Working with parents The Early Start Denver Model

1. Working with parentsThe 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 Eight consecutive referrals, diagnosis of AD, no health or medical problems, interest in objects

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

16. Curriculum Checklist

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. 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 Parent Manual Chapters

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

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!