A randomized controlled trial of Pivotal Response Treatment Group for parents of children with autism

Autism spectrum disorder: pathogenesis, biomarker, and intervention therapy

Autism spectrum disorder (ASD) has become a common neurodevelopmental disorder. The heterogeneity of ASD poses great challenges for its research and clinical translation. On the basis of reviewing the heterogeneity of ASD, this review systematically summarized the current status and progress of pathogenesis, diagnostic markers, and interventions for ASD. We provided an overview of the ASD molecular mechanisms identified by multi-omics studies and convergent mechanism in different genetic backgrounds. The comorbidities, mechanisms associated with important physiological and metabolic abnormalities (i.e., inflammation, immunity, oxidative stress, and mitochondrial dysfunction), and gut microbial disorder in ASD were reviewed. The non-targeted omics and targeting studies of diagnostic markers for ASD were also reviewed. Moreover, we summarized the progress and methods of behavioral and educational interventions, intervention methods related to technological devices, and research on medical interventions and potential drug targets. This review highlighted the application of high-throughput omics methods in ASD research and emphasized the importance of seeking homogeneity from heterogeneity and exploring the convergence of disease mechanisms, biomarkers, and intervention approaches, and proposes that taking into account individuality and commonality may be the key to achieve accurate diagnosis and treatment of ASD.

Exploring the Acquisition of Social Communication Skills in Children with Autism: Preliminary Findings from Applied Behavior Analysis (ABA), Parent Training, and Video Modeling

Social communication skills, especially eye contact and joint attention, are frequently impaired in autism spectrum disorder (ASD) and predict functional outcomes. Applied behavior analysis is one of the most common evidence-based treatments for ASD, but it is not accessible to most families in low- and middle-income countries (LMICs) as it is an expensive and intensive treatment and needs to be delivered by highly specialized professionals. Parental training has emerged as an effective alternative. This is an exploratory study to assess a parental intervention group via video modeling to acquire eye contact and joint attention. Four graded measures of eye contact and joint attention (full physical prompt, partial physical prompt, gestural prompt, and independent) were assessed in 34 children with ASD and intellectual disability (ID). There was a progressive reduction in the level of prompting required over time to acquire eye contact and joint attention, as well as a positive correlation between the time of exposure to the intervention and the acquisition of abilities. This kind of parent training using video modeling to teach eye contact and joint attention skills to children with ASD and ID is a low-cost intervention that can be applied in low-resource settings.

Do Naturalistic Developmental Behavioral Interventions improve family quality of life? A systematic review and meta-analysis

LAY ABSTRACT

Naturalistic Developmental Behavioral Interventions have been described as culturally responsive and family-friendly interventions, with research demonstrating improvements in children's development following the receipt of these interventions. Given the child-directed nature of Naturalistic Developmental Behavioral Interventions and the intervention's integration within families' daily routines, many studies have examined the impact of Naturalistic Developmental Behavioral Interventions on family and family member quality of life. We conducted a systematic review and meta-analysis to explore the relationship between Naturalistic Developmental Behavioral Interventions and family quality of life. Results suggest that the provision of a Naturalistic Developmental Behavioral Intervention neither improved nor worsened family or family member quality of life. For those involved in delivering Naturalistic Developmental Behavioral Intervention services, there is an immediate need to convey to families that children's improvements will likely not translate into improvements in family quality of life.

Overview of Meta-Analyses on Naturalistic Developmental Behavioral Interventions for Children with Autism Spectrum Disorder

We conducted an overview of reviews to determine the effects of naturalistic developmental behavioral interventions (NDBIs; Schreibman et al. (2015) J Autism Dev Disorders 45:2411-2428) on children with autism spectrum disorder under 8 years old. We conducted an electronic database search of Academic Search Premier, CINHAL, ERIC, Medline, and APA PsycINFO in October 2022 and August 2023 and utilized snowball methods to locate relevant reviews of NDBI. We included reviews meeting the following inclusion criteria: (1) review included a meta-analytic synthesis for at least one child outcome; (2) primary studies examined a NDBI; (3) primary studies included children with ASD with a mean pre-treatment age under eight years; (4) primary studies were conducted using a two-group comparison design; and (5) review was published in English. We extracted data on characteristics of the review, participant characteristics from the primary studies, intervention characteristics, and assessed the risk of bias of the included reviews. We conducted a narrative synthesis across outcomes reported in the included reviews. We included five reviews from six reports in this overview. Two reviews included studies that examined the Early Start Denver Model, two reviews included studies that examined the Pivotal Response Treatment, and one review included studies examining NDBIs collectively. We found positive effects of NDBIs on child's communication/language, cognition, and adaptive behavior. We found mixed effects for NDBIs on autism symptomatology and restricted and repetitive behaviors. Examination of moderator analyses reported in the included reviews suggested variables influencing the effects of NDBIs included proximity of outcome to intervention, boundedness of outcome to intervention, and study location. As shown in this overview, positive effects of NDBI for young children with ASD are supported by meta-analytic evidence. While the overall findings for NDBI across reviews are positive, the findings on specific outcomes and influential variables moderating the effects of NDBI are inconsistent. Additional evidence from randomized controlled trials and future meta-analyses are needed to strengthen our knowledge of the effects of NDBI for young children with ASD.Protocol Registration: PROSPERO CRD42022353045.

The devil is in the details: Advancing our collective understanding of naturalistic developmental behavioral interventions

Given the growing body of randomized trials examining various Naturalistic Developmental Behavioral Intervention (NDBI) approaches, a dialog has emerged exploring the overlap in strategies across NDBIs to create single measures that propose to capture core strategies across the interventions. This commentary will ask readers to consider the current state of the science, the potential value of looking not only for similarities but also for differences across approaches, and present five scientific next steps to advance our collective understanding of the NDBIs including: (a) operationalizing intervention strategies and outcomes, (b) expansion of the effectiveness evidence base and begin testing implementation strategies for individual NDBIs, (c) rigorous testing of core intervention components and the mechanism of each intervention, (d) personalization, and (e) supporting transparency with a priori trial registration.

Oral language interventions can improve language outcomes in children with neurodevelopmental disorders: A systematic review and meta-analysis

Background

Young people who fail to develop language as expected face significant challenges in all aspects of life. Unfortunately, language disorders are common, either as a distinct condition (e.g., Developmental Language Disorder) or as a part of another neurodevelopmental condition (e.g., autism). Finding ways to attenuate language problems through intervention has the potential to yield great benefits not only for the individual but also for society as a whole.

Objectives

This meta-analytic review examined the effect of oral language interventions for children with neurodevelopmental disorders.

Search Methods

The last electronic search was conducted in April 2022.

Selection Criteria

Intervention studies had to target language skills for children from 2 to 18 years of age with Developmental Language Disorder, autism, intellectual disability, Down syndrome, Fragile X syndrome, and Williams syndrome in randomised controlled trials or quasi-experimental designs. Control groups had to include business-as-usual, waiting list, passive or active conditions. However, we excluded studies in which the active control group received a different type, delivery, or dosage of another language intervention. Eligible interventions implemented explicit and structured activities (i.e., explicit instruction of vocabulary, narrative structure or grammatical rules) and/or implicit and broad activities (i.e., shared book reading, general language stimulation). The intervention studies had to assess language skills in receptive and/or expressive modalities.

Data Collection and Analysis

The search provided 8195 records after deduplication. Records were screened by title and abstract, leading to full-text examinations of 448 records. We performed Correlated and Hierarchical Effects models and ran a retrospective power analysis via simulation. Publication bias was assessed via p-curve and precision-effect estimate.

Main Results

We examined 38 studies, with 46 group comparisons and 108 effects comparing pre-/post-tests and eight studies, with 12 group comparisons and 21 effects at follow-up. The results showed a mean effect size of d = 0.27 at the post-test and d = 0.18 at follow-up. However, there was evidence of publication bias and overestimation of the mean effects. Effects from the meta-analysis were significantly related to these elements: (1) receptive vocabulary and omnibus receptive measures showed smaller effect sizes relative to expressive vocabulary, grammar, expressive and receptive discourse, and omnibus expressive tests; and (2) the length of the intervention, where longer sessions conducted over a longer period of time were more beneficial than brief sessions and short-term interventions. Neither moderators concerning participants' characteristics (children's diagnosis, diagnostic status, age, sex, and non-verbal cognitive ability and severity of language impairment), nor those regarding of the treatment components and implementation of the language interventions (intervention content, setting, delivery agent, session structure of the intervention or total number of sessions) reached significance. The same occurred to indicators of study quality. The risk of bias assessment showed that reporting quality for the studies examined in the review was poor.

Authors’ Conclusions

In sum, the current evidence base is promising but inconclusive. Pre-registration and replication of more robust and adequately powered trials, which include a wider range of diagnostic conditions, together with more long-term follow-up comparisons, are needed to drive evidence-based practice and policy.

Effects of Parent-Implemented Interventions on Outcomes of Children with Autism: A Meta-Analysis

Children with autism spectrum disorder (ASD) have been shown to benefit from parent-implemented interventions (PIIs). This meta-analysis improved on prior reviews of PIIs by evaluating RCTs and multiple potential moderators, including indicators of research quality. Fifty-one effect sizes averaged moderately strong overall benefits of PIIs (g = 0.553), with studies having lower risk of research bias yielding lower estimates (g = 0.47). Parent and observer ratings yielded similar averaged estimates for positive behavior/social skills (g = 0.603), language/communication (g = 0.545), maladaptive behavior (g = 0.519), and to a lesser extent, adaptive behavior/life skills (g = 0.239). No other study, intervention, or participant characteristic moderated outcomes. PIIs with children with ASD tend to be effective across a variety of circumstances.

Efficacy of a Parent-Implemented Pivotal Response Treatment for Children with Autism Spectrum Disorder

PURPOSE

Pivotal response treatment (PRT) is a well-established intervention addressing core symptoms of autism spectrum disorder (ASD), with parent involvement as a key component. The current study aimed to examine the effects of PRT parent training on parent fidelity and provide descriptive analyses of parent-child interactions before and after parent training. It also probed parental acceptance and satisfaction with the program.

METHODS

A concurrent multiple baseline design across participants was used to evaluate the effectiveness of the parent training program. Four parents (range 32-47 years old) and their children with ASD participated in the study. The intervention comprised 12 one-on-one parent training sessions over six consecutive weeks. The visual analysis and effect size calculation (Tau-U) were used to evaluate functional relationship between independent and dependent variables. The descriptive analysis was used to analyze parent-child interaction data.

RESULTS

The findings reveal that all parents learned and maintained PRT with a high level of fidelity, they also enhanced awareness to create more opportunities for interactions during free play, and the parents were very satisfied with the program. The results also indicate that the six-week parent training program is effective in teaching parents to implement PRT with their children.

CONCLUSION

These results suggest that the parent training program may be a promising treatment model that is effective, efficient, and cost-effective. Implications for future research and practice are then discussed.

Comparing Anxiety Levels during the COVID-19 Pandemic among Mothers of Children with and without Neurodevelopmental Disorders

The COVID-19 pandemic undoubtedly burdened families, perhaps even more for parents of children with neurodevelopmental disabilities. This research aims to determine the anxiety levels in mothers of children with neurodevelopmental disorders (autism spectrum disorder and specific language impairment) and mothers of typically developed children. The cross-sectional study comprised 280 mothers from the period of the COVID-19 pandemic in Serbia. A confidential survey included main demographic data and the State-Trait Anxiety Inventory (STAI). Results revealed that the mean levels of STAI-S and STAI-T are elevated in the observed sample of mothers in the first pandemic wave; the STAI-S level is in the high category (STAI-S mean = 46.69), while STAI-T is in the intermediate category near the cut-off value for the high level (STAI-T mean = 43.04). A statistically significant strong positive correlation between STAI-S and STAI-T is seen (r = 0.802, p = 0.001). GLMM analysis revealed that interactions, rather than independent variables, significantly impact anxiety, implying a complex relationship between the observed variables and STAI. Compared with the results from the pre-pandemic study, our findings reveal that COVID-19 affects mothers of children with and without neurodevelopmental disorders in a complex manner, imposing a need for psychological support, which may positively affect mothers' mental health and the development of their offspring.

The earlier the better: An RCT of treatment timing effects for toddlers on the autism spectrum

LAY ABSTRACT

Behavioral interventions that incorporate naturalistic, developmental strategies have been shown to improve outcomes for young children who receive an autism spectrum disorder (ASD) diagnosis. Although there is broad consensus that children on the spectrum should begin supports as soon as possible, the empirical evidence for this is relatively limited and little is known about the optimal age to start autism-specific interventions. Our team conducted a randomized controlled trial (RCT) to test the effects of starting intervention at different ages, using the Early Social Interaction (ESI) model, a parent-implemented intervention for toddlers on the spectrum. Participants included 82 autistic toddlers and their caregiver(s) who received 9 months of Individual-ESI and 9 months of Group-ESI, with the timing/order of these two treatment conditions randomized. Thus, families received the more intensive and individualized Individual-ESI at either 18 or 27 months of age. Results revealed that children who received Individual-ESI earlier showed greater treatment gains than those who received this intervention later. Gains were demonstrated in several areas, which included the use and understanding of language, social use of communication skills, and self-help skills. Importantly, these findings were specific to the intensive and individualized parent coaching model compared to group-based treatment, allowing us to rule out the possibility that these timing effects were due to children getting older rather than the treatment itself. Our results suggest that even a narrow window of 18 versus 27 months may have an impact on outcomes and underscore the importance of screening and evaluation as young as possible.

Addressing current barriers to autism diagnoses through a tiered diagnostic approach involving pediatric primary care providers

Formal autism diagnosis from a specialist trained in autism assessment is customary prior to a child accessing early, intensive autism-specific services. However, long wait lists for diagnostic evaluations and limited specialty workforce have created substantial delays. Additionally, lengthy multidisciplinary evaluations are costly to insurers, inconvenient to families, and disproportionally impact under-resourced families. Diagnostic delays can impede access to intervention services. These barriers, combined with evidence regarding the importance of receiving early, autism-specific treatment, demand new approaches enabling access to autism specific services before comprehensive evaluation. Pediatric primary care providers (PCPs) are often the only health care professionals with whom a family interacts during early childhood and can play a crucial role in helping children with autism symptoms access services. Many strategies for autism diagnosis in primary care are being developed and tested; however, they have yet to be broadly adopted by PCPs, primarily due to critical implementation barriers in primary care settings. There is also not enough evidence on the accuracy of PCPs' diagnostic impressions without extensive specialty support, resulting in PCP hesitancy in diagnosing ASD, as well as family and service provider hesitancy in accepting a PCP autism diagnosis. In this commentary, we explore the acute need for shortening waitlists for autism evaluations through a tiered diagnostic approach, in which PCPs can rule in or rule out autism in children, for whom diagnosis is clear, and refer more complex cases for specialist evaluations, and explore implementation challenges to this approach.

Feasibility and Acceptability of Delivering Pivotal Response Treatment for Autism Spectrum Disorder via Telehealth: Pilot Pre-Post Study

BACKGROUND

Pivotal response treatment (PRT), an evidence-based and parent-delivered intervention, is designed to improve social communication in autistic individuals.

OBJECTIVE

The aim of this study was to assess the feasibility, acceptability, and clinical effects of an online model of PRT delivered via MindNest Health, a telehealth platform that aims to provide self-directed and engaging online modules, real-time coaching and feedback, and accessible stepped-care to large populations of parents seeking resources for their autistic children.

METHODS

Male and female autistic children, aged 2-7 years with single-word to phrase-level speech, and their parents were eligible to participate in the study. Families were randomized to the online parent training condition or control condition. The online component of the intervention consisted of eight 20-minute online courses of content describing parent training principles in PRT. Four 1-hour videoconferences were held after course 1, course 3, course 5, and course 8. Parents were given 1-2 weeks to complete each course. Parents completed the Client Credibility Questionnaire (CCQ) at week 2 and at the study endpoint, as well as the Behavioral Intervention Rating Scale (BIRS) at the study endpoint to assess parental expectancies, and treatment acceptability and effectiveness.

RESULTS

Nine of 14 participants completed the study curriculum in the online parent training condition, and 6 of 12 participants completed the control condition. Thus, a total of 58% (15/26) participants across both groups completed the study curriculum by study closure. Within the online parent training condition, there was a significant increase in mean CCQ total scores, from 25.38 (SD 3.25) at baseline to 27.5 (SD 3.74) at study endpoint (P=.04); mean CCQ confidence scores, from 6.0 (SD 1.07) at baseline to 6.75 (SD 0.89) at study endpoint (P=.02); and mean CCQ other improvement scores, from 5.25 (SD 0.89) at baseline to 6.25 (SD 1.28) at study endpoint (P=.009). Within the control condition, a modest increase in mean CCQ scores was noted (Confidence, difference=+0.25; Recommend, difference=+0.25; Total Score, difference=+0.50), but the differences were not statistically significant (Confidence P=.38, Recommend P=.36, Total Score P=.43). Among the 11 parents who completed the BIRS at the study endpoint, 82% (n=9) endorsed that they slightly agree or agree with over 93% of the Acceptability factor items on the BIRS.

CONCLUSIONS

The feasibility of this online treatment is endorsed by the high rate of online module completion and attendance to videoconferences within the online parent training group. Acceptability of treatment is supported by strong ratings on the CCQ and significant improvements in scores, as well as strong ratings on the BIRS. This study's small sample size limits the conclusions that can be drawn; however, the PRT MindNest Health platform holds promise to support parents of autistic children who are unable to access traditional, in-person parent-mediated interventions for their child.

The Efficacy of Early Interventions for Children with Autism Spectrum Disorders: A Systematic Review and Meta-Analysis

The superiority of early interventions for children with autism spectrum disorders (ASDs) compared to treatment as usual (TAU) has recently been questioned. This study was aimed to investigate the efficacy of early interventions in improving the cognitive ability, language, and adaptive behavior of pre-school children with ASDs through a systematic review of randomized controlled trials (RCTs). In total, 33 RCTs were included in the meta-analysis using the random effects model. The total sample consisted of 2581 children (age range: 12–132 months). Early interventions led to positive outcomes for cognitive ability (g = 0.32; 95% CI: 0.05, 0.58; p = 0.02), daily living skills (g = 0.35; 95% CI: 0.08, 0.63; p = 0.01), and motor skills (g = 0.39; 95% CI: 0.16, 0.62; p = 0.001), while no positive outcomes were found for the remaining variables. However, when studies without the blinding of outcome assessment were excluded, positive outcomes of early interventions only remained for daily living skills (g = 0.28; 95% CI: 0.04, 0.52; p = 0.02) and motor skills (g = 0.40; 95% CI: 0.11, 0.69; p = 0.007). Although early intervention might not have positive impacts on children with ASDs for several outcomes compared to controls, these results should be interpreted with caution considering the great variability in participant and intervention characteristics.

Evaluating a Two-Tiered Parent Coaching Intervention for Young Autistic Children Using the Early Start Denver Model

OBJECTIVES

Early intervention can improve the outcomes of young autistic children, and parents may be well placed to deliver these interventions. The Early Start Denver Model (ESDM) is a naturalistic developmental behavioral intervention that can be implemented by parents with their own children (P-ESDM). This study evaluated a two-tiered P-ESDM intervention that used a group parent coaching program, and a 1:1 parent coaching program. We evaluated changes in parent use of the ESDM and parent stress, as well as child engagement, communication, and imitation.

METHODS

Seven autistic or probably autistic children (< 60 months old) and their parents participated. A multiple-baseline design was used to compare individual changes between Baseline 1, Group Coaching (Tier 1), Baseline 2, and 1:1 Coaching (Tier 2). Parent and child behaviors were analyzed from weekly videos and graphed. Parenting stress was measured.

RESULTS

All parents improved in their use of ESDM strategies after the Tier 1 intervention. Changes in parent fidelity during Tier 2 were mixed, but all parents maintained higher than baseline levels of fidelity. Six parents demonstrated above 75% ESDM fidelity in at least one session. There were positive changes in parent stress levels pre- post-intervention. Positive results were found for most children's levels of engagement, imitation, and communication. There were significant positive relationships between parent fidelity and both child engagement and child functional utterances.

CONCLUSIONS

Group P-ESDM is a promising approach for improving parent fidelity and some child outcomes. Future randomized and controlled studies of group P-ESDM, using standardized outcome measures, are warranted.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s41252-022-00264-8.

Pivotal Response Treatment (PRT) parent group training for young children with autism spectrum disorder: a pilot study

Pivotal Response Treatment (PRT) is a promising intervention addressing core symptoms of autism spectrum disorder (ASD), with parent involvement as key component. Parent group-delivered PRT may be an effective treatment model, but currently the evidence is limited. Also, little attention has been paid to therapeutic involvement of multiple important contexts (e.g. home, school, community) of the young child. The current study explores a 14-week protocol of PRT parent group training (PRT-PG), complemented with individual parent–child sessions and involvement of teachers and other childcare providers. Children aged 2–6 years old with ASD and their parents (n = 20) were included. Preliminary results showed a significant increase in spontaneous initiations during a semi-structured therapist-child interaction together with widespread gains in clinical global functioning. No significant improvement on parent-rated general social-communication skills was observed. These findings justify further research on parent group delivered PRT models.

Can EEG Correlates Predict Treatment Efficacy in Children with Overlapping ASD and SLI Symptoms: A Case Report

Evaluation of the rehabilitation efficacy may be an essential indicator of its further implementation and planning. The research aim is to examine whether the estimation of EEG correlates of auditory-verbal processing in a child with overlapping autism spectrum disorder (ASD) and specific language impairment (SLI) symptoms may be a predictor of the treatment efficacy in conditions when behavioral tests do not show improvement during the time course. The prospective case report reports follow-up results in a child aged 36 to 66 months. During continuous integrative therapy, autism risk index, cognitive, speech–language, sensory, and EEG correlates of auditory-verbal information processing are recorded in six test periods, and their mutual interrelation was analyzed. The obtained results show a high statistically significant correlation of all observed functions with EEG correlates related to the difference between the average mean values of theta rhythm in the left (F1, F3, F7) and right (F2, F4, F8) frontal region. The temporal dynamics of the examined processes point to the consistency of the evaluated functions increasing with time flow. These findings indicate that EEG correlates of auditory-verbal processing may be used to diagnose treatment efficacy in children with overlapping ASD and SLI.

Brief report: Validity and reliability of the Nigerian Autism Screening Questionnaire

Informant-report measures for screening symptoms of autism spectrum disorder (ASD) and other neurodevelopmental disorders (NDDs) are needed for low-resource settings if early identification is to be prioritized because early developmental concerns are likely to be expressed by parents and other caregivers. This paper describes the initial psychometric evaluation of the Nigeria Autism Screening Questionnaire (NASQ). Parents and other caregivers completed the NASQ on 12,311 children ages 1 to 18 in a Nigerian population sample as part of the World Bank National General Household Survey conducted in the country in 2016. Factor analyses indicated a parsimonious three-factor structure with social communication/interaction, repetitive sensory motor, and insistence on sameness dimensions. Measurement invariance was excellent across age and sex. Reliability of the subscales and total scale was good, and item response theory analyses indicated good measurement precision in the range from below average to high scores, crucial for screening, and tracking ASD symptoms. Studies with gold standard ASD diagnostic instruments and clinical confirmation are needed to evaluate screening and diagnostic accuracy. The NASQ appears to be a reliable instrument with a clear factor structure and potential for use in screening and tracking ASD symptoms in future Nigerian samples.

Using the Clinical Global Impression scale to assess social communication change in minimally verbal children with autism spectrum disorder

Assessing improvements in social communication behaviors in minimally verbal children with autism spectrum disorder (ASD) is often challenging. The Clinical Global Impression Scale (CGI) is a 7-point scale that has been adapted so that clinicians can easily and quickly rate social communication behaviors. The current study evaluated the CGI-Improvement (CGI-I) subscale as a measure of social communication change in minimally verbal children with ASD. The sample included 54 minimally verbal school-age children with ASD enrolled in a social communication intervention trial. CGIs were rated by interventionists and the study coordinator at baseline and at Week 6 of intervention, and were compared to scores on the Communication Complexity Scale (CCS). Results indicated that CGI ratings corresponded with CCS scores at baseline and Week 6. Children who were rated as more severe on social communication at baseline demonstrated lower complexity of communication compared to those who were rated as less severe. Those who demonstrated fast response to intervention at Week 6 showed greater improvement in their joint attention than those who were slower responders. These results provide support for the utility and validity of the CGI-I as a measure of social communication change in minimally verbal children. This study tested the CGI, a clinician rating scale, with a group of children with ASD with limited language who received intervention to improve social interactions and communication. Children's CGI ratings were comparable to other assessments in measuring social communication. The CGI may be a useful tool for those interested in quickly and easily tracking changes in children's social communication over the course of treatment. LAY SUMMARY: This study tested the Clinical Global Impression (CGI), a clinician rating scale, with a group of children with ASD with limited language who received intervention to improve social interactions and communication. Children's CGI ratings were comparable to other assessments in measuring social communication. The CGI may be a useful tool for those interested in quickly and easily tracking changes in children's social communication over the course of treatment.

Pivotal Response Treatment (PRT) - Parent Group Training for Young Children with Autism Spectrum Disorder: A Qualitative Study on Perspectives of Parents

Pivotal Response Treatment (PRT) is considered to be an empirically supported parent-mediated treatment for children with autism spectrum disorder (ASD), but research on parental experiences is lacking. This qualitative study examined the perspectives of parents of young children with ASD who participated in a 14-week PRT with parent group training (PRT-PG). Semi-structured interviews (n = 12) were carried out, based on Grounded Theory principles. Results indicated that facilitators and barriers were related to timing and expectations, training setting and characteristics, and participant characteristics. Perceived effects were related to improved child’s social-communication skills and well-being, parental insights into their child’s needs and own habitual patterns in communication and behavior, and positive changes in family cohesion. The findings indicate that in general parents value PRT-PG as feasible and effective.

Pivotal Response Treatment with and without robot-assistance for children with autism: a randomized controlled trial

Pivotal response treatment (PRT) is a promising intervention focused on improving social communication skills in children with autism spectrum disorder (ASD). Since robots potentially appeal to children with ASD and may contribute to their motivation for social interaction, this exploratory randomized controlled trial (RCT) was conducted comparing PRT (PRT and robot-assisted PRT) with treatment-as-usual (TAU). Seventy-three children (PRT: n = 25; PRT + robot: n = 25; TAU: n = 23) with ASD, aged 3-8 years were assessed at baseline, after 10 and 20 weeks of intervention, and at 3-month follow-up. There were no significant group differences on parent- and teacher-rated general social-communicative skills and blindly rated global functioning directly after treatment. However, at follow-up largest gains were observed in robot-assisted PRT compared to other groups. These results suggest that robot-assistance may contribute to intervention efficacy for children with ASD when using game scenarios for robot-child interaction during multiple sessions combined with motivational components of PRT. This trial is registered at https://www.trialregister.nl/trial/4487 ; NL4487/NTR4712 (2014-08-01).

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.

Clinician Delivery of Virtual Pivotal Response Treatment with Children with Autism during the COVID-19 Pandemic

This concept paper describes how the evidence-based Pivotal Response Treatment (PRT) model of autism treatment was adapted for delivery via telehealth during the COVID-19 pandemic. Multiple features of existing video conference technology were utilized for implementation of PRT motivational strategies with young children with autism spectrum disorder (ASD). PRT is an empirically supported treatment for ASD which can be taught to parents and delivered directly by trained therapists. During the COVID-19 pandemic, when the majority of clinical care for children with ASD had to be transitioned to telehealth delivery, models for parent training had been previously established. However, no model for direct clinician delivery of virtual PRT existed. This manuscript outlines practical details of the model developed by our team and provided to a total of 17 families between April 2020 and May 2021. Key lessons from technological adaptations of the PRT motivational strategies are described in order to inform future empirical investigation of this approach. The virtual PRT delivery model can serve as a guide for engaging children in meaningful social interaction and communication practice via video conference software, with implications for expanding access to autism treatment as well as for motivating a wide range of children in distance learning activities.

Pilot Randomized Controlled Trial of the WHO Caregiver Skills Training in Public Health Services in Italy

Parents of children with ASD (N = 86; mean age 44.8 months; 67 boys) were randomized to either WHO Caregiver Skills Training (CST) delivered in public health settings in Italy or enhanced treatment-as-usual. Primary blinded outcomes were 3-months post-intervention change scores of autism severity and engagement during caregiver-child interaction. CST was highly acceptable to caregivers and feasibly delivered by trained local clinicians. Intention-to-treat analysis showed a large and significant effect on parent skills supporting joint engagement and a smaller significant effect on flow of interaction. Expected changes in child autism severity and joint engagement did not meet statistical significance. Analysis of secondary outcomes showed a significant effect on parenting stress, self-efficacy, and child gestures. Strategies to improve the effectiveness of CST are discussed.

Pivotal response treatment for autism: A brief report on training for rural communities

Many providers from rural communities feel ill-prepared to treat children with autism spectrum disorder (ASD). Cost-effective training in Pivotal Response Treatment (PRT), an evidence-based ASD treatment, can address unmet needs for rural communities. The current study examined a 1-day general PRT workshop for parents and professionals followed by a 3-day small, intensive training for professionals. Fifty-two parents and providers completed surveys before and after Day 1, indicating improvements in perceived stress and confidence. Three providers were trained during Days 2-4, and submitted four 10-min videos (i.e., baseline, 1-week, 1-month, and 2-months post-training) working with a target child discussed in the training and another child. Videos were coded for correct PRT implementation and analyzed using a single-subject A-B design with generalization and maintenance probes. All providers learned to apply PRT techniques with the target child and generalized skills to another child within 1-week post-training, with partial maintenance. Implications for rural mental health training in evidence-based practices are discussed.

Acceptability and feasibility of the World Health Organization's Caregiver Skills Training implemented in the Italian National Health System

LAY ABSTRACT

Across the globe, children with neurodevelopmental disorders, including autism, have limited access to care through public services. To improve access to care the World Health Organization developed a novel, open-access programme: the Caregiver Skills Training programme. The Caregiver Skills Training consists of nine group sessions and three individual home visits, focused on training the caregiver on how to use everyday play and home routines as opportunities for learning and development. We implemented Caregiver Skills Training in public child neuropsychiatry services in Italy and examined with questionnaires and focus groups how feasible it was to deliver the programme in public health settings and how acceptable and relevant it was for caregiver users. We found that the Caregiver Skills Training was largely considered acceptable and relevant for families and feasible to deliver. We discuss potential solutions to address the specific implementation challenges that were identified, such as strategies to improve training of interventionists and overcome barriers to caregiver participation.

The Effect of Teaching Initiations on the Communication of Children with Autism Spectrum Disorder: A Randomized Clinical Trial

This study examined the effect of Pivotal response treatment (PRT) to improve verbal initiations in children with Autism Spectrum Disorder, age 6-12 years old, using a Randomized Clinical Trial design. Intervention was conducted three times a week for 2 months, for a total of 24 one-hour sessions. The PRT intervention taught a variety of questions and attention/assistance-seeking initiations. The treatment as usual (TAU) group received standard language intervention. Results showed that the PRT group made significant improvements in their number of verbal initiations as well as collateral gains in general communicative skills and mean length of utterance (MLU) compared to the TAU group. Theoretical implications of including motivational approaches to develop social initiations are reviewed.

Evidence-based use of scalable biomarkers to increase diagnostic efficiency and decrease the lifetime costs of autism

Challenges associated with the current screening and diagnostic process for autism spectrum disorder (ASD) in the US cause a significant delay in the initiation of evidence-based interventions at an early age when treatments are most effective. The present study shows how implementing a second-order diagnostic measure to high risk cases initially flagged positive from screening tools can further inform clinical judgment and substantially improve early identification. We use two example measures for the purposes of this demonstration; a saliva test and eye-tracking technology, both scalable and easy-to-implement biomarkers recently introduced in ASD research. Results of the current cost-savings analysis indicate that lifetime societal cost savings in special education, medical and residential care are estimated to be nearly $580,000 per ASD child, with annual cost savings in education exceeding $13.3 billion, and annual cost savings in medical and residential care exceeding $23.8 billion (of these, nearly $11.2 billion are attributable to Medicaid). These savings total more than $37 billion/year in societal savings in the US. Initiating appropriate interventions faster and reducing the number of unnecessary diagnostic evaluations can decrease the lifetime costs of ASD to society. We demonstrate the value of implementing a scalable highly accurate diagnostic in terms of cost savings to the US. LAY SUMMARY: This paper demonstrates how biomarkers with high accuracy for detecting autism spectrum disorder (ASD) could be used to increase the efficiency of early diagnosis. Results also show that, if more children with ASD are identified early and referred for early intervention services, the system would realize substantial costs savings across the lifespan.

A Systematic Review of Family-Mediated Social Communication Interventions for Young Children with Autism

Social communication deficits are a core symptom of autism spectrum disorder (ASD). The present paper reviews 54 studies evaluating social communication interventions delivered by parents and siblings to children with ASD under 6 years old. Fifty studies evaluated parent-mediated intervention, and four studies evaluated sibling-mediated intervention. Fourteen studies evaluated interventions using telehealth. Treatment effects and research strength were variable across studies. Treatment modality, setting, and dosage had inconclusive impact on treatment effect. Parent-implemented intervention packages, Pivotal Response Treatment (PRT), Early Start Denver Model (ESDM), and Joint Attention, Symbolic Play, Engagement & Regulation (JASPER), qualified as established evidence-based practice for this population. Most studies reported successful generalization of skills for some, but not all, children. Telehealth and sibling-mediated intervention are promising areas of further research and clinical practice.

A Longitudinal Study of Language Trajectories and Treatment Outcomes of Early Intensive Behavioral Intervention for Autism

The present study examined language trajectories and placement outcomes for children with autism spectrum disorder (ASD) receiving early intensive behavioral intervention (EIBI). Language measures were collected at baseline and 6, 12, 18, 24, and 36 months or until exit from EIBI in 131 children with ASD. Growth models estimated overall and subgroup language trajectories. Overall, children receiving EIBI showed substantial increases in language relative to normative expectations. Earlier age at EIBI start, higher baseline cognitive function, and lower baseline ASD severity predicted better language trajectories. Although there was significant variability in language trajectories and educational outcomes, most children showed significant increases in language scores, relative to normative expectations. Additional research, in more representative samples, is needed to understand this variability.

Pivotal Response Treatment for School-Aged Children and Adolescents with Autism Spectrum Disorder: A Randomized Controlled Trial

Pivotal Response Treatment (PRT) is promising for children with Autism Spectrum Disorder (ASD), but more methodologically robust designed studies are needed. In this randomized controlled trial, forty-four children with ASD, aged 9-15 years, were randomly allocated to PRT (n = 22) or treatment-as-usual (TAU; n = 22). Measurements were obtained after 12- and 20-weeks treatment, and 2-month follow-up. PRT resulted in significant greater improvements on parent-rated social-communicative skills after 12 weeks treatment (p = .004, partial η² = 0.22), compared to TAU. Furthermore, larger gains in PRT compared to TAU were observed on blindly rated global functioning, and parent-rated adaptive socialization skills and attention problems. Implications for clinical practice and suggestions for future research are discussed.

Training Teachers to Implement Classroom Pivotal Response Teaching during Small-group Instruction: A Pilot Study

Background: Providing effective education to students with autism spectrum disorder (ASD) poses a significant challenge to educators. Although several evidence-based practices (EBPs) have been developed, few have been systematically implemented in educational settings. Pivotal response treatment (PRT) is a naturalistic behavioral intervention that has been adapted for implementation in the school context. Methods: This pilot study used a concurrent multiple baseline design across seven teachers and students with ASD to examine the effectiveness of teacher training in classroom pivotal response teaching (CPRT) on teacher fidelity of implementation during small-group instruction and students' communication skills and maladaptive behaviors in schools for special education in the Netherlands. Results: Results indicated no replicated effect of CPRT training on teachers' fidelity of implementation or children's communications skills and maladaptive behavior, although teachers reported high satisfaction with the CPRT training. Discussion: Implications for clinical practice and directions for future research are discussed.

Adverse event reporting in intervention research for young autistic children

LAY ABSTRACT

In this study, we looked at published research on interventions for young autistic children that did not involve administering medication. We were interested in determining how often studies reported on whether adverse events (i.e. physical or psychological distress to the participants) or adverse effects (i.e. adverse events that are thought to be caused by the intervention) had occurred. We found that of the 150 reports we examined, only 11 mentioned adverse events. One of these studies reported adverse events occurred, and three reported that adverse effects occurred. We also reviewed the studies to examine the reasons that were given to explain why any participants dropped out of the intervention (termed "withdrawal"), to determine if any of these reasons could be considered adverse events or adverse effects. Fifty-four studies described reasons for withdrawal, and 10 of these studies had reasons that could be categorized as an adverse event, 8 studies had reasons that could be categorized as an adverse effect, and an additional 12 studies had reasons that were too vaguely described to determine whether they were adverse events or not. We recommend that autism intervention researchers develop more systematic methods of looking for and reporting adverse events and effects, so that professionals and families can be better informed when choosing to enroll their autistic children in interventions.

When Will He Talk? An Evidence-Based Tutorial for Measuring Progress Toward Use of Spoken Words in Preverbal Children With Autism Spectrum Disorder

Purpose Professionals face substantial challenges determining whether and when children with autism spectrum disorder (ASD) who are not yet using spoken words will use spoken language as their primary means of communication. This tutorial provides speech-language pathologists with practical guidance on how to measure expressive language predictors for progress monitoring and making intervention decisions for children with ASD who are preverbal. Method This tutorial is a repackaging effort that seeks to make the research accessible to clinicians wishing to implement evidence-based practice. Results We describe intentional communication, consonant inventory in communication acts, and responding to joint attention as particularly valuable prelinguistic skills to measure. We explain how and when to efficiently assess progress using published assessments periodically and using brief (5-min) communication samples for more frequent progress monitoring. Conclusions Communication samples can be used to show how a child performs within a therapeutic setting during teaching (treatment data) and outside of the therapeutic setting (generalization probe data). Both types of data are critical for determining whether the child is exhibiting progress and which aspects of intervention are facilitating progress toward use of spoken words. These recommendations also balance the evidence for best practices for progress monitoring and the demands on clinicians' time and effort. To encourage the measurement of prelinguistic skills of children with ASD who are preverbal in clinical practice, we include (a) example data collection documents, (b) examples with hypothetical data and interpretation, and (c) guidance on communication sampling procedures. Supplemental Material https://doi.org/10.23641/asha.13557836.

Enhancing Social Initiations Using Naturalistic Behavioral Intervention: Outcomes from a Randomized Controlled Trial for Children with Autism

Deficits in social skills are common in children with Autism Spectrum Disorder (ASD), and there is an urgent need for effective social skills interventions, especially for improving interactions with typically developing peers. This study examined the effects of a naturalistic behavioral social skills intervention in improving social initiations to peers through a randomized controlled trial. Analyses of multimethod, multi-informant measures indicated that children in the active group (SIMI) demonstrated greater improvement in the types of initiations which were systematically prompted and reinforced during treatment (i.e., behavior regulation). Generalization to joint attention and social interaction initiation types, as well as collateral gains in broader social functioning on clinician- and parent-rated standardized measures were also observed.

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.

Language Improvement Following Pivotal Response Treatment for Children With Developmental Disorders

Given the high prevalence of communication deficits in developmental disorders, there is need for efficient early interventions. The aim of this pilot study is to examine benefits of pivotal response treatment (PRT) for improving language in young children with developmental disorders without autism spectrum disorder. Parents of 15 children with developmental disorders received weekly PRT parent training for 12 weeks. Standardized parent-rated assessments were administered at baseline and post-treatment to measure changes in language. Structured laboratory observation indicated children demonstrated significantly greater frequency of utterances and improvement on standardized questionnaires measuring expressive language and adaptive communication skills following PRT. Findings suggest that PRT may be efficacious in improving language abilities among children with developmental disorders.

Examining Effectiveness and Predictors of Treatment Response of Pivotal Response Treatment in Autism: An Umbrella Review and a Meta-Analysis

The current study aimed to provide a comprehensive appraisal of the current evidence on the effectiveness of Pivotal Response Training (PRT) for individuals with autism spectrum disorder (ASD) and to explore predictors of treatment response. We conducted a systematic review of the following electronic databases and registers: PsycINFO, Medline, Embase, Cochrane Central Register of Controlled Trials, ERIC, Linguistics and Language Behavior Abstracts. Six systematic reviews were identified, two with meta-analytic component. Identified reviews varied widely in terms of their aims, outcomes, and designs which precluded a unified and consistent set of conclusions and recommendations. Ten RCTs were identified. Eight of identified RCTs reported at least one language and communication-related outcome. Statistically significant effects of PRT were identified across a majority of identified RCTs for a range of language and communication skills. However, evidence for positive treatment effects of PRT on outcome measures assessing other domains was less robust and/or specific. Overall, both previous systematic reviews and new meta-analysis of the RCTs suggest that PRT shows promise for improving language and communication. Only four RCTs examined the association between baseline child characteristics and treatment outcomes, however, no consistent pattern emerged. This review has identified several key methodological and design improvements that are needed to enable our field to fully capitalize on the potential of RCT designs and characterize detailed profiles of treatment responders. These findings are essential for informing the development of evidence-based guidelines for clinicians on what works for whom and why.

Parent-Mediated Interventions for Children and Adolescents With Autism Spectrum Disorders: A Systematic Review and Meta-Analysis

There has been increasing interest in parent-mediated interventions (PMIs) for children with autism spectrum disorders (ASDs). The objective of this systematic review and meta-analysis was to examine the effect of PMIs compared to no PMI for children with ASD aged 2-17 years. The primary outcome was adaptive functioning rated by a parent or clinician. The secondary outcomes were long-term adaptive functioning rated by the parents, adverse events, core symptoms of ASD, disruptive behavior, parental well-being, quality of life of the child rated by the parents and anxiety. The MEDLINE, PsycInfo, Embase, and CINAHL databases were searched in March 2020. The Cochrane Risk of Bias Tool was used to rate the individual studies, and the certainty in the evidence was evaluated using GRADE. We identified 30 relevant randomized controlled trials (RCTs), including 1,934 participants. A clinically relevant effect of PMIs on parent-rated adaptive functioning was found with a low certainty of evidence [Standard mean difference (SMD): 0.28 (95% CI: -0.01, 0.57)] on Vineland Adaptive Behavior Scales (VABS), whereas no clinically relevant effect was seen for clinician-rated functional level, with a very low certainty of evidence [SMD on Clinical Global Impressions (CGI)-severity scale: SMD -0.45 [95% CI: -0.87, -0.03)]. PMIs may slightly improve clinician-rated autism core symptoms [SMD: -0.35 (95% CI: -0.71, 0.02)]. Additionally, no effect of PMIs on parent-rated core symptoms of ASD, parental well-being or adverse effects was identified, all with a low certainty of evidence. There was a moderate certainty of evidence for a clinically relevant effect on disruptive behavior [SMD: 0.55 (95% Cl: 0.36, 0.74)]. The certainty in the evidence was downgraded due to serious risk of bias, lack of blinding, and serious risk of imprecision due to few participants included in meta-analyses. The present findings suggest that clinicians may consider introducing PMIs to children with ASD, but more high-quality RCTs are needed because the effects are not well-established, and the results are likely to change with future studies. The protocol for the systematic review is registered at the Danish Health Authority website (www.sst.dk).

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.

The effectiveness of parent training for children with autism spectrum disorder: a systematic review and meta-analyses

BACKGROUND

Various parent training interventions have been shown to have some effect on the symptoms of children with autism. We carried out a systematic review and meta-analyses to assess effectiveness of parental training for children with autism on their symptoms and parental stress.

METHODS

Four electronic databases, CINAHL, EMBASE, MEDLINE and PsycINFO were searched until March 2020 for relevant literature. Two reviewers independently screened bibliographies using an eligibility checklist and extracted data using a structured proforma. We have also carried out meta-analyses when data were available for pooling.

RESULTS

Seventeen papers from 15 studies were included for data analysis. Fifteen papers showed a positive treatment effect when compared with the control group, although not always significant. Meta-analysis based on pooled data from only two studies in each respective intervention, showed small to moderate treatment effects for three interventions, DIR/Floortime, Pivotal Response and Parent focused training respectively.

CONCLUSIONS

As in previous systematic reviews there was a mild to moderate treatment effects of three specific types of interventions respectively. However, it was difficult to draw any definitive conclusion about the effectiveness and generalisability of any intervention because of the wide variation in the interventions, control groups, outcome measures, small sample size, small number of studies in meta-analysis, overlap between the intervention and control procedures used in the included studies. There is an urgent need for experts in various international centres to jointly standardise a parent training intervention for children with autism and carry out a large scale RCT to assess its clinical and economic effectiveness. Research Registry Unique Identifying Number: reviewregistry915.

Brief Report: A Pilot Online Pivotal Response Treatment Training Program for Parents of Toddlers with Autism Spectrum Disorder

Despite advances in evidence-based treatment for autism spectrum disorder (ASD), disparities in service access remain a serious concern. Current treatment models may not be feasible for families who live in remote geographical regions or have limited resources. To address this, studies have begun to explore parent-implemented interventions via an online format. The current study examined a new online course designed to help parents implement Pivotal Response Treatment (PRT) for their toddler with ASD. Parents submitted videos of parent-child interactions which were coded for fidelity of implementation (FOI) and social communicative behaviors. The data indicate that PRT fidelity and child behaviors significantly improved following course participation. This suggests that an online intervention may be a feasible approach to disseminating PRT strategies.

Identifying and measuring the common elements of naturalistic developmental behavioral interventions for autism spectrum disorder: Development of the NDBI-Fi

LAY ABSTRACT

Naturalistic developmental behavioral interventions for young children with autism spectrum disorder share key elements. However, the extent of similarity between programs within this class of evidence-based interventions is unknown. There is also currently no tool that can be used to measure the implementation of their common elements. This article presents a multi-stage process which began with defining all intervention elements of naturalistic developmental behavioral interventions. Next, intervention experts identified the common elements of naturalistic developmental behavioral interventions using a survey. An observational rating scheme of those common elements, the eight-item NDBI-Fi, was developed. We evaluated the quality of the NDBI-Fi using videos from completed trials of caregiver-implemented naturalistic developmental behavioral interventions. Results showed that the NDBI-Fi measure has promise; it was sensitive to change, related to other similar measures, and demonstrated adequate agreement between raters. This unique measure has the potential to advance intervention science in autism spectrum disorder by providing a tool to measure the implementation of common elements across naturalistic developmental behavioral intervention models. Given that naturalistic developmental behavioral interventions have numerous shared strategies, this may ease clinicians' uncertainty about choosing the "right" intervention package. It also suggests that there may not be a need for extensive training in more than one naturalistic developmental behavioral intervention. Future research should determine whether these common elements are part of other treatment approaches to better understand the quality of services children and families receive as part of usual care.

Parent Training for Youth with Autism Served in Community Settings: A Mixed-Methods Investigation Within a Community Mental Health System

Parent training programs focus on parent knowledge and/or skill development regarding strategies to improve child outcomes. Parent training programs are considered evidenced-based treatments for autism spectrum disorder (ASD). Yet little is known about parent training use for youth with ASD served in community settings. This mixed methods project examined parent training for Medicaid-enrolled youth with ASD under age 21. Data were obtained from Medicaid claims for 879 youth and surveys from 97 applied behavior analysis (ABA) providers. Open-ended survey items were analyzed with content analysis. Results demonstrated that the frequency of parent training was low and providers' conceptualization of parent training was inconsistent with evidence-based models. Providers are largely unaware of evidence-based components (i.e., modeling, caregiver practice with feedback) and use them infrequently. Implications for increasing parent training in community settings are discussed.

A randomised clinical pilot trial to test the effectiveness of parent training with video modelling to improve functioning and symptoms in children with autism spectrum disorders and intellectual disability

BACKGROUND

Poor eye contact and joint attention are early signs of autism spectrum disorder (ASD) and important prerequisites for developing other socio-communicative skills. Teaching parents evidence-based techniques to improve these skills can impact the overall functioning of children with ASD. We aimed to analyse the impact of conducting a group parent-training intervention with video modelling to improve the intelligent quotient (IQ), social and communication functioning and to minimise symptoms in children with ASD and intellectual disability (ID).

METHODS

Study design: A multicentre, single-blinded, randomised clinical pilot trial of parent training using video modelling was conducted.

SAMPLE

Sixty-seven parents of children with ASD, aged between 3 and 6 years and with IQs between 50 and 70, were randomised: 34 to the intervention group and 33 to the control group. Intervention program: The intervention group received parent training over 22 sessions, and the control group received the standard community treatment.

INSTRUMENTS

Pre-evaluation and post-evaluation (week 28), the following were used: Autism Diagnostic Interview, Vineland Adaptive Behaviour Scale I, Snijders-Oomen Nonverbal Intelligence Test, Autism Behaviour Checklist and Hamilton Depression Rating Scale.

DATA ANALYSIS

Intention to treat and complier-average causal effect (CACE) were used to estimate the effects of the intervention.

RESULTS

There was a statistically significant improvement in the Vineland standardized communication scores in CACE (Cohen's d = 0.260). There was a non-statistically significant decrease in autism symptomatology (Autism Behaviour Checklist total scores) and a significant increase in the non-verbal IQ in the intervention group. After the false discovery rate correction was applied, IQ remained statistically significant under both paradigms. The effect size for this adjusted outcome under the intention-to-treat paradigm was close to 0.4, and when considering adherence (CACE), the effect sizes were more robust (IQ's Cohen's d = 0.433).

CONCLUSIONS

Parent training delivered by video modelling can be a useful technique for improving the care given to children with ASD and ID, particularly in countries that lack specialists.

Cooperative parent-mediated therapy for Italian preschool children with autism spectrum disorder: a randomized controlled trial

Parent-mediated intervention is widely used for pre-schoolers with autism spectrum disorder (ASD). Previous studies indicate small-to-moderate effects on social communication skills, but with a wide heterogeneity that requires further research. In this randomized controlled trial (RCT), cooperative parent-mediated therapy (CPMT) an individual parent coaching program for young children with ASD was administered to preschool children with ASD. All children received the same low-intensity psychosocial intervention (LPI) delivered in community settings, to evaluate the potential additional benefit of CPMT. Thirty-four participants with ASD (7 females; 27 males; aged 2, 6, 11 years) and their parents were included in the trial. The primary blinded outcome was social communication skills, assessed using the ADOS-G social communication algorithm score (ADOS-G SC). Secondary outcomes included ASD symptom severity, parent-rated language abilities and emotional/behavioral problems, and self-reported caregiver stress. Evaluations were made at baseline and post-treatment (at 6 months) by an independent multidisciplinary team. Results documented that CPMT showed an additional benefit on LPI with significant improvements of the primary blinded outcome, socio-communication skills, and of some secondary outcomes such as ASD symptom severity, emotional problems and parental stress related to parent-child dysfunctional interaction. No additional benefit was found for language abilities. Findings of our RCT show that CPMT provide an additional significant short-term treatment benefit on ASD core symptoms, when compared with active control group receiving only LPI.