Community-Based Early Intervention For Children With Autism Spectrum Disorder

One in 68 children has been identified with Autism Spectrum Disorder (ASD), a disorder defined by 1) deficits in social-communication and social interactions and 2) restricted, repetitive patterns of behavior, interests or activities. Research has shown that children with ASD who receive high-quality early intervention (EI) services in university-based research trials can make large gains in cognitive, communication, and adaptive behaviors skills, with positive long term effects. However, less is known about the outcomes for the over 50,000 children who receive EI in community settings. This dissertation provides initial evidence of the current state of community-based EI for children with ASD. Chapter 1 presents a meta-analysis of cognitive, communication, social, and adaptive behavior outcomes for children with ASD in community-based EI programs, and demonstrates that the gains made in the community are much smaller than those observed in university-based trials. In Chapter 2, prospective, longitudinal data collected from a local EI system is studied to understand which characteristics of preschool EI predict cognitive gains for 79 preschoolers with ASD that received publicly-funded services in classroom placements. The best predictor of gains was the utilization of recommended intervention practices to support the development of social and peer relationships. Chapter 3 discusses measurement of executive functioning (EF) among preschoolers with ASD, as executive functioning skills likely play an important role in response to EI. However existing EF measures have not been validated for use with low-functioning, nonverbal preschoolers with ASD. Results are presented from the development and the validation of a battery of nonverbal, performance-based EF tasks. These measures can be utilized in future community-based treatment trials

Outcomes in patients with gunshot wounds to the brain.

Introduction:Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. Methods:We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. Results:825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. Conclusion:We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. Level of evidence:Level II

Effectiveness of community-based early intervention for children with autism spectrum disorder: a meta-analysis.

BackgroundResearch trials of early intervention (EI) programs for children with autism spectrum disorder (ASD) generally demonstrate medium-to-large gains, on average, compared with "treatment as usual," in different developmental domains. Almost all children with ASD receive their treatment through community-based services, however, and studies suggest that evidence-based interventions rarely make their way into community practice. Understanding the effectiveness of community-based EI and factors associated with these effects is the first step in developing strategies for wide-scale implementation of effective EI.MethodsStudies of community-based EI for children with ASD were identified through a systematic search. Changes in cognitive, communication, social, and adaptive functioning from pre-treatment to post-treatment were assessed using standardized mean gain scores. Effect sizes were estimated using random effects models. Moderators of interest included type of community EI program, year of publication, intervention duration, and sample selection. Moderator effects were assessed using analysis of variance of mixed-effects models and meta-regression analyses.ResultsForty-six groups from 33 studies met inclusion criteria (1,713 participants, mean age 37.4 months, 81.1% male). There were small but statistically significant gains in each of the four domains. Hedges's g ranged from 0.21 for adaptive behavior to 0.32 for communication outcomes, after removing outliers and correcting for publication bias. EI programs associated with universities and hospitals were superior, on average, to other community EI programs for cognitive and adaptive behavior outcomes. Intervention duration was negatively associated with effect sizes for communication and adaptive behavior outcomes.ConclusionsThese results indicate that there remains a large gap between outcomes observed in community settings and those reported in efficacy trials

A randomized controlled trial of Hanen's 'More Than Words' in toddlers with early autism symptoms

BACKGROUND: This randomized controlled trial compared Hanen’s ‘More than Words’ (HMTW), a parent-implemented intervention, to a ‘business as usual’ control group. METHODS: Sixty-two children (51 boys and 11 girls; M age = 20 months; SD = 2.6) who met criteria for autism spectrum disorders (ASD) and their parents participated in the study. The HMTW intervention was provided over 3.5 months. There were three measurement periods: prior to randomization (Time 1) and at 5 and 9 months post enrollment (Times 2 and 3). Children’s communication and parental responsivity were measured at each time point. Children’s object interest, a putative moderator, was measured at Time 1. RESULTS: There were no main effects of the HMTW intervention on either parental responsivity or children’s communication. However, the effects on residualized gains in parental responsivity from Time 1 to both Times 2 and 3 yielded noteworthy effect sizes (Glass’s Δ = .71, .50 respectively). In contrast, there were treatment effects on child communication gains to Time 3 that were moderated by children’s Time 1 object interest. Children with lower levels of Time 1 object interest exhibited facilitated growth in communication; children with higher levels of object interest exhibited growth attenuation. CONCLUSIONS: The HMTW intervention showed differential effects on child communication depending on a baseline child factor. HMTW facilitated communication in children with lower levels of Time 1 object interest. Parents of children who evidence higher object interest may require greater support to implement the HMTW strategies, or may require different strategies than those provided by the HMTW curriculum

Practice-driven research for statewide scale up: Implementation outcomes of the California Autism Professional Training and Information Network

Lay abstractSupporting use of evidence-based practice in public service programs for autistic individuals is critical. The California Autism Professional Training and Information Network (CAPTAIN) brings together best practices from intervention and implementation research to support scale up of autism services. The current study was designed to evaluate the impact of CAPTAIN on provider-level outcomes including attitude toward, knowledge, fidelity, and use of autism EBPs and overall classroom quality. Overall, results indicated variability across measures, with some significant differences between CAPTAIN-trained and non-CAPTAIN-trained providers. These preliminary findings show promise for the efficacy of the CAPTAIN model to increase dissemination and implementation of EBP at the classroom level

An Illustration of Using Multiple Imputation Versus Listwise Deletion Analyses: The Effect of Hanen's More Than Words on Parenting Stress

Abstract This investigation illustrates the effects of using different missing data analysis techniques to analyze effects of a parent-implemented treatment on stress in parents of toddlers with autism symptomatology. The analysis approaches yielded similar results when analyzing main effects of the intervention, but different findings for moderation effects. Using listwise deletion, the data supported an iatrogenic effect of Hanen's “More Than Words” on stress in parents with high levels of pretreatment depressive symptoms. Using multiple imputation, a significant moderated treatment effect with uninterpretable regions of significance did not support an iatrogenic effect of treatment on parenting stress. Results highlight the need for caution in interpreting analyses that do not involve validated methods of handling missing data.</jats:p

Concordance between a U.S. Educational Autism Classification and the Autism Diagnostic Observation Schedule.

States in the United States differ in how they determine special education eligibility for autism services. Few states include an autism-specific diagnostic tool in their evaluation. In research, the Autism Diagnostic Observation Schedule (ADOS for first edition, ADOS-2 for second edition) is considered the gold-standard autism assessment. The purpose of this study was to estimate the proportion of children with an educational classification of autism who exceed the ADOS/ADOS-2 threshold for autism spectrum (concordance rate). Data were drawn from 4 school-based studies across 2 sites (Philadelphia, Pennsylvania, and San Diego, California). Participants comprised 627 children (2-12&nbsp;years of age; 83% male) with an autism educational classification. Analyses included (a) calculating the concordance rate between educational and ADOS/ADOS-2 classifications and (b) estimating the associations between concordance and child's cognitive ability, study site, and ADOS/ADOS-2 administration year using logistic regression. More San Diego participants (97.5%, all assessed with the ADOS-2) met ADOS/ADOS-2 classification than did Philadelphia participants assessed with the ADOS-2 (92.2%) or ADOS (82.9%). Children assessed more recently were assessed with the ADOS-2; this group was more likely to meet ADOS/ADOS-2 classification than the group assessed longer ago with the ADOS. Children with higher IQ were less likely to meet ADOS/ADOS-2 classification. Most children with an educational classification of autism meet ADOS/ADOS-2 criteria, but results differ by site and by ADOS version and/or recency of assessment. Educational classification may be a reasonable but imperfect measure to include children in community-based trials