Social Communication and Parent Verbal Responsiveness Across Interaction Contexts in Toddlers on the Autism Spectrum.

PURPOSE: Interactions with caregivers during the ordinary activities that occur as families go about their everyday lives are critical to supporting children's acquisition of social communication and language skills. The purpose of this study was to examine child communication and parent verbal responsiveness across interaction contexts in 211 children (Mage = 20 months) on the autism spectrum (n = 121), with developmental delay (n = 46), or with typical development (n = 44). METHOD: Families participated in up to eight activities during an hour-long, video-recorded home observation. We tested differences in the strength of associations between diagnostic group and interaction context using linear mixed-effects models, with child rate per minute of communication and proportions of parent follow-in comments and directives as outcome variables. Child communicative functions expressed across contexts were also examined. RESULTS: Children across groups communicated at significantly higher rates per minute during book sharing and play with people compared to other interaction contexts. Most child communication was for the function of joint attention during book sharing, for social interaction during play with people, and for behavior regulation during necessary activities such as family chores and meals. On average, parents of children responded using proportionally more follow-in comments during book sharing and play compared to necessary activities, during which parents used more follow-in directives. CONCLUSION: Results provide a glimpse into the dyadic communication that may occur within everyday activities at home, which supports the need for future intervention research and may aid clinicians seeking to identify activities that serve as important contexts for intervention.

The earlier the better: An RCT of treatment timing effects for toddlers on the autism spectrum.

LAY ABSTRACT: Behavioral interventions that incorporate naturalistic, developmental strategies have been shown to improve outcomes for young children who receive an autism spectrum disorder (ASD) diagnosis. Although there is broad consensus that children on the spectrum should begin supports as soon as possible, the empirical evidence for this is relatively limited and little is known about the optimal age to start autism-specific interventions. Our team conducted a randomized controlled trial (RCT) to test the effects of starting intervention at different ages, using the Early Social Interaction (ESI) model, a parent-implemented intervention for toddlers on the spectrum. Participants included 82 autistic toddlers and their caregiver(s) who received 9 months of Individual-ESI and 9 months of Group-ESI, with the timing/order of these two treatment conditions randomized. Thus, families received the more intensive and individualized Individual-ESI at either 18 or 27 months of age. Results revealed that children who received Individual-ESI earlier showed greater treatment gains than those who received this intervention later. Gains were demonstrated in several areas, which included the use and understanding of language, social use of communication skills, and self-help skills. Importantly, these findings were specific to the intensive and individualized parent coaching model compared to group-based treatment, allowing us to rule out the possibility that these timing effects were due to children getting older rather than the treatment itself. Our results suggest that even a narrow window of 18 versus 27 months may have an impact on outcomes and underscore the importance of screening and evaluation as young as possible.

The Early Screening for Autism and Communication Disorders: Field-testing an autism-specific screening tool for children 12 to 36 months of age.

LAY ABSTRACT: There is a critical need for accurate screening tools for autism spectrum disorder in very young children so families can access tailored intervention services as early as possible. However, there are few screeners designed for children 18-24 months. Developing screeners that pick up on the signs of autism spectrum disorder in very young children has proved even more challenging. In this study, we examined a new autism-specific parent-report screening tool, the Early Screening for Autism and Communication Disorders for children between 12 and 36 months of age. Field-testing was done in five sites with 471 children screened for communication delays in primary care or referred for familial risk or concern for autism spectrum disorder. The Early Screening for Autism and Communication Disorders was tested in three age groups: 12-17, 18-23, and 24-36 months. A best-estimate diagnosis of autism spectrum disorder, developmental delay, or typical development was made. Analyses examined all 46 items and identified 30 items that best discriminated autism spectrum disorder from the non-spectrum groups. Cutoffs were established for each age group with good sensitivity and specificity. Results provide preliminary support for the accuracy of the Early Screening for Autism and Communication Disorders as an autism-specific screener in children 12-36 months with elevated risk of communication delay or autism spectrum disorder.

Anxiety, Depression, and the Interpersonal Theory of Suicide in a Community Sample of Adults with Autism Spectrum Disorder.

The present study examines occurrence of depression, anxiety, and suicidality in adults with autism spectrum disorder (ASD), relationships between social difficulties and mental health, and application of the Interpersonal Theory of Suicide in this population. Ninety-eight adults with ASD completed an online survey. Data were analyzed using bivariate correlations, independent samples t-tests, and simple mediational analyses. A substantial proportion reported a lifetime history of anxiety (63%), depression (55%), and suicide attempts (19%), as well as recent suicidal ideation (12%). Social difficulty was associated with higher psychiatric concerns. Thwarted belongingness and perceived burdensomeness were associated with social dissatisfaction, current suicidal ideation, and history of depression. Results suggest the need for widespread screening and intervention services for co-occurring psychiatric conditions in this population.

Exploring message framing to engage parents in early screening for autism spectrum disorder.

OBJECTIVE: With the average age of diagnosis of autism hovering between 4 and 5 years of age, many children do not receive critical early intervention. Health information messages may be useful for increasing parents' understanding of the importance of early autism screening. METHODS: Messages promoting autism screening were presented to 282 parents in a 2 (message frame: gain, loss) x 3 (evidence type: narrative, statistical, and hybrid), online, between-participants factorial design. Participants' involvement, affective responses, perceived threat to behavioral freedom, attitudes, and intentions to discuss screening with a healthcare provider were analyzed. RESULTS: Loss-framed messages that included a hybrid of first-person narrative and statistical evidence were related to favorable ratings for most outcomes. Levels of perceived threat to behavioral freedom partially mediated involvement and attitudes, in a negative direction, for loss-framed narrative messages. CONCLUSION: Results of this preliminary study supported the inclusion of both evidence types in messages developed to encourage parents to engage in early screening for autism, and partially supported focusing these messages on the potential costs of not screening. PRACTICE IMPLICATIONS: Effective use of messaging with parents could help to increase knowledge and facilitate shared decision-making with health care providers to engage in early screening for autism.

Factors associated with enrollment into a clinical trial of caregiver-implemented intervention for infants at risk for autism spectrum disorder.

LAY ABSTRACT: Early intervention helps to address developmental delays in young children with autism spectrum disorder. Yet, research suggests there are barriers to enrollment into research studies that test the effectiveness of these interventions for infants at risk. This study identifies family characteristics that were associated with agreement to enroll in a clinical trial of early intervention for 12-month-old infants at risk for autism spectrum disorder. As part of a large longitudinal study, infants were evaluated for early signs of autism spectrum disorder at 1 year of age. Of the fifty-seven infants who were showing signs of autism and deemed eligible for the early intervention trial, 44% declined enrollment. Results suggest that families were more likely to decline enrolling into the intervention study if the mother was working full time, the total household income was between US$60,000 and US$100,000, and they lived further from the clinic. In contrast, infant autism symptoms and parental concern at 12 months were not significantly associated with enrollment. These findings highlight the need for intervention studies that are more accessible to parents, for example, intervention that takes place in the home, in addition to more research on how parental understanding of, and willingness to act on, early social-communication delays impact intervention study enrollment. Future research can then examine how to address these barriers to enrollment in early intervention studies. Such findings will shed light on best practices for dissemination of early identification and intervention strategies.

Rates of Prelinguistic Communication and Early Symbol Use in Young Children With Down Syndrome: Using a Progress-Monitoring Tool to Model Growth.

Purpose This study aims to provide descriptive data on rates of expressive communication skill use in young children with Down syndrome (DS) across early childhood. Children with DS are known to have delays in expressive communication, but there are little current data on rates of communication in early skills, such as gestures, vocalizations, words, and word combinations. In addition, few studies use measures that offer a composite or "across-skills" view of early development across time. Method This article used a longitudinal descriptive design to generate growth curves for expected rates of communication in young children with DS in 4 major skill elements as measured by the Individual Growth and Development Indicator-Early Communication Index. Using data from 19 children aged 11-42 months with DS, we used hierarchical linear modeling to generate growth curves for children with DS while comparing them to the benchmarked data available for children who are typically developing. Results Results indicate relative strengths in gesture use, a longer period of vocalizations, and lower rates of growth in single and multiple word combinations across time. Children differed significantly from one another on all parameters. Conclusion These data indicate a need to develop and research interventions to support the transition from gestures to words and that support early word combinations in young children with DS.

Changing Developmental Trajectories of Toddlers With Autism Spectrum Disorder: Strategies for Bridging Research to Community Practice.

Purpose: The need for community-viable, evidence-based intervention strategies for toddlers with autism spectrum disorder (ASD) is a national priority. The purpose of this research forum article is to identify gaps in intervention research and needs in community practice for toddlers with ASD, incorporate published findings from a randomized controlled trial (RCT) of the Early Social Interaction (ESI) model (Wetherby et al., 2014) to illustrate community-based intervention, report new findings on child active engagement from the ESI RCT, and offer solutions to bridge the research-to-community practice gap. Method: Research findings were reviewed to identify gaps in the evidence base for toddlers with ASD. Published and new findings from the multisite ESI RCT compared the effects of two different ESI conditions for 82 toddlers with ASD to teach parents how to support active engagement in natural environments. Results: The RCT of the ESI model was the only parent-implemented intervention that reported differential treatment effects on standardized measures of child outcomes, including social communication, developmental level, and adaptive behavior. A new measure of active engagement in the natural environment was found to be sensitive to change in 3 months for young toddlers with ASD and to predict outcomes on the standardized measures of child outcomes. Strategies for utilizing the Autism Navigator collection of web-based courses and tools using extensive video footage for families and professional development are offered for scaling up in community settings to change developmental trajectories of toddlers with ASD. Conclusions: Current health care and education systems are challenged to provide intervention of adequate intensity for toddlers with ASD. The use of innovative technology can increase acceleration of access to evidence-based early intervention for toddlers with ASD that addresses health disparities, enables immediate response as soon as ASD is suspected, and rapidly bridges the research-to-practice gap.

Interprofessional Collaborative Practice in Early Intervention.

Professionals in pediatric practice encounter infants and toddlers with developmental delays, disabilities, or complex chronic health conditions eligible for Part C early intervention (EI) services. The most frequently identified concern by families is communication emphasizing the importance of the role of the speech language pathologist (SLP). This article provides a conceptual framework for SLP services in early intervention, based on the principles of interprofessional collaboration. The history of collaboration, EI, and the role of SLPs as members of the EI team are summarized. The competencies mandated for interprofessional education and practice are juxtaposed with the principles of EI and guidelines for SLPs.

Toward innovative, cost-effective, and systemic solutions to improve outcomes and well-being of military families affected by autism spectrum disorder.

The burdens faced by military families who have a child with autism are unique. The usual challenges of securing diagnostic, treatment, and educational services are compounded by life circumstances that include the anxieties of war, frequent relocation and separation, and a demand structure that emphasizes mission readiness and service. Recently established military autism-specific health care benefits set the stage for community-viable and cost-effective solutions that can achieve better outcomes for children and greater well-being for families. Here we argue for implementation of evidence-based solutions focused on reducing age of diagnosis and improving access to early intervention, as well as establishment of a tiered menu of services, individualized to the child and family, that fit with the military ethos and system of health care. Absence of this new model of care could compromise the utility and sustainability of the autism-specific benefit.

Parent-implemented social intervention for toddlers with autism: an RCT.

OBJECTIVES: To compare the effects of two 9-month parent-implemented interventions within the Early Social Interaction (ESI) Project. Both individual-ESI, offered 2 or 3 times per week at home or in the community, and group-ESI, offered once per week in a clinic, taught parents how to embed strategies to support social communication throughout everyday activities. METHODS: Participants in the randomized controlled trial included 82 children diagnosed with autism spectrum disorder at 16 to 20 months. Children were matched on pretreatment nonverbal developmental level and pairs were randomly assigned to treatment condition. Child outcomes included measures of social communication, autism symptoms, adaptive behavior, and developmental level. Child outcomes are reported from baseline to the end of the 9-month interventions. RESULTS: Children in individual-ESI showed differential change on a standardized examiner-administered observational measure of social communication, as they improved at a faster rate than children in group-ESI. Individual-ESI also showed differential efficacy on a parent report measure of communication, daily living, and social skills, as they showed improvement or stability, whereas group-ESI led to worsening or no significant change on these skills. Finally, individual-ESI showed differential change on examiner-administered measures of receptive language skills, as children in individual-ESI improved significantly, whereas group-ESI showed no change. CONCLUSIONS: These findings support the efficacy of individual-ESI compared with group-ESI on child outcomes, suggesting the importance of individualized parent coaching in natural environments. The efficacy of a parent-implemented intervention using little professional time has potential for community viability, which is particularly important in light of the lack of main effects on child outcomes of most other parent-implemented interventions.

Participation as a basis for developing early intervention outcomes.

PURPOSE: This article describes how participation in activities/routines can be used as a basis for understanding children's communication and language skills and how that knowledge can be extended to collaborate with families and caregivers to develop meaningful early intervention outcomes. METHOD: The approach is centered on children's use of communication and language skills to participate in typical activities/routines. Implementation of the approach is based on an understanding of children's performance abilities/disabilities and their use of those abilities to participate in family-identified activities/routines in their natural environments. Discussion and case examples illustrate how communication and language skills can enhance or enable participation in such activities. Family-centered procedures for gathering information about activities/routines from caregivers are described, and strategies for developing outcomes in collaboration with caregivers are presented. IMPLICATIONS: Participation-based outcomes offer speech-language pathologists an option for embedding skills within important activities/routines, thereby promoting children's communication and language growth in natural contexts.

Collaborative consultation in natural environments: strategies to enhance family-centered supports and services.

PURPOSE: This article presents current information on recommended practices related to the delivery of early intervention (EI) supports and services to infants and toddlers with, or at risk for, communication deficits and their families. METHOD: The focus is on presenting the changing paradigm for speech-language pathologists (SLPs) working in EI based on the best available research evidence and expert opinion. The article includes a brief review of the recommended and promising practices for early communication intervention and applies the content to the role of the SLP as a consultant to caregivers. It provides strategies for "how to" join into the everyday activities/routines and places with the caregiver and child in order to facilitate caregiver-implemented intervention that will enhance caregiver-child interactions and promote the child's participation and learning. The importance of, and strategies for, collaborative consultation with diverse caregivers within a family-centered approach is presented. IMPLICATIONS: This article provides important and timely information for professionals and families related to family-centered EI practices, caregiver-implemented interventions, adult teaching strategies, and collaborative consultation with families of infants and toddlers with, or at risk for, communication deficits. SLPs can use the information presented to inform their practices when working with these young children and their families.

Enhancing generalized teaching strategy use in daily routines by parents of children with autism.

PURPOSE: The purpose of this study was to examine the effects of facilitating generalized use of teaching strategies by parents of children with autism within daily routines. METHOD: Five preschool children with autism participated in intervention with a parent within daily routines in the family's home. Parents learned to include 2 teaching strategies in target routines to address their child's communication objectives. Parent-child interactions in routines were videotaped for data coding and analysis. Proactive programming of generalization occurred by systematic selection of intervention routines and by embedding intervention in multiple routines. Generalization data were collected by measuring strategy use in untrained routines. A multiple baseline design across teaching strategies was used to assess experimental effects. RESULTS: All parents demonstrated proficient use of teaching strategies and generalized their use across routines. The intervention had positive effects on child communication outcomes. All parents perceived the intervention to be beneficial. CONCLUSION: Results from this study add to the limited body of evidence supporting parent-implemented interventions in natural environments with young children with autism spectrum disorder. Additional research that replicates this approach with children of varying ages and disabilities and families with diverse characteristics is needed to support the generality of these findings.

Early indicators of autism spectrum disorders in the second year of life.

Three groups of 18 children were selected for this study, one group with autism spectrum disorders (ASD), one group with developmental delays in which ASD was ruled out (DD), and one group with typical development (TD), from a pool of 3026 children who were screened with the Communication and Symbolic Behavior Scales Developmental Profile (CSBS DP, Wetherby & Prizant. 2002) Infant-Toddler Checklist under 24 months of age. The CSBS DP Behavior Sample was videotaped on selected children as a second-level evaluation during the second year of life. The Infant-Toddler Checklist had a sensitivity and specificity of 88.9% for this sample of children. Significant group differences were found on the Infant-Toddler Checklist and the Behavior Sample, however, these differences did not distinguish children with ASD and DD with high accuracy. The videotapes of the Behavior Sample were reanalyzed to identify red flags of ASD. Nine red flags differentiated children in the ASD group from both the DD and TD groups and four red flags differentiated children in the ASD Group from the TD group but not the DD group. These 13 red flags were found to discriminate the three groups with a correct classification rate of 94.4%.

Early Identification of and Intervention for Infants and Toddlers Who Are at Risk for Autism Spectrum Disorder.

Providing intensive early intervention is critical to maximizing outcomes for children with autism spectrum disorder (ASD), and evidence suggests that the earlier intervention can begin, the better the outcome. The first purpose of this article is to review the earliest indicators of ASD in very young children-social and communication impairments-which have important implications for early identification. The second purpose is to review evidence-based intervention practices for children with ASD and to develop a set of guiding principles for providing intervention for infants and toddlers who are at risk for ASD. Issues that are delineated include providing intervention in natural environments, supporting families in early intervention, and embedding intervention in daily routines.