Slide 1

Early Identification and Intervention for Autism Spectrum Disorders

Washington Speech-Language Hearing Association

Annette Estes

October 8-10, 2015

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Slide 2 Overview

• What is an Autism Spectrum Disorder (ASD)?

• When can we first see ASD?– Current research on early identification

• What can we do?– Current research on early intervention

– Long-term outcomes of early intervention

– Putting research into practice

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Slide 3 Autism Spectrum Disorder (ASD)

• ASD is a neurodevelopmental disorder1

• The collection of symptoms vary from individual to individual2

• Prevalence: 1 in 68; 1 in 42 boys to 1 in 189 girls

• Co-occurring disorders include: Intellectual disability, ADHD, Learning Disorders, Mood Disorders, Speech Disorders

http://www.cdc.gov/ncbddd/autism/index.html

1 DSM-V, 2013; 2 Siegel, 1996

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Slide 4 Diagnosis of Autism Spectrum Disorder: DSM-5

*Social & Communication

Deficits

*Fixated Interests *Repetitive Behaviors

*Rigidity

*Hyper-/Hypo-Sensory

Differences

*Slide adapted from Jennifer Gerdts, Ph.D.

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Slide 5 ___________________________________

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Slide 6 Early risk signs:12-24 months of age

• Social• Less social orienting• Less initiation of social interaction• Less sustained engagement• Less coordinated engagement

• Communication• Limited gestures• Delayed language milestones possible

• Repetitive Behavior* • Present but mild• Repetitive play with objects

(*RRB- Wolff, JJ., Botteron, KN, Dager, SR, Elison, JT, Estes, AM, Gu, H., Hazlett, HC, Pandey, J., Paterson, SJ, Schultz, RT, Zwaigenbaum, L., Piven, J. Longitudinal patterns of repetitive behavior in toddlers with autism. Journal of Child Psychology and Psychiatry, doi: 10.1111/jcpp.12207 (epub ahead of print)

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Slide 7

Children’s Hospital of Philadelphia

Washington UniversityUniversity of Utah

University of Washington

University of Alberta

McGill University

IBIS (Infant Brain Imaging Study) NetworkNIH Autism Center of Excellence (www.ibis-network.org) Piven, PI

UW: Dager, EstesWash U: Botteron, McKinstryCHOP: Schultz, PatersonUNC: Piven, Hazlett

Data Core: EvansImage processing: Gehrig, StynerBehavioral Core: Estes, Zwaigenbaum

University of North Carolina

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Slide 8 IBIS-Infant Brain Imaging Study

• Focus on infants with older siblings with autism– Recurrence risk for infants with older siblings with

ASD about 20% (e.g., Ozonoff et al, 2011)

– Risk for other learning and developmental difficulties about 30% (Messinger et al., 2013)

• Assess and monitor infants at-risk before symptoms emerge

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Slide 9 IBIS Research Design

Devel. evaluationMRI

Clinical feedbackGenetic testing

Devel. evaluationMRI

Clinical feedback

6 month 12 month

Diagnostic evaluationMRI

Clinical feedback

24 month

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Slide 10 Development in infants at high-risk for ASD in the first two years of life

N = 49

N = 222

N =107N = 4

(Estes et al., 2015, Behavioral, cognitive, and adaptive development in infants with autism spectrum disorder in the first two years of life. Journal of Neuro Dev Disorders)

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Slide 11 Cognitive Development: Mullen Scales of Early Learning

• Mullen Early Learning Composite score

– Visual Reception

– Expressive Language

– Receptive Language

– Fine Motor

– Gross Motor

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Slide 12 Gross motor trajectories

+ group trajectory differences- Increase in differences over time+ differences at 6 months

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Slide 13 Visual reception trajectories

+ group trajectory differences+ Increase in differences over time+ differences at 6 months

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Slide 14 Adaptive Functioning: Vineland Adaptive Behavior Scales

• Vineland Adaptive Behavior Composite

– Communication

– Social

– Daily Living Skills

– Motor

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Slide 15 Adaptive functioning: Composite

+ group trajectory differences+ increase in differences+ differences at 6 months

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Slide 16 Adaptive functioning: Motor

+ group trajectory differences- increase in differences over time+ differences at 6 months

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Slide 17 IBIS 6 MONTH-OLD DTI RESULTS:

HR+ VS HR-

Wolff et al, AJP- 2014

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Slide 18 IBIS findings: developmental

differences detected by 6 months of age

• Development may differ as early as 6 months

– Motor development

– Visual reception/non-verbal problem solving

• Alterations in development are not yet clinically significant delays

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Slide 19 Early diagnosis

• Early risk-signs typically precede the full syndrome

• The full ASD syndrome presents in almost all children by 36 months of age

• Some babies have the full syndrome before 12 months

• Most babies can be diagnosed by 24 months

• Average age of diagnosis in the US is 4-6 years– 4 year gap from symptoms to diagnosis

– Over 1 year gap between first evaluation and diagnosis

• Most children don’t have access to high quality early intervention for ASD

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Slide 20 Age of onset vs age of diagnosis

Median age of first diagnosis: 5 years old*

*National Center for Health Statistics databrief, 2012

Most children show signs by 24 months

Fully manifest ASD symptom expression at 9 months is rare, but possible

Fully manifest ASD symptom expression starting at 36 months or later is rare, and likely due to missed earlier signs

Age of full expression of ASD

symptoms

9 mos 36 mos

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Slide 21 What can we do?

• Start intervention as soon as possible after ASD symptoms emerge– Early identification allows early intervention– Early intervention = improved outcomes– Early intervention reduces ASD symptoms in children

• Provide intervention and support across the lifespan– People with ASD usually need support at all steps,

school age through adults

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Slide 22

model design outcomes

Remington

2007

Lovaas DTT Community tx

group, 44 ss

++IQ, language

Wetherby and

Woods 2006

Early Social

Interaction

Community tx

group, n=17

++on commun.

targets

Dawson et al

2010

ESDM RCT, 48 ss ++IQ, language,

AB, sx

Published efficacy findings of comprehensive

Interventions for children under age 3

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Slide 23 The Early Start Denver Model (ESDM)

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Slide 24 What is the ESDM?

Curriculum Specific teaching practices

For home programs, group programs,parent training, or disciplinary therapies

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Slide 25 Intervention Throughout the DayToddlers interact all day long

With parents*** In preschool

1:1 interactions With peers

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Slide 26 Early intervention improves outcomes(Dawson et al., 2010, Pediatrics)

(Estes et al., 2015, JAACAP)

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Slide 27 Study design

• 48 toddlers with ASD, ages 18-30 months

• Randomized to ESDM or Community intervention as usual

• Provided with annual diagnosis and developmental evaluations

• ESDM group offered 20 hrs per week in home 1:1 treatment and 2 parent training sessions per month

• COM group received individualized recommendations based on research evaluation and families pursued intervention in the community.

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Slide 28 Child outcomes after comprehensive intensive early intervention

(Dawson et al., 2010)

• Intervention with ESDM for 1-2 years begun before 30 months was effective in

– improving IQ

– improving communication

– reducing diagnostic severity

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Slide 29 Child outcomes at age 6: 2 years after early intervention is

over(NIH and Autism Speaks, U54MH066399, Estes, PI)

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Slide 30 Participants

• The same children who were randomized to ESDM or community intervention beginning at 18-30 months of age

• Thirty-nine children available for follow-up – (ESDM n=21; COM n=18)

– 6 years of age at follow-up

– 72% Caucasian,

– 9 girls (30 boys)

– Mothers on the whole were highly educated

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Slide 31 Cognitive changes-age 2, 3, 4, 6 years

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Slide 32 Cognitive changes-age 2, 3, 4, 6 years

ES 0.18 0.61 0.58 0.42

T1/18mos T2 T3 T4/age 6

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Slide 33 Autism symptom severity-age 2, 3, 4, 6 years

ES 0.17 0.42 0.18 0.60

T1/18 mos T2 T3 T4/age 6

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Slide 34

2

18321

T3/4 year old

outcome diag

T1

baseline diagnosis

2714 1 5 0

AD AD PDD-NOS

AD PDD AD PDD AD PDD

6

PDD-NOS

115

AD PDD

ESDM COM

Diagnostic outcomes

12 7

T4/6 year old

follow-up dx**

AD PDD No Dx AD PDD No Dx

14 4 0

**Attrition age 6

3 ESDM, 3 COM

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Slide 35 Summary

• Early intervention may have lasting effects – Gains maintained 2 years post treatment

• Evidence for continued gains post EI– 4 years old (end of intervention)- No group

differences in ASD symptom severity

– 6 years old (2 yrs post intervention)– Group differences in ASD symptom severity

(Estes et al., 2015, JAACAP)

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Slide 36 Discussion

• The ESDM group showed improved core symptoms from 4-6 years age- at the same time as receiving significantly less intervention

• Both the Community and ESDM groups increased intellectual ability from 4 -6 years old

• Future research is needed with families who are less educated, lower resource, rural and from multiple different cultures

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Slide 37 We gratefully acknowledge the families who have

participated in these studies

AND

our funding agencies

NIH & Autism Speaks

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Slide 38 UW Autism Center Mission

Clinical Services

Training

Research

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Slide 39 Research to Practice

UW AC Infant Clinic • Assess and monitor development in infants at-risk

for ASD

• Provide very early diagnosis for infants under 24 months

• Offer seamless transition to individualized intervention as soon as ASD symptoms emerge

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Slide 40 Research to Practice

Early Intervention Services • Evidence-based Applied Behavior Analysis (ABA) geared

to the developmental level of the child

• Individualized in-home programs and short-term problem-focused treatment

• Team of trained paraprofessionals deliver in-home intervention under supervision

• Support parents as they build a team tailored to the needs of their child and family

• Train Registered Behavior Technicians (RBTs)

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Slide 41 Research to Practice

Apex Summer Camp• Evidence-based program

• Age 6-12 years of age

• Children with ASD, ADHD, siblings and peers

• Over 80 campers

• Over 40 counselors and staff

• Weekly Booster Camp during the school year

– Magic the Gathering pilot program for 12-16 year olds with ASD

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