Combining Single Case Design and Group Experimental Design Research Ann P. Kaiser, PhD Vanderbilt University IES SCD June 2017

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 IES SCD June 2017

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 2017

Enhanced Milieu Teaching IES SCD June 2017

IES SCD June 2017

Enhanced Milieu Teaching Program of research 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

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 2017

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, 2017 ) 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., in press) 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) 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 2017

Training communication partners as interventioists is an essential component of EMT Interventionists 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 2017

A Cascading Intervention Model Interventionist Training Interventionists Use of Strategies Child Language How to Teach Interventionists? What to Teach Interventionists? IES SCD June 2017

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 2017

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., in press*). Parents maintain their newly-learned skills over 6-18 months (Kaiser, et al 2001*; Kaiser & Roberts, 2012;Roberts & Kaiser, 2015; Hampton et al., in press). IES SCD June 2017

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 CRE AUSTRALIA 2017

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] CRE AUSTRALIA 2017

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 CRE AUSTRALIA 2017

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, in press 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 CRE AUSTRALIA 2017

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 2017

Single Case Design Studies Foundational Demonstrations Train Implementers Differentiate for Child Population Differentiate for Implementation Context Design and Demonstrate Systems IES SCD June 2017

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 2017

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., ercent 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 with social intent) # of different words or unique multiword targets # of uses of specific target classes % responsiveness to obligatory and non obligatory partner communication Secondary target measures IES SCD June 2017

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 Estimating dosage of interventions Acquisition of EMT procedures at criterion by interventionists Mastery of EMT procedures sufficient for generalization and maintenance; e.g., training across routines Child dosage of EMT treatment needed to demonstrate global gains varies by population ( see above) Development of fidelity measures and standards For EMT, for TMCR IES SCD June 2017

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 Smart Design (Planned, multisite) Planning 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 Made further adaptations in EMT and TMCR Small RCT ( ongoing) Single Case MBL with MV ASD w/SGD (planned) IES SCD June 2017

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 Low Resource Spanish Speaking Parents IES SCD June 2017

Strengths of SCD Developing intervention Demonstrating package interventions Testing individual components of interventions Developing fidelity measures and criterion standards Examining dosage in relation to proximal outcomes Flexible design could allow modification of treatment, adjustment of dosage Thorough examination of generalization and maintenance Examining individual differences in response to treatment on primary and secondary measures IES SCD June 2017

Limitations in bridging SCD to RCT 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 SCD that can be used May not be clear what characteristics of individuals are related to differences in responding Challenges in estimating effects ; Not certain if ES estimates translate from SCD to RCT due to measurement differences Measures used in RCTs are global and not appropriate for SCD Replications would be useful to increase confidence at each step of development, but rarely available for new approaches Cost of SCD for complex interventions and time series data are not trivial IES SCD June 2017

Suggested Guidelines Determine your long term goal(s) for your research Identify key questions Build one or more logic models; revise as needed 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 answered and what can be developed in SCD Choose the optimal, strongest design SCD for the information needed Design the SCD for statistical analysis Pilot global measures that will be used in RCT in SCDs IES SCD June 2017

Suggested Guidelines Determine when SCD replication is needed and how replication can inform RCT Remember the Risley rule! (3X) Determine if SCD can be an initial component of an RCT to provide replication Consider SCD as second phase for non responders in an RCT or as a sequence in SCD initial studies (within or across studies) Use SCD in developing and testing training for interventionists IES SCD June 2017

Additional Considerations Research is an iterative process: life is long Standards change: you should too New knowledge informs both questions and methods ”Failed” studies are sometimes the most informative Analyzing data and writing are not just about publication, but essential to the next, best study– even with the “transparent” data from an SCD. IES SCD June 2017

Questions? Contact information: Ann P. Kaiser PhD Dept. of Special Education Vanderbilt University Ann.Kaiser@Vanderbilt.edu 615 322 8160 CRE Australia 2017