Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment

Importance

Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months' corrected age.

Objectives

To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy-specific early intervention that should follow early diagnosis to optimize neuroplasticity and function.

Evidence Review

This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument.

Findings

Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months' corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months' corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence.

Conclusions and Relevance

Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

Management of children with autism spectrum disorders

Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child's ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed.

Minimally verbal school-aged children with autism spectrum disorder: the neglected end of the spectrum

It is currently estimated that about 30% of children with autism spectrum disorder remain minimally verbal, even after receiving years of interventions and a range of educational opportunities. Very little is known about the individuals at this end of the autism spectrum, in part because this is a highly variable population with no single set of defining characteristics or patterns of skills or deficits, and in part because it is extremely challenging to provide reliable or valid assessments of their developmental functioning. In this paper, we summarize current knowledge based on research including minimally verbal children. We review promising new novel methods for assessing the verbal and nonverbal abilities of minimally verbal school-aged children, including eye-tracking and brain-imaging methods that do not require overt responses. We then review what is known about interventions that may be effective in improving language and communication skills, including discussion of both nonaugmentative and augmentative methods. In the final section of the paper, we discuss the gaps in the literature and needs for future research.

Preventing conduct problems in Head Start children: strengthening parenting competencies

The effectiveness of a parenting program with 394 Head Start mothers was examined. Nine Head Start centers were randomly assigned to either an experimental condition in which parents, teachers, and family service workers participated in the intervention or a control condition in which the regular Head Start program was offered. Mothers in the intervention group were observed at home to have significantly fewer critical remarks and commands, to use less harsh discipline, and to be more positive and competent in their parenting when compared with control mothers. Teachers reported that intervention mothers were more involved in their children's education and that their children were more socially competent. Intervention children were observed to exhibit significantly fewer conduct problems, less noncompliance, less negative affect, and more positive affect than control children. One year later most of the improvements were maintained.

Effects of a brief Early Start Denver model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: a randomized controlled trial

OBJECTIVE

This study was carried out to examine the efficacy of a 12-week, low-intensity (1-hour/wk of therapist contact), parent-delivered intervention for toddlers at risk for autism spectrum disorders (ASD) aged 14 to 24 months and their families.

METHOD

A randomized controlled trial involving 98 children and families was carried out in three different sites investigating the efficacy of a parent delivery of the Early Start Denver model (P-ESDM), which fosters parental use of a child-centered responsive interaction style that embeds many teaching opportunities into play, compared to community treatment as usual. Assessments were completed at baseline and 12 weeks later, immediately after the end of parent coaching sessions.

RESULTS

There was no effect of group assignment on parent-child interaction characteristics or on any child outcomes. Both groups of parents improved interaction skills, and both groups of children demonstrated progress. Parents receiving P-ESDM demonstrated significantly stronger working alliances with their therapists than did the community group. Children in the community group received significantly more intervention hours than those in the P-ESDM group. For the group as a whole, both younger child age at the start of intervention and a greater number of intervention hours were positively related to the degree of improvement in children's behavior for most variables.

CONCLUSIONS

Parent-implemented intervention studies for early ASD thus far have not demonstrated the large effects seen in intensive-treatment studies. Evidence that both younger age and more intervention hours positively affect developmental rates has implications for clinical practice, service delivery, and public policy.

CSRP's Impact on low-income preschoolers' preacademic skills: self-regulation as a mediating mechanism

Based on theoretically driven models, the Chicago School Readiness Project (CSRP) targeted low-income children's school readiness through the mediating mechanism of self-regulation. The CSRP is a multicomponent, cluster-randomized efficacy trial implemented in 35 Head Start-funded classrooms (N = 602 children). The analyses confirm that the CSRP improved low-income children's self-regulation skills (as indexed by attention/impulse control and executive function) from fall to spring of the Head Start year. Analyses also suggest significant benefits of CSRP for children's preacademic skills, as measured by vocabulary, letter-naming, and math skills. Partial support was found for improvement in children's self-regulation as a hypothesized mediator for children's gains in academic readiness. Implications for programs and policies that support young children's behavioral health and academic success are discussed.

Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants

BACKGROUND

Infants born preterm are at increased risk of developing cognitive and motor impairment compared with infants born at term. Early developmental interventions have been provided in the clinical setting with the aim of improving overall functional outcomes for these infants. Long-term benefits of these programmes remain unclear.

OBJECTIVES

Primary objective To compare the effectiveness of early developmental intervention programmes provided post hospital discharge to prevent motor or cognitive impairment in preterm (< 37 weeks) infants versus standard medical follow-up of preterm infants at infancy (zero to < three years), preschool age (three to < five years), school age (five to < 18 years) and adulthood (≥ 18 years). Secondary objectives To perform subgroup analyses to determine the following.• Effects of gestational age, birth weight and brain injury (periventricular leukomalacia (PVL)/intraventricular haemorrhage (IVH)) on cognitive and motor outcomes when early intervention is compared with standard follow-up. ∘ Gestational age: < 28 weeks, 28 to < 32 weeks, 32 to < 37 weeks. ∘ Birth weight: < 1000 grams, 1000 to < 1500 grams, 1500 to < 2500 grams. ∘ Brain injury: absence or presence of grade III or grade IV IVH or cystic PVL (or both) or an abnormal ultrasound/magnetic resonance image (MRI) before initiation of the intervention.• Effects of interventions started during inpatient stay with a post-discharge component versus standard follow-up care.• Effects of interventions focused on the parent-infant relationship, infant development or both compared with standard follow-up care.To perform sensitivity analysis to identify the following.• Effects on motor and cognitive impairment when early developmental interventions are provided within high-quality randomised trials with low risk of bias for sequence generation, allocation concealment, blinding of outcome measures and selective reporting bias.

SEARCH METHODS

The search strategy of the Cochrane Neonatal Review Group was used to identify randomised and quasi-randomised controlled trials of early developmental interventions provided post hospital discharge. Two review authors independently searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Advanced, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE (1966 to August 2015).

SELECTION CRITERIA

Studies included had to be randomised or quasi-randomised controlled trials of early developmental intervention programmes that began within the first 12 months of life for infants born before 37 weeks' gestational age. Interventions could commence on an inpatient basis but had to include a post-discharge component for inclusion in this review. Outcome measures were not prespecified, other than that they had to assess cognitive outcomes, motor outcomes or both. Rates of cerebral palsy were documented.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted and entered data. Cognitive and motor outcomes were pooled by four age groups: infancy (zero to < three years), preschool age (three to < five years), school age (five to < 18 years) and adulthood (≥ 18 years). Meta-analysis using RevMan 5.1 was carried out to determine the effects of early developmental interventions at each age range. Subgroup analyses focused on gestational age, birth weight, brain injury, commencement of the intervention, focus of the intervention and study quality.

MAIN RESULTS

Twenty-five studies met the inclusion criteria (3615 randomly assigned participants). Only 12 of these studies were randomised controlled trials with appropriate allocation concealment. Variability was evident with regard to focus and intensity of the intervention, participant characteristics and length of follow-up. Meta-analysis led to the conclusion that intervention improved cognitive outcomes at infancy (developmental quotient (DQ): standardised mean difference (SMD) 0.32 standard deviations (SDs), 95% confidence interval (CI) 0.16 to 0.47; P value < 0.001; 16 studies; 2372 participants) and at preschool age (intelligence quotient (IQ); SMD 0.43 SDs, 95% CI 0.32 to 0.54; P value < 0.001; eight studies; 1436 participants). However, this effect was not sustained at school age (IQ: SMD 0.18 SDs, 95% CI -0.08 to 0.43; P value = 0.17; five studies; 1372 participants). Heterogeneity between studies for cognitive outcomes at infancy and at school age was significant. With regards to motor outcomes, meta-analysis of 12 studies showed a significant effect in favour of early developmental interventions at infancy only; however, this effect was small (motor scale DQ: SMD 0.10 SDs, 95% CI 0.01 to 0.19; P value = 0.03; 12 studies; 1895 participants). No effect was noted on the rate of cerebral palsy among survivors (risk ratio (RR) 0.82, 95% CI 0.52 to 1.27; seven studies; 985 participants). Little evidence showed a positive effect on motor outcomes in the long term, but only five included studies reported outcomes at preschool age (n = 3) or at school age (n = 2).

AUTHORS' CONCLUSIONS

Early intervention programmes for preterm infants have a positive influence on cognitive and motor outcomes during infancy, with cognitive benefits persisting into preschool age. A great deal of heterogeneity between studies was due to the variety of early developmental intervention programmes tested and to gestational ages of included preterm infants; thus, comparisons of intervention programmes were limited. Further research is needed to determine which early developmental interventions are most effective in improving cognitive and motor outcomes, and to discern the longer-term effects of these programmes.

Early intervention and early experience

For 4 decades, vigorous efforts have been based on the premise that early intervention for children of poverty and, more recently, for children with developmental disabilities can yield significant improvements in cognitive, academic, and social outcomes. The history of these efforts is briefly summarized and a conceptual framework presented to understand the design, research, and policy relevance of these early interventions. This framework, biosocial developmental contextualism, derives from social ecology, developmental systems theory, developmental epidemiology, and developmental neurobiology. This integrative perspective predicts that fragmented, weak efforts in early intervention are not likely to succeed, whereas intensive, high-quality, ecologically pervasive interventions can and do. Relevant evidence is summarized in 6 principles about efficacy of early intervention. The public policy challenge in early intervention is to contain costs by more precisely targeting early interventions to those who most need and benefit from these interventions. The empirical evidence on biobehavioral effects of early experience and early intervention has direct relevance to federal and state policy development and resource allocation.

Parent implemented early intervention for young children with autism spectrum disorder: a systematic review

BACKGROUND

Recent estimates concerning the prevalence of autism spectrum disorder (ASD) suggest that at least one in 200 children is affected. This group of children and families have important service needs. The involvement of parents in implementing intervention strategies designed to help their autistic children has long been accepted as helpful. The potential benefits are increased skills and reduced stress for parents as well as children.

METHODS

This research review focused on interventions for children aged 1-6 years, and was carried out using systematic methodology: a comprehensive search of psychological, educational and biomedical databases, as well as bibliographies and reference lists of key articles, contact with experts in the field, and hand search of key journals. Only studies which involved a concurrent element of control were included.

RESULTS

The review found very few studies that had adequate research design from which to draw conclusions about the effectiveness of parent-implemented early intervention. Both randomized and controlled studies tended to suggest that parent training leads to improved child communicative behaviour, increased maternal knowledge of autism, enhanced maternal communication style and parent child interaction, and reduced maternal depression.

CONCLUSION

It seems that parent training can successfully contribute to intervention for young children with ASD. However, the review highlights the need for improved research in this area.

Efficacy of early interventions for infants and young children with, and at risk for, autism spectrum disorders

With advances in the field's ability to identify autism spectrum disorders (ASD) at younger ages, the need for information about the evidence-base for early intervention continues to rise. This review of the ASD early intervention (EI) literature focuses on efficacy studies published within the past 15 years. The neurodevelopmental context for early intervention, timing of initiating intervention, primary intervention approaches, and predictors of treatment outcomes are discussed. The evidence indicates that young children with ASD benefit from EI, and their parents learn to implement child-responsive engagement strategies when a parent-coaching intervention is provided. Evidence supports combining parent-mediated and direct clinician-implemented intervention to maximize child developmental gains. Clinical practice recommendations are presented, based on the literature reviewed.

Indulgent feeding style and children's weight status in preschool

PURPOSE

The primary aim of this study was to examine whether parent affect and child temperament characteristics differ across feeding styles in low-income families, given suggestive evidence. The secondary aim was to examine whether feeding styles were still related to children's body mass index independent of parent affect, child temperament, and known correlates.

METHODS

Participants in this study were 718 parents of children attending Head Start programs across two sites (Texas and Alabama). Parents were categorized into feeding styles of authoritative (n = 118), authoritarian (n = 219), indulgent (n = 240) and uninvolved (n = 141) using a parent-report questionnaire characterizing feeding in a general parenting paradigm. Parents completed questionnaires and measured height and weight was obtained from parents and children.

RESULTS

Differences were found across feeding styles on parent affect and child temperament characteristics. Indulgent parents reported lower Negative Affect for themselves and lower Negative Affectivity for their children. The indulgent feeding style was significantly associated with higher child body mass index after controlling for parent affect, child temperament, and correlates (ethnicity, child age, parent body mass index).

CONCLUSIONS

The results of this study not only show a robust association between the indulgent feeding style and weight status of low-income preschool children, but also suggest how congruence between parent emotional affect and child temperament characteristics may contribute to excess consumption among children of indulgent parents.

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD)

BACKGROUND

The rising prevalence of autism spectrum disorders (ASD) increases the need for evidence-based behavioral treatments to lessen the impact of symptoms on children's functioning. At present, there are no curative or psychopharmacological therapies to effectively treat all symptoms of the disorder. Early intensive behavioral intervention (EIBI), a treatment based on the principles of applied behavior analysis delivered for multiple years at an intensity of 20 to 40 hours per week, is one of the more well-established treatments for ASD.

OBJECTIVES

To systematically review the evidence for the effectiveness of EIBI in increasing the functional behaviors and skills of young children with ASD.

SEARCH METHODS

We searched the following databases on 22 November 2011: CENTRAL (2011 Issue 4), MEDLINE (1948 to November Week 2, 2011), EMBASE (1980 to Week 46, 2011), PsycINFO (1806 to November Week 3, 2011), CINAHL (1937 to current), ERIC (1966 to current), Sociological Abstracts (1952 to current), Social Science Citation Index (1970 to current), WorldCat, metaRegister of Controlled Trials, and Networked Digital Library of Theses and Dissertations. We also searched the reference lists of published papers.

SELECTION CRITERIA

Randomized control trials (RCTs), quasi-randomized control trials, or clinical control trials (CCTs) in which EIBI was compared to a no-treatment or treatment-as-usual control condition. Participants must have been less than six years of age at treatment onset and assigned to their study condition prior to commencing treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently selected and appraised studies for inclusion and assessed the risk of bias in each included study. All outcome data were continuous, from which standardized mean difference effect sizes with small sample correction were calculated. We conducted random-effects meta-analysis where possible, which means we assumed individual studies would provide different estimates of treatment effects.

MAIN RESULTS

One RCT and four CCTs with a total of 203 participants were included. Reliance on synthesis from four CCTs limits the evidential base and this should be borne in mind when interpreting the results. All studies used a treatment-as-usual comparison group. We synthesized the results of the four CCTs using a random-effects model of meta-analysis of the standardized mean differences. Positive effects in favor of the EIBI treatment group were found for all outcomes. The mean effect size for adaptive behavior was g = 0.69 (95% CI 0.38 to 1.01; P < 0.0001). The mean effect size for IQ was g = 0.76 (95% CI 0.40 to 1.11; P < 0.0001). Three measures of communication and language skills all showed results in favor of EIBI: expressive language g = 0.50 (95% CI 0.05 to 0.95; P = 0.03), receptive language g = 0.57 (95% CI 0.20 to 0.94; P = .03), and daily communication skills g = 0.74 (95% CI 0.30 to 1.18; P = 0.0009). The mean effect size for socialization was g = 0.42 (95% CI 0.11 to 0.73; P = 0.0008), and for daily living skills was g = 0.55 (95% CI 0.24 to 0.87; P = 0.0005). Additional descriptive analyses of other aspects related to quality of life and psychopathology are presented. However, due to the inclusion of non-randomized studies, there is a high risk of bias and the overall quality of evidence was rated as 'low' using the GRADE system, which rates the quality of evidence from meta-analyses to determine recommendations for practice.

AUTHORS' CONCLUSIONS

There is some evidence that EIBI is an effective behavioral treatment for some children with ASD. However, the current state of the evidence is limited because of the reliance on data from non-randomized studies (CCTs) due to the lack of RCTs. Additional studies using RCT research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD.

Behavioural and developmental interventions for autism spectrum disorder: a clinical systematic review

BACKGROUND

Much controversy exists regarding the clinical efficacy of behavioural and developmental interventions for improving the core symptoms of autism spectrum disorders (ASD). We conducted a systematic review to summarize the evidence on the effectiveness of behavioural and developmental interventions for ASD.

METHODS AND FINDINGS

Comprehensive searches were conducted in 22 electronic databases through May 2007. Further information was obtained through hand searching journals, searching reference lists, databases of theses and dissertations, and contacting experts in the field. Experimental and observational analytic studies were included if they were written in English and reported the efficacy of any behavioural or developmental intervention for individuals with ASD. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively and, where possible, meta-analyses of the study results were conducted. One-hundred-and-one studies at predominantly high risk of bias that reported inconsistent results across various interventions were included in the review. Meta-analyses of three controlled clinical trials showed that Lovaas treatment was superior to special education on measures of adaptive behaviour, communication and interaction, comprehensive language, daily living skills, expressive language, overall intellectual functioning and socialization. High-intensity Lovaas was superior to low-intensity Lovaas on measures of intellectual functioning in two retrospective cohort studies. Pooling the results of two randomized controlled trials favoured developmental approaches based on initiative interaction compared to contingency interaction in the amount of time spent in stereotyped behaviours and distal social behaviour, but the effect sizes were not clinically significant. No statistically significant differences were found for: Lovaas versus special education for non-verbal intellectual functioning; Lovaas versus Developmental Individual-difference relationship-based intervention for communication skills; computer assisted instruction versus no treatment for facial expression recognition; and TEACCH versus standard care for imitation skills and eye-hand integration.

CONCLUSIONS

While this review suggests that Lovaas may improve some core symptoms of ASD compared to special education, these findings are based on pooling of a few, methodologically weak studies with few participants and relatively short-term follow-up. As no definitive behavioural or developmental intervention improves all symptoms for all individuals with ASD, it is recommended that clinical management be guided by individual needs and availability of resources.

Parent training in head start: a comparison of program response among African American, Asian American, Caucasian, and Hispanic mothers

The effectiveness of the Incredible Years Parenting Program was evaluated in a low-income sample of Caucasian, African American, Hispanic, and Asian mothers whose children were enrolled in Head Start. Data from two prior intervention studies [Webster-Stratton (1998) Journal of Consulting and Clinical Psychology, 66(5), 715-730; Webster-Stratton et al. (in press) Journal of Clinical Child Psychology] were combined, yielding a sample of 634 families (370 Caucasian, 120 African American, 73 Asian, 71 Hispanic) across 23 Head Start centers. Centers were matched and assigned randomly to either an experimental condition (8-12 weeks of weekly 2-hr parenting classes), or a control condition (the regular Head Start Program without parenting groups). Families in both conditions were assessed using home observations of parent-child interactions and parent reports of parenting style and discipline strategies and child behavior problems in the fall (baseline) and spring (postintervention) of the children's Head Start year. Families were reassessed 1 year later. Following treatment, intervention mothers were observed to be more positive, less critical, more consistent, and more competent in their parenting than were control mothers. Additionally, children of intervention parents were observed to exhibit fewer behavior problems than were control children. Differences in treatment response across ethnic groups were few, and did not exceed the number expected by chance. Parents from all groups reported high satisfaction levels following the parenting program. Results indicate that the Incredible Years Program is accepted by and effective with diverse populations.

Efficacy of language intervention in the early years

BACKGROUND

Oral language skills in the preschool and early school years are critical to educational success and provide the foundations for the later development of reading comprehension.

METHODS

In a randomized controlled trial, 180 children from 15 UK nursery schools (n = 12 from each setting; M(age) = 4;0) were randomly allocated to receive a 30-week oral language intervention or to a waiting control group. Children in the intervention group received 30 weeks of oral language intervention, beginning in nursery (preschool), in three group sessions per week, continuing with daily sessions on transition to Reception class (pre-Year 1). The intervention was delivered by nursery staff and teaching assistants trained and supported by the research team. Following screening, children were assessed preintervention, following completion of the intervention and after a 6-month delay.

RESULTS

Children in the intervention group showed significantly better performance on measures of oral language and spoken narrative skills than children in the waiting control group immediately after the 30 week intervention and after a 6 month delay. Gains in word-level literacy skills were weaker, though clear improvements were observed on measures of phonological awareness. Importantly, improvements in oral language skills generalized to a standardized measure of reading comprehension at maintenance test.

CONCLUSIONS

Early intervention for children with oral language difficulties is effective and can successfully support the skills, which underpin reading comprehension.

Child development and long-term outcomes: a population health perspective and summary of successful interventions

Studies of socioeconomic gradients in mortality in wealthy societies reveal that they have been persist, and included most of the principal causes of death, even during the era when these principal causes of death have entirely changed. This observation has led to an interest in the ways in which the diversity of conditions of life, unfolding over the life cycle, can become embedded in human biology and subsequently affect health status and vitality. There is evidence that childhood experiences affect subsequent health status (as well as well-being and competence) in profound and long-lasting ways. Conflicting explanatory models of the impact of childhood experiences have been advanced, whose conflicts are political in nature, in that the reflect divergent beliefs about how human potential expresses itself, and, also, about the nature of the obligations which members of society have to one another. Notwithstanding these conflicts, a body of evidence derived from intervention studies in the post-neonatal, preschool, and school age periods suggest that performance in two basic domains of child development, the cognitive and the social-emotional, can be modified in ways which improve health, well-being, and competence in the long-term.

Early intervention and prevention of anxiety disorders in children: results at 2-year follow-up

The Queensland Early Intervention and Prevention of Anxiety Project evaluated a child- and family-focused group intervention for preventing anxiety problems in children. This article reports on 12- and 24-month follow-up data to previously reported outcomes at posttreatment and at 6-month follow-up. A total of 1,786 7- to 14-year-olds were screened for anxiety problems using teacher nominations and children's self-report. After diagnostic interviews, 128 children were selected and assigned to either a 10-week school-based child- and parent-focused psychosocial intervention or a monitoring group. Both groups showed improvements immediately at postintervention and at 6-month follow-up; the improvement was maintained in the intervention group only reducing the rate of existing anxiety disorder and preventing the onset of new anxiety disorders. At 12 months, the groups converged, but the superiority of the intervention group was evident again at 2-year follow-up. Severity of pretreatment diagnoses, gender, and parental anxiety predicted poor initial response to intervention, whereas pretreatment severity was the only predictor of chronicity at 24 months. Overall, follow-up results show that a brief school-based intervention for children can produce durable reductions in anxiety problems.

Parent-mediated early intervention for young children with autism spectrum disorders (ASD)

BACKGROUND

Young children with autism spectrum disorders (ASD) have impairments in the areas of communication and social interaction and often display repetitive or non-compliant behaviour. This early pattern of difficulties is a challenge for parents. Therefore, approaches that help parents develop strategies for interaction and management of behaviour are an obvious route for early intervention in ASD. This review updates a Cochrane review first published in 2002 but is based on a new protocol.

OBJECTIVES

To assess the effectiveness of parent-mediated early interventions in terms of the benefits for both children with ASD and their parents and to explore some potential moderators of treatment effect.

SEARCH METHODS

We searched a range of psychological, educational and biomedical databases including CENTRAL, MEDLINE, Embase, PsycINFO and ERIC in August 2012. As this is an update of a previous review, we limited the search to the period following the original searches in 2002. Bibliographies and reference lists of key articles were searched, field experts were contacted and key journals were handsearched.

SELECTION CRITERIA

We included only randomised controlled trials of early intervention for children with ASD. The interventions in the experimental condition were mediated by parents; the control conditions included no treatment, treatment as usual, waiting list, alternative child-centred intervention not mediated by parents, or alternative parent-mediated intervention of hypothesised lesser effect than the experimental condition.

DATA COLLECTION AND ANALYSIS

Two review authors (HM and IPO) independently screened articles identified in the search and decided which articles should be retrieved in full. For each included study, two review authors (IPO and EH) extracted and recorded data, using a piloted data collection form. Two review authors (IPO and HM) assessed the risk of bias in each study. We performed data synthesis and analysis using The Cochrane Collaboration's Review Manager 5.1 software.

MAIN RESULTS

The review includes 17 studies from six countries (USA, UK, Australia, Canada, Thailand and China), which recruited 919 children with ASD. Not all 17 studies could be compared directly or combined in meta-analyses due to differences in the theoretical basis underpinning interventions, the duration and intensity of interventions, and the outcome measurement tools used. Data from subsets of 10 studies that evaluated interventions to enhance parent interaction style and thereby facilitate children's communication were included in meta-analyses. The largest meta-analysis combined data from 316 participants in six studies and the smallest combined data from 55 participants in two studies. Findings from the remaining seven studies were reported narratively.High risk of bias was evident in the studies in relation to allocation concealment and incomplete outcome data; blinding of participants was not possible.Overall, we did not find statistical evidence of gains from parent-mediated approaches in most of the primary outcomes assessed (most aspects of language and communication - whether directly assessed or reported; frequency of child initiations in observed parent-child interaction; child adaptive behaviour; parents' stress), with findings largely inconclusive and inconsistent across studies. However, the evidence for positive change in patterns of parent-child interaction was strong and statistically significant (shared attention: standardised mean difference (SMD) 0.41; 95% confidence interval (CI) 0.14 to 0.68, P value < 0.05; parent synchrony: SMD 0.90; 95% CI 0.56 to 1.23, P value < 0.05). Furthermore, there is some evidence suggestive of improvement in child language comprehension, reported by parents (vocabulary comprehension: mean difference (MD 36.26; 95% CI 1.31 to 71.20, P value < 0.05). In addition, there was evidence suggesting a reduction in the severity of children's autism characteristics (SMD -0.30, 95% CI -0.52 to -0.08, P value < 0.05). However, this evidence of change in children's skills and difficulties as a consequence of parent-mediated intervention is uncertain, with small effect sizes and wide CIs, and the conclusions are likely to change with future publication of high-quality RCTs.

AUTHORS' CONCLUSIONS

The review finds some evidence for the effectiveness of parent-mediated interventions, most particularly in proximal indicators within parent-child interaction, but also in more distal indicators of child language comprehension and reduction in autism severity. Evidence of whether such interventions may reduce parent stress is inconclusive. The review reinforces the need for attention to be given to early intervention service models that enable parents to contribute skilfully to the treatment of their child with autism. However, practitioners supporting parent-mediated intervention require to monitor levels of parent stress. The ability to draw conclusions from studies would be improved by researchers adopting a common set of outcome measures as the quality of the current evidence is low.

Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD)

BACKGROUND

The rising prevalence of autism spectrum disorders (ASD) increases the need for evidence-based behavioral treatments to lessen the impact of symptoms on children's functioning. At present, there are no curative or psychopharmacological therapies to effectively treat all symptoms of the disorders. Early intensive behavioral intervention (EIBI) is a treatment based on the principles of applied behavior analysis. Delivered for multiple years at an intensity of 20 to 40 hours per week, it is one of the more well-established treatments for ASD. This is an update of a Cochrane review last published in 2012.

OBJECTIVES

To systematically review the evidence for the effectiveness of EIBI in increasing functional behaviors and skills, decreasing autism severity, and improving intelligence and communication skills for young children with ASD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 12 additional electronic databases and two trials registers in August 2017. We also checked references and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized control trials (RCTs), quasi-RCTs, and controlled clinical trials (CCTs) in which EIBI was compared to a no-treatment or treatment-as-usual control condition. Participants must have been less than six years of age at treatment onset and assigned to their study condition prior to commencing treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.We synthesized the results of the five studies using a random-effects model of meta-analysis, with a mean difference (MD) effect size for outcomes assessed on identical scales, and a standardized mean difference (SMD) effect size (Hedges' g) with small sample correction for outcomes measured on different scales. We rated the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies (one RCT and four CCTs) with a total of 219 children: 116 children in the EIBI groups and 103 children in the generic, special education services groups. The age of the children ranged between 30.2 months and 42.5 months. Three of the five studies were conducted in the USA and two in the UK, with a treatment duration of 24 months to 36 months. All studies used a treatment-as-usual comparison group.Primary outcomesThere is low quality-evidence at post-treatment that EIBI improves adaptive behaviour (MD 9.58 (assessed using Vineland Adaptive Behavior Scale (VABS) Composite; normative mean = 100, normative SD = 15), 95% confidence interval (CI) 5.57 to 13.60, P < 0.0001; 5 studies, 202 participants), and reduces autism symptom severity (SMD -0.34, 95% CI -0.79 to 0.11, P = 0.14; 2 studies, 81 participants; lower values indicate positive effects) compared to treatment as usual.No adverse effects were reported across studies.Secondary outcomesThere is low-quality evidence at post-treatment that EIBI improves IQ (MD 15.44 (assessed using standardized IQ tests; scale 0 to 100, normative SD = 15), 95% CI 9.29 to 21.59, P < 0.001; 5 studies, 202 participants); expressive (SMD 0.51, 95% CI 0.12 to 0.90, P = 0.01; 4 studies, 165 participants) and receptive (SMD 0.55, 95% CI 0.23 to 0.87, P = 0.001; 4 studies, 164 participants) language skills; and problem behaviour (SMD -0.58, 95% CI -1.24 to 0.07, P = 0.08; 2 studies, 67 participants) compared to treatment as usual.

AUTHORS' CONCLUSIONS

There is weak evidence that EIBI may be an effective behavioral treatment for some children with ASD; the strength of the evidence in this review is limited because it mostly comes from small studies that are not of the optimum design. Due to the inclusion of non-randomized studies, there is a high risk of bias and we rated the overall quality of evidence as 'low' or 'very low' using the GRADE system, meaning further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.It is important that providers of EIBI are aware of the current evidence and use clinical decision-making guidelines, such as seeking the family's input and drawing upon prior clinical experience, when making recommendations to clients on the use EIBI. Additional studies using rigorous research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD.

A two-year prospective follow-up study of community-based early intensive behavioural intervention and specialist nursery provision for children with autism spectrum disorders

BACKGROUND

This prospective study compared outcome for pre-school children with autism spectrum disorders (ASD) receiving autism-specific nursery provision or home-based Early Intensive Behavioural Interventions (EIBI) in a community setting.

METHODS

Forty-four 23- to 53-month-old children with ASD participated (28 in EIBI home-based programmes; 16 in autism-specific nurseries). Cognitive, language, play, adaptive behaviour skills and severity of autism were assessed at intake and 2 years later.

RESULTS

Both groups showed improvements in age equivalent scores but standard scores changed little over time. At follow-up, there were no significant group differences in cognitive ability, language, play or severity of autism. The only difference approaching significance (p = .06), in favour of the EIBI group, was for Vineland Daily Living Skills standard scores. However, there were large individual differences in progress, with intake IQ and language level best predicting overall progress.

CONCLUSIONS

Home-based EIBI, as implemented in the community, and autism-specific nursery provision produced comparable outcomes after two years of intervention.

Barriers to, and facilitators of, parenting programmes for childhood behaviour problems: a qualitative synthesis of studies of parents' and professionals' perceptions

Disruptive behaviour problems (DBPs) during childhood exert a high burden on individuals, families and the community as a whole. Reducing this impact is a major public health priority. Early parenting interventions are recommended as valuable ways to target DBPs; however, low take-up of, and high drop-out rates from, these programmes seriously reduce their effectiveness. We present a review of published qualitative evidence relating to factors that block or facilitate access and engagement of parents with such programmes using a thematic synthesis approach. 12 papers presenting views of both parents and professionals met our inclusion and quality criteria. A large number of barriers were identified highlighting the array of challenges parents can face when considering accessing and engaging with treatment for their child with behavioural problems. Facilitating factors in this area were also identified. A series of recommendations were made with regard to raising awareness of programmes and recruiting parents, providing flexible and individually tailored support, delivering programmes through highly skilled, trained and knowledgeable therapists, and highlighting factors to consider when delivering group-based programmes. Clinical guidelines should address barriers and facilitators of engagement as well as basic efficacy of treatment approaches.

Behavioral family intervention for children with developmental disabilities and behavioral problems

The outcomes of a randomized clinical trial of a new behavioral family intervention, Stepping Stones Triple P, for preschoolers with developmental and behavior problems are presented. Forty-eight children with developmental disabilities participated, 27 randomly allocated to an intervention group and 20 to a wait-list control group. Parents completed measures of parenting style and stress, and independent observers assessed parent-child interactions. The intervention was associated with fewer child behavior problems reported by mothers and independent observers, improved maternal and paternal parenting style, and decreased maternal stress. All effects were maintained at 6-month follow-up.

Telehealth and autism: A systematic search and review of the literature

PURPOSE

Research interest in telehealth and autism spectrum disorder (ASD) has grown. There is a need to review the literature to allow speech-language pathologists (SLPs) and other service providers to consider applicability to their settings. The aim of this review was to examine the nature and outcomes of studies examining telehealth assessment and/or intervention in ASD.

METHOD

A systematic search of the literature was undertaken, with 14 studies meeting inclusion criteria. The authors extracted information from each included article, including participant characteristics, technology used, measures and reported outcomes. Quality review of articles was undertaken.

RESULT

The 284 participants with ASD across the 14 included studies ranged in age from 19 months to adulthood. The quality of the studies varied. A range of services were provided via telehealth, including diagnostic assessments, early intervention and language therapy. Results suggested that services delivered via telehealth were equivalent to services delivered face to face, and superior to comparison groups without telehealth sessions.

CONCLUSION

The findings suggest there may be a range of benefits in using telehealth with individuals with ASD, their families, and teachers. Further research, however, is required particularly regarding the use of telehealth directly with children with ASD for assessment and intervention.