Thursday, 22 January 2015

At-risk kids avoiding an autism diagnosis?

The paper from Jonathan Green and colleagues [1] (open-access) discussing results based on a "two-site, two-arm assessor-blinded randomised controlled trial of families with an infant at familial high risk of autism aged 7–10 months, testing the adapted Video Interaction to Promote Positive Parenting (iBASIS-VIPP) versus no intervention" caught quite a few eyes recently. With accompanying media headlines such as 'Parents May Be Able to Lower Kids’ Autism Risk' you can imagine the interest created in such a study. I'll also at this point refer you to a commentary on the study from Cathy Lord [2].

Video interaction to promote positive parenting is by no means a new thing to autism research as per the paper by Poslawsky and colleagues [3]. The adapted - BASIS - program "works with parents using video-feedback to help them to understand and adapt to their infant's individual communication style to promote the best possible social and communicative development." Further: "the therapist makes videotapes of interactions between the parent and child in the home setting and uses video excerpts to work with the parent in a series of sessions that are developmentally sequenced to improve the quality of parent understanding of infant's communication." Treading carefully in this area, the idea that family processes can impact on autism presentation is gaining traction (see here).

Green and colleagues reported results based on 54 families with an infant deemed at high-risk of autism by virtue of having a sibling diagnosed with an autism spectrum disorder (ASD). Twenty eight families were randomly allocated to the intervention group and 26 to a "no intervention" group and participants were monitored and assessed over 5 months. Various measures were used during the trial including the "Manchester Assessment of Caregiver–Infant interaction (MACI)...  to measure infant attentiveness to parent and other interaction variables" and "the Autism Observation Scale for Infants (AOSI)" for the assessment of "early behavioural risk markers for children with ASD."

Results: "point estimates suggest that the intervention increased the primary outcome of infant attentiveness to parent." The authors are rightly careful about this result however because "CIs [confidence intervals] sometimes include the null" across various results. Wide CI's crossing the null are to be viewed with some degree of caution. Likewise other results such as "the intervention reduced autism-risk behaviours" carry the same optimistic yet guarded message.

That all being said, the headline about such intervention potentially 'lowering autism risk' are perhaps a little premature based on the current results. As per some of the media on the study and Prof. Green commenting: "He stressed that the babies have not been tested yet for autism, which will occur when they are around 3 years old, but that the changes he and his team saw strongly suggest that the path to autism may have been interrupted, or at least suppressed in some way." So we wait to see what actually happened to those infants at high-risk and whether intervention actually provided some protection against receipt of a diagnosis of ASD.

I have to say that I was really quite interested in these findings. I am cautious following some of the other findings reported by the authors as per the potential effect of such an intervention on "developmental language measures" and possible "reduced responsiveness to language sounds in the intervention group" but await further results on how this might eventually pan out. Early intervention such as this is a up-coming area in autism research (see here) and the idea that brain and behaviour are plastic and development not potentially as immutable as was once thought. I personally would like to see this area developed further bearing in mind the concept of differing developmental trajectories being associated with autism, and I assume similarly pertinent to high-risk siblings too. I'd also be minded to suggest that a greater focus on the broader autism phenotype (BAP) might be implied in further research (see here) as well as some additional data on the possible genetic/epigenetic/biochemical/neurological correlates which might coincide with the potential efficacy of such early intervention.

Given the previous not-so-effective results of the PACT initiative by some of the authors (see here) I can also imagine the current results were probably received in a more optimistic fashion by the team involved. We wait for further research...


[1] Green J. et al. Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial. Lancet Psychiatry. 2015. Jan 22.

[2] Lord C. Infant autism: parents' role in ameliorating risk? Lancet Psychiatry. Jan 22.

[3] Poslawsky IE. et al. Development of a Video-feedback Intervention to promote Positive Parenting for Children with Autism (VIPP-AUTI). Attach Hum Dev. 2014;16(4):343-55.

---------- Jonathan Green, Tony Charman, Andrew Pickles, Ming W Wan, Mayada Elsabbagh, Vicky Slonims, Carol Taylor, Janet McNally, Rhonda Booth, Teodora Gliga, Emily J H Jones, Clare Harrop, Rachael Bedford, Mark H Johnson, & the BASIS team (2015). Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial The Lancet Psychiatry :