Address for Correspondence:
Dr. Beena Johnson, MBBS, DCH, MD, PhD, Senior Consultant in
Child Guidance; Behavioural & Developmental Paediatrician,
Baby Memorial Hospital, Kozhikode, Kerala, India. Email:
jiacam@gmail.com
Abstract:
Children with autism spectrum disorders have impairment in
reciprocal social interaction and impairment in communication
skills. They also have repetitive behaviours and preoccupation
with stereotyped patterns of behaviours. The most important
therapy is early individualized intensive behavioural
intervention. Intensive behavioural interventions should be
provided to all young children at the onset of symptoms. If
not, they will have lifelong difficulties in communication and
social interaction. Parent mediated behavioural interventions
are effective in the management of young children with autism
spectrum disorders. Children with autistic symptoms who
receive earlier referrals to specialists and obtain intensive
behavioural intervention achieve optimal outcomes.
Keywords: autism spectrum disorders, young children,
early behavioural interventions
Introduction
Autism spectrum disorders include Autistic Disorder,
Asperger's Disorder and Pervasive Developmental Disorder Not
Otherwise Specified (PDD-NOS). Autism spectrum disorders are
characterized by impairment of social and communication
abilities as well as repetitive, stereotyped patterns of
behaviour that range from very mild to severe [1]. The onset
of symptoms is usually before three years of age. Prevalence
of autism spectrum disorders is increasing every year. The
proportion of children with autistic symptoms increased
2.04-fold from 1998 to 2012 [2]. Early individualized
intensive behavioural intervention is the well-established
treatment for young children with autism spectrum disorders
[3]. If not intervened at the earliest, these individuals will
have lifelong difficulties in communication skills. Hence
parents should be guided to develop strategies for management
of these problems at the earliest. Parent mediated behavioural
interventions are effective in improving parent child
interaction and language comprehension of these children [4].
Early interventions for autism spectrum disorders represent
the merging of applied behavioural and developmental sciences
[5].
Clinical features of Autism Spectrum Disorders
The onset of symptoms is usually gradual. One of the early
warning signs is reduced social interactions in infancy. These
children fail to initiate eye contact. Many children with
autism spectrum disorders begin to speak by one year of age
and then lose their language skills before 2 years of age. The
child may refuse to make eye contact and stop responding to
social cues. Vision and hearing tests will be normal.
Classical clinical features are the following:
1. Impairment in reciprocal social interactions:
lack of eye contact, joint attention, and empathy [6-8].
These interactions are essential for everyday social
functioning, and include initiating, maintaining and
terminating conversation, demonstrating interest and paying
attention to social cues. These children have significant
difficulties in sensing the feelings or reactions of others.
2. Impairment in communication: In Autistic Disorder, there
is delay in, or total lack of, language development. Even if
some language skills develop, they fail to initiate or
sustain conversations. But in Asperger's Disorder, there is
no significant delay in the acquisition of language, though
the individual lacks subtleties of language such as: the
jokes, humour and melodies of language, as well as
interpretation of facial expressions and body language
[6-8]. Clinical presentation in PDD-NOS is variable.
3. Repetitive or restricted behaviours and special
interests, often consisting of motor mannerisms like hand or
finger flapping, toe walking and preoccupation with
stereotyped patterns of behaviours [6-8]. This will
exacerbate the communication difficulties. The child focuses
on narrow or restricted interests and hence loses
perspective of the world around. Autistic savants are those
who can master extraordinary skills in maths, spelling,
drawing or music.
Diagnosis is made if behaviours are not better accounted for
by mental retardation, Rett's Disorder or Childhood
Disintegrative Disorder [6]. Autism may be diagnosed
co-morbidly with other behavioural or developmental disorders.
Treatment Objectives
The major challenges for effective learning in children with
Autism Spectrum Disorders are difficulties in
social interaction and communication [9]. There are also
problems in joint attention and selective attention which are
very important for successful learning. Lack of social
interaction leads to numerous problem behaviours which cause
further challenges for effective learning. Hence the goals for
management of children with autism spectrum disorder are to
minimize the problem behaviours of autism which negatively
impact learning and stimulate normative developmental
processes [9]. The treatment goals are set based on the
strengths and weaknesses of the individual child. The
behavioural and developmental intervention programs for autism
spectrum disorders must be guided by individual needs [10].
Importance of Early Behavioural Interventions
Very early intensive behavioural and developmental
interventions for young children with autistic symptoms will
enhance developmental outcomes [11]. The mainstay of
therapy and the well-established treatment for autism spectrum
disorders is early individualized intensive behavioural
intervention [3]. Children treated early develop the
skills to communicate, recognize and respond to social
interactions and can curb repetitive self-stimulatory
behaviours. Intensive behavioural intervention programs will
also prevent aggressive behaviours that occur commonly in
children with autism spectrum disorders. Children with autism
spectrum disorders, who receive early intensive interventions
make major developmental gains in the elementary school years
[12].
Overview of 5 meta-analyses of early intensive behavioural
intervention (EIBI) for young children with autism spectrum
disorders published in 2009 and 2010 showed that EIBI is an
effective intervention strategy for many children [3,13].
EIBI leads to positive effects in intellectual functioning,
language skills and adaptive behaviours of young children with
autistic symptoms. EIBI programs that include parents in
treatment are more effective. Child characteristics impact
program effectiveness. Hence individualized treatment is very
important [14].
Early and sustained intensive well-structured behavioural
interventions based on principles of applied behaviour
analysis is the most effective treatment [15]. Children
receiving applied behaviour analysis therapy have good
outcomes [16]. In addition to development of basic language
skills such as vocabulary, focus of attention should be given
to improve social and functional communication [17].
Scientific teaching of social skills with extrinsic
reinforcement is necessary, as children with autism spectrum
disorders cannot acquire these skills through observation
alone [18]. For addressing maladaptive behaviours in home
environment, specific interventions addressing the problem
behaviours should be provided. [19]. Emphasis is also given to
counselling and problem-focused therapies from
cognitive-behavioural perspectives [20].
Early psycho educational intervention that include behavioural
elements, has proved to be capable of modifying the course of
children with autism spectrum disorders and is currently the
only and most suitable approach that have proved to be
effective in research studies [21].
Parent mediated early interventions
Practice and research have demonstrated the importance and
efficacy of parent-delivered early interventions for children
with developmental delay [22]. There is scientific evidence
for the effectiveness of parent-mediated interventions in
improving reciprocal social interaction and communication
skills. Hence importance should be given to early behavioural
interventions that enable parents to contribute skilfully in
the management of their child with autism spectrum disorder
[4]. Parent-mediated intervention improves the
developmental outcomes for infants at risk of autism spectrum
disorders [23].
Parental sensitivity and responsivity to children's cues have
been found to predict language outcomes in autistic children,
as in normal children [24-26]. Studies on mother-toddler
interactions have shown that maternal sensitivity at 18 months
predicted expressive language development from age 2 to 3
years in children with emergent autism spectrum disorders
[27]. The quality and quantity of parent-child interactions
will predict the effectiveness of parent-delivered toddler
interventions.
The inclusion of parents and other family members has been
identified as the most important component of effective early
intervention programs [9]. Several studies have demonstrated
the positive effects of parent-delivered interventions in
reducing behaviour problems, improving communication skills
and increasing the play and imitation skills [28-34].
Parent-implemented early intervention leads to better
maintenance of skills than direct clinic treatment [35].
Early Start Denver Model
The Early Start Denver Model is a comprehensive behavioural
early intervention program for children aged 12 to 48 months
with early symptoms of autism. This
relationship-based intervention involves approaches validated
by the science of child development and the science of applied
behaviour analysis [36, 37]. The program includes a
developmental curriculum defining the skills to be taught and
a set of procedures used to deliver the content. It involves a
child-centred interaction using the parents that embeds many
teaching opportunities into play activities.
Dawson D et al conducted randomized controlled trial to
evaluate the efficacy of the Early Start Denver Model, a
comprehensive developmental behavioural intervention, for
improving the skills of toddlers between 18 and 30 months of
age with autism spectrum disorder. Children who received Early
Start Denver Model showed significant improvements in
intelligence and adaptive behaviour. These children also
maintained the rate of growth in adaptive behaviour compared
with a normative sample of typically developing children. This
randomized controlled trial demonstrated the efficacy of a
comprehensive developmental behavioural intervention for
toddlers with autism spectrum disorders, for improving
cognitive and adaptive behaviour. This study gives significant
evidence for the importance of early detection of and
intervention in autism [38].
Parent-delivered intervention of the Early Start Denver model
were given for toddlers at risk for autism spectrum disorders
aged 14 to 24 months. Assessments were done at baseline and 12
weeks later. Younger age of the child at the start of
intervention and greater number of intervention hours were
positively related to the amount of improvement in the
behaviour of the children with autism spectrum disorders [36].
Joint attention interventions demonstrate positive outcomes in
preschool-age children [40].
Very early interventions in infancy
Recent prospective studies of infants identified impairments
in four key developmental domains that are predictive of
autism spectrum disorders. These domains are early attentional
control, emotion regulation, social orienting/approach, and
communication development. By targeting the earliest
manifestations of atypical development in infants we can
improve the skills before the developmental cascade that leads
to autism spectrum disorders is fully manifested [41].
The current recommendation is to assess one year olds whose
parents are concerned about autism, so that the youngest
children can immediately receive very early
interventions. There is no "wait and see" approach in
management of autism spectrum disorders, we should always "act
fast" [36].
Conclusion
Young children with autism spectrum disorders have significant
impairment in social skills and communication skills. They
often display repetitive as well as non-compliant behaviour.
This early pattern of difficulties is a real challenge for the
parents. Hence therapies that guide parents to develop
strategies for interaction and management of the behaviour
problems are very important in early intervention of children
with autism spectrum disorders. Parent-mediated early
behavioural interventions are effective in improving the
communication skills and reciprocal social interaction of
these children. Comprehensive developmental and behavioural
interventions are necessary for toddlers with autism spectrum
disorders for improving cognitive skills and adaptive
behaviour. Many studies give strong evidence for beginning
early intervention as soon as possible, and highlight the
importance of identifying young children at risk for autism
spectrum disorders as early as possible. More intensive
interventions lead to greater developmental gains.
Professionals in child guidance can help families to maximize
intervention hours by teaching them to provide high quality
learning opportunities at home as soon as the autistic
symptoms appear.
References
1. Mash EJ, Russell AB. Child Psychopathology. 3. New York:
The Guilford Press; 2014. p. 531.
2. Zhou WZ, Ye AY, Sun ZK, Tian HH, Pu TZ, Wu YY, Wang DD,
Zhao MZ, Lu SJ, Yang CH, Wei L. Statistical analysis of twenty
years (1993 to 2012) of data from mainland China's first
intervention center for children with autism spectrum
disorder. Mol Autism. 2014 Nov 12;5:52.
3. Reichow B, Barton EE, Boyd BA, Hume K. Early intensive
behavioral intervention (EIBI) for young children with autism
spectrum disorders (ASD).Cochrane Database Syst Rev. 2012 Oct
17;10:CD009260.
4. Oono IP, Honey EJ, McConachie H. Parent-mediated early
intervention for young children with autism spectrum disorders
(ASD). Cochrane Database Syst Rev. 2013 Apr 30;4:CD009774.
5. Schreibman L, Dawson G, Stahmer AC, Landa R, Rogers SJ,
McGee GG, Kasari C, Ingersoll B, Kaiser AP, Bruinsma Y,
McNerney E, Wetherby A, Halladay A. Naturalistic Developmental
Behavioral Interventions: Empirically Validated Treatments for
Autism SpectrumDisorder. J Autism Dev Disord. 2015 Mar 4.
[Epub ahead of print]
6. APA. Diagnostic and Statistical Manual of Mental Disorders:
DSM-IV-TR. Washington, DC: American Psychiatric Association;
2000.
7. Lord C, Risi S, Lambrecht L, Cook EH, Leventhal BL,
DiLavore PC, Pickles A, Rutter M. The autism diagnostic
observation schedule-generic: a standard measure of social and
communication deficits associated with the spectrum of autism.
J Autism Dev Disord. 2000;30:205-223.
8. Volkmar FR, Pauls D. Autism. Lancet. 2003;362:1133-1141.
9. National Research Council . Educating Young Children with
Autism. Catherine Lord, James P. McGee, editors. National
Academy Press; Washington, DC. 2001.
10. Ospina MB, Krebs Seida J, Clark B, Karkhaneh M, Hartling
L, Tjosvold L, Vandermeer B, Smith V. Behavioural and
developmental interventions for autism spectrum disorder: a
clinical systematic review. PLoS One. 2008;3(11):e3755.
11. Warren Z, McPheeters ML, Sathe N, Foss-Feig JH, Glasser A,
Veenstra-VanderWeele J. A systematic review of early intensive
intervention for autism spectrum disorders. Pediatr.
2011;127(5):e1303-e1311.
12. Loveland K, Tunali-Kotoski B. The School-Age Child with an
Autistic Spectrum Disorder. In: Volkmar FR, Klin A, Paul R,
Cohen DJ, editors. Handbook of Autism and Pervasive
Developmental Disorders. Wiley; Hoboken, NJ: 2005.
13. Reichow B, Wolery M. Comprehensive synthesis of early
intensive behavioral interventions for young children with
autism based on the UCLA young autism project model. J Autism
Dev Disord. 2009 Jan;39(1):23-41.
14. Strauss K, Mancini F; SPC Group, Fava L. Parent inclusion
in early intensive behavior interventions for young children
with ASD: a synthesis of meta-analyses from 2009 to 2011. Res
Dev Disabil. 2013 Sep;34(9):2967-85.
15. James McPartland, Fred R. Volkmar. Autism and Related
Disorders. Handb Clin Neurol. 2012;
106:10.1016/B978-0-444-52002-9.00023-1.
16. Orinstein AJ, Helt M, Troyb E, Tyson KE, Barton ML, Eigsti
IM, Naigles L, Fein DA Intervention
for optimal outcome in children and adolescents with a history
of autism. J Dev Behav Pediatr. 2014 May;35(4):247-56.
17. Paul R. Assessing communication in autism spectrum
disorders. In: Volkmar F, Klin A, Paul R, Cohen DJ, editors.
Handbook of Autism and Pervasive Developmental Disorders.
Wiley; New York: 2005.
18. Kransny L, Williams B, Provencal S, Ozonoff S. Social
skills interventions for the autism spectrum: Essential
ingredients and a model curriculum. Child & Adolescent
Psychiatric Clinics of North America. 2003;12(1):107-122.
19. Powers M. Behavioral Assessment of Individuals with
Autism: A Functional Ecological Approach. In: Volkmar FR, Klin
A, Paul R, Cohen DJ, editors. Handbook of Autism and Pervasive
Developmental Disorders. Wiley; Hoboken, NJ: 2005.
20. Volkmar Fred, Wiesner Lisa. A Practical Guide to Autism.
John Wiley; Hoboken, NJ: 2009.
21. Mulas F, Ros-Cervera G, Milla MG, Etchepareborda MC, Abad
L, Tellez de Meneses M. [Models of intervention in children
with autism]. [Article in Spanish] Rev Neurol. 2010 Mar 3;50
Suppl 3:S77-84.
22. Wallace KS, Rogers SJ. Intervening in infancy:
Implications for autism spectrum disorders. J Child Psychol
Psychiatr. 2010;51(12):1300-1320.
23. Baranek GT, Watson LR, Turner-Brown L, Field SH, Crais ER,
Wakeford L, Little LM, Reznick JS. Preliminary efficacy of
adapted responsive teaching for infants at risk of autism
spectrum disorder in a community sample. Autism Res Treat.
2015; 2015:386951.
24. Moes DR, Frea WD. Contextualized behavioral support in
early intervention for children with autism and their
families. J Autism Dev Disord. 2002;32(6):519-533.
25. Siller M, Sigman M. The behaviors of parents of children
with autism predict the subsequent development of their
children's communication. J Autism Dev Disord.
2002;32(2):77-89.
26. Mahoney G, Perales F. Relationship-focused early
intervention with children with pervasive developmental
disorders and other disabilities: A comparative study. J Dev
Behav Pediatr. 2005;26(2):77-85.
27. Baker JK1, Messinger DS, Lyons KK, Grantz CJ. A pilot
study of maternal sensitivity in the context of emergent
autism. J Autism Dev Disord. 2010 Aug;40(8):988-99.
28. Koegel RL, Koegel LK, Surratt A. Language intervention and
disruptive behavior in preschool children with autism. J
Autism Dev Disord. 1992;22(2):141- 153.
29. Koegel RL, Symon JB, Koegel LK. Parent education for
families of children with autism living in geographically
distant areas. J Posit Behav Interv. 2002;4(2):88-103.
30. Lutzker JR, Steed SE. Handbook of parent training: Parents
as co-therapists for children's behavior problems. 2. Hoboken,
NJ: John Wiley and Sons; 1998. Parent training for families of
children with developmental disabilities; pp. 281-307.
31. Anderson SR, Romanczyk RG. Early intervention for young
children with autism: Continuum-based behavioral models. Res
Pract Persons Severe Disabl. 1999;24(3):162-173.
32. Stahmer AC. Teaching symbolic play skills to children with
autism using pivotal response training. J Autism Dev Disord.
1995;25(2):123-141.
33. Ingersoll B, Gergans S. The effect of a parent-implemented
imitation intervention on spontaneous imitation skills in
young children with autism. Res Dev Disabil.
2007;28(2):163-175.
34. Dababnah S, Parish SL. Feasibility of an empirically based
program for parents of preschoolers with autism spectrum
disorder. Autism. 2015 Feb 25. pii: 1362361314568900. [Epub
ahead of print]
35. Koegel RL, Schreibman L, Britten KR, Burke JC, O'Neill RE.
A comparison of parent to direct clinic treatment. In: Koegel
RL, Rincover A, Egel AL, editors. Educating and understanding
autistic children.San Diego: College Hill; 1982. pp. 260-279.
36. Rogers SJ, Estes A, Lord C, Vismara L, Winter J,
Fitzpatrick A, Guo M, Dawson G. Effects of a brief Early Start
Denver model (ESDM)-based parent intervention on toddlers at
risk for autism spectrum disorders: a randomized controlled
trial. J Am Acad Child Adolesc Psychiatry. 2012 Oct; 51(10):
1052-1065.
37. Rogers SJ, Dawson G. The Early Start Denver Model for
Young Children with Autism: Promoting language, learning, and
engagement. NY: Guilford; 2010.
38. Dawson G, Rogers S, Munson J, Smith M, Winter J, Greenson
J, Donaldson A, Varley J. Randomized, controlled trial of an
intervention for toddlers with autism: the Early Start Denver
Model. Pediatrics. 2010 Jan;125(1):e17-23.
40. Therapies for Children With Autism Spectrum Disorder:
Behavioral Interventions Update [Internet]. Weitlauf AS,
McPheeters ML, Peters B, Sathe N, Travis R, Aiello R,
Williamson E, Veenstra-VanderWeele J, Krishnaswami S, Jerome
R, Warren Z, editors. Source Rockville (MD): Agency for
Healthcare Research and Quality (US); 2014 Aug. Report No.:
14-EHC036-EF.
41. Brian JA1, Bryson SE, Zwaigenbaum L. Autism spectrum
disorder in infancy: developmental considerations in treatment
targets. Curr Opin Neurol. 2015 Apr;28(2):117-23.