close

Enter

Log in using OpenID

Acr group-14-885 - OMICS Publishing Group

embedDownload
Autism-Open Access
Alavi, et al., Autism-Open Access 2014, 4:3
http://dx.doi.org/10.4172/2165-7890.1000137
Research Article
Open Access
Outcome Study of Intensive Day Treatment for Children with Pervasive
Developmental Disorders
Nazanin Alavi1*, Nasreen Roberts2, and Elizabeth DeGrace2
1Department
of Psychiatry, Queen’s University, Kingston, Ontario, Canada
2Department
of Child and Adolescent Psychiatry, Queen’s University, Kingston, Ontario, Canada
*Corresponding
author: Nazanin Alavi, Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada, Tel: 6135332000; E-mail: nazanin.alavi@queensu.ca
Rec date: October 13, 2014; Acc date: Nov 17, 2014; Pub date: Nov 24, 2014
Copyright: © 2014 Alavi N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Objectives: a) To study the characteristics of children referred to day treatment for Pervasive Developmental
Disorders (PDD). b) To study association between outcome and the variables understudy.
Method: This was a retrospective chart review of all children and adolescents with PDD, who attended a hospital
based Day treatment program. Demographic data and variables such as type of community classroom they came
from, Length of Stay (LOS), full scale IQ scores, DSM-IV Diagnosis and type of placement at discharge were
extracted. Descriptive statistic was used for categorical data and multinomial logistic regression was used for
association between outcome and variables understudy.
Results: There was an association between gender and outcome, female’s had better outcome than males. 2/3
of the patients with and without comorbidities had a significant reduction in behavioral symptoms allowing successful
reintegration into community schools. Conclusions: A proportion of children with Autistic Spectrum Disorder (ASD)
present with severe emotional and behavioral dysregulation which are unmanageable. These children have multiple
comorbidities and require more intensive longitudinal assessment by a skilled multidisciplinary team and specific
evidence -based interventions to enable them to return to community school. Intensive Day treatment in a
therapeutic classroom by skilled multidisciplinary staff reduces theimpairing behaviors and allows families and
schools to better manage these children.
Keywords: Pervasive developmental disorder; Day treatment; Child
and adolescent
Introduction
Autism was declared one of the five priorities in the Kirby report on
Mental Health, Mental illness and Addiction services in Canada in
2006 [1] The DSM-IV TR Classifies Autism, Asperger’s Syndrome,
Pervasive Developmental Disorders Not Otherwise Specified (PDD
NOS) under the PDD [2]. The prevalence of these disorders is
estimated at 60/10000 live births or 6% in children 3-17 years of age.
Approximately 1 in 165 children have ASD) [3]. The effects of ASD
vary for each individual on the spectrum, for example in those who are
"high functioning", social differences may be more disabling than any
actual symptoms or problems caused by ASD. In others there may be
severely disabling behavioral and communication problems.
Intervention, treatments and services are fundamentally necessary for
the majority of people with ASD, to help them reach their full
potential. The right to reach one's full potential and to receive a
meaningful education is often dependent upon the availability and
accessibility of scientifically validated treatment. Access to
individualized education coupled with effective treatment can greatly
improve a person's quality of life, including their ability to learn
communication and care for themselves.
Various interventions, alone or in combinations, are being
investigated to examine the efficacy, reliability and validity of these
interventions. Behaviorally-based programs have the largest body of
Autism-Open Access
ISSN:2165-7890 AUO, an open access journal
published research and it has been shown that they are effective in
helping children and adults, by teaching new skills in a step-by-step
approach, enabling the individual to have more success at home, at
school, at work, and out in the community [4,5]. However Research
has also demonstrated that, not all that we think works, affects
outcome [6]. One such intervention is group based social skills
development [7].Social reciprocity deficits are a core feature of the
autism spectrum disorders and group based social skills training
programs abound. A review of all published studies of group based
social skills interventions between 1985 and 2006, identified 14 studies
which met the requirements developed by National Institute of Mental
Health (NIMH) work group to study their effectiveness. This study
revealed incomplete empirical support for this modality [8].
There is very little extant literature on the outcome of intensive day
treatment for this population [9,10]. To address this gap to a small
measure we undertook our study in hospital based classroom model,
Day treatment program. The classroom had 8 places and referrals were
primarily from schools through our outpatient clinics. The schools
made referrals after having tried all other interventions, including in
some cases their own autism class placement, which had failed to
address the behavioral issues. The treatment team consisted of an
Occupational Therapist (OT), psychologist, behavioral therapist and
Social Worker, all trained in assessing and treating this population, a
full time teacher from the school board and a part time child and
adolescent psychiatrist. The treatment team conducted a
comprehensive assessment, reviewed diagnosis and medication and
then developed individualized behavioral program, parent training
Volume 4 • Issue 3 • 1000137
Citation:
Alavi N, Roberts N, DeGrace E (2014) Outcome Study of Intensive Day Treatment for Children with Pervasive Developmental
Disorders. Autism-Open Access 4: 137. doi:10.4172/2165-7890.1000137
Page 2 of 4
and interventions such as focused adaptive technology and Applied
Behavior Analysis (ABA) to facilitate change and gradual transition
back to community schools. The average Length of Stay (LOS) ranged
between 6 weeks to 4 months.
Only 19% had a poor outcome with unremitting problems and
inability to return to full time community school attendance in any
setting (Figure 3).
Day program was consisted of highly structured teaching, based on
applied behavior analysis and positive behavioral support for
managing behavioral problems. This program provided intervention
and direct instruction, using ABA principles and procedures, in order
to increase their cognitive and social abilities in the home, school and
community. A psychologist, OT and behavioral therapist spent several
hours with children every day to help the patients reach their potential
in a positive, learning environment by using a team- based approach,
individualized program planning and recreational activities.
Method
This was a retrospective chart review of all children and adolescents
who attended a hospital based Day treatment program from
September 2000 to June 2010 and met criteria for DSM-IV-TR for
ASD, Asperger’s Syndrome or PDD NOS.
Demographic data included age, gender, caretaker, referral source.
Data was extracted for other variables; type of class referred from and
sent to at discharge, LOS, full scale IQ scores, DSM-IV diagnosis and
outcome. Due to the small sample we divided the IQ into two groups,
of average or above and below average. Outcome was rated as a) Good:
return to full-time community school regular class with some support
b) Fair: manageable in special class at community school and c) Poor:
non return or not manageable in the classroom they were assigned to
or had behavioral deterioration leading to either re-entry to Day
treatment or inpatient ward. Descriptive statistic was used for
categorical data and multinominal logistic regression was used for
association between outcome and variables understudy.
Figure 1: Gender (male, female)
Results
There were 120 patients at the Day treatment program, from 2000
to 2010. Of these, 63 patients met the criteria for one of the PDD
diagnoses.
Figure 2: School grade at the time of admission to the Day program
Age: The average age of both girls and boys was 11 years; range was
7 to 15 year. 2 girls and 6 boys had more than 1 admission (12.6%
readmission) in different academic years with different outcomes and
are counted as separate admissions n=71.
Gender: There were 7 females and 56 males (Figure 1).
Grade level at the time of admission to the program: The largest
referral rate was for grades 6 to 8 followed by grades 2 to 5 and the
least for grade 9 to 10 (Figure 2).
Living arrangement: It is remarkable that none of the children were
under the custody of Children’s Aid or in foster homes and that 65 %
of children lived with both biological parents and remainder with
other family members.
Intelligence: Those who had come without intellectual assessments
were tested using the Wechsler Intelligence Scale for Children-IV
(WISC-IV). One’s form the community who came with WISC-III,
were accepted as such. Forty eight had average or above average and
15 had IQ at below average.
Outcome at discharge: More than 2/3 of the children had a fair to
good outcome, returning to full time school in various class settings.
Autism-Open Access
ISSN:2165-7890 AUO, an open access journal
Figure 3: outcome (a) Good: return to regular class with some
support b) Fair: manageable in special class at community school c)
Poor: non return or not manageable in the classroom they were
assigned to.
Relationship between outcome and other variables: An association
was found between gender and outcome. A Multinomial logistic
regression showed that females had a significantly better outcome
compared to males (p=0.025). However there was no association
Volume 4 • Issue 3 • 1000137
Citation:
Alavi N, Roberts N, DeGrace E (2014) Outcome Study of Intensive Day Treatment for Children with Pervasive Developmental
Disorders. Autism-Open Access 4: 137. doi:10.4172/2165-7890.1000137
Page 3 of 4
between outcome and age, caretaker, grade level, type of class, LOS
and IQ. (For age: p=0.6 For caretaker: p=0.16, For grade: p=0.74, For
class: p=0.17, For LOS: p=0.21, For IQ: p=0.71) (Table 1).
Fair vs. Poor
B (SE)
Intercept
-22.05(4.06)
Age
that after that sharp rise in grade 6 to 8, very few children presented in
grade 9-10 for the first time.
Our study didn’t show any association between either caretaker or
IQ with outcome, which suggests that the outcome was more related to
being involved in structured teaching and a relationship-based
approach to learning. Therapists carried out the intervention toward
individualized goals for each child, and worked collaboratively to
improve how the children were responding socially and
communicating.
Lower
Odds Ratio
Upper
.42(.71)
0.39
1.53
6.06
Grade
-.41(.69)
0.17
0.66
2.57
LOS
-.21(.16)
0.59
0.81
1.11
Gender
18.45(.00)
1.03
1.03
1.03
Caretaker
1.09(.77)
0.65
2.98
13.59
Class
1.33(.79)
0.81
3.81
18.02
Limitation
IQ
.66(.87)
0.35
1.93
10.75
This is a retrospective chart review of a small sample size, based on
records which were for clinical purposes rather than systematic data
for research. Thus discrepancies such as using different versions of the
WISC and using Autism Diagnostic Observation Schedule (ADOS)
[14], Behavior Rating Inventory of Executive Function (BRIEF) [15]
and SWANN [16]only for later admissions, occurred in our study.
Good vs. Poor
Intercept
-18.99(5.01)
Age
-.63(.98)
0.08
0.53
3.65
Grade
.39(1.004)
0.21
1.48
10.58
LOS
.182(.197)
0.81
1.2
1.76
Gender
20.92(.00)
1.21
1.21
1.21
Caretaker
-1.07(1.17)
0.03
0.34
3.42
Class
.95(.92)
0.43
2.6
15.73
IQ
-.26(1.24)
0.07
0.77
8.83
Table 1: relationship between outcome andage, grade, LOS, gender,
caretaker, class and IQ
Discussion
Pervasive developmental disorders bring children to the psychiatric
services most frequently due to the social behavioral problems that
cause significant impairment in interpersonal functioning and pose
problems for the management in the school setting; these problems
may result in exclusion from school and other social situations. Thus
both early recognition and effective sustained interventions to
ameliorate symptoms and behaviors, such as pharmacotherapy, special
education, speech/communication therapy, and behaviour
modification is necessary [11-13].
This retrospective study provides support for the recommendations
made by Volkmar et al. [11] that, provision of sustained special
educational setting, pharmacotherapy, intensive behavior intervention
and social communication skills have a significant positive outcome
for these children and adolescents. It is also apparent from the
distribution of grade level at entry into the day program that schools
and families try hard to address these problems prior to approaching
psychiatric intervention. Further, that school based autism classroom
may not be able to manage some of these children without
additionaleducation from specialized psychiatric multidisciplinary
teams. We speculate that if we intervened earlier, at grade 2 to 5, we
would reduce the numbers presenting at grade 6-8,as it is apparent
Autism-Open Access
ISSN:2165-7890 AUO, an open access journal
About 80% of the children had a fair to good outcome, returning to
full time school in various class settings which suggests that children
improve in functioning with intensive intervention, although there
was no association between outcome and length of treatment.
In addition our study showed that females had a significantly better
outcome compared to males, however this conclusion may be biased
due to the unequal gender distribution in our sample.
Conclusion
There is a significant impact on the daily functioning of a child who
presents with moderate to severe behavioral problems. Addressing
these problems early, would reduce the amount of time lost and the
burden of suffering for the child and the family. As it is evident from
this small study, a large proportion of moderate to severe impairment
can become manageable both at home and in school. Our future
research will look at the results from our dedicated PDD classroom in
a community school which has replaced our hospital based classroom.
References
1.
2.
3.
4.
5.
6.
7.
Kirby MJL (2006) “Out of the Shadows at Last- Transforming Mental
health, Mental illness and Addiction services in Canada” chapter 6:
137-156.
American Psychiatric Association (2000) Diagnostic Statistical Manual of
Mental Disorders –IV TR.
Fombonne E, Zakarian R, Bennett A, Meng L, McLean-Heywood D
(2006) Pervasive developmental disorders in Montreal, Quebec, Canada:
prevalence and links with immunizations. Pediatrics 118: 139-150.
Magiati I, Charman T, Howlin P (2007) A two-year prospective followup study of community-based early intensive behavioral intervention and
specialist nursery provision for children with autism spectrum disorders.
the Journal of Child Psychology and Psychiatry. 48: 803-812
Cohen H, Amerine-Dickens M, Smith T (2006) Early intensive
behavioral treatment: Replication of the UCLA model in a community
setting. Journal of Developmental and Behavioral Pediatrics. 27: 145-155.
Francis K (2005) Autism interventions: a critical update. Dev Med Child
Neurol 47: 493-499.
Rao PA, Beidel DC, Murray MJ (2008) Social skills interventions for
children with Asperger's syndrome or high-functioning autism: a review
and recommendations. J Autism Dev Disord 38: 353-361.
Volume 4 • Issue 3 • 1000137
Citation:
Alavi N, Roberts N, DeGrace E (2014) Outcome Study of Intensive Day Treatment for Children with Pervasive Developmental
Disorders. Autism-Open Access 4: 137. doi:10.4172/2165-7890.1000137
Page 4 of 4
8.
9.
10.
11.
12.
Williams White S, Keonig K, Scahill L (2007) Social skills development in
children with autism spectrum disorders: a review of the intervention
research. J Autism Dev Disord 37: 1858-1868.
Sverd J, Dubey DR, Schweitzer R, Ninan R (2003) Pervasive
developmental disorders among children and adolescents attending
psychiatric day treatment. Psychiatr Serv 54: 1519-1525.
Bryson SE, Rogers SJ, Fombonne E (2003) Autism spectrum disorders:
early detection, intervention, education, and psychopharmacological
management. Can J Psychiatry 48: 506-516.
Volkmar F, Cook EH Jr, Pomeroy J, Realmuto G, Tanguay P (1999)
Practice parameters for the assessment and treatment of children,
adolescents, and adults with autism and other pervasive developmental
disorders. American Academy of Child and Adolescent Psychiatry
Working Group on Quality Issues. Journal of American Academy of
Child and Adolescent Psychiatry 38: 32-54.
Baghdadli A, Picot MC, Michelon C, Bodet J, Pernon E, et al. (2007)
What happens to children with PDD when they grow up? Prospective
Autism-Open Access
ISSN:2165-7890 AUO, an open access journal
13.
14.
15.
16.
follow-up of 219 children from preschool age to mid-childhood. Acta
Psychiatr Scand 115: 403-412.
Burd L, Kerbeshian J, Westerland A, Labine J, Barth A, et al. (2002)
Prospective long-term follow-up of patients with pervasive
developmental disorders. J Child Neurol 17: 681-688.
Lord C, Risi S, Lambrecht L, Cook EH, Jr., Leventhal BL, et al. (2000) The
Autism Diagnostic Observation Schedule–Generic: A Standard Measure
of Social and Communication Deficits Associated with the Spectrum of
Autism. Journal of Autism and Developmental Disorders 30.
Gioia GA, Isquith PK, Guy SC, Kenworthy L (2000) Behavior rating
inventory of executive function. Child Neuropsychol 6: 235-238.
Swanson JM, Schuck SP, Miranda M, Carlson C, Hartman C, et al. (2012)
Categorical and dimensional definitions and evaluations of symptoms of
ADHD: history of the SNAP and SWAN Rating Scales. The International
Journal of Educational and Psychological Assessment 10.
Volume 4 • Issue 3 • 1000137
1/--pages
Report inappropriate content