The PREAUT research :
Evaluation of a consistent set of tools identifying early communication perturbations which could lead to a developmental disorder of the autistic spectrum

PHRC: Pr C.Bursztejn
PREAUT: G.C. Crespin, PhD
M.C. Laznik PhD
Dr J.P.Muyard
Dr J.L.Sarradet

Introduction

The autistic spectrum disorders are specified by qualitative and quantitative alterations of social and communication interactions, as well as by restricted, repetitive and stereotyped behaviors and activities.  At the moment, these disorders are most of the time diagnosed at the age of three, but it still occurs that they are identified around the age of 4, during the systematic pediatric exams conducted in France by public health doctors in pre-primary school.

There is a wide agreement about the interest for early diagnosis in order to reduce handicaps due to autistic disorders, and numerous publications state the favorable evolution of children with autistic spectrum disorders when early diagnosis and intervention have been done.  Furthermore, even if the autistic signs are not obvious and rarely complete under the age of 3, all collected data, and essentially parents’ observations, verify that such signs exist in 75% to 80% of the cases before the age of 2, and in 31% to 55% of the cases during the first year of life.

Consequently, it seemed very important to validate reliable markers, easy to use within the framework of routine pediatric consultations, in order to identify, during the first two years of life, signs of communication disturbances that could lead to developmental disorders of the autistic spectrum.

Historical background

In 1998, a group of psychiatrists, psychologists and psychoanalysts, all autistic disorders practitioners, founded the PREAUT association in order to carry out a research aiming at the validation of such early communication disturbances that could be linked to an autistic disorder risk.

The PREAUT research, called “Evaluation of a consistent set of tools identifying early communication perturbations, which could lead to a developmental disorder of the autistic spectrum”, is promoted both by the PREAUT Association (Paris, France), represented by its President, Dr. Jean-Louis Sarradet, and the Programme Hospitalier de Recherche Clinique (PHRC) of the Strasbourg University Hospital (France), represented by Prof. Claude Bursztejn.

The PREAUT research is aimed at pediatricians and general practitioners working on the frontlines, who see babies from birth and during the earliest months of life within the framework of the Protection Maternelle et Infantile (French public health centers for free pediatric care).   Since 1999, PREAUT psychoanalysts have trained over 600 pediatricians and GPs all over France to recognize early warning signs of the risk of an autistic evolution.

Without favoring any particular etiology, the PREAUT hypothesis is that there must be psycho-relational situations that support cognition, making it possible, during the early months of life.  These situations should be observed in the relationship between the baby and his familiar others (usually, his parents), well before the cognitive markers usually sought -like proto-declarative pointing and pretend play of the CHAT scale, for instance- become observable.

The PREAUT Research protocol

- The PREAUT signs

M. C. Laznik proposed her hypothesis of the PREAUT signs: the baby who is at risk for autism, would have a failure of the third phase of the drive circuit.

Several theories show evidence that from birth, the baby shows an interest for certain specific elements of his mother’s voice: the motherese phenomenon pointed out by Fernald, and later studied by Prof. Trevarthen and al.,  which coincides with what Lacan proposes as the invocatory drive.  During the first year of life, two other drives are also easily detected by pediatricians: the interest the baby shows for watching and being watched (called the scopic drive), and for eating and being “eated up” for fun (Oral drive).

According to Freud, the drive move, to complete its circuit, has to go through three phases:
– The 1st phase is active: the baby seeks the object of satisfaction ;
– The 2nd phase is considered to be auto-erotic: the baby takes a part of his own body as an object of satisfaction ;
– The 3rd phase turns into drive passivation : the baby makes himself the  object for a familiar Other (usually, his mother), and seeks his/her satisfaction.

If we put these three phases of the drive circuit into clinical terms, we can consider, as far as the oral drive is concerned, that in the first phase, active, the baby seeks the object of satisfaction : the breast or the bottle ; in the second phase, auto-erotic, the baby takes a part of his own body as an object : his thumb, fingers or the pacifier.

Pediatricians and GPs, who consider them as important developmental markers, usually observe these two phases, already well known.

But the third phase of the oral drive circuit is less known, and may not be as well observed; it goes like this:

» The baby offers a part of his body to the mother to “taste” if it’s good (usually, his fingers, toes or tummy);
» The mother pretends to taste and says, joyfully, something like : “We could eat up a  baby like that!”
» The baby shows his joy at having caused the pleasure he reads in his mother’s face (scopic drive), and in her voice (invocatory drive).

Lots of spontaneous family films show this type of fun playing between mothers and normal babies, during everyday feeding, changing panties or bath scenes.

The following scenes are taken out of video recording of family films used by PREAUT for the training of paediatricians, which show evidence of a normal baby, Fabien, who seeks to provoke his mother’s joyful reaction, while a sick baby, Marco, doesn’t.

Fabien, a normal developing 4 months baby, offers his fingers and toes to his mother to “taste” if they are good to eat:

» The mother pretends to taste and says, joyfully, “We could eat up a baby like that!”:
Then Fabien re-starts the interaction, offering his toes to his mother to have her “taste” them again

And finally Fabien shows his joy at having caused the pleasure he reads in his mother’s face (scopic drive), and in her voice (invocatory drive):

This third phase is necessary to allow the second one become “auto-erotic”.  Babies who will become autistic can have sucking movements which are pacifying procedures, but not yet auto-erotic, since the erotic link to the important others (usually, the parents), is lacking.  Family movies show that babies who have become autistic can sometimes smile and look back during “proto-conversation”, but don’t look and mainly don’t seek to be looked at during every day activities, such as changing panties, feeding or bathing.

In the following scenes of the PREAUT video recording, Marco doesn’t seek to provoke his parents’ joyful reactions in everyday activities, but remains able to respond when actively stimulated by his parents in the « proto-conversation » situation, as described by C. Trevarthen.

Marco, 2 and half months, smiles and looks back during the proto-conversation situation:

But he doesn’t look nor seeks to be looked at during everyday changing panties or bath scenes:

Therefore, within the PREAUT research, we consider that the early warning signs start flashing when the baby does not seek to be looked at for fun, either by his mother or the doctor, during the regular pediatric consultation, at the age of 4 and 9 months.  Normal babies perform very easily the “seeking to be looked at for fun” sign, usually long before the age of 4 months.

Consequently, the PREAUT signs result from the combination of these two behaviors current in normally developing babies:

1) the baby does not seek to be looked at by his mother (or his significant other), while she is not stimulating him;
2) the baby does not seek to provoke the joyful reaction of his mother (or his significant other), while she is not stimulating him.

There is a consistency between the PREAUT signs and the CHAT items validated as autism-risk indicators, particularly the pretend play.

Let’s consider the oral drive PREAUT sign, as being the fact that the baby does not try to get his mother “eat him all up”, in a joyful mood.  In this example, this means that the baby does not feel to be a good object of satisfaction for his mother, and therefore he does not seek to verify how satisfactory he is for her.  This is the absence of drive passivation.

In the pretend play item tested by the CHAT, children are supposed to pour something good and pretend to drink or eat it.  Normal developing children perform very easily this item and also do something else: they give the good thing to eat or drink to the mother –or the adult who is playing with them.  We can consider that hereby, the child feels he has a very satisfactory object to give to the other, and thus verify how satisfactory he is being with him/her.

Bob is a charming 6 year-old autistic boy who is able to pretend play that he is eating, but is not able to give someone else something to eat .   His pretend play stays thus completely autistic.  Following the PREAUT hypothesis, in spite of his capability to perform pretend play, we can consider that his drive-circuit is not completed.

Consequently, we pretend the PREAUT research to be an “Evaluation of a consistent set of tools identifying early communication perturbations, which could lead to a developmental disorder of the autistic spectrum”.

The QDC and the CHAT

Several years ago, the CHAT scale (Checklist for Autism in Toddlers) was validated by S. Baron-Cohen and coll.   This scale studies three items which have been assessed to be absent in autistic children: joint attention, proto-declarative pointing and pretend play.  At the end of the study on 16.000 children, the 10 suspected children were assessed to be autistic at the age of 42 months.  The CHAT can therefore be considered as specific, although not sufficiently reliable, as a later study carried out by the same team  showed it.  In spite of this limitation, the PREAUT team considered the CHAT as an interesting tool to be tested within our protocol, with some complementary items added in order to improve its reliability.

Within the framework of a multicentric study carried out by Prof. C. Bursztejn and his team of the Strasbourg University Hospital (CHRU de Strasbourg, France), 27 items identified as being possibly predictive of autistic disturbances have been tested on 2 350 children of 8 to 13 months during the routine paediatric exams.  As a result of this study, 8 of those items, which have been assessed to be present in normally developing babies, were selected to constitute the Communication Development Questionnaire (Questionnaire du développement de la Communication - QDC).

The PREAUT team decided to include both these scales along with the PREAUT signs, and therefore, the PREAUT protocol will test the complete set of these tools, as follows:

- The PREAUT signs (M.C.Laznik and coll.), on babies at 4 and 9 months of age;
- The QDC - Communication Development Questionnaire (C. Bursztejn and coll.), on babies of 12 months of age; and
- The CHAT scale, in the currently modified French version (C. Bursztejn and coll.) on babies of 24 months of age.

Running the research

The PREAUT research has been set up in France on a nation-wide basis in cooperation with districts where the partnership between pediatricians and psychiatrists already exists, or where there is a desire to create it.  So far, this partnership has been established with 10 French districts . Three other districts should be joining the program in 2006.

Pediatricians training program :

» 1st day :

- The importance of early interactions with the significant others in the construction of the psychical apparatus;
- Paternal and maternal functions: their relative influence upon the link set up;
- The three main drives during the first year of life : oral drive, scopic drive and invocatory drive;
- Positive signs of development and signs of link disturbances within each drive;
- Prevention and intervention in early link disturbances: a practical guide.

» 2nd day :

- Presentation of theoretical and clinical elements of the PREAUT signs:
- The three phases of the drive circuit according to Freud; importance of the third phase or drive passivation;
- The relationship between gaze and voice: the “proto conversation” situation;
- The relationship between drive and cognition.

- Presentation of the QDC (Communication Development Questionnaire)

- Presentation of the CHAT (Checklist for Autism in Toddlers) scale as modified by the complementary items added by the Strasbourg team.

» 3rd day:

- Presentation of methodological and logistical aspects of the PREAUT research to the medical teams joining it;
-  Setting up partnership networks between PMI (public health pediatricians in France) and the professionals of the child-psychiatric departments. This day is jointly organized with colleagues from the local child-psychiatric departments.

Pediatricians receive a booklet for each child, composed of four duplicating forms to be sent back for data collecting.  Each form corresponds to the 4th and 9th month exams (PREAUT signs), the 12th month (QDC questionnaire), and 24th month (the CHAT). An English translation of the original forms of these questionnaires is attached.

A Regional Research Team has been built up with child psychiatrists and psychoanalysts in each district participating to the research.  Thus, the medical teams will be able to refer to their closest research member about any child identified as at risk according to the research criteria.

For every child included in the research sample, the four questionnaires will be systematically fulfilled, whether they presented risk or not.  Children, for whom a risk has been detected according to the research criteria at anyone of the exams, will be oriented towards clinical assessment at the age of 24 months, and, if necessary, diagnosis verification through internationally recognized standardized tools (CARS, ADI, ADOS).

A monthly teaching seminar on early interactions has been set up in Paris for the medical teams since March 2003.  Several other seminars have been created in other districts since then.   They allow the medical teams to present and discuss clinical situations as well as prevention and early intervention issues.  The clinical situations discussed in the Seminars are published yearly in the “Cahiers de PREAUT” , along with scientific and clinical issues about autism and early intervention and care.

Feasibility study results

From January 2002 to November 2004, a feasibility study had been run in three pilot districts (Hauts de Seine, Aude and Gard), out of which 47 free pediatric consultation centers participated.

The feasibility study included 1.800 babies.   Out of the 1.800 responses, none could be said at risk of autism at both exams (4 and 9 months).   Only one baby presented risk criteria at 4 months, but he recovered at 5 months and his 9 month exam was normal.  About 8% of the babies seen were engaged in a link difficulty with their mother, not specific of autism.  These data correspond to the presently admitted statistical incidence.

The Operational phase

The operational phase started in late 2005 till December 2007 in ten districts.  Two other districts will follow in late 2008 and in 2009.  In June 2008, 178 public health centers for free pediatric care out of these districts, participating in the research, have included 7.340 babies in the data base.

The whole study should include 15.000 babies, which means that, in all the districts, a 3-year inclusion will be necessary to meet the sample size required by the low statistical incidence of the developmental disorders of the autistic spectrum.

Associated PREAUT programs in the world

Three associated programs are starting to provide pediatricians training :
» The “Mirar y prevenir” program in Buenos Aires, Argentina (started in July 2005)
» The Instituto da Familia of Sao Paulo, Brazil (started in July 2006)
» The School of Infant Mental Health, London, U.K.(started in November 2006)

Research back-up

» A Regional Research Team : has been set up with child psychiatrists and psychoanalysts in each district participating to the research.  Thus, the medical teams will be able to refer to their closest research member about any child identified as at risk according to the research criteria.
» Clinical teaching seminars
A clinical teaching seminar on early interactions has been set up in Paris for the medical teams since March 2003.
It allows medical teams to present and discuss clinical situations as well as prevention and early intervention issues.
Six other seminars have been created since 2005 in Carcassonne (Aude), Dijon (Côte d’Or), Orléans (Loiret), Marseille (Bouches du Rhône), Nîmes (Gard). and Pointe à Pitre (Guadeloupe).

» “Cahiers de PREAUT”
The clinical situations discussed in the Seminars are published yearly in the “Cahiers de PREAUT” along with scientific and clinical issues about autism and early intervention and care.

» Five « Cahiers de PREAUT » are currently available :
- « Aspects cliniques et pratiques de la prévention de l’autisme »,  2004
- « Psychanalyse et neurosciences face à la clinique de l’autisme et du bébé », 2005
- « Autismes: Etat de lieux du soin  », 2006
- « Actualités du soin : approches cognitivo-comportementales and analytiques des troubles autistiques, 2007
- « Evaluations diagnostiques, évaluations des traitements de l’autisme : état des lieux et débats », 2008.

» « Cahiers de PREAUT » foreign versions:
A portuguese version has been published in Brazil in August 2007, and a Spanish version is being considered in Buenos Aires, along with the PREAUT affiliated programs.

Expected results and perspectives

Besides the interest of the evaluation of the set of tools, we are confident that using the database raised by our research will hopefully lead to numerous possibilities of developing further knowledge on the autism spectrum disorders as well as on larger link disturbances of early infancy.

Paris, June 2008

ANNEXES

The PREAUT Questionnaire :_4th &  9th months

1st part of the questionnaire
QUESTIONS TO THE DOCTOR ANSWER VALUE
1 Does the baby seek to look at you ?
a) Spontaneously   Yes 4
No 0
b) When you talk to him (proto-conversation) Yes 1
No 0
2) Does the baby seek to be looked at by his mother (or his important other) ?
a) When she doesn’t solicit him, babbling, wriggling and intensely looking at her ? Yes 8
No 0
b) When she talks to him (proto-conversation) Yes 2
No 0
TOTAL SCORE

If the score is over 3, you don’t need to answer to questions 3 and 4.

4th & 9th months : 2nd part of the questionnaire
QUESTIONS TO THE DOCTOR ANSWER VALUE
3) When his mother (or his important other) is not soliciting him

a) Does he look at his mother (or his important other) ? Yes 1
No 0
b) Does he smile at his mother (or his important other) ? Yes 2
No 0
c) Does the baby seek to provoke a joyful interaction with his mother (or his important other), for instance proposing his tummy, hands or toes to be eaten up for fun ? Yes

No 4

0
4) While being stimulated by his mother (or his important other)
a) Does he look at his mother (or his important other) ? Yes 1
No 0
b) Does he smile at his mother (or his important other) ? Yes 2
No 0
c) Does the baby seek to provoke a joyful interaction with his mother (or his important other), for instance proposing his tummy, hands or toes to be eaten up for fun ? Yes

No 4

0

Clinical remarks :

COMMUNICATION DEVELOPMENTQUESTIONNAIRE (QDC)

Communication development exam - 9- 13mois
Date :
Parents’ answer Observed by the doctor
No Yes No Yes
1  Can you easily obtain eye-to-eye contact with the child  ?  •  •
2 c Can you easily understand what the child feels through his facial expressions ?  •  •
3  Does the child take an object or a toy you hold out to him ?  •  •
4  Does the child smile to his mother or his important others ? (”smile- answer”)  •  •
5  Does the child respond when you talk to him ; for instance, looking, listening, smiling or babbling ?  •  •
6  During the paediatric exam, did you find the postural exchanges adapted? (adequate holding)
 •

Clinical remarks:

CHECKLIST FOR AUTISM IN TODDLERS

C.H.A.T.

Nom de l’enfant :
Date de naissance :
Age :
Adresse de l’enfant :
N° de téléphone :

SECTION A :   Ask parent

(9 items)

1. Does your child enjoy being swung, bounced on your knee, etc. ?
yes   no

2. Does your child take an interest in other children ?
yes  no

3. Does your child like climbing on things, such as up stairs ?
yes  no

4. Does your child enjoy playing peek-a-boo/ hide-and-seek ?
yes   no

5. Does your child ever PRETEND, for example, to make a cup of tea using a toy cup and teapot, or pretend other things ?
yes   no

6. Does your child ever use his/her index finger to point, to ASK for something ?
yes no

7. Does your child ever use his/her index finger to point, to indicate INTEREST in something ?
yes  no

8. Can your child play properly with small toys (ex : cars or bricks) without just mouthing, fidding, or dropping them ?
yes   no

9. Does your child ever bring objects over to you (parent), to SHOW you something ?
yes  no

SECTION B :    GP or HV observation

(5 items)

i. During the appointment, has the child made eye contact with you ?
yes   no

ii. Get child’s attention, then point across the room at an interesting object and say “oh look ! There’s a (name of toy) !” Watch the child’s face. Does the child look across to see what you are pointing at ?
yes  no

iii. Get the child’s attention, then give child a miniature toy cup and teapot and say “Can you make a cup of tea ?’. Does the child pretend to pour out tea, drink it, etc. ?
yes   no

iv. Say to the child “where’s the light ?” or “show me the light”. Does the child POINT with his/her index finger at the light ?
yes   no

v. Can the child build a tower of bricks ? (if so, how many ?) (number of bricks…)
yes   no

Complementary items to be tested for the french version :
Parents’ answer Observed by the doctor
No Yes No Yes
1°.  You can easily understand the child’s feelings from his facial expression
2°.  He stretches out his arms when you propose to pick him up
3°.  He is interested and accepts the objects or toys proposed to him
4°.  He is interested by other children or adults
5°.  He responds when called by his christian name
6°.  He seeks help from well-known people when he gets hurt
7°.  He attracts other people’s attention through mimics, sounds or words*
8°.  He says “goodbye”, or “no” nodding his head, or he sends kisses
9°.  He doesn’t make any repetitive movements – other than when going asleep

Clinical remarks :