Title: Intervention with Toddlers Showing Early Indicators of Autism: A Parent-Mediated Model for Promoting Joint Attention
1Intervention with Toddlers Showing Early
Indicators of Autism A Parent-Mediated Model
for Promoting Joint Attention
- Kathleen Baggett, Ph.D.
- Stacia Mitchell, Ed.S.
- University of Kansas
Autism Across the Life Span A Conference for
Professionals and Families Sponsored by the
Kansas Center for Research and Training November
6, 2009
2Joint Attention Mediated Learning (JAML) Study
- Multi-site research study
- Investigators include
- Hannah Schertz, Ph.D. (Principal Investigator
University of Indiana) - Samuel Odom, Ph.D. (Co-Principle Investigator,
University of North Carolina) - Kathleen Baggett, Ph.D. (Co-Principle
Investigator, University of Kansas)
3JAML Project Aims
- Refine and evaluate the JAML intervention
- Improve child performance in targeted precursors
of joint attention (focusing on faces and
turn-taking) - Demonstrate that joint attention is achievable
and generalizable through parent-child
interaction - Hypothesis
- Toddlers will acquire joint attention as an
effect of the intervention
4Intervention description
- Phases
- Focusing on faces
- Turn-taking
- Joint Attention
- Mediated learning principles Examples
illustrated for parent-child and
interventionist-parent interaction - Focusing (on child on parent)
- Organizing/planning (for child for parent)
- Encouraging (child parent)
- Expanding (child parent)
- Giving meaning (child parent)
5Focusing on Faces
- The child focuses on the parents face
6Turn-Taking
- The child takes turns with parents
- Parent or child initiates
- Parent or child responds
- Partner responds
7Joint Attention
- The child shifts attention back and forth between
the parents face and an object for the purpose
of social sharing
8Intensity
- Weekly home visit with parent
- Parent implements daily parent-child play
interaction - 30-60 minutes daily for planned sessions
- Incidentally through natural learning
opportunities
9Unique Features of the JAML Intervention
- Developmental appropriateness for toddlers
- Targeted outcomes are supported within the
parent-child relationship - Parents are supported in tailoring the
intervention to their individual relationship
with their child - Intensity is reframed in terms of ongoing
parent-child interaction
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11Inclusion/Exclusion Criteria
- Inclusion Criteria
- Children age 14 29 months
- With or at-risk for autism (Fails M-CHAT)
- Absence of joint attention (based on observation
of parent-child interaction) - Exclusion Criteria
- Confounding diagnosis
12Project Interventionists
- Masters level clinicians with training and
experience in early childhood, special education,
and/or counseling. - Work closely with the research team and their
site investigator
13An Interventionists Perspective
14Session description
- Review parent daily log and reported successes
challenges from the week - Provide introduction for each phase
- Discuss targeted outcomes and show video examples
- Discuss parent mediated learning strategies to
support targeted behaviors and show video
examples - Parent tries out the mediated learning principles
- Video-record 10-minute parent-child interaction
session - View and discuss the recorded interaction
- Jointly plan activities for the week
15Implementation Roles
- Interventionist Guide on the side
- Provide rationale and activity examples for each
phase - Show video examples to introduce new phases
- Provide support encouragement return to
mediated learning strategies if parent is stuck - Parent Lead role in the intervention
- Demonstrate parent-child interaction at weekly
sessions - Use knowledge of child interests to identify
activities consistent with active phase of
intervention - Use mediated learning principles in planned and
incidental daily activities - Record brief daily notes on successes and
challenges
16The Collaborative Relationship
17Challenges to Collaboration
- Grief
- Secrecy
- Shame, guilt, depression, low self-esteem
- General support needed for healthy
developmentally appropriate play/interaction in
general - Pre-conceived expectations about the
parent-interventionist relationship based on
other program experiences - Expert who comes in and does direct teaching with
the child - Valuing of an authoritarian expert
- Struggle with viewing themselves as the active
change agent with their child and engaging in
intervention accordingly - Parents who have previously bought into an
intervention model that - Does not reflect or value healthy parent-child
play and interaction in general - Involves drilling which competes with
spontaneity, reciprocity (fun, turn-taking)
18Building the Relationship to Change
- How Parent and Child begin to grow and change
- Dialogue with Coach
- What to try
- Collaborative Relationship working together
- Strengths based
- Where are childs skills and what does child
enjoy - Encouragement and positive focus
- Focus on parts of interaction that are working
well - What is mom doing that is working
19Building the Relationship to Change
- Support
- Discuss challenges and successes of the week
- Practice then discuss interaction
- Encourage parent reflection and debrief
- What happens when parents get stuck?
- Revisit Mediated Learning Principles
- Revisit video examples
- What other parents have tried
- Discuss previous success and how we use those
skills again - Follow childs lead
20A Parents Perspective
- What drew you to the program?
- Help with socialization and engagement with other
children - Once we were in the program, we realized we
needed more help - What do you think was most helpful?
- Weekly accountability
- Tangible Goals
- On childs level of interest, not some arbitrary
goals - What surprised you?
- The progress and skills that made everything else
start coming together
21A Parents Perspective
- What was unique about this program?
- Sequence
- Eye contact was the biggest piece
- What kept you in the program given the time
commitment? - Progress was motivation
- What would be helpful to share with other
parents? - Joint Attention and steps to nonverbal and then
verbal communication - Bringing them out of their world to connect with
us through Joint Attention
22A Parents Perspective
- What changes have you seen in your child that you
attribute to this program? - Eye contact
- Turn Taking skills
- Ready to engage and learn
- How have you changed?
- Learned how to play differently
- Quality play
- What message would you give other parents about
the program? - Stick with it
- When we were frustrated we came out with some of
the biggest change - Dialogue with Coach
23Participant Description Table Single Subject
Design Studies
24Study Designs/Participants
- Multiple Baseline Design across behaviors
- Participants N 23
- Years 1 and 2
- Randomized Control Trial
- Participants N 24
- Year 3
25Baseline/Pre-Intervention Measures Diagnostic
and Descriptive
- ADOS
- M-CHAT
- Mullen
- Vineland
26Primary Outcome Variables Measures
- Primary Outcome Variables
- Focusing on Faces
- Turn-Taking
- Responding to Joint Attention
- Initiating Joint Attention
- Precursors of Joint Attention Coding Criteria
- Micro-social coding of 10 minute parent-child
interaction at home during play) - (Mullen Vineland in Yr 3 Group Design)
27Measures of Intervention Fidelity
- Interventionist Implementation
- Parent Implementation
28Fidelity of Interventionist Implementation
- 12-item checklist based observation
- Self-ratings completed by interventionists after
every session - 25 of all session audio recordings are
independently coded - Inter-observer agreement is calculated based on
exact agreement between independent coders and
interventionists - Interventionists receive feedback on
inter-observer agreement scores to facilitate
adherence to intervention implementation protocol - Mean Inter-observer Agreement gt 90
29Fidelity of Interventionist Implementation
Content- Example Items
- Introduction of new intervention phases only
after criteria have been met - Response to parents intervention-specific
questions and concerns - Clear description to parents of targeted outcomes
- Review of videos with targeted outcomes
illustrated - Encouragement of parent discretion and creativity
in choice of activities
30Fidelity of Parent Implementation
- 14 items- extent to which parent implements
mediated learning principles during session
activity with child - 3-point scale (full, partial, none)
- Interventionists complete rating following every
session - Independent observers rate 12.5 of sessions
based on session video recording -
31Measures of Other Treatment
- Parents complete an initial questionnaire about
other treatments that the child is receiving - Every 30 days, information is updated
32Kansas Single Subject Data
- Multiple Baseline Design across behaviors
- Focusing on Faces
- Turn-Taking
- Responding to/Initiating Joint Attention
- Each family represents a replication
- 5 families (mothers and their toddlers)
33Data from Families Who Have Completed
Intervention
34KS 10 11/08 8/09
35KS 08- 10/08 9/09
36Video Example
- Baseline observation video clip
- Joint attention phase video clip
37Summary
- Single subject design data show significant
improvement in targeted phases of the JAML for - Focusing on Faces
- Turn-Taking
- Joint Attention
38Questions Discussion
39Contact and Information
- Kbaggett_at_ku.edu
- http//www.continuinged.ku.edu/programs/autism/
- http//www.jgcp.ku.edu/jgcp/publications/presenta
tions/