A TREATMENT NOT A CURE Can a parent child interaction (PCI) treatment help young children with autism?
The Lancet Volume 388, Issue 10059, Pages 2501-2509 (November 2016) DOI: 10.1016/S0140-6736(16)31229-6 Institute of Psychiatry, Psychology & Neuroscience IoPPN
Infants with autism impact on parental style • Fail to establish a communicative fit • Infant communicative signals are too weak or infrequent • Reduced meshing – ‘asynchrony’ • Parents may resort to didactic style • Parents perplexity • Parents ‘fill in the gaps’ or withdraw • Adult increased initiations • Strategies to re- direct child’s attention • Interactions are non-reciprocal
Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial RCT Design & Treatment Model (Green et al., 2010) − Parent-mediated, communication-focused intervention ... so ... Parent has few Child initiates little leads to follow and signals poorly ... and therefore... ... and therefore... Parent attempts to Child is prompted so makes compensate by responses (including protests) controlling interaction rather than initiations ... so ... • Olga Tennison Autism Research Centre 5
Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial RCT Design & Treatment Model (Green et al., 2010) − Parent-mediated, communication-focused intervention ... so ... Parent has few Child initiates little leads to follow and signals poorly ... and therefore... ... and therefore... Parent attempts to Child is prompted so makes compensate by responses (including protests) controlling interaction rather than initiations ... so ... • Olga Tennison Autism Research Centre 6
Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial RCT Design & Treatment Model (Green et al., 2010) − Parent-mediated, communication-focused intervention ... so ... Parent has few Child initiates little leads to follow and signals poorly ... and therefore... ... and therefore... Parent attempts to Child is prompted so makes compensate by responses (including protests) controlling interaction rather than initiations ... so ... • Olga Tennison Autism Research Centre 7
Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial RCT Design & Treatment Model (Green et al., 2010) − Parent-mediated, communication-focused intervention ... so ... Parent has few Child initiates little leads to follow and signals poorly ... and therefore... ... and therefore... Parent attempts to Child is prompted so makes compensate by responses (including protests) controlling interaction rather than initiations ... so ... • Olga Tennison Autism Research Centre 8
Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial RCT Design & Treatment Model (Green et al., 2010) − Parent-mediated, communication-focused intervention Improve parent ... so ... observation? Parent has few Child initiates little leads to follow and signals poorly ... and therefore... ... and therefore... Parent attempts to Child is prompted so makes compensate by responses (including protests) controlling interaction rather than initiations ... so ... Improve parent responsiveness/synchrony? • Olga Tennison Autism Research Centre 9
Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial RCT Design & Treatment Model (Green et al., 2010) − Parent-mediated, communication-focused intervention Improve parent ... so ... observation? Parent has few Child initiates little leads to follow and signals poorly ... and therefore... ... and therefore... Parent attempts to Child is prompted so makes compensate by responses (including protests) controlling interaction rather than initiations ... so ... Improve parent Increase child: responsiveness/synchrony? • Motivation to communicate? • Clarity of signals? • Olga Tennison Autism Research Centre 10
Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial RCT Design & Treatment Model (Green et al., 2010) − Parent-mediated, communication-focused intervention Improve child interaction Improve parent ... so ... with others??? observation? Parent has few Child initiates little leads to follow and signals poorly ... and therefore... ... and therefore... Parent attempts to Child is prompted so makes compensate by responses (including protests) controlling interaction rather than initiations ... so ... Improve parent Increase child: responsiveness/synchrony? • Motivation to communicate?? • Clarity of signals?? • Olga Tennison Autism Research Centre 11
Clinician referral Design Full baseline assessment • First large RCT of an early Diagnostic, cognitive, psychosocial treatment interaction 3 site 2 arm, N=152 2-4,11 yrs; core autistic disorder Randomisation (ADOS-G/ADI-R) Testing a model deliverable in PACT + TAU TAU the NHS Cost effectiveness analysis Fortnightly Community SALT sessions services • Pre-specified primary outcome and analysis plan 7m: Brief midpoint assessment • Blinded rating of outcomes PACT +TAU TAU Monthly • Testing mediating mechanisms Community boosters services Use of RCT design to test basic science hypotheses 13m: Full endpoint assessment
RESULTS
Primary outcome ADOS-G; modified SC algorithm total 30 20 10 0 TAU baseline PACT baseline TAU endpoint PACT endpoint ADOS-G: - 3.9 in PACT, - 2.9 in TAU, ES -0.24 (95%CIs -0.59 to 0.11, ns)
Parent child interaction Parental synchrony Child initiations 100 100 80 80 60 60 40 40 20 20 0 0 TAU base PACT base TAU mid PACT mid TAU end PACT end TAU base PACT base TAU mid PACT mid TAU end PACT end Endpoint ES 1.22 (0.85 to 1.59) Endpoint ES 0.41 (0.08 to 0.74)
Language (PLS) Receptive language Expressive language 50 50 40 40 30 30 20 20 10 10 0 0 TAU baseline PACT baseline TAU endpoint PACT endpoint TAU baseline PACT baseline TAU endpoint PACT endpoint ES 0.07 (-1.95 to 2.08, ns) ES -0.35(-1.85 to 1.16, ns)
Communication and autism symptom outcomes Study Design Comm Comm Autism symptoms Dyadic Generic Kasari et al. T in nursery Yes Direct = Yes Not reported (2008) Daily for 6 weeks Dawson et al. Intensive T and P for 24 Not Direct = Yes No (2010) months reported Report = Yes Kasari et al. 24 P sessions in 8 weeks; Yes Not reported Not reported (2010) FU 12 m Green et al. Fortnightly then monthly Yes Direct = No No (2010) P input 12m Report = Yes Landa et al. Daily nursery T input and ? No Not reported (2011) P weekly 6m Carter et al. 3.5m parent-training No No Not reported (2011) Kasari et al. 2 hours per week for 12 Yes Not reported Not reported weeks; FU 12 weeks (2014) Wetherby et al. 3 hours per week for 9m Yes Yes No (2014)
Measurement of outcome • PACT: Developmental approach to expected treatment effects (though pathway analysis suggests not working at a whole group level) Child Child Parent PACT Interaction Interaction Interaction Intervention with Assessor with Parent with Child External environment (school)
Conclusions • Impact on autism – PACT training strongly influenced behaviour with majority of dyads developing interaction in ways that very few TAU dyads were able – However outcomes on the ADOS in were only modestly different – Changing parent interaction alone is not sufficient to change externally assessed autism symptoms • The challenge of generalisation – Measuring proximal and distal outcomes – In line with other recent trials; PACT effected changes to communication but this did not generalise to other people or other contexts
TAU N=75 Random 13 months later allocation 82 months later PACT N=77 Parent synchrony PACT Parent synchrony Child communication intervention Child communication Autism Symptoms in early Autism Symptoms Child Language development Child language Social functioning Core autism • Age average 45 months • 79% learning difficulties • Language ability ~18 month level • 23% phrase speech
Effect of therapy on targeted parent behaviour The substantial increase in parent ‘ synchrony ’ achieved during therapy lost over follow-up
Effect of therapy on targeted child behaviour with parent Increase in child social communication with parent persisted
The time path of autism symptom severity The reduction in researcher-rated autism symptom severity persists long after end of therapy
Summary A therapy designed for children with severe autism with or • without learning disability Parents are involved in the treatment and feel empowered • Therapy with parents led to a reduction in child symptoms and • enhanced child communication sustained for 6 years Sessions were lengthy but time limited, is this an efficient of use • therapist time? - designed to be applicable to NHS Is the benefit of value to • Child and family? • Provider services? • At a national and commissioning level? •
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