Telehealth Treatment of Behavior Problems in Young Children With Developmental Delay: A Randomized Clinical Trial.

Importance: Early behavior problems in children with developmental delay (DD) are prevalent and impairing, but service barriers persist. Controlled studies examining telehealth approaches are limited, particularly for children with DD. Objective: To evaluate the efficacy of a telehealth parenting intervention for behavior problems in young children with DD. Design, Setting, and Participants: A randomized clinical trial was conducted from March 17, 2016, to December 15, 2020, in which children with DD and externalizing behavior problems were recruited from early intervention and randomly assigned to a telehealth parenting intervention or control group and evaluated through a 12-month follow-up. Most children were from ethnic or racial minoritized backgrounds. Over one-half of children were in extreme poverty or low income-need ratio categories. Interventions: Internet-delivered parent-child interaction therapy (iPCIT), which leverages videoconferencing to provide live coaching of home-based caregiver-child interactions. Families received 20 weeks of iPCIT (provided in English or in Spanish) or referrals as usual (RAU). Main Outcomes and Measures: Observational and caregiver-report measures of child and caregiver behaviors and caregiving stress were examined at preintervention, midtreatment, and postintervention and at 6- and 12-month follow-ups. Results: The sample included a total of 150 children (mean [SD] age, 36.2 [1.0] months; 111 male children [74%]) and their caregivers with 75 each randomly assigned to iPCIT or RAU groups. Children receiving iPCIT relative to RAU displayed significantly lower levels of externalizing problems (postintervention Cohen d = 0.48; 6-month Cohen d = 0.49; 12-month Cohen d = 0.50) and significantly higher levels of compliance to caregiver direction after treatment. Of those children with data at postintervention, greater clinically significant change was observed at postintervention for children in the iPCIT group (50 [74%]) than for those in the RAU group (30 [42%]), which was maintained at the 6-month but not the 12-month follow-up. iPCIT did not outperform RAU in reducing caregiving stress, but caregivers receiving iPCIT, relative to RAU, showed steeper increases in proportion of observed positive parenting skills (postintervention odds ratio [OR], 1.10; 95% CI, 0.53-2.21; 6-month OR, 1.31; 95% CI, 0.61-2.55; 12-month OR, 1.64; 95% CI, 0.70-3.07) and sharper decreases in proportion of observed controlling/critical behaviors (postintervention OR, 1.40; 95% CI, 0.61-1.52; 6-month OR, 1.72; 95% CI, 0.58-1.46; 12-month OR, 2.23; 95% CI, 0.53-1.37). After treatment, iPCIT caregivers also self-reported steeper decreases in harsh and inconsistent discipline than did than RAU caregivers (postintervention Cohen d = 0.24; 6-month Cohen d = 0.26; 12-month Cohen d = 0.27). Conclusions and Relevance: Results of this randomized clinical trial provide evidence that a telehealth-delivered parenting intervention with real-time therapist coaching led to significant and maintained improvements for young children with DD and their caregivers. Findings underscore the promise of telehealth formats for expanding scope and reach of care for underserved families. Trial Registration: ClinicalTrials.gov Identifier: NCT03260816.

Effect of Therapist Coaching Statements on Parenting Skills in a Brief Parenting Intervention for Infants.

Behavioral parenting interventions have been shown to decrease early childhood behavior problems by improving parenting skills. Few studies have examined the impact of therapist coaching statements on parenting skill acquisition, especially among ethnic minority families and non-English-speaking families. In this study, we examined therapists' use of responsive and directive coaching statements during the first coaching session in a brief parenting intervention, the Infant Behavior Program (IBP), on changes in parenting skill acquisition. Participants were 24 mothers of 12- to 15-month-olds, with elevated levels of behavioral problems from primarily Latinx and low-income backgrounds. Mothers who heard more responsive coaching from their therapist showed greater increases in positive parenting skills. Spanish-speaking therapists used fewer responsive coaching statements and more commands, however, language spoken did not moderate the effect of these statements on changes in parenting skills. Responsive coaching statements in English and Spanish had a positive impact on parenting skill acquisition.

Multifaceted empathy differences in children and adults with autism.

Although empathy impairments have been reported in autistic individuals, there is no clear consensus on how emotional valence influences this multidimensional process. In this study, we use the Multifaceted Empathy Test for juveniles (MET-J) to interrogate emotional and cognitive empathy in 184 participants (ages 8-59 years, 83 autistic) under the robust Bayesian inference framework. Group comparisons demonstrate previously unreported interaction effects between: (1) valence and autism diagnosis in predictions of emotional resonance, and (2) valence and age group in predictions of arousal to images portraying positive and negative facial expressions. These results extend previous studies using the MET by examining differential effects of emotional valence in a large sample of autistic children and adults with average or above-average intelligence. We report impaired cognitive empathy in autism, and subtle differences in emotional empathy characterized by less distinction between emotional resonance to positive vs. negative facial expressions in autism compared to neurotypicals. Reduced emotional differentiation between positive and negative affect in others could be a mechanism for diminished social reciprocity that poses a universal challenge for people with autism. These component- and valence- specific findings are of clinical relevance for the development and implementation of target-specific social interventions in autism.

Predicting BMI in Young Children with Developmental Delay and Externalizing Problems: Links with Caregiver Depressive Symptoms and Acculturation.

BACKGROUND: Caregiver depression is associated with increased risk for childhood obesity. However, studies assessing the relation between caregiver depression and childhood obesity have focused primarily on typically developing, school-aged children and have not examined the influence of cultural factors. OBJECTIVES: To evaluate the association between caregiver depressive symptoms and body mass index (BMI) scores in young children with developmental delay (DD) and externalizing behavior problems, as well as the moderating role of acculturation and enculturation on this association. METHODS: We examined the association between caregiver depressive symptoms and child BMI scores in 147 3-year-old children with DD and elevated levels of externalizing behavior problems. Caregivers of all participating children self-identified as coming from cultural minority backgrounds. We also examined the association between caregiver depressive symptoms and child BMI across levels of caregiver acculturation and enculturation. RESULTS: Higher levels of caregiver depressive symptoms were associated with higher child BMI scores (b = .189, p = .001). Acculturation significantly moderated the association between caregiver depressive symptoms and child BMI scores (b = .21, p = .01), such that the association was stronger for more acculturated caregivers. Enculturation was not a significant moderator. CONCLUSIONS: Caregiver depressive symptoms may confer elevated risk for child obesity when caregivers are highly acculturated to the United States, suggesting clinicians should consider levels of acculturation to optimize services for children and families from cultural minority backgrounds.

Elevated Thresholds for Light Touch in Children With Autism Reflect More Conservative Perceptual Decision-Making Rather Than a Sensory Deficit.

Individuals with autism spectrum disorder (ASD) are often behaviorally hyper-reactive to light touch, but it is unclear to what degree this arises from a fundamental sensory difference vs. higher order systems for attention or emotion processing. Thus far, experimental findings for light touch detection are mixed, and few previous studies have independently considered sensitivity (the ability to discriminate signal from noise) and decision criterion (the overall response bias or tendency to answer "yes" or "no" in a detection task). We tested a large sample of children, adolescents, and adults with ASD (n = 88) and with neurotypical (NT) development (n = 59) using von Frey filaments to derive light touch thresholds at the palm. We calculated signal detection metrics for sensitivity (Az) and response criterion (c) from hit and false alarm rates. Both metrics exhibited significant group differences, such that the ASD group was less sensitive, but had a much more conservative response criterion. We used a best subset model selection procedure in three separate ordinal regressions for the whole group, adults, and children/adolescents. In all selected models, c was by far the most significant predictor of threshold, supplanting effects of diagnostic group that were significant in the baseline models. In contrast, Az was not a significant predictor of threshold in any of the models. Mean values of c were similar for adults with and without autism and for children/adolescents with ASD, but lower (more liberal) in neurotypical children/adolescents. This suggests that children with ASD exhibit a conservatism in their perceptual decision-making that differs from their NT peers but resembles that of adults. Across the sample, the value of c was significantly and positively correlated with age and with autism symptoms (SRS-2 total score), in addition to thresholds. The results of this study suggest that, rather than a sensory difference in detection of light touch, there is a difference in response bias such that children with ASD are more conservative/likely to report "no" if unsure, than their young NT peers. Future work should consider the implications of conservative response criterion in ASD for commonly used forced-choice psychophysical paradigms.

Neural Correlates of Cardiac Interoceptive Focus Across Development: Implications for Social Symptoms in Autism Spectrum Disorder.

Interoception involves the processing of sensory information relevant to physiological functioning and is integral to building self-awareness, emotional states, and modulating social behaviors. With the role of interoception in emotional processing and social functioning, there is growing interest in characterizing interoception in autism spectrum disorder (ASD), yet, there are mixed results regarding cardiac interoceptive accuracy in ASD. In this study, we explored the neural basis of cardiac interoception using an fMRI heartbeat-counting task in order to assess neural correlates of primary interoception. We predicted that interoceptive-specific response in the insula, a "hub" for interoception, would be related to ASD symptomatology. We investigated the relationship of insula responses during cardiac interoceptive focus and a self/caregiver-reported autism-related symptom scale (Social Responsiveness Scale-2 (SRS)). Participants included 46 individuals with autism spectrum disorder (ASD) (age 8-54, mean = 19.43 ± 10.68 years) and 54 individuals with typical development for comparison (TC, age 8-53, mean = 21.43 ± 10.41 years). We found no significant difference in cardiac interoceptive accuracy or neural response to cardiac interoception focus in ASD. Several insula subdivisions had a curvilinear relationship to age, peaking in early adulthood. Interoceptive-specific insula response was associated with adult self-report SRS scores; this association differed by diagnostic group and was not present for caregiver-reported scores. This work suggests that (a) there is no global deficit in cardiac interoception in ASD, but integrating interoceptive cues with social information may distinguish individuals with ASD, and (b) there is a developmental trajectory for interoceptive processing in the insula that may be relevant for socio-emotional health. Autism Res 2020, 13: 908-920. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We use internal sensory information from the body, such as signals from the heart, to understand our emotional response to the external world. We measured how accurately people with autism feel their heartbeat and how the brain responds to this type of information. We found no differences between the autism and comparison groups in how the brain senses heartbeats, or in how accurately people feel their heartbeats. However, for people with autism, brain responses while sensing heartbeats were related to social difficulties. This work suggests people with autism may use internal and external information in a different way.

Infant-directed language following a brief behavioral parenting intervention: The importance of language quality.

Behavioral parenting interventions decrease early childhood behavior problems and increase positive parenting skills. However, few studies have examined the impact of low intensity interventions for infants at risk for behavior problems on changes in parent language. This study examined the effect of a brief parenting intervention, the Infant Behavior Program, on changes in parent linguistic input and its influence on infant language. Participants were 58 mothers and their12- to 15-month-olds, with elevated levels of behavioral problems. Mothers and their infants were from primarily Hispanic and low-income backgrounds. Mother-infant dyads were randomly assigned to receive the Infant Behavior Program or standard pediatric primary care. Mothers receiving the Infant Behavior Program provided more linguistic input, which indirectly influenced infant language, and suggest targeting infants at risk for behavior problems can have a broader impact on language development.

Impact of Parenting Intervention on Observed Aggressive Behaviors in At-Risk Infants.

Aggressive behaviors in early childhood persist through childhood and adolescence and result in negative outcomes. However, studies assessing aggressive behaviors in early childhood have focused primarily on parent report. Additionally, the effects of parenting interventions and associated parenting skills on early observed aggression have not been examined. In the present study, we examined the direct effect of a brief, in-home adaptation of Parent-Child Interaction Therapy, the Infant Behavior Program (IBP), on observed frequency of aggressive behaviors and global ratings of aggression in infants ages 12 to 15 months. Additionally, we examined behaviorally-based parenting skills as a mechanism by which the IBP impacted observed infant aggressive behaviors. Sixty infants with elevated levels of behavior problems were randomized to receive the IBP or standard pediatric primary care. Infants receiving the IBP demonstrated a significant decrease in the observed frequency of aggressive behaviors during infant-led play across a 3-month follow-up. Furthermore, the intervention led to decreases in parental use of don't skills (i.e., directive and negative parent statements), which, in turn, led to decreases in the frequency of observed aggressive behaviors at a 3-month follow-up. However, effects were not maintained at a 6-month follow-up. Results provide preliminary evidence for the efficacy of a brief parenting intervention on reducing the frequency of infant aggressive behaviors, including the indirect effect of the IBP on the frequency of aggressive behaviors through reductions in parenting skills. The study highlights the importance of targeting negative parenting practices to decrease subsequent aggressive behaviors in early childhood.

Apps As Learning Tools: A Systematic Review.

CONTEXT: Young children have increasing access to interactive applications (apps) at home and at school. Existing research is clear on the potential dangers of overuse of screens, but there is less clarity around the extent to which interactive apps may be helpful in supporting early learning. OBJECTIVE: In this systematic review, we present a narrative synthesis of studies examining whether children <6 years can learn from interactive apps. DATA SOURCES: The PsycInfo, PubMed, ACM Digital Library, and ERIC databases were searched. STUDY SELECTION: Studies were included if the study design was randomized or nonrandomized controlled (quasi-experimental), the sample mean age was <6 years, the intervention involved children playing with an interactive app, and academic, cognitive, or social-emotional skill outcomes were measured. DATA EXTRACTION: Of 1447 studies, 35 were included. RESULTS: Evidence of a learning benefit of interactive app use for early academic skills was found across multiple studies, particularly for early mathematics learning in typically developing children. Researchers did not find evidence of an intervention effect for apps aiming to improve social communication skills in children with autism spectrum disorder. LIMITATIONS: Risk of bias was unclear for many studies because of inadequate reporting. Studies were highly heterogenous in interventions, outcomes, and study design, making comparisons of results across studies difficult. CONCLUSIONS: There is emerging evidence to suggest that interactive apps may be useful and accessible tools for supporting early academic development. More research is needed to evaluate both the potential of educational apps to support early learning, and their limitations.

Thermal Perceptual Thresholds are typical in Autism Spectrum Disorder but Strongly Related to Intra-individual Response Variability.

Individuals with autism spectrum disorder (ASD) are often reported to exhibit an apparent indifference to pain or temperature. Leading models suggest that this behavior is the result of elevated perceptual thresholds for thermal stimuli, but data to support these assertions are inconclusive. An alternative proposal suggests that the sensory features of ASD arise from increased intra-individual perceptual variability. In this study, we measured method-of-limits warm and cool detection thresholds in 142 individuals (83 with ASD, 59 with typical development [TD], aged 7-54 years), testing relationships with diagnostic group, demographics, and clinical measures. We also investigated the relationship between detection thresholds and a novel measure of intra-individual (trial-to-trial) threshold variability, a putative index of "perceptual noise." This investigation found no differences in thermal detection thresholds between individuals with ASD and typical controls, despite large differences between groups in sensory reactivity questionnaires and modest group differences in intra-individual variability. Lower performance IQ, male sex, and higher intra-individual variability in threshold estimates were the most significant predictors of elevated detection thresholds. Although no psychophysical measure was significantly correlated with questionnaire measures of sensory hyporeactivity, large intra-individual variability may partially explain the elevated psychophysical thresholds seen in a subset of the ASD population.

Intrainsular connectivity and somatosensory responsiveness in young children with ASD.

BACKGROUND: The human somatosensory system comprises dissociable paths for discriminative and affective touch, reflected in separate peripheral afferent populations and distinct cortical targets. Differences in behavioral and neural responses to affective touch may have an important developmental role in early social experiences, which are relevant for autism spectrum disorder (ASD). METHODS: Using probabilistic tractography, we compared the structural integrity of white matter pathways for discriminative and affective touch in young children with ASD and their typically developing (TD) peers. We examined two tracts: (1) a tract linking the thalamus with the primary somatosensory cortex, which carries discriminative tactile information, and (2) a tract linking the posterior insula-the cortical projection target of unmyelinated tactile afferents mediating affective touch-with the anterior insula, which integrates sensory and visceral inputs to interpret emotional salience of sensory stimuli. We investigated associations between tract integrity and performance on a standardized observational assessment measuring tactile discrimination and affective responses to touch. RESULTS: Both the thalamocortical and intrainsular tracts showed reduced integrity (higher mean diffusivity) in the ASD group compared to those in the TD group. Consistent with the previous findings, the ASD group exhibited impaired tactile discriminative ability, more tactile defensiveness, and more sensory seeking (e.g., enthusiastic play or repetitive engagement with a specific tactile stimulus). There was a significant relation between intrainsular tract integrity and tactile seeking. The direction of this relation differed between groups: higher intrainsular mean diffusivity (MD) (reflecting decreased tract integrity) was associated with increased tactile seeking in the TD group but with decreased tactile seeking in the ASD group. In the TD group, decreased tactile defensiveness was also associated with higher intrainsular MD, but there was no relation in the ASD group. Discriminative touch was not significantly associated with integrity of either tract in either group. CONCLUSIONS: These results support previous findings suggesting a central role for the insula in affective response to touch. While both discriminative and affective touch and both somatosensory tracts are affected in ASD, the restriction of brain-behavior associations to the intrainsular tract and tactile seeking suggests more complex and perhaps higher-order influence on differences in tactile defensiveness and discrimination.