Early intervention for autism
Catherine Aldred University of Manchester, Royal Manchester Childrens Hospital
and Manchester Academic Health Sciences Centre
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Parent and therapist
interaction changes parent
behaviour
Changed parental
behviour leads to improved child dyadic
communication
Improved child dyadic
communication generalises to other contexts
Developmentally staged:
Intervention delivered through parents to enhance social development in the neurologically-vulnerable child
Parent-mediated intervention
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What is special about parent-mediated intervention?
• Parent motivation – The naturalistic developmental system– Benefits for parental engagement, confidence, family function – – (does not imply poor initial parenting) • Targets developmental processes known to predict autism outcomes• Carried forward into the main context for social communication
development• Potential 24/7 therapeutic effect • Extending beyond treatment end, therefore efficient use of professional time
• But to do this well, interventions have to make substantial, focused, reproducible impact on targeted parental behavio– more than education or coaching
• Value of video-feedback to produce this intervention effect– known to be very effective for observation, reflection and adult learning
styles
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What is special about parent-mediated intervention?
• But to do this well, interventions have to make substantial, focused, reproducible impact on targeted parental behaviours– more than education or coaching
• Value of video-feedback to produce this intervention effect– known to be very effective for observation, reflection and adult learning
styles
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Examples from:
Pre-school intervention Cross-cultural implementation
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The Lancet (2010), 375, 9732; 2152-2160
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Theoretical base• Focus on parent-child dyad - 80% of the child’s communication
• Abnormal communication in autism– Reduced shared attention and mutuality– Pragmatic impairments– Language disorder
• Imbalanced Parent-Child interaction– Perplexity– Reduced ‘meshing’ - ‘asynchrony’– Reduced child opportunities for communication learning, relating
• But positively – from the language intervention literature– Attending to communication acts increases them– Expansion from child’s base (‘semantic contingency’) leads to more vocabulary– Children with autism need a high dose of this
• Developmental hierarchy - of pre-cursor skills for communication
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Parent and therapist
interaction changes parent
behaviour
Changing parental
synchrony impacts child initiations in
dyad
Changing initiations by child affects
interaction with researcher in
ADOS
Preschool Autism Communication Therapy (PACT)
Developmentally staged:Shared attention, parental synchronous response, adapted communication strategies, communication enhancement
Initial 6 months – Biweekly clinic visits (3 hrs) + home work (30 mins/day) – viz 2hrs/wk
Next 6 months – Consolidation – Monthly clinic visits + homework (30 mins/day) and generalisation
18 sessions possible (median 16 (IQR 13-17) attended in PACT)
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Parent and therapist
interaction changes parent
behaviour
Changing parental
synchrony impacts child initiations in
dyad
Changing initiations by child affects
interaction with researcher in
ADOS
Preschool Autism Communication Therapy (PACT)
Developmentally staged:Shared attention, parental synchronous response, adapted communication strategies, communication enhancement
Initial 6 months – Biweekly clinic visits (3 hrs) + home work (30 mins/day) – viz 2hrs/wk
Next 6 months – Consolidation – Monthly clinic visits + homework (30 mins/day) and generalisation
18 sessions possible (median 16 (IQR 13-17) attended in PACT)
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Parent and therapist
interaction changes parent
behaviour
Changing parental
synchrony impacts child initiations in
dyad
Changing initiations by child affects
interaction with researcher in
ADOS
Preschool Autism Communication Therapy (PACT)
Developmentally staged:Shared attention, parental synchronous response, adapted communication strategies, communication enhancement
Initial 6 months – Alternate weekly clinic/home visits (2 hrs) + home work (30 mins/day)Next 6 months – Consolidation – Monthly clinic/ home visits + homework (30 mins/day) and generalisation
18 sessions possible (median 16 (IQR 13-17) attended in PACT)
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ASSESSED
n=242
EXCLUDED
n=90
RANDOMISED
n = 152
TAU
n = 75
PACT + TAU
n = 77 (>3 sess n=74)
LOST TO FOLLOW UP
n = 3
LOST TO FOLLOW UP
n = 3
ENDPOINT DATA
n = 72
ENDPOINT DATA
n = 74
Study flow
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PACT Interventio
n
Attenuation of treatment effect on generalisation across interaction and context
Parent interaction with
Child
Parental synchrony
ES=1.22 (0.85, 1.59)
Child interaction
with Parent
Child interaction
with Assessor
Child in
School
Child initiations
ES=0.41 (0.08, 0.74)
Autism SC symptoms (ADOS)ES=-0.24 (-0.59, 0.11)
CSS ES= 0.63 (0.02,1.29)
Social functioning in school
ES=-0.19 (-0.44, 0.07)
CONTEXT
MEASURE
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• 8-min parent-child free play videotaped in clinic• Dyadic Communication Measure for Autism(DCMA ;Aldred et al., 2012, 2014) • Coding parent and child communication acts, mutual shared attention,
parental communication responses
Primary outcomes
Mutuality
Child responsiveness
Parent Synchronicity
Sensitive responsiveness
Child communication initiation
Parent-infant interactionPACT Parent-child communication interaction
Primary outcome
At 13 months predicts child communication
Predicts child communication at follow-up
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Parent and therapist
interaction changes parent
behaviour
Changing parental
synchrony impacts child initiations in
dyad
Changing initiations by child affects interaction
with researcher in ADOS
Treatment effect on parental synchrony 70% mediates child communication change
Child communication change mediates treatment effect on autism SC symptoms
Longitudinal association studies - parent synchrony effects child communication in autism (Siller and Sigman 2002/8)
Mediation analysis confirms theory and implementation (Pickles et al 2015)
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TAUN=75
PACTN=77
follow-up
Random allocation
PACT Therapy impacts target processes in synchrony
Parent synchronyChild communicationChild Language
ADOS and RRB
13 months later
Core autism
Child languageSocial functioningAutism symptomsRRBFamily wellbeing
‘Hybrid trial’ to test causal association between parent-child interaction, intermediate development and outcome autism phenotype
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PACT-G – moving to the next phase of generalisation
Efficacy and Mechanism Evaluation
Intervention at home and school
Extended age range 2-11yrs
Collaboration Neil Humphrey/Richard Emsley
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Examples from:
Pre-emptive InterventionPre-school intervention
Cross-cultural implementation
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Parent-mediated intervention for autism spectrum disorders in South Asia (PASS)
Institute of Psychiatry, Rawalpindi, PakistanFareed Minhas
Ayesha Minhas
Zafar Iqbal
University of LiverpoolAtif Rahman
University of ManchesterJonathan Green
Catherine Aldred
Carol Taylor
Kathy Leadbitter
Sangath, Goa, IndiaVikram Patel
Gauri Divan
Vivek Vajaratkar
The feasibility and acceptability of the implementation of the adapted PACT intervention in settings in South Asia
The success of a “task-shifting” approach in delivering fidelity to the intervention model.
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Training and Supervision cascade
PACT (Intervention) Specialists
South Asia Child Development Specialists
Non-specialist workers
Parents/Carers
Child with ASD
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PASS results RCT N=65 (in press Lancet Psychiatry)
Acceptability high, with 80% completing the sessions Therapist fidelity high to PACT standards
Treatment effect Greater effect on dyadic interaction than UK PACT!
• parental synchrony [SMD 0.25 (95% CI 0.14-0.36); ES 1.61]• child communication initiation [SMD 0.15 (CI 0.04-0.24); ES 0.99]
First definitive RCT of an evidence-based intervention delivered by non-specialists in a low-income setting
New scale up study - Parent-mediated intervention for Autism Spectrum Disorders in South Asia PLUS (PASS+) 2014-2016
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Summary
Early parent-mediated video-aided intervention in ASD aims to increase child social functioning through optimising parental dyadic social interactionAcross preschool and transcultural intervention we show treatment effects on:•The targeted parental dyadic behaviours•Child communication •Child autism symptoms
– PACT shows causal mediation in line with treatment theory
•Cross cultural implementation in LMIC with cascading internet ‘tele-communication’ training and supervision and local partners is feasible and effective
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Future trialPACT-G
The Paediatric Autism Communication Trial – Generalised
Working with families and schools in three UK centres:
•Manchester
•Newcastle
•London
Led by The University of Manchester
Sponsored by Central Manchester University Hospitals Foundation Trust
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Thank you -
[email protected]/mentalhealth/research/psychopathology/socialdevelopment/
To the Families and Children who have worked so hard with usTo the Manchester team and our Collaborators
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