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

Delivering Enhanced Milieu Teaching to Toddlers With Down Syndrome via Hybrid Telepractice: A Single-Case Experimental Design

PURPOSE

This pilot study investigated delivering enhanced milieu teaching tailored for children with Down Syndrome (EMT-DS) through hybrid telepractice.

METHOD

In this multiple-baseline design across behaviors study, a speech-language pathologist (SLP) taught EMT-DS to three caregivers and their children with DS (22-40 months) using a hybrid service delivery model. Sessions were conducted in person and via telepractice. The SLP taught caregivers EMT-DS, emphasizing the use of (a) four target EMT strategies: matched turns, expansions, time delays, and milieu teaching episodes; (b) augmentative and alternative communication (AAC; manual signs, speech-generating device); and (c) aided AAC modeling. The SLP provided caregiver instruction following the teach-model-coach-review approach. Caregiver outcomes were the accuracy (primary) and frequency (secondary) of EMT strategy use. Child outcomes were exploratory and included the rate of symbolic communication acts, weighted number of communication acts, and number of different words (NDW).

RESULTS

There was a functional relation between the intervention and the accuracy and frequency of EMT strategy use for all three caregivers. All caregivers showed an increase in the accuracy for all four target strategies. Caregivers also increased the frequency of the three EMT strategies: expansions, time delays, and milieu teaching episodes. There were no changes in the frequency of matched turns. Caregiver use of EMT strategies maintained for 6 weeks post-intervention. After caregivers learned EMT strategies, gradual increases in the rate of symbolic communication acts and NDW occurred for all three children.

CONCLUSION

Results demonstrate the preliminary efficacy of using a hybrid service delivery model to teach caregivers EMT-DS.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27115252.

Research on pragmatic impairment in autistic children during the past two decades (2001-2022): hot spots and frontiers-based on CiteSpace bibliometric analysis

Pragmatic impairment has become a critical aspect of language development in autistic children and has gained significant academic attention over the past two decades. This study leverages bibliometric methods to conduct an exhaustive analysis of literature derived from Web of Science database. Utilizing CiteSpace software, we construct a knowledge map to dissect the academic hotspots in research related to pragmatic impairment in autistic children. This enables us to delineate the evolutionary trajectory of this research domain, analyze the prevailing research dimensions, and anticipate potential future dimensions. Our findings indicate that research hotspots in this field over the past two decades predominantly concentrate on assessing and diagnosing pragmatic impairment in autistic children, intervention strategies, and theory of mind. The research scope on pragmatic impairment in autistic children has progressively broadened and deepened. Research has evolved from initial descriptions and interpretations of autism to exploring the theory of mind in high-functioning, school-aged children. The current emphasis is on examining the specific skills that these children possess.

Joint Engagement in Mother-Child Dyads of Autistic and Non-Autistic Children Among Asian Indian Tamil Speaking Families

This study profiled various levels of engagement and related communication behaviours among 50 Asian Indian Tamil autistic children (AUT) and their mothers. The interaction was compared with two groups of mother-child dyads of non-autistic (NA) children, 50 in each group, matched for chronological age (CA), and for language level (LL). Results indicated that despite mother's efforts to engage with their children, autistic children were often 'engaged with objects' or remained 'unengaged' due to children's preference for solitary play, while NA children were often engaged in 'co-ordinated' and 'people engagement'. Across the three groups, mothers predominantly took the lead and dominated the interaction, irrespective of children's language levels. These initiations by the mothers were often to provide instructions and to ask 'What' questions. Autistic children initiated communication predominantly to ask for an object and responded often in the form of negations and protests with limited verbal output or non-verbally. Most of the communication behaviours of both children and mothers in AUT group was quantitatively and qualitatively different when compared to those in both the NA groups, indicating unique nature of interactions despite matching for CA or LL. The observations from the study highlights the need for considering adult's contingent behaviours also, while assessing communication skills of autistic children in order to provide effective intervention.

Characterizing social communication among minimally verbal children with autism: An application of item response theory

Minimally verbal children constitute a portion of the autism spectrum. The paucity of proper measurement tools that sensitively and accurately assess behaviors has been one limiting factor in the improved knowledge of these children. Short of creating and validating a new measurement tool for this subpopulation, this study took an alternative and more immediate approach: conduct a secondary data analysis and examine an existing social communication measure, the Early Social Communication Scales (ESCS), with item response theory. The final sample consisted of 453 minimally verbal children culled from four different completed studies. The IRT models analyzed the frequency of social communication gestures from the ESCS and returned an objective difficulty hierarchy regarding initiations of joint attention and behavior regulation gestures. The best-fitting and final model was a zero-inflated negative binomial model (ZINBM), which determined that joint attention gestures were, on average, more difficult than behavior regulation gestures. Joint attentional shows and gives were essentially absent in the children's repertoire, and behavior regulation reaches were the easiest gestures for this sample. The ZINBM separately modeled children with some gestures and children who did not present with any gestures and determined that behavior regulation reaches and gives were likely the first gestures a child will eventually exhibit among children with no gestures. Methodological contributions and potential future applications of IRT are discussed.

Does Gestural Communication Influence Later Spoken Language Ability in Minimally Verbal Autistic Children?

PURPOSE

The current study examined the predictive role of gestures and gesture-speech combinations on later spoken language outcomes in minimally verbal (MV) autistic children enrolled in a blended naturalistic developmental/behavioral intervention (Joint Attention, Symbolic Play, Engagement, and Regulation [JASPER] + Enhanced Milieu Teaching [EMT]).

METHOD

Participants were 50 MV autistic children (40 boys), ages 54-105 months (M = 75.54, SD = 16.45). MV was defined as producing fewer than 20 spontaneous, unique, and socially communicative words. Autism symptom severity (Autism Diagnostic Observation Schedule-Second Edition) and nonverbal cognitive skills (Leiter-R Brief IQ) were assessed at entry. A natural language sample (NLS), a 20-min examiner-child interaction with specified toys, was collected at entry (Week 1) and exit (Week 18) from JASPER + EMT intervention. The NLS was coded for gestures (deictic, conventional, and representational) and gesture-speech combinations (reinforcing, disambiguating, supplementary, other) at entry and spoken language outcomes: speech quantity (rate of speech utterances) and speech quality (number of different words [NDW] and mean length of utterance in words [MLUw]) at exit using European Distributed Corpora Project Linguistic Annotator and Systematic Analysis of Language Transcripts.

RESULTS

Controlling for nonverbal IQ and autism symptom severity at entry, rate of gesture-speech combinations (but not gestures alone) at entry was a significant predictor of rate of speech utterances and MLUw at exit. The rate of supplementary gesture-speech combinations, in particular, significantly predicted rate of speech utterances and NDW at exit.

CONCLUSION

These findings highlight the critical importance of gestural communication, particularly gesture-speech (supplementary) combinations in supporting spoken language development in MV autistic children.

Implementation of Learn to Play Therapy for Children in Special Schools

IMPORTANCE

Play is the primary occupation in childhood and fundamental to occupational therapy practice.

OBJECTIVE

To evaluate a play intervention in special school settings.

DESIGN

Pre- and postinvolvement of a 7-mo play program.

SETTING

Four special schools in Victoria, Australia, for children with IQs < 70.

PARTICIPANTS

Thirty-eight children with diagnoses including intellectual disability, autism, and global developmental delay, 7 teachers, 2 speech pathologists, and 2 occupational therapists.

INTERVENTION

Learn to Play Therapy for 1 hr per week over a 7-mo period.

OUTCOMES AND MEASURES

Pre-post outcome measures included children's pretend play skills, language, social skills, emotional regulation, and academic competence.

RESULTS

Mean age of 38 children (15 girls and 23 boys) at baseline was 5 yr 7 mo (SD = 0.46 yr). Results showed significant changes in children's pretend play (p = .03), ability to recall sentences (p = .02), social skills (p = .022), and academic competence (p = .012). Learn to Play had a large effect on children's narrative skills (d = 2.72). At follow-up, object substitution at baseline influenced expressive language (p < .001), narrative mean language utterance (MLU; p = .015), social skills (p < .001), and academic competence (p < .001); elaborate play at baseline plus time influenced social skills (p < .001); and elaborate play at baseline influenced narrative MLU (p =. 016), sentence recall (p = .009), and academic competence (p = .001).

CONCLUSIONS AND RELEVANCE

Embedding pretend play within practice positively influenced children's language, narrative, social, and academic skills. Plain-Language Summary: This study adds to the limited research on play-based therapy programs in special school settings for children with an IQ of less than 70. Children participated in Learn to Play Therapy, during which an occupational therapist, who has observed and assessed the child's play and understands the child's play abilities, played beside the child. Learn to Play Therapy is a child-centered therapy that is used to increase a child's ability to self-initiate and enjoy pretend play. The positive impacts of supporting the children's pretend play ability were highlighted by increases in their pretend play, language, social skills, academic competence, and narrative language after participating in Learn to Play Therapy in their special schools.

Comparing the Implementation Context for Early Intervention Services Before and During the COVID-19 Pandemic

The COVID-19 pandemic not only led to drastic changes in the implementation context for early intervention and early childhood special education services in 2020, but has had an enduring effect on the organizations, educators, families, and children with developmental delays and disorders. Through secondary data analysis, characteristics of toddlers with autism being served in a publicly funded center-based early intervention program as well as the characteristics of their educators are examined, comparing those who were enrolled in (a) two randomized trials conducted prior to the pandemic and (b) one ongoing randomized trial that launched in return to in-person educational services after the pandemic shutdown. Significant demographic differences are found for toddlers, where the current study includes more girls (p = 0.002), who are younger (p < .001) than the prior studies. Further, toddlers enrolled in the current trial are entering with significantly younger receptive (p < .001) and expressive language age-equivalent scores (p < .001) than toddlers from the prior studies. In addition, significant differences are also found for teaching assistants (TAs), who are younger (p < .001), less experienced supporting children with autism (p < .001), have spent less time in this position (p < .001), and who are still working toward college degrees (p < .001) than TAs in the prior studies. Implications of these changes for both intervention strategies to support the strengths and needs of the toddlers (e.g., reduce frequency of TA-child pairing changes to build rapport, increase time in adult-child JASPER before adding peers) as well as implementation strategies (e.g., increase foundational content, TA teaming) to support the training and retention of the TAs are discussed. Clinical Trials Registry number: NCT04283045.

A Chinese version of the communication complexity scale (CCS): psychometric evaluation in children with minimal verbal skills

PURPOSE

This study aimed to evaluate the reliability and validity of the translated Chinese version of the Communication Complexity Scale (C-CCS) in a Chinese sample of preschool-aged children with minimal verbal skills.

METHODS

A total of 120 children with autism spectrum disorders or children with developmental delays aged 2 to 5 years with minimal verbal skills (i.e., produced less than 20 functional words) were recruited to complete the C-CCS. First, we tested the protocol with 20 children and shortened it based on their results. Second, the interrater reliability, test-retest reliability, and concurrent validity for 100 participants were examined. C-CCS scores were compared with scores from the Chinese Communicative Development Inventories (CCDI) for concurrent validity.

RESULTS

Ten C-CCS interactive scripts were administered to 100 participants. Intraclass correlation coefficients (ICC) between independent observers were high. The ICCs for overall optimal scores, optimal BR scores and optimal JA scores were 0.978, 0.971 and 0.977 respectively. Agreement for scores within scripted opportunities and communication level were high-Kappa coefficients 0.869 and 1.000 respectively. The test-retest reliability was high (r = 0.911). A moderate correlation was found between the C-CCS and the CCDI (r = 0.401).

CONCLUSIONS

The results indicate that C-CCS could be used as a measurement tool in research and clinical practice to describe communication levels in children with minimal verbal skills in China.

Profiles of minimally verbal autistic children: Illuminating the neglected end of the spectrum

Heterogeneity among individuals on the autism spectrum is widely acknowledged as a barrier to develop effective interventions. Overcoming this challenge requires characterization of individual differences, especially for children that are minimally verbal and often excluded from research studies. Most studies that describe autistic subgroups identify a single minimally verbal verbal group based on a single identifying measure (e.g., ADOS module one or single item indicating absence of phrase speech). Determining personalized courses of intervention requires a more detailed understanding since a single intervention will not be effective for all who are minimally verbal. The present study identified comprehensive profiles of cognitive, language, and social communication skills within a large, diverse, group of minimally verbal children with autism. The analysis combined baseline data from two studies to yield a sample of 344 participants, who were 3 to 8 years old at the time of study onset, with 60% who identified as having a race/ethnicity other than White. Via latent profile analysis (LPA), a three-group model was identified as best fit to the data. Profile identification was dependent on a participant's combination of cognitive, expressive, and social communication characteristics, rather than a single domain. One group (n = 206) had global delays, while the other two groups (n = 95 and n = 43) had variable strengths in cognition and communication. Findings suggest that low-frequency/minimally verbal communicators with autism have heterogeneous characteristics that can be systematically organized.

Autistic preschoolers display reduced attention orientation for competition but intact facilitation from a parallel competitor: Eye-tracking and behavioral data

LAY ABSTRACT

Recent research suggests that we might have underestimated the social motivation of autistic individuals. Autistic children might be engaged in a social situation, even if they seem not to be attending to people in a typical way. Our study investigated how young autistic children behave in a "parallel" situation, which we call "parallel competition," where people participate in friendly contests side-by-side but without direct interaction. First, we used eye-tracking technology to observe how much autistic children pay attention to two video scenarios: one depicting parallel competition, and the other where individuals play directly with each other. The results showed that autistic children looked less toward the parallel competition video than their typically developing peers. However, when autistic children took part in parallel competitions themselves, playing physical and cognitive games against a teacher, their performance improved relative to playing individually just as much as their typically developing peers. This suggests that even though autistic children pay attention to social events differently, they can still benefit from the presence of others. These findings suggest complementing traditional cooperative activities by incorporating parallel activities into educational programs for young autistic children. By doing so, we can create more inclusive learning environments for these children.

The Autism Constellation and Neurodiversity: Long-Term and Adult Outcomes in Autism Spectrum Disorder

Research on autistic adults suggests significant heterogeneity in outcomes. A significant proportion of individuals struggle with intellectual disability and limited communication skills. Of the 67% who have age-appropriate cognitive skills, around half are expected to attain a college education, and 25% are likely to hold a full-time job. Outcomes have been improving over time, in part because of earlier diagnosis and earlier intervention. Indeed, an estimated 10% to 20% are expected to lose all symptoms of autism by adolescence.

Infants who develop autism show smaller inventories of deictic and symbolic gestures at 12 months of age

Gestures are an important social communication skill that infants and toddlers use to convey their thoughts, ideas, and intentions. Research suggests that early gesture use has important downstream impacts on developmental processes, such as language learning. However, autistic children are more likely to have challenges in their gestural development. The current study expands upon previous literature on the differences in gesture use between young autistic and non-autistic toddlers by collecting data using a parent-report questionnaire called the MCDI-Words and Gestures at three time points, 12, 18, and 24 months of age. Results (N = 467) showed that high-likelihood infants who later met diagnostic criteria for ASD (n = 73 HL-ASD) have attenuated gesture growth from 12 to 24 months for both deictic gestures and symbolic gestures when compared to high-likelihood infants who later did not meet criteria for ASD (n = 249 HL-Neg) and low-likelihood infants who did not meet criteria for ASD (n = 145 LL-Neg). Other social communicative skills, like play behaviors and imitation, were also found to be impacted in young autistic children when compared to their non-autistic peers. Understanding early differences in social communication growth before a formal autism diagnosis can provide important insights for early intervention.

Brief Report: Response to Joint Attention and Object Imitation as Predictors of Expressive and Receptive Language Growth Rate in Young Children on the Autism Spectrum

Joint attention and imitation are thought to facilitate a developmental cascade of language and social communication skills. Delays in developing these skills may affect the quality of children's social interactions and subsequent language development. We examined how responding to joint attention and object imitation skills predicted rate of expressive and receptive communication growth rate in a heterogeneous sample of autistic children. Children's baseline skills in responding to joint attention uniquely predicted expressive, but not receptive, language growth rate over time, while object imitation did not significantly predict language growth rate over and above joint attention skills. Future research should examine the potential moderating roles of child age and developmental level in explaining associations between joint attention and object imitation and later language development.

Deriving relations at multiple levels of complexity following minimal instruction: A demonstration

Recommendations for achieving generalized instructional outcomes often overlook the capacity for generative learning for most verbally competent humans. Four children (ages 5-8) participated in this project. In Study 1, we provided decontextualized discrete trial teaching to establish arbitrary relations between colors, pictures of characters, and researcher motor actions. All participants engaged in derivative responding, providing evidence of relational framing. Subsequently, we demonstrated that, with no additional instruction, these derivatives contributed to effective action within a socially valid context (i.e., Candyland gameplay). Study 2 extended the demonstration by teaching frames of opposition. Following teaching, all participants engaged in novel and contextually appropriate responding that entailed the derivation of both coordination and opposition between untrained stimuli. This outcome demonstrates how teaching simple relations can result in learning that manifests at higher levels of complexity (i.e., relational networking), providing some evidence that there can be socially valid benefits to decontextualized discrete trial instruction.

Determining an Effective Language Sample Elicitation Strategy for Early Language Learners Who Speak Using Augmentative and Alternative Communication

PURPOSE

This study evaluates three different language sample elicitation strategies to determine a valid elicitation strategy for early language learners who speak using augmentative and alternative communication (AAC).

METHOD

Ten children who speak using AAC participated in this study. Language samples were elicited from each participant using three strategies: the Communication and Symbolic Behavior Scales (CSBS), a generic play-based elicitation strategy, and automatic data logging. Samples were transcribed and coded. Additionally, each participant's school speech-language pathologist completed a Communication Matrix. Data from coded language samples were correlated with Communication Matrix results to determine the elicitation strategy that yielded the most valid language sample in comparison to Communication Matrix results.

RESULTS

Both the CSBS and the play-based strategy yielded clinically relevant information. Because the log lacked communicative context, resulting data from the log was limited. An analysis of variance revealed significant differences in the amount of information elicited from each elicitation strategy. The CSBS repeatedly elicited the most data, followed by the play-based strategy and then the log. Generic play-based strategy results yielded the most correlations with Communication Matrix data.

CONCLUSIONS

This preliminary data suggest that the play-based elicitation strategy elicited the most valid language sample when compared to the Communication Matrix from early language learners who speak using AAC. Additionally, results suggest that the CSBS may be an effective tool to measure the limits of this population's expressive language abilities.

Behavioral Interventions for Autism Spectrum Disorder: A Brief Review and Guidelines With a Specific Focus on Applied Behavior Analysis

We conducted a comprehensive review of behavioral and educational interventions for individuals with autism spectrum disorder (ASD). The most prominent type of intervention, Comprehensive Early Intervention, often referred to as Early Intensive Behavioral Intervention (EIBI), has been found to be particularly effective in improving intelligence and adaptive behaviors. The naturalistic developmental behavioral intervention, designed to enhance social and communication abilities, showed effectiveness in improving language, cognitive function, and social initiation. However, more studies are needed to examine its effectiveness. Intensive individualized intervention, which provides a tailored intervention for a specific target behavior, was effective in improving social skills and communication, as well as reducing sleep, eating, and toileting problems. Cognitive behavioral therapy (CBT) is the most effective method for dealing with emotional difficulties, but it has not been widely used because of the shortage of trained experts. Parent-mediated intervention (PMI) involves parents acquiring knowledge and specific skills to improve their child's functioning or reduce challenging behaviors. Speech and language therapy, sensory integration, Treatment and Education of Autistic and related Communications Handicapped Children, developmental approaches, and social stories are frequently used interventions. However, evidence of their effectiveness has yet to be well established. Based on these findings, intervention recommendations for autism include EIBI, Early Start Denver Model, intensive individualized intervention, CBT, and PMI. The choice of intervention should be tailored to the individual's needs and delivered by qualified professionals with expertise in the specific intervention.

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.

"They aren't waiting for an SLP, they think 'what can I as a parent do now?'" course leaders' perceptions of AAC interventions targeting parents

Parental interventions can help parents use strategies to support their child's language and communication development. The ComAlong courses are parental interventions that focus on responsive communication, enhanced milieu teaching, and augmentative and alternative communication. This interview study aimed to investigate the course leaders' perceptions of the three ComAlong courses, ComAlong Habilitation, ComAlong Developmental Language Disorder, and ComAlong Toddler, and to evaluate their experiences of the implementation of the courses. Qualitative content analysis was used to analyze the interview data. Thereafter, three categories resulted from the findings: Impact on the Family, A Great Course Concept, and Accessibility of the Courses. The results indicate that participants perceived that the courses had positive effects on both parents and themself. Furthermore, it was described that parents gained knowledge about communication and strategies in how to develop their child's communication; however, the courses were not accessible to all parents. The collaboration between the parents and course leaders improved, and course leaders viewed the courses as an important part of their work. The following factors had an impact on the implementation: several course leaders in the same workplace, support from colleagues and management, and recruitment of parents to the courses.

Automated movement tracking of young autistic children during free play is correlated with clinical features associated with autism

LAY ABSTRACT

Play-based observations allow researchers to observe autistic children across a wide range of ages and skills. We recorded autistic children playing with toys in the center of a room and at a corner table while a caregiver remained seated off to the side and used video tracking technology to track children's movement and location. We examined how time children spent in room regions and whether or not they approached each region during play related to their cognitive, social, communication, and adaptive skills to determine if tracking child movement and location can meaningfully demonstrate clinical variation among autistic children representing a range of ages and skills. One significant finding was that autistic children who spent more time in the toy-containing center of the room had higher cognitive and language abilities, whereas those who spent less time in the center had higher levels of autism-related behaviors. In contrast, children who spent more time in the caregiver region had lower daily living skills and those who were quicker to approach the caregiver had lower adaptive behavior and language skills. These findings support the use of movement tracking as a complementary method of measuring clinical differences among autistic children. Furthermore, over 90% of autistic children representing a range of ages and skills in this study provided analyzable play observation data, demonstrating that this method allows autistic children of all levels of support needs to participate in research and demonstrate their social, communication, and attention skills without wearing any devices.

Developmental Play Skills as Outcomes of Early Intervention

Play is critical in the development of cognitive and language skills in young children with autism; however, few studies have examined the impact of the intervention on the development of play skills. The current study aims to address the change in developmental skills, including play after participation in the JASPER intervention, and to examine the initiation of joint attention as a moderator of the effect of treatment on changes in play skills. The study included 109 preschool-age children who participated in the JASPER intervention and examined changes in developmental skills, including play skills. Children who received JASPER improved significantly in both play diversity (F(1,99) = 4.89, p = 0.029, ES = 0.22) and complexity (F(1,98) = 5.21, p = 0.025; ES = 0.23) compared to children in control conditions. These gains in play skills were associated with concurrent improvements in cognition and communication skills. Additionally, children with more initiations of joint attention skills at entry made greater progress in play diversity (F(1,97) = 15.85, p < 0.001 ES = 0.40) and complexity (p = 0.096). Play and joint attention skills are critical intervention targets and outcomes for children with autism.

Parental scaffolding in play: A comparison of fetal alcohol spectrum disorders and autism spectrum disorder

BACKGROUND

Parental support of child play varies based on child needs; however, how parental play level differs from child play level remains an understudied area of research, especially in relation to specific developmental disabilities.

AIMS

To preliminarily explore differences in child and parent play levels in age- and IQ-matched children with fetal alcohol spectrum disorders (FASD) and autism spectrum disorder (ASD).

METHODS

and Procedures: Parent-child dyads were recorded during free-play sessions. Parent/child play levels were coded for highest level achieved during each minute of play. Mean play level and dPlay (difference in parent versus child play level) were calculated across play sessions for each dyad.

OUTCOMES AND RESULTS

On average, parents of children with FASD demonstrated higher levels of play than other parents. Children with FASD demonstrated higher levels of play than their own parents. In contrast, the play level of parents of children with ASD did not differ from their child's. There were no between-group differences in dPlay.

CONCLUSIONS AND IMPLICATIONS

This preliminary exploratory study suggests that parents of children with developmental disabilities may differentially 'match' their child's play level. Further research on developmental play levels during parent-child play is warranted.

Language and communication skills in multilingual children on the autism spectrum: A systematic review

LAY ABSTRACT

Both parents and service providers have voiced concerns about the potential negative impact of exposure to multiple languages on the language and communication skills of autistic children. The current literature review summarized research that assessed the language and communication skills of multilingual autistic children in comparison with their autistic and nonautistic peers. After a comprehensive search, 22 relevant publications were identified that met the inclusion criteria of the current review. Thirteen studies used both direct (directly administered screening/diagnostic tools) and indirect language assessments (e.g. parent questionnaires). Receptive and expressive vocabulary was the most frequently assessed language skill. Available research does not support the assumption that bilingualism has negative effects on the language and communication skills of autistic children. The language and communication skills of multilingual autistic children frequently resembled their monolingual autistic peers in both strengths and areas of growth. Preliminary findings indicate that multilingual autistic children may share some advantages of multilingualism with their multilingual nonautistic peers. Studies often excluded participants with intellectual disabilities or complex communication needs, which means that a large population of autistic children is not yet represented in research about the effects of multilingualism.

Spoken language outcomes in limited language preschoolers with autism and global developmental delay: RCT of early intervention approaches

Preschool autistic children with significant global developmental delays and very limited language skills are at high risk for remaining minimally verbal at entry into primary school. This study compared two early intervention models for improving social communication and spoken language outcomes in 164 children who received intervention in their community preschool program for 6 months, with a six-month follow-up. The primary outcome measure was a standardized language assessment, and secondary measures focused on social communication. Results indicated children on average made 6 months gain in language development in the active 6 months of intervention with no difference between intervention models. Children who initiated joint attention more frequently, or who had higher receptive language at baseline made more progress if assigned to receive JASPER, a naturalistic developmental behavioral intervention. Children who received Discrete Trial Training made greater spoken language progress from exit to follow-up. These findings suggest that progress can be made in autistic children who have very little spoken language and who receive targeted early interventions. Individual trajectories vary and depend in part on initial abilities in social communication and receptive language. Future research might consider methods to systematically personalize approaches to fit child characteristics and family preference. LAY SUMMARY: This study compared two different early intervention approaches for teaching spoken language to minimally verbal, globally delayed autistic preschoolers. Children were given an hour of therapy daily for 6 months and then reassessed 6 months later. The majority of the 164 participants were from historically excluded populations (low income and minority), and therapy was delivered in school community settings by expert clinicians. Results indicated that the participants made significant progress regardless of intervention approach: 6 months gain in standardized language scores over 6 months, but slower progress during the period after therapy ended. Children who initiated joint attention more frequently, or who had higher language understanding at baseline made more progress if assigned to receive JASPER, a naturalistic developmental behavioral intervention. Children who received Discrete Trial Training made greater language progress during 6-month period after therapy ended. These findings suggest that progress can be made in children with ASD who have very little spoken language and who receive targeted early interventions.

Ayres Sensory Integration® for Addressing Play in Autistic Children: A Multiple-Baseline Examination

IMPORTANCE

Play is an area of difficulty for autistic children, and occupational therapy practitioners need evidence to guide interventions to improve play for this population. Ayres Sensory Integration® (ASI) intervention has not yet been studied for its impact on play outcomes.

OBJECTIVE

To examine the impact of ASI intervention on play types in autistic children.

DESIGN

Nonconcurrent, multiple-baseline design across subjects.

SETTING

Outpatient occupational therapy clinic in New England.

PARTICIPANTS

Three autistic children, ages 5, 6, and 6 yr.

INTERVENTION

Twenty-four ASI sessions.

OUTCOMES AND MEASURES

Frequency of play type was coded using partial interval coding. Progress monitoring used Goal Attainment Scaling.

RESULTS

All three participants demonstrated changes in the frequency of specific types of play, but changes varied among them.

CONCLUSIONS AND RELEVANCE

Findings suggest that ASI intervention may alter a child's patterns of play. What This Article Adds: This study is the first to examine the impact of ASI on play and the third that documents the feasibility of single-subject research for studying ASI. If confirmed in future studies, ASI could become an evidence-based intervention for improving play, an important outcome for autistic children and the profession of occupational therapy. Positionality Statement: This article uses the identity-first language autistic people. This nonableist language describes their strengths and abilities and is a conscious decision. This language is favored by autistic communities and self-advocates and has been adopted by health care professionals and researchers (Bottema-Beutel et al., 2021; Kenny et al., 2016).

Interventions to Support Participation in Play for Autistic Children and Youth (Dates of Review: 2013-2021)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings to support participation in play for autistic1 children and adolescents (birth to 18 yr).

The effect of responsiveness to speech-generating device input on spoken language in children with autism spectrum disorder who are minimally verbal†

The use of speech-generating devices (SGD) in early interventions for children with autism spectrum disorder (ASD) can improve communication and spoken language outcomes. The purpose of this study was to describe children's responsiveness to SGD input modeled by a social partner during adult-child play interactions over a 24-week intervention trial and explore the effect of that responsiveness on spoken language growth. This secondary analysis consisted of 31 children with less than 20 functional words at study entry who received a blended behavioral intervention (JASPER + EMT) as part of a randomized controlled trial. Significant improvements were seen in rate of responsiveness to both adult SGD models and adult natural speech models; only rate of responsiveness to SGD models at entry was a significant predictor of frequency of commenting and was a more robust predictor of number of different words post-intervention. Lastly, at entry, children with more joint attention and language responded to SGD models at significantly higher rates. Attention and responsiveness to SGD output may be important mechanisms of language growth and children who have more joint attention skills may particularly benefit from use of an SGD.

Profiles and trajectories of executive functioning in young children with Down syndrome

BACKGROUND

Language acquisition strongly predicts executive functioning (EF) in early childhood in typical development and in children with Down syndrome (DS). Both language and EF are critical contributors to later positive social and academic outcomes yet are often areas of concern in children with DS. Despite the wider availability of interventions targeting language development in DS, no efforts have been made to understand how these interventions may influence the development of EF in this population.

METHODS

This study examined secondary data from 76 preschoolers with DS collected as part of a randomised waitlist control trial of an early social communication intervention (JASPER-EMT). Children's EF skills were measured using the BRIEF-P, at three timepoints over 6 months. Linear regression was used to examine the baseline relationship between child characteristics and the three indices of the BRIEF-P: Emergent Metacognition, Flexibility and Inhibitory Self-Control. Linear mixed effects models were used to estimate change across the three indices of the BRIEF-P and whether that change was moderated by treatment.

RESULTS

Children in this sample exhibited an uneven profile of EF at baseline, with relative strengths in the Flexibility Index and the Inhibitory Self-Control Index, and relative weaknesses in the Emerging Metacognition Index. Chronological age was associated with all indices at baseline (all P < 0.05). Children in the intervention group exhibited improvements in the Flexibility Index from entry to exit (3 months later) compared with the control, although this treatment effect did not maintain at the follow up at 6 months.

CONCLUSIONS

Baseline EF profiles of children were consistent with findings of other studies with children with DS. Longitudinal findings suggest that behavioural interventions targeting language may have positive collateral effects on certain EF skills, however these effects may be transitory without ongoing support. These findings illustrate both the need for further exploration of the impact of early language interventions on EF abilities and the malleability of certain EF domains in young children with DS.

Robot dramas may improve joint attention of Chinese-speaking low-functioning children with autism: stepped wedge trials

INTRODUCTION

Children with autism spectrum disorder (ASD), especially those with low cognitive functioning, have deficits in joint attention. Previous research has found that these children are interested in engaging with social robots.

PURPOSE

In the present study, we designed a robot drama intervention for promoting responses to joint attention abilities (RJA) of children with low-functioning autism (IQs < 70).

MATERIALS AND METHODS

Using a stepped wedge design, Chinese-speaking children aged six to eight were randomly assigned to three tiers (N = 18). Children of all three tiers had comparable autism severity, language and cognitive function, and joint attention abilities. Tier 1 first received intervention, followed by Tiers 2 and 3. They watched six dramas in which social robots demonstrated RJA behaviours.

RESULTS

The RJA of children of all tiers improved after intervention and such improvement was maintained over time. Despite initiation of joint attention (IJA) not being explicitly taught, IJA of all children was found to improve after intervention.

CONCLUSIONS

It was, therefore, concluded that a robot drama could enhance the joint attention of children with low-functioning ASD.Implications for rehabilitationIn comparison to typically developing children, children with autism spectrum disorder (ASD), especially those with low cognitive functioning, have deficits in joint attention.Robot-based drama intervention program was developed to promote responses to joint attention (RJA) abilities of children with low-functioning autism (IQs < 70).Modelling RJA in robot dramas can promote RJA abilities in these children.An improvement in RJA also yielded an increase in the initiation of joint attention (IJA) abilities.Children with low-functioning autism might be able to extract the initiation of joint attention skills from the drama, even though these behaviours were not explicitly taught.

Cost-effectiveness of immune checkpoint inhibition and targeted treatment in combination as adjuvant treatment of patient with BRAF-mutant advanced melanoma

BACKGROUND

Immune checkpoint inhibitors (ICIs) and targeted treatments have improved the health outcomes of patients with advanced melanoma. However, due to the high cost of novel therapies, it is crucial to evaluate their value by considering both effectiveness and cost. To compare the cost-effectiveness of these novel agents (atezolizumab-vemurafenib-cobimetinib, vemurafenib-plus-cobimetinib, dabrafenib-plus-trametinib, and encorafenib-plus-binimetinib) for first-line treatment of metastatic melanoma with the BRAF^V600 mutation.

METHODS

A patient-level model was developed to project the health outcomes of 4 strategies for patients with advanced melanoma. We estimated transition probabilities from the IMspire150 (ClinicalTrials.gov, NCT02908672), COMBI-AD (NCT01682083), and COLUMBUS (NCT01909453) trials using a parametric survival model. All health outcomes, including direct cost, quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER), were estimated from the US payer perspective. Lifetime cost, QALYs, life-years (LYs), and ICERs were calculated. Univariable and probabilistic sensitivity analyses were performed to test model robustness, along with multiple scenario analyses.

RESULTS

Of the 4 competing strategies, atezolizumab-vemurafenib-cobimetinib produced the best health outcomes, and the vemurafenib-cobimetinib strategy was the least expensive option. Atezolizumab-vemurafenib-cobimetinib, dabrafenib-plus-trametinib, and vemurafenib-cobimetinib formed the cost-effective frontier, indicating that the ordered ICERs were $325,113/QALYs for dabrafenib-plus-trametinib vs. vemurafenib-cobimetinib strategies and $2,247,500/QALYs for atezolizumab-vemurafenib-cobimetinib vs. dabrafenib-plus-trametinib strategies. Encorafenib-plus-binimetinib was dominated by the other 3 competing strategies. The drug price and first-line utility significantly influenced the model utcomes.

CONCLUSIONS

For BRAF-mutant advanced melanoma, the vemurafenib-cobimetinib strategy could be considered the most cost-effective treatment at the willingness-to-pay threshold of $150,000.

Play therapy in children with autism: Its role, implications, and limitations

Play is a pleasurable physical or mental activity that enhances the child’s skills involving negotiation abilities, problem-solving, manual dexterity, sharing, decision-making, and working in a group. Play affects all the brain's areas, structures, and functions. Children with autism have adaptive behavior, adaptive response, and social interaction limitations. This review explores the different applications of play therapy in helping children with autism disorder. Play is usually significantly impaired in children with autism. Play therapy is mainly intended to help children to honor their unique mental abilities and developmental levels. The main aim of play therapy is to prevent or solve psychosocial difficulties and achieve optimal child-healthy growth and development. Play therapy helps children with autism to engage in play activities of their interest and choice to express themselves in the most comfortable ways. It changes their way of self-expression from unwanted behaviors to more non-injurious expressive behavior using toys or activities of their choice as their words. Play therapy also helps those children to experience feeling out various interaction styles. Every child with autism is unique and responds differently. Therefore, different types of intervention, like play therapy, could fit the differences in children with autism. Proper evaluation of the child is mandatory to evaluate which type fits the child more than the others. This narrative review revised the different types of play therapy that could fit children with autism in an evidence-based way. Despite weak evidence, play therapy still has potential benefits for patients and their families.

Educators apply new teaching strategies despite initial attributions of autistic students' controllability of their behaviors

Autistic children are less likely to be jointly engaged with a play partner than nonautistic children, negatively impacting social communication development. Promoting joint engagement during play can be an important target for educators of autistic students, but educator perceptions of autistic students may affect their interactions with students. This secondary data analysis investigated educator perceptions of the behaviors of their autistic students, their relationship on educator behavior, and their relationship on the implementation of an intervention promoting joint engagement. Participants included 66 autistic preschool students, and twelve educators from six preschools. Schools were randomized to educator training or a waitlist. Before training, educators rated their students' controllability over autism related behaviors. To observe educator behavior, they were filmed playing for ten minutes with students, before and after receiving training. Ratings of controllability were positively correlated with cognitive scores, and negatively correlated with ADOS (Autism Diagnostic Observation Schedule) comparison scores. Furthermore, educator ratings of controllability predicted joint engagement strategies used by educators during play. Educators tended to use strategies promoting joint engagement for students perceived as more able to control their autism spectrum disorder behavior. Among educators that received JASPER (Joint Attention, Symbolic Play, Engagement, and Regulation) training, ratings of controllability did not predict changes in strategy scores after training. Educators were able to learn and implement new joint engagement strategies despite their initial perceptions.

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.

The Effects of the Pragmatic Intervention Programme in Children with Autism Spectrum Disorder and Developmental Language Disorder

PURPOSE

Children with Autism Spectrum Disorder (ASD) and Developmental Language Disorder (DLD) frequently face pragmatic impairments which may result in learning, socialization, and mental health difficulties, therefore early intervention is crucial. In Portugal, the Pragmatic Intervention Programme (PICP) has been recently developed and validated, but its effects are unknown. This study aims to determine the effects of the PICP on preschool-age children with ASD or DLD with pragmatic impairments.

METHODS

A non-randomized controlled trial has been conducted. The children (n = 20) were assigned to the intervention (n = 11) or the control group (waiting list) (n = 9). Each child attended 24 PICP-based intervention sessions provided by a Speech and Language Therapist in kindergarten. The primary outcome measure was a Goal Attainment Scale (GAS) rated by parents and kindergarten teachers. Secondary outcomes include parent/teacher-reported communication skills (Escala de Avaliação de Competências Comunicativas) and an assessment of the child's general language ability (Teste de Linguagem-Avaliação da Linguagem Pré-Escolar).

RESULTS

GAS results show that all the children in the intervention group made progress. Statistically significant differences between pre- and post-intervention assessments were found for all secondary outcomes.

CONCLUSIONS

The main findings suggest that the PICP improves language in preschool-age children with ASD and DLD with pragmatic difficulties. Further research is needed to analyse the effects of the PICP for each neurodevelopmental disorder individually. These results are crucial and will contribute to future research and evidence-based practice.

Using eCoaching to Support Mothers' Pretend Play Interactions at Home

A unique component of early childhood involves understanding how caregivers and educators promote children's developmental outcomes, with play opportunities being a key avenue for enhancing these skills. Targeted coaching is one type of support that can tap into active family engagement during playful learning. This collective case study examined how remote-based eCoaching could support family-centered practices related to the facilitation of pretend play in caregivers of preschool children in the home setting. Four mother-child dyads of preschool children, with and without a disability, participated in eCoaching focusing on pretend play behaviors. During the implementation of eCoaching, three primary findings emerged related to knowledge acquisition, mothers' facilitation of play with their children, and changes in children's pretend play behaviors. In general, both mothers and children benefited from the eCoaching experience. In addition, mothers' perceptions of eCoaching as a means of family-based support were positive, and all deemed eCoaching easy to engage in and beneficial.

Participant characteristics predicting communication outcomes in AAC implementation for individuals with ASD and IDD: a systematic review and meta-analysis

This meta-analysis examined communication outcomes in single-case design studies of augmentative and alternative communication (AAC) interventions and their relationship to participant characteristics. Variables addressed included chronological age, pre-intervention communication mode, productive repertoire, and pre-intervention imitation skills. Investigators identified 114 single-case design studies that implemented AAC interventions with school-aged individuals with autism spectrum disorder and/or intellectual disability. Two complementary effect size indices, Tau(AB) and the log response ratio, were applied to synthesize findings. Both indices showed positive effects on average, but also exhibited a high degree of heterogeneity. Moderator analyses detected few differences in effectiveness when comparing across diagnoses, age, the number and type of communication modes, participant's productive repertoires, and imitation skills to intervention. A PRISMA-compliant abstract is available: https://bit.ly/30BzbLv.

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.

Parent-mediated play-based interventions to improve social communication and language skills of preschool autistic children: A systematic review and meta-analysis protocol

Early years interventions have shown to be effective in improving the social communication and language skills of autistic children. Therefore, various play-based interventions have been developed to support those developmental areas of autistic children. Although researchers have previously reported the overall effectiveness of different types of play-based interventions on the social communication and language skills of autistic children, no previous systematic reviews have yet evaluated the effectiveness of parent-mediated play-based interventions in preschool autistic children. The overarching aims of the study will be to (i) report the key characteristics and (ii) synthesise the results of studies evaluating parent-mediated play-based interventions targeting the social communication and language skills of preschool autistic children using experimental designs. A comprehensive search for and screening of the relevant studies published between 2000 and 2021 will be undertaken. To be included, studies will have to (i) use either a randomised control trial or quasi-experimental design, (ii) focus on preschool autistic children aged six years old or younger, (iii) deliver a play-based intervention in non-educational settings, and (iv) include at least one parent as the mediator of the intervention. Data extraction of all included studies will be undertaken using a specially devised template and they will also be assessed for risk of bias using an adapted form from the Cochrane Risk of Bias tool. The overall characteristics of the included studies will be reported and a narrative synthesis of the results of the included studies will be undertaken. A meta-analysis may be performed (if justified) to report the pooled effect size of the parent-mediated play-based interventions on the social communication and language skills of preschool autistic children. Trial registration: The current study protocol was pre-registered with the international prospective register of systematic reviews (PROSPERO: CRD42022302220).

Effects of Rhythmic Gymnastics on Joint Attention and Emotional Problems of Autistic Children: A Preliminary Investigation

The adaptive rhythmic gymnastics (ARG) course has been specially designed for children with autism spectrum disorders (ASD). The purpose of this study is to discover the influence of the course on the joint attention and emotional problems of ASD children. This study adopted A-B-A cross-subject multibaseline design in a single case research design. The joint attention behaviour of two 6-year-old ASD children was examined. The experiment process was recorded and coded, and the results were analysed. The results illustrated the following: (1) ARG is effective in promoting the development of joint attention in ASD children, but it has a better effect on increasing responding joint attention, and (2) to a certain extent, ARG can boost the classroom participation of ASD children and improve their emotional problems.

Lexical Acquisition and Phonological Development in Minimally Verbal Children With Autism Spectrum Disorders

PURPOSE

This study examines two components of lexical acquisition and phonological development that occur during the first 50-word stage of language development in neurotypical (NT) children. One component is how children learn words based on their existing speech sound inventories (i.e., in-phonology and out-of-phonology word learning). The other component is the relationship between the children's number of words and the number of phonemes in their speech sound inventories. The goal of this study is to determine if the same two components occur in children with autism spectrum disorders (ASDs) who are older than their NT peers but are in the same stage of lexical development.

METHOD

This study involved 20 minimally verbal children with ASDs, ages 28-72 months, who produced five to 50 spoken words. The children's spoken words were obtained from the MacArthur-Bates Communicative Development Inventories. The speech sound inventories were obtained from the utterances produced during assessment/play sessions with the children. The children's spoken words from the Communicative Development Inventories (CDI) were categorized as either in-phonology or out-of-phonology based on whether the words began with a phoneme in the child's existing speech sound inventory. Additionally, the children's number of spoken words on the CDI was compared to the number of phonemes in their speech sound inventories.

RESULTS

The children in this study produced in-phonology words more often than out-of-phonology words (z = -3.922; p < .001). Moreover, there was a moderate positive correlation between the children's number of spoken words and the number of phonemes in their speech sound inventories (r = .534, p = .019).

CONCLUSIONS

The relationship between lexical acquisition and phonological development appears to exist for the children in this study, who are in the first 50-word stage of development. Clinical implications for increasing the expressive language of children with ASDs were discussed.

Joint attention performance in preschool-aged boys with autism or fragile X syndrome

Early development marks a period of rapid learning facilitated by children's natural curiosity about the people around them. In children with typical development, these early social attentional preferences set the foundation for learning about and from the surrounding world of people. Much of this learning happens using joint attention, the ability to coordinate attention between people and objects of mutual interest. It is well documented that decreased gaze use is commonly observed in individuals with autism and individuals with fragile X syndrome (FXS). Despite the growing body of research comparing phenotypic similarities between individuals with autism and individuals with FXS, no studies have directly compared joint attention performance between these groups. In the present study, we considered the similarities and differences in joint attention between preschool-aged boys with autism or FXS, and the relation between joint attention, language, and other phenotypic characteristics known to differ between boys with autism and boys with FXS. Although joint attention appeared similar, between-group differences emerged when controlling for the influence of age, non-verbal IQ, and autism symptom severity. Differences were also observed when considering how joint attention performance related to other aspects of the phenotype. For example, strong positive associations were observed between joint attention and language performance in boys with autism but not boys with FXS, even after controlling for non-verbal IQ. In contrast, the negative association between joint attention and anxiety symptom severity was significant and stronger in boys with FXS than in autism. These data offer preliminary insights into the similarities and differences between the autism and FXS phenotypes.

Intervention Response by Genetic Subtype: PRETEND-Preschool Program for Children with Prader-Willi Syndrome via Remote Parent Training

Prader-Willi Syndrome (PWS) is a rare neurodevelopmental disorder associated with social cognitive challenges, and pretend play has been demonstrated as a tool to achieve developmental goals. Following previous report on feasibility and acceptability of a remote, play-based parent-training program (Zyga, Russ, & Dimitropoulos, 2018), we now report on preliminary efficacy of this program to enhance pretend play skills and social cognitive skills in preschoolers with PWS. Results across two studies demonstrated efficacy when live-coaching play sessions incorporated children into the intervention. Increases in play skills were observed for children with the mUPD subtype of PWS who underwent intervention, compared with children with mUPD who were waitlisted. Children with DEL subtype were less likely to respond to intervention. Implications for results are discussed.

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.

Playing to Pretend or "Pretending" to Play: Play in Children with Autism Spectrum Disorder

Children diagnosed with autism spectrum disorder (ASD) exhibit early delays and deficits in play. In infancy, they engage in unusual exploratory behaviors with toys. As toddlers, they are slow to develop functional play, and in preschool some children with ASD fail to develop symbolic play despite having the necessary cognitive and language skills. Furthermore, when children with ASD are engaged in play, they demonstrate less playfulness. This article reviews the literature on the characteristics of exploratory, functional, and symbolic/pretend play in children with ASD and possible reasons for their unusual patterns of play development. Increased quantity and quality of play are frequent therapeutic goals for children with ASD. If play interventions are to be successful, it is critical that speech-language pathologists have an adequate assessment of children's play skills. Several frameworks and tools appropriate for assessing play in typical children and children with ASD are described.

Characterizing difficulties with emotion regulation in toddlers with autism spectrum disorder

Background

Difficulties with emotion regulation (ER) underlie emotional/behavioral challenges and co-occurring psychiatric symptoms in autism spectrum disorder (ASD), yet very little is known about the early development of emotion dysregulation. The present study aimed to identify differences in positive and negative emotional reactivity and regulation strategies in toddlers with and without ASD.

Method

Nine tasks from the Laboratory Temperament Assessment Battery (Lab-TAB) were completed with 37 toddlers with and without ASD (22-28 months). Video-recordings of these tasks were coded by research assistants using a behavioral coding scheme tapping facial, bodily, and vocal affect and the frequency of ER strategies. Mixed model analyses were performed to examine the mean affect and total regulation strategies across each task and t-tests were conducted to assess the types of ER strategies utilized.

Results

Toddlers with ASD showed significantly less positive affect and greater frustration compared to non-ASD toddlers; reactivity was comparable between the groups for fear. Both groups used ER strategies in a similar pattern across tasks, with the exception that toddlers with ASD more often engaged in distraction to regulate. Effects of age and developmental level are discussed.

Conclusions

Toddlers with ASD were robustly characterized by greater frustration and lower joy despite frequent and age appropriate attempts to regulate their emotions. This study provides preliminary evidence that observable indicators of emotion dysregulation are present by two years of age. Clinical implications and future research directions are discussed.

Advances in Supporting Parents in Interventions for Autism Spectrum Disorder

The rising prevalence of autism spectrum disorder (ASD) calls for clear referral and treatment guidelines for children with ASD and their caregivers. Caregiver involvement in intervention is a standard practice of care and research suggests that teaching intervention strategies to caregivers can improve child outcomes and increase caregiver efficacy. Caregiver-mediated interventions that are naturalistic, developmental, and behavioral are effective in improving social and communication skills for children with ASD. Caregiver training models that use behavioral strategies are effective in reducing challenging behaviors. Finally, reducing caregiver barriers to treatment implementation, including stress and strain, are becoming critical components for improving the well-being and care of children with ASD and their families.

Super responders: Predicting language gains from JASPER among limited language children with autism spectrum disorder

Early intervention can provide a great benefit for children with autism spectrum disorder (ASD). However, no single intervention is effective for all children. Even when an intervention is effective overall, individual child response varies. Some children make incredible progress, and others make slow or no progress. Therefore, it is important that the field move towards developing methods to personalize intervention. Operationalizing meaningful change and predicting intervention response are critical steps in designing systematic and personalized early intervention. The present research used improvement in expressive language to group children that received a targeted social communication early intervention, Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER), into super responders and slow responders. Using baseline data from traditional standardized assessments of cognition and behavioral data from validated experimental measures of play and social communication, we used conditional inference tree models to predict responder status. From a sample of 99 preschool age, limited language children with ASD, play diversity was the most significant predictor of responder status. Children that played functionally with a wider variety of toys had increased odds of being a super responder to JASPER. A combination of lower play diversity and impairments in fine motor abilities increased the odds of children being slow responders to JASPER. Results from the present study can inform future efforts to individualize intervention and systematic approaches to augmenting treatment in real time. LAY SUMMARY: To help us answer the question of for whom an intervention works best, we examined 99 children, age three to five, who qualified as being limited spoken language communicators, and received a targeted intervention for social communication and language. We used child characteristics before intervention to predict which children would improve their language the most and found that the ability to play appropriately with a wider variety of toys predicted the best improvements in expressive language. These findings will help better inform future work to individualize intervention based on the unique needs of each child.

Assessing the Satisfaction and Acceptability of an Online Parent Coaching Intervention: A Mixed-Methods Approach

Background

Parent-mediated intervention (PMI) has been studied in promoting skill acquisition or behavior change in the children with autism spectrum disorder. Most studies emphasize on the improvement of child's core symptoms or maladaptive behaviors, making parental perceived competence and self-efficacy secondary. Yet, the evaluations of intervention implementation are under-reported, especially when translating such interventions into a new population or context. This research investigated the intervention implementation of a 12-week parent coaching intervention which was delivered through telehealth and tailored to Chinese population. The intervention was based on the Parent-mediated Early Start Denver Model with culturally adapted lectures, manuals, and demonstration and commentary videos. This study aimed to evaluate the intervention implementation by assessing parents' satisfaction, acceptability, appropriateness, and feasibility.

Method

A randomized controlled trial was conducted with two telehealth conditions: self-directed and web+group therapy. Parents in the self-directed condition received intervention individually through the online learning platform. The web+group therapy condition navigated the same program with weekly 1.5-h group coaching sessions via videoconferencing. This mixed-methods study used a concurrent convergent design to evaluate the intervention implementation at post-intervention. The quantitative data was collected from the Program Evaluation Survey and the qualitative data was collected from five focus groups.

Results

Parents in self-directed group reported significantly lower scores in total perceived competence than parents in web+group therapy condition, while there was no group difference on the total self-efficacy. Tailored feedback, demonstration and commentary videos, peer commenting, live coaching, and guided reflection were the top-five acceptable telehealth strategies that were strongly endorsed by parents. Family centered care, home-based intervention, strategies relative to daily activities, the remote learning platform, and the program-based community were elements that parents considered when evaluating the program's appropriateness. Parent modeling, step-by-step instructions, and tailored feedback were key components in making intervention strategies feasible for parents to implement at home.

Conclusion

Findings indicate the application of telehealth was acceptable, appropriate, and feasible for Chinese parents. Group-based parent coaching intervention via videoconferencing could be a promising home-based service model to increase parental perceived competence. A large-scale RCT is needed to investigate the effectiveness of group-based PMI via telehealth.

Effectiveness of the SCERTS Model-Based Interventions for Autistic Children: A Systematic Review

PURPOSE

This systematic review aimed to examine the effectiveness of the Social Communication, Emotional Regulation, and Transactional Support (SCERTS) Model-based interventions in supporting developmental skills of children who were diagnosed with or at increased likelihood of autism.

METHOD

We searched six electronic databases, in addition to Google Scholar and the reference lists, using terms related to SCERTS, the Early Social Interaction project, and autism spectrum disorder. Of the 70 articles, six published between 2014 and 2021 (a total of 455 children) were eligible for inclusion and were analyzed in terms of study design, type of publication, participant characteristics, intervention procedures, and major findings.

RESULTS

Most reviewed studies that were relatively less vulnerable to the given risk of bias suggested that SCERTS may be an effective approach for promoting children's social communication skills, and implementers were able to achieve an adequate level of intervention fidelity through training. Further implications could not be drawn concerning children's language, reduction in restricted repetitive behaviors, emotional regulation, adaptive behavior, play, cognitive skills, academic competence, and motor skills due to contradicting findings within limited evidence.

CONCLUSIONS

Although SCERTS is a promising intervention with emerging evidence, more methodologically rigorous studies are needed to progress the research base of SCERTS and draw firm conclusions about its effectiveness in improving a wide range of skills for children and implementers. Several areas for future research are discussed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20151842.

Still-face redux: Infant responses to a classic and modified still-face paradigm in proximal and distal care cultures

Literature on infant emotion is dominated by research conducted in Western, industrialized societies where early socialization is characterized by face-to-face, vocal communication with caregivers. There is a dearth of knowledge of infant emotion in the context of social interaction outside of the visual and vocal modalities. In a three-population cross-cultural comparison, we used the still-face task to measure variation in behavior among infants from proximal care (practicing high levels of physical contact) communities in Bolivia and distal care (emphasizing vocal and visual interaction) communities in the U.S. and Fiji. In a modified version of the face-to-face still-face (FFSF), Study 1, infants in the U.S. and Fiji displayed the typical behavioral response to the still-face episode: increased negative affect and decreased social engagement, whereas infants in Bolivia showed no change. For tactile behavior, infants in Bolivia showed an increase in tactile self-stimulation from the interaction episode to the still-face episode, whereas U.S. infants showed no change. In Study 2, we created a novel body-to-body version of the still-face paradigm ("still-body") with infants in US and Bolivia, to mimic the near-constant physical contact Bolivian infants experience. The U.S. and Bolivian infant response was similar to Study 1: US infants showed decreased positive affect and increased negative affect and decreased social engagement from the interaction to the still-body episode and Bolivian infants showed no change. Notably, there were overall differences in infant behaviors between the two paradigms (FFSF and Still-Body). Infants in Bolivia and the U.S. showed increased positive facial affect during the FFSF paradigm in comparison with the Still-Body paradigm. Our results demonstrate the need for more globally representative developmental research and a broader approach to infant emotion and communication.

The Hebrew Web Communicative Development Inventory (MB-CDI): Lexical Development Growth Curves

This article presents data on lexical development of 881 Israeli Hebrew-speaking monolingual toddlers ages 1;0 to 2;0. A Web-based version of the Hebrew MacArthur-Bates Communicative Development Inventories (H-MB-CDI) was used for data collection. Growth curves for expressive vocabulary, receptive vocabulary, actions and gestures were characterized. Developmental trajectories of toddlers with various demographic characteristics, such as education, income, religiosity level, birth order of the child, and child-care arrangements were compared. Results show that the lexical growth curves for Hebrew are comparable to those reported for other languages. Sex, birth order, and child-care arrangements were found to influence the size of lexicons. It is recommended that the trajectories presented here be used as norms for lexical growth among typical Hebrew-speaking toddlers in the second year of life.