A social communication intervention in preschool children with autism, although improving parent-child interaction, does not deliver clinically significant benefit in autism symptoms. This is the conclusion of an Article published Online First and in an upcoming Lancet, written by Professor Jonathan Green, University of Manchester, UK and colleagues from the *PACT Consortium. The study is being presented at the International Meeting For Autism Research (IMFAR), 9th Annual Meeting, Philadelphia, USA, 20-22 May.
Autism is a severe developmental syndrome affecting about 1% of children and resulting in an annual UK cost in childhood of £2.7 billion – higher than asthma or diabetes. Effective early intervention is an international health priority PACT is important as it is by some way the largest autism treatment trial of its type yet undertaken internationally. Results of small trials have indicated that early interventions for social communication may be effective for the treatment of autism in children. In PACT, the authors aimed to provide a stringent test of a parent-child communication-focused intervention in children aged 2 years to 4 years and 11 months with diagnosed autism.
The rationale behind the PACT intervention was that these children would respond with enhanced communicative and social development if parents were able to adapt their communication to their child's specific impairments. The intervention consisted of one-to-one clinic sessions with therapist and parents and children. The aim of the intervention was firstly to increase parental sensitivity and responsiveness to the autistic child's particular pattern of communication using direct work with parents and video feedback methods. Then, the further incremental development of the child's communication was encouraged by introducing a range of strategies such as action routines, matching language to the child's understanding, and the use of pauses. After an initial orientation meeting, families attended fortnightly 2 hour clinic sessions for 6 months followed by monthly booster sessions for 6 months (maximum 18). Between sessions, families were also asked to do 30 minutes of daily home practice.
The study assessed 152 children, aged 2 years to 4 years and 11 months, across three UK sites. 77 children were assigned to the PACT intervention plus treatment as usual and 75 to just treatment as usual. Treatment as usual consisted of various generic and specialist autism services provided by local health, education and social care services.
Severity and improvement in autism symptoms were assessed using a modification of the Autism Diagnostic Observation Schedule-Generic [ADOS-G] total social communication score. At the 13-month endpoint, the severity of symptoms was reduced by 3•9 points in the group assigned to PACT and treatment as usual, and 2•9 in the group assigned to only treatment as usual. This represented a small between-group effect size in favour of PACT, after adjustment for centre, sex, socioeconomic status, age, and verbal and non-verbal abilities—a difference the authors deemed not significant in terms of clinical effect. However, the PACT intervention did lead to improvements in the timing of parents' communicative interactions with their child and the amount that children communicated using speech and gestures when playing with their parents. Parents also reported improvements in their child's language abilities.
The authors conclude: "On the basis of our findings, we cannot recommend the addition of this PACT intervention to treatment as usual for the purpose of reduction in autism symptoms. The intervention does, however, significantly alter parent-child dyadic social communication in ways that are associated with subsequent positive child outcomes in longitudinal studies, and are likely to be positive for parents themselves. Techniques to aid transmission of these gains in parent-child interaction to children's communication skills in wider contexts need to be assessed."
The authors add that this study adds to the positive evidence-base for preschool interventions for children with autism that focus on improving children's social interaction and communication, and that also offer support to parents following a diagnosis. However, in line with other recent studies these improvements did not lead to a reduction in the severity of autism symptoms. This difficulty in generalisation is a challenge for clinicians and researchers in trying to improve interventions for this disorder.
In an accompanying Comment, Dr Sarah J Spence, and Dr Audrey Thurm, Pediatrics and Behavioral Neuroscience Branch, Intramural Research Program of the National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA, say: "This study furthers the field by setting a new bar for the minimum standards of rigorous methodology needed in trials that have potentially far-reaching service and policy implications... At the same time, today's study exemplifies the complexity of attempting to detect change in samples of young children with such a heterogeneous condition. There are very few positive published trials in autism, for behavioural interventions, traditional pharmaco¬therapy, or complementary/alternative therapies. Is this due to non-efficacious treatments, lack of sensitive outcome measures, or heterogeneity of autism—or perhaps all three?"
They conclude: "In addition to those [variables] examined within this study (eg, variability in diagnoses, baseline language and cognitive levels, socioeconomic status, and parent's education, age, and sex), there remains a long list of issues that are difficult to even measure and certainly to account for in any sample of individuals with autism. These factors include environmental context, other treatments, co-morbid conditions, and as yet unknown differences in genetics and neuropathophysiology. Ultimately, the challenge is to define subtypes within this disorder. These definitions might have not only important treatment implications, but also aid in understanding aetiology."
Note: To arrange an interview with a family who took part in this study, please call Aeron Howarth in list below.
For a list of Q & A prepared by the authors on this study, see attached word document.
Professor Jonathan Green, University of Manchester, UK. T) +44 (0)7957541206 (UK mobile but currently at IMFAR meeting, USA) E) jonathan.green@manchester.ac.uk also Press Office: Aeron Howarth T) +44 (0)161 275 8383 E) aeron.haworth@manchester.ac.uk and Mikaela Sitford T) +44 (0) 161 275 2111 E) mikaela.sitford@manchester.ac.uk
Professor Tony Charman, Centre for Research in Autism and Education, Institute of Education, London, UK. T) +44 (0)7976 708 766 (UK mobile but currently at IMFAR meeting, USA) E) t.charman@ioe.ac.uk Also Diane Hofkins, Press Office. T) +44 (0) 7976 703455 E) d.hofkins@ioe.ac.uk and David Budge E) d.budge@ioe.ac.uk
Professor Helen McConachie, Institute of Health and Society Newcastle University, UK. T) +44 (0)191 282 1396 E) h.r.mcconachie@newcastle.ac.uk
For Professor Patricia Howlin, Institute of Psychiatry, King's College London, UK please contact The Institute of Psychiatry, King's College London press office: Louise Pratt. T) +44 (0) 7966 265084 E) louise.a.pratt@kcl.ac.uk/ patricia.howlin@kcl.ac.uk
Dr Sarah J Spence, and Dr Audrey Thurm, Pediatrics and Behavioral Neuroscience Branch, Intramural Research Program of the National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA. T) +1 (301)443-4536 E) nimhpress@mail.nih.gov
For full Article and Comment see: http://press.thelancet.com/autism.pdf
Note to editors : *PACT Consortium: The study, funded by the Medical Research Council, was led by Professor Jonathan Green and colleagues from the University of Manchester and comprised a team of researchers from the Institute of Education, Newcastle University, King's College and Guy's Hospital, and the NHS Primary Care Trusts of Stockport, North Tyneside, Southwark and Lewisham.
Journal
The Lancet