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

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

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

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)…”

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)

Benefits of Parent Training 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)

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

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

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

M.I.N.D. Parent-Toddler Intervention Study (Vismara, Colombi, & Rogers, in press) Intervention right after diagnosis before intensive treatment Effective tools for helping child’s development in all areas 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

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

Research Design Single subject design across 8 subjects 17 1 hour contacts across a 26 week period Evaluate Treat Follow-up 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

Fidelity to treatment delivery Progress on Objectives What do we measure? Fidelity to treatment delivery Therapist – Child Parent – Child Therapist - Parent Progress on Objectives % of objectives mastered Dependent Variables Standardized measures (e.g, Mullens, Vineland, CARS, ADOS) 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

EVALUATION

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

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

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

Treatment Objectives 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? B: What is the behavior, defined measurably? C: What is the criterion for mastery of this objective?

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.

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

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

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

Conducting the parent-child session

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

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

Play Assessment with Parents

Sensory routine with Dr Rogers – wk 6

Joint activity with father – wk 6

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.

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

Average Number of Spontaneous Words

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

Average Number of Imitative Behaviors

Will parent skills improve child engagement? 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

Will parent skills improve child initiations? 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.

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

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

Effects of the intervention: children increased attention and engagement with others increased spontaneous social initiations and responses increased number of words 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

Conclusions 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

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