Mediation of meaningful outcomes in early intervention: a commentary on Carruthers et al. (2023).

Across the spectrum of behavioral, naturalistic developmental behavioral, and developmental/relational interventions for young children with autism, there has been limited empirical testing of the mechanism of these early intervention approaches. Testing mediation provides insights to the how or why the intervention condition may be preferred in comparison to a control in the population sample (Kraemer, American Journal of Psychiatry, 2016, 173, 672). Combined with an understanding of moderation (for whom or under what conditions), we move toward a better understanding of how to personalize interventions to build on strengths and maximize skill gains for autistic children. Yet, to date there are very few published texts of mechanism in early intervention for young children with autism. This commentary explores a recently published article by Carruthers et al (2023) and examines themes and considerations for measurement of intervention outcomes and mediators.

Comparing the Implementation Context for Early Intervention Services Before and During the COVID-19 Pandemic.

The COVID-19 pandemic not only led to drastic changes in the implementation context for early intervention and early childhood special education services in 2020, but has had an enduring effect on the organizations, educators, families, and children with developmental delays and disorders. Through secondary data analysis, characteristics of toddlers with autism being served in a publicly funded center-based early intervention program as well as the characteristics of their educators are examined, comparing those who were enrolled in (a) two randomized trials conducted prior to the pandemic and (b) one ongoing randomized trial that launched in return to in-person educational services after the pandemic shutdown. Significant demographic differences are found for toddlers, where the current study includes more girls (p = 0.002), who are younger (p < .001) than the prior studies. Further, toddlers enrolled in the current trial are entering with significantly younger receptive (p < .001) and expressive language age-equivalent scores (p < .001) than toddlers from the prior studies. In addition, significant differences are also found for teaching assistants (TAs), who are younger (p < .001), less experienced supporting children with autism (p < .001), have spent less time in this position (p < .001), and who are still working toward college degrees (p < .001) than TAs in the prior studies. Implications of these changes for both intervention strategies to support the strengths and needs of the toddlers (e.g., reduce frequency of TA-child pairing changes to build rapport, increase time in adult-child JASPER before adding peers) as well as implementation strategies (e.g., increase foundational content, TA teaming) to support the training and retention of the TAs are discussed. Clinical Trials Registry number: NCT04283045.

Coma Recovery Scale-Revised Predicts Disability Rating Scale in Acute Rehabilitation of Severe Traumatic Brain Injury.

OBJECTIVE: To explore the prognostic value of the Coma Recovery Scale-Revised (CRS-R) in predicting disability outcomes in patients with severe traumatic brain injury using the Disability Rating Scale (DRS). DESIGN: Secondary analysis including linear and logistic regressions were performed. SETTING: Data were collected in a previous clinical trial. PARTICIPANTS: One hundred eighty-four participants across 3 countries (N=184). MAIN OUTCOME MEASURES: Disability Rating Scales. RESULTS: Analyses showed an inverse relation between CRS-R scores obtained at baseline and change in DRS scores at 6 weeks. Similarly, changes in CRS-R scores between baseline and 4 weeks were also found to have an inverse relation to change in DRS scores at 6 weeks. CONCLUSIONS: This study generates a tool that can be used to predict the probability that a patient with severe traumatic brain injury lands in 1 of 3 disability categories. The CRS-R may be useful in prognostication of disability in patients with severe traumatic brain injury.

Effect of Exclusion Diets on Symptom Severity and the Gut Microbiota in Patients With Irritable Bowel Syndrome.

BACKGROUND & AIMS: Altered fecal microbiota have been reported in irritable bowel syndrome (IBS), although studies vary, which could be owing to dietary effects. Many IBS patients may eliminate certain foods because of their symptoms, which in turn may alter fecal microbiota diversity and composition. This study aimed to determine if dietary patterns were associated with IBS, symptoms, and fecal microbiota differences reported in IBS. METHODS: A total of 346 IBS participants and 170 healthy controls (HCs) completed a Diet Checklist reflecting the diet(s) consumed most frequently. An exclusion diet was defined as a diet that eliminated food components by choice. Within this group, a gluten-free, dairy-free, or low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet was further defined as restrictive because they often are implicated in reducing symptoms. Stool samples were obtained from 171 IBS patients and 98 HCs for 16S ribosomal RNA gene sequencing and microbial composition analysis. RESULTS: Having IBS symptoms was associated with consuming a restrictive diet (27.17% of IBS patients vs 7.65% of HCs; odds ratio, 3.25; 95% CI, 1.66-6.75; P value = .006). IBS participants on an exclusion or restrictive diet reported more severe IBS symptoms (P = .042 and .029, respectively). The composition of the microbiota in IBS patients varied depending on the diet consumed. IBS participants on an exclusion diet had a greater abundance of Lachnospira and a lower abundance of Eubacterium (q value, <.05), and those on a restrictive diet had a lower abundance of Lactobacillus (q value, <.05). CONCLUSIONS: Restrictive diets likely are consumed more by IBS patients than HCs to reduce GI symptom severity. Dietary patterns influence the composition of the fecal microbiota and may explain some of the differences between IBS and HCs.

Using Novel Implementation Tools for Evidence-based Intervention Delivery (UNITED) across public service systems for three evidence-based autism interventions in under-resourced communities: study protocol.

BACKGROUND: There are a growing number of evidence-based interventions (EBIs) for autistic individuals, but few are successfully implemented with fidelity in under-resourced communities and with families from traditionally disenfranchised groups. Implementation science offers tools to increase EBI use in communities, but most implementation strategies are designed specific to a single EBI. It is not feasible to develop a new implementation strategy each time a new EBI is introduced in the community. Therefore, to test the effectiveness and generalizability of implementation strategies we are developing and testing a multifaceted implementation strategy with three EBIs concurrently. The goal of this protocol paper is to describe the randomized field trial of an implementation strategy for use across autism EBIs, diverse settings and participants, with the goal of increasing rapid uptake of effective practices to reach our most vulnerable children. METHODS: We developed a multifaceted implementation strategy called Using Novel Implementation Tools for Evidence-based intervention Delivery (UNITED) to facilitate the implementation and sustainment of three EBIs in under-resourced settings. We will compare fidelity to, and effectiveness of, each intervention [Mind the Gap (MTG), Remaking Recess (RR), Self-Determined Learning Model of Instruction (SDLMI)] with and without UNITED in a randomized field trial. Randomization will be stratified using a minimization allocation method. We will train community practitioners using remote delivery of modules specific to the intervention, and active coaching via Zoom for at least 6 sessions and up to 12 as dictated by each EBI. Our primary outcome is fidelity to each EBI, and our secondary outcome is at the child or family level (family empowerment for MTG, child peer social engagement for RR, and adolescent self-determination for SDLMI, respectively). We will measure progress through the implementation phases using the Stages of Implementation Completion and cost-effectiveness of UNITED. DISCUSSION: The results of this study will provide rigorous data on the effectiveness and generalizability of one relatively light-touch implementation strategy in increasing use of autism EBIs and associated outcomes in diverse under resourced public service settings for underrepresented autistic youth. TRIAL REGISTRATION: Mind the Gap: Clinicaltrials.gov Identifier:  NCT04972825 (Date registered July 22, 2021); Remaking Recess: Clinicaltrials.gov Identifier:  NCT04972838 (Date registered July 22, 2021); Self-Determined Learning Model of Instruction: Clinicaltrials.gov Identifier:  NCT04972851 (Date registered July 22, 2021).

The Role of Resilience in Irritable Bowel Syndrome, Other Chronic Gastrointestinal Conditions, and the General Population.

BACKGROUND & AIMS: Resilience is the ability to adapt positively to stress and adversity. It is a potential therapeutic target as it is reduced in irritable bowel syndrome (IBS) compared to healthy controls and associated with worse symptom severity and poorer quality of life. The aim of this study was to examine if these findings are generalizable by comparing resilience between IBS versus the general population and other chronic gastrointestinal (GI) conditions. METHODS: Participants in the general population completed an online survey containing questionnaires measuring demographics, diagnosis of IBS and other GI conditions, symptom severity, psychological symptoms, resilience, and early adverse life events (EALs). IBS was defined as having a physician diagnosis of IBS and/or meeting Rome criteria without co-morbid GI disease. All others were included in the general population group. The chronic GI conditions group included those with inflammatory bowel disease, celiac disease and/or microscopic colitis. RESULTS: Resilience was lower in IBS (n = 820) than the general population (n = 1026; p < 0.001) and associated with worse IBS symptom severity (p < 0.05). Global mental health affected resilience differently in IBS compared to the general population (all p's < 0.05). EALs were associated with decreased ability to bounce back from adversity in both IBS and the general population (p < 0.001). Resilience scores were similar in IBS and other chronic GI conditions that present with similar symptoms. CONCLUSIONS: Resilience is lower compared to the general U.S. population but does not appear to be specific to IBS as it is comparable to other chronic GI conditions. Low resilience negatively affects symptom severity and mental health and thus, may serve as a novel therapeutic target.

Joint engagement is a potential mechanism leading to increased initiations of joint attention and downstream effects on language: JASPER early intervention for children with ASD.

BACKGROUND: Social communication interventions benefit children with ASD in early childhood. However, the mechanisms behind such interventions have not been rigorously explored. This study examines the mechanism underlying a naturalistic developmental behavioral intervention, JASPER (Joint Attention, Symbolic Play, Engagement, and Regulation), delivered by educators in the community. Specifically, the analyses focus on the mediating effect of joint engagement on children's initiations of joint attention (IJA) skills and whether IJA postintervention are associated with later gains in children's receptive and expressive language. METHODS: One hundred seventy-nine children, age 2-5 years, were randomized to immediate JASPER treatment or waitlist (treatment as usual) control. Independent assessors blinded to time and treatment coded children's time jointly engaged and IJA during a 10-min teacher-child interaction at baseline, exit, and follow-up. Age-equivalent receptive and expressive language scores from the Mullen Scales of Early Learning were collected at baseline and follow-up. Mediation analyses with linear mixed models were used to explore the potential mediating effect of joint engagement on IJA. RESULTS: Joint engagement significantly mediated 69% of the intervention effect on young children's IJA and IJA predicted improvements in standardized language scores. CONCLUSIONS: Small but sustained changes in child-initiated joint engagement improved IJA, a core challenge in children with ASD, which in turn led to improvements in language.

Arteriovenous fistula maturation: Physical exam versus flow study.

PURPOSE: The purpose of this study was to determine the utility of routine duplex flow study 4 to 6 weeks after primary AVF creation and to compare physical exam against a duplex flow study in predicting fistula maturation. A surveillance algorithm was established to evaluate the naïve fistula after primary creation. METHODS: This was a single institution retrospective review of 155 veterans with primary autogenous AVF creation from 2016 to 2018. All patients received a duplex flow study evaluation after primary creation. A comparison was made between physical exam (PE) and flow study at 4 to 6 weeks post creation. Sensitivities and specificities of physical exam and duplex flow study were compared head-to-head in predicting unassisted fistula maturation. A mature AVF was defined as a fistula that could be repetitively cannulated and provided adequate flow for dialysis. Failure of maturation was defined as an AVF that was never usable for dialysis. An abnormal duplex included thrombosis, stenosis (> 50% on gray scale imaging), inadequate vein diameter (< 4 mm), inadequate vein length or superficialization, or poor flow (< 500 ml/min). Bivariate comparisons were conducted using Pearson's χ², Fishers exact test, and Wilcoxon test depending on distribution. Significance was defined as P < 0.05. RESULTS: There were 53 patients with radiocephalic (RC) fistulas, 41 patients with brachiocephalic (BC) fistulas, and 6 patients with brachiobasilic (BB) fistulas. Of patients with a confirmed abnormal duplex ultrasound, 53% had an abnormal PE (sensitivity 53%; PPV 96.3%, P < 0.001). Of the patients with a confirmed normal duplex, 98% had a normal PE (specificity 98%; NPV 68.5%, P < 0.001). An abnormal duplex flow study had a 67% sensitivity for predicting AVF failure or need for reintervention while an abnormal physical examination had a 42% sensitivity in predicting AVF failure or need for reintervention (P < 0.001). In total, 48 fistulas needed reintervention, however only 20 (42%) were associated with an abnormal physical examination. Of those 48 reinterventions, 20 (42%) fistulas exhibited primary assisted maturation (P < 0.001). On duplex flow study alone, 32 patients had hemodynamically significant lesions necessitating reintervention, which went on to afford 9 (28%) primary assisted mature fistulas (P = 0.69). CONCLUSION: Abnormal duplex flow studies have a better sensitivity for detecting AVF failure or the need for reintervention compared to physical exam alone. An abnormal duplex correlates more with needing a reintervention to achieve maturation than physical exam. Therefore, we advocate routine use of a postoperative duplex flow study to identify potentially correctable issues and optimize fistula maturation.

Impact of transplant center volume on donor heart offer utilization rates in the United States.

BACKGROUND: We tested the hypothesis that transplant centers (TCs) with higher volumes have higher donor heart (DH) offer utilization rates. METHODS: Using the Annual Data reports of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (SRTR) we reviewed all adult heart transplant offers between July 1, 2016 and June 29, 2019. Unadjusted donor offer utilization rates and observed to expected (O/E) DH utilization ratios adjusted using the SRTR model were calculated for each TC for all DH offers and for the following sub-categories: DH with left ventricular ejection fraction <60%, DH >40 years, DH >500 miles from TC, "hard-to-place hearts" (defined as those offered to >50 TCs) and DH designated as increased infectious risk. Univariable linear regression was used to identify a relationship between average yearly center volume and DH utilization. RESULTS: During the study 118,841 total offers were made to 107 TCs and 8300 transplants were performed. The unadjusted utilization rate was not associated with TC volume for all donor offers (p = .517). However, among all subcategories other than DH >40 years, the unadjusted DH utilization rate was associated with TC volume (p < .05). In addition, using the adjusted SRTR O/E ratio, there was a significant impact of TC volume on utilization rate for all donor offers (for an increase TC volume of 10 transplants/year coefficient = 0.095, 95% confidence interval: 0.037-0.151, p = .001). This relationship persisted with an identifiable change for each of the subcategories (p ≤ .001). CONCLUSIONS: TC volume is significantly correlated to DH offer utilization rate.

Risk and Protective Factors Related to Early Adverse Life Events in Irritable Bowel Syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) is a stress-sensitive disorder of brain-gut interactions associated with a higher prevalence of early adverse life events (EALs). However, it is incompletely understood how trauma severity or disclosure influence the risk of developing IBS or symptom severity. AIMS: To determine whether (1) IBS patients report a greater number of EALs compared with healthy controls; (2) trauma severity and first age of EAL increase the odds of IBS; (3) confiding in others reduces the odds of IBS; (4) the number, trauma severity, and first age of EAL are associated with symptom severity; (5) sex differences exist. METHODS: In total, 197 IBS patients (72% women, mean age=30.28 y) and 165 healthy controls (59% women, mean age=30.77 y) completed the Childhood Traumatic Events Scale, measuring severity of EALs and degree of confiding in others. Regression analyses were used to predict IBS status from EALs and association between gastrointestinal symptoms and EALs. RESULTS: A greater number of EALs [odds ratio (OR)=1.36, 95% confidence interval (CI), 1.14-1.62; P<0.001] and higher perceived trauma severity (OR=1.13, 95% CI, 1.08-1.19; P<0.001) were associated with increased odds of IBS. Confiding in others decreased the odds of having IBS (OR=0.83, 95% CI, 0.72-0.96; P=0.012). The first age of EAL was not predictive of IBS. No sex differences were found. CONCLUSIONS: Assessing the traumatic severity of EALs and amount of confiding in others is important as they can affect the risk of having IBS. Our findings emphasize early intervention to improve health outcomes in individuals with EALs.

Negative Events During Adulthood Are Associated With Symptom Severity and Altered Stress Response in Patients With Irritable Bowel Syndrome.

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is a stress-sensitive disorder associated with dysregulation of the hypothalamic-pituitary-adrenal axis. We studied the cumulative effect of events during adulthood on this pathway in patients with IBS. METHODS: We studied 129 patients with IBS, based on Rome III criteria (mean age 28.1 years, 66% women), and 108 healthy individuals (controls; mean age 29.8 years, 60% women) who completed the Life Experiences Survey from August 2013 to September 2017. Data were collected on the presence and effects of events since age 18, IBS severity scores, and IBS-related quality of life. For a subset of subjects, we measured serum cortisol and adrenocorticotropic hormone (ACTH) production in response to administration of corticotropin-releasing factor and ACTH. RESULTS: Compared with controls, patients with IBS perceived more adulthood life events as negative and had a significantly higher negative life event impact score (14.17 ± 12.04 vs 10.83 ± 9.98; P=.022). In patients with IBS, the presence of more-negatively perceived adulthood life events was associated with worse IBS symptom severity (ß = 1.53, 95% CI, 0.21-2.84; P = .025) and IBS-related quality of life (ß = -0.70; 95% CI, -1.02 to -0.38; P < .001). Negatively perceived adulthood life events were associated with reduced production of ACTH in response to corticotropin-releasing factor in patients with IBS compared with controls (P < .05). CONCLUSION: In a study of more than 200 subjects, we associated more-negatively perceived events during adulthood with an increased risk for IBS, worse symptom severity and quality of life, and a dysregulated stress response. Understanding the effects of events that cause stress in adults and their perceived effects on IBS may help guide disease management.

Predictors of Health-related Quality of Life in Irritable Bowel Syndrome Patients Compared With Healthy Individuals.

BACKGROUND: Irritable bowel syndrome (IBS) reduces health-related quality of life (HRQOL). It is unclear how having IBS modifies the impact of gastrointestinal (GI), psychosocial, and somatic symptom variables on HRQOL compared with healthy controls (HCs). AIMS: (1) Determine psychosocial, somatic, and physical status variables most predictive of HRQOL in IBS and HCs and (2) determine if IBS status modifies relationships between predictive factors and HRQOL. METHODS: IBS patients and HCs completed validated questionnaires measuring GI symptoms, psychosocial/somatic variables, and physical [physical component score (PCS)] and mental [mental component score (MCS)] HRQOL via the Short-Form-36. Associations between these variables and HRQOL were evaluated with multiple linear regressions. Variables were standardized to determine the strongest predictors of HRQOL. Statistical significance level was 0.01. RESULTS: Mean HRQOL was higher in 417 HCs versus 290 IBS subjects (PCS: 55.6 vs. 48.6, P<0.001; MCS: 53.7 vs. 44.8, P<0.001). The GI symptom measures were negatively associated with PCS in IBS, but only usual severity was associated with MCS (P<0.01). In all subjects, psychosocial and somatic measures were associated with MCS and not PCS excluding GI symptom anxiety, which correlated with both (P<0.01). The strongest predictor of MCS was perceived stress in IBS and depression symptoms in HCs. GI symptom anxiety was the strongest predictor of PCS in both. Greater perceived stress and somatic symptom severity and less mindfulness was linked to larger reductions in HRQOL for IBS compared with HCs (P<0.01). CONCLUSIONS: GI symptom severity and anxiety correlate with PCS, whereas psychosocial/somatic measures parallel MCS. However, HRQOL is comparable in IBS and HCs when perceived stress, somatic symptom severity, and mindfulness are at optimal levels. These findings may have important implications in the management of IBS.

Characteristics of socially successful elementary school-aged children with autism.

BACKGROUND: The extant literature demonstrates that children with autism spectrum disorder (ASD) often have difficulty interacting and socially connecting with typically developing classmates. However, some children with ASD have social outcomes that are consistent with their typically developing counterparts. Little is known about this subgroup of children with ASD. This study examined the stable (unlikely to change) and malleable (changeable) characteristics of socially successful children with ASD. METHODS: This study used baseline data from three intervention studies performed in public schools in the Southwestern United States. A total of 148 elementary-aged children with ASD in 130 classrooms in 47 public schools participated. Measures of playground peer engagement and social network salience (inclusion in informal peer groups) were obtained. RESULTS: The results demonstrated that a number of malleable factors significantly predicted playground peer engagement (class size, autism symptom severity, peer connections) and social network salience (autism symptom severity, peer connections, received friendships). In addition, age was the only stable factor that significantly predicted social network salience. Interestingly, two malleable (i.e., peer connections and received friendships) and no stable factors (i.e., age, IQ, sex) predicted overall social success (e.g., high playground peer engagement and social network salience) in children with ASD. CONCLUSIONS: School-based interventions should address malleable factors such as the number of peer connections and received friendships that predict the best social outcomes for children with ASD.

Hybrid implementation model of community-partnered early intervention for toddlers with autism: a randomized trial.

BACKGROUND: Interventions found to be effective in research settings are often not as effective when implemented in community settings. Considering children with autism, studies have rarely examined the efficacy of laboratory-tested interventions on child outcomes in community settings using randomized controlled designs. METHODS: One hundred and thirteen children with autism enrolled in public early intervention classrooms in low resource neighborhoods were randomized to Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) intervention or treatment as usual waitlist for 10 weeks with 1-month follow-up. RESULTS: Teaching assistants delivered JASPER at adequate fidelity. Children randomized to JASPER demonstrated significant gains over treatment as usual in core developmental outcomes of joint engagement, joint attention, and play skills that were maintained at follow-up. CONCLUSIONS: Supervised teaching assistants delivered JASPER intervention with a range of toddlers with autism leading to significant gains in developmental outcomes.

Children with autism spectrum disorder and social skills groups at school: a randomized trial comparing intervention approach and peer composition.

BACKGROUND: Peer relationships improve for children with autism spectrum disorder (ASD) in clinic-based social skills groups but rarely generalize to real world contexts. This study compares child outcomes of two social skills interventions conducted in schools with children in Kindergarten through fifth grade. METHOD: Children with ASD were randomized to one of two interventions that varied on group composition (mixed typical and ASD vs. all ASD or social difficulties) and intervention approach (didactic SKILLS based vs. activity-based ENGAGE groups). Interventions were implemented at school for 8 weeks (16 sessions) with an 8-week follow-up. Innovative measures of peer nomination and playground peer engagement, as well as teacher reports of child behavior problems and teacher-child relationship were analyzed for 137 children with ASD across four sites. RESULTS: On the primary outcome of social network connections from the peer nomination measure, there was no main effect of treatment, but there were moderator effects. Children with low teacher-child closeness or high conflict improved more in their social connections if they received the SKILLS intervention, whereas children with higher teacher-child closeness improved more if they received the ENGAGE intervention. Only two secondary outcome measures yielded significant effects of treatment. Children in the SKILLS groups increased peer engagement and decreased isolation during recess. Child behavior problems and teacher-child closeness moderated peer engagement such that children with higher behavior problems and lower closeness benefitted more from SKILLS groups. CONCLUSIONS: These findings suggest that social skills groups conducted at school can affect both peer engagement during recess as well as peer acceptability. Child characteristics and teacher-child relationship prior to intervention yield important information on who might benefit from a specific social skills intervention.

Developing an Adaptive Treatment Strategy for Peer-Related Social Skills for Children With Autism Spectrum Disorders.

The purpose of this study was to understand the trajectories of children's response to an intervention prior to the end of the treatment in order to inform adaptive treatment models for future studies. Participants with autism spectrum disorder (ASD) were drawn from a randomized controlled trial comparing 2 different social skills interventions at children's schools. We excluded children with ASD who entered the study with at least 80% time engaged (the average time of neurotypical children in the same classes) in order to examine only those who were engaged below the typical developing peers' average percentage of time engaged. The final sample included 92 children with ASD (82% male, average age = 8.14 years, average IQ = 89.6). We explored whether playground engagement scores measured at entry and midpoint of treatment predicted their engagement scores at end of treatment using the Classification and Regression Tree (CART) method. Using the CART approach, 4 meaningful subgroups based on children's playground engagement scores measured at entry and changes from entry to midpoint were identified. These data suggest that measurements of children's behavior midstudy can be used to predict children's treatment outcomes. Such data may be used to inform decisions to augment or alter programming prior to treatment end in order to tailor intervention to best meet the needs of individual children.

The peer relationships of girls with ASD at school: comparison to boys and girls with and without ASD.

BACKGROUND: This study examines the social relationships of elementary school children with high-functioning autism, focusing on how gender relates to social preferences and acceptance, social connections, reciprocal friendships, and rejection. METHOD: Peer nomination data were analyzed for girls with and without ASD (n = 50) and boys with and without ASD (n = 50). Girls and boys with ASD were matched by age, gender, and IQ. Each child with ASD was matched by age and gender to a typically developing classmate. RESULTS: Consistent with typically developing populations, children with ASD preferred, were accepted by, and primarily socialized with same-gender friends. With fewer nominations and social relationships, girls and boys with ASD appear more socially similar to each other than to the same-gender control group. Additionally, girls and boys with ASD showed higher rates of social exclusion than their typically developing peers. However, boys with ASD were more overtly socially excluded compared to girls with ASD, who seemed to be overlooked, rather than rejected. CONCLUSIONS: Our data suggest a number of interesting findings in the social relationships of children with ASD in schools. Like typically developing populations, children with ASD identify with their own gender when socializing and choosing friends. But given the social differences between genders, it is likely that girls with ASD are experiencing social challenges that are different from boys with ASD. Therefore, gender is an important environmental factor to consider when planning social skills interventions at school.

Comparative efficacy of an early intervention "parent and me" program for infants showing signs of autism: The Baby JASPER model.

Despite important advancements into the early detection of autism, there are still few empirically supported interventions for children under the age of two years who are showing early signs. Caregiver-mediated interventions have gained in popularity as a method for delivering support to the child and family. The current study builds on current work by enrolling a comparatively large cohort of infants (ages 12-22 months of age) displaying early signs of autism into a randomized controlled intervention program. Infants and parents received a group-based program using a standard early childhood curriculum. In addition, all families were randomly assigned to receive parent training in the form of either parent-mediated Joint Attention Symbolic Play Engagement and Regulation (JASPER) training or psychoeducation. Infants in both classrooms made substantial gains in social-communication, play, and cognition during a brief, 8-week period. All infants gained over an average of 10 points in DQ and increased in standardized measures of social-communication and play, with these gains maintaining at a 2-month follow-up visit. The classroom that also received JASPER increased in child initiated joint engagement and play level during dyadic interactions with their parents, while the classroom that received psychoeducation increased in joint attention during a standardized assessment delivered by an independent assessor. Infant familial risk for autism (older sibling with autism) also moderated the effect of treatment on child initiated joint engagement where infants in the JASPER classroom without familial risk made the most gains from baseline to exit of the program. This study highlights the promise of intervening at the earliest stages to promote positive outcomes for children and families.

Does Gestural Communication Influence Later Spoken Language Ability in Minimally Verbal Autistic Children?

PURPOSE: The current study examined the predictive role of gestures and gesture-speech combinations on later spoken language outcomes in minimally verbal (MV) autistic children enrolled in a blended naturalistic developmental/behavioral intervention (Joint Attention, Symbolic Play, Engagement, and Regulation [JASPER] + Enhanced Milieu Teaching [EMT]). METHOD: Participants were 50 MV autistic children (40 boys), ages 54-105 months (M = 75.54, SD = 16.45). MV was defined as producing fewer than 20 spontaneous, unique, and socially communicative words. Autism symptom severity (Autism Diagnostic Observation Schedule-Second Edition) and nonverbal cognitive skills (Leiter-R Brief IQ) were assessed at entry. A natural language sample (NLS), a 20-min examiner-child interaction with specified toys, was collected at entry (Week 1) and exit (Week 18) from JASPER + EMT intervention. The NLS was coded for gestures (deictic, conventional, and representational) and gesture-speech combinations (reinforcing, disambiguating, supplementary, other) at entry and spoken language outcomes: speech quantity (rate of speech utterances) and speech quality (number of different words [NDW] and mean length of utterance in words [MLUw]) at exit using European Distributed Corpora Project Linguistic Annotator and Systematic Analysis of Language Transcripts. RESULTS: Controlling for nonverbal IQ and autism symptom severity at entry, rate of gesture-speech combinations (but not gestures alone) at entry was a significant predictor of rate of speech utterances and MLUw at exit. The rate of supplementary gesture-speech combinations, in particular, significantly predicted rate of speech utterances and NDW at exit. CONCLUSION: These findings highlight the critical importance of gestural communication, particularly gesture-speech (supplementary) combinations in supporting spoken language development in MV autistic children.

Profiles of minimally verbal autistic children: Illuminating the neglected end of the spectrum.

Heterogeneity among individuals on the autism spectrum is widely acknowledged as a barrier to develop effective interventions. Overcoming this challenge requires characterization of individual differences, especially for children that are minimally verbal and often excluded from research studies. Most studies that describe autistic subgroups identify a single minimally verbal verbal group based on a single identifying measure (e.g., ADOS module one or single item indicating absence of phrase speech). Determining personalized courses of intervention requires a more detailed understanding since a single intervention will not be effective for all who are minimally verbal. The present study identified comprehensive profiles of cognitive, language, and social communication skills within a large, diverse, group of minimally verbal children with autism. The analysis combined baseline data from two studies to yield a sample of 344 participants, who were 3 to 8 years old at the time of study onset, with 60% who identified as having a race/ethnicity other than White. Via latent profile analysis (LPA), a three-group model was identified as best fit to the data. Profile identification was dependent on a participant's combination of cognitive, expressive, and social communication characteristics, rather than a single domain. One group (n = 206) had global delays, while the other two groups (n = 95 and n = 43) had variable strengths in cognition and communication. Findings suggest that low-frequency/minimally verbal communicators with autism have heterogeneous characteristics that can be systematically organized.