Predictors of Treatment Outcome in Preschoolers with Autism Spectrum Disorder: An Observational Study in the Greater Geneva Area, Switzerland

Mega-analytic support for Early Start Denver Model, age at intervention start, and pre-intervention developmental level as factors differentiating early intervention outcomes in autism

Objective

Autism early intervention meta-analyses have provided initial answers to questions such as 'what types of interventions work' and 'for what outcomes'? However, we also want to know 'for whom' is early intervention most effective for? Mega-analysis can offer up complementary insights to meta-analyses regarding the 'what works' and 'for what', while also offering unique insights into the 'for whom' question.

Methods

Here we conduct a mega-analysis with linear mixed effect modeling on AEIR consortium early intervention datasets totaling n=645 children spanning several countries (e.g., USA, Switzerland, Italy, Israel, and Australia). Early Start Denver Model (ESDM) and other non-ESDM approaches (e.g., EIBI, NDBI, other community/treatment as usual approaches) was evaluated as contrasting intervention types. Models also evaluated intervention intensity, type, participant sex, age at intervention start, and pre-intervention developmental quotient. Subscales of Mullen Scales of Early Learning (MSEL), Vineland Adaptive Behavior Scales (VABS), and Autism Diagnostic Observation Schedule (ADOS) were utilized as outcome measures.

Results

Neither intervention intensity nor participant sex affected outcomes. ESDM showed faster growth in language and non-verbal cognition compared to non-ESDM intervention. Irrespective of intervention type, earlier intervention start was associated with increased MSEL and VABS scores and decreased ADOS severity. Growth trajectories on the MSEL also varied by pre-intervention developmental quotient, with higher quotients predicting faster growth irrespective of intervention type.

Conclusions

Age at intervention start and pre-intervention developmental quotient are important individualized factors that predict early intervention response. ESDM also impacts language, non-verbal cognition, and core autism features.

Automated Autism Assessment With Multimodal Data and Ensemble Learning: A Scalable and Consistent Robot-Enhanced Therapy Framework

Navigating the complexities of Autism Spectrum Disorder (ASD) diagnosis and intervention requires a nuanced approach that addresses both the inherent variability in therapeutic practices and the imperative for scalable solutions. This paper presents a transformative Robot-Enhanced Therapy (RET) framework, leveraging an intricate amalgamation of an Adaptive Boosted 3D biomarker approach and Saliency Maps generated through Kernel Density Estimation. By seamlessly integrating these methodologies through majority voting, the framework pioneers a new frontier in automating the assessment of ASD levels and Autism Diagnostic Observation Schedule (ADOS) scores, offering unprecedented precision and efficiency. Drawing upon the rich tapestry of the DREAM Dataset, encompassing data from 61 children, this study meticulously crafts novel features derived from diverse modalities including body skeleton, head movement, and eye gaze data. Our 3D bio-marker approach achieves a remarkable predictive prowess, boasting a staggering 95.59% accuracy and an F1 score of 92.75% for ASD level prediction, alongside an RMSE of 1.78 and an R-squared value of 0.74 for ADOS score prediction. Furthermore, the introduction of a pioneering saliency map generation method, harnessing gaze data, further enhances predictive models, elevating ASD level prediction accuracy to an impressive 97.36%, with a corresponding F1 score of 95.56%. Beyond technical achievements, this study underscores RET's transformative potential in reshaping ASD intervention paradigms, offering a promising alternative to Standard Human Therapy (SHT) by mitigating therapist variability and providing scalable therapeutic approaches. While acknowledging limitations in the research, such as sample constraints and model generalizability, our findings underscore RET's capacity to revolutionize ASD management.

Examining the Link Between Social Affect and Visual Exploration of Cute Stimuli in Autistic Children

Baby schema refers to physical features perceived as cute, known to trigger attention, induce positive emotions, and prompt social interactions. Given the reduced visual attention to social stimuli observed in individuals on the autism spectrum, the current study examines whether the sensitivity to baby schema is also affected. We expected that the looking time towards cute-featured stimuli would vary with symptom severity levels and would be associated with social affect. Ninety-four children (31 typically developing; 63 diagnosed with autism spectrum disorder - ASD) aged 20-83 months (M = 49.63, SD = 13.59) completed an eye-tracking visual exploration task. Autistic participants were separated into two groups based on symptom severity: children with high autism severity symptoms (HS ASD; N = 23) and low-moderate autism symptoms (LMS ASD; N = 40). Animals and neutral objects were simultaneously presented on the screen along with either human babies (condition 1) or adults (condition 2). The results indicated that visual attention oriented to cute-featured stimuli varied with autism symptom severity: only LMS and TD groups spend more time looking at cute-featured stimuli (babies; animals) than neutral objects. Moreover, children with higher severity in the social affect domain spent less time on the stimuli depicting cute than non-cute stimuli. These findings suggest that autism symptom severity and social skills are linked to variations in visual attention to cute stimuli. Implications of baby schema sensitivity are discussed in relation to the development of social competencies and play, responsiveness to robot-based interventions, as well as appraised relevance in autistic children.

Early identification of autism spectrum disorder based on machine learning with eye-tracking data

BACKGROUND

Early identification of autism spectrum disorder (ASD) improves long-term outcomes, yet significant diagnostic delays persist.

METHODS

A retrospective cohort of 449 children (ASD: 246, typically developing [TD]: 203) was used for model development. Eye-movement data were collected from the participants watching videos that featured eye-tracking paradigms for assessing social and non-social cognition. Five machine learning algorithms, namely random forest, support vector machine, logistic regression, artificial neural network, and extreme gradient boosting, were trained to classify children with ASD and TD. The best-performing algorithm was selected to build the final model which was further evaluated in a prospective cohort of 80 children. The Shapley values interpreted important eye-tracking features.

RESULTS

Random forest outperformed other algorithms during model development and achieved an area under the curve of 0.849 (< 3 years: 0.832, ≥ 3 years: 0.868) on the external validation set. Of the ten most important eye-tracking features, three measured social cognition, and the rest were related to non-social cognition. A deterioration in model performance was observed using only the social or non-social cognition-related eye-tracking features.

LIMITATIONS

The sample size of this study, although larger than that of existing studies of ASD based on eye-tracking data, was still relatively small compared to the number of features.

CONCLUSIONS

Machine learning models based on eye-tracking data have the potential to be cost- and time-efficient digital tools for the early identification of ASD. Eye-tracking phenotypes related to social and non-social cognition play an important role in distinguishing children with ASD from TD children.

Development and Preliminary Validation of the Patient Outcome Planning Calculator (POP-C): A Tool for Determining Treatment Dosage in Applied Behavior Analysis

Board certified behavior analysts (BCBA) are responsible for determining the medically necessary treatment dosage for patients (i.e., the number of hours of therapy a patient should receive per week to optimize progress) during applied behavior analysis (ABA) therapy. However, because there is currently no standard method for making these determinations, BCBAs must rely on their own clinical judgment. Given that clinical judgment may be underdeveloped in some BCBAs, particularly those who are newly certified, more formal strategies are needed to guide decision making as it relates to medical necessity and treatment dosage. In this article we describe the development of the Patient Outcome Planning Calculator (POP-C), a standardized decision-making tool designed to assist novice practitioners in determining the medically necessary ABA treatment intensity and appropriate treatment setting for individuals with autism spectrum disorder (ASD). We present preliminary reliability data as well as construct validity data indicating statistically significant correlations between the POP-C and several norm-referenced and criterion-referenced assessments commonly used to estimate skill level and the corresponding degree of support needed within the ASD population to inform the ABA treatment model and goals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00861-6.

Family-Centric Applied Behavior Analysis Promotes Sustained Treatment Utilization and Attainment of Patient Goals

BACKGROUND/OBJECTIVES

 Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social communication difficulties and restricted repetitive behaviors or interests. Applied behavior analysis (ABA) has been shown to significantly improve outcomes for individuals on the autism spectrum. However, challenges regarding access, cost, and provider shortages remain obstacles to treatment delivery. To this end, parents were trained as parent behavior technicians (pBTs), improving access to ABA, and empowering parents to provide ABA treatment in their own homes. We hypothesized that patients diagnosed with severe ASD would achieve the largest gains in overall success rates toward skill acquisition in comparison to patients diagnosed with mild or moderate ASD. Our secondary hypothesis was that patients with comprehensive treatment plans (>25-40 hours/week) would show greater gains in skill acquisition than those with focused treatment plans (less than or equal to 25 hours/week).  Methods: This longitudinal, retrospective chart review evaluated data from 243 patients aged two to 18 years who received at least three months of ABA within our pBT treatment delivery model. Patients were stratified by utilization of prescribed ABA treatment, age, ASD severity (per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), and treatment plan type (comprehensive vs. focused). Patient outcomes were assessed by examining success rates in acquiring skills, both overall and in specific focus areas (communication, emotional regulation, executive functioning, and social skills).

RESULTS

Patients receiving treatment within the pBT model demonstrated significant progress in skill acquisition both overall and within specific focus areas, regardless of cohort stratification. Patients with severe ASD showed greater overall skill acquisition gains than those with mild or moderate ASD. In addition, patients with comprehensive treatment plans showed significantly greater gains than those with focused treatment plans.

CONCLUSION

The pBT model achieved both sustained levels of high treatment utilization and progress toward patient goals. Patients showed significant gains in success rates of skill acquisition both overall and in specific focus areas, regardless of their level of treatment utilization. This study reveals that our pBT model of ABA treatment delivery leads to consistent improvements in communication, emotional regulation, executive functioning, and social skills across patients on the autism spectrum, particularly for those with more severe symptoms and those following comprehensive treatment plans.

Changes in Autistic Symptoms and Adaptive Functioning of Children Receiving Early Behavioral Intervention in a Community Setting: A Latent Growth Curve Analysis

Despite showing effects in well-controlled studies, the extent to which early intensive behavioral intervention (EBI) produces positive changes in community-based settings remains uncertain. Thus, our study examined changes in autistic symptoms and adaptive functioning in 233 children with autism receiving EBI in a community setting. The results revealed nonlinear changes in adaptive functioning characterized by significant improvements during the intervention and a small linear decrease in autistic symptoms from baseline to follow-up. The intensity of intervention, initial age, IQ and autistic symptoms were associated either with progress during the intervention or maintenance during the follow-up. The next step to extend this line of research involves collecting detailed data about intervention strategies and implementation fidelity to produce concrete recommendations for practitioners.

Children with autism exhibit similar longitudinal changes in core symptoms when placed in special or mainstream education settings

LAY ABSTRACT

Today, children with autism spectrum disorder (ASD) are placed in mainstream or special education settings somewhat arbitrarily with no clear clinical recommendations. Here, we compared changes in core ASD symptoms, as measured by the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2) clinical assessment, across ASD preschool children placed in special or mainstream education. Longitudinal changes in ADOS-2 scores did not differ significantly across settings over a 1- to 2-year period. While some children improved in core ASD symptoms, others deteriorated in both settings. This highlights the need to identify specific criteria for establishing meaningful placement recommendations.

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

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

Measuring social orienting in preschoolers with autism spectrum disorder using cartoons stimuli

Altered social orienting (SO) was proposed as the primary source of socio-communicative difficulties in autism spectrum disorder (ASD). Eye-tracking studies generally confirm a decreased SO in ASD population. However, SO has been scarcely investigated using minimally social stimuli such as cartoons. The extent to which SO might be decreased when watching cartoons is therefore unknown. Yet, it could allow for malleable and child-friendly paradigms that could be sensitive to early atypical visual preference. In this study, 90 preschoolers with ASD (age = 3.19 ± 0 .88) and 20 TD (age = 2.95 ± 1.26) watched two eye-tracking preference tasks. One Realistic task, displaying children dancing versus geometric shapes moving repetitively and a Cartoon task, displaying social and non-social cartoon stimuli with similar movements. We measured SO percentage along with refined visual exploration parameters and compared those of ASD children to TDs. In addition, we investigated their relations with behavioral measures such as symptom severity, developmental and adaptive levels. We evidenced a decreased SO percentage in ASD compared to TD children when watching the Realistic task but not the Cartoon task. We did not identify any other between groups differences. However, we identified several correlations between eye-tracking measures and developmental as well as adaptive measures within the Cartoon task. Together, our results support a preferential orientation of children with autism towards repetitively moving shapes but no decreased SO when measured with minimally social stimuli. Nonetheless, when investigating finer visual exploration parameters, even socially simple stimuli elicited atypical gaze patterns related to early developmental delay.

Professional Development of Behavior Analysts in Europe: A Snapshot for 21 Countries

Behavior analysts are not recognized or regulated as a distinct profession in Europe. For the most part, European behavior analysts adhered to the standards set by the U.S.-based Behavior Analyst Certification Board (BACB). However, the BACB certification has not been recognized officially in any European jurisdiction. The recent decision by the BACB to discontinue eligibility of non-U.S. residents to apply for the BCBA exam by the end of 2022 has brought the issue of professional regulation outside of the United States into sharp focus. This article offers a snapshot in time of professional recognition of behavior analysts in 21 European countries. It stems from the Erasmus+ funded EuroBA project and its Professional Advisory Group (PAG). The EuroBA project aims to develop common standards and competences for behavior analysts to facilitate national regulation and mutual recognition across Europe.

Differential Predictors of Response to Early Start Denver Model vs. Early Intensive Behavioral Intervention in Young Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

The effectiveness of early intensive interventions for Autism Spectrum Disorder (ASD) is now well-established, but there continues to be great interindividual variability in treatment response. The purpose of this systematic review is to identify putative predictors of response to two different approaches in behavioral treatment: Early Intensive Behavioral Interventions (EIBI) and the Early Start Denver Model (ESDM). Both are based upon the foundations of Applied Behavioral Analysis (ABA), but the former is more structured and therapist-driven, while the latter is more naturalistic and child-driven. Four databases (EmBase, PubMed, Scopus and WebOfScience) were systematically screened, and an additional search was conducted in the reference lists of relevant articles. Studies were selected if participants were children with ASD aged 12-48 months at intake, receiving either EIBI or ESDM treatment. For each putative predictor, p-values from different studies were combined using Fisher's method. Thirteen studies reporting on EIBI and eleven on ESDM met the inclusion criteria. A higher IQ at intake represents the strongest predictor of positive response to EIBI, while a set of social cognitive skills, including intention to communicate, receptive and expressive language, and attention to faces, most consistently predict response to ESDM. Although more research will be necessary to reach definitive conclusions, these findings begin to shed some light on patient characteristics that are predictive of preferential response to EIBI and ESDM, and may provide clinically useful information to begin personalizing treatment.

Pupillometric measures of altered stimulus-evoked locus coeruleus-norepinephrine activity explain attenuated social attention in preschoolers with autism spectrum disorder

Attenuated social attention has been described as a reduced preference for social compared to geometric motion in preschoolers with autism spectrum disorder (ASD). The locus coeruleus-norpinephrine (LC-NE) system modulates sensory reactivity and is a promising underlying mechanism. LC-NE activity is indexed by a stimulus-evoked pupillary response (SEPR) and partially by a luminance-adaptation pupillary response (LAPR), which were both shown to be aberrant in ASD. We examined whether SEPR and LAPR explain an attenuated social motion preference. We applied pupillometry via video-based eye tracking in young children (18-65 months) with ASD (n = 57) and typically developing (TD) children (n = 39) during a preferential looking paradigm of competing social and geometric motion and a changing light condition paradigm. We found an attenuated social motion preference in the ASD compared to the TD group. This was accompanied by atypical pupillometry showing a smaller SEPR to social motion, a larger SEPR to geometric motion and a reduced LAPR to a dark screen. SEPR but not LAPR explained the group difference in social motion preference. An ASD diagnosis was statistically predicted by the social motion preference, while this effect was mediated by the inclusion of SEPR to geometric and social motion. Our findings suggest a decreased sensory reactivity to social and increased reactivity to non-social motion in ASD, which may concurrently contribute to an attenuated social attention. The LC-NE system is supported as a promising underlying mechanism of altered social attention in young children with ASD, while the specificity of findings remains to be addressed.

Overall prognosis of preschool autism spectrum disorder diagnoses

BACKGROUND

Autism spectrum disorder is a neurodevelopmental disorder characterised by social communication difficulties, restricted interests and repetitive behaviours. The clinical pathway for children with a diagnosis of autism spectrum disorder is varied, and current research suggests some children may not continue to meet diagnostic criteria over time.

OBJECTIVES

The primary objective of this review was to synthesise the available evidence on the proportion of preschool children who have a diagnosis of autism spectrum disorder at baseline (diagnosed before six years of age) who continue to meet diagnostic criteria at follow-up one or more years later (up to 19 years of age).

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO, and eight other databases in October 2017 and ran top-up searches up to July 2021. We also searched reference lists of relevant systematic reviews.

SELECTION CRITERIA

Two review authors independently assessed prospective and retrospective follow-up studies that used the same measure and process within studies to diagnose autism spectrum disorder at baseline and follow-up. Studies were required to have at least one year of follow-up and contain at least 10 participants. Participants were all aged less than six years at baseline assessment and followed up before 19 years of age.

DATA COLLECTION AND ANALYSIS

We extracted data on study characteristics and the proportion of children diagnosed with autism spectrum disorder at baseline and follow-up. We also collected information on change in scores on measures that assess the dimensions of autism spectrum disorder (i.e. social communication and restricted interests and repetitive behaviours). Two review authors independently extracted data on study characteristics and assessed risk of bias using a modified quality in prognosis studies (QUIPS) tool. We conducted a random-effects meta-analysis or narrative synthesis, depending on the type of data available. We also conducted prognostic factor analyses to explore factors that may predict diagnostic outcome.

MAIN RESULTS

In total, 49 studies met our inclusion criteria and 42 of these (11,740 participants) had data that could be extracted. Of the 42 studies, 25 (60%) were conducted in North America, 13 (31%) were conducted in Europe and the UK, and four (10%) in Asia. Most (52%) studies were published before 2014. The mean age of the participants was 3.19 years (range 1.13 to 5.0 years) at baseline and 6.12 years (range 3.0 to 12.14 years) at follow-up. The mean length of follow-up was 2.86 years (range 1.0 to 12.41 years). The majority of the children were boys (81%), and just over half (60%) of the studies primarily included participants with intellectual disability (intelligence quotient < 70). The mean sample size was 272 (range 10 to 8564). Sixty-nine per cent of studies used one diagnostic assessment tool, 24% used two tools and 7% used three or more tools. Diagnosis was decided by a multidisciplinary team in 41% of studies. No data were available for the outcomes of social communication and restricted and repetitive behaviours and interests. Of the 42 studies with available data, we were able to synthesise data from 34 studies (69% of all included studies; n = 11,129) in a meta-analysis. In summary, 92% (95% confidence interval 89% to 95%) of participants continued to meet diagnostic criteria for autism spectrum disorder from baseline to follow-up one or more years later; however, the quality of the evidence was judged as low due to study limitations and inconsistency. The majority of the included studies (95%) were rated at high risk of bias. We were unable to explore the outcomes of change in social communication and restricted and repetitive behaviour and interests between baseline and follow-up as none of the included studies provided separate domain scores at baseline and follow-up. Details on conflict of interest were reported in 24 studies. Funding support was reported by 30 studies, 12 studies omitted details on funding sources and two studies reported no funding support. Declared funding sources were categorised as government, university or non-government organisation or charity groups. We considered it unlikely funding sources would have significantly influenced the outcomes, given the nature of prognosis studies.

AUTHORS' CONCLUSIONS

Overall, we found that nine out of 10 children who were diagnosed with autism spectrum disorder before six years of age continued to meet diagnostic criteria for autism spectrum disorder a year or more later, however the evidence was uncertain. Confidence in the evidence was rated low using GRADE, due to heterogeneity and risk of bias, and there were few studies that included children diagnosed using a current classification system, such as the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the eleventh revision of the International Classification of Diseases (ICD-11). Future studies that are well-designed, prospective and specifically assess prognosis of autism spectrum disorder diagnoses are needed. These studies should also include contemporary diagnostic assessment methods across a broad range of participants and investigate a range of relevant prognostic factors.

Examining Predictors of Different ABA Treatments: A Systematic Review

In the recent literature, there is a broad consensus on the effectiveness of Applied Behavior Analysis interventions for autism spectrum disorder (ASD). Despite their proven efficacy, research in clinical settings shows that these treatments are not equally effective for all children and the issue of which intervention should be chosen for an individual remains a common dilemma. The current work systematically reviewed studies on predictors and moderators of response to different types of evidence-based treatment for children with ASD. Specifically, our goal was to critically review the relationships between pre-treatment child characteristics and specific treatment outcomes, covering different aspects of functioning (i.e., social, communicative, adaptive, cognitive, motor, global functioning, play, and symptom severity). Our results questioned the binomial “better functioning-better outcome”, emphasizing the complex interplay between pre-treatment child characteristics and treatment outcomes. However, some pre-treatment variables seem to act as prerequisites for a specific treatment, and the issue of “what works for whom and why” remains challenging. Future research should focus on the definition of evidence-based decision-making models that capture those individual factors through which a specific intervention will exert its effects.

Symptoms of Autism Spectrum Disorders Measured by the Qualitative Checklist for Autism in Toddlers in a Large Sample of Polish Toddlers

This study aimed to assess some early symptoms of autism spectrum disorders (ASD) measured by a screening tool developed for an early detection of ASD. We investigated if the early symptoms were associated with toddlers' age, gender or ASD familial risk status. We used the Polish version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT) to assess 1024 children aged 16 to 36 months. The sample included four groups of participants: typically developing toddlers, toddlers with parent-reported ASD-specific concerns, toddlers at risk for autism due to having an older sibling with ASD, and toddlers with a developmental delay. We found that mean Q-CHAT scores were significantly higher in boys than in girls. We did not find any associations between Q-CHAT scores and age. We observed that toddlers with a familial risk for ASD and those with a developmental delay scored significantly higher than controls. We collated these results with previous studies that used the Q-CHAT and other instruments.

Trajectories of imitation skills in preschoolers with autism spectrum disorders

Background

Imitation skills play a crucial role in social cognitive development from early childhood. Many studies have shown a deficit in imitation skills in children with autism spectrum disorders (ASD). Little is known about the development of imitation behaviors in children with ASD. This study aims to measure the trajectories of early imitation skills in preschoolers with ASD and how these skills impact other areas of early development.

Methods

For this purpose, we assessed imitation, language, and cognition skills in 177 children with ASD and 43 typically developing children (TD) aged 2 to 5 years old, 126 of which were followed longitudinally, yielding a total of 396 time points.

Results

Our results confirmed the presence of an early imitation deficit in toddlers with ASD compared to TD children. The study of the trajectories showed that these difficulties were marked at the age of 2 years and gradually decreased until the age of 5 years old. Imitation skills were strongly linked with cognitive and language skills and level of symptoms in our ASD group at baseline. Moreover, the imitation skills at baseline were predictive of the language gains a year later in our ASD group. Using a data-driven clustering method, we delineated different developmental trajectories of imitation skills within the ASD group.

Conclusions

The clinical implications of the findings are discussed, particularly the impact of an early imitation deficit on other areas of competence of the young child.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11689-021-09412-y.

Distinct Patterns of Cognitive Outcome in Young Children With Autism Spectrum Disorder Receiving the Early Start Denver Model

Evidence-based, early intervention significantly improves developmental outcome in young children with autism. Nonetheless, there is high interindividual heterogeneity in developmental trajectories during the therapy. It is established that starting intervention as early as possible results in better developmental outcomes. But except for younger age at start, there is no clear consensus about behavioral characteristics that could provide a reliable individual prediction of a child's developmental outcome after receiving an early intervention. In this study, we analyze developmental trajectories of preschoolers with autism who received 2 years of intervention using the Early Start Denver Model (ESDM) approach in Geneva, Switzerland in an individual setting (n = 55, aged 28.7 ± 5.1 months with a range of 15-42). Our aim was to identify early predictors of response to intervention. We applied a cluster analysis to distinguish between 3 groups based on their cognitive level at intake, and rates of cognitive change over the course of intervention. The first group of children only had a mild cognitive delay at intake and nearly no cognitive delay by the end of intervention (Higher Cognitive at baseline: HC). The children in the two other groups all presented with severe cognitive delay at baseline. However, they had two very different patterns of response to intervention. The majority significantly improved developmental scores over the course of intervention (Optimal Responders: OptR) whereas a minority of children showed only modest improvement (Minimal Responders: MinR). Further analyses showed that children who ended up having an optimal 2-year intervention outcome (OptR) were characterized by higher adaptive functioning at baseline combined with rapid developmental improvement during the first 6 months of intervention. Inversely, less significant progress by the sixth month of intervention was associated with a less optimal response to treatment (MinR).

Early alterations of large-scale brain networks temporal dynamics in young children with autism

Autism spectrum disorders (ASD) are associated with disruption of large-scale brain network. Recently, we found that directed functional connectivity alterations of social brain networks are a core component of atypical brain development at early developmental stages in ASD. Here, we investigated the spatio-temporal dynamics of whole-brain neuronal networks at a subsecond scale in 113 toddlers and preschoolers (66 with ASD) using an EEG microstate approach. We first determined the predominant microstates using established clustering methods. We identified five predominant microstate (labeled as microstate classes A-E) with significant differences in the temporal dynamics of microstate class B between the groups in terms of increased appearance and prolonged duration. Using Markov chains, we found differences in the dynamic syntax between several maps in toddlers and preschoolers with ASD compared to their TD peers. Finally, exploratory analysis of brain-behavioral relationships within the ASD group suggested that the temporal dynamics of some maps were related to conditions comorbid to ASD during early developmental stages.

Attention to Face as a Predictor of Developmental Change and Treatment Outcome in Young Children with Autism Spectrum Disorder

The beneficial effect of early intervention is well described for children with autism spectrum disorder (ASD). Response to early intervention is, however, highly heterogeneous in affected children, and there is currently only scarce information about predictors of response to intervention. Based on the hypothesis that impaired social orienting hinders the subsequent development of social communication and interactions in children with ASD, we sought to examine whether the level of social orienting modulates treatment outcome in young children with ASD. We used eye-tracking technology to measure social orienting in a group of 111 preschoolers, comprising 95 young children with ASD and 16 children with typical development, as they watched a 29 s video of a woman engaging in child-directed speech. In line with previous studies, we report that attention to face is robustly correlated with autistic symptoms and cognitive and adaptive skills at baseline. We further leverage longitudinal data in a subgroup of 81 children with ASD and show that the level of social orienting at baseline is a significant predictor of developmental gains and treatment outcome. These results pave the way for identifying subgroups of children who show a better response to early and intensive intervention, a first step toward precision medicine for children with autism.

Using 2D video-based pose estimation for automated prediction of autism spectrum disorders in young children

Clinical research in autism has recently witnessed promising digital phenotyping results, mainly focused on single feature extraction, such as gaze, head turn on name-calling or visual tracking of the moving object. The main drawback of these studies is the focus on relatively isolated behaviors elicited by largely controlled prompts. We recognize that while the diagnosis process understands the indexing of the specific behaviors, ASD also comes with broad impairments that often transcend single behavioral acts. For instance, the atypical nonverbal behaviors manifest through global patterns of atypical postures and movements, fewer gestures used and often decoupled from visual contact, facial affect, speech. Here, we tested the hypothesis that a deep neural network trained on the non-verbal aspects of social interaction can effectively differentiate between children with ASD and their typically developing peers. Our model achieves an accuracy of 80.9% (F1 score: 0.818; precision: 0.784; recall: 0.854) with the prediction probability positively correlated to the overall level of symptoms of autism in social affect and repetitive and restricted behaviors domain. Provided the non-invasive and affordable nature of computer vision, our approach carries reasonable promises that a reliable machine-learning-based ASD screening may become a reality not too far in the future.

The impact of social complexity on the visual exploration of others' actions in preschoolers with autism spectrum disorder

BACKGROUND

Typical development of socio-communicative skills relies on keen observation of others. It thus follows that decreased social attention negatively impacts the subsequent development of socio-communicative abilities in children with autism spectrum disorders (ASD). In addition, studies indicate that social attention is modulated by context and that greater social difficulties are observed in more socially demanding situations. Our study aims to investigate the effect of social complexity on visual exploration of others' actions in preschoolers.

METHODS

To investigate the impact of social complexity, we used an eye-tracking paradigm with 26 typically developing preschoolers (TD, age = 3.60 ± 1.55) and 37 preschoolers with ASD (age = 3.55 ± 1.21). Participants were shown videos of two children engaging in socially simple play (parallel) versus socially complex play (interactive). We subsequently quantified the time spent and fixation duration on faces, objects, bodies, as well as the background and the number of spontaneous gaze shifts between socially relevant areas of interest.

RESULTS

In the ASD group, we observed decreased time spent on faces. Social complexity (interactive play) elicited changes in visual exploration patterns in both groups. From the parallel to the interactive condition, we observed a shift towards socially relevant parts of the scene, a decrease in fixation duration, as well as an increase in spontaneous gaze shifts between faces and objects though there were fewer in the ASD group.

LIMITATIONS

Our results need to be interpreted cautiously due to relatively small sample sizes and may be relevant to male preschoolers, given our male-only sample and reported phenotypic differences between males and females.

CONCLUSION

Our results suggest that similar to TD children, though to a lesser extent, visual exploration patterns in ASD are modulated by context. Children with ASD that were less sensitive to context modulation showed decreased socio-communicative skills or higher levels of symptoms. Our findings support using naturalistic designs to capture socio-communicative deficits in ASD.

Emotional vs. Neutral Face Exploration and Habituation: An Eye-Tracking Study of Preschoolers With Autism Spectrum Disorders

Diminished orienting to social stimuli, and particularly to faces, is a core feature of autism spectrum disorders (ASDs). Impaired face processing has been linked to atypical attention processes that trigger a cascade of pathological development contributing to impaired social communication. The aim of the present study is to explore the processing of emotional and neutral faces using an eye-tracking paradigm (the emotional faces task) with a group of 24 children with ASD aged 6 and under and a group of 22 age-matched typically developing (TD) children. We also measure habituation to faces in both groups based on the presentation of repeated facial expressions. Specifically, the task consists of 32 pairs of faces, a neutral face and an emotional face from the same identity, shown side by side on the screen. We observe differential exploration of emotional faces in preschoolers with ASD compared with TD. Participants with ASD make fewer fixations to emotional faces than their TD peers, and the duration of their first fixation on emotional faces is equivalent to their first fixation on neutral faces. These results suggest that emotional faces may be less interesting for children with ASD. We also observe a habituation process to neutral faces in both children with ASD and TD, who looked less at neutral faces during the last quarter of the task compared with the first quarter. By contrast, TD children show increased interest in emotional faces throughout the task, looking slightly more at emotional faces during the last quarter of the task than during the first quarter. Children with ASD demonstrate neither habituation nor increased interest in the changing emotional expressions over the course of the task, looking at the stimuli for equivalent time throughout the task. A lack of increased interest in emotional faces may suggest a lack of sensitivity to changes in expression in young children with ASD.

Short-Term and Highly Intensive Early Intervention FIAS: Two-Year Outcome Results and Factors of Influence

BACKGROUND

Comprehensive behaviorally or developmentally based early intervention programs have been shown to be effective in improving cognitive, social communicative, and adaptive skills of children with autism spectrum disorder (ASD). Besides the definition of relevant outcome predictors, the question of whether early intensive intervention positively changes core autism symptoms in children, as well as their long-term outcome, is an important issue for current research. The primary objective of the current study was to examine whether symptomatic and behavioral changes in children up to 4.5 years with ASD were sustained one and two years after an initial 18 days of intensive FIAS (Frühintervention bei autistischen Störungen) intervention.

METHODS

We analyzed the data of 32 young children with moderately severe to severe ASD who had been treated at the FIAS center between January 2011 and July 2017 and who had completed their 2-year follow-up in summer 2019.

RESULTS

ADOS total scores decreased significantly from baseline to the 1-year follow-up and from baseline to the 2-year follow-up (p < 0.01), with the most prominent change being from baseline to 2-year follow-up. The DD-C-GAS, a global scale used to assess four areas of everyday functioning, showed highly significant improvements on all subdomains. We found mostly significant correlations between results on both rating instruments at all time points, yet mostly no meaningful correlation between their changes over time. There was a close and statistically significant relationship between parents' treatment adherence and ADOS scores, indicating that the better parents' treatment adherence, the lower the children scored on the ADOS at 1- and 2-year follow-up. Overall, improvement on both scales was virtually independent of age and autism symptom severity at baseline, suggesting that older (>43 months) and more severely affected children (ADOS total score >20) may benefit from the FIAS intervention to the same extent as younger children do.

CONCLUSIONS

The results of the study indicate that the FIAS approach of providing an initial highly intensive 18-day intervention period, followed by 2 years of less intensive follow-up care had an impact on the core autism symptoms as well as the adaptive functioning of children with ASD.