Early Intervention for Young Children with ASD:
An Evidence-based Approach to Identification and Improving
Outcomes
Rebecca Landa, Ph.D., Director,
Center for Autism and Related Disorders
Virginia Creating Connections to Shining Stars
July 22, 2013
Disclosures
• None
2
Thank you
•
•
•
•
NIH
Autism Speaks
Families and children who participate
My wonderful staff
3
Focus of this talk:
• Detection of autism spectrum disorders as early as
possible
– Early signs and trajectories
• Screening
• Early intervention: Early Achievements
4
Early Detection of ASD
• Why?
5
Early Intervention is important because
• Early experiences influence brain development
• The brain is a thinking organ
• It learns and grows by interacting with people and
objects, through perception and action
• Able to continually adapt and rewire itself
• Constraints – need good intervention
6
Early experiences matter
Richer, more diverse
repertoire
Learning
Sustained
engagement
Bids for
attention
Attention
from other
Hopefully
responsive:
optimality of
development
Connection
7
Developmental Cascades
More highly
specified and
effectively directed
Bids for
attention
Attention
from other
Learning
Sustained
engagement
Greater
expansions in
form and
content
Connection
Rewarding
Tomasello et al., 2005
8
Developmental Cascades
Bids for
attention
Attenuated
Learning
Briefer
Sustained
engagement
Ambiguous, poorly
integrated
Attention
from other
Less
frequent
Connection
Less frequent
9
Importance of early detection of ASD
• Early intervention experiences are designed to
address core ASD deficits (Kasari et al., 2008; Landa
et al., 2011)
10
We want this:
Early Achievements Intervention: 1-year-olds
Note:
*Purposeful
*Notice each other
*Imitating
*Sustained
meaningful
engagement
*Sequences of
meaningful,
intentional action
Landa, Holman, O’Niell, Stuart. (2011).
Journal of Child Psychology and Psychiatry
11
To understand the earliest behavioral
markers of ASD
• Must begin in infancy, before we know the child will
have ASD
• Research designs for doing so:
12
Research Designs
• Retrospective studies
– Interview parents about the past (problems with memory of
details)
– Scoring home videos of older children diagnosed with ASD
• Videos made when children were infants or toddlers
13
Problem with Retrospective Designs
• Can’t control the context (cues, distractions, difficulty
of task, camera angle)
• Can’t give the child specialized tests targeting
specific behaviors or abilities of interest
• Can’t control the age
14
Research designs
• Prospective studies
– Highly efficient to study infants at increased genetic risk for ASD
– Can control the
• Age at time of assessment
• Context (cues, camera angle, difficulty, distractions)
• Types of tasks to study specific abilities
15
To understand ASD in infants and toddlers
• Two groups studied:
– High Risk (HR) for ASD: Infant siblings of children with ASD
– Low Risk (LR) for ASD: No family history of ASD
• Recently added a group at increased risk for delay,
but less risk for ASD than HR infants: Preterm
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High risk for ASD
• High risk infants (younger sibs of children with ASD):
• 18.7% will have ASD
(Landa et al., 2006; Landa et al., 2007; Ozonoff et al., 2011)
• 30% will have non-ASD language and social delays
by the third birthday (Messinger et al., in press)
17
Assessment ages
High Risk (HR)
Low Risk (HR)
6m
10 m
14 m
18 m
24 m
Rate confidence of presence of
ASD at each age
18
30 m
36 m
Outcome classifications
Autism Diagnostic
Observation Schedule
+ Clinical judgment
ASD
Intermediate
(Broader
Autism
Phenotype)
36
months
Unaffected
19
Main points to be addressed
1. When do the signs of ASD first appear?
2. What are those signs?
3. What is the course of development for infants and
toddlers with ASD in the first 3 years of life?
20
What are the first signs of ASD?
When do the signs of ASD appear?
• At 6 months:
–
–
–
–
Signs are subtle
Most evident signs involve motor delay
Temperament: Passive
Social: Lower duration of self-generated looks to parent
Yellow Flags
21
When do the signs of ASD appear?
• At 6 months:
–
–
–
–
Signs are subtle
Most evident signs involve motor delay
Temperament: Reactivity, Distractability
Social: Lower duration of self-generated looks to parent
22
Typical head control: age 6 months
*Baby is laid on flat
surface
*Make sure nothing
of interest behind or
above baby
*Try to get baby’s
attention
*Gently pull on arms
*Goal: Baby pulls
self upward into sit
with a little help
24
Evidence of poor postural control at age 6
months
• N=58 sibs-A at mean age 6 months
• Clinical judgment of head lag scored from videotapes
of pull-to-sit item on Mullen GM Scale
% with head lag
100
80
60
40
20
0
93%
59%
30%
% with head lag
ASD
BAP
Non
Delay
How is the motor system developing in
children with and without ASD?
• Participants
– ASD n=52
– Non ASD n=152
• Tested at 6, 14, 24, 36 months
• Mullen Scales of Early Learning (Mullen, 1995)
– Fine Motor T score
– Gross Motor T score
• Delay: scoring at least 1.5 standard deviations below
the test mean on either motor scale
26
% ASD and non ASD with motor delay from
6-36 months
% with motor delay
70
60
50
40
ASD
Non ASD
30
20
10
0
6 mo
14 mo
24 mo
36 mo
Motor Delay: Fine Motor and/or Gross Motor T score
<35
27
Examples of Mullen Early Motor Items
Gross Motor
Fine Motor
Supports self on forearms when on
tummy
Grasp reflex
Sits with support, head control
Grasps peg touched to palm of hand
(ulnar grasp)
Rolls over
Reaches for and grasps block (radial
palmar grasp, no thumb)
** Holds on to fingers, pulls self to sit
Transfers, bangs, drops
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Examples Later Mullen Motor Items
Gross Motor
Fine Motor
Balances on one foot
Imitates 4-block train
Runs, turns corner, stops
Unscrews and screws nut and bolt
Hops at least two times
Strings beads
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Clinical implication
• Motor score on a standardized test is not sufficiently
sensitive at age 6 months to detect developmental
disruption in infants at risk for ASD
• Quality of movement:
– Postural control (head lag, changing positions)
• Likely to affect quality of imitation, gesture
30
Trajectories in Sibs-A with and without ASD
• Sibs-A n=204
• Low Risk Controls n=31
• Tested:
– 6, 14, 18, 24, 30, 36 months
• Measures:
– Mullen Scales of Early Learning
– Communication and Symbolic Behavior Scales Developmental Profile
Landa, Gross, Stuart, & Faherty. (2013). Child Development.
31
Different onset patterns: 52 with ASD
Early Diagnosed:
At 14 months
Later Diagnosed:
After 14 months
• 28 (51.8%)
• 78.5% male
• 42.8% parents
concerned at age 6 mos
• 70.4% concerned at age
14 months
• 26 (48.2%)
• 84.6% male
• 29.4% parents
concerned at 6 mos
• 65.4% parents
concerned at 14 mos
• At 14 mos: language or
social delay
32
IQ at Age 14 months
120
100
80
Early Dx
Later Dx
Non-ASD
60
40
20
0
IQ
Mullen Early Learning Composite
33
Receptive Language Raw Scores
•All groups WNL at 6 months
40
rlraw
Score
30
•Absence of typical language
growth spurt in ASD
10
20
•Plateau in Early dx group
6
14
18
24
30
36
Age (Months)
Non-ASD group
Later Dx ASD group
Early Dx ASD group
Landa, Gross, Stuart, Faherty. 2013. Child Development
Frequency of Initiation of Joint Attention
35
Another aspect of joint attention:
• Social attention:
• Tuning in to others body language:
– gesture
– gaze cues
• Understand that these cues ‘tell’ what the person is
thinking about, what interests them
• By looking at the object of their attention, you ‘share
attention’ with them
• This results in a moment of joint (shared) attention
36
Shared positive affect
• When you look at someone and smile, you
– Invite them to share something with you
– Invite them to communicate with you
– Make them feel that you want to connect with them
37
Frequency of Shared Positive Affect
Landa, Gross, Stuart, Faherty. 2013. Child Development
Heterogeneity in Trajectories of Sibs-A
70
60
50
Mullen T-score
70
60
50
40
30
20
Latent class analysis:
Heterogeneity
40
6
14 18
24
30
20
30
36
6
14 18
24
Age (Months)
Age (Months)
n=46 (22.3%)
n=24 (12%)
Early Language & Outcome Fine Motor Delay
70
50
40
30
36
Developmental Slowing
MSEL T scores
70
60
Mullen T-score
60
30
50
40
30
20
20
6
14 18
24
30
Age (Months)
MSEL Fine Motor
Landa,
Stuart,
MSELGross,
Gross Motor
Bauman, 2012, JCPP
MSEL Visual Reception
MSEL Receptive Language
MSEL Expressive Language
36
6
14 18
24
Age (Months)
30
36
Within-phenotype proportions in diagnostic
classes
Group
•
Early •ASD
N
Accelerated
Normative
Delay then
catch up
Slowing
27
0
14.8
29.6
55.6
Later ASD
25
4
36
32
28
41
Clinical implications
• Mid infancy (6 months):
– Signs are subtle
– Mostly motor delay
– Nonspecific to ASD
• Declining skills between 6 and 36 months
• By 14 months, ASD signs clear in about half of
children with ASD
– Low social responsiveness and reciprocity
– Infrequent initiation of joint attention and response to social
cues
– Language delay
– Repetitive and stereotyped interests
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Clinical implications
• Screen early
• Screen repeatedly in children with older sibling with
ASD
• Discuss parent concerns
• Early intervention
43
Screening
44
Who might voice the first concerns?
Parent, family
member,
friend
Early
Intervention
provider or
teacher
Pediatrician
45
Screening
•
•
•
•
Need multiple approaches
Parent-initiated
Health care professional (Pediatrician)-initiated
Child care provider-initiated
46
Learn the Signs, Act Early
• http://www.cdc.gov/ncbddd/actearly/
9-minute tutorial on early signs of ASD
• Autism.kennedykrieger.org
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GOLD STANDARD DIAGNOSIS 36 mos
Positive
Negative
“early”
classification
True Positives
ASD
positive
False
Positives
“early”
classification
False Negatives
True Negatives
as Non-ASD
negative
SE =TP/TP+FN
SP =TN/TN+FP%
% really ASD who were
% of non-ASD
identified at younger age to children identified at
have ASD
younger age as NonASD
PPV =
TP/TP+FP
% with positive
test results who
are really ASD
NPV=
TN/TN+FN
My data: Prospective study of ASD
• ASD n=49
– At every age, beginning at 14 months, CJ and confidence
rating
– Outcome classification made at 36 months
• Non ASD n=189
AAP Screening Guidelines
• All children be screened for DD during regular well-child
doctor visits at:
• 9, 18, and 24 or 30 months
• Additional screening might be needed if increased risk due
to preterm birth or low birth weight.
• Screen for ASDs during regular well-child doctor visits at:
• 18 & 24 months
• Additional screening might be needed if high risk for ASDs
(e.g., sibling with an ASD) or symptoms present.
Modified Checklist for Autism in Toddlers (MCHAT)
•
•
•
•
•
Parent report?
Targeted ages:
Number of questions:
Time to complete:
Free to use?
Yes
16-30 months
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5-10 minutes
Yes
– Available through the M-CHAT website: https://www.mchat.org/
M-CHAT Studies
Robins Study (2001)
•
•
•
•
•
Sample Size: 1283
Age Range:18-30 m
Well visits
Mean Age: 26 mo.
Gold Standard
Snow Study (2008)
•
•
•
•
(SD= 14.1)
•
Sensitivity: 0.97
Specificity: 0.99
PPV: 0.68
NPV: 0.99
JADD
Gold Standard
– Clinical diagnosis based on IQ
measures, VABS, ADOS, CARS,
GARS, PDDBI
– Psychological Evaluation
•
•
•
•
Sample Size: 82
Age Range: 18-70 mo.
Consecutive referrals possible PDD
Mean Age: 42.7 mo.
•
•
•
•
Sensitivity: 0.70
Specificity: 0.38
PPV: 0.79
NPV: 0.28
Autism
M-CHAT Best7
• Score items: 2, 5, 7, 9, 14, 15, 20
Fail 2 of these=screen positive; need follow-up.
• Interest in other ch; pretend; point; bring to show; response to
name; RJA; wonder if child deaf
• Robins et al., 2010: “M-CHAT Best7: A New Scoring
Algorithm Improves Positive Predictive Power of the M-CHAT”
–
–
–
–
–
–
–
–
Sample Size: 15,650
Age Range: 14-30 mo.
Mean Age: 20.6 mo. (SD= 3.1)
Gold Standard: Diagnostic evaluation
Sensitivity: 0.86
Specificity: 0.99
PPV: 0.18, (0.61 with follow-up interview)
NPV: Not assessed
Early Detection of Autism
and Social Communication Delays
Rebecca Landa, Ph.D., CCC-SLP
Kennedy Krieger Institute
Baltimore, MD
©Rebecca Landa
Detect Risk, Enrichment, Surveillance,
Treatment
• Screen: Social AND language delay
• Set the bar low
• Universal parent education about child development
and responsive parenting
• Culturally competent curricula for parent training
• MD training (train the eye, what to do)
• EI providers: need curriculum and strategies
• Flexible models of intervention
• Parent-to-parent
Summary and Implications
• Sibs-A: risk for early motor and language delay
• Motor disruption already present at 6 months
– Postural control
– Grasping
• Object exploration and play
• Some of the children plateau or decline, with atypical
features emerging
ASD
• Loss can come on at different times in different
children with ASD; and affects language or social
• Very few children with ASD have typical trajectories
• Even fewer have typical trajectories if sx
onset is early (by 14 m)
57
Implications
• Theoretical, neurobiological, clinical implications
• Early motor disruption, non specific but signal for
need for developmental stimulation
• Early motor disruption
– Affects play/object exploration immediately
– Related to language and social functioning later
• Can’t consider standard scores
• Must look at quality of behavior
• At 6 months: postural control, initiating and shifting
postures (Bhat, Galloway, Landa, 2012), grasping
58