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Autism as a heterogeneous disorder

Interventions for Autism Spectrum Disorders

Amy Esler, Ph.D.

•  Although defined by behavior, these characteristic behaviors are very diverse.

University of Minnesota Autism Spectrum Disorders Program May 3, 2011

Prognosis •  Very much affected by language level and whether or not there is intellectual disability •  Usually a lifelong disorder, but many more students now attending regular school •  Many more young adults now employed at least part-time and living in the community

Recovery? •  Large-scale longitudinal studies have found high diagnostic stability –  McGovern and Sigman (2005): at 19, 91% met ADOS criteria and 96% met ADI-R –  Lord et al. (2006) North Carolina and Chicago early diagnosis study: •  From age 2 to 9, of those originally diagnosed with autism, 99% stayed on the spectrum (84% autistic, 15% PDDNOS) •  Age 2-9, of those originally diagnosed with PDDNOS, 98% stayed on the spectrum, with most moving to an Autism diagnosis (71%).

–  Deborah Fein s group reports 3-25% (2008) –  Sutera and Fein study (2007): most of the children who lost their diagnoses had originally received PDDNOS.

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Self-published by ARI

Most popular treatments Consensus across Autism Speaks, Healing Thresholds, ASA, etc.

•  ABA •  Floortime/Developmental •  Gluten Free, Casein Free Diet •  Occupational Therapy •  PECS and Visual supports •  PRT

•  27,000 parents completed questionnaires

•  Relationship Development Intervention •  SCERTS •  Sensory Integration •  Speech Therapy •  TEACCH •  Verbal Behavior Intervention •  Supplements •  Medication 8

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ARI Biomedical/non-drug/supplements

•  Current research is looking at comparing different ASD programs to one another •  In general, studies have found comprehensive programs to be more effective than eclectic programs •  Drift from program purity—fidelity--??? •  Teacher training and individual factors 9

What is effective?

Levels of evidence

•  CEC definition: –  Researchers cannot just address a simple question about whether a practice in special education is effective; they must specify clearly for whom the practice is effective and in what context. Odom et al., 2005

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National Academy of Sciences

Characteristics of Effective Interventions: The following features are critical:

Committee on Educational Interventions for Children with Autism Birth to 8 Years

www.nap.edu

Odom et al. 2010: Evaluation of 30 Comprehensive Treatment Models •  Quality ratings of 1-5 in key areas: –  Operationalization –  Implementation measurement –  Off-site replication –  Outcome data presented –  Overall quality of outcome data –  Other research has been published documenting efficacy of key ingredients

Warren et al. 2011: Evidence for early intervention

•  Entry into intervention early •  Active engagement in intensive instruction for at least 25 hours/week, 12 months/year •  Individualized attention on a daily basis •  Systematically planned developmentally appropriate activity aimed toward identified objectives •  Family component •  Low student/teacher ratios •  Ongoing program evaluation •  Involvement of typically-developing peers

Model Comprehensive Programs: Highest rating: • Denver Model • LEAP • Lovaas • May Institute • Princeton Child Development Institute

Pretty good: • DIR (Floortime) • Douglass • PRT • Responsive Teaching • SCERTS • TEACCH

Of 30 comprehensive programs evaluated, over half (16) had no published research. For those that had published research, quality was often low, and randomized clinical trials rarely used.

National Autism Center

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Scientific Merit Rating Scale

Strength of evidence

•  5-point scale with 5 meeting the highest standard, decreasing in strictness to 1 •  5=RCT; larger group size; for single subject, multiple baselines and comparisons; standard protocol for identification of subjects and measuring outcomes; blind evaluators; measurement of fidelity; generalization and maintenance documented •  1=post-test only; data loss; weak psychometric measures; limited observational data; inadequate descriptions of treatment and control conditions; no fidelity data; generalization in one setting

Strength of evidence

Beneficial, Unknown, Ineffective, and Harmful

Established Treatments

Established and Favorable

•  Comprehensive Behavioral Treatment for Young Children –  Combination of ABA strategies

•  •  •  •  •  •  •  • 

Joint Attention Intervention Modeling Naturalistic Teaching Strategies Pivotal Response Treatment Social Stories Peer Training Package Schedules Self-management

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Established and favorable by age and diagnosis

Applied Behavior Analysis •  A method, not a specific treatment •  Behavioral methods are used to teach new skills –  Positive reinforcement, differential reinforcement –  Prompting, levels of prompts –  Breaking down complex behaviors into smaller components for teaching –  Data used in making decisions about interventions

Lovaas

Research findings: Lovaas •  Original Lovaas study 1987

•  •  •  •  •  • 

Most studied method 25-40 hours/week Discrete Trial Training Elimination of problem behaviors Usually provided at home Usually 1:1 Earn your way into inclusion

Blends •  PRT: Pivotal Response Training –  Motivation to interact –  Responding to multiple cues –  Self-regulation –  Self-initiations –  Theoretical approach=ABA –  Mostly single-subject research

–  Recovery controversy (47%)

•  Follow-up study 1993 –  Best outcome maintained

•  UCLA trial in community settings –  Kids who received 3 years of treatment had higher IQ and adaptive; not receptive or nonverbal skills

PRT Study •  Nova Scotia EIBI (I. Smith et al., 2010) •  N=53, age 2 to 6 years Consistent with other applications of PRT, intervention did not follow a curriculum (cf. Rogers & Vismara, 2008). Instead, each child s intervention team, including a clinical supervisor (a psychologist or occupational therapist), speech–language pathologist, interventionist, and parents, developed individual goals with an emphasis on functional communication and developmentally appropriate skills, accomplished in the context of play and other functional daily routines. All teaching took place within naturalistic interactions. Children s motivation to communicate was maximized by following their preferred activities or giving them choices, using natural reinforcers and other empirically validated PRT techniques (see R. Koegel & Koegel, 2006).

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NS PRT Results

Blends… •  Verbal Behavior –  Main focus = spontaneous communication –  Theoretical approach: Skinner & ABA –  Basic principles of behavior are sufficient to account for language development –  reinforcement, extinction, stimulus control etc. –  Research on different strategies with single-subject design

Emerging Treatments "

Augmentative and Alternative Communication Device {14 studies} " " ◖ Cognitive Behavioral Intervention Package {3 studies} " " ◖ Developmental Relationship-based Treatment {7 studies} " " ◖ Exercise {4 studies} " ◖ Exposure Package {4 studies} " " ◖ Imitation-based Interaction {6 studies} " " ◖ Initiation Training {7 studies} " " ◖ Language Training (Production) {13 studies} " " ◖ Language Training (Production & Understanding) {7 studies} ◖ Massage/Touch Therapy {2 studies}" " ◖ Music Therapy {6 studies}

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Emerging: PECS

◖ Peer-mediated Instructional Arrangement {11 studies} " " ◖ Picture Exchange Communication System {13 studies} " " ◖ Reductive Package {33 studies} " " ◖ Scripting {6 studies} " " ◖ Sign Instruction {11 studies}" " ◖ Multi-component Package {10 studies}

◖ Social Communication Intervention (5 studies)

◖ Social Skills Package {16 studies}

◖ Structured Teaching {4 studies}

◖ Technology-based treatment {19 studies}

◖ Theory of Mind Training {4 studies}

PECS Meta-analysis (Flippin et al., 2010)

Emerging: Developmental/ Relationship based

•  11 studies (8 single-subject, 3 group) •  Synthesized outcomes: –  Communication (requests, exchanges, initiations): small to moderate ES, short term –  Speech: negligible

•  Moderating variables: –  Joint attention –  Object exploration –  Imitation: •  PECS better for low motor imitation skills than sign •  Verbal imitation may moderate

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Developmental approaches

DIR/Floortime/Greenspan 1. Home-based, developmentally appropriate interactions and practices –  –  –  – 

•  Incorporate teaching strategies into natural situations •  Following child s lead •  Focus = Play and social interactions •  Some research support, but no RCT

Floortime™ sessions Semi-structured problem-solving Motor and sensory activities Peer play with one other child

2. Individual Therapies –  Speech, language, and oral motor therapy –  Sensory motor and sensory integration based occupational therapy and/or physical therapy –  Other therapies as required (e.g. mental health support and guidance)

3. Educational program –  Dependent on language and intellectual level

4. When indicated, other interventions: Biomedical interventions, Nutrition and diet and Technologies geared to improve processing abilities

Developmental…

Early Start Denver Model

•  Denver Model –  Inclusive preschool 20 hours/week –  Parent-implemented training ~ 16 hours/week –  Biweekly home visits –  Emphasis on affect and relationships •  Increasing attention and motivation •  Imitation •  Sensory social routines •  Social interactions and reciprocity •  Teaching the power of communication (verbal and nonverbal) •  Symbolic communication system •  Antecedent-Behavior-Consequence

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RCT Social Skills Studies

Emerging: Social Skills Groups •  •  •  •  • 

Lopata et al., 2010 Skillstreaming curriculum, fidelity measured N=36, 7-12 years old Waitlist-control Parent, child, and staff measures all showed improvements

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RCT Social Skills

Lopata RCT

Koenig et al., 2010 Planned, structured social interaction activities Child measures: CASL Idioms, social skills knowledge, emotion recognition in faces

TEACCH

Fidelity measured

Cognitive Behavioral Therapy

•  Structured teaching •  Use of visuals, predictability •  Use of physical environment

Cognitive-Behavioral Therapy

Unestablished Treatments " ◖ Academic Interventions "

12-14 y.o., average to high IQ Supplemented by social skills group and parent ed

" ◖ Auditory Integration Training " " ◖ Facilitated Communication " " ◖ Gluten- and Casein-Free Diet " " ◖ Sensory Integrative Package "

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GFCF Diet •  Autism Society of American recommends all children with ASD try it •  2002 study (Kvinsberg) found reduction in ASD symptoms •  Multiple randomized-clinical trials have not upheld this finding •  Unintended side effect: Osteoporosis •  Subgroup that experiences benefit?

Supplements The theory: children with ASD do not break down or process the nutrients they consume in expected ways. To address this, providers sometimes recommend a daily multi-vitamin, especially if the children: –  Have self-restricted diets –  Follow a specific diet –  Have chronic diarrhea, constipation, or gastrointestinal inflammation • Vitamin B12 • Vitamin D • Omega 3 and essential fatty acids Vitamins/supplements are not harmless: • Megadose vitamins • Vitamin A toxicity

Ineffective/Harmful

Active ingredients •  •  •  •  •  •  • 

Toddler School Akshoomoff et al., 2010

Frequency, duration, intensity Data-based decision-making Training and ongoing support Fidelity of implementation Funding Plan for generalization Involvement of typically-developing children

Response to Intervention

•  N=8, 1/2 day program for 21 hrs/week of direct service; 8 typically-developing toddlers attend all day

• 3 hours classroom, 1 hour outside classroom, 2 hours in-home parent education

• Parents commit to providing 10 hours per week at home • Systematic blend of incidental teaching, PRT, structured teaching, PECS, and DIR/ Floortime

•  Most studies have looked at IQ and/or special ed placement as outcome •  What predicts an individual s response?

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Predictors Study Ben-Itzchak & Zachor, 2011

Perry et al., 2011 Ontario province-wide IBI initiative Eikeseth et al., 2002 Norway Zachor & BenItzchak, 2011

N Age group 68 18-35 months

322 20-86 months

25 5-6 year olds 60 18-35 months

Intervention

Study Design

Predictors

Full time; 2/3 behavioral intervention, 1/3 eclectic Intensive behavioral intervention

Pre/post

Receptive language skills

Pre/post

13 received Behavioral; 12 eclectic Full time; 2/3 behavioral intervention, 1/3 eclectic

Pre/post

IQ (biggest), age at entry, duration of treatment, initial rate of response Full Scale IQ and adaptive skills

Pre/post

ADOS symptom severity x intervention type: Milder symptoms did better in eclectic

Other Predictors •  •  •  •  • 

Joint attention Expressive language Number of social initiations Imitation Nonverbal IQ

Predicting response to intervention: Beyond IQ •  Little research •  Sherer & Schreibman, 2005 •  3 responders and 3 nonresponders, matched on IQ, language, Vineland •  Predictors: Toy play, Approach, Avoidant (low), Verbal stim (high), Nonverbal stim (low)

For more information: •  Autism Speaks: autismspeaks.org •  Healing Thresholds: autism.healingthresholds.com •  Council for Exceptional Children (guidance on evaluating EBP): www.cec.sped.org •  Complementary/alternative: –  UMN: www.takingcharge.csh.umn.edu/conditions/ 58 autism-spectrum-disorders

Amy N. Esler, Ph.D. University of Minnesota Autism Spectrum Disorders Program [email protected]

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