Saturday, October 31, 2015

Group Pivotal Response Treatment for Parents of Children with Autism

More children than ever before are being diagnosed with autism spectrum disorder (ASD). The dramatic increase in the prevalence of children with ASD has created an urgent need for effective and efficient service delivery models. Parents and caregivers everywhere are eager for credible, research-based information on the most effective treatments for ASD. 

Utilizing a group training format, researchers have found that parents can learn to successfully incorporate an established treatment for ASD into everyday interactions with their children. According to findings published in the Journal of Child Psychology and Psychiatry, parents learned to successfully apply an evidence-based therapy method called Pivotal Response Treatment (PRT), also referred to as Pivotal Response Training, and observed meaningful improvement in their children.

PRT is one of the best studied and validated behavioral treatments for autism. It is a naturalistic behavioral intervention derived from the principles of Applied Behavior Analysis (ABA). PRT builds on learner initiative and interests, and is particularly effective for developing communication, language, play, and social behaviors. PRT was developed to create a more efficient and effective intervention by enhancing four pivotal learning variables: motivation, responding to multiple cues, self-management, and self-initiations. According to theory, these skills are pivotal because they are the foundational skills upon which learners with ASD can make widespread and generalized improvements in many other areas.

The objective of the study was to evaluate a PRT parent training group (PRTG) for targeting language deficits in young children with ASD. For the study, researchers randomly assigned parents of 53 children with autism to participate in 12 weeks of classes on PRT or a psychoeducation group (PEG). All of the children were between the ages of 2 and 6 and had language delays. The PRTG taught parents behavioral techniques to facilitate language development. The PEG taught general information about ASD. All of the children were assessed at the outset of the study, at six weeks and at 12 weeks to determine their language abilities. Parents were also videotaped at six and 12 weeks to measure how well they were applying the treatment.

The results indicated that parents were able to learn PRT in a group format, as the majority of parents in the PRTG (84%) were using it correctly by the end of the study. Children also demonstrated improvement in adaptive communication skills. Children whose parents learned the technique reported greater gains in both the number of words used and how they used them as compared to children in the psychoeducation (control) group.

This study is considered the first randomized controlled test of group-delivered PRT and one of the largest experimental investigations of the PRT model to date. The findings suggest that specific instruction in PRT results in greater skill acquisition for both parents and children, especially in functional and adaptive communication skills. Even with the improvements, researchers said that parent-implemented approaches are intended to augment, not replace, autism therapies from professionals. Likewise, further research in PRT is warranted to replicate the observed results and address other core ASD symptoms. It should also be noted that research findings are not the only factor involved when selecting an intervention. Professional judgment and the values and preferences of parents, caregivers, and the individual are also important.

Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., Frazier, T. W. and Minjarez, M. B. (2014), A randomized controlled trial of Pivotal Response Treatment Group for parents of children with autism. Journal of Child Psychology and Psychiatry. doi: 10.1111/jcpp.12354

Tuesday, October 27, 2015

Sibling Study Reveals Early Signs of Autism


Younger siblings of children with autism spectrum disorder (ASD) are at high risk for developing ASD as well as features of the broader autism phenotype. About 20% of younger siblings of children with Autism Spectrum Disorder (ASD) will develop the condition by age 3. A study by Yale School of Medicine researchers has found that 57% of these younger siblings who later develop the condition already showed warning signs like poor eye contact and repetitive behaviors at just a year and a half old. Published in the Journal of the American Academy of Child & Adolescent Psychiatry, this is the first large-scale, multi-site study aimed at identifying specific social-communicative behaviors that distinguish infants with ASD from their typically and atypically developing high-risk peers as early as 18 months of age. For the study, researchers looked at data on 719 infants who had older siblings on the spectrum. The children were assessed at 18 months and again at 36 months to identify social, communication and repetitive behaviors that could be predictive of autism.

Three distinct combinations of features at 18 months were predictive of ASD outcome: 1) poor eye contact combined with lack of communicative gestures and giving; 2) poor eye contact combined with a lack of imaginative play; and 3) lack of giving and presence of repetitive behaviors, but with intact eye contact. These 18-month behavioral profiles predicted ASD versus non-ASD status at 36 months with 82.7% accuracy in an initial test sample and 77.3% accuracy in a validation sample. Clinical features at age 3 among children with ASD varied as a function of their 18-month symptom profiles. Children with ASD who were misclassified at 18 months were higher functioning, and their autism symptoms increased between 18 and 36 months.

"While the majority of siblings of children with ASD will not develop the condition themselves, for those who do, one of the key priorities is finding more effective ways of identifying and treating them as early as possible," said lead author Katarzyna Chawarska, associate professor in the Yale Child Study Center and the Department of Pediatrics at Yale School of Medicine. "Our study reinforces the need for repeated diagnostic screening in the first three years of life to identify individual cases of ASD as soon as behavioral symptoms are apparent." Early detection, especially when toddlers have siblings with autism, is critical. Chawarska added, "Linking these developmental dynamics with underlying neurobiology may advance our understanding of causes of ASD and further efforts to personalize treatment for ASD by tailoring it to specific clinical profiles and their developmental dynamics."

Other authors of the study included: Suzanne Macari, Frederick Shic, Daniel J. Campbell, Jessica Brian, Rebecca Landa, Ted Hutman, Charles A. Nelson, Sally Ozonoff, Helen Tager-Flusberg, Gregory S. Young, Lonnie Zwaigenbaum, Ira L. Cohen, Tony Charman, Daniel S. Messinger, Ami Klin, Scott Johnson, and Susan Bryson.

“18-Month Predictors of Later Outcomes in Younger Siblings of Children With Autism Spectrum Disorder: A Baby Siblings Research Consortium Study.” Published online 06 October 2014. Journal of the American Academy of Child & Adolescent Psychiatry.

Citation: JACC doi: 10.1016/j.jaac.2014.09.015


Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Wednesday, October 21, 2015

Identification of Latino Children At-Risk for Autism



It is well established that early intervention is a critical determinant in the course and outcome of autism spectrum disorder (ASD). The earlier the child is identified and intensive intervention can begin, the better the outcomes tend to be for children with ASD. In fact, numerous studies have described the benefits of early identification and intervention for children with developmental disabilities and, particularly, for children on the autistic spectrum. However, many children meeting ASD diagnostic criteria may be missed or diagnosed years after onset of symptoms. Moreover, studies have shown racial and ethnic differences in ASD diagnostic trends. For example, there is evidence to suggest that Latino children are diagnosed with ASD 2.5 years later than white children and have more severe symptoms at time of diagnosis.
The reasons for low rates of ASD diagnosis and diagnostic delay among Latino children are poorly understood. Delays may reflect family factors, including ethnic differences in parent knowledge, beliefs, and concerns about overall child development and developmental delay. A study published in the journal Pediatrics sought to examine why Latino children are diagnosed with ASD less often and later than white children. Researchers mailed a self-administered survey to a random sample of California pediatricians to assess rates of bilingual general developmental and ASD screening, perceptions of parent ASD knowledge in Latino and white families, reports of difficulty assessing for ASD in Latino and white children, and perceptions of barriers to early ASD identification for Latinos.
The results indicated that although 81% of respondents offered some form of developmental screening, 29% of pediatricians offered Spanish ASD screening per American Academy of Pediatrics guidelines, and only 10% offered both Spanish general developmental and Spanish ASD screening per American Academy of Pediatrics guidelines. Most practitioners thought that Latino (English and Spanish primary family language) parents were less knowledgeable about ASD than other parents. They also had more difficulty assessing ASD risk for Latino children with Spanish primary family language than for white children. The most frequent barrier to ASD identification in Latinos was access to developmental specialists.
These findings have important practice and policy implications. For example, rates of Spanish language developmental and ASD screening need targeted improvement. Developing and promoting free or low-cost screening resources could improve early identification and reduce language-based disparities. Pediatricians may also need information about bilingualism and language development, accurate interpretation of screening results in Latino children, and strategies for discussing this difficult topic with parents from a different culture.  In sum, promoting language appropriate screening, disseminating culturally appropriate ASD materials to Latino families, improving the specialist workforce, and providing practitioner support in screening and referral of Latino children may be important ways to reduce racial and ethnic differences in care.
Pediatrician Identification of Latino Children at Risk for Autism Spectrum Disorder Katharine E. Zuckerman, Kimber Mattox, Karen Donelan, Oyundari Batbayar, Anita Baghaee and Christina Bethell. Pediatrics; originally published online August 19, 2013 DOI: 10.1542/peds.2013-0383

Lee A. Wilkinson, PhD, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a best-selling text in the American Psychological Association (APA) School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Thursday, October 1, 2015

Group Cognitive Behavioral Therapy (CBT) for Adults on the Autism Spectrum

The dramatic increase in the prevalence of autism spectrum conditions among children and adolescents and the correspondingly large number of youth transitioning into adulthood has created an urgent need to address the problems faced by many adults on the autism spectrum. Unfortunately, there are few validated treatment options are available for adults with autism spectrum disorder (ASD). Much of the published literature is clinical or anecdotal, or purely based on theory. There is unquestionably a need for the development of treatment options for adults with ASD. At present, alternative treatment options to psycho-therapeutical interventions are social training programs and other group activities. Group settings enable social interaction and sharing experiences with others, thereby reducing social isolation. 

A study published in the peer reviewed journal Autism assessed the effectiveness of two group interventions for adults with ASD: cognitive behavioral therapy (CBT) and recreational activity. A total of 68 adults with ASD participated in the study and were stratified by gender and blindly randomized to one of the two treatment conditions. Both interventions comprised 36 weekly 3-hour sessions led by two therapists in groups of 6–8 participants. The CBT group intervention was adapted to suit adults with ASD and consisted of five elements: (a) structure, (b) group setting, (c) psycho-education (e.g. lectures and discussions on ASD and psychiatric symptoms, including learning to identify and reappraise maladaptive thoughts), (d) social training (e.g. skill building such as practicing phone calls and asking for help) and (e) cognitive behavioral techniques (e.g. setting goals, role-playing, exposure exercises and conducting behavior analysis). A manual describing the 36 individual sessions was created prior to starting the treatment. Each session followed a strict agenda: (a) introduction and presentation of the agenda of the day, (b) review of homework assignments from the previous session, (c) psycho-educative lecture and discussions on the session topic, (d) coffee break with buns or sandwiches and social interaction, (e) relaxation or mindfulness exercise, (f) discussions and exercises on the session topic, (g) distribution of homework and (h) evaluation and end of session.
The purpose of the recreational activity intervention was to facilitate social interaction and to break social isolation. The therapists did not provide any deliberate techniques, such as psycho-education, social training, or CBT. Rather, this intervention relied on structure and group setting only. During the first session, participants were asked to write down group activities they would like to engage in. The therapists created a list of the suggested activities, such as visiting museums, playing board games, cooking, restaurant visits, boating, cinema, and taking walks. Each week, participants voted for the next session’s activity.
The researchers hypothesized that both interventions would lead to improvement in primary measures of quality of life, sense of coherence, and self-esteem, as well as in the exploratory analysis of the secondary measures of psychiatric symptoms. A greater effect in the CBT intervention compared to recreational activity was also expected, due to participants in the CBT intervention receiving a wider range of psychotherapeutic techniques. Several self-report questionnaire measures were administered to the adults before and after the interventions: Quality of Life Inventory (health, relationships, employment, and living conditions), Sense of Coherence (manageability and meaningfulness in life), Rosenberg Self Esteem Scale and an exploratory analysis on measures of psychiatric health (e.g., anxiety and depression). A long-term follow-up was conducted which ranged from 8 to 57 months after treatment termination.
Participants in both treatment conditions reported an increased quality of life at post-treatment, with no significant difference between the group CBT and group recreational activity interventions. Comorbid psychiatric symptoms, sense of coherence, and self-esteem were not affected by either intervention. CBT resulted in less attrition (drop out) than recreational activity. Participants who received CBT also rated themselves as more improved at post-treatment. At follow-up, CBT participants reported better well-being, greater understanding of their own difficulties and improved ability to express needs, compared to participants in the recreational activity intervention. This may reflect the recreation activity intervention’s focus on the intervention elements of structure and group setting, while the CBT intervention also included the elements of psycho-education, social training and CBT techniques. As a result, participants in CBT may have developed greater understanding of their own difficulties and improved ability to express needs and receive support because the objective of psycho-education and social training is to enhance these capabilities. The difference in well-being scores at follow-up may also represent greater insight gained from CBT rather than recreational activity.
Both interventions appear to be promising treatment options for adults with ASD, as they appeared to improve the participants’ quality of life. The similar efficacy of the interventions may be due to the common elements of structure and group setting. The group setting of both interventions enabled social interaction and sharing experiences. This may have promoted participants’ self-acceptance by allowing them to gain insight into both the impairments and the strengths that characterize ASD, and to recognize that others share similar challenges. CBT may be additionally beneficial in terms of increasing specific skills, greater understanding and insight, and minimizing dropout. Future studies on treatment of comorbid psychiatric symptoms in ASD should include larger samples to differentiate between adults with specific psychiatric problems in order to more effectively assess treatment effects.
Hesselmark, E., Plenty, S., & Bejerot, S. (2014). Group cognitive behavioural therapy and group recreational activity for adults with autism spectrum disorders: A preliminary randomized controlled trial. Autism, 18(6) 672–683. doi: 10.1177/1362361313493681

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

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