Predictors and Moderators of Treatment Efficacy in Children and Adolescents with Autism Spectrum Disorder

Generalisation of Social Communication Skills by Autistic Children During Play-Based Assessments Across Home, School and an Unfamiliar Research Setting

We investigated autistic children's generalisation of social communication over time across three settings during a play-based assessment with different adults and explore the potential moderating effects on generalisation of age, nonverbal IQ and level of restricted and repetitive behaviours. The social communication abilities of 248 autistic children (2-11 years, 21% female, 22% single parent, 60% white) from three UK sites were assessed from 1984 video interactions in three contexts with three different interaction partners (parent/home, teaching assistant/school, researcher/clinic) at baseline, midpoint (+ 7m) and endpoint (+ 12m) within the Paediatric Autism Communication Trial-Generalised (PACT-G), a parent-mediated social communication intervention. Children's midpoint social communication at home generalised to school at midpoint and to clinic at endpoint. Generalisation was stronger from home to school and clinic than school to home and clinic. Generalisation was not moderated by age, nonverbal IQ or restricted and repetitive behaviour. Broader child development did not explain the pattern of results. The current study is the largest study to date to explore generalisation with autistic children and provides novel insight into their generalisation of social communication skills. Further research is needed to gain a more comprehensive understanding of facilitators of generalisation across settings and interaction partners in order to develop targeted strategies for interventions to enhance outcomes for young autistic children.

The devil is in the details: Advancing our collective understanding of naturalistic developmental behavioral interventions

Given the growing body of randomized trials examining various Naturalistic Developmental Behavioral Intervention (NDBI) approaches, a dialog has emerged exploring the overlap in strategies across NDBIs to create single measures that propose to capture core strategies across the interventions. This commentary will ask readers to consider the current state of the science, the potential value of looking not only for similarities but also for differences across approaches, and present five scientific next steps to advance our collective understanding of the NDBIs including: (a) operationalizing intervention strategies and outcomes, (b) expansion of the effectiveness evidence base and begin testing implementation strategies for individual NDBIs, (c) rigorous testing of core intervention components and the mechanism of each intervention, (d) personalization, and (e) supporting transparency with a priori trial registration.

PEERS® for Preschoolers preliminary outcomes and predictors of treatment response

PEERS® for Preschoolers (P4P) is a social skills group program for young autistic children and their caregivers, which provides everyday tools for interacting and communicating with others. Twenty-two caregiver-child dyads participated and completed pre-treatment, post-treatment, and follow-up measures (4-16 weeks after). Using single-subject analyses to examine social skills, 60% demonstrated post-treatment improvement, and 53.85% demonstrated follow-up improvement. Regarding a secondary outcome of behavioral difficulties, 33.33% demonstrated post-treatment reduction, and 7.69% demonstrated follow-up reduction. Using regressions, autistic traits predicted outcomes; fewer social communication difficulties predicted both greater social skills and fewer behavioral difficulties at post-treatment, while fewer repetitive behaviors predicted fewer post-treatment and follow-up behavioral difficulties. These results preliminarily demonstrate the benefits of P4P and how autistic traits may impact P4P outcomes.

Predictors of Treatment Response to a Community-Delivered Group Social Skills Intervention for Youth with ASD

Group social skills interventions (GSSIs) are among the most commonly used treatments for improving social competence in youth with ASD, however, results remain variable. The current study examined predictors of treatment response to an empirically-supported GSSI for youth with ASD delivered in the community (Ntotal=75). Participants completed a computer-based emotion recognition task and their parents completed measures of broad psychopathology, ASD symptomatology, and social skills. We utilized generalized estimating equations in an ANCOVA-of-change framework to account for nesting. Results indicate differential improvements in emotion recognition by sex as well as ADHD-specific improvements in adaptive functioning. Youth with both co-occurring anxiety and ADHD experienced iatrogenic effects, suggesting that SDARI may be most effective for youth with ASD without multiple co-occurring issues. Findings provide important directions for addressing variability in treatment outcomes for youth with ASD.

Animal-Assisted Interventions for Autism Spectrum Disorder: A Systematic Review of the Literature from 2016 to 2020

In the last five years, the literature on animal-assisted intervention (AAI) for Autism Spectrum Disorder (ASD) has doubled in size from 42 studies prior to 2015 to 85 studies (cumulative total assessed in 2020). Horses remain the most commonly researched animal for AAI, followed by dogs. The most commonly researched outcome was social interaction, across 21 studies. Though the quantity of studies has increased, issues with methodological rigor remain. Results highlight the need for a continued focus on methodological rigor as well as refining the structure of animal-assisted interventions, addressing the welfare needs of the animals involved, and continuing to establish an evidence base of both significant and nonsignificant findings for AAI for individuals with 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.

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.

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.

Shared familial risk factors between autism spectrum disorder and obesity - a register-based familial coaggregation cohort study

BACKGROUND

Meta-analyses suggest an association between autism spectrum disorder (ASD) and obesity, but the factors underlying this association remain unclear. This study investigated the association between ASD and obesity stratified on intellectual disability (ID). In addition, in order to gain insight into possible shared etiological factors, the potential role of shared familial liability was examined.

METHOD

We studied a cohort of 3,141,696 individuals by linking several Swedish nationwide registers. We identified 35,461 individuals with ASD and 61,784 individuals with obesity. Logistic regression models were used to estimate the association between ASD and obesity separately by ID and sex and by adjusting for parental education, psychiatric comorbidity, and psychotropic medication. Potential shared familial etiologic factors were examined by comparing the risk of obesity in full siblings, maternal and paternal half-siblings, and full- and half-cousins of individuals with ASD to the risk of obesity in relatives of individuals without ASD.

RESULTS

Individuals with ASD + ID (OR = 3.76 [95% CI, 3.38-4.19]) and ASD-ID (OR = 3.40 [95% CI, 3.23-3.58]) had an increased risk for obesity compared with individuals without ASD. The associations remained statistically significant when adjusting for parental education, psychiatric comorbidity, and medication. Sex-stratified analyses indicated a higher relative risk for males compared with females, with statistically significant interaction effects for ASD-ID, but not for ASD+ID in the fully adjusted model. First-degree relatives of individuals with ASD+ID and ASD-ID had an increased risk of obesity compared with first-degree relatives of individuals without ASD. The obesity risk was similar in second-degree relatives of individuals with ASD+ID but was lower for and ASD-ID. Full cousins of individuals with ASD+ID had a higher risk compared with half-cousins of individuals with ASD+ID). A similar difference in the obesity risk between full cousins and half-cousins was observed for ASD-ID.

CONCLUSIONS

Individuals with ASD and their relatives are at increased risk for obesity. The risk might be somewhat higher for males than females. This warrants further studies examining potential common pleiotropic genetic factors and shared family-wide environmental factors for ASD and obesity. Such research might aid in identifying specific risks and underlying mechanisms in common between ASD and obesity.

Beyond group differences: Exploring the preliminary signals of target engagement of an executive function training for autistic children

Understanding both for whom and how interventions work is a crucial next step in providing personalized care to children with autism spectrum disorder (ASD). Autistic children present with heterogeneity both within core ASD criteria and with respect to co‐occurring mental health challenges, which may affect their ability to benefit from intervention. In a secondary data analysis of a randomized control trial evaluating an executive function (EF) training with 70 7‐ to 11‐year‐old autistic children, we explored: (1) whether co‐occurring attention‐deficit/hyperactivity disorder (ADHD) features or anxiety features at baseline moderated the extent to which children benefited from the EF training. In other words, we asked, “For whom is training effective?” We also explored: (2) the extent to which changes in a brain‐based measure of target engagement predicted the clinical outcomes of the EF training. This is a step towards asking, “How is training effective?” We found that EF training improved behavioral inhibition only for children with clinically significant co‐occurring ADHD features. Anxiety features, while prevalent, did not moderate EF training efficacy. Finally, for the EF training group only, there was a significant correlation between pre‐to‐post change in an EEG‐based measure of target engagement, N2 incongruent amplitude during a flanker task, and change in repetitive behaviors, a behavioral outcome that was reported in the parent RCT to have improved with training compared to waitlist control. This study provides preliminary evidence that EF training may differentially affect subgroups of autistic children and that changes at the neural level may precede changes in behavior.

Caregiver Language Input Supports Sentence Diversity in Young Children With Autism Spectrum Disorder

PURPOSE

Sentence diversity is a measure of early language development that has yet to be applied to individuals with autism spectrum disorder (ASD). The primary aim of this study was to identify whether children with ASD show change in sentence diversity over 6 months of treatment with Naturalistic Developmental Behavioral Intervention (NDBI). The secondary aim was to examine possible predictors of changes in children's sentence diversity, including caregiver use of NDBI strategies, naturally occurring instances of caregiver Toy Talk, and child characteristics.

METHOD

Fifty children with ASD (ages 2-4 years) and their caregivers, who were receiving NDBI, engaged in two 10-min video-recorded play interactions, 6 months apart. Child speech was transcribed and coded for sentence diversity. Caregiver input was transcribed and coded for naturally occurring Toy Talk. Zero-inflated negative binomial mixed models were used to explore predictors of change in child sentence diversity.

RESULTS

Children's sentence diversity improved over time. Changes in caregiver NDBI strategy use and caregiver baseline Toy Talk were significant predictors of changes in sentence diversity, as were baseline age, nonverbal ratio IQ, and child sex. Additionally, a significant interaction of caregiver baseline Toy Talk and change in caregiver NDBI strategies emerged; the effect of caregiver baseline Toy Talk on children's sentence diversity change was stronger when NDBI strategy use improved.

CONCLUSIONS

Sentence diversity is a developmentally sensitive measure of language development in ASD. NDBI strategies that facilitate reciprocal social communication, combined with input composed of declarative sentences with noun or third-person pronoun subjects, may provide optimal support for children's sentence development.

Anxiety and Trauma-Related Disorders in Children on the Autism Spectrum

PURPOSE OF REVIEW

To summarize recent findings regarding anxiety and trauma-related disorders in children diagnosed with autism spectrum disorder (autism), focusing on the distinct ways in which these conditions may be expressed, as well as advances in evidence-based assessment and treatment.

RECENT FINDINGS

Current findings suggest both anxiety and trauma-related disorders may be more prevalent, yet more complicated to address in autistic relative to non-autistic children. Overlapping symptoms and distinct manifestations of these disorders pose challenges for the accurate identification, assessment, and treatment of anxiety and trauma-related disorders in autistic children. Emerging evidence recommends adapting traditional assessment and treatment approaches to better meet the needs of autistic children. Recent research suggests autism-centered conceptualizations, which accommodate complexity in how anxiety and trauma-related disorders are experienced and expressed by autistic people, are needed to enhance the psychiatric care of this population.

Caregiver responsiveness as a mechanism to improve social communication in toddlers: Secondary analysis of a randomized controlled trial

Early intensive behavioral interventions (EIBI) for children at elevated likelihood for a later diagnosis of autism spectrum disorder (EL-ASD), are often delivered through parent-mediated models. An area of current exploration is whether changes in caregiver behaviors are a mechanism through which to improve and track child behaviors in these interventions. Toddlers and their caregivers participated in an intervention trial (randomized controlled trial) and were randomized to either a parent-mediated intervention (adapted responsive teaching; ART) or a control condition (referral to early intervention and monitoring; REIM). Changes in toddler social communication (SC) behaviors and characteristics of caregiver responsiveness (CR) were quantified over 8 months. Analyses were conducted to assess whether changes in CR mediated the relation between group (ART vs. REIM) and changes in child SC. Results of the current study indicated that caregivers who participated in a parent-mediated intervention improved in three domains of CR (contingent verbal sensitivity, responsivity, affect). CR was also found to be a mechanism through which children's SC skills improved. This work provides evidence that qualities of CR serve as mechanisms through which to improve and monitor child behaviors over the course of EIBIs. These results may lead to novel intervention targets, methods for tracking change, and tailored treatment planning for toddlers with EL-ASD. The data used in this study comes from a clinical trial that was prospectively registered with the Registry of Efficacy and Effectiveness Studies (Registry ID: 316.1v1). LAY SUMMARY: Interventions for toddlers with high likelihood for a later diagnosis of autism often include the caregiver as an active participant in the intervention. In this study, we aimed to understand qualities of caregiver responsiveness (CR) that facilitate improvements in child behaviors during intervention. Results show that increasing verbal CR and affect are ways to improve child social skills over the course of intervention.

Predictors and moderators of outcome of psychotherapeutic interventions for mental disorders in adolescents and young adults: protocol for systematic reviews

BACKGROUND

Adolescence and young adulthood is a risk period for the emergence of mental disorders. There is strong evidence that psychotherapeutic interventions are effective for most mental disorders. However, very little is known about which of the different psychotherapeutic treatment modalities are effective for whom. This large systematic review aims to address this critical gap within the literature on non-specific predictors and moderators of the outcomes of psychotherapeutic interventions among adolescents and young adults with mental disorders.

METHODS

The protocol is being reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement. PubMed and PsycINFO databases will be searched for randomized controlled and quasi-experimental/naturalistic clinical trials. Risk of bias of all included studies will be assessed by the Mixed Methods Appraisal Tool. The quality of predictor and moderator variables will be also assessed. A narrative synthesis will be conducted for all included studies.

DISCUSSION

This systematic review will strengthen the evidence base on effective mental health interventions for young people, being the first to explore predictors and moderators of outcome of psychotherapeutic interventions for a wide range of mental disorders in young people.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020166756 .

Embracing Scientific Humility and Complexity: Learning "What Works for Whom" in Youth Psychotherapy Research

Clinical psychological scientists have spent decades attempting to understand "what works for whom" in the context of youth psychotherapy, toward the longstanding goal of personalizing psychosocial interventions to fit individual needs and characteristics. However, as the articles in this Special Issue jointly underscore, more than 50 years of psychotherapy research has yet to help us realize this goal. In this introduction to the special issue, we outline how and why "aspiration-method mismatches" have hampered progress toward identifying moderators of youth psychotherapy; emphasize the need to embrace etiological complexity and scientific humility in pursuing new methodological solutions and propose individual and structural strategies for better-aligning clinical research methods with the goal of personalizing mental health care for youth with diverse identities and treatment needs.