Transcription:
Autism Intervention

Melanie Cole (Host):  According to the CDC, autism spectrum disorders now affect approximately 1 in 88 American children.  However, it’s important for clinicians to have a comprehensive assessment for intervention planning so that they may begin the next steps in the intervention process, including development and implementation of an intervention plan.  My guest today, is Dr. John Constantino.  He’s a Washington University Pediatric Psychiatrist at Saint Louis Children’s Hospital.  Welcome to the show, Dr. Constantino.  Speak about a comprehensive assessment that can help guide clinicians with intervention.  What are some of the first steps?

Dr. John Constantino (Guest):  Ascertaining from the clinical observation of a child and family, the basics of what are the relative contributions of autism type symptoms, language difficulties or early language delays, potential cognitive disabilities, and certainly any hearing or vision impairments are all elements of a solid, early appraisal of a child that will help in the design of a comprehensive intervention plan.  We talked a lot, last time, about differentiating autistic symptomatology from speech and language impairment and cognitive impairment and how relative contributions of each of those can affect any given child.  A child may not be one or the other, but many children – most children, are probably an amalgam of deficiencies or hurdles in these different areas.  Designing an intervention plan keeping in mind what those relative contributions are is very important.  

Melanie:  When would you like to see assessment and interventions implemented with children?  How young can these things begin?

Dr. Constantino:  That’s a great question.  There’s a conundrum in the field of autism right now because the research and scientific knowledge base regarding the impact of early intervention on the long-term outcomes of children affected by autism and related disorders is still unknown.  The conundrum is unless we try to apply interventions as early as possible, we may not be realizing the optimal effects of those interventions.  And yet, because we don’t have a scientific base for universal recommendations for intervention in the first or second year of life for many of these children.  

Very recently, and a major controversy in the field, is that the US Preventative Services Task Force could not recommend universal screening for 18-month-olds for autism spectrum disorders because we don’t know that there’s a real bang for the buck in outcome in implementing currently available interventions for those children.  I think that most people who are in this field feel that there is an absurdity to that -- and that most of us who are engaged in efforts to optimize intervention for children affected by autism -- would love to identify these children by the end of the first year of life if possible.  It’s becoming more and more possible for more and more children affected by autism to be identified early.  The question is whether the implementation of very specific interventions earlier than children are usually availed to those interventions, will have an even high impact than what we can currently know on the basis of these promising, but still, as of yet, not fully understood the impact of early intervention.

Melanie:  Based on your own experience, Dr. Constantino, do you feel that evidence based practice and scientific research can lead to improved outcomes, and have you see this in some of your patients?

Dr. Constantino:  We definitely have seen this in our patients, and I think the goal now, is to take interventions that are – as I said, very promising – maybe I’ll talk a little bit about what that intervention looks like.  If the listeners keep in mind that oftentimes, children do not get access to these interventions until late in the second year of life, often not until the third year of life, and very often, not even until later in their preschool years.  Some children never get early intervention.

What does the intervention landscape look like?  There is both parent implemented, and therapist implemented strategies for improving the developmental outcome of a young child.  In the realm of autism, there are specific interventions that have been devised over – very recently.  I would say that most of these are -- fundamentally over the last ten years -- that improve over the historic, usual application of speech therapy, physical therapy, occupational therapy as the go-to developmental therapies for children to add several different types of focused intervention when autism is suspected.  What those look like fall under a number of names that are given to specific branches of this work.  Most of them depend on the principals of what’s called applied behavior analysis in which children are rewarded and conditioned to focus and respond in ways that don’t necessarily come naturally to them or come naturally to their parents’ prompting.  

The names of some of these interventions include the Early-Start Denver Model in which therapist enhances the reward value of basic social engagements with children.  There’s another overlapping therapy called Pivotal Response Training in which the therapists are trying to recapitulate very specific responses they want children to make in the context of prompts in the environment by the people around them.  Another type of therapy that’s focused on what’s called Joint Attention, and that’s designed to elicit a shared attention of a young child with their caregiver or with the people around them and very specifically focusing on that aspect of development, which is often missing in children with autism.  

When you put all of those principles together, the amalgam of all of that is referred to as JASPER in some circles.  It includes Joint Attention, Symbolic Play, high levels of engagement and preventing dysregulation.  The acronym, JASPER, refers to Joint Attention, Symbolic Play, and Regulation.  Those are the elements that are really focused on now for comprehensive therapies for young children affected by autism.  If we can move those therapies as early in the lives of these children as possible; if we can arm parents with the ability to help their children develop these fundamental skills, then we think that there is going to be a lot higher impact that’s not necessarily apparent when many of these interventions are not even put on the table for a young child until they’re three, or four, or five years of age.  

Melanie:  And Dr. Constantino, as a child transitions to adolescence, how important and what is the intervention?  How does that change a little bit?  How important is community collaboration because now this child is out in the community, they’re seeing their pediatrician hopefully, for their well-visits and maybe some specialists, but what is that community collaboration as they transition into adolescence?

Dr. Constantino:  Sure.  If we just took a look at the long view.  When a young child is aging up, again, the first place we try to implement intervention is to affect development – developmental therapies that are going to improve basic developmental capacities that are behind or delayed or deficient in the autism spectrum condition.  One of the most important outcomes of all of this – and one of the things that predict the outcome of all children with autism broadly, is the extent to which a child acquires the capacity for some functional version of language – of interpersonal communication, whether that’s verbal language, sign language, augmented communication based use of devices to help to communicate, which some children really benefit from.  Language in any form is the name of the game.  

As they age up, assuming that they acquire a functional form of language that they can use to interact with the people around them, some of the things that shift during school age have to do with managing difficulties with regulating behavior and with optimizing learning in the classroom setting, sometimes through the individualized education planning process that all public schools have as a federal entitlement to children who are educated in public schools.  Those become very important aspects of the care and support of a child with autism during school age.  As they make that transition to adolescence and later school ages – in high school and beyond – I think it’s really important for all of those who are caring for and supporting a child with autism to recognize that the transition to adolescence for all children as a time for identity formation, honoring what are the elements of a child’s capacity to give of themselves, to contribute to the environment around them that these are very important things to think about and understand and to help that child forge their own identity, their own sense of being able to make a contribution, their own sense of place in the community around them.  That is what all adolescents need to do to come to a peaceful transition to that stage of their life.

I think the take-home message here is that it’s very important for people to think of these individual patients as children first and having autism second and not the other way around.  Since all children need that kind of support for that particular striving for the formation of their own identity, to pay very careful attention to that as they make that transition.

Melanie:  In summary, Dr. Constantino, please tell other pediatricians what you would like them to know about assessing their patients on the spectrum, initiating the interventions, and when they should refer to a specialist.  

Dr. Constantino:  I think any suspicion of autism warrants referral to a specialist.  Specialists who have particular training in this area are typically developmental pediatricians, child neurologists, and child psychiatrists who have practiced or focus on the care of children with autism spectrum disorders.  I think that the application of developmental therapies as early and as intensively as possible in those preschool years is very important for the acquisition of developmental schools and particularly language as the primary end game for that kind of support.

And then, as they age up through the lifespan, keeping in mind what are the things that are going optimize their learning, what are the things that are going to minimize both stigmatization and problems with adaptation because of behavior problems that all of which can be addressed in various ways -- that aren’t even necessarily specific to autism, they are done for all children with other kinds of behavioral disabilities -- and making sure that as they age up into adolescence that identity formation is something that is on everybody’s mind that is trying to support and care for a young person aging up with autism.

Melanie:  Thank you, so much, for being with us today, Dr. Constantino.  A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678- 4357.  You’re listening to Radio Rounds at Saint Louis Children’s Hospital.  For more information on resources available at Saint Louis Children’s Hospital, you can go to SaintLouisChildrens.org, that’s SaintLouisChildrens.org.  This is Melanie Cole.  Thanks, so much for listening.