Intervention with Toddlers Showing Early Indicators of Autism: A Parent-Mediated Model for Promoting Joint Attention

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Intervention 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
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Joint 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)

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JAML 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

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Intervention 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)

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Focusing on Faces

• The child focuses on the parents face

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Turn-Taking

• The child takes turns with parents
• Parent or child initiates
• Parent or child responds
• Partner responds

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Joint Attention

• The child shifts attention back and forth between
  the parents face and an object for the purpose
  of social sharing

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Intensity

• Weekly home visit with parent
• Parent implements daily parent-child play
  interaction
• 30-60 minutes daily for planned sessions
• Incidentally through natural learning
  opportunities

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Unique 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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Inclusion/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

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Project 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

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An Interventionists Perspective
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Session 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

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Implementation 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

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The Collaborative Relationship
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Challenges 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)

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Building 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

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Building 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

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A 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

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A 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

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A 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

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Participant Description Table Single Subject
Design Studies
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Study Designs/Participants

• Multiple Baseline Design across behaviors
• Participants N 23
• Years 1 and 2
• Randomized Control Trial
• Participants N 24
• Year 3

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Baseline/Pre-Intervention Measures Diagnostic
and Descriptive

• ADOS
• M-CHAT
• Mullen
• Vineland

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Primary 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)

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Measures of Intervention Fidelity

• Interventionist Implementation
• Parent Implementation

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Fidelity 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

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Fidelity 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

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Fidelity 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

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Measures of Other Treatment

• Parents complete an initial questionnaire about
  other treatments that the child is receiving
• Every 30 days, information is updated

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Kansas 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)

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Data from Families Who Have Completed
Intervention
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KS 10 11/08 8/09
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KS 08- 10/08 9/09
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Video Example

• Baseline observation video clip
• Joint attention phase video clip

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Summary

• Single subject design data show significant
  improvement in targeted phases of the JAML for
• Focusing on Faces
• Turn-Taking
• Joint Attention

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Questions Discussion
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Contact and Information

• Kbaggett_at_ku.edu
• http//www.continuinged.ku.edu/programs/autism/
• http//www.jgcp.ku.edu/jgcp/publications/presenta
  tions/