When it comes to treatment for communication development, earlier is always better. We want to take advantage of the neuroplasticity of young brains. We're helping children develop more and stronger connections between different parts of the brain, which lays the foundation for all their later learning.
This post is a summary of a 2018 paper by Dr. Rebecca Landa. She reviewed research on early intervention for autism that has been done in the past 15 years. Skip to the end for a list of recommendations for early intervention.
EARLY IS IMPORTANT
Landa pointed out that the average age of diagnosis for autism is 4 years in the U.S., even though it can be diagnosed at 14–18 months. This emphasizes the importance of beginning treatment as soon as you see a sign of communication delay, even if you don’t have any diagnosis yet.
Early intervention capitalizes on the neuroplasticity in young brains. As a young child experiences the world, their neurons are making and organizing connections across the brain. Observing things happen is not effective for building these connections. The child must be actively involved. (see How Much Screen Time Is OK?)
Infants who are later diagnosed with autism don't use typical attention and engagement in activities. This restricts their learning opportunities.They also have different sensory and motor functioning, which can interfere with their experience.
Enriched learning experiences can compensate for some of the disruptions in a child's attention, engagement, sensory and motor abilities. Adults help their child learn how to participate in a back-and-forth social interaction. At the same time, they help their child focus on and experience an activity. We say the adult mediates the experience for the child, so the child can learn more efficiently.
Brain scans show that adult mediation builds better brain connections in areas like facial recognition and language. The neural network (brain connections) is expanded to broader regions in the brain. That broad network provides a better foundation for building more learning.
It’s important for intervention to start early, address multiple aspects of development, and continue for years because new challenges unfold as the child gets older.
REVIEWED TWO APPROACHES
Landis reviewed two categories of intervention: Naturalistic developmental behavioral interventions (NDBI) and applied behavior analysis (ABA, also known as early intensive behavioral intervention or EIBI).
NDBIs target skills within the context of back-and-forth social interactions; use cues, reinforcement and prompts as needed to boost the child’s performance; model what to do; and expand on the child’s performance. Goals are to build more consistent, complex and differentiated language, social and play performance. Skills are interspersed throughout the interaction rather than being taught separately. Targets are usually selected based on typical child development.
ABA/EIBI follows the procedures of operant conditioning and uses explicit, structured teaching outside of a natural context. Skills are broken into a task analysis and taught in that order. The adult selects the materials and sets the expectations for how the child should respond. Structured prompt hierarchies and reinforcement schedules are used. Reinforcers that are generally motivating (food, favorite toys) are used, rather than natural reinforcements available in the environment. Some time after a skill is mastered, it is later taught in a generalization program so the child will use it at other times and places.
Review of NDBI
Before diagnosis, programs for infants and toddlers: Positive results were found with short-term programs of 12 weeks or less. Parents learned to use interaction strategies but tended to not continue using them at a one-year follow-up.
Post-diagnosis parent-mediated programs: Children showed improvements in vocabulary comprehension, reduced symptom severity, and improved engagement and shared attention. Some parents had difficulty learning or maintaining the strategies and needed additional coaching when their child’s performance and needs changed over time.
Post-diagnosis, clinician/teacher implemented programs: The greatest gains in social interaction and spoken language were found when both parent and clinician (combined) delivered the intervention, rather than parent-only or clinician-only programs. Parents in the combined group reported a greater sense of competence and quality of life than parents in the other groups. It’s important to implement the program with fidelity, which means periodic checking to make sure strategies are being used accurately.
Review of ABA/EIBI
Early intervention studies tend to report results for IQ and adaptive behaviors. Reports show 19–30% of children show gains in IQ, about 20% show gains in adaptive skills. “Little is known about the efficacy of EIBI for language and social functioning in young children with ASD.” The wide variety of skills taught probably contributes to the IQ gains.
PREDICTORS OF OUTCOMES
Several factors are related to children’s progress, including age, cognitive level, severity of ASD symptoms and treatment approach. The most common finding is that earlier intervention gets better outcomes. The fastest gains take place in the first two years of intervention. Clinicians who have been specifically trained and mentored in a NDBI intervention approach get twice the gains as clinicians who learn a NDBI on their own.
RECOMMENDATIONS BASED ON REVIEW OF RESEARCH
Start intervention early when ASD risk is present.
Address all developmental domains.
Adjust targets and strategies as children’s language develops.
Give parent coaching for at least 9–12 months more frequently than once per month.
Give video feedback to parents to help them learn strategies, gain insights into their child’s social and communication signals, and recognize relationships between their actions and the child’s.
Include hands-on coaching to parents, not just information.
Give part of the parent training in structured situations with few distractions, with opportunities for parents to practice how to use the strategies.
Coach parents in a few strategies at a time to integrate their practice.
Give coaching in multiple settings to build generalization.
Give parents booster sessions for ongoing use and adaptation after the coaching support ends.
Consider AAC (speech generating device or PECS) when speech does not emerge early. AAC will not impede spoken language acquisition.
Combine parent-mediated and clinician-delivered intervention.
Train intervention providers to use the approach with fidelity (consistently and accurately).
HOW I'M USING THE RECOMMENDATIONS
All my materials are based on the principles of naturalistic developmental behavioral intervention. You can maximize your child's outcomes by using an approach that combines parent-mediated activities throughout the day combined with programming from a trained clinician. That's why I'm actively recruiting NDBI-trained speech-language pathologists (SLPs) to be listed in the SLP Directory. Read the clinicians' biographical information to find out their training and experience. My Strategies courses offer increasing levels of support for your learning. You can work on the lessons independently at your own pace. You may also participate in weekly, online small-group coaching with a licensed SLP to get your questions answered and feedback on using the strategies. Be sure to listen to The Interaction Coach podcast for additional learning support that addresses all developmental domains. I give examples in many settings to help you generalize using the strategies many different times and places. You have the option of "booster sessions" arranged with your group-coach SLP after your course ends.