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Working with parents The Early Start Denver Model Costanza Colombi & Sally Rogers M.I.N.D. Institute, UC Davis.

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Presentation on theme: "Working with parents The Early Start Denver Model Costanza Colombi & Sally Rogers M.I.N.D. Institute, UC Davis."— Presentation transcript:

1 Working with parents The Early Start Denver Model Costanza Colombi & Sally Rogers M.I.N.D. Institute, UC Davis

2 This work is based on Rogers & collaborators, University of Colorado Denver Rogers & collaborators, University of Colorado Denver Dawson & Rogers, University of Washington Dawson & Rogers, University of Washington Rogers, Vismara, & Colombi, M.I.N.D. Institute at UC Davis Rogers, Vismara, & Colombi, M.I.N.D. Institute at UC Davis

3 Topics I. Parent Training, introduction and experimental evidence II. The Early Start Denver Model (ESDM) Parent Training III. A single subject study of ESDM

4 Recommendations for the Education of Children with Autism (NRC, 2001) “…Across primarily preschool programs, there is a very strong consensus that the following features are critical: …Inclusion of a family component, including parent training (p. 219)…”

5 Parents successfully learned: Parent–child relationship (e.g., Koegel, 1996; Mahoney & Perales, 2003) Communication skills (e.g., Harris, 1986; Rogers et al., 2006) Decrease inappropriate behavior (Marcus et al., 1978)

6 Benefits of Parent Training Trained parents continuous gains in children (Lovaas et al., 1973) Trained parents continuous gains in children (Lovaas et al., 1973) Increased generalization and maintenance overtime (Koegel et al, 1982) Reduced stress Increased quality of life in family (Koegel et al., 1996) More leisure time (Koegel et al., 1982) More optimism about child’s development (Koegel et al., 1982)

7 Procedures successfully taught Discrete Trial Training (DTT) Discrete Trial Training (DTT) Pivotal Response Training (PRT) Pivotal Response Training (PRT) Relationship Development Training (RDI) Relationship Development Training (RDI) Denver Model Denver Model

8 A new intervention need: infants and toddlers with autism Are infants “special”? Where do we look for models of infant therapy? Are infants “special”? Where do we look for models of infant therapy? Are maternal relationships with infants “special”? Parent training/parent support Are maternal relationships with infants “special”? Parent training/parent support Who should deliver tx? Who should deliver tx? Treatment intensity? Treatment intensity? Delivery settings? Delivery settings? Level of directiveness? Level of directiveness?

9 Partnerships with families in Denver Model Parents are part of all activities and meetings Parents are part of all activities and meetings Parents help set goals Parents help set goals Parents determine focus of home interventions Parents determine focus of home interventions Parent deliver intervention at home Parent deliver intervention at home Parent/family needs are part of plan Parent/family needs are part of plan Parent supports actively fostered Parent supports actively fostered

10 M.I.N.D. Parent-Toddler Intervention Study (Vismara, Colombi, & Rogers, in press) Intervention right after diagnosis before intensive treatment Intervention right after diagnosis before intensive treatment Effective tools for helping child’s development in all areas Effective tools for helping child’s development in all areas A positive experience of self as teacher, child as learner A positive experience of self as teacher, child as learner To develop a manualized intervention for coaching parents in ESDM To examine parents’ acquisition of ESDM To examine changes in children’s social communication

11 Children Eight consecutive referrals, diagnosis of AD, no health or medical problems, interest in objects ageethnic Rec MA Exp MA ADOS Child 1 26 m Cauc 10 m 11 m 14 Child 2 31 m Cauc 9 m 9 m 14 m 19 Child 3 26 m Latino 11 m 13 m 18 Child 4 27 m Cauc 8 m 8 m 9 m 9 m17 Child 5 35 m Latino 9 m 9 m 10 m 22 Child 6 10 m Cauc 6 m 6 m -- Child 7 36 m Cauc 13 m 12 m 17 Child 8 29 m Cauc 14 m 17 m 22

12 Research Design Single subject design across 8 subjects Single subject design across 8 subjects 17 1 hour contacts across a 26 week period 17 1 hour contacts across a 26 week period Weeks 1 and 2 Evaluate Gather baseline data Develop treatment plan Weeks 3 – 15 Provide 1 hr of parent- Child treatment per week Gather behavior samples weekly Weeks 16 – 26 4 follow-up visits Gather maintenance and generalization data EvaluateTreatFollow-up

13 What do we measure? Fidelity to treatment delivery Therapist – Child Therapist – Child Parent – Child Parent – Child Therapist - Parent Therapist - Parent Progress on Objectives % of objectives mastered % of objectives mastered Dependent Variables Standardized measures (e.g, Mullens, Vineland, CARS, ADOS) Standardized measures (e.g, Mullens, Vineland, CARS, ADOS) Frequency of target behaviors (words, imitative acts, child attention, child initiation) Frequency of target behaviors (words, imitative acts, child attention, child initiation) Data gathered in two 10 min play samples per session One with parent, one with therapist Coded from videos by coders blind to date and order

14 EVALUATION EVALUATION

15 Step 1: Curriculum Assessment Receptive language Receptive language Expressive language Expressive language Joint attention Joint attention Social interaction Social interaction Fine motor Fine motor Gross motor Gross motor Imitation Imitation Cognition Cognition Play Play Personal independence Personal independence –Eating –Dressing –Grooming –chores Autism affects all aspects of development

16 Curriculum Checklist Level 1ObservedTA Report Parent Report Code Receptive Communication 1Localizes to sounds by turning toward sound source 2Looks to playful vocal sounds (raspberry, whistle) 3Responds to voice by turning toward person 4Looks at indicated pictures as adult points to pictures in books 5Follows a proximal point to place objects in containers, puzzle pieces, etc 6Looks when shown an object and told, “Name, look” 7Looks to partner when name is called 8Follows proximal point to object or location 9Follows distal point to retrieve toy 10Looks, reaches, or smiles in response to adult gestures and voice in social games

17 Step 2: Writing Specific Treatment Objectives 12 week objectives developed with parents; 2-3 per developmental area 12 week objectives developed with parents; 2-3 per developmental area Objectives define interventions across people and settings Objectives define interventions across people and settings Objectives target functional, Objectives target functional, adaptive actions-in-context adaptive actions-in-context

18 Treatment Objectives Objectives written in ABC format; measurable, targeting generalization and independent or spontaneous performance Objectives written in ABC format; measurable, targeting generalization and independent or spontaneous performance A: What is the antecedent or stimulus that is to cue the behavior? A: What is the antecedent or stimulus that is to cue the behavior? B: What is the behavior, defined measurably? B: What is the behavior, defined measurably? C: What is the criterion for mastery of this objective? C: What is the criterion for mastery of this objective?

19 Objective - example (A) In sensory social routines, when adult says the names of five different games (e.g. so big, peekaboo, little piggies, here comes a mousey, pattycake) unaccompanied by gestures, (B) the child will respond with an appropriate gesture or body movement (C)75% of the first four opportunities both in therapy and at home with parents over 3 consecutive days. (A) In sensory social routines, when adult says the names of five different games (e.g. so big, peekaboo, little piggies, here comes a mousey, pattycake) unaccompanied by gestures, (B) the child will respond with an appropriate gesture or body movement (C)75% of the first four opportunities both in therapy and at home with parents over 3 consecutive days.

20 Step 3: Developmental Task Analysis of Each Objective Each objective is broken down into 4-6 teaching steps Each objective is broken down into 4-6 teaching steps First step: baseline level of skill First step: baseline level of skill Last step: mastery level of skill Last step: mastery level of skill Intermediate steps define Intermediate steps define progress towards mastery progress towards mastery

21 Step 4: Build the Data Sheet Daily data sheet constructed from task analysis for each objective Daily data sheet constructed from task analysis for each objective Data collected at 15 minute intervals Data collected at 15 minute intervals Data used to adjust daily teaching practices Data used to adjust daily teaching practices Goal: measurable progress Goal: measurable progress within three instructional sessions

22 Daily Data Sheet Example RECEPTIVE COMMUNICATION Looks to adult vocal. in 5 minutes of play : 1X  2X  3X Stops activity, turns and looks to name : looks no distractions  turns and looks  looks while playing  turns and looks while playing  from 5 feet  across room Responds to give gesture and verbal request: extends towards hand  makes contact with hand  places no release  places and releases Follows proximal point to retrieve object: looks at object  touches object  takes object Follows proximal point to place object: looks at indicated target  makes contact with indicated target  inconsistently places on target  consistently places on target

23 Conducting the parent-child session

24 Parent Manual Chapters Attention and motivation Attention and motivation Sensory social routines Sensory social routinesroutines Taking turns during play Taking turns during play Joint activity routines Joint activity routines Imitation Imitation Talking bodies Talking bodies Speech development Speech development ABC’s of learning ABC’s of learning Understanding and managing unwanted behaviors Understanding and managing unwanted behaviors Prompting, shaping, fading, chaining Prompting, shaping, fading, chaining

25 Intervention Session 5-10 minutes – review of past week 5-10 minutes – review of past week 5-10 minutes – play sample with parent 5-10 minutes – play sample with parent 5-10 minutes – discuss new concept 5-10 minutes – discuss new concept 5-10 minutes – demonstrate new concept 5-10 minutes – demonstrate new concept 5-10 minutes – parent practices new concept with coaching until mastered 5-10 minutes – parent practices new concept with coaching until mastered 5-10 minutes – review of objectives, discussion of practice in varying environs 5-10 minutes – review of objectives, discussion of practice in varying environs goodbye goodbye

26 Play Assessment with Parents

27 Sensory routine with Dr Rogers – wk 6

28 Joint activity with father – wk 6

29 Can parents learn to improve their teaching skills in short period of time? Yes, mastery of ESDM by 6th intervention session Maintenance their skill level during program and 3 ms follow up. Maintenance their skill level during program and 3 ms follow up.

30 Will parent skills increase child word acquisition ? Similar levels of child performance occur both with parents and therapists. Similar levels of child performance occur both with parents and therapists.

31 Average Number of Spontaneous Words

32 Will parent skills increase child imitative behaviors? Higher levels are maintained in follow up both with parents and unfamiliar therapists compared to baseline levels.

33 Average Number of Imitative Behaviors

34 Will parent skills improve child engagement? Higher levels of child engagement to adult (i.e., attention, persistence, cooperation, interest) compared to baseline levels. Higher levels of child engagement to adult (i.e., attention, persistence, cooperation, interest) compared to baseline levels. Gains are maintained during follow up with parent Gains are maintained during follow up with parent

35 Higher levels of initiation to adult (i.e., joint attention, affect) compared to baseline levels. Higher levels of initiation to adult (i.e., joint attention, affect) compared to baseline levels. Gains are maintained during follow up with parent and unfamiliar therapist. Gains are maintained during follow up with parent and unfamiliar therapist. Will parent skills improve child initiations?

36 Participant Post-Treatment Mastered Objectives Follow-Up Mastered Objectives Child 1 73%100% Child 2 93%100% Child 3 87%93% Child 4 67%*NA Child 5 56%*NA Child 6 85%98% Child 7 64%100% Child 8 77%100% Developmental Objectives

37 Effects of the intervention: Parents learned play based intervention strategies learned play based intervention strategies learned principles of behavior change and learned how to apply them learned principles of behavior change and learned how to apply them used these skills in real-life contexts and interactions used these skills in real-life contexts and interactions taught children their developmental objectives taught children their developmental objectives maintained skills for 12 weeks after treatment ended maintained skills for 12 weeks after treatment ended

38 Effects of the intervention: children increased attention and engagement with others increased attention and engagement with others increased spontaneous social initiations and responses increased spontaneous social initiations and responses increased number of words more than 10 fold increased number of words more than 10 fold increased number of imitations more than 10 fold increased number of imitations more than 10 fold continued to develop and generalize skills 12 weeks after the end of treatment continued to develop and generalize skills 12 weeks after the end of treatment

39 Conclusions Short term parent based interventions begun soon after diagnosis can: Short term parent based interventions begun soon after diagnosis can: –Provide parents with powerful teaching skills –Address their motivation to act immediately after diagnosis –Stimulate changes in child development –Provide an important intervention while waiting for other treatments to begin –Prepare children for participation in more intensive therapist based interventions

40 Thanks To all the contributors To all the contributors To the participating families To the participating families To YOU! To YOU!


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