Research roundup: Children with autism

An estimated 12 in 1,000 children in the United States have an autism spectrum disorder (ASD; Durkin et al., 2017)—worth noting at any time, but particularly in April, which is designated Autism Awareness Month. Because individuals diagnosed with this family of disorders display a wide range of ability levels in social interaction, communication, and behavioral functioning, children with autism often receive multiple treatment modalities, including behavioral interventions, speech and language therapy, and occupational therapy.

The following research studies examine the treatment patterns of children with ASD in the United States and investigate the effectiveness of two novel treatment options: a robotic intervention designed to enhance social engagement and a multisystem aquatic therapy program.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Monz, B.U., Houghton, R., Law, K., & Loss, G. (2019). Treatment patterns in children with autism in the United States. Autism Research. Advance online publication. http://dx.doi.org/10.1002/aur.2070.

Summary

The authors of this study sought to better understand the patterns of treatment that children with ASD are receiving in the U.S., including variations by geographic region and type of health care coverage.

Two online questionnaires were completed by 5,122 parents or guardians of children with ASD recruited from the Simons Foundation Powering Autism Research for Knowledge cohort. The Autism Impact Measure was used to assess frequency and impact of ASD symptoms. A survey regarding the nondrug therapies received over the preceding 12 months asked questions about the types and intensities of the treatments, geographic location, and health care coverage type.

Treatment types were classified into seven groups: behavioral, developmental and/or relationship-based, speech and language (SLT), occupational, psychological, “other,” and parent/caregiver training. For analysis, the six-level urban-rural classification scheme for geography was collapsed into a two-level metric of nonmetropolitan (rural) and metropolitan (urban). Health care coverage type was limited to two categories: private via employer and Medicaid.

Results indicated that 96% of children received at least one type of nondrug treatment with SLT (71.4%) being the most common. Overall 28.7% of children received psychological interventions with no significant difference by location or healthcare coverage type. A higher proportion of children in metropolitan areas received behavioral therapy (57.2% vs 46.4%) and SLT (72.3% vs 65%).

No significant differences were found between the proportions of children covered by Medicaid versus those covered by private insurance regarding receiving at least one therapy service; however, children with Medicaid received occupational therapy more frequently (61.8% vs 55.7%) and “other” therapies less frequently (63.4% vs 69.9%).

SLT and occupational therapy were more often provided at school, while behavioral therapy and psychological interventions were more frequently provided outside of school. When looking at geography, behavioral therapy was most often received in public schools in nonmetropolitan areas (44.7%) but at home in metropolitan areas (46.3%).

Barriers to treatment were reported as an issue for 44.8% of respondents including being on a “waiting list” for care (26.4%) and “no coverage” (17.9%). Three quarters reported that they were satisfied with the current level of care, and over half indicated that their child benefitted “much” or “very much” from care (58.2%).

Practical considerations

Children with autism in the United States are highly likely to be receiving nondrug treatments; however, differences exist depending on where the family lives.

SLT and occupational therapies were most frequently reported and were generally provided at public schools, making them more accessible and less dependent on infrastructure such as specialists’ offices or healthcare coverage.

Behavioral therapy was less often used in nonmetro settings and where used was much less intense than in metropolitan areas. Clinicians providing behavioral therapy may wish to consider the use of telehealth programs to provide better access to behavioral therapy in remote areas.

Chung, E. Y.-h. (2018). Robotic intervention program for enhancement of social engagement among children with autism spectrum disorder. Journal of Developmental and Physical Disabilities. Advance online publication. http://dx.doi.org/10.1007/s10882-018-9651-8.

Summary

Traditional intervention approaches for children with ASD may lack the child preferred and intrinsic reinforcers that can lead to improvement in social skills (Kim et al., 2013). Previous research found that children with ASD are more responsive to feedback when it is administered through technology rather than by a human and that they are intrinsically interested in treatment when it involves electronic or robotic components (Diehl et al., 2012).

This study sought to examine the effectiveness of an intervention using a humanoid robot in enhancing the social skills of this population.

Participants were 14 boys with ASD aged 9–11 who demonstrated moderate to severe levels of social impairment as measured using the Social Responsiveness Scale. The participants received 12 sessions of social skills training using the NAO humanoid robot as an instructor that assisted the researcher. The children received no other clinical interventions during the study period.

The robot performs a variety of behaviors including walking, standing, sitting, and dancing, and can recognize speech, sounds, and objects. Intervention activities followed a training protocol and included a structured interactive social game, a story-based activity, and a singing and dancing activity. All of the activities were administered by the robot.

Three targeted variables (frequency of eye contact, duration of eye contact, and frequency of verbal initiation) were analyzed based on four data points: preintervention, midintervention, end of intervention, and three weeks later for maintenance.

Results indicated that the robotic intervention program significantly enhanced both the frequency of eye contact and the duration of eye contact from baseline to the end of the intervention that was then maintained through the maintenance phase. Additionally, the robotic intervention program significantly increased the frequency of eliciting relevant verbal initiation among the children with ASD.

Practical considerations

Psychologists who work with children with ASD may wish to consider the use of technologies or electronics such as robots that can serve as role models and facilitate therapeutic transactions between the child, the environment, and intervention activities to elicit self-initiated changes in the client. Psychologists may need to advocate for funding for these technologies in their work settings or consider innovative strategies to expand the range of tools available to facilitate care.

Caputo, G., Ippolito, G., Mazzotta, M., Sentenza, L., Muzio, M.R., Salzano, S., & Conson, M. (2018). Effectiveness of a multisystem aquatic therapy for children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 48(6), 1945–1956. http://dx.doi.org/10.1007/s10803-017-3456-y.

Summary

Previous research has shown that improving motor skills in children with ASD is associated with improvements in a variety of nonmotor domains including imitation, social attention, and speech and communication (Srinivasan et al., 2015 & 2016) but less is known about the impacts on adaptive/daily living skills and overall ASD symptoms.

In this study, the authors aimed to test the effectiveness of a multisystem aquatic therapy on the behavioral, emotional, social, and swimming skills of children with ASD.

26 participants were included in the study—13 in the CI-MAT (Multisystem Aquatic Therapy; Caputo and Ippolito 2016) group and 13 in a control group. CI-MAT is a formalized treatment program based on a multisystem approach that uses cognitive-behavioral strategies and principles of attachment theory to enhance functions, emotions and social aspects of children with ASD as well as to teach swimming skills.

The protocol includes three phases:

• Emotional adaptation that is focused on building a functional attachment relationship between the expert and the child
• Swimming adaptation that aims to teach swimming skills by means of aquatic exercises specifically adapted for individuals with disabilities
• Social integration where the child participates in classical group swimming activities and games

Participants in both groups received the standard-of-care treatment (a widely used combination in Italy) that consisted of a combination of conventional language therapy and psychomotricity (a psychomotor training for the enhancement of goal-directed actions and motor coordination). Participants were assessed preintervention and again 10 months later at postintervention. Autism symptomology was measured using the Childhood Autism Rating Scale (CARS), adaptive behavior using the Vineland Adaptive Behavior Scales (VABS), and aquatic skills using the Humphries’ Assessment of Aquatic Readiness (HAAR).

Results demonstrated significant improvements of the CI-MAT group when compared to the control group on CARS emotional response, adaptation to change, and activity level. Within-group comparisons in the CI-MAT group showed significant improvement on almost all CARS items, whereas the control group displayed no significant advancement. The CI-MAT group also showed significant improvement on daily living skills and general growth of the adaptive behaviors measures by VABS. The HAAR checklist revealed learning of swimming skills as well.

Practical considerations

Multisystem aquatic therapies can be effectively combined with the standard-of-care treatment for promoting positive changes in relevant aspects of ASD, including enhancing several functional behaviors, as well as swimming skills of children with ASD.

This study provides further support of previous research suggesting that movement-based interventions within social context can effectively activate dysfunctional brain networks in children with ASD (Srinivasan et al., 2015 & 2016). Additionally, it has been suggested that children with movement difficulties experience more success in an aquatic environment because of the buoyancy of the water, and of the decreased effects of gravity which may allow an individual to exercise motor skills with fewer body constraints (Pan, 2011).

Families may find that pools, especially those in community settings, offer chances for participation and social interaction for children with ASD. Psychologists may want to encourage community settings to offer programs to families with children with ASD or incorporate ASD-friendly accommodations to be more welcoming of these children and families.