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Early stage interventions promote developmental progress in children with ASD

Discuss about the Foundations Of Inquiry In Health And Social Care.

The current research is a literature review on the effectiveness of early interventions for the management of the conditions of children suffering from Autism spectrum disorder (ASD). Autism is known to be a condition involving the brain which affects communication and behavior within an individual. It generally affects an individual at an early age of 2-3 years and   has an effect on several parameters such as learning and development, social interactions and relationships developed by an individual in the course of their lifetime. The ones contacted with ASD often depict poor social behavioral skills and have relatively low cognition which affects their speed of learning and understanding capability in schools and colleges (Mukaetova-Ladinska & Stuart-Hamilton, 2015).

Another problem area depicted by the ones suffering from ASD is poor decision making abilities. The lack of sufficient resources and guidance from proper channels can also impact the quality of life of the ones suffering from ASD (Buescher, Cidav, Knapp & Mandell, 2014).  A number of health and social care channels could provide additional level of support to the people suffering from ASD. The help is provided in various domains such as learning and development, life support. Early intervention has been regarded as a solution to address the issue of long term complications and delayed identification of ASD. To find evidence for the effectiveness of early intervention for children with ASD, the following research questions guides the literature review: ‘How can the health and social care practices reduce the impact of ASD on children by implementing early stage intervention?  

The above question has been used search for relevant research articles and understands the affect of early life intervention strategies on development of children suffering from ASD. By searching for articles in databases like CINAHL and Medline, nine articles were retrieved. Thematic analysis approach was used to find common meanings from research data and represent them in the form of themes. Themes have been developed by categorizing research data based on similar findings and then using themes to represent those data. This method of theme development helped to get an idea regarding the main findings coming out from the literature review. Thematic analysis helps in easy interpretation of research data.

Zwaigenbaum et al., (2015) carried out a research for highlighting the recommendations for practice and research in relation to early intervention for children suffering from Autism Spectrum Disorder (ASD) for children who are aged below three years. According to the researchers, the prime objective of early detection and screening in children for ASD is to ensure that children can gain access to evidence-based interventions aimed at providing suitable opportunity for optimal outcomes. Interventional approaches for children aged less than three years are to be developmentally appropriate. Based on this knowledge, the researchers carried out a literature search in relation to intervention programs targeting ASD children below the age of three years. The search had brought into focus 419 references of which articles focusing on clinical trials of behavioral or developmental interventions were considered for the review. A scoping approach had been used for selecting the final set of 24 articles that were either randomized controlled trial, or quasi-experimental or open labeled studies. In this regard it can be mentioned that scoping reviews are the form of research that undertakes an exploratory study for systematically mapping the existing literature on a concerned topic. Such a review has the aim of addressing more complex and broader exploratory research question. Such a methodology needs further clarification for understanding its applicability in research (Bowling, 2014). The research highlighted that present best practices in relation to interventions to be given to children aged below three years with confirmed or suspected ASD must include a combination of behavioral and developmental approaches that are to be commenced as early as possible. Further, interventions are to have an active and effective involvement of caregivers and families as a crucial part of the intervention. Early stage interventions enhance the developmental progress in children and bring about an improvement in the functioning concerned to the associated and core characteristics presented by ASD children. These include emotional regulation, communication, and adaptive behaviours. A key insight that was received from the review was the interventional services for ASD children are to consider the diverse socio-cultural beliefs upheld by the family along with the family dynamics. The economic capability of the families is to be adjudged before outlining the interventions in terms of assessment and delivery of intervention factors.

Role of early intervention in promoting early identification of ASD in children

Certain implications for research on the topic of early interventions for ASD children were highlighted from the paper of Tachibana et al., (2017). It was suggested that intervention research on ASD must consider culturally and socially diverse populations of those taking part in the study. Research must also carry out an evaluation of the familial factors affecting acceptability, participation and outcomes of therapeutic approaches. The willingness of the respondents to take part in the exploratory studies is also a key concern. Bacon et al., (2014) had mentioned in their research paper that measurement of progress made by ASD children at the time of intervention programs is known to be a key challenge that clinicians and researchers face. On a general basis, standardized assessments regarding development of children are referred to for measurement of usefulness and benefits of early intervention programs within the context of research settings. However, there are certain limitations of the assessments, such as absence of sensitivity in relation to measurement of slow progress, and testing constraints affecting performance of the child. Further, lack of comprehensive information brought into focus through the assessments is also a key concern. The researcher proposed a standardized testing for providing fine details on progress of child after receiving early interventions. An adapted student learning profile (aSLP) was proposed for measuring progress of child in a systematic manner. The families taking part in the investigation were participants of a broader multidisciplinary research project undertaking an examination of early neurobiological features and development of ASD. The aSLP showed promising results in measurement of intervention provided. The researchers however pointed out that the most important challenge that intervention researcher face is need of useful and accurate method of assessing responses of children to intervention.

The above two evidences highlight the advantage of early interventions for children with ASD.  Although both the studies discusses about some best practice intervention that can promote developmental progress in such children, however certain gaps in research methods limits the direct application of the findings in health and social care setting. Zwaigenbaum et al., (2015) used literature review method and search process was comprehensive. However, lack of systematic analysis limited the relevance of the data. Tachibana et al. (2017) conducted a comparison of three interventions for pre-school children with ASD, however a gap found in those work was that it lacked estimation of effect size of each interventions. Future research by the use of primary research design was needed to estimate quality standards of early stage interventions.

Implications for research on early interventions for ASD children

Rortholz et al., (2017) had carried out a research to establish an appropriate example of a novel and successful state-wide initiative for increasing early identification and intervention for young children who are at risk of suffering from autism spectrum disorder (ASD). The researchers used a 2 tiered screening process along with enhanced quality assessment and policy coordination. It was the responsibility of the South Carolina Act early Team (SCAET) for focusing on collaboration among health and social care leaders who represented universities, state agencies and health care system, and families for improving quality of life of ASD children. Particular focus was given on implementation of policy changes for leading to early identification of ASD as well as home-based behavioural interventions. Modified state agency practices, training and policy changes were accomplished. Presumptive eligibility had been implemented by South Carolina’s Early Intervention Program. It was found that a fivefold augmentation was evident in children who could be given early intense behavioural interventions. It was therefore inferred that improvements in early intervention for ASD is possible is focus is given on coordinative policy changes. The children affected with ASD have been seen to develop low cognition which affects their learning and understanding skills in high school.  As reported by Uljarevi?, Richdale, Evans, Cai and Leekam (2017), 7.3% of the children affected with Autism have been seen to drop out of higher studies of colleges and universities. Hence, policy changes can address long terms issues for children with ASD too.  

As mentioned by Salamone et al, (2015) autism spectrum disorder has the main characteristic of impairment of social interaction as well as communication in addition to which individuals demonstrate restrictive patterns of interests and behaviors. The researchers highlighted that there existed a mounting body of research studies from randomized controlled trials that report on results of effectiveness of early and intense interventions for ASD, including both behavioral intervention and developmental interventions. Different studies had explored the efficacy of interventions in a number of countries in particular France, United Kingdom, and the United States. Nevertheless, due to diverse focus of the studies such as parental satisfaction and service costs, and the research sites, it had been difficult to compare the studies among themselves. Other discrepancies in studies related to the facts that parents were inquired about contacts with professionals instead of use of different interventions; a systematic approach was not taken for asking about the interventional approaches; the samples were not representative of the larger community.

Against this background the researcher aimed at describing the existing stage of psychosocial, developmental and behavioural intervention for ASD children in 20 different countries of Europe. The objectives of the study was two-faced; the first objective was to carry out an assessment of whether the extent of intervention implemented was a function of area in Europe; the second objective was to understand whether characteristics of children and education level of parents had a relationship with intervention use. This research was significant because the disease burden has resulted in adverse social issues where the children have been abandoned by their parents owing to multiple social challenges. The study recruited 1680 parents having children with ASD aged less than seven years across 18 countries of Europe. Online survey was completed regarding the interventions delivered. The study pointed out that there was a distinct variation across the use of interventions. Further, about 20% of children with ASD did not receive interventions in certain countries. The mostly delivered interventions were language and speech therapy and relationship based interventions. Further, in certain countries of Europe, there was an association between development, relationship-based and behavioural interventions, and education level of parents. The findings highlighted the requirement of continual monitoring of interventions delivered to ASD children at the early stages for combating inequalities (Salamone et al, 2015).

The limitations found in theme is however noteworthy.  In the study conducted by Rortholz et al. (2017), some families had faced issues in receiving services as a result of limited availability of early intensive behavioral intervention service providers. This implies that effectiveness of an early intervention for ASD is reliant on the strength of workforce available (Kuhaneck, Madonna, Novak & Pearson, 2015). Further challenges were experienced in recruitment, training and retention of service providers for treating children with ASD. In this regard, the state legislatures must increase funding for recruiting and training interventionalists (French & Kennedy, 2018). It was concluded that future research is necessary for determining the affect presumptive eligibility has on longitudinal outcomes of early interventions for ASD. Varied limitations of this study are to be acknowledged at this context. The recruitment method selected for the study by (Salamone et al, 2015) is online survey through parent associations which might be prone to subjected to selection bias since parents of those with autism attached to a support group are to have high educational level and income (Taylor, Bogdan & DeVault, 2015). As recruitment had been carried out on a local basis by each national association, possibility is there that differences lying in the outreach exhibited by the different organizations might have exerted influence on the sampling method (DePoy & Gitlin, 2015). The other limitation of the study was cross-sectional study design. Lastly, dependency on parents to self-report brings is a limitation (Bowling 2014).

Estes et al., (2015) prospectively carried out an examination of the evidence existing on impact of early stage intervention on the basis of a follow-up study of 39 ASD children. The participants took part in a randomized controlled trial for assessing the effectiveness of a certain Early Start Denver Model (ESDM) delivered to children between 18 and 30 months. The ESDM model is a naturalistic behavioral intervention that considers integrating the method of applied behavior analysis (ABA) with parent coaching. The model is known for its potential to be used for a variety of care settings and the goals for intervention can be set in relation to particular curriculum. 48 children had been randomly allocated to the intervention group or comparison group. The results indicated that ESDM was effective in maintaining gains achieved as a result of early intervention at the time of two years follow-up period in terms of adaptive behavior, intellectual ability, challenging behavior and symptom severity. Improvement was also marked in core symptoms of autism.

Early Start Denver Model (ESDM) holds the potential to affect the primary outcomes for ASD children in a positive manner, as highlighted from the previous study. Eapen et al., (2013) in this regard mentioned that programs that involve one-to-one interventions based on intensive resources might not be available to the community in a direct manner. As a result, children might miss out on important elements of evidence-based early interventions during the most pivotal preschool years. The researchers therefore carried out a study for evaluating the effectiveness of ESDM for children in pre-school age. The participants were 26 ASD children out of whom 21 were male. ESDM was delivered by the help of trained therapists while the children attended child-care centre. Group based intervention was given for 15-20 hours and one-to-one session was given for one hour, for one week, for about ten months. The outcomes measured were assessed through the Mullen Scales of Early Learning (MSEL); and two parent-report questionnaires - the Social Communication Questionnaire (SCQ) and Vineland Adaptive Behaviours Scales–Second Edition (VABS-II). Statistical improvements were observed in terms of performance of the children in relation to receptive language, visual reception, and expressive language domains of the MSEL. Improvement was also evident in intellectual functioning of the children. Statistically significant decreases in features of ASD were marked and receptive communication of children was enhanced.

The study therefore indicated the potential held by ESDM which is easily accessible as well as cost-effective. This particular study is also marked by certain limitations that bring into limelight the directions for future research in this arena. Firstly, there was an absence of control group as well as standardized observational measure of severity of ASD. In addition, there was an indication of conducting further studies that involve group intervention (Haglund, Dahlgren, Råstam, Gustafsson & Källén, 2017).

Another significant study that had been carried out to study the efficiency ESDM presents was that carried out by Dawson et al., (2010). The justification for the study was that no previous studies had been conducted to assess quality of early developmental behavioral intervention for ASD children through a research design of randomized controlled trial. The present research was carried out with 48 children diagnosed with ASD. The children’s age was between 18 and 30 months. Random allocation was done to either ESDM intervention or intervention provided by community providers on a common basis. The results of the study indicated that children who received intervention through ESDM had major improvement in adaptive behavior, IQ and diagnosis of autism. Further, those receiving ESDM had more chances of experiencing a shift in diagnosis to pervasive developmental disorder. The results underscored the relevancy of early intervention in autism. The validity of the research lies in the advantage of randomized controlled trial research methodology. It was possible for the researchers to generate causal inferences regarding effectiveness of ESDM as a result of the study design. Randomization minimized selection bias of the participants. Statistical test of significance was also interpretable in a ready manner (Bowling, 2014).

The ESDM model is of much importance in intervention delivery, as indicated by literature. Nevertheless, certain aspects of the study could be highlighted as limiting the study’s generalizability.  Firstly, recruitment of sample was done from an area that was geographically constrained, implying that families recruited in the comparison group had proper access to different intervention providers (DePoy & Gitlin, 2015). Secondly, the families taking part in the longitudinal study might be differing from the families not taking part in the study in relation to motivation for delivering early stage intervention for their children (Jones, Dawson, Kelly, Estes & Jane Webb, 2017). Further, a weakness in the community intervention-asusual study is that there lies no possibility of quantifying intervention given in community settings. The challenge could have been augmented at the time of follow-up period for the study (Bowling, 2014). More studies are however entailed that consider control groups for intervention study.

Another model that had carried out a randomized controlled trial of an early intervention model for ASD was LEAP (Learning Experiences and Alternative Program for Preschoolers and Their Parents) model. Researchers Strain and Bovey (2011) carried out a clustered randomized design study for which 28 inclusive preschool classrooms had been allocated for receiving LEAP preschool model. 28 inclusive preschool classrooms received only intervention manuals. The total number of children in each of the two groups was 177 in intervention group and 117 in comparison group. The results indicated that those receiving intervention through LEAP model showed advancement in terms of autism symptoms, problem behavior, social skills, language and cognitive ability. The researchers highlighted that LEAP was one of the two noted evidence based inclusion models focused on educating young children and the only one that could be implemented in public school settings. It is to be remembered that such a model is crucial for segregating service provisions for children with autism in the present era (Colombi, 2017).

The LEAP model is of relevance to early stage intervention for ASD children. However, some research gap that has been identified is that the study did not use direct observation method to assess child behavior after the intervention. Future research is needed for highlighting the cognitive, behavioral, and language outcomes in relation to this model. This may help to overcome current issue related to poor quality of assessment in many areas because of funding limitations and distance issues.

Conclusion:

The literature review summarized the potential of early stage intervention that can be given to autistic children.  In the review, the problem of interest which had been taken into consideration was management of autism spectrum disorder through health and social care. The review of research literature gave indicated about the efficacy of various types of early intervention models that could aid health and social workers to reduce health issues and long term impact for children with ASD.  Some of methods and strategies which were discussed include use of state-wide initiative to promote early screening for ASD, behavioral interventions like ESDM and social skills based interventions like LEAP. Although the analysis of the study indicated the potential of LEAP in expanding service provisions for children with autism, however one contradictory that points to the gaps in the intervention includes not taking observation method to evaluate outcome of children. Relying on interview method contributed to bias in response. Use of small sample size also limited the internal and external validity of the intervention. Hence, it points to research implication which is to investigated about the effectiveness of LEAP intervention by using observation methods

The analysis of the effectiveness of ESDM model indicates that behavioral interventions like parent coaching can address challenging behavior in children. Improvements in perceptions and language expressions were also reported by research studies. However, the gaps found in one literature were addressed by other by the use of randomized controlled trial and the use of cause inferences to interpret outcome. Further, there remains a distinct agreement that efficient early intervention must encompass family and caregiver components. Future research must be prioritizing sampling strategies that are well-defined, investigative design that are rigorous. In addition, fidelity of the study’s implementation is also to be considered as the same leads to meaningful outcome measures. Research is also required for determining the active elements of different interventions such as agent of intervention delivery and treatment duration. Further, studies to be undertaken in the future are to examine behavioral and biological heterogeneity as key moderators of responses put forward against the varied interventions. If researchers adopt a common set of research-validated core measures of ASD symptoms across multiple settings, comparisons would be possible across gamut of studies with ASD children.

References

Bacon, E. C., Dufek, S., Schreibman, L., Stahmer, A. C., Pierce, K., & Courchesne, E. (2014). Measuring outcome in an early intervention program for toddlers with autism spectrum disorder: use of a curriculum-based assessment. Autism research and treatment, 2014. DOI https://dx.doi.org/10.1155/2014/964704

Baxter, A. J., Brugha, T. S., Erskine, H. E., Scheurer, R. W., Vos, T., & Scott, J. G. (2015). The epidemiology and global burden of autism spectrum disorders. Psychological medicine, 45(3), 601-613. DOI 10.1017/S003329171400172X.

Bowling, A. (2014). Research methods in health: investigating health and health services. McGraw-Hill Education (UK). Retrieved from https://books.google.co.in/books?hl=en&lr=&id=6lOLBgAAQBAJ&oi=fnd&pg=PR3&dq=health+and+social+care,+research,+method,+book&ots=YeGb5ycHcB&sig=ugwVJQAL3Ocdio0Ym7qyYDV6IlA#v=onepage&q=health%20and%20social%20care%2C%20research%2C%20method%2C%20book&f=false

Buescher, A. V., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). Costs of autism spectrum disorders in the United Kingdom and the United States. JAMA pediatrics, 168(8), 721-728. DOI 10.1001/jamapediatrics.2014.210

Colombi, C. (2017). Current Challenges in Early Intervention for Children with Autism Spectrum Disorder (ASD): A Narrative Review. Medical Research Archives, 5(7). Retrieved from https://www.journals.ke-i.org/index.php/mra/article/view/1271

Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., ... & Varley, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics, 125(1), e17-e23. DOI 10.1542/peds.2009-0958

DePoy, E., & Gitlin, L. N. (2015). Introduction to Research-E-Book: Understanding and Applying Multiple Strategies. Elsevier Health Sciences. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=XDETBwAAQBAJ&oi=fnd&pg=PP1&dq=health+and+social+care,+research,+method,+book&ots=m9g4sBhoOp&sig=VXnXzjIQBOxo0ChKdm00Lx-Upl0#v=onepage&q=health%20and%20social%20care%2C%20research%2C%20method%2C%20book&f=false

Eapen, V., ?rn?ec, R., & Walter, A. (2013). Clinical outcomes of an early intervention program for preschool children with autism spectrum disorder in a community group setting. BMC pediatrics, 13(1), 3. DOI https://www.biomedcentral.com/1471-2431/13/3

Estes, A., Munson, J., Rogers, S. J., Greenson, J., Winter, J., & Dawson, G. (2015). Long-term outcomes of early intervention in 6-year-old children with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54(7), 580-587. DOI https://doi.org/10.1016/j.jaac.2015.04.005

French, L., & Kennedy, E. M. (2018). Annual Research Review: Early intervention for infants and young children with, or at?risk of, autism spectrum disorder: a systematic review. Journal of Child Psychology and psychiatry, 59(4), 444-456. DOI 10.1111/jcpp.12828

Haglund, N., Dahlgren, S., Råstam, M., Gustafsson, P., & Källén, K. (2017). Improvement of autism symptoms after comprehensive intensive early interventions in a clinical setting. European Psychiatry, 41, S129. DOI  https://doi.org/10.1016/j.eurpsy.2017.01.1940

Jones, E. J., Dawson, G., Kelly, J., Estes, A., & Jane Webb, S. (2017). Parent?delivered early intervention in infants at risk for ASD: Effects on electrophysiological and habituation measures of social attention. Autism Research, 10(5), 961-972. DOI https://doi.org/10.1002/aur.1754

Kuhaneck, H. M., Madonna, S., Novak, A., & Pearson, E. (2015). Effectiveness of interventions for children with autism spectrum disorder and their parents: A systematic review of family outcomes. American Journal of Occupational Therapy, 69(5), 6905180040p1-6905180040p14. DOI https://dx.doi.org/10.5014/ajot.2015.017855

Mukaetova-Ladinska, E. B., & Stuart-Hamilton, I. (2015). Adults with Autism Spectrum Disorder (ASD): service user perspective on ageing transition (s). Journal of Autism, 2(1), 1-11. DOI 10.7726/aja.2016.1001 

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Tachibana, Y., Miyazaki, C., Ota, E., Mori, R., Hwang, Y., Kobayashi, E., ... & Kamio, Y. (2017). A systematic review and meta-analysis of comprehensive interventions for pre-school children with autism spectrum disorder (ASD). PloS one, 12(12), e0186502. DOI https://doi.org/10.1371/journal

Taylor, S. J., Bogdan, R., & DeVault, M. (2015). Introduction to qualitative research methods: A guidebook and resource. John Wiley & Sons. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=pONoCgAAQBAJ&oi=fnd&pg=PR11&dq=health+and+social+care+research+method,+book&ots=Qhvidy6v5Q&sig=WXUArMlXV1P3RTaPvBr6VmeVEQ4#v=onepage&q=health%20and%20social%20care%20research%20method%2C%20book&f=false

Uljarevi?, M., Richdale, A. L., Evans, D. W., Cai, R. Y., & Leekam, S. R. (2017). Interrelationship between insistence on sameness, effortful control and anxiety in adolescents and young adults with autism spectrum disorder (ASD). Molecular autism, 8(1), 36. DOI  10.1186/s13229-017-0158-4

Zwaigenbaum, L., Bauman, M. L., Choueiri, R., Kasari, C., Carter, A., Granpeesheh, D., ... & Pierce, K. (2015). Early intervention for children with autism spectrum disorder under 3 years of age: recommendations for practice and research. Pediatrics, 136(Supplement 1), S60-S81. DOI  10.1542/peds.2014-3667E

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