The Developmental Sequence and Relations Between Gesture and Spoken Language in Toddlers With Autism Spectrum Disorder.

In typical development, gestures precede and predict language development. This study examines the developmental sequence of expressive communication and relations between specific gestural and language milestones in toddlers with autism spectrum disorder (ASD), who demonstrate marked difficulty with gesture production and language. Communication skills across five stages (gestures, word approximations, first words, gesture-word combinations, and two-word combinations) were assessed monthly by blind raters for toddlers with ASD participating in an randomized control trial of parent-mediated treatment (N = 42, 12-30 months). Findings revealed that toddlers acquired skills following a reliable (vs. idiosyncratic) sequence and the majority of toddlers combined gestures with words before combining words in speech, but in contrast to the pattern observed in typical development, a significant subset acquired pointing after first words.

Future Directions for Infant Identification and Intervention for Autism Spectrum Disorder from a Transdiagnostic Perspective.

By the time they are typically detected, neurodevelopmental disorders like autism spectrum disorder (ASD) are already challenging to treat. Preventive and early intervention strategies in infancy are critical for improving outcomes over the lifespan with significant cost savings. However, the impact of prevention and early intervention efforts is dependent upon our ability to identify infants most appropriate for such interventions. Because there may be significant overlap between prodromal symptoms across neurodevelopmental disorders and child psychopathology more broadly which may wax and wane across development, we contend that the impact of prevention and early intervention efforts will be heightened by identifying early indicators that may overlap across ASD and other commonly co-occurring disorders. This paper summarizes the existing literature on infant symptoms and identification of ASD to demonstrate the ways in which a transdiagnostic perspective could expand the impact of early identification and intervention research and clinical efforts, and to outline suggestions for future empirical research programs addressing current gaps in the identification-to-treatment pipeline. We propose four recommendations for future research that are both grounded in developmental and clinical science and that are scalable for early intervention systems: (1) development of fine-grained, norm-referenced measures of ASD-relevant transdiagnostic behavioral domains; (2) identification of shared and distinct mechanisms influencing the transition from risk to disorder; (3) determination of key cross-cutting treatment strategies (both novel and extracted from existing approaches) effective in targeting specific domains across disorders; and (4) integration of identified measures and treatments into existing service systems.

Assessment Fidelity of Parents Implementing a Standardized Telehealth Infant Autism Screener.

Telehealth is effective for service delivery in pediatric occupational therapy across ages and diagnoses. Remote parent coaching provides unique benefits for both parents and infants. As a result of COVID-19, practitioners and researchers pivoted to remote assessment and intervention without much preparation or training. It is critical that we evaluate the quality of these telehealth services. One important component of remote evaluations is assessment fidelity. To examine assessment fidelity of a telehealth-delivered observational autism screening tool for infants. An assessment fidelity checklist was applied as the primary outcome measure. Parents conducted assessments with 82% adherence to the fidelity checklist. Implications: A parent coaching telehealth approach may be valid for assessment in pediatric telehealth. Continually monitoring the assessment fidelity of a tool is critical for the valid administration of remote services.

Leveraging telehealth to evaluate infants with prodromal autism spectrum disorder characteristics using the telehealth evaluation of development for infants.

LAY ABSTRACT: Many families seeking early evaluations for autism spectrum disorder face long waitlists, must often travel to centers with appropriate expertise, and are frequently told by providers to "wait and see." This results in significant stress for families and delayed supports to infants and their caregivers who could benefit. This study evaluated whether telehealth could be used to identify and evaluate infants with early autism spectrum disorder characteristics in the first year of life. In this study, we evaluated 41 infants via telehealth using a standard set of probes and scored behavior related to social communication, play, imitation, and other developmental domains. We found the majority of infants demonstrated elevated likelihood of autism spectrum disorder on both parent-reported questionnaires and examiner-rated behavior. Caregiver ratings of the overall utility of the protocol used in this study were high. Overall, this study demonstrates the feasibility for telehealth-based approaches to evaluate infants' with elevated likelihood of autism spectrum disorder in the first year of life, which could help to improve families' access to care and to expand our capacity to conduct studies evaluating possible intervention supports.

Short report: Experiences of Caregivers Participating in a Telehealth Evaluation of Development for Infants (TEDI).

A growing literature supports the feasibility and validity of telehealth-based assessments for autism spectrum disorder (ASD). Better understanding families' experiences is crucial for sustained use beyond the COVID-19 pandemic. This study qualitatively examines caregiver experiences with the Telehealth Evaluation of Development for Infants (TEDI) protocol to better understand benefits and challenges of telehealth-based evaluations. Caregivers (N = 32) completed an online survey following a telehealth-based evaluation with their 6-12 month-old infants. Open-ended text responses to queries about perceived benefits, challenges, and suggestions for future adaptations were coded. Most caregivers reported positive experiences with minor feedback relating to tailoring of individual needs. Responses suggest the TEDI is a feasible approach and provide guidance for components of successful telehealth evaluations more broadly.

Examining US Public Early Intervention for Toddlers With Autism: Characterizing Services and Readiness for Evidence-Based Practice Implementation.

As the rates of Autism Spectrum Disorder (ASD) increase and early screening efforts intensify, more toddlers with high likelihood of ASD are entering the United States' (US') publicly funded early intervention system. Early intervention service delivery for toddlers with ASD varies greatly based on state resources and regulations. Research recommends beginning ASD-specific evidence-based practices (EBP), especially caregiver-implemented intervention, as early as possible to facilitate the development of social-communication skills and general learning. Translating EBP into practice has been challenging, especially in low-resourced areas. The main goal of this study was to obtain a more comprehensive understanding of public early intervention system structure, service delivery practices, and factors influencing EBP use for children with ASD in the US. Participants (N = 133) included 8 early intervention state coordinators in 7 states, 29 agency administrators in those states, 57 early intervention providers from those agencies, and 39 caregivers of children with ASD receiving services from those providers. Online surveys gathered stakeholder and caregiver perspectives on early intervention services as well as organizational factors related to EBP implementation climate and culture. Stakeholders identified key intervention needs for young children with ASD. In general, both agency administrators and direct providers reported feeling somewhat effective or very effective in addressing most needs of children with ASD. They reported the most difficulty addressing eating, sleeping, family stress, and stereotyped behaviors. Data indicate that children from families with higher income received significantly higher service intensity. While administrators and providers reported high rates of high-quality caregiver coaching (>60%), caregivers reported low rates (23%). Direct providers with more favorable attitudes toward EBP had greater EBP use. In turn, provider attitudes toward EBP were significantly associated with implementation leadership and culture at their agency. Results suggest that publicly funded early intervention programs in the US require additional resources and training for providers and leaders to support improved implementation climate and attitudes toward ASD EBPs. Results also suggest that more state system support is needed to increase use of ASD-specific EBP use, including high-quality caregiver coaching, to better serve toddlers with ASD. Recommendations for implementation strategies are addressed.

Brief Report: Preliminary Feasibility of the TEDI: A Novel Parent-Administered Telehealth Assessment for Autism Spectrum Disorder Symptoms in the First Year of Life.

Families with early concerns about infant symptoms of ASD have limited access to experienced professionals for screening and guidance. Telehealth has been used to reduce access disparities in other pediatric populations and has shown promise in parent-implemented interventions for ASD. We investigated the feasibility of a novel level-2 telehealth assessment of infants' early social communication and ASD symptoms, the Telehealth Evaluation of Development for Infants (TEDI). Parents of eleven infants aged 6-12 months were coached to administer specific semi-structured behavioral probes. Initial feasibility, reliability, and acceptability benchmarks were met. These findings suggest the feasibility of screening infants via telehealth, and are supportive of further large-scale efforts to validate this method for longitudinal monitoring of symptomatic infants in community settings.

Lateralization of ERPs to speech and handedness in the early development of Autism Spectrum Disorder.

BACKGROUND: Language is a highly lateralized function, with typically developing individuals showing left hemispheric specialization. Individuals with autism spectrum disorder (ASD) often show reduced or reversed hemispheric lateralization in response to language. However, it is unclear when this difference emerges and whether or not it can serve as an early ASD biomarker. Additionally, atypical language lateralization is not specific to ASD as it is also seen more frequently in individuals with mixed- and left-handedness. Here, we examined early asymmetry patterns measured through neural responses to speech sounds at 12 months and behavioral observations of handedness at 36 months in children with and without ASD. METHODS: Three different groups of children participated in the study: low-risk controls (LRC), high risk for ASD (HRA; infants with older sibling with ASD) without ASD, and HRA infants who later receive a diagnosis of ASD (ASD). Event-related potentials (ERPs) to speech sounds were recorded at 12 months. Utilizing a novel observational approach, handedness was measured by hand preference on a variety of behaviors at 36 months. RESULTS: At 12 months, lateralization patterns of ERPs to speech stimuli differed across the groups with the ASD group showing reversed lateralization compared to the LRC group. At 36 months, factor analysis of behavioral observations of hand preferences indicated a one-factor model with medium to high factor loadings. A composite handedness score was derived; no group differences were observed. There was no association between lateralization to speech at 12 months and handedness at 36 months in the LRC and HRA groups. However, children with ASD did show an association such that infants with lateralization patterns more similar to the LRC group at 12 months were stronger right-handers at 36 months. CONCLUSIONS: These results highlight early developmental patterns that might be specific to ASD, including a potential early biomarker of reversed lateralization to speech stimuli at 12 months, and a relation between behavioral and neural asymmetries. Future investigations of early asymmetry patterns, especially atypical hemispheric specialization, may be informative in the early identification of ASD.

Maternal Vocal Feedback to 9-Month-Old Infant Siblings of Children with ASD.

Infant siblings of children with autism spectrum disorder display differences in early language and social communication skills beginning as early as the first year of life. While environmental influences on early language development are well documented in other infant populations, they have received relatively little attention inside of the infant sibling context. In this study, we analyzed home video diaries collected prospectively as part of a longitudinal study of infant siblings. Infant vowel and consonant-vowel vocalizations and maternal language-promoting and non-promoting verbal responses were scored for 30 infant siblings and 30 low risk control infants at 9 months of age. Analyses evaluated whether infant siblings or their mothers exhibited differences from low risk dyads in vocalization frequency or distribution, and whether mothers' responses were associated with other features of the high risk context. Analyses were conducted with respect to both initial risk group and preliminary outcome classification. Overall, we found no differences in infants' consonant-vowel vocalizations, the frequency of overall maternal utterances, or the distribution of mothers' response types. Both groups of infants produced more vowel than consonant-vowel vocalizations, and both groups of mothers responded to consonant-vowel vocalizations with more language-promoting than non-promoting responses. These results indicate that as a group, mothers of high risk infants provide equally high quality linguistic input to their infants in the first year of life and suggest that impoverished maternal linguistic input does not contribute to high risk infants' initial language difficulties. Implications for intervention strategies are also discussed.

Maternal gesture use and language development in infant siblings of children with autism spectrum disorder.

Impairments in language and communication are an early-appearing feature of autism spectrum disorders (ASD), with delays in language and gesture evident as early as the first year of life. Research with typically developing populations highlights the importance of both infant and maternal gesture use in infants' early language development. The current study explores the gesture production of infants at risk for autism and their mothers at 12 months of age, and the association between these early maternal and infant gestures and between these early gestures and infants' language at 18 months. Gestures were scored from both a caregiver-infant interaction (both infants and mothers) and from a semi-structured task (infants only). Mothers of non-diagnosed high risk infant siblings gestured more frequently than mothers of low risk infants. Infant and maternal gesture use at 12 months was associated with infants' language scores at 18 months in both low risk and non-diagnosed high risk infants. These results demonstrate the impact of risk status on maternal behavior and the importance of considering the role of social and contextual factors on the language development of infants at risk for autism. Results from the subset of infants who meet preliminary criteria for ASD are also discussed.

Diary Reports of Concerns in Mothers of Infant Siblings of Children with Autism Across the First Year of Life.

We examined the home-based concerns reported by mothers of infant siblings of children with autism across the first year of life. At all three ages measured, mothers of high-risk infants were significantly more likely than mothers of low-risk infants to report language, social communication, and restricted and repetitive behavior concerns but were not more likely to report general, medically based concerns. At 6 and 9 months of age, maternal concerns were poorly related to infant or family variables. At 12 months of age, there were moderate correlations between maternal concerns and infant behavior, and concerns were associated with the proband's autism symptoms and mothers' concurrent depressive symptoms. These findings highlight the need to examine high-risk infants' development in the family context.

Identifying early-risk markers and developmental trajectories for language impairment in neurodevelopmental disorders.

The effective identification of neurodevelopmental disorders is essential for early diagnosis and provision of intervention services. For many of these conditions, one of the primary domains of abnormality is language development. This review addresses what is known about the earliest indicators of language impairment across a range of neurodevelopmental disorders; consideration is given to both behavioral and neural markers, as well as patterns of change over time. A summary of the current state of the field, including challenges in research, is presented. The earliest features of the language phenotype in Down syndrome, Williams syndrome, Fragile X, specific language impairment (SLI), and autism spectrum disorder (ASD) are described, along with recent findings in the early neural markers of language impairment in SLI and ASD.