Development of an interactive tool of early social responsiveness to track autism risk in infants and toddlers.

AIM: To evaluate the psychometric properties of a 4-minute assessment designed to identify early autism spectrum disorder (ASD) status through evaluation of early social responsiveness (ESR). METHOD: This retrospective, preliminary study included children between 13 and 24 months (78 males, 79 females mean age 19.4mo, SD 3.1) from two independent data sets (an experimental/training sample [n=120] and a validation/test sample [n=37]). The ESR assessment examined social behaviors (e.g. eye contact, smiling, ease-of-social-engagement) across five common play activities (e.g. rolling a ball, looking at a book). Data analyses examined reliability and accuracy of the assessment in identifying ESR abilities and in discriminating children with and without ASD. RESULTS: Results indicated adequate internal consistency and test-retest reliability of the ESR assessment. Receiver operator curve analysis identified a cutoff score that discriminated infants with ASD-risk from peers in the training sample. This score yielded moderate sensitivity and high specificity for best-estimate ASD diagnosis in the validation sample. INTERPRETATION: Preliminary findings indicated that brief, systematic observation of ESR may assist in discriminating infants with and without ASD, providing concrete evidence to validate or supplement parents', pediatricians', or clinicians' concerns. Future studies could examine the utility of ESR 'growth curves'.

A Meta-analytic Review of the Five Minute Speech Sample as a Measure of Family Emotional Climate for Youth: Relations with Internalizing and Externalizing Symptomatology.

The Five Minute Speech Sample's (FMSS) measure of parental expressed emotion (EE), defined as criticism (CRIT) and emotional overinvolvement (EOI), has been increasingly used to measure family emotional climate in relation to youth psychopathological development. As CRIT and EOI were defined based on adults, a meta-analysis and systematic review was conducted to analyze the presence and strength of an effect among maternal CRIT and EOI with youth internalizing and externalizing problems. A random effects model was used to analyze the 42 studies on families of youth (aged 1.5 to 19). There was a small, significant relation among maternal CRIT with youth internalizing and externalizing problems and among EOI with youth internalizing problems. EOI was not significantly related to externalizing problems. The current study suggests that the FMSS measure of CRIT is a more robust correlate of youth internalizing and externalizing symptoms than EOI, but EOI does relate to internalizing behaviors. Few moderators emerged, highlighting a continued need to identify factors accounting for heterogeneity. The current results suggest that the FMSS measure of CRIT may be a valuable measure of the family emotional climate in families of youth, but care should be taken when including analyses on EOI.

Examining Feasibility and Outcomes of the PEERS® for Preschoolers Program.

Social impairments characteristic of autism spectrum disorder (ASD) are evident in early childhood and often worsen. There is a paucity of evidence-based interventions explicitly targeting social skill development for young children with ASD and few actively integrate caregivers. The PEERS® program, an evidence-based caregiver-assisted social skills program, was extended for young children with ASD (i.e., PEERS® for Preschoolers (P4P)). This pilot study expands upon initial results by examining the feasibility of a briefer intervention period and the effectiveness in improving child social skills among 15 children with ASD. Results suggest P4P recruitment, participant retention, and implementation are feasible across clinicians and sites. Further, P4P appears to improve social skills, maintained post-intervention. Future research might examine mechanisms that lead to results.

PEERS® for Preschoolers preliminary outcomes and predictors of treatment response.

PEERS® for Preschoolers (P4P) is a social skills group program for young autistic children and their caregivers, which provides everyday tools for interacting and communicating with others. Twenty-two caregiver-child dyads participated and completed pre-treatment, post-treatment, and follow-up measures (4-16 weeks after). Using single-subject analyses to examine social skills, 60% demonstrated post-treatment improvement, and 53.85% demonstrated follow-up improvement. Regarding a secondary outcome of behavioral difficulties, 33.33% demonstrated post-treatment reduction, and 7.69% demonstrated follow-up reduction. Using regressions, autistic traits predicted outcomes; fewer social communication difficulties predicted both greater social skills and fewer behavioral difficulties at post-treatment, while fewer repetitive behaviors predicted fewer post-treatment and follow-up behavioral difficulties. These results preliminarily demonstrate the benefits of P4P and how autistic traits may impact P4P outcomes.

Examining indicators of psychosocial risk and resilience in parents of autistic children.

Background: Parents of autistic children experience increased levels of caregiver strain and adverse mental health outcomes, even in comparison to parents of children with other neurodevelopmental disabilities. Previous studies have largely attributed these increased levels of mental health concerns to their child behavioral concerns and autism symptomatology, but less attention has been given to other potential child factors, such as child adaptive functioning. Additionally, little is known about potential protective factors, such as parents' emotion regulation (ER) abilities, that may ameliorate the experience of caregiver strain, anxiety, and depression. Objective: The current study examined the impact of child characteristics (restricted and repetitive behaviors, adaptive functioning and behavioral concerns) on parent mental health outcomes (caregiver strain, anxiety, depression and wellbeing). Additionally, we explore parents' ER abilities as a moderator of the impact of child characteristic on parents' mental health outcomes. Results: Results of linear mixed effect models indicated a significant relationship between parents' ER abilities and all four parent outcomes. Additionally, children's adaptive functioning abilities and repetitive behaviors (RRBs) were significant predictors of caregiving strain. Parents' ER abilities were a significant moderator of the effect of children's repetitive behaviors and adaptive functioning challenges on caregiver strain, such that better ER abilities mitigated the impact of child clinical factors on caregiver strain. Finally, a significant difference was detected for mothers' and fathers' mental health, with mothers reporting higher caregiver strain, and more symptoms of anxiety and depression than did fathers. Conclusion: This study leveraged a large sample of autistic children and their biological parents to examine the relationship between children's clinical characteristics and parents' psychological wellbeing. Results indicate that, although parents of autistic children do experience high rates of internalizing mental health concerns that relate to child adaptive functioning and RRBs, parent ER abilities act as a protective factor against parents' adverse mental health outcomes. Further, mothers in our sample reported significantly higher rates of depression, anxiety, and caregiver strain, as compared with fathers.

Remote PEERS® for preschoolers: A pilot parent-mediated social skills intervention for young children with social challenges over telehealth.

Introduction: Social differences characteristic of autism spectrum disorder (ASD) and other developmental disabilities are evident in early childhood and are associated with later difficulties. Unfortunately, there is a paucity of evidence-based interventions explicitly targeting social skills development for young children, few actively integrate parents and caregivers, and even fewer have remote models. The importance of providing accessible, tailored services for families in the wake of the COVID-19 pandemic, prompted the creation of a parent-mediated telehealth version of Program for the Education and Enrichment of Relational Skills (PEERS®) for Preschoolers (P4P), a pre-existing, evidence-based social skills intervention for children 4-6 years focused on making and keeping friends. Method: This methodological paper documents the implementation, feasibility, and satisfaction of a novel telehealth group-based delivery of P4P. Results: Qualitative results indicate acceptable feasibility and satisfaction. Additionally, following completion there was an increase in parental confidence in social coaching and increased use of child social skills. Discussion: Future work will evaluate quantitative outcomes and comparisons between delivery methods (e.g., telehealth vs. in-person).

An Initial Pilot Study Examining Child Social Skills, Caregiver Styles, and Family Functioning in the PEERS® for Preschoolers Program for Young Autistic Children and their Caregivers.

BACKGROUND: Social impairments characteristic of autism spectrum disorder (ASD) are evident in early childhood and worsen as the child matures. Though many interventions for young children exist, few specifically target social skills and involve caregivers. AIMS: This pilot study examined PEERS® for Preschoolers, focusing on temporal change in child social skills, caregiver style, and family functioning in the context of a caregiver-assisted social skills intervention. This extension of the PEERS® program builds on the success of the intervention for older children, presenting skills in a developmentally appropriate manner to young autistic children and their caregivers. METHODS AND PROCEDURES: The present pilot study used a non-concurrent multiple baseline design to examine the above variables with 15 autistic children (Mage = 4.87, SD = 1.25; 11 boys). Children and caregivers participated in PEERS® for Preschoolers groups, with each group randomly assigned three different baseline periods (1.5, 2, or 2.5 weeks) before beginning. OUTCOMES AND RESULTS: Simulation Modeling Analysis (SMA) revealed concurrent improvements in social and caregiving skills, with subsequent changes in family functioning occurring over the course of this 16-session intervention. CONCLUSIONS AND IMPLICATIONS: Future research will need to examine mechanisms of change in PEERS® for Preschoolers for children and caregivers. WHAT THIS PAPER ADDS: There is a dearth of research that specifically examines social skills interventions for young autistic children that incorporates caregivers and examines family functioning as well. This paper is one of the first to evaluate the PEERS® for Preschoolers (P4P) intervention by: 1) exploring changes in child social skills, caregiver efficacy, and family functioning, and 2) analyzing the sequence of improvements in the aforementioned variables to measure systematic change. This pilot study presents results using appropriate methodology for a small sample size of children and caregivers. Results suggested concurrent improvements in social and caregiving skills and subsequent changes in family functioning. These can be built upon for further research on the PEERS® for Preschoolers intervention. This study supports PEERS® for Preschoolers as a feasible intervention that likely contributes to improvements for the child, caregiver in their relationship with their child and parenting styles in general, as well as functioning of the entire family. In sum, this work is essential to furthering the provision of a much needed service of social skills interventions for young autistic children.

A pilot study of PEERS® for Careers: A comprehensive employment-focused social skills intervention for autistic young adults in the United States.

BACKGROUND: Autistic young adults are at elevated risk for poor employment/internship outcomes, despite having many strengths relevant to the workplace. Currently, very few employment interventions for this population comprehensively promote skills development and success across the various stages of employment. AIMS: To address this gap, the current study aimed to test the feasibility, acceptability, and efficacy of a novel college to career intervention program, PEERS® for Careers. METHODS AND PROCEDURES: Twelve autistic young adults (19-30 years old) were enrolled and matched to a career coach. The pilot program consisted of 90-minute sessions delivered twice per week, for 10 weeks, covering content relevant to obtaining, maintaining, and thriving in employment/internship settings. OUTCOMES AND RESULTS: Results indicated that young adults showed a significant improvement in employment-related social skills knowledge, p < .001. Participants also reported significant improvements in their feelings of preparedness for employment over the course of the study, p = .009, with all young adults self-identifying as "somewhat prepared" or "very prepared" post-intervention. Additionally, in only a brief 10-week intervention, a slight increase in participants who secured or maintained internship/employment-related activities was observed. Overall, lesson content and coaching were perceived as helpful. No significant changes were observed in self-reported autism symptomatology. CONCLUSIONS AND IMPLICATIONS: In sum, the PEERS® for Careers program shows promise as a college to career intervention program for autistic young adults. WHAT THIS PAPER ADDS: There is a dearth of evidence-based interventions for autistic young adults, despite significant need for supports to bolster vocational and relational success. This paper is the first to evaluate the PEERS® for Careers intervention in a pilot study by exploring feasibility, acceptability, and efficacy of this novel college to career intervention program, which teaches ecologically valid employment-related skills using a strengths-based approach. Results suggest PEERS® for Careers shows significant potential as a comprehensive intervention to address the multi-faceted needs of autistic individuals in the workplace through didactic lessons, behavioral rehearsals to practice skills, and out of group assignments. Autistic young adult participants reported a high level of satisfaction with the program and lessons surrounding employment-related social skills. They also endorsed increased feelings of internship/employment readiness and increased knowledge of workplace etiquette, with most participants maintaining or securing employment. This study supports PEERS® for Careers as a feasible intervention that likely benefits autistic individuals' vocational outcomes, which emerge as a strong correlate of well-being in adulthood. This work is essential to furthering the development and provision of effective services to meet needs of the autism community.

The Association of the Broader Autism Phenotype with Emotion-Related Behaviors in Mothers of Children With and Without Autism Spectrum Traits.

Broader autism phenotype (BAP) characteristics (pragmatic language deficits, aloofness, and rigidity) are prevalent in families of individuals with autism spectrum disorder (ASD) and may influence emotion-related behaviors. The current study analyzed associations among BAP characteristics with emotion-related behaviors in mothers of children with and without ASD. Twenty-seven mothers completed BAP and emotion regulation (ER) questionnaires. Maternal affect was coded during an interaction task. BAP rigidity negatively correlated with the ER strategy reappraisal. BAP total and pragmatic scores positively correlated with observed negative affect. Associations remained significant in step-wise regressions that controlled for other BAPQ subscale scores. Findings suggest that pragmatic difficulties may interfere with positive mother-child interactions and mothers with high rigidity may benefit from learning adaptive ER strategies.

How Do Graduate Teaching Assistants Perceive and Understand Their Autistic College Students?

Background: As autistic college students increase in number, it is important to identify how to best support them. Beyond the increased academic demands of higher education, many autistic young adults struggle with social interactions, time management, emotion regulation, and routine changes. Having an accurate understanding of Graduate Teaching Assistants' (GTAs') knowledge of neurodiverse learners could inform improvements to GTA training programs. Methods: We explored GTAs' understanding of autism spectrum disorder (ASD) and any related pedagogical training. We used the Autism Awareness Survey by Tipton and Belcher and several supplemental questions to assess 92 GTAs' knowledge of ASD (65% female [n = 59], mean age = 27 years [standard deviation, SD = 4 years], 69% Caucasian [n = 62]). Results: Most GTAs (n = 76; 83%) had heard of ASD, primarily from a family member (n = 51; 66%). Out of 14 questions, 61% (n = 56) of GTAs answered at least 10 accurately. Eight questions were answered correctly by more than 75% of respondents, indicating some understanding of ASD, although room for improvement remained. GTAs with an autistic family member were not more knowledgeable about ASD, nor did they report feeling better-equipped to support autistic students. The majority of GTAs (n = 89; 97%) had not received any ASD-specific pedagogical training and only 15% of GTAs felt well-equipped to teach autistic students. Conclusions: While most GTAs answered basic knowledge questions about ASD correctly, they did not feel prepared to support autistic students. Increased understanding of neurodiverse learners could help GTAs foster a more supporting and inclusive environment and improve academic and social outcomes for autistic students. Further research is needed on what specific supports autistic learners need in the college classroom, how to train GTAs on how to provide these supports, and how to measure the effectiveness of such interventions.

Maternal Affect During a Challenging Mother-Child Interaction: The Effects of Broad Autism Phenotype and Respiratory Sinus Arrhythmia Reactivity in Mothers of Children With and Without Autism Spectrum Disorder.

Respiratory sinus arrhythmia (RSA) is proposed to index cognitive and behavioral inflexibility. Broad autism phenotype (BAP) traits are prevalent in family members of children with autism spectrum disorder (ASD). The study investigated whether RSA and BAP traits in mothers of typically developing (TD) children and mothers of children with ASD influence maternal affect. It was hypothesized that these factors would interact to influence mother-child interactions. Twenty-three mother-child dyads participated in a challenging interaction while measuring mother's RSA. Results indicated that mothers of children with ASD show different RSA reactivity than mothers of TD children. Furthermore, preliminary analyses revealed RSA reactivity moderated the relationship between mothers' rigidity and maternal affect during this interaction. Implications for future research and interventions are discussed.

A Machine Learning Strategy for Autism Screening in Toddlers.

OBJECTIVE: Autism spectrum disorder (ASD) screening can improve prognosis via early diagnosis and intervention, but lack of time and training can deter pediatric screening. The Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) is a widely used screener but requires follow-up questions and error-prone human scoring and interpretation. We consider an automated machine learning (ML) method for overcoming barriers to ASD screening, specifically using the feedforward neural network (fNN). METHODS: The fNN technique was applied using archival M-CHAT-R data of 14,995 toddlers (age 16-30 months, 46.51% male). The 20 M-CHAT-R items were inputs, and ASD diagnosis after follow-up and diagnostic evaluation (i.e., ASD or not ASD) was the output. The sample was divided into subgroups by race (i.e., white and black), sex (i.e., boys and girls), and maternal education (i.e., below and above 15 years of education completed) to examine subgroup differences. Each subgroup was evaluated for best-performing fNN models. RESULTS: For the total sample, best results yielded 99.72% correct classification using 18 items. Best results yielded 99.92% correct classification using 14 items for white toddlers and 99.79% correct classification using 18 items for black toddlers. In boys, best results yielded 99.64% correct classification using 18 items, whereas best results yielded 99.95% correct classification using 18 items in girls. For the case when maternal education is 15 years or less (i.e., associate degree and below), best results were 99.75% correct classification when using 16 items. Results were essentially the same when maternal education was 16 years or more (i.e., above associate degree); that is, 99.70% correct classification was obtained using 16 items. CONCLUSION: The ML method was comparable to the M-CHAT-R with follow-up items in accuracy of ASD diagnosis while using fewer items. Therefore, ML may be a beneficial tool in implementing automatic, efficient scoring that negates the need for labor-intensive follow-up and circumvents human error, providing an advantage over previous screening methods.

All in the Family: A Systematic Review of the Effect of Caregiver-Administered Autism Spectrum Disorder Interventions on Family Functioning and Relationships.

A number of intervention models aimed at addressing Autism Spectrum Disorder (ASD)-related behaviors require caregivers to perform intensive and oftentimes extended protocols (Bearss et al. in Clin Child Fam Psychol Rev 18(2):170-182, 2015). Though a number of research findings describe how characteristics of the child with ASD affect the mental health and stress experienced by caregivers and family members (Davis and Carter in J Autism Dev Disord 38(7):1278-1291, 2008; Tomanik et al. in J Intellect Dev Disabil 29(1):16-26, 2004), few studies investigate effects on overall family functioning and relationships among other family members. This review aimed to examine caregiver-delivered interventions as they relate to ASD, the impact of these caregiver-administered interventions on the family unit and family relationships, and potential future targets of treatments and treatment structures that include family members. The results of the review illustrate the nature of caregiver-administered interventions, which largely benefit family functioning and relationships.

Gender differences in restricted and repetitive behaviors and interests in youth with autism.

Previous work has found gender differences in restricted and repetitive behaviors and interests (RRBI) for autism spectrum disorder (ASD). Compared to girls, affected boys have increased stereotyped and restricted behaviors; however much less is known about gender differences in other areas of RRBI. This study aims to identify whether specific RRBI (i.e., stereotyped, self-injurious, compulsive, insistence on sameness, ritualistic, and restricted), as measured by item-level data on the Repetitive Behavior Scale-Revised (RBS-R), can distinguish girls from boys with ASD. Participants included 615 individuals with ASD (507 boys; 82.4%), ages 3-18 years of age (M = 10.26, SD = 4.20), who agreed to share data with the National Database for Autism Research (NDAR). Multivariate analysis of variance and discriminant function analysis (DFA) were used to determine whether item-level RBS-R data could correctly classify cases by gender. DFA results suggest that RBS-R items significantly differentiate gender. Strongly differentiating RBS-R items had greater success in correctly classifying affected boys (67.90%) than girls (61.00%). Items that best-discriminated gender were heightened stereotyped behaviors and restricted interests items in boys and compulsive, sameness, restricted, and self-injurious behavior items in girls. This study is the first to find that girls with ASD may have increased compulsive, sameness, and restricted RRBI compared to boys. Additionally, findings support heightened self-injurious behaviors in affected girls. Future research should disentangle whether elevated rates of RRBI in girls are central to the presentation of ASD in girls or an epiphenomenon of the high rates of co-occurring disorders (e.g., anxiety) noted in girls. Autism Res 2019, 12: 274-283 © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study is the first to examine a comprehensive measure of repetitive behavior in children with autism, with findings of increased compulsive, insistence on sameness, and self-injurious behavior characterizing girls and increased stereotyped and restricted behavior characterizing boys. Future research should determine whether these elevated behaviors in girls are directly part of the autism presentation in girls or symptoms of co-occurring psychopathology. It is important for autism diagnostic measures to best capture the types of repetitive behavior girls may demonstrate.

Teaching emotion regulation to children with autism spectrum disorder: Outcomes of the Stress and Anger Management Program (STAMP).

Young children with autism spectrum disorder (ASD) struggle with emotion regulation (ER), which is developmentally preceded by lability/negative affect (L/N), and their parents face unique challenges to parenting and providing assistance. The Stress and Anger Management Program (STAMP) is a cognitive-behavioral treatment designed to address ER deficits in young children with ASD through child skill-building and parent training. The current study evaluated child L/N, ER, and parental confidence outcomes in 4- to 7-year-old children with ASD (N = 23; 19 boys) and their parents randomly assigned to a treatment (n = 12) or a waitlist control group (n = 11). Child L/N decreased, regulation was not significantly changed, and parental confidence regarding the child's ability to manage anger and anxiety increased from pre- to posttreatment in the treatment group, but not in the waitlist group. Implications for future interventions that address ER in children with ASD and their parents are discussed.

Marching to the beat of your own drum?: A proof-of-concept study assessing physiological linkage in Autism Spectrum Disorder.

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by difficulty in dynamically adjusting behavior to interact effectively with others, or social reciprocity. Synchronization of physiological responses between interacting partners, or physiological linkage (PL), is thought to provide a foundation for social reciprocity. In previous work we developed a new technique to measure PL using dynamic linear time series modeling to assess cardiac interbeat interval (IBI) linkage in typically developing same-sex unacquainted dyads (Scarpa et al., 2017). The current article describes a proof-of-concept study with three dyads of young adults with ASD interacting with same-sex unacquainted typically developing (TD) partners. This pilot data is applied to propose potential benefits of using this technique to quantify and assess PL in individuals with ASD, both for basic research and for intervention science. Discussion focuses on applications of this measure to potentially advance knowledge of the biology-behavior link in ASD.

Child Autism Spectrum Disorder Traits and Parenting Stress: The Utility of Using a Physiological Measure of Parental Stress.

Caregivers of children with autism spectrum disorder (ASD) report greater stress due to unique parenting demands (e.g.; Estes et al. in Brain Dev 35(2):133-138, 2013). Stress is often studied through self-report and has not been extensively studied using physiological measures. This study compared parenting stress in mothers of children with and without ASD traits. Twenty-seven mother-child dyads participated in an interaction task while measuring mother's heart rate variability (HRV) and mothers self-reported stress levels. Results demonstrated that while self-report and physiological stress measures were not correlated, ASD symptomology did account for HRV change score (i.e., more severe ASD symptoms were positively related to HRV change). This may reflect an atypical coping response. Implications for using physiological indicators for studying parenting stress are explored.

Does the Presence of Anxiety and ADHD Symptoms Add to Social Impairment in Children with Autism Spectrum Disorder?

Children with autism spectrum disorder (ASD) experience internalizing and externalizing problems at higher rates than typically developing children, which could worsen social impairment. The present study compared impairment scores (social responsiveness scale, 2nd edition; SRS-2 scores) in 57 children (3-17 years, 82.5% male) with ASD, either with or without heightened levels of anxiety or ADHD symptoms, all per parent report. Children with heightened anxiety problems showed higher scores on four SRS-2 subscales (Social Cognition, Social Communication, Social Motivation, and Restricted Interests and Repetitive Behavior). Children with heightened ADHD traits showed higher scores on two subscales (Social Communication and Social Awareness). These findings suggest similarities and differences in how social deficits in ASD may worsen with anxiety or ADHD symptoms.

Brief Report: Insistence on Sameness, Anxiety, and Social Motivation in Children with Autism Spectrum Disorder.

While the function of restricted repetitive behaviors (RRBs) in autism spectrum disorder (ASD) is unclear, RRBs may function as anxiety reduction strategies (Joosten et al. J Autism Dev Disord 39(3):521-531, 2009. Moreover, anxiety in ASD is associated with low social motivation (Swain et al. J Autism Dev Disord, 2015. The present study examined social motivation as a mediator between anxiety and RRBs in a sample of 44 children (2-17 years old; 80 % male) with ASD. The relationship between anxiety and IS, but not other RRBs, was partially mediated by social motivation. These findings suggest anxiety is linked to social motivation deficits in children with ASD, which may increase ritualized behaviors and difficulties with changes in routine. Implications are discussed for differing functions and treatment of RRB domains.