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Early Intervention for Children

with Autism Spectrum Disorder UCL talk

27th June 2014

Tony Charman Chair in Clinical Child Psychology

Here under false pretences…

• Katrina’s email:

– “We are hoping that you might be happy to speak

about your work on early interventions for children

with ASD, and particularly your thoughts what has led

to this work becoming as influential as it is, from the

initial idea to its current wide impact”.

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Here under false pretences…

• Katrina’s email:

– “We are hoping that you might be happy to speak

about your work on early interventions for children

with ASD, and particularly your thoughts what has led

to this work becoming as influential as it is, from the

initial idea to its current wide impact”.

• My response:

Overview • Early social-communication symptoms of ASD

• Theoretical and empirical literature on infant

development of social-communication

• Similar developmental evidence in ASD

• Testing developmental theory

• Towards a social-communication EB (incl. PACT)

• An alternative evidence-base (North American)

– Intensive behavioural intervention

– Poor research, mixed evidence, strong views + strong

disagreement

• NICE guidance

• Glass half-full or half-empty?

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Autism Spectrum Disorder (DSM-5)

• Deficits in social communication and social

interaction across multiple contexts

– Deficits in social-emotional reciprocity

– Deficits in nonverbal communicative behaviors used for social

interaction

– Deficits in developing, maintaining + understanding relationships

• Restricted, repetitive patterns of behavior, interests,

or activities, as manifested by at least two

– Stereotyped/repetitive motor movements, use of objects, speech

– Insistence on sameness, inflexible adherence to routines, or

ritualized patterns or verbal nonverbal behavior

– Highly restricted, fixated interests that are abnormal in intensity

or focus

– Hyper- or hypo-reactivity to sensory input or unusual interests in

sensory aspects of the environment

Time period Behaviour Studies

~6 months Dyadic and intersubjective

behaviours

Less attention to social

stimuli

Reduced affect

Maestro et al (2002,

2005)

Clifford & Dissanayake

(2008)

~12 months + Reduced response to name

Less joint attention

Abnormal eye contact

Reduced looking at people

Motor abnormalities

Adrien et al (1991,

1993)

Osterling & Dawson

(1994); Werner &

Dawson (2005)

Baranek (1999)

Ozonoff et al (2008) +

others

Earliest signs identified in home movies

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Earliest signs in screening studies

• Lack of joint attention behaviours

– Gaze monitoring, pointing for interest

• Reduced response to name

• Lack of early pretend play

• Reduced range of early play behaviours

• Impoverished range of facial expressiveness

• Reduced interest in people

What is joint attention?

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Joint attention behaviours are elicited in communicative exchanges

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Psycholinguistic theory or ‘How babies learn to talk’

• Synchronous interaction b/t parent + child is

scaffold for emerging communication

─ Referential understanding (what is being said)

─ Intersubjectivity (comprehension that the acts of others

have intent and communicative significance)

• Referential understanding is pivotal for

vocabulary growth and pragmatics

• Behaviour of caregiver influences

development

─ Attending to communication acts increases them

─ Expansion from child’s base (‘semantic contingency’)

leads to more vocabulary

Early social communication in ASD

• Although deficits in JA are amongst the earliest

signs of ASD…

– Early JA abilities related to later language (Charman et

al., 2003; Mundy et al., 1990)

– Early JA related to later symptom severity (Charman,

2003)

– In TD early JA related to later theory of mind skills

(Charman et al., 2000)

– JA skills at 2 years predict outcomes at 7 years

(Charman et al., 2005; Veness et al., 2014)

• Whilst an early impairment; developmental

continuity with that seen in typical

development

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Testing developmental theory

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Staged programme with a focus on adapting parental communication

• Eliciting shared attention, communication, enjoyment

– Child’s focus, inferring intentions

• Enhancing parental synchronous response

– Comment, acknowledge, child’s focus, timing

• Adapted communication strategies for parents

– Predictable sequences, routines, repetition, rehearsed play, imitation

• Developing/elaborating child communication

– Expansions, elaborations, teasers

Clinician referral

Full baseline assessment

Diagnostic, cognitive, interaction

PACT + TAU

Fortnightly SALT sessions

7m: Brief midpoint assessment

TAU

Community services

13m: Full endpoint assessment

PACT +TAU Monthly boosters

TAU

Community services

Randomisation

Design

• First large RCT of an early psychosocial treatment

–3 site 2 arm, N=152 –2-4;11 yrs –core autistic disorder (ADOS-G/ADI-R) –Testing a model deliverable in the NHS –Cost effectiveness analysis

•Pre-specified primary outcome and analysis plan • Blinded rating of outcomes •Testing mediating mechanisms •Use of RCT design to test basic science hypotheses

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Outcome measures • Primary outcome

– ADOS-G Social + Communication total

– External validity and change sensitivity

– Modified implementation of module rules and scoring for use as an index of change (pers. comm. Cathy Lord)

• Blinded secondary outcomes – Parent-child interaction (PCI)

– Language (PLS)

– Social adaptation (teacher VABS)

• Non-blinded secondary outcomes – parent rated – Language (MCDI)

– Early social communicative development (CSBS-DP-CQ)

020

40

60

80

100

PC

I: p

erc

ent

of

child

acts

initia

tion

TAU base PACT base TAU mid PACT mid TAU end PACT end

020

40

60

80

100

PC

I: p

erc

ent

of

pare

nt

acts

in s

ynchro

ny

TAU base PACT base TAU mid PACT mid TAU end PACT end

Parent child interaction

Parental synchrony Child initiations

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01

02

03

0

Mo

difie

d A

DO

S-G

socia

l-co

mm

un

ica

tio

n to

tal

TAU baseline PACT baseline TAU endpoint PACT endpoint

Primary outcome ADOS-G

PACT Intervention

Attenuation of treatment effect on generalisation across interaction and context

Parent interaction with

Child

Parental synchrony

ES=1.22

Child interaction with Parent

Child interaction

with Assessor

Child in School

Child initiations ES=0.41

Autism symptoms (ADOS) ES=-0.24

Social functioning in school ES=-0.19

CONTEXT

MEASURE

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Communication and autism symptom outcomes

Study Design Comm

Dyadic

Comm

Generic

Autism symptoms

Kasari et al. (2008)

T in nursery

Daily for 6 weeks

Yes Direct = Yes

Not reported

Dawson et al. (2010)

Intensive T and P for 24 months

Not reported

Direct = Yes

Report = Yes

No

Kasari et al. (2010)

24 P sessions in 8 weeks; FU 12 m

Yes Not reported Not reported

Green et al. (2010)

Fortnightly then monthly P input 12m

Yes

Direct = No

Report = Yes

No

Landa et al. (2011)

Daily nursery T input and P weekly 6m

? No Not reported

Carter et al. (2011)

3.5m parent-training No No Not reported

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(Some) agreement on shared targets, content

• Targeting early social communication skills

• Within the context of dyadic relational

interaction

• Core curriculum includes:

– Promoting joint attention and joint engagement,

imitation and pretend play

– Emphasise reciprocity, emotional attunement,

following child initiated exchanges

• Differences in structure, delivery + intensity

– Degree of directiveness and behavioural techniques

– Parent- or therapist-mediated, intensity and length

Why was the work liked (by some)?

• Based on well-established psychological

theory (developmental not autism)

• The fact that similar associations were found

in typical and atypical development

strengthened confidence in the finding

• Combination of longitudinal and intervention

effects further strengthened confidence

• Focused on (putative) ‘core’ or ‘primary’

symptoms

• Developmental cascade model is inherently

attractive (if you are an optimist)…

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An alternative evidence-base?

• 40 year story going back to 1970s

• Intensive behavioural intervention

– Lovaas/ABA/Early Intensive Behavioural Intervention

– Originally ‘discrete trial training’ (DTT), now includes

‘pivotal response training’ (PRT)

– Strongly held views (primarily in North America)

regarding the evidence-base for EIBI

• Against NICE/Cochrane evidence weak

– Very few RCTs, mostly case/control studies

– No primary outcome, unclear re. blinding, small Ns

• Claims of positive outcome and ‘cure’

– In mainstream class and ‘Indistinguishable from peers’

For some consensus has been reached

• Promising Early Start Denver Model (ESDM)

– Dawson et al (2010) Pediatrics

– 2 years, 25 hours per week, combined behavioural

and developmental/dyadic

• Many reviews and states now mandate EIBI

as the best-evidenced intervention for ASD

– View that 15-25 hours is required

– Main technique (and theory) is behavioural/ABA

– Focus is on skills acquisition

– Vary in social-communication/developmental focus

• RCTs not possible

– Beyond equipoise; very intensive treatment; ethics

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NICE systematic review process • NCCMH team agreed with GDG early on

– At least 2 RCTs allowing some meta-analysis

– Many/most trials low quality criterion

• Paucity of trials and those with similar

outcomes prevented much meta-analysis

• Some aspects of social-communication

interventions just ‘missed the cut’

• More cautious (on the basis of evidence)

than some other (child) MH NICE guidance

• Recent Cochrane reviews more positive

– Parent-mediated, JA-theory of mind, social skills…

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NICE – Children and Young People

• ‘Consider’ a social-communication

intervention

– To increase joint attention, engagement, reciprocal

communication

– Mediated by parent, teacher or (school-age) peers

• Support in developing life skills

• Adapted CBT for anxiety

• Interventions for challenging behaviour and

co-existing mental health problems

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Glass half full or half empty?

• At last autism field conducting RCTs!

• Standards of reporting improving

– Primary outcomes; blinding; ITT analyses

• Many of the programmes have overlapping

theoretical basis, aims and techniques

– Target social communication and social interaction

– Often combine (in different proportions) behavioural

and developmental theory

• How to compare and integrate ‘best practice’

from the accumulating evidence?

• What are the appropriate goals/outcomes?

– And how do we measure them?

Ways forward…? • Clearly need to conduct more trials

– iBASIS

– Group parent training in NIHR PG

– Current applications (EME, H2020)

• How to square the circle between NICE and

‘received wisdom’ poorer quality studies…?

• How to square with current highly variable

(and often low) post-diagnostic provision?

– What treatment is provided (in health, in education)..?

– How well evidence-based it is..?

– What should the model of treatment be for ‘chronic’

neurodevelopmental disorders…as opposed to

episodic psychiatric disorders?