Publications by authors named "Jessica Bradshaw"

34 Publications

[Formula: see text] Social-environmental moderators of neurodevelopmental outcomes in youth born preterm: A systematic review.

Child Neuropsychol 2021 Apr 21;27(3):351-370. Epub 2020 Dec 21.

Department of Psychology, University of South Carolina, Columbia, SC, USA.

: Preterm birth represents a significant medical event that places infants at a markedly greater risk for neurodevelopmental problems and delays. Although the impact of medical factors on neurodevelopment for those born preterm has been thoroughly explored, less is known about how social-environmental factors (e.g., socioeconomic status, family functioning) moderate outcomes. This review explores the quantity and methodological rigor of research on social-environmental factors as moderators of the relationship between preterm birth and neurodevelopmental outcomes.: Articles published between January 1980 and December 2016 were identified from a comprehensive meta-analysis and systematic review on neurodevelopmental outcomes following preterm birth. A systematic review of MEDLINE was conducted to identify articles published from January 2017 through April 2019.: Eighty articles met the inclusion criteria. The majority of studies matched preterm and control groups on social-environmental factors (n = 49). The remaining studies included social-environmental factors as moderators (n = 13) or correlates (n = 11) of neurodevelopmental outcomes. Only seven studies did not include reports on social-environmental factors.: This systematic review suggests that social-environmental factors are often considered to be ancillary risk factors to the larger medical risk imparted by prematurity. Studies typically focused on socioeconomic status rather than more modifiable parent/family factors that can be targeted through intervention (e.g., parental mental health) and evidenced mixed findings regarding the significance of social-environmental factors as moderators. Further research is needed to identify the relative influence of social-environmental factors to inform future psychosocial interventions.
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http://dx.doi.org/10.1080/09297049.2020.1861229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969400PMC
April 2021

Emergence and rate of autism in fragile X syndrome across the first years of life.

Dev Psychopathol 2020 10;32(4):1335-1352

Department of Psychology, University of South Carolina, Columbia, SC, USA.

Prospective longitudinal studies of idiopathic autism spectrum disorder (ASD) have provided insights into early symptoms and predictors of ASD during infancy, well before ASD can be diagnosed at age 2-3 years. However, research on the emergence of ASD in disorders with a known genetic etiology, contextualized in a developmental framework, is currently lacking. Using a biobehavioral multimethod approach, we (a) determined the rate of ASD in N = 51 preschoolers with fragile X syndrome (FXS) using a clinical best estimate (CBE) procedure with differential diagnoses of comorbid psychiatric disorders and (b) investigated trajectories of ASD symptoms and physiological arousal across infancy as predictors of ASD in preschoolers with FXS. ASD was not diagnosed if intellectual ability or psychiatric disorders better accounted for the symptoms. Our results determined that 60.7% of preschoolers with FXS met the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5) criteria for ASD using the CBE procedure. In addition, 92% of these preschoolers presented with developmental delay and 45.4% also met criteria for psychiatric disorders, either anxiety, ADHD, or both. ASD diagnoses in preschoolers with FXS were predicted by elevated scores on traditional ASD screeners in addition to elevated autonomic arousal and avoidant eye contact from infancy.
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http://dx.doi.org/10.1017/S0954579420000942DOI Listing
October 2020

Luteolin-induced vasorelaxation in uterine arteries from normal pregnant rats.

Pregnancy Hypertens 2021 Mar 23;23:11-17. Epub 2020 Oct 23.

Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States; Department of Surgery, The University of Mississippi Medical Center, Jackson, MS 39216, United States.

Background: The flavonoid, luteolin, promotes vasorelaxation in various arteries through endothelial-dependent and independent mechanisms. Although there is growing interest in the vasoactive effects of flavonoids on maternal vascular function during pregnancy, it is unknown whether luteolin elicits vasorelaxation in the uterine circulation. We tested the hypothesis that luteolin induces vasorelaxation via endothelial-dependent mechanisms in uterine arteries from normal pregnant rats during late gestation.

Methods: Uterine arteries and aortas were isolated from Sprague-Dawley rats at gestational day 19 and prepared for wire myography.

Results: The potency of luteolin-induced vasorelaxation was examined between uterine arteries and the aortas. By 50 µM of luteolin, there was complete relaxation (100.5 ± 5.2%) in uterine arteries as compared to aortas (27.5 ± 10.0%). Even the highest concentration of 100 µM luteolin produced less than half relaxation (43.6 ± 8.6%) in aortas compared to uterine arteries. We then explored if luteolin-induced vasorelaxation in uterine arteries from pregnant rats was mediated by endothelial-dependent vasorelaxation pathways, including nitric oxide synthase (NOS), cyclooxygenase (COX), or potassium (K) channels. Blocking these pathways with N(G)-Nitro-l-arginine methyl ester hydrochloride (L-NAME), indomethacin, or tetraethylammonium (TEA)/high potassium chloride (KCl), respectively, did not alter luteolin responses in uterine arteries from pregnant rats. These findings suggested that endothelial factors may not mediate luteolin-induced vasorelaxation in uterine arteries during pregnancy. Indeed, experiments where the endothelium was removed did not alter luteolin-induced vasorelaxation in uterine arteries during pregnancy.

Conclusions: Luteolin directly promotes vasorelaxation in the medial smooth muscle layer of uterine arteries during normal pregnancy.
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http://dx.doi.org/10.1016/j.preghy.2020.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904643PMC
March 2021

Predictors of Caregiver Strain for Parents of Children with Autism Spectrum Disorder.

J Autism Dev Disord 2020 Nov 5. Epub 2020 Nov 5.

Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30322, USA.

Parents of children with autism spectrum disorder (ASD) face higher levels of caregiver strain compared to parents of children with other disabilities. This study examined child clinical features that predict high levels of caregiver strain for 374 parents of children with ASD. Caregiver strain was measured using the Caregiver Strain Questionnaire (CGSQ) objective, subjective internalized, and subjective externalized subscales. Confirmatory factor analysis indicated an acceptable fit for the original CGSQ three-factor solution. The strongest child predictors across CGSQ subscales were: disruptive behavior for objective strain, autism severity and disruptive behavior for subjective internalized strain, and oppositional behavior and hyperactivity for subjective externalized strain. Individualized interventions that attend to specific elements of parental strain may reduce strain and improve family wellbeing.
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http://dx.doi.org/10.1007/s10803-020-04625-xDOI Listing
November 2020

Transformation of nonencapsulated Streptococcus pneumoniae during systemic infection.

Sci Rep 2020 11 3;10(1):18932. Epub 2020 Nov 3.

Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, MS, USA.

Streptococcus pneumoniae (pneumococcus) is a principal cause of bacterial middle ear infections, pneumonia, and meningitis. Capsule-targeted pneumococcal vaccines have likely contributed to increased carriage of nonencapsulated S. pneumoniae (NESp). Some NESp lineages are associated with highly efficient DNA uptake and transformation frequencies. However, NESp strains lack capsule that may increase disease severity. We tested the hypothesis that NESp could acquire capsule during systemic infection and transform into more virulent pneumococci. We reveal that NESp strains MNZ67 and MNZ41 are highly transformable and resistant to multiple antibiotics. Natural transformation of NESp when co-administered with heat-killed encapsulated strain WU2 in a murine model of systemic infection resulted in encapsulation of NESp and increased virulence during bacteremia. Functional capsule production increased the pathogenic potential of MNZ67 by significantly decreasing complement deposition on the bacterial surface. However, capsule acquisition did not further decrease complement deposition on the relatively highly pathogenic strain MNZ41. Whole genome sequencing of select transformants demonstrated that recombination of up to 56.7 kbp length occurred at the capsule locus, along with additional recombination occurring at distal sites harboring virulence-associated genes. These findings indicate NESp can compensate for lack of capsule production and rapidly evolve into more virulent strains.
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http://dx.doi.org/10.1038/s41598-020-75988-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641166PMC
November 2020

Social attention to activities in children and adults with autism spectrum disorder: effects of context and age.

Mol Autism 2020 10 19;11(1):79. Epub 2020 Oct 19.

Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA.

Background: Diminished visual monitoring of faces and activities of others is an early feature of autism spectrum disorder (ASD). It is uncertain whether deficits in activity monitoring, identified using a homogeneous set of stimuli, persist throughout the lifespan in ASD, and thus, whether they could serve as a biological indicator ("biomarker") of ASD. We investigated differences in visual attention during activity monitoring in children and adult participants with autism compared to a control group of participants without autism.

Methods: Eye movements of participants with autism (n = 122; mean age [SD] = 14.5 [8.0] years) and typically developing (TD) controls (n = 40, age = 16.4 [13.3] years) were recorded while they viewed a series of videos depicting two female actors conversing while interacting with their hands over a shared task. Actors either continuously focused their gaze on each other's face (mutual gaze) or on the shared activity area (shared focus). Mean percentage looking time was computed for the activity area, actors' heads, and their bodies.

Results: Compared to TD participants, participants with ASD looked longer at the activity area (mean % looking time: 58.5% vs. 53.8%, p < 0.005) but less at the heads (15.2% vs. 23.7%, p < 0.0001). Additionally, within-group differences in looking time were observed between the mutual gaze and shared focus conditions in both participants without ASD (activity: Δ = - 6.4%, p < 0.004; heads: Δ = + 3.5%, p < 0.02) and participants with ASD (bodies: Δ = + 1.6%, p < 0.002).

Limitations: The TD participants were not as well characterized as the participants with ASD. Inclusion criteria regarding the cognitive ability [intelligence quotient (IQ) > 60] limited the ability to include individuals with substantial intellectual disability.

Conclusions: Differences in attention to faces could constitute a feature discriminative between individuals with and without ASD across the lifespan, whereas between-group differences in looking at activities may shift with development. These findings may have applications in the search for underlying biological indicators specific to ASD. Trial registration ClinicalTrials.gov identifier NCT02668991.
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http://dx.doi.org/10.1186/s13229-020-00388-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574440PMC
October 2020

Oxidative killing of encapsulated and nonencapsulated Streptococcus pneumoniae by lactoperoxidase-generated hypothiocyanite.

PLoS One 2020 30;15(7):e0236389. Epub 2020 Jul 30.

Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, United States of America.

Streptococcus pneumoniae (Pneumococcus) infections affect millions of people worldwide, cause serious mortality and represent a major economic burden. Despite recent successes due to pneumococcal vaccination and antibiotic use, Pneumococcus remains a significant medical problem. Airway epithelial cells, the primary responders to pneumococcal infection, orchestrate an extracellular antimicrobial system consisting of lactoperoxidase (LPO), thiocyanate anion and hydrogen peroxide (H2O2). LPO oxidizes thiocyanate using H2O2 into the final product hypothiocyanite that has antimicrobial effects against a wide range of microorganisms. However, hypothiocyanite's effect on Pneumococcus has never been studied. Our aim was to determine whether hypothiocyanite can kill S. pneumoniae. Bactericidal activity was measured in a cell-free in vitro system by determining the number of surviving pneumococci via colony forming units on agar plates, while bacteriostatic activity was assessed by measuring optical density of bacteria in liquid cultures. Our results indicate that hypothiocyanite generated by LPO exerted robust killing of both encapsulated and nonencapsulated pneumococcal strains. Killing of S. pneumoniae by a commercially available hypothiocyanite-generating product was even more pronounced than that achieved with laboratory reagents. Catalase, an H2O2 scavenger, inhibited killing of pneumococcal by hypothiocyanite under all circumstances. Furthermore, the presence of the bacterial capsule or lytA-dependent autolysis had no effect on hypothiocyanite-mediated killing of pneumococci. On the contrary, a pneumococcal mutant deficient in pyruvate oxidase (main bacterial H2O2 source) had enhanced susceptibility to hypothiocyanite compared to its wild-type strain. Overall, results shown here indicate that numerous pneumococcal strains are susceptible to LPO-generated hypothiocyanite.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236389PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392276PMC
September 2020

Factors associated with enrollment into a clinical trial of caregiver-implemented intervention for infants at risk for autism spectrum disorder.

Autism 2020 10 29;24(7):1874-1884. Epub 2020 Jun 29.

Florida State University, USA.

Lay Abstract: Early intervention helps to address developmental delays in young children with autism spectrum disorder. Yet, research suggests there are barriers to enrollment into research studies that test the effectiveness of these interventions for infants at risk. This study identifies family characteristics that were associated with agreement to enroll in a clinical trial of early intervention for 12-month-old infants at risk for autism spectrum disorder. As part of a large longitudinal study, infants were evaluated for early signs of autism spectrum disorder at 1 year of age. Of the fifty-seven infants who were showing signs of autism and deemed eligible for the early intervention trial, 44% declined enrollment. Results suggest that families were more likely to decline enrolling into the intervention study if the mother was working full time, the total household income was between US$60,000 and US$100,000, and they lived further from the clinic. In contrast, infant autism symptoms and parental concern at 12 months were not significantly associated with enrollment. These findings highlight the need for intervention studies that are more accessible to parents, for example, intervention that takes place in the home, in addition to more research on how parental understanding of, and willingness to act on, early social-communication delays impact intervention study enrollment. Future research can then examine how to address these barriers to enrollment in early intervention studies. Such findings will shed light on best practices for dissemination of early identification and intervention strategies.
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http://dx.doi.org/10.1177/1362361320928829DOI Listing
October 2020

Promoting social attention in 3-year-olds with ASD through gaze-contingent eye tracking.

Autism Res 2020 01 30;13(1):61-73. Epub 2019 Aug 30.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington.

Young children with autism spectrum disorder (ASD) look less toward faces compared to their non-ASD peers, limiting access to social learning. Currently, no technologies directly target these core social attention difficulties. This study examines the feasibility of automated gaze modification training for improving attention to faces in 3-year-olds with ASD. Using free-viewing data from typically developing (TD) controls (n = 41), we implemented gaze-contingent adaptive cueing to redirect children with ASD toward normative looking patterns during viewing of videos of an actress. Children with ASD were randomly assigned to either (a) an adaptive Cue condition (Cue, n = 16) or (b) a No-Cue condition (No-Cue, n = 19). Performance was examined at baseline, during training, and post-training, and contrasted with TD controls (n = 23). Proportion of time looking at the screen (%Screen) and at actresses' faces (%Face) was analyzed. At Pre-Training, Cue and No-Cue groups did not differ in %Face (P > 0.1). At Post-Training, the Cue group had higher %Face than the No-Cue group (P = 0.015). In the No-Cue group %Face decreased Pre- to Post-Training; no decline was observed in the Cue group. These results suggest gaze-contingent training effectively mitigated decreases of attention toward the face of onscreen social characters in ASD. Additionally, larger training effects were observed in children with lower nonverbal ability, suggesting a gaze-contingent approach may be particularly relevant for children with greater cognitive impairment. This work represents development toward new social attention therapeutic systems that could augment current behavioral interventions. Autism Res 2020, 13: 61-73. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: In this study, we leverage a new technology that combines eye tracking and automatic computer programs to help very young children with ASD look at social information in a more prototypical way. In a randomized controlled trial, we show that the use of this technology prevents the diminishing attention toward social information normally seen in children with ASD over the course of a single experimental session. This work represents development toward new social attention therapeutic systems that could augment current behavioral interventions.
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http://dx.doi.org/10.1002/aur.2199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256927PMC
January 2020

Selective pressure: Rise of the nonencapsulated pneumococcus.

PLoS Pathog 2019 08 29;15(8):e1007911. Epub 2019 Aug 29.

Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America.

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http://dx.doi.org/10.1371/journal.ppat.1007911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715154PMC
August 2019

Development of attention from birth to 5 months in infants at risk for autism spectrum disorder.

Dev Psychopathol 2020 05;32(2):491-501

Emory-Children's-Georgia Tech Pediatric Research Alliance, Atlanta, USA.

Social-communication skills emerge within the context of rich social interactions, facilitated by an infant's capacity to attend to people and objects in the environment. Disruption in this early neurobehavioral process may decrease the frequency and quality of social interactions and learning opportunities, potentially leading to downstream deleterious effects on social development. This study examined early attention in infant siblings of children with autism spectrum disorder (ASD) who are at risk for social and communication delays. Visual and auditory attention was mapped from age 1 week to 5 months in infants at familial risk for ASD (high risk; N = 41) and low-risk typically developing infants (low risk; N = 39). At 12 months, a subset of participants (N = 40) was administered assessments of social communication and nonverbal cognitive skills. Results revealed that high-risk infants performed lower on attention tasks at 2 and 3 months of age compared to low-risk infants. A significant association between overall attention at 3 months and developmental outcome at 12 months was observed for both groups. These results provide evidence for early vulnerabilities in visual attention for infants at risk for ASD during a period of important neurodevelopmental transition (between 2 and 3 months) when attention has significant implications for social communication and cognitive development.
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http://dx.doi.org/10.1017/S0954579419000233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812597PMC
May 2020

The Use of Eye Tracking as a Biomarker of Treatment Outcome in a Pilot Randomized Clinical Trial for Young Children with Autism.

Autism Res 2019 05 20;12(5):779-793. Epub 2019 Mar 20.

Department of Counseling, Clinical, and School Psychology, University of California Santa Barbara, Santa Barbara, California.

There is a pressing need for objective, quantifiable outcome measures in intervention trials for children with autism spectrum disorder (ASD). The current study investigated the use of eye tracking as a biomarker of treatment response in the context of a pilot randomized clinical trial of treatment for young children with ASD. Participants included 28 children with ASD, aged 18-48 months, who were randomized to one of two conditions: Pivotal Response Intervention for Social Motivation (PRISM) or community treatment as usual (TAU). Eye-tracking and behavioral assessment of developmental functioning were administered at Time 1 (prior to randomization) and at Time 2 (after 6 months of intervention). Two well-established eye-tracking paradigms were used to measure social attention: social preference and face scanning. As a context for understanding relationships between social attention and developmental ability, we first examined how scanning patterns at Time 1 were associated with concurrent developmental functioning and compared to those of 23 age-matched typically developing (TD) children. Changes in scanning patterns from Time 1 to Time 2 were then compared between PRISM and TAU groups and associated with behavioral change over time. Results showed that the social preference paradigm differentiated children with ASD from TD children. In addition, attention during face scanning was associated with language and adaptive communication skills at Time 1 and change in language skills from Time 1 to Time 2. These findings highlight the importance of examining targeted biomarkers that measure unique aspects of child functioning and that are well-matched to proposed mechanisms of change. Autism Research 2019, 12: 779-793. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Biomarkers have the potential to provide important information about how and why early interventions effect positive change for young children with ASD. The current study suggests that eye-tracking measures of social attention can be used to track change in specific areas of development, such as language, and points to the need for targeted eye-tracking paradigms designed to measure specific behavioral changes. Such biomarkers could inform the development of optimal, individualized, and adaptive interventions for young children with ASD.
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http://dx.doi.org/10.1002/aur.2093DOI Listing
May 2019

A Pilot Randomized Clinical Trial of an Enhanced Pivotal Response Treatment Approach for Young Children with Autism: The PRISM Model.

J Autism Dev Disord 2019 Jun;49(6):2358-2373

University of California Santa Barbara, Santa Barbara, CA, USA.

The symptoms of autism spectrum disorder are conceptualized to alter the quality of parent-children interactions, exposure to social learning exchanges, and ultimately the course of child development. There is evidence that modifying the procedures of Pivotal Response Treatment (PRT) to explicitly target social motivation enhances child engagement and parent-child synchrony in moment-by-moment exchanges. However, it is unclear if these within session improvements ultimately yield favorable developmental outcomes over time. The current investigation presents feasibility, utility, and preliminary efficacy data of a pilot randomized clinical trial (RCT) of a Pivotal Response Intervention for Social Motivation (PRISM) model. Data on participant factors, treatment protocol acceptability, and outcome variance and effect size are highly favorable and support the pursuit of a future, large scale RCT.
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http://dx.doi.org/10.1007/s10803-019-03909-1DOI Listing
June 2019

Pulmonary Disease Associated With Nonencapsulated .

Open Forum Infect Dis 2018 Jul 8;5(7):ofy135. Epub 2018 Jun 8.

Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, Mississippi.

We discuss 3 patients presenting with pneumonia associated with nonencapsulated (NESp), an emerging pathogen commonly causing upper respiratory infections. Clinical isolates obtained from these patients were characterized to evaluate their respective antibiotic resistance and virulence mechanisms. We demonstrate that NESp resistant to classical drug treatments are isolated during pneumonia.
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http://dx.doi.org/10.1093/ofid/ofy135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299459PMC
July 2018

Early emergence of discrepancy in adaptive behavior and cognitive skills in toddlers with autism spectrum disorder.

Autism 2019 08 7;23(6):1485-1496. Epub 2018 Dec 7.

2 Emory University School of Medicine, USA.

Individuals with autism spectrum disorder and average IQ exhibit a widening discrepancy between lagging adaptive skills relative to their cognitive potential, but it is unknown when this discrepancy emerges in development. To address this important question, we measured adaptive and cognitive skills longitudinally, from 12-36 months, in 96 low-risk typically developing infants and 69 high-risk siblings of children with autism spectrum disorder who at 36 months were diagnosed with autism spectrum disorder ( = 21), the broader autism phenotype ( = 19), or showed no concerns (unaffected;  = 29). Results indicate that both cognitive and adaptive communication skills remained stable over time for all four groups, but toddlers with autism spectrum disorder and the broader autism phenotype failed to keep pace with unaffected and typically developing toddlers with regard to adaptive socialization skills and, to a lesser extent, daily living skills. The odds of having a discrepant developmental profile, with average cognitive skills and below average adaptive skills, was significantly greater for socialization and daily living skills in toddlers with autism spectrum disorder or the broader autism phenotype and increased over time from 12 to 36 months. The discrepancy between adaptive skills and cognition emerges early and widens over time for infants with autism spectrum disorder symptomology, supporting early assessment and intervention of adaptive socialization and daily living skills.
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http://dx.doi.org/10.1177/1362361318815662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6555695PMC
August 2019

Walking Ability is Associated with Social Communication Skills in Infants at High Risk for Autism Spectrum Disorder.

Infancy 2018 Sep-Oct;23(5):674-691. Epub 2018 May 3.

Marcus Autism Center, Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine.

Achievement of early motor milestones in infancy affords new opportunities for social interaction and communication. Research has shown that both motor and social deficits are observed in infants who later develop autism spectrum disorder (ASD). The current study examined associations between motor and social-communication skills in 12-month-old infant siblings of children with ASD who are at heightened risk for developmental delays (N=86) and low-risk, typically developing infants (N=113). Infants were classified into one of three groups based on their walking ability: walkers (walks independently), standers (stands independently), or pre-walkers (does not yet stand or walk independently). Social-communication and cognitive skills were assessed with two standardized assessments (Communication and Symbolic Behaviors Scales [CSBS] and Mullen Scales of Early Learning) and compared across the three walking groups. Results demonstrated that high-risk walkers showed superior social-communication skills, but commensurate cognitive skills, compared to high-risk pre-walkers. In contrast, social-communication and cognitive skills were largely comparable for low-risk infants, regardless of walking status. Findings suggest that for high-risk infants, who are already vulnerable to developmental delays and ASD, independent walking may facilitate the emergence of social-communication abilities. Pivotal motor milestones may serve as useful indicators of social-communication delays and targets for intervention.
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http://dx.doi.org/10.1111/infa.12242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159946PMC
May 2018

Screening for Autism Spectrum Disorder: Profiles of Children Who Are Missed.

J Dev Behav Pediatr 2018 12;39(9):673-682

Marcus Autism Center, Children's Healthcare of Atlanta, Atlanta, GA.

Objective: To characterize children presenting with concerns for autism spectrum disorder (ASD) missed by parent-report screeners and to examine benefits of a combined screening approach with the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) and the Ages and Stages Questionnaire, Third Edition (ASQ-3).

Methods: Participants included were 154 children aged 16 to 42 months presenting for an evaluation at an autism center. Caregivers completed the M-CHAT-R, ASQ-3, and a demographic questionnaire. Children participated in an autism diagnostic evaluation consisting of the Mullen Scales of Early Learning (Mullen) and Autism Diagnostic Observation Schedule, Second Edition (ADOS-2).

Results: A total of 124 children (81%) were diagnosed with ASD. The M-CHAT-R identified 85% (n = 105) of these children. Children with ASD missed by the M-CHAT-R had significantly higher scores on the Mullen and significantly lower scores on the ADOS-2. Of the ASQ-3 domains, the majority (n = 102, 82%) of children with ASD failed the communication domain; missed cases showed similar patterns of higher Mullen scores and lower ADOS-2 scores. When adopting a combined screening approach, using a failed screen from either the M-CHAT-R or ASQ-3 communication domain, 93% of children were identified. Parent-reported concerns on an open-ended questionnaire revealed ASD red flags for many missed cases.

Conclusion: Children with ASD missed by screeners had higher scores on developmental testing and lower scores on the ADOS-2; however, children still performed below average on developmental tests. Our findings suggest that a combined screening approach was most effective for identifying children with ASD from a sample group referred for an ASD evaluation.
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http://dx.doi.org/10.1097/DBP.0000000000000607DOI Listing
December 2018

Protease IV Exacerbates Pneumococcal Pneumonia and Systemic Disease.

mSphere 2018 May-Jun;3(3). Epub 2018 May 2.

Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, Mississippi, USA

Pneumonia is a pulmonary disease affecting people of all ages and is consistently a leading cause of childhood mortality and adult hospitalizations. and are major lung pathogens commonly associated with community-acquired and nosocomial pneumonia. Additionally, mixed lung infections involving these bacterial pathogens are increasing in prevalence and are frequently more severe than single infections. The cooperative interactions of these two pathogens that impact pulmonary disease severity are understudied. A major secreted virulence factor of , protease IV (PIV), cleaves interleukin 22 (IL-22), a cytokine essential for maintaining innate mucosal defenses against extracellular pathogens. Here, we investigate the ability of PIV to augment the virulence of a pneumococcal strain with limited virulence, EF3030, in a C57BL/6 murine model of pneumonia. We demonstrate that pulmonary coinfection involving 103-29 and EF3030 results in pneumococcal bacteremia that is abrogated during pneumococcal coinfection with a PIV-deficient strain. Furthermore, intratracheal administration of exogenous PIV and EF3030 resulted in abundant immune cell infiltration into the lung with large abscess formation, as well as severe bacteremia leading to 100% mortality. Heat-inactivated PIV did not worsen pneumonia or reliably induce bacteremia, suggesting that the specific activity of PIV is required. Our studies also show that PIV depletes IL-22 Moreover, PIV-mediated enhancement of pneumonia and disease severity was dependent on the expression of pneumolysin (Ply), a prominent virulence factor of Altogether, we reveal that PIV and Ply additively potentiate pneumonia in a murine model of lung infection. remains the leading cause of bacterial pneumonia despite widespread use of pneumococcal vaccines, forcing the necessity for appropriate treatment to control pneumococcal infections. Coinfections involving with other bacterial pathogens threaten antibiotic treatment strategies and disease outcomes. Currently, there is not an effective treatment for alveolar-capillary barrier dysfunction that precedes bacteremia. An understanding of the dynamics of host-pathogen interactions during single and mixed pulmonary infections could elucidate proper treatment strategies needed to prevent or reduce invasive disease. Antibiotic treatment decreases bacterial burden in the lung but also increases acute pathology due to cytotoxins released via antibiotic-induced bacterial lysis. Therefore, targeted therapeutics that inhibit or counteract the effects of bacterial proteases and toxins are needed in order to limit pathology and disease progression. This study identifies the cooperative effect of PIV and Ply, products of separate lung pathogens that additively alter the lung environment and facilitate invasive disease.
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http://dx.doi.org/10.1128/mSphere.00212-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5932373PMC
October 2018

Increased Virulence of an Encapsulated Streptococcus pneumoniae Upon Expression of Pneumococcal Surface Protein K.

J Infect Dis 2018 04;217(10):1637-1644

Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson.

Background: Current Streptococcus pneumoniae vaccines selectively target capsular polysaccharide of specific serotypes, leading to an increase in nonencapsulated S. pneumoniae (NESp). Cocolonization by encapsulated pneumococci and NESp increases the opportunity for intraspecies genetic exchange. Acquisition of NESp genes by encapsulated pneumococci could alter virulence and help vaccine-targeted serotypes persist in the host.

Methods: Adhesion and invasion assays were performed using immortalized human pharyngeal or lung epithelial cells. In vivo models assessing murine nasopharyngeal colonization and pneumonia, as well as chinchilla otitis media (OM), were also used.

Results: Pneumococcal surface protein K (PspK) expression increased encapsulated pneumococcal adhesion and invasion of lung cells and enhanced virulence during pneumonia and OM. Additionally, PspK increased nasopharyngeal colonization, persistence in the lungs, and persistence in the middle ear when expressed in a capsule deletion mutant. Competition experiments demonstrated encapsulated pneumococci expressing PspK also had a selective advantage in both the lungs and nasopharynx.

Conclusions: PspK increases pneumococcal virulence during pneumonia and OM. PspK also partially compensates for loss of virulence in the absence of capsule. Additionally, PspK provides a selective advantage in a competitive environment. Therefore, acquisition of PspK increases encapsulated virulence in a condition-dependent manner. Together, these studies demonstrate risks associated with pneumococcal intraspecies genetic exchange.
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http://dx.doi.org/10.1093/infdis/jiy058DOI Listing
April 2018

Mucosal Infections and Invasive Potential of Nonencapsulated Are Enhanced by Oligopeptide Binding Proteins AliC and AliD.

mBio 2018 01 16;9(1). Epub 2018 Jan 16.

Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, Mississippi, USA

Nonencapsulated (NESp) is an emerging human pathogen that colonizes the nasopharynx and is associated with noninvasive diseases such as otitis media (OM), conjunctivitis, and nonbacteremic pneumonia. Since capsule expression was previously thought to be necessary for establishment of invasive pneumococcal disease (IPD), serotype-specific polysaccharide capsules are targeted by currently licensed pneumococcal vaccines. Yet, NESp expressing oligopeptide binding proteins AliC and AliD have been isolated during IPD. Thus, we hypothesize AliC and AliD are major NESp virulence determinants that facilitate persistence and development of IPD. Our study reveals that NESp expressing AliC and AliD have intensified virulence compared to isogenic mutants. Specifically, we demonstrate AliC and AliD enhance murine nasopharyngeal colonization and pulmonary infection and are required for OM in a chinchilla model. Furthermore, AliC and AliD increase pneumococcal survival in chinchilla whole blood and aid in resistance to killing by human leukocytes. Comparative proteome analysis revealed significant alterations in protein levels when AliC and AliD were absent. Virulence-associated proteins, including a pneumococcal surface protein C variant (CbpAC), were significantly downregulated, while starvation response indicators were upregulated in the double mutant relative to wild-type levels. We also reveal that differentially expressed CbpAC was essential for NESp adherence to epithelial cells, virulence during OM, reduction of C3b deposition on the NESp surface, and binding to nonspecific IgA. Altogether, the rise in NESp prevalence urges the need to understand how NESp establishes disease and persists in a host. This study highlights the roles of AliC, AliD, and CbpAC in the pathogenesis of NESp. Despite the effective, widespread use of licensed pneumococcal vaccines over many decades, pneumococcal infections remain a worldwide burden resulting in high morbidity and mortality. NESp subpopulations are rapidly rising in the wake of capsule-targeted vaccine strategies, yet there is very little knowledge on NESp pathogenic potential and virulence mechanisms. Although NESp lacks a protective capsule, NESp lineages expressing AliC and AliD have been associated with systemic infections. Furthermore, higher antibiotic resistance rates and transformation efficiencies associated with emerging NESp threaten treatment strategies needed to control pneumococcal infections and transmission. Elucidating how NESp survives within a host and establishes disease is necessary for development of broadened pneumococcal prevention methods. Our study identifies virulence determinants and host survival mechanisms employed by NESp with a high pathogenic potential. Moreover, our study also identifies virulence determinants shared by NESp and encapsulated strains that may serve as broad prevention and therapeutic targets.
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http://dx.doi.org/10.1128/mBio.02097-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5770551PMC
January 2018

Assessing Risk of Bias in Randomized Controlled Trials for Autism Spectrum Disorder.

Front Psychiatry 2017 29;8:265. Epub 2017 Nov 29.

Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil.

Aim: To determine construct validity and reliability indicators of the Cochrane risk of bias (RoB) tool in the context of randomized clinical trials (RCTs) for autism spectrum disorder (ASD).

Methods: Confirmatory factor analysis was used to evaluate a unidimensional model consisting of 9 RoB categorical indicators evaluated across 94 RCTs addressing interventions for ASD.

Results: Only five of the nine original RoB items returned good fit indices and so were retained in the analysis. Only one of this five had very high factor loadings. The remaining four indicators had more measurement error than common variance with the RoB latent factor. Together, the five indicators showed poor reliability (ω = 0.687; 95% CI: 0.613-0.761).

Conclusion: Although the Cochrane model of RoB for ASD exhibited good fit indices, the majorities of the items have more residual variance than common variance and, therefore, did not adequately capture the RoB in ASD intervention trials.
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http://dx.doi.org/10.3389/fpsyt.2017.00265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5712530PMC
November 2017

Anxiety Disorders and Obsessive-Compulsive Disorder in Individuals with Autism Spectrum Disorder.

Curr Psychiatry Rep 2017 Oct 30;19(12):92. Epub 2017 Oct 30.

Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital of Rome, Rome, Italy.

Purpose Of Review: This review aims to synthesize the most recent research on anxiety disorders and obsessive-compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD) and discuss the relationship between these conditions and challenges for assessment. Furthermore, implications for treatment and future directions are discussed.

Recent Findings: Research suggests that anxiety disorders and OCD are highly prevalent in individuals with ASD. However, the significant overlap of ASD features with anxiety and OCD symptomology makes differential diagnosis of these disorders particularly challenging. Though several treatments for anxiety have been adapted for youth with ASD (e.g., cognitive behavior therapy), pharmacological treatments and treatments for adults are still marked undeveloped. Despite the high prevalence of anxiety disorders and OCD in ASD and some recent advances in assessment and treatment, research is needed to clarify the multifaceted relationship of these conditions and develop tailored assessment and treatment approaches appropriate for a full range of individuals with ASD.
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http://dx.doi.org/10.1007/s11920-017-0846-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846200PMC
October 2017

Parent Education for Young Children With Autism and Disruptive Behavior: Response to Active Control Treatment.

J Clin Child Adolesc Psychol 2018 19;47(sup1):S445-S455. Epub 2017 Oct 19.

a Marcus Autism Center, Department of Pediatrics , Emory University School of Medicine.

This study examines parent and child characteristics in young children with autism spectrum disorder and disruptive behavior who showed a positive response to a parent education program in a randomized clinical trial of parent training. Children with autism spectrum disorder (N = 180) were randomized to parent training (PT) or parent education program (PEP) for 6 months. Using the Clinical Global Impression-Improvement scale, masked independent evaluators rated positive response in 68.5% of children in PT compared to 39.6% in PEP. We compared baseline characteristics and change in parental stress, strain, competence, and mental health for participants who showed a positive response to PEP (PEP-R) to those who did not (PEP-NR). We also compared change in child and parent measures for PEP-R participants to those who showed a positive response to PT (PT-R). At baseline, PEP-R and PEP-NR participants did not differ on any demographic or clinical characteristics. Parents in PEP-R reported significant reductions on the Parenting Stress Index, Caregiver Strain Questionnaire, and Parent Health Questionnaire, and increases on the Parenting Sense of Competence scale. Improvements in child disruptive behavior and parental stress, strain, competence, and mental health for PEP-R participants were similar to PT-R participants. Vineland Daily Living Skills improved only for children in PT-R. PEP was an active control treatment with nearly 40% of participants showing a positive response. Change in child disruptive behavior and parental stress, strain, competence, and mental health were remarkably similar for participants independently rated with a positive response to PEP and PT.
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http://dx.doi.org/10.1080/15374416.2017.1381913DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6242765PMC
September 2019

Polyamine transporter potABCD is required for virulence of encapsulated but not nonencapsulated Streptococcus pneumoniae.

PLoS One 2017 6;12(6):e0179159. Epub 2017 Jun 6.

Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America.

Streptococcus pneumoniae is commonly found in the human nasopharynx and is the causative agent of multiple diseases. Since invasive pneumococcal infections are associated with encapsulated pneumococci, the capsular polysaccharide is the target of licensed pneumococcal vaccines. However, there is an increasing distribution of non-vaccine serotypes, as well as nonencapsulated S. pneumoniae (NESp). Both encapsulated and nonencapsulated pneumococci possess the polyamine oligo-transport operon (potABCD). Previous research has shown inactivation of the pot operon in encapsulated pneumococci alters protein expression and leads to a significant reduction in pneumococcal murine colonization, but the role of the pot operon in NESp is unknown. Here, we demonstrate deletion of potD from the NESp NCC1 strain MNZ67 does impact expression of the key proteins pneumolysin and PspK, but it does not inhibit murine colonization. Additionally, we show the absence of potD significantly increases biofilm production, both in vitro and in vivo. In a chinchilla model of otitis media (OM), the absence of potD does not significantly affect MNZ67 virulence, but it does significantly reduce the pathogenesis of the virulent encapsulated strain TIGR4 (serotype 4). Deletion of potD also significantly reduced persistence of TIGR4 in the lungs but increased persistence of PIP01 in the lungs. We conclude the pot operon is important for the regulation of protein expression and biofilm formation in both encapsulated and NCC1 nonencapsulated Streptococcus pneumoniae. However, in contrast to encapsulated pneumococcal strains, polyamine acquisition via the pot operon is not required for MNZ67 murine colonization, persistence in the lungs, or full virulence in a model of OM. Therefore, NESp virulence regulation needs to be further established to identify potential NESp therapeutic targets.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0179159PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5460881PMC
September 2017

Improving Functional Language and Social Motivation with a Parent-Mediated Intervention for Toddlers with Autism Spectrum Disorder.

J Autism Dev Disord 2017 08;47(8):2443-2458

Counseling/Clinical/School Psychology Department, University of California, Santa Barbara, CA, USA.

Recent research suggests that children with autism spectrum disorder (ASD) may now be reliably identified in later infancy, highlighting the need for empirically-validated interventions for infants and toddlers with early symptoms of ASD. Using a multiple baseline design across 15- to 21-month-old toddlers, this study implemented a brief, parent-mediated, Pivotal Response Treatment program, focusing on improving expressive communication. The results indicated that verbal communication improved as a consequence of the intervention, with concomitant improvements in untreated areas for all participants. Following the intervention, symptoms of autism decreased and parents reported satisfaction with the program's ease of implementation and observed child gains. The results are discussed in terms of developing very early interventions to improve developmental trajectories for infants and toddlers.
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http://dx.doi.org/10.1007/s10803-017-3155-8DOI Listing
August 2017

Surface Proteins and Pneumolysin of Encapsulated and Nonencapsulated Streptococcus pneumoniae Mediate Virulence in a Chinchilla Model of Otitis Media.

Front Cell Infect Microbiol 2016 18;6:55. Epub 2016 May 18.

Department of Microbiology and Immunology, University of Mississippi Medical Center Jackson, MS, USA.

Streptococcus pneumoniae infections result in a range of human diseases and are responsible for almost one million deaths annually. Pneumococcal disease is mediated in part through surface structures and an anti-phagocytic capsule. Recent studies have shown that nonencapsulated S. pneumoniae (NESp) make up a significant portion of the pneumococcal population and are able to cause disease. NESp lack some common surface proteins expressed by encapsulated pneumococci, but express surface proteins unique to NESp. A chinchilla model of otitis media (OM) was used to determine the effect various pneumococcal mutations have on pathogenesis in both NESp and encapsulated pneumococci. Epithelial cell adhesion and invasion assays were used to examine the effects in relation to deletion of intrinsic genes or expression of novel genes. A mouse model of colonization was also utilized for comparison of various pneumococcal mutants. It was determined that pneumococcal surface protein K (PspK) and pneumolysin (Ply) affect NESp middle ear pathogenesis, but only PspK affected epithelial cell adhesion. Experiments in an OM model were done with encapsulated strains testing the importance of native virulence factors and treatment of OM. First, a triple deletion of the common virulence factors PspA, PspC, and Ply, (ΔPAC), from an encapsulated background abolished virulence in an OM model while a PspC mutant had detectable, but reduced amounts of recoverable bacteria compared to wildtype. Next, treatment of OM was effective when starting antibiotic treatment within 24 h with resolution by 48 h post-treatment. Expression of NESp-specific virulence factor PspK in an encapsulated strain has not been previously studied, and we showed significantly increased adhesion and invasion of human epithelial cells by pneumococci. Murine colonization was not significantly increased when an encapsulated strain expressed PspK, but colonization was increased when a capsule mutant expressed PspK. The ability of PspK expression to increase colonization in a capsule mutant despite no increase in adhesion can be attributed to other functions of PspK, such as sIgA binding or immune modulation. OM is a substantial economic burden, thus a better understanding of both encapsulated pneumococcal pathogenesis and the emerging pathogen NESp is necessary for effective prevention and treatment.
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http://dx.doi.org/10.3389/fcimb.2016.00055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870244PMC
September 2017

Nonencapsulated Streptococcus pneumoniae as a cause of chronic adenoiditis.

IDCases 2016 12;4:56-8. Epub 2016 Apr 12.

Department of Microbiology and Immunology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, United States.

Streptococcus pneumoniae is an important human pathogen. To cause disease, it must first colonize the nasopharynx. The widespread use of pneumococcal-conjugate vaccines which target the capsular polysaccharide has led to decreased nasopharyngeal carriage of vaccine serotypes, but a concomitant increase in carriage of non-vaccine serotypes and nonencapsulated S. pneumoniae (NESp). Some NESp express pneumococcal surface protein K (PspK), a virulence factor shown to contribute to nasopharyngeal colonization. We present the case of a child with chronic adenoiditis caused by a PspK(+) NESp. We tested the pneumococcal isolate, designated C144.66, for antimicrobial resistance, the presence of the pspK gene and the expression of PspK. Sequence typing and genome sequencing were performed. C144.66 was found to be resistant to erythromycin and displayed intermediate resistance to penicillin and trimethoprim/sulfamethoxazole. C144.66 has the pspK gene in place of the capsule locus. Additionally, PspK expression was confirmed by flow cytometry. NESp are a growing concern as an emerging human pathogen, as current pneumococcal vaccines do not confer immunity against them. An inability to vaccinate against NESp may result in increased carriage and associated pathology.
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http://dx.doi.org/10.1016/j.idcr.2016.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4840421PMC
May 2016

Assessing and Improving Early Social Engagement in Infants.

J Posit Behav Interv 2014 Apr;16(2):69-80

University of California, Santa Barbara.

Empirical studies have documented a variety of social abnormalities in infancy that indicate risk for later social and behavioral difficulties. There is very little research illustrating the presence of such behavioral vulnerabilities with frequent repeated measures, and the feasibility of designing interventions for improving social engagement in infants under one year of age. In the context of a multiple baseline research design, three young infants, ages 4, 7, and 9 months referred for concerns about social engagement were assessed for affect, social interest, eye contact avoidance, and response to name. Additionally, the feasibility of implementing an intervention to target social behaviors was examined. Results demonstrated that: (1) consistently low or erratic levels of social behavior were evident throughout the baseline assessment period; (2) these patterns could be improved with a brief intervention (a modified Pivotal Response Treatment) showing an immediate increase and stability of social engagement; and (3) social engagement remained at a stable and high level at follow-up. The results are discussed in terms of implications of early assessment and intervention for clinical populations, including infants with Autism Spectrum Disorder.
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http://dx.doi.org/10.1177/1098300713482977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193383PMC
April 2014

Feasibility and effectiveness of very early intervention for infants at-risk for autism spectrum disorder: a systematic review.

J Autism Dev Disord 2015 Mar;45(3):778-94

Counseling, Clinical, and School Psychology Department, Koegel Autism Center, Graduate School of Education, University of California, Santa Barbara, CA, USA,

Early detection methods for autism spectrum disorder (ASD) in infancy are rapidly advancing, yet the development of interventions for infants under two years with or at-risk for ASD remains limited. In order to guide research and practice, this paper systematically reviewed studies investigating interventions for infants under 24 months with or at-risk for ASD. Nine studies were identified and evaluated for: (a) participants, (b) intervention approach (c) experimental design, and (d) outcomes. Studies that collected parent measures reported positive findings for parent acceptability, satisfaction, and improvement in parent implementation of treatment. Infant gains in social-communicative and developmental skills were observed following intervention in most of the reviewed studies, while comparisons with treatment-as-usual control groups elucidate the need for further research. These studies highlight the feasibility of very early intervention and provide preliminary evidence that intervention for at-risk infants may be beneficial for infants and parents.
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http://dx.doi.org/10.1007/s10803-014-2235-2DOI Listing
March 2015

The importance of early identification and intervention for children with or at risk for autism spectrum disorders.

Int J Speech Lang Pathol 2014 Feb 11;16(1):50-6. Epub 2013 Dec 11.

University of California , Santa Barbara, CA , USA.

There has been a dramatic rise in the number of children being diagnosed with autism spectrum disorders (ASD), which has led to increased attention paid to assessment and intervention issues. This manuscript agrees with Camarata (2014) that the evidence base for early assessment and intervention should be expanded. However, it disagrees with Warren et al.'s (2011) assumption that there are not empirically validated early interventions. Reliable diagnosis has been documented during infancy and toddlerhood, and evidence suggests that the earlier the onset of intervention, the greater likelihood of an improved developmental trajectory. It is argued that early intervention is more cost and time efficient than a "wait and see" approach. With regard to published studies, the large amount of heterogeneity in the ASD population supports the use of rigorous single case experimental design research. It is an error to limit empirical evidence for treatments to only randomized clinical trials, which have the weakness of masking individual differences. Single case experimental designs examine the effects of intervention beyond typical maturation by allowing for clear estimations of developmental trajectories prior to the onset of intervention, followed by evaluation of the impact of the intervention. This commentary discusses the short- and long-term benefits of early diagnosis and intervention.
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http://dx.doi.org/10.3109/17549507.2013.861511DOI Listing
February 2014