Pre-treatment clinical and gene expression patterns predict developmental change in early intervention in autism.

Early detection and intervention are believed to be key to facilitating better outcomes in children with autism, yet the impact of age at treatment start on the outcome is poorly understood. While clinical traits such as language ability have been shown to predict treatment outcome, whether or not and how information at the genomic level can predict treatment outcome is unknown. Leveraging a cohort of toddlers with autism who all received the same standardized intervention at a very young age and provided a blood sample, here we find that very early treatment engagement (i.e., <24 months) leads to greater gains while controlling for time in treatment. Pre-treatment clinical behavioral measures predict 21% of the variance in the rate of skill growth during early intervention. Pre-treatment blood leukocyte gene expression patterns also predict the rate of skill growth, accounting for 13% of the variance in treatment slopes. Results indicated that 295 genes can be prioritized as driving this effect. These treatment-relevant genes highly interact at the protein level, are enriched for differentially histone acetylated genes in autism postmortem cortical tissue, and are normatively highly expressed in a variety of subcortical and cortical areas important for social communication and language development. This work suggests that pre-treatment biological and clinical behavioral characteristics are important for predicting developmental change in the context of early intervention and that individualized pre-treatment biology related to histone acetylation may be key.

Rethinking the idea of late autism spectrum disorder onset.

A common theory of autism spectrum disorder (ASD) symptom onset includes toddlers who do not display symptoms until well after age 2, which are termed late-onset ASD cases. Objectives were to analyze differences in clinical phenotype between toddlers identified as ASD at initial evaluations (early diagnosed) versus those initially considered nonspectrum, then later identified as ASD (late diagnosed). Two hundred seventy-three toddlers recruited from the general population based on a failed developmental screening form or parent or physician concerns were followed longitudinally from 12 months and identified as early- and late-diagnosed cases of ASD, language delayed, or typically developing. Toddlers completed common standardized assessments and experimental eye-tracking and observational measures every 9-12 months until age 3. Longitudinal performance on standardized assessments and experimental tests from initial evaluations were compared. Delay in social communication skills was seen in both ASD groups at early-age initial assessment, including increased preference for nonsocial stimuli, increased stereotypic play, reduced exploration, and use of gestures. On standardized psychometric assessments, early-diagnosed toddlers showed more impairment initially while late-diagnosed toddlers showed a slowing in language acquisition. Similar social communication impairments were present at very early ages in both early-detected ASD and so-called late-onset ASD. Data indicate ASD is present whether detected or not by current methods, and development of more sensitive tools is needed.

Neural correlates of verbal and nonverbal semantic integration in children with autism spectrum disorders.

BACKGROUND: Autism is a pervasive developmental disorder characterized by deficits in social-emotional, social-communicative, and language skills. Behavioral and neuroimaging studies have found that children with autism spectrum disorders (ASD) evidence abnormalities in semantic processing, with particular difficulties in verbal comprehension. However, it is not known whether these semantic deficits are confined to the verbal domain or represent a more general problem with semantic processing. The focus of the current study was to investigate verbal and meaningful nonverbal semantic processing in high-functioning children with autism (mean age = 5.8 years) using event-related potentials (ERPs). METHOD: ERPs were recorded while children attended to semantically matching and mismatching picture-word and picture-environmental sound pairs. RESULTS: ERPs of typically developing children exhibited evidence of semantic incongruency detection in both the word and environmental sound conditions, as indexed by elicitation of an N400 effect. In contrast, children with ASD showed an N400 effect in the environmental sound condition but not in the word condition. CONCLUSIONS: These results provide evidence for a deficiency in the automatic activation of semantic representations in children with ASD, and suggest that this deficit is somewhat more selective to, or more severe in, the verbal than the nonverbal domain.

Teaching reciprocal imitation skills to young children with autism using a naturalistic behavioral approach: effects on language, pretend play, and joint attention.

Children with autism exhibit significant deficits in imitation skills which impede the acquisition of more complex behaviors and socialization, and are thus an important focus of early intervention programs for children with autism. This study used a multiple-baseline design across five young children with autism to assess the benefit of a naturalistic behavioral technique for teaching object imitation. Participants increased their imitation skills and generalized these skills to novel environments. In addition, participants exhibited increases in other social-communicative behaviors, including language, pretend play, and joint attention. These results provide support for the effectiveness of a naturalistic behavioral intervention for teaching imitation and offer a new and potentially important treatment option for young children who exhibit deficits in social-communicative behaviors.

The collateral effects of joint attention training on social initiations, positive affect, imitation, and spontaneous speech for young children with autism.

Joint attention may be a core deficit in autism which underlies the abnormal development of later emerging social-communication behaviors. Given this theory, researchers have suggested that teaching young children with autism to engage in joint attention may lead to collateral increases in other non-targeted social-communication behaviors. In this study, children with autism participated in a 10-week joint attention training program and collateral changes in non-targeted behaviors were assessed. Following participation in the intervention, positive collateral changes were observed in social initiations, positive affect, imitation, play, and spontaneous speech. Results support the hypothesis that teaching joint attention skills leads to improvement in a variety of related skills and have implications for the treatment of young children with autism.

Consonant production patterns of young severely language-delayed children with autism.

UNLABELLED: While much attention has been given to documenting the language skills of verbal children with autism, the basic speech sound development patterns of severely language-impaired children with autism are unknown. Previous research has shown that certain consonants are generally produced earlier in development than other consonants, both in typically developing children and in children with language-learning impairments. While several large studies indicate that children with autism who have strong verbal skills have intact phonological development, there is some evidence that children with autism who are more severely language impaired may have abnormal phonological production. This study documents the speech sound development of non-verbal and minimally verbal children with autism. Prompts were administered for each individual speech sound while spontaneous and imitated sounds were recorded and scored. Results indicate that children with autism show the same general speech sound production patterns as typically developing and language-learning impaired children. LEARNING OUTCOMES: Individuals who read this manuscript will obtain information regarding: (1) normal phonological development, (2) a comparison of speech sound production of a group of 14 children with a diagnosis of autism spectrum disorder with the production of a group of 10 typically developing children, and (3) comparisons of imitated and spontaneous sound production of the children diagnosed with autism spectrum disorder.

Individual behavioral profiles and predictors of treatment effectiveness for children with autism.

Differential responsiveness to intervention programs suggests the inadequacy of a single treatment approach for all children with autism. One method for reducing outcome variability is to identify participant characteristics associated with different outcomes for a specific intervention. In this investigation, an analysis of archival data yielded 2 distinct behavioral profiles for responders and nonresponders to a widely used behavioral intervention, pivotal response training (PRT). In a prospective study, these profiles were used to select 6 children (3 predicted responders and 3 predicted nonresponders) who received PRT. Children with pretreatment responder profiles evidenced positive changes on a range of outcome variables. Children with pretreatment nonresponder profiles did not exhibit improvements. These results offer promise for the development of individualized treatment protocols for children with autism.

Examination of the prevalence of stimulus overselectivity in children with ASD.

Many individuals with autism spectrum disorders (ASD) display stimulus overselectivity, wherein a subset of relevant components in a compound stimulus controls responding, which impairs discrimination learning. The original experimental research on stimulus overselectivity in ASD was conducted several decades ago; however, interventions for children with ASD now typically include programming to target conditional discriminations in ways that might minimize the prevalence of stimulus overselectivity. The present study assessed 42 children who had been diagnosed or educationally identified with ASD using a discrimination learning assessment. Of these 42 children, 19% displayed overselective responding, which is a lower percentage than that seen in early research. Possible explanations for this decreased percentage, implications for intervention, and future directions for research are discussed.

Naturalistic Developmental Behavioral Interventions: Empirically Validated Treatments for Autism Spectrum Disorder.

Earlier autism diagnosis, the importance of early intervention, and development of specific interventions for young children have contributed to the emergence of similar, empirically supported, autism interventions that represent the merging of applied behavioral and developmental sciences. "Naturalistic Developmental Behavioral Interventions (NDBI)" are implemented in natural settings, involve shared control between child and therapist, utilize natural contingencies, and use a variety of behavioral strategies to teach developmentally appropriate and prerequisite skills. We describe the development of NDBIs, their theoretical bases, empirical support, requisite characteristics, common features, and suggest future research needs. We wish to bring parsimony to a field that includes interventions with different names but common features thus improving understanding and choice-making among families, service providers and referring agencies.

Effect of sensory feedback on immediate object imitation in children with autism.

This study examined the effect of sensory feedback (e.g., flashing lights and sound) on the imitation performance of children with autism and typical children group-matched for mental age. Participants were administered an immediate object-imitation task with six novel toys constructed for this study: three with a sensory effect that could be activated by imitating the modeled action and three without a sensory effect. Although overall imitation performance did not differ significantly between the two groups, the imitation performance of the participants with autism was significantly higher with sensory toys than with nonsensory toys. Typical participants' imitation performance did not differ between the two sets of toys. Both groups played significantly more with the sensory toys during free play, indicating that sensory toys were more reinforcing for both groups. Additional results demonstrated that typical children used significantly more social behaviors during imitation than children with autism, but they did not differ in object-oriented behaviors, replicating previous findings. It is argued that children with autism may be less motivated to imitate by social interaction, but may be motivated to imitate to receive a nonsocial reward (sensory feedback).

A randomized trial comparison of the effects of verbal and pictorial naturalistic communication strategies on spoken language for young children with autism.

Presently there is no consensus on the specific behavioral treatment of choice for targeting language in young nonverbal children with autism. This randomized clinical trial compared the effectiveness of a verbally-based intervention, Pivotal Response Training (PRT) to a pictorially-based behavioral intervention, the Picture Exchange Communication System (PECS) on the acquisition of spoken language by young (2-4 years), nonverbal or minimally verbal (≤9 words) children with autism. Thirty-nine children were randomly assigned to either the PRT or PECS condition. Participants received on average 247 h of intervention across 23 weeks. Dependent measures included overall communication, expressive vocabulary, pictorial communication and parent satisfaction. Children in both intervention groups demonstrated increases in spoken language skills, with no significant difference between the two conditions. Seventy-eight percent of all children exited the program with more than 10 functional words. Parents were very satisfied with both programs but indicated PECS was more difficult to implement.

Measuring outcome in an early intervention program for toddlers with autism spectrum disorder: use of a curriculum-based assessment.

Measuring progress of children with autism spectrum disorder (ASD) during intervention programs is a challenge faced by researchers and clinicians. Typically, standardized assessments of child development are used within research settings to measure the effects of early intervention programs. However, the use of standardized assessments is not without limitations, including lack of sensitivity of some assessments to measure small or slow progress, testing constraints that may affect the child's performance, and the lack of information provided by the assessments that can be used to guide treatment planning. The utility of a curriculum-based assessment is discussed in comparison to the use of standardized assessments to measure child functioning and progress throughout an early intervention program for toddlers with risk for ASD. Scores derived from the curriculum-based assessment were positively correlated with standardized assessments, captured progress masked by standardized assessments, and early scores were predictive of later outcomes. These results support the use of a curriculum-based assessment as an additional and appropriate method for measuring child progress in an early intervention program. Further benefits of the use of curriculum-based measures for use within community settings are discussed.

Stimulus overselectivity in typical development: implications for teaching children with autism.

Stimulus overselectivity is widely accepted as a stimulus control abnormality in autism spectrum disorders and subsets of other populations. Previous research has demonstrated a link between both chronological and mental age and overselectivity in typical development. However, the age at which children are developmentally ready to respond to discriminations involving simultaneous multiple cues has not been established. Thirty-seven typically developing preschoolers completed a task requiring response to simultaneous cues (color and shape) to establish the age at which typically developing children can successfully respond to multiple cues. Results demonstrate that typically developing children under 36 months of age have difficulty responding to multiple cues. Implications for behavioral treatment for autism are discussed.

Implementation challenges in translating pivotal response training into community settings.

Implementing evidence-based practices (EBPs) for children with autism is challenging for teachers because these practices are often complex, requiring significant training and resources that are not available in most school settings. This brief investigation was designed to identify areas of strength and difficulty for teachers implementing one such EBP, pivotal response training (PRT). Observational data were gathered from 41 teachers participating in two separate investigations involving PRT. Despite differences in training procedures, teachers demonstrated similarities in areas of strength (clear opportunities/instruction and child choice) and difficulty (turn taking and multiple cues). These findings suggest next steps toward systematic adaptation of PRT for classroom use. The research may serve as a model for the process of adapting EBPs for practice settings.

What works for you? Using teacher feedback to inform adaptations of pivotal response training for classroom use.

Several evidence-based practices (EBPs) have been identified as efficacious for the education of students with autism spectrum disorders (ASD). However, effectiveness research has rarely been conducted in schools and teachers express skepticism about the clinical utility of EBPs for the classroom. Innovative methods are needed to optimally adapt EBPs for community use. This study utilizes qualitative methods to identify perceived benefits and barriers of classroom implementation of a specific EBP for ASD, Pivotal Response Training (PRT). Teachers' perspectives on the components of PRT, use of PRT as a classroom intervention strategy, and barriers to the use of PRT were identified through guided discussion. Teachers found PRT valuable; however, they also found some components challenging. Specific teacher recommendations for adaptation and resource development are discussed. This process of obtaining qualitative feedback from frontline practitioners provides a generalizable model for researchers to collaborate with teachers to optimally promote EBPs for classroom use.

Toward a technology of treatment individualization for young children with autism spectrum disorders.

Although the etiology of autism spectrum disorders (ASD) and early development of the ASD are not yet well understood, recent research in the field of autism has heavily emphasized the importance of early intervention (i.e. treatment before the age of 4 years). Currently, several methods have been demonstrated to be efficacious with some children however no treatment completely ameliorates the symptoms of ASD or works for all children with the disorder. The heterogeneity and developmental nature of the disorder make it unlikely that one specific treatment will be best for all children, or will work for any one child throughout his or her educational career. Thus, this paper examines early research validating different technologies for individualizing treatment. A discussion of current research on pre-treatment characteristics associated with differential outcomes in treatment, including child, family, and practitioner variables; and how specific intervention techniques address each of those pre-treatment characteristics is provided. The ultimate goal of this line of research is to enable practitioners to prospectively tailor treatments to specific children and increase the overall rate of positives outcomes for children with autism. Research that furthers understanding of how to match clients with efficacious treatments will decrease the outcome variability that characterizes early intervention research at present, and provide for the most efficient allocation of resources during the critical early intervention time-period. This type of research is in its infancy, but is imperative if we are to determine a priori which treatment method will be most effective for a specific child.

Brief Report: Toward Refinement of a Predictive Behavioral Profile for Treatment Outcome in Children with Autism.

Previously researchers identified a behavioral profile that predicted treatment response of children with autism to a specific behavioral intervention, Pivotal Response Training (PRT). This preliminary investigation sought to refine this profile by obtaining six participants matching the original nonresponder profile on all but one of the profile behaviors (toy contact or avoidance) and then assessing their response to PRT. In addition, participants received a course of Discrete Trial Training (DTT) to determine whether the profile predicted child response to this intervention. Altering the original profile behavior of toy contact led to improved response to PRT while, altering the profile behavior of high avoidance had little impact on treatment response, and the profile was not predictive of response to DTT.

Stereotypy in Autism: The Importance of Function.

We argue for the utility of a functional definition of stereotypy based on evidence of both sensory automatic and socially mediated reinforcement contingencies in the occurrence of stereotypy in children with autism. A predetermined sensory function of stereotypy is often invoked in the behavioral literature and the term "self-stimulatory behavior" is commonly misused as interchangeable with "stereotypy." We discuss evidence for a variety of potential functional properties of stereotypy. Diagnostic definitions are reviewed and support for both sensory and social functions is outlined. We argue that stereotypies should be described and categorized according to their function, rather than form. Furthermore, treatment decisions should be based on a functional interpretation of stereotypy, which acknowledges its operant and heterogeneous quality in autism.

Joint attention training for children with autism using behavior modification procedures.

BACKGROUND: Deficits in joint attention are considered by many researchers to be an early predictor of childhood autism (e.g., Osterling & Dawson, 1994) and are considered to be pivotal to deficits in language, play, and social development in this population (Mundy, 1995). Although many researchers have noted the importance of joint attention deficits in the development of children with autism (e.g., Mundy, Sigman, & Kasari, 1994) and have called for intervention strategies (e.g., Mundy & Crowson, 1997), few studies have attempted to target joint attention. In this study, joint attention behaviors were taught to children with autism using a behavior modification procedure. METHODS: A multiple-baseline design was implemented to evaluate intervention effects. The following target behaviors were included in the intervention: 1) Responding to showing, pointing, and gaze shifting of adult; 2) Coordinated gaze shifting (i.e., coordinated joint attention); and 3) Pointing (with the purpose of sharing, not requesting). Generalization to setting and parent, follow-up sessions, and social validation measures were also analyzed. RESULTS: Joint attention behaviors were effectively trained and targeted behaviors generalized to other settings. In addition, positive changes were noted by naive observers using social validation measures. CONCLUSIONS: Integrating joint attention training into existing interventions may be important for children with autism. In addition, training parents in these techniques may help to maintain joint attention skills outside of the treatment setting.