May 11, 2012

Targeting Child's Play to Help Tackle Autism

Some simple exercises when done early, show promise in helping autistic kids socialize and communicate.

As efforts expand to diagnose autism earlier and more accurately, researchers also are striving to figure out ways to treat children as young as 1 year old.

Specialists at the Kennedy Krieger Institute here, who focus on disorders of the brain, spinal cord and musculoskeletal system, are testing the use of early intervention groups to improve social and communication skills for 1- and 2-year-olds who are considered at high risk for autism and related disorders.

The average age of children diagnosed with autism in the U.S. is around 4 years old, according to the Centers for Disease Control and Prevention. Interventions typically start later than that to treat the spectrum of disorders that leave about one in 88 children struggling to socialize and communicate. Many also exhibit repetitive behaviors.

Early diagnosis and intervention is a mantra in the field: The earlier children can get help, the brighter their long-term prospects, say experts. But it isn't certain what, if any, type of intervention is helpful with very young children, so researchers have been testing different approaches.

Kennedy Krieger's programs aim to help children improve basic skills like noticing what other people are noticing, coordinating and imitating behaviors and activities with others, and sharing positive emotions, says Rebecca Landa, a speech pathologist who directs Kennedy Krieger's Center for Autism and Related Disorders and designed the intervention model.

Kids are trained in classroom sessions lasting between 90 minutes to 2½ hours, two to four days a week. They play games, sing songs and do book-sharing exercises—all standard fare for any small child, but done in a simplified manner highlighting the relevant social cues. Parents also are taught how to apply the skills learned in the classroom at home.

The key to the interventions' success is "saturation and routine," says Dr. Landa. "We just give every child everything we can at every moment."

Children who develop more typically, beginning early in infancy, gain an understanding of other people's behaviors. Babies, for instance, lift up their arms when they are about to picked up, anticipating the adult's intention, says Dr. Landa.

Kids with autism, however, don't appear to understand what other people are doing or thinking, and therefore what is expected from them.

Dr. Landa and other researchers say these skills can be learned and improved with practice. And they think the earlier the better.

Classrooms at Kennedy Krieger, an independent research and clinical institute, look similar to any for young children, with brightly colored rooms filled with toys, books and drawings. The children have circle time, read books and play games and sing during sessions. But each activity and the clinicians' every movement has a therapeutic purpose, says Dr. Landa.

She says some colleagues have told her the programs looks like glorified preschool, but she says she doesn't want the classroom to appear unusual, and the strategic design and execution of the programs are useful to parents and children.

One clinician and two assistants typically work with five children at a time. They usually speak in unison when directing the children and use coordinated hand gestures. For instance, children with autism often don't look in the direction where someone else is pointing. So clinicians constantly coach the children by simultaneously calling out for their attention and pointing, then praising them if they look. If a child doesn't pay attention, the clinicians knock on a surface to make a noise.

The children in a program for 2-year-olds have all been diagnosed with autism. Another group of 1-year-olds is considered high risk because they exhibit signs of an autism-spectrum disorder and have a sibling with the condition, but it isn't clear whether all of them have autism or if they are developing somewhat differently or slowly.

Being in such a program should yield benefits, even if it turns out a child isn't autistic, says Dr. Landa.

Children with autism also have a hard time forming concepts. They may recognize individual car parts, like the wheels, but not how the pieces fit together to form a recognizable shape called a car, researchers have found. So, when the clinicians teach concepts, they fill the classroom with related objects and images, splashing car pictures on the walls, reading car books and playing games about cars. When the next concept is taught, all of the décor and learning materials are swapped out.

In classroom sessions with 1-year-olds and their parents, the adults are shown how to direct and praise their children, as well as teach flexibility and creativity in thinking that many with autism find difficult.

In a recent class, a mother pushed her son, who sat in a toy wheelbarrow, through a wall of play blocks. The mother and her son repeated the action until the boy learned he could knock over the wall by lifting his feet. Each time he did it, a clinician and his mother cheered and clapped.

After doing it several times, he clapped—for the first time ever—and appeared pleased. The mother looked up at the clinician with tears in her eyes, saying she couldn't believe it.

Dr. Landa, along with colleagues at Kennedy Krieger, is systematically evaluating the programs. Early results are promising.

In one study, published in 2010 in the Journal of Consulting and Clinical Psychology, 50 toddlers between 21 and 33 months received intense training from parents plus 10 hours a week in the classroom. Half of those children were randomly assigned activities focused on improving "interpersonal synchrony," targeting social skills. Standardized tests and play-based interaction showed a reduction in core autism symptoms compared with the group that didn't do those activities.

The next step in the research is to isolate which components of the overall program are most effective in order to further refine treatment, Dr. Landa says. They also are working to translate the interventions for use in public settings, like schools.

The researchers say they have noted substantial improvement in children over the course of a school year. When kids first arrive, few of them can even sit in their chairs at circle time, videos of the early sessions show. Some throw tantrums, kicking and screaming on the floor, for the entire two-hour session.

Anna David, 2½, was barely talking when she started the toddler program, says her mother, Stephanie. She wasn't pointing or interested in other people.

Now, about nine months in, she talks, sings, dances and shares things with others. Says Ms. David, 32, of Alexandria, Va.: "She's waking up."


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