Alice S. Carter - US grants

The proposed project will examine the role of maternal, environmental and infant factors (e.g., social support, infant temperament) which combine with maternal depression to place infants at risk for problems in social- emotional functioning. I am proposing to screen 600 women for depression in the second trimester of pregnancy in order to ascertain 60 clinically depressed mothers and 60 nondepressed mothers. Mothers who meet criteria for DSM-III-R major depression on the screening instrument and a matched sample of mothers with very few depressive symptoms will be administered a structured psychiatric interview at two months post partum. Mothers who meet DSM-III-R criteria for major depression based on the interview information and those who have no history of depression will be followed with their infants in a short-term longitudinal study. Mother-infant pairs will be evaluated at 4 and 14 months post partum. I anticipate a final sample of at least 50 depressed and 50 nondepressed mother-infant dyads at the 14 month follow-up. The specific aims of the study are: 1) to compare depressed and nondepressed mothers with respect to: a) social supports; and b) dimensions of parenting; 2) to compare infants of depressed and nondepressed mothers with respect to: a) affective displays; b) social responsivity; c) temperament; and d) attachment patterns; 3) to address individual differences within depressed mothers by examining whether maternal characteristics such as concomitant psychopathology, severity of global psychopathology, social supports, and parenting styles differentially predict infant security of attachment at 14 months postpartum; and 4) to examine maternal factors in pregnancy and at 4 months postpartum in combination with measures of infant temperament at 4 months to predict infant security of attachment and maternal sensitivity at 14 months postpartum. A unique aspect of the proposed study is the careful characterization of the infant in terms of behaviors which are hypothesized to influence the infant's ability to participate in a reciprocal interaction with their caregiver (e.g., emotional reactivity, sociability). While treatments are currently available which will potentially remediate the symptoms of maternal depression, more data are required to develop prevention strategies which will minimize risk to offspring of depressed mothers. Identifying those depressed mothers who are at greatest risk for difficulties in parenting and those infants who are at greatest risk for problems in affect regulation should inform the development of specific preventive interventions.

DESCRIPTION (Adapted from applicant's abstract): Serious and persistent social-emotional and behavior problems in children under three years of age are well documented by clinical observations and empirical research. However, little is known about the prevalence, pattern and course of psychopathology in infants and toddlers. Recent developments in public policy and legislation mandate epidemiologic research on children's mental health and offer new opportunities to provide proven intervention and prevention services to eligible infants and toddlers. Valid and reliable instruments for assessing social-emotional and behavior problems are essential to achieve these research and service provision goals. Yet, no validated measure of social-emotional problems and competencies exists for 1- and 2- year old children. The primary goal of this project is to examine the prevalence, developmental patterns and correlates of psychopathology in 1- to 3-year old children. To achieve this goal, we must first validate and refine the Infant-Toddler Social & Emotional Assessment (ITSEA), a questionnaire that will be employed to assess social-emotional problems and competencies in 1- and 2- year old children. A representative community sample of 1,200 parents with 1- and 2- year old children will be recruited from the birth records at Yale-New Haven Hospital. In addition, parents of 240 1- and 2- year-old children referred for possible behavioral, developmental and/or social-emotional problems will be recruited form the South Central Region of the Connecticut Birth to Three System. To examine developmental patterns and correlates of social-emotional problems and competencies, all parents will complete measures of child behavior and temperament, family functioning, parenting stress, and parental affective symptoms. Three smaller substudies will examine the specific psychometric properties of the ITSEA (i.e., test-retest, cross-method, and inter-rater reliabilities), as well as the validity of the competence scales. All children participating in the 3 smaller studies will receive a developmental evaluation. Finally to evaluate the stability of and risk-factors associated with social-emotional problems and delays in competence, all children will be reassessed in a 1-year follow-up.

DESCRIPTION (Adapted from applicant's abstract): Serious and persistent social-emotional and behavior problems in children under three years of age are well documented by clinical observations and empirical research. However, little is known about the prevalence, pattern and course of psychopathology in infants and toddlers. Recent developments in public policy and legislation mandate epidemiologic research on children's mental health and offer new opportunities to provide proven intervention and prevention services to eligible infants and toddlers. Valid and reliable instruments for assessing social-emotional and behavior problems are essential to achieve these research and service provision goals. Yet, no validated measure of social-emotional problems and competencies exists for 1- and 2- year old children. The primary goal of this project is to examine the prevalence, developmental patterns and correlates of psychopathology in 1- to 3-year old children. To achieve this goal, we must first validate and refine the Infant-Toddler Social & Emotional Assessment (ITSEA), a questionnaire that will be employed to assess social-emotional problems and competencies in 1- and 2- year old children. A representative community sample of 1,200 parents with 1- and 2- year old children will be recruited from the birth records at Yale-New Haven Hospital. In addition, parents of 240 1- and 2- year-old children referred for possible behavioral, developmental and/or social-emotional problems will be recruited form the South Central Region of the Connecticut Birth to Three System. To examine developmental patterns and correlates of social-emotional problems and competencies, all parents will complete measures of child behavior and temperament, family functioning, parenting stress, and parental affective symptoms. Three smaller substudies will examine the specific psychometric properties of the ITSEA (i.e., test-retest, cross-method, and inter-rater reliabilities), as well as the validity of the competence scales. All children participating in the 3 smaller studies will receive a developmental evaluation. Finally to evaluate the stability of and risk-factors associated with social-emotional problems and delays in competence, all children will be reassessed in a 1-year follow-up.

DESCRIPTION: (adapted from Investigator's abstract) One in every five students in the Nation's schools has significant mental health problems. Mental health and psychosocial problems interfere with the ability of schools to educate, limit students' learning and academic performance, and ultimately interfere with individuals' opportunities to succeed in society. The social-emotional and behavioral precursors to the problems in early elementary school often begin in infancy and toddler hood. In our currently funded study, information was collected about social-emotional and behavioral problems and competencies, language acquisition, and psychosocial risk in an ethnically diverse, representative sample of 1- and 2- year old children. We achieved a response rate of 80 percent in our first year and a retention rate of 92 percent in our second year of data collection. Preliminary findings suggest a prevalence of 11-12 percent for social-emotional and behavioral problems and a prevalence of 17 percent for language delays. In addition, there was significant stability in problems over a 1-year period, with 61 percent of children persisting in the extreme 10th percentile for problem behaviors for their age and sex. Working within a transactional ecological model and informed by developmental psychopathology, we are proposing to follow this unique and diverse sample of children. Specifically, using a longitudinal enriched sample design, we propose to survey parents and teachers (N-1093 to 1158) about child social-emotional problems and competencies, language ability, school functioning, and ecological risk when children are in Kindergarten. Using information about emotional! behavior problems and language functioning, a subsample of children at high risk for psychopathology and school adjustment problems and some children at low risk will be identified for inclusion in Direct Assessments in Kindergarten and Grade 2 (Enriched Sample, N-493 to 513). Teachers of children in the Enriched Sample will be surveyed in Grade 2. The following three outcomes are the focus of the proposed work: 1) emotional/problem behaviors; 2) psychiatric disorders; and 3) school adjustment. Further, we examine the direct and indirect influences of child competence, neurocognitive vulnerability, child sex, and cumulative family/community risk on emotional! behavioral trajectories, psychiatric disorders, and problems in school adjustment. By following this unique representative birth cohort through the critical transition to formal schooling, we hope to understand continuities and discontinuities in emotional/behavioral development and to gather critically needed data that can inform early identification, prevention and intervention efforts.

DESCRIPTION: (adapted from Investigator's abstract) One in every five students in the Nation's schools has significant mental health problems. Mental health and psychosocial problems interfere with the ability of schools to educate, limit students' learning and academic performance, and ultimately interfere with individuals' opportunities to succeed in society. The social-emotional and behavioral precursors to the problems in early elementary school often begin in infancy and toddler hood. In our currently funded study, information was collected about social-emotional and behavioral problems and competencies, language acquisition, and psychosocial risk in an ethnically diverse, representative sample of 1- and 2- year old children. We achieved a response rate of 80 percent in our first year and a retention rate of 92 percent in our second year of data collection. Preliminary findings suggest a prevalence of 11-12 percent for social-emotional and behavioral problems and a prevalence of 17 percent for language delays. In addition, there was significant stability in problems over a 1-year period, with 61 percent of children persisting in the extreme 10th percentile for problem behaviors for their age and sex. Working within a transactional ecological model and informed by developmental psychopathology, we are proposing to follow this unique and diverse sample of children. Specifically, using a longitudinal enriched sample design, we propose to survey parents and teachers (N-1093 to 1158) about child social-emotional problems and competencies, language ability, school functioning, and ecological risk when children are in Kindergarten. Using information about emotional! behavior problems and language functioning, a subsample of children at high risk for psychopathology and school adjustment problems and some children at low risk will be identified for inclusion in Direct Assessments in Kindergarten and Grade 2 (Enriched Sample, N-493 to 513). Teachers of children in the Enriched Sample will be surveyed in Grade 2. The following three outcomes are the focus of the proposed work: 1) emotional/problem behaviors; 2) psychiatric disorders; and 3) school adjustment. Further, we examine the direct and indirect influences of child competence, neurocognitive vulnerability, child sex, and cumulative family/community risk on emotional! behavioral trajectories, psychiatric disorders, and problems in school adjustment. By following this unique representative birth cohort through the critical transition to formal schooling, we hope to understand continuities and discontinuities in emotional/behavioral development and to gather critically needed data that can inform early identification, prevention and intervention efforts.

The revised aims of this project are (1) To investigate the early course of development in children with autism, examining the influence of specific child, family, and intervention factors on stability and change in the core symptoms of autism (i.e., social impairment, communication, and repetitive behaviors/interests); and (2) To investigate the psychological well-being of mothers and fathers of children with autism during early childhood, examining relations between child, family, and intervention factors on stability and change in both positive and negative well-being. This work is based in a developmental contextual framework, in which child level processes are best understood within a complex context that includes parent and family processes and the interventions available to the child and family. We hypothesize that (1) The severity of core symptoms of autism are influenced directly by the presence of co-occurring problem behaviors, competencies and the intensity of intervention services, and indirectly by the child's predisposing temperament and parental well being. (2) Parental well-being is influenced directly by parental resources, family climate, severity of the broader autism phenotype, and the child's symptoms and problem behaviors. These variables also mediate the effects of other child factors and the parents' satisfaction with the intervention services received by their child. To test these hypotheses, we plan to recruit through early intervention specialty service programs 300 18-33 month-old children diagnosed with autism and to conduct a five-year, accelerated cross-sequential longitudinal study of their development and the changes that take place in the family and in the parents' well-being. We believe that the knowledge gained will inform developmental theory and will lead to the development of more effective and responsive child and parent support interventions.

DESCRIPTION (provided by applicant): The goal of the proposed work is to implement a system-level intervention to (a) improve early detection of autism spectrum disorders (ASD) and (b) increase early access to autism specific early intervention services, especially for children who often are not given the known benefits of early intervention services. The proposed study builds on a funded multi-stage screening study that is currently being implemented in 3 Early Intervention programs serving children in the Circle of Promise, a Boston region with high social/economic risk and comprised of a high percentage of children from racial/ethnic minority populations, English language learners, or living in poverty. ASD Rates are increasing in the U.S., with recent estimates indicating that 1 in 88 children have ASD. Early diagnosis and intervention are crucial to ensuring optimal long-term outcomes; yet significant disparities exist in rates and age of diagnosis. Children in the above groups are less likely to be diagnosed and are diagnosed 1-2 years later than White, non-poor, English speaking children. This delay limits access to autism-specific early treatments. Timely identification and treatment requires at least two steps: 1) knowing and identifying the early signs of ASD, and 2) acting early. Pediatricians, parents, and EI providers must decide whether a child is showing enough signs to justify further assessment or treatment, or whether the child is at low enough risk to forego immediate action. Thus, acting early requires the about groups to evaluate the early signs and choose a yes/no course of action, which we refer to as a clinical threshold. We believe that early identification and access to care can be improved both by increasing knowledge of the early signs of ASD and by influencing these decision thresholds regarding when to screen, assess, and refer to ASD-specific interventions. Moreover, access to services requires agreement and cooperation among these decision-makers. Guided by our prior theoretical work and engagement with pediatricians and EI providers, we will influence improved access and receipt of needed services for children with ASD by offering: (1) multistage ASD screening to all EI-enrolled children ages 14-24 months, (2) motivational interviewing to parents whose children qualify for ASD services, and (3) systematic outreach to pediatricians from EI sites. This system- level approach involves altering the context in which pediatricians, EI providers, and parents assess and act on signs of ASD to reduce disparities in access to ASD diagnosis and services. This study will test the following hypotheses: 1) Exposed children with ASD will be more likely to be identified, referred, and receive ASD services, regardless of race/ethnicity, language or poverty status; 2) Exposed pediatricians and EI providers will identify more children with ASDs and refer to assessment and services at higher rates; and 3) Exposed parents of children with ASD will report greater agreement with and will be more likely to follow through on ASD-specific assessment and service referrals.

Project(Summary/Abstract(( Despite significant advances in the early detection of autism spectrum disorders (ASD), racial and ethnic disparities persist in rates and age of detection among children from low socioeconomic status (1). With support from NIMH (R01MH104400), our team developed and is now evaluating the effectiveness of a multi-stage screening protocol to address these health disparities among at-risk toddlers in an underserved region of Greater Boston Massachusetts (MA) referred to as the ?Circle of Promise,? where 98% of children come from racial/ethnic minority populations and 47% are English language learners. Our intervention approach involves partnering with early intervention (EI) agencies to provide targeted multi-stage screening to at-risk toddlers enrolled in Part C EI, the publicly-funded programs to which pediatricians typically refer children experiencing delays in language and other areas of development. In this project, we leverage the experiences of parents, providers and pediatricians in this multi-stage screening protocol to assess potential risks and benefits associated with ASD screening, detection, and treatment, as well as investigate challenges to retention over time among underserved communities. Expanding upon data collected from 21 parents engaged in the ASD multi-stage screening protocol, 22 EI service providers, and over 40 hours of observational data, we first propose to conduct an additional semi-structured interviews with 30 parents who were more likely to experience harms and risks associated with ASD screening (e.g., ?false positives,? loss-to-follow-up), EI service providers with extensive experience implementing the protocol (n=30), and pediatricians whose patients were diagnosed with ASD through this protocol (n=20). Employing a modified grounded theory approach, we will analyze these data and develop a conceptual framework of the risks and benefits associated with ASD screening, detection, and treatment. Given the diverse sample of parents engaged in this process, our findings will be especially germane to building new theoretic understanding of risks and benefits associated with growing disparities in early detection and treatment. Based on findings, we will then conduct a systematic evidence review to identify measures that operationalize identified risks and benefits and disseminate findings through a web-based measures clearinghouse. The clearinghouse will be made available to the research community, including the ASD Pediatrics Network, and include user surveys to facilitate a process of continuous quality improvement. !

PROJECT SUMMARY Despite strong consensus that early, specialized intervention for children with Autism Spectrum Disorder (ASD) can have a dramatic impact on outcomes, the U.S. health system?s capacity to provide such services is severely challenged by the rapid rise in ASD prevalence. The long-term goal is to improve outcomes for children with early signs of ASD by increasing the capacity to provide appropriately specialized treatment within an existing infrastructure: the Part C Early Intervention (EI) service delivery system. Part C is publicly funded, available in all areas, and serves children under age 3 who have developmental delays or disabilities. Currently, the effectiveness of EI services is limited by high practice variation and infrequent use of evidence- based interventions. The study objective is to improve services and outcomes for children with early signs of ASD by conducting a randomized controlled trial (RCT) testing the effectiveness of training EI providers to deliver Reciprocal Imitation Training (RIT). RIT is a naturalistic developmental behavioral intervention (NDBI) that is ideally suited for EI settings because it is low intensity, play-based, easy to learn and implement, and can be taught to families for their independent use, thus increasing intervention dosage. This RCT will employ a hybrid type 1 effectiveness/implementation design, and will use a unique mixed methods approach to gather evidence that will be essential for implementing RIT at scale, pending positive trial results. The sample includes 20 EI agencies across 4 U.S. States and comprises a total of 160 EI providers and 440 families of children with early symptoms of ASD, which not only provides a robust sample size, but also affords the opportunity to assess generalizability of this approach across regions that vary in their implementation of Part C services. EI providers will be randomly assigned to the RIT training group (n=80) or treatment as usual (TAU; n=80). Providers in both groups will identify 2-5 children in their caseload who are 16-30 months old with early symptoms of ASD (n=220 children per group). Intensive, state-of-the art, multi- method assessment technology will be used to measure the impact of the intervention on children?s language and social communication, as well as parents? self-efficacy and well-being. Importantly, this study will examine putative mechanisms (i.e., child gains in imitation and joint attention; parent contingent responsiveness) through which the intervention improves clinically-relevant outcomes. Data regarding provider-initiated modifications to the intervention and delivery will be analyzed to identify fidelity-consistent vs. fidelity- inconsistent changes, which will inform refinement of future RIT training and quality assurance procedures. In sum, this study will generate the evidence necessary to implement RIT at scale, thereby increasing the capacity of the existing EI system to deliver effective, evidence-based intervention to the rapidly growing population of children who show early signs of ASD.