Autistic Kids Make Progress with PLAY

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A unique program that tries to draw autistic children out of their shells through intensive, guided play sessions with their parents and trained specialists has shown promising results in a one-year pilot study of 41 young children, University of Michigan Health System researchers say.

The approach, called the PLAY Project (for Play and Language for Autistic Youngsters), helped about half the children make good to excellent progress, as measured by standard scales of autism severity and by independent assessments of videotapes made at their homes. Another one-third of the children made fair progress. And the children whose parents spent the most time -- 15 hours or more a week -- interacting with them using the program's guidelines tended to do the best.

The children, who were on average 3 1/2 years old, had mild to severe forms of autistic spectrum disorders, a group of problems involving children's thinking, language, behavior and social skills. In addition to the hours with their parents, they also had monthly at-home visits by trained consultants, and evaluations by study leader Rick Solomon, M.D., chief of Behavioral and Developmental Pediatrics at UMHS.

The new results, published in conjunction with the Pediatric Academic Societies meeting in Seattle, suggest that the U-M approach could help young children with autism overcome their brains' delayed or stunted development. The approach was relatively inexpensive, costing about $2,500 per year per child.

"Our research has been very encouraging," says Solomon, who based the PLAY Project on a decade of his own work, guidance from the National Academy of Sciences, and the developmental, individualized, relationship-based (DIR) principles of noted child behavior expert Stanley Greenspan, M.D. "These children go from not talking to talking, from ignoring their parents to being playful and interactive."

The approach is based on new knowledge about autism's roots in the brain, and about the ability of very young children's brains to absorb new knowledge and develop new skills -- even if their initial development was stunted by autism. Between 18 months and 6 years of age, children's brains are the most "plastic," making early detection of autism, and early intervention, all the more important.

Now, Solomon is working with school systems trying to cope with dramatic increases in the number of children diagnosed with autism, holding workshops for parents and professionals, and developing a CD-ROM that can be used to train parents.

"In Michigan, there's been an astounding and frightening increase in the number of children with autism," Solomon says, adding that the number of children on the state school rolls with an autism-related diagnosis increased from 250 in 1983 to about 5,000 today. Recently published studies in other states, such as California, have shown similar increases.

Solomon and others attribute the increases in part to better diagnosis of autistic spectrum disorders, especially the milder forms of the disorder, and in part to absolute rises in the number of children affected. No matter what the source of the rise, though, school systems across the nation are facing an onslaught of children whose autism will require special attention.

The precise cause of autism is not known, but experts suspect both genetic and environmental factors are at work. Speculation that the measles, mumps and rubella vaccine is involved has been refuted by careful study.

Researchers can now see the precise physical effects of the disorders more clearly, via brain scans and studies of how the neurons, or brain cells, of autistic children differ from unaffected children. The effects are most visible in brain areas involved in language and learning.

The PLAY Project seeks to help those neurons find new ways to work together to help the children develop their language and social skills, through a process called "relationship building." Says Solomon, "There is a latent capacity of these children's brains to respond to the environment, which is what makes behavioral therapeutic intervention so effective for them."

Even though the intervention used in the PLAY Project may look like mere child's play to the casual observer, Solomon and his team coach parents on having intensive one-on-one interactions with the child, and engaging in playful but structured activities to draw the child out.

"If you teach parents how to hone in on what their child enjoys doing, they are wonderful players with their children," he notes. "This model involves engaging a child in such a way that they love to play with you. It starts where the child's at, and takes them where they need to go." No matter where a child falls on the autistic spectrum, Solomon believes, he or she should be able to make progress in behavioral development -- but only if intervention is started early.

Parents who enrolled in the study began with an office visit with Solomon for a full evaluation of the severity of their child's condition. Then, a trained specialist visited the family at home to begin the observation and training process, and returned each month.

In the meantime, parents were asked to spend as much time as possible pursuing structured play time with their children, and to record the number of hours per week they did it. Since autistic children often have the most interest in activities that use their senses or their movement, or motor, skills, Solomon's specialists teach parents to start with jumping, opening and closing doors, turning on and off light switches, and swinging.

"For instance, in a child who likes to open and close doors, the parents first enjoy their child's joy at watching the door open and close, and begin to engage with them as they open and close the door, saying 'open' and 'close'," Solomon explains. "And once they're engaged, then you begin this process of a relationship that's back and forth. You keep extending this and stretching it out, and soon they understand when you say 'open' and 'close'. And eventually, they gain language from that. They begin to control the environment around them by using their language, and before you know it, you have two-way communication."

The children and their parents were videotaped at the start of their participation and one year later, and the videos were viewed by specialists who had been "blinded" to the study, not knowing which parents had spent the most time with their children.

The blinded reviewers rated the children's developmental gains and the parents' interaction skills. Parents were also surveyed about their satisfaction before and after the intervention began, and a second formal evaluation of the children was performed at the end of the year.

Forty-one percent of parents reported spending 15 or more hours a week in structured play with their children, while 32 percent spent between 10 and 14 hours. More than 62 percent of those children whose parents interacted with them more than 15 hours a week made good or excellent progress, compared with 20 percent of those whose parents spent less than 10 hours.

Solomon notes that not all children find success with PLAY intervention, and that the new findings reinforce the importance of spending as much time as possible in the structured interaction. But, he says, the new data suggest the approach may help chip away at the invisible shell that seems to surround so many autistic children.

One family's experience with the PLAY Project: Ben Gretchko, age 4 1/2, runs up to his mother Lisa after a day at his public preschool, saying "I had a great day in school today!" That wouldn't be out of the ordinary for any other child, but Ben isn't like the 22 other children in his class. He wore diapers, only drank from a bottle and didn't speak a word until he was nearly three years old, and showed little emotion.

"From a very young age, we sensed there was something going on with Ben that was not quite normal," says his mother. At first, she and her husband waited for him to "grow out of" his developmental problems. Then, their pediatrician referred them to a center that tried speech and physical therapy, but after eight months of effort Ben only managed one nonsense word.

That's when the family was referred to Solomon at the University of Michigan Health System, for a full evaluation that revealed Ben's autistic disorder. They enrolled in the PLAY Project in early 2001, and have spent countless hours working with their son in structured play. "We just did what they told us to do and the results have been truly spectacular," says Lisa. "Thanks to the PLAY Project, it's like I have my child back. There's hope out there for these children."

Facts about autism, autistic spectrum disorders and the PLAY Project: -One in every 250 children may have some kind of autistic spectrum disorder.-Autism, which means "to oneself", is marked by various behaviors and developmental delays. Children may not make eye contact or speak, or may repeat sounds or actions.-Autism can be diagnosed in children as young as 18 months, though the typical age at which autistic children are diagnosed and begin treatment is often around 3 years.-Children's brains are the most "plastic", or able to learn new skills and information, in the first few years of life, so autism therapies are most effective when begun early.-The National Academy of Sciences endorses autism interventions that are intensive (more than 25 hours a week), engage the child and aim toward a strategic goal.-The U-M PLAY Project trains parents to interact with their children for at least 15 hours a week, guiding their play and taking cues from them to shape the interaction.

Find more information by phone or on the World Wide Web at:

U-M Play Project: http://www.med.umich.edu/1libr/yourchild/playproject.htm or 734-615-3338

UMHS Your Child web site -- Autism: http://www.med.umich.edu/1libr/yourchild/autism.htm

National Academy of Sciences -- Educating Children with Autism: http://www.nap.edu/books/0309072697/html

National Institutes of Health -- Autism: http://www.ninds.nih.gov/autism

First Signs: http://www.firstsigns.org