Laura Schreibman - US grants

The literature and the results of our previous finding periods have supported the position that parent training is an extremely effective approach to the treatment of autism. It is fast, economical, and produces relatively broad treatment changes. During our research program our work has been concerned with identifying specific variables related to the best-practice parent training and developing an improved program designed to address these variables. Accordingly, our research has assured a progressive direction in the development of a parent training treatment delivery package that is optimal for the child and for the family. In our previous research we have typically compared one type of treatment to another type of treatment. Looking back at our efforts in this area we now feel we have a substantial corpus of data both comprehensive in scope and rich in detail; and based on our pilot studies and preliminary investigations we believe that careful analyses of these data now allow us to specify several variables important for the purpose of developing "individualized" treatments for children with autism and their parents. Our data indicate that although we have consistently found one standard type of treatment to be more beneficial overall than another standard type of treatment, each individual treatment contains aspects that are very powerful for specific purposes. In fact, our data suggest that a combination of these treatment procedures, individualized based on child, family and target behavior characteristics will be far superior than implementing one type of treatment for all children as if they were all the same. Because of the large amount of heterogeneity in child and parent characteristics seen in the area of autism it is becoming abundantly clear that individualized treatment will be greatly superior to a standard package. We hypothesize that this type of treatment will significantly improve the treatment of autism, with respect to both direct measures of child behavior and with respect to measures of overall family functioning. We thus propose to carefully compare tow treatment conditions. Our control condition will be our current best-practice parent training package (the Self-Management condition, now called the Standard Package or SP condition). Our experimental condition will be one in which treatment will be "individualized" for each family in that the specifies of the treatment plan will be dictated by the characteristics of the child and of the family (the Individualized Package or IP condition).

The results of our previous funding period indicate that parent training is an extremely effective approach to the treatment of autism. It is fast, economical, and produces relatively broad treatment changes. However, one rather serious limitation to date has been that the children are extremely dependent upon their treatment provider (in this case their parents) and continue to exhibit relatively limited autonomous peer related responding even after treatment. Based upon the literature and existing pilot data, we hypothesize that the most productive parent training avenue will be one that involves the child as a major component in the treatment delivery. Specifically, we feel the parents are going to need to learn how to teach self-management skills to these children. The types of changes that are required of the children over the years are those that need to be evidenced in an almost infinite number of environments. Also, as the child matures, the need for independence becomes increasingly great. As a result, we are proposing to compare a control treatment condition consisting of a typical parent training approach where the parents are taught to manage their children's behavior (Parent-Management or PM condition) in comparison to a new parent training approach where the parents are taught to include their child as a central part of the treatment delivery through self-management techniques (Self-Management or SM condition).

[unreadable] DESCRIPTION (provided by applicant): There is very little known about methods of designing interventions for very young nonverbal children. For example, the literature and our preliminary studies suggest that many nonverbal children may acquire functional communication with an intervention program that is focused entirely on verbal communication. Other children seem to require augmentative communication systems. These augmentative systems may be effective in further producing verbal communication for some nonverbal children, and may remain as the sole effective means of communication for other children who do not acquire expressive verbal communication. The purpose of the proposed research project is to systematically compare two widely used types of intervention programs (see Koegel, 2000, NIH Autism Conference; Lord & McGee, 2001, National Research Council report; Stiebel, 1999). Both approaches are consistent with our general theoretical model in that both target the key pivotal area of motivation to communicate. The primary difference in the approaches is one accomplishes this through a primarily verbal only approach, whereas the other accomplishes this through a primarily visual approach. This difference has been of major interest to the field of autism, but has not been systematically compared in scientific research. While it does not make any difference with respect to our theoretical position as to which condition turns out to be better, it may make a large difference with respect to translation from research to practice, and with respect to understanding autism, which are major NIMH priority areas. In one condition, randomly assigned children will be provided with an intervention using a well-documented manualized intervention focused on verbal expressive communication only (Pivotal Response Training, PRT). In the other condition, randomly assigned children will receive an intervention for the same social communication functions using a well-documented manualized augmentative system of intervention (Picture Exchange Communication System, PECS). Children in the two conditions will be compared for development of verbal and nonverbal communication, changes in disruptive behavior, changes in symptoms of autism, and general adaptive behavior gains. In addition, parent satisfaction and stress measures will be gathered in order to assess the effects of each intervention on family functioning. [unreadable] [unreadable]

Research has shown that despite significant rigor and intensity, some children with an autism spectrum disorder fail to make significant gains in response to behavioral treatment (e.g., Sherer &Schreibman, 2005). The behavioral characteristics of children who excel versus those that do not are not well understood. The biological characteristics of such treatment responders and nonresponders are completely unknown. In order to determine what behavioral and biological factors predict treatment responsiveness, consistency regarding various aspects of treatment must be provided. For all children the type of treatment, age at which treatment is administered, and length of treatment must be consistent. Therefore, a Treatment Core (TxC) has been established to implement an evidence-based treatment for toddlers with autism participating in the ACE projects. A specific, manualized treatment, the STAR Program (see Appendix A), has been chosen as the foundation for the treatment. This curriculum incorporates evidence-based behavioral methods, including discrete trial teaching, pivotal response training, and teaching within functional routines, that are of documented effectiveness. This curriculum will be adapted to accommodate 2-year-old children and to include additional social goals and developmental strategies. Recently, a developmental, social-pragmatic intervention that incorporates both developmental and naturalistic behavioral strategies has been examined as a parent education adjunct to the STAR curriculum. This program incorporates early developmental strategies such as Responsive Teaching and Floor Time/DIR, which encourage joint attention, social responsiveness, and engagement in children with autism. We believe, and preliminary data agree, that this combination of curricula and strategies will provide an effective and consistent treatment for children with autism. Overall, the Treatment Core (TxC), has two main goals: The first is to provide state-of-the art behavioral treatment to all participants who meet provisional criteria for autism at 2 years. In order to meet this goal, the TxC will ensure consistent application of treatment practices by training all study personnel in treatment protocol to mastery level. Additionally, the TxC will ensure fidelity of implementation of the treatment protocol throughout the funding period. The second goal is to provide a quantitative index of level of response to treatment for each at-risk toddler for use in predictive analyses in Projects 1-4. As such, the TxC will collect data throughout treatment to assess learning rate and speed of progress in each curriculum area. Finally, the TxC will establish an overall response-to-treatment profile for each study toddler in the domains of symptom severity, cognitive, language, and social behavior. These profiles will be used by each project as well as the Integrated Biostatistics and Bioinformatic Analysis Core to determine the profiles of treatment responders and nonresponders.