Combined effects of early behavioral intervention and propranolol on ASD
We investigated the mechanisms by which Pivotal Response Treatment (PRT) improves social communication in a case series of 10 preschool-aged children with Autism Spectrum Disorder (ASD). Functional magnetic resonance imaging (fMRI) identified brain responses during a biological motion perception task conducted prior to and following 16 weeks of PRT treatment. Overall, the neural systems supporting social perception in these 10 children were malleable through implementation of PRT; following treatment, neural responses were more similar to those of typically developing children (TD). However, at baseline, half of the children exhibited hypoactivation, relative to a group of TD children, in the right posterior superior temporal sulcus (pSTS), and half exhibited hyperactivation in this region. Strikingly, the groups exhibited differential neural responses to treatment: The five children who exhibited hypoactivation at baseline evidenced increased activation in components of the reward system including the ventral striatum and putamen. The five children who exhibited hyperactivation at baseline evidenced decreased activation in subcortical regions critical for regulating the flow of stimulation and conveying signals of salience to the cortex-the thalamus, amygdala, and hippocampus. Our results support further investigation into the differential effects of particular treatment strategies relative to specific neural targets. Identification of treatment strategies that address the patterns of neural vulnerability unique to each patient is consistent with the priority of creating individually tailored interventions customized to the behavioral and neural characteristics of a given person.
Earlier autism diagnosis, the importance of early intervention, and development of specific interventions for young children have contributed to the emergence of similar, empirically supported, autism interventions that represent the merging of applied behavioral and developmental sciences. “Naturalistic Developmental Behavioral Interventions (NDBI)” are implemented in natural settings, involve shared control between child and therapist, utilize natural contingencies, and use a variety of behavioral strategies to teach developmentally appropriate and prerequisite skills. We describe the development of NDBIs, their theoretical bases, empirical support, requisite characteristics, common features, and suggest future research needs. We wish to bring parsimony to a field that includes interventions with different names but common features thus improving understanding and choice-making among families, service providers and referring agencies.
There is growing evidence that efficacious autism-related interventions rarely are adopted or successfully implemented in public schools, in part because of the lack of fit between the intervention and the needs and capacities of the school setting. There is little systematic information available regarding the barriers to implementation of complex interventions such as those addressing social engagement for children with autism.The present study used fieldnotes from an implementation trial to explore barriers that emerged during the training of school personnel and subsequent implementation of a social engagement intervention. A number of barriers at the individual (training) and school levels (policies surrounding recess, staffing, prioritization of competing demands, level of respect and support, and availability of resources) interfered with the continued use and sustainment of the intervention. We offer potential strategies to overcome these barriers and provide directions for future research in this critical area.
Keywords: autism; implementation; intervention; schools; social engagement.
This study sought to validate a new measure, the Classroom Cohesion Survey (CCS), designed to examine the relationship between teachers and classroom assistants in autism support classrooms. Teachers, classroom assistants, and external observers showed good inter-rater agreement on the CCS and good internal consistency for all scales. Simple factor structures were found for both teacher- and classroom assistant-rated scales, with one-factor solutions for both scales. Paired t tests revealed that on average, classroom assistants rated classroom cohesion stronger than teachers. The CCS may be an effective tool for measuring cohesion between classroom staff and may have an important impact on various clinical and implementation outcomes in school settings.
Keywords: autism; classroom cohesion; classroom team; teacher-staff relationship.
Schools have become the main provider of services to children with mental health needs. Although there is substantial literature on barriers to implementation of evidence-based practices (EBPs) in under-resourced school districts, less has been written on how to overcome those barriers. Providing mental health services in the school setting presents a tremendous opportunity to increase access to quality mental health care for underserved youth. This review provides a brief overview of the barriers to successful implementation and sustainment of EBPs in under-resourced public schools and provides recommendations for overcoming them. The discussion is organized around an established conceptual framework adapted for the delivery of services in under-resourced schools that focuses on interdependent factors that exist at the individual-, team, school-, and macro-levels. This manuscript explores some recommendations and strategies for effectively addressing challenges related to implementation of EBPs. Research ideas are offered to bridge the research-to-practice gap that impacts many under-resourced public school districts.
Keywords: Implementation; evidence-based practices; mental health services; sustainment; under-resourced schools.
Classroom assistants and one-to-one assistants are an important part of the staffing structure of many autism support classrooms. Limited studies, however, have examined how one-to-one assistants spend their time in the classroom. The purpose of this article was to examine the percentage of time one-to-one assistants were engaged in instruction or support of students with autism and to determine the factors associated with their engagement. Direct observations were conducted in 46 autism support classrooms. Teachers and classroom assistants were engaged in instruction or support 98% and 91% of the time, respectively. One-to-one assistants were engaged in instruction or support 57% of the time. Classroom assistants’ and one-to-one assistants’ engagement was significantly correlated. The low rate of one-to-one assistants’ engagement suggests an inefficient use of an important resource.
Keywords: autism; autism spectrum disorder; classroom staff engagement; one-to-one assistants; paraprofessionals.
Early detection methods for autism spectrum disorder (ASD) in infancy are rapidly advancing, yet the development of interventions for infants under two years with or at-risk for ASD remains limited. In order to guide research and practice, this paper systematically reviewed studies investigating interventions for infants under 24 months with or at-risk for ASD. Nine studies were identified and evaluated for: (a) participants, (b) intervention approach (c) experimental design, and (d) outcomes. Studies that collected parent measures reported positive findings for parent acceptability, satisfaction, and improvement in parent implementation of treatment. Infant gains in social-communicative and developmental skills were observed following intervention in most of the reviewed studies, while comparisons with treatment-as-usual control groups elucidate the need for further research. These studies highlight the feasibility of very early intervention and provide preliminary evidence that intervention for at-risk infants may be beneficial for infants and parents.
The current paper provides an overview of an evidence-based treatment, Pivotal Response Treatment (PRT), for autism spectrum disorder (ASD). The paper describes PRT principles and then illustrates the approach using two case reports. The children are preschool-aged children with high-functioning ASD. They were participating in a four-month clinical trial of PRT. At the start of treatment, they presented with significant social communication impairments, including a minimal understanding of reciprocity, limited play skills, and repetitive behaviors and speech. The paper outlines how behavioral treatment goals were identified and then how activities were designed, using principles of PRT, to target skill acquisition. Following the treatment course, both children made substantial and meaningful gains in social communication skill development.
There is a growing literature on children with autism spectrum disorder (ASD) who respond favorably to behavioral treatment, which is often termed “optimal outcome.” Rates and definitions of optimal outcome vary widely. The current case series describes an empirically validated behavioral treatment approach called Pivotal Response Treatment (PRT). We present two preschool-aged children who received an intensive course of PRT and seem to be on a trajectory toward potential optimal outcome. Understanding response to treatment and predictors of response is crucial, not necessarily to predict who may succeed, but to individualize medicine and match children with customized treatment programs that will be best tailored to their unique and varied needs.
Keywords: autism; outcome; pivotal response treatment.