5/20/2016. Can parents do this? Early parent-mediated interventions for autism. Parent-mediated intervention. Jonathan Green

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1 Early parent-mediated interventions for autism Jonathan Green University of Manchester, Royal Manchester rens Hospital and Manchester Academic Health Sciences Centre Changed behviour leads to improved child ic communication Parent-mediated intervention Intervention delivered through parents to enhance social development Developmentally in the staged: neurologically-vulnerable child Improved child ic communication generalises to other contexts What is special about parent-mediated intervention? The naturalistic developmental system main context for social communication development (does not imply poor initial parenting) Targets developmental processes known to predict autism outcomes Benefits for engagement, confidence, family function Efficient of professional time Potential 24/7 therapeutic effect extending beyond treatment end What is special about parent-mediated intervention? The naturalistic developmental system main context for social communication development (does not imply poor initial parenting) Targets developmental processes known to predict autism outcomes Benefits for engagement, confidence, family function Efficient of professional time Potential 24/7 therapeutic effect extending beyond treatment end But to do this well, interventions have to make substantial, focused, reproducible impact on targeted s more than education or coaching Value of video-feedback to produce this intervention effect known to be very effective for observation, reflection and adult learning styles But to do this well, interventions have to make substantial, focused, reproducible impact on targeted s more than education or coaching Value of video-feedback to produce this intervention effect known to be very effective for observation, reflection and adult learning styles What is special about parent-mediated intervention? The naturalistic developmental system main context for social communication development (does not imply poor initial parenting) Targets developmental processes known to predict autism outcomes Benefits for engagement, confidence, family function Efficient of professional time Potential 24/7 therapeutic effect extending beyond treatment end But to do this well, interventions have to make substantial, focused, reproducible impact on targeted s more than education or coaching Value of video-feedback to produce this intervention effect known to be very effective for observation, reflection and adult learning styles Can parents do this? PCI: percent of parent acts in Parental (PACT n=152) TAU base PACT base TAU mid PACT mid TAU end PACT end Endpoint ES 1.22 (0.85 to 1.59) OR (quintiles) 9.10 (4.39 to 18.9, sig) Green et al The Lancet (2010), 375, 9732;

2 Is it effective? How effective? Proximal outcomes parent-child Distal outcomes autism symptoms Prodromal intervention for infants at risk (i, n=54) Green et al The Lancet Psychiatry (2015). 2; Effects on hypothesised risk markers targeted for intervention change Effects on hypothesised risk markers targeted for intervention change Observation Scale for Infants (AOSI) Change in scores from 8-m to 14-m Control Intervened Social Attention/motor skills Control Intervened

3 Effects on hypothesised risk markers targeted for intervention change Green et al The Lancet (2010), 375, 9732; ASSESSED n=242 EXCLUDED n=90 RANDOMISED n = 152 TAU n = 75 PACT + TAU n = 77 (>3 sess n=74) LOST TO FOLLOW UP n = 3 LOST TO FOLLOW UP n = 3 ENDPOINT DATA n = 72 ENDPOINT DATA n = 74 Long-term outcome Attenuation of treatment effect on generalisation across and context Critical to judging the success of developmental intervention PACT Interventio n Parent with with Parent with Assessor in School CONTEXT i Intervention 9- Endpoint analysis FU and PACT Intervention years Parental ES=1.22 (0.85, 1.59) initiations ES=0.41 (0.08, 0.74) SC symptoms () ES=-0.24 (-0.59, 0.11) CSS ES= 0.63 (0.02,1.29) Social functioning in school ES=-0.19 (-0.44, 0.07) MEASURE Endpoint analysis 5 years FU 10 years, mean nearly 6 years following treatment end Mediation analysis confirms theory and implementation (Pickles et al 2015) Treatment effect on 70% mediates child communication change PACT mediation and iterative intervention design PACT mediation communication change 73% mediates treatment effect on autism SC symptoms a DCMA: home 6 months b e PACT-G Intervention at home and school Extended age range 2-11yrs with Longitudinal association studies - parent effects child communication in autism (Siller and Sigman 2002/8) Random allocation c DCMA: education f d Outcomes: BOSCC 11 months 3

4 Aims of intervention What should be our targets for change? What is a good outcome? Theory Theory in infancy Interactive specialisation of the social brain and social functioning experience dependent Severity of defining al phenotype Social effectiveness/functioning Relationships/emotional wellbeing Communication Special abilities Associated mental health How interrelated? Many hours of caregiver-infant in the first year fine tuning of perceptual systems, joint attention, intentional communication, social imitation Alterations of early related to early atypical infant developmental biases Wan et al 2012, 2013.may act to reduce learning opportunities and amplify an initially disordered developmental trajectory at a al and neural level Modification of this social environment as a prodromal intervention A transactional model - going with the grain of development (Zeliadt 2015) i infancy intervention Targeted at -infant communicative as a social enrichment for infant learning VIPP model (Juffer et al 2008) Timing at 9- Parent-mediated video-aided, home based (Green et al 2013) Manualised 12 sessions over 5 months Written material, feedback, daily practice plans for parents Discovery of early biomarkers British Siblings (n>250) Predict autism emergence at 3yrs Participation of the parent consultation group 2 site 2 arm RCT Intervention vs no intervention N=54 Good internal validity British Prodromal Intervention i 9- British Prodromal Intervention i 9- biomarker proximal outcomes 4

5 British Prodromal Intervention i 9- Discovery of early intermediate phenotypes (IP) British Intervention to optimise the social environment for the infant impacts these risk markers for later autism biomarker proximal outcomes?sustained effects at 24 and Downstream symptoms/ al phenotype outcome Pre-school theoretical base Focus on parent-child - 80% of the child s communication Abnormal communication in autism Reduced shared attention and mutuality Pragmatic impairments Language disorder Imbalanced Parent- Perplexity Reduced meshing - a Reduced child opportunities for communication learning, relating But positively from the language intervention literature Attending to communication acts increases them Expansion from child s base ( semantic contingency ) leads to more vocabulary ren with autism need a high dose of this Developmental hierarchy - of pre-cursor skills for communication with Preschool Communication Therapy (PACT) Developmentally staged: Shared attention, synchronous response, adapted communication strategies, communication enhancement Initial 6 months Biweekly clinic visits (3 hrs) + home work (30 mins/day) viz 2hrs/wk Next 6 months Consolidation Monthly clinic visits + homework (30 mins/day) and generalisation 18 sessions possible (median 16 (IQR 13-17) attended in PACT) Preschool Communication Therapy (PACT) Developmentally staged: Shared attention, synchronous response, adapted communication strategies, communication enhancement Preschool Communication Therapy (PACT) Developmentally staged: Shared attention, synchronous response, adapted communication strategies, communication enhancement Initial 6 months Biweekly clinic visits (3 hrs) + home work (30 mins/day) viz 2hrs/wk Initial 6 months Biweekly clinic visits (3 hrs) + home work (30 mins/day) viz 2hrs/wk Next 6 months Consolidation Monthly clinic visits + homework (30 mins/day) and generalisation Next 6 months Consolidation Monthly clinic visits + homework (30 mins/day) and generalisation with 18 sessions possible (median 16 (IQR 13-17) attended in PACT) with 18 sessions possible (median 16 (IQR 13-17) attended in PACT) 5

6 Examples from: Parent-mediated intervention for autism spectrum disorders in South Asia (PASS) Pre-emptive Intervention Pre-school intervention Cross-cultural implementation Institute of Psychiatry, Rawalpindi, Pakistan Fareed Minhas Ayesha Minhas Zafar Iqbal The feasibility and acceptability of the implementation of the adapted PACT intervention in settings in South Asia Sangath, Goa, India Vikram Patel Gauri Divan Vivek Vajaratkar University of Manchester Jonathan Green Catherine Aldred Carol Taylor Kathy Leadbitter The success of a task-shifting approach in delivering fidelity to the intervention model. University of Liverpool Atif Rahman Training and Supervision cascade PACT (Intervention) Specialists South Asia Development Specialists Non-specialist workers Parents/Carers with ASD PASS RCT results Rahman et al The Lancet Psychiatry Dec 2015, S (15) N=65 Acceptability high, with 80% completing the sessions Therapist fidelity high to PACT standards Treatment effect Greater effect on ic than UK PACT! [SMD 0.25 (95% CI ); ES 1.61] child communication initiation [SMD 0.15 (CI ); ES 0.99] First definitive RCT of an evidence-based intervention delivered by nonspecialists in a low-income setting New scale up study - Parent-mediated intervention for Spectrum Disorders in South Asia PLUS (PASS+) Summary Early parent-mediated video-aided intervention in ASD aims to increase child social functioning through optimising ic social Across prodromal, preschool and transcultural intervention we show treatment effects on: The targeted ic s communication autism symptoms PACT shows causal mediation in line with treatment theory Thank you - To the Families and ren who have worked so hard with us To the Manchester team and our Collaborators jonathan.green@manchester.ac.uk search/psychopathology/socialdevelopment/ Cross cultural implementation in LMIC with cascading telemedicine training and supervision and strong local partners is feasible and effective 6

7 First session By the end having looked at communication functions and discussing ideas for setting up situations in which different functions of language could be firstly modelled and then elicited through sensitive use of teasers (we discussed the use of these in play but mum found it much more useful to discuss the use of these in everyday contexts), J was using language to Ask questions and give instructions Negate J: 2 years 10 months Very object focused. No initiation of play. Mum having to work hard to try and engage him, but with little success. Very little language: observed ready steady go some colours and numbers used. Combining the strengths of UMIST and The Victoria University Make comments of Manchester Take part in social routines 7