1. Combining Single Case Design and Group Experimental Design Research
Ann P. Kaiser, PhD
Vanderbilt University
IES SCD June 2018

2. Today’s Talk Overview of research on Enhanced Milieu Teaching (EMT)
Illustrate how single case and group experimental designs have been used to build an evidence base
Discuss the advantages and limitations
Guidelines for developing research program drawing on both single case and group design methods
Part 1 now and Part 2 on Thursday
IES SCD June 2018

3. Background: Young Children with Language Impairment
Language development is one of the strongest predictors of children’s long term academic and social outcomes
Primary language delays: Young children with typical cognitive development but significant delays in receptive and expressive language at age 2 are at-risk for later social and academic development.
These risks increase when children live in low resourced homes and communities
Secondary language delays: Young children with intellectual disabilities, Down syndrome, autism spectrum disorders, cleft lip and/or palate are likely to have significant deficits in vocabulary, syntax and social language use that impact overall development, social engagement, behavior and academic performance
IES SCD June 2018

4. Enhanced Milieu
Teaching
IES SCD June 2018

5. IES SCD June 2018

6. Enhanced Milieu Teaching
Program of research
Funded by a ranges of agencies
NICHD program project on children with intellectual disabilities; IES Goal 3 projects, Autism Speaks, OSERS model project, HRSA, John Merck Foundation
Broad population of children
ID, DS, ASD, language delayed, children at-risk due to poverty, children with CLP, children with language delays across Spanish and English
Multiple methods
group experimental, RCT, single case designs, descriptive group analyses
Goals:
Improving generalized communication outcomes for children
Understanding the conditions in which communication and language are learned
IES SCD June 2018

7. EMT Principles and Strategies
Promote adult-child communication in immediate interactions
Notice and respond
Follow the child’s lead
Increase child engagement with objects and activities
Child preferred activities
Join the child in play and activity
Teach play and participation
Expand the social basis of communicative interactions
Arrange environment to increase engagement
Teach joint attention strategies
Balance turns (mirror and map)
Increase person engagement
Teach child communication target forms to advance language
Respond
Model
Expand
Prompt
IES SCD June 2018

8. Evidence For Child Outcomes
Increases child use of language targets
Vocabulary (Kaiser et al, l993*; Scherer & Kaiser, 2010*; Roberts & Kaiser, 2012; Kaiser & Roberts, 2013; Roberts & Kaiser, 2015; Kaiser, Scherer, Frey & Roberts, )
Early syntactic forms (Kaiser & Hester, 1994*)
Moderately complex syntax (Warren & Kaiser, l986*)
Increases child frequency of communication (Warren et al., l994*; Kaiser et al, l993*; Kasari et al., 2016; Curtis, et al.,2017)
Generalization across settings, people, and language concepts (Warren & Bambara, l989; Goldstein & Mousetis, l989; Kaiser & Roberts, 2013)
Maintenance of newly learned targets (Warren & Kaiser, l986; Kaiser & Roberts, 2012; Roberts et al., 2013*)
More effective than drill-practice methods (Yoder, Kaiser, & Alpert, l991*; Kaiser, Yoder, et al., 1996*)
A lot of evidence around how EMT affects speech specifically
More effective than drill-practice methods for teaching spontaneous, generalizable, language concepts
IES SCD June 2018

9. Training communication partners as interventionists is an essential component of EMT
Key Skills
Environmental Arrangement
Notice and Respond
Balance Turns
Model/ Expand
Target Talk
Time Delay
Milieu Prompting Sequence
Mode: Signs, SGD, Speech
Therapists
Parents
Siblings
Teachers and assistants
IES SCD June 2018

10. A Cascading Intervention Model
Interventionist Training
Interventionists
Use of Strategies
Child Language
How to Teach
Interventionists?
What to Teach Interventionists?
IES SCD June 2018

11. Maximizing Intervention Effects
Interventionist Training
Interventionist
Use of Strategies
Child Language
Teach-Model-Coach-Review Training
(Parent Intervention)
Teach
First 10 minutes of each session
Re-stated the strategy, gave example
Role played
Discussed ways to use the strategy
Model
15 minutes of each session
Modeled the language support strategy
Highlighted strategy use
Coach
15 minutes of each intervention session
Coached the caregiver while she practiced the strategy with the child
Review
Last 10 minutes of each session
Discussed the session
Linked parent and child behaviors
Made a plan for home use of strategies
Based on 6 adult learning strategies (Dunst & Trivette, 2009).
Simultaneous use of different methods has the largest effect (d=1.25).
IES SCD June 2018

12. Evidence for Training Parents
Parents learn a range of strategies to criterion levels.
Environmental arrangement (Alpert & Kaiser, 1992*; Hemmeter & Kaiser 1990*)
Responsive interaction strategies (Hancock & Kaiser, 2002*; Kaiser et al., 1996*, Kaiser & Roberts, 2012; Roberts, Kaiser, et al submitted)
Modeling language targets (Hancock & Kaiser, 2002*; Roberts & Kaiser,2015)
Prompting target production using MT techniques (Kaiser, Hancock & Nietfeld*, 2001; Roberts et al, 2015; Wright & Kaiser, 2013*)
Parents generalize these strategies to home interactions with their children (Hancock & Kaiser, 2002; Kaiser & Roberts, 2012; Roberts et al, 2015*Wright & Kaiser, 2013*; Peredo, et al., 2017*).
Parents maintain their newly-learned skills over 6-18 months (Kaiser, et al 2001*; Kaiser & Roberts, 2012;Roberts & Kaiser, 2015; Hampton et al.,2018).
IES SCD June 2018

13. EMT Modifications to Child Characteristics
Teach imitation
Add discrete trials
Increase dosage
Teach joint attention skills
Support partner comprehension
Teach play
Increase person engagement
Teach coordinated joint attention
Provide alternative mode
Signs
SGD
Teach partners mode
Mode
Engage-ment Strategies
Learning Strategies
Baseline Communi-cation
IES SCD June 2018

14. Modifications of EMT JASPER + EMT [J-EMT]
Teaches joint attention, symbolic play, regulation
JASPER + EMT + AAC [J-EMT+ SGD ; Words + Signs]
Includes speech generating device or signs for input and output
Phonological Emphasis + EMT [PE-EMT]
Models speech targets
Recasts for speech
+ Discrete trial training [Rescue protocol]
- Reduce prompt complexity, number of prompts [Simplify]
+ Increase Dosage [Dosage]
+ Support Partners to use mode and EMT [Partner]
IES SCD June 2018

15. Phenotypic Specific Modifications
Population
Modifications
Mode
Engagement
Learning Strategy
Support
Baseline Communication
Toddlers with Receptive/
Expressive
Delay No
Support partner as teacher
Down syndrome
+ Sign or SGD
Teach play
+Dosage
Support partner comprehension
Cleft Lip +/or Palate
+ Speech targets
+Recast
+ Speech practice
Increase rate of child talk
Minimally Verbal ASD
+ SGD
Teach play, engagement
+Rescue Protocol: imitation, receptive language
Teach joint attention skills
IES SCD June 2018

16. EMT Active Ingredient Modification EMT Type Population Study
Play and engage
Teach play,
Use person engaged activity to reinforce social engagement
J-EMT
ASD
Minimally verbal ASD
Kasari, et al., 2006
Kasari, Kaiser et al 2014
Kasari et al in progress
Follow child’s lead in play and activity
Teach play
Provide more motivating materials, choices
 Kasari, et al., 2006
Respond to child communication
Modify mode
Train partners to recognize communication
Target simple rate increases first
Words & Signs
J-EMT +SGD DS
Wright, Kaiser, Roberts & Reikowsky 2012*;
Kasari, Kaiser et al 2014;
Model language in context
Teach imitation skills
Modify modeling to fit speech or mode characteristics
Rescue protocol
 PE-EMT
Words + Signs
Cleft toddlers
Kasari, et al in progress
Scherer & Kaiser, 2011*
Kaiser, Scherer,& Frey, 2017
Expand child communication
Teach prelinguistic skills ( point, show, give)
Increase intelligibility
Make mode more transparent to partner
J-EMT+ SGD
Kasari et al 2006 Kasari, Kaiser et al, 2014;
Kaiser Hampton, & Fuller, in progress
Wright et al 2012*
Use time delay to prompt requests or initiations
Modify time delay (lessen production demand) until child regularly responds
Choose highly preferred objects
 EMT
Words + Signs/SGD
Simplify to accept gesture
Toddlers with receptive/expressive delay
ASD toddlers
Roberts & Kaiser 2012; 2015
Wright et al 2012*; 2015*
Use Milieu teaching prompts to promote practice
Teach responding to prompts and least to most support sequence,
Increase reinforcement for responding
EMT
Simplify
Roberts & Kaiser, 2015
Kasari, Kaiser , 2014
Scherer & Kaiser, 2011*;
Kaiser, Scherer & Frey, in press
IES SCD June 2018

17. Using Single Case Designs
Foundations
Primary demonstrations of components of EMT
Demonstration of new combinations
Training Interventionists
Demonstrating parent training, sibling training, teacher training
Developing Teach-Model-Coach-Review
Training parent trainers
Examining generalization and maintenance
By intervention agents
By children
Differentiating intervention
Child population demonstrations
Adding mode: sign, SGD
Adding components: JASPER (Kasari et al 2006), positive behavior supports, direct instruction
Modifications for intervention context: Spanish speaking, siblings, classroom
IES SCD June 2018

18. Single Case Design Studies
Foundational
Demonstrations
Train Implementers
Differentiate for Child Population
Differentiate for Implementation Context
Design and Demonstrate Systems
IES SCD June 2018

19. Single Case Design Studies: Measurement
Measurement of Key Components
Primary, Generalized, Maintained
Measurement of Implementation.; develop criteria for implementers, for training implementers
Differentiated components, dosage, mode, combination treatments
Differentiated components of implementation to fit culture, language, child needs , setting
Measures of System
Environmental support
Implementation in context
IES SCD June 2018

20. Measurement Development Based on SCD
Observational measures of EMT components
Definitions, reliability standards and protocols, observer training protocols,
Specified to population’s baseline communication, target skills, mode, language
Criteria for primary EMT implementation
E.g., percent responsiveness, percent talk at target level, number and percentage correct use of prompts
Used for therapist implementation fidelity and parent implementation fidelity
Child proximal targets
# of social communicative utterances (word, gesture, sign, SGD)
# of different words or unique multiword targets
# of uses of specific target classes
% responsiveness to obligatory and non obligatory partner communication
Secondary target measures
Use of SCD, problem behavior, generalization, maintenance, general linguistic development
IES SCD June 2018

21. Preparation for RCTs
Estimating relationship between proximal gains and global or distal gains
Therapist implemented produces more rapid gains in proximal targets for children with ID, DS and language impairment
Parent implemented produces slightly more rapid gains and better global gains for children with ASD ( See Kaiser, 2012)
Amount of gain in intervention (Words Observed) needed for 1 point gain on a standardized assessment varies by population
Development of fidelity measures and standards
Estimating dosage of interventions
Acquisition of EMT at criterion
Mastery of EMT sufficient for generalization and maintenance: training across routines
Child dosage to demonstrate global gains varies by population
Could we have done this better with statistical ES estimates?
IES SCD June 2018

22. Two Examples of Blending SCD and RCT
Toddlers with delayed language
Toddlers with delayed language from Spanish-speaking low resourced homes
Single case MBL with 4 families
Dosage based on proximal outcomes
Tested TMCR training protocol
Developed training modules
Estimated power for distal outcomes
RCT Treatment vs Control
Longitudinal follow-up
Examined relation of parent fidelity to outcomes
Examined mediation of behavior and language outcomes
Examined predictors of response to treatment
RCT multisite clinical trial ( beginning July 2018)
Planning: acceptability, feasibility, adaptions
Reviewed data from Spanish speaking families in our previous studies
Interviewed families, providers; validated adapted EMT and TMCR procedures
Single case MBL with 3 families with generalization, social validity, maintenance
Made further adaptations in EMT and TMCR
Small RCT ( ongoing) powered for parent outcomes,
Medium scale RCT powered for child outcomes (proposed, not funded, revised)
Single Case MBL with children with ASD (planned)
IES SCD June 2018

23. Group Experimental Studies
Parent vs Therapist (ID)+ SCD embedded
Parent + Therapist ( Toddlers)
Minimally verbal ASD w/AAC
Minimally verbal ASD DT VS JEMT
Minimally verbal ASD DT+JEMT
ASD Toddlers JEMT
Cleft Lip+/-Palate EMT+PE
DS Preschoolers w/AAC
Spanish Speaking Parents
IES SCD June 2018

24. Strengths of SCD Developing intervention
Demonstrating package interventions
Testing individual components of interventions
Developing fidelity measures and criterion standards
Examine dosage in relation to proximal outcomes
Flexible design could allow modification of treatment, adjustment of dosage
Thorough examination of generalization and maintenance
Examine individual differences in response to treatment on proximal primary and secondary measures
IES SCD June 2018

25. Limitations
Focus in on proximal, malleable outcomes: construct validity and relation to global measures may be a limitation
The nature of the intervention is influenced by the design of treatment delivery
Continuous monitoring
Feedback for performance, fidelity
Some behaviors limit the types of flexible SCD that can be used
May not be clear what characteristics of individuals are related to differences in responding
Challenges in estimating effects; Not how ES estimates for proximal outcomes translate from SCD to RCT
Measures used in RCTs are usually not the same proximal measures in context of intervention
Replications would be useful to increase confidence at each step of development, but rarely conducted
IES SCD June 2018

26. Suggested Guidelines
Determine your long term goal(s) for your research
Theory of change
Indigenous implementers
Naturalistic context
Analyze what you need to know, have and measure
Participant characteristics
Treatment protocols, training materials,
Fidelity protocols
Measures of dependent variables
Dosage, intensity
Determine what questions can be asked using SCD
Determine the optimal, strongest contemporary design SCD for the question
Determine if designing the SCD for statistical analysis is possible
Determine iwhat SCD replications are needed
Pilot global measures that will be used in RCT
IES SCD June 2018

27. Thanks for your time and attention!
More information about EMT research can be found at :
Complete List of Published Work :
MyBibliography: v/sites/myncbi/1busdkbkcgaQ6/bibliogra phy/ /public/?sort=date&directi on=ascending
me:
IES January 2018