Exploring the evidence
for early interventions
Helen McConachie
Interventions
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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
Challenges
 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
12
Current age
10
17 + yrs
13 to 16
9 to 12
5 to 8
up to 4
8
6
4
2
0
high functioning
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lower
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
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Involvement of parents
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Early diagnosis
Synchrony
Noticing child cues and responding
 Mediator of child progress (Siller & Sigman 2002, 2008;
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Landa et al 2011; Aldred et al 2011)
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Parental stress
Awareness that involvement may increase stress
 Stress predicts poorer child outcome (Strauss et al 2012)
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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
nursery
 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
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to increase communication
Green et al ‘10 individual
McConachie et al ’05 group
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to manage difficult behaviour Tonge et al ‘06
More Than Words
Structure
 Parent group training, up
to 8 families
 20 hours group teaching
(8-10 sessions), 3 months
 3 home visits, video
feedback on parent-child
interaction
 led by speech & language
therapists
Content
 focus on interpersonal
interaction
 follow child’s lead
 daily routines
 visual supports
 adapt environment
From ‘More Than Words’, Sussman (1999)
The Hanen Centre, Canada
More Than Words
OWL
Observe, Wait, Listen
ROCK
Repeat what you say & do
Offer opportunities
Cue your child
Keep it fun, keep it going
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Four I’s
Include child’s interest
Interpret, Imitate, Intrude
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Four S’s
Say less and Stress
Go Slow and Show
Families and Communication
Training and Support
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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
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Parents overwhelmingly positive
reduced isolation
 course was inspiring at a time when parents felt
particularly low (ie. around diagnosis)
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Course was well presented and practical
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home visits helpful for specific questions
General
learning as a couple, chance for fathers to talk
 learn about local services
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Model for measurement
Parent adaptation to child;
QRS-F stress
parent feelings
More Than Words
interaction
child skills
child progress
ADOS; BSQ;
MCDI
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)
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Parent stress
Parent adaptation to the child
Child language (checklist of words MCDI)
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Child social communication
Child behaviour problems
= significant group difference
Change in parent interaction strategies
JAFA
Similar findings:
Carter et al 2011 RCT
J Ch Psychol & Psychiat
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McConachie et al 2005 J Pediatrics
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Parent responsivity
medium to large effect
No effect on child
communication
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