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

1. 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

2. 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)

3. 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

4. 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)

5. Focusing on Faces • The child focuses on the parent’s face

6. Turn-Taking • The child takes turns with parents • Parent or child initiates • Parent or child responds • Partner responds

7. Joint Attention • The child shifts attention back and forth between the parent’s face and an object for the purpose of social sharing

8. 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

9. 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

11. 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

12. 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

13. An Interventionist’s Perspective

14. 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

15. 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

16. The Collaborative Relationship

17. 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)

18. 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 child’s 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

19. 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 child’s lead

20. A Parent’s 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 child’s level of interest, not some arbitrary goals • What surprised you? • The progress and skills that made everything else start coming together

21. A Parent’s 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

22. A Parent’s 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

23. Participant Description Table Single Subject Design Studies

24. Study Designs/Participants • Multiple Baseline Design across behaviors • Participants: N = 23 • Years 1 and 2 • Randomized Control Trial • Participants: N = 24 • Year 3

25. Baseline/Pre-Intervention Measures: Diagnostic and Descriptive • ADOS • M-CHAT • Mullen • Vineland

26. 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)

27. Measures of Intervention Fidelity • Interventionist Implementation • Parent Implementation

28. 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 > 90

29. 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

30. 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

31. Measures of Other Treatment • Parents complete an initial questionnaire about other treatments that the child is receiving • Every 30 days, information is updated

32. 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)

33. Data from Families Who Have Completed Intervention

34. KS 10 11/08 – 8/09

35. KS 08- 10/08 – 9/09

36. Video Example • Baseline observation video clip • Joint attention phase video clip

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

38. Questions & Discussion

39. Contact and Information • Kbaggett@ku.edu • http://www.continuinged.ku.edu/programs/autism/ • http://www.jgcp.ku.edu/~jgcp/publications/presentations/