Early parent-mediated interventions for autism aim to improve child social functioning by optimizing parental dyadic interactions. The Preschool Autism Communication Therapy (PACT) targets behaviors like parental synchrony and child communication initiation through video-assisted parent training. Studies show PACT improves these behaviors and reduces autism symptoms. Mediation analysis found treatment effects on parental synchrony partially explain improved child communication. The intervention was also successfully implemented cross-culturally in South Asia with comparable treatment effects. Future research will generalize PACT effects to family and school contexts.

1. Early intervention for autism
Catherine Aldred
University of Manchester, Royal Manchester Childrens Hospital
and Manchester Academic Health Sciences Centre
1

2. Parent and
therapist
interaction
changes parent
behaviour
Changed
parental
behviour leads
to improved
child dyadic
communication
Improved child
dyadic
communication
generalises to
other contexts
Developmentally staged:
Intervention delivered through
parents to enhance social
development in the
neurologically-vulnerable child
Parent-mediated intervention
2

3. What is special about parent-mediated intervention?
• Parent motivation
– The naturalistic developmental system
– Benefits for parental engagement, confidence, family function
–
– (does not imply poor initial parenting)
• Targets developmental processes known to predict autism outcomes
• Carried forward into the main context for social communication
development
• Potential 24/7 therapeutic effect
• Extending beyond treatment end, therefore efficient use of professional time
• But to do this well, interventions have to make substantial, focused,
reproducible impact on targeted parental behavio
– more than education or coaching
• Value of video-feedback to produce this intervention effect
3

4. What is special about parent-mediated intervention?
• But to do this well, interventions have to make substantial, focused,
reproducible impact on targeted parental behaviours
– more than education or coaching
• Value of video-feedback to produce this intervention effect
– known to be very effective for observation, reflection and adult learning
styles
4

5. Examples from:
Pre-school intervention
Cross-cultural implementation
5

6. The Lancet (2010), 375, 9732; 2152-2160
6

7. Theoretical base
• Focus on parent-child dyad - 80% of the child’s communication
• Abnormal communication in autism
– Reduced shared attention and mutuality
– Pragmatic impairments
– Language disorder
• Imbalanced Parent-Child interaction
– Perplexity
– Reduced ‘meshing’ - ‘asynchrony’
– Reduced child opportunities for communication learning, relating
• But positively – from the language intervention literature
– Attending to communication acts increases them
– Expansion from child’s base (‘semantic contingency’) leads to more
vocabulary
– Children with autism need a high dose of this
• Developmental hierarchy - of pre-cursor skills for communication
7

8. Parent and
therapist
interaction
changes parent
behaviour
Changing
parental
synchrony
impacts child
initiations in
dyad
Changing
initiations by
child affects
interaction with
researcher in
ADOS
Preschool Autism Communication
Therapy (PACT)
Developmentally staged:
Shared attention, parental synchronous
response, adapted communication
strategies, communication enhancement
Initial 6 months – Biweekly clinic visits (3
hrs) + home work (30 mins/day) – viz
2hrs/wk
Next 6 months – Consolidation – Monthly
clinic visits + homework (30 mins/day) and
generalisation
18 sessions possible (median 16 (IQR 13-
17) attended in PACT)
8

9. Parent and
therapist
interaction
changes parent
behaviour
Changing
parental
synchrony
impacts child
initiations in
dyad
Changing
initiations by
child affects
interaction with
researcher in
ADOS
Preschool Autism Communication
Therapy (PACT)
Developmentally staged:
Shared attention, parental synchronous
response, adapted communication
strategies, communication enhancement
Initial 6 months – Biweekly clinic visits (3
hrs) + home work (30 mins/day) – viz
2hrs/wk
Next 6 months – Consolidation – Monthly
clinic visits + homework (30 mins/day) and
generalisation
18 sessions possible (median 16 (IQR 13-
17) attended in PACT)
9

10. Parent and
therapist
interaction
changes parent
behaviour
Changing
parental
synchrony
impacts child
initiations in
dyad
Changing
initiations by
child affects
interaction with
researcher in
ADOS
Preschool Autism Communication
Therapy (PACT)
Developmentally staged:
Shared attention, parental synchronous
response, adapted communication
strategies, communication enhancement
Initial 6 months – Alternate weekly
clinic/home visits (2 hrs) + home work (30
mins/day)
Next 6 months – Consolidation – Monthly
clinic/ home visits + homework (30
mins/day) and generalisation
18 sessions possible (median 16 (IQR 13-
17) attended in PACT)
10

11. ASSESSED
n=242
EXCLUDED
n=90
RANDOMISED
n = 152
TAU
n = 75
PACT + TAU
n = 77 (>3 sess n=74)
LOST TO FOLLOW UP
n = 3
LOST TO FOLLOW UP
n = 3
ENDPOINT DATA
n = 72
ENDPOINT DATA
n = 74
Study
flow
11

12. PACT
Interventio
n
Attenuation of treatment effect on generalisation
across interaction and context
Parent
interaction with
Child
Parental
synchrony
ES=1.22
(0.85, 1.59)
Child
interaction
with Parent
Child
interaction
with
Assessor
Child
in
School
Child
initiations
ES=0.41
(0.08, 0.74)
Autism SC
symptoms
(ADOS)
ES=-0.24
(-0.59, 0.11)
CSS ES=
0.63
(0.02,1.29)
Social
functioning
in school
ES=-0.19
(-0.44, 0.07)
CONTEXT
MEASURE
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13. • 8-min parent-child free play videotaped in clinic
• Dyadic Communication Measure for Autism(DCMA ;Aldred et al., 2012, 2014)
• Coding parent and child communication acts, mutual shared attention,
parental communication responses
Primary outcomes
Mutuality
Child
responsiveness
Parent
Synchronicity
Sensitive
responsiveness
Child communication
initiation
Parent-infant interactionPACT Parent-child communication interaction
Primary outcome
At 13 months
predicts child
communication
Predicts child
communication at
follow-up
13

14. Parent and
therapist
interaction
changes parent
behaviour
Changing
parental
synchrony
impacts child
initiations in
dyad
Changing
initiations by
child affects
interaction with
researcher in
ADOS
Treatment effect
on parental
synchrony 70%
mediates child
communication
change
Child communication
change mediates
treatment effect on
autism SC symptoms
Longitudinal association studies -
parent synchrony effects child
communication in autism (Siller and
Sigman 2002/8)
Mediation analysis
confirms theory and
implementation
(Pickles et al 2015)
14

15. TAU
N=75
PACT
N=77
follow-up
Random
allocation
PACT
Therapy
impacts
target
processes in
synchrony
Parent synchrony
Child communication
Child Language
ADOS and RRB
13 months later
Core autism
Child language
Social functioning
Autism symptoms
RRB
Family wellbeing
‘Hybrid trial’ to test causal association between parent-child interaction,
intermediate development and outcome autism phenotype
15

16. PACT-G – moving to the next phase of generalisation
Efficacy and Mechanism Evaluation
Intervention at home and school
Extended age range 2-11yrs
Collaboration Neil Humphrey/Richard Emsley
DCMA: home
6 months
Random
allocation
a
DCMA:
education
8 months
c
Outcomes:
BOSCC
11 months
d
b
f
e
16

17. Examples from:
Pre-emptive Intervention
Pre-school intervention
Cross-cultural implementation
17

18. Parent-mediated intervention for autism spectrum
disorders in South Asia (PASS)
Institute of
Psychiatry,
Rawalpindi,
Pakistan
Fareed Minhas
Ayesha Minhas
Zafar Iqbal
University of
Liverpool
Atif Rahman
University of
Manchester
Jonathan Green
Catherine Aldred
Carol Taylor
Kathy Leadbitter
Sangath, Goa,
India
Vikram Patel
Gauri Divan
Vivek Vajaratkar
The feasibility and
acceptability of the
implementation of the
adapted PACT
intervention in settings
in South Asia
The success of a “task-shifting”
approach in delivering fidelity
to the intervention model.
18

19. Training and Supervision cascade
PACT (Intervention)
Specialists
South Asia Child
Development Specialists
Non-specialist
workers
Parents/Carers
Child with
ASD
19

20. PASS results RCT N=65 (in press Lancet Psychiatry)
Acceptability high, with 80% completing the sessions
Therapist fidelity high to PACT standards
Treatment effect Greater effect on dyadic interaction than UK PACT!
• parental synchrony [SMD 0.25 (95% CI 0.14-0.36); ES 1.61]
• child communication initiation [SMD 0.15 (CI 0.04-0.24); ES 0.99]
First definitive RCT of an evidence-based intervention delivered by non-
specialists in a low-income setting
New scale up study -
Parent-mediated intervention for Autism
Spectrum Disorders in South Asia PLUS
(PASS+) 2014-2016
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21. Summary
Early parent-mediated video-aided intervention in ASD aims to increase
child social functioning through optimising parental dyadic social
interaction
Across preschool and transcultural intervention we show treatment
effects on:
•The targeted parental dyadic behaviours
•Child communication
•Child autism symptoms
– PACT shows causal mediation in line with treatment theory
•Cross cultural implementation in LMIC with cascading internet ‘tele-
communication’ training and supervision and local partners is feasible
and effective
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22. Future trial
PACT-G
The Paediatric Autism Communication Trial –
Generalised
Working with families and schools in three UK centres:
•Manchester
•Newcastle
•London
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23. Thank you -
jonathan.green@manchester.ac.uk
www.medicine.manchester.ac.uk/mentalhealth/re
search/psychopathology/socialdevelopment/
To the Families and Children who have worked so hard with us
To the Manchester team and our Collaborators
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