More Evidence Early Intervention in Autism Gets Results

An early behavioral intervention may not only improve behaviors in young children with autism but it could also lead to "striking" brain changes, according to new imaging research.

A small case series study showed that after receiving a pivotal response treatment (PRT) intervention, the participating children with autism spectrum disorders (ASD), who were only 5 years of age, showed significant improvements in adaptive behavior as well as in communication.

They also had increased activation in brain regions that support social perception, as shown by functional magnetic resonance imaging (fMRI) scans.

Dr. Fred Volkmar

"I think this is the first time fMRI has been used to identify neural correlates of response to a treatment such as this. And parents really like it," coinvestigator Fred R. Volkmar, MD, director of the Child Study Center at the Yale University School of Medicine in New Haven, Connecticut, and chief of child psychiatry at the Children's Hospital at Yale–New Haven, told Medscape Medical News.

The study was published online October 27 in the Journal of Autism and Developmental Disorders.

Remarkable Changes

The PRT intervention includes parental training and uses motivational play activities in its methods. Although this initial analysis focused only on 2 children, Dr. Volkmar reported that the results have led to a new full-scale study that includes 60 children.

"For now, I wanted to get this information out there because I thought this was interesting and promising news," said Dr. Volkmar, adding that the findings represent a first step in a novel approach to individualized treatment planning.

"Autism research has come a long way. These findings are exciting because they show that early intervention works in autism. It's telling us that we're really making a difference."

"We've known that early intervention is important and that most children with autism — not all but most — get markedly better with good intervention," said Dr. Volkmar.

"We have truly seen over the past several decades really remarkable changes. Again, I do emphasize that not everyone gets better even with very good treatment, and we don't understand why. But on balance, kids are doing better," he said.

A recent multicenter study published in the November issue of the Journal of the American Academy of Child and Adolescent Psychiatry and reported by Medscape Medical News showed that young children with an ASD who received the Early Start Denver Model behavioral intervention had normalized patterns of brain activity in electroencephalographic measurements. They also had improved social behavior.

"This is another very good model, and they had similar results to ours. They had a larger sample, but they did not do an fMRI. But if you look at theirs and ours together, it's really encouraging in terms of being able to document progress," said Dr. Volkmar.

He added that there are "a number of models of good interventions" currently available for treating ASDs.

"And we're using them in younger and younger children because our detection methods are improving, as is public awareness," he said.

Play-Based Intervention

For this study, 2 5-year-old children (1 boy, 1 girl) with an ASD were assessed before and after receiving 4 months of the PRT intervention.

Developed at the University of California–Santa Barbara, this program "combines developmental aspects of learning and development, and is easy to implement in children younger than age two," according to a release.

"This targets behaviors that are very important to making developmental progress," added Dr. Volkmar.

Dr. Pamela Ventola

Coinvestigator Pamela Ventola, PhD, associate research scientist at the Yale Child Study Center and a clinical psychologist, noted that the researchers wanted to look at an intervention that could easily be made available to the community.

"This is something that can be used across the lifespan. But we found that it's an especially good fit for these preschool-aged and younger children because it's play-based. It's very natural, and it's fun for them," said Dr. Ventola.

At baseline, adaptive behavior was measured using the Vineland Adaptive Behavior Scales–II Survey Form, and language skills were measured using the Clinical Evaluation of Language Fundamentals, Fourth Edition. In addition, fMRI was used to measure neural response to social stimuli.

All measurements were repeated at the end of treatment.

Dramatic Improvement

Results demonstrated that both of the children showed significant improvement after receiving the intervention in pragmatic language, with the boy receiving a posttreatment score found in a range normally seen in typically developing children.

Both children also showed dramatic improvement in adaptive behavior skills, including receptive, written, play and leisure time, and coping. However, interpersonal relationship skills and personal daily living skills scores remained stable or even declined after treatment.

Nevertheless, the participants did have "increased activation to social stimuli in brain regions utilized by typically developing children," report the researchers.

They add that this shows that "neural systems supporting social perception are malleable" through the use of PRT.

The girl showed greater posttreatment activation in 2 regions of the left fisuform gyrus and a portion of the left dorsolateral prefrontal cortex. The boy showed greater activation in a portion of the right posterior superior temporal sulcus, the left ventrolateral prefrontal cortex, and both the left and right fusiform gyri.

"Both children showed increased activation in portions of State and Trait, but not Compensatory regions after treatment," write the investigators.

Coinvestigator Kevin A. Pelphrey, PhD, also from the Yale Child Study Center, noted in a release that the overall results "were not homogeneous because ASD is a multifaceted disorder that has a unique effect on each child."

"Both the children in our study made progress, but their degree of progress and level of skills at the end of treatment were distinct," he said.

Early Treatment Is Effective

"I think the take-away message is that interventions are effective. And we think, based on the results of our study, that interventions can even modify brain functioning and alter development," said Dr. Ventola.

"It can help these children to develop the core social communication skills that are the hallmark deficits in autism. It's very hopeful, as we're altering their behavior in a positive way."

Dr. Volkmar added that although this journal article focused on only 2 children, "we have a number of cases done now. So we'll obviously publish a broader series in the future."

"We're trying, in a very slow and careful way, to do something that is strongly scientific and evidence-based. Our initial findings show that kids are doing better — but again, not everyone is doing better. So I think it's important to never overpromise parents," he said.

"For now, I think the main thing, especially for pediatricians, family practitioners, and primary care providers, is to be aware of how important early detection and treatment of autism is. And what a difference it can make."

The study was supported by the Harris Professorship at the Yale Child Study Center and Allied World and by a grant from the National Institute of Mental Health. The study authors have disclosed no relevant financial relationships.

J Autism Dev Disord. Published October 27, 2012. Abstract