Laurie A. Vismara, Ph.D., BCBA-D, R.B.A. (Ont.) details caregiver strategies for building infant social interaction. She introduces the Infant Start Manual, an extension of the Early Start Denver Model. The speaker outlines contemporary research on early-in-life autism support strategies and underscores the need for collaborative, family-centered support tactics for parents and caregivers. Vismara details six (6) infant learning characteristics, how they present, and what caregivers can do to foster these social communication skills during infancy.

Handouts are online HERE (.zip)

In this webinar: 

1:30 – Introduction
6:10 – Infant Start Manual
11:40 – Research findings
17:55 – Infant learning characteristics
20:25 – Attentional flexibility
27:10 – Object use
33:00 – Prelinguistic development
36:55 – Combined, pragmatic communication
42:25 – Speech
47:30 – Social attention and engagement
54:20 – Tips for baby learning
58:00 – Resources

Introduction

Vismara introduces the Infant Start Manual, an extension of the Early Start Denver Model that focuses on infant social interactions (1:30). She highlights the need for innovative, flexible approaches to support strategies that match the needs, goals, and priorities of parents and caregivers. The speaker outlines specific language used in the talk and notes presentation learning objectives (4:20). The vision of the Infant Start Manual is to facilitate families in their caregiving journey with interactive early-in-life topics aimed at infant social communication vulnerabilities (6:10). The manual provides supports through family-centered coaching and does not substitute for a diagnosis, fix, or cure. The Infant Start Model can be accessed freely at esdmonline.com/about in the Encouraging Infant Communication and Play Manual (Rogers & Vismara). Free access is for personal use only and should not be posted online. 

What the research says

Research on the efficacy of early-in-life autism supports is still emerging. Studies show mixed results across high (10-15 hrs/week) and low-intensity (0.5 – 3 hrs/week) supports delivered by parents and clinicians. All studies aim to teach caregiving skills for social and joint engagement through play and other activities. Results show improvements in caregiving domains, infant proximal behaviors, and interactive styles for caregivers. In contrast, infant autism domains show minimal changes (13:00). One pilot study of the Infant Start has been published. Overall, caregivers shared positive perspectives on content and delivery techniques, and infant vulnerability around social characteristics diminished over time compared to families that did not participate (11:40). 

Vismara posits that the cumulative benefits of small initial changes in interaction become more apparent over time, meaning the full impact of these interventions cannot yet be measured. However, these studies provide an opportunity to understand the acceptability of these support mechanisms from diverse caregiver perspectives, which will allow for the creation of individualized, culturally aligned support systems (15:00). 

Autism Treatment in the First Year of Life: A Pilot Study of Infant Start, a Parent-Implemented Intervention for Symptomatic Infants (Rogers et al., 2014)

Autistic and autism community perspectives on infant and family support in the first two years of life: Findings from a community consultation survey (Bent et al., 2024)

A Developmental Social Neuroscience Perspective on Infant Autism Interventions (Dawson et al., 2023)

Feasibility and acceptability of a caregiver-mediated early support program, delivered online, for infants at elevated familial likelihood for autism: A feasibility randomized controlled trial (Meera et al., 2024)

The Earlier, the Better? An In-Depth Interview Study on the Ethics of Early Detection with Parents of Children at an Elevated Likelihood for Autism (Jan-Vanaken et al., 2023)

Preemptive interventions for infants and toddlers with a high likelihood for autism: A systematic review and meta-analysis (Hampton et al., 2021)

Efficacy of very early interventions on neurodevelopmental outcomes for infants and toddlers at increased likelihood of or diagnosed with autism: A systematic review and meta-analysis (McGlade et al., 2023)

Parent-Mediated Interventions for Infants under 24 Months at Risk for Autism Spectrum Disorder: A Systematic Review of Randomized Controlled Trials (Law et al., 2022)

Infant learning characteristics

The presenter emphasizes that babies come ready to explore, learn, and respond just as caregivers have intuitive skills to nurture, love, and protect. Both shape and influence the others’ actions, resulting in a communication “dance” of synchronized rhythmic steps and movements. No matter who is leading, both sides must be aware of the other and sensitive to each other’s movements and what they mean (17:55). When there is a “misstep,” the dance may stop, and working to regain that attention and engagement is where the Early Start Manual comes in. Vismara outlines six (6) infant learning characteristics, how they present in infants, and how to strengthen caregiver-baby social interactions. 

Attentional flexibility

Attentional flexibility refers to babies’ ability to pay attention to people, objects, and experiences that they find interesting, even when there are distractions. Babies do this when they pick up and explore objects, move from one toy to the next, watch people doing things, or shift focus when something new is introduced (20:25). Attentional flexibility helps babies gather information, build on their learning experiences, and filter out distractions to stay on task.

The speaker provides play recommendations for supporting attentional flexibility (23:15). She suggests offering toys or materials that encourage exploration and interactive play. Holding pieces to your face and naming or commenting about them before you give them to the baby can help them orient your voice to your face. She suggests helping babies complete goals, adding playful sounds, hand gestures, or body movements to help call attention back to you, and giving babies choices for which objects they want to play with (25:15). 

Object use

Babies are naturally curious about objects, and playing with them allows them to explore, try out new behaviors, express ideas, and receive feedback. Vismara explains that babies develop play through patterns of repeated actions, called schemas, which are constantly changing and overlapping (27:10). During play, she suggests taking turns with the same object(s) to create a back-and-forth dance (baby does, you do – repeat) which encourages skill adoption and lets babies know that you are part of the activity/conversation. It is also helpful to be face-to-face during play, to set up toys and spaces in visually clear ways that are not over-stimulating, and to follow babies’ play before leading with your own (29:10). The speaker provides a resource table with play schema definitions and ideas (31:20).

Prelinguistic development

Vismara explains that baby communication begins with crying, which lets caregivers know the baby is hungry, uncomfortable, or upset. This quickly develops into “talking bodies” communication, where babies use their facial expressions, bodies, actions, and gestures to communicate in many different ways (33:00). We chat back to babies when we name and describe things, hold or point to things, copy sounds and expressions, and add silly sounds, hand gestures, or movements to play routines.

To support prelinguistic development, the speaker again suggests playing face-to-face with the baby and talking about everything. Describe what you are doing as you go through routines and make your own “talking body” stand out to babies with playful sounds and exaggerated facial expressions and movements (34:15). It is important to give babies time to respond and for you to put words to their communication methods (35:35). The presenter shows a resource table with activity ideas for strengthening talking bodies.

 Combined, pragmatic communication

Bundling communication behaviors is a critical step in the infant communication journey. Combining face, body, and voice makes communication more efficient and complex, allowing for information retention, skill expansion, and relationship building. Caregivers naturally encourage bundling when we model back-and-forth conversations with babies. For example, when a baby smiles and makes a sound, a caregiver can comment on what excited them (36:55). Vismara suggests giving babies time to think of what they want to say and going with the communication methods that the baby is naturally using. The speaker suggests starting with any two bundles (voice and body, face and voice, etc.) and being flexible, remembering you can always try again later. She warns against holding out for specific communication bundles and underscores working with the babies’ strengths (39:30). The speaker provides another resource table on encouraging bundling through daily routines. 

Speech

Baby babbling is a universal aspect of early speech development that unfolds across several stages and serves as a stepping stone to first words. Babbling is a continuous string of sounds that express babies’ emotions and desire to talk. They often mimic words and language qualities such as tone, pitch, and accent (42:25). To support speech development, Vismara suggests talking to babies and then pausing for them to listen and respond. It’s essential to interpret the intent of what babies say and to keep the conversation going as long as they wish to babble. Helpful tips include mouthing games, imitating baby, and using props to encourage sounds (44:45). The presenter shares a resource table with activities that encourage baby sounds and potential props that you can use to promote conversations. 

Social attention and engagement

Human beings are born with the need and desire to connect with the people around us. We can see this social-emotional connection through babies’ visual attention to people, desire for attention, and drive to start interactions (47:30). Early signs of the social-emotional journey include turning toward familiar faces, turning away when overwhelmed, following faces or objects, and responding to people in their environment. Caregivers can foster this bonding by pausing an activity to cue a response from the baby. For example, hold out a toy, show the play action, and wait for baby to say, “I like this, do it again” (reach, look, smile, move body, make sound) (50:00). 

The speaker reminds viewers to respect babies’ preferences and that it may take some detective work to find their comfort zone inside activities. It helps to repeat your actions when babies are watching and read their cues for what makes them smile. Tips for finding their comfort zone include changing movement pace, adjusting voice and animation, and moving closer or backing up until they feel comfortable. Once you find their smile, create a predictable routine for setting up the fun and pausing for a reaction from the baby before continuing the action (51:15). 

Tips for baby learning

The presenter reminds viewers to build on babies’ interests and experiences with other ideas only after you can follow their play patterns. Building on their preferences can include showing different ways to play with their favorite toys, increasing interaction, and introducing new toys and songs they may like. She notes that not all ideas are winners on the first try but that bridging their interests with new ideas will create understanding and participation through which their skills can expand. Vismara underscores the importance of active play and urges caregivers to expand their involvement in baby interactions (54:20). 

The speaker reiterates that the Infant Start Model is about supporting families with programs and resources that build off of dynamic, authentic early learning experiences. She asserts the need for researchers, families, and clinicians to think deeply about what early autism care looks like and to listen intently to what families are telling us to create collaborative, culturally-informed strategies (55:41). Vismara provides links to manuals, videos, and other resources as well as an Infant Start workshop for professionals (58:55).

Originally posted on October 8, 2024

Dr. Waizbard-Bartov discusses changes in autism symptoms across childhood. She outlines the Autism Phenome Project and study methods for her recent work. The speaker presents findings on the frequency, patterns, and predictors of symptom severity changes across childhood periods in autism. Waizbard-Bartov touches on the intersection of autism symptom severity, assigned sex, and environmental factors. She summarizes presentation findings and considers pathways of future research before the Q&A. 

In this webinar:

1:09 – What is autism
5:00 – Social communication and RRB
12:06 – Autism Phenome Project
16:15 – Study methods
20:15 – Changes in autism symptom severity across childhood
24:30 – Variations in patterns of symptom change
28:05 – Predictors of changes in severity across childhood
30:25 – Sex differences
35:40 – Adaptive function
37:44 – Parental characteristics
39:10 – Co-occurring mental health conditions

What is autism?

Waizbard-Bartov describes autism as a neurodevelopmental condition broadly defined by difficulties with social communication and restrictive, repetitive behaviors (RRB) (1:09). For an autism assessment, social communication differences are subcategorized into social-emotional behavior, atypical nonverbal social behavior, and difficulty creating and maintaining relationships (2:15). RRBs are also subcategorized into stereotyped repetitive speech or actions, excessive adherence to non-functional routines, restricted/fixated interests, and atypical sensory behaviors (4:19). The speaker draws on her time working with preschoolers to illustrate how core characteristics/symptoms of autism range in presentation and severity across individuals and time (8:00). 

Study methods

The presenter outlines the Autism Phenome Project (APP), a longitudinal study of nearly 700 autistic and non-autistic children across five time points from early childhood to early adulthood (12:06). At each time point, the ongoing study assesses blood, MRI, language development, memory and attention, co-occurring conditions, and parental perspectives (14:20). Waizbard-Bartov describes her recent work on autism symptom trajectories across early (ages 3 – 6) and middle childhood (ages 6 – 11.5) (11:25). Her team used APP data for 183 autistic children (30% female-presenting) at three times points: between ages two and three and a half (2 – 3.5 yrs), between ages four and six (4 – 6 yrs), and again between ages nine and twelve (9 – 12 yrs) (16:15). Researchers used the calibrated severity scores from the Autism Diagnostic Observation Schedule (ADOS) to track symptom severity across time and domains (17:50). 

Q1: How common is change in autism symptom severity across childhood?

Researchers divided children into three groups based on observed changes in symptom severity across the first two time points (early childhood; ages 3 – 6). Of these, 54% remained stable, 29% significantly decreased, and 17% increased dramatically in symptom severity across early childhood (20:15). Correlations between behaviors and brain development were also found, where children with increased severity had slower white matter development compared to those with decreased symptom severity (21:43). When assessments were extended to the third time point (middle childhood; around age 11.5), the same three groups were identified, where 49% remained stable, 27% experienced a consistent decrease, and 24% experienced a consistent increase in symptom severity (22:55). Waizbard-Bartov reiterates that about half of children in the study demonstrated changes in severity across early and middle childhood, suggesting that such changes may be expected in autism (24:00). 

Q2: Do patterns of change vary across periods of childhood?

To understand patterns of symptom change across time, the presenter and her team compared early childhood severity changes to those of middle childhood (third time point). Results showed increases in symptom severity are equally as likely to occur during early and middle childhood, while decreases in severity are significantly more likely to occur in early childhood only (24:30). Researchers also found that more than 60% of the sample showed different patterns of change across childhood periods (i.e., decreased in early childhood and stable or increasing during middle childhood) (25:35). Waizbard-Bartov summarizes these findings, asserting that patterns of severity change across periods of childhood in autism (27:15). 

Q3: What predicts directional changes in symptoms across childhood?

To assess predictors of symptom severity changes in autism, Waizbard-Bartov and her team assessed related variables:

Cognitive ability/IQ

Results showed that children with decreased severity in early childhood had a higher IQ at the first two time points and exhibited IQ gains over time (28:45). Comparatively, those with increased severity had lower IQ at both time points that remained stable across time (29:30). The speaker asserts that these findings suggest a strong association between cognitive abilities and symptom severity during early development. 

Sex differences

Researchers found in female-presenting participants, symptom severity is likely to decrease or remain stable. However, for male-presenting participants, increases and decreases in severity are equally likely to occur (30:25). Further, calibrated severity scores revealed that female-presenting individuals show significant severity decreases in total symptoms and, more specifically, in RRB, especially during middle school. Conversely, male-presenting individuals show stable total symptom and RRB scores across childhood (31:15). The presenter discusses sex-compared changes across ADOS items, highlighting the stark trajectory differences between sex groups (33:15).  

Adaptive function

Adaptive functioning is meaningful for everyday life, and all three groups had the same score at age one. However, by age six, those experiencing decreases in severity had significantly higher adaptive functioning than those with increasing severity (35:40). The presenter explains how those with increasing severity did not necessarily lose adaptive function skills but that their rate of progress steadily slowed over time (36:40). 

Parental characteristics

Waizbard-Bartov and her team also found that fathers and mothers of children with decreasing severity were generally older and more educated. Contrastingly, parents of children with increasing severity were younger and less educated. The speaker notes the intersectionality of education and socioeconomic status and its impact on resource accessibility and self-advocacy (37:44). 

Co-occurring mental health conditions

Results showed a significant correlation between aspects of mental health and autism symptom domains (39:10). For example, 21% of participants had significant increases in both the severity of social communication issues and anxiety as they entered elementary school. ADHD levels also rose across middle school, and by age eleven, 84% of participants met the clinical requirements for an anxiety disorder (41:25). In female-presenting participants, improvements in RRB overtime ran parallel to increases in anxiety, where 94% had clinical anxiety disorders by age eleven (44:26). Waizbard-Bartov and her team found no evidence that initial symptom severity can predict changes across childhood, meaning everyone has the same potential for change (45:05). The presenter summarizes the findings for question three, noting that severity changes are correlated with assigned sex, IQ, adaptive functioning, parental characteristics, and mental health conditions (46:45).

• Trajectories of Autism Symptom Severity Change During Early Childhood (Waizbard-Bartov et al., 2021)
• Identifying autism symptom severity trajectories across childhood (Waizbard-Bartov et al., 2022)
• Changes in the severity of autism symptom domains are related to mental health challenges during middle childhood (Waizbard-Bartov et al., 2023)

Conclusion

Waizbard-Bartov summarizes research findings, underscoring that the severity of autism symptoms can change substantially across childhood periods and that patterns of change are not linear. She highlights that a child’s characteristics and environment can predict directional changes and that children have the potential for different severity trajectories regardless of their initial levels (47:55). 

She outlines future research directions, including how severity is affected during adolescence and how interactions between symptom severity and other characteristics play out over time (49:15). The presenter highlights current research around the impact of sex on symptom severity, underscoring the potential effects of camouflaging specific to female-presenting individuals (51:10). The speaker provides thanks and acknowledgments before the Q&A (53:25). 

Originally published on May 15, 2024

In this webinar: 

1:05 – New way of looking at autism
2:55 – Goals of autism research
4:17 –  Maternal Autoantibody Related Autism (MAR-ASD)
6:35 – Initial studies and findings
9:29 – MAR target proteins
13:24 – ADOS and SCQ
15:05 – Modifiable risk factors
16:03 – Pathogenic autoantibodies
17:05 – Passive transfer models
19:35 – Rhesus Monkeys – atypical social development and brain volume
20:57 – Maternal autoantibody model
21:00 – MAR antibodies localize in the brain
23:38 – MAR antibodies taken up into developing neurons
26:03 – Golgi strain of mature neurons
27:25 – Development of rodent model
31:32 – Clarity imaging of MAR-ASD offspring
33:43 – Video: decreased sociability in juvenile MAR-ASD mice
36:10 – Voice prints of MAR-ASD male mice
37:40 – Development of preclinical rat model
40:25 – Video: rat behavior
42:00 – Commonalities across models
42:35 – Conclusions
45:05 – Q&A

Summary

Over the last two decades, autism researchers have shifted focus to studying immune systems and their role in autism and development (1:05). Van de Water outlines Maternal Autoantibody Related Autism (MAR-ASD), a new subtype characterized by the maternal transfer of autoantibodies to the gestational immune environment (4:30). Autoantibodies are antibodies that mistakenly bind to self-proteins instead of foreign bodies (2:00). In MAR-ASD, autoantibodies cross the placenta and bind to targets in the developing brain, changing neuronal development. MAR-ASD cases make up 18-26% of autism diagnoses, and individuals in this subgroup have more severe behaviors, pronounced stereotypy, and significantly larger brain volume (6:11). 

Van de Water outlines the initial findings of a subset of mothers who produced anti-brain antibodies and have children with autism (7:00). She lists subsequent studies relating autoantibodies to autism behavior, genetics, animal models, and more (6:35). Eight MAR target proteins have been identified (9:25) as potential biomarkers associated with autism (100% accuracy) (12:55). Studies have also found that MAR+ children score significantly higher on the ADOS and SCQ compared to MAR- groups (13:24). Specifically, when the CRMP1 autoantibody is present, ADOS severity increases by 2.3 points. The speaker lists modifiable risk factors for mothers (15:05) and outlines her research approach to assessing whether these autoantibodies are pathogenic (16:00). 

She describes Passive Transfer models where human IgG reactive to target proteins are injected into an animal during pregnancy (17:04). A Rhesus Monkey study (17:18) found mothers to be overprotective, and offspring showed evidence of impaired social behaviors (18:10). The same study revealed that monkeys with MAR antibodies (LDH, STIP1, CRMP1) had larger brains (20:30). These findings replicate a previous brain volume study on human children with MAR-ASD (20:57), suggesting that these antibodies have some physiologic effect on brain development. 

A passive transfer rodent model of MAR-ASD found that autoantibodies localize to the brain during gestation and up to 12 hours after birth (21:00). Van de Water outlines similar findings that show MAR antibodies taken up into developing neurons (23:38) and change the way neurons mature (26:03). She describes the development of a MAR autism rodent model using active immunization before breeding (27:05) and discusses the lack of behavioral differences between males and females and the revealed relationship between brain size and severity of behaviors (29:00). A clarity imaging (3-D) study of postnatal mice brains found autoantibodies bound to target proteins inside dividing cells (31:32). 

The speaker presents video studies showing decreased sociability in juvenile MAR-ASD mice offspring compared to stimulus mice (33:43) and highlights the fact that these antibodies are causing differences in brain development and pathology (35:26). Similarly, MAR-ASD male mice recorded significantly smaller voice prints when first exposed to estrus (ready to breed) females compared to the control (36:10). Comparable studies conducted with rats (37:40) reported the same outcomes for social interaction, increased repetitive behaviors, and reduced vocalization (38:50). Dr. Van de Water highlights commonalities across the models presented (42:00) and summarizes the main findings (42:35). 

She emphasizes that gestational immune dysregulation may be an underlying mechanism linked to infections during pregnancy and that humans, mice, monkeys, and rats exposed to MAR autoantibodies all have enlarged brains. The presenter notes that rodent MAR-ASD models capture all three domains of autism (social, communication, and repetitive behavior) and that autoantibodies have structural effects on neurodevelopment and cerebral volume. Van de Water closes with a Q & A session where she discusses details of current studies and more (45:05). 

Dr. Matthew Lerner, Ph.D., discusses social development in individuals with autism. He emphasizes understanding theoretical mechanisms that underly processes generally accepted as social “skills.” The presenter outlines recent findings and discusses their implication in treatments and personal understanding. Lerner highlights the importance of enabling individuals to create meaningful connections and relationships instead of focusing on how people act in social situations. He presents a new model for understanding social development in autism and closes with a question-and-answer session.  

In this presentation

2:50 – Background and outline
3:20 – How to understand social “skills” problems
5:30 – Why study adolescents with autism
10:00 – Story: I want to be a psychic
12:30 – Populations that may have social difficulties
15:00 – Mechanisms
16:08 – Social skills mechanisms
25:30 – Social knowledge
28:00 – Social cognition
32:12 – Insight/self-awareness
37:00 – Social motivation
39:54 – Social information processing
45:00 – Social creativity
47:42 – Quantity of social interaction
52:25 – New model for understanding social development in autism
54:30 – Practical/intervention implications and questions
56:30 – Q & A 

Introduction

Lerner differentiates between social “skills” and theoretical mechanisms related to social engagement. He asserts that we should consider how individuals present in social contexts and how theoretical mechanisms relate to social engagement (3:20). The presenter highlights that this is not a new idea – we understand pathways of medication in our bodies and the mechanisms they impact (15:20). Therefore, we can create more supportive and direct treatments when equivalent mechanical processes for social functioning are understood.  

Theoretical mechanisms and social skills

Dr. Lerner emphasizes that treatments should aim to enhance individual abilities to create and maintain deep relationships instead of how individuals act in social situations (13:30). He outlines research on eight theoretical mechanisms generally understood as social skills. He defines each “skill,” outlines study methods and findings, and discusses their implication in treatments and research (16:08): 

Social knowledge (SK) 

Studies have found no correlation between the amount of SK and successful social interaction. Findings also revealed no significant difference in SK between individuals with autism and their neurotypical peers (25:30).  

Take home: Social knowledge may not be as important as we thought.

Social cognition (SC)

A digital multi-site study looking at aspects of social cognition across domains in individual patients showed slight variation between groups and significant variability within and between participants (28:00). 

Take home: Individual profiles matter in social cognition and treatment development.

Insight/self-awareness 

Multiple studies reveal that children with autism generally rate their own social skills considerably higher than their peers or parents/caretakers rate them (32:12). He defines positive illusory bias as it occurs in ADHD and notes its importance in building self-esteem (33:08). Lerner states that we need to focus on things individuals are doing well instead of the things they are not doing well enough.

Take home: Self-awareness may matter more than previously thought.

Social motivation (SM)

Studies have shown that children with autism and high SM generally have poorer emotion recognition (ER). In some cases, individuals are so motivated to interact that it overwhelms their ability to read the responses of others (37:00). 

Take home: Social motivation is important – but complicated.

Social information processing (SIP)

EEG results show the speed of initial brain processing relates to better SIP and a meta-analysis revealed the n170 blip (41:10) occurs between 30 – 50 milliseconds slower in individuals with autism (42:15). A third study revealed that individuals with and without autism can effectively decode emotional information (43:30). Therefore, treatments should make SIP mechanisms work well for individual patients. 

Take home: SIP is encoded but not always translated.

Social creativity (SC) ­– flexibility in thinking (opposite of social knowledge)

Survey and questionnaire studies reveal SC as one of the only mechanisms related to successful social interactions (47:42). Therefore, if we can find ways to promote SC, we could support more effective social interaction.

Take home: Social creativity is very promising.

Quantity of social interaction

Studies have found that individuals who can effectively read their own emotions engage in significantly more social situations (47:42). Therefore, Lerner posits that effective social interactions may naturally progress if practitioners aim to help individuals identify their own emotions. 

Take home: Quantity of social interaction is not necessarily reduced in autism, and we should consider other factors.

Contextual variability

A recent study found that the ability to adjust behaviors in different social contexts may matter even more than symptom/behavior severity (50:33).  

Take home: Contextual variability is more important than symptom/behavior severity.

Lerner concludes by outlining a model for supporting effective social interactions in individuals with autism (52:25). He describes current research aims and objectives (54:30) before opening a question-and-answer session (56:30).