Early Interventions for ASD: State of the Science

Transcription

1 Early Interventions for ASD: State of the Science Connie Kasari, Ph.D. University of California, Los Angeles Malaysian Regional Conference April 22-23

2 Today What is the evidence for current early interventions? At 22 months, developmental age of 8 months What have we learned from research? What is the future? At age 7, in regular school, typical functioning

3 The evidence for early intervention.. Behavioral interventions work! (no effective medications yet!) Clear one size does not =it all all children No comparisons of different models so cannot determine which is best! Most effective interventions use a combination of very structured and naturalistic strategies Behavioral interventions result in. Higher cognitive skills (Dawson et al, 2010; Smith et al, 2000) Better language skills (Dawson et al, 2010; Kasari et al, 2008, 2012) Improved social skills (Kasari et al, 2012) Families are less stressed and happier (Breterton & Tonge, 2004)

4 What are early interventions really about? Most use some form of ABA (applied behavior analysis) Often what parents in the US request is DTT (discrete trial training) Approach involves repetition of discrete skills and is likely most effective for some pre-academic tasks, such as matching or sequencing 4 year old boy at his school

5 Behavioral interventions require intensity Involve high dose (20+ hours per week) Structure (1:1) Highly trained professionals Outcomes on IQ New evidence indicates that results can be obtained with far less dose, structure Challenges still exist in who benefits most from current interventions (with about a third remaining minimally verbal)

6 WHAT HAVE WE LEARNED FROM RESEARCH? Very early interventions Active ingredients

7 Autism develops early and over time requiring the need to develop very early interventions Increased research on high risk infants, those with an older sibling with ASD North American statistics: ~19% of younger siblings will be diagnosed with ASD at 3; higher if more than 1 sibling or if a boy At 6 months these babies look fine normal development Beginning at 12 months, babies start losing social, communication skills or fail to make progress Variable age of onset (12 24 months) Ozonoff et al, Eye gaze Social smiles CON ASD CON ASD

8 Effect of these early signs of autism Autism affects the foundational skills for Social development Cognitive development and learning Language Basic early symptoms are all critical for later development Play Joint attention Gestural communication Imitation

9 Early signs of social communication Connection/ Communication Typical 17 month old Shared Attention/Affect 17 month old with ASD

10 Evidence is strong for improving core deficits Several randomized controlled clinical trials involving more than 500 children with ASD Ø Joint engagement with parent Ø Joint attention Ø Play skills Ø Language

11 Targeted evidence of early intervention studies on core deficits These studies are typically 3 to 6 months in duration with a 3 to 6 month follow up Studied across young age groups (2 to 8 years) Sometimes focused on specialized subgroups---minimally verbal, low resourced Delivered by expert therapists, teachers, parents In home or school community settings

12 EXAMPLES JASPER intervention approach 1. Parent-mediated 2 to 5 y 2. Minimally Verbal 5 to 8 y 3. Deployment to teachers in low-resourced schools

13 Parents can improve child engagement JASPER (joint attention, symbolic play, engagement, regulation) 20 sessions of 30 minutes Increase Joint Engagement Kasari, Gulsrud, Wong, Kwon, & Locke, JADD, 2010

14 Set of strategies that make up the intervention module on core de=icits- - - JASPER FIRST- - - Goal is selected for child that is developmentally on target PHASE 1 (3 weeks) Environmental arrangements (setting up the environment) (and knowing child play level) Allowing the child to initiate an activity (following the child s attentional focus) Establishing and playing within established routines PHASE 2 (3 weeks) Facilitating, maintaining states Balance between imitating and modeling Expansions, showing enjoyment, eye- contact Joint attention: recognizing, responding, modeling PHASE 3 (3-5 weeks) Allowing child access to communication Initiating and expanding language Generalizing skills across other routines Practice.up to 2 weeks more Some additional modules can =loat. unengaged module ; behavior regulation

15 Comparison of 2 parent mediated approaches 112 low-resourced preschoolers and their parents In homes, 3 months, with 3 month follow up Approach: JASPER with parent coaching OR group education model (same information) Both models designed for in home daily routines Playing Eating Grooming

16 Joint engagement improves for parents who receive active coaching Active Coaching Group Education Entry Exit Follow up Kasari et al, Pediatrics, 2014

17 Joint attention and symbolic play also improved with active coaching of parents Active coaching JASPER group also made greater progress in initiating joint attention and symbolic play CONCLUSIONS: 1. Changes can be made with a targeted, brief intervention 2. Active coaching needed to change core deficits 3. Important to COMPARE active interventions---offer some intervention to all participants

18 For whom does an intervention work for best? We know that one size does not fit all! In early intervention studies you expect that the intervention you apply will work for the majority of children so we expect group effects from research We also expect there will be moderators of treatment effects---in other words, some children will benefit more than others We consistently find that children who are minimally verbal (or nonverbal) make the LEAST progress---we have not yet found the best intervention for these children

19 Difference between preverbal and nonverbal children Most young children are preverbal..we can get them to talk Concern is for the children who remain nonverbal at age entering kindergarten (about 30% of all children) Best social and adaptive outcomes are often found for children who are verbal by school age Children who are nonverbal (minimally verbal) at school age are UNDERSERVED, UNDER- STUDIED

20 What does it mean to be minimally verbal Unclear how many children remain minimally verbal Somewhere between 25% and 55% Clear most children are not nonverbal They have words, often for requesting, and sometimes scripted phrases They may not use language functionally They may be quiet, and not talk very much although they can talk Some children physically seem unable to make sounds, words (but this appears to be a smaller percentage) (Tager-Flusberg & Kasari, 2013; Kasari, Brady, Lord, & Tager-Flusberg, 2013)

21 Characterizing Cognition in Nonverbal Children with ASD (CCNIA) Intervention 61 children aged 5 to 8 years Minimally verbal (fewer than 20 functional words) Had already received 2 years of intensive early intervention ALL received JASPER plus a spoken language intervention (EMT) HALF randomized to also receive Speech Generating Device (ipad) Kasari et al, JAACAP, 2014

22 Minimally verbal 5 ½ year old No words in beginning; needs access to communication Results positive for SGD in addition to behavioral intervention! JASP+EMT+SGD JASP+EMT Total Socially Communicative Utterances !!!!! ç! Kasari et al, JAACAP, Week 2014

23 Extension to Teachers in Classrooms Teachers taught modules similar to parent- mediated model Teachers can =it within their classroom model; may be 1:1 or may be in centers Blinded observer coded teacher and child behaviors in class 6 week intervention (2 sessions per week)

24 Targeted JASPER Intervention with Teachers as the Mediators Lawton & Kasari, 2012, JCCP

25 Materials for teachers Preschool deployment study (LA and NY)

26 FUTURE FOR EARLY INTERVENTIONS

27 The future Widespread awareness and appreciation that autism is a disorder that is biological in origin but manifest in behavior Behavior should be the target for both diagnosis and treatment Knowledge that change is possible and the earlier the child is diagnosed the greater the chance of achieving significant improvement with the implementation of effective interventions Supports and materials available for individuals and families that can be implemented with few additional resources

28 Thank you! Funding: NIH RO1s..ICAN; AIM-ASD HRSA..AIR-B Network Autism Speaks..Early access to care; Preschool Deployment