Search

Evidence supports early intervention for toddlers with ASD, but barriers to access remain, including system costs, workforce constraints, and a range of family socio-demographic factors. An urgent need exists for innovative models that maximize resource efficiency and promote widespread timely access. We examined uptake and outcomes from 82 families participating in a parent-mediated intervention comprising group-based learning and individual coaching, delivered either in-person (n = 45) or virtually (n = 37). Parents from diverse linguistic, ethnic, and educational backgrounds gained intervention skills and toddlers evidenced significant social-communication gains. Few differences emerged across socio-demographic factors or delivery conditions. Findings highlight the feasibility, acceptability, and promise of group-based learning when combined with individual coaching, with added potential to increase program reach via virtual delivery.

Recent efforts have focused on developing and evaluating early intervention for toddlers with probable or emerging autism spectrum disorder. Parent-mediated approaches have gained traction, with mounting evidence of efficacy, but a research-to-practice gap exists, and community effectiveness remains to be firmly established. We report outcomes of a parent-mediated toddler intervention delivered through a research-community partnership, using a community-partnered participatory framework. Data were available for 179 of 183 toddler-parent dyads receiving Social ABCs parent coaching (mean toddler age: 25.18 months; range, 14-34 months). Of these, 89.4% completed the 12-week program and 70.6% returned for 3-month follow-up assessment. Parents attained implementation fidelity exceeding 75%, and toddlers made gains on proximal and distal measures of social communication. Parent fidelity was associated with toddlers' responsivity at week 12, and responsivity predicted later language gains and reduced autism spectrum disorder symptoms. The roles of child, family, and system factors are discussed. Community delivery of an evidence-based parent-mediated intervention for toddlers with autism spectrum disorder is feasible and effective. Given resource efficiencies associated with parent-mediated approaches, findings bolster current efforts to promote earlier and more widespread access to intervention at the first signs of developmental concern.

Research concerning temperament in children and adults with autism spectrum disorder (ASD) has suggested a consistent profile of low positive affect, high negative affect, and low regulation (Visser et al., 2016). One area receiving less attention is individual differences among children diagnosed with ASD. The primary objective of this study was to use a person-centered approach to explore heterogeneity of early temperament precursors of regulation in a large sample of infants with elevated familial likelihood of ASD. Early precursors of regulation included temperament assessed at 6, 12, and 24 months whereas outcome measures were diagnosis of ASD, cognitive ability and adaptive behavior at 36 months. Participants included 176 low-likelihood and 473 elevated-likelihood infants, 129 of whom were diagnosed with ASD at 3 years. Results supported a three-profile solution: a well-regulated profile (high positive affect and high attentional focus and shifting), a low attention focus profile (higher attentional shifting compared to attentional focus), and a low attention shifting profile (higher attentional focus compared to attentional shifting). A higher proportion of children diagnosed with ASD were classified into the low attention shifting profile. Furthermore, children with the well-regulated profile were differentiated from the other profiles by a pattern of higher social competence and lower dysregulation whereas children with the low attention focus profile were distinguished from the other profiles by higher cognitive ability at 3 years. The findings indicate that the combination of early positive affect with attention measures may provide an enhanced tool for prediction of self-regulation and later outcomes.

Families with early concerns about infant symptoms of ASD have limited access to experienced professionals for screening and guidance. Telehealth has been used to reduce access disparities in other pediatric populations and has shown promise in parent-implemented interventions for ASD. We investigated the feasibility of a novel level-2 telehealth assessment of infants' early social communication and ASD symptoms, the Telehealth Evaluation of Development for Infants (TEDI). Parents of eleven infants aged 6-12 months were coached to administer specific semi-structured behavioral probes. Initial feasibility, reliability, and acceptability benchmarks were met. These findings suggest the feasibility of screening infants via telehealth, and are supportive of further large-scale efforts to validate this method for longitudinal monitoring of symptomatic infants in community settings.

Parent-mediated intervention programs have demonstrated benefits for toddlers with autism spectrum disorder (ASD). Interest is emerging in other community-level models, such as those that can be integrated into child care settings. These programs have the potential to reach a wide range of high-risk toddlers who spend the majority of their day in child care. The objective of this study was to translate and evaluate the feasibility of the "Social ABCs" caregiver-mediated intervention program into a community child care setting by training front-line early childhood educators (ECEs). Twenty-two ECEs attended a workshop on early intervention and ASD, and six ECEs and one special needs resource consultant received hands-on intervention training. Nineteen participants completed a workshop quiz, with significant mean improvement of 22.26% from pre- to post-workshop. After 12 weeks of live coaching (4 weeks in one case), participants attained a high level of fidelity in implementing the intervention strategies (> 80%), which was maintained after a 3-month period of non-contact with the training team. Nine of ten specific strategies were mastered after the 12-week training period, with only one technique failing to reach a mean fidelity level of 75%. Findings reveal that the model of training front-line child care staff in a community child care setting is feasible using a relatively short-term training approach.

Despite considerable progress in characterizing the early signs of autism spectrum disorder (ASD), more remains to be learned about how symptoms emerge in the first year of life. Parents with a new baby who already had at least one biological child diagnosed with ASD (high-risk) or no family history of ASD (low-risk) completed two measures when their baby was 9 months of age, the Autism Parent Screen for Infants (APSI) questionnaire and the interview-based Parent Concerns Form. Children underwent a blinded independent diagnostic assessment for ASD at age 3 years. Total scores on the APSI and the Parent Concerns Form were both able to independently differentiate high-risk children who were later diagnosed with ASD from other high-risk and low-risk children who were not. Using logistic regression, we found that the total score on the APSI predicted ASD outcomes at age 3 with 70% accuracy, but the Parent Concerns Form did not contribute any unique variance when the APSI was already in the model. The results suggest that the APSI identifies early features predictive of ASD in high-risk infants and can be used to flag them for targeted follow-up and screening.

The objectives were to characterize behavioral signs of autism spectrum disorder (ASD) in younger siblings of diagnosed children (high-risk; HR) and examine classification features of the Autism Observation Scale for Infants (AOSI). Participants (501 HR and 180 low-risk [LR]) were assessed between 6 and 18 months using the AOSI and at age 3 for ASD diagnoses. Total AOSI scores differentiated HR infants later diagnosed with ASD starting at 12 months. ROC analyses identified 12- and 18-month cutoff scores associated with 0.52 sensitivity and 0.74 specificity and 0.73 sensitivity and 0.65 specificity, respectively. Although classification accuracy does not support use as a standalone screen, the AOSI identifies features associated with ASD starting at 6 months and differentiates HR infants with ASD by 12 months.

Social-emotional behavior in autism spectrum disorder (ASD) was examined among high-risk (HR; siblings of children diagnosed with ASD) and low-risk (LR; no family history of ASD) toddlers. Caregivers completed the Infant-Toddler Social Emotional Assessment (ITSEA) at 18 months, and blind diagnostic assessment for ASD was conducted at 36 months. Results indicated impairment in social-emotional functioning among HR toddlers subsequently diagnosed with ASD compared to other HR and LR toddlers, such that ITSEA domains (Internalizing, Dysregulation, Competence) and subdomains predicted later ASD symptoms and diagnosis. Receiver operating curves of optimal ITSEA cutoffs ranged from 0.23 to 0.44 for sensitivity, and 0.74 to 0.89 for specificity. Although classification accuracy for ASD was limited, group differences highlight the importance of considering social-emotional development when assessing ASD risk.

This study examined the performance of the First Year Inventory (FYI; version 2.0), a community-normed parent-reported screening instrument, in a high-risk (HR) sample of 12-month-olds with older siblings diagnosed with autism spectrum disorder (ASD). The FYI 2.0 was completed by parents of 86 HR infants and 35 low-risk control infants at age 12 months, followed by clinical diagnosis at 36 months. HR infants later diagnosed with ASD had significantly higher FYI 2.0 risk scores in both the social-communication and sensory-regulatory domains than typically developing infants. New FYI 2.0 cutoff scores for HR sample were explored by evaluating various cutoff options after considering tradeoffs between sensitivity and specificity and sample characteristics.

Messinger et al. found a 3.18 odds ratio of male to female ASD recurrence in 1241 prospectively followed high-risk (HR) siblings. Among high-risk siblings (with and without ASD), as well as among 583 low-risk controls, girls exhibited higher performance on the Mullen Scales of Early Learning, as well as lower restricted and repetitive behavior severity scores on the Autism Diagnostic Observation Schedule (ADOS) than boys. That is, female-favoring sex differences in developmental performance and autism traits were evident among low-risk and non-ASD high-risk children, as well as those with ASD. Constantino (Mol Autism) suggests that sex differences in categorical ASD outcomes in Messinger et al. should be understood as a female protective effect. We are receptive to Constantino's (Mol Autism) suggestion, and propose that quantitative sex differences in autism-related features are keys to understanding this female protective effect.

This study measured resource utilization and costs for pre-school autism spectrum disorder (ASD)-related services in community-based sectors from multiple payer perspectives in two Canadian provinces, Nova Scotia (NS) and New Brunswick (NB), during the 12 months prior to and following the start of early intensive behavioural intervention (EIBI). The results indicate significant differences between NB and NS in utilization of services and costs to families, public sector and society. Differences can be attributed to variation in EIBI delivery models and may also be influenced by differences in diagnostic assessment practices. The study results provide resource utilization rates and costs which could be used in future economic evaluations and to inform policy making to improve outcomes for children with ASD.

This study examined the potential of the short form of the Quantitative Checklist for Autism in Toddlers (Q-CHAT-10) to identify autism spectrum disorder (ASD) in a high-risk sibling cohort. High-risk (HR; siblings of children diagnosed with ASD) and low-risk (LR; no family history of ASD) toddlers were assessed prospectively at 18 and 24 months of age using the Q-CHAT-10 and underwent blind diagnostic assessment for ASD at 36 months of age. The results indicated that at 18 and 24 months, total score differentiated between HR toddlers subsequently diagnosed with ASD from other HR and LR toddlers. The sensitivity at both time points was acceptable; however, the specificity was below the level recommended for clinical application.

BackgroundThe increased male prevalence of autism spectrum disorder (ASD) may be mirrored by the early emergence of sex differences in ASD symptoms and cognitive functioning. The female protective effect hypothesis posits that ASD recurrence and symptoms will be higher among relatives of female probands. This study examined sex differences and sex of proband differences in ASD outcome and in the development of ASD symptoms and cognitive functioning among the high-risk younger siblings of ASD probands and low-risk children.MethodsPrior to 18 months of age, 1824 infants (1241 high-risk siblings, 583 low-risk) from 15 sites were recruited. Hierarchical generalized linear model (HGLM) analyses of younger sibling and proband sex differences in ASD recurrence among high-risk siblings were followed by HGLM analyses of sex differences and group differences (high-risk ASD, high-risk non-ASD, and low-risk) on the Mullen Scales of Early Learning (MSEL) subscales (Expressive and Receptive Language, Fine Motor, and Visual Reception) at 18, 24, and 36 months and Autism Diagnostic Observation Schedule (ADOS) domain scores (social affect (SA) and restricted and repetitive behaviors (RRB)) at 24 and 36 months.ResultsOf 1241 high-risk siblings, 252 had ASD outcomes. Male recurrence was 26.7 % and female recurrence 10.3 %, with a 3.18 odds ratio. The HR-ASD group had lower MSEL subscale scores and higher RRB and SA scores than the HR non-ASD group, which had lower MSEL subscale scores and higher RRB scores than the LR group. Regardless of group, males obtained lower MSEL subscale scores, and higher ADOS RRB scores, than females. There were, however, no significant interactions between sex and group on either the MSEL or ADOS. Proband sex did not affect ASD outcome, MSEL subscale, or ADOS domain scores.ConclusionsA 3.2:1 male:female odds ratio emerged among a large sample of prospectively followed high-risk siblings. Sex differences in cognitive performance and repetitive behaviors were apparent not only in high-risk children with ASD, but also in high-risk children without ASD and in low-risk children. Sex differences in young children with ASD do not appear to be ASD-specific but instead reflect typically occurring sex differences seen in children without ASD. Results did not support a female protective effect hypothesis.

ObjectiveThere is a paucity of randomized clinical trials (RCTs) for adolescents with bulimia nervosa (BN). Prior studies suggest cognitive-behavioral therapy adapted for adolescents (CBT-A) and family-based treatment for adolescent bulimia nervosa (FBT-BN) could be effective for this patient population. The objective of this study was to compare the relative efficacy of these 2 specific therapies, FBT-BN and CBT-A. In addition, a smaller participant group was randomized to a nonspecific treatment (supportive psychotherapy [SPT]), whose data were to be used if there were no differences between FBT-BN and CBT-A at end of treatment.MethodThis 2-site (Chicago and Stanford) randomized controlled trial included 130 participants (aged 12-18 years) meeting DSM-IV criteria for BN or partial BN (binge eating and purging once or more per week for 6 months). Outcomes were assessed at baseline, end of treatment, and 6 and 12 months posttreatment. Treatments involved 18 outpatient sessions over 6 months. The primary outcome was defined as abstinence from binge eating and purging for 4 weeks before assessment, using the Eating Disorder Examination.ResultsParticipants in FBT-BN achieved higher abstinence rates than in CBT-A at end of treatment (39% versus 20%; p = .040, number needed to treat [NNT] = 5) and at 6-month follow-up (44% versus 25%; p = .030, NNT = 5). Abstinence rates between these 2 groups did not differ statistically at 12-month follow-up (49% versus 32%; p = .130, NNT = 6).ConclusionIn this study, FBT-BN was more effective in promoting abstinence from binge eating and purging than CBT-A in adolescent BN at end of treatment and 6-month follow-up. By 12-month follow-up, there were no statistically significant differences between the 2 treatments.Clinical trial registration informationStudy of Treatment for Adolescents With Bulimia Nervosa; http://clinicaltrials.gov/; NCT00879151.

BackgroundThe diagnosis of autism spectrum disorder (ASD) made before age 3 has been found to be remarkably stable in clinic- and community-ascertained samples. The stability of an ASD diagnosis in prospectively ascertained samples of infants at risk for ASD due to familial factors has not yet been studied, however. The American Academy of Pediatrics recommends intensive surveillance and screening for this high-risk group, which may afford earlier identification. Therefore, it is critical to understand the stability of an ASD diagnosis made before age 3 in young children at familial risk.MethodsData were pooled across seven sites of the Baby Siblings Research Consortium. Evaluations of 418 later-born siblings of children with ASD were conducted at 18, 24, and 36 months of age and a clinical diagnosis of ASD or Not ASD was made at each age.ResultsThe stability of an ASD diagnosis at 18 months was 93% and at 24 months was 82%. There were relatively few children diagnosed with ASD at 18 or 24 months whose diagnosis was not confirmed at 36 months. There were, however, many children with ASD outcomes at 36 months who had not yet been diagnosed at 18 months (63%) or 24 months (41%).ConclusionsThe stability of an ASD diagnosis in this familial-risk sample was high at both 18 and 24 months of age and comparable with previous data from clinic- and community-ascertained samples. However, almost half of the children with ASD outcomes were not identified as being on the spectrum at 24 months and did not receive an ASD diagnosis until 36 months. Thus, longitudinal follow-up is critical for children with early signs of social-communication difficulties, even if they do not meet diagnostic criteria at initial assessment. A public health implication of these data is that screening for ASD may need to be repeated multiple times in the first years of life. These data also suggest that there is a period of early development in which ASD features unfold and emerge but have not yet reached levels supportive of a diagnosis.

ObjectiveThis study provides data on the psychometric properties of a newly developed measure of treatment fidelity in Family-Based Treatment (FBT) for adolescent anorexia nervosa (AN). The Family Therapy Fidelity and Adherence Check (FBT-FACT) was created to evaluate therapist adherence and competency on the core interventions in FBT.MethodParticipants were 45 adolescents and their families sampled from three randomized clinical trials evaluating treatment for AN. Trained fidelity raters evaluated 19 therapists across 90 early session recordings using the FBT-FACT. They also rated an additional 15 session 1 recordings of an alternate form of family therapy-Systemic Family Therapy for the purpose of evaluating discriminant validity of the FBT-FACT. The process of development and the psychometric properties of the FBT-FACT are presented.ResultsOverall fidelity ratings for each session demonstrated moderate to strong inter-rater agreement. Internal consistency of the measure was strong for sessions 1 and 2 and poor for session 3. Principal components analysis suggests sessions 1 and 2 are distinct interventions.DiscussionThe FBT-FACT demonstrates good reliability and validity as a measure of treatment fidelity in the early phase of FBT.

This study examined whether a novel parent-report questionnaire, the Autism Parent Screen for Infants, could differentiate infants subsequently diagnosed with autism spectrum disorder from a high-risk cohort (siblings of children diagnosed with autism spectrum disorder (n = 66)) from high-risk and low-risk comparison infants (no family history of autism spectrum disorder) who did not develop autism spectrum disorder (n = 138 and 79, respectively). Participants were assessed prospectively at 6, 9, 12, 15, 18, and 24 months of age. At 36 months, a blind independent diagnostic assessment for autism spectrum disorder was completed. Parent report on the Autism Parent Screen for Infants was examined in relation to diagnostic outcome and risk status (i.e. high-risk sibling with autism spectrum disorder, high-risk sibling without autism spectrum disorder, and low-risk control). The results indicated that from 6 months of age, total score on the Autism Parent Screen for Infants differentiated between the siblings with autism spectrum disorder and the other two groups. The sensitivity, specificity, and positive and negative predictive validity of the Autism Parent Screen for Infants highlight its potential for the early screening of autism spectrum disorder in high-risk cohorts.

ObjectiveYounger siblings of children with autism spectrum disorder (ASD) are at high risk (HR) for developing ASD as well as features of the broader autism phenotype. Although this complicates early diagnostic considerations in this cohort, it also provides an opportunity to examine patterns of behavior associated specifically with ASD compared to other developmental outcomes.MethodWe applied Classification and Regression Trees (CART) analysis to individual items of the Autism Diagnostic Observation Schedule (ADOS) in 719 HR siblings to identify behavioral features at 18 months that were predictive of diagnostic outcomes (ASD, atypical development, and typical development) at 36 months.ResultsThree distinct combinations of features at 18 months were predictive of ASD outcome: poor eye contact combined with lack of communicative gestures and giving; poor eye contact combined with a lack of imaginative play; and lack of giving and presence of repetitive behaviors, but with intact eye contact. These 18-month behavioral profiles predicted ASD versus non-ASD status at 36 months with 82.7% accuracy in an initial test sample and 77.3% accuracy in a validation sample. Clinical features at age 3 years among children with ASD varied as a function of their 18-month symptom profiles. Children with ASD who were misclassified at 18 months were higher functioning, and their autism symptoms increased between 18 and 36 months.ConclusionThese findings suggest the presence of different developmental pathways to ASD in HR siblings. Understanding such pathways will provide clearer targets for neural and genetic research and identification of developmentally specific treatments for ASD.

This paper provides an overview of selective research on autism. Autism forms part of a spectrum of related developmental disorders that vary in severity. Both their prevalence and severity argue for concerted efforts aimed at improving our understanding and treatment of the many individuals affected. We begin by outlining an important discovery that implicates an early prenatal insult to the developing brain stem in at least some people with autism (hereafter, the thalidomide discovery; Miller & Stromland, 1993). Several lines of evidence consistent with this claim are summarized. We then turn to recent research on early developing mechanisms of attention and emotion in autism. Evidence to be reviewed points to impairment in the disengage function of visual attention, and data are provided on the relationship between disengagement and the regulation of emotional states. Research on emotion focuses on the hypothesis, derived from the thalidomide discovery, that there may be a physical/anatomical basis to the lack of facial expressiveness in autism. We end by discussing the implications of this work for future research and for supporting children and adults with autism.

ImportanceAnorexia nervosa (AN) is a serious disorder with high rates of morbidity and mortality. Family-based treatment (FBT) is an evidence-based therapy for adolescent AN, but less than half of those who receive this approach recover. Hence, it is important to identify other approaches to prevent the development of the chronic form of AN for which there is no known evidence-based treatment.ObjectiveTo compare FBT with systemic family therapy (SyFT) for the treatment of adolescent-onset AN.Design, setting, and participantsResearch in Anorexia Nervosa (RIAN) is a 2-group (FBT and SyFT) randomized trial conducted between September 2005 and April 2012. Interviewers were blinded to the treatment condition. A total of 564 adolescents receiving care at 6 outpatient clinics experienced in the treatment of AN were screened. Of these, 262 adolescents did not meet the inclusion criteria and 138 declined to participate; hence, 164 adolescents (aged 12-18 years) of both sexes meeting the criteria for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, AN (except for amenorrhea) were enrolled. Three participants were withdrawn from FBT and 7 were withdrawn from SyFT after serious adverse events occurred.InterventionsTwo manualized family therapies with 16 one-hour sessions during 9 months. Family-based therapy focuses on the facilitation of weight gain, whereas SyFT addresses general family processes.Main outcomes and measuresThe primary outcomes were percentage of ideal body weight (IBW) and remission (≥95% of IBW). The a priori hypothesis was that FBT would result in faster weight gain early in treatment and at the end of treatment (EOT).ResultsThere were no statistically significant differences between treatment groups for the primary outcome, for eating disorder symptoms or comorbid psychiatric disorders at the EOT or follow-up. Remission rates included FBT, 33.1% at the EOT and 40.7% at follow-up and SyFT, 25.3% and 39.0%, respectively. Family-based therapy led to significantly faster weight gain early in treatment, significantly fewer days in the hospital, and lower treatment costs per patient in remission at the EOT (FBT, $8963; SyFT, $18 005). An exploratory moderator analysis found that SyFT led to greater weight gain than did FBT for participants with more severe obsessive-compulsive symptoms.Conclusions and relevanceThe findings of this study suggest that FBT is the preferred treatment for adolescent AN because it is not significantly different from SyFT and leads to similar outcomes at a lower cost than SyFT. Adolescents with more severe obsessive-compulsive symptoms may receive more benefits with SyFT.Trial registrationclinicaltrials.gov Identifier NCT00610753.

ObjectiveLong-term follow-up studies documenting maintenance of treatment effects are few in adolescent anorexia nervosa (AN). This exploratory study reports relapse from full remission and attainment of remission during a 4-year open follow-up period using a convenience sample of a subgroup of 65% (n = 79) from an original cohort of 121 participants who completed a randomized clinical trial comparing family-based therapy (FBT) and adolescent-focused individual therapy (AFT).MethodFollow-up assessments were completed up to 4 years posttreatment (average, 3.26 years). Available participants completed the Eating Disorder Examination as well as self-report measures of self-esteem and depression at 2 to 4 years posttreatment.ResultsTwo participants (6.1%) relapsed (FBT: n = 1, 4.5%; AFT: n = 1, 9.1%), on average 1.98 years (SD = 0.14 years) after remission was achieved at 1-year follow-up. Ten new participants (22.7%) achieved remission (FBT: n = 1, 5.9%; AFT: n = 9, 33.3%). Mean time to remission for this group was 2.01 years (SD = 0.82 years) from 1-year follow-up. There were no differences based on treatment group assignment in either relapse from full remission or new remission during long-term follow-up. Other psychopathology was stable over time.ConclusionThere were few changes in the clinical presentation of participants who were assessed at long-term follow-up. These data suggest that outcomes are generally stable posttreatment regardless of treatment type once remission is achieved. Clinical trial registration information-Effectiveness of Family-Based Versus Individual Psychotherapy in Treating Adolescents With Anorexia Nervosa; http://www.clinicaltrials.gov/; NCT00149786.

ObjectiveAlthough early brain overgrowth is frequently reported in autism spectrum disorder (ASD), the relationship between ASD and head circumference (HC) is less clear, with inconsistent findings from longitudinal studies that include community controls. Our aim was to examine whether head growth in the first 3 years differed between children with ASD from a high-risk (HR) sample of infant siblings of children with ASD (by definition, multiplex), HR siblings not diagnosed with ASD, and low-risk (LR) controls.MethodParticipants included 442 HR and 253 LR infants from 12 sites of the international Baby Siblings Research Consortium. Longitudinal HC data were obtained prospectively, supplemented by growth records. Random effects nonlinear growth models were used to compare HC in HR infants and LR infants. Additional comparisons were conducted with the HR group stratified by diagnostic status at age 3: ASD (n = 77), developmental delay (DD; n = 32), and typical development (TD; n = 333). Nonlinear growth models were also developed for height to assess general overgrowth associated with ASD.ResultsThere was no overall difference in head circumference growth over the first 3 years between HR and LR infants, although secondary analyses suggested possible increased total growth in HR infants, reflected by the model asymptote. Analyses stratifying the HR group by 3-year outcomes did not detect differences in head growth or height between HR infants who developed ASD and those who did not, nor between infants with ASD and LR controls.ConclusionHead growth was uninformative as an ASD risk marker within this HR cohort.

ObjectiveDetermine whether early weight gain predicts full remission at end-of-treatment (EOT) and follow-up in two different treatments for adolescent anorexia nervosa (AN), and to track the rate of weight gain throughout treatment and follow-up.MethodParticipants were 121 adolescents with AN (mean age = 14.4 years, SD = 1.6), from a two-site (Chicago and Stanford) randomized controlled trial. Adolescents were randomly assigned to family-based treatment (FBT) (n = 61) or individual adolescent focused therapy (AFT) (n = 60). Treatment response was assessed using percent of expected body weight (EBW) and the global score on the Eating Disorder Examination (EDE). Full remission was defined as having achieved ≥95% EBW and within one standard deviation of the community norms of the EDE. Full remission was assessed at EOT as well as 12-month follow-up.ResultsReceiver operating characteristic analyses showed that the earliest predictor of remission at EOT was a gain of 5.8 pounds (2.65 kg) by session 3 in FBT (area under the curve (AUC) = 0.670; p = .043), and a gain of 7.1 pounds (3.20 kg) by session 4 in AFT (AUC = 0.754, p = .014). Early weight gain did not predict remission at follow-up for either treatment. A survival analysis showed that weight was marginally superior in FBT as opposed to AFT (Wald chi-square = 3.692, df = 1, p = .055).DiscussionAdolescents with AN who receive either FBT or AFT, and show early weight gain, are likely to remit at EOT. However, FBT is superior to AFT in terms of weight gain throughout treatment and follow-up.

ObjectiveThis study aimed to describe the role of parent alliance in Family-Based Treatment (FBT) for adolescents with anorexia nervosa (AN). Differences between parent and child alliance with the therapist, mothers' and fathers' alliance, and their relationship to outcome were examined.MethodIndependent observers rated audiotapes of early therapy sessions to assess the therapeutic alliance of parents and adolescents with AN in FBT. Outcome was defined using a previously established cut-point for recovery from AN.ResultsMothers' and fathers' alliance scores with the therapist were similar and significantly higher than adolescent alliance scores early in treatment. Combined parent alliance did not predict recovery at the end of treatment. Difference in alliance scores between mothers and fathers, and parents and their child also did not predict recovery at the end of treatment.ConclusionsIn FBT, parents developed a strong alliance with the therapist early in treatment. These scores were consistent with the focus in FBT on parental management of eating disorder symptoms, as was the fact that alliance between adolescents and therapists was lower. Although parental therapeutic alliance was likely important in FBT, its role in treatment response remains uncertain.

ObjectiveTo examine the predictive value of end of treatment (EOT) outcomes for longer term recovery status.MethodWe used signal detection analysis to identify the best predictors of recovery based on outcome at EOT using five different eating disorder samples from randomized clinical treatment trials. We utilized a transdiagnostic definition of recovery that included normalization of weight and eating related psychopathology.ResultsAchieving a body weight of 95.2% of expected body weight by EOT is the best predictor of recovery for adolescents with anorexia nervosa (AN). For adults with AN, the most efficient predictor of weight recovery (BMI > 19) was weight gain to greater than 85.8% of ideal body weight. In addition, for adults with AN, the most efficient predictor of psychological recovery was achievement of an eating disorder examination (EDE) weight concerns score below 1.8. The best predictor of recovery for adults with Bulimia Nervosa (BN) was a frequency of compensatory behaviors less than two times a month. For adolescents with BN, abstinence from purging and reduction in the EDE restraint score of more than 3.4 from baseline to EOT were good predictors of recovery. For adults with binge eating disorder, reduction of the Global EDE score to within the normal range (

Purpose: Impairments in the social use of language are universal in autism spectrum disorder (ASD), but few standardized measures evaluate communication skills above the level of individual words or sentences. This study evaluated the Expression, Reception, and Recall of Narrative Instrument (ERRNI; Bishop, 2004) to determine its contribution to assessing language and communicative impairment beyond the sentence level in children with ASD. Method: A battery of assessments, including measures of cognition, language, pragmatics, severity of autism symptoms, and adaptive functioning, was administered to 74 8- to 9-year-old intellectually able children with ASD. Results: Average performance on the ERRNI was significantly poorer than on the Clinical Evaluation of Language Fundamentals-Fourth Edition (CELF-4). In addition, ERRNI scores reflecting the number and quality of relevant story components included in the participants' narratives were significantly positively related to scores on measures of nonverbal cognitive skill, language, and everyday adaptive communication, and significantly negatively correlated with the severity of affective autism symptoms. Conclusion: Results suggest that the ERRNI reveals discourse impairments that may not be identified by measures that focus on individual words and sentences. Overall, the ERRNI provides a useful measure of communicative skill beyond the sentence level in school-aged children with ASD. [The Pathways in AST study team assisted in the writing of this article.]

Prospective studies of infant siblings of children diagnosed with autism spectrum disorder (ASD) provide a unique opportunity to characterize ASD as it unfolds. A critical question that remains unanswered is whether and how these children with ASD resemble other children identified from the community, including those with no family history. The purpose of this study was to compare clinical characteristics of children with ASD identified by each method (n = 86 per group), drawn from two Canadian longitudinal research cohorts. Children ascertained from a prospective cohort were less severely affected and included a larger proportion of girls, compared to the clinically referred sample. These results may have important implications for conclusions drawn from studies of high-risk and clinically referred cohorts.

The aim of the study is to explore whether identified parental and patient behaviors observed in the first few sessions of family-based treatment (FBT) predict early response (weight gain of 1.8 kg by session four) to treatment. Therapy film recordings from 21 adolescent participants recruited into the FBT arm of a multi-site randomized clinical trial were coded for the presence of behaviors (length of observed behavior divided by length of session recording) in the first, second and fourth sessions. Behaviors that differed between early responders and non-early responders on univariate analysis were entered into discriminant class analyses. Participants with fewer negative verbal behaviors in the first session and were away from table during the meal session less had the greatest rates of early response. Parents who made fewer critical statements and who did not repeatedly present food during the meal session had children who had the greatest rates of early response. In-vivo behaviors in early sessions of FBT may predict early response to FBT. Adaptations to address participant resistance and to decrease the numbers of critical comments made by parents while encouraging their children to eat might improve early response to FBT.

ObjectiveThe aim of this study was to examine the relationship between therapeutic alliance and treatment outcome (remission status) in family-based treatment (FBT) and adolescent-focused therapy (AFT) for adolescents with anorexia nervosa (AN).MethodIndependent observers rated audiotapes of early therapy sessions using the Working Alliance Inventory-Observer Version (WAI-o). Outcome was defined using established cut-points for full and partial remission. To control for effects of early symptom improvement, changes in weight- and eating-related psychopathology prior to the alliance session were calculated and entered as a covariate in each analysis.ResultsParticipants in AFT had significantly higher alliance scores; however, overall scores were high in both therapies. The alliance was not a predictor of full remission for either treatment, though it was a non-specific predictor for partial remission.DiscussionTherapeutic alliance is achievable in adolescents with AN in both AFT and FBT, but demonstrated no relationship to full remission of the disorder.

Autism spectrum disorders (ASDs) are common, heritable neurodevelopmental conditions. The genetic architecture of ASDs is complex, requiring large samples to overcome heterogeneity. Here we broaden coverage and sample size relative to other studies of ASDs by using Affymetrix 10K SNP arrays and 1,181 [corrected] families with at least two affected individuals, performing the largest linkage scan to date while also analyzing copy number variation in these families. Linkage and copy number variation analyses implicate chromosome 11p12-p13 and neurexins, respectively, among other candidate loci. Neurexins team with previously implicated neuroligins for glutamatergic synaptogenesis, highlighting glutamate-related genes as promising candidates for contributing to ASDs.

Autism spectrum disorders (ASDs) are common, heritable neurodevelopmental conditions. The genetic architecture of ASDs is complex, requiring large samples to overcome heterogeneity. Here we broaden coverage and sample size relative to other studies of ASDs by using Affymetrix 10K SNP arrays and 1,181 [corrected] families with at least two affected individuals, performing the largest linkage scan to date while also analyzing copy number variation in these families. Linkage and copy number variation analyses implicate chromosome 11p12-p13 and neurexins, respectively, among other candidate loci. Neurexins team with previously implicated neuroligins for glutamatergic synaptogenesis, highlighting glutamate-related genes as promising candidates for contributing to ASDs.

Considerable evidence on autism spectrum disorder emergence comes from longitudinal high-risk samples (i.e. younger siblings of children with autism spectrum disorder). Diagnostic stability to age 3 is very good when diagnosed as early as 18-24 months, but sensitivity is weaker, and relatively little is known beyond toddlerhood. We examined stability and change in blinded, clinical best-estimate diagnosis from age 3 to middle childhood (mean age = 9.5 years) in 67 high-risk siblings enrolled in infancy. Good agreement emerged for clinical best-estimate diagnoses (89.6% overall; kappa = 0.76, p < 0.001, 95% confidence interval = 0.59-0.93). At age 3, 18 cases (26.9%) were classified with "autism spectrum disorder": 17 retained their autism spectrum disorder diagnosis (94.4%; 13 boys, 4 girls) and 1 no longer met autism spectrum disorder criteria at follow-up. Among "non-autism spectrum disorder" cases at age 3, 43/49 remained non--autism spectrum disorder at follow-up (87.8%; 22 boys, 21 girls) and 6/49 met lower autism symptomatology criteria ("Later-Diagnosed"; 3 boys, 3 girls). Later-diagnosed cases had significantly lower autism spectrum disorder symptomatology and higher receptive language at age 3 and trends toward lower autism symptoms and higher cognitive abilities at follow-up. Emerging developmental concerns were noted in all later-diagnosed cases, by age 3 or 5. High-risk children need to be followed up into middle childhood, particularly when showing differences in autism-related domains.

Background: Differences in how developmental pathways interact dynamically in children with autism spectrum disorder (ASD) likely contribute in important ways to phenotypic heterogeneity. This study aimed to model longitudinal reciprocal associations between social competence (SOC) and language (LANG) pathways in young children with ASD. Methods: Data were obtained from 365 participants aged 2-4 years who had recently been diagnosed with an ASD and who were followed over three time points: baseline (time of diagnosis), 6- and 12 months later. Using structural equation modeling, a cross-lagged reciprocal effects model was developed that incorporated auto-regressive (stability) paths for SOC (using the Socialization subscale of the Vineland Adaptive Behavior Scales-2) and LANG (using the Preschool Language Scale-4 Auditory Comprehension subscale). Cross-domain associations included within-time correlations and lagged associations. Results: SOC and LANG were highly stable over 12 months. Small reciprocal cross-lagged associations were found across most time points and within-time correlations decreased over time. There were no differences in strength of cross-lagged associations between SOC-LANG and LANG-SOC across time points. Few differences were found between subgroups of children with ASD with and without cognitive impairment. Conclusions: Longitudinal reciprocal cross-domain associations between social competence and language were small in this sample of young children with ASD. Instead, a pattern emerged to suggest that the two domains were strongly associated around time of diagnosis in preschoolers with ASD, and then appeared to become more independent over the ensuing 12 months.

This study assessed sensory processing differences between 24-month infants at high-risk of autism spectrum disorder (ASD), each with an older sibling with ASD, and low-risk infants with no family history of ASD. Sensory processing differences were assessed using the Infant/Toddler Sensory Profile, a parent-reported measure. Groups were compared based on 3-year outcomes: (a) high-risk infants subsequently diagnosed with ASD; (b) high-risk infants without an ASD diagnosis; and (c) low-risk infants without an ASD diagnosis. Analyses showed that high-risk infants diagnosed with ASD have more difficulty with auditory processing (i.e., responses to auditory stimuli) and lower registration (i.e., lacking sensation awareness) compared to controls. Thus, behavioral responses to sensory input represent early risk markers of ASD, particularly in high-risk infants.

Path analysis within a structural equation modeling framework was employed to examine the relationships between two types of parent stress and children's externalizing and internalizing behaviors over a 4-year period, in a sample of 184 mothers of young children with autism spectrum disorder. Parent stress was measured with the Parenting Stress Index-Short Form and child behavior was measured with Child Behavior Checklist/1.5-5. Across all time points, parent general distress predicted both types of child behaviors, but not vice versa. In addition, there was modest evidence of a bidirectional relationship between parenting distress and both types of child behaviors from 12 months post-diagnosis to age 6. Results are compared to previous work in this area, with implications for early intervention.

Background: Parental concerns persist that immunization increases the risk of autism spectrum disorder, resulting in the potential for reduced uptake by parents of younger siblings of children with autism spectrum disorder ("younger sibs"). Objective: To compare immunization uptake by parents for their younger child relative to their older child with autism spectrum disorder ("proband") and controls. Design: Immunization status was obtained for 98 "younger sibs," 98 "probands," and 65 controls. Results: A significant group difference emerged for overall immunization status (Fisher's exact test = 62.70, "p" < 0.001). One or more immunizations in 59/98 younger sibs were delayed (47/98; 48%) or declined (12/98; 12.2%); immunizations were delayed in 16/98 probands (16.3%) and declined in only one. All controls were fully immunized, with only 6 (9.2%) delayed. Within the "younger sibs" group, 25/98 received an autism spectrum disorder diagnosis; 7 of whom (28%) were fully immunized. The rates of autism spectrum disorder diagnosis did not differ between immunized and nonimmunized younger sib groups, although small sample size limits interpretability of this result. Conclusion: Parents who already have one child with autism spectrum disorder may delay or decline immunization for their younger children, potentially placing them at increased risk of preventable infectious diseases.

The primary objective of this mixed methods study was to identify educators' professional development needs to determine how best to support them in providing quality programming for children with Autism Spectrum Disorders (ASD) within an inclusive educational system. Information was collected through focus groups with key school board informants (n = 33) and a survey of educators (n = 225). The results indicate that educators have found it difficult to meet the wide-ranging and varying needs of children with ASD within a strictly defined model of inclusive education. Educators consistently emphasized the need for multileveled and multipronged professional development that is accessible in a timely fashion and available as needs arise. The need for educational programs that work for children with ASD being taught within inclusive education settings is highlighted.

Given recent advances in science, policy, and practice of early identification in autism spectrum disorder (ASD), questions about the effectiveness of early intervention have far-reaching service and policy implications. However, rigorous research evaluating the efficacy and effectiveness of intervention programs for toddlers with ASD faces a multitude of novel scientific challenges. The Autism Speaks Toddler Treatment Network (ASTTN) was formed in 2007 to provide an infrastructure for ongoing communication between the investigators of eight research projects evaluating parent-mediated interventions for toddlers with ASD. The present article describes and compares the research studies of the ASTTN; highlights specific challenges with regard to research design, participants, recruitment, eligibility criteria, enrollment, and intervention approach; and outlines practical considerations that may guide the next generation of parent-mediated intervention studies involving toddlers with ASD.