Critical analysis of a articles

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8 Increasing Generalization by Training Teachers to Provide Parent Training for Young Children with Autism Spectrum Disorders Brooke Ingersoll and Anna Dvortcsak

Children with autism spectrum disorders (ASDs) have pervasive deficits in social and communication skills, as well as restricted interests and attention, which interfere with learning and disrupt family life (American Psychiatric Association, 2000). The educational needs of children with ASDs are significant, with most chil- dren requiring many hours of intensive intervention provided by highly trained staff. Interventions that are applied early and intensively have been found to lead to significant improvements in child outcome (Dawson & Osterling, 1997; National Research Council [NRC], 2001). In fact, after a comprehensive review of the scientific, theoretical, and policy literature surrounding the education of young children with ASDs, the NRC (2001 recommended that “educational services should include a minimum of 25 hours a week, 12 months a year, in which the child is engaged in systematically planned, developmentally appropri- ate educational activity aimed toward identified objectives” (p. 220). The educa- tional requirements make providing effective intervention for children with ASDs within a cost-effective, public program a challenge for school districts throughout the nation. With the growing number of children qualifying for special education services under the ASD eligibility, school districts are hard pressed to provide the level of intensity required to educate their toddler and preschool-age students with ASDs. Many publicly funded early intervention (EI) and early childhood special education (ECSE) programs have difficulty meeting the recommended number of hours (Hume, Bellini, & Pratt, 2005).

Even when provided with the recommended number of hours, many children with ASDs still struggle to generalize gains shown in treatment to meaningful life activities (Schreibman, 1988). This lack of generalization is an issue for all interventions; however, children with ASDs seem to have more pronounced generalization deficits than children with developmental delays (Schreibman, 1988). Thus, it is necessary to develop intervention models for young children with ASDs that maximize opportunities for generalization and maintenance of skills.

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One effective strategy for promoting generalization is to provide instruction in the natural environment (Sandall, Hemmeter, Smith, & McLean, 2005). The natural environment has been defined as routines, materials, and people familiar to the child and family (Dunst, Hamby, Trivette, Raab, & Bruder, 2000). This approach has been adopted by the Individuals with Disabilities Education Act of 1990 (PL 101-476) for the education of young children with special needs (Walsh, Rous, & Lutzer, 2000); it requires that services provided by the public sector use more naturalistic approaches to intervention (Wetherby & Woods, 2006). There is still debate as to which settings constitute the natural environment for young chil- dren with ASDs in relation to service provision (e.g., center vs. home, group vs. one-to-one). However, interventions that each families how to use intervention strategies are an excellent option since the family is the most “natural environ- ment” for young children. A further benefit of teaching parents is that it can lead to increased hours of intervention, making it more likely that families can achieve the recommended intensity of intervention for their children with ASDs.

BENEFITS OF PARENT TRAINING

A significant body of research demonstrates the benefit of teaching parents of chil- dren with disabilities to implement the intervention themselves (Shearer & Shearer, 1977). Although less research exists for children with ASDs, parent train- ing has also been shown to be effective for this population (see McConachie & Diggle, 2007, for a review). A variety of intervention methods have been taught to parents of young children with ASDs, including discrete trial training (e.g., Smith, Groen, & Wynn, 2000) and structured teaching (Ozonoff & Cathcart, 1998). Most parent-implemented approaches are naturalistic, meaning that instruction occurs around the child’s focus of interest and during meaningful routines and activities. For this reason, only naturalistic parent training approaches are reviewed herein.

Several reasons exist for using a naturalistic approach with parents of young children with ASDs. First, naturalistic intervention strategies have been shown to be effective for teaching a variety of social-communicative skills, including language (see Kaiser, Yoder, & Keetz, 1992, for review), gestures (Ingersoll, Lewis, & Kroman, 2007; Warren, Yoder, Gazdag, & Kim, 1993), play skills (Stahmer, 1995; Thorp, Stahmer, & Schreibman, 1995), peer interaction (Pierce & Schreibman, 1995), and joint attention skills (Pierce & Schreibman, 1995; Whalen & Schreibman, 2003) in children with ASDs and developmental delays. Second, research indicates that naturalistic strategies lead to better generalization and maintenance (Charlop-Christy & Carpenter, 2000; Delprato, 2001; McGee, Krantz, & McClannahan, 1985; Miranda-Linne & Melin, 1992), as well as more spontaneous use of skills (Schwartz, Anderson, & Halle, 1989) than more structured teaching approaches. Finally, these approaches are more similar to natural adult–child interactions (Schreibman, Kaneko, & Koegel, 1991); this fact makes them more acceptable to parents and easier to implement in the course of daily routines. Indeed, research has shown that parents who were taught to use Pivotal Response Training (PRT), a naturalistic intervention, used more positive affect while teach- ing their children (Schreibman et al., 1991), and both the parents and children exhibited more happiness and interest and less stress during family interactions than families in which the parents were trained to implement highly structured behavioral techniques (Koegel, Bimbela, & Schreibman, 1996).

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Training Teachers to Provide Parent Training 3

NATURALISTIC PARENT TRAINING APPROACHES

Two general naturalistic intervention approaches have been used with parents: one approach based on the developmental, social-pragmatic (DSP) literature and one based on the naturalistic behavioral literature.

Developmental, Social-Pragmatic Approaches

DSP interventions are derived from research on typical parent–child interactions, which suggests a relationship between a parent’s responsiveness to a child’s behavior and the child’s level of social-communicative development (Bornstein, Tamis-LeMonda, & Haynes, 1999; Hoff-Ginsburg & Shatz, 1982; Mahoney & Perales, 2003; Prizant, Wetherby, & Rydell, 2000). Thus, the goal of developmen- tally based, parent-implemented interventions is to teach parents strategies to increase their responsiveness to the child’s behavior. These interventions share several common characteristics (Prizant et al., 2000):

1. Teaching follows the child’s lead or interest.

2. The adult arranges the environment to encourage initiations from the child.

3. All communicative attempts including unconventional (e.g., jargon, echolalia, hand leading, nonverbal protests) and preintentional communication (e.g., reaching and grabbing, eye gaze, crying, facial expressions, body postures) are responded to as if they are purposeful.

4. Emotional expressions and affect sharing are emphasized by the adult.

5. The adult uses simplified language around the child’s attentional focus.

Several studies have examined the effectiveness of teaching parents to use DSP interventions with their children with ASDs. For example, Mahoney and Perales (2003) examined the efficacy of responsive teaching for promoting social- emotional functioning in young children with ASDs using a single-group, pre-/posttest design. In their study, 20 young children with ASDs and their moth- ers participated in an 8- to 14-month intervention in which the mothers were taught a variety of strategies that increased their responsiveness to their children’s behavior. At pre- and posttreatment (approximately 1 year later), the children and their mothers were videotaped while playing with a set of developmentally appropriate toys, and mothers were asked to complete the Infant Toddler Social Emotional Assessment (Carter & Briggs-Gowan, 2000) and the Temperament and Atypical Behavior Scale (Bagnato, Neisworth, Salvia, & Hunt, 1999). Mothers exhibited significant improvements in their responsiveness, and the children exhibited significantly higher ratings on social interactive behavior during the videotaped interactions from pre- to posttreatment. The children were also rated as showing significant improvements in social-emotional functioning on the two standardized rating scales at posttreatment. This study did not include a control group of children whose mothers did not receive training, so it is difficult to con- clude that the positive gains seen in the children were due to responsive teaching. However, there was a positive correlation between changes in the mothers’ level of responsiveness and changes in the children’s social interactive behavior on the videotaped observations. In addition, changes in maternal level of responsiveness

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were predictive of a child’s improvements on the standardized assessments of social-emotional functioning. These findings are consistent with the authors’ hypothesis that maternal responsiveness promotes developmental gains in chil- dren with ASDs and other developmental disorders.

Wetherby and Woods (2006) used a quasi-experimental design to examine the effectiveness of the early social interaction project, a developmentally based, parent-implemented intervention designed for very young children with ASDs. Seventeen at-risk children younger than 2 years and their families were selected to participate. Children were identified as at risk for ASDs based on the presence of a significant number of indicators from the Communication and Symbolic Behavior Scales Developmental Profile behavior sample (Wetherby & Prizant, 2002). Parents received individualized coaching twice per week in the home for a minimum of 12 months. These coaching sessions were focused on teaching the parents to use a variety of developmentally based intervention strategies during daily routines with their child. Participating children were assessed at pre- and posttreatment on the Communication and Social Behavior Scales (Wetherby & Prizant, 2003). An independent comparison group of 18 children who were referred for concerns of ASDs were also examined at age 3 years to determine developmental trajectories of children with ASDs who did not receive the parental intervention. The results suggested that the children whose parents were trained in early social interaction made statistically significant gains in a variety of social-communicative skills from pre- to posttreatment. In addition, the early social interaction participants scored significantly better than the comparison group at age 3 years on measures of social signals, rate of communicating, com- municative functions, and understanding.

These findings suggest that the children whose parents received training made improvements over the course of a year on their social-communicative development and outperformed a group of children who did not receive treat- ment at age 3 years. Although this study offers some preliminary evidence for the effectiveness of a developmental, parent-implemented approach because the participants were not randomly assigned, it is possible that the groups were not similar at intake.

Interestingly, the early social interaction participants’ pretreatment profiles resembled the comparison group’s profiles, although the comparison group was an average of 1 year older. This finding could be interpreted to indicate that the treatment group would have continued to look similar to the control group at age 3 years had they not received treatment. However, additional research using a ran- domized or single-subject design is needed to conclude that the children’s changes were due to the intervention.

In a randomized trial, Aldred, Green, and Adams (2004) examined the efficacy of a developmentally based, parent-implemented intervention on social- communicative development in young children with autism. Twenty-eight children with autism and their parents were randomly assigned to a treatment or a control group. Parents of the children in the treatment group participated in workshops, followed by individual coaching sessions that focused on teaching the parents to use a number of developmentally based intervention strategies with their child. After 1 year, the parents of the children in the treatment group showed improvements in their responsiveness towards their children on an observational

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Training Teachers to Provide Parent Training 5

measure of parent–child interaction compared with parents in the control group. In addition, the children in the treatment group showed more improvement (reduced symptomology) on the Reciprocal Social Interaction subdomain of the Autism Diagnostic Observation Schedule (Lord et al., 2000), greater gains in expressive language as measured by the MacArthur Communicative Development Inventory (Fenson et al., 1993), and a greater increase in number of communication acts on an observational measure of parent–child interaction than the children in the control group.

These studies offer preliminary evidence for the effectiveness of developmen- tally based, parent-implemented approaches for promoting social-communicative development in young children with ASDs. The studies found general improve- ments in social engagement (Mahoney & Perales, 2003) and general communica- tive behavior (Aldred et al., 2004; Wetherby & Woods, 2006). However, they did not examine whether the children also experienced increases in specific language behaviors, such as vocabulary or mean length of utterance. Thus, the effect of this approach on the development of more specific language skills is unknown. In addition, in each of these studies, parent training was conducted individually over an extended period of time. Therefore, it is unclear whether children with ASDs and their parents would benefit from a shorter or less intense parent train- ing format. This issue is particularly important because many publicly funded programs may not be able to offer such extensive parent education services.

Naturalistic Behavioral Approaches

Naturalistic behavioral approaches focus on teaching parents to use prompting, shaping, and reinforcement strategies to increase specific social-communicative skills in their child with ASD. In keeping with the naturalistic emphasis, parents are taught to use these teaching strategies around their child’s focus of interest and within daily routines and activities (Kaiser et al., 1992). Parent-implemented interventions using a naturalistic behavioral approach share the following charac- teristics (Delprato, 2001; Kaiser et al., 1992):

1. The learning environment is loosely structured.

2. Teaching occurs within ongoing interactions between the child and the adult.

3. The child initiates the teaching episode by indicating interest in an item or activity.

4. Teaching materials are selected by the child and varied often.

5. The child’s production of the target behavior is explicitly prompted.

6. A direct relationship exists between the child’s response and the reinforcer.

7. The child is reinforced for attempts to respond.

A large body of work has examined the effectiveness of naturalistic behav- ioral interventions for teaching language skills to children with ASDs and other developmental disorders (see Kaiser et al., 1992, for review). Among this litera- ture, several studies have trained parents to be the intervention providers. For example, Laski, Charlop, and Schreibman (1988) used a multiple-baseline design

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to examine the effect of teaching eight parents to use the natural language paradigm, now referred to as PRT, with their children with ASDs. The results suggested that parents increased the frequency with which they required their children to speak. In addition, all children increased their frequency of speech with their parents. These increases generalized to three nontraining settings, suggesting that once the parents learned the intervention techniques, they were able to elicit their child’s language in a variety of environments.

In addition, research has shown that parents can also learn naturalistic behav- ioral intervention strategies for increasing other social-communicative skills, including imitation, joint attention, and play. For example, Ingersoll and Gergans (2007) taught three parents naturalistic intervention strategies to increase their children’s object and gesture imitation during play. All parents improved their abilities to use the intervention techniques, and their children showed concomi- tant improvements in their imitation skills. Rocha, Schreibman, and Stahmer (2007) taught three parents to teach their children with autism to respond to joint attention bids. Children improved their abilities to respond as well as to initiate joint attention, despite the fact that the intervention did not directly target joint attention initiations. Gillett and LeBlanc (2007) taught three parents to use the natural language paradigm with their children with autism; they found that, in addition to improvements in spontaneous and prompted language, two of the children also showed improvements in their use of appropriate play.

These studies have mainly used single-subject designs with a small number of participants, which limits the generalizability of the results to a wide range of children with ASDs and their parents. However, the use of an experimental design allows for the determination that changes in the parents’ behavior directly affect their children’s behavior.

Combined Approaches

One additional naturalistic intervention approach has been to combine interven- tion strategies from both the DSP and naturalistic behavioral models with the hope of developing even more powerful interventions. For example, Kaiser, Hancock, and Niefeld (2000) used a multiple-baseline design to examine the effi- cacy of parent-implemented enhanced milieu teaching with six mother–child dyads. This intervention included both naturalistic behavioral strategies designed to teach specific language targets and DSP strategies to increase parent respon- siveness. Parents learned a variety of naturalistic behavioral strategies to use with their children with ASDs via 24 weekly coaching sessions. Although coaching was conducted in a clinic, all parents generalized their use of the strategies to the home and maintained their use of the strategies (although at a lower rate than posttreat- ment) at a 6-month follow-up.

All children in this study showed an increase in their use of language targets (e.g., two-word requests, action verbs, attribute object combinations), and most children also increased the complexity and diversity of their language. Not sur- prisingly, those children who exhibited less significant communication delays made the most gains in productive language. This study indicates that a parent- implemented naturalistic behavioral approach combined with responsiveness strategies can be effective for increasing specific social-communicative skills. However, additional research is needed to determine whether the combined approach is more effective than either component implemented in isolation.

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ADDITIONAL BENEFITS OF PARENT TRAINING

Parent training appears to confer a number of other benefits when compared with therapist-implemented interventions. For example, one early study compared the effects of teaching parents to implement behavior therapy with their child to clinician-implemented intervention (Koegel, Schreibman, Britten, Burke, & O’Neill, 1982). Parents in the parent training group received 5 hours per week of training with their child until mastery for a total of approximately 25–50 hours; the clinic treatment group received 4 1/2 hours of treatment per week for 1 year for a total of approximately 225 hours. The results indicated that children in both groups made similar gains when observed with the treatment provider, but chil- dren in the parent training group were more likely to respond appropriately to parent questions and directions in the home. This finding indicates that parent-implemented intervention leads to better generalization than therapist- implemented intervention and requires significantly fewer hours of therapist time. In addition, parents in the parent training group exhibited a significant increase in the amount of recreational/leisure activities they participated in, whereas parents in the clinic treatment group showed no change.

Parent-implemented interventions for young children with ASDs are compat- ible with recommendations from the NRC and the Individuals with Disabilities Education Act regarding teaching within the natural environment. More impor- tantly, the research suggests that parent training is an effective intervention approach and leads to better generalization than traditional therapist-delivered services. In addition, it has been shown to improve other aspects related to family functioning and allows for an increase in the number of hours of intervention a child receives per week, without an increase in the number of hours of direct inter- vention provided by professionals.

Given these findings, the NRC’s Committee on Educational Interventions for Children with Autism concluded,

As part of local educational programs and intervention programs for children from

birth to age 3, families of children with autistic spectrum disorders should be pro-

vided the opportunity to learn techniques for teaching their child new skills and

reducing problem behaviors. (NRC, 2001, p. 216)

OBSTACLES TO IMPLEMENTATION

Although parent training is now considered an essential component of successful early intervention programs for children with autism (NRC, 2001), formal parent training programs are still the exception rather than the rule in community-based ECSE settings for children with ASDs age 3–5 years (Hume et al., 2005). There are several obstacles that can prevent the inclusion of parent training programs in ECSE classrooms. The first obstacle involves the structure of most empirically based parent training programs, which are typically conducted individually with the parent, child, and parent educator once to twice per week over many months (Aldred et al., 2004; Kaiser et al., 2000; Mahoney & Perales, 2003; Wetherby & Woods, 2006). While this structure may be appropriate for private services or EI services delivered in the home, most publicly funded ECSE programs for children with ASDs older than 3 years are provided in a classroom setting that allows very

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little time for teachers to meet individually with a parent and child. This differ- ence makes it difficult for most special educators serving children with ASDs in a classroom setting to envision using these models within their programs. To increase the likelihood that ECSE staff will include parent training in their cur- riculum, it is important to develop a parent training format that works within a classroom setting.

A second obstacle to the inclusion of parent training in community-based programs is the lack of quality parent training materials developed for families of children with ASDs. Many of the empirically based programs mentioned in the literature have developed materials for parent training; however, because they are typically conducted in a one-to-one setting, they lack many of the features neces- sary for providing training to a group of parents, such as slide presentations and video examples. Most ECSE teachers are unlikely to adapt materials designed for use in a one-to-one training program to a group program because of the amount of time necessary to develop group presentation materials.

A final obstacle to the provision of parent training is the lack of appropriate preparation for providers working with children with ASDs and their families. Most specialists—especially those who work with children ages 3 years and older—have been trained to work with children, not adults. In addition, they often are not trained to understand how adults learn or techniques for teaching parents specific skills (Mahoney et al., 1999). The lack of specific preparation acti- vities for early childhood special educators in parent training is evident in the lack of courses available in this area in preparation programs in special education. To illustrate this point, McCollum (1999) reported her own cursory inspection of a variety of EI/ECSE textbooks revealed that, although the topic of families received a significant amount of attention, the topic of parent education was con- spicuously absent. Thus, it is necessary to develop an effective teacher preparation protocol to encourage ECSE staff to provide parent-implemented intervention.

To address these issues, Ingersoll and Dvortcsak (2006, in press) developed Project ImPACT (Improving Parents As Communication Teachers), a parent train- ing program designed specifically for use with children with ASDs and their families in ECSE classroom settings. The goal was to develop an evidence-based parent training curriculum using a format compatible with a classroom-based intervention model, including user-friendly materials, and incorporating an effec- tive teacher preparation protocol.

PARENT TRAINING CURRICULUM

The parent training curriculum focuses on teaching families naturalistic interven- tion techniques to increase their child’s social-communicative skills during daily activities and routines (Ingersoll & Dvortcsak, 2006). The specific intervention strategies have been drawn from a variety of evidence-based interventions shown to be effective for young children with ASDs and other developmental disorders. Parents are first taught strategies for setting up their home to ensure successful parent–child interactions. Subsequently, they are taught the interven- tion strategies (see Appendix 8.1). Project ImPACT is composed of developmental strategies to encourage parent responsiveness (e.g., Mahoney & Perales, 2003) and naturalistic behavioral strategies to teach specific social-communicative skills (e.g., Kaiser et al., 1992). Table 8.1 provides a description of the individual

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Table 8.1. Intervention strategies

Topic 1: Set up your home for success Parents are taught strategies for arranging their home to increase the likelihood of positive parent-

child interactions, including having a well-defined play space, limiting distractions, rotating toys, and scheduling predictable play routines (Davis & Fox, 1999).

Topic 2: Follow your child's lead In order to increase their child's motivation, parents are taught to follow their child's focus of

attention and to provide teaching opportunities around the activities their child chooses. Parents are taught to provide a variety of highly motivating materials (e.g., toys, games, snacks), respond to their child's changing interests, and assist their child in his or her play. This technique is used in all naturalistic interventions and has been shown to increase parent responsiveness and child motivation (e.g., Kaiser et al., 1992).

Topic 3: Imitate your child Parents are taught to imitate their child's vocalizations, actions with objects, and gestures. This

strategy has been show to increase child responsiveness and coordinated joint attention and is used to increase social engagement (Klinger & Dawson, 1992)

Topic 4: Animation Parents are taught to exaggerate their gestures, facial expressions, and vocal qualities in order to

increase their child's interest and to model appropriate nonverbal communication (Mahoney & MacDonald, 2007).

Topic 5: Modeling and expanding language Parents are taught to use a variety of indirect language stimulation techniques (e.g., descriptive

talk, conversational recast) to talk about their child's focus of interest. These techniques have been shown to be effective at increasing the rate and complexity of children's language skills (e.g., Camarata, Nelson, & Camarata, 1994; Ingersoll, Dvortcsak, Whalen, & Sikora, 2005; Kaiser et al., 1996).

Topic 6: Playful obstruction Parents are taught to gain their child's attention during an interaction by playfully interrupting their

child's activity. This technique is used to increase initiations from the child (Greenspan, Wieder, & Simons, 1998).

Topic 7: Balanced turns Parents are taught to use balanced turns with their child to increase their reciprocity and to provide

opportunities for child initiations (Mahoney & MacDonald, 2007).

Topic 8: Communicative temptations Parents are taught to use a variety of communicative temptations (e.g., in sight, out of reach; assis-

tance; inadequate portions; sabotage; protest; silly situations) to encourage their child to initiate communication (e.g., Kaiser, Ostrosky, & Alpert, 1993).

Topic 9: Prompting and reinforcement Parents are taught prompting and reinforcement strategies to teach their child more complex

social-communication skills, including the use of natural environment prompts and reinforcement. Parents are taught how to use prompting effectively, including providing clear and appropriate prompts, monitoring motivation, providing wait time, and moving from less to more supportive prompts to help the child respond correctly (e.g., Kaiser et al., 1992). Parents are also taught to use immediate reinforcement that is contingent on appropriate behavior, to provide praise, and to expand their child's response (e.g., Kaiser et al., 1992).

Topic 10: Teaching your child expressive language Parents are taught to use a variety of prompts (e.g., physical prompt, gestural prompt, verbal

model, verbal routines, choices, cloze procedure, questions, time delay) and reinforcement to teach their child new expressive language forms (e.g., Kaiser et al., 1992).

Topic 11: Teaching your child to understand and follow directions (receptive language) Parents are taught to use clear and direct verbal instructions and to use a variety of prompts

(e.g., physical prompt, visual prompt, verbal instruction) and reinforcement to teach their child to follow directions and increase receptive language (e.g., Kaiser et al., 1992).

(continued)

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Week Session Topic

1 Group Introduction to the program; set up your home for success (Topic 1) 2 Individual Set up your home for success; goal development 3 Group Make play interactive and modeling and expanding language

(Topics 2–5) 4 Individual Make play interactive and modeling and expanding language 5 Group Create opportunities for your child to engage or communicate;

overview of direct teaching (Topics 6–9) 6 Individual Create opportunities for your child to engage or communicate 7 Group Teaching your child expressive language and following directions

(Topics 10–11) 8 Individual Teaching your child expressive language and following directions 9 Group Teaching your child social imitation and play (Topics 12–13) 10 Individual Teaching your child social imitation and play 11 Group Putting it all together (Topic 14) 12 Individual Putting it all together

10 Ingersoll and Dvortcsak

teaching techniques. Teacher’s manual that contains detailed procedures for con- ducting each session, PowerPoint presentations for the group sessions, a video with examples of parents using the intervention techniques with their children with ASDs, and coaching forms for the individual sessions. It also includes a man- ual for parents, which provides a description of each technique in parent-friendly language and homework (Ingersoll & Dvortcsak, in press).

PROGRAM FORMAT

The program is designed to be implemented over the course of 12 weeks. It is composed of six 2-hour group sessions and six 45-minute individual coaching sessions with the parent and child. Group and individual coaching sessions are alternated weekly, such that the parents receive instruction on the intervention techniques in a group format and then have an opportunity to practice the tech- niques with their child while receiving feedback individually (see Table 8.2).

Topic 12: Teaching your child social imitation Parents are taught to use a number of strategies to encourage their child to imitate their play with

toys and gestures in a reciprocal fashion (Ingersoll & Gergans, 2007).

Topic 13: Teaching your child play Parents are taught to use a variety of prompts (e.g., physical prompt, gestural prompt, modeling,

instruction, leading question, leading comment) to teach their child more complex play skills (Stahmer, 1995).

Topic 14: Putting it all together Parents are taught how to use the interactive and direct teaching strategies together. In

particular, parents are taught when to emphasize the interactive strategies (e.g., parents cannot control access to desired items or activities and/or the child is less motivated by the activity) and the direct teaching strategies (e.g., parents are able to control access to the desired item or activity and the child is highly motivated) and how to move back and forth between the two within an interaction.

Table 8.2. Format of the parent training program

Table 8.1. Intervention strategies (continued)

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Group sessions are attended by parents only and consist of a didactic presen- tation, videotaped examples, group discussion and problem solving, and home- work. Group sessions are designed to be conducted during the day or in the evening, depending on the needs of the teachers and families. The first session consists of an initial didactic presentation that reviews the research on parent training for children with ASDs, a description of the parent training program, an overview of the intervention techniques encompassed in the program, and strate- gies for setting up the home environment to encourage successful interactions. After the first session, subsequent sessions begin with a 20-minute discussion of the parents’ use of the different intervention strategies in the home. The educator then introduces a new intervention strategy via didactic presentation, videotaped examples of parents using the techniques with children with ASDs, and group dis- cussion. At the end of each group session, parents are instructed to write down one or two of their child’s goals, activities they typically complete with their child, and the intervention techniques they would use to target the child’s goals. Each parent is then instructed to go home and practice the techniques over the next week and to write down how their child responds.

The techniques are introduced in a specific sequence because they build on each other. The interactive techniques are introduced first to improve the child’s initiations and engagement; the direct teaching techniques are then introduced to teach the child a specific skill.

Individual Coaching Sessions

The individual coaching sessions are attended by the parent and child and are typ- ically conducted during the school day in the children’s classrooms. Each parent coaching session is scheduled for 45 minutes, with 15 minutes between families so that the educator can see up to eight families per day. Similar to the group sessions, the individual coaching sessions begin with a review of the homework. In the first coaching session, the parent educator helps the parent develop goals for the child to target over the course of the program. In subsequent coaching sessions, the educator briefly reviews the technique and models use of the tech- niques with the child for 5–10 minutes; the parent then practices the techniques during play with the child while the parent educator provides feedback. For example, the parent might practice eliciting single words from their child while playing with cars by playfully obstructing the child’s access to the cars and prompting him or her to say, “Car.”

At the end of each session, the educator helps the parent brainstorm how to use the techniques in the home during daily routines to target the child’s social- communicative goals. For example, the parent might be encouraged to use the same techniques practiced with the car to elicit language during meals. The edu- cator then writes down the child’s goals, home activities, and specific techniques to address the child’s goals. The parent practices the techniques at home and writes down how the child responds.

TEACHER PREPARATION

Preparation for the program involves a combination of didactic training and hands-on technical assistance, totaling about 30 hours of direct training. At this

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point, teacher preparation is conducted by the program developers. However, the goal is to disseminate the preparation training to specialists working in the schools.

Initial Workshop

The initial 2-day workshop provides an overview of parent training, research on the effectiveness of parent training for children with ASDs and their families, and the intervention strategies. The training then focuses on specific skills that are involved in presenting information in a group format and providing online feed- back to parents during coaching sessions (see Table 8.3). This initial workshop consists of a combination of didactic presentation, group discussion, role play, and practice with students while receiving feedback from the instructors. In addition, attendees are shown a variety of video clips of parents working with their children and are asked to give online feedback based on the videotaped vignette.

After the initial training, participating staff receive onsite technical assistance to help them implement the program. Technical assistance is provided during the initial parent group session and during three or four of the coaching sessions. The trainer observes the teacher conducting the first group session and provides feedback to the teacher. During the individual coaching sessions, the trainer first demonstrates how to coach parents, then observes the teacher coaching parents and provides feedback. After each coaching session, the trainer meets with the teachers to answer any questions regarding parent coaching and provides feedback to the teachers on their coaching.

PROGRAM IMPLEMENTATION

As of the writing of this chapter, the parent training program has been imple- mented in 11 ECSE sites in Oregon as part of the Oregon Statewide Regional Program Autism Training Sites (RPATS). The RPATS were established as a collab- orative effort between Portland State University, the Oregon State Department of Education, and Oregon Regional and Special Education programs in an effort to improve the quality of education for students with ASDs in the state. Several classrooms in each region have been selected as model sites. Teachers at these sites receive intensive, hands-on training in research-based practices for children with ASDs. After training, other teachers working with children with ASDs in the region can visit the model sites to learn how to implement the interventions in their own classrooms. All RPATS classrooms use the STAR curriculum with their students (Arick, Loos, Falco, & Krug, 2004), which is based on the principles of applied behavior analysis and includes three instructional formats: discrete trial training, PRT, and functional routines.

Table 8.3. Parent training strategies

Developing individual and group rapport Selecting appropriate treatment goals Presenting the information Demonstrating the intervention techniques with the child Providing positive and corrective feedback to parents Assigning and discussing homework Building independence Taking data

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Training Teachers to Provide Parent Training 13

The number of staff who have received training in the parent training pro- gram per site has ranged from one to four, with the average being three per site. These staff members have included early childhood special educators, speech-lan- guage pathologists, occupational therapists, and autism specialists. The average number of participating families per site is 6 (with a range of 3–14). After receiv- ing training in the parent program, participating sites are expected to offer the program one to two times per year.

PROGRAM EVALUATION

The feasibility of this program has been evaluated in several ways. With the first group of participating families, gains in parent knowledge of the intervention tech- niques were assessed via a pre-/postquiz and parents’ satisfaction with the pro- gram (Ingersoll & Dvortcsak, 2006). These data suggested that parents increased their understanding of the intervention techniques substantially through the course of the program. Parents also reported a high rate of satisfaction with the program and felt that their children gained social-communicative skills as a direct result of it (for additional discussion of these data, see Ingersoll & Dvortcsak, 2006).

An anonymous web-based survey of participating teaching staff was also conducted 1– 40 months posttraining to determine the teachers’ assessment of the utility of the parent training model and their perception of parents’ and children’s response to the program. The survey was sent to 27 staff members, and 23 responded, yielding a high response rate (85%). Staff members were asked to rate

their responses to a variety of questions on a 5-point scale (1 � strongly disagree,

5 � strongly agree), as well as to answer a number of open-ended questions. To evaluate how easily the program could be integrated into the existing ECSE

curriculum, the teachers were asked a number of questions regarding the appropri- ateness of the program in terms of content, format, materials, and preparation. Overall, the participating teachers found the parent training program to be very

100 100

80

96 91 91

87 91

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Intervention strategies

appropriate

Format appropriate for parents

Format appropriate

for classroom

Materials sufficient

Amount of training

appropriate

Type of training

appropriate

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Figure 8.1. Teachers’ perceptions of the parent training curriculum, format, and teacher preparation protocol.

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14 Ingersoll and Dvortcsak

appropriate for use in ECSE settings and user friendly (see Figure 8.1). The teaching staff felt strongly that intervention strategies used in the program were appropriate for use with young children with ASDs and their parents. They also reported that the format of the program was appropriate for training parents and for use in a classroom setting. The teachers reported that the program materials (session outlines, PowerPoint presentations, parent manual, and DVD) were sufficient for implementing the program. Finally, the majority felt that the amount and type of training they received would allow them to implement the program effectively. However, a number of teachers reported that they would have liked more training.

The teachers’ perception of the parents’ and children’s response to the pro- gram was assessed to determine whether the teachers saw a benefit to including the program in their curriculum (see Figures 8.2 and 8.3). The teachers felt strongly that the program was beneficial for both the participating parents and their children. The teachers reported that parents improved their understanding of their child’s skills and increased their ability to promote their child’s social- communicative skills. They also reported that the children improved their social engagement and communication skills with their parents as a result of the pro- gram. Several additional benefits of the program were also endorsed, including increased social support for the parents and improved parent–teacher relation- ships. A smaller number of teachers also felt that the participating children gener- alized their improvement in social engagement and communication skills to the classroom. Finally, teachers were asked whether they felt that the program was a beneficial addition to the curriculum. A total of 100% of the teachers agreed with this statement, and 87% said that they would use the program in the future.

Through a series of open-ended questions, teachers were asked to report any concerns they had regarding the parent training program. A number of teachers suggested that, although attendance among participating families was high, overall participation among eligible families was more limited. Teachers sug- gested that the lack of participation was due to issues with child care, difficulty

100 100

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96 91 91

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Attendance was high

Improved understanding of child’s ability

Improved ability to promote social communication

Increased social support received

Improved parent-teacher relationships

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Figure 8.2. Teachers’ perceptions of participating parents’ responses to the parent training program.

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Training Teachers to Provide Parent Training 15

with scheduling, and the large number of non–English-speaking families in some programs. Teachers also reported concerns about the amount of time that the program took them to implement and difficulty receiving appropriate compen- sation for time spent on the program outside of the typical workday.

In sum, the participating teachers were very positive about the program and felt that it was a beneficial addition to the ECSE curriculum. More importantly, they were encouraged by the amount of progress they perceived the children to have made with their parents and in the classroom. As one teacher reported, “Children whose parents take this program tend to make much more progress than those who do not.”

CONTRIBUTORS TO SUCCESS

Several factors that contribute to the success of this program were identified. First and foremost, strong administrative support greatly enhanced teachers’ enthusi- asm and commitment to the program. Administrative support was seen in terms of a commitment on the part of the administrator to the program in the form of help and flexibility with scheduling, securing teacher compensation (e.g., extra duty pay, comp time), and child care. In addition, teachers who were most suc- cessful implementing the program already had initial skill with the implementa- tion of the treatment techniques in the program and a strong philosophical com- mitment to parent education. Finally, strong parent enthusiasm for the program helped deepen staff’s commitment. Those staff who worked with parents who were outwardly appreciative of the teachers’ efforts reported more success with the implementation of the program.

FUTURE DIRECTIONS

The initial evaluation of the parent training program appears promising in that teachers and parents find its content and format to be compatible with an ECSE inter-

100 97

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97

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74

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Improved social engagement with parent

improved communication

with parent

improved social engagement in

classroom

improved communication

in classroom

P e rc

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Figure 8.3. Teachers’ perceptions of participating children’s responses to the parent training program.

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16 Ingersoll and Dvortcsak

vention setting and perceive it to be effective for promoting social-communicative skills of young children with ASDs in the home. However, there are some limitations in its implementation, particularly in the ability of the ECSE classrooms to encourage maximal family participation. The addition of child care, flexibility in scheduling, and the use of interpreters for non–English-speaking families would likely have enhanced family involvement.

On the whole, the participating teachers expressed the view that the program led to improved child and family outcomes, as well as improved parent–teacher relationships. However, many of these same teachers felt that the program was time intensive and that they were not compensated for the time they spent outside of regular school hours. This fact seemed to lessen some of the teachers’ enthusi- asm for the program. For this reason, future research is needed to examine ways in which parent training can be more easily incorporated into the existing ECSE curriculum and/or ways to better compensate teachers for their efforts.

The next step is to empirically evaluate the effectiveness of the program on parent and child outcomes, both in the home and school settings. This evalua- tion will examine both the immediate and long-term outcomes of adding a par- ent training component to the ECSE curriculum on parent and child behavior. It will determine whether parents are able to maintain their use of the interven- tion strategies over time and whether gains in child skills maintain after the training program has ended. Furthermore, it will examine whether such a par- ent training program positively affects parents’ satisfaction with their relation- ship with their child, as well as the parent–teacher relationship. This research is currently underway.

Given the fact that most other parent training programs for young children with ASDs are implemented on an individualized basis over many months, it will be important to compare individualized to group delivery formats to determine whether short-term group models, such as the one described here, are as effective as long-term, individualized models. If so, this less intense program may be more likely to be adopted by programs serving young children with ASDs in a group setting. Finally, it will be important to examine the effectiveness of the current teacher preparation protocol.

In summary, parent-implemented intervention is an effective method for pro- moting generalization in young children with ASDs. However, most parent train- ing models for young children with ASDs are not compatible with classroom- based ECSE settings. The parent training program described in this chapter was designed specifically for use in such settings and our initial evaluation suggests that it can be effectively implemented within public ECSE classrooms. Future research is needed to determine the short- and long-term effectiveness of the program on parent and child outcomes.

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Chapter 8

Appendix

Appendix 8.1. Communicative temptations

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APPENDIX 8.1

Communicative Temptations

Use communicative temptations to increase opportunities for your child to inter- act with you and wait for a response. Your child can respond in any appropriate way (eye contact, affect, vocalization/words). If your child does not respond after several seconds, continue with the activity. These strategies are easy to implement during everyday activities such as meals and snacks, dressing, bath time, and bed- time. Plan extra time during these daily child care routines to use these strategies to enhance your child’s communication. The following are suggestions for using these techniques during daily routines.

MEAL TIME

• Serve food whole that needs to be cut or diced for your child to eat it. (Assistance)

• Serve your child small portions of his or her favorite food items. Keep the rest of your child’s meal in the middle of the table or in a sealed container. (In sight and out of reach)

• Pour small amounts of liquid from a larger pitcher into your child’s cup. (Inadequate portions)

• If your child uses silverware, have certain necessary pieces of silverware missing (e.g., no spoon with ice cream). (Sabotage)

• Offer your child food items that he or she does not like. (Protest)

• Pretend to eat a nonedible item (e.g., napkin). Make sure that you indicate that you are being silly by being animated, wait for a response, and then describe the cor- rect way to do it (e.g., “Oh, I can’t eat this, I need to eat the food!”). (Silly situations)

BATH TIME

• If your child likes water toys that wind up, have these available. Most young chil- dren will need assistance to operate them. (Assistance)

• Place all of your child’s favorite bath time items (e.g., tub toys, bubble bath) on a shelf in the tub that he or she can see but cannot reach when sitting in the tub. (In sight and out of reach)

• Place your child’s favorite bath time items in clear plastic containers with lids. When the lid is on, the containers should float, making the toys inside very attrac- tive. (In sight and out of reach)

• If your child enjoys being washed, only wash one body part at a time. For exam- ple, wash one hand and then stop and wait for your child to indicate that you should continue washing. (Inadequate portions)

• If your child needs assistance undressing, only take off one item of clothes at a time, and wait for your child to indicate to you that you need to continue to help. (Inadequate portions)

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• If your child has an established bath time routine that he or she enjoys, you can attempt to do certain steps out of order. For example, wash your child’s feet before his or her head. (Protest)

BED TIME

• If you read your child a book at bedtime, only read one page at a time. Wait for your child to indicate that he or she wants you to turn the page. (Inadequate portions)

• If you sing your child specific bedtime songs, only sing one or two lines at a time and wait for your child to indicate that he or she wants you to continue singing. (Inadequate portions)

• If you play certain music or videos at bedtime, stop the tape/CD or video period- ically. Wait for your child to indicate that he or she wants you to continue to play it or give your child the tape/CD or video case without the tape/CD or video in it. (Inadequate portions)

• Offer your child a book, toy, music, or video that he or she does not like. (Protest)

DRESSING

• Only put on or take off one item of the child’s clothing at a time. Wait for the child to request the next item. (Inadequate portions)

• Offer your child clothing items to wear that he or she does not like. (Protest)

• Try to put your child’s clothes on incorrectly (e.g., put a shoe on his or her head, put your child’s shirt on his or her feet). Make sure that you indicate that you are being silly by being animated, wait for a response, and then describe the correct way to do it (e.g., “Oh, your shirt goes over your head!). (Silly situations)

• Try to take your child’s clothes off out of the correct order (e.g., try to take his or her sock off before you take off his or her shoe). Make sure that you indicate that you are being silly by being animated, wait for a response, and then describe the correct way to do it (e.g., “Oh, I need to take your shoe of first!). (Silly situations)

Real Life, Real Progress for Children with Autism Spectrum Disorders, edited by Christina Whalen. Copyright © 2009 Brookes Publishing Co. All right reserved.

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