The effect of early autism intervention on parental sense of efficacy in a randomized trial depends on the initial level of parent stress.

LAY ABSTRACT: This is a study of the secondary effects of interventions for young children with autism on their parents. Specifically, we were interested in the impact on parent's sense of efficacy, or how confident and competent a parent feels about themselves as a parent. We tested three ideas: (1) that the style of the intervention, whether it was more or less structured and whether the parent had a more or less formal role, would impact a parent's sense of efficacy; (2) that the intensity of the intervention, how many hours per week the intervention was delivered, would impact parental efficacy; and (3) that the parent's level of stress prior to intervention would impact how intensity and style effected efficacy. We randomly assigned 87 children with autism, age 13-30 months, into one of four conditions: 15 versus 25 intervention hours crossed with two different styles of intervention. We used statistical tests to examine these ideas. We found that parental efficacy was related to intervention intensity but not style. Parents with higher stress at the beginning of a 1-year, home-based, comprehensive intervention program had a higher sense of parenting efficacy if their child received lower intensity intervention; parents with lower stress at baseline had a higher sense of efficacy if their child received higher intensity intervention. If a parent can emerge from the process of diagnosis and early intervention with an increased sense that they can make a difference in their child's life (i.e. increased sense of efficacy), it may set the stage for meeting the long-term demands of parenting a child with autism.

Stability of Vocal Variables Measured During the Early Communication Indicator for Children With Autism Spectrum Disorder.

The Early Communication Indicator (ECI) was designed to measure expressive communication progress in young children. We evaluated using the 6-min ECI procedure for a new purpose-a sampling context for stable measures of vocal development of young children with autism spectrum disorder (ASD). We evaluated how many ECI sessions were required to adequately stabilize estimates of volubility, communicative use, and phonological complexity of vocalizations at two periods (average of 10 months apart). Participants included 83 young children with ASD (M age = 23.33 months). At study initiation, two phonological complexity variables required two sessions; other variables required three. At study endpoint, all variables required fewer sessions. Findings support the feasibility and stability of using the ECI for the new purpose.

The role of early social motivation in explaining variability in functional language in toddlers with autism spectrum disorder.

LAY ABSTRACT: About one-third of children with autism spectrum disorder never develop the language that they need in different day-to-day situations. Identifying potential factors that can predict later language development is crucial to understanding why some children with autism spectrum disorder successfully develop language while others do not. This study sought to investigate one of the understudied predictors of language development, social motivation, and to test theories for why this association may occur. Testing the theories requires that we measure children's ability to deliberately and directly communicate with others (i.e. intentional communication) and children's language understanding between the measures of social motivation and later expressive language. We tested 87 children with autism spectrum disorder, aged 14-31 months, at four times over 24 months. We found that children with relatively stronger social motivation had relatively better language use 2 years later. This positive link was partly due to a child's ability to produce intentional communication and to understand language. Although we did not measure parents' talking to their children, a theory that inspired this study suggests that children who use frequent intentional communication probably motivate others to talk with them frequently, which facilitates children's language understanding which leads to the development of expressive language. This theory, if confirmed to be true, can provide guidance for parents who want to help their children learn to talk. Parents could look for intentional communication from their children and respond by talking to their children. Effective intervention on both parent and child targets will likely enhance treatment efficacy. Future work is needed to test these ideas.

A Multisite Randomized Controlled Trial Comparing the Effects of Intervention Intensity and Intervention Style on Outcomes for Young Children With Autism.

OBJECTIVE: This randomized, multisite, intent-to-treat study tested the effects of 2 levels of treatment intensity (number of hours) and 2 treatment styles on the progress of young children with autism spectrum disorder (ASD). We predicted that initial severity of developmental delay or autism symptoms would moderate the effects of intensity and style on progress in 4 domains: autism symptom severity, expressive communication, receptive language, and nonverbal ability. METHOD: A total of 87 children with ASD, mean age 23.4 months, were assigned to 1 of 2 intervention styles (naturalistic developmental/behavioral or discrete trial teaching), each delivered for either 15 or 25 hours per week of 1:1 intervention for 12 months by trained research staff. All caregivers received coaching twice monthly. Children were assessed at 4 timepoints. Examiners and coders were naive to treatment assignment. RESULTS: Neither style nor intensity had main effects on the 4 outcome variables. In terms of moderating the effects of initial severity of developmental delay and of autism symptom severity, neither moderated the effects of treatment style on progress in any of the 4 domains. In terms of treatment intensity, initial severity moderated effect of treatment intensity on only 1 domain, namely, change in autism symptom severity; in a secondary analysis, this effect was found in only 1 site. CONCLUSION: Neither treatment style nor intensity had overall effects on child outcomes in the 4 domains examined. Initial severity did not predict better response to 1 intervention style than to another. We found very limited evidence that initial severity predicted better response to 25 vs 15 hours per week of intervention in the domains studied. CLINICAL TRIAL REGISTRATION INFORMATION: Intervention Effects of Intensity and Delivery Style for Toddlers With Autism: https://clinicaltrials.gov/; NCT02272192.

Developmental associations between joint engagement and autistic children's vocabulary: A cross-lagged panel analysis.

LAY ABSTRACT: In this study, we used a cross-lagged panel analysis to examine correlations over time between two types of engagement between children and their parents and children's later expressive and receptive vocabularies. This kind of design can help researchers understand which early developmental achievements "drive" later developmental achievements. It is important for intervention researchers to know which developmental achievements happen first, so that they can set intervention goals appropriately. The two joint engagement variables we examined were (a) higher order supported joint engagement, which occurs when caregivers influence their child's play with toys and the child reciprocally responds to the caregiver, but does not manage the interaction by shifting gaze between the toys and the caregiver, and (b) higher order supported joint engagement that co-occurs with caregiver's follow-in talk (higher order supported joint engagement + follow-in). Follow-in talk occurs when the caregiver talks about objects and events that the child is focused on. Ninety-one autistic children (n = 91) with language delay (mean chronological age = 39 months) participated, along with their primary caregivers. Each of the four variables was measured twice, 8 months apart. Our statistical procedures showed that early higher order supported joint engagement and early higher order supported joint engagement + follow-in were significantly associated with later expressive and receptive vocabulary. In contrast, associations between early vocabulary variables and later joint engagement variables were not significant. Our results suggest that higher order supported joint engagement and higher order supported joint engagement + follow-in may be useful initial intervention targets, for developmental interventions aimed at promoting language development in autistic children who are initially language delayed.

Parent utilization of ImPACT intervention strategies is a mediator of proximal then distal social communication outcomes in younger siblings of children with ASD.

LAY ABSTRACT: Later born siblings of children with autism spectrum disorders (ASD) are at elevated risk for language delay or ASD. One way to manage this risk may be for parents to use techniques taught in Improving Parents as Communication Teachers (ImPACT) with the younger siblings during the period in which language delay and ASD may be too subtle to be diagnosed. ImPACT targets children's play, imitation, and communication skills. Improvement in these skills may reduce the severity of language delays and social communication deficits associated with ASD. In this study, 97 younger siblings of children with ASD and their primary parents were randomly assigned to ImPACT or a control group. We measured whether parents used ImPACT teaching strategies and whether children used the skills that ImPACT targets. We also measured children's later language ability and social communication skills. The results confirmed our predictions that parents' use of ImPACT strategies improves language ability by improving children's motor imitation and communication skills. Use of ImPACT also had a positive effect on children's language delay and ASD symptoms, supporting the clinical value of the findings. The study's methodological strengths make this one of the most rigorous tests of ImPACT and supports one way to manage the risk of language delay and ASD in younger siblings of children with ASD.

For which younger siblings of children with autism spectrum disorder does parent-mediated intervention work?

LAY ABSTRACT: In this second of two primary papers, we examined two pre-intervention characteristics that might describe for whom a parent-implemented intervention, "Improving Parents As Communication Teachers," worked. Investigators randomized 97 high-risk siblings and their primary parent to either the Improving Parents As Communication Teachers or control group, used intent-to-treat analysis, and used assessors and coders who were blinded to group assignment. We predicted that a combined risk score (incorporating young siblings' sex, multiplex status, and behavioral risk) would describe the subgroup for whom Improving Parents As Communication Teachers affected the targeted skills related to reducing communication challenges. We also predicted that pre-intervention level of parents' depressive symptoms would describe the parents whose parenting stress and effectiveness as parents would be improved by learning to use Improving Parents As Communication Teachers. In girls with only one older sibling with autism spectrum disorder and who scored at low risk on an autism spectrum disorder screen, parental receipt of Improving Parents As Communication Teachers training had an indirect effect on children's expressive language ability or autism spectrum disorder diagnosis through earlier effects on high-risk siblings' intentional communication or expressive vocabulary. We did not confirm our prediction regarding Improving Parents As Communication Teachers' effect on parenting-related stress or sense of parenting effectiveness.

Protocol and Feasibility-Randomized Trial of Telehealth Delivery for a Multicomponent Upper Extremity Intervention in Infants With Asymmetric Cerebral Palsy.

BACKGROUND: Past work showed that an in-person, therapist-guided, parent-implemented multicomponent intervention increased the motor functioning of the more affected upper extremity (UE) in infants with asymmetric cerebral palsy. The authors document treatment fidelity and provide initial testing of telehealth intervention delivery in a new subject sample. METHODS: The authors adapted the intervention manual used in the previous trial for telehealth. Infants (6-24 months) were randomly assigned to intervention (n = 7) or waitlist (n = 6). The intervention prescribed soft-constraint wear on the less affected UE for 6 hours, 5 d/wk, and exercises. After an initial in-person training session, three 15- to 45-minute telehealth sessions were performed. RESULTS: Median weekly constraint wear was 21 hours (interquartile range = 10.3-29.7); average parent-treatment fidelity was 95.7% (SD 11.2). A significant large (Cohen d = 0.92) between-group differences occurred on fine motor functioning of more affected UEs. CONCLUSION: The telehealth intervention was feasible and potentially effective, but a larger trial is needed to evaluate efficacy.

Interaction of Treatment Intensity and Autism Severity on Frequency and Maturity of Spontaneous Communication in Toddlers with Autism Spectrum Disorder.

This study tested whether the effect of treatment intensity or treatment style on children's frequency and maturity of spontaneous communication varied by initial severity of disability. Eighty-seven toddlers with autism spectrum disorders were randomly assigned to either (a) 15 hrs per week of discrete trial teaching (DTT), (b) 25 hrs per week of DTT, (c) 15 hrs per week of a naturalistic developmental behavioral intervention (NDBI), or (d) 25 hrs per week of NDBI. Trained research staff implemented the 1:1 treatments in homes or educational centers over 12 months. We quantified the frequency and maturity of spontaneous communication during monthly 6-min communication samples. We quantified disability severity at Time 1 using the developmental quotient from the Mullen Scales of Early Learning and the total calibrated severity score from the Autism Diagnostic Observation Schedule-second edition. Higher levels of treatment intensity (i.e., more hours per week) benefited frequency and maturity of spontaneous communication growth rate only in children with relatively mild autism symptoms. Other results were nonsignificant. Autism Res 2020, 13: 1902-1912. © 2020 International Society for Autism Research and Wiley Periodicals LLC LAY SUMMARY: Eighty-seven toddlers with autism spectrum disorders were randomly assigned to 15 hrs per week of discrete trial teaching (DTT), 25 hrs per week of DTT, 15 hrs per week of a naturalistic developmental behavioral intervention (NDBI), or 25 hrs per week of NDBI. Trained research staff implemented the treatments in homes or educational centers over 12 months. More hours of treatment per week benefited frequency and maturity of spontaneous communication growth rate only in children with relatively mild autism symptoms. Other results were nonsignificant.

Kinematic and Somatosensory Gains in Infants with Cerebral Palsy After a Multi-Component Upper-Extremity Intervention: A Randomized Controlled Trial.

Upper extremity (UE) impairments in infants with cerebral palsy (CP) result from reduced quality of motor experiences and "noisy" sensory inputs. We hypothesized that a neuroscience-based multi-component intervention would improve somatosensory processing and motor measures of more-affected (UEs) in infants with CP and asymmetric UE neurologic impairments, while remaining safe for less-affected UEs. Our randomized controlled trial compared infants (6-24 months) with CP receiving intervention (N = 37) versus a waitlisted group (N = 36). Treatment effects tested a direct measurement of reach smoothness (3D-kinematics), a measure of unimanual fine motor function (Bayley unimanual fine motor raw scores), and EEG measures of cortical somatosensory processing. The four-week therapist-directed, parent-administered intervention included daily (1) bimanual play; (2) less-affected UE wearing soft-constraint (6 h/day, electronically-monitored); (3) reach training on more-affected UE; (4) graduated motor-sensory training; and (5) parent education. Waitlist infants received only bimanual play. Effectiveness and safety were tested; z-scores from 54 posttest-matched typically-developing infants provided benchmarks for treatment effects. Intervention and waitlist infants had no pretest differences. Median weekly constraint wear was 38 h; parent-treatment fidelity averaged > 92%. On the more affected side, the intervention significantly increased smoothness of reach (Cohen's d = - 0.90; p < .001) and unimanual fine motor skill (d = 0.35; p = .004). Using unadjusted p values, intervention improved somatosensory processing (d = 0.53; p = .04). All intervention effects referenced well to typically developing children. Safety of the intervention was demonstrated through positive- or non-effects on measurements involving the constrained, less-affected UE and gross motor function; unexpected treatment effects on reach smoothness occurred in less-affected UEs (d = - 0.85; p = .01). This large clinical trial demonstrated intervention effectiveness and safety for developing sensory and motor systems with improvements in reach smoothness, and developmental abilities.Clinical Trail Registration: ClinicalTrials.gov NCT02567630, registered October 5, 2015.

Neonatal Multisensory Processing in Preterm and Term Infants Predicts Sensory Reactivity and Internalizing Tendencies in Early Childhood.

Multisensory processes include the capacity to combine information from the different senses, often improving stimulus representations and behavior. The extent to which multisensory processes are an innate capacity or instead require experience with environmental stimuli remains debated. We addressed this knowledge gap by studying multisensory processes in prematurely born and full-term infants. We recorded 128-channel event-related potentials (ERPs) from a cohort of 55 full-term and 61 preterm neonates (at an equivalent gestational age) in response to auditory, somatosensory, and combined auditory-somatosensory multisensory stimuli. Data were analyzed within an electrical neuroimaging framework, involving unsupervised topographic clustering of the ERP data. Multisensory processing in full-term infants was characterized by a simple linear summation of responses to auditory and somatosensory stimuli alone, which furthermore shared common ERP topographic features. We refer to the ERP topography observed in full-term infants as "typical infantile processing" (TIP). In stark contrast, preterm infants exhibited non-linear responses and topographies less-often characterized by TIP; there were distinct patterns of ERP topographies to multisensory and summed unisensory conditions. We further observed that the better TIP characterized an infant's ERPs, independently of prematurity, the more typical was the score on the Infant/Toddler Sensory Profile (ITSP) at 12 months of age and the less likely was the child to the show internalizing tendencies at 24 months of age. Collectively, these results highlight striking differences in the brain's responses to multisensory stimuli in children born prematurely; differences that relate to later sensory and internalizing functions.

Predicting Expressive Language From Early Vocalizations in Young Children With Autism Spectrum Disorder: Which Vocal Measure Is Best?

Purpose This study was designed to test the incremental validity of more expensive vocal development variables relative to less expensive variables for predicting later expressive language in children with autism spectrum disorder (ASD). We devote particular attention to the added value of coding the quality of vocalizations over the quantity of vocalizations because coding quality adds expense to the coding process. We are also interested in the added value of more costly human-coded vocal variables relative to those generated through automated analyses. Method Eighty-seven children with ASD aged 13-30 months at study initiation participated. For quantity of vocalizations, we derived one variable from human coding of brief communication samples and one from an automated process for daylong naturalistic audio samples. For quality of vocalizations, we derived four human-coded variables and one automated variable. A composite expressive language measure was derived at study entry, and 6 and 12 months later. The 12 months-centered intercept of a simple linear growth trajectory was used to quantify later expressive language. Results When statistically controlling for human-coded or automated quantity of vocalization variables, human-coded quality of vocalization variables exhibited incremental validity for predicting later expressive language skills. Human-coded vocal variables also predicted later expressive language skills when controlling for the analogous automated vocal variables. Conclusion In sum, these findings support devoting resources to human coding of the quality of vocalizations from communication samples to predict later expressive language skills in young children with ASD despite the greater costs of deriving these variables. Supplemental Material https://doi.org/10.23641/asha.12276458.

Effects of pivotal response treatment on reciprocal vocal contingency in a randomized controlled trial of children with autism spectrum disorder.

LAY ABSTRACT: A recent randomized controlled trial found that children with autism spectrum disorder who received a pivotal response treatment package showed improved language and social communication skills following the intervention. The pivotal response treatment package includes clinician-delivered and parent-implemented strategies. Reciprocal vocal contingency is an automated measure of vocal reciprocity derived from daylong audio samples from the child's natural environment. It may provide stronger and complementary evidence of the effects of the pivotal response treatment package because it is at lower risk for detection bias than parent report and brief parent-child interaction measures. The current study compared reciprocal vocal contingency for 24 children with autism spectrum disorder in the pivotal response treatment package group and 24 children with autism spectrum disorder in the control group. The pivotal response treatment package group received 24 weeks of the pivotal response treatment package intervention. The control group received their usual intervention services during that time. The groups did not differ in reciprocal vocal contingency when the intervention started or after 12 weeks of intervention. However, after 24 weeks the pivotal response treatment package group had higher ranked reciprocal vocal contingency scores than the control group. These findings are consistent with results from parent report and parent-child interaction measures obtained during the trial. The participants in the pivotal response treatment package exhibited greater vocal responsiveness to adult vocal responses to their vocalizations than the control group. Findings support the effectiveness of the pivotal response treatment package on vocal reciprocity of children with autism spectrum disorder, which may be a pivotal skill for language development.

Validity of Vocal Communication and Vocal Complexity in Young Children with Autism Spectrum Disorder.

To identify valid measures of vocal development in young children with autism spectrum disorder in the early stages of language learning, we evaluated the convergent validity, divergent validity, and sensitivity to change (across 12 months) of two measures of vocal communication and two measures of vocal complexity through conventional coding of communication samples. Participants included 87 children with autism spectrum disorder (M = 23.42 months at entry). All four vocal variables demonstrated consistent evidence of convergent validity, divergent validity, and sensitivity to change with large effect sizes for convergent validity and sensitivity to change. The results highlight the value of measuring vocal communication and vocal complexity in future studies.

Vocal Communication With Canonical Syllables Predicts Later Expressive Language Skills in Preschool-Aged Children With Autism Spectrum Disorder.

Purpose We examined associations between vocal communication with canonical syllables and expressive language and then examined 2 potential alternative explanations for such associations. Method Specifically, we tested whether the associations remained when excluding canonical syllables in identifiable words and controlling for the number of communication acts. Participants included 68 preverbal or low verbal children with autism spectrum disorder (M age = 35.26 months). Results Vocal communication with canonical syllables and expressive language were concurrently and longitudinally associated with moderate to strong (R 2s = .13-.70) and significant (ps < .001) effect sizes. Even when excluding spoken words from the vocal predictor and controlling for the number of communication acts, vocal communication with canonical syllables predicted expressive language. Conclusions The findings provide increased support for measuring vocal communication with canonical syllables and for examining a causal relation between vocal communication with canonical syllables and expressive language in children with ASD who are preverbal or low verbal. In future studies, it may be unnecessary to eliminate identifiable words when measuring vocal communication in this population. Following replication, vocal communication with canonical syllables may be considered when making intervention- planning decisions.

Children with Autism Spectrum Disorder May Learn from Caregiver Verb Input Better in Certain Engagement States.

The relation between caregiver follow-in utterances with verbs presented in different states of dyadic engagement and later child expressive verb vocabulary in children with autism spectrum disorder (ASD) was examined in 29 toddlers with ASD and their caregivers. Caregiver verb input in follow-in utterances presented during higher order supported joint engagement (HSJE) accounted for a significant, large amount of variance in later child verb vocabulary; R2= .26. This relation remained significant when controlling for early verb vocabulary or verb input in lower support engagement states. Other types of talk in follow-in utterances in HSJE did not correlate with later verb vocabulary. These findings are an important step towards identifying interactional contexts that facilitate verb learning in children with ASD.

The Relation Between Early Parent Verb Input and Later Expressive Verb Vocabulary in Children With Autism Spectrum Disorder.

Purpose The purpose of this study was to evaluate if higher quantity, diversity, and grammatical informativeness of verb phrases in parent follow-in utterances (i.e., utterances that mapped onto child attentional leads) were significantly related to later expressive verb vocabulary in children with autism spectrum disorder (ASD). Method We examined these associations in a sample of 31 toddlers with ASD and their parents in a longitudinal correlational study. Key aspects of parents' verb input were measured in 2 video-recorded 15-min parent-child free-play sessions. Child expressive verb vocabulary was measured using parent report. Results An aggregate variable composed of the quantity, diversity, and grammatical informativeness of parent verb input in follow-in utterances across the 2 parent-child sessions strongly and positively predicted later child expressive verb vocabulary, total R 2 = .25, even when early child expressive verb vocabulary was controlled, R 2 change = .17. Parent follow-in utterances without verbs were not significantly related to later child expressive verb vocabulary, R 2 = .001. Conclusions These correlational findings are initial steps toward developing a knowledge base for how strong verb vocabulary skills might be facilitated in children with ASD.

Randomized controlled trial protocol to improve multisensory neural processing, language and motor outcomes in preterm infants.

BACKGROUND: Premature infants are at risk for abnormal sensory development due to brain immaturity at birth and atypical early sensory experiences in the Neonatal Intensive Care Unit. This altered sensory development can have downstream effects on other more complex developmental processes. There are currently no interventions that address rehabilitation of sensory function in the neonatal period. METHODS: This study is a randomized controlled trial of preterm infants enrolled at 32-36 weeks postmenstrual age to either standard care or standard care plus multisensory intervention in order to study the effect of multisensory intervention as compared to standard care alone. The study population will consist of 100 preterm infants in each group (total n = 200). Both groups will receive standard care, consisting of non-contingent recorded parent's voice and skin-to-skin by parent. The multisensory group will also receive contemporaneous holding and light pressure containment for tactile stimulation, playing of the mother's voice contingent on the infant's pacifier sucking for auditory stimulation, exposure to a parent-scented cloth for olfactory stimulation, and exposure to carefully regulated therapist breathing that is mindful and responsive to the child's condition for vestibular stimulation. The primary outcome is a brain-based measure of multisensory processing, measured using time locked-EEG. Secondary outcomes include sensory adaptation, tactile processing, speech sound differentiation, motor and language function, measured at one and two years corrected gestational age. DISCUSSION: This is the first randomized controlled trial of a multisensory intervention using brain-based measurements in order to explain the causal effects of the multisensory intervention on neural processing changes to mediate neurodevelopmental outcomes in former preterm infants. In addition to contributing a critical link in our understanding of these processes, the protocolized multisensory intervention in this study is therapist administered, parent supported and leverages simple technology. Thus, this multisensory intervention has the potential to be widely implemented in various NICU settings, with the opportunity to potentially improve neurodevelopment of premature infants. TRIAL REGISTRATION: NIH Clinical Trials ( clinicaltrials.gov ): NCT03232931 . Registered July 2017.

Longitudinal associations across vocabulary modalities in children with autism and typical development.

We examined differences between children with autism spectrum disorder and typically developing children over an 8-month period in: (a) longitudinal associations between expressive and receptive vocabulary and (b) the extent to which caregiver utterances provided within an "optimal" engagement state mediated the pathway from early expressive to later receptive vocabulary. In total, 59 children (28-53 months at Time 1) comprised the autism spectrum disorder group and 46 children (8-24 months at Time 1) comprised the typically developing group. Groups were matched on initial vocabulary sizes. Results showed that the association between early expressive and later receptive vocabulary was moderated by group. A moderated mediation effect was also found, indicating linguistic input provided within an optimal engagement state only mediated associations for the autism spectrum disorder group.

Comparing Auditory-Only and Audiovisual Word Learning for Children With Hearing Loss.

Although reducing visual input to emphasize auditory cues is a common practice in pediatric auditory (re)habilitation, the extant literature offers minimal empirical evidence for whether unisensory auditory-only (AO) or multisensory audiovisual (AV) input is more beneficial to children with hearing loss for developing spoken language skills. Using an adapted alternating treatments single case research design, we evaluated the effectiveness and efficiency of a receptive word learning intervention with and without access to visual speechreading cues. Four preschool children with prelingual hearing loss participated. Based on probes without visual cues, three participants demonstrated strong evidence for learning in the AO and AV conditions relative to a control (no-teaching) condition. No participants demonstrated a differential rate of learning between AO and AV conditions. Neither an inhibitory effect predicted by a unisensory theory nor a beneficial effect predicted by a multisensory theory for providing visual cues was identified. Clinical implications are discussed.