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 -

jonathan.green@manchester.ac.ukwww.medicine.manchester.ac.uk/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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