Early Social Interaction: Parent Implemented Intervention in Everyday Activities for Young Children with ASD

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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
• http//esi.fsu.edu

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Early Social Interaction ProjectAmy 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 childs progress
• Comprehensive, coordinated services guided by IFSP

Funded by OSEP, US DOE
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Theoretical Principles

• A family-centered approach to meet the familys
  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

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Theoretical Principles cont.

• Focus on the core deficits associated with
  autismsocial 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

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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

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Intensity StrategiesThroughout the day
Special times

• 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

• 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

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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
  caregivers ability to enhance the childs
  development
• Daily caregivers, parents and teachers, have many
  more opportunities to impact a childs
  development

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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

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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

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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 childs disorder

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Operationalizing the Principles for
ParentsInstruction 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
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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.

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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 childs success and
  to increase complexity of communication and
  interaction.

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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

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Empirically Supported Strategies for Initiation
and Generalization

• Environmental Arrangementmodify the environment
  to prompt or cue a child to initiate social
  interaction
• Natural Reinforcersprovide access to objects or
  events that the child desires or removing
  undesired objects or events
• Time Delayprovide a stimulus and wait briefly
  before giving a verbal prompt for a child to
  respond
• Contingent Imitationimitate a childs actions
  immediately following the childs actions
• (Hwang Hughes, 2000 Koegel, 1995 McGee,
  1999)

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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)

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ESI Caregiver Instructional Strategies

• Modeling
• Guided practice and feedback
• Conversations and suggestions
• Problem solving
• Handouts and recommendations
• Video tape feedback
• Group or individual training

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What research says doesnt 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)

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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

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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 3rd 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 3rd 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.

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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

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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

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No easy answers Its 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!