Monday, December 6, 2010

Early Intervention in Autism - it works

Autism, in its broadest interpretation, has a prevalence of about 1:110 population. There is a severe shortage of early intervention facilities for persons with autism in India. World Disability Day is commemorated on 3rd December. Autism is not specifically included as a disability in the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995. This may be contributing to the lack of funding for early intervention facilities.

Protodeclarative pointing - joint attention
 Disability in autism manifests during infancy in three domains
  1. Social - Infants with autism show delays in smiling, gazing at their mothers and responding to their names and gesturing (e.g., pointing, waving bye-bye). This pattern continues, with the most impaired children growing to be avoidant or aloof from all social interaction.
  2. Communication - Infants and toddlers with autism have delays in babbling, using single words, and forming sentences. Effective language acquisition and use remains a problem throughout life. 50% of people with autism never learn to speak.
  3. Behavioural - Children with autism have difficulty tolerating any changes in routine leading to frequent tantrums. They display repetitive movements of the hands in front of the face, later giving rise to other peculiar and stereotyped movements and behaviours that stigmatise them as individuals.
These disabilities affect the ability of the person with autism to live independently and to carry out normal day-to-day activities of life

Various treatments clamour for the attention of parents of children with autism. These include HBOT (Hyperbaric oxygen therapy), chelation, animal therapies (dolphins, horses), various diets, and secret therapies. Despite celebrity and other endorsements there is no unbiased evidence that any of these therapies is effective, they are never curative. At best they are harmless and provide some diversion for the child and caregivers, at worst they can be life threatening.

Early intervention is effective in autism (Dawson et al 2010). The earlier the intervention the better. Effective early intervention programs can reduce disability to the extent that after two years nearly 30% of affected children no longer meet the diagnostic criteria for autism. There are numerous programs based on different philosophies and strategies, but most have some common components. Educational and behavioural techniques form the mainstay of these programs. Family involvement is essential. There is currently no evidence that any one program is better than the other.

Educational interventions
  • Most programs involve 15 to 25 hours of intervention a week. They capitalize on natural tendency of children with autism to respond to visual structure, routines, schedules, and predictability.
  • Good programs incorporate the child’s current interests and actively engage the child in a predictable environment with few distractions.
  • They incorporate effective and systematic instructional approaches and use standard behavioural principles. The aim is generalization and maintenance of skills learned in therapy to life situations.
Behavioural interventions
  • Challenging behaviours are managed with functional behavioural assessment and positive behavioural supports

Before starting on an Early Intervention program parents should check that the program
1. Is conducted by qualified professionals
2. Addresses deficit areas
  • Inability to attend to relevant aspects of the environment, shift attention, and imitate the language and actions of others
  • Difficulty in social interactions, including appropriate play with toys and others, and symbolic and imaginative play
  • Difficulty with language comprehension and use, and functional communication.
3. Focuses on long-term outcomes
4. Considers individual developmental level and formulates goals.

I understand the anxiety of a parent confronted with a diagnosis of autism in their child. Unfortunately there are no quick-fix treatments or miraculous cures. Early intervention is time consuming and labour intensive, but in the long run it pays off.

Geraldine Dawson, Sally Rogers, Jeffrey Munson, Milani Smith, Jamie Winter, Jessica Greenson, Amy Donaldson, and Jennifer Varley. Randomized, Controlled Trial of an Intervention for Toddlers with Autism: The Early Start Denver Model. Pediatrics 2010; 125: e17-e23