Early intervention in autism: Joint attention and symbolic play

A comparative study of cognitive and socio-emotional development in children with Rubinstein-Taybi syndrome and children with Autism Spectrum Disorder associated with a severe intellectual disability, and in young typically developing children with matched developmental ages

BACKGROUND

Cognitive and socio-emotional profiles of children with CREBBP-related Rubinstein-Taybi syndrome (RSTS 1), children with Autism Spectrum Disorder (ASD) with severe intellectual disability and developmental ages (DA) under 24 months, and typically developing (TD) children with similar DA were compared.

PARTICIPANTS

Thirty-one children with RSTS 1 (mean chronological age, CA = 59,8 months; 33-87) and thirty children with ASD, matched on CA and DA and developmental quotients (DQ), were compared to thirty TD children (CA ranged from 12 to 24 months).

METHODS

Cognitive and socio-emotional developmental levels, DA and DQ were assessed with appropriated tests.

RESULTS

More socio-emotional developmental similarities were observed between TD and RSTS 1 than between TD and ASD children. Clinical groups displayed similar developmental delays in cognitive (self-image, symbolic play, means-ends, and object permanence) and socio-emotional domains (language and imitation). Children with RSTS 1 exhibited higher developmental levels in behavior regulation, joint attention, affective relations, emotional expression domains, and a lower developmental level in spatial relations domain.

CONCLUSIONS

Common interventions centered on symbolic play, self-image, language, and imitation for both clinical groups, and differentiated interventions centered on spatial abilities for RSTS 1 children and on social abilities for ASD could be used by caregivers were suggested.

Early Intervention with Parents of Children with Autism Spectrum Disorders: A Review of Programs

The aim of this article was to analyze the evidence regarding the effectiveness of intervention programs for children with autism based on the participation of their parents. To obtain the data, a systematic search was carried out in four databases (PsycARTICLES (ProQuest), ERIC (ProQuest), PubMed (ProQuest), and Scopus). The retrieved documents were refined under the inclusion/exclusion criteria, and a total of 51 empirical studies were selected. These studies were first classified according to the function of the intervention objective and, later, by the methodology applied (19 studies were based on comprehensive interventions, 11 focused on the nuclear symptoms of autism spectrum disorder (ASD), 12 focused on the promotion of positive parenting, and nine interactions focused on child play). Once all of the documents had been analyzed, the evidence indicated scientific efficacy in most studies, mainly in those based on child development and the application of behavioral analysis principles. Moreover, the positive influence of parent participation in such programs was demonstrated.

Predictors of Expressive Language Change for Children with Autism Spectrum Disorder Receiving AAC-Infused Comprehensive Intervention

Comprehensive interventions for children with autism spectrum disorder (ASD) often incorporate augmentative and alternative communication (AAC); however, variability in outcomes exists even among children who access similar intervention. This study investigated predictors of expressive language change for 48 children with ASD aged 31 to 67 months receiving AAC-infused intervention. The relationships between participants' initial responses to AAC and expressive language change were examined. Commonly reported predictors (IQ, chronological age, ASD symptomatology) did not significantly predict expressive language change. AAC factors (visual attention, object play, word learning) entered at Step 2 of a hierarchical multiple regression, explained an additional 42% of the variance. The findings provide preliminary data on child characteristics associated with expressive language changes within AAC-infused comprehensive interventions.

Joint attention, language, social relating, and stereotypical behaviours in children with autistic disorder

This study aimed to investigate the relationships between abilities to initiate and respond to joint attention and symptoms of autism that have, and have not, been theoretically linked to joint attention. Participants were 51 boys and five girls with autistic disorder, aged between 2 years and 6 years 5 months. Measures of joint attention behaviours, language, social relating, and stereotypical behaviour were administered during a single assessment. As predicted, the correlations between joint attention and the two behaviours theoretically linked to joint attention (i.e. social relating and language) were significantly stronger than those between joint attention and the behaviour not theoretically linked (i.e. stereotypical behaviour). While causation cannot be inferred from this study, these results support the suggestion that difficulties with joint attention behaviours commonly found among children with autism are linked to language and social relating, beyond what might be expected simply due to their co-occurrence as symptoms.

Knowledge, attitudes, and perceptions of autism spectrum disorder in a stratified sampling of preschool teachers in China

BACKGROUND

In China, children with Autism Spectrum Disorder (ASD) can potentially benefit from universal education policies and recent initiatives designed to address the needs of children with developmental disorders. However, adequate schooling is often unavailable for children with ASD, in part because teachers lack the knowledge and skills needed to work with this population. To better understand the current state of knowledge of ASD in China, we surveyed knowledge and attitudes regarding the disorder in preschool teachers.

METHODS

A total of 471 preschool teachers in the cities of Guangzhou and Foshan, China completed questionnaires assessing participant demographics, knowledge of typical child development and knowledge of ASD, attitudes towards ASD, practices and self-perceptions of efficacy in the education of children with ASD, and awareness of organizations and intervention approaches devoted to the care of individuals with ASD. The correlation between individual- and school-level variables with current knowledge of typical child development and ASD was examined using univariate and multivariate analyses.

RESULTS

The majority (84%) of participants answered correctly more than half of the questionnaire items assessing understanding of typical child development. In contrast, 83% provided inaccurate responses to more than half of the questionnaire items assessing knowledge of ASD. Knowledge of typical child development and knowledge of ASD were both associated with geographic region (teachers in Guangzhou had greater knowledge than those in Foshan, p < 0.0001). Knowledge of ASD was also associated with a higher education level (p < 0.05) and school type (p = 0.023). In general, participants believed fairly strongly in the need for greater service provision for children with ASD, and were receptive towards receiving additional specialized training. Most participants were unaware of ASD-specific organizations and empirically validated intervention approaches.

CONCLUSIONS

Knowledge of ASD is lacking in preschool teachers in China, and greater teacher training and instruction is needed. Nonetheless, teachers report a willingness and motivation to gain the skills needed to maximize the educational experiences of children with ASD.

Predicting language outcomes for children learning augmentative and alternative communication: child and environmental factors

PURPOSE

To investigate a model of language development for nonverbal preschool-age children learning to communicate with augmentative or alternative communication.

METHOD

Ninety-three preschool children with intellectual disabilities were assessed at Time 1, and 82 of these children were assessed 1 year later, at Time 2. The outcome variable was the number of different words the children produced (with speech, sign, or speech-generating devices). Children's intrinsic predictor for language was modeled as a latent variable consisting of cognitive development, comprehension, play, and nonverbal communication complexity. Adult input at school and home, and amount of augmentative or alternative communication instruction, were proposed mediators of vocabulary acquisition.

RESULTS

A confirmatory factor analysis revealed that measures converged as a coherent construct, and a structural equation model indicated that the intrinsic child predictor construct predicted different words children produced. The amount of input received at home, but not at school, was a significant mediator.

CONCLUSIONS

The hypothesized model accurately reflects a latent construct of Intrinsic Symbolic Factor (ISF). Children who evidenced higher initial levels of ISF and more adult input at home produced more words 1 year later. The findings support the need to assess multiple child variables and suggest interventions directed to the indicators of ISF and input.

Symbolic play of preschoolers with severe communication impairments with autism and other developmental delays: more similarities than differences

Children with autism are often described as having deficient play skills, particularly symbolic play. We compared the play of 35 children with autism to 38 children with other developmental delays. All children were preschool-age and produced less than 20 different words. Results indicated no significant differences across the two groups in their play. Children with autism engaged in more conventional play, that is, putting objects together according to how the toys were constructed (e.g., pieces in a puzzle, lid on a teapot). Results also indicated high correlations between play, language, and cognitive measures. Findings indicate that play relates to language and cognitive levels yet may not discriminate children with autism and children with other developmental delays early in their development.

Modelling the coevolution of joint attention and language

Joint attention (JA) is important to many social, communicative activities, including language, and humans exhibit a considerably high level of JA compared with non-human primates. We propose a coevolutionary hypothesis to explain this degree-difference in JA: once JA started to aid linguistic comprehension, along with language evolution, communicative success (CS) during cultural transmission could enhance the levels of JA among language users. We illustrate this hypothesis via a multi-agent computational model, where JA boils down to a genetically transmitted ability to obtain non-linguistic cues aiding comprehension. The simulation results and statistical analysis show that: (i) the level of JA is correlated with the understandability of the emergent language; and (ii) CS can boost an initially low level of JA and 'ratchet' it up to a stable high level. This coevolutionary perspective helps explain the degree-difference in many language-related competences between humans and non-human primates, and reflects the importance of biological evolution, individual learning and cultural transmission to language evolution.

Toward a behavioral analysis of joint attention

Joint attention (JA) initiation is defined in cognitive-developmental psychology as a child's actions that verify or produce simultaneous attending by that child and an adult to some object or event in the environment so that both may experience the object or event together. This paper presents a contingency analysis of gaze shift in JA initiation. The analysis describes reinforcer-establishing and evocative effects of antecedent objects or events, discriminative and conditioned reinforcing functions of stimuli generated by adult behavior, and socially mediated reinforcers that may maintain JA behavior. A functional analysis of JA may describe multiple operant classes. The paper concludes with a discussion of JA deficits in children with autism spectrum disorders and suggestions for research and treatment.

Play and developmental outcomes in infant siblings of children with autism

We observed infant siblings of children with autism later diagnosed with ASD (ASD siblings; n = 17), infant siblings of children with autism with and without other delays (Other Delays and No Delays siblings; n = 12 and n = 19, respectively) and typically developing controls (TD controls; n = 19) during a free-play task at 18 months of age. Functional, symbolic, and repeated play actions were coded. ASD siblings showed fewer functional and more non-functional repeated play behaviors than TD controls. Other Delays and No Delays siblings showed more non-functional repeated play than TD controls. Group differences disappeared with the inclusion of verbal mental age. Play as an early indicator of autism and its relationship to the broader autism phenotype is discussed.

Evidence-based comprehensive treatments for early autism

Early intervention for children with autism is currently a politically and scientifically complex topic. Randomized controlled trials have demonstrated positive effects in both short-term and longer term studies. The evidence suggests that early intervention programs are indeed beneficial for children with autism, often improving developmental functioning and decreasing maladaptive behaviors and symptom severity at the level of group analysis. Whether such changes lead to significant improvements in terms of greater independence and vocational and social functioning in adulthood is also unknown. Given the few randomized controlled treatment trials that have been carried out, the few models that have been tested, and the large differences in interventions that are being published, it is clear that the field is still very early in the process of determining (a) what kinds of interventions are most efficacious in early autism, (b) what variables moderate and mediate treatment gains and improved outcomes following intervention, and (c) the degree of both short-term and long-term improvements that can reasonably be expected. To examine these current research needs, the empirical studies of comprehensive treatments for young children with autism published since 1998 were reviewed. Lovaas's treatment meet Chambless and colleague's (Chambless et al., 1998; Chambless et al., 1996) criteria for "well-established" and no treatment meets the "probably efficacious" criteria, though three treatments meet criteria for "possibly efficacious" (Chambless & Hollon, 1998). Most studies were either Type 2 or 3 in terms of their methodological rigor based on Nathan and Gorman's (2002) criteria. Implications of these findings are also discussed in relation to practice guidelines as well as critical areas of research that have yet to be answered.

Pilot study of a parent training program for young children with autism: the PLAY Project Home Consultation program

The PLAY Project Home Consultation (PPHC) program trains parents of children with autistic spectrum disorders using the DIR/Floortime model of Stanley Greenspan MD. Sixty-eight children completed the 8-12 month program. Parents were encouraged to deliver 15 hours per week of 1:1 interaction. Pre/post ratings of videotapes by blind raters using the Functional Emotional Assessment Scale (FEAS) showed significant increases (p <or= 0.0001) in child subscale scores. Translated clinically, 45.5 percent of children made good to very good functional developmental progress. There were no significant differences between parents in the FEAS subscale scores at either pre-or post-intervention and all parents scored at levels suggesting they would be effective in working with their children. Overall satisfaction with PPHC was 90 percent. Average cost of intervention was $2500/ year. Despite important limitations, this pilot study of The PLAY Project Home Consulting model suggests that the model has potential to be a cost-effective intervention for young children with autism.

Promoting joint attention in toddlers with autism: a parent-mediated developmental model

Joint attention, a foundational nonverbal social-communicative milestone that fails to develop naturally in autism, was promoted for three toddlers with early-identified autism through a parent-mediated, developmentally grounded, researcher-guided intervention model. A multiple baseline design compared child performance across four phases of intervention: focusing on faces, turn-taking, responding to joint attention, and initiating joint attention. All toddlers improved performance and two showed repeated engagement in joint attention, supporting the effectiveness of developmentally appropriate methods that build on the parent-child relationship. A complementary qualitative analysis explored family challenges, parent resilience, and variables that may have influenced outcomes. Intervention models appropriate for toddlers with autism are needed as improved early identification efforts bring younger children into early intervention services.

Joint attention and symbolic play in young children with autism: a randomized controlled intervention study

BACKGROUND

Delays and deficits in joint attention and symbolic play constitute two important developmental problems in young children with autism. These areas of deficit have been well studied in autism but have rarely been the focus of treatment efforts (see Kasari, Freeman, & Paparella, 2001). In this study, we examine the efficacy of targeted interventions of joint attention and symbolic play.

METHODS

Participants were 58 children with autism aged 3 and 4 years (46 boys). Children were randomized to a joint attention intervention, a symbolic play intervention, or control group. Interventions were conducted 30 minutes daily for 5-6 weeks. Both structured assessments of joint attention and play skills and mother-child interactions were collected pre and post intervention by independent assessors.

RESULTS

Results indicate that both intervention groups improved significantly over the control group on certain behaviors. Children in the joint attention intervention initiated significantly more showing and responsiveness to joint attention on the structured joint attention assessment and more child-initiated joint attention in the mother-child interaction. The children in the play group showed more diverse types of symbolic play in interaction with their mothers and higher play levels on both the play assessment and in interaction with their mothers.

CONCLUSIONS

This randomized controlled trial provides promising data on the specificity and generalizability of joint attention and play interventions for young children with autism. Future studies need to examine the long-term effects of these early interventions on children's development.

Examination of the time between first evaluation and first autism spectrum diagnosis in a population-based sample

Early identification of young children with an autism spectrum disorder (ASD) can lead to earlier entry into intervention programs that support improved developmental outcomes. The purpose of the present study was to examine identification and diagnostic patterns of children with ASD who live in a large metropolitan area. One hundred fifteen 8-year-old children diagnosed with ASD were identified from a population-based surveillance system at the Centers for Disease Control and Prevention. Primary variables of interest included earliest age of evaluation and earliest age of diagnosis identified from surveillance records, type of initial ASD diagnosis, evaluation sources that documented first ASD diagnosis, characteristics of professionals assigning first ASD diagnosis, and diagnostic tools used to aid the diagnostic process. We found that children with ASD identified by the surveillance system were initially evaluated at a mean of 48 months but were not diagnosed with ASD until a mean age of 61 months. There were no differences in timing of diagnosis based on sex or racial/ethnic classification, although degree of impairment associated with ASD predicted mean age at first evaluation and mean age at first ASD diagnosis. Most children were identified at non-school sources, such as hospitals and clinics; 24% of the sample did not receive a documented ASD diagnosis until entering school. Most practitioners (70%) did not use a diagnostic instrument when assigning the first ASD diagnosis. Implications for early identification of ASD are discussed.

Developmental deficits in social perception in autism: the role of the amygdala and fusiform face area

Autism is a severe developmental disorder marked by a triad of deficits, including impairments in reciprocal social interaction, delays in early language and communication, and the presence of restrictive, repetitive and stereotyped behaviors. In this review, it is argued that the search for the neurobiological bases of the autism spectrum disorders should focus on the social deficits, as they alone are specific to autism and they are likely to be most informative with respect to modeling the pathophysiology of the disorder. Many recent studies have documented the difficulties persons with an autism spectrum disorder have accurately perceiving facial identity and facial expressions. This behavioral literature on face perception abnormalities in autism is reviewed and integrated with the functional magnetic resonance imaging (fMRI) literature in this area, and a heuristic model of the pathophysiology of autism is presented. This model posits an early developmental failure in autism involving the amygdala, with a cascading influence on the development of cortical areas that mediate social perception in the visual domain, specifically the fusiform "face area" of the ventral temporal lobe. Moreover, there are now some provocative data to suggest that visual perceptual areas of the ventral temporal pathway are also involved in important ways in representations of the semantic attributes of people, social knowledge and social cognition. Social perception and social cognition are postulated as normally linked during development such that growth in social perceptual skills during childhood provides important scaffolding for social skill development. It is argued that the development of face perception and social cognitive skills are supported by the amygdala-fusiform system, and that deficits in this network are instrumental in causing autism.

Autism and pervasive developmental disorders

The quantity and quality of research into autism and related conditions have increased dramatically in recent years. Consequently we selectively review key accomplishments and highlight directions for future research. More consistent approaches to diagnosis and more rigorous assessment methods have significantly advanced research, although the boundaries of the 'broader phenotype' remain to be defined and the validity of Asperger's disorder as a discrete syndrome remains controversial. Recent epidemiological studies have shown that Autism Spectrum Disorders are common, but there continues to be debate about the causes of the increase in the frequency with which autism is diagnosed. Psychological research has helped to develop new developmental models for the disorder and there have also been significant advances in the molecular genetics of autism and understanding of the underlying neurobiological processes. Areas important for future research include the study of autism as it first develops, i.e., in infants and very young children, and of specific processes (psychological and neurobiological) which underlie the disorder. Significant challenges lie ahead in evaluating the growing number of treatments for autism and in integrating the results of research into treatment and educational settings.

Why is joint attention a pivotal skill in autism?

Joint attention abilities play a crucial role in the development of autism. Impairments in joint attention are among the earliest signs of the disorder and joint attention skills relate to outcome, both in the 'natural course' of autism and through being targeted in early intervention programmes. In the current study, concurrent and longitudinal associations between joint attention and other social communication abilities measured in a sample of infants with autism and related pervasive developmental disorders at age 20 months, and language and symptom severity at age 42 months, were examined. Extending the findings from previous studies, joint attention ability was positively associated with language gains and (lower) social and communication symptoms, and imitation ability was also positively associated with later language. Some specificity in the association between different aspects of joint attention behaviours and outcome was found: declarative, triadic gaze switching predicted language and symptom severity but imperative, dyadic eye contact behaviours did not. Further, although joint attention was associated with later social and language symptoms it was unrelated to repetitive and stereotyped symptoms, suggesting the latter may have a separate developmental trajectory. Possible deficits in psychological and neurological processes that might underlie the impaired development of joint attention in autism are discussed.