230

J. Indian Assoc. Child Adolesc. Ment. Health 2016; 12(3):230-252

Award paper Niloufer Award 2015

The effectiveness of an intensive, parent mediated, multi-component, early

intervention for children with autism

Raman Krishnan, Merlin Thanka Jemi Alwin Nesh, Paul Swamidhas Sudhakar Russell,

Sushila Russell, Priya Mammen

Address for correspondence: Dr Raman Krishnan, Associate Professor, Saveetha Medical

College, Chennai. Email : dr_ramkrish@yahoo.com

Abstract

Aim: Most children with autism do not receive early intervention, unless parents are

trained, in countries with low child mental health resources. To maximize the existing

resource, we evaluated the feasibility and effectiveness of an intensive, parent mediated,

multi-component, early intervention for autism in India.

Methods: Data of 77 children with an ICD-10 diagnosis of autism who completed a 12-

week, five days a week, intervention program and regular practice at home was collected

from the database of a teaching hospital. Intervention components included the standard

intervention protocol, the Psycho-Educational Profile intervention (PEP-R) and the

Carolina Curriculum for Infants and Toddlers with Special Needs. Pre and post-

intervention PEP-R rating of parents were used to evaluate the intervention outcome.

Appropriate bivariate, multivariate and resampling techniques were used to evaluate the

intervention effectiveness.

Results: The effect size (ES) for the intervention was moderate to large for the PEP-R

developmental age as well as perception, fine motor, gross motor, eye-hand coordination,

231

cognitive performance and cognitive verbal domain among children with mild to

moderate (ES ranged from 0.70 to 0.88) and severe autism (ES ranged from 0.73 to 0.87).

There was no difference in the intervention effect between the groups (ES ranged from

0.004 to 0.30). The effectiveness of the intervention continued after controlling the

confounding effect of baseline developmental quotient, developmental age and adaptive

skills.

Conclusion: It is feasible to provide an effective parent mediated early intervention for

mild to severe autism in countries where parents are the cornerstone in childhood

disability care.

Key Words: Autism, effectiveness, early intervention, parent-mediated, India.

Introduction

Prevalence of autism is greater than previously recognised at 116.1 per 10 000 [1]. As

impairment emerge during the first three years of life [2], early diagnosis followed by

early intervention can improve outcomes for individuals with autism, possibly more than

in any other developmental disability [3,4].

While there is no cure for autism, an array of interventions like Applied Behavioural

Analysis, Communication-focussed Intervention, Developmental Interventions,

Integrative Programs, Sensory-motor Interventions have been proposed to improve the

symptoms associated with autism. Although reviews of many of the above interventions

show either no or modest intervention effects [5], found them complex and resource

intensive [6], those treatments that demonstrated intervention gain have not only

232

ameliorated autistic symptoms but improved adaptive functioning and parent-child

dyadic relationship [7-10].

Interestingly, among the many intervention models available, parent mediated early

interventions are known to have the most significant intervention effects which have not

been tested in low and middle income countries with paucity of child mental health-care

resources [11]. Therefore, the current study was designed to evaluate: (1) if it is feasible

to provide a therapist guided, parent mediated, multi-component, early intervention for

children with autism in a country with low child mental health resources; (2) if this

multi-component intervention program, which is an integration of a standard autism

treatment protocol combined with the Psycho-Educational Profile intervention (PEP-R)

and The Carolina Curriculum for Infants and Toddlers with Special Needs (CCITSN), is

effective for children with autism; (3) if the intervention is more effective for either the

mild to moderate or severe autism group.

Methods

Setting and sample

This study was conducted at the Autism Clinic, Child and Adolescent Psychiatry Unit of a

tertiary care, teaching hospital in South India. The charts of children and adolescents

enrolled for autism training either for a residential or day care program with complete

data set were identified from the unit’s database for a three-year period. The enrolled

toddlers and children had an ICD-10 based clinical diagnosis of Autism Spectrum

Disorder (Pervasive Developmental Disorder). Children with a diagnosis of Overactive

disorder associated with mental retardation and stereotyped movements (F84.4) were

233

excluded because of its uncertain nosological status [12]. All clinical diagnoses were

made by consultant psychiatrists and endorsed by the multidisciplinary team with a mean

(SD) clinical experience of 12.74(8.21) years.

Measures

The Psycho-Educational Profile-Revised (PEP-R) [13] was developed to assess children

with autism and formulate their Individualized Education Programs (IEP). The

Developmental Scale of PEP-R assesses the overall functioning of the child, the

developmental age, based on the imitation, perception, fine motor, gross motor, eye-hand

coordination, cognitive performance and cognitive verbal subscales. The PEP-R also

includes a Behavioral Scale, which is used to identify the degree of behavioral

abnormality The Developmental Scale of PEP-R has been validated for children with

autism in India [14]. The pre-intervention and post-intervention PEP-R scores rated, in

terms of improvement in months, was used as the intervention outcome measure in this

study.

The Childhood Autism Rating Scale (CARS) [15], is a 15-item behavior-rating scale,

designed to detect and quantify symptoms of autism. Children with scores of 30.5 to 37

are rated as mildly–moderately autistic, and 37.5 to 60 as severely autistic by CARS. This

measure has been validated for India [16].

Gesell’s Developmental Schedule (GDS) [17] gives the developmental skills in four

areas in months: motor behavior, adaptive behavior, language and personal as well as

social behavior.

234

Vineland Social Maturity Scale (VSMS) [18] measures the adaptive skills of the child in

eight areas in weeks: self help general, self help dressing, self help eating, socialization,

self direction, communication, locomotion and occupation.

As the baseline GDS developmental quotient and VSMS adaptive skills can confound the

intervention outcome independent of the severity of autism both had to be controlled in

this study [19, 20].

The study was reviewed and approved by the local institutional review board.

Intervention

Within the first week of starting the intervention and at end of 12th week the parent

assisted by the therapists assessed the child using the PEP-R and CCITSN assessment

schedules. This clinic based multi-component early intervention package had three

components.

(1) the standard clinical intervention being used for the past 11 years in the clinic that

included training in self-care skills, social skills and control of problem behaviour using

special education and behavioural techniques. Throughout the 12-week program, the

parents, using interactive group psycho education technique, were taught about various

aspects of autism and developmental disabilities. This psycho education module is

proven to improve the knowledge and attitude of the parents towards developmental

disability [21].;

(2) The PEP-R intervention [22] included teaching activities from Individualized

Assessment and Treatments for Autistic and Developmentally Disabled Children,

235

Teaching Strategies for Parents and Professionals and Teaching Activities for Autistic

Children and

(3) the CCITSN module [23] addressed the intellectual disability component with focus

mainly on cognition, communication, social adaptation, fine motor, and gross motor of

the children using a developmental approach.

Each session of the therapist guided, parent mediated intervention process would start

with a 10-minute briefing about the goals for the day which are set on a weekly basis.

The child was engaged in play routines and social stories and each parent–child dyad

received applied behaviour analysis aimed at improving the behavioural control and

interactive skills of parents using principles of rewarding and guided practice. The whole

intervention was in the form of closed group sessions conducted five times a week by two

therapists and each session lasted for 4 hours. The parents were encouraged to continue

the intervention, at home using adaptations to suit the home environment. Participation

from other significant family members was encouraged.

Data analysis

Non-parametric analyses were used because of the relatively small and skewed sample.

The baseline differences between the groups were analyzed using Fisher’s Exact Test and

Mann-Whitney U test for the categorical and continuous variables respectively. To

compare the change in PEP-R scores within the mild to moderate and severe autism

group, before and after intervention, Wilcoxon matched pair rank test was used. Based on

the median of the post and pre intervention PEP-R scores, within groups and between

groups, the effect size (ES) for both groups was calculated using the formula r=z/n. For

236

the comparison of difference (post-pre intervention) between the groups, Mann-Whitney

U test was used. Also, 95% confidence intervals were calculated by resampling with

replacement, using boot strapping (1000 times), for all the effect sizes. In addition, for the

outcomes, multiple regression analysis was used to take into account the possible

confounding effect of the developmental age, adaptive skills and baseline PEP-R

developmental age imbalance autism groups. P<0.05 (2-tailed test) was considered

significant. Statistical analyses were performed using the SPSS (version 19) and R

(Version 2.14.2).

Results

Participant and baseline characteristics

The mean (SD) chronological age of the children was 3.66(1.64) years. There were more

boys (81.8%) than girls (18.2%) in the sample. The chronological age (mild vs. severe =

3.74 (1.86) vs. 3.64 (1.59), z=-0.20; P=0.8) in the mild to moderate and severe autism

group were comparable at the baseline. Similarly, other socio-demographic and clinical

variables were not different between the groups (Table 1).

As expected, the mean (SD) CARS score [mild vs. severe = 34.03 (1.58) vs. 41.24

(2.88), z= -5.95; P=0.001] was statistically different between the groups. Also the GDS

developmental quotient [mild vs. severe = 62.62 (19.27) vs. 48.08 (14.11); z=-2.76;

P=0.006] and VSMS adaptive functioning [mild vs. severe = 2.71 (1.03) vs. 2.04 (0.73);

z=-2.48; P=0.01] were statistically significantly different between the groups.

The mean (SD) outcome measure, total PEP-R score (developmental age), at the baseline

was statistically significantly different between the groups [mild vs. severe =

25.43(11.13) vs. 17.13(7.18), z=-2.72; P=0.007]. Similarly, the domains of imitation,

237

238

perception, fine-motor, gross motor, eye hand integration, cognitive performance and

cognitive verbal were statistically significantly different between the mild and severe

autism groups.

Feasibility of parent mediating intervention

The attrition of parents from this intensive multi-component early intervention was only

2% over three months of training and there was no difference between the groups.

Clinical observations demonstrated that parents were able to implement different aspect

of the intervention effectively. The ability to continue the training at home, for about 3 to

4 hours a day (high level) was observed in 74% of the parents. There was no difference

between the groups in participation by other family members in the training.

Effectiveness of the intervention within group

The intervention was effective in children with mild to moderate and severe autism in the

bivariate analysis (Table 2). The mean (SD) gain in the total PEP-R score (developmental

age) was 9.88 (3.47) months and 7.50 (1.97) months among those with mild to moderate

and severe autism respectively. The effect size (ES) for the intervention, as indicated by

the PEP-R developmental age, was 0.87 for both groups indicating a large effect size.

The effect size for the various PEP-R subscale scores also varied between 0.70 to 0.88 for

the mild to moderate autism group and 0.73 to 0.87 for the severe autism group,

indicating moderate to large effect size for the intervention. The confidence intervals for

the effect sizes, indicated that the intervention effects would fall within the mentioned

range 95% of the time and remain significant even if the study were to be repeated as

many as thousand times (Table 2).

239

240

Effectiveness of the intervention between groups

In the bivariate analysis, when the post-intervention differences in the total and subscale

PEP-R scores was compared, there was no statistically significant difference except in the

cognitive verbal subscale (Table 3). The mean (SD) gain in the developmental age was

2.37 (1.16) months between autism groups. The effect size for the intervention was 0.21

between the mild and severe autism group. The intervention effect for the PEP-R

subscales of cognitive verbal and cognitive perceptual was 0.20 and 0.30 respectively

suggesting a small intervention effect. The effect size for all the other PEP-R subscales

varied between 0.004 and 0.18 indicating no difference in the intervention effect between

the groups. The confidence intervals for the effect sizes, indicated that the intervention

effects would fall within the mentioned range 95% of the time and remain insignificant

even if the study were to be repeated as many as thousand times (Table 3).

In the multivariate analyses, despite controlling for the possible confounding effect of the

developmental age, adaptive functioning and the baseline PEP-R differences, neither the

post-intervention total PEP-R-score nor any other subscale demonstrated a statistically

significant difference between the groups (Table 4).

241

Discussion

In summary, the findings of this study are that: (1) it is feasible to provide a parent

mediated multi-component, early interventions for children with autism in a low child

mental health resource country; (2) this intervention is effective for enhancing the PEP-R

developmental age and its domains for children with autism (both mild to moderate and

severe group). It is proven that it is critical to include parents in the early intervention for

242

243

autism and without parental participation the intervention gains are unlikely to be

maintained [24]. The observation based on this real world study can pave way to

primary-care intervention models involving parents.

The overall intervention gain in this study was an increase in the developmental age of

about 9 and 7.6 months during the 3 month training among children with mild to

moderate and severe autism respectively. The within group intervention effect size (ES)

of 0.87 in our study was comparable with the effect size of 0.88, 0.82 and 0.80 reported

in the literature [25-27] but lesser than that documented by others [28-30]. Our

intervention effect size was far better than the -0.05 reported by Salt et al [31].

The intervention was equally effective in the mild to moderate and severe autism group

except for the cognitive verbal domain. This difference in the cognitive verbal domain

did not persist when the confounders were controlled. Similar intervention effectiveness

across varying severity of autism has also been documented in the literature although

effect sizes are not available [32].

We speculate that our intervention was greatly effective, firstly, because of the

integration of the multiple components as it also addressed the adaptive behaviour and

behavioural problems. Studies documenting the efficaciousness of various multi-

component interventions have consistently revealed that they improve the developmental

age significantly (ES = 0.92 to 1.35), develops play behaviours (ES = 0.84 to 1.18) [33],

decreases symptoms of autism (ES = 2.27) [34] , improves other abilities like perceptual–

fine motor, cognition, language, social/emotional (ES = 0.66 to 1.04) and

244

receptive/expressive language skills (p =0.001, ES = 1.64) had significantly improved

with multi-component intervention [34], which is much similar to our finding.

Secondly, the parent involvement possibly has been an enhancing factor in the outcome

measure in this study which is reported in literature as well [35-38]. When parents were

used as co-therapists in the training of their children, pre-academic skills (ES=0.59),

problem behaviours (ES= 1.07 to 1.38) (36), face gaze (ES=1.04) and socialisation

(ES=1.27), autism symptom clusters (ES = 0.86) [39] and language skills (ES=0.86) had

significantly improved. It is also known that parents can be trained to effectively

implement early interventions for children as young as 3 years of age [40].

Thirdly, the early intervention could have played a role in the intervention success. The

mean age of the children in our study was 3.66(1.64) years, possibly the earliest age that

can be enrolled for clinical intervention in a country with poor awareness about autism

[41]. The role of early intervention in improving outcome has been documented [42].

Fourthly, the intervention program was intensive in its approach and perhaps enabled

children to learn skills. Our intervention was for 4 hours a day for 5 days a week for 12

weeks. Intensive approaches have been known to bring about significant therapeutic

effects in areas of intelligence, self-help, pre-academic skills, communication (ES=0.57

to 2.14) [43,33] and autistic symptoms (ES = 2.58) in a previous study [45].

Finally, closely related to the intensity is the treatment duration. Although the clinic

based treatment was only for 20 hours a week, the parents seemingly followed training at

home, which couldn’t be quantified. A rough estimate is that the parents would have

achieved about 20 to 40 hours of total training a week. Although the recent studies show

245

that longer treatments, of more than 40 hours, yielded positive outcome (ES = 0.86 to

2.11) [46] considering home setting, researchers suggest at least 30 hours of training [30].

Limitations would include its retrospective design. The generalisability is compromised

as the study children have greater familial resources and less heterogeneity than those

served in community settings [47]. But these children in clinical setting present more

challenges [48] and hence this study which has participants closer to real world improves

the external validity of our finding.

In conclusion, we document that it is feasible to provide an intensive, therapist guided,

parent mediated, multi-component, early intervention program in an Indian setting. In

future, the best age for intervention, optimal intensity, duration of treatment and parental

involvement as predictive factors need to be quantified, and thus prospective pragmatic

trials with factorial design are warranted.

References

1. Baird G, Simonoff E, Pickles A, et al: Prevalence of disorders of the autism spectrum

in a population cohort of children in South Thames: the Special Needs and Autism

Project (SNAP). Lancet 2006, 368(9531): 210-15.

2. Bethea TC, Sikich L: Early pharmacological treatment of autism: a rationale for

developmental treatment. Biol Psychiatry 2007,61(4): 521-37.

3. Olley JG: Curriculum and classroom structure. In: Volkmar FR, Paul R, Klin A,

Cohen D, eds. Handbook of autism and pervasive developmental disorders. 3rd edn.

New Jersey: J. Wiley & Sons; 2005: 863-881.

246

4. Lipkin PH, Schertz M: Early intervention and its efficacy. In: Accardo PJ, Paul H.

Brookes, eds. Capute and Accardo's Neurodevelopmental Disabilities in Infancy and

Childhood: Neurodevelopmental diagnosis and treatment. Vol I. 3rd edn. . Baltimore

MD: 2008; 519– 552.

5. Ospina MB, Krebs Seida J, et al: Behavioural and developmental interventions for

autism spectrum disorder: a clinical systematic review. PLoS One 2008, 3(11): e3755.

6. Motiwala SS, Gupta S, Lilly MB, Ungar WJ, Coyte PC: The cost-effectiveness of

expanding intensive behavioural intervention to all autistic children in Ontario.

Healthcare Policy 2006, 1(2): 135–151.

7. Aldred C, Green J, Adams C: A new social communication intervention for children

with autism: pilot randomised controlled treatment study suggesting effectiveness. J

Child Psychol Psychiatry 2004 Nov; 45(8): 1420-30.

8. Tonge B, Brereton A, Kiomall M, Mackinnon A, King N, Rinehart N: Effects on

parental mental health of an education and skills training program for parents of

young children with autism: a randomized controlled trial. J Am Acad Child Adolesc

Psychiatry 2006 May; 45(5): 561-9.

9. Ben Itzchak E, Lahat E, Burgin R, Zachor AD: Cognitive, behavior and intervention

outcome in young children with autism. Res Dev Disabil. 2008 Sep-Oct; 29(5): 447-

58.

10. Dawson G, Rogers S, Munson J, et al: Randomized controlled trial of an intervention

for toddlers with autism: the Early Start Denver Model. Pediatrics 2010 Jan; 125(1):

e17-23.

247

11. McConachie H, Diggle T: Parent implemented early intervention for young children

with autism spectrum disorder: a systematic review. J Eval Clin Pract. 2007 Feb;

13(1): 120-9.

12. Sponheim E: Changing criteria of autistic disorders: a comparison of the ICD-10

research criteria and DSM-IV with DSM-III-R, CARS, and ABC. J Autism Dev

Disord. 1996 Oct; 26(5): 513-25.

13. Schopler E, Reichler RJ, Bashford A, Lansing MD, Marcus LM: Individual

assessment and treatment for autistic and developmental disabled children.

Psychoeducational Profile Revised (PEP-R), Vol I. Pro-Ed. Austin TX: 1990.

14. Alwin Nesh MTJ, Joseph RBJ, Daniel A, Abel JS, Shankar SR, Mammen P, Russell

S, Russell PS: Psychometrics and utility of Psycho Educational Profile-Revised (PEP-

R) as a Developmental quotient measure among children with the dual disability of

intellectual disability and autism. Journal of Intellectual Disabilities (in press).

15. Schopler E, Reichler RJ, Renner BR: Childhood Autism Rating Scale. Los Angeles:

Western Psychological Services;1988.

16. Russell PS, Daniel A, Russell S, Mammen P, Abel JS, Raj LE, et al: Diagnostic

accuracy, reliability and validity of Childhood Autism Rating Scale in India. World J

Pediatr. 2010 May; 6(2): 141-7.

17. Gesell A: The first five years of life: The preschool years. New York: Harper and

Brothers publishers;1940.

18. Doll EA: A Genetic Scale of Social Maturity. American Journal of Orthopsychiatry,

1935; 5: 180-188.

248

19. Ben Itzchak E, Zachor DA: The effects of intellectual functioning and autism

severity on outcome of early behavioral intervention for children with autism. Res

Dev Disabil. 2007 May-Jun; 28(3): 287-303.

20. Gordon K, Pasco G, McElduff F, Wade A, Howlin P, Charman TA: Communication-

based intervention for nonverbal children with autism: what changes? Who benefits?

J Consult Clin Psychol. 2011 Aug; 79(4): 447-57.

21. Russell PS, John JK, Lakshmanan JL: Family intervention for intellectually disabled

children. Randomised controlled trial. Br J Psychiatry 1999 Mar; 174: 254-8.

22. Schopler E, Reichler RJ, Lansing MD: Teaching Strategies for Parents and

Professionals: Individualized Assessment and Treatment for Autistic and

Developmentally Disabled Children. Vol II. Pro-ed. Austin, TX: 1980.

23. Johnson-Martin NM, Jens GK, Attermeier SM, Hacker BJ: The Carolina Curriculum

for Infant and Toddlers with special Needs, 2nd edn. Baltimore, Maryland: Paul H.

Brookes Publishing Co; 1991.

24. Whalen C, Schreibman L, Ingersoll B: The collateral effects of joint attention

training on social initiations, positive affect, imitation, and spontaneous speech for

young children with autism. J Autism Dev Disord. 2006 Jul; 36(5): 655-64.

25. McEachin JJ, Smith T, Lovaas OI: Long-term outcome for children with autism who

received early intensive behavioral treatment. Am J Ment Retard. 1993 Jan; 97(4):

359-72.

26. Shallows, Graupner TD:Replicating Lovaas' treatment and findings: Preliminary

results. PEACH Putting Research into Practice Conference, London: 1999.

249

27. Lovaas OI: Behavioral treatment and normal educational and intellectual functioning

in young autistic children. Journal of Consulting and Clinical Psychology, 1987; 55:

3-9.

28. Eikeseth S, Jahr E, Eldevik E: Intensive school-based behavioral treatment for four to

seven year old children with autism: A one-year follow-up. PEACH Putting Research

into Practice Conference, London: 1999.

29. Smith T: Outcome of early intervention for children with autism. Clinical

Psychology: Science and Practice 1999; 6: 33-49.

30. Smith T, Groen AD, Wynn JW: Randomized trial of intensive early intervention for

children with pervasive developmental disorder. Am J Ment Retard. 2000; 105: 269-

85.

31. Salt J, Shemilt J, Sellars V, Boyd S, Coulson T, McCool S: The Scottish Centre for

autism preschool treatment programme. II: The results of a controlled treatment

outcome study. Autism 2002 Mar; 6(1): 33-46.

32. Rogers SJ, Vismara LA: Evidence-based comprehensive treatments for early autism.

J Clin Child Adolesc Psychol. 2008 Jan; 37(1): 8-38.

33. Rogers SJ, Lewis H: An effective day treatment model for young children with

pervasive developmental disorders. J Am Acad Child Adolesc Psychiatry 1989 Mar;

28(2): 207-14.

250

34. Rogers SJ, DiLalla D: A comprehensive study of a developmentally based preschool

curriculum on young children with autism and young children with other disorders of

behavior and development. Topics in Early Childhood Special Education 1991; 11:

29-48.

35. Dawson G, Osterling J: Early intervention in autism. In: Guralnick MJ, ed. The

Effectiveness of Early Intervention. Baltimore MD: Paul H. Brookes Publishing Co.,

1997; 307-326.

36. Robbins FR, Dunlap G: Effects of task difficulty on parent teaching skills and

behavior problems of young children with autism. Am J Ment Retard. 1992 May;

96(6): 631-43.

37. Ozonoff S, Cathcart K: Effectiveness of a home program intervention for young

children with autism. J Autism Dev Disord. 1998 Feb; 28(1): 25-32.

38. Jocelyn LJ, Casiro OG, Beattie D, Bow J, Kneisz J: Treatment of children with

autism: a randomized controlled trial to evaluate a caregiver-based intervention

program in community day-care centers. J Dev Behav Pediatr. 1998 Oct; 19(5): 326-

34.

39. Zappela M: Young autistic children treated with ethologically oriented family

therapy. Family Systems Medicine 1990; 8 (1): 14-27.

40. Moes DR, Frea WD: Contextualized behavioral support in early intervention for

children with autism and their families. J Autism Dev Disord. 2002 Dec; 32(6): 519-

33.

251

41. Daley TC, Sigman MD: Diagnostic conceptualization of autism among Indian

psychiatrists, psychologists, and pediatricians. J Autism Dev Disord. 2002 Feb; 32(1):

13-23.

42. National Research Council. Educating children with autism. Committee on

Educational Interventions for Children with Autism. Division of Behavioral and

Social Sciences and Education. Washington, DC: National Academy Press, 2001.

43. Anderson SR, Avery DL, DiPietro EK, et al: Intensive home-based early intervention

with autistic children. Education & Treatment of Children. Special Issue: New

developments in the treatment of persons exhibiting autism and severe behavior

disorders 1987; 10(4): 352-66.

44. Sheinkopf SJ, Siegel B: Home-based behavioral treatment of young children with

autism. J Autism Dev Disord 1998 Feb; 28(1): 15-23.

45. Weiss MJ: Differential rates of skill acquisition and outcomes of early intensive

behavioral intervention for autism. Behavioral Interventions 1999; 14(1): 3-22.

46. Schleien SJ, Mustonen T, Rynders JE: Participation of children with autism and

nondisabled peers in a cooperatively structured community art program. J Autism

Dev Disord. 1995 Aug; 25(4): 397-413.

47. Lord C, Wagner A, Rogers S, Szatmari P, Aman M, Charman T, et al: Challenges in

evaluating psychosocial interventions for Autistic Spectrum Disorders. J Autism Dev

Disord. 2005 Dec; 35(6): 695-708.

252

48. Cochran-Smith M, Lytle S: Relationships of knowledge and practice: Teacher

learning in communities. In: Iran-Nejar A, Pearson PD, eds. Review of research in

education. Washington, DC: American Educational Research Associates, 1999.

Raman Krishnan, Associate Professor, Saveetha Medical College, Chennai , Merlin

Thanka Jemi Alwin Nesh – Psychologist, Christian Medical College, Vellore,Paul

Swamidhas Sudhakar Russell- Professor and Head, Sushila Russell,Assistant Professor,

Clinical Psychology, Priya Mammen, Professor, Child and Adolescent Psychiatry,

Christian Medical College, Vellore.