Preschool based JASPER intervention in minimally verbal children with autism: pilot RCT

Sensory-movement underpinnings of lifelong neurodivergence: getting a grip on autism

While the autism diagnosis emphasizes "deficits" in social communication, the article advances that sensory-movement differences underpin autism through a review of the following sources of evidence. This account critically challenges "autistic regression", with evidence that sensory-movement features appear by birth as the earliest signs of autism and underlie the behavioral differences used for diagnosis, which may reflect adaptations to inherent differences and misunderstandings from others. Sensory and motor differences are salient to autistic people, but they often go underrecognized by others. They cause cascading effects in infancy on behavior and communication through differences in sensorimotor learning, automatic imitation, eye contact, sensory perception, and interests. The article then explains how sensory processing differences may influence reduced perceptual narrowing, which involves a bottom-up information processing style grounded in the surrounding environment. Furthermore, this bottom-up processing may grow from reduced sensory integration in feedback loops potentially involving the cerebellum of the brain. The article then moves into implications for the widespread consequences of these inherent differences on quality of life. The article closes with implications for autism as a construct (including underestimated empathy and pain), testing the theory, providing sensory-sensitive support and acceptance of autistic people, and applications to diverse autistic people. The theory may apply particularly well to autistic women and girls, autistic people with speech divergence, autistic people with ADHD, and autistic people with co-occurring sensory and motor-related neurodivergences. Throughout the article, the theory also provides clinical, neurological, and experiential evidence for sensory and motor differences as lifelong, challenging the notion of "losing" (an) autism (diagnosis) as instead reflecting (risky and not necessarily "successful") camouflaging.

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.

Exploring social stages of play through eye to I© intervention model

The study explores the role of the Eye to I© intervention model in facilitating advancement through social stages of play in which skills contribute to the quality of social interaction and communication in children with autism. Data were collected on 11 participants, ages of 2-6 years, formally diagnosed with autism, receiving Eye to I© Social Communication therapy at Potentials Therapy Center, New Delhi, India. Eye to I© is developed in-house at Potentials and is further discussed in the paper. All participants attended a form of group intervention. A mixed-method design included quantitative measures administered pre and post intervention (Communication DEALL Developmental Checklist, Communication Matrix) and video coding of Social Communication sessions. Qualitative measures were semi-structured parent interviews conducted at the end of intervention. Thematic analysis and quantitative statistical analysis results show that by the end of the Eye to I© intervention period children engaged in social stages of play of greater developmental complexity and showed increased scores in assessments of social skills as well as generalization of skills. This suggests that skill acquisition necessary to directly support two diagnostic criteria areas of autism as per DSM-V; i.e., communication and social interaction occurred during the period of intervention.

Reciprocal Associations Between Language Ability and Social Functioning Development in Pre-verbal Autistic Children

Longitudinal research on language abilities and social functioning in young children suggests that gains in one domain affect gains in the other. However, few studies have examined inter-relations of language and social functioning jointly among young children diagnosed with autism spectrum disorder (ASD). Pre-verbal toddlers with ASD are a group of particular clinical relevance, given that greater language abilities at school entry have been associated with positive long-term adjustment in many areas, including adaptive and social functioning. Reduced attention to and engagement in social interactions among autistic toddlers who are not yet speaking may interfere with language development concurrently and over time. The present study examined reciprocal associations between language ability and social functioning over a 2-year period across three time points in a sample of 90 pre-verbal autistic toddlers using cross-lagged panel analyses conducted in MPlus. Cross-lagged panel analyses revealed significant within-timepoint synchronous correlations, within-domain autoregressive paths over time, and as hypothesized, reciprocal significance in all cross-lagged paths. For very young pre-verbal children with ASD, language ability and social functioning appear to exert concurrent and cascading developmental influences on one another. Targeting both language and social functioning simultaneously may enhance intervention efficacy for very young pre-verbal children with ASD.

Occupational Therapy Practice Guidelines for Autistic People Across the Lifespan

IMPORTANCE

Occupational therapy practitioners need evidence to support interventions that promote subjective well-being among autistic people and their families through optimal engagement and participation in occupations.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews to expand knowledge of interventions that promote access, inclusion, engagement, and optimal participation in occupations that are meaningful to autistic people. Our intent was to foster occupational therapy practitioners' clinical decision-making and reasoning when working with autistic people and their care partners.

METHOD

These Practice Guidelines were developed on the basis of four systematic reviews, supporting evidence and literature, along with continued revisions and integration through an iterative and collaborative process.

RESULTS

A total of 98 articles were included in the systematic reviews, which are the foundation for practice recommendations in these guidelines. Forty-eight of the systematic review articles were used to inform the clinical recommendations included in these Practice Guidelines.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence indicates the need for multidisciplinary, goal-oriented interventions to support autistic people in different contexts. Although there is only emerging evidence in the inclusion of autistic people's strengths, interests, and perspectives to guide occupational therapy interventions, such practices can enhance the delivery of neurodiversity-affirming and trauma-informed practices. In addition, evidence is needed to support participation in activities of daily living (ADLs) for autistic youths. We recommend the use of strengths-based language to describe autistic people and the use of environmental adaptations, care partner education, and coaching to enhance occupational therapy service delivery. Plain-Language Summary: The literature is sparse regarding neurodiversity-affirming and trauma-informed practices for autistic youths, as well as for participation in activities of daily living (ADLs). These Practice Guidelines provide new information on positive mental health development; self-determination; ADLs, instrumental ADLs, play, and leisure occupations for children, adolescents, and adults; person-centered planning for adolescents and adults; and rest and sleep. Information on health management is also provided. 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). However, we respect the use of person-first language and have made a conscious decision to include research articles that have used this language.

Play brick therapy to aid the social skills of children and young people with autism spectrum disorder: the I-SOCIALISE cluster RCT

Background

Social skills interventions are commonly recommended to help children and young people with autism spectrum disorder develop social skills, but some struggle to engage in these interventions. LEGO® (LEGO System A/S, Billund, Denmark) based therapy, a group social skills intervention, aims to be more interesting and engaging.

Objective

To evaluate the clinical effectiveness of LEGO® based therapy on the social and emotional skills of children and young people with autism spectrum disorder in school settings compared with usual support. Secondary objectives included evaluations of cost-effectiveness, acceptability and treatment fidelity.

Design

A cluster randomised controlled trial randomly allocating participating schools to either LEGO® based therapy and usual support or usual support only.

Setting

Mainstream schools in the north of England.

Participants

Children and young people (aged 7-15 years) with autism spectrum disorder, their parent/guardian, an associated teacher/teaching assistant and a facilitator teacher/teaching assistant (intervention schools only).

Intervention

Schools randomised to the intervention arm delivered 12 weekly sessions of LEGO® based therapy, which promotes collaborative play and encourages social problem-solving in groups of three children and young people with a facilitator (trained teacher or teaching assistant). Participants received usual support from school and community services. Participants in the control arm received usual support only. Research assistants and statisticians were blind to treatment allocation.

Main outcome measure

The social skills subscale of the Social Skills Improvement System (SSIS), completed by the children and young people's unblinded teacher pre randomisation and 20 weeks post randomisation. The SSIS social skills subscale measures social skills including social communication, co-operation, empathy, assertion, responsibility and self-control. Participants completed a number of other pre- and post-randomisation measures of emotional health, quality of life, loneliness, problem behaviours, academic competence, service resource utilisation and adverse events.

Results

A total of 250 children and young people from 98 schools were randomised: 127 to the intervention arm and 123 to the control arm. Intention-to-treat analysis of the main outcome measure showed a modest positive difference of 3.74 points (95% confidence interval -0.16 to 7.63 points, standardised effect size 0.18; p = 0.06) in favour of the intervention arm. Statistical significance increased in per-protocol analysis, with a modest positive difference (standardised effect size 0.21; p = 0.036). Cost-effectiveness of the intervention was found in reduced service use costs and a small increase in quality-adjusted life-years. Intervention fidelity and acceptability were positive. No intervention-related adverse events or effects were reported.

Conclusions

The primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes of between 0.15 and 0.21. There were positive health economics and qualitative findings, corroborated by the difference between arms for the majority of secondary outcomes, which were not statistically significant but favoured the intervention arm. Post hoc additional analysis was exploratory and was not used in drawing this conclusion. Given the small positive change, LEGO® based therapy for children and young people with autism spectrum disorder in schools should be considered.

Limitations

The primary outcome measure was completed by an unblinded teacher (rather than by the facilitator).

Future work

The study team recommends future research into LEGO® based therapy, particularly in school environments.

Trial registration

This trial is registered as ISRCTN64852382.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information.

The Effect of Combined Intervention on Improvement of Early Lexical Development in Minimally Verbal Children with Autism Spectrum Disorder

Background

Autism spectrum disorder (ASD) is a neurodevelopmental disorder defined by severe communication deficits and limited and repetitive behavioral tendencies. There are several treatment approaches and methods for minimally verbal children with ASD; nonetheless, there is inconclusive evidence about how early lexical development could be improved. The present study aimed to investigate the effect of combined intervention derived from the principles of different theories-including contemporary behaviorism, schemas, sociocultural, and event representation theories-to improve early lexical development in minimally verbal children with ASD.

Methods

In this single-group pretest-posttest study, 10 children with ASD (mean age, 47.9 ± 8.3 months), including 7 boys and 3 girls, participated. Participants received 16 intervention sessions in 8 weeks. The combined intervention consisted of various methods derived from contemporary behaviorism, schemas, sociocultural, and event representation approaches. The MacArthur-Bates Communicative Development Inventory 1 (Infant form) assessed early lexical development before and after intervention and after a 2-month follow-up. The Friedman test was used to analyze the data, and pairwise comparisons were performed with the Will-Coxon test. Cohen's d was used to investigate the effect sizes.

Results

Significant increases in expressive vocabulary (P < 0.001) and receptive language (P < 0.001) were seen after the end of the intervention and at the follow-up (P = 0.005). Large effect sizes were found for expressive vocabulary (d = 3.7) and receptive vocabulary (d = 2.17).

Conclusion

This study suggests that the combination of intervention based contemporary behaviorism, schemas, sociocultural, and event representation approaches improved receptive and expressive vocabulary in minimally verbal children with ASD.

Applied behavioral analysis for the skill performance of children with autism spectrum disorder

Introduction

Autism spectrum disorder (ASD) has characteristics that have been observed to develop over time, such as the difficulty of affective, sensory, and emotional processing, which trigger some problems during childhood, limiting children's development. Applied behavior analysis (ABA) is among the therapeutic approaches for ASD, in which treatment can be tailored according to the patient's objectives.

Objective

Based on ABA, we aimed to analyze the therapeutic strategy for independence in different skill performance tasks of patients diagnosed with ASD.

Method

This is a retrospective observational case series study including 16 children diagnosed with ASD who received ABA-based treatment at a therapeutic clinic in Santo Andre city, São Paulo State, Brazil. Individual task performance of different skill domains was registered in the ABA+ affective intelligence® software throughout the 12 months (from January 2021 to January 2022) of routine treatment.

Results

The evolution of skills was observed between the T0 and T1 intervals, with improved skills over the observed period.

Conclusion

The strategy based on the ABA methodology improved children's skill performance over the observed period.

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).

Investigating associations between cognitive empathy, affective empathy and anxiety in adolescents with autism spectrum disorder

Autism spectrum disorder (ASD) is strongly associated with socio-cognitive impairments that may result in vulnerability to other mental health conditions, particularly anxiety disorders. This study examined the relationship between anxiety disorders and two key socio-cognitive impairments (cognitive empathy, affective empathy) in 60 adolescents (aged 11-18 years) with and without ASD. Adolescents with ASD showed cognitive empathy was negatively associated with separation anxiety disorder, whereas positive associations between affective empathy and generalized anxiety disorder, and positive marginal associations between affective empathy, social phobia, total anxiety, and separation anxiety disorder were observed. These findings suggest that cognitive and affective empathy show different patterns of associations with anxiety-related issues in ASD, and these differences should be considered for interventions and treatment programs.

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.

Promoting Well-Being in Individuals With Autism: Applying Positive Psychology in Rehabilitation Counseling

Positive psychology is a subdomain that addresses the importance of human strengths and personal assets in individuals’ well-being. The principles of positive psychology align with the philosophy of rehabilitation counseling by emphasizing individuals’ strengths to promote psychosocial adjustment to disability. Considering the intersection between positive psychology and rehabilitation counseling, applying the positive psychology framework to rehabilitation counseling will be a promising foundation for improvement in services and outcomes. As the number of individuals on the autism spectrum increases, more innovative services are needed to keep abreast of their needs. This article discusses how positive psychology can be applied to the population of individuals with autism spectrum disorder (ASD) and explores possible practices that can be replicated by practitioners to provide quality services for this emerging disability population. Implications for education and research are also discussed.

RJAfinder: An automated tool for quantification of responding to joint attention behaviors in autism spectrum disorder using eye tracking data

Deficits in responding to joint attention (RJA) are early symptoms of autism spectrum disorder (ASD). Currently, no automated tools exist for identifying and quantifying RJA behaviors. A few eye tracking studies have investigated RJA in ASD children but have produced conflicting results. In addition, little is known about the trajectory of RJA development through developmental age. Here, a new video was designed including 12 clips of an actor pointing to or looking at an object. Eye tracking technology was used to monitor RJA in three groups: 143 ASD children assessed with the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) (4-7 years old), 113 age- and gender-matched typically developing children (TDC), and 43 typically developing adults (TDA) (19-32 years old). RJAfinder was developed in R and MATLAB to quantify RJA events from the eye tracking data. RJA events were compared among the three groups. Spearman correlation coefficients between total number of RJA events in ASD and the Social Responsiveness Scale (SRS) scores were calculated. A logistic regression model was built using the average valid sampling rate and the total number of RJA events as two predictive variables to classify ASD and TDC groups. ASD children displayed statistically significantly less RJA events than the TDC and TDA groups with medium-to-large-sized effects. ASD and TDC children both displayed more RJA events in response to pointing stimuli than to looking stimuli. Our logistic regression model predicted ASD tendency with 0.76 accuracy in the testing set. RJA ability improved more slowly between the ages of 4-7 years old in the ASD group than in the TDC group. In ASD children, RJA ability showed negative correlation with SRS total T-score as well as the scores of five subdomains. Our study provides an automated tool for quantifying RJA and insights for the study of RJA in ASD children, which may help improve ASD screening, subtyping, and behavior interventions.

Migration is associated with baseline severity and progress over time in autism spectrum disorder: Evidence from a French prospective longitudinal study

Background

The prevalence of autism-spectrum disorder (ASD) has been shown to be higher in migrant families, but it is also a challenge for health care professionals to offer adequate services to families that face multiple challenges. In the context of the EPIGRAM study (a French prospective, multisite, longitudinal observational study implementing integrative care practices (ICPs) for children with ASD), we aimed to assess the impact of migration on children with ASD.

Method and findings

89 children with ASD aged 3 to 6 years old (92% males) were recruited and followed up for 12 months. The children were clinically assessed using several instruments. At baseline, children had severe autism on average on the Children Autism Rating Scale (CARS, mean = 44; SD = 6.51) and moderate autism on the PsychoEducational profile-3-R (PEP-3-R) maladaptive behavior category (mean = 30; SD = 29.89). Thirty percent of the families had a low socio-economic status, and 56% were first-generation immigrants. For all clinical variables, children of immigrant parents had more severe autism and developmental delays at baseline. A linear mixed model established an improvement in all clinical characteristics over the 12 months of the study. This trend may be attributed to ICPs or any naturally occurring event during that period. Families shared this positive view over time. However, the improvements were slower for two clinical dimensions of the PEP-3-R in children from migrant families. For the inappropriate behavior category, the time effect diminished by an average of 0.83 percentile/month for children whose parents were migrants vs. children whose parents were non-migrants. Similarly, for verbal behavior characteristics, the time effect diminished by an average of 1.32 percentile/month for children whose parents were migrants vs. children whose parents were non-migrants.

Conclusion

Despite an overall positive improvement, we found that migration is associated baseline severity and progress over time in children with ASD. There is an urgent need to target the migrant population with specific research and understand the avenues that carry such higher severity.

Clinical trial registration

Study registration on clinicaltrials.gov under the number NCT02154828.

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).

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.

Intervention Goals for Preschoolers With Language Difficulties and Disorders: A Scoping Review Using the International Classification of Functioning, Disability and Health Framework

PURPOSE

The primary aim of this scoping review was to categorize language therapy goals reported in intervention studies for preschoolers (i.e., children from birth to 5;0 [years;months]) with language difficulties and disorders within the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework. A secondary aim was to determine whether different therapy goals were reported for two language difficulty/disorder subtypes (i.e., comparing language difficulty/disorder associated with a biomedical condition to those without an associated biomedical condition).

METHOD

The scoping review followed Arksey and O'Malley (2005) guidelines. Articles were retrieved from speechBITE, with age (under 5 years), intervention area (language), and study design (all but systematic reviews and clinical practice guidelines) specified as inclusion criteria. Language goals were extracted and categorized into the ICF components, and the distribution of goals across ICF components was compared for studies involving children with the two language difficulty/disorder subtypes.

RESULTS

A total of 287 articles were identified; 140 met inclusion criteria. Of the 293 goals extracted, 48% aligned with the activities component of the ICF framework, followed by participation (26%), environmental factors (20%), body functions and structures (3%), and personal factors (3%). Most participation-focused goals were reported from intervention studies involving preschoolers with a language difficulty/disorder associated with a biomedical condition.

CONCLUSIONS

Few participation-focused goals were reported in intervention studies for preschoolers with language difficulty/disorder without an associated condition. Future work is needed to support integrating the ICF framework in goal setting for both research and practice.

Diagnosis and Treatment of Childhood Apraxia of Speech Among Children With Autism: Narrative Review and Clinical Recommendations

PURPOSE

Treatment for children with autism spectrum disorder (ASD) and low verbal ability is a largely neglected area of study. Existing research focuses on language abilities; however, a subset of children with ASD also has speech sound disorders (SSDs). The purpose of this tutorial is to provide clinicians with evidence-based recommendations to guide speech assessment and treatment among children with ASD, low verbal ability, and suspected childhood apraxia of speech (CAS).

METHOD

Multifaceted search procedures were used to identify studies that have assessed or treated speech sound production among children with ASD. A narrative review and synthesis of the literature is followed by practical clinical recommendations based on best available evidence.

CONCLUSIONS

It is critically important to consider all possible hindrances to the development of functional communication ability for children with ASD. Speech sound production has been identified as a key predictor of expressive language outcomes, yet there are very few studies that address assessment and treatment of SSDs among children with ASD. Less is known about the presentation of CAS among children with ASD and low verbal ability. More research is needed to determine whether existing speech assessment and treatment methods are appropriate for children with ASD, if modifications are needed, or if new methods should be designed.

Exploring Growth in Expressive Communication of Infants and Toddlers With Autism Spectrum Disorder

One of the earliest indicators of autism spectrum disorder (ASD) is delay in language and social communication. Despite consensus on the benefits of earlier diagnosis and intervention, our understanding of the language growth of children with ASD during the first years of life remains limited. Therefore, this study compared communication growth patterns of infants and toddlers with ASD to growth benchmarks of a standardized language assessment. We conducted a retrospective analysis of growth on the Early Communication Indicator (ECI) of 23 infants and toddlers who received an ASD diagnosis in the future. At 42 months of age, children with ASD had significantly lower rates of gestures, single words, and multiple words, but significantly higher rates of nonword vocalizations. Children with ASD had significantly slower growth of single and multiple words, but their rate of vocalization growth was significantly greater than benchmark. Although more research is needed with larger samples, because the ECI was designed for practitioners to monitor children's response to intervention over time, these findings show promise for the ECI's use as a progress monitoring measure for young children with ASD. Limitations and the need for future research are discussed.

Characterizing Parent–Child Interactions in Families of Autistic Children in Late Childhood

Parent–child interactions are influential to a wide range of positive developmental processes in neurotypical children, yet contributions to our understanding of these interactions using observational methods in families of children on the autism spectrum are lacking. The aim of the current study is to investigate how autism symptoms might impact these interactions. We use a family discussion task to: (1) compare families of autistic children aged 8–12 years (n = 21) to families of typically developing children (n = 21, matched on age and cognitive abilities) on the observed levels of supportive and directive behaviors in the parent–child relationship, and (2) examine the associations between parent–child interaction characteristics and child functioning. Results showed no differences in the observed levels of supportive behavior exhibited by parents, but significantly less supportive behavior in autistic children compared to neurotypical children. In addition, parents of autistic children had higher levels of observed directive behavior compared to parents of neurotypical children. Levels of supportive behavior in parents and autistic children were negatively associated with child ADHD symptoms. Findings reinforce literature on younger children describing positive parenting characteristics and further rebuke historical accounts of negative parenting qualities of parents of autistic children.

Early Intervention in Severe Autism: Positive Outcome Using Exchange and Development Therapy

Early intervention programs positively affect key behaviors for children with autism spectrum disorder (ASD). However, most of these programs do not target children with severe autistic symptomatology associated with intellectual disability (ID). This study aimed to investigate the psychological and clinical outcomes of children with severe autism and ID enrolled in the Tailored and Inclusive Program for Autism-Tours (TIPA-T). The first step of the TIPA-T is the Exchange and Development Therapy (EDT): an individual neurofunctional intervention consisting of one-to-one exchanges between a child and a therapist taking place in a pared-down environment. It aims to rehabilitate psychophysiological abilities at the roots of social communication through structured sequences of "social play." Cognitive and socio-emotional skills and general development were evaluated with the Social Cognitive Evaluation Battery scale and the Brunet-Lézine Scale-Revised, respectively, before and after 9 months of intervention in 32 children with ASD and ID. Autistic symptomatology was evaluated with the Behavior Summarized Evaluation-Revised scale at five time-points in a subset of 14 children, both in individual and group settings. Statistically significant post-intervention improvements were found in cognitive and socio-emotional skills. All but one child showed improvements in at least one social domain, and 78% of children gained one level in at least four social domains. Twenty-nine children improved in cognitive domains, with 66% of children improving in at least three cognitive domains. Autistic symptomatology evaluated in one-to-one settings significantly decreased with therapy; this reduction was observed in more than 85% of children. In group settings, autistic symptomatology also decreased in more than 60% of children. Global developmental age significantly increased by 3.8 months. The TIPA-T, including EDT in particular, improves socio-emotional skills of most children with ASD and reduces autistic symptomatology, yet with heterogeneous outcomes profiles, in line with the strong heterogeneity of profiles observed in ASD. At the group level, this study highlights the benefits of the TIPA-T for children with severe autism and associated ID. Assessment of autistic core symptoms showed an improvement of social interaction, both in one-to-one and group evaluations, demonstrating the generalizability of the skills learned during the EDT.

Effectivity of Play-Based Interventions in Children with Autism Spectrum Disorder and Their Parents: A Systematic Review

Evidence of the effectivity of play-based interventions in children with autism spectrum disorder (ASD) was evaluated by PRISMA-based literature study and a Risk of Bias (RoB) assessment. Many of the 32 eligible randomized controlled trials (RCT) reported improved social interaction, communication, daily functioning and play behaviour. They also reported decreased problem behaviour, better parental attunement and parent-child interaction. We assessed 25/32 of the RCTs with high RoB, mainly related to homogeneity of the study population, lack of power, and performance bias. We concluded with due care that the effectivity of play-based interventions differed across RCTs, most reported improvements are found in ASD symptoms, everyday functioning, and parental attunement. In future research, findings should be replicated, taking account of the RoB.

Effectiveness of Responsivity Intervention Strategies on Prelinguistic and Language Outcomes for Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis of Group and Single Case Studies

We conducted a systematic review to identify randomized controlled trials (RCTs) and single case research design (SCRD) studies of children with autism spectrum disorder that evaluate the effectiveness of responsivity intervention techniques for improving prelinguistic and/or language outcomes. Mean effect sizes were moderate and large for RCTs (33 studies; g = 0.36, 95% CI [0.21, 0.51]) and SCRD (34 studies; between-case standardized mean difference = 1.20, 95% CI [0.87, 1.54]) studies, respectively. Visual analysis (37 studies) revealed strong evidence of a functional relation for 45% of the opportunities and no evidence for 53%. Analyses of moderator effects and study quality are presented. Findings provide support for responsivity intervention strategies with more robust support for context-bound outcomes than more generalized outcomes.

Predicting progress in word learning for children with autism and minimal verbal skills

Background

Approximately 30% of children diagnosed with autism remain minimally verbal past age 5. Interventions are often effective in increasing spoken communication for some of these children. Clinical and research decisions would be facilitated by identifying early indicators of progress in interventions. The purpose of this study was to investigate the relationship between speech sound measures obtained from the early phases of treatment and later treatment outcomes in children with autism and minimal verbal skills.

Methods

Twenty-three children (18 boys) between 5 and 9 years of age participated. We compared scores reflecting the phonemic features of word attempts produced during probes, and the number of correct words after 4 weeks of intervention to later word learning outcomes.

Results

Correlational and hierarchical regression analyses showed that both predictors were positively correlated with outcomes, but the phonemic scores were more strongly related than number of correct words.

Conclusion

We conclude that phonemic scoring may be a useful measure to determine proximal gains in a spoken word learning intervention. Proximal measures are particularly helpful when trying to decide if the current course of intervention should be maintained or altered.

Trial registration

https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=2&cx=-jg9qo3.

Duplication of Chromosome 16p13.11-p12.3 with Different Expressions in the Same Family

The knowledge about genetic involvement in neurodevelopmental disorders, and especially in autism, is currently rising. To date, more than 100 gene mutations related to autistic syndromes have been described. Some disorders that affect multiple family members are caused by gene mutations, which can be inherited. Recently, array comparative genomic hybridization (aCGH) has identified sub microscopic deletions and duplications as a common cause of mental retardation and autism. In this article we report the occurrence of the same genetic finding (chromosome 16p13.11-p12.3 duplication) in a family with four small children, where two older siblings manifested a global neurodevelopmental delay associated with an autism spectrum disorder (ASD), but younger twin brothers with the same mutation, have typical development. Genetic analysis showed that the chromosomal duplication was inherited from the father, in which phenotype and functioning are quite typical. As is known, the duplication can pass from parents to children. The 16p13.11 micro duplication has been implicated in several neurodevelopmental and behavioral disorders and is characterized by variable expressivity and incomplete penetrance.

A Systematic Review of Play-Based Interventions Targeting the Social Communication Skills of Children with Autism Spectrum Disorder in Educational Contexts

Children with autism spectrum disorder (ASD) experience social communication difficulties which can be compounded by increased social demands and expectations of the school environment. Play offers a unique context for social communication development in educational settings. This systematic review aimed to synthesize play-based interventions for the social communication skills of children with ASD in educational contexts and identified nine studies. Overall, studies in this review provided a promising evidence base for supporting social communication skills through play in education for children with ASD. The review also highlighted gaps in research on play-based interventions for the social communication skills of children with ASD within naturalistic educational settings.

The effects of JASPER intervention for children with autism spectrum disorder: A systematic review

Naturalistic developmental behavioural interventions are promising approaches for young children with, or suspected of having, autism spectrum disorder. Joint attention, symbolic play, engagement and regulation intervention (JASPER) is a well-researched naturalistic developmental behavioural intervention but, to date, no reviews have specifically evaluated its effects. This systematic literature review examined the effects of JASPER intervention and its components on child, parent and educator outcomes. Of the 96 articles screened, 19 were eligible for inclusion in the review. Most studies found that children who received JASPER intervention showed significantly greater improvements in at least one outcome related to child joint attention, joint engagement, play skills and language skills compared to the comparison group. Implementation outcomes for parents and educators were generally positive. There were no consistent predictors or mediators of treatment effects. None of the studies met all of the quality indicators outlined by the Council of Exceptional Children, and the majority of outcome measures were classified as proximal. Overall, JASPER intervention appears promising in improving child outcomes directly targeted during treatment. More research is needed to determine whether it is also effective in improving a wider range of outcomes for children with autism spectrum disorder.Lay abstractInterventions which are delivered in natural contexts and use both developmental and behavioural techniques may be helpful for children with, or suspected of having, autism spectrum disorder. Joint attention, symbolic play, engagement and regulation (JASPER) is a type of intervention, which falls under this category. Although several studies have examined the effects of JASPER, this has not yet been summarised in a review. This systematic literature review examined the effects of JASPER intervention, and the techniques that make up JASPER, on child, parent and educator outcomes. We screened 96 articles and, of these, 19 were included in the review. Most studies found that children who received JASPER intervention showed significantly greater improvements in at least one outcome related to child joint attention, joint engagement, play skills, and language skills compared to children who did not receive JASPER intervention. Parents and educators were mostly able to use the JASPER techniques. There were no consistent child, parent, teacher or treatment characteristics that influenced the effects of the JASPER intervention. None of the studies met all of the indicators of being a good quality study outlined by the Council of Exceptional Children. Overall, JASPER intervention appears promising in improving child outcomes directly targeted during treatment. More research is needed to determine whether it is also effective in improving a wider range of outcomes for children with autism spectrum disorder.

From Gaze Perception to Social Cognition: The Shared-Attention System

When two people look at the same object in the environment and are aware of each other's attentional state, they find themselves in a shared-attention episode. This can occur through intentional or incidental signaling and, in either case, causes an exchange of information between the two parties about the environment and each other's mental states. In this article, we give an overview of what is known about the building blocks of shared attention (gaze perception and joint attention) and focus on bringing to bear new findings on the initiation of shared attention that complement knowledge about gaze following and incorporate new insights from research into the sense of agency. We also present a neurocognitive model, incorporating first-, second-, and third-order social cognitive processes (the shared-attention system, or SAS), building on previous models and approaches. The SAS model aims to encompass perceptual, cognitive, and affective processes that contribute to and follow on from the establishment of shared attention. These processes include fundamental components of social cognition such as reward, affective evaluation, agency, empathy, and theory of mind.

Clinician Proposed Predictors of Spoken Language Outcomes for Minimally Verbal Children with Autism Spectrum Disorder

Our aim was to explore insights from clinical practice that may inform efforts to understand and account for factors that predict spoken language outcomes for children with Autism Spectrum Disorder who use minimal verbal language. We used a qualitative design involving three focus groups with 14 speech pathologists to explore their views and experiences. Using the Framework Method of analysis, we identified 9 themes accounting for 183 different participant references to potential factors. Participants highlighted the relevance of clusters of fine-grained social, communication, and learning behaviours, including novel insights into prelinguistic vocal behaviours. The participants suggested the potential value of dynamic assessment in predicting spoken language outcomes. The findings can inform efforts to developing clinically relevant methods for predicting children's communication outcomes.

Understanding the Effects of Naturalistic Developmental Behavioral Interventions: A Project AIM Meta-analysis

We examined the quality of evidence supporting the effects of Naturalistic Developmental Behavioral Interventions (NBDIs) for facilitating change in young children with autism. We also investigated whether effects varied as a function of specific features of the intervention, samples, and outcomes measured. Twenty-seven studies testing the effects of NDBIs were extracted from data collected for the Autism Intervention Meta-analysis (Project AIM), a comprehensive meta-analysis of group design, nonpharmacological intervention studies for children with autism aged 0-8 years. We extracted effect sizes for 454 outcomes from these studies for use in meta-regression analyses testing associations between intervention effects and mean participant chronological age, language age, autism symptomatology, percentage of sample reported as male, cumulative intervention intensity, interventionist, outcome boundedness, outcome proximity, and risk of parent/teacher training correlated measurement error. The extant literature on NDBIs documents effects on social communication, language, play, and cognitive outcomes. However, our confidence in the positive and significant summary effects for these domains is somewhat limited by methodological concerns. Intervention effects were larger for context-bound outcomes (relative to generalized), and for proximal outcomes (relative to distal). Our results indicate that NDBIs have promise as an approach for supporting development for some, but not all of the core and related features of autism in early childhood. Confidence in summary effect estimates is limited by study quality concerns, particularly an overreliance on measures subject to high detection bias. The results of this review support the use of proximity and boundedness as indicators of the limits of intervention effects. LAY SUMMARY: Naturalistic Developmental Behavioral Interventions may increase language, social communication, play skills, and cognition in young children with autism, but these increases are largest for skills directly targeted by the intervention, and in contexts that are similar to that of the intervention. These conclusions are tempered by some concerns regarding research design across the studies that have been conducted to date. Autism Res 2021, 14: 817-834. © 2021 International Society for Autism Research and Wiley Periodicals LLC.

Feasibility of a syndrome-informed micro-intervention for infants with Down syndrome

BACKGROUND

Infants with Down syndrome (DS) are at risk for a range of phenotypic outcomes, including delays in the onset of reaching behaviour, a critical skill that facilitates early learning. This parallel-group feasibility and pilot study presents findings from a parent-mediated micro-intervention that aimed to support the development of reaching behaviour in a sample of infants with DS.

METHODS

Participants were 73 infants with DS and their caregivers. Infants who qualified for the home-based intervention (based on manual skill performance on Bayley Scales of Infant and Toddler Development, Third Edition items) were randomly assigned individually or by geographical region to a treatment or an alternative treatment condition that involved toy-based interactions with caregivers. Infants in the treatment condition experienced facilitated reaching during the toy-based interactions through the use of Velcro-affixed mittens and toys.

RESULTS

Forty-two infants met criteria to participate in the intervention, and 37 participated in both baseline and post-treatment visits. At post-treatment, infants in the treatment condition demonstrated shorter latencies to make contact with objects and showed higher frequencies of reach attempts and swats at objects than infants in the alternative treatment group. These findings were more pronounced when examining a chronological age-restricted subgroup of infants 5 to 10 months.

CONCLUSIONS

Findings suggest that a syndrome-informed approach to targeted intervention may be a promising application of phenotyping science in DS and other neurogenetic conditions associated with intellectual disability.

How do minimally verbal children and adolescents with autism spectrum disorder use communicative gestures to complement their spoken language abilities?

BACKGROUND AND AIMS

Prior work has examined how children and adolescents with autism spectrum disorder who are minimally verbal use their spoken language abilities during interactions with others. However, social communication includes other aspects beyond speech. To our knowledge, no studies have examined how minimally verbal children and adolescents with autism spectrum disorder are using their gestural communication during social interactions. Such work can provide important insights into how gestures may complement their spoken language abilities.

METHODS

Fifty minimally verbal children and adolescents with autism spectrum disorder participated (M _age = 12.41 years; 38 males). Gestural communication was coded from the Autism Diagnostic Observation Schedule. Children (n = 25) and adolescents (n = 25) were compared on their production of gestures, gesture-speech combinations, and communicative functions. Communicative functions were also assessed by the type of communication modality: gesture, speech, and gesture-speech to examine the range of communicative functions across different modalities of communication. To explore the role gestures may play the relation between speech utterances and gestural production was investigated.

RESULTS

Analyses revealed that (1) minimally verbal children and adolescents with autism spectrum disorder did not differ in their total number of gestures. The most frequently produced gesture across children and adolescents was a reach gesture, followed by a point gesture (deictic gesture), and then conventional gestures. However, adolescents produced more gesture-speech combinations (reinforcing gesture-speech combinations) and displayed a wider range of communicative functions. (2) Overlap was found in the types of communicative functions expressed across different communication modalities. However, requests were conveyed via gesture more frequently compared to speech or gesture-speech. In contrast, dis/agree/acknowledging and responding to a question posed by the conversational partner was expressed more frequently via speech compared to gesture or gesture-speech. (3) The total number of gestures was negatively associated with total speech utterances after controlling for chronological age, receptive communication ability, and nonverbal IQ.

CONCLUSIONS

Adolescents may be employing different communication strategies to maintain the conversational exchange and to further clarify the message they want to convey to the conversational partner. Although overlap occurred in communicative functions across gesture, speech, and gesture-speech, nuanced differences emerged in how often they were expressed across different modalities of communication. Given their speech production abilities, gestures may play a compensatory role for some individuals with autism spectrum disorder who are minimally verbal.

IMPLICATIONS

Findings underscore the importance of assessing multiple modalities of communication to provide a fuller picture of their social communication abilities. Our results identified specific communicative strengths and areas for growth that can be targeted and expanded upon within gesture and speech to optimize social communication development.

Implementation of Video Feedback Within a Community Based Naturalistic Developmental Behavioral Intervention Program for Toddlers With ASD: Pilot Study

Video feedback (VF) is an intervention delivery technique that complements naturalistic developmental behavioral interventions (NDBI) and parent-mediated interventions (PMI) by using caregiver-child interaction videos reviewed with a clinician to facilitate behavioral change in caregivers. Although VF has been implemented in PMI with young children with ASD, examinations of feasibility and acceptability, as well as the potential effectiveness of VF in community settings, have been limited. In this pilot randomized control trial (NCT03397719; https://clinicaltrials.gov/ct2/show/NCT03397719), families were randomized into a state-funded Early Intervention (EI) NDBI program or the NDBI program augmented with VF. Results demonstrated high levels of implementation and acceptability of VF augmenting the community-based EI program in caregivers and clinicians. Both groups showed significant improvements after 6 months in social communication symptoms and some areas of developmental and adaptive skills. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03397719, identifier: NCT03397719.

Play-based interventions to support social and communication development in autistic children aged 2-8 years: A scoping review

Background and aims

Play is used by practitioners from across disciplinary backgrounds as a natural and enjoyable context for providing intervention and support in early childhood. In the case of autism interventions, many therapies are based on the association between social play and the development of social skills, language development, and communication skills, as these are often particular areas of challenge for autistic children. However, play is a wide-ranging concept and the extant literature on play-based interventions is large and heterogeneous. This means it is challenging for practitioners and families to navigate the evidence base and make choices about differing intervention strategies. This review aims to provide a comprehensive map of the research on this topic and to develop a conceptual framework to inform clinical decision-making.

Methods

An initial stakeholder consultation confirmed the relevance of the topic to practitioners and autistic people. A scoping review methodology (preregistered) was used to identify relevant literature. We systematically searched seven databases to find peer-reviewed primary intervention studies of play-based approaches targeting language, social and communication outcomes for autistic children aged 2-8 years. We then summarised the literature using narrative synthesis and Evidence Gap Maps (EGMs). The literature was summarised according to a range of characteristics, including study design, population characteristics, agent of intervention and outcomes measured, among others. These summaries were then used to develop a framework for some key considerations for practitioners appraising play-based approaches.

Results

388 studies met inclusion criteria. Approximately 21% of studies were RCTs, and over 50% had ≤10 participants. Over 45% of studies reported multiple relevant outcomes, with social play skills being the most common single intervention target. Girls and minority background groups are under-represented. A range of intervention types were identified, and some high-level categorisations are proposed.Main contribution: On the basis of the evidence synthesis we suggest important dimensions for appraisal of play-based interventions, including the role of play within an intervention (as a context, a key developmental mechanism, or a component of a larger approach), the underpinning philosophy (e.g. behaviourist or developmental), and the role of the practitioner (providing parent feedback, 1:1 intervention, group facilitation).

Conclusions

The wide range of approaches uncovered by this review is a testament to the wonderful diversity inherent to both play and autism. However, research could usefully focus on consolidating the evidence base for existing approaches, rather than aiming for further diversification. Implications: The conceptual framework proposed in this review can help practitioners appraise the literature and aid their advice to families when making shared intervention decisions.

Early Intervention with Parents of Children with Autism Spectrum Disorders: A Review of Programs

The aim of this article was to analyze the evidence regarding the effectiveness of intervention programs for children with autism based on the participation of their parents. To obtain the data, a systematic search was carried out in four databases (PsycARTICLES (ProQuest), ERIC (ProQuest), PubMed (ProQuest), and Scopus). The retrieved documents were refined under the inclusion/exclusion criteria, and a total of 51 empirical studies were selected. These studies were first classified according to the function of the intervention objective and, later, by the methodology applied (19 studies were based on comprehensive interventions, 11 focused on the nuclear symptoms of autism spectrum disorder (ASD), 12 focused on the promotion of positive parenting, and nine interactions focused on child play). Once all of the documents had been analyzed, the evidence indicated scientific efficacy in most studies, mainly in those based on child development and the application of behavioral analysis principles. Moreover, the positive influence of parent participation in such programs was demonstrated.

A developmental and sequenced one-to-one educational intervention (DS1-EI) for autism spectrum disorder and intellectual disability: A three-year randomized, single-blind controlled trial

BACKGROUND

Children with autism spectrum disorder (ASD) and intellectual disability (ID) are an understudied population whose school inclusion is challenging.

METHODS

We assessed the effects of "Developmental and Sequenced one-to-one Educational Intervention" (DS1-EI), a ten-hour-per-week adapted instruction programme for five- to nine-year-old children with ASD and ID treated in outpatient health care institutions. A single-blind multisite randomized controlled trial was conducted to compare DS1-EI given for three years with treatment as usual (TAU)(trial registration numbers: ANSM130282B-31 (April 16, 2013) and ACTRN12616000592448). The primary outcome was the change in the psycho-educational profile (PEP). Secondary variables included the Childhood Autism Rating Scale (CARS), Autism Diagnostic Interview-Revised (ADI-R), Vineland Adaptive Behaviour Scale-II (VABS-II), Children's Global Assessment Scale (CGAS) and annual assessment of educational achievement. Statistical analyses used linear mixed models.

FINDINGS

Seventy-two participants with severe ASD and ID were recruited. Intention-to-treat and per-protocol analyses showed no significant group*time interaction for the PEP, CARS, ADI-R, VABS-II and CGAS but a significant effect for educational achievement with a better improvement in the DS1-EI group. At the 36-month time point, more DS1-EI children were included in mainstream classrooms. Additional analyses using multivariate models taking into account moderating variables at the baseline (e.g., Developmental Quotient) confirmed that DS1-EI had a significant effect on educational outcomes.

INTERPRETATION

DS1-EI did not improve communication or social skills in children with ASD and ID compared with TAU. However, DS1-EI enhanced school skills in four domains (language, mathematics, inter modality, and school autonomy) favouring inclusion in mainstream classrooms more than TAU. Providing such adapted instruction is feasible and should be encouraged.

FUNDING

CNSA; Fondation Bettencourt-Schueller; Fondation EDF.

Gesture Production in Toddlers with Autism Spectrum Disorder

Children with Autism Spectrum Disorder (ASD) demonstrate delayed and atypical communication development. These deficits constitute a core criterion for the diagnosis of ASD, though information regarding gestural communication in toddlers with ASD remains limited. The present investigation implemented a robust gesture classification system in order to obtain quantitative measures of gesture production in a cohort of toddlers with ASD (n = 40) and controls (n = 40) during 10-min, play-based interactions with caregivers. Children with ASD produced fewer overall gestures and gesture subtypes compared to controls. The ASD group also displayed atypical patterns of gesture production. These findings highlight the need for evidence-based screening, assessment, and intervention protocols pertaining to gestural communication in toddlers with ASD.

Recent Developments in Treatment Outcome Measures for Young Children With Autism Spectrum Disorder (ASD)

Significant advancements have been made in early intervention programs for children with Autism spectrum disorder (ASD). However, measuring treatment response for children with ASD is difficult due to the heterogeneity of changes in symptoms, which can be subtle, especially over a short period of time. Here we outline the challenge of evaluating treatment response with currently available measures as well as newly developed or refined measures that may be useful in clinical trials for young children with ASD. Continued development of treatment outcome measures will help the field identify and compare efficacious interventions and tailor treatments for children with ASD.

Developmental and sequenced one-to-one educational intervention (DS1-EI) for autism spectrum disorder and intellectual disability: a two-year interim report of a randomized single-blind multicenter controlled trial

Background

Children with autism spectrum disorder (ASD) and moderate to severe intellectual disability (ID) face many challenges. There is little evidence-based research into educational settings for children with ID and ASD and in France. Little is known about how this unserved population could benefit from intervention and education. This study assessed the feasibility and efficacy of a new intervention model using an individualized educational approach.

Methods

We conducted a randomized, single-blind controlled trial to assess a novel intervention: the “Developmental and Sequenced One-to-One Intervention (DS1-EI)”. In DS1-EI, trained teachers worked one-to-one with each child in a small classroom setting, offering 10 h per week of the intervention. The focus was on encouraging spontaneous communication, promoting skills through play with peers, supporting positive interactions, and developmental and sequenced learning. We enrolled 5- to 9-year-old children with ASD and ID across 11 French child care institutions for children with co-occurring ASD and ID. Participants were matched in dyads by developmental quotient and randomized to the treatment-as-usual (TAU) group or the DS1-EI group. Independent raters blindly assessed the primary variables: The Childhood Autism Rating scale (CARS) and the Psychoeducational Profile, third edition (PEP-3). The secondary variables included the Vineland Adaptive Behavior Scale II (VABS-II) and the Clinical Global Assessment Scale (CGAS). Here we perform interim analyses at 24 months.

Results

At baseline, 72 participants were randomized. Nine patients (5 in the DS1-EI group and 4 in the TAU group) dropped out of the study. Using linear mixed models, both intent-to-treat (ITT) and per-protocol (PP) analyses at the 12-, 18- and 24-month outcomes showed no significant group nor group-by-time interaction effects. However, we found significant improvements in most primary and secondary variables over time in both groups.

Conclusions

The study did not show that DS1-EI was superior to TAU in treating children with ASD and ID over 24 months. However, the low dropout rate shows that DS1-EI is feasible, and well accepted. As the study is still ongoing, we need to wait for data at 36 months to ensure whether DS1-EI could be recommended.

Trial registration

ANSM130282B-31 (April 16, 2013) and ACTRN12616000592448. Registered 6 May 2016, retrospectively registered, http://www.anzctr.org.au/

The Effects of Early Intervention on Social Communication Outcomes for Children with Autism Spectrum Disorder: A Meta-analysis

This meta-analysis examined the effects of early interventions on social communication outcomes for young children with autism spectrum disorder. A systematic review of the literature included 1442 children (mean age 3.55 years) across 29 studies. The overall effect size of intervention on social communication outcomes was significant (g = 0.36). The age of the participants was related to the treatment effect size on social communication outcomes, with maximum benefits occurring at age 3.81 years. Results did not differ significantly depending on the person implementing the intervention. However, significantly larger effect sizes were observed in studies with context-bound outcome measures. The findings of this meta-analysis highlight the need for further research examining specific components of interventions associated with greater and more generalized gains.

Are early visual behavior impairments involved in the onset of autism spectrum disorders? Insights for early diagnosis and intervention

A correct use of the visual behavior (VB), and its integration with motor function, represents the earliest mean used by infants to explore and act on the social and non-social surrounding environment. The aim of this mini review is to present influential evidence of abnormalities in the VB domain in ASD individuals and to discuss the implication of these findings for early identification and intervention. We analyzed the possible anomalies in oculomotor abilities, visual attention, and visual-motor integration, as parts of a wider visual behavior defect, that could affect children with autism spectrum disorders (ASD) since the early stages of development.Conclusion: According to the literature, difficulties in these three areas have been often reported in children with ASD, and the visual-perception deficit could have cascading effects on learning processes and on social development. Despite this evidence of atypical VB in ASD, their investigation is not yet included into diagnostic processes, and they are not yet considered a specific treatment target.What is Known:•Atypical social use of visual behavior is one the first symptoms in children with autism spectrum disorders•Individuals with autism spectrum disorders often show unusual visual exploration of the surrounding environmentWhat is New:•It is possible to hypothesize that early visual behavior abnormalities may affect experiences that permit learning processes and social and communicative development in infants•An early assessment of visual behavior, as a core symptom of ASD, might improve the diagnostic processes and might help to developing more individualized treatments.

Preverbal Communication Complexity in Infants

The development of prelinguistic communication in typically developing infants is marked by changes in complexity as well as frequency, yet most measures focus on frequency. In the current study we used the Communication Complexity Scale (CCS) to measure prelinguistic complexity of typically developing infants in a cross-sectional sample of 6-, 8-, 10- and 12-month-olds (N = 204) during semi-structured play interaction. For each toy/interactive episode, infants' highest level of communication complexity (ranging from 0 for no response to 12 for multi-word verbalization), for both joint attention (i.e., social) and behavior regulation (e.g., requesting) functions, was scored. In addition, the same interaction was coded for frequency of all prelinguistic communication acts. Results of multivariate models indicated age-related differences in prelinguistic complexity. Measures of prelinguistic complexity and frequency evidenced moderate to strong correlations, with age-related differences by function (joint attention and behavior regulation). Significant associations with parent-report communication questionnaires were observed for both complexity and frequency measures. Results indicate that evaluating complexity of infant preverbal communication skill with the CCS is a valuable approach that can meaningfully index developmental differences in prelinguistic and early linguistic communication.

Communicative Use of Triadic Eye Gaze in Children With Down Syndrome, Autism Spectrum Disorder, and Other Intellectual and Developmental Disabilities

Purpose This study examines differences in the communicative use of triadic eye gaze (TEG) during a communicative interaction in 2 neurodevelopmental disorders: Down syndrome (DS) and autism spectrum disorders (ASD), and a 3rd group of varying disabilities associated with intellectual and developmental disabilities (IDDs). Also, the relationship between TEG use and language abilities was explored. Method Participants were 45 children, 15 in each group. The frequency of TEG was coded during a scripted communication assessment when children were between 3 and 6 years of age (37-73 months). Receptive and expressive language was measured using raw scores from the Mullen Scales of Early Learning concurrently between 3 and 6 years and again 2 years later when children were between 5 and 8 years (59-92 months). Results Descriptively, children with DS had a higher frequency of TEG than children with ASD and IDD, but significant differences were only observed between children with DS and ASD. More TEG at Time 1 in children with DS was associated with higher receptive language at Time 1 and higher expressive language at Time 2. For children with ASD, a trend for a positive association between TEG at Time 1 and language abilities at Time 2 was observed. No significant associations were observed for children with IDD. Conclusion Children with DS used TEG significantly more than children with ASD in this sample. Identifying strengths and weaknesses in TEG use is important because providing caregiver training to facilitate TEG can result in increased opportunities to respond with language models and promote language development.

Behavioural and psychological characteristics in Pitt-Hopkins syndrome: a comparison with Angelman and Cornelia de Lange syndromes

Background

Pitt-Hopkins syndrome (PTHS) is a genetic neurodevelopmental disorder associated with intellectual disability. Although the genetic mechanisms underlying the disorder have been identified, description of its behavioural phenotype is in its infancy. In this study, reported behavioural and psychological characteristics of individuals with PTHS were investigated in comparison with the reported behaviour of age-matched individuals with Angelman syndrome (AS) and Cornelia de Lange syndrome (CdLS).

Methods

Questionnaire data were collected from parents/caregivers of individuals with PTHS (n = 24), assessing behaviours associated with autism spectrum disorder (ASD), sociability, mood, repetitive behaviour, sensory processing, challenging behaviours and overactivity and impulsivity. For most measures, data were compared to data for people with AS (n = 24) and CdLS (n = 24) individually matched by adaptive ability, age and sex.

Results

Individuals with PTHS evidenced significantly higher levels of difficulties with social communication and reciprocal social interaction than individuals with AS, with 21 of 22 participants with PTHS meeting criteria indicative of ASD on a screening instrument. Individuals with PTHS were reported to be less sociable with familiar and unfamiliar people than individuals with AS, but more sociable with unfamiliar people than individuals with CdLS. Data also suggested areas of atypicality in sensory experiences. Challenging behaviours were reported frequently in PTHS, with self-injury (70.8%) occurring at significantly higher rates than in AS (41.7%) and aggression (54.2%) occurring at significantly higher rates than in CdLS (25%). Individuals with PTHS also evidenced lower reported mood than individuals with AS.

Conclusions

Behaviours which may be characteristic of PTHS include those associated with ASD, including deficits in social communication and reciprocal social interaction. High rates of aggression and self-injurious behaviour compared to other genetic syndrome groups are of potential clinical significance and warrant further investigation. An atypical sensory profile may also be evident in PTHS. The specific aetiology of and relationships between different behavioural and psychological atypicalities in PTHS, and effective clinical management of these, present potential topics for future research.

Delayed M50/M100 evoked response component latency in minimally verbal/nonverbal children who have autism spectrum disorder

Abnormal auditory neuromagnetic M50 and M100 responses, reflecting primary/secondary auditory cortex processing, have been reported in children who have autism spectrum disorder (ASD). Some studies have reported an association between delays in these responses and language impairment. However, as most prior research has focused on verbal individuals with ASD without cognitive impairment, rather little is known about neural activity during auditory processing in minimally verbal or nonverbal children who have ASD (ASD-MVNV)-children with little or no speech and often significant cognitive impairment. To understand the neurophysiological mechanisms underlying auditory processing in ASD-MVNV children, magnetoencephalography (MEG) measured M50 and M100 responses arising from left and right superior temporal gyri during tone stimuli in three cohorts: (1) MVNV children who have ASD (ASD-MVNV), (2) verbal children who have ASD and no intellectual disability (ASD-V), and (3) typically developing (TD) children. One hundred and five participants (8-12 years) were included in the final analyses (ASD-MVNV: n = 16, 9.85 ± 1.32 years; ASD-V: n = 55, 10.64 ± 1.31 years; TD: n = 34, 10.18 ± 1.36 years). ASD-MVNV children showed significantly delayed M50 and M100 latencies compared to TD. These delays tended to be greater than the corresponding delays in verbal children with ASD. Across cohorts, delayed latencies were associated with language and communication skills, assessed by the Vineland Adaptive Behavior Scale Communication Domain. Findings suggest that auditory cortex neural activity measures could be dimensional objective indices of language impairment in ASD for either diagnostic (e.g., via threshold or cutoff) or prognostic (considering the continuous variable) use.