Interventions for Autism: Translating Research into...
Transcript of Interventions for Autism: Translating Research into...
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Interventions for Autism:Translating Research into Practice
Cindy Canceko Llego, MD, MSc
Developmental-Behavioral Pediatrician
Clinical Epidemiologist
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Objectives
• To discuss the importance of good scientific research in the management of children with special needs
• To discuss the autism interventions that have the best scientific evidence
• To discuss challenges in autism research
• To discuss practical tips for parents, therapists, teachers and doctors when using scientific research
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The Scientific Method
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Three pictures with caption
Caption
Varying
theories in
Autism lead
to hypotheses
Interventions
need to be
tested
systematically
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Why good scientific research is important
• To advance knowledge
• To improve on current conditions
• To avoid harm
• To evaluate effectiveness of what is being done
• To provide basis for recommendations for public funding
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Hierarchy of evidence
Anecdotes and opinions
Animal & cell studies
Observational research
Randomized controlled trials
Meta-analyses
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Why testimonials are not enough
Testimonials/case reports
Placebo-controlled trial
INTERVENTION “A” WITHOUT INTERVENTION “A”
“placebo effects”
-other factors are causing the
improvement
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Randomized controlled trials (RCT)
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Meta-analysis
• Systematic review that combines the results of 2 or more RCTs
• Resolves uncertainty when results of single studies are conflicting
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The story of Secretin
In 1998: 3 autistic children given Secretin
dramatic improvement in eye contact and
language
Randomized, placebo-controlled trials
1999 Sandler et al
2000 Chez et al
2000 Dunn-Geier et al
2001 Roberts et al
2001 Owley et al
NO
EFFECT!
Owley et al, 2001. J Am Acad Chil Adolesc Psychiatry 40:11
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RCT maneuvers that increase validity
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RandomizationEnsures that the groups
being compared are EQUAL in most aspects
- Severity
- Age
- Family support, etc.
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Placebo controlParticipants & their
families in both groups should believe they are
receiving an intervention
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Blinding Outcome assessors should NOT know
which intervention the participant has
received
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Balance of benefits and harms
• Benefits should outweigh the harms
• Requirements for establishing benefits are stricter compared to establishing harms
benefits
harms
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Strength of evidence classification
Established high-quality studies
• EFFECTIVE show benefits
• INEFFECTIVE high-quality studies show no benefit
Emerging need for high-quality studies to confirm
Unestablished conflicting results; no RCTs
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ESTABLISHED InterventionsHigh-quality studies have provided evidence
- EFFECTIVE: Meta-analysis of RCTs with blinding,
RCT + high-quality cohort studies
- INEFFECTIVE/HARMFUL: at least one RCT
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Early intensive behavioral intervention
increases social communication, decreases problem behaviors, improves academic skills and motor skills
• Intensive at 25-40 hours per week for 2-3 years
• Targets the defining symptoms of ASD
• Based on Applied Behavior Analysis (ABA) principles
• Individualized instruction in various settings (home, school, community) and small group instruction
• Functional behavior assessments are often needed even in older children to target specific problems
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Parent-mediated social-communication intervention
improves social interaction, communication acts, joint attention and joint engagement
• Play-based
• Adjusted to the child’s developmental level
• Speech therapists teach parents/ caregivers techniques such as joint action routines, following the child’s lead, using play to elicit and reward communication
• Therapist modelling and video-interaction feedback
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Naturalistic teaching strategies
improve joint attention and social communication
• A.k.a. incidental teaching, milieu teaching, embedded teaching, responsive education, focused stimulation
• Observing the child’s interests and structuring teaching sessions around them
• Use of materials that the child encounters daily
• Includes strategies such as modelling and physical prompting
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Peer-mediated social-communication intervention
improves child-initiated social interactions and peer-child joint engagement
• For school-age children (average age: 8-9 years old)
• Typically-developing peers are taught techniques such as social modelling and reinforcement, how to deal with aggressive behavior and how to engage a child with autism
• Orientation, role-playing, free-play sessions
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Social skills group intervention
improves social behaviors
• Use of instruction, modelling, rehearsal and performance feedback in a group
• Target skills included playing cooperatively, taking turns, listening, reciprocal conversation, team-working
• Parents also trained to organize play dates to increase generalization
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Anti-psychotic medication (Risperidone, Aripiprazole)
lessens aggressive and self-injurious behaviors
• Not effective for addressing core Autism features
• Considered only when psychosocial interventions are insufficient
• Functional assessment of behavior should be done
• Interventions also given for co-existing contributory factors (communication impairments, pain, environmental conditions)
• Use lowest effective dose, re-evaluate effects after 3-4 weeks, stop after 6 weeks if no response
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Parent training
improves social skills in children with Asperger
• Education of parents regarding the disorder, expected behavior problems and reason for these behaviors
• Use of social stories and comic strip conversations to teach social skills
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Cognitive-behavioral techniques
reduce anxiety, hyperactivity and conduct problems; improve anger management
• Used for older children (mean age 10 years)
• Techniques included recognizing anxiety symptoms, using coping skills and relaxation techniques
• Usual CBT adapted for ASD by using more visual aids, providing lists of alternative responses and devoting more time to concrete exercises
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INEFFECTIVE Interventions (placebo effects)
• Anti-depressants (Fluoxetine, Citalopram)- stereotypy, hyperactivity, decreased attention
• Anti-convulsants (Divalproex sodium)
• Secretin- diarrhea, vomiting, irritability
• Chelation- hypocalcemia, renal impairment
• Neurofeedback- worsening semantics
• Auditory integration training
• Hyperbaric oxygen therapy- ear barotrauma
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EMERGING InterventionsAt least one study shows favorable outcomes but more high-quality studies are needed
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EMERGING (Promising) Interventions
• Combined teacher and parent interventions (e.g., LEAP) for overall autistic behaviors, language skills, academic skills and motor skills
• PECS for social communication and language
• Computer-based emotional recognition therapy for emotional and facial recognition (proximal measures of social communication)
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EMERGING (Promising) Interventions
• Multi-vitamins for overall autistic behaviors and receptive language
• Music therapy for expressive language
• Sensory integration therapy for sensory problems
• Melatonin + CBT for sleep problems
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UNESTABLISHED InterventionsStudies show no significant benefit or show conflicting results; future studies may prove it to be effective or ineffective
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UNESTABLISHED Interventions with RCTs
• DIR/ Floortime
• Theory of Mind
• Gluten-free, casein-free diet
• Acupuncture/ acupressure
• Qigong massage
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UNESTABLISHED Interventions with RCTs
• Horseback riding
• Kata (Shotokan) techniques
• Omega-3/DHA supplement
• L-carnosine supplement
• Atomoxetine for ADHD symptoms in ASD
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Challenges in Autism Research
• Heterogeneity of children with ASD and confounding factors
• Importance of randomization
• Blinding
• Importance of choosing outcome measures (not self-rated or parent-rated)
• Heterogeneity in interventions and outcomes
• Importance of structuring and defining the intervention and the target outcome
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Challenges in Autism Research
• Small sample sizes
• Importance of doing what others have been doing (instead of formulating a new program), and publishing, to combine results
• Lack of researchers
• Importance of doing research for Filipinos by Filipinos
• Research provides opportunities for novel interventions to be given for free while still unestablished
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Practical tips
• Start with established interventions
• Consider values and preferences of the family and individual
• Consider availability and access to services
• Consider capacity of service providers to correctly implement the intervention
• Use emerging interventions if established interventions are not working or not available
• Explore unestablished interventions only in addition to established
• Consider safety
• Consider cost/allocation of family resources
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Where to get good information
• Government websites, professional society websites
• Avoid websites that are selling products or interventions
• Discuss options with your doctor
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In the Philippines
• Need to increase parent/caregiver training interventions
• Need to increase peer-mediated interventions in schools
• Need to strengthen publicly-funded early detection and intervention
• Explore Filipino strengths (extended families)
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Take-home messages
• Be open-minded but skeptical.
• A lack of evidence doesn’t always mean it isn’t effective, but it makes it harder to evaluate effectiveness and safety.
• Prioritize doing established interventions first.
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Thank you!
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Main References
• UK National Collaborating Centre for Mental Health, National Institute for Health and Care Excellence (2013). Autism: The Management and Support of Children and Young People on the Autism Spectrum.
• US National Autism Center (2015). Findings and Conclusions: National Standards Project, Phase 2: Addressing the Need for Evidence-based Practice Guidelines for Autism Spectrum Disorder.