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Summary of Advances Cover 2018

Summary of Advances

In Autism Spectrum Disorder Research


Question 4: Which Treatments and Interventions Will Help?

Cluster randomized trial of the classroom SCERTS intervention for elementary students with autism spectrum disorder.
Morgan L, Hooker JL, Sparapani N, Reinhardt VP, Schatschneider C, Wetherby AM. J Consult Clin Psychol. 2018 Jul;86(7):631-644. [PMID: 29939056]

Nearly half a million school-aged children in the United States are estimated to have ASD, therefore it is critical to identify and optimize interventions that will improve their school experiences. While several classroom-based interventions have been developed, researchers have faced several obstacles in assessing the efficacy of these interventions. Additionally, staffing challenges, availability of resources, and teachers’ time constraints pose significant barriers to the high-fidelity implementation of the interventions.

The researchers in this study therefore sought to evaluate the effectiveness of the recently-developed Classroom Social Communication, Emotional Regulation, and Transactional Support (SCERTS) Intervention (CSI). CSI is a teacher-implemented intervention in which the teacher develops individualized goals for each child with ASD to foster healthy social interactions and learning . This intervention model seeks to build students’ competence in the domains of social communication and emotional regulation, as well as provide transactional supports to address the needs and interests of each student. CSI also seeks to increase students’ active engagement in the classroom by addressing the social and learning challenges that children with ASD may face. This study was conducted over three years, from 2011 to 2014, in general and special education classrooms across 60 elementary schools in California, Florida, and Georgia. For eight months (one school year), teachers were assigned to receive either CSI or Autism Training Modules (ATM) as a control. Teachers in the ATM group had access to online training in evidence-based practices, but they were not required to complete the training or implement the practices.

To measure and compare the effectiveness of the two treatments, the researchers assessed active engagement using the Classroom Measure of Active Engagement (CMAE), which measures emotional regulation, productivity, social connectedness, directed communication, generative language production, and academic independence. Researchers used video recordings to evaluate changes in the CMAE from the beginning to the end of the study period. In addition to the CMAE, researchers measured changes in the children’s language skills and analyzed parent and teacher reports of the children’s skills and behavior. The researchers also measured the fidelity of implementation, or the degree to which teachers implemented the intervention as intended.

The researchers found that the children who received CSI scored higher in measures of social interaction at the end of treatment, relative to ATM. They also showed greater improvement in social skills and executive functioning, and their teachers reported a larger decrease in the children’s problematic behaviors. Parents reported that children in the CSI group significantly improved on the Vineland Communication Scale compared to students who received ATM. However, there was no difference in parent-reported measures of daily living skills and socialization between the two groups. The researchers also found that 70 percent of teachers trained in CSI implemented the intervention with fidelity, indicating a commitment to delivering all of the techniques detailed in the CSI.

This is one of the largest studies to measure the effect of school-based active engagement intervention in children with ASD. Due to the study’s broad sample, the results suggest that the effects of CSI are generalizable to students of diverse ethnicity, location, cognitive level, and symptom severity. Direct observation of the students through video recordings also provided an advantage over relying on teacher and/or parent reports. The researchers concluded that the results of this study show promise for teacher-implemented interventions focusing on active engagement for improving outcomes for children with ASD.

Meta-analysis of parent-mediated interventions for young children with autism spectrum disorder.
Nevill RE, Lecavalier L, Stratis EA. Autism. 2018 Feb;22(2):84-98 [PMID: 29490483]

Numerous studies have shown that children with ASD benefit from early behavioral intervention. It is recommended that children engage in at least 25 hours weekly of targeted intervention to improve social skills and reduce attention deficits; however, such intensive levels of intervention can be difficult to implement outside the home. Parents are in an ideal position to provide such intervention, and studies show that parents feel more confident and less stressed when they are trained and involved in their child’s treatment.

There have been several studies evaluating the effectiveness of parent-implemented interventions, but it has been difficult to compare multiple studies at a time due to differences in the methods used and the outcome measures. Thus, the purpose of this study was to analyze the current state of research on parent-mediated interventions for children between one and six years old. The researchers reviewed 19 randomized controlled trials that were conducted in the United States, United Kingdom, Australia, Canada, Asia, or the Netherlands between 2000 and 2015. They assessed the results of each study for changes in ASD symptom severity, socialization, communicationlanguage, daily living skills, and cognitive functioning as a result of the interventions. They also gathered data on the association between parent training and child outcomes.

They found that, in general, parent-mediated interventions resulted in small but significant improvements to children’s ASD symptom severity, socialization, and cognition, but smaller improvements in communication-language skills. In studies where parents received fewer than 20 hours of training, children were reported to have made significant improvements in communication-language skills and socialization. Meanwhile, in studies where parents received 20 or more hours of training, children were reported to have made significant improvements in socialization skills and cognition. The researchers also found that parent-rated measures were more likely to report significant improvements to the child’s communication and language skills but not their socialization skills, while clinician-reported measures found that the child’s socialization improved but not their communication and language skills.

The researchers concluded that parent-mediated intervention has only modest effects on outcomes for children. They speculate that this may be due to differences in parent training and program methodology, such as differences in hours of intervention delivered to the child and categorization of outcomes.

Are Children Severely Affected by Autism Spectrum Disorder Underrepresented in Treatment Studies? An Analysis of the Literature.
Stedman A, Taylor B, Erard M, Peura C, Siegel M. J Autism Dev Disord. 2018 Dec 10. [PMID: 30536112]

The field of ASD research has expanded over the past several years, however some experts are concerned that there is a lack of research on individuals severely affected by ASD. This research imbalance could have far-reaching implications, including a focus on the development of medical and behavioral interventions that may not address the most significant concerns of those with severe disabilities. To determine whether research on interventions and outcomes are representative of the entire ASD spectrum, the authors conducted a critical analysis of ASD treatmentrelated research published between 1990 and 2013. In addition to determining how much of the existing research focuses on individuals severely affected by ASD, the researchers also sought to examine the ways that ASD severity is classified in the literature. They used three factors to evaluate whether ASD severity was assessed in a given study: cognitive functioning, communication ability, and adaptive functioning (e.g., communication, daily living skills, and socialization).

From an initial library of 9,408 ASD research articles, the authors focused on 367 studies that involved treatment studies in children. Most of these studies included both male and female children with ASD, with average ages between 1.5 and 16 years old. Importantly, about half of these studies included individuals severely affected by ASD. The other studies either explicitly stated that severely affected individuals were not included, or inclusion was unable to be determined. Studies that assessed drug-related treatments were three times more likely to include severe ASD populations. Excluding studies in which the severity of ASD was undetermined, nearly all studies of early intervention or parent- and home-based interventions included severely affected populations.

The most common factor used to report ASD severity was cognitive function, which was used in nearly two-thirds of studies. Communication ability was used in about half of the studies, and adaptive function was the least frequently reported. Most studies only used one factor to assess severity and only 45 studies reported on all three severity domains. Between the years 1990 and 2013, inclusion of children severely affected by ASD decreased overall by 16.5 percent. Across the studies, cognitive function and communication ability was measured using 30 different scales, while only 7 different scales were used to measure adaptive function.

Though this study was limited in that it only included analysis of treatment-related research of the pediatric ASD population, the results indicate a clear decline over time in the number of studies involving those severely affected by ASD. The authors attributed this to the increased rate of diagnosis of individuals less severely affected by ASD. The researchers also note that the variability in measures used to rate severity reflects the need for the research community to assign standard rating instruments. Analyses such as this will hopefully guide the research community in its efforts to be more inclusive of the entire autism spectrum.

Question 4

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