Interest in toys predicts effectiveness of Hanen’s More than Words in toddlers with early autism symptoms
As part of the Autism Speaks funded Toddler Treatment Network, a multi-site randomized clinical trial was conducted to examine the efficacy of Hanen’s “More Than Words” intervention (Carter, Messinger, Stone, Celimli, Nahmias, & Yoder, 2011). This is a very important funding initiative, as very few studies provide empirical validation for autism-specific interventions with toddlers who are evidencing symptoms consistent with ASD. Parents of 62 (51 boys and 11 girls) toddlers with symptoms consistent with an autism spectrum disorder (ASD) between 14- to 23- months of age were enrolled in Boston, Miami, and Nashville. Hanen’s “More Than Words” was selected for study because there was some previous experimental support for its effectiveness, it is developmentally appropriate for parents raising toddlers, and it is a short-term, relatively low-cost intervention.
This study provided some evidence that parents were able to learn and use new parenting strategies, such as practicing taking turns, encouraging eye contact and modeling simple sentences from the child’s perspective. However, Hanen’s “More Than Words” was not effective for all children. This is not surprising, given that there is great variability among toddlers with ASD. Toddlers who played with a limited number of toys prior to beginning Hanen’s “More Than Words” intervention showed more improvement in their social-communication skills following the intervention than those only receiving other community-based treatments. Specifically, they showed more instances of making eye contact, pointing to or reaching for objects of interest and showing or giving the experimenter a toy. These effects lasted for at least four months after the intervention ended. Importantly, there was evidence that these children showed gains that were observed in interactions with both parents and an unfamiliar adult as well as based on their parents’ responses to questionnaires.
This report adds to our emerging knowledge about which interventions work for which children with ASD. It also adds to our understanding of how to match children to interventions that can optimize their development and not waste time enrolling them in treatments that are not well-suited for them.
Co-authors are Alice Carter, professor of psychology at the University of Massachusetts Boston; Paul Yoder, professor of special education at Vanderbilt University; Daniel Messinger, associate professor of psychology at the University of Miami; Wendy Stone, professor of psychology and Director of the University of Washington’s Autism Center; Seniz Celimli, postdoctoral researcher at the University of Miami; and Allison Nahmias, a psychology graduate student at the University of Pennsylvania. For more information, contact Carter at firstname.lastname@example.org, Stone at email@example.com, Yoder at firstname.lastname@example.org or Messinger at email@example.com.
Carter, A. S., Messinger, D. S., Stone, W. L., Celimli, S., Nahmias, A. S. and Yoder, P. , A randomized controlled trial of Hanen’s ‘More Than Words’ in toddlers with early autism symptoms. Journal of Child Psychology and Psychiatry, no. doi: 10.1111/j.1469-7610.2011.02395.x
A Toy Story: Toddler Treatment Network finds an effective treatment strategy for some young children with ASD
It is now possible to screen for autism spectrum disorder in toddlers as young as 18 months of age and ways of screening even earlier are being tested. When a parent learns that their young son or daughter is showing symptoms of autism, it is important that they be offered intervention strategies that can help their toddler at risk for ASD have the most positive outcome. To address this need, in the summer of 2006, Autism Speaks began an initiative to support research on early intervention targeting toddlers with autism spectrum disorder (ASD) from 18-24 months of age. There are many questions that need to be addressed: Who should deliver the intervention? How many hours are required? What strategies should be used? Are these strategies effective? Research funded by Autism Speaks is addressing these questions.
At the time the initiative was started, many clinicians were already referring children to birth to three services in their communities and developing their own programs using techniques that could improve communication, social behavior, and language in toddlers. However, very few randomized clinical trials – the gold standard for determining whether a treatment is really effective – had been performed in toddlers with ASD. Of the randomized clinical trials that did exist for this young age, the number of children participating was low, so it was not clear how well the results would generalize to other children.
To solve this problem, Autism Speaks provided resources to clinicians and researchers who were working with children with ASD as young as 18 months of age to determine what types of interventions were effective, what made them beneficial, and how symptoms improved over time. As a result, 7 projects involving multiple sites around the US and Canada began in 2007 and the Toddler Treatment Network was born.
Each project is unique in the type and style of the intervention, but all the projects shared a common link: they all included parent training for delivery of interventions at home. This model is attractive because parents or other caregivers are able to deliver the intervention through the day in familiar settings. This model offered more time in intervention and wascost-effective. Members of the Toddler Treatment Network came together to share ideas, best practices, and a plan to combine their data at the end of their studies. As a result, over 250 toddlers have been recruited to participate in these studies, and a meta-analysis combining data from all studies will be completed in 2012. Full descriptions of the projects can be found here: http://www.autismspeaks.org/science/research/initiatives/toddler_treatment_network.php
Recently, one of these research groups published their first set of findings in the Journal of Child Psychology and Psychiatry. At study sites in Miami, Boston and Tennessee, children with ASD were enrolled in the Hanen More than Words program, which is focused on developing language and communication skills in toddlers. The comparison group of children with ASD were enrolled in local early intervention programs, support groups, and other behavioral interventions. Children and parents were assessed at the beginning of the study, during the study, and 4 months after the intervention ended.
At the beginning of the study, a number of behaviors were examined, including the number of toys or objects a child played with. While the Hanen intervention was not effective for all children, it was particularly effective for children who did not play with many toys before the program started.
Why? The researchers speculate that during the intervention the toddlers who were less object- focused may have been more easily engaged with their parents during the intervention and thus spent more time learning appropriate responses. These results suggest that as toddler interventions are developed it will be important to understand which kids are most likely to benefit from each type of intervention.
This study adds to the body of evidence showing that early intervention in autism can lead to meaningful improvements in social, behavioral, and communication outcomes. However, one type of intervention strategy is not going to work for all children affected with ASD.
With this in mind, studies that are part of the Toddler Treatment Network focus on different programs and different methods for promoting development. A higher-intensity program may be needed in some children. For other children, however, the Hanen style of intervention strategy, which allowed parents to deliver the intervention in different settings, resulted in significant improvement in outcome compared to traditional methods.
Wendy Stone, Ph.D., study co-author and director of the University of Washington Autism Center described what she saw as a successful result of early intervention for autism: “Our ultimate goal is to catch the symptoms early and find effective preventive interventions so that these children can attain their full potential.” Autism Speaks is looking forward to the findings from all these studies, and will keep you updated when they are published.
A New York Times’ article on autism highlighted the challenges of obtaining an early diagnosis and treatment for parents who are facing a second child who is at risk for ASD. The story follows a family who has a diagnosed 5 year old son and a 7 month old baby boy who is showing signs of departing from a normal developmental trajectory, especially his interactions with other people.
The story is an excellent portrayal of the challenges and successes of a family living with autism and features two scientists engaged in the Autism Speaks’ High Risk Baby Siblings Research Consortium, Sally Rogers, Ph.D. and Sally Ozonoff, Ph.D. The ability to distinguish autism from variations in development that lead to an otherwise normal outcome is limited at the early ages, but research is finding new ways to identify the earliest signs of autism risk. Since the best bet for a good outcome is early, intensive behavioral intervention, identifying these early signs are extremely valuable.
The story highlights the Early Start Denver Model, an intervention approach developed by Rogers and Geraldine Dawson, Autism Speaks’ Chief Science Officer. This intervention method, which was evaluated in a controlled trial, can be used with children at risk for ASD as young as 12 months of age.
While early intervention methods for toddlers with ASD are becoming increasingly available, there are still many families that have difficulty accessing early intervention services. Autism Speaks is working to disseminate research that has been established as best practices while simultaneously pressing for more research in needed areas. Our partnership with the Early Autism Risk Longitudinal Investigation (EARLI) has helped to broaden the participation and scope of this important study of early risk factors. In terms of intervention, Autism Speaks’ support of the Toddler Treatment Network is focused on both the dissemination and further research needs in young children identified with autism. At the same time, our continued advocacy for ending insurance discrimination for behavioral health services for children with autism (www.autismvotes.org ) is essential to our goal of providing every child with autism the services they need and deserve.
By strategically investing our scientific resources in areas of need and advocating for families, Autism Speaks seeks to improve the outcomes for those struggling with ASD today and to lessen the struggles for those who will be diagnosed tomorrow.
5|25: Celebrating Five Years of Autism Science Day 24: Early Intervention for Toddlers with Autism Spectrum Disorders
In honor of the anniversary of Autism Speaks’ founding on Feb 25, for the next 25 days we will be sharing stories about the many significant scientific advances that have occurred during our first five years together. Our 24th item, Early Intervention for Toddlers with Autism Spectrum Disorders, is from Autism Speaks’ Top 10 Autism Research Events of 2009.
Although previous studies have found that early intervention can be helpful for preschool-aged children, interventions for children who are toddlers are just now being tested. As 2009 came to a close, the results were unveiled for the first controlled study of an intensive early intervention appropriate for children with ASD who are less than 2½ years of age. Published in Pediatrics, results of this study showed that a novel early intervention program was effective for improving IQ, language ability, and adaptive behavior in children as young as 18 months.
The intervention, called the Early Start Denver Model, combines applied behavioral analysis (ABA) teaching methods with developmental ‘relationship-based’ approaches, thereby blending the rigor of ABA with play-based routines that focus on building a relationship with the child. Children in the study were separated into two groups, one that received 20 hours a week of the intervention – two two-hour sessions five days a week – from University of Washington specialists. They also received five hours a week of parent-delivered therapy. Children in the second group were referred to community-based programs for therapy. Researchers closely monitored the progress of both groups.
At the beginning of the study there was no difference in functioning between the two groups. At the conclusion of the study, the IQs of the children in the intervention group had improved by an average of close to 18 points, compared to only 7 points in the comparison group. The intervention group also had a nearly 19-point improvement in receptive language (listening and understanding) compared to approximately 10 points in the control group. Whereas only one child in the community-based intervention group had an improved diagnosis, seven of the children in the intervention group had enough improvement in overall skills to warrant a change in diagnosis from autism to the milder condition known as ‘pervasive developmental disorder not otherwise specified.’
While the youngest children in the study were 18 months old, this particular intervention is designed to be appropriate for children with ASD as young as 12 months of age. Given that the American Academy of Pediatrics recommends that all 18- and 24- month-old children be screened for ASD, it is crucial that we are able to offer parents effective therapies for children within this age range. This new study strongly affirms the positive outcomes of early intervention and the need for the earliest possible start.
Did you know?: To encourage research in early intervention, at the end of 2006 Autism Speaks funded a set of multi-site randomized trials to investigate the efficacy of different early intervention techniques in toddlers who show early signs of autism. From this effort a Toddler Treatment Network (TTN) was born to establish the groundwork for collaborative studies that can incorporate different aspects of these various intervention approaches. The TTN investigators have also been collecting and sharing information on a variety of best practices, including how to build partnerships with local communities. Importantly, all studies are testing interventions that can be implemented outside the clinic, with the aim of decreasing the time between parent’s first concern and initiation of treatment.