Rebecca Landa, Ph.D., Director, Center for Autism and Related Disorders

Virginia Creating Connections to Shining StarsJuly 22, 2013

Early Intervention for Young Children with ASD:An Evidence-based Approach to Identification and Improving Outcomes

Disclosures

• None

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Thank you

• NIH• Autism Speaks• Families and children who participate• My wonderful staff

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Focus of this talk:

• Detection of autism spectrum disorders as early as possible– Early signs and trajectories

• Screening• Early intervention: Early Achievements

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Early Detection of ASD

• Why?

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Early Intervention is important because

• Early experiences influence brain development

• The brain is a thinking organ• It learns and grows by interacting with people

and objects, through perception and action• Able to continually adapt and rewire itself• Constraints – need good intervention

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Early experiences matter

Bids for attention

Attention from other

ConnectionSustained engageme

nt

Learning

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Richer, more diverse repertoire

Hopefully responsive: optimality of development

Developmental Cascades

Bids for attention

Attention from other

ConnectionSustained engageme

nt

Learning

8RewardingTomasello et al., 2005

Greater expansions in form and content

More highly specified and effectively directed

Developmental Cascades

Bids for attention

Attention from other

ConnectionSustained engageme

nt

Learning

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Less frequent

Less frequent

Briefer

Attenuated

Ambiguous, poorly integrated

Importance of early detection of ASD

• Early intervention experiences are designed to address core ASD deficits (Kasari et al., 2008; Landa et al., 2011)

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We want this:

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Landa, Holman, O’Niell, Stuart. (2011).Journal of Child Psychology and Psychiatry

Early Achievements Intervention: 1-year-olds

Note:*Purposeful*Notice each other*Imitating*Sustained meaningful engagement*Sequences of meaningful, intentional action

To understand the earliest behavioral markers of ASD

• Must begin in infancy, before we know the child will have ASD

• Research designs for doing so:

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Research Designs

• Retrospective studies – Interview parents about the past (problems with

memory of details)– Scoring home videos of older children diagnosed with

ASD• Videos made when children were infants or

toddlers

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Problem with Retrospective Designs

• Can’t control the context (cues, distractions, difficulty of task, camera angle)

• Can’t give the child specialized tests targeting specific behaviors or abilities of interest

• Can’t control the age

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Research designs

• Prospective studies– Highly efficient to study infants at increased genetic risk

for ASD– Can control the

• Age at time of assessment• Context (cues, camera angle, difficulty, distractions)• Types of tasks to study specific abilities

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To understand ASD in infants and toddlers

• Two groups studied:– High Risk (HR) for ASD: Infant siblings of children

with ASD– Low Risk (LR) for ASD: No family history of ASD

• Recently added a group at increased risk for delay, but less risk for ASD than HR infants: Preterm

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High risk for ASD

• High risk infants (younger sibs of children with ASD):

• 18.7% will have ASD (Landa et al., 2006; Landa et al., 2007; Ozonoff et al., 2011)

• 30% will have non-ASD language and social delays by the third birthday (Messinger et al., in press)

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Assessment ages

6 m 10 m

14 m

18 m

24 m

30 m

36 m

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Rate confidence of presence of ASD at each age

High Risk (HR)Low Risk (HR)

Outcome classifications

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36 month

s

ASD

Intermediate(Broader Autism Phenotype)

Unaffected

Autism Diagnostic Observation Schedule + Clinical judgment

Main points to be addressed

1. When do the signs of ASD first appear?2. What are those signs?3. What is the course of development for infants

and toddlers with ASD in the first 3 years of life?

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What are the first signs of ASD?When do the signs of ASD appear?

• At 6 months:– Signs are subtle– Most evident signs involve motor delay– Temperament: Passive– Social: Lower duration of self-generated looks to

parent

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Yellow Flags

When do the signs of ASD appear?

• At 6 months:– Signs are subtle– Most evident signs involve motor delay– Temperament: Reactivity, Distractability– Social: Lower duration of self-generated looks to

parent

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Typical head control: age 6 months

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*Baby is laid on flat surface*Make sure nothing of interest behind or above baby*Try to get baby’s attention*Gently pull on arms*Goal: Baby pulls self upward into sit with a little help

Evidence of poor postural control at age 6 months

• N=58 sibs-A at mean age 6 months• Clinical judgment of head lag scored from

videotapes of pull-to-sit item on Mullen GM Scale

ASD BAP Non Delay0

20406080

100

% with head lag

% with head lag

30%

59%

93%

How is the motor system developing in children with and without ASD?

• Participants– ASD n=52– Non ASD n=152

• Tested at 6, 14, 24, 36 months• Mullen Scales of Early Learning (Mullen, 1995)

– Fine Motor T score– Gross Motor T score

• Delay: scoring at least 1.5 standard deviations below the test mean on either motor scale

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% ASD and non ASD with motor delay from 6-36 months

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Motor Delay: Fine Motor and/or Gross Motor T score <35

6 mo 14 mo 24 mo 36 mo0

10

20

30

40

50

60

70

ASDNon ASD

% w

ith m

otor

de

lay

Examples of Mullen Early Motor Items

Gross Motor Fine Motor

Supports self on forearms when on tummy

Grasp reflex

Sits with support, head control Grasps peg touched to palm of hand (ulnar grasp)

Rolls over Reaches for and grasps block (radial palmar grasp, no thumb)

** Holds on to fingers, pulls self to sit

Transfers, bangs, drops

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Examples Later Mullen Motor Items

Gross Motor Fine Motor

Balances on one foot Imitates 4-block train

Runs, turns corner, stops Unscrews and screws nut and bolt

Hops at least two times Strings beads

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Clinical implication

• Motor score on a standardized test is not sufficiently sensitive at age 6 months to detect developmental disruption in infants at risk for ASD

• Quality of movement:– Postural control (head lag, changing positions)

• Likely to affect quality of imitation, gesture

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Trajectories in Sibs-A with and without ASD

• Sibs-A n=204• Low Risk Controls n=31• Tested:

– 6, 14, 18, 24, 30, 36 months• Measures:

– Mullen Scales of Early Learning – Communication and Symbolic Behavior Scales Developmental

Profile

Landa, Gross, Stuart, & Faherty. (2013). Child Development.

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Different onset patterns: 52 with ASD

Early Diagnosed: At 14 months

Later Diagnosed: After 14 months

• 28 (51.8%) • 78.5% male• 42.8% parents

concerned at age 6 mos

• 70.4% concerned at age 14 months

• 26 (48.2%) • 84.6% male• 29.4% parents

concerned at 6 mos • 65.4% parents

concerned at 14 mos

• At 14 mos: language or social delay

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IQ at Age 14 months

IQ0

20

40

60

80

100

120

Early DxLater DxNon-ASD

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Mullen Early Learning Composite

Receptive Language Raw Scores10

2030

40Sc

ore

6 14 18 24 30 36

Age (Months)

Non-ASD group Early Dx ASD group

Later Dx ASD group

rlraw

Landa, Gross, Stuart, Faherty. 2013. Child Development

• All groups WNL at 6 months

• Absence of typical language growth spurt in ASD

• Plateau in Early dx group

Frequency of Initiation of Joint Attention

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Another aspect of joint attention:

• Social attention:• Tuning in to others body language:

– gesture – gaze cues

• Understand that these cues ‘tell’ what the person is thinking about, what interests them

• By looking at the object of their attention, you ‘share attention’ with them

• This results in a moment of joint (shared) attention

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Shared positive affect

• When you look at someone and smile, you– Invite them to share something with you– Invite them to communicate with you– Make them feel that you want to connect with them

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Frequency of Shared Positive Affect

Landa, Gross, Stuart, Faherty. 2013. Child Development

Heterogeneity in Trajectories of Sibs-A

Latent class analysis: Heterogeneity

20

30

40

50

60

70

Mul

len T

-scor

e

6 14 18 24 30 36

Age (Months)

Accelerated class

20

30

40

50

60

70

Mul

len T

-scor

e

6 14 18 24 30 36

Age (Months)

Normative class

20

30

40

50

60

70

Mul

len T

-scor

e

6 14 18 24 30 36

Age (Months)

Early Language & Outcome Fine Motor Delay

20

30

40

50

60

70M

ullen

T-sc

ore

6 14 18 24 30 36

Age (Months)

Developmental Slowing

MSEL Fine Motor

MSEL Gross Motor

MSEL Visual Reception

MSEL Receptive Language

MSEL Expressive Language

Landa, Gross, Stuart, Bauman, 2012, JCPP

MSEL T scores

n=46 (22.3%) n=24 (12%)

Within-phenotype proportions in diagnostic classes

•  •  

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Group N Accelerated Normative Delay then catch up

Slowing

Early ASD 27 0 14.8 29.6 55.6

Later ASD 25 4 36 32 28

Clinical implications

• Mid infancy (6 months): – Signs are subtle– Mostly motor delay– Nonspecific to ASD

• Declining skills between 6 and 36 months• By 14 months, ASD signs clear in about half of

children with ASD– Low social responsiveness and reciprocity– Infrequent initiation of joint attention and response

to social cues– Language delay– Repetitive and stereotyped interests

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Clinical implications

• Screen early• Screen repeatedly in children with older

sibling with ASD• Discuss parent concerns• Early intervention

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Screening

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Who might voice the first concerns?

Parent, family

member, friend

Early Interventi

on provider

or teacher

Pediatrician

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Screening

• Need multiple approaches• Parent-initiated• Health care professional (Pediatrician)-initiated• Child care provider-initiated

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• http://www.cdc.gov/ncbddd/actearly/

Learn the Signs, Act Early

9-minute tutorial on early signs of ASD

• Autism.kennedykrieger.org

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GOLD STANDARD DIAGNOSIS 36 mos

Positive Negative

“early” classification

ASD positive

True Positives False Positives

PPV = TP/TP+FP

% with positive test results who are really ASD

“early” classification as Non-ASD

negative

False Negatives True NegativesNPV=

TN/TN+FN

SE =TP/TP+FN% really ASD who were

identified at younger age to have ASD

SP =TN/TN+FP% % of non-ASD

children identified at younger age as Non-

ASD

My data: Prospective study of ASD

• ASD n=49– At every age, beginning at 14 months, CJ and

confidence rating– Outcome classification made at 36 months

• Non ASD n=189

• All children be screened for DD during regular well-child doctor visits at:

• 9, 18, and 24 or 30 months • Additional screening might be needed if increased risk

due to preterm birth or low birth weight.• Screen for ASDs during regular well-child doctor visits

at: • 18 & 24 months • Additional screening might be needed if high risk for

ASDs (e.g., sibling with an ASD) or symptoms present.

AAP Screening Guidelines

• Parent report? Yes• Targeted ages: 16-30 months

• Number of questions: 23• Time to complete: 5-10 minutes• Free to use? Yes

– Available through the M-CHAT website: https://www.m-chat.org/

Modified Checklist for Autism in Toddlers (M-CHAT)

M-CHAT Studies

JADD Autism

Robins Study (2001)• Sample Size: 1283• Age Range:18-30 m• Well visits• Mean Age: 26 mo.• Gold Standard

– Psychological Evaluation• Sensitivity: 0.97• Specificity: 0.99• PPV: 0.68• NPV: 0.99

Snow Study (2008)• Sample Size: 82• Age Range: 18-70 mo.• Consecutive referrals possible PDD• Mean Age: 42.7 mo.

(SD= 14.1)• Gold Standard

– Clinical diagnosis based on IQ measures, VABS, ADOS, CARS, GARS, PDDBI

• Sensitivity: 0.70• Specificity: 0.38• PPV: 0.79• NPV: 0.28

• Score items: 2, 5, 7, 9, 14, 15, 20Fail 2 of these=screen positive; need follow-up.

• Interest in other ch; pretend; point; bring to show; response to name; RJA; wonder if child deaf

• Robins et al., 2010: “M-CHAT Best7: A New Scoring Algorithm Improves Positive Predictive Power of the M-CHAT”– Sample Size: 15,650– Age Range: 14-30 mo.– Mean Age: 20.6 mo. (SD= 3.1)– Gold Standard: Diagnostic evaluation– Sensitivity: 0.86– Specificity: 0.99– PPV: 0.18, (0.61 with follow-up interview)– NPV: Not assessed

M-CHAT Best7

Early Detection of Autismand Social Communication Delays

Rebecca Landa, Ph.D., CCC-SLPKennedy Krieger InstituteBaltimore, MD

©Rebecca Landa

• Screen: Social AND language delay• Set the bar low• Universal parent education about child

development and responsive parenting• Culturally competent curricula for parent training• MD training (train the eye, what to do)• EI providers: need curriculum and strategies• Flexible models of intervention• Parent-to-parent

Detect Risk, Enrichment, Surveillance, Treatment

Summary and Implications

• Sibs-A: risk for early motor and language delay• Motor disruption already present at 6 months

– Postural control– Grasping

• Object exploration and play• Some of the children plateau or decline, with

atypical features emerging ASD• Loss can come on at different times in different

children with ASD; and affects language or social

• Very few children with ASD have typical trajectories

• Even fewer have typical trajectories if sx onset is early (by 14 m)

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Implications

• Theoretical, neurobiological, clinical implications

• Early motor disruption, non specific but signal for need for developmental stimulation

• Early motor disruption– Affects play/object exploration immediately– Related to language and social functioning later

• Can’t consider standard scores• Must look at quality of behavior• At 6 months: postural control, initiating and

shifting postures (Bhat, Galloway, Landa, 2012), grasping

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