Comparison of Clinic & Home Observations of Social Communication Red Flags in Toddlers with ASD

Transcription

1 Comparison of Clinic & Home Observations of Social Communication Red Flags in Toddlers with ASD David McCoy, Ph.D. California State University, Chico Sheri Stronach, University of Minnesota Juliann Woods and Amy M. Wetherby, Florida State University ASHA Convention 2014 Orlando

2 Conflicts of Interest D. McCoy, S. Stronach, and J. Woods have no potential conflicts of interest to disclose. A. M. Wetherby receives royalties from the Communication and Symbolic Behavior Scales but not from this study.

3 Early Identification of ASD The median age for children with Asperger Syndrome is 75 months of age or just over 6 years of age (CDC, 2012) The American Academy of Pediatrics recommended screening for ASD of all children at 18 and 24 months of age (Johnson et al., 2007; 2012) Parent report measures are the most common instruments currently used M-CHAT, ITC, ESAC and others. No interactive screeners were recommended by the AAP but such tools are available for the 18 to 36-month-old range

4 Interactive Instruments: Screening Tool for Autism in Two-Year Olds (STAT) Initially the STAT differentiated children with ASD for 24 to 36 month olds (Stone et al., 2000; Stone et al., 2004) but only included children with autism and not the wider range of ASD STAT results reported for children under 24 months (Stone, McMahon, & Henderson, 2008) Differentiated children with ASD from other children Fair to Good psychometrics for recommended cut-off scores Clinic-referred and high-risk siblings sample

5 Initial Study: Systematic Observation of Red Flags for ASD (SORF) (Wetherby, Woods, Allen, Cleary, Dickinson, & Lord, 2004) Prospective and longitudinal sample of children from the general population Identified using a broadband screening tool (Infant Toddler Checklist) Participants obtained from a population 3,026 ASD n = 18, Developmental Delay (DD) n = 18, and Typical Development (TD) n = 18 Included children months old

6 6

7 Follow-up SORF Study (McCoy, Wetherby, & Woods, 2009; Wetherby, Stronach, Woods, McCoy, & Lord, In Preparation) Participants were selected from a larger pool of 6,581 children Replication of initial SORF study with more participants in matched groups (N = 150) Same ratings of both the lack of typical social communication behaviors and the presence of atypical repetitive and restrictive behaviors

8 11 Social Communication Red Flags Impairment in Social Interaction Inappropriate gaze Lack of warm, joyful expressions Lack of sharing interests Lack of response to contextual cues Lack of response to name Lack of coordination of nonverbal communication Impairment in Communication Lack of showing Lack of pointing Unusual prosody Lack of communicative consonants Using person s hand as a tool

9 Multiple Sources of Information Checklists Clinic Evaluation Parent Interview ASD Diagnosis Home Video

10 Home Videos Findings from most home video studies had retrospective collection lack of standardized instructions sample bias small sample sizes High-risk sibling videos are collected prospectively using a sample with less generalization to the general population

11 General Population Sample Prospective Home Videos Book (2009) reported descriptive results using a modified version of the SORF with a sample of children with ASD and DD 7 Social Communication red flags were observed in most of children with ASD in more than half of the intervals coded Swineford (2011) examined communicative acts in the home setting and reported lower rates of communication in the home compared to the clinic

12 Research Needed Measuring behaviors at a time point consistent with recommended screening guidelines Prospective video samples with standardized instructions instead of a biased sample collected retrospectively Using the same observational measure across two contexts Recruiting participants from a general population sample Including non-spectrum participants with DD and TD

13 Purpose To examine the social communication skills of three groups of children with ASD, DD, and TD late in the second year of life using two concurrent methods of observation: a standardized clinical sample and a semi-structured home sample.

14 Research Questions 1. Are there group differences in social communication measured with the CSBS standard scores, and social communication red flags rated with the SORF in the clinic and home observations? 2. What percent of each group falls at least 1 SD below the mean on each of the CSBS cluster and composite scores? 3. What are the concurrent relationships among the CSBS standard scores and the social communication red flags measured in the clinic and home observations?

15 Research Questions 4. What are the predictive relationships among the CSBS standard scores, the social communication red flags measured in the clinic and home observations, and standardized measures of developmental level and autism symptoms? 5. How much of the variance in developmental level and autism symptoms is accounted for by the social communication red flags measured during the home and clinic observation and the CSBS standard scores, individually and in combination?

16 Methods Recruited from the FIRST WORDS Project using a 3 step process Step 1: Screening from general population with Brief Parent Report Checklist (ITC) Prospective sample of participants

17 Methods Step 2: Interactive Child Evaluation Video recorded CSBS DP Behavior Sample (Wetherby & Prizant, 1998; 2002) Obtained detailed standardized, norm-referenced scores of social communication and play skills The clinic setting videos included in the current study were also coded for social communication red flags during a review of this archived video

18 Methods Step 3: Diagnostic Evaluation Completed the ADOS, MSEL, and developmental history to make best estimate diagnosis at months and follow up Home Observation Video completed within 3 months of the CSBS with a minimum of 33 min. of video available The home setting social communication red flags were coded during a review of this archived video

19 Participants Videos selected from archival database for participants that met selection criteria 11% of participants had videos submitted to the archive from the FIRST WORDS Project site at the University of Michigan The institutional review board initially approved the longitudinal collection of data and subsequently approved use of the archival videos for the current study The selection criteria were met for 180 toddlers: 3 groups of participants: 114 ASD, 32 DD, and 34 TD

20 Demographics (%) Table 1 ASD DD TD n = Males First born Caucasian African-American Other

21 Participants Table 2 ASD DD TD Clinic Video Age in Months 19.8 (2.1) 19.8 (2.0) 19.0 (1.5)* Home Video Age in Months 20.4 (2.2) 20.8 (1.9) 20.2 (1.6) MSEL: Mean Age in Months 32.2 (8.3) 25.0 (7.0)* 26.7 (6.5)* NVQ 84.4 (20.8) 90.2 (18.9)* (16.5)* VQ 71.1 (25.7) 74.9 (19.3)* (21.2)* ADOS: Mean Age in Months 27.9 (7.8) 22.7 (6.8)* 20.9 (2.7)* Social Affect (SA) 12.1 (4.3) 5.0 (2.7)* 4.6 (4.3)* Repetitive (RRB) 3.7 (2.0) 1.4 (1.1)* 1.1 (1.3)* *p <=.05, difference with ASD

22 Settings Clinic Setting minutes Parent, child, & examiner Object-based interactions and play Standardized and norm-referenced Home Setting minutes Family and child Daily parent-child activities Standardized instructions

23 Settings Clinic Setting Wind-up Toys in Bag Balloon Bubbles Jar with food Feeding and Cooking Set Home Setting Play with people Play with toys Meals and snacks Caregiving Books and media Family Chores

24 SORF Measure (Wetherby et al., 2004; Book, 2009; & Wetherby, Woods, McCoy, & Stronach, 2009) Items are scored per interval and summed for the lack of behavior present for the observation Higher scores = deficits in social communication Clinic setting scored per temptation (12 intervals) Home setting scored per 3 minutes (15 intervals) Proportions were computed to control for unequal number of intervals and comparisons across settings

25 Lack of shared interest or enjoyment Directs an adult s attention to objects, actions or events using eye gaze, gesture or sound. Lack of coordination Communication acts with 3 of the following: gaze, facial expressions, gestures, and/or sounds 4 Core Social Communication Red Flags Lack of consonants for communication Communication acts with clear consonants Lack of pointing or showing Using the index finger or holding out an object towards an adult without giving to reference at object of interest

26 Interrater Reliability Table 4 Percent Agreement Cohen s kappa Lack of shared interest Lack of coordination Lack of consonants Lack of pointing & showing 94 & &.66 Samples Coded 20.7%

27 RESULTS 1. Are there group differences? Measured between the groups using: CSBS cluster and composite standard scores 4 social communication red flags observed in the clinic and home settings

28 CSBS Clusters and Composites Clusters of Behaviors 1. Emotion & Eye Gaze 2. Communication 3. Gestures 4. Sounds 5. Words 6. Understanding 7. Object Use Composite Scores 1. Social 2. Speech 3. Symbolic 4. Total

29 1a. Group differences in social communication measured with the CSBS standard scores (Table 5) Significant group differences for all 7 clusters and all 4 composites F statistic ranged from to 76.89, all p s <=.001 ASD differed from TD for all items ASD differed from DD for Clusters: emotion & eye gaze, gestures, & understanding Composites: social, symbolic, & total

30 Group differences of red flags in the clinic settings (z-scores; M = 0, SD = 1) * * * * * * ASD DD TD Lack Share Lack Coord * Lack Cons Lack Point

31 Group differences of red flags in the home settings (z-scores; M = 0, SD = 1) * Lack Share * * Lack Coord. * * * * Lack Cons. Lack Point ASD DD TD

32 Percent of each group that falls at least 1 standard deviation below the mean on each of the CSBS composite scores 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% ASD DD TD Social Speech Symbolic

33 Concurrent relationships among the CSBS standard scores and the social communication red flags measured in the clinic and home observations All CSBS cluster and composite scores significantly negatively correlated with the red flags in both the clinic and home settings (r = -.66 to -.26) CSBS scores were strongly correlated with the SORF red flags

34 Relationships between the red flag z-scores in the clinic and home settings Home Setting Clinic Setting Lack of Shared interest.52*.34*.48*.45* 2. Lack of Coordination.41*.42*.44*.39* 3. Lack of Consonants.49*.29*.46*.65* 4. Lack of Point or Show.45*.41*.44*.40* *p <=.001; α =.05

35 Relationships among the clinic and home setting red flags to measures of development Developmental measure (MSEL): Verbal quotient (VQ) and nonverbal quotient (NVQ) significantly negatively correlated with all items in both settings VQ -.57 to -.28 DVQ -.45 to -.27

36 Relationships among the clinic and home setting red flags to measures of autism symptoms Autism symptoms (ADOS) Social affect (SA): All items significantly positively correlated (.24 to.47) in both settings RRB for the clinic setting: Significant correlations for lack of shared interest, lack of coordination, and lack of consonants (.28 to.31) RRB for the home setting: All items significantly positively correlated (.25 to.37)

37 How much of the variance in developmental level and autism symptoms is accounted for by the social communication red flags? Dependent variables are the CSBS and SC red flags Predictor variables are the MSEL VQ & NVQ and the ADOS SA and RRB composite scores Hierarchical regression Model 1: SC items from the home setting Model 2: added SC items from the clinic setting Model 3: added CSBS composites

38 1 st Regression: MSEL VQ ***p<=.001, **p<.01. *p<.05 R R 2 ΔR 2 β sr 2 f 2 Model 1 Home.60***.36***.56 Lack of consonants -.45***.06***.09 Lack of pointing.24*.03*.05 Model 2 Home & Clinic.64***.41*** Lack of consonants HV -.32*.02*.03 Model 3 Home, Clinic, CSBS.77***.59***.19***.46 Lack of consonants HV -.28*.02*.05 CSBS Social SS.35**.04**.10 CSBS Symbolic SS.22*.02*.05

39 2 nd Regression: MSEL NVQ R R 2 ΔR 2 β sr 2 f 2 Model 1 Home.50***.25***.50 Lack of pointing -.28*.03*.04 Model 2 Home & Clinic.52***.27*** Model 3 Home, Clinic, CSBS.72***.52***.25***.52 CSBS Social SS.40*.05*.11 CSBS Symbolic SS.36**.05*.11 ***p<=.001, **p<.01. *p<.05

40 3 rd Regression: ADOS SA R R 2 ΔR 2 β sr 2 f 2 Model 1 Home.52***.27***.56 Model 2 Home & Clinic.59***.35***.08**.12 Model 3 Home, Clinic, CSBS.71***.50***.15**.30 CSBS Social SS -.31*.03*.06 CSBS Symbolic SS -.32**.04**.08 ***p<=.001, **p<.01. *p<.05

41 4 th Regression: ADOS RRB R R 2 ΔR 2 β sr 2 f 2 Model 1 Home.39***.15***.18 Model 2 Clinic & Home.41***.17*** Model 3 Home, Clinic, CSBS.53***.28***.11**.15 No individually significant predictors of ADOS RRB ***p<=.001, **p<.01

42 Discussion Early social communication can be used to distinguish children with ASD Prospective home observations of children in the second year of life can meaningfully add information to the diagnostic process Consistent with previous research showing that red flags can be identified in home videos

43 Strengths Large sample size, new prospective sample Use of non-expert coders of red flags Concurrent measures of red flags Standardized video instructions and collection Age range of participants consistent with recommendations for universal screenings

44 Limitations Differences may result from the structure of the observation rather than the setting Limited subset of social communication behaviors that distinguish ASD Interval coding may mask frequency differences for some behaviors

45 Future Directions Inclusion of additional social communication and added RRB red flags aligned with newly published DSM5 criteria for ASD Test a protocol for parents to collect systematic video observations Relationship of parent observations of behaviors in the clinic and home setting to buy-in at time of diagnosis

46 Acknowledgements Thanks to the many families with children participating in the FIRST WORDS Project Grant Support: NIH/NIDCD; CDC; NIH/NICHD

47 Questions