Breakthrough research demonstrating that children with autism as young as 18 months can vastly improve their language, cognition and social skills with an early intervention developed by UC Davis Professor Sally Rogers has been replicated in a major new study.
Rogers, a professor of Psychiatry and Behavioral Sciences at the MIND Institute, began work on a novel developmental approach to autism in Denver in 1981, and in partnership with her colleague and co-author Geraldine Dawson developed an approach to improving long-term outcomes for very young children. The Early Start Denver Model has since become a method used throughout the U.S. and around the world.
But until now ESDM had not been tested in the most rigorous fashion − a multi-site randomized trial, comparing the approach with community-based autism interventions. The study, which appears today in Journal of the American Academy of Child and Adolescent Psychiatry, began in 2007 at three university sites around the country. The new research replicates an ESDM study published in 2010. Rogers emphasized that replication studies are rare and costly but critical to validate novel scientific findings.
The new study found that children receiving intensive ESDM in their homes for an average of 15 hours per week made significantly greater language gains than did children in the community interventions, and this was true for both children with more severe delays and those with less.
In addition to validating the efficacy of ESDM for language development, the study also found that children receiving services in the community settings made large gains in several areas.
“The idea that little children with autism who are getting good treatment can make this much IQ and language gain means we should expect this from quality early-intervention experiences,” Rogers said. “These findings should raise families’ hopes a whole lot.”
Pioneering autism treatment was a new idea
What distinguishes ESDM from the more traditional, behavioral interventions used with children with autism is that it combines developmental and behavioral approaches and is carried out within in everyday routines. ESDM is built on moment-to-moment interactions that young children typically have with other people, especially their parents, and uses children’s interests and favorite activities to assure that social interaction is interesting and fun.
“Unlike other approaches popular at the time that the Denver Model began, we used a typical preschool physical environment and focused on the learning opportunities that existed in social interactions between children and adults to accelerate children’s development,” Rogers said. “This was a new idea at the time.”
In 2012, TIME magazine named ESDM one of the top 10 medical breakthroughs because their work demonstrated that brain function among young children with autism can normalize with effective early intervention in profound, enduring ways.
For the current study 118 children with autism, ages 14 months to two years, were enrolled and randomly assigned to either ESDM or community interventions for 27 months. Children assigned to ESDM intervention received three months of weekly parent coaching followed by 24 months of one-on-one treatment about 15 hours per week in homes or daycare settings from supervised therapy assistants. Parents received coaching four hours monthly from a certified ESDM therapist. In the community setting, hours of treatment varied by site.
What researchers found was that at two of the three sites, children receiving ESDM had significantly more language improvement than the children in the community interventions, and there was no significant difference in language gain at the third site between the two modalities. When results from all three sites were pooled, there was a significant advantage for the children in the ESDM group overall.
“Language is the bridge to learning,” Rogers said. “Language is the door that opens up social communication and education and interactions with people in your community. It’s how you share with people. It’s a main vehicle for social interaction once you pass infancy.”
Autism treatment in the community greatly improved over time
The study also found that in terms of cognition and social skills, both the ESDM and community treatment groups made significant gains. Fortunately, Rogers said, laws requiring insurance coverage for early autism intervention and new knowledge about effective treatment have greatly improved community options for families seeking help for young children diagnosed with autism.
Rogers said families with a child diagnosed with autism should take some comfort knowing that the early treatments now widely available do make a difference.
“It says the autism scores at the time of diagnosis are just a starting point,” she said. “It says that the developmental paths and learning capacity of young children with autism are more plastic than we knew, and there are many ways to get learning opportunities to them.”
In addition to Rogers, UC Davis authors on the study were Marie Rocha, Laurie Vismara and Meagan Talbott. Other co-authors on the study included: Annette Estes and Jessica Greenson of the University of Washington; Catherine Lord and Jamie Winter of Weill Cornell Medicine, Cornell University; Costanza Colombi of University of Michigan; Geraldine Dawson of Duke University, and Gerhard Hellemann of UCLA.
This study was supported by individual Autism Speaks grants to Annette Estes and to Sally Rogers and by NIMH/NICHD award number R01 081757 as part of the Autism Centers of Excellence (ACE) Treatment Network, clinicaltrials.gov identifier NCT 00698997.
Ten Signs of Possible Autism-Related Delays in 6- to 12-Month-Old Children
Though autism is often not diagnosed until the age of three, some children begin to show signs of developmental delay before they turn a year old. While not all infants and toddlers with delays will develop autism spectrum disorders (ASD), experts point to early detection of these signs as key to capitalizing on early diagnosis and intervention, which is believed to improve developmental outcomes.
According to Dr. Rebecca Landa, director of the Center for Autism and Related Disorders at the Kennedy Krieger Institute in Baltimore, Md., parents need to be empowered to identify the warning signs of ASD and other communication delays. “We want to encourage parents to become good observers of their children’s development so that they can see the earliest indicators of delays in a baby’s communication, social and motor skills,” says Dr. Landa, who also cautions that some children who develop ASD don’t show signs until after the second birthday or regress after appearing to develop typically.
For the past decade, Dr. Landa has followed infant siblings of children with autism to identify red flags of the disorder in their earliest form. Her research has shown that diagnosis is possible in some children as young as 14 months and sparked the development of early intervention models that have been shown to improve outcomes for toddlers showing signs of ASD as young as one and two years old. Dr. Landa recommends that as parents play with their infant (6 – 12 months), they look for the following signs that have been linked to later diagnosis of ASD or other communication disorders: 1. Rarely smiles when approached by caregivers2. Rarely tries to imitate sounds and movements others make, such as smiling and laughing, during simple social exchanges3. Delayed or infrequent babbling4. Does not respond to his or her name with increasing consistency from 6 – 12 months 5. Does not gesture to communicate by 10 months6. Poor eye contact7. Seeks your attention infrequently8. Repeatedly stiffens arms, hands, legs or displays unusual body movements such as rotating the hands on the wrists, uncommon postures or other repetitive behaviors9. Does not reach up toward you when you reach to pick him or her up10. Delays in motor development, including delayed rolling over, pushing up and crawling
“If parents suspect something is wrong with their child’s development, or that their child is losing skills, they should talk to their pediatrician or another developmental expert,” says Dr. Landa. “Don’t adopt a ‘wait and see’ perspective. We want to identify delays early in development so that intervention can begin when children’s brains are more malleable and still developing their circuitry.”
About the Kennedy Krieger Institute Internationally recognized for improving the lives of children and adolescents with disorders and injuries of the brain and spinal cord, the Kennedy Krieger Institute in Baltimore, MD serves more than 16,000 individuals each year through inpatient and outpatient clinics, home and community services and school-based programs. Kennedy Krieger provides a wide range of services for children with developmental concerns mild to severe, and is home to a team of investigators who are contributing to the understanding of how disorders develop while pioneering new interventions and earlier diagnosis. For more information on Kennedy Krieger Institute, visit: www.kennedykrieger.org.
Photo by Quin Stevenson
BINGHAMTON, NY – Children with autism spectrum disorder (ASD) are more likely to experience bullying than children without ASD and this bullying gets worse with age, according to new research from Binghamton University, State University of New York.
Hannah Morton, a graduate student in the clinical psychology PhD program at Binghamton University, aimed to conceptualize bullying in children with ASD in order to specifically identify different bullying and behavior types. Her research also emphasizes the need to establish better definitions of bullying behaviors.
“This research is important because it contributes to our understanding of how bullying is nuanced,” said Morton. “This variability means it is crucial to establish a definition for bullying and have standard assessments to know when and what types of bullying are occurring.”
Morton, along with Binghamton psychologists Jennifer Gillis, Richard Mattson and Raymond Romanczyk, focused this study on teachers and parents of children with ASD, and community members without an ASD child. Participants took a survey containing 80 scenarios of interactions between two school-aged children. The scenarios varied from children ages four to fifteen. Sixty-four of these scenarios contained a type of bullying behavior (i.e. physical, verbal, interpersonal and cyber). The participants were randomly presented with 16 scenarios, and were asked to rate the severity of the interaction between the two children, as well as indicate which types of bullying were present.
Results showed that a child’s increased age predicted higher bullying severity ratings. The findings also showed that bullying among older children with ASD is viewed as especially problematic by their parents, and that perceived bullying severity differed according to the type of bullying behavior (i.e., physical, verbal, interpersonal, and cyber).
“This paper emphasizes that bullying is a really broad construct,” said Morton. “What any two people might be referring to when they use the term ‘bullying’—regardless if they are parents, teachers, researchers, etc.— likely differs, and perhaps in subtle ways.”
Morton plans to further her research on this topic by focusing specifically on the bullying behaviors that children with ASD experience compared to children without ASD.
This research was conducted through Binghamton University’s Institute for Child Development, which offers early intervention services, speech services and more to children and families in the Binghamton region.
A drug commonly given to autistic children to reduce repetitive behaviors is ineffective compared to placebo and, in some children, may actually increase repetitive behaviors, the largest study of autistic children to date has found.
“What we found, much to our surprise, is that there was no significant difference in positive response between kids treated with citalopram and kids who received the placebo. And the kids treated with citalopram tended to have more side effects,” said Linmarie Sikich, M.D., a co-author of the study and associate professor of psychiatry in the University of North Carolina at Chapel Hill School of Medicine.
“I cannot emphasize this enough: This was not at all what we expected to see,” Sikich said.
Results of the study, a randomized controlled clinical trial of the drug citalopram, are published in the June 29, 2009 issue of Archives of General Psychiatry. It was funded by the National Institutes of Health and took place at six academic medical centers across the country. Principal investigator and lead author of the study is Bryan H. King, M.D., who began the study at Dartmouth and continued to oversee it there after he moved to the University of Washington, where he is currently director of psychiatry and behavioral medicine at Seattle Children’s Hospital.
Citalopram, which is sold under the brand name Celexa, is one of a class of antidepressant drugs called selective serotonin reuptake inhibitors, or SSRIs. SSRIs are the most frequently used medications for children with autism. They are also used to treat depression, anxiety and obsessive compulsive disorder in both adults and children. Prior to this study there was very little scientific evidence to support the use of SSRIs in autistic children, but some preliminary studies showed promising results for citalopram, Sikich said.
Hypothesizing that citalopram would improve the overall functioning of autistic children and adolescents by reducing repetitive behavior, Sikich and colleagues recruited 149 children ages 5 to 17 to take part in the 12-week trial. Seventy-three received daily doses of liquid citalopram while 76 received daily doses of liquid placebo. Researchers measured the children’s’ response to treatment using the Clinical Global Impression-Improvement scale (CGI-I). They also recorded measures of repetitive behavior and side effects.
At the end of the trial, some children in both groups showed a positive response. However, there was no significant difference between the groups: the positive response in the citalopram group was 32.9 percent versus 34.2 percent in the placebo group. In addition, children in the citalopram group were significantly more likely to experience adverse side effects such as increased energy level, impulsiveness, decreased concentration, hyperactivity, increased repetitive movements and behaviors, diarrhea, insomnia, and dry itchy skin.
The researchers concluded that citalopram “is not an effective treatment” for autistic children with repetitive behaviors. In addition, they wrote, this trial shows that the use of SSRIs in autistic children “is not without risk” and “at present there is insufficient research evidence to merit a clear recommendation regarding the use of SSRIs as a class” for the treatment of repetitive behavior in children with autism spectrum disorders.
“The obvious short term message is, this treatment didn’t work. And that surprised us a great deal,” Sikich says. “But the really important take-home message is that we have to do large, scientifically-sound comparative studies like this to really know whether a specific treatment works and is safe. Simply relying on doctors’ and families’ impressions often leads us to use medications that really don’t work and may do more harm than good” says Sikich.
Safe and effective medication and behavioral treatments are desperately needed to help children with autism realize their potentials and keep from harming themselves or others, Sickish says.
“Well-done studies, using methods like the ones in this study, have shown that another drug, risperidone, is useful in reducing irritability and aggression in children with autism,” she says. “Thus, this study shouldn’t be interpreted as saying all medications don’t help people with autism and are harmful. Instead it says that citalopram doesn’t help most children with autism and is harmful to some children. Clearly we need more research to develop and test other interventions for this important problem.”
People with autism are severely impaired by the disorder and experience major problems with highly repetitive behaviors, often including self-injurious behaviors, communicating and interacting appropriately with others. Frequently the repetitive behaviors keep children with autism from learning in school or participating in age appropriate activities. When it is time to stop the repetitive behavior and begin a new, functional activity, many children with autism become distraught and aggressive. These repetitive behaviors also contribute to the difficulties that make it hard for most people with autism to live independently or work as adults, Sikich says.
In addition to UNC, academic medical centers taking part in the study were Mt. Sinai School of Medicine, North Shore-Long Island Jewish Health System, Dartmouth, UCLA and Yale University.
The study was conducted as part of the NIH-sponsored Studies to Advance Autism Research and Treatment network.