Research Pinpoints Early Signs of Autism and Develops Key Intervention Programs for Toddlers
Autism is the nation’s fastest growing developmental disorder, with current incidence rates estimated at 1 in 110 children. This year, more children will be diagnosed with autism than AIDS, diabetes and cancer combined, yet profound gaps remain in our understanding of both the causes and cures of the disorder. Continued research and education about developmental disruptions in individuals with autism is crucial, as early detection and evidence-based intervention can lead to improved outcomes in individuals with autism.
One of the nation’s leading programs for autism research is the Center for Autism and Related Disorders at the Kennedy Krieger Institute in Baltimore, MD. As director of this multi-faceted, multidisciplinary program for children with autism spectrum disorders (ASD) and their family members, I work together with my team to conduct research to understand how to promote development in toddlers who show social and communication delays. This research includes direct intervention with the children as well as approaches for parent training and parent education.
In 2007, our study published in the Archives of General Psychiatry found that approximately half of all children with autism can be diagnosed around the first birthday. The most common very early signs of autism include poor eye contact, infrequent response to his or her name being called, infrequent attempts to initiate communication with others and the presence of repetitive behaviors. By identifying these early signs of autism, we open the door to early intervention, which can provide toddlers with tools and skills to increase social opportunities throughout their lifetime, positioning them to have the best possible outcomes. The “wait and see” method, which is still often recommended to concerned parents, could lead to missed opportunities for early intervention.
The importance of early intervention for all medical and behavioral diagnoses is well recognized. In the case of autism, early intervention not only helps to put children’s development on a healthier track, it may also serve to prevent certain difficulties, such as aggressive behavior, additional delays and the development of unusual learning styles. Early learning experiences are important, particularly in the first three years of life, because the brain is most malleable early in life. As children learn, there are anatomic and physiologic changes in the brain. The brain literally changes the way it develops, with healthy and more mature connections within and across brain areas.
In a 2010 study published in the Journal of Child Psychology and Psychiatry, my fellow Kennedy Krieger researchers and I found that early intervention can improve the core symptoms of ASD in very young children. This was the first randomized clinical trial measuring how a group-based early intervention model impacts social development in toddlers with ASD. Participants included two groups of 24 toddlers with ASD, ages 21 to 33 months, who received identical intervention for six months. However, one group received a greater number of orchestrated opportunities for social engagement. This specially designed socially-directed intervention provided organized opportunities to respond to and initiate joint attention (pointing out things of interest, showing and giving for social purposes), imitate others during social interaction and share positive affect (smiling paired with eye contact). The most significant improvements were found in how the children connected and socialized with others, a defining stumbling block for children with autism.
We placed a heavy focus on the ability of toddlers to pay attention to other people’s actions and communication behaviors and prepare them to respond and initiate with others in socially appropriate ways. This is critically important because it opens the door to ongoing learning opportunities for toddlers with ASD. When toddlers are attuned to people, people are more motivated to stay engaged with them. Additionally, children learn through imitating others. The ability to connect with peers through imitation can open the door to acceptance and being chosen as a playmate in the classroom or on the playground, for example.
We found that children in both groups showed improvements. However, the most significant finding was that the children who received the specialized socially-directed intervention developed greater socially engaged imitation, which increased from 17 percent of imitated acts being paired with eye contact prior to the intervention to 42 percent at the end of the intervention. This skill was generalized, or carried over into “real life” outside the classroom, and maintained through the six-month follow-up. Similar improvements were observed in the group for initiation of joint attention and shared positive affect. Specifically, how frequently toddlers initiated joint attention more than tripled from pre- to post- treatment, and the shared positive affect more than doubled. Overall, the children receiving the socially-directed intervention made 10 months of non-verbal cognitive gains in only six months time. The second most significant finding was that toddlers in both groups made improvements in expressive language (spoken language), with the greatest gains occurring during the time that the intervention was taking place. These results indicate that the improvement was due to the intervention.
From this study, several very important findings have emerged. We have found that the degree of social impairments involving imitation, face-to-face emotion sharing and initiation of social communication are diminished through these specially-designed interventions. In addition, gains in language and cognitive skills also occurred for children enrolled in these intervention programs. Gains are strongest when an intervention is comprehensive, addresses multiple aspects of development, and when there is a concerted effort to improve social learning. Gains are also improved when parents consistently attend parent-training sessions. For best results, therapists must use a comprehensive curriculum and create learning opportunities that are meaningful and motivating for children. They must build on children’s strengths, interests and existing knowledge. It is important to find creative ways to engage children with different types of toys and to help young children learn how to use toys together in meaningful ways (putting blocks in a dump truck, putting a spoon into a cup and “stirring”). Play and interaction routines should be established to help children predict what will happen and respond in appropriate ways. As children learn these routines, new twists in the action should be introduced in order to help children learn to apply their new skills in different ways. A continuum of adult-imposed structure should be used in early intervention, such that children have opportunities for guided play and discovery within natural contexts as well as explicit instruction targeting isolated skills.
Through our research, the Early Achievements intervention model has been empirically-validated. This cost-effective model offers a combination of center-based and parent-mediated intervention. The model is novel in that it is anchored in the developmental sciences, yet integrates principles of applied behavior analysis. The unique combination of group and individual intervention in the center-based component offers children the opportunity to learn with and from peers, as well as to receive intensive, highly individualized intervention. We are hopeful that the socially-directed early intervention model can achieve similar social skills gains in older children.
For more information about the Center for Autism and Related Disorders at the Kennedy Krieger Institute in Baltimore, MD, please visit www.kennedykrieger.org or call (443) 923-9200.
