. The Operant Demand Framework is presented, its utility for characterizing patterns of treatment consumption is discussed, and a preliminary application of cross-price analyses of demand is performed to illustrate how various factors jointly influence treatment-related choice. Results indicated that caregivers endorsing interest in receiving behavioral parent training regularly pursued pseudoscientific alternatives as a functional substitute for an established therapy, despite explicit language stating a lack of evidence. These findings question the presumption of rationality in models of treatment choice and degree to which scientific evidence influences the consumption of therapies. This report concludes with a discussion of Consumer Behavior Analysis and how quantitative analyses of behavior can be used to better understand factors that enhance or detract from the dissemination of evidence-based practices.

The feasibility of implementing autism intervention methods in formal education settings welcoming refugee and asylum-seeking children: A systematic review of the literature

Given the significant amount of time that refugee and asylum-seeking children (RASC) spend in schools, these institutions play an important role in their lives and represent an ideal environment in which to help them to adapt to their host society. The present study aimed to draw attention to the possibility of transferring intervention methods designed for children with ASD to formal education settings welcoming newly arrived RASC to support their adaptation to their new school environment. For this purpose, a systematic review was undertaken to assess the feasibility of implementing three specific ASD intervention methods (i.e., TEACCH, PECS, and PMI) in schools welcoming RASC. While the review did not reveal previous attempts to implement and evaluate ASD intervention methods with newcomer RASC, 21 records were uncovered providing preliminary evidence in support of this idea. Hypothesized strengths and limitations, as well as considerations about implementation, are discussed.

Do Health Insurance Mandates Spillover to Education? Evidence from Michigan's Autism Insurance Mandate

Social programs and mandates are usually studied in isolation, but unintended spillovers to other areas can impact individual behavior and social welfare. We examine the presence of spillovers from health care policy to the education sector by studying how health insurance coverage affects the education of students with Autism Spectrum Disorder (ASD). We leverage a state mandate that increased insurance coverage of ASD-related services, which often are provided by both the private sector and within public schools. The mandate primarily affected coverage for children with private health insurance, so we proxy for private insurance coverage with students' economic disadvantage status and estimate effects via triple-differences. While we find little change in ASD identification, the mandate crowds-out special education supports for students with ASD. A lack of short-run impact on achievement supports our crowd-out interpretation and indicates that the mandate had little net effect on the academic achievement of ASD students.

Content Validity Evidence for the Verbal Behavior Milestones Assessment and Placement Program

The purpose of this study is to provide content validity evidence for the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP). A national panel of 13 experts provided an evaluation of the domain relevance, age appropriateness, method of measurement appropriateness, and domain representation across the three levels of the Milestones Assessment, Early Echoic Skills Assessment (EESA), and Barriers Assessment. Overall, the content validity evidence for the VB-MAPP Milestones, EESA, and Barriers Assessment was moderate to strong across the evaluated areas although there were areas with limited or conflicting support. The evidence suggests that the scores of the VB-MAPP provide information relevant to the target behaviors of interest but a few domains may not be fully represented by their specific items.

Housing of A350V IQSEC2 pups at 37 °C ambient temperature prevents seizures and permits the development of social vocalizations in adulthood

OBJECTIVES

Mutations in the human IQSEC2 gene are associated with drug-resistant epilepsy and severe behavioral dysfunction. We have focused on understanding one human IQSEC2 missense mutation (A350V) for which we have created a corresponding A350V IQSEC2 mouse model by CRISPR which demonstrates seizures when the mice are 15-20 days old and impaired social vocalizations in adulthood. We observed that a child with the A350V mutation stops having seizures when experiencing a fever of greater than 38 °C. In this study, we first sought to determine if we could recapitulate this phenomenon in A350V 15-20 day old mice using a previously established protocol to raise body temperature to 39 °C achieved by housing the mice at 37 °C. We then sought to determine if mice in whom seizure activity had been prevented as pups would develop social vocalization activity in adulthood.

METHODS

15-20 day old A350V male mice were housed either at 37 °C or 22 °C. Ultrasonic vocalizations of these mice were assessed at 8-10 weeks in response to a female stimulus.

RESULTS

Housing of 15-20 day old A350V mice at 37 °C resulted in a reduction in lethal seizures to 2% (1/41) compared to 45% (48/108) in mice housed at 22 °C, p = 0.0001. Adult A350V mice who had been housed at 37 °C as pups displayed a significant improvement in the production of social vocalizations.

CONCLUSION

Raising the body temperature by raising the ambient temperature might provide a means to reduce seizures associated with the A350V IQSEC2 mutation and thereby allow for an improved neurodevelopmental trajectory.

Importance of Trauma-Informed Practice in Evaluation of Children Diagnosed with Autism Spectrum Disorder

CASE

As part of a multidisciplinary adoption support clinic, Erin, a 5-year-old girl, adopted approximately 6 months before the clinic visit, presents for postadoption evaluation. Erin was born at full term. Her birth history was significant for reported maternal treatment for liver failure during pregnancy. Her previous medical history included hospitalization for a viral illness at age 2 months, recurrent ear infections, and a fractured forearm. Family history was significant for a maternal history of bipolar disorder, depression, anxiety, borderline personality disorder, and concern for substance abuse; a paternal history of attention-deficit/hyperactivity disorder (ADHD) and depression; and full biological brother with a history of ADHD and oppositional defiant disorder. Erin and her brother lived with their parents until she was approximately 3 years old. At that time, there were concerns for poor hygiene, inconsistent medical care, poor school attendance for her brother, financial instability, and significant neglect. Erin was reportedly confined to her crib for hours at a time. She and her older brother were removed from the home because of concerns for significant neglect and placed into foster care. Approximately 3 months after foster placement, Erin underwent testing because of concerns for abnormal behaviors and possible developmental delays. Symptoms included poor sleep, repetitive behaviors such as head banging, delayed speech that primarily involved grunting, and lack of toilet training. She was hyperactive and aggressive and had poor caregiver attachment. On evaluation, she was small for age, poorly groomed, and easily distracted with poor eye contact and did not tolerate interactions with examiners. Neuropsychological testing consisted of symptom checklists and caregiver interview only because she did not tolerate diagnostic testing. She was diagnosed with autism spectrum disorder and global developmental delay with intellectual and language impairments. Over the following year, Erin was transitioned to a second foster family and was subsequently adopted. She received speech, occupational, and physical therapy, along with trauma-informed therapy. She made significant gains in multiple domains and was able to graduate from trauma-informed therapy after 1 year. On examination, Erin greets you with appropriate eye contact and reports that she is feeling "good." She is verbal and interactive with her brother and parents. She looks to parents for support when asked to participate in the physical examination. She does not display any significant repetitive behaviors. Erin's parents are concerned that her initial diagnoses of autism spectrum disorder and global developmental delay do not accurately reflect her current level of functioning and are afraid she may have been misdiagnosed. How would you proceed with next steps to address these diagnoses?

The Role of Applied Behavior Analysis to Improve Knowledge on Oral Hygiene Practices among Cooperative Autistic Children: A Cross-Sectional Study from Jazan, Saudi Arabia

Objective

To assess the effectiveness of Applied Behavior Analysis (ABA) to improve knowledge regarding oral hygiene practices among cooperative autistic children.

Materials and Methods

A cross-sectional study was conducted among 15 children between the age group of 6–12 years and their parents who were randomly chosen from a special care autistic school in Jazan, Saudi Arabia. A mobile application was custom designed and programmed with videos on oral hygiene. A close-ended questionnaire comprising 14 questions for the cooperative autistic children and 21 questions for their parents was designed to assess their knowledge in relation to oral health and hygiene. After four weeks, a questionnaire-based knowledge assessment was conducted. The mean knowledge score was then calculated for children and their parents and compared using paired sample t-test.

Results

Poor knowledge regarding oral hygiene practices was revealed among the study participants. The estimated mean score among the children was 4.73 before the intervention, which significantly increased to 9.0. The estimated mean score for the parents was 9.3 before intervention and 14.6 after four weeks' period (P < 0.0001).

Conclusion

The application of ABA using avatars and delivered through videos can significantly improve knowledge regarding oral health hygiene among cooperative autistic children.

Social and Nonsocial Reward Anticipation in Typical Development and Autism Spectrum Disorders: Current Status and Future Directions

PURPOSE OF REVIEW

While there has been sustained interest in understanding the role of reward processing in autism spectrum disorder (ASD), researchers are just beginning to focus on the anticipation phase of reward processing in this population. This review aimed to briefly summarize recent advancements in functional imaging studies of anticipatory social and nonsocial reward processing in individuals with and without ASD and provide suggestions for avenues of future research.

RECENT FINDINGS

Reward salience and activation of the complex network of brain regions supporting reward anticipation vary across development and by important demographic characteristics, such as sex assigned at birth. Current research comparing social and nonsocial reward anticipation may possess confounds related to the mismatch in tangibility and salience of social and nonsocial experimental stimuli. Growing evidence suggests individuals with ASD demonstrate aberrant generalized reward anticipation that is not specific to social reward. Future research should carefully match social and nonsocial reward stimuli and consider employing a longitudinal design to disentangle the complex processes contributing to the development of reward anticipation. It may be useful to conceptualize differences in reward anticipation as a transdiagnostic factor, rather than an ASD-specific deficit.

Framework for the Development of Affective and Smart Manufacturing Systems Using Sensorised Surrogate Models

Human Factor strategy and management have been affected by the incorporation of Key Enabling Technologies (KETs) of industry 4.0, whereby operator 4.0 has been configured to address the wide variety of cooperative activities and to support skills that operate in VUCA (volatile, uncertain, complex, and ambiguous) environments under the interaction with ubiquitous interfaces on real and virtual hybrid environments of cyber-physical systems. Current human Competences-Capacities that are supported by the technological enablers could result in a radically disempowered human factor. This means that in the processes of optimization and improvement of manufacturing systems from industry 4.0 to industry 5.0, it would be necessary to establish strategies for the empowerment of the human factor, which constitute symbiotic and co-evolutionary socio-technical systems through talent, sustainability, and innovation. This paper establishes a new framework for the design and development of occupational environments 5.0 for the inclusion of singularized operators 4.0, such as individuals with special capacities and talents. A case study for workers and their inclusion in employment is proposed. This model integrates intelligent and inclusive digital solutions in the current workspaces of organizations under digital transformation.

Intensive intervention for adolescents with autism spectrum disorder: comparison of three rehabilitation treatments

INTRODUCTION

Autism spectrum disorder (ASD) is a set of heterogeneous neurodevelopmental conditions, characterised by difficulties in social communication and restricted, repetitive behaviours and interests. There are several rehabilitative interventions for individuals with ASD but the evidence of their effectiveness is low or moderate overall. The transition phase of ASD individuals from adolescence to adulthood represents an important challenge. Adults with ASD struggle to access employment or independent living.

METHODS

In our study, we evaluated the effect of three different high-intensity interventions, namely Applied Behaviour Analysis (ABA), Treatment and Education of Autistic and Communication-Handicapped Children (TEACCH) and Behavioural Educational Intervention (BEI), in 93 ASD (levels 2 and 3) adolescents (age range 12-18 years).

RESULTS

Our results showed that all adolescents with ASD reported an improvement of core symptoms, regardless of the type of treatment.

CONCLUSIONS

A high intensity intervention ameliorates the core symptoms of ASD, enriching evidence of effectiveness regarding adolescents with ASD.KEY POINTSIndividuals with ASD need lifespan support and they struggle to access employment, independent living and community inclusion.There are several rehabilitative interventions for individuals with ASD but the evidence of their effectiveness in adolescents is insufficient.The main purpose of this study was to evaluate the possible enhancement produced by three intensive interventions (ABA, TEACCH, BEI) of symptom severity and adaptive functions.Results show that independently of the treatment, individuals with ASD decrease in ASD severity.Individuals who were treated with the BEI and TEACCH programmes reported improvements in the adaptive domains.

Barriers and Facilitators of Access to Psychological Services for Indigenous Populations: A Scoping Review and Thematic Analysis

Background: The extent to which behavior-analytic interventions are offered to Indigenous populations across CANZUS in accessible and culturally appropriate ways is unknown. We conducted a scoping review with a thematic analysis of the extant literature to find: (1) what are the barriers and facilitators for providing effective and equitable delivery of psychological services (with a behavioral component) to Indigenous populations; and (2) what tools and practices exist for an effective and equitable service delivery. Methods: We systematically reviewed Medline, CINAHL, PubMed, PsycInfo, Web of science, Ovid and INNZ databases between 1990 and 2020. For the scoping review, we adhered to the JBI methodological approach (2015) and the PRISMA strategy for the identification, selection, and appraisal of the reviewed articles. A total of 1265 unique articles met the criteria for the screening by title; 238 by abstract; 57 were included for full text assessment; and 37 were included in the final analysis. Results: Three themes were revealed to account for the barriers and facilitators of culturally friendly practices: (1) connecting practices are about interactions shaping the relationship between service provider and service client; (2) innovative practices test new approaches and innovations that could facilitate access to psychological services and overcome barriers, and (3) reflective practices are about critically examining the processes and actions undertaken toward effective cultural adaptation of services. Conclusions: Our analysis suggests that the level of success in bringing together services and the recipients of treatment (connection), showing flexibility and persistence in finding solutions (innovation) and examining the role of our behaviors in reaching our goals (reflection) is determined by the providers' action in the aforementioned three dimensions of practice.

Therapeutic Pitfalls in the Transition of Neurologic Patients from Pediatric to Adult Health Care Providers

Transitions of care from the pediatric to adult setting are fraught with difficulty. For patients whose neurologic problems began in childhood, there is often a lack of organized multidisciplinary care with the desired neurologic expertise in the adult setting. This monograph highlights those difficulties, reviewing disease-specific instances of the problems with transition from pediatric to adult neurologic care. The use of an arbitrary chronologic age cutoff for transition from pediatric to adult expertise in specific disease state may be a disservice in provision of care, and the disease-specific expertise of providers may outweigh the benefit of an age-related provider focus.

A comparative feasibility study of two parent education and training programmes for autism spectrum disorder in a low-resource South African setting

LAY ABSTRACT

After a diagnosis of autism, it is an important first step to give families information about autism and skills to help them support their child. These interventions are called Parent Education and Training programmes. Little is known about these programmes or if they can make a difference to families, particularly in countries with few autism resources. In this study, we compared two Parent Education and Training programmes in South Africa. EarlyBird/EarlyBird Plus was developed in the United Kingdom, and Autism Cares in South Africa. We wanted to know if parents found the programmes useful, and if any changes were required. We collected information from parents through questionnaires and interviews before and after the group. We also asked a panel of experts (including parents) to compare the programmes. In total, 18 parents attended the EarlyBird/EarlyBird Plus group and 11 attended the Autism Cares group. Parents found both programmes helpful and made suggestions for improvements. Parents showed less stress, more knowledge of autism, and saw improvements in their children. The expert panel rated EarlyBird/EarlyBird Plus as better because it was more supportive of parents and was seen as easier to run in the country. Our study showed that Parent Education and Training programmes are important, but that researchers must study not only the outcomes but also the implementation needs of these programmes.

A Mobile Game for Automatic Emotion-Labeling of Images

In this paper, we describe challenges in the development of a mobile charades-style game for delivery of social training to children with Autism Spectrum Disorder (ASD). Providing real-time feedback and adapting game difficulty in response to the child's performance necessitates the integration of emotion classifiers into the system. Due to the limited performance of existing emotion recognition platforms for children with ASD, we propose a novel technique to automatically extract emotion-labeled frames from video acquired from game sessions, which we hypothesize can be used to train new emotion classifiers to overcome these limitations. Our technique, which uses probability scores from three different classifiers and meta information from game sessions, correctly identified 83% of frames compared to a baseline of 51.6% from the best emotion classification API evaluated in our work.

Efficacy of Interventions Based on Applied Behavior Analysis for Autism Spectrum Disorder: A Meta-Analysis

OBJECTIVE

To systematically evaluate evidence for the use of interventions based on appied behavior analysis (ABA) to manage various symptoms of children with autism spectrum disorder (ASD).

METHODS

Sensitivity analyses were conducted by removing any outlying studies and subgroup analyses were performed to compare the effectiveness of ABA and early start denver model (ESDM), picture exchange communication systems (PECS) and discrete trial training (DTT).

RESULTS

14 randomized control trials of 555 participants were included in this meta-analysis. The overall standardized mean difference was d=-0.36 (95% CI -1.31, 0.58; Z=0.75, p=0.45) for autism general symptoms, d=0.11 (95% CI -0.31, 0.54; Z=0.52, p=0.60) for socialization, d=0.30 (95% CI -0.02, 0.61; Z=1.84, p=0.07) for communication and d=-3.52 (95% CI -6.31, -0.72; Z=2.47, p=0.01) for expressive language, d=-0.04 (95% CI -0.44, 0.36; Z=0.20, p=0.84) for receptive language. Those results suggested outcomes of socialization, communication and expressive language may be promising targets for ABA-based interventions involving children with ASD. However, significant effects for the outcomes of autism general symptoms, receptive language, adaptive behavior, daily living skills, IQ, verbal IQ, nenverbal IQ, restricted and repetitive behavior, motor and cognition were not observed.

CONCLUSION

The small number of studies included in the present study limited the ability to make inferences when comparing ABA, ESDM, PECS and DTT interventions for children with ASD.

Sex/Gender Phenotypes and the Diagnosis and Treatment of Autism Spectrum Disorder: Implications for Applied Behavior Analysts

Research has consistently reported a higher rate of autism spectrum disorder (ASD) diagnoses in males than in females, but until recently, the impact of sex/gender differences has received little attention from applied behavior analysts. The underlying reasons for the difference in rates of diagnosis could be related to genetic or hormonal differences, sociocultural expectations of behavior based on sex/gender norms, or biases built into the assessment and observation of ASD symptoms. It is necessary to engage in further discussion and research in order to improve the treatment and quality of life of persons with ASD because misdiagnosis or late diagnosis can delay the start of early intervention and limit its proven benefits. Furthermore, differences in symptom presentation can impact interventions selected. We suggest that applied behavior analysts should be knowledgeable of these issues and the implications they may have on the field of applied behavior analysis in general.

Point OutWords: protocol for a feasibility randomised controlled trial of a motor skills intervention to promote communicative development in non-verbal children with autism

BACKGROUND

Point OutWords is a caregiver-delivered, iPad-assisted intervention for non-verbal or minimally verbal children with autism. It aims to develop prerequisite skills for communication such as manual and oral motor skills, sequencing, and symbolic representation. This feasibility trial aims to determine the viability of evaluating the clinical efficacy of Point OutWords.

METHODOLOGY

We aim to recruit 46 non-verbal or minimally verbal children with autism and their families, approximately 23 per arm. Children in the intervention group will use Point OutWords for half an hour, five times a week, for 8 weeks. Children in the control group will have equal caregiver-led contact time with the iPad using a selection of control apps (e.g. sensory apps, drawing apps). Communication, motor, and daily living skills are assessed at baseline and post-intervention. Parents will keep diaries during the intervention period and will take part in focus groups when the intervention is completed.

DISCUSSION

Point OutWords was developed in collaboration with children with autism and their caregivers, to provide an intervention for a subgroup of autism that has been historically underserved. As autism is a heterogeneous condition, it is unlikely that one style of intervention will address all aspects of its symptomatology; the motor skills approach of Point OutWords can complement other therapies that address core autistic symptoms of social cognition and communication more directly. The current feasibility trial can inform the selection of outcome measures and design for future full-scale randomised controlled trials of Point OutWords and of other early interventions in autism.

TRIAL REGISTRATION

ISRCTN, ISRCTN12808402. Prospectively registered on 12 March 2019.

Circuits for social learning: A unified model and application to Autism Spectrum Disorder

Early life social experiences shape neural pathways in infants to develop lifelong social skills. This review presents the first unified circuit-based model of social learning that can be applied to early life social development, drawing together unique human developmental milestones, sensitive learning periods, and behavioral and neural scaffolds. Circuit domains for social learning are identified governing Activation, Integration, Discrimination, Response and Reward (AIDRR) to sculpt and drive human social learning. This unified model can be used to identify social delays earlier in development. We propose social impairments observed in Autism Spectrum Disorder are underpinned by early mistimed sensitive periods in brain development and alterations in amygdala development to disrupt the AIDRR circuits. This model directs how interventions can target neural circuits for social development and be applied early in life. To illustrate, the role of oxytocin and its use as an intervention is explored. The AIDRR model shifts focus away from delivering broad treatments based only on diagnostic classifications, to specifying and targeting the relevant circuits, at the right time of development, to optimize social learning.

Why are individuals with autism spectrum disorder at risk group for unhealthy weight?

Several studies have indicated that the prevalence of unhealthy body weight in individuals with autism spectrum disorder (ASD) is high. It is unclear whether factors related to the weight status of children and adolescents with ASD are the same or different from factors associated with the weight status of typically developing children (TDC). The objective of this review was to identify key factors associated with the higher rates of unhealthy weight observed in individuals with ASD and create a structural model, which could be used for future autism intervention research. This review summarizes the current state of knowledge on the genetic basis of obesity in ASD, special treatment (behavioral and medical, including diet and psychotropic medications), psychological (depression and anxiety) as well as somatic comorbid disorders such as feeding problems, sensory processing disorders, gastrointestinal problems and sleep disorders, physical activity and sedentary behaviors, loneliness and social isolation, and family functioning (maternal depression and stress).

Behavioral Artistry: Examining the Relationship Between the Interpersonal Skills and Effective Practice Repertoires of Applied Behavior Analysis Practitioners

This study investigated interpersonal skills associated with the concept of behavioral artistry (BA), a repertoire of practitioner behaviors including care, attentiveness, and creativity, among others, associated with the effective delivery of applied behavior analysis (ABA) treatment. Survey results indicated parents of children with autism preferred BA descriptors for ABA therapists over non-BA descriptors. A separate survey of 212 university students on a standardized personality assessment revealed students majoring and/or working in the field of ABA had lower levels of BA than those in other human services professions. Practitioners with higher BA scores were observed and rated more positively in their delivery of ABA for children with autism. Implications for training/supervising effective ABA practitioners within a BA model are discussed.

Pulling back the curtain: Issues in conducting an intervention study with transition-aged youth with autism spectrum disorder and their families

The transition from high school to adulthood is difficult for youth with autism spectrum disorder and their families. Recognizing these challenges, there is a small but emerging body of literature testing interventions to improve the transition process. But there are many challenges in performing intervention research that have yet to be fully addressed. We discuss issues that should be considered when conducting interventions with individuals with autism spectrum disorder to improve the transition to adulthood, drawing from our study of a parent training to facilitate access to adult services during the transition years. Issues covered include (1) timing (when is an intervention most effective?), (2) mode of delivery (what is the best way to present information?), (3) outcomes (how can intervention outcomes be accurately measured?), (4) target population (who is the intervention designed to help?), and (5) level of intervention (who should the intervention target?). Our answers, though preliminary, show the need to be flexible, to adopt a trial-and-error stance, and to listen to the needs-both explicit and implicit-of youth with autism spectrum disorder and their parents as they navigate the difficult transition from adolescence to adulthood.

Autism spectrum disorder: Review of literature and dental management

With an increase in the number of cases of autism spectrum disorder (ASD), dental professionals need to be aware of the different techniques required to ensure safe dental treatments for affected patients. The concerns and preferences of the parents and the medical and dental history of each patient should be considered. The aim of this article was to provide a comprehensive update on the medical and dental health of patients with ASD. A detailed search of the electronic database PubMed/Medline/Lilacs was performed for the terms “Autism”, “Autistic”, “Autism Spectrum Disorder”, “ASD”, “Dentistry” and “Dentist”, in the period between 2006 and 2017. Systemic reviews, research articles, and literature reviews were included. Expert opinions, case series, and case reports were excluded from the search. A detailed family-centered approach based on the preferences and concerns of parents is an important foundation for appropriate individualized dental treatment of patients with ASD. In addition, the knowledge of disruptive behaviors and patient´s challenges may guide dental practitioners in improving treatment planning, oral management, and the overall oral health of patients with ASD.

Constipation in Children with Autism Spectrum Disorder Associated with Increased Emergency Department Visits and Inpatient Admissions

OBJECTIVE

To evaluate whether constipation in children with autism spectrum disorder (ASD) is associated with increased emergency department (ED) visits and inpatient admissions compared with constipation in children without ASD.

STUDY DESIGN

The Nationwide Emergency Department Sample was used to retrospectively examine demographic data, clinical characteristics, and outcomes of children with ASD and children without ASD who visited the ED for constipation between 2006 and 2014.

RESULTS

ED visits by children with ASD were more likely to be constipation-related compared with visits by children with other chronic conditions or children with no chronic conditions (1.9% vs 0.6% vs 0.9%; P < .001). Children with ASD were more likely than children with other chronic conditions or no chronic conditions to be admitted to the hospital after an ED visit for constipation (15.0% vs 10.6% vs 1.2%; P < .001). Hospital charges were higher in children with ASD than in those without chronic conditions.

CONCLUSIONS

Constipation is responsible for a large proportion of ED visits and more inpatient admissions resulting from these ED visits. These findings suggest a need for developing more effective outpatient therapies for constipation in children with ASD.

Tablet-based interventions for individuals with ASD: Evidence of generalization and maintenance effects

BACKGROUND

Despite positive effects of and established empirical evidence for tablet-based interventions for individuals with autism spectrum disorder (ASD), it is not known whether such findings can be applicable to maintenance and generalization effects of those interventions.

AIMS

This systematic review evaluated peer-reviewed single-case experimental design (SCED) studies concerning evidence of generalization and maintenance effects of tablet-based interventions for individuals with ASD.

METHODS

To evaluate the methodological rigor of the literature in terms of generalization and maintenance effects, the authors adopted four of the basic design standards developed by What Works Clearinghouse (WWC; Kratochwill et al., 2010/2014). In addition, the authors used Tau-U effect size measure and attempted to calculate effect sizes differentiated by the type of generalization and maintenance teaching strategies.

RESULTS

A total of 21 studies assessed generalization and/or maintenance effects. In the first evaluation of evidence of generalization and maintenance effects, it was found that more than half of the studies included in this review collected interobserver agreement (IOA) on at least 20% of sessions across all generalization and maintenance conditions and met the minimum quality thresholds of IOA. Meanwhile, less than one third of the studies included more than three data points in each generalization and maintenance condition. With regard to maintenance of effects, about half of the reviewed studies did not report the latency to the maintenance measure, which may hamper the assessment of the clinical and practical significance of the effect of the tablet-based intervention. In the second evaluation, the omnibus Tau-U effect size for baseline to generalization comparisons resulted in a moderate effect. For the contrasts between intervention and generalization comparisons resulted in a small effect. The omnibus Tau-U effect size for baseline and maintenance comparisons resulted in a strong effect. For the contrasts between intervention to maintenance comparisons, the omnibus Tau-U effect size resulted in a small effect.

CONCLUSIONS AND IMPLICATION

Findings in this review suggest that efforts should be made to establish a system for appraising generalization and maintenance procedures in SCED studies. In addition, future studies should investigate if tablet-based interventions are truly effective in creating sustainable behavioral change in individuals with ASD.

An external review of the conclusions regarding the peak direct training module

Promoting the Emergence of Advanced Knowledge-Direct Training Module (PEAK-DTM) is a commercially available assessment and curriculum for individuals whose language skills are not developmentally adequate. In their review of PEAK-DTM, Reed and Luiselli (2016) analyzed the extant literature on PEAK-DTM and concluded that it has a sound and growing body of empirical support on its efficacy, usability, and psychometric properties. Similar conclusions are mirrored in the PEAK-DTM literature and promotional material. I review these conclusions and contend that many overrate the research that backs them. Suggestions for a more rigorous research agenda on PEAK-DTM and its related modules are provided.

Social Hierarchy Representation in the Primate Amygdala Reflects the Emotional Ambiguity of Our Social Interactions

Group living can help individuals defend against predators and acquire nutrition. However, conflicts between group members can arise (food sharing, mating, etc), requiring individuals to know the social status of each member to promote survival. In our recent paper, we sought to understand how the brain represents the social status of monkeys living in the same colony. Primates learn the social status of their peers through experience, including observation and direct interactions, just like they learn the rewarding or aversive nature of stimuli that predict different types of reinforcement. Group members may thereby be viewed as differing in value. We found in the amygdala, a brain area specialized for emotion, a neural representation of social hierarchy embedded in the same neuronal ensemble engaged in the assignment of motivational significance to previously neutral stimuli. Interestingly, we found 2 subpopulations of amygdala neurons encoding the social status of individuals in an opposite manner. In response to a stimulus, one population encodes similarly appetitive nonsocial images and dominant monkeys as well as aversive nonsocial stimuli and submissive monkeys. The other population encodes the opposite pattern later in time. This mechanism could reflect the emotional ambiguity we face in social situations as each interaction is potentially positive (eg, food access, protection, promotion) or negative (eg, aggression, bullying).

Shared neural coding for social hierarchy and reward value in primate amygdala

The social brain hypothesis posits that dedicated neural systems process social information. In support of this, neurophysiological data have shown that some brain regions are specialized for representing faces. It remains unknown, however, whether distinct anatomical substrates also represent more complex social variables, such as the hierarchical rank of individuals within a social group. Here we show that the primate amygdala encodes the hierarchical rank of individuals in the same neuronal ensembles that encode the rewards associated with nonsocial stimuli. By contrast, orbitofrontal and anterior cingulate cortices lack strong representations of hierarchical rank while still representing reward values. These results challenge the conventional view that dedicated neural systems process social information. Instead, information about hierarchical rank-which contributes to the assessment of the social value of individuals within a group-is linked in the amygdala to representations of rewards associated with nonsocial stimuli.

Expanding Access to Clinical Services for Toddlers with Autism Spectrum Disorders

Autism spectrum disorder (ASD) is a neurodevelopmental disorder typically diagnosed in the toddler and preschool years. Intensive early intervention (EI) using applied behavior analytic procedures is the evidenced-based intervention most effective in improving developmental outcomes. Unfortunately, there are numerous barriers to accessing EI services for toddlers with ASD. This article addresses (a) the process of developing an EI program using primarily applied behavior analytic services with multidisciplinary health care providers, (b) a description of the service delivery provided, (c) educational and training programs to increase qualified staff, and (d) advocacy efforts to improve community capacity. The EI program has sustained growth, improved child developmental outcomes, served as a training ground for EI providers, and yielded high parent satisfaction ratings. Suggestions for continued advocacy, education, research, and policy development related to the lack of access to EI for children with ASD is offered for pediatric health care providers.