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
Dawson & Rogers, University of Washington
Rogers, Vismara, & Colombi, M.I.N.D. Institute at UC Davis

3. Topics Parent Training, introduction and experimental evidence
The Early Start Denver Model (ESDM) Parent Training
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)
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)
Pivotal Response Training (PRT)
Relationship Development Training (RDI)
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 maternal relationships with infants “special”? Parent training/parent support
Who should deliver tx?
Treatment intensity?
Delivery settings?
Level of directiveness?

9. 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

10. 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

11. 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

12. 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

13. 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

14. EVALUATION

15. 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

16. 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

17. 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

18. 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?

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.

20. 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

21. 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

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
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

25. 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

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.

30. Will parent skills increase child word acquisition ?
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.
Gains are maintained during follow up with parent

35. 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.

36. 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%

37. 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

38. 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

39. 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

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