Cognitive, Language, and Behavioral Outcomes in Children With Autism Spectrum Disorders Exposed to Early Comprehensive Treatment Models: A Meta-Analysis and Meta-Regression

Racial and ethnic disparities in the co-occurrence of intellectual disability and autism: Impact of incorporating measures of adaptive functioning

Intellectual disability (ID) commonly co-occurs in children with autism. Although diagnostic criteria for ID require impairments in both cognitive and adaptive functioning, most population-based estimates of the frequency of co-occurring ID in children with autism-including studies of racial and ethnic disparities in co-occurring autism and ID-base the definition of ID solely on cognitive scores. The goal of this analysis was to examine the effect of including both cognitive and adaptive behavior criteria on estimates of co-occurring ID in a well-characterized sample of 2- to 5-year-old children with autism. Participants included 3264 children with research or community diagnoses of autism enrolled in the population-based Study to Explore Early Development (SEED) phases 1-3. Based only on Mullen Scales of Early Learning (MSEL) composite cognitive scores, 62.9% (95% confidence interval [CI]: 61.1, 64.7%) of children with autism were estimated to have co-occurring ID. After incorporating Vineland Adaptive Behavior Scales, Second Edition (VABS-II) composite or domains criteria, co-occurring ID estimates were reduced to 38.0% (95% CI: 36.2, 39.8%) and 45.0% (95% CI: 43.1, 46.9%), respectively. The increased odds of meeting ID criteria observed for non-Hispanic (NH) Black and Hispanic children relative to NH White children when only MSEL criteria were used were substantially reduced, though not eliminated, after incorporating VABS-II criteria and adjusting for selected socioeconomic variables. This study provides evidence for the importance of considering adaptive behavior as well as socioeconomic disadvantage when describing racial and ethnic disparities in co-occurring ID in epidemiologic studies of autism.

The challenges for early intervention and its effects on the prognosis of autism spectrum disorder: a systematic review

Autism spectrum disorder (ASD) is expressed with neurobehavioral symptoms of different degrees of intensity. It is estimated that, for every three cases detected, there are two cases that reach adulthood without treatment.

Objective

To establish what challenges are still present in the implementation of early intervention (EI) and its effects on the prognosis of ASD.

Methods

A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Prisma) methodology was carried out in the PubMed and ScienceDirect databases in January 2023. The search keywords were "autism spectrum disorder", "early intervention" and "prognosis".

Results

Sixteen studies were included, two randomized and 14 non-randomized. Knowledge about the signs of ASD, diagnostic and therapeutic methods, age at the start of treatment, and socioeconomic factors were the main challenges encountered in the implementation of the EI.

Conclusion

EI is capable of modifying the prognosis of ASD and challenges in its implementation persist, especially in developing regions with low socioeconomic status.

Strategies for addressing the needs of children with or at risk of developmental disabilities in early childhood by 2030: a systematic umbrella review

BACKGROUND

There are over 53million children worldwide under five with developmental disabilities who require effective interventions to support their health and well-being. However, challenges in delivering interventions persist due to various barriers, particularly in low-income and middle-income countries.

METHODS

We conducted a global systematic umbrella review to assess the evidence on prevention, early detection and rehabilitation interventions for child functioning outcomes related to developmental disabilities in children under 5 years. We focused on prevalent disabilities worldwide and identified evidence-based interventions. We searched Medline, Embase, PsychINFO, and Cochrane Library for relevant literature from 1st January 2013 to 14th April 2023. A narrative synthesis approach was used to summarise the findings of the included meta-analyses. The results were presented descriptively, including study characteristics, interventions assessed, and outcomes reported. Further, as part of a secondary analysis, we presented the global prevalence of each disability in 2019 from the Global Burden of Disease study, identified the regions with the highest burden and the top ten affected countries. This study is registered with PROSPERO, number CRD42023420099.

RESULTS

We included 18 reviews from 883 citations, which included 1,273,444 children under five with or at risk of developmental disabilities from 251 studies across 30 countries. The conditions with adequate data were cerebral palsy, hearing loss, cognitive impairment, autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder. ASD was the most prevalent target disability (n = 8 reviews, 44%). Most reviews (n = 12, 67%) evaluated early interventions to support behavioural functioning and motor impairment. Only 33% (n = 10/30) of studies in the reviews were from middle-income countries, with no studies from low-income countries. Regarding quality, half of reviews were scored as high confidence (n = 9/18, 50%), seven as moderate (39%) and two (11%) as low.

CONCLUSIONS

We identified geographical and disability-related inequities. There is a lack of evidence from outside high-income settings. The study underscores gaps in evidence concerning prevention, identification and intervention, revealing a stark mismatch between the available evidence base and the regions experiencing the highest prevalence rates of developmental disabilities.

Social motivation in infancy is associated with familial recurrence of ASD

Pre-diagnostic deficits in social motivation are hypothesized to contribute to autism spectrum disorder (ASD), a heritable neurodevelopmental condition. We evaluated psychometric properties of a social motivation index (SMI) using parent-report item-level data from 597 participants in a prospective cohort of infant siblings at high and low familial risk for ASD. We tested whether lower SMI scores at 6, 12, and 24 months were associated with a 24-month ASD diagnosis and whether social motivation's course differed relative to familial ASD liability. The SMI displayed good internal consistency and temporal stability. Children diagnosed with ASD displayed lower mean SMI T-scores at all ages and a decrease in mean T-scores across age. Lower group-level 6-month scores corresponded with higher familial ASD liability. Among high-risk infants, strong decline in SMI T-scores was associated with 10-fold odds of diagnosis. Infant social motivation is quantifiable by parental report, differentiates children with versus without later ASD by age 6 months, and tracks with familial ASD liability, consistent with a diagnostic and susceptibility marker of ASD. Early decrements and decline in social motivation indicate increased likelihood of ASD, highlighting social motivation's importance to risk assessment and clarification of the ontogeny of ASD.

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

BACKGROUND

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

OBJECTIVES

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

METHODS

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

RESULTS

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

CONCLUSION

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

TRIAL REGISTRATION

NCT05551728 in Clinical Trial Registry (https://clinicaltrials.gov).

Predicting Communication Skills Outcomes for Preschool Children with Autism Spectrum Disorder Following Early Intervention

Purpose

This study aims to assess changes in the receptive and expressive language skills and to determine if the baseline characteristics such as communication, cognitive and motor skills, predict outcomes in preschool children with Autism Spectrum Disorder (ASD) following early intervention.

Methods

We recruited 64 children participating in the Early Start Denver Model (ESDM) early intervention program at an Autism Specific Early Learning and Care Center (ASELCC) in Australia. Baseline characteristics across various developmental domains was measured using the Mullen Scales of Early Learning (MSEL), Vineland Adaptive Behaviour Scales, 2nd Edition (VABS-II), and the ESDM Curriculum Checklist. Linear mixed-effects models were used to examine the effects of the intervention on outcomes. Fixed-effects such as time, groups (verbal and minimally verbal), and time-by-group interactions were assessed whilst adjusting for covariates. Further, multiple linear regression models were used to determine if the baseline characteristics were significant predictors of the outcomes following the early intervention.

Results

Among the 64 children who participated in this study, 38 children were verbal, whereas 26 were deemed to have minimal verbal skills. The mean age of the sample was 4.1 years with a significant male predilection (83%) and from a culturally and linguistically diverse (CALD) background (64%). Findings of the linear mixed effects model showed significant within and between group differences in the ESDM subscales, indicating higher magnitude of changes in the verbal group compared to the minimally verbal group. Finally, the multiple linear regression models suggested that baseline MSEL visual reception and expressive language scores were predictive of changes in the ESDM receptive and expressive communication scores.

Conclusion

Understanding a child's baseline skill levels may provide valuable clues regarding what interventions would work best, or which interventions may be less suitable for individual preschool-aged children with ASD.

Assessing Parental Perceptions of Meaningful Outcomes for Children with Autism Spectrum Disorder

BACKGROUND

Outcomes of children diagnosed with autism spectrum disorder (ASD) generally focus on cognition, language, behavioral, and adaptive functioning, yet it is unknown whether this reflects patient and caregiver priorities.

OBJECTIVE

Identify parental perceptions of ASD outcomes and identify whether health care providers are currently addressing these concerns.

METHODS

Participant were 60 parents of school-aged children previously diagnosed with ASD participating in a larger autism outcomes study. Parents answered the open-ended question, "What aspect of your child's functioning matters most for your child at this time?" They also ranked a list of outcome categories (thinking and reasoning skills, daily living skills, etc). Parents answered a second open-ended question, "What should healthcare providers be asking about how your child is doing, that they may not be currently asking?" Open-ended independent coding and thematic analysis were used to identify themes for the open-ended questions.

RESULTS

The most common themes identified with "what aspect of your child's functioning matters most" were "Social," "Communication," "Emotional," and "Behavior." These were similar to the results of a ranking question in which parents ranked "Communicating with and understanding others," "Social skills," and "Behavior" as most important. "Emotional" was a unique theme, although there is potential overlap between this and the theme of "Behavior." The most common theme identified with the question about what health care providers should be asking was "Social," followed by "Nothing."

CONCLUSION

This study demonstrates that parental concerns largely match previous outcome categories, with the exception of a theme identified as "Emotional" which may overlap with "Behavior."

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

Background

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

Objectives

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

Methods

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

Results

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

Conclusion

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

Randomized, controlled trial of a mixed early start Denver model for toddlers and preschoolers with autism

The early start Denver model (ESDM) has been extensively studied as a promising early intervention approach for young children with autism spectrum disorder (ASD). Various methodological drawbacks from earlier ESDM investigations must be rectified to expand the application scopes. For this purpose, the present study recruited a very large sample of 249 autistic children (aged 24-47 months), and used a randomized controlled design to compare outcomes from a mixed ESDM (M-ESDM) intervention with a mixed discrete trial teaching (M-DTT) intervention which remains one of the most commonly-used programming for early intervention. Over the course of a 12-week period, both groups (i.e., M-ESDM and M-DTT groups) received 25 h of intensive intervention per week using individual, group, and parent coaching techniques. Findings showed that: (i) the M-ESDM significantly outperformed the M-DTT in enhancing children's developmental abilities in gross motor and personal-social skills for toddlers and preschoolers, as well as in language for preschoolers with mild/moderate ASD and toddlers; and (ii) the M-ESDM dramatically reduced the severity of autistic symptoms in toddlers with severe ASD only, when compared to the M-DTT. However, the M-ESDM did not outperform the M-DTT in terms of improving children's developmental abilities in adaptability and fine motor for toddlers and preschoolers, as well as in language for preschoolers with severe ASD. In addition, when compared to the M-DTT, the M-ESDM did not show an advantage in reducing the severity of autistic symptoms in toddlers with mild/moderate ASD and preschoolers. Clinical Trial Registration: Chinese Clinical Trial Registry. Registration number ChiCTR200039492.

Importance of Early Intervention in Reducing Autistic Symptoms and Speech-Language Deficits in Children with Autism Spectrum Disorder

The intervention focused on starting treatment at an early age to develop the child’s full potential, which is known as early intervention. Given that autistic symptoms and language deficits occur at an early age and affect other areas of development in children with autistic spectrum disorder, we wanted to examine if early intervention is more effective in the reduction in autistic symptoms and language deficits in children aged 36−47 months old when compared to children 48−60 months old. The sample consisted of 29 children diagnosed with ASD who were admitted for integrative therapy. All participants were divided into two groups based on age: G1: 36−47 months old children, and G2: 48−60 months old children. To estimate the presence of autistic symptoms, we used the GARS-3, and for the assessment of speech−language abilities, we used the subscale Estimated Speech and Language Development (ESLD). Our results regarding the effect of the group on the difference in the scores at two time points showed that there was a statistically significant effect of the group on the reduction in autistic symptoms (p < 0.05) but no effect of the group on the differences in speech−language abilities between the two time points (p > 0.05). Our study highlights the importance of emphasizing the exact age when using the terms “early intervention” and “early development” in future studies and practice because it is necessary to determine and establish guidelines about which particular ages are crucial for starting treatment in certain developmental aspects.

Non-pharmacological interventions for autism spectrum disorder in children: an overview of systematic reviews

OBJECTIVE

To assess the effectiveness of non-pharmacological interventions for the treatment of autism spectrum disorder (ASD) in children.

DESIGN

Overview of systematic reviews (SRs).

PARTICIPANTS

Children aged 12 years and under with ASD.

SEARCH METHODS

In October 2021, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and Epistemonikos placing no restrictions on language or date of publication.

INTERVENTIONS

17 non-pharmacological interventions compared with placebo, no-treatment (including waiting list) or other interventions (ie, usual care, as defined by the authors of each study).

DATA COLLECTION AND ANALYSIS

We rated the methodological quality of the included SRs using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). We reported the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty of the evidence (CoE) according to the analysis conducted by the authors of the included SRs.

MAIN OUTCOME MEASURES

A multidisciplinary group of experts agreed on analysing nine critical outcomes evolving core and non-core ASD symptoms.

PUBLIC AND PATIENT INVOLVEMENT STATEMENT

Organisations of parents of children with ASD participated in external revision of the final version of the report.

RESULTS

We identified 52 reports that were within our scope, of which 48 were excluded for various reasons. After excluding less reliable SRs, we included four SRs. Non-pharmacological interventions (ie, Early Intensive Behavioural Intervention, Applied Behaviour Analysis, Picture Exchange Communication System and Naturalistic Developmental Behavioural Interventions) may have favourable effects on some core outcomes including language, social and functioning, play or daily living skills in children with ASD (with either no GRADE assessment, very low or low CoE). In addition, we identified a lack of report for other key outcomes in the included SRs (ie, restricted, repetitive behaviour; play and sensory processing).

CONCLUSIONS

Synthesised evidence regarding the efficacy of non-pharmacological interventions for children with ASD is scarce. High-quality SRs addressing the variety of both non-pharmacological interventions and relevant outcomes are needed.

PROSPERO REGISTRATION NUMBER

CRD42020206535.

Decreased in vivo glutamate/GABA ratio correlates with the social behavior deficit in a mouse model of autism spectrum disorder

To diagnose autism spectrum disorder (ASD), researchers have sought biomarkers whose alterations correlate with the susceptibility to ASD. However, biomarkers closely related to the pathophysiology of ASD are lacking. Even though excitation/inhibition (E/I) imbalance has been suggested as an underlying mechanism of ASD, few studies have investigated the actual ratio of glutamate (Glu) to γ-aminobutyric acid (GABA) concentration in vivo. Moreover, there are controversies in the directions of E/I ratio alterations even in extensively studied ASD animal models. Here, using proton magnetic resonance spectroscopy (¹H-MRS) at 9.4T, we found significant differences in the levels of different metabolites or their ratios in the prefrontal cortex and hippocampus of Cntnap2^−/− mice compared to their wild-type littermates. The Glu/GABA ratio, N-acetylaspartate (NAA)/total creatine (tCr) ratio, and tCr level in the prefrontal cortex were significantly different in Cntnap2^−/− mice compared to those in wild-type mice, and they significantly correlated with the sociability of mice. Moreover, receiver operating characteristic (ROC) analyses indicated high specificity and selectivity of these metabolites in discriminating genotypes. These results suggest that the lowered Glu/GABA ratio in the prefrontal cortex along with the changes in the other metabolites might contribute to the social behavior deficit in Cntnap2^−/− mice. Our results also demonstrate the utility of ¹H-MRS in investigating the underlying mechanisms or the diagnosis of ASD.

Screening for Autism Spectrum Disorder in Toddlers During the 18- and 24-Month Well-Child Visits

OBJECTIVE

Early screening contributes to the early detection of children with autism spectrum disorder (ASD). We conducted a longitudinal ASD screening study in a large community setting. The study was designed to investigate the diagnostic rate of ASD screening and determine the effectiveness of ASD screening model in a community-based sample.

METHODS

We enrolled children who attended 18- and 24-month well-child care visits in Shanghai Xuhui District. Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F) and Binomial Observation Test (BOT) were selected as screening instruments. Screen-positive children were referred to a tertiary diagnostic center for comprehensive ASD diagnostic evaluation. Screen-negative children received well-child checkups and follow-up every 3-6 months until age three and were referred if they were suspected of having ASD.

RESULTS

A total of 11,190 toddlers were screened, and 36 screen-positive toddlers were diagnosed with ASD. The mean age at diagnosis for these children was 23.1 ± 4.55 months, diagnosed 20 months earlier than ASD children not screened. The diagnostic rate of ASD was 0.32% (95% CI: 0.23-0.45%) in this community-based sample. In addition, 12 screen-negative children were diagnosed with ASD during subsequent well-child visit and follow-up. The average diagnostic rate of ASD rose to 0.43% (95% CI: 0.32-0.57%) when toddlers were followed up to 3 years old. The positive predictive values (PPVs) of M-CHAT-R/F, M-CHAT-R high risk, and BOT for ASD were 0.31, 0.43, and 0.38 respectively.

CONCLUSION

Our findings provide reliable data for estimating the rate of ASD detection and identifying the validity of community-based screening model. M-CHAT-R/F combined with BOT can be an effective tool for early detection of ASD. This community-based screening model is worth replicating.

Association of Breastfeeding for the First Six Months of Life and Autism Spectrum Disorders: A National Multi-Center Study in China

Previous studies have shown that exclusive breastfeeding is associated with lower odds of having autism spectrum disorders (ASD) in children, but data are lacking in Asian countries, especially China. This cross-sectional study of seven cities in China collected data from August 2016 to March 2017 from 6049 toddlers aged 16-30 months and their parents who responded to questionnaires. The breastfeeding status was collected via questionnaires based on recommendations from the World Health Organization. The standard procedure for screening and diagnosis was applied to identify toddlers with ASD. Among the 6049 toddlers (3364 boys [55.6%]; mean [SD] age, 22.7 [4.1] months), 71 toddlers (1.2%) were identified as ASD. The prevalence of exclusive breastfeeding, partial breastfeeding, and not breastfeeding was 48.8%, 42.2%, and 9.1%, respectively. Compared to toddlers with exclusive breastfeeding, toddlers with partial breastfeeding or without breastfeeding had higher odds of having ASD (odd ratios [OR]: 1.55, 95% confidence interval [CI]: 0.90-2.74; OR: 2.34, 95% CI: 1.10-4.82). We did not find significant modification of demographic characteristics on the associations. The results remained robust in multiple sensitivity analyses. Toddlers without breastfeeding for the first six months of life had higher odds of having ASD, and our findings shed light on the necessity of strengthening public health efforts to increase exclusive breastfeeding in China.