1 Early Social Interaction: Parent Implemented Intervention in Everyday Activities for Young Children with ASD Juliann J. Woods, Ph.D. CCC-SLP Department of Communication Disorders Florida State University

2 Early Social Interaction Project Amy Wetherby & Juliann Woods, Co-Directors Family education, supports, and participation Individualized curriculum emphasizing social communication and play in a developmental framework Family-guided, routine based intervention Specialized services with intensity matching needs of child and family Community based programs in natural environments Positive behavioral support Methods and intensity modified every 3 months as needed based on child’s progress Comprehensive, coordinated services guided by IFSP Funded by OSEP, US DOE

3 Theoretical Principles A family-centered approach to meet the family’s needs, concerns, and priorities throughout the assessment and intervention process Embedded intervention in natural environments for the child and family to enhance generalization Parent-implemented intervention

4 Theoretical Principles cont. Focus on the core deficits associated with autism—social communication, family and peer interaction, and play skills Intensity of programming for at least 25 hours of intervention per week Systematic instruction and evaluation using individualized and evidence-based strategies

5 Developmental Behavioral Intervention Uses a developmental sequence for goal setting Advocates for developmentally and individually appropriate practice Identifies observable and measurable goals and instructional strategies Uses behavioral technology – ARC- in an ecological model Applies intervention in systematic and replicable sequences with adequate intensity

6 Intensity Strategies Throughout the day Special times What we know works: Embedded intervention Planning within typical contexts: classroom schedules, family routines Joining into the classroom or family preferred contexts Problem solving, team based decisions What we see happening: Pull out intervention Created lessons or training activities: flash cards, special toys and materials Taking over and becoming adult directed Professionally driven, discipline specific recommendations

7 Natural Environments - How is More Important than Where Intervention at home or child care meets the letter of the law but not the spirit Intended to change the focus of intervention from working directly with the child to supporting caregiver’s ability to enhance the child’s development Daily caregivers, parents and teachers, have many more opportunities to impact a child’s development

8 ESI Practices Sequence Use developmental and functional assessment to identify strengths, concerns Discuss positive and negative “contexts” for child and family; identify frequency, appropriateness Establish “first line” communication and interaction outcomes with other priority targets –Behavior regulation (requesting and protesting) –Joint attention –Gestures (social signals) and choice making –Initiating and turn-taking (rate and quality) Problem solve and coordinate strategies for engaging child, embedding practice, and monitoring progress among team Expand contexts, communication and play partners, settings

9 Types of Routines Play Routines –Construction, pretend, physical, social games Caregiving Routines –Dressing, hygiene, eating, comfort Pre-academic/Literacy Routines –Books, songs, rhymes, computer, video, drawing Community and Family Routines –Errands, chores, socialization, recreation

11 Building Routines with Caregivers Clearly identify intervention routines and activities of interest to child and family Match intervention targets (outcomes) to the appropriate routine or activity Observe sequence and strategies used Embed as appropriate across entire routine –Initiation and set up –Activity and clean up Embed targets within typical sequence UNLESS sequence is dictated by child’s disorder

12 Operationalizing the Principles for Parents: Instruction and Consultation Gathering and Giving Share information and resources Enhance competence through conversations Establish supportive environment Observing and Guiding Watch and suggest simple adaptations Focus attention to salient features Practice or model with feedback Problem Solving and Planning Collaborate on goal setting Monitor child and caregiver progress Plan implementation

13 Identifying Instructional Strategies There are many evidence-based instructional strategies available to use in natural environments for communication and social skill development. Key to success is the match between the child, the skill to be taught, the context, the careprovider and the instructional strategy used. Behavioral challenges should be considered.

14 Identifying Instructional Strategies (cont.) Systematic planning and progress monitoring by the team increases the outcomes for the child and the success for the careprovider. Using the instructional strategies that are natural and comfortable for the careprovider is a good starting point. Additional instructional strategies can be introduced as needed for the child’s success and to increase complexity of communication and interaction.

15 Specific Responsive and Directive Instructional Strategies Contextual support Balanced turn-taking Descriptive talking Increasing opportunities with activities & environmental arrangements Model/request imitation Waiting/time delay Prompts & cues

16 Empirically Supported Strategies for Initiation and Generalization Environmental Arrangement —modify the environment to prompt or cue a child to initiate social interaction Natural Reinforcers —provide access to objects or events that the child desires or removing undesired objects or events Time Delay —provide a stimulus and wait briefly before giving a verbal prompt for a child to respond Contingent Imitation —imitate a child’s actions immediately following the child’s actions (Hwang & Hughes, 2000; Koegel, 1995; McGee, 1999)

17 Family Choices of Routines, Methods, & Service Intensity Logan –Play, snack, dressing (Initial) –Environmental Arrangements, Wait, Incidental Teaching (Expanded), PBS – Sign & Visuals –Service Delivery Home & child care with SLP & EI - 3 hours Child care (3x week- 3 hours) – 6 hours Family implemented routines – 12 hours Loren –Meals, interactive games, music –Establishing routines, Increasing opportunities, Wait –Service Delivery Home with EI & SLP – 2 hours Family implemented routines- 8 (increased over time to 12)

18 ESI Caregiver Instructional Strategies Modeling Guided practice and feedback Conversations and suggestions Problem solving Handouts and recommendations Video tape feedback Group or individual training

19 What research says doesn’t work for generalization Modeling (McBride & Peterson) Handouts (Fox & Dunlap) Group training without feedback and follow-up (Strain et al.) Facility based service delivery (NAS report)

20 Initial results for children with ASD receiving ESI All caregivers demonstrated an increase in ability to embed intervention into routines Intervention strategy use was maintained following transition to other services Rate and pattern of strategy use varied across routines, strategies, and caregivers All caregivers generalized the use of strategies to untrained play and care giving routines Caregivers rated RBI as effective, positive, and time saving

21 Conclusions Early intervention provided to children with ASD in the second year of life appears to lead to better outcomes than waiting until the third year. –Children in the ESI group performed significantly better than the 3 rd year contrast group on social signals, rate of communicating, communicative functions, and understanding, suggesting a treatment effect on these skills. –Children in the ESI group performed comparable to the 3 rd year contrast group on communicative means and play, suggesting a maturation effect on these skills. Parent-implemented intervention in daily routines can minimize professional time and maximize intensity of intervention. A developmental approach can lead to improvements in social communication in children with ASD.

Caregiver Reported Key Learning Strategies  Problem solving weekly with clinician  Demonstration by provider or initial video of other parent using strategy  Discussion of pros and cons to make a good match between strategy, outcome, routine and child interest  Time to talk about the data  Feedback

Problem-Solving as a Communication and Instructional Strategy with Families  Problem solving is an integral component of the consultative model and should be consistently included in each contact  The ability to problem solve independently facilitates generalization for caregivers  Parents identify the opportunity to problem solve as one of their favorite instructional strategies  Key for ESI is to problem solve within the caregivers in a coordinated effort across all team members

24 No easy answers: It’s thinking on your feet! Remember your role is to enhance the confidence and competence of the caregivers Use the ESI theoretical principles Use familiar routines for new skills and new routines for expansion Problem solve with the parent, collect data on the hypothesis, and review the results Expand across the day and contexts systematically Coordinate with the team!