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DEVELOPMENTAL INTERVENTIONS FOR CHILDREN WITH AUTISM SPECTRUM DISORDERS: A LITERATURE REVIEW

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Developmental approaches characterized interventions based on the typical sequences of the child's development, paying particular attention to the linguistic, motor and socio-emotional aspects, within a relational perspective. The purpose of this paper was to identify developmental interventions for children with Autism Spectrum Disorders (ASD) aged between 0 and 12 years old. A literature review was carried out searching on MEDLINE, PsycINFO, and PsycARTICLES and manually on key journals and reference lists of key articles [...] This review highlights the need for improved research on intervention programs and the important service needs for families and children with Autism Spectrum Disorders.
In: Understanding Children with Autism ISBN: 978-1-53617-647-6
Editor: Anne Bourque © 2020 Nova Science Publishers, Inc.
Chapter 3
DEVELOPMENTAL INTERVENTIONS
FOR CHILDREN WITH AUTISM SPECTRUM
DISORDERS: A LITERATURE REVIEW
Magda Di Renzo1, MD, Viviana Guerriero1, PhD,
Valeria Mammarella2, MD
and Federico Bianchi di Castelbianco1, MD
1Institute of Ortofonologia (IdO) of Rome, Rome, Italy
2Sapienza University of Rome, Rome, Italy
ABSTRACT
Developmental approaches characterized interventions based on the
typical sequences of the child’s development, paying particular attention
to the linguistic, motor and socio-emotional aspects, within a relational
perspective. The purpose of this paper was to identify developmental
interventions for children with Autism Spectrum Disorders (ASD) aged
between 0 and 12 years old. A literature review was carried out searching
on MEDLINE, PsycINFO, and PsycARTICLES and manually on key
journals and reference lists of key articles. All the electronic databases have
been consulted by setting a range of year of publication between 2009 and
2019, and only articles in English have been considered. Two reviewers
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Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
58
assessed studies against predetermined inclusion criteria and 72 unique
studies met our inclusion criteria. The interventions selected were
described and the main outcomes discussed. This review highlights the
need for improved research on intervention programs and the important
service needs for families and children with Autism Spectrum Disorders.
Keywords: developmental interventions, autism spectrum disorder,
children, psychotherapy
INTRODUCTION
According to the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) of the American Psychiatric Association [1] Autism Spectrum
Disorders (ASD) are diagnosed in presence of persistent communication and
social interaction deficits and restricted or repetitive interests or activities,
emerging from the early stages of child development.
In recent years there has been an increase in the prevalence of Autism
Spectrum Disorders. A 2012 systematic review [2] presenting
epidemiological investigations since 2000 on ASD and Pervasive
Developmental Disorders (PDD) worldwide, showed that the median of
prevalence estimates was 12/10,000 children (range 2.894) and 62/10,000
children (range 1-189) respectively. A more recent review [3] showed a
prevalence range of 21.7 cases (children and adolescents) every 10,000 in
24 countries. The studies found by these authors were then divided into those
that were published from 1966 to 2000 (29 studies) and those that had been
published from 2001 to 2013 (43 studies) and a prevalence of 11.9 cases
every 10,000 and 28.4 cases per 10,000 respectively emerged, showing a
significant increase in prevalence over the years. The authors also presented
data supporting the hypothesis that DSM-5 diagnostic criteria for ASD
applied to studies with samples diagnosed with DSM-IV [4] or DSM-IV-TR
[5], did not facilitate the identification of individuals with ASD. The data
presented in this study suggest what is also indicated by other authors [6],
namely that the estimates prevalence for ASD may depend on several factors
Developmental Interventions for Children
59
like the age range of the target population, the diagnostic manual, or the
social system in which the investigation is conducted.
In a recent study [7], the prevalence of this disorder in 4 States (United
States) among 4-year-olds individuals ranged from 13.4 per 1,000 children
in 2012 to 17.0 per 1,000 children in 2014, while the prevalence of this
disorder in 11 States among 8-year-olds individuals ranged from 13.1 to 29.3
per 1,000 children in 2014, with an m/f ratio of 4 to 1 [8]. This study also
showed a comparison between the prevalence detected using the DSM-IV-
TR and the DSM-5 for the diagnosis of ASD, and highlighted an overlapping
of approximately 86% of cases, with a decrease in diagnosed cases using
DSM-5.
European prevalence data from the 2018 network “Autism Spectrum
Disorders in the European Union (ASDEU) out of a total of 631,619
children recruited, found a prevalence of 12.2 children per 1,000 (1 in 89)
aged 7 and 9 years, ranging from 4.4 to 19.7 children per 1,000 [9].
For a more comprehensive view of the Italian context, we report below
some of the most recent prevalence studies. According to ISTAT data
published in 2018 on the position of students with disabilities in primary and
secondary schools, for the school year 2016-2017, 25.6% of pupils with
disabilities in primary school and 21.7% of pupils with disabilities in lower
secondary school have been diagnosed with a developmental disorders
(Autism Spectrum Disorders) with a prevalence of 0.84% of the total [10].
A recent study that aimed to assess the prevalence of ASD in 10,138 children
aged 7 to 9 in the province of Pisa (Italy) estimated a 0.79% prevalence [11].
Finally, data from two Italian regions (Piemonte and Emilia Romagna)
indicate a prevalence of PDD in the 6-10 age group of 4.2/1000 children in
2010 and 2.8/1000 children in 2011 [6]. The serious data of ASD prevalence
and the high complexity of this disorder demand for deepening the study of
interventions aimed at children with ASD.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
60
DEVELOPMENTAL THERAPIES FOR CHILDREN
WITH AUTISM SPECTRUM DISORDER
Despite the high importance of early and appropriate interventions
addressing children’s and families needs to promote positive outcomes,
considerable variation regarding both access to interventions and the type of
intervention received emerges across countries [12].
A study involving 1,680 parents of children with ASD from 18 European
countries (Belgium, Czech Republic, Denmark, Finland, France, Germany,
Hungary, Iceland, Ireland, Italy, The Netherlands, Norway, Poland,
Portugal, Romania, Spain, the former Yugoslav Republic of Macedonia and
the United Kingdom), aimed at collecting data about the interventions
provided to children aged 7 and under. Data showed that 91% used at least
one type of intervention among behavioral intervention, developmental
and/or relationship-based intervention, speech and language therapy,
occupational therapy, other educational and psychological interventions or
parent training [12]. The speech and language therapies were the most
widely used, while the behavioral, developmental and/or relationship-based
interventions accounted for 45% among those applied, representing the
second most widely used type of intervention in all the countries involved.
Furthermore, the developmental and relationship-based therapies were most
commonly used in southern and eastern Europe.
In this field, we can identify several developmental interventions, but
among them we can find some core characteristics that seem useful to clarify
[13]. The first key feature concerns the strong link with the scientific theories
and knowledge of the developmental approach, which also include
Attachment Theory and Infant Research [14, 15, 16, 17, 18, 19].
Developmental theories guide both assessment and intervention planning.
These interventions consider the importance of critical period (or
developmental windows) in common to all children for the promotion and
the acquisition of essential skills. Simultaneously they consider the
importance to set specific goals for each individual, bearing in mind both
risk and protective factors [20]. Great importance is also given to the child’s
Developmental Interventions for Children
61
relationship with significant adults and reciprocal social interactions [21]. In
this perspective, the child is seen as an active subject who participates,
interacts and co-constructs the therapy [22]. Finally, developmental
approaches typically use play sessions to encourage spontaneity, initiative,
motivations and provides them opportunities to engage in interpersonal
relationships [23, 24, 25]. In sum, developmental approaches characterized
interventions based on the typical sequences of the child’s development,
paying particular attention to the linguistic, motor and socio-emotional
aspects, within a relational perspective.
Before proceeding with our review, it is necessary to give a short mention
of early intervention for toddler-aged children (from birth to 36 months) with
or at risk of ASD. The identification of ASD in toddler-aged children has
begun especially important in the past decade, to identify positive prognostic
indicators and to plan adequate psycho-educational interventions to support
the child’s development [26]. A 2011 review [27] identified 14 different
developmental domains among 27 papers selected: joint attention,
motivation, acceptable behavior or compliance, communication, play,
imitation, turn-taking, social interaction, eye contact or looking at faces,
cognition, adaptive/self-help, motor, sensory and affect/social-emotional.
The majority of the interventions focused on joint attention or
communication areas. Among these early interventions, the majority were
conducted out of the natural child environment and by professionals as the
principal agents of intervention, rather than parents. Furthermore, this paper
stated that less than half interventions reviewed promote internal child
motivation or child initiative in learning and that all the interventions
reported using functional systematic intervention methods “not always
easily determined from descriptions provided” (p. 17) [27]. About
developmentally targeted interventions, the authors concluded that they
varied in their accounting of the role of developmental foundations in their
work, especially for the social communication area, and that additional study
is needed for distinguishing developmental outcomes of interventions
targeting joint attention and those aimed at more developmentally remote
abilities.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
62
METHODS OF THE LITERATURE REVIEW
The survey methodology for the current literature review was based on
the use of Medline, PsycArticles, PsycInfo, ProQuest and Psychology
electronic database, using the following combination of keywords: “autism”
or “ASD” or “Autism Spectrum Disorder and “developmental
intervention or “developmental treatment or “developmental therapy”. All
electronic databases were consulted in a publication range between 2009 and
2019, considering studies carried out on the population of children aged
from 0 to 12 years. Only full-text articles in English were considered, and
all papers other than journal articles or book chapters, including book
reviews, commentaries, and dissertations, were excluded. Additional
scientific articles were found by manually examining key scientific journals
in this area and references of key articles. Finally, 72 scientific articles
dealing with the topic of interest of this review have been selected.
THE DEVELOPMENTAL INDIVIDUAL-DIFFERENCES,
RELATIONSHIP-BASED MODEL
The Developmental Individual-Differences, Relationship-Based Model
(DIR®) was developed by Stanley Greenspan and Serena Weider [28] for
understanding and promoting the positive development of children, focusing
on a variety of children capacities. Greenspan has listed six steps or stages
of typical development and the corresponding pathologies that might occur
if a stage did not progress appropriately: the first stage is called
“homeostasis” and it relates to the child internal regulation and a well-
balanced interest in the world; the second stage is “attachment” and it is
characterized by an emotional investment in animated world, especially
caregivers; the third stage is about the “somatopsychological
differentiation”, typified by the child acquisition to be flexible, multisystem,
affective within reciprocal interactions with primary caregivers; the fourth
step concerns the child “behavioral organization, initiative, and
Developmental Interventions for Children
63
internalization in which the child creates more stable and organized mental
representations that organize his/her behavior; the fifth stage, that is the
“representational capacity, differentiation, and consolidation”, is
characterized by the consolidation of the child internal representations, the
ability to evoke internal object and to organize multisensory experiences,
resulting also in a stabilization of mood; the sixth stage occours from middle
childhood through adolescence, and it is characterized by a gradual
consolidation of derivative and multiple reppresentational systems, greater
flexibility and ability to organize, integrate and differentiate a great amount
of affective and ideational content. The failure in the development of
adaptive capacities, usually matched by maladaptive caregiver behaviors,
may conclude with regulatory disorders; autistic patterns; narrow, rigid or
stereotyped responses to others, and random or chaotic behavior and affect;
disorganized withdrawn, compliant, or aggressive behavior, stereotyped and
polarized behavior and emotion; poor sense of self and others, concreteness
of behavior and affect; impulse regulation, mood stabilization and
compromised reality testing, depending on the developmental stage
impaired. The typical outcomes described for each step represent core
therapeutic goals in the treatment of children who have not acquired the
abilities of a particular step.
DIRFloortime® (Floortime) is the application of the DIR model in a
comprehensive intervention, commonly utilized with children with ASD or
other developmental or socio-emotional challenges. It aims at working with
the child on the abilities missed in his/her developmental process, through
one-to-one interactions between a therapist and a trained parent. In order to
accomplish this, the therapy is designed to stimulate child interest through
play in a natural environment.
Pajareya and Nopmaneejumruslers [29] presented positive data
confirming the results obtained by a previous pilot study [30] using the
(DIR)/Floortime™ intervention for preschool children with ASD. Mercer
[31] wrote an interesting review on theory and research of DIR/Floortime™
as a treatment for children with ASD, listing several adjuvant treatments to
DIR/Floortime that seems to be less plausible. They include speech therapy
[32], sensory integration theory (SIT) [33] and developmental optometry
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
64
[34]. Against this background, Au and Coulter [35] suggested combining
traditional Vision Therapy (VT) techniques with the DIRFloortime model
for providing a more comprehensive intervention for children with ASD.
This paper also suggested that DIR/Floortime™ is congruent with the
developmental theory about ASD, but it does not have the status of an
evidence-based treatment yet, letting us deduce that additional randomized
control trials are needed.
THE JOINT ATTENTION, SYMBOLIC PLAY,
ENGAGEMENT AND REGULATION
The Joint Attention, Symbolic Play, Engagement & Regulation
(JASPER) [36] approach was developed by Connie Kasari with the goal of
interacting with children with autism through naturalistic strategies to target
the foundations of social-communication in terms of joint attention,
imitation, and play. JASPER model is based on the assumption that joint
attention and play skills represent a key component of the child’s future
ability of understanding other’s mental representations, and as a
consequence, they may positively influence children’s social, cognitive, and
language abilities [37]. On the basis of this model, a combined
developmental and behavioral intervention was implemented, to improve
joint attention and symbolic play skills in children with ASD, that are
supposed to be characterized by significant deficits in social communication
skills. This evidence-based social communication approach consists of
approximately 36 months of service (minimum 24 sessions) conducted by
clinicians, special education teachers or caregivers, typically delivered one-
to-one, as well as in group/classroom sessions.
When 16 children were randomly assigned to 6-week JASPER
intervention implemented by public school teachers or a control group, data
showed more JASPER strategies used by teachers and more joint attention
and more time in supported engagement in children of the JASPER group
than the control group [36]. In a pilot study [38] the effects of JASPER were
Developmental Interventions for Children
65
tested on a sample of 15 minimally verbal children with autism aged
between 3 and 5 years old. Children were randomly assigned to the control
group or JASPER intervention (implemented by graduate students in
educational psychology). Data showed greater play diversity, more gestures
and less time spent unengaged for children in JASPER treatment compared
with the control group.
The JASPER intervention conducted by a caregiver was evaluated
comparing children’s improvements after a group of 24 sessions with 1year
follow-up to control group of children in the waitlist and showing significant
differences in targeted areas of joint engagement [39]. The intervention
conducted by the caregiver was also evaluated in a study [40] comparing
two small group training for caregivers with or without the child being
present. Data showed that both intervention groups improved child outcome,
but the caregiver group with the child being present was more effective when
compared to the group without the child.
One study [41] compared a 10 weeks caregiver-child JASPER with a
parent-only psychoeducational intervention, showing a significant effect of
JASPER in dyadic joint engagement, and a significant effect of the parent-
only psychoeducational intervention in reducing parenting stress associated
with child characteristics.
Regarding teacher implementation, a 2016 study [42] highlighted that
teachers and teaching assistants can deliver JASPER with high fidelity in
their preschool classroom day, after a brief but sustained coaching support
throughout the 2 months of intervention. Furthermore, significant effects in
joint attention gestures, child-initiated joint engagement, joint attention
language, and length of language emerged for children who have received 2
months of daily classroom JASPER, when compared to children in the
waitlist. Shire and colleagues [43] also compared data on JASPER
intervention or treatment on children with ASD living in low resource
neighborhoods. Children were randomized to Joint Attention, Symbolic
Play, Engagement, and Regulation or waitlist and results showed that
teaching assistants implementation of JASPER intervention had an adequate
fidelity and that children treated with JASPER had significant gains in joint
engagement, joint attention, and play skills when compared to children in
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
66
the waitlist. A more recent study [44] explored the fidelity of teacher
assistants delivering JASPER, showing maintained quality implementation
of many of the intervention strategies investigated. Data also showed that
teaching assistants helped the children to get into longer periods of joint
engagement and to maintain that level of engagement, during the second
year of working.
One paper [45] expanded the results that emerged from the study by
Almirall and colleagues [46], comparing the longitudinal improvement of
minimally verbal children with a diagnosis of autism, aged between 5 and 8
years old. Two treatment (only JASPER and Enhanced Milieu Teaching
intervention versus JASPER, Enhanced Milieu Teaching intervention and
the use of a speech-generating device) outcomes were compared showing
similar play level improvements over a 6-month intervention, but few
differences between the two treatments.
According to this study’s presentation, we can conclude that the data
available on the efficacy of the JASPER approach in improving children’s
joint attention, and symbolic play skills were generally successfully
achieved by different operators, but these results need to be replicated with
larger sample size.
THE EARLY START DENVER MODEL INTERVENTION
The Early Start Denver Model is a comprehensive developmental
behavioral intervention for improving outcomes of infants to preschool-aged
children with ASD. This intervention integrates Applied Behavior Analysis
(ABA) with relationship-based and developmental theories, and it is
provided in the children’snatural environment and delivered by trained
therapists and parents.
Reports from the first studies using the ESDM delivered by therapists
showed children decreasing of symptoms severity and improvements in
children’s development, especially in the language domain [47, 48, 49].
Children’s improvements after this intervention were also associated with
normalized patterns of brain activity when this intervention was compared
Developmental Interventions for Children
67
with a community intervention [50]. A longitudinal study on 39 6-year-old
children with ASD showed also that the gains were maintained and an
improvement in core autism symptoms and adaptive behavior when
compared with the group of intervention, as usual, two years after the
intervention ended [51]. Rogers and colleagues [52] replicated and extended
the 2010 study by Dawson and colleagues [47], in which the outcomes of
forty-eight children diagnosed with ASD between 18 and 30 months of age
were compared when assigned to an ESDM intervention or an intervention
as usual, demonstrating the efficacy of this developmental behavioral
intervention for toddlers with ASD.
A 2016 review [53] indicated positive child, parent, and therapist
outcomes reported in the identified studies, but it also showed a weakness in
terms of effectiveness. Recently one study [54] on a parent-implemented
Early Start Denver Model (P-ESDM) was implemented with one hundred
eighteen children aged between 14 to 24 months and parents to determine its
efficacy for children outcomes. A short-term intervention for toddlers with
ASD lasting twelve weeks was compared with an enhanced ESDM version,
including also motivational interviewing, multimodal learning tools, and a
weekly home visit. Parents in the enhanced ESDM group showed increased
sensitivity and skills in supporting children’s development as compared to
the parents of the control group, while children showed similar gains for
both groups over time.
Further implementation of ESDM is based on the delivery of this
intervention in group-based settings. In this context, a recent review [55]
described it as a feasible and sustainable early intervention for young autistic
children, that is showing initial promising data. This data was confirmed by
a 2019 study involving 44 preschoolers children with ASD receiving the
Group-Early Start Denver Model in classroom setting [56], in which
children showed improvements and mothers experienced a reduction in
stress. Nevertheless, this review stressed the importance of deepening the
community viability of this model, the permanence of activities and
resources after the training, and the long-term outcomes.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
68
MILIEU TEACHING
The Milieu Teaching (MT) [57] is an intervention for children focused
on teaching new communication skills and behaviors within children’s
natural settings (i.e., home or school). It was performed with children with
ASD and is about modeling children’s correct responses and correcting them
as necessary. It includes a social interactionist perspective, with an emphasis
on parents as interventionists [58]. There are several versions of the Milieu
Teaching approach including Milieu Language Teaching (MT) [59], Milieu
Communication Teaching (MCT) [60] and Prelinguistic Milieu Teaching
(PMT) [61], taking into account additional environmental variables to that
of the traditional Milieu Teaching.
Christensen-Sandfort and Whinnery [62] examined the effectiveness of
the Milieu Teaching classroom intervention for young children during a
period of 5 months. Participants attended a preschool classroom for children
with varying exceptionalities, and the intervention was provided by a trained
teacher. This paper demonstrated the positive impact of the Milieu strategies
in increasing spontaneous speech in children with ASD and the usefulness
of this intervention for teachers of young children with ASD during
classroom activities.
The Prelinguistic Milieu Teaching (PMT) [61] targets prelinguistic
social communication outcomes (i.e., eye gaze, gestures, vocalizations) used
to request and share attention and it is embedded in play routines within a
child’s natural environment. Six non-verbal children aged between 5 and 8
years old, with a diagnosis of autism were taught to initiate communication
using vocalizations, gestures, and eye gaze within play routines. Data
revealed an improvement in children’s number of communicative
interactions during play routines and initiated intentional communication
[58]. One recent paper [63] has deepened the efficacy and the feasibility of
PMT with three preschoolers with or at risk for ASD in the context of their
classrooms, showing an increase in their engagement in communicative acts.
Another implementation of this intervention is the Responsivity
Education/Prelinguistic Milieu Teaching (RE/PMT) therapy consisting of
both Prelinguistic Milieu Teaching delivered to the children and responsivity
Developmental Interventions for Children
69
education delivered to the parents. The Responsivity Education deals with
teaching parents to be highly responsive to their children’s intentional and
unintentional communication and focus of attention, waiting for their child
to initiate vocal/motor behaviors and providing proper behaviors as a
consequence of their child communication [64]. Yoder and Lieberman [65]
compared thirty-six children outcomes comparing RE/PMT or Picture
Exchange Communication System (PECS) sessions per week for 6 months
and revealed that children receiving RE/PMT intervention were lower in the
picture exchanges compared to children receiving in a generalized context.
Mcduffie and colleagues [66] compared thirty-two children with ASD aged
1860 months outcomes when randomly assigned to the (PECS) or RE/PMT
treatments. This paper showed that object interest in young children with
ASD in the RE/PMT intervention showed a gain in object interest as
compared to children in the PECS intervention.
The Enhanced Milieu Teaching (EMT) [59] is an evidence-based and
manualized language intervention based on “a naturalistic model of early
language intervention in which child interest and initiations are used as
opportunities to model and prompt language use in everyday contexts” (p.
296) [67]. It is delivered by a parent and therapist or only by a therapist, who
uses developmentally responsive strategies and behavioral teaching
strategies to improve children’s language. The study by Kaiser and Roberts
[67] showed more gains in preschool children receiving EMT implemented
by parents and therapist when compared with the control group of therapist-
only EMT. When Jasper plus EMT intervention with or without the
augmentation of a speech-generating device (SGD) was provided to sixty-
one children with autism, aged 5 to 8 years, received a JASP+EMT
intervention, data showed that a JASP+EMT intervention incorporating an
SGD had a significant and rapid gain in children language [68]. A recent
study [69] deepened the effects of the EMT implemented by the therapist on
three children with ASD in South Africa and highlighted an increase in the
number of words and the number of spontaneous utterances expressed by
the children.
In sum, as revealed in a 2009 review on early research conducted in the
area of Milieu Therapy, this intervention revealed an increase in children
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
70
targeted communication skills [69], while a more recent review [71]
suggested a lack of consistency and the need of better define the quality and
the quantity of these interventions. Studies investigating Milieu
interventions are also limited in terms of participants age, diagnosis,
language severity, and intellectual functioning, and these aspects should be
further explored.
TREATMENT AND EDUCATION OF AUTISTIC
AND RELATED COMMUNICATION
HANDICAPPED CHILDREN
The Treatment and Education of Autistic and Related Communication
Handicapped Children (TEACCH) [72] is a comprehensive treatment
method using children preferred activities that are supposed to be more easy
to understand, practice, and generalize. The primary aim of this intervention
is to improve many different areas of an individual’s development, focusing
on children’s strengths, interests, and needs [73]. This treatment relies on
traditional behavioral, neo-behavioral and developmental techniques,
usually as part of classroom-based programs of structured teaching. Within
this model, the Structured Teaching is a set of teaching principles and
intervention strategies helping practictioners’ understanding of children
needs and learning styles [74]. Children are supported in processing
information visually and in choosing, engaging in, and making sense of daily
activities. Parents are trained as co-therapists, so home-based programs are
also possible. TEACCH programs are not based on children typical
development and do not include a standardized curriculum for each child,
but they pay attention to the following key elements: “organization of the
physical environment, visual information, task organization, and work
systems” (pag. 429) [75]. The development of this treatment relies on Eric
Schopler theories hypothesizing a better chance for children with autism to
learn through visual perceptions than through auditory perceptions, and to
have better outcomes when the interventions take place in structured
Developmental Interventions for Children
71
sessions than in unstructured sessions [76]. A 2013 meta-analysis [77] of
intervention studies
1
about TEACCH program for children and adults with
autism provided limited support for the clinical effects of the TEACCH
program (see Table 1). But nevertheless, Virues-Ortega and colleagues [75]
underline that the 2013 review shows also evidence for good practice in
TEACCH program like the standardized assessments, the presence of semi-
independent international teams, and training carried directly by the first
TEACCH center. Besides, reviewed studies in 2013 showed better gains in
adaptive, verbal, cognitive, perceptual and motor areas among older
participants (617 years of age) then younger children (05 years of age).
Some authors [78] compared ABA and TEACCH treatment models
applied at students with ASD, also studying their comprehensiveness and
fidelity, concluding that there is no reliable data for favoring one approach
over the other; that parents, teachers, and administrators did not prefer one
intervention over the other; but they rated as significantly valid some
components specific to autism treatment of both approaches. The outcome
of TEACCH treatment was also compared to that of children on the waiting
list. A pilot randomized controlled trial [79] recruited eleven children with
High Functioning Autism, aged between 5 and 6 years old and their mothers,
showing better improvements if the individuals were assigned to the
TEACCH program than to the control group. When the TEACCH was
compared to the LEAP (Learning Experiences - An Alternative Program for
Preschoolers and Parents) intervention. A study from our review shows that
teachers in special education programs showed a similar level of
commitment to both programs in teachers [80] and children [81], although
for TEACCH more beneficial to children with greater cognitive impairments
emerged.
1
The papers published since 2009 and cited in this meta-analysis [77] were considered in our
review but not extensively descripted.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
72
Table 1. List of papers included in the Virues-Ortega, Julio and Pastor
(2013) meta-analysis
Papers
Participants
age (years)
Aoyama, S. (1995). “The efficacy of structuring the work system:
Individualization of the work format and the use of a 3-level paper rack
in a special education class.” [82]
School age
Ozonoff, S., & Cathcart, K. (1998). “Effectiveness of a home program
intervention for young children with autism. [83]
4,4
Persson, B. (2000). “Brief report: A longitudinal study of quality of life
and independence among adult men with autism. [84]
32,3
Panerai, S., Ferrante, L., & Zingale, M. (2002). “Benefits of the
Treatment and Education of Autistic and Communication Handicapped
Children (TEACCH) programme as compared with a non-specific
approach.” [85]
9,1
Van Bourgondien, M. E., Reichle, N. C., & Schopler, E. (2003).
“Effects of a model treatment approach on adults with autism. [86]
23,7
Siaperas, P., & Beadle-Brown, J. (2006). “A case study of the use of a
structured teaching approach in adults with autism in a residential home
in Greece. [87]
21,3
Siaperas, P., Higgins, S., & Proios, P. (2007). “Challenging behaviors
on people with autism: A case study on the effect of a residential
training programme based on structured teaching and TEACCH
method.” [88]
21,3
Tsang, S., Shek, D., Lam, L., Tang, F., & Cheung, P. (2007). “Brief
report: Application of the TEACCH program on Chinese pre-school
children with autism Does culture make a difference?” [89]
4,6 years
Probst, P., & Leppert, T. (2008). “Brief report: Outcomes of a teacher
training program for autism spectrum disorders.” [90]
10,0 years
Panerai, S., Zingale, M., Trubia, G., Finocchiaro, M., Zuccarello, R.,
Ferrei, R., et al. (2009). “Special education versus inclusive education:
The TEACCH program.” [91]
8,7 years
9,7 years
McConkey, R., Truesdale-Kennedy, M., Crawford, H., McGreevy, E.,
Reavey, M., & Cassidy, A. (2010). “Preschoolers with autism spectrum
disorders: Evaluating the impact of a home-based intervention to
promote their communication.” [92]
2,8
Developmental Interventions for Children
73
Papers
Participants
age (years)
Braiden, H. J., McDaniel, B., McCrudden, E., Hanes, M., & Crozier, B.
(2012). “A practice-based evaluation of Barnardo’s forward steps early
intervention programme for children diagnosed with autism. [93]
3,2
Welterlin, A., Turner-Brown, L. M., Harris, S., Mesibov, G., &
Delmolino, L. (2012). “The home TEACCHing program for toddlers
with autism. [94]
2,5
Note. The black line distinguishes the papers published before and after 2009.
R-TEACCH= residential TEACCH; NS-TEACCH= natural setting TEACCH.
An implementation of the TEACCH is the Family Implemented
TEACCH for Toddlers (FITT), designed for improving the services intended
to occur in children’s natural settings like homes (usually called Part C).
This parent-mediated approach aims at enhancing parental skills for better
targeting the needs, understanding and engaging with toddlers with ASD. In
a 2016 study [95] forty-nine participants were recruited and randomly
assigned to FITT or services as usual. For FITT intervention approach
positive effects on parents stress and their mental well-being, no specific
treatment effect on children’s developmental skills, and better toddler social
communication outcomes emerged.
In conclusion, this review of studies about the TEACCH highlights that
this intervention model incorporates techniques from different perspectives,
that more evidence of effectiveness is needed, and key concepts of the
intervention are not fully operationalized [75].
HANENS ‘MORE THAN WORDS
Hanen’s ‘More than Words’ (HMTW) [96] is a parent-implemented
training program targeted in enhancing children’s communication/language
and consisting of eight weekly group sessions and three individual family
sessions. The HMTW program consists of enhancing parents responsivity
to children’s attention and communication signals, increasing the frequency
of playful parentchild interactions and facilitate children’s communication,
through support, education, and practical skills.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
74
Parents are taught to structure everyday routines with the aim of
improving parentchild interactions in a more sensitive way, providing more
appropriate verbal and non-verbal stimuli to children’s communication [97].
Since 2009 there are only few studies investigating HMTW, to our
knowledge. One pilot study [98] recruited four families of children with
ASD aged between 37 months to 69 months pointing out that HMTW had a
positive impact on children’s social interaction and vocabulary
development. The study by Carter and colleagues [96] enrolled 62 children
aged 1525 months with autism and their parents. Children were assigned
to either the experimental treatment or to a community treatment but no
significant differences between the two interventions were found on parental
responsivity and children’s communication. In contrast, there were
improvements in communication depending on children’s levels of object
interest at the beginning of treatment, showing that this intervention had
better effects on child communication with early lower levels of object
interest. Fifty children with ASD, and aged 1- 5 years were recruited in a
2017 study [99] to explore the effectiveness of the HMTW intervention
programfor ASD children. This study showed significant improvements in
children’s level of communication and activities, including joint attention,
turntaking, eye contact, and toilet training, over time.
Finally, in 2018 a study [100] about the effectiveness of HMTW on
parents of children with ASD in Malaysia was conducted. Thirty-one
children with ASD and their parents were recruited and assigned either to
intervention or control group. Data showed a significant increase in
responsive interactions, the retention of facilitative strategies in parents
during time, and higher levels of satisfaction than parents in the control
group.
As shown above, data on the effectiveness of the HMTW treatment are
promising, but further studies are needed to support the use of this
intervention.
Developmental Interventions for Children
75
PRESCHOOL AUTISM COMMUNICATION TRIAL
The Preschool Autism Communication Trial (PACT) [101] is a parent-
child communication-focused intervention for children with core autism,
aged between 2 and 5 years. This treatment targets “increasing parental
sensitivity to child communication and reducing mistimed responses using
video feedback, and […] promoting a range of positive social
communication strategies [102] (page. 427). According to this approach the
intervention consists of sessions between therapist and parents with the child
present, with the aim of increasing parental sensitivity and responsiveness
to child communication, and the help of video-feedback methods to address
parent-child interaction.
A first study [101] exploring this kind of intervention compared
children’s gains when randomly assigned to PACT or intervention as usual.
Data demonstrated an improvement in both groups, with a little difference
in favor of the PACT intervention, and better perceptions of children’s
language and social communication by parents of the PACT group. A 2015
paper [103] explored the direct and indirect effects of PACT on child
behavior and ADOS-G score via parent behavior. Data suggested the
mediating role of the parent synchrony and child initiations on the ADOS-G
score and supported the PACT theoretical model.
In a subsequent follow-up of this study [104], it was found a reduction
of autism symptoms in both autism repetitive symptom and social-
communication domains, until 6 years later the treatment endpoint. Similar
results to the 2010 study were found in a research [105] conducted in south
Asia, India and Pakistan for 64 children aged 29 years. A more recent study
[106] recruited a sample of caregivers of children with autism aged 812
years and did not find a specific protective effect of PACT on parenting
stress and well-being, over and above the effect of all the other risk factors.
The results of these studies are not fully promising at present, though
more research on the effectiveness of this intervention is needed.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
76
JOINT ATTENTION MEDIATED LEARNING
The Joint Attention Mediated Learning (JAML) [107] is a recent parent-
mediated interaction-based intervention for toddlers with ASD, focused on
children’s social functions of preverbal communication. This intervention is
driven by 5 main concepts adapted by Klein’s [108] principles of mediated
learning: parents should help their children focusing their attention on the
objectives, organizing and planning to communicate socially (improving
self-regulation), encouraging self-confidence, giving meaning of socially
important interaction cues, and expanding interactions in varied settings and
with different people.
The JAML includes three phases targeted on the acquisition of joint
attention and other early social communication abilities. During the first
phase (Focusing on Faces, FF), the child is aided in looking to the parent’s
face, during the second phase (Turn-Taking, TT) the child is helped in
engaging with the parent in play interactions; during the third phase (Joint
Attention, JA) the child is engaged in triadic interactions using toys. The
authors also stressed that the focus of this intervention is on social rather
than instrumental communicative functions [109].
A 2013 study [107] aimed at examining the efficacy of JAML for
promoting joint attention and early communication for toddlers with ASD.
Twenty-three parents and their children were recruited and were randomly
assigned to JAML intervention or a control condition. Data showed more
frequent responses to parents’ joint attention approaches and improvement
in children’s communication, guiding children learning from simpler to
more complex forms of preverbal social communication. Another study
[110] recruited 144 children with ASD aged 1630 months and their parents
to examine the efficacy and implementation of the JAML intervention in
promoting children’s early social communication. The children were
randomly assigned to JAML or community control conditions. Results
showed sustaining treatment differences over 6 months after intervention,
nevertheless to our knowledge there are still few studies investigating the
effectiveness of the JAML intervention.
Developmental Interventions for Children
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THE DEVELOPMENTAL, EMOTIONAL REGULATION,
RELATIONSHIP AND BODY-BASED INTERVENTION
The Developmental, Emotional regulation, Relationship and Body-
Based model (DERBBI) [111] is an approach that attaches great importance
to the connection between affect, motor planning and sequencing (see the
“affective diathesis” by Greenspan [112]), in the core deficit of children with
ASD. Within this model was developed a specific intervention for children
with ASD: the Turtle Project. The Turtle Project [113] is an individualized
intervention based on an individual’s profile to use developmentally
appropriate and meaningful targets. This profile is developed thanks to an
accurate diagnostic process, including the TULIP protocol [114], for a
comprehensive assessment of the predictors of positive outcomes in children
with ASD.
In this model, the diagnostic process is carried out by a group of experts
(psychologists, neuropsychiatrists, and other specialized figures) with the
means to select targets and measures according to the specific child, useful
for early indicators of treatment and follow-up monitoring.
The Turtle Project generally plans to improve parent-child affective
attunement, the child-peer imitation process, and the child’s ability to
integrate and process sensory perceptions, during the first year of therapy.
The second year of intervention typically refers to the psychomotor/
communicative-relational area, with the aim of improving childrens motor
initiative and emotion regulation, towards the re-definition of their body
schema. During the third year, this intervention commonly aims to improve
children’s linguistic, behavioral, relational, cognitive, playing skills,
personal autonomy and motivation to relate with. Finally, during the fourth
year the intervention keeps improving the children verbal and non-verbal
relational strategies, with a focus on the school learning. At this stage a
special attention is paid to the holophony technique. This is a sound
reproduction technique that simulates human listening strategies by
immersing the listener in a three-dimensional hearing reality. Through
sound-motor and graphic-interactive paths and games children are driven to
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
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improve emotion regulation, visual-spatial, speech, and learning abilities
and executive functioning [115].
The targets of the Turtle Project are met through the combination of
different settings: group settings for children with similar functioning levels,
parent-child dyadic and triadic settings, parents support groups, school
support service and animal-assisted therapy. The treatment has an average
duration of 4 years and it consists of 10 hours of treatment per week
including 6 hours of child individual/group therapy, 2 hours of parental
support, and 2 hours of school observation and counseling [111].
The Turtle Project is an example of a program that both reflects and
contributes to the evidence base of autism interventions, through various
studies that have shown an assessment protocol useful for capturing the
complexity and the uniqueness of every child [114, 116, 117]. Furthermore,
the studies deepening the effectiveness of the Turtle Project highlighted the
protective factors identified during the diagnostic assessment and useful in
predicting children’s developmental trajectories and children for whom this
type of treatment could lead to a greater improvement in symptoms [113,
114, 118, 119]. Third, recent papers have brought new reflections on the
need to customize the intervention according to the characteristics not only
of the autistic disorder but above all of the child and his/her family.
More specifically, in the 2015 paper [118] on a sample of 90 individuals
with ASD aged between 2 years and six months and 16 years, data showed
an improvement in autistic symptoms after 4 years of treatment. The 2016
paper [113] provided further data supporting the effectiveness of Turtle
Project, indicating that after two and four years of treatment children
exhibited a significant improvement in all assessed areas (speech and
communication, mutual social interaction, play, restricted and repetitive
behaviors, and Intelligence Quotient), in addition to a significant reduction
in core autistic symptoms.
In this context, research studies should try to identify a specific
population among the autisms, that could get better improvements from this
type of developmental intervention, that gives special emphasis to the body
and relational aspects.
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79
IMPROVING PARENTS AS COMMUNICATION
TEACHERS (PROJECT IMPACT)
The Improving Parents As Communication Teachers Project (ImPACT)
is a training for parents intervention to promote children’s social
engagement, language, social imitation, and play during daily routines [120].
It can be implemented in either a group or individual settings to teach parents
first to promote their responsiveness and social reciprocity trough
videotaped examples, homework written and spoken descriptions of
techniques, and practice with coaching.
In a single-subject study [121], 8 children with their mothers were
recruited to examine the efficacy of this model and showed an increase in
parents intervention techniques, children use of language, and a significant
association between parents’ abilities and children language. In 2015 a pilot
study [122] compared ImPACT intervention group with the community
group addressed to 30 children with ASD. The paper had the aim to explore
the effectiveness of this intervention and showed a strong parent intervention
adherence and a significant improvement in the child’s social-
communication skills.
The Project ImPACT for Toddlers is a toddler-specific adaptation of
ImPACT that included a parent-mediated intervention specifically
addressed to 12 to 36 months children, and focused on improving children’s
play, social engagement, communication, and imitation in children’s natural
setting. It provides to parents brief didactic information sessions alternate
with practice sessions with clinician feedback [123]. Recently, some authors
[124] compared parent-child improvements when children where assigned
to either the Project ImPACT for Toddlers or usual care and showed more
positive parentchild interactions and children’s social and communication
skills, for individuals in the Project ImPACT for Toddlers group than usual
care group.
Limited data from clinical studies support the effectiveness of this
intervention, that however needs further monitoring and investigations.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
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FURTHER DEVELOPMENTAL INTERVENTIONS
This section aims to mention recently or poorly investigated
developmental interventions for children with ASD, as revealed by our
literature review.
As part of intervention focused on joint attention, a recent study [118]
described a brief parent-mediated home-based intervention focused on joint
attention, imitation and social engagement skills of children with ASD. This
study compared improvements in children and parents who underwent this
specific intervention or a intervention as usual, over five sessions. Data
showed significant improvements in children and lower levels of perceived
stress and better coping in parents of the parent-mediated intervention group
when compared to parents of the intervention as usual, along with high
fidelity of intervention and parental adherence to the parent-mediated
intervention.
In the broader framework of early intervention programs for children
with autism, data suggest the positive effects of interventions focused on
joint attention and play skills, with a lack or limited follow-up data. In this
context, one long-term follow-up study by Kasari and colleagues [126]
recruited a sample of children with autism assigned to joint attention (JA),
symbolic play (SP), or control (CO) group. Results showed that a
comprehensive intervention targeting joint attention and play skills
positively affects the children long-term language outcomes.
As part of the parent-mediated interventions, we mention the Pathways
Early Autism Intervention [127, 128]. It is a community-based, intensive
behavioral and developmental intervention program for toddlers with ASD.
According to this intervention, parent-child interactions are video recorded
and reviewed with the parent, providing feedback on intervention strategies.
The interventionist introduces new topics, clarifies parent questions,
demonstrates new strategies with the child, plans activities and routines.
This intervention is aimed to promote children’s communication and social
engagement. In a pilot study [126] for demonstrating its effectiveness, four
boys with ASD and their mothers were recruited and the authors found that
this intervention program is useful for improving children’s early social
Developmental Interventions for Children
81
communication but not for nonverbal turn-taking. Furthermore, a 2019 study
[129] stressed that parents in the Pathways group experienced a decrease in
stress levels and an increase in responsiveness when compared with parents
in the control group.
The Relationship Development Intervention (RDI) [130, 131] is a
parent-delivered intervention aimed at improving children’s emotional
referencing, declarative language, social coordination, relational
information processing, flexible thinking, and foresight and hindsight of
children with ASD. The intervention is implemented by parents who learn
to perceive and support their children’s perceptual, cognitive, and emotional
patterns through a intensive training in RDI theory, principles, and
components. A modified version of the RDI was recently implemented in
China [132]. Forty-two children were recruited and assigned to RDI or a
control group. Results showed better improvements in language, social,
sensory and behavioral domains than those in the control group, after a 6
months training.
The Responsive Teaching (RT) [133], is a parent-mediated
developmental intervention focused on children’s communication,
cognition, and social-emotional domains. Parents are trained to address their
children with responsive interaction strategies to reach 19 predefined
objectives within daily routines. Data on RT intervention shows an
improvement in children developmental and social-emotional functioning
and parents responsiveness and affect [134, 135]. In a recent study [136], a
sample of 28 Saudi Arabian children and their parents were recruited, and
mothers who participated in Responsive Teaching intervention showed
improvements in parenting stress and depression.
The Video-feedback Intervention to promote Positive Parenting adapted
to Autism (VIPP-AUTI) is a video feedback attachment-based intervention
program, aiming to enhance parental sensitivity to their child’s signals and
improving parentchild interaction [137]. This is an adapted version of the
original VIPP by Juffer and colleagues [138], already employed in various
families of infants, toddlers and preschoolers. The VIPP-AUTI program
comprise a short-term parent-child interaction, videotaped in a natural
environment, with video feedback. Data showed [139] a decrease in parental
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
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intrusiveness towards the child and an increase in parental efficacy.
Significant differences between VIPP-AUTI and control group emerged in
child-initiated joint attention skills, at follow-up.
Finally, among the studies reviewed as part of the play intervention, we
found the Play and Language for Autistic Youngsters (PLAY) [140] model
that is a parent-mediated developmental model focused on helping parents
to increase their interaction with the child, and children to improve their
social interaction and emotional development. This intervention is shown to
be effective in parental responsiveness, affect and depression and children’s
social engagement [140, 141].
CONCLUSION
As stated by Zhou and colleagues [49] the Naturalistic Developmental
Behavioral Interventions (NDBIs) “integrate developmental and
relationship-based approaches with strategies of applied behavior analysis,
and emphasize establishing joint activity routines in natural environments,
including play and daily life activities in which many learning opportunities
can be embedded” (p. 655). Within this broad panorama of intervention, our
review identified several developmental approaches as empirically and
theoretically supported interventions for children with ASD.
In conclusion, this review showed different developmental therapies
underlying the specific components in each of the approaches presented.
Some of them are specifically implemented by the therapist, others are
carried out by trained parents and/or teachers/educators. Some treatments
focus on several developmental areas, others are focused on specific
developmental areas, like joint attention. Some of them represent a
combination of behavioral and developmental methods, others are more
closely developmental approaches. This review also shows that a few of
these methods require a comprehensive assessment as a prerequisite to
calibrate the intervention. Additionally, despite its great significance, little
attention is still given to early intervention for ASD, and the study of the
effectiveness of these methods in long-term longitudinal studies. For future
Developmental Interventions for Children
83
research it is also important to increase the number of individuals involved,
focusing on different children’s developmental ages, giving greater
emphasis to the approaches with more significant effect sizes.
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BIOGRAPHICAL SKETCHES
Magda di Renzo
Affiliation: Institute of Ortofonologia (IdO) in Rome, Italy
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
102
Education: MD in Philosophy, Speech Therapy and Psychology.
Jungian analyst.
Research and Professional Experience: Since 1974 she has been
carrying out clinical activities and teaching in the field of developmental
pathologies. Her research interests concern developmental
psychopathology, and especially on autism.
Professional appointments: Head of the Child and Adolescent
Psychotherapy clinical service of the Institute of Ortofonologia (IdO).
Member of CIPA (Italian Center for Analytical Psychology) and IAAP
(International Association for Analytical Psychology).
Publications from the Last 3 Years:
1. Di Renzo, M., Guerriero, V., Petrillo, M., Racinaro, L., Vanadia, E., &
di Castelbianco, F. B. (2019). A comprehensive assessment process for
children with autism spectrum disorders. Advances in Autism.
2. Di Renzo, M. (2017). The Theoretical Principles of the Body-Centered
Therapy to Promote Affective Attunement in Children with Autism
Spectrum Disorder. Journal of Behavioral and Brain Science, 7(12),
545.
3. Di Renzo, M., Bianchi di Castelbianco, F. B., Vanadia, E., & Racinaro,
L. (2017). The psychomotor profile in children with autistic spectrum
disorders: clinical assessments and implications for therapy. Autism
Open Access, 7(209), 2.
4. Di Renzo, M., Marini, C., Bianchi di Castelbianco, F., Racinaro, L., &
Rea, M. (2017). Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother, 7(291),
2161-0487.
5. Di Renzo, M., Bianchi di Castelbianco, F., Vanadia, E., Petrillo, M.,
Racinaro, L., & Rea, M. (2017). Sensory processing and repetitive
behaviors in clinical assessment of preschool children with autism
Developmental Interventions for Children
103
spectrum disorder. Journal of Child and Adolescent Behavior, 5(2), 1-
8.
6. Renzo, M. D., Palladino, G., & Bianchi di Castelbianco F., Racinaro L.
(2017). When the Intellectual Potential is Concealed from Symptoms: A
Case Report. Journal of Clinical Case Report, 7(943), 2.
Viviana Guerriero
Affiliation: Institute of Ortofonologia (IdO) in Rome, Italy
Education: PhD, Clinical psychology, and Psychotherapist.
Research and Professional Experience: In the research field she
mainly works within the framework of attachment theory. In this area she
participated in studies about parenting and couple relationships. She is
currently investigating psychological experiences of adopted
children/adolescents and their mothers, and children diagnosed with serious
diseases and their parents. Her private practice as psychotherapist is focused
on children, parents and young adults.
Publications from the Last 3 Years:
1. Pace, C. S., Guerriero, V., & Zavattini, G. C. (2020). Children’s
attachment representations: A pilot study comparing family drawing
with narrative and behavioral assessments in adopted and community
children. The Arts in Psychotherapy, 67, 101612.
2. Pace, C. S., Di Folco, S., Guerriero, V., & Muzi, S. (2019). Late-adopted
children grown up: a long-term longitudinal study on attachment
patterns of adolescent adoptees and their adoptive mothers. Attachment
& human development, 21(4), 372-388.
3. Di Renzo, M., Guerriero, V., Petrillo, M., Racinaro, L., Vanadia, E., &
di Castelbianco, F. B. (2019). A comprehensive assessment process for
children with autism spectrum disorders. Advances in Autism.
Magda Di Renzo, Viviana Guerriero, Valeria Mammarella, et.al.
104
4. de Campora, G., Giromini, L., Guerriero, V., Chiodo, C., Zavattini, G.
C., & Larciprete, G. (2019). Influence of maternal reflective functioning
on mothers’ and children’s weight: A follow‐up study. Infant Mental
Health Journal, 40(6), 862-873.
5. Pace, C. S., Di Folco, S., & Guerriero, V. (2018). Late‐adoptions in
adolescence: Can attachment and emotion regulation influence
behaviour problems? A controlled study using a moderation approach.
Clinical psychology & psychotherapy, 25(2), 250-262.
6. Guerriero V., de Campora G., Gnazzo A., Vegni E., Zavattini G. C.
(2017). Parents facing their child disease: insights from attachment
theory. In Alexandra M. Columbus (Eds.), Advances in Psychology
Research (Vol. 126). Nova Science Publishers.
Valeria Mammarella
Affiliation: Sapienza University of Rome
Education: MD in Medicine and Surgery
Research and Professional Experience: General practitioner
substitute, Medical doctor, Specializing in Child neurology and psychiatry.
Federico Bianchi di Castelbianco
Affiliation: Institute of Ortofonologia (IdO) in Rome, Italy
Education: MD in Psychology, Developmental psychotherapist.
Research and Professional Experience: His research interests focus
on developmental psychopathology, and especially on Autism Spectrum
Disorders.
Developmental Interventions for Children
105
Professional Appointments: Head of the Institute of Ortofonologia (IdO),
Honorary Member of the Italian Society of Pediatry (SIP).
Publications from the Last 3 Years:
1. Di Renzo, M., Guerriero, V., Petrillo, M., Racinaro, L., Vanadia, E.,
& di Castelbianco, F. B. (2019). A comprehensive assessment
process for children with autism spectrum disorders. Advances in
Autism.
2. Di Renzo, M., Bianchi di Castelbianco, F. B., Vanadia, E., &
Racinaro, L. (2017). The psychomotor profile in children with
autistic spectrum disorders: clinical assessments and implications
for therapy. Autism Open Access, 7(209), 2.
3. Di Renzo, M., Marini, C., Bianchi di Castelbianco, F., Racinaro, L.,
& Rea, M. (2017). Correlations between the Drawing Process in
Autistic Children and Developmental Indexes. J Psychol
Psychother, 7(291), 2161-0487.
4. Di Renzo, M., Bianchi di Castelbianco, F., Vanadia, E., Petrillo, M.,
Racinaro, L., & Rea, M. (2017). Sensory processing and repetitive
behaviors in clinical assessment of preschool children with autism
spectrum disorder. Journal of Child and Adolescent Behavior, 5(2),
1-8.
5. Renzo, M. D., Palladino, G., & Bianchi di Castelbianco F., Racinaro
L. (2017). When the Intellectual Potential is Concealed from
Symptoms: A Case Report. Journal of Clinical Case Report, 7(943),
2.
... At the Institute of Orthophonology (IdO) of Rome, psychological support for parents has been incorporated into the D.E.R.B.B.I. intervention (known in full as the Developmental, Emotional Regulation and Body-Based Intervention) within the Turtle Project (Di Renzo et al., 2016). The project combines various interventions offered to children and parents including child assessment (Di Renzo et al., 2019), counseling for parents, clinical sessions with the professionals who work with the child, thematic seminars and experiential workshops, mothers/fathers-child in care settings, and groups of parents (Di Renzo et al., 2020a). ...
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Early parent–child relationships are an important factor influencing many domains of child development, even in the presence of autism. In this study, we investigated the associations between parent–child attunement during play, parental insightfulness, and parental acceptance of their child’s diagnosis of an autism spectrum disorder. A sample of 50 parents (26 mothers and 24 fathers) of 26 children aged between 24 and 58 months were videotaped during parent–child play interactions and then interviewed about what they thought had gone through their child’s head during the play interaction, and about their feelings and thoughts about their child’s diagnosis. Play interactions were evaluated using a coding protocol to assess parental attunement. The results showed that parents who were more able to accept their child’s diagnosis and to see things from their child’s perspective were more likely to also be attuned during play interactions with their children. These findings highlight the importance of studying the parental ability of insightfulness and acceptance of their child diagnosis of ASD for the implementation of intervention programs for supporting parental attunement and improving the interactions between the parents and the children with autism spectrum disorders.
... At the Institute of Orthophonology (IdO) support for parents has been incorporated into the D.E.R.B.B.I. intervention (known in full as the Developmental, Emotional Regulation and Body-Based Intervention) within the Turtle Project (Di Renzo et al., 2016). The project combines various interventions offered to children and parents including child assessment (Di Renzo et al., 2019), counseling for parents, clinical sessions with the professionals who work with the child, thematic seminars and experiential workshops, mothers/fathers-child in care settings, and groups of parents (Di Renzo et al., 2020a). ...
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Robots are more and more present in our lives, particularly in the health sector. In therapeutic centers, some therapists are beginning to explore various tools like video games, Internet exchanges, and robot-assisted therapy. These tools will be at the disposal of these professionals as additional resources that can support them to assist their patients intuitively and remotely. The humanoid robot can capture young children’s attention and then attract the attention of researchers. It can be considered as a play partner and can directly interact with children or without a third party’s presence. It can equally perform repetitive tasks that humans cannot achieve in the same way. Moreover, humanoid robots can assist a therapist by allowing him to teleoperated and interact from a distance. In this context, our research focuses on robot-assisted therapy and introduces a humanoid social robot in a pediatric hospital care unit. That will be performed by analyzing many aspects of the child’s behavior, such as verbal interactions, gestures and facial expressions, etc. Consequently, the robot can reproduce consistent experiences and actions for children with communication capacity restrictions. This work is done by applying a novel approach based on deep learning and reinforcement learning algorithms supported by an ontological knowledge base that contains relevant information and knowledge about patients, screening tests, and therapies. In this study, we realized a humanoid robot that will assist a therapist by equipping the robot NAO: 1) to detect whether a child is autistic or not using a convolutional neural network, 2) to recommend a set of therapies based on a selection algorithm using a correspondence matrix between screening test and therapies, and 2) to assist and monitor autistic children by executing tasks that require those therapies.
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Purpose The assessment of Autism Spectrum Disorders (ASD) in childhood has two essential aspects: the identification of the risk (under 30 months of age) and the definition of a diagnosis that takes into account its core areas as well as further non-specific aspects. The purpose of this paper is to present an approach that considers the combination of clinical evaluation with the use of tools that analyse the various levels of the child’s functioning as fundamental. Design/methodology/approach The comprehensive assessment at the Institute of Ortofonologia in Rome provides the ADOS-2 and the Leiter-R for the evaluation of the symptomatology, the severity level, the non-verbal cognitive functioning and the fluid reasoning; the TCE and the UOI are used to identify, respectively, the child’s emotional skills and the ability to understand the intentions of others, as precursors of the theory of mind. Within this assessment, the Brief-P, the Short Sensory Profile and the RBS are also included for the evaluation of executive functions, sensory pattern and of restricted and repetitive behaviours, as observed by parents. Findings How to define a reliable development profile, which allows to plan a specific intervention calibrated on the potential of the child and on his development trajectory, is described. Two clinical cases are also presented. Originality/value The entire process is aimed both at a detailed assessment of the child’s functioning and at identifying a specific therapeutic project and predictive factors for achieving an optimal outcome.
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We examined the relationship between initial parenting stress and change in parental responsivity for 56 culturally and socioeconomically diverse families in a 12 week randomized control trial of Pathways Early ASD Intervention. Families were randomized into the Pathways (n = 32) or treatment-as-usual (TAU n = 24) group. Overall, Pathways parents experienced decreased stress, while TAU parents experienced an increase. The relationship between initial parental stress and change in parent responsivity was moderated by group membership. Pathways parents became more responsive but responsivity was not influenced by initial parental stress. In contrast, responsivity was negatively affected by initial parenting stress in the TAU group. Results are discussed in terms of components of a parent-mediated ASD intervention that may reduce parental stress.
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The study assesses the acceptability and feasibility of a brief parent-mediated home-based intervention for children with autism spectrum disorder (ASD), deliverable in resource-limited settings, with an emphasis on addressing parental stress from a socio-cultural perspective. 50 children (2–6 years), with a DSM 5 diagnosis of ASD were randomized to intervention (n = 26) or active control group (n = 24). The intervention based on naturalistic developmental behavioral approach, focusing on joint attention, imitation, social and adaptive skills was structured to be delivered in five outpatient sessions over 12 weeks. All children were followed up at 4, 8 and 12 weeks. Parents of children randomized to the intervention group reported more improvements across parental stress and child outcome measures compared to those in the control group. The intervention was found to be acceptable and feasible, with high fidelity measures and retention rates.
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Problem/Condition Autism spectrum disorder (ASD) is estimated to affect up to 3% of children in the United States. Public health surveillance for ASD among children aged 4 years provides information about trends in prevalence, characteristics of children with ASD, and progress made toward decreasing the age of identification of ASD so that evidence-based interventions can begin as early as possible. Period Covered 2010, 2012, and 2014. Description of System The Early Autism and Developmental Disabilities Monitoring (Early ADDM) Network is an active surveillance system that provides biennial estimates of the prevalence and characteristics of ASD among children aged 4 years whose parents or guardians lived within designated sites. During surveillance years 2010, 2012, or 2014, data were collected in seven sites: Arizona, Colorado, Missouri, New Jersey, North Carolina, Utah, and Wisconsin. The Early ADDM Network is a subset of the broader ADDM Network (which included 13 total sites over the same period) that has been conducting ASD surveillance among children aged 8 years since 2000. Each Early ADDM site covers a smaller geographic area than the broader ADDM Network. Early ADDM ASD surveillance is conducted in two phases using the same methods and project staff members as the ADDM Network. The first phase consists of reviewing and abstracting data from children’s records, including comprehensive evaluations performed by community professionals. Sources for these evaluations include general pediatric health clinics and specialized programs for children with developmental disabilities. In addition, special education records (for children aged ≥3 years) were reviewed for Arizona, Colorado, New Jersey, North Carolina, and Utah, and early intervention records (for children aged 0 to <3 years) were reviewed for New Jersey, North Carolina, Utah, and Wisconsin; in Wisconsin, early intervention records were reviewed for 2014 only. The second phase involves a review of the abstracted evaluations by trained clinicians using a standardized case definition and method. A child is considered to meet the surveillance case definition for ASD if one or more comprehensive evaluations of that child completed by a qualified professional describes behaviors consistent with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder–not otherwise specified (PDD-NOS, including atypical autism), or Asperger disorder (2010, 2012, and 2014). For 2014 only, prevalence estimates based on surveillance case definitions according to DSM-IV-TR and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) were compared. This report provides estimates of overall ASD prevalence and prevalence by sex and race/ethnicity; characteristics of children aged 4 years with ASD, including age at first developmental evaluation, age at ASD diagnosis, and cognitive function; and trends in ASD prevalence and characteristics among Early ADDM sites with data for all 3 surveillance years (2010, 2012, and 2014), including comparisons with children aged 8 years living in the same geographic area. Analyses of time trends in ASD prevalence are restricted to the three sites that contributed data for all 3 surveillance years with consistent data sources (Arizona, Missouri, and New Jersey). Results The overall ASD prevalence was 13.4 per 1,000 children aged 4 years in 2010, 15.3 in 2012, and 17.0 in 2014 for Early ADDM sites with data for the specific years. ASD prevalence was determined using a surveillance case definition based on DSM-IV-TR. Within each surveillance year, ASD prevalence among children aged 4 years varied across surveillance sites and was lowest each year for Missouri (8.5, 8.1, and 9.6 per 1,000, for 2010, 2012, and 2014, respectively) and highest each year for New Jersey (19.7, 22.1, and 28.4 per 1,000, for the same years, respectively). Aggregated prevalence estimates were higher for sites that reviewed education and health care records than for sites that reviewed only health care records. Among all participating sites and years, ASD prevalence among children aged 4 years was consistently higher among boys than girls; prevalence ratios ranged from 2.6 (Arizona and Wisconsin in 2010) to 5.2 boys per one girl (Colorado in 2014). In 2010, ASD prevalence was higher among non-Hispanic white children than among Hispanic children in Arizona and non-Hispanic black children in Missouri; no other differences were observed by race/ethnicity. Among four sites with ≥60% data on cognitive test scores (Arizona, New Jersey, North Carolina, and Utah), the frequency of co-occurring intellectual disabilities was significantly higher among children aged 4 years than among those aged 8 years for each site in each surveillance year except Arizona in 2010. The percentage of children with ASD who had a first evaluation by age 36 months ranged from 48.8% in Missouri in 2012 to 88.9% in Wisconsin in 2014. The percentage of children with a previous ASD diagnosis from a community provider varied by site, ranging from 43.0% for Arizona in 2012 to 86.5% for Missouri in 2012. The median age at earliest known ASD diagnosis varied from 28 months in North Carolina in 2014 to 39.0 months in Missouri and Wisconsin in 2012. In 2014, the ASD prevalence based on the DSM-IV-TR case definition was 20% higher than the prevalence based on the DSM-5 (17.0 versus 14.1 per 1,000, respectively). Trends in ASD prevalence and characteristics among children aged 4 years during the study period were assessed for the three sites with data for all 3 years and consistent data sources (Arizona, Missouri, and New Jersey) using the DSM-IV-TR case definition; prevalence was higher in 2014 than in 2010 among children aged 4 years in New Jersey and was stable in Arizona and Missouri. In Missouri, ASD prevalence was higher among children aged 8 years than among children aged 4 years. The percentage of children with ASD who had a comprehensive evaluation by age 36 months was stable in Arizona and Missouri and decreased in New Jersey. In the three sites, no change occurred in the age at earliest known ASD diagnosis during 2010–2014. Interpretation The findings suggest that ASD prevalence among children aged 4 years was higher in 2014 than in 2010 in one site and remained stable in others. Among children with ASD, the frequency of cognitive impairment was higher among children aged 4 years than among those aged 8 years and suggests that surveillance at age 4 years might more often include children with more severe symptoms or those with co-occurring conditions such as intellectual disability. In the sites with data for all years and consistent data sources, no change in the age at earliest known ASD diagnosis was found, and children received their first developmental evaluation at the same or a later age in 2014 compared with 2010. Delays in the initiation of a first developmental evaluation might adversely affect children by delaying access to treatment and special services that can improve outcomes for children with ASD. Public Health Action Efforts to increase awareness of ASD and improve the identification of ASD by community providers can facilitate early diagnosis of children with ASD. Heterogeneity of results across sites suggests that community-level differences in evaluation and diagnostic services as well as access to data sources might affect estimates of ASD prevalence and age of identification. Continuing improvements in providing developmental evaluations to children as soon as developmental concerns are identified might result in earlier ASD diagnoses and earlier receipt of services, which might improve developmental outcomes.
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This study compared an attachment-based coding system for family drawings with narrative and observational attachment measures in adopted children and those living with their natural parents (“community-based”) in Italy. Attachment patterns of 41 children (ages 5–8) were assessed by: a graphic measure, the Family Drawing (FD); a narrative measure, the Manchester Child Attachment Story Task (MCAST); and an observational measure, the Separation-Reunion Procedure (SRP). In the community sample, a significant association emerged between the FD and MCAST disorganized vs. organized classifications, and a number of expected correlations between the FD Global Scales and the MCAST Coherence and Mentalizing continuous scales were found. In the adopted group, some FD Global Scales linked with insecure and disorganized representations revealed negative correlations with the MCAST Mentalizing scale. No correlations were found between the children’s FD and SRP classifications and scales in both groups. The FD attachment-based coding system revealed a particular capacity to assess attachment representations during childhood capturing closely both insecure and disorganized patterns, both in adopted and community children. A special focus was put on the measurement of disorganization, as reflected in one drawing classified as disorganized.
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Much research exists supporting the efficacy of naturalistic behavioral interventions on increasing social communication skills for children with autism spectrum disorder (ASD); however, these evidence-based interventions are not consistently utilized in preschool classrooms. Prelinguistic Milieu Teaching was used to teach early intentional communication (i.e., purposeful and coordinated use of vocalizations, gestures, and eye contact) to three preschool students with or at risk for ASD. The present study extends prior research demonstrating the effects of PMT in increasing intentional communication through implementation in a preschool special education classroom, measurement of collateral gains related to PMT targets, and measurement of maintenance and generalization of gains. Results indicate students increased their rates of intentional communication upon introduction of PMT. These gains maintained over time for two students. Present study results have implications for future research and practice regarding the efficacy and feasibility of implementing PMT in preschool classrooms.
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This study reports child and family outcomes from a community-based, quasi-experimental pilot trial of Project ImPACT for Toddlers that is a parent-mediated, naturalistic, developmental behavioral intervention for children with or at-risk for autism spectrum disorder developed through a research–community partnership. Community early interventionists delivered either Project ImPACT for Toddlers ( n = 10) or Usual Care ( n = 9) to families based on Part C assigned provider. Twenty-five families participated, with children averaging 22.76 months old ( SD = 5.06). Family and child measures were collected at intake, after 3 months of service, and after a 3-month follow-up. Results indicate significantly greater improvements in positive parent–child interactions for Project ImPACT for Toddlers than usual care families, as well as large, but non-significant, effect sizes for Project ImPACT for Toddlers families in children’s social and communication skills.
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Based on cross-sectional research linking poor reflective functionining (RF) to eating disorders, the current follow-up study tested whether maternal RF would explain the variance of mothers' and children's weight beyond the effects of maternal emotional dysregulation. During pregnancy (Time 1 [T1]), 51 women were administered the Difficulties in Emotion Regulation Scale (DERS) and interviewed using the Adult Attachment Interview (AAI). Seven months after delivery (Time 2 [T2]), mother-baby dyads who remained in the study (n = 44) were videotaped (Feeding Scale) during their feeding interaction. Last (Time 3 [T3]), the weight of the 34 children who were still in the study was collected at 3 years of age. Maternal AAI-RF at T1 did not correlate with the DERS at T1 nor with the quality of the feeding interacions at T2. However, it correlated, significantly, with maternal body mass index (BMI) at T1, r = -.298, P = .034, and marginally significantly with baby's BMI at T3, r = -.296, P = .089. Moreover, multiple regression models showed a trend indicating that maternal AAI-RF might explain the variance of mothers' and children's weight beyond the effects of maternal emotional dysregulation. These findings suggest that working on maternal mentalization might contribute to helping prevent childhood obesity from pregnancy. © 2019 Michigan Association for Infant Mental Health.
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Abstract: This article provides an overview of the Group-based Early Start Denver Model (G-ESDM), an early intervention approach for young children with autism spectrum disorder (ASD). The G-ESDM is based on the delivery of the evidence-supported Early Start Denver Model (ESDM) techniques in group-based settings such as early learning and care settings, with one adult delivering instruction to small groups of three to four children. The program is informed by research documenting the positive impact of early interaction with peers and preschool experiences for social-cognitive development, and is designed to maximize cost-effectiveness by providing evidence-based treatment during daycare hours. Additionally, it capitalizes on the culturally universal tradition of educating young children in group settings, and on the social learning opportunities provided by peers. We review principles, strategies and empirical support for the G-ESDM, as well as challenges and future directions. Keywords: Autism; early intervention; Early Start Denver Model (ESDM); Group-Early Start Denver Model (G-ESDM)
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The relationship between turn taking (i.e., back-and-forth preverbal communicative exchanges) and joint attention has not been studied in interactions between children with autism and caregivers. In joint attention, a form of preverbal social communication, young children socially share attention with a partner about objects, a competency that is difficult for toddlers with autism. Video data of interactions between caregivers and 61 toddlers with autism who received joint attention-focused intervention were analyzed to determine associations between turn taking and joint attention. Results indicate a positive relationship between the two forms of social communication. Further study is needed to determine the extent to which turn taking may play a foundational role in supporting joint attention development for toddlers with autism.