NOT A CURE Can a parent child interaction (PCI) treatment help - - PowerPoint PPT Presentation

A TREATMENT NOT A CURE

Can a parent child interaction (PCI) treatment help young children with autism?

Institute of Psychiatry, Psychology & Neuroscience IoPPN

The Lancet Volume 388, Issue 10059, Pages 2501-2509 (November 2016) DOI: 10.1016/S0140-6736(16)31229-6

Infants with autism impact on parental style

• Fail to establish a communicative fit
• Infant communicative signals are too weak or infrequent
• Reduced meshing – ‘asynchrony’
• Parents may resort to didactic style
• Parents perplexity
• Parents ‘fill in the gaps’ or withdraw
• Adult increased initiations
• Strategies to re-direct child’s attention
• Interactions are non-reciprocal

5

• RCT Design & Treatment Model (Green et al., 2010)

− Parent-mediated, communication-focused intervention

• Olga Tennison Autism Research Centre

Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial

Child initiates little and signals poorly Parent has few leads to follow Parent attempts to compensate by controlling interaction Child is prompted so makes responses (including protests) rather than initiations ... and therefore... ... and therefore... ... so ... ... so ...

6

• RCT Design & Treatment Model (Green et al., 2010)

− Parent-mediated, communication-focused intervention

• Olga Tennison Autism Research Centre

Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial

Child initiates little and signals poorly Parent has few leads to follow Parent attempts to compensate by controlling interaction Child is prompted so makes responses (including protests) rather than initiations ... and therefore... ... and therefore... ... so ... ... so ...

7

• RCT Design & Treatment Model (Green et al., 2010)

− Parent-mediated, communication-focused intervention

• Olga Tennison Autism Research Centre

Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial

Child initiates little and signals poorly Parent has few leads to follow Parent attempts to compensate by controlling interaction Child is prompted so makes responses (including protests) rather than initiations ... and therefore... ... and therefore... ... so ... ... so ...

8

• RCT Design & Treatment Model (Green et al., 2010)

− Parent-mediated, communication-focused intervention

• Olga Tennison Autism Research Centre

Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial

Child initiates little and signals poorly Parent has few leads to follow Parent attempts to compensate by controlling interaction Child is prompted so makes responses (including protests) rather than initiations ... and therefore... ... and therefore... ... so ... ... so ...

9

• RCT Design & Treatment Model (Green et al., 2010)

− Parent-mediated, communication-focused intervention

• Olga Tennison Autism Research Centre

Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial

Child initiates little and signals poorly Parent has few leads to follow Parent attempts to compensate by controlling interaction Child is prompted so makes responses (including protests) rather than initiations ... and therefore... ... and therefore... Improve parent

• bservation?

Improve parent responsiveness/synchrony? ... so ... ... so ...

10

• RCT Design & Treatment Model (Green et al., 2010)

− Parent-mediated, communication-focused intervention

• Olga Tennison Autism Research Centre

Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial

Child initiates little and signals poorly Parent has few leads to follow Parent attempts to compensate by controlling interaction Child is prompted so makes responses (including protests) rather than initiations ... and therefore... ... and therefore... Improve parent

• bservation?

Improve parent responsiveness/synchrony? ... so ... ... so ... Increase child:

• Motivation to communicate?
• Clarity of signals?

11

• RCT Design & Treatment Model (Green et al., 2010)

− Parent-mediated, communication-focused intervention

• Olga Tennison Autism Research Centre

Who Benefits from Early Intervention? Treatment Response within the Preschool Autism Communication Trial

Child initiates little and signals poorly Parent has few leads to follow Parent attempts to compensate by controlling interaction Child is prompted so makes responses (including protests) rather than initiations ... and therefore... ... and therefore... Improve parent

• bservation?

Improve parent responsiveness/synchrony? Increase child:

• Motivation to communicate??
• Clarity of signals??

... so ... ... so ... Improve child interaction with others???

Clinician referral Full baseline assessment

Diagnostic, cognitive, interaction

PACT + TAU Fortnightly SALT sessions 7m: Brief midpoint assessment TAU Community services 13m: Full endpoint assessment

PACT +TAU Monthly boosters

TAU Community services Randomisation

Design

• First large RCT of an early

psychosocial treatment 3 site 2 arm, N=152 2-4,11 yrs; core autistic disorder

(ADOS-G/ADI-R)

Testing a model deliverable in the NHS Cost effectiveness analysis

• Pre-specified primary outcome and

analysis plan

• Blinded rating of outcomes
• Testing mediating mechanisms

Use of RCT design to test basic science hypotheses

RESULTS

10 20 30 TAU baseline PACT baseline TAU endpoint PACT endpoint

ADOS-G: - 3.9 in PACT, - 2.9 in TAU, ES -0.24 (95%CIs -0.59 to 0.11, ns) Primary outcome ADOS-G; modified SC algorithm total

20 40 60 80 100 TAU base PACT base TAU mid PACT mid TAU end PACT end 20 40 60 80 100 TAU base PACT base TAU mid PACT mid TAU end PACT end

Parent child interaction

Endpoint ES 1.22 (0.85 to 1.59) Endpoint ES 0.41 (0.08 to 0.74)

Parental synchrony Child initiations

Language (PLS)

ES 0.07 (-1.95 to 2.08, ns) ES -0.35(-1.85 to 1.16, ns)

Receptive language Expressive language

10 20 30 40 50 TAU baseline PACT baseline TAU endpoint PACT endpoint 10 20 30 40 50 TAU baseline PACT baseline TAU endpoint PACT endpoint

Communication and autism symptom outcomes

Study Design Comm Dyadic Comm Generic Autism symptoms Kasari et al. (2008) T in nursery Daily for 6 weeks Yes Direct = Yes Not reported Dawson et al. (2010) Intensive T and P for 24 months Not reported Direct = Yes Report = Yes No Kasari et al. (2010) 24 P sessions in 8 weeks; FU 12 m Yes Not reported Not reported Green et al. (2010) Fortnightly then monthly P input 12m Yes Direct = No Report = Yes No Landa et al. (2011) Daily nursery T input and P weekly 6m ? No Not reported Carter et al. (2011) 3.5m parent-training No No Not reported Kasari et al. (2014) 2 hours per week for 12 weeks; FU 12 weeks Yes Not reported Not reported Wetherby et al. (2014) 3 hours per week for 9m Yes Yes No

Measurement of outcome

• PACT: Developmental approach to expected

treatment effects (though pathway analysis suggests not working at a whole group level)

PACT Intervention Parent Interaction with Child Child Interaction with Parent Child Interaction with Assessor External environment (school)

Conclusions

• Impact on autism

– PACT training strongly influenced behaviour with majority of dyads developing interaction in ways that very few TAU dyads were able – However outcomes on the ADOS in were only modestly different – Changing parent interaction alone is not sufficient to change externally assessed autism symptoms

• The challenge of generalisation

– Measuring proximal and distal outcomes – In line with other recent trials; PACT effected changes to communication but this did not generalise to other people or other contexts

TAU

N=75

PACT

N=77

82 months later

Random allocation

PACT intervention in early development Parent synchrony Child communication Autism Symptoms Child Language 13 months later

Core autism

Parent synchrony Child communication Autism Symptoms Child language Social functioning

• Age average 45 months
• 79% learning difficulties
• Language ability ~18 month level
• 23% phrase speech

Effect of therapy on targeted parent behaviour The substantial increase in parent ‘synchrony’ achieved during therapy lost over follow-up

Effect of therapy on targeted child behaviour with parent Increase in child social communication with parent persisted

The time path of autism symptom severity The reduction in researcher-rated autism symptom severity persists long after end of therapy

Summary

• A therapy designed for children with severe autism with or

without learning disability

• Parents are involved in the treatment and feel empowered
• Therapy with parents led to a reduction in child symptoms and

enhanced child communication sustained for 6 years

• Sessions were lengthy but time limited, is this an efficient of use

therapist time? - designed to be applicable to NHS

• Is the benefit of value to
• Child and family?
• Provider services?
• At a national and commissioning level?