presentatie autisme escap 2015m4 madrid how_malleable_is_autism_escap_post
TRANSCRIPT
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How malleable is autism? Outcome studies of the youngest
children with ASD
Sally J. Rogers University of California Davis
MIND Institute
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AcknowledgementsNICHD U19 HD 85468 (Rogers) NIMH R01 MH 081757 (Rogers) NIDCD DC R03 05574 (Rogers) NIMH U54 MH66399 (Dawson) OSERS #G008100247 (Rogers) NICHD R21 065275 (Rogers) Autism Speaks, NAAR, CAN
OAR, MIND (Vismara) OSERS (Rogers) MIND Institute
Coleman Institute Children’s Miracle Network
John & Marcia Goldman Foundation
Geraldine Dawson Laurie Vismara Diane Osaki Annette Estes Cathy Lord Jeff Munson Nick Lange Giacomo Vivanti Greg Young Maria Rocha Jamie Winter Children and families
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Conflict of interest
royalties honoraria
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Mse
l ELC
20
30
40
50
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70
80
90
2 yr 9 yr
Lord et al., 2006
20
30
40
50
60
70
80
90
2-3 yr 10-12 yr
ASD Other ID
Sigman & Ruskin, 1999
IQ scores in ASD across childhood
n 79
n 42
n 84
n 50
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Life Magazine, May 7, 1965 “Screams, Slaps, and Love”
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The game-changer Lovaas,1987; McEachin et al 1993
40
50
60
70
80
90
32 mon age 7-8 13 yr
Exp Comp
IQ scores
40
50
60
70
80
90
Adaptive Behavior at 13
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Meta-analysis of DTT studiesReichow & Wohler, 2009
.69
Effect Size
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Remington 2007 Lovaas Early Intensive Behavioral Intervention
Wetherby et al, 2006, 2015 Early Social Interaction
Dawson, Rogers et al 2010 Early Start Denver Model (ESDM)
High intensity, global intervention models. How much
can impairment be reduced? (Rogers & Vismara, 2013)
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Wetherby ESI 2014: change scores
*
***ESI-1:1ESI-Group
**
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Early Start Denver Model ASD specific Comprehensive Interdisciplinary Integrates developmental and
learning science Evidence-based teaching Data-based
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2010 outcomes from RCT of ESDM versus community care (Dawson et al., 2010)
Mul
len
Com
posi
te S
tand
ard
Scor
e
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50
60
70
80
90
100
Baseline 1 year 2 years
InterventionCommunity
p < .05
IQ Language
p < .05
(Dawson NIMH U54 MH66399)
p < .05
p < .05
15
22
29
36
43
50
Baseline 2 years
p < .05
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Replication: ESDM in 1:4 groups Vivanti, Dissanayake et al., 2014
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80
90
IQ 1 IQ2
ESDM n=27ASD n=30
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50
60
70
80
90
Adapt 1 Adapt 2
*p=.05
30405060708090
Rec Lang1 Rec Lang2
*p=.05
*p=.05
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+ COMM TxESDM Tx
Gains last for years
(Estes et al., 2015)
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• Hard to isolate effective elements
• Cost • Complex to learn and
deliver
Strengths Weaknesses
• Significant change • In multiple areas • Unified approach
High intensity, comprehensive interventions
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Low intensity models: target a specific change
with a specific procedure
Kasari et al, 2015 JASPER: Joint attention, engagement, symbolic play
Ingersoll et al, 2012, 2012 Reciprocal Imitation: RIT
Green, et al, 2015 VIPP: Video Interaction for Producing Positive Parenting
Steiner et al, 2013 PRT: Pivotal Response Training
Baranek et al, 2015 Responsive Teaching + social commun, sensory reg
sensory regulation
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Effective with other groups
Allow for intensity, generalization
Implementable using distance technology
More than 5 with demonstrated efficacy
Parent Implemented Interventions
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Process: How many interventionists think about it
Professional ChildParent
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How it really goes
Professional
Child
Parent
Other family and Care providers
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New: Parent-ESDM from a distance; effects on child communication
Vismara et al, in press
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Parallel Processes
Procedural & declarative
Hands on, guided learning
Goal focused,self-assessed
Much practice
Mastery
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Effective Low cost Low intensity Brief Parent learning
No long term data Addresses a few needs Not meant to stand alone Requires variety of plans to address all needs
Strengths Weaknesses
Low intensity models
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Biology of autism
Child does not adequately engage in social learning
Increasing social deprivation due to isolating effects of autism
Lack of social learning alters course of neural and psychological development
Model: Interactional Effects of AutismMundy 1995, Dawson et al.1998
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Smiles per minGaze per min
Directed voc per min Quality soc engage
25 25
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DQ scores of infant sibs (n=48) who develop ASD and comparisons (n=92) (Ozonoff et al)
Mse
l EL
C
60
75
90
105
120
6m 9m 12m 18 m 24 m 36 m
ASDTD
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Can we begin sooner?Rogers & Vismara, NICHD R21 HD065275; Autism Speaks
Decreased gaze, social interest
Little intentional communication
Little coordinated voice, gaze, gesture
Delayed phonemic development
Visual fixations on objects Atypical repetitive behaviors
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Treated Group/Refused Group
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Five comparison groups: autism onset, declined enrollment, high risk (sibs), low risk, treated
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The most effective interventions
30
Majority have skills in normal range by 6-7.
90% (ESDM) spontaneous, generative, phrase or sentence speech, by 4.
How is this possible?
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Phenotype is emerging
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Phenotype is emerging Neural readiness
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Phenotype is emerging Neural readiness
Positive emotion
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Phenotype is emerging Neural readiness
Positive emotion
Social attention - resonance
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Phenotype is emerging Neural readiness
Positive emotion
Social attention - resonance
Targeted learning, enrichment
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Phenotype is emerging Neural readiness
Positive emotion
Social attention - resonance
Targeted learning, enrichment
Self-righting
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Phenotype is emerging Neural readiness
Positive emotion
Social attention - resonance
Targeted learning, enrichment
Self-righting
Growth or compensation?
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How do we move forward?
to find them?
to diagnose them?
to treat them?
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30–50% concerns by 12 months
Age of first concern = 18 – 19 months
Age of U.S. diagnosis 48 – 53 months (CDC, 2012)
Find them
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Find them
pediatric contacts news articles parent advocacy groups autism treatment groups child care educational groups
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Age 3 Clinical best estimate outcomes Of 294 infant sibs Ozonoff et al, 2014
Monitor sibs
Find them
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Diagnose them
Use formal tools: screeners and tests Good screeners
Infant-Toddler Checklist (ITC) 6 – 24 months http://firstwords.fsu.edu/pdf/checklist.pdf
Modified Checklist for Autism in Toddlers 16 – 30 months https://www.m-chat.org
Good tests Autism Observation Scale for Infants (AOSI) ADOS-Toddler Module
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Early diagnosis provisional, descriptive
Goal of early diagnosis is early treatment
Cannot predict outcomes from infant behavior
If parents did not want to know, they would not be here
Infant mental health mindset
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Act for earlier evidence-based services
Learn, provide a parent-implemented tx
Find those already seeing infants and network
Use your influence in public children’s services
We need to help families get more treatment availability
Treat them
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Prevent
Reverse
Improve