Amelia Walter

Clinical outcomes of an early intervention program for preschool children with Autism Spectrum Disorder in a community group setting

BackgroundAvailable evidence indicates that early intervention programs, such as the Early Start Denver Model (ESDM), can positively affect key outcomes for children with Autism Spectrum Disorder (ASD). However, programs involving resource intensive one-to-one clinical intervention are not readily available or deliverable in the community, resulting in many children with ASD missing out on evidence-based intervention during their early and most critical preschool years. This study evaluated the effectiveness of the ESDM for preschool-aged children with ASD using a predominantly group-based intervention in a community child care setting.MethodsParticipants were 26 children (21 male) with ASD with a mean age of 49.6 months. The ESDM, a comprehensive early intervention program that integrates applied behaviour analysis with developmental and relationship-based approaches, was delivered by trained therapists during the child’s attendance at a child care centre for preschool-aged children with ASD. Children received 15–20 hours of group-based, and one hour of one-to-one, ESDM intervention per week. The average intervention period was ten months. Outcome measures were administered pre- and post-intervention, and comprised a developmental assessment - the Mullen Scales of Early Learning (MSEL); and two parent-report questionnaires - the Social Communication Questionnaire (SCQ) and Vineland Adaptive Behaviours Scales–Second Edition (VABS-II).ResultsStatistically significant post-intervention improvements were found in children’s performance on the visual reception, receptive language and expressive language domains of the MSEL in addition to their overall intellectual functioning, as assessed by standardised developmental quotients. Parents reported significant increases in their child’s receptive communication and motor skills on the VABS-II, and a significant decrease in autism-specific features on the SCQ. These effects were of around medium size, and appeared to be in excess of what may have been expected due to maturation. Nonetheless, these results need to be confirmed in a controlled study.ConclusionsThis study suggests community dissemination of the ESDM using predominantly group-based intervention may be an effective intervention. Making the ESDM accessible to the wider ASD community in child care settings has the potential for significant clinical and economic benefits. Further studies are indicated in this area, including those with younger children, and which incorporate a control group and standardised ASD assessments.Trial registrationThis trial is registered with the Australian New Zealand Clinical Trials Registry: Registry number ACTRN12612000461897.

Exploring Links between Genotypes, Phenotypes, and Clinical Predictors of Response to Early Intensive Behavioral Intervention in Autism Spectrum Disorder

Autism spectrum disorder (ASD) is amongst the most familial of psychiatric disorders. Twin and family studies have demonstrated a monozygotic concordance rate of 70–90%, dizygotic concordance of around 10%, and more than a 20-fold increase in risk for first-degree relatives. Despite major advances in the genetics of autism, the relationship between different aspects of the behavioral and cognitive phenotype and their underlying genetic liability is still unclear. This is complicated by the heterogeneity of autism, which exists at both genetic and phenotypic levels. Given this heterogeneity, one method to find homogeneous entities and link these with specific genotypes would be to pursue endophenotypes. Evidence from neuroimaging, eye tracking, and electrophysiology studies supports the hypothesis that, building on genetic vulnerability, ASD emerges from a developmental cascade in which a deficit in attention to social stimuli leads to impaired interactions with primary caregivers. This results in abnormal development of the neurocircuitry responsible for social cognition, which in turn adversely affects later behavioral and functional domains dependent on these early processes, such as language development. Such a model begets a heterogeneous clinical phenotype, and is also supported by studies demonstrating better clinical outcomes with earlier treatment. Treatment response following intensive early behavioral intervention in ASD is also distinctly variable; however, relatively little is known about specific elements of the clinical phenotype that may predict response to current behavioral treatments. This paper overviews the literature regarding genotypes, phenotypes, and predictors of response to behavioral intervention in ASD and presents suggestions for future research to explore linkages between these that would enable better identification of, and increased treatment efficacy for, ASD.

Reducing maladaptive behaviors in preschool-aged children with autism spectrum disorder using the early start denver model.

The presence of maladaptive behaviors in young people with autism spectrum disorder (ASD) can significantly limit engagement in treatment programs, as well as compromise future educational and vocational opportunities. This study aimed to explore whether the Early Start Denver Model (ESDM) treatment approach reduced maladaptive behaviors in preschool-aged children with ASD in a community-based long day care setting. The level of maladaptive behavior of 38 children with ASD was rated using an observation-based measure on three occasions during the intervention: on entry, 12 weeks post-entry, and on exit (post-intervention) over an average treatment duration of 11.8 months. Significant reductions were found in children’s maladaptive behaviors over the course of the intervention, with 68% of children showing a treatment response by 12 weeks and 79% on exit. This change was accompanied by improvement in children’s overall developmental level as assessed by the Mullen scales of early learning, but not by significant changes on the Vineland Adaptive Behavior Scales-II or Social Communication Questionnaire. Replication with a larger sample, control conditions, and additional measures of maladaptive behavior is necessary in order to determine the specific factors underlying these improvements; however, the findings of the present study suggest that the ESDM program may be effective in improving not only core developmental domains, but also decreasing maladaptive behaviors in preschool-aged children with ASD.

Conceptualisation and Development of a Quality of Life Measure for Parents of Children with Autism Spectrum Disorder

Parents of children with autism spectrum disorder (ASD) tend to experience greater psychological distress than parents of typically developing children or children with other disabilities. Quality of Life (QoL) is increasingly recognised as a critical outcome measure for planning and treatment purposes in ASD. There is a need for ASD-specific QoL measures as generic measures may not capture all relevant aspects of living with ASD. This paper describes the conceptualisation and development of an autism-specific measure of QoL, the Quality of Life in Autism Questionnaire (QoLA) for parents and caregivers of children with ASD, that is suitable to clinical and research settings. Preliminary psychometric properties (reliability and validity) of the measure are also presented. The QoLA has 48 items in two subscales: one comprising QoL items and the second a parent report of how problematic their childs ASD symptoms are. A study involving 39 families suggested the QoLA has excellent internal consistency as well as good known-groups validity between parents of children with ASD and those who were typically developing. The QoLA also showed good convergent validity with other measures of QoL and ASD symptom severity, respectively. The QoLA may be a valuable assessment tool and merits further psychometric evaluation.

Psychosoziale Aspekte bei motorischen Behinderungen

ZusammenfassungIn Australien wurde Stepping Stones Triple P als verhaltenstherapeutisch orientiertes Elterntraining für Familien mit einem behinderten Kind bereits erfolgreich evaluiert. Im Rahmen einer deutschlandweiten Multizenterstudie in verschiedenen Sozialpädiatrischen Zentren (SPZ) und weiteren Versorgungseinrichtungen wurde es als Gruppentraining eingeführt und auf seine Wirksamkeit überprüft. Die Daten ergaben eine signifikante Reduktion von dysfunktionalem Erziehungsverhalten, elterlichen Belastungen und kindlichen Verhaltensproblemen. Günstige psychosoziale Rahmenbedingungen beeinflussen kurz- und mittelfristig das Erziehungsverhalten positiv. Stepping Stones Triple P verbessert das Verhalten motorisch behinderter Kinder am günstigsten, bei gleichzeitig ausgeprägter Stressreduktion ihrer Eltern.AbstractStepping Stones Triple P offers behavioural parenting training for families with a handicapped child and has already been successfully evaluated in its country of origin, Australia. As part of a multicentre study involving several social paediatric centers (SPCs) and other clinical institutions, it has been established as a group parenting training in Germany and proved its effectiveness in terms of reducing dysfunctional parenting behaviour, parental stress and child behavioural problems. The present study indicates that a favourable psychosocial context has a positive influence on functional parenting in both the short and medium term. Stepping Stones improves the behaviour of physically handicapped children most favourably while simultaneously reducing parental stress.

Screen time of infants in Sydney, Australia: a birth cohort study

Objectives To determine the amount of daily screen time in children 18 months of age and ascertain correlations that may be contributing to excessive screen use. Design A birth cohort was followed with telephone interviews at 6, 12 and 18 months of age. Information about screen time was collected at 18 months. Setting Parents were recruited from postnatal wards of 2 major public hospitals and at home visits conducted for new mothers within 4 weeks of birth in South Western Sydney (SWS). Participants Parents of 500 children with infants 18 months of age residing in SWS. Primary and secondary outcomes Screen time in infants 18 months of age and associated correlations. Results A large percentage of children 18 months of age (40%) had screen times >2 hours daily. There were significant associations between more than 2 hours of screen time daily and mothers without a partner (OR 4.32 (95% CI 1.67 to 11.15)); having <3 siblings (no siblings: OR 2.44 (95% CI 1.20 to 4.94); 1–2 siblings: OR 2.08 (95% CI 1.06 to 4.08)); an employed father (OR 1.96 (95% CI 1.09 to 3.52)); no outdoor equipment at home (OR 1.89 (95% CI 1.08 to 3.34)) and fewer than 5 outings per week (OR 2.08 (95% CI 1.37 to 3.17)). Conclusions There is emerging evidence that excess screen time in children causes adverse cognitive, developmental and health outcomes. This study has shown that a large proportion of very young children residing in SWS have screen exposures for >2 hours per day. Factors contributing to excess screen time have also been identified in this study; however, a greater understanding of risk factors needs to be ascertained in order to facilitate greater public health efforts to reduce screen exposure.

There are Gains, But can we Tell for Whom and Why? Predictors of TreatmentResponse Following Group Early Start Denver Model Intervention in Preschool -Aged Children with Autism Spectrum Disorder

There is significant variability in treatment outcomes across different interventions for Autism Spectrum Disorder and between individuals receiving the same intervention. This is likely related to the considerable phenotypic variability in ASD, which is posited to arise from a developmental cascade whereby a primary deficit in attention to social stimuli leads ultimately to widespread and diverse behavioural and functional difficulties. Purpose: To provide data on predictors of treatment outcome in a cohort of preschool - aged children with ASD receiving a group Early Start Denver Model (ESDM) intervention. Methodology: Forty-nine children (mean age 52 months) with ASD receiving group ESDM over 10 months were assessed pre - and post-intervention for ASD symptoms, developmental level, and adaptive functioning; together with measures of parental stress and coping. Results: Lower initial ASD symptomatology, particularly higher social affect and play skills, and younger age at entry to intervention predicted better outcomes. Conclusion: Reflective of hypotheses from the developmental cascade theory, younger age at entry predicted treatment gains, supporting efforts to include children in comprehensive treatment promptly. Moreover, greater initial social impairments led to relatively poorer outcomes, potentially suggesting that children with greater social affect difficulties may require a higher dose, or modified intervention, to that used in this study.

Maternal help-seeking for child developmental concerns: Associations with socio-demographic factors

To examine socio‐demographic factors associated with maternal help‐seeking for child developmental concerns in a longitudinal birth cohort study. An understanding of these factors is critical to improving uptake of services to maximise early identification and intervention for developmental concerns.

The role of transcranial direct current stimulation (tDCS) in tourette syndrome: a review and preliminary findings

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that is being investigated for a variety of neurological and psychiatric conditions. Preliminary evidence suggests that tDCS may be useful in the treatment of Tourette Syndrome (TS). This paper reviews the literature on the use of tDCS in commonly occurring comorbid conditions that are relevant to its proposed use in TS. We describe the protocol for a double-blind, crossover, sham-controlled trial of tDCS (Trial ID: ACTRN12615000592549, registered at www.anzctr.org.au) investigating the efficacy, feasibility, safety, and tolerability of tDCS in patients with TS aged 12 years and over. The intervention consists of cathodal tDCS positioned over the Supplementary Motor Area. Patients receive either sham tDCS for three weeks followed by six weeks of active tDCS (1.4 mA, 18 sessions over six weeks), or six weeks of active sessions followed by three weeks of sham sessions, with follow-up at three and six months. Pilot findings from two patients are presented. There was a reduction in the frequency and intensity of patients’ tics and premonitory urges, as well as evidence of improvements in inhibitory function, over the course of treatment. Larger scale studies are indicated to ascertain the maintenance of symptom improvement over time, as well as the long-term consequences of the repetitions of sessions.

Heterogeneity in Tics and Gilles de la Tourette Syndrome

Abstract Gilles de la Tourette syndrome (GTS) is no longer considered a unitary condition, with converging evidence emerging on potential subphenotypes. This chapter explores the heterogeneity of GTS, beginning with a thorough review of factor, cluster, and latent class analysis studies. Despite methodological differences, several findings are replicated across these studies. These include the presence of a “pure tics” factor, clustering of tic symptoms by complexity and type, and the existence of groups of related comorbid symptoms such as impulse control difficulties and obsessive-compulsive behaviors. This chapter then reviews epidemiological studies with a focus on clinical features, comorbidities, and associated psychopathologies, as well as genetic underpinnings. An improved understanding of the heterogeneity of GTS and its potential subphenotypes is critical to explaining differential treatment response and improving overall outcomes.