Developmental; week 5; therapies and interventions

Neurodevelopmental conditions

what we know so far

• causes

  • genetic

  • environmental

  • unknown

• prevalence can be influenced by numerous factors

• different profiles

  • strengths

  • weaknesses

  • assessed using standardised tests and experimental designs

• interventions

Williams Syndrome: strengths

• strengths for this syndrome tend to be classes as ‘relative’; not a strength compared to general others, but rather it’s a real strength compared to the other elements in their cognitive profile

• delayed compared to age matched peers, but a real strength in their overall profile

• a well documented strength is their verbal language ability

• related strengths:

  • speech production

  • fluency

  • syntax

  • grammar

• difficulties with pragmatics (understanding intended meaning of words)

Williams syndrome: weaknesses

• Executive Function:

• Numerous studies suggesting that individuals with William’s Syndrome experience difficulties across several executive functions, including:

  • Inhibitory Control

  • Planning

  • Working Memory

• Visuospatial abilities

  • e.g. as measured by the WISC (standardised IQ test)

Autism: potential strengths

• Excellent attention to detail & pattern recognition

  • ‘strong systemising’ abilities = heightened attention to detail and advanced capabilities in pattern recognition (Baron-Cohen et al., 2009).

• Superior visual search skills are consistently reported

• Shirama, Kato & Kashino (2017) used two visual search tasks and increased the level of difficulty of each task:

  • Conjunction search

  • Feature search

• Regardless of the difficulty of the task autistic individuals outperformed neurotypical individuals on every task

Real life application?

• airport luggage X-ray

• identify whether the target image is present as quickly and accurately as possible in the x-ray image

• 

• ASD adults improved overtime in accurately rejecting bags where the target wasn’t present

• 

• Both ASD & control adults were able to accurately identify when the target was present

Conclusions:

• 1)when tasks tap into particular strengths of ASD enhanced performance may be observed.

• 2)Further research should investigate whether autistic individuals are especially well suited to specific real-world visual search tasks

Autism: potential weaknesses

• Executive Function:

  • Numerous studies suggesting that autistic individuals experience difficulties across executive functioning:

    • Inhibitory Control

    • Cognitive Flexibility

    • Working Memory

• Theory of Mind:

  • Difficulties in understanding the emotions, thoughts and intentions of others?

Theory of mind and autism

• Traditionally a popular way to assess ToM in Autism was by using false belief tasks, such as the unexpected transfer ‘Sally-Anne’

• autistic children show failures in ToM tasks, but research is equivocal

Interventions & support

Identifying the profile of strengths & weaknesses for each child allows clinicians, psychologists, parents & educators to identify the best and most appropriate support for that child

there are many different therapies and interventions

physical:

• physiotherapy

  • individuals with William’s syndrome often have poor muscle tone, balance & coordination difficulties

Behavioural

• ABA

• Early Start Denver Model → developed for autism

psychological

• music therapy

• play therapy

language

• PECs

Speech & Language therapy: PECS

• Both William’s Syndrome and Autism are associated with delays or difficulties in speech

• Picture Exchange Communication System (PECS) – a form of alternative communication

Stages of PECS (Picture Exchange System)

• picture exchange

  • swap a picture for an item

• generalise to other locations & people

  • realise they can use PECS outside of the home

• two picture exchange

  • use two pictures to ask for an item

• sentence construction

  • add ‘I want’ before the picture

• verbs, adjectives

  • more complex aspects of speech

• answer a question

  • use PECs to respond to other’s questions

• commenting

  • more complex sentences e.g. starting with ‘I see’, ‘I hear’

Makaton

• Makaton uses symbols (pictures), signs (gestures) and speech to enable people to communicate

• Supports the development of essential communication skills such as attention and listening, comprehension, memory, recall and organisation of language and expression

• Two vocabularies (learned sequentially):

  • A Core Vocabulary of essential words or concepts presented in stages of increasing complexity

  • A much larger, open-ended, topic-based resource vocabulary providing an enormous bank of further signs and symbols covering broader life experiences

• Makaton and British Sign Language (BSL) are entirely distinct and are used by very different communities of people

Play therapy

• If a child can’t express themselves in an adult world, the therapist should join the child in their world, on their level

• Children learn to understand the world and their place in it through play.

• It’s where they’re free to act out their inner feelings and deepest emotions.

• Toys can act as symbols and take on greater meaning — if you know what to look for.

• There’s a bit of a communication gap between children and adults. Depending on age and stage of development, children simply don’t have the language skills of adults. They may feel something, but in many cases, they either can’t express it to an adult or don’t have a trusted adult to express it to.

• On the other end, adults can misinterpret or completely miss the child’s verbal and nonverbal cues.

• Children learn to understand the world and their place in it through play. It’s where they’re free to act out their inner feelings and deepest emotions. Toys can act as symbols and take on greater meaning — if you know what to look for.

Play therapy sessions:

• Typically 30mins – 1 hour once a week. Therapy can take place individually or in groups.

• Can be directive or non-directive

• Directive - therapist will take the lead by specifying the toys or games that’ll be used in the session

• Non-directive - less structured. The child is able to choose toys and games and play in their own way. The therapist will observe closely and participate as appropriate.

• Techniques include: storytelling, role-playing, toy phones, puppets, dolls, action figures, arts and crafts, blocks and construction toys and more

• Demonstrated to reduce behaviours associated with ADHD & social anxiety and to increase social-emotional competency in autistic children

Music therapy

potential benefits of music therapy:

• helps a child to listen

• stimulate language development through songs and turn taking

• aid self-expression

• improve concentration

  • both autism and WS can be co-morbid with ADHD

• strengthen muscles & coordination

• encourage spontaneous play

Music as an educational tool in WS

study:

• two groups

  • those with music training

  • those without

• better verbal recall when the information was sung for those without lessons

• those with training show good recall for spoken information

• music aids verbal working memory in WS

• 

Applied behavioural analysis (ABA)

• Applied behavioural analysis (ABA) is a type of therapy that can improve social, communication, and learning skills through positive reinforcement.

• Originally developed to focus on autism (Lovaas, 1987), but is now used across a range of disorder/conditions

• An intensive therapy, it was originally recommended for 40 hrs per week 1-1, although more recently this contact time has lowered

how does ABA work?

• Positive conditioning – children are rewarded for showing a desired behaviour

• First a therapist will observe the child, consult with the parents and make a plan to address certain behaviours e.g.

• Reducing tantrums or harmful behaviours

• Increasing or improving communication

• The plan will include specific strategies caregivers, teachers, and the therapist can use to achieve treatment goals.

• ABA relies on parents and caregivers to help reinforce desired behaviours outside of therapy.

Effectiveness of ABA

• Peters-Scheffer, Didden, Korzilius & Sturmey (2011)

• Meta analysis on effectiveness of Early Intensive Behavioural Intervention (a type of ABA)

• 11 studies with 344 children

• Groups who received EIBI outperformed the control groups on IQ, non-verbal IQ, expressive and receptive language and adaptive behaviour. 

• 

Summary

• Important to gain a clear understanding of each individuals strengths and weaknesses

• There are a range of different therapies, including:

  • Physical therapy

  • Behavioural therapy

  • Speech and Language therapy

  • Psychological therapy

• Whilst behavioural therapies are useful they are not without criticism

Reading

Abstract

Excitement and controversy have surrounded the effectiveness of Early Intensive Behavioural Intervention (EIBI) for young children with autism. The purpose of this meta-analysis was to investigate the effectiveness of EIBI based on applied behaviour analysis in young children with Autism Spectrum Disorders (ASD). There were 11 studies with 344 children with ASD. Quality of studies was assessed using the Downs and Black Checklist. Experimental groups who received EIBI outperformed the control groups on IQ, non-verbal IQ, expressive and receptive language and adaptive behaviour. Differences between the experimental and control groups were 4.96–15.21 points on standardized tests. These results strongly support the effectiveness of EIBI.

Introduction

Autism Spectrum Disorder (ASD) is characterized by severe and sustained impairment in communication and social interaction and restricted patterns of ritualistic and stereotyped behaviours manifested prior to age 3 years.

In approximately 26–40% of young children with ASD intellectual disability (ID) is also present.

A range of behaviour problems are common, including self-injury, anxiety, compulsions, withdrawal, uncooperative behaviour, aggression, and destruction of property.

There are many intervention approaches including applied behaviour analysis (ABA), diets and vitamins, floor time, holding, medication, options, Picture Exchange Communication System, sensory integration, speech and music therapy, special education and visual schedules; however, there is little empirical evidence for the effectiveness of many of these approaches and available evidence shows mixed results.

EIBI

Building on research from the 1960s, Early Intensive Behavioural Intervention (EIBI) is the most often studied type of intervention for children with ASD.

It is based on principles of operant learning and focuses on remediation of deficient language, imitation, pre-academics, self-help and social interaction skills which are broken down into discrete components and taught on a one-to-one basis in school and/or at home, typically using discrete trial teaching (with subsequent planned generalization), reinforcement, backward chaining, shaping, extinction, prompting and prompt fading.

Parental participation is considered essential to achieve generalization and maintenance. EIBI is effective when it is both intensive (i.e. approximately 40h per week) and extensive minimally 2 years.

Empirical evidence of EIBI

Studies have reported mixed outcomes. Several descriptive reviews have concluded that, although EIBI generally has meaningful benefits for young children with ASD, there were large individual differences in treatment response and most children continued to require specialized services.

Two meta-analyses found an average medium to large effect size for IQ change despite using different effect sizes (standardized mean change effect size versus a standardized mean difference effect size) and differences in study selection criteria.

Eldeviketal.(2009) also found a medium effect size on change of the adaptive behaviour composite. Several studies have also reported supplementary measures of adaptive behaviour; however, meta-analyses have not systematically analysed full scale, verbal and performance IQ and measures of adaptive behaviour. Thus, it is unclear if the effects of EIBI are robust across all these measures. Therefore, this meta-analysis synthesized the outcomes of comprehensive EIBI programs in which data were collected in group designs using full scale, verbal and performance IQs and measures of adaptive behaviour.

Method

2.1 search methods and selection of studies

There were three search strategies.

First, computerised literature searches of MedLine, Psych info and Eric were conducted using the keywords ‘‘behavioural treatment’’ or ‘‘behavioural intervention’’ in combination with ‘‘autism’’, ‘‘autism spectrum disorder’’ or ‘‘pervasive developmental disorder’’.

Second, a manual search of the following journals was performed: American Journal on Mental Retardation/American Journal on Intellectual and Developmental Disabilities, Autism, Behavioural Interventions, Behaviour Modification, Focus on Autism and Other Developmental Disabilities, Journal of Applied Behaviour Analysis, Journal of Autism and Developmental Disorders, Journal of Intellectual Disability Research, Intellectual and Developmental Disabilities/Mental Retardation, Research in Autism Spectrum Disorders and Research in Developmental Disabilities.

Third, recent publications on EIBI were inspected to confirm the manual and computer searches. Each article on EIBI retrieved through the manual or computerised search was checked on relevant studies. All EIBI studies in young children with ASD were selected and reviewed if:

• (1) interventions addressed all three core deficits in autism using ABA;

• (2) only studies with a pre-test post-test control group were included;

• (3) all participants had a diagnosis of Autism Spectrum Disorder, including DSM-III, DSM-III-R DSM-IV or ICD diagnosed Autistic Disorder (AD) and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS)

• (4) children were aged 10 years or younger at treatment onset;

• (5) studies contained quantitative outcome data including means and standard deviations on standardized measures of IQ, language and adaptive behaviour; and

• (6) the study was published in English in a peer-reviewed journal between 1980 and 2009.

  Eleven studies met inclusion criteria.

Ten were retrieved by computer search and a manual search and reference tracking resulted in one additional study. Each study sample could contribute only one data point to the meta analysis; therefore, since Eikeseth, Smith, Jahr, and Eldevik (2002, 2007) used the same participants, these two studies were treated as one study. Only Smith, Groen, and Wynn (2000) was a fully randomized control trial. Other studies used a pre-test post-test control group design, which was not fully randomized. A second reviewer examined the first 50 articles of the MedLine database. Agreement between the reviewer and the first author was 100%. Study quality was assessed by two independent reviewers using Downs and Black’s (1998) checklist.

Data extraction

Outcome variables were IQ and adaptive behaviour. All means and standard deviations were obtained directly from published papers when available. When the study did not provide these data, the standard scores were calculated using the following formula: outcome in months/ chronological age in months 100. When studies did not report means and standard deviations of pre- and post-tests, the study was excluded. For each study, mean differences and standard deviations between baseline and treatment were calculated. When a study had two control groups, a weighted mean and standard deviation was calculated, since the similarity between both control groups and the experimental group and the control groups of the other studies made it problematic to select one control group over the other. The meta-analysis was conducted using meta-analysis with interactive explanations (MIX)

Results

3.1 study characteristics

Participants’ average age ranged from 33.56 to 65.68 months. Reported gender was 65.70% male, 10.47% female; 23.84% was not reported. All had an Autism Spectrum Disorder and average IQ ranged from 27.52 to 76.53. Experimental groups received on average 12.5 to 38.6h of EIBI for 10 months to more than 2years. Control groups consisted of less intensive EIBI (<10hperweek), 12.5–29.08 h per week eclectic treatment, parent-directed ABA or treatment as usual (e.g., public early intervention, nursery provision, Portage, school based intervention). Howard et al. (2005) and Reed et al. (2007) had two control groups. Table 1 shows the demographic characteristics.

3.2 child outcomes

The EIBI group outperformed the control group on all dependent variables. Full scale and non-verbal IQ improved in the EIBI group 11.98 and 11.09 points more than in the control groups, respectively. In receptive and expressive language, the average increases were 13.94 and 15.21 points more, respectively. The EIBI groups surpassed the control groups on composite adaptive behaviour, communication, daily living skills and socialization subscales the experimental groups surpassed the control groups by 5.92, 10.44, 5.48, and 4.96 points, respectively. Consistent with the results based on mean differences, Cohen’s D indicates moderate (adaptive behaviour: daily living skills subscale) to large effect sizes (IQ, non-verbal IQ, adaptive behaviour, receptive and expressive language).

Figs. 2–9 summarize the means, confidential intervals and standard deviations for each study and totals on each dependent variable.

Table 2 displays Cohen’s D for each study on each dependent variable. The mean quality score was 24.65 out of 32. Intraclass correlation (average measures, two-way random effects model using an absolute agreement definition) between the two reviewers was 0.70 (p=0.04; 95% CI: 0.15 to 0.93).

Publication bias and statistical heterogeneity were attested with funnel plots, adjusted rank correlations, Galbraith plots and Tau-squared measures. Funnel plots indicated some publication bias; however, this was not confirmed by adjusted rank correlations which indicated that publication bias was absent (all p’s>0.22). Galbraith plots showed there was statistical heterogeneity. IQ and the communication and daily living skills domains of the Vineland Adaptive Behaviour Scale (VABS) had diverse variances. Tau-squared measures of heterogeneity showed rather high values for full scale IQ, expressive language and VABS communication domain and low values for non-verbal IQ, the receptive language and the composite score, the daily living skills domain and the socialization domain of the VABS. Thus, the meta-analysis for EIBI contains statistically heterogeneous studies.

4. Discussion

Children with ASD participating in EIBI generally outperformed children receiving other treatments or treatment as usual on both IQ and adaptive behaviour measures. This confirms findings from other studies on EIBI and two other recent meta-analyses. The average differences of 11.09 to 15.21 standardized points in scores between the experimental and control groups on IQ, non-verbal IQ and receptive and expressive language and the large effect sizes may be considered clinically significant. Consistent with Eldeviketal. (2009), this study found smaller differences on adaptive behaviour between the experimental and the control group (4.96–10.44points) suggesting that future applied work might focus more intensively to improve child adaptive behaviour. This might include a greater quantity of teaching and/or improved quality of teaching of skills in these domains. Results varied considerable between studies and participants. Differences may be attributable to treatment intensity, EIBI quality, intensity of supervision, participant characteristics, and the control group’s treatment, if any. Further research should determine which child characteristics, beside baseline IQ and age at start of treatment, are related to treatment outcome. Children who do not make dramatic responses are often readily identifiable within a few weeks or months of EIBI. Future research might evaluate what strategies should be adopted to further improve outcomes for these children who may need even more intense EIBI or perhaps technically very precise teaching and a very high degree of treatment integrity to accelerate development. Perhaps these children enter EIBI with key deficits that are not readily remediable with routine EIBI. These might include acquisition of prerequisite skills such as sitting and attending, joint attention skills, and acquisition of praise as a secondary reinforcer or perhaps some of these children have interfering challenging behaviour that routine EIBI does not address effectively in the first few months of intervention. An alternate explanation might be that the quality of the teaching that these children receive might be poor and staff and parents working with these children require more careful training and supervision than other staff. Since a meta-analysis is only based on published studies, publication bias is a threat to validity. Funnel plots and rank correlation tests of expressive language suggested some evidence for publication bias. More studies with positive than non-significant or negative results are published; however, another explanation might be that behavioural treatment is indeed effective. Galbraith plots showed that there was indication of statistical heterogeneity. This could be explained in terms of differences in characteristics of the treatment (e.g., setting, amount of supervision provided, intensity) and the participants (age at treatment onset, IQ at treatment onset, diagnosis). This seems typical for the field and for autistic children. As Reichow and Wolery (2009) and Eldevik et al. (2009) stated, results need to be interpreted cautiously, since studies in this area contain several methodological limitations including small sample sizes, non-randomized assignments to groups, non-uniform assessments protocols, use of quasi-experimental designs, lack of equivalent groups, lack of adequate fidelity measures, unknown characteristics of comparison conditions, and selection bias; only one study (Smithetal.,2000) was a fully randomized control trial. Despite these potential limitations, this meta analysis demonstrated that EIBI has a moderate to large effect in young children with autism on full scale and non-verbal IQ and adaptive behaviour.