Speech Emerges In Children On The Autism Spectrum With Severe Language Delay At Greater Rate Than Previously Thought

New findings published in Pediatrics (Epub ahead of print) by the Kennedy Krieger Institute’s Center for Autism and Related Disorders reveal that 70 percent of children with autism spectrum disorders (ASD) who have a history of severe language delay, achieved phrase or fluent speech by age eight. This suggests that more children presenting with ASD and severe language delay at age four can be expected to make notable language gains than was previously thought. Abnormalities in communication and language are a defining feature of ASD, yet prior research into the factors predicting the age and quality of speech attainment has been limited.

The study used the largest sample to date to examine the relationship between key deficits associated with ASD and attainment of phrase and/or fluent speech following a severe language delay, characterized by a child not putting words together into meaningful phrases by age four. As a common milestone of speech development, phrase speech is defined as using non-echoed three-word utterances that sometimes involve a verb and are spontaneous meaningful word combinations; whereas fluent speech is defined as the ability to use complex utterances to talk about topics outside of the immediate physical context.

“We found that nonverbal intelligence was the strongest predictor of phrase speech, while social interest and engagement were as robust, if not greater, when predicting the age that children attained phrase speech and fluent speech,” said Ericka L. Wodka, Ph.D., a neuropsychologist in Kennedy Krieger’s Center for Autism and Related Disorders and lead study author. “Children with typical nonverbal intelligence attained language almost six months ahead of those with scores below the average.”

These findings reinforce that core abilities, such as nonverbal intelligence and social engagement, have a greater influence on the development of communication than other behaviors associated with ASD, such as repetitive and abnormal sensory behaviors. “Our findings continue to support the importance of considering both nonverbal intellectual level and social communication in treatment planning, highlighting the differing impact of these factors as related to treatment goals,” said Dr. Wodka.

Data for this retrospective study were from the Simon Simplex Collection (SSC), a unique multi-site database project that gathers biological and phenotypic data on children with ASD aged four- to eighteen-years-old without a previous genetic history of ASD. The database establishes a permanent repository of genetic samples from 2,700 families, each of which has one child affected with an ASD and unaffected parents and siblings.

From the SSC, a total of 535 children, ages eight years or older, were studied. Using the Autism Diagnostic Interview-Revised (ADI-R), a standard parent-interview that distinguishes children with ASD from non-ASD populations, and the Autism Diagnosis Observation Schedule (ADOS), a clinician-administered observation that assesses social, communicative and stereotyped behaviors, researchers selected children because they either had no phrase speech at their time of enrollment in the SSC or their phrase speech onset occurred after age four. Based on ADI-R results and their language presentation, children in this study were administered one of four evaluation modules – no words or single words (Module 1), phrase speech (Module 2) or fluent speech (Module 3 or 4). Of the 535 participants in the study, 119 children mastered phrase speech and 253 children were speaking fluently by their eighth birthday, while 163 children never attained phrase or fluent speech

“We hope the results of this study empower parents of children with autism and severe language delays to know that, with the appropriate therapy, a child will likely make significant gains in this area over time; however, progress should be expected to be slower for those children with lower intellectual abilities,” said Dr. Wodka. “Additionally, we hope these findings provide clinicians with better defined therapeutic targets for their patients with autism.”

Future longitudinal studies, including both simplex and multiplex families, are required to fully capture the prevalence and predictors of language development in children with ASD. Additionally, further research into the impact of social cognition strategies (e.g., perspective taking) on the development of language, as well as the relationship among specific social deficits and fluent speech development, may hold important implications to the design of intervention.

Source: Kennedy Krieger Institute

Thanks to Sue Marinez for alerting me to this report.

Most Children with ASD Diagnosed After Age 5, Use Multiple Services and Medications

Fewer than one out of five school-aged children with special health care needs were diagnosed with autism spectrum disorder (ASD) by age 2, according to new data from an NIMH-funded study. These diagnoses were made by a variety of health care providers, and most children in the study used multiple health care services (such as speech or language therapy) and multiple medications.

Background

Identifying ASD at an early age allows children to start treatment sooner, which can improve their later development and learning, and may also reduce a child’s need for specialized services or treatments later in life.

To determine the experiences of school-aged children with special health care needs, Lisa Colpe, Ph.D., M.P.H., and Bev Pringle, Ph.D., of the NIMH Division of Services and Intervention Research, collaborated with colleagues who conducted more than 4,000 telephone interviews with parents or guardians of a child between the ages of 6-17 who had a confirmed diagnosis of ASD, intellectual disability, and/or developmental delay.

These survey interviews were a part of the Pathways to Diagnosis and Services Study, sponsored by NIMH using funds available from the American Recovery and Reinvestment Act of 2009 (Recovery Act). Additional collaborators on this project include the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC) and the Maternal and Child Health Bureau at the Health Resources and Services Administration (HRSA).

Results of the Study

Key findings include:

• The median age when school aged children with special health care needs and ASD were first identified as having ASD was 5 years.
• Those identified as having ASD at younger than 5 years were diagnosed most often by generalists (such as pediatricians, family physicians, and nurse practitioners) and psychologists. Those identified later than 5 years were diagnosed primarily by psychologists and psychiatrists.
• Nine out of ten school-aged children with special health care needs and ASD used at least one health care service, such as behavioral intervention or modification services, sensory integration therapy, cognitive based therapy, occupational therapy, physical therapy, social skills training, or speech or language therapy.
  • Social skills training and speech or language therapy were the most commonly used service, each used by almost 60 percent, or three out of five, of these children.
• More than half of school-aged children with special health care needs and ASD used at least one psychotropic medication. “Psychotropic medication” refers to any medication used to treat a mental disorder.
  • Almost 33 percent of these children used stimulant medications
  • 25 percent used anti-anxiety or mood-stabilizing medications
  • 20 percent used antidepressants.

Further findings are available in the NCHS Data Brief and Frequently Asked Questions.

Significance

The new data detail the experiences of young children with ASD, describing when they are first identified as having ASD, who is making those identifications, and the services and medications the children use to meet their developmental needs.

What’s Next

NIMH encourages researchers to access and analyze the new dataset to produce more studies on the early life experiences and the diagnostic, service, and treatment issues relevant to children with ASD and special health care needs. The Pathways to Diagnosis and Services Study dataset can be accessed at http://www.cdc.gov/nchs/slaits/spds.htm.

Reference

Pringle BA, Colpe LJ, Blumberg SJ, Avila RM, Kogan MD. Diagnostic History and Treatment of School-Aged Children with Autism Spectrum Disorder and Special Health Care Needs. NCHS data brief, no 97. Hyattsville, MD: National Center for Health Statistics. 2012.

Source: NIMH

Participation in Social Activities among Adolescents with an Autism Spectrum Disorder

There’s a new study out this month on socialization in teens with ASD by Paul T. Shattuck, Gael I. Orsmond, Mary Wagner, and Benjamin P. Cooper:

Background

Little is known about patterns of participation in social activities among adolescents with an autism spectrum disorder (ASD). The objectives were to report nationally representative (U.S.) estimates of participation in social activities among adolescents with an ASD, to compare these estimates to other groups of adolescents with disabilities, and examine correlates of limited social participation.

Methods and Findings

We analyzed data from wave 1 of the National Longitudinal Transition Study 2, a large cohort study of adolescents enrolled in special education. Three comparison groups included adolescents with learning disabilities, mental retardation, and speech/language impairments. Adolescents with an ASD were significantly more likely never to see friends out of school (43.3%), never to get called by friends (54.4%), and never to be invited to social activities (50.4%) when compared with adolescents from all the other groups. Correlates of limited social participation included low family income and having impairments in conversational ability, social communication, and functional cognitive skills.

Conclusions

Compared with prior research, our study significantly expands inquiry in this area by broadening the range of social participation indicators examined, increasing the external validity of findings, focusing on the under-studied developmental stage of adolescence, and taking an ecological approach that included many potential correlates of social participation. There were notable differences in social participation by income, a dimension of social context seldom examined in research on ASDs.

The complete research report is available as a free resource online, here (pdf).

Having done a first reading of it, it confirmed my guess that a lot of the significant social impairment they noted was limited to those with more severe communication deficits and lower IQs. Indeed, their overall findings are likely to somewhat overestimate the extent of socialization problems in teens with an ASD because their sample was drawn from those who are classified for special education under the Autism category. As many of us know, students who are high-functioning (e.g., students with Asperger’s Disorder) are often not categorized under the Autism category and are categorized under “Other Health Impairment” or some other category. That said, if your child has severe communication deficits and an IQ <85, these results are likely to be applicable. Not surprisingly, perhaps, families with greater financial resources have children who participate in more social activities.

When thinking about why teens with ASD engage in less socialization outside of school, one factor that I want to mention here is that there are likely fewer opportunities in communities for youth with ASD than for youth with other challenges. As part of advocacy efforts, parents can help their children by working with community agencies to create more opportunities for socialization. Stuck for ideas? Try contacting the child psychiatry department at a large hospital and ask them if they will work with you to create some programs. And try contacting the special education program at a nearby university and see if you can get their staff and students to work with you creating a camp or outings or other opportunities for socialization.

As parents, we tend to spend a vast amount of our energy on dealing with schools and doctors/therapists, but there is much to be done in the community. When my son was young, I routinely went to camps I had picked out for him and arranged to train all the staff so that they could understand him and so that he could attend a regular camp. It was a wonderful experience for him and the camps would subsequently be more available to other children with similar problems.

As one of the overheads Sherry Pruitt and I use in our workshops says: Everything in Life is Social. If your child’s life outside of school is not providing enough socialization opportunities, network with other parents and reach out to agencies and programs in your area to see what you can develop. If your child needs it, there are probably at least 10 other children around who need it, too.

Training Peers Improves Social Outcomes for Some Kids with ASD

Children with autism spectrum disorder (ASD) who attend regular education classes may be more likely to improve their social skills if their typically developing peers are taught how to interact with them than if only the children with ASD are taught such skills. According to a study funded by the National Institutes of Health, a shift away from more commonly used interventions that focus on training children with ASD directly may provide greater social benefits for children with ASD. The study was published online ahead of print on November 28, 2011, in the Journal of Child Psychology and Psychiatry.

“Real life doesn’t happen in a lab, but few research studies reflect that,” said Thomas R. Insel, director of the National Institute of Mental Health (NIMH), a part of NIH. “As this study shows, taking into account a person’s typical environment may improve treatment outcomes.”

The most common type of social skills intervention for children with ASD is direct training of a group of children with social challenges, who may have different disorders and may be from different classes or schools. The intervention is usually delivered at a clinic, but may also be school-based and offered in a one-on-one format. Other types of intervention focus on training peers how to interact with classmates who have difficulty with social skills. Both types of intervention have shown positive results in studies, but neither has been shown to be as effective in community settings.

Connie Kasari, Ph.D., of the University of California, Los Angeles, and colleagues compared different interventions among 60 children, ages 6-11, with ASD. All of the children were mainstreamed in regular education classrooms for at least 80 percent of the school day.

These children were randomly assigned to either receive one-on-one training with an intervention provider or to receive no one-on-one intervention. The children were also randomized to receive a peer-mediated intervention or no peer-mediated intervention. The two-step randomization resulted in four intervention categories, each with 15 children who had ASD:

• Child-focused: direct, one-on-one training between the child with ASD and intervention provider to practice specific social skills, such as how to enter a playground game or conversation
• Peer-mediated: group training with the intervention provider for three typically developing children from the same classroom as the student with ASD; the affected student did not receive any social skills training. The participating children were selected by study staff and teachers and were taught strategies for engaging students with social difficulties.
• Both child-focused and peer-mediated interventions
• Neither intervention.

All interventions were given for 20 minutes two times a week for six weeks. A follow-up was conducted 12 weeks after the end of the study. After the follow up phase, all children with ASD who had received neither intervention were re-randomized to one of the other treatment categories.

Children with ASD whose peers received training—including those who may also have received the child-focused intervention—spent less time alone on playgrounds and had more classmates naming them as a friend, compared to participants who received the child-focused interventions. Teachers also reported that students with ASD in the peer-mediated groups showed significantly better social skills following the intervention. However, among all intervention groups, children with ASD showed no changes in the number of peers they indicated as their friends.

At follow-up, children with ASD from the peer-mediated groups continued to show increased social connections despite some of the children having changed classrooms due to a new school year and having new, different peers.

According to the researchers, the findings suggest that peer-mediated interventions can provide better and more persistent outcomes than child-focused strategies, and that child-focused interventions may only be effective when paired with peer-mediated intervention.

In addition to the benefits of peer-mediated interventions, the researchers noted several areas for improvement. For example, peer engagement especially helped children with ASD to be less isolated on the playground, but it did not result in improvement across all areas of playground behavior, such as taking turns in games or engaging in conversations and other joint activities. Also, despite greater inclusion in social circles and more frequent engagement by their peers, children with ASD continued to cite few friendships. Further studies are needed to explore these factors as well as other possible mediators of treatment effects.

The study was supported by NIMH, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Neurological Disorders and Stroke, and the National Institute on Deafness and Other Communication Disorders through the Studies to Advance Autism Research and Treatment (STAART)network program and received additional funding from the Health Resources and Services Administration (HRSA).

Reference

Kasari C, Rotheram-Fuller E, Locke J, Gulsrud A. Making the Connection Randomized Controlled Trial of Social Skills at School for Children with Autism Spectrum Disorders. J Ch Psychol Psychiatry. 2011 Nov 28. [epub ahead of print]

Clinical Trials Number: NCT00095420

Source: National Institute of Mental Health

Can oxytocin help social skills in individuals with autism?

Two studies out this month and next suggest that oxytocin inhalation may be of benefit.   Here are the abstracts:

 Andari E, Duhamel JR, Zalla T, Herbrecht E, Leboyer M, Sirigu A: Promoting social behavior with oxytocin in high-functioning autism spectrum disorders. Proc Natl Acad Sci U S A. 2010 Mar 2;107(9):4389-94.

Social adaptation requires specific cognitive and emotional competences. Individuals with high-functioning autism or with Asperger syndrome cannot understand or engage in social situations despite preserved intellectual abilities. Recently, it has been suggested that oxytocin, a hormone known to promote mother-infant bonds, may be implicated in the social deficit of autism. We investigated the behavioral effects of oxytocin in 13 subjects with autism. In a simulated ball game where participants interacted with fictitious partners, we found that after oxytocin inhalation, patients exhibited stronger interactions with the most socially cooperative partner and reported enhanced feelings of trust and preference. Also, during free viewing of pictures of faces, oxytocin selectively increased patients’ gazing time on the socially informative region of the face, namely the eyes. Thus, under oxytocin, patients respond more strongly to others and exhibit more appropriate social behavior and affect, suggesting a therapeutic potential of oxytocin through its action on a core dimension of autism.

Guastella AJ, Einfeld SL, Gray KM, Rinehart NJ, Tonge BJ, Lambert TJ, Hickie IB: Intranasal oxytocin improves emotion recognition for youth with autism spectrum disorders. Biol Psychiatry. 2010 Apr 1;67(7):692-4.

BACKGROUND: A diagnostic hallmark of autism spectrum disorders is a qualitative impairment in social communication and interaction. Deficits in the ability to recognize the emotions of others are believed to contribute to this. There is currently no effective treatment for these problems. METHODS: In a double-blind, randomized, placebo-controlled, crossover design, we administered oxytocin nasal spray (18 or 24 IU) or a placebo to 16 male youth aged 12 to 19 who were diagnosed with Autistic or Asperger’s Disorder. Participants then completed the Reading the Mind in the Eyes Task, a widely used and reliable test of emotion recognition. RESULTS: In comparison with placebo, oxytocin administration improved performance on the Reading the Mind in the Eyes Task. This effect was also shown when analysis was restricted to the younger participants aged 12 to 15 who received the lower dose. CONCLUSIONS: This study provides the first evidence that oxytocin nasal spray improves emotion recognition in young people diagnosed with autism spectrum disorders. Findings suggest the potential of earlier intervention and further evaluation of oxytocin nasal spray as a treatment to improve social communication and interaction in young people with autism spectrum disorders. Copyright 2010 Society of Biological Psychiatry.

This is not the first time that oxytocin has been suggested as a possible treatment for autism-related social skills deficits. The first suggestion was in 1992, and there have been almost 100 articles and reports since then discussing the possibility. While the results are encouraging, I do not mention the studies here as a suggestion that parents run out and start this treatment for their children. But if you’d like to know more or perhaps participate in clinical trials, see the federal government’s site for studies that are recruiting participants.

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