SMARTer Approach to Personalizing Intervention for Children With Autism Spectrum Disorder

Do Caregiver Perceptions of the Virtual More Than Words® Program Differ Based on Autistic Children's Attributes?

PURPOSE

More Than Words® (MTW) is a caregiver-mediated intervention program led by a speech-language pathologist (SLP) who teaches caregivers strategies to support their autistic child's early social communication and play development. The program includes group sessions composed of multiple families with children of varying profiles. We explored whether caregiver experiences and perceived outcomes of the virtual MTW program differed depending on the child's age and social communication stage.

METHOD

As part of a program evaluation of virtual MTW delivered to over 2,000 families in Ontario, Canada, between 2020 and 2021, we randomly selected 31 families across four social communication stages and two age groups using stratified sampling (n = 4, in all but one subgroup). The Final Reflection and Evaluation form was analyzed both qualitatively and quantitatively, and a modified RE-AIM framework guided our analyses, including theme development.

RESULTS

Child attributes did not appear to impact caregivers' experiences, but perceived child skill improvements varied by children's social communication stage. The majority of caregivers reported changes in how they interact with their child. Four themes emerged: (a) perceived child skill improvements differed by social communication stage, (b) caregivers gained new knowledge and strategies regardless of child attributes, (c) SLPs effectively managed families' individual needs, and (d) program components were appropriate for a variety of families.

CONCLUSIONS

Findings suggest that the content taught in the MTW program was relevant for a variety of children, including those beyond the program's intended age of 5 years and under. Grouping families of children with varying profiles does not appear to negatively influence caregivers' experiences or perceived outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25237009.

Persistence of Autism Spectrum Disorder From Early Childhood Through School Age

Importance

While the prevalence of autism spectrum disorder (ASD) continues to increase and early diagnosis is emphasized, there is limited information on outcomes for children diagnosed with ASD in early childhood using contemporary diagnostic criteria.

Objectives

To determine the frequency with which children who are clinically diagnosed with ASD at 12 to 36 months of age continue to meet diagnostic criteria for ASD at 5 to 7 years of age and to evaluate whether baseline child-specific and demographic characteristics and receipt of interventions are associated with ASD persistence.

Design, Setting, and Participants

In this natural history cohort study, children who received a clinical ASD diagnosis at 12 to 36 months of age underwent a research diagnostic assessment at 5 to 7 years of age. Research assessments occurred from August 14, 2018, to January 8, 2022.

Intervention

Children received community-based interventions, and parents provided details about interventions received.

Main Outcomes and Measures

The main outcome was persistence of ASD diagnosis based on current functioning. An experienced research psychologist assigned an ASD diagnosis (present or absent) according to criteria from the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) after the research assessment. The research assessment included administration of the Autism Diagnostic Observation Schedule-2, Autism Diagnostic Interview-Research, and a cognitive measure.

Results

Of the 213 participants diagnosed with ASD at initial clinical assessment (mean [SD] age, 24.6 [3.9] months; 177 boys [83.1%]), 79 (37.1%) did not continue to meet diagnostic criteria for ASD (nonpersistent ASD) at research assessment (mean [SD] age, 74.3 [7.1] months). All children with nonpersistent ASD had IQ of at least 70, while there was a bimodal distribution of IQ for those with persistent ASD (46 with IQ <70 and 88 with IQ ≥70). All children received some interventions, and 201 (94.4%) received ASD-specific intervention, mostly applied behavioral analysis. In a multilevel logistic regression model, the only variables associated with increased odds of being in the nonpersistent ASD group at 6 years of age were higher baseline adaptive skills (b coefficient = -0.287 [SE, 0.108]) and female sex (b = 0.239 [SE, 0.064]).

Conclusions and Relevance

The findings of this cohort study suggest that among toddlers diagnosed with ASD, baseline adaptive function and sex may be associated with persistence of ASD.

Child-therapist interaction features impact Autism treatment response trajectories

BACKGROUND

Identifying mechanisms of change in Autism treatment may help explain response variability and maximize efficacy. For this, the child-therapist interaction could have a key role as stressed by developmental models of intervention, but still remains under-investigated.

AIMS

The longitudinal study of treatment response trajectories considering both baseline and child-therapist interaction features by means of predictive modeling.

METHODS AND PROCEDURES

N = 25 preschool children were monitored for one year during Naturalistic Developmental Behavioral Intervention. N = 100 video-recorded sessions were annotated with an observational coding system at four time points, to extract quantitative interaction features.

OUTCOMES AND RESULTS

Baseline and interaction variables were combined to predict response trajectories at one year, and achieved the best predictive performance. The baseline developmental gap, therapist's efficacy in child engagement, respecting children's timing after fast behavioral synchronization, and modulating the interplay to prevent child withdrawal emerged as key factors. Further, changes in interaction patterns in the early phase of the intervention were predictive of the overall response to treatment.

CONCLUSIONS AND IMPLICATIONS

Clinical implications are discussed, stressing the importance of promoting emotional self-regulation during intervention and the possible relevance of the first period of intervention for later response.

Neurodiversity and Autism Intervention: Reconciling Perspectives Through a Naturalistic Developmental Behavioral Intervention Framework

Proponents of autism intervention and those of the neurodiversity movement often appear at odds, the former advocating for intensive treatments and the latter arguing that autism must be accepted as a form of diversity. The history of behavioral intervention has understandably outraged many in the Autistic community, though many still value supports focused on quality of life. This commentary argues that Naturalistic Developmental Behavioral Interventions (NDBIs) hold promise for bridging the gap between early intervention and the neurodiversity movement. However, we recognize NDBIs have much room to grow and suggest multiple strategies for improvement. We believe these updates are not only feasible for clinicians and researchers to implement but will ultimately lead to improved quality of life for Autistic individuals.

Examining Predictors of Different ABA Treatments: A Systematic Review

In the recent literature, there is a broad consensus on the effectiveness of Applied Behavior Analysis interventions for autism spectrum disorder (ASD). Despite their proven efficacy, research in clinical settings shows that these treatments are not equally effective for all children and the issue of which intervention should be chosen for an individual remains a common dilemma. The current work systematically reviewed studies on predictors and moderators of response to different types of evidence-based treatment for children with ASD. Specifically, our goal was to critically review the relationships between pre-treatment child characteristics and specific treatment outcomes, covering different aspects of functioning (i.e., social, communicative, adaptive, cognitive, motor, global functioning, play, and symptom severity). Our results questioned the binomial “better functioning-better outcome”, emphasizing the complex interplay between pre-treatment child characteristics and treatment outcomes. However, some pre-treatment variables seem to act as prerequisites for a specific treatment, and the issue of “what works for whom and why” remains challenging. Future research should focus on the definition of evidence-based decision-making models that capture those individual factors through which a specific intervention will exert its effects.

Toward Personalized Affect-Aware Socially Assistive Robot Tutors for Long-Term Interventions with Children with Autism

Affect-aware socially assistive robotics (SAR) has shown great potential for augmenting interventions for children with autism spectrum disorders (ASD). However, current SAR cannot yet perceive the unique and diverse set of atypical cognitive-affective behaviors from children with ASD in an automatic and personalized fashion in long-term (multi-session) real-world interactions. To bridge this gap, this work designed and validated personalized models of arousal and valence for children with ASD using a multi-session in-home dataset of SAR interventions. By training machine learning (ML) algorithms with supervised domain adaptation (s-DA), the personalized models were able to trade off between the limited individual data and the more abundant less personal data pooled from other study participants. We evaluated the effects of personalization on a long-term multimodal dataset consisting of 4 children with ASD with a total of 19 sessions, and derived inter-rater reliability (IR) scores for binary arousal (IR = 83%) and valence (IR = 81%) labels between human annotators. Our results show that personalized Gradient Boosted Decision Trees (XGBoost) models with s-DA outperformed two non-personalized individualized and generic model baselines not only on the weighted average of all sessions, but also statistically ( p <.05) across individual sessions. This work paves the way for the development of personalized autonomous SAR systems tailored toward individuals with atypical cognitive-affective and socio-emotional needs.

A method for defining the CORE of a psychosocial intervention to guide adaptation in practice: Reciprocal imitation teaching as a case example

LAY ABSTRACT

Interventions that support social communication include several "components," or parts (e.g. strategies for working with children and families, targeting specific skills). Some of these components may be essential for the intervention to work, while others may be recommended or viewed as helpful but not necessary for the intervention to work. "Recommended" components are often described as "adaptable" because they can be changed to improve fit in different settings where interventions are offered or with different individuals. We need to understand which parts of an intervention are essential (and which are adaptable) when translating interventions from research to community settings, but it is challenging to do this before studying an intervention in the community. This article presents the CORE (COmponents & Rationales for Effectiveness) Fidelity Method-a new method for defining the essential components of evidence-based interventions-and applies it to a case example of Reciprocal Imitation Teaching, an intervention that parents are taught to deliver with their young children with social communication delays. The CORE Fidelity Method involves three steps: (1) gathering information from multiple sources; (2) integrating information from previous research and theory; and (3) drafting a CORE model for ongoing use. The benefits of using the CORE Fidelity Method may include: (1) improving consistency in intervention and research materials to help all providers emphasize the most important skills or strategies; (2) clarifying which parts of the intervention can be adapted; and (3) supporting future research that evaluates which intervention components work and how they work.

Rethinking Autism Intervention Science: A Dynamic Perspective

Recent advances in longitudinal methodologies for observational studies have contributed to a better understanding of Autism as a neurodevelopmental condition characterized by within-person and between-person variability over time across behavioral domains. However, this finer-grained approach to the study of developmental variability has yet to be applied to Autism intervention science. The widely adopted experimental designs in the field-randomized control trials and quasi-experimental designs-hold value for inferring treatment effects; at the same time, they are limited in elucidating what works for whom, why, and when, given the idiosyncrasies of neurodevelopmental disorders where predictors and outcomes are often dynamic in nature. This perspective paper aims to serve as a primer for Autism intervention scientists to rethink the way we approach predictors of treatment response and treatment-related change using a dynamic lens. We discuss several empirical gaps, and potential methodological challenges and opportunities pertaining to: (1) capturing finer-grained treatment effects in specific behavioral domains as indexed by micro-level within-person changes during and beyond intervention; and (2) examining and modeling dynamic prediction of treatment response. Addressing these issues can contribute to enhanced study designs and methodologies that generate evidence to inform the development of more personalized interventions and stepped care approaches for individuals on the heterogeneous spectrum of Autism with changing needs across development.

Editorial: Individualizing Interventions for Young Children With Autism: Embracing the Next Generation of Intervention Research

If you have known one child with autism, you have known one child with autism. Clinical heterogeneity is a defining feature of autism spectrum disorder (ASD). This includes heterogeneity of implicated genes, etiological pathways, neurocognitive mechanisms, behavioral characteristics, comorbid conditions, and developmental trajectories. It is not surprising that children with ASD also vary greatly in their response to interventions. A better understanding of which children benefit from which intervention is critical to ensure that each child has access to the most effective intervention, delivered at optimal intensity and implemented within a context that is most conducive to learning/generalization (eg, home, preschool). Evidence-based strategies to individualize intervention programs can guide parents and clinicians as they consider different intervention options throughout development.¹ The study that is the focus of this editorial expands the available literature in 2 important ways. First, the authors evaluate predictors of treatment response across multiple intervention approaches. Second, their results highlight the conceptual and practical distinction between child characteristics that predict outcome and child characteristics that predict treatment response.

Effectiveness of a technology-assisted, family volunteers delivered, brief, multicomponent parents' skills training intervention for children with developmental disorders in rural Pakistan: a cluster randomized controlled trial

Background

Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization’s mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents’ skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan.

Methods

In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2–12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child’s functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents’ health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters.

Results

At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), − 2.63; 95% CI − 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes.

Conclusions

In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers’ health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention.

Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894

Stability of Vocal Variables Measured During the Early Communication Indicator for Children With Autism Spectrum Disorder

The Early Communication Indicator (ECI) was designed to measure expressive communication progress in young children. We evaluated using the 6-min ECI procedure for a new purpose-a sampling context for stable measures of vocal development of young children with autism spectrum disorder (ASD). We evaluated how many ECI sessions were required to adequately stabilize estimates of volubility, communicative use, and phonological complexity of vocalizations at two periods (average of 10 months apart). Participants included 83 young children with ASD (M age = 23.33 months). At study initiation, two phonological complexity variables required two sessions; other variables required three. At study endpoint, all variables required fewer sessions. Findings support the feasibility and stability of using the ECI for the new purpose.

Social Interaction Skill Intervention for Autistic Adults with Intellectual Disability and Limited Language: A Pilot of the SKILL Program

There is a dearth of research that focuses on social intervention efforts for adults on the autism spectrum with intellectual disability and limited conversational language. Using a multiple baseline experimental design, this pilot investigation of the Socialization Knowledge for Individuals with Limited Language (SKILL) program evaluated a novel peer-facilitated group program specifically designed to target social interaction skills for this population. Findings from five pilot participants yielded evidence of social improvements across specific verbal skills (on-topic conversational contributions and responses) and nonverbal behaviors (eye-contact, active listening), as evidenced by coded social conversation probes and parent-report measures. These findings demonstrate the promise of a socialization intervention for a population that has historically been neglected in the social intervention research literature.

Integrating the Early Start Denver Model into Israeli community autism spectrum disorder preschools: Effectiveness and treatment response predictors

Early intensive intervention has been shown to significantly affect the development of children with autism spectrum disorder. However, the costly implementation of such interventions limits their wide dissemination in the community. This study examined an integration of the Early Start Denver Model into community preschool programs for children with autism spectrum disorder in Israel. Four community preschools implemented the preschool-based Early Start Denver Model and four implemented a multidisciplinary developmental intervention which is widely applied in Israeli community autism spectrum disorder preschools. Fifty-one children (aged 33–57 months) participated in the study. Twenty-six attended the preschool-based Early Start Denver Model preschools and twenty-five attended the multidisciplinary developmental intervention settings. Groups were comparable on age, developmental functioning, and socio-economic status. Compared to the multidisciplinary developmental intervention group, children in the preschool-based Early Start Denver Model treatment made greater gains on blinded measures of overall cognitive development, receptive and expressive language skills, as well as on parent- and teacher-reported adaptive communication and socialization abilities. In the preschool-based Early Start Denver Model group, children with lower symptom severity, higher adaptive functioning, and receptive language abilities at pre-treatment showed greater improvement. This study documents the successful integration of an Early Start Denver Model intervention into pre-existing community preschools, underlining the importance of disseminating evidence-based early intervention in community settings.

Comparing the 1-year impact of preschool autism intervention programs in two Canadian provinces

Autism spectrum disorder (ASD) is associated with early differences in children's social interactions, communication, and play/interests. In many countries, considerable resources are invested in early intensive behavioral intervention (EIBI) programs for children with ASD, which aim to build adaptive skills and prevent or treat problem behavior. However, these programs vary widely in structure and delivery. Research evidence supports the efficacy of EIBI, but large knowledge gaps remain about the effectiveness of publicly funded EIBI programs. With policy-makers as formal research partners, we compared children's progress over 1 year in public preschool programs in adjacent Canadian provinces, New Brunswick (NB) and Nova Scotia (NS). In NB, children received up to 20 hr/week of comprehensive EIBI in a publicly funded, privately provided program. In NS, children received up to 15 hr/week of Pivotal Response Treatment and Positive Behavior Support delivered through the publicly funded healthcare system. In this observational parallel cohort study, we collected parent-reported data on 298 NB preschoolers (76.5% boys) and 221 NS preschoolers (86.9% boys) at EIBI start and 1 year later. Multilevel analysis revealed significant differences at baseline: NS children were older, with lower adaptive functioning and more severe ASD symptoms than NB children. Despite these pre-treatment differences that favor NB, children in both provinces showed similar adaptive functioning gains and reductions of maladaptive behavior. No changes were seen in mean ASD symptom severity in either province over time. Results highlight the value of evaluating interventions in their implementation contexts, and have important implications for devising optimal ASD policy. Autism Research 2019, 12: 667-681. © 2019 International Society for Autism Research,Wiley Periodicals, Inc. LAY SUMMARY: We need to know more about the impact of different forms of early intensive behavioral intervention (EIBI) for young children with autism spectrum disorder (ASD). We showed that preschoolers with ASD gained important skills while in public EIBI programs in two Canadian provinces. We also saw that differences in how EIBI programs are structured and characteristics of children who are served may affect outcomes. For these reasons, policy making requires evidence that fits the local context.

Introduction to the Research Symposium Forum

The purpose of this introduction is to provide an overview of the articles contained within this research forum of JSLHR. Each of these articles is based upon presentations from the 2017 ASHA Research Symposium.