Responding to Autism in Low and Middle Income Countries (LMIC): What to Do and What Not to Do

Video-based interventions promoting social behavioural skills for autistic children and young people: An evidence and gap map

Background

Video-based interventions (VBIs) are an approach that can be used to promote social behavioural skills for autistic children and young people. Despite an abundance of literature in this area, previous evidence syntheses are limited by their exclusive search strategies and eligibility criteria. Therefore, there is a lack of comprehensive evidence syntheses to provide insight on whether these interventions work, for whom, and in what circumstances. Evidence and Gap Maps (EGMs) are used to collate vast literature on a broad topic area such as this, highlighting areas for synthesis, and identifying gaps for future research.

Objectives

To identify, map and synthesise existing primary research on VBIs promoting social behavioural skills for autistic children and young people, creating a live, searchable and publicly available EGM.

Search Methods

Searches were conducted in electronic databases (n = 8), web search engines, and other repositories including published papers and grey literature. The search strategy was developed around two concepts including (1) terms related to autism, and (2) terms related to VBIs. Searches were conducted in May 2021.

Selection Criteria

All primary studies evaluating the effectiveness of VBIs in promoting social behaviours for autistic children and young people aged 3-18 were included in the EGM.

Data Collection and Analysis

Search results were imported into Eppi-Reviewer where duplicates of identical studies were removed. Titles and abstracts were then screened by two independent reviewers. Potentially eligible full texts were located and also screened by two reviewers. Data were then extracted on study design, participant characteristics, type of intervention, type of outcome, and country of study, by one of three reviewers. EPPI-Mapper was used to create the interactive EGM.

Main Results

The current EGM contains 438 studies reporting on 394 single subject research designs, 25 randomised controlled trials, 15 non-randomised group designs, and 8 pretest-posttest designs. Included studies evaluated VBIs in all male (n = 238), mixed gender (n = 172) or all female (n = 17) samples. VBIs employed included video modelling (n = 273), video self-modelling (n = 82), point-of-view modelling (n = 61), video prompting (n = 57), video feedback (n = 12) and computer-based video instruction (n = 4). The most frequently used models were adults (n = 191) and peers (n = 135). In relation to social outcomes, almost half evaluated social engagement (n = 199) with limited studies looking at safety (n = 9) and community (n = 7) skills.

Authors' Conclusions

This EGM provides a valuable resource for policy-makers, practitioners, researchers, funders and members of the public to access evidence on VBIs promoting social behavioural skills in autistic children and young people. The map has identified areas of sufficient research where evidence can undergo synthesis. In addition, important gaps in the evidence were highlighted and suggest further research is warranted in all female samples and less frequently evaluated types of VBIs and social outcomes. Evidence included in this EGM will be further explored via systematic review and meta-analysis on control group designs.

Nurturing the Positive Mental Health of Autistic Children, Adolescents and Adults alongside That of Their Family Care-Givers: A Review of Reviews

The rising prevalence of autism internationally has been accompanied by an increased appreciation of the poorer mental health experienced by people with this condition and also of their family care-givers. In particular, higher incidences of anxiety and depression are reported in high-income nations and these conditions are likely to be under-recognised and under-reported in lower-resourced regions or countries. Mainstream mental health services seem to be ill-equipped to respond adequately to the needs of autistic persons and their care-givers. This literature review of 29 recently published reviews covering nearly 1000 journal articles summarises the insights and strategies that have been shown to promote the mental health and emotional wellbeing of autistic persons. In particular, a focus on family-centred, community-based supports is recommended that aim to enhance social communication, extend social connections and promote an individual's self-esteem, self-determination and social motivation. These low-cost interventions are especially pertinent in low-resourced settings, but they can be used internationally to prevent mental illness and assist in the treatment of anxiety and depression in autistic persons and their family carers. The priority is to focus on primary-care responses with cross-sectoral working rather than investing in high-cost psychiatric provision.

Parental developmental screening with CARE: A pilot hybrid assessment and intervention with vulnerable families in Colombia

Poverty and scarcity of resources make children in low-and-middle-income countries at risk of not reaching their developmental potential. Despite a near-universal interest in risk reduction, effective interventions like enhancing reading skills in parents to diminish developmental delay remain elusive for the great majority of vulnerable families. We undertook a efficacy study for parental use of a booklet called CARE for developmental screening of children between 36 to 60 months old (M = 44.0, SD = 7.5). All participants (N = 50), lived in vulnerable, low-income neighborhoods in Colombia. The study followed a pilot Quasi-Randomised Control Trial design (i.e., control group participants assigned based on non-random criteria) of parent training with a CARE intervention group compared to a control group. Data was analyzed using two-way ANCOVA for sociodemographic variables' interaction with follow-up results and one-way ANCOVA to evaluate the relations between the intervention and post-measurement of developmental delays and cautions and other language related-skills outcomes, while controlling for pre-measurements. These analyses indicated that the CARE booklet intervention enhanced children's developmental status and narrative skills (developmental screening delay items, F(1, 47) = 10.45, p = .002, partial η2 = .182; narrative devices scores, F(1, 17) = 4.87, p = .041, partial η2 = .223). Several limitations (e.g., sample size) and possible implications for the analysis of children's developmental potential are discussed and considered for future research, along with the effects of the COVID-19 pandemic on the closure of preschools and community care centers.

Exposure to Methylmercury at Juvenile Stage Worsens Autism-like Symptoms in Adult BTBR T+tf/J Mice Due to Lack of Nuclear Factor Erythroid 2-Related Factor 2 Signaling Upregulation in Periphery and Brain

Autism spectrum disorder (ASD) is a multifaceted developmental condition that first appears in infancy. The condition is characterized by recurrent patterns in behavior and impairments in social and vocalization abilities. Methylmercury is a toxic environmental pollutant, and its derivatives are the major source of organic mercury to human beings. Inorganic mercury, which is released from a variety of pollutants into oceans, rivers, and streams, is transformed into methylmercury by bacteria and plankton in the water, which later builds up in fish and shellfish, and then enters humans through the consumption of fish and shellfish and increases the risk of developing ASD by disturbing the oxidant-antioxidant balance. However, there has been no prior research to determine the effect of juvenile exposure of methylmercury chloride on adult BTBR mice. Therefore, the current study evaluated the effect of methylmercury chloride administered during the juvenile stage on autism-like behavior (three-chambered sociability, marble burying, self-grooming tests) and oxidant-antioxidant balance (specifically Nrf2, HO-1, SOD-1, NF-kB, iNOS, MPO, and 3-nitrotyrosine) in the peripheral neutrophils and cortex of adult BTBR and C57BL/6 (B6) mice. Our results show that exposure to methylmercury chloride at a juvenile stage results in autism-like symptoms in adult BTBR mice which are related to a lack of upregulation of the Nrf2 signaling pathway as demonstrated by no significant changes in the expression of Nrf2, HO-1, and SOD-1 in the periphery and cortex. On the other hand, methylmercury chloride administration at a juvenile stage increased oxidative inflammation as depicted by a significant increase in the levels of NF-kB, iNOS, MPO, and 3-nitrotyrosine in the periphery and cortex of adult BTBR mice. This study suggests that juvenile exposure to methylmercury chloride contributes to the worsening of autism-like behavior in adult BTBR mice through the disruption of the oxidant-antioxidant balance in the peripheral compartment and CNS. Strategies that elevate Nrf2 signaling may be useful to counteract toxicant-mediated worsening of ASD and may improve quality of life.