# Helping Give Away Psychological Science/Autism Speaker Series/The Heterogenous Phenotype part 2

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# The Heterogenous Phenotype: Predicting Outcomes in ASD

Rebecca Grzadzinski PhD. Research Assistant Professor University of North Carolina at Chapel Hill. Carolina Institute for developmental Disabilities (CIDD)

## Introduction

ASD has a complex heterogeneity in areas including
* Genetic vulnerability, adaptive skills and IQ, sex/ geneder, resiliancy factors, co-occuring psychiatric conditions, age/ maturation/ development, langiage abilities, brain substrates, outcomes and response to treatment, co-occuring medical conditions, and environmental exposures.
* With all this complexity it becomes very hard for families to pinpoint an intervention that will help their children
** On average parents spend 20 plus hours a week planning and attempting intervention causing a great deal of stress on families.
Children with ASD vary in their outcomes and treatment related change
* Every child responds to ASD intervention extremely differently
* Progress isn't linear; there is a lot of variability.
* Children ho dont get proper help may see their skills decrease over time
** Problem: the field has struggled to find a standardized way to measure the changes in skill levels of aSD children over short periods of time.
Measuring ASD symptom change is very hard
* The changes may be very subtle and hard to detect
* Diagnostic tools are not sensitive enough
* Relying on parent or clinical report has inherent bias.

## Overview

In a review of 195 trials of intervention over 200 different outcome measures were used
* There was a huge variety of measurement methods used
** Single studies
** Not flexible enough to be used across sites/ studies
** Time consuming
** Expensive
** Require substantial training and experience
* Wanted to create a method that would alleviate some of these issues called BOSCC.

### The goals include

* Sensitive to changes over short periods of time
* Observation = the objective
* Standardized yet flexible procedure
* Easy to use for whoever is applying the intervention
* The coding scheme is applied to video observations and is based off of the autism diagnostic observation schedule (ADOS)
** ADOS is put on a scale from 0-2.
** Instead, BOSCC is put on a scale of 0-5 in order to accommodate for small nuances that may be present.
*** Zero says that abnormality is not present
*** 5 says that abnormality is present and significantly impairs functioning

## Methods
### Items included on the BOSCC are broken into categories

* Social communication
** Eye contact
** Facial expressions
** Gestures
** Vocalization
** Integration of vocal and non vocal communication
** Social overtunes
** Social responses
** Engagement
** Play
* Restricted, repetitive behavior (RRB)
** Unusual sensory interests
** hand/ finger/ body mannerisms
** repetitive/ stereotyped interests/ behaviors
* Other abnormal behaviors
** Activity level
** Disruptive behavior/ irritability
** Anxious behaviors
All of these items were rated on a scale when it comes to quantity and quality of actions, behaviors, mannerism, etc.

## Results

Study found inside and outside of the lab high inter-rater and test retest reliability.

### BOSCC was able to detect significant amounts of change over a six month period compared to ADOS

BOSCC change aligns with receptive language change
* These changes aligned with other measures over the same time period
* BOSCC change aligns with parent report of communication change

### Children with ASD vary in their outcomes and treatment-related changes

* The BOSCC is a way to measure the variability and the variety of ASD related treatment outcomes
There are many things that change and influence a child's progress trajectory
* It appears that children who start out with lower skills progress more than children who begin with middle of the range skills.
** This suggest that child's social skill severity may be a predictor of the treatment success and trajectory
* Baseline cognitive skills can also impact the treatment trajectory.
* Language qualities can also be a predictor for treatment trajectory.
* Child sensory reactivity can lead to varied child outcomes
** Children with or a risk for ASD often display sensory reactivity which can include
*** Hypo-reactivity
*** Hyper-reactivity
*** Seeking behavior
** Child sensory responsivity impact outcome slike communications

## Discussion

The study hypothesized that sensory domains at the age of 14 months and changes from 14 to 23 months may contribute to the heterogenous severity of ASD between 3 and 5 years of age.
* Hypo and hyper reactivity can lead to later child ASD symptoms
Observation:
* Increased hypo-reactivity at 14 months lead to an increase in ASD SA severity between the ages of 2-5 years
Parental report
* Hyper-reactivity at 14 months increased ASD RRB severity between 3-5 years
The question is whether or not it is possible to intervene on these influencing factors and if so, can it lead to better outcomes
What is known
* An increase in child hyporeactivity is associated with decreased child communication
* An increase in hyporeactivity is associated with decreased parent verbal response (PVR)
* And an increase in PVR is associated with an increase in child communication

## Future Directions

Can parent verbal responsiveness ameliorate the impact of child hyporeactivity?
* It is possible that parental responsiveness is a mediator between the relationship of child hypo-reactivity and the later decrease in child communication skills
** This is based on the idea that an increase in PVR is associated with an increase in parental affect which subsequently leads to an increase in parental sensitivity
** All of which are significant mediators
* Looking at Qualities of the parent-child interaction