Literature Review: PROMPT Therapy

1
Literature Review PROMPT Therapy

• Craig Domanski
• PS 572--Teaching Language and Social Skills to
  Children with Autism
• Caldwell College

2
Overview

• Article summary
• Search terms and parameters
• Critique
• Guidelines for evidence-based practice
• References

3
Journal article summary

• Teaching young nonverbal children with autism
  useful speech A pilot study of the Denver Model
  and PROMPT Interventions
• Rogers, S., Hayden, D., Hepburn, S.,
  Charlifue-Smith, R., Hall, T., Hayes, A. (2006)

4
Introduction

• Children with autism have significant deficits in
  speech and language production
• Language proficiency as an indicator for
  predicting outcomes
• Many interventions focus on language acquisition

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• Two approaches have been used historically
• Discrete trial teaching
• Didactic, adult-directed instruction delivered
  from a pre-set curriculum often taught in massed
  trials (Rogers et al., 2006)
• After initial discrete trials, more complex
  language skills are taught through associative
  learning
• Motivation is provided through external rewards

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• Naturalistic teaching methods (I.e., natural
  language teaching, incidental teaching, or
  pivotal response training)
• Child-initiated behavior in a natural
  interactive context (Rogers et al., 2006)
• Incorporates modeling, shaping, and natural
  reinforcers

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Differences between DTT and naturalistic
approaches

• Adult-directed v. child-directed
• Individualization of each learning opportunity
• Type of reinforcement
• Role of child as initiator
• Degree of generalization promotion

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• Both are behavioral approaches
• Language impairment for children with autism is a
  developmental disorder
• Developmental interventions (Prizant) focus on
• Social engagement
• Imitation skills
• Means-ends concepts
• Understanding language

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The Denver Model

• A developmental approach to language acquisition
• Specific developmental curriculum
• Individualized
• Based on discrete trials, naturalistic teaching
  methods, and dyadic exchanges
• Teaching based on attention to both teaching
  techniques and interpersonal relationships
  (Rogers et al., 2006)
• Can be implemented in inclusive classrooms,
  individual therapies, or 11

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The Denver Model (cont.)

• Only 1 aspect of model implemented in current
  study (the communication curriculum)
• Frequency 1x/week, 50-min. session daily home
  review by parents
• Why? typical of area programs
• Description of session naturalistic
  social-affective teaching interactions (sensory
  social routines) alternated with didactic
  instruction

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• Structure of sessions
• Highly motivating social games and activities
• Naturalistic teaching
• High frequency of social interactions
• Imitation of actions (objects, body parts,
  oral-facial movements, speech sounds)
• Massed trials and naturalistic teaching
• Receptive understanding (simple instructions)
• Naturalistic teaching
• Object associations
• Matching (objects-pictures, pictures-objects)
• Verbal approximations
• Naturalistic teaching
• Modeling, shaping, and reinforcement
• Put in a notebook with goals and objectives,
  lesson plans, and data

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PROMPT Therapy

• PROMPT Prompts for Restructuring Oral Muscular
  Phonetic Targets
• Based on neuromotor principles of speech
  production (Chumpelik (Hayden), 1984)
• Use of touch can
• Develop, rebalance, or re-establish speech motor
  control
• Provide a foundation for integrating sensory
  modalities in developing concepts and expressive
  language
• Enhance social-emotional interaction and trust
  between clinician and client (Rogers et al.,
  2006)

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Elements of PROMPT

• Use of tactile-kinesthetic information as a
  critical modality for recognizing, developing,
  re-balancing, and integrating cognitive,
  linguistic, and motor behavior
• Determining a Communication Focus or an aspect
  of development in which to embed and focus
  communication intervention
• Developing goals and embedding objectives that
  embody the Communication Focus whil working on
  motor/language, cognitive, and social function

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Elements of PROMPT (cont.)

• Analyzing the global and speech motor
  sub-systems to determine three priority areas
  that need immediate development or rebalancing
  and create an initial, functional lexicon (core
  vocabulary)
• Deciding on the purpose of prompting and what
  types of prompts should be used to support and
  develop motor control for speech and language
  and/or interaction and cognitive development
• Concrete understanding of how chosen goals and
  objectives will directly affect motor resourcing
  and, therefore, materials, activity choices

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Elements of PROMPT (cont.)

• Insuring that a high degree of motor-sound
  practice (using prompts for accuracy of
  production) and generalization of these into
  novel syllables and words within naturalistic
  activities are used within each session
• The inclusion of reciprocal interaction or
  choice-making, in all activities, in almost every
  turn.
• Presentation of the same or similar activities
  over time to provide a structure in which
  increased motor-language complexity and cognitive
  learning of events and sequences may be
  practiced. (Rogers et al., 2006)

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PROMPT in use

• Initially, use play-based activities, wait for
  child to initiate, and require a sound production
• Then, use vocal modeling and manual manipulation
  (of jaw, lips, or other speech mechanisms) while
  child vocalizes
• Fade tactile prompts to visual prompts (of hands
  moving)

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The Denver Model v. PROMPT

• Similarities
• Developmentally-based
• Focus on shared attention and social interactions
• Use naturalistic teaching methods
• Match activities to developmental levels
• Initially, adult-structured

• Differences
• Organization of evaluation data
• How goals and objectives are chosen
• Organization of motor systems towards tasks
• Use of imitation v. tactual-kinesthetic prompts
• How tasks are taught
• How programs are modified

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Present study

• Purpose
• Develop the methods and tests of both models for
  developing speech in non-verbal pre-schoolers
  with autism
• Gather empirical support for both approaches
• See if typical frequency of speech sessions with
  daily parent review would be sufficient in
  producing speech

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• Participants
• 10 children (aged 20-65 months)
• Recruited through clinic specializing in
  treatment of ASD parent-groups
• Criteria for participation
• Diagnosis of autism
• Spontaneous functional use of less than 5 words
  per day
• From parent reports and clinical observations
• Developmental quotient of gt30
• No co-morbid conditions
• NOTE All participants received varying levels of
  outside therapies

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• Setting
• 2-room suite w/ one-way mirror
• University of Colorado Autism and Developmental
  Disabilities Research Laboratory
• All sessions videotaped

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• Design
• ABA design (replicated 9 times)
• Pre- and post-treatment tests
• Diagnostic, developmental, and speech-language
  assessments
• 10-min. speech samples in baseline, treatment,
  and maintenance phases

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Procedure

• Pre-treatment assessments
• Autism Diagnostic Observation Scale (ADOS)
• Social Communication Questionnaire (SCQ)
• Mullen Scales of Early Learning
• Vineland Adaptive Behavior Scales
• MacArthur Communicative Development Inventory
  (CDI)
• Previous intervention history (through parent
  interview)
• Type of treatment, staffstudent ratio, hours in
  therapy
• Background information

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Baseline

• Baseline speech probes (x3)
• 15-min.
• Examiner put out a new toy every 5 min. and
  encouraged child to play with it
• Play partner instructed not to initiate any
  activities
• Made statements regarding childs play
• Examiner asked for 1 request and 1 episode of
  joint attention
• Scored of words and of phrases emitted

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Treatment

• Children randomly assigned to Denver Model or
  PROMPT
• Received 1 hr./ week therapy (12 weeks)
• Denver Model parents present during session
• Taught to implement one new skill in each of 4
  areas and had them practice
• Asked to implement procedures for 45 min. per day

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• PROMPT
• Parents observed sessions via video
• Parents asked to practice new words or
  approximations
• Not required to manually prompt any responses
• Asked to implement procedures for 30 min. per day
• Family decided how to incorporate practice into
  daily routines

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Procedure (cont.)

• Speech samples
• Each session was videotaped a 10-min. sample was
  randomly selected from each session
• Data collection
• of novel words or approximations
• of novel phrases
• Function of communication (I.e., joint attention,
  social interaction)
• Spontaneous v. prompted
• Summarized in graphs at end of the study

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• Post-treatment
• 3 weeks after completion
• Same assessments as in pre-treatments
• Three month follow-up
• Used to score childs functional use of speech
• Identical to speech probes in baseline

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• Treatment integrity
• 2 independent speech therapists trained up to
  fidelity on both interventions
• Likert scales developed for both
• Developers of scales viewed videotapes regularly,
  visited quarterly, and supervised (by phone)
  monthly
• Scored at 85 or better for 25 of sessions

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Results
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Results (cont.)

• 8 of 10 participants engaged in functional use of
  at least 5 novel words
• Generalization probes showed less use
• Reasons?
• Not enough sessions (12)
• Sessions not targeted for generalization and
  maintenance
• Generalization sessions looked at too many novel
  features
• Children not spontaneous enough

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Results (cont.)

• Overall gains
• Significant gains score of 2 or 3 on ADOS in
  pre-treatment, score of 0 on post-treatment
• Significant gains observed in both interventions
• Denver Model more in imitation skills
• PROMPT more in functional play skills
• Generalization
• 9 of 10 participants used novel words at home
  after treatment
• Based on parent report

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• Most gains
• One child in each group demonstrated very high
  levels of increases in target behaviors
• Regular use of over 50 words per session
• Increases in joint attention
• Both exhibited milder forms of autism symptoms
• These children may well have acquired functional
  speech without these treatments. (Rogers et al.,
  2006)
• NOTE 2 participants did not acquire any new words

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Discussion

• Purpose was preliminary tests of interventions
• Experimenters urge more research
• More replication and extensions
• 8 participants generated some new speech, 4
  generated novel phrases, 2 used phrases in
  generalized manners (novel statements in novel
  settings)
• Positive parent feedback

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Limitations

• Children already in a developmental period where
  language is observed to accelerate
• Gains observed were still considered limited
  compared to typical children
• Better gains observed for participants with
  higher levels of parent involvement
• Parents provided extra practice opportunities
  than what was specified
• Implementation monitored by parent report

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Limitations (cont.)

• Direct comparison of 2 interventions was
  impossible
• Too many similarities
• Participants differed from one another (age,
  mental ages, expressive language capabilities)
• Many components to each treatment
• Limited generalization and maintenance data
• Children were receiving outside therapies
  concurrently
• No IOA

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Future research

• Obtain similar participants
• Control for effects of treatment
• Component analysis of each treatment
• Control for more extraneous variables
• I.e., outside therapies

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Search parameters

• JABA
• PsycINFO
• Google
• First, attempted PROMPT Therapy
• 0 in JABA mixed results in PsycINFO, 8060 on
  Google
• Link for www.promptinstitute.com
• Tab for research provides a research summary
• No articles mentioned were peer-reviewed
• Out of 6 articles mentioned
• 2 unpublished research, 2 conference proceedings,
  2 manuals authored by Hayden
• Other links to research were all presentations
  given by Hayden or colleagues
• 1 study available (Rogers et al.)

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• PROMPT Introduction to Technique A Manual
  (2006)
• References section
• Chumpelik--3 articles (2 unpublished, 1
  theoretical)
• Hayden--11 articles (0 research studies)
• Guides, manuals, assessments, etc.

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• Rogers et al. study (Hayden co-authors)
• References section
• Looked at all research containing PROMPT
• 5 references (all Chumpelik or Hayden)
• All unpublished, theoretical, or conference
  proceedings
• Google search for entire titles of all possible
  research studies
• None available

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• ASAT online
• Research Summary One small study indicates that
  an oral-motor therapy, PROMPT, may be efficacious
  in establishing early language skills in
  nonverbal children with autism (Rogers et al.,
  2006). There have been no other peer-reviewed
  scientific studies on Oral-Motor Training or
  Therapy for individuals with autism spectrum
  disorders. (2008)
• Recommendations Researchers may wish to conduct
  studies with strong scientific designs to
  evaluate Oral-Motor Therapies. Professionals
  should present Oral-Motor Therapies as
  under-researched and encourage families who are
  considering these interventions to evaluate them
  carefully. (2008)

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Does PROMPT have enough evidence to support its
use?

• Gina Greens gold standards for evidence based
  practice
• At least 3 between group designs demonstrating
  efficacyNO
• At least 3 single case designs demonstrating
  efficacyNO
• At least 3 investigators needed for
  corroborationNO
• Documentation of
• How participants were obtainedYES
• Continuous measurement of DVNO
• Calibrated data collectionNO
• Inter-observer agreementNO
• Procedural integrityYES (25 of sessions)
• Operationally defined baseline conditionYES
• Treatment effectsNO

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Conclusions?
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References

• Rogers, S., Hayden, D., Hepburn, S.,
  Charlifue-Smith, R., Hall, T., Hayes, A.
  (2006). Teaching young nonverbal children with
  autism useful speech A pilot study of the Denver
  Model and PROMPT interventions. Journal of Autism
  and Developmental Disorders, 36, 1007-1024.
• Hayden, D. (2006). PROMPT Introduction to
  Technique A Manual. Santa Fe, NM The Prompt
  Institute.
• Association for Science in Autism Treatment
  (2008). Retrieved June 11, 2008, from
  http//www.asatonline.org/resources/treatments/ora
  l.htm
• The Prompt Institute (2008). Retrieved June 11,
  2008 from http//www.promptinstitute.com
• Green, G. (2008). Evaluating Evidence about
  Treatments for Autism. Presentation for Applied
  Behavior Analysis International Conference, San
  Diego, CA.