This is the first randomized clinical trial measuring how a group-based early intervention model impacts social development in toddlers with ASD. The most significant improvements were found in how the children connected and socialized with others, a defining stumbling block for children with autism.
The development of group-based, empirically-validated intervention models is critical to increasing access to autism services for toddlers because they are more easily and affordably replicated than intensive one-on-one intervention models. Group-based interventions also offer children with autism more opportunities for social interaction. Because early social development is a major predictor of outcomes for children with ASD, the researchers at Kennedy Krieger aimed to improve social and communication skills through a comprehensive, behavioral intervention program targeting social development.
“We placed a heavy focus on the ability of toddlers to pay attention to other people’s actions and communication behaviors and prepare them to respond and initiate with others in socially appropriate ways,” said Rebecca Landa, PhD, CCC-SLP, lead study author and director of Kennedy Krieger’s Center for Autism and Related Disorders. “This is critically important because it opens the door to ongoing learning opportunities for toddlers with ASD. When toddlers are attuned to people, people are more motivated to stay engaged with them. Additionally, children learn through imitating others. The ability to connect with peers through imitation can open the door to acceptance and being chosen as a playmate in the classroom or on the playground, for example.”
Participants included two groups of 24 toddlers with ASD, ages 21 to 33 months, who received identical intervention for six months. However, one group received a greater number of orchestrated opportunities for social engagement. Social improvements were measured by:
- Changes in socially engaged imitation: imitating others’ actions while indicating their social connectedness through eye contact
- Initiating joint attention: gaining others’ attention for the purely social purpose of sharing — showing something, giving something
- Affect sharing: sharing emotions with others through facial expressions paired with eye contact, expressed as simply as the child looking at you and smiling.
Researchers found that intervention led to improvements in both groups. However, the most significant finding was that the children who received more of the socially-directed intervention developed greater socially engaged imitation, which increased from 17 percent of imitated acts being paired with eye contact to 42 percent. This skill was generalized, or carried over into “real life” outside the classroom, and maintained through the six-month follow-up. Similar improvements were observed in the group for initiation of joint attention (pointing out things of interest, showing and giving for social purposes) and shared positive affect (smiling paired with eye contact). Specifically, how frequently toddlers initiated joint attention more than tripled from pre- to post- treatment, and the shared positive affect more than doubled. Overall, the children receiving the socially-directed intervention made 10 months of non-verbal cognitive gains in only six months time when compared to the other group.
The second most significant finding was that toddlers in both groups made improvements in expressive language (spoken language), with the greatest gains occurring during the time that the intervention was occurring. This indicates that the improvement was due to the intervention.
Researchers are hopeful that the group-based socially-directed early intervention model can achieve similar social skills gains in older children. Kennedy Krieger researchers have applied for funding to adapt the intervention for preschoolers.
About the Intervention
The intervention, named Early Achievements, focused on all aspects of child development, but also included activities specially designed to encourage frequent communication intentionally initiated by the children, prompt them to play with diverse objects and expand their language and cognitive development. One group received a greater number of organized opportunities to respond to and initiate joint attention, imitate others during social interaction and share positive affect. These opportunities included placing objects or pictures on the walls for children to use to gain others’ attention and social engagement activities involving imitating their peers and adults, as well as developmentally appropriate activities designed to focus children’s attention on faces and the sharing of emotions with others. Therapists used language combined with pointing, showing, modeling, labeling facial expressions and imitating children’s actions.
Both interventions provided identical intensity (10 hours per week in classroom for 6 months), student-to-teacher ratio (5:3), schedule, home-based parent training (1.5 hours per month), parent education (38 hours) and instructional strategies.
“This and other autism studies suggest that the ‘wait and see’ method, which is often recommended to concerned parents, could lead to missed opportunities for early intervention,” said Dr. Landa. “By acting early, we are providing toddlers with tools and skills to increase social opportunities throughout their lifetime and positioning them to have the best possible outcomes. This study also shows that a cost-effective group-based intensive intervention for toddlers with ASD should be considered as a complement to parent training.”
Support for this research and manuscript preparation was provided by grants from the National Institutes of Health and the Health Resources and Services Administration.
After the completion of this research study, the Maryland State Department of Education and Baltimore City Infants and Toddlers partnered with Kennedy Krieger Institute’s Center for Autism and Related Disorders to provide training in the implementation of the Early Achievements intervention model to public school teachers and therapists who work with young children with ASD.
Autism spectrum disorders (ASD) is the nation’s fastest growing developmental disorder, with current incidence rates estimated at 1 in 110 children. This year more children will be diagnosed with autism than AIDS, diabetes and cancer combined, yet profound gaps remain in our understanding of both the causes and cures of the disorder. Continued research and education about developmental disruptions in individuals with ASD is crucial, as early detection and intervention can lead to improved outcomes in individuals with ASD.
About the Kennedy Krieger Institute
Internationally recognized for improving the lives of children and adolescents with disorders and injuries of the brain and spinal cord, the Kennedy Krieger Institute in Baltimore, MD serves more than 16,000 individuals each year through inpatient and outpatient clinics, home and community services and school-based programs. Kennedy Krieger provides a wide range of services for children with developmental concerns mild to severe, and is home to a team of investigators who are contributing to the understanding of how disorders develop while pioneering new interventions and earlier diagnosis. For more information on Kennedy Krieger Institute, visit www.kennedykrieger.org.
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