AUTCON 2020 – Session 1 – Very Young Children with Autism – DR. Subramanian, NICE

Hi All,

posting details on another conference on the ASD (Autism Spectrum Disorder). This was organized by NICE (Nishta Center of Excellence) and Growth Development & Behavioral Pediatrics. This happened in 1st of March 2020, in St.Isabel’s Hospital, Mylapore, Chennai. It is an one day event with multiple sessions scheduled for shorter durations. (I would say really short, something i experienced in conference organized by Chettinadu Hospital early this year as well)

The conference began with lighting of lamp, and invocation to god through Maithreem Bhajatha song. It was a Sunday, not many showed up in the morning, but there was a decent crowd when the conference ended in the late evening.

This post contains details about the first scientific session of the conference.

TOPIC – VERY YOUNG CHILDREN WITH AUTISM – WHEN TO START, WHAT and HOW TO TEACH?

Presented by Dr.Subramanian, Pediatrician – NICE

Following points were shared by him:

• ASD has steadily increased over the past 30 years, which was never heard of during under graduation days of many professionals who are practicing as of now.
• Need for Early Intervention
  • From neurodevelopmental context, studies show early intervention provides positive outcomes.
  • The reason for positive outcome is due to the Neuroplasticity of the brain, which keeps learnings from experiences around the environment.
  • Self-generated experiences are more relevant than the observations or passive experiences which the child undergoes
• Warning Signs present on an Infant who would grow up to be an ASD Child are:
  • Atypical attention
  • Engagement Patterns
  • Altered Sensory Motor Functioning
  • In Prodromal stage,
    • Progressive Diminished, Unelaborated, truncated social communication
  • For a neuro-typical child, in the above phase, he would have developed the Dyadic and Triadic interactions.
  • For an ASD child, the experiences received by the brain is different/altered, hence the cortical specialization of face recognition and language is not fully developed, which is later represented by Disruptive brain networking i.e. Interactions between the various regions of the brain, causing cognitive and sensory neuro motor functioning.
• Video was played showing an experiment where, how a child’s response depends on the environment. It is called The Still Face experiment by Edward Tronick M.D (https://www.youtube.com/watch?v=apzXGEbZht0)
• Early Intervention cannot be done on Infants as it cannot be diagnosed at that age, whereas one can begin early intervention on children who are in potential high risk category, such as a sibling of a Child with Autism. In this case, early intervention can begin much earlier.

EARLY INTERVENTION APPROACHES

Two basic concepts are there for early intervention, they are:

• NDBI – Naturalistic Developmental Behavioral Intervention (NDBI)
  • Continuous flow of social engagement between the child and the therapist
  • Therapist provides it in the natural setting of the child.
  • Social setting of the child is used as the jumping point for teaching social skills.
  • Skills gained from this is more generalizable, one does not have to make an effort to generalize these skills in to the society.

For example, playing ball with the child is much easier way to teach about the ball, than showing a picture of the ball.

• EIBI – Early Intensive Behavioral Intervention

• • It works on an operand conditioning principle.
  • Setting is context realized and highly structured.
  • Specific discrete skills are taught in a prescribed manner
  • Adult selects the materials, adult initiates the intervention, it is characterized by ABC (Antecedent, Behavioral and Consequence)
  • The reinforcement used are not related to the social context of the child.
  • It is very useful in reducing outburst, Tantrums, to teach specific skills like sitting quietly, use words to make request or wait for a turn in the playground.
  • In Discrete Trial training, where the therapist gives a specific instruction, when the child comply to it, the reinforcement is given and vice versa.

BASIC MODELS OF CARE AVAILABLE

A) CTMS – Comprehensive Treatment models

• TEACCH – Treatment and Education of Autistic and Related Communication Handicapped Children.
• ESDM – Early Start Denver Model (little evidence beyond America)
• P-ESDM – Parent delivered early start Denver model
• LEAP – Learning experiences and alternate program for preschoolers and their parents

B) FIPs – Focused Intervention practices

• Pivotal Response Treatment
• PECS – Picture Exchange Communication System
• Discrete Trial Training

FACTORS THAT INFLUENCE OUTCOMES

• Parental involvement and training as the lead therapist or co therapist
• Teacher involvement and teacher training
• Importance of in class intervention
• Typically developed children who interact with the ASD Child also influence the outcomes

We have to train the whole environment and sensitize them.

EVIDENCED BASED RECOMMENDATION

• Initiate Intervention as early as possible.
• Address all the developmental domains
• Shift Strategies and Targets as the child develops
• Parental Training is very important
• Video feedbacks are important
• Provide direct hands on training for parent rather than psycho education
• Parental training should have a structure to it.
• Child responsive parental skills are to be taught.
• Provide AAC earlier if the chances of child becoming verbal is limited.
• Always better to combine professional delivered interventions with parent mediated interventions
• Train intervention provides to fidelity in implementation of interventional approaches

OTHERS POINTERS FROM Q&A:

• Sharanya Anil replied that her earliest child who underwent intervention was 12 months, but typically they start by 18 months where the signs are seen. At 12 months, we start with naturalistic model, play based therapy, and shared experiences.
• How early is the child with such deficits are referred to pediatricians who have expertise in Autism. There is a big barrier in this area across globe. Response provided was that the pediatric community needs to be sensitized regarding these issues, general parenting workshops would help. (There are parents from nuclear family who does not know that their child is supposed to start speaking by a certain age, instead of laughing at them, we should train them with necessary knowledge)

• M Chat screening should be made compulsory during the vaccination visits, to pick up such signs. In UK, they follow Q Chat which is a 10 point questionnaire.
• At the same time we have to be careful about wrong diagnosis based on google, which puts needless pressure/stress on the entire family.
• In addition to pediatricians being sensitized, the Gynecologists should also be added to that list, as the child barring age has gone up considerably in recent years, in addition to the high pregnancy risk they should be made aware of these areas post pregnancy.

Regards,

Saranya and Karthikeyan

karthiksaranyaparents@gmail.com