Slides -

Exploring the evidence
for early interventions
Helen McConachie
There is no ‘typical’ autistic child
There is not a single specific cause for autism
There cannot be a ‘best’ treatment for autism
Therefore family needs
 Early diagnosis and information
 Family support
 Coordinated services
 Specific therapy/training
Early interventions
Main therapeutic goals
 Social and communication development
 Enhance learning and problem solving
 Reduce behaviour which interferes with gaining
skills and achieving potential
 Management of habit patterns (eg. sleep, eating)
Evaluation of interventions
 Children with ASD are heterogeneous group
 Outcome: need validated measures sensitive
to change in core features
 Participants: numbers, representativeness
 Design: control, length of follow-up
 Research: evaluates single approach
Age at diagnosis is reducing
Median age
Current age
17 + yrs
13 to 16
9 to 12
5 to 8
up to 4
high functioning
Early identification
Early signs: eg limited social orienting, social
initiation, limited gestures and other communication,
repetitive motor behaviours
 But diagnosis before 30 months might be unstable
Involvement of parents
Early diagnosis
Noticing child cues and responding
 Mediator of child progress (Siller & Sigman 2002, 2008;
Landa et al 2011; Aldred et al 2011)
Parental stress
Awareness that involvement may increase stress
 Stress predicts poorer child outcome (Strauss et al 2012)
How effective is early intervention?
We know:
 Some elements help children progress: structured
teaching, visual cues, build communication skills,
parent training,….
We don’t know
 Which approaches for which parents & children
Evaluation of early intervention
Comprehensive programme:
30 children - special nursery + parent training
29 children – special nursery
(Rickards et al ’07 J Dev Behav Pediatr)
Significant benefits of parent training:
 better cognitive development and behaviour in
 more improvement for children in families with
high stress
Evaluated approaches to intervention
Early intensive behavioural intervention
Smith et al ’00, RCT compared with parent
implementation: 4 year follow-up, best for
children with ASD, IQ primary outcome.
Magiati et al ’07 Compared with specialist nursery
(>15 hours): 2 year follow-up, no difference in
cognitive ability, play, language or autism severity
Eldevik et al ’10 Meta-analysis of individual data
(n=309) found change in IQ and adaptive
behaviour – but great variability
Evaluation of early intervention
Early Start Denver Model
24 children – therapists 15 hrs/week, plus
training parents (16 hrs/week reported)
24 children – usual services
Children < 30 mos
2 year follow-up
(Dawson et al ’10 Pediatr)
Significant benefits:
 better language development and adaptive skills
 no data on parents
Evaluated approaches to intervention
These 3 examples involve a range of hours.
NAP-C recommends 15 hours, with parents part
of the intervention
Parent training
to increase communication
Green et al ‘10 individual
McConachie et al ’05 group
to manage difficult behaviour Tonge et al ‘06
More Than Words
 Parent group training, up
to 8 families
 20 hours group teaching
(8-10 sessions), 3 months
 3 home visits, video
feedback on parent-child
 led by speech & language
 focus on interpersonal
 follow child’s lead
 daily routines
 visual supports
 adapt environment
From ‘More Than Words’, Sussman (1999)
The Hanen Centre, Canada
More Than Words
Observe, Wait, Listen
Repeat what you say & do
Offer opportunities
Cue your child
Keep it fun, keep it going
Four I’s
Include child’s interest
Interpret, Imitate, Intrude
Four S’s
Say less and Stress
Go Slow and Show
Families and Communication
Training and Support
Evaluation of 14 ‘More Than Words’ courses
56 children aged 2 or 3 years, & their parents
Immediate intervention & delayed controls
7 & 15 month follow up
Interview responses
Parents overwhelmingly positive
reduced isolation
 course was inspiring at a time when parents felt
particularly low (ie. around diagnosis)
Course was well presented and practical
home visits helpful for specific questions
learning as a couple, chance for fathers to talk
 learn about local services
Model for measurement
Parent adaptation to child;
QRS-F stress
parent feelings
More Than Words
child skills
child progress
parent strategies
Joy and Fun Assessment
Group comparison at Time 2
Taking into account Time 1 scores, level of ability,
diagnostic category and interval between assessments:
Parent strategies (JAFA)
Parent stress
Parent adaptation to the child
Child language (checklist of words MCDI)
Child social communication
Child behaviour problems
= significant group difference
Change in parent interaction strategies
Similar findings:
Carter et al 2011 RCT
J Ch Psychol & Psychiat
McConachie et al 2005 J Pediatrics
Parent responsivity
medium to large effect
No effect on child
Children with limited
interest in objects
benefited most
How effective is early intervention?
We know:
 Some elements help children progress: structured
teaching, visual cues, communication skills,….
 Parent involvement as part of comprehensive
programme helps child and parent
We need to explore further:
 Which approaches for which parents & children
 How to combine communication intervention &
management of difficult/repetitive behaviours

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