Posts Tagged ‘
early intervention ’
Thursday, November 7th, 2013
Early diagnosis of autism spectrum disorders (ASD) offers the promise of early intervention – with the premise being the earlier, the better. New research suggests that we may be on the horizon of finding signs of ASD in the first 6 months of life. Here’s the breakdown of why this study – which examined attention to eyes in infants as a predictor of a diagnosis of ASD in toddlerhood – is so important.
Why Is This Study Design Powerful? This study – which builds on substantial prior research on eye contact in ASD – uses a powerful longitudinal design to search for the early signs of ASD in infants, including some at high risk (babies of older siblings with ASD). These design features give confidence in the results – the sampling frame goes from early infancy through the typical age of first diagnosis of ASD, and the high-risk component ensures enough cases to draw meaningful conclusions. And the construct of interest – attention to eyes – has been well-studied, is theoretically grounded, and can be measured with precision.
Why Are The Findings Provocative? Two reasons. First, while ASD (or the risk, or liability, to develop ASD) is assumed to be present at birth, early signs of ASD have been elusive. This study offers hope that by detecting a lack of attention to eyes in the first 6 months of life may offer one potentially powerful screen for risk for ASD. But there’s more. An especially novel finding is that infants later diagnosed with ASD started out in life attending to eyes – but that that ability declined over time. This may eventually be a clue in terms of underlying brain mechanisms – and it also suggests that if these fundamental mechanisms are “in tact” at birth and then decline, perhaps there is even more room for change with very early intervention. Either way, a strong signal of risk in the first 6 months of life may be translated – perhaps rapidly – into very early intervention strategies.
What’s The Take-Home Message? Parents have been encouraged to be mindful of some of the signals of risk for ASD in the early years – including 7 early signs of ASD. Although this study has not yet led to formal recommendations for parents, it does suggest how important face-to-face interaction is during infancy – and also highlights that parents should be vigilant about seeing how their baby reacts when eye contact is expected. The way a baby looks at the human face changes a lot over the first year in life – but the constant is that they spend a lot of time looking at it. The suggesting from this new research is that babies at risk for ASD show a decrease in their interest in the face during infancy. If this is happening, it is certainly worth bringing to the attention of a pediatrician, who will be positioned to look for other developmental milestones and indicators.
What’s The Future? Research studies are especially influential if they give a glimpse into the future. Here the hope is that a screening protocol can be developed to route infants into very early intervention – a developmental time that may hold promise for a lot of plasticity and response to intervention. Bear in mind that some of the most exciting findings to date about intervention – based on application of the Early Start Denver Model (ESDM) – demonstrated that one of the results of intensive intervention is changing the brain response to the human face, with normative patterns of brain activity achieved in some cases. Starting that process in infancy might lead to even more effective intervention programs for ASD.
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Friday, August 30th, 2013
Not yet. But someday it may be a possibility.
Researchers are developing a technique that analyzes the placenta for troboblast inclusions (TIs) – which are folds and creases that can be observed at a microscopic level. Preliminary research is suggesting that a density of these may indicate risk for Autism Spectrum Disorder (ASD). Longitudinal studies will now track babies for a few years to determine the magnitude of that risk.
We often hear about exciting science that will not come to fruition for a long time. But what’s intriguing about this project is that the scientists argue that the biological screening will promote the earliest environmental intervention possible. This is a terrific perspective because we know early environmental intervention can have profound effects on the development of kids with ASD. So rather than waiting for biological cures that may never happen, it’s quite smart to think about using biological science to bolster our ability to deliver interventions that we know have positive and sometimes quite powerful benefits.
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Wednesday, May 22nd, 2013
The DSM-5 has made major changes in the way that Autism Spectrum Disorder (ASD) is diagnosed. Here are 5 practical tips for parents based on these changes:
1) Understand the implications of eliminating Asperger’s Disorder. For most children, this change should not have much impact in the diagnostic process. It will impact some children who are higher functioning and who would have, in the past, been diagnosed with Asperger’s Disorder. The DSM-5 includes severity criteria which were designed in part to incorporate these types of kids into the new diagnostic framework. That said, many in the field think that some kids may no longer receive a diagnosis if their symptoms are less severe. Some of the initial studies demonstrate that some kids who would have been diagnosed in the prior DSM will not receive a diagnosis using DSM-5. As a parent, be ready to have this discussion with a clinical provider – and be ready to ask questions like “If the old system was in place, would my child have been diagnosed as Asperger’s?” You may need to advocate more strongly than before for your child. Focus on the need for services that could make a difference for your child’s development and collaborate with your practitioners to make sure your child has every opportunity to benefit from intervention.
2) Understand the implications of eliminating other alternate diagnoses. DSM-5 does away with other diagnostic options like Pervasive Developmental Disorder Not Otherwise Specified. The impact may be felt for kids who have many symptoms of ASD but not necessarily the exact profile. There may be no alternative diagnosis despite the fact that they have many developmental issues that need attention. Make sure your practitioners seem savvy about DSM-V and know how to make sure a kid with this kind of mixed presentation doesn’t get lost in the transition to the new diagnostic framework. Have that discussion with them and be satisfied – or seek out another opinion.
3) Beware of the severity criteria and insurance. Many clinicians have told me that they are concerned that insurers may balk at covering services for some children who are rated to show less severe symptoms. We don’t know this yet. Make sure your clinician is on top of these issues and that the team is ready to take on battles if necessary. You want to have confidence in your providers because this is all new and it is not clear how it will all unfold.
4) Remain vigilant about the early signs of autism. Just because the way ASD is diagnosed has changed in DSM-5, that doesn’t mean the warning signs have changed. They remain the same and you should be aware of the 7 early signs of autism.
5) Remember that early intervention still matters. If you suspect that your child may have ASD, it is better to get started as early as possible with the evaluation process – and if necessary intervention. Intervention helps any child, no matter what the severity, and early intervention is, right now, the best we have to offer kids with ASD. The fact that we have switched to DSM-5 does not alter the importance of early intervention – though, again, you need to be aware that you might need to fight harder to get intervention. It’s a fight worth taking on.
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Thursday, January 17th, 2013
There is a long history of reports of small numbers of individuals with Autism Spectrum Disorder (ASD) experiencing recovery – meaning they no longer met diagnostic criteria. While such claims have generated controversy over the years, a new study provides the best scientific evidence documenting recovery from ASD in a small number of individuals.
A team of researchers (led by Dr. Deborah Fein at the University of Connecticut) identified 34 individuals with suspected recovery who had a clear documented history of ASD, but no longer met diagnostic criteria for it. By comparing this group to two other groups – a high-functioning ASD group (44 individuals), and a typical development group without ASD (34 individuals) – the study reported these two key findings:
- The 34 potential recovery cases not only no longer met criteria for ASD, but in fact lost all symptoms of ASD
- Their social and communicative functioning was within the nonautistic range (and as a group similar to the typical development group)
The study authors suggested the phrase “optimal outcome” for these individuals to convey the idea that their overall functioning across multiple domains was in the normative range. There was a wide age range in the sample – from 8 to 21 years – and the conclusion was that some children with a diagnosis and history of autism may in fact go on to experience an optimal outcome later in development.
More reports will come in the future from this research group on this sample. In particular, they will be analyzing collected data on intervention history to see if there were commonalities in those who experienced an optimal outcome. They will also be looking at psychiatric data to examine the possibility that some with optimal outcome experience anxiety, depression, and impulsivity. Based on the data published to date, the group with optimal outcomes were reported to have milder symptoms of ASD when they were younger (but only in terms of social symptoms, not communicative or repetitive behavior symptoms), and IQ scores in the high average range. But more work will be done to see if there are clear factors which are predictive of optimal outcome.
While every child with ASD will not have an optimal outcome as defined in this study, the larger message is that the developmental trajectory of kids with ASD can be modified. We’ve seen over the past year stories about how as many as 10% of youth with ASD may “bloom” by age 8 and lose many of the debilitating symptoms. A recent study reported “a small breakthrough” for some kids with ASD (achieved with the Early Start Denver Model intervention) that resulted in “typical” brain activity activated by viewing faces. The bottom line is that whether small or big steps are made via intervention, the parents and intervention specialists who put in extraordinary time and effort will improve the lives of kids with ASD. The two key considerations continue to be early diagnosis, and early intervention. To that end, it’s critical that parents know the early signs of ASD:
The 7 Early Signs of Autism Spectrum Disorder That Every Parent Should Know
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Thursday, October 4th, 2012
The impact of the newly proposed diagnostic criteria for autism have been debated this year and the conversation continues with a new study published online in the American Journal of Psychiatry (you can read it here). The key issue has been the extent to which the new criteria will lead to fewer diagnoses of autism. Here’s a summary of where things stand right now.
1) The new criteria lumps all disorders along the autism spectrum together under one diagnosis. This means, for example, that separate criteria for Asperger’s Syndrome would no longer be in place. Whenever diagnostic lumping takes place, the criteria become less specific, in order to take in a large range of symptoms. A result of this is that clinicians making diagnoses have to use even more professional insight and discretion to determine if a diagnosis is warranted because the criteria are more general than before.
2) To account for the wide range of symptom expression that can be observed within this broad autism spectrum, there will be a severity scale, ranging from mild to severe.
3) A key concern has been that the new diagnostic criteria will result in fewer diagnoses of autism in the future. Some have claimed that this effect will be profound. The study cited above suggests that less than 10% of current cases would no longer meet diagnostic criteria for autism.
Now this is where the fuzziness in the debate comes into play. Whenever a child is not diagnosed with a condition, then the availability of services gets reduced. Do these 10% of kids still need services? Will they get a diagnosis that will permit access to services? This is really the crux of the question. Furthermore, there are suggestions that this study was a “best-case scenario” because it focused on more clear-cut cases and used expert clinicians with lots of experience (see, for example, the New York Times report on this). The implication is that once the new diagnostic criteria are used out in the real world, with a range of clinicians in terms of experience, the number of cases that will not be diagnosed may be higher than the 10% reported in the study.
Earlier this year, I asked an experienced clinician – Dr. Gil Tippy – to offer his take on the matter. He suggested that the rates of autism will not be severely affected if experienced clinicians are doing the assessments. His greatest concern was that the use of the new severity criteria would substantially decrease the number of kids who could receive services for their condition. His argument was that insurance companies could deny coverage to those who were given a “lower” severity rating of mild impairment – even though that “mild impairment” requires intervention. You can read the entire blog post here if you are interested in the details.
So I think there are 2 take-home messages right now:
1) The rate of diagnosis will go down – but it’s not clear to what degree.
2) The impact of the severity criteria on the ability of families to secure coverage needs to be considered in more detail, as this could result in impediments to secure treatment.
If you read Dr. Tippy’s suggestions noted above, he offers advice on how to advocate to ensure that kids are not denied services in the future. This is especially important as early screening and early intervention continue to be the most effective strategies for accelerating the development of youth diagnosed with autism. To that end, it’s important that all parents know the early signs of autism that would indicate the need for early screening – if you haven’t seen it before, here is a prior blog post that lists 7 key early signs that should never be ignored.
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