A pre-school communication
intervention for autism – practice
and evidence
Jonathan Green
University of Manchester,
Manchester Academic Health Sciences Centre
Royal Manchester Childrens Hospital
Manchester, UK
Developmental Communication
Focused Approach to Pre-school
Intervention
Background
• Focus on parent-child dyad - 80% of the child’s communication pre-school
• 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
Programme structure
http://www.medicine.manchester.ac.uk/pact/
• Parent-mediated video-aided intervention
• 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)
Case Study
Child J
First session
J: 2 years 10 months
Very object focused. No initiation of play.
Mum having to work hard to try and engage him, but with little success.
Very little language: observed “ready steady go” some colours and
numbers used.
Session 5:
having worked on stage 1 targets: key
target allowing J to lead
Following J’s lead has been a key factor in this stage of treatment.
J is now initiating some play activities, interaction and joint attention.
Mum is having to work less hard to engage J.
Language: Some use of single words and some jargon.
By the end…
having looked at communication functions and discussing ideas for setting up situations in which different functions of
language could be firstly modelled and then elicited through sensitive use of teasers (we discussed the use of these in
play but mum found it much more useful to discuss the use of these in everyday contexts), J was using language to…
Ask questions and give instructions
Make comments
Negate
Take part in social routines
The Lancet (2010), 375, 9732; 2152-2160
Prof Jonathan Green
Dr Catherine Aldred
Prof Andrew Pickles
Dr Wendy Macdonald
Dr Kathy Leadbitter
University of Manchester
Prof Helen McConachie
Prof Ann Le Couteur
Kathryn Temple
Newcastle University
Prof Tony Charman
Dr Kristelle Hudry
Dr Vicky Slonims
Institute of Education, London
Prof Pat Howlin
Dr Sarah Byford
Dr Barbara Barrett
Kings College, London
Guys Hospital, London
Design
• First large RCT of an early psychosocial
treatment
3 site 2 arm, N=152
2-4,11 yrs; core autistic disorder
(ADOS-G/ADI-R)
Testing a model deliverable in the
NHS
• Pre-specified primary outcome and
analysis plan
• Blinded rating of outcomes
•Testing mediating mechanisms
Use of RCT design to test basic
science hypotheses
Clinician referral
Full baseline assessment
Diagnostic, cognitive,
interaction
Randomisation
PACT + TAU
TAU
Fortnightly
SALT sessions
Community
services
7m: Brief midpoint assessment
PACT +TAU
TAU
Monthly
boosters
Community
services
13m: Full endpoint
assessment
Hypotheses
• A targeted parent-mediated video-aided intervention
will enhance parental communicative responsiveness
• …which will in turn elicit improved social
responses/communication initiations from the child
• ….and reduced abnormality in communication
• …which will generalise to reduction in objectively
rated autism social/communicative symptoms
– Suggestive evidence from 2004 pilot study, other
related parent interventions (for non-ASD ‘atrisk’ populations) and developmental theory
Hypotheses
• A targeted parent-mediated video-aided intervention
will enhance parental communicative responsiveness
• …which will elicit improved social
responses/communication initiations from the child
• ….and reduced abnormality in communication
• …which will generalise to reduction in objectively
rated autism social/communicative symptoms
– Suggestive evidence from 2004 pilot study, other
related parent interventions (for non-ASD ‘atrisk’ populations) and developmental theory
Hypotheses
• A targeted parent-mediated video-aided intervention
will enhance parental communicative responsiveness
• …which will elicit improved social
responses/communication initiations from the child
• …reduce abnormality in communication
• …which will generalise to reduction in objectively
rated autism social/communicative symptoms
– Suggestive evidence from 2004 pilot study, other
related parent interventions (for non-ASD ‘atrisk’ populations) and developmental theory
Hypotheses
• A targeted parent-mediated video-aided intervention
will enhance parental communicative responsiveness
• …which will elicit improved social
responses/communication initiations from the child
• …reduce abnormality in communication
• …and generalise to reduction in autism
social/communicative symptoms
– Suggestive evidence from 2004 pilot study, other
related parent interventions (for non-ASD ‘atrisk’ populations) and developmental theory
Outcomes
• Primary outcome
– ADOS-G Social + Communication total
– Modified implementation of module rules and scoring for use as an index
of change (Cathy Lord)
• Blinded secondary outcomes
– Parent-child interaction (PCI)
– parent synchronous responses
– child communication initiations
– Language (PLS)
– Social adaptation (teacher VABS)
• Non-blinded secondary outcomes – parent rated
– Language (MCDI)
– Early social communicative development (CSBS-DP-CQ)
Study flow
ASSESSED
n=242
EXCLUDED
n=90
RANDOMISED
n = 152
TAU
n = 75
LOST TO FOLLOW UP
n=3
ENDPOINT DATA
n = 72
PACT + TAU
n = 77 (>3 sess n=74)
LOST TO FOLLOW UP
n=3
ENDPOINT DATA
n = 74
Hypotheses
• A targeted parent-mediated video-aided intervention
will enhance parental communicative responsiveness
• …which will elicit improved social
responses/communication initiations from the child
• ….and reduced abnormality in communication
• …which will generalise to reduction in objectively
rated autism social/communicative symptoms
– Suggestive evidence from 2004 pilot study, other
related parent interventions (for non-ASD ‘atrisk’ populations) and developmental theory
Parent child interaction
Child initiations
80
0
0
20
40
60
PCI: percent of child acts initiation
20
40
60
80
100
100
Parental synchrony
TAU base PACT base TAU mid
PACT mid
TAU end
PACT end
Endpoint ES 1.22 (0.85 to 1.59) –
(Midpoint 1.44)
OR (quintiles) 9.10 (4.39 to 18.9, sig)
TAU base PACT base TAU mid
PACT mid
TAU end
PACT end
Endpoint ES 0.41 (0.08 to 0.74) –
(Midpoint 0.5)
OR (quintiles) 2.32 (1.21 to 4.42, sig)
Hypotheses
• A targeted parent-mediated video-aided intervention
will enhance parental communicative responsiveness
• …which will elicit improved social
responses/communication initiations from the child
• …reduce abnormality in communication
• …and generalise to reduction in autism
social/communicative symptoms
– Suggestive evidence from 2004 pilot study, other
related parent interventions (for non-ASD ‘atrisk’ populations) and developmental theory
0
10
20
30
Primary outcome ADOS-G; modified SC algorithm total
TAU baseline
PACT baseline
TAU endpoint
PACT endpoint
ADOS-G: - 3.9 in PACT, - 2.9 in TAU, ES -0.24 (95%CIs -0.59 to 0.11, ns)
Moderator analysis: centre (p=0.52), non-verbal ability (p=0.47), language (p=0.51), ADOS
severity (p=0.85), age (p=0.46), SES (p=0.10)
Parental reports
• Language (MCDI) – big changes with treatment
– Receptive: OR 3.4 (1.48 to 7.79)
– Expressive: OR 1.63 (0.76 to 3.51)
• Early social communication abilities (CSBS) - ditto
– Social composite: OR 2.49 (1.27 to 4.89)
Highly ‘ecologically valid’ but how much result of
hope/expectation?
• Parent Evaluations in 18 post treatment interviews…..
• ‘It was a revelation to me … I thought I was
the only person who knew my child … and I
didn’t. When I watched the video he had his
back to me … he wasn’t playing with me at all
… now I know him best … but I didn’t at the
start of PACT.’
Attenuation of treatment effect on generalisation
across interaction and context
PACT
Interventio
n
Child
interaction
with Parent
Child
interaction
with
Assessor
Parental
synchrony
Child
initiations
ES=1.22
(0.85, 1.59)
ES=0.41
(0.08, 0.74)
Autism
symptoms
(ADOS)ES
=-0.24
(-0.59, 0.11)
Parent
interaction with
Child
Child
in
School
Social
functioning
in school
ES=-0.19
(-0.44, 0.07)
CONTEXT
MEASURE
Mediation
PACT (n=152) - Change in synchrony (ES 1.44 at 6/12) mediated
improvement in child initiations (ES .41) and ADOS (ES .24) (Pickles,
Green, Charman et al IMFAR 2011)
PACT pilot (n=28) - Change in parental synchrony mediated effect of
treatment on child ADOS (ES.95) (Aldred, Green, Emsley, McConachie 2011 JADD)
Interpretation
• Changes in dyadic interaction and parent-rated
outcomes
– Consequences for child development, parental
morale, family environment, parent-child
relationship, child adjustment?
• ..but in line with other recent trials; PACT effected
changes to proximal outcomes but less effect on
distal outcomes
– Measurement sensitivity?
– Improvement in TAU?
– ‘Transmission gap’; need for adjunctive Rx?
Current/Future work
• Prodromal intervention in infancy - iBASIS
• PASS – ‘Parent-mediated intervention for ASD
in South Asia’ - Adaptation and
implementation of PACT in India and Pakistan
(Autism Speaks GAPH)
• ‘PACT 2’ - use of mediation and process
analysis to generate evidenced-based
generalisation strategies to home and school
• PACT Follow up – in middle childhood to test
developmental outcomes
Thank you!
jonathan.green@manchester.ac.uk
www.medicine.manchester.ac.uk/pact/
www.medicine.manchester.ac.uk/ibasis/
basisnetwork.org