using case study methods to investigate the effects of ...web.hku.hk/~zhao0909/study 2.pdf · using...

Using case study methods to investigate the

effects of interactive intervention for children

with autism spectrum disorders

Luigi Girolametto a,*, Fern Sussman b,Elaine Weitzman b

a Department of Speech-Language Pathology, University of Toronto,

#160-500 University Avenue,Toronto, Ontario, Canada M5G 1V7b The Hanen Centre, Toronto, Ontario, Canada

Received 30 May 2006; received in revised form 6 November 2006; accepted 8 November 2006

Abstract

Purpose: The purpose of this multiple case study was to describe outcomes for three parents and

their children following participation in a social interactive model of language intervention. More

specifically, this study sought to clarify if changes in children’s participation, engagement, and

initiation of social interaction could be observed following an 11-week intervention.

Method: Three preschool children with autism spectrum disorders and their mothers participated in

an 11-week intervention program. The intervention taught parents to follow the children’s lead,

promote children’s participation in routines, and model language at the children’s level. Outcome

measures included estimates of parents’ responsive language input, and measures of children’s rate of

communication, number of engagements in social interaction, and initiations.

Results: The results indicated that all three mothers increased their responsive comments during

play interactions and were rated as being more responsive on a rating scale. All three children

evidenced positive outcomes in vocabulary and the number of engagements in social interaction. In

addition, improvement was observed in social initiation skills for all three children.

Conclusions: Increases in mothers’ responsiveness and children’s engagement in social interactions

are consistent with the theoretical mechanisms of the social interaction model of language inter-

Journal of Communication Disorders 40 (2007) 470–492

* Corresponding author. Tel.: +1 416 978 3353; fax: +1 416 978 1596.

E-mail addresses: [email protected] (L. Girolametto), [email protected] (F. Sussman),

[email protected] (E. Weitzman).

0021-9924/$ – see front matter # 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.jcomdis.2006.11.001

mailto:[email protected]



http://dx.doi.org/10.1016/j.jcomdis.2006.11.001

vention. The results suggest that further randomized control trials of this intervention approach are

warranted.

# 2006 Elsevier Inc. All rights reserved.

Keywords: Autism; Interactive intervention; Responsiveness; Case study; Parent–child interaction

1. Introduction

Autism is a developmental disorder characterized by pervasive deficits in social

communication behaviour, including language, joint attention, and pragmatics (American

Psychiatric Association, 2000). A commonly used method of providing language

intervention for young children with Autism Spectrum Disorder (ASD) is parent-focused

intervention (e.g., Drew et al., 2002; Howlin & Rutter, 1989; Jocelyn, Casiro, Beattie, Bow,

& Kneisz, 1998). Recently, there has been growing interest in naturalistic intervention

models that are based on social-interactionist theories of language acquisition. In programs

ascribing to these naturalistic approaches, parents are taught to use responsive interaction

strategies (e.g., follow the child’s lead, take turns, imitate) during naturally occurring

activities with their children (Tannock & Girolametto, 1992). Several parent-focused

programs that ascribe to social-interactionist theories have been developed for children

with ASD and include: Relationship-Focused Intervention (Mahoney & Perales, 2003),

Social Communication Intervention (formerly Child’s Talk Aldred, Green, & Adams,

2004; Aldred, Pollard, & Adams, 2001), More Than Words (Sussman, 1999), and the

Developmental, Social-Pragmatic Approach (Ingersoll, Dvortcsak, Whalen, & Sikora,

2005; Prizant & Wetherby, 1998).

In social-interactionist interventions, parents learn to encourage the child’s social

participation in interaction by interpreting and responding to the child’s communicative

attempts as if they were meaningful (Keen, Sigafoos, & Woodyatt, 2001; Mahoney &

Perales, 2003). Behavioural teaching strategies are not used to elicit targets and learning is

presumed to occur as a result of the adult’s responsive scaffolding (Ingersoll et al., 2005;

Vygotsky, 1978). Parents learn four major strategies to foster the development of two major

skills that are areas of core deficit in young children with autism, that is, joint attention

skills (Mundy, Sigman, Ungerer, & Sherman, 1986) and pragmatic communication skills

(Prizant & Meyer, 1993). First, parents learn to use child-oriented strategies (e.g., follow

the child’s lead) to create communicative interactions around the child’s interests or focus

of attention. Second, by waiting and arranging the environment (e.g., violating common

routines, omitting items necessary for an activity), parents motivate their children to attend,

initiate communication, or participate in ongoing interactions. Third, parents use

interaction-promoting strategies (e.g., use predictable routines, take one turn and wait) to

encourage extended sequences of joint attention on a shared topic. Fourth, parents are

encouraged to interpret and respond to all of the child’s communicative attempts as if they

were intentional. Parents’ responses include simplified language input (e.g., responsive

labels, comments) that matches the children’s plan-of-the-moment and models pragmatic

communication in naturalistic contexts. A small, but growing body of evidence supports

the usefulness of the social-interactionist intervention model for children with ASD and

L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 471

their parents (Aldred et al., 2004; Ingersoll et al., 2005; Mahoney & Perales, 2003;

McConachie, Randle, Hammal, & Le Couteur, 2005).

The purpose of this multiple case study is to examine the outcomes of three mothers and

their children following participation in a social-interactionist model of intervention

entitled More Than Words: The Hanen Program for Parents of Children with Autism

Spectrum Disorders (Sussman, 1999). To date, only one published study has examined the

efficacy of this program (McConachie et al., 2005). While it revealed significant outcomes

for children’s vocabulary development, it failed to detect intervention gains in core areas of

deficit for children with ASD, such as social interaction and social initiation skills. One

criticism of the study is that it did not include microanalytic techniques to code videotapes

of mother–child interaction to examine these interactive behaviours. Consequently, the

current study was undertaken to examine whether hypothesized outcomes in social

interaction and initiation skills could be detected using microanalytic coding techniques.

A case study approach is a useful methodology when a holistic, in-depth investigation is

needed to explore a theoretical construct (Yin, 2003). There are multiple definitions and

understandings of the case study. Yin (2003) describes three types of case studies:

exploratory, descriptive, and explanatory. The exploratory case study design, selected for

this investigation, seeks to develop pertinent hypotheses for further study concerning the

relationship between an intervention mechanism (i.e., parental responsiveness) and

outcomes. In this case the outcomes include social interaction skills for children with ASD.

The case study approach was chosen for this study because characteristics of children with

ASD differ widely from each other and large groups of children with ASD who have

similar characteristics are difficult to recruit. Moreover, large group designs obscure

findings at the level of the individual unit, and fail to provide useful information about the

uptake of program strategies by individual parents or their impacts on the individual

children. Given this intervention model’s lack of findings for children’s social interaction

skills, case study methods afforded a desirable alternative to an experimental design for

examining hypothesized theoretical links between related events (i.e., intervention and

parent–child changes) over time (Yin, 2003). Consequently, one potential implication from

this current study is to suggest whether further large-scale experimental research using

microanalytic techniques for examining parent–child interaction is warranted.

1.1. The interactive model of language intervention

Theoretically, social-interactionist theories of language acquisition hypothesize that the

adult’s enhanced responsiveness supports the child’s motivation to engage in social

interaction while the accompanying linguistic input stimulates the acquisition of early

social communication skills, vocabulary, and syntax development (Bohannon &

Bonvillian, 1997). The premise that adults can influence children’s developmental

progress finds support in Vygotskian theory, which maintains that adult–child interactions

provide cultural and social guidance that mediates children’s development of

communication and learning (Rogoff, 1990; Vygotsky, 1978). Vygotsky (1981)

maintained that the social interactions occurring between young children and more

capable adults provide the context for a shared construction of knowledge and

understanding. Promoting children’s communication development within the context of

L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492472

naturalistic conversations reflects the social and pragmatic nature of language learning.

Within Vygotsky’s perspective, the process of learning is facilitated without direct

instruction but through ongoing mediation and scaffolding (Jarvis & Robinson, 1997).

Integral to the concept of scaffolding is the notion of using language that is within the

child’s ‘‘zone of proximal development’’, which refers to the level of performance that is

between independence and frustration (Vygotsky, 1978).

While it appears that social-interactionist intervention may have a facilitatory effect on the

development of communication skills, the precise mechanisms that are responsible for child

change are unclear. It has been suggested that a key mechanism for promoting

communication development is the adult’s responsiveness. Responsive caregiving leads

to secure attachments between child and adult, thereby laying the foundations for positive

social adjustment and optimal communication development (Mahoney & Perales, 2003;

Richter, 2004). Complementary evidence from the field of neuroscience suggests that

children’s neurological development occurs in response to social and interpersonal processes

(Nelson & Bloom, 1997) and the brain’s development is dependent upon supportive

experiences with adults (Richter, 2004). The facilitatory effect of parental responsiveness

may reside in a match between the child’s processing mechanisms and the adult’s responsive

input. Language input that is responsive to the child’s plan-of-the-moment reduces

contextual ambiguities, provides redundancy, and increases the saliency of the input such that

more cognitive resources can be available for attending to language and the social-pragmatic

rules of communication (Harris, Jones, Brookes, & Grant, 1986; Tomasello & Todd, 1983;

Yoder, Kaiser, Alpert, & Fischer, 1993). Thus, responsive speech input (including imitating,

interpreting child’s vocalizations as words, labeling objects to which the child is attending,

and expanding the child’s words into phrases) models semantic and syntactic content that is

more easily understood and promotes both receptive and expressive language learning.

1.2. Empirical evidence of efficacy of interactive intervention

Because of its recent development, there is relatively little information to inform

clinicians about expected outcomes for parents and children with ASD following parent-

focused interactive intervention. Thus far, interactive intervention has been used

successfully with parents of late-talking toddlers (Girolametto, Pearce, & Weitzman,

1996) and parents of children with cognitive and language impairments, such as Down

syndrome (Girolametto, Weitzman, & Clements-Baartman, 1998). A small but growing

body of evidence from descriptive studies (Mahoney & Perales, 2003) and control group

designs (Aldred et al., 2004; McConachie et al., 2005) is suggestive of favorable outcomes

for children with ASD as well.

Mahoney and Perales (2003) used a pretest–posttest design to investigate the outcomes

of twenty mothers and their preschool children with ASD. Families participated in a year-

long study in which mothers were trained to use responsive interaction strategies, such as

reciprocity, contingency, shared control, affect, and match. Following intervention, the

authors reported that 80% of the mothers increased their level of responsiveness. This was

accompanied by improvements in ratings of children’s attention, persistence, initiation,

and joint attention. The data also suggest that mothers who made the greatest changes in

responsiveness had children who made the greatest improvement. Although there was no


experimental control for maturation effects, the results of this study suggest that

mechanisms involved in responsive interaction may play an important role in facilitating

social interactive behavior in children with ASD.

The first randomised control trial of a parent-administered social-interactionist

intervention model utilized a program called Social Communication Intervention (Aldred

et al., 2004). This study randomly assigned 28 children with ASD into experimental and

control groups. In the 12-month experimental program, parents were trained to respond

sensitively to the child, interpret the child’s actions as having meaning, use action routines, set

up repeated scripts, and pause to elicit the child’s interaction and communication. Following

intervention, the children in the experimental group demonstrated significant increases in

expressive vocabulary as measured by the MacArthur–Bates Communicative Developmental

Inventory (CDI) (Fenson et al., 2003). The experimental group increased their expressive

vocabulary from 28.0 to 199.4 words. An examination of videotaped play interaction

revealed significantly more responsive parent–child interaction and significantly more child

communication acts relative to the control group. The mothers in the treatment group

increased their frequency of responsive comments from 57.8 to 65.1 in 30 min of play

interaction. Their children increased their frequency of communicative acts from 30.8 to 37.6

in the same time frame. However, no group differences were found for shared attention during

the play interaction and social initiations were not measured in this context. These results

suggest that a year-long social-interactionist program may produce positive outcomes in the

vocabulary and social communication skills of children with ASD. However, the impact of

this intervention on social interaction sequences and social initiations was not supported.

The specific intervention utilized in this study, More Than Words, has been trialled in

one quasi-experimental study that assigned 51 preschool-aged children with ASD into

experimental and control groups according to the timing of their recruitment (McConachie

et al., 2005). Parents participated in an 11-week program, More Than Words (Sussman,

1999), and received 20 h of instruction in groups of eight families. Each family also

received three home visits (for parent and child) during the program to monitor their

progress and provide individualized coaching. Instruction focused on improving parents’

ability to follow the child’s lead, promote social interactions, and model language at the

child’s level. Following intervention, the authors reported significantly higher mean ratings

of the Joy and Fun Assessment (JAFA) relative to the control group. This scale assessed

parental interaction strategies, including use of fun words (e.g., ‘‘whee’’), simplified

language, expansions, fun physical contact (e.g., hugging child), pretend games, and turn-

taking routines. The mothers of children with autism who were in the experimental group

received higher ratings on the JAFA (i.e., from 11.2 to 13.9) based on a 5-min play

interaction. In addition, the study found significant gains in children’s vocabulary size as

measured by parental report on the CDI relative to the control group. In this study, the

children with autism increased their vocabulary size from 34.7 to 72.6 words from pretest

to posttest (in a 7-month period). However, social communication skills as measured by the

Autism Diagnostic Observation Schedule (ADOS) (Lord, Rutter, DiLavore, & Risi, 1999)

did not differentiate between the two groups of children at posttest. While this study

provides preliminary evidence that More Than Words may impact on parental interaction

style and children’s vocabulary, it did not use microanalytic techniques to examine

children’s social interaction or initiation skills within dyadic parent–child interaction.


The purpose of the present study was to investigate social interaction and social

initiation outcomes for three children with ASD following their mothers’ participation in

More than Words. This study improves on the procedures used by previous investigators

(Aldred et al., 2004; McConachie et al., 2005) by employing microanalytic coding

techniques to examine parent–child interactions. Parents also completed subjective surveys

in which they described changes they perceived in themselves and their children during the

intervention. The first aim of this study was to confirm that parents used responsive

interaction strategies following intervention. This study improved on previous work by

examining this aim in relation to the children’s antecedent behaviour, that is, how parents

responded when their children communicated versus when their children were unengaged

in the interaction. To improve the validity of results obtained using the coding system,

parental responsiveness was also examined using the same rating scale (i.e., JAFA)

employed by McConachie et al. (2005). Based on the results of previous studies of this

intervention model (Aldred et al., 2004; Mahoney & Perales, 2003; McConachie et al.,

2005), it was predicted that parents would increase their responsiveness as measured by (a)

the frequency of responsive interaction codes and (b) ratings on the JAFA. The second aim

of this study was to replicate the previous findings of increased vocabulary development for

children with ASD following intervention. It was hypothesized, that all three children

would demonstrate increases in vocabulary development on two different measures,

including (a) a parent report questionnaire and (b) the frequency of unique lexical items

used during the play interactions. Previous studies on children with autism spectrum

disorders (Aldred et al., 2004; McConachie et al., 2005) have demonstrated the impact of

this parent-focused intervention in facilitating vocabulary development using the CDI. A

lexical diversity measure was added to confirm parental perceptions. The third and most

important aim of the study was to examine the children’s social interaction skills following

intervention, specifically their rate of communicative acts, participation in social

interaction sequences, and initiation of social interaction. Although year-long interventions

employing social-interactionist approaches have reported positive outcomes in these areas

for children with ASD (Aldred et al., 2004; Mahoney & Perales, 2003), these important

outcomes have not been observed consistently by the three studies reviewed above. Based

on previous work, it was hypothesized that the children in this study would experience

gains in social interaction (i.e., communicative acts, frequency and length of interaction

sequences, social initiations) measured using microanalytic techniques during play

interactions with their mothers.

2. Method

2.1. Participants

Three families were recruited from waiting lists for parent-focused language

intervention programs offered by The Hanen Centre in Toronto. These families were

selected because the children (a) were close in age and language level, (b) had received a

confirmed diagnosis of ASD from a developmental pediatrician or a registered

psychologist, and (c) were not participating concurrently in intensive behavioral


intervention (or applied behavioral analysis). The children were between 2.8 and 3.2 years

of age and used intentional communication acts at entry into the study (e.g., conventional

gestures, a few single words). Table 1 summarizes the intake characteristics of the children.

The characteristics of the children’s parents are summarized in Table 2. The mothers

ranged in age from 27 to 38 years of age. One mother had completed a 2-year

postsecondary diploma while two mothers had completed university degrees. One child

was raised in a single-parent family and two children were raised in two-parent families.

All mothers were employed outside the home on a full-time basis. Only two fathers were

involved in their children’s care and both were also employed full-time.

2.2. Procedure

2.2.1. Design

To address the study aims, a multiple case study methodology was employed. This

design is an alternative to traditional experimental designs for exploring theoretical

presuppositions (Yin, 2003). In this case, the study sought to determine whether the

intervention mechanism underlying the social-interactionist model (i.e., enhanced

responsiveness) was associated with hypothesized outcomes in social interaction skills.

According to Yin (2003) a case study design must emphasize the units of analysis,

determine of how the data are linked to the hypotheses, and state criteria for interpreting the

findings. In this study, the units of analysis were the play interactions of three mother–child

dyads. The data collection focused on parental responsiveness as the primary intervention


Table 1

Characteristics of the childrena

Jackson Ana Anthony

Diagnosis Autism PDD Autism

Age at diagnosis 1.11 2.10 2.11

Sex Male Female Male

Age at pretest 2.8 3.2 3.2

Communication SSb 62 60 63

Socialization SSb 72 64 68

Child care Day care (full-time) In home care (grandmother) Day care (full-time)

Siblings None Older brother Younger brother

a Names are pseudonyms.b Standard scores on the communication and socialization scales of the Vineland Adaptive Behavior Scales.

Table 2

Parental characteristics

Jackson Ana Anthony

Family status Single mother Both parents Both parents

Mother’s age (years) 27 38 25

Mother’s educationa University University Postsecondary

Father’s age (years) N/A 37 28

Father’s educationa N/A High school High school

a Highest level of schooling completed.

mechanism and concomitant changes in children’s vocabulary and social interaction

behaviours as outcomes. Criteria for interpreting findings were developed for four

measures that had yielded significant group differences in two previous experimental trials

(Aldred et al., 2004; McConachie et al., 2005), and included (a) the rate of parental

responsiveness, (b) ratings on the JAFA, (c) the rate of children’s communication acts, and

vocabulary size. The specific criteria are described in the results section.

2.2.2. Assessment sessions

All pretest and posttest sessions were completed immediately before and after an 11-

week intervention program and were conducted during home visits lasting approximately

1.5 h each. During the assessment sessions, each mother–child dyad was videotaped in

their homes in four 5-min activities that included storybook reading (with a familiar book),

a known social game, a daily routine (e.g., feeding, dressing), and play with bubbles.

Parents were encouraged to interact with their children as they normally would if there was

no observer in the home. Filming was discontinued if the child began to cry or fuss and

could not be re-engaged. Subsequently, the parents completed the MacArthur–Bates

Communicative Development Inventory (CDI) (Fenson et al., 2003) Words and Gestures.

At the pretest only, the examiner interviewed the parents using the Socialization and

Communication Domains of the Vineland Adaptive Behavior Scales: Interview Edition

(VABS) (Sparrow, Balla, & Cicchetti, 1984) to obtain developmental information.

2.2.3. Intervention program

The 11-week intervention program used in this study was More Than Words: The Hanen

ProgramTM for Parents of Children with Austism Spectrum Disorders (Sussman, 1999).

The families participated in eight group sessions and three home visits to learn responsive

interaction strategies. The weekly group sessions were held in the evening, lasted

approximately 2.5 h, and included a combination of interactive presentations, group

discussions, videotape analysis, and opportunities to practice. Parents used a guidebook

entitled, More Than Words (Sussman, 1999). Three home visits were conducted to monitor

the parents’ progress and children’s outcomes. The purpose of these visits was for parents

to (a) practice program strategies in real-life contexts, with coaching and feedback from the

speech-language pathologist, (b) review and revise the child’s goals, and (c) discuss any

concerns that may have arisen. Once the formal training program ended, families were

supported in their roles by community-based speech-language pathologists. The program

emphasized responsiveness to the child to promote reciprocal interactions and social

communication skills in children with ASD. The content of the intervention program

included child-oriented strategies (e.g., observe the child, follow the child’s lead, be face-

to-face), interaction-promoting strategies (e.g., use routines, take a turn and pause for a

response, cue your child to take a turn), and language-modelling strategies (e.g., interpret

your child’s actions, label, expand). Parents learned four ways to support children’s

initiations: (a) include the children’s interests by commenting or joining in, (b) interpret the

child’s actions or vocalizations as meaningful, (c) imitate the child’s actions or

vocalizations, and (d) intrude when children are unengaged or involved in repetitive

behaviours. In this latter case, parents initiated a topic, routine, or game and supported their

children’s engagement in interaction. To promote longer interactions, parents learned to


use structured and predictable routines as contexts for increasing the length of their

children’s engagement in interaction sequences. The content of the program is outlined in

Appendix A.

2.3. Measurement

Case study methodology is designed to highlight outcomes of individual participants by

using multiple sources of data (Yin, 2003). The data sources utilized in this study included

two primary sources (a) videotapes of parent–child interaction and (b) parent report on

questionnaires and surveys. Moreover, in order to increase validity of findings, the parent

interaction outcomes were examined by two different sets of observers, each using a

different methodology. One observer coded interactions at a microanalytic level while the

other independently used a rating scale (i.e., JAFA) to score the interactions holistically.

Interrater reliability estimates were calculated for all measures by research assistants who

were unaware of the questions of the study.

2.4. Transcription of parent–child interaction

A research assistant who was blind to the purpose and design of the study transcribed the

parents’ utterances using the Systematic Analysis of Language Transcripts (SALT) (Miller

& Chapman, 2002). In a second pass, the child’s communicative acts were transcribed.

Communicative acts included (a) vocalizations accompanied by eye gaze to the parent or to

the parent’s referent, (b) conventional gestures (e.g., pointing, nodding, shaking head,

offering, pushing away object to reject), and (c) words and word approximations. A second

research assistant who was blind to the study questions and design verified all

transcriptions of the parent–child interactions following a procedure used by Johnston

(2001). This research assistant read each transcript while listening to the videotape, and

noted any disagreements on the transcript. Disagreements were resolved through

discussions with the original transcriber. Where agreement could not be reached, an X was

entered on the transcript. This procedure, while time-consuming, assured that every

transcript was examined and corrected (as opposed to a randomly selected number of

transcripts). Consensus reliability was conducted on 100% of the transcripts (before they

were amended) using the formula: number of agreements/ (the number

agreements + disagreements) � 100. Consensus reliability for the mothers was 99.3%

for utterance boundaries (N = 2,762) and 98.4% for words (N = 6,911). Consensus

reliability for the children’s communicative acts was 90.8% for vocalizations accompanied

by eye gaze (N = 782), 89.8% for gestures (N = 490), and 97.1% for words (N = 1,017).

These reliability figures reflected the extent to which the second individual agreed with the

original transcription prior to making any corrections on the transcripts.

2.5. Outcome measures

2.5.1. Parent interaction coding

All parental utterances were coded using a system that classified utterances as attention

calls, commands, prompts, Wh-questions, yes/no questions, choice questions, test


questions, and responsive comments (e.g., imitations, labels, expansions, comments,

acknowledgements). The codes were derived from a coding system previously used by

Girolametto and Weitzman (2002) and is described in Appendix B. For the purposes of this

study, responsive language input consisted of four codes (i.e., Wh-questions, yes–no

questions, choice questions, responsive comments). The inclusion of questions as

responsive input takes into account the use of questions to promote conversation as

opposed to directing the interaction (McDonald & Pien, 1982). All codes in Appendix B

were mutually exclusive and each maternal utterance received only one code. If a parent

code immediately followed a child’s communicative act, it was considered to be in

response to that communicative act. All other parent codes were considered to follow the

child’s unengagement in the interaction. The total length of the videotaping sessions varied

from 15.5 to 18.5 min at pretest and 16.2 to 20.1 min at posttest (due to variability in the

children’s attention spans and engagement in interaction). Consequently, the coded data

were expressed as rates per minute. Twenty-five percent of the transcripts were recoded

independently by the first author to provide reliability estimates. Interrater reliability

was calculated using the formula: number of agreements/(the number

agreements + disagreements) � 100 (Sackett, 1978). Reliability for the individual

responsive codes used in this study was: Wh-questions = 92% (N = 13), yes/no

questions = 96% (N = 131), choice questions = 100% (N = 1), and comments = 97%

(N = 425). The interrater reliability for all responsive codes combined was 94% (N = 954).

2.5.2. Parent Interaction rating

The Joy and Fun Assessment (JAFA) (McConachie et al., 2005) is an observational

checklist that assesses parents’ use of responsive interaction during play. Nine parental

strategies are rated: use of fun words (e.g., ‘‘whee’’), simplified language, musicality of

speech, fun physical contact, praise, pretend games, smiles and laughter, turn-taking

routines, imitations and expansions. The scale has a maximum of 36 points. The scale was

applied to two 5-min play interactions using toys and a storybook by an independent

observer (who was not involved in coding the parents’ utterances) and averaged. (The scale

could not be applied to the remaining 10 min of interaction because the scenarios varied

considerably across children for social play and daily routines.) Twenty-five percent of

the videotaped interactions were re-scored independently by a research assistant who

was blind to the group assignment and questions of the study. Interrater reliability

was calculated using the formula: number of agreements/(the number

agreements + disagreements) � 100 (Sackett, 1978). The overall scale reliability was

87.5% (N = 36).

2.5.3. Vocabulary size

Parent report of children’s vocabulary size was obtained by asking parents to complete

the CDI at all test times. A research assistant calculated frequency counts of expressive

vocabulary size.

2.5.4. Lexical diversity and rate of communication acts

The number of different (i.e., unique) words used by the children during the videotaped

interaction was calculated using SALT. Communicative acts, defined as a vocalization


accompanied by eye gaze to the parent or the parents referent, a gesture, or a word, were

transcribed in a separate pass through the transcript. Reliability for communicative acts and

words is reported above (see Section 2.4). Lexical diversity was automatically calculated

by SALT.

2.5.5. Engagement in social interaction sequences

A research assistant identified reciprocal social interaction sequences that were defined

as chains of parent-to-child turns. Turns consisted of verbal utterances or nonverbal

communicative acts (i.e., vocalizations or conventional gestures accompanied by eye

gaze). The end of a reciprocal social interaction sequence was marked by the absence of a

response from the mother or child. Measures include the number of sequences as well as

the average length of sequences. Interrater reliability of social interaction sequences was

conducted on 25% of the sample. Interrater reliability was calculated using the formula:

number of agreements/(the number agreements + disagreements) � 100 (Sackett, 1978).

The reliability for the correct identification of sequences (i.e., both initiation and

termination of the sequence) was 97% (N = 187).

2.5.6. Children’s initiations of social interaction

Children’s initiations were measured by counting all social interaction sequences that

were initiated by the children. The proportion of sequences initiated by the child was

calculated by dividing the number of child-initiated sequences by the total number of

sequences. Interrater reliability was calculated on 25% of the transcripts using the formula:

number of agreements/(the number agreements + disagreements) � 100 (Sackett, 1978).

Reliability for correct identification of child-initiated sequences was 97%.

2.5.7. Parent report of program progress

At the end of each home visit, parents completed a short subjective survey that asked

what changes they made as a result of their participation in the program and what changes

they had noticed in their children.

3. Results

This section provides a description of the intervention outcomes of three children and

their parents following an 11-week parent-focused program. All names are pseudonyms.

Yin (2003) suggests that effects pattern criteria for evaluating intervention gains in case

studies may be derived from previous experimental studies employing similar measures

and subjects. For the current study, criteria for two parent measures and two child

measures were derived from variables that significantly differentiated the experimental

and control groups in extant investigations of the social-interactionist model (i.e.,

Aldred et al., 2004; McConachie et al., 2005). The study by McConachie and colleagues

(2005) used the same intervention program, More Than Words, and provided data for

expressive vocabulary acquisition and maternal ratings on the JAFA scale. The study by

Aldred and colleagues (2004) used a similar intervention and supplied data derived from

videotaped play interactions, including the rate of mothers’ responsive comments and


children’s communication acts. All four effects pattern criteria represent treatment

effects that were experienced by experimental participants in published studies. A

criterion was met if the gain score experienced by the participants in the current study

equalled or exceeded the following values: rate of maternal responses = 0.24 responsive

comments per minute (Aldred et al., 2004), rating of maternal general responsive-

ness = 2.8 scale points on the JAFA (McConachie et al., 2005), rate of expressive

vocabulary growth = 5.4 words per month (McConachie et al., 2005), and rate of

children’s communication acts = 0.23 acts per minute (Aldred et al., 2004). No a priori

data were available to establish criteria for social interaction sequences or social

initiations.

3.1. Child 1: Jackson

3.1.1. Developmental and clinical history

Jackson, a male, was diagnosed as having ASD at 2.3 years of age by a

developmental pediatrician. He obtained a communication score of 6 and a socialization

score of 10 on Module 1 of the ADOS, for a total score of 16, which met the criteria for a

diagnosis of autism. His hearing was tested using visual reinforcement audiometry with

headphones. Responses were within the normal range bilaterally with normal middle ear

function.

Jackson’s mother enrolled in the parent-administered intervention program when he was

2.8 years of age. At the pretest, a case history form completed by his mother indicated that

early motor milestones were within normal limits (e.g., he walked at 13 months) and he

acquired his first words at 18 months of age. She reported that by 2.8 years of age he had


Table 3

Rates of parental responsiveness following children’s communicative acts and children’s unengaged behaviour

Variable Jackson’s mother Ana’s mother Anthony’s mother

Rate of conversational responsivenessa

Following the child’s communicative actsb

Pre 3.5 1.5 1.1

Post 6.1 2.8 1.4

Gain +2.6 +1.3 +0.3

Following the child’s unengaged behaviourc

Pre 3.5 1.7 2.4

Post 3.6 4.2 7.1

Gain +0.1 +2.5 +4.7

Total gain in responsiveness +2.7 +3.8 +5.0

Note: Rates are expressed as the frequency of units per minute of interaction. The duration of pretest/posttest

interactions was 18.5/16.2, 15.5/20.1, and 18.5/20.1 min for participants 1, 2, and 3, respectively.a Conversational responsiveness included all parents’ Wh-questions, yes/no questions, choice questions, and

comments.b Communicative acts include all vocalizations or words accompanied by gestures or eye gaze towards the

parent (including towards the parent’s referent).c Unengaged behaviour included all noncommunicative behaviour (e.g., passive watching, looking around the

room, wandering, touching or playing with objects; not accompanied by a communicative act).

acquired several single words and communicated primarily using nonverbal means (e.g.,

taking his mother’s hand and pulling her to what he wanted).

3.1.2. Participation in intervention

Jackson’s mother attended all eight evening sessions and all three home visits. On the

home visit surveys, Jackson’s mother reported that she was learning to encourage more

turn-taking in social interactions and to create more opportunities for Jackson to

communicate during play. During the third home visit (i.e., week 10), she reported that

Jackson had learned many new words and was starting to use short phrases (e.g., from

‘‘Go’’ to ‘‘Mommy go’’). In addition, she noted that Jackson’s functional play had

improved and that he engaged in more turn-taking activities since the program began.

3.1.3. Outcomes

Tables 3 and 4 display the parental interaction data. Jackson’s mother increased her rate

of responsiveness by 3.7 utterances per minute when he communicated (i.e., 60 additional

responses during the 16.2 min posttest interaction). In contrast, her responsiveness to

Jackson’s unengaged behaviour remained consistent over the intervention period.

Independent observation using the JAFA yielded a 2.0 increase in the average rating of

parental responsiveness.

As can be seen from Table 5, Jackson’s vocabulary increased from 30 to 74 words

during the intervention period (a rate of 14.7 per month). In the posttest play interaction, his

lexical diversity increased by sixteen words and his rate of communicative acts increased

by 5.1 acts per minute. In addition, Jackson’s overall participation in social interactions

increased from 53 to 74 sequences and the proportion of sequences that he initiated

increased from 5.6% to 20.7%.

3.1.4. Summary

The observed gains substantiated the mother’s report of progress that she made

during the home visits. Gains observed for two maternal and two child measures were in

excess of the four criteria derived from previous studies: the rate of maternal

responsiveness, ratings of maternal interaction on the JAFA, gains in child vocabulary,

and the rate of the child’s communication acts. Jackson’s social initiations tripled from

pretest to posttest. Gains in lexical diversity that were obtained from the videotaped

interactions supported this mother’s report of an increase in Jackson’s vocabulary size

on the M-BCDI.


Table 4

Pretest, posttest, and gain scores of parental responsive interaction on the Joy and Fun Assessment (JAFA)

Variable Jackson’s mother Ana’s mother Anthony’s mother

Mean JAFA scorea

Pre 13.0 13.0 9.0

Post 15.0 33.0 12.5

Gain +2.0 +10.0 +3.5

a The mean JAFA score is the average of ratings obtained in two 5-min activities (i.e., bubbles, storybook

reading). The maximum score obtainable is 36.

3.2. Child 2: Ana


Ana, a female, was diagnosed as having autism spectrum disorder at 2.10 years of age by

a developmental psychologist. On Module 1 of the ADOS, she obtained a communication

score of 2 and a socialization score of 4, yielding a total score of 6, which met the criteria

for a diagnosis of pervasive developmental disorder. An audiogram was completed using

behavioural testing and indicated a moderate reversely sloping loss for at least one ear.

Ana’s parents reported that she had numerous ear infections that were controlled using

antibiotics.

Ana’s parents enrolled in the parent-administered intervention program when she was

3.2 years of age. At intake, a case history form completed by Ana’s mother indicated that


Table 5

Pre- and postintervention scores (and gain scores) for children’s vocabulary, communication, and interaction

measures

Variable Jackson Ana Anthony

Vocabulary development

Vocabulary size (CDI)a

Pre 30 96 380

Post 74 133 589

Gain +44 +37 +209

Different words (video)

Pre 10 27 3

Post 26 54 15

Gain +16 +27 +12

Social interaction (video)

Rate of communicative actsb

Pre 7.0 5.4 2.2

Post 12.1 8.3 3.1

Gain +5.1 +2.9 +0.9

Sequencesc

Pre 53 31 18

Post 74 88 37

Gain +21 +57 +19

Initiationsd (video)

% Child-initiated sequences

Pre 5.6% 3.2% 11.1%

Post 20.7% 20.5% 0.0%

Gain +15.1 +17.3 �11.1

a Vocabulary size as estimated by the MacArthur–Bates Communicative Development Inventories (Fenson

et al., 2003).b Rates of communication acts are expressed as frequencies per minute of interaction.c Social interaction sequences are chains of parent and child communicative acts without interruption (a

communicative act consists of a vocalization accompanied by eye gaze to the parent, a conventional gesture, or a

verbalization).d The percentage of social interaction sequences that are initiated by the child.

her early motor milestones were within normal limits (e.g., she walked at 14 months) and

that she spoke her first words at 13 months of age. By 3.2 years of age, she used

approximately 96 single words and several short phrases. Ana did not receive any speech-

language pathology treatment prior to participating in the parent program.


Ana’s mother attended all eight evening sessions and all three home visits; her father

attended all evening sessions and participated in the first home visit. During the second

home visit (i.e., week 6), Ana’s mother reported that she was following Ana’s lead more

often, engaging her in more frequent turn-taking routines, and using simplified language

(specifically, more labels and short sentences). She also reported that Ana was beginning to

use more words in social routines and participate in longer social interactions.

3.2.3. Outcomes

An examination of the parent–child interaction data (see Tables 3 and 4) indicates that

Ana’s mother increased her rate of responsive comments following communicative acts as

well as following unengaged behaviors. The combined increase was 3.8 responsive

comments per minute. On the JAFA rating scale, the average rating increased by 10.0

points from pretest to posttest.

As can be seen from Table 5, Ana learned 37 new words from pretest to posttest (a rate

of 12.3 words per month). During the videotaped parent–child interaction, she used 27

different words and increased her rate of communicative acts by 2.9 per minute. Ana also

increased her participation in social interactions from 31 to 88 sequences and the

proportion of sequences that she initiated from 3.2% to 20.5%.

3.2.4. Summary

The observations made by Ana’s mother during the home visits were supported by the

observed outcomes. Gains in two maternal measures and two child measures equaled or

exceeded the effects pattern criteria: rate of maternal responsiveness, mean rating on the

JAFA, and the child’s rate of communication acts and acquisition of words. Ana’s social

interaction sequences and social initiations more than doubled from pretest to posttest.

Ana’s increase in vocabulary diversity supported her mother’s report of increased

vocabulary size on the M-BCDI.

3.3. Child 3: Anthony


Anthony, a male, was diagnosed as autistic at 2.11 years of age by a registered

psychologist. During a developmental assessment, he obtained a communication score of 6

and a socialization score of 9 on Module 1 of the ADOS, for a total score of 15, which met

the criteria for a diagnosis of autism. An audiogram conducted using sound field testing

indicated hearing within normal limits. Impedance testing revealed a slight conductive

hearing loss.

Anthony’s mother enrolled in the parent-administered intervention program when he

was 3.2 years of age. She reported that his motor milestones were within normal limits


(e.g., he walked at 11 months) and that he acquired his first words at 24 months of age. By

3.2 years of age Anthony was reported to have many single words but communicated

primarily using nonverbal means (e.g., taking his mother’s hand and pulling her to what he

wanted). Anthony had not received prior speech-language therapy.


Anthony’s mother attended seven of the eight evening sessions and all three home visits.

His father did not participate in the intervention program. In the first home visit survey,

Anthony’s mother reported that she was learning how to involve herself in her child’s

solitary play to create turn-taking games. She reported that Anthony started learning new

words by the first home visit and that word learning continued throughout the intervention

period. By the third home visit (i.e., week 10) she was following Anthony’s lead more often

and waiting longer for him to respond in familiar routines. In addition, Anthony was

starting to use two- and three-word utterances appropriately. She also noted that Anthony

had learned to say ‘‘more’’ to ask for recurrence during social routines and was starting to

engage in pretend play.

3.3.3. Outcomes

An examination of the parent–child interaction data in Tables 3 and 4 indicate that

Anthony’s mother increased her rate of total responsive comments by 5.0 per minute from

pretest to posttest. An examination of the child’s antecedent behavior revealed that she

made large gains in responsive comments following his unengaged behaviors but only

marginally increased her responsiveness following his communication acts. On the JAFA

rating scale, her average rating increased by 3.5 points.

The data in Table 5 indicate that Anthony’s vocabulary increased by 209 new words (a

rate of 69.6 words per month) and his lexical diversity, as measured in videotaped

interaction, increased by twelve words from pretest to posttest. Anthony’s rate of

communicative acts increased by almost 1.0 per minute and his participation in social

interaction sequences doubled from 18 to 37. In contrast, the proportion of sequences that

he initiated decreased from 11.1% to 0.0%, indicating that his communicative acts were

primarily responsive in nature.

3.3.4. Summary

The gains noted by Anthony’s mother during the home visits were supported by the

observed outcomes. Gains in two maternal measures and two child measures equaled or

exceeded the pre-established criteria: the rate of maternal responsiveness, responsiveness

ratings on the JAFA, the child’s vocabulary size and rate of communicative acts.

Additionally, Anthony’s vocabulary diversity and number of social interaction sequences

more than doubled from pretest to posttest. No gains in social initiation skills were noted.

4. Discussion

The data presented in this multiple case study permitted an investigation of parental

responsiveness and outcomes for three children with ASD following intervention. The


purpose of this study was to investigate the use of microanalytic techniques for detecting

outcomes in parent–child interaction following participation in a social-interactionist

intervention. It is important to note that the results of this study cannot be used to conclude

that there is a causal relationship between the intervention and the outcomes because there

was no experimental control to account for maturation effects. However, case study

methods are very useful for examining the theoretical links between an intervention

mechanism (i.e., responsiveness) and hypothesized outcomes. The results may be used to

propose justification for future research and methods of measurement that are sensitive to

change. Moreover, although the case study design precludes generalization of results to

other children with ASD, it does permit the generalization of a set of results to a broader

theory (Yin, 2003).

The first aim of this study was to examine changes in parental responsiveness before

and after an 11-week intervention. Microanalytic techniques were used to investigate

this outcome. Responsive comments were investigated in two contexts—when the child

communicated versus when the child was unengaged in interaction. Consistent with the

hypothesized outcomes, all three mothers increased their rate of responsive comments

during a play interaction and their gains exceeded those observed in a previous study

utilizing a similar coding system (Aldred et al., 2004). An examination of the

contextual data (i.e., whether the child communicated or was unengaged in interaction)

revealed that maternal gains were idiosyncratic. Only Ana’s mother made gains in both

contexts. Jackson’s mother made gains in responsiveness following communicative acts

whereas Anthony’s mother made gains in responsiveness following unengaged

behaviour. The children’s interactive behaviour may explain these findings. Jackson

was the most communicative of all three children and used twelve communicative acts

per minute at posttest, offering many opportunities for his mother to respond. In

contrast, Anthony communicated the least of all three children at postintervention, and

his mother appears to focus her energies on re-engaging him in interaction. Anthony’s

posttest data suggest that his mother missed opportunities to respond to his

communicative acts (he used 3.1 acts per minute but her response rate was 1.4 per

minute). These data indicate the importance of examining the child’s antecedent

behaviour when counselling parents to increase responsiveness. Clinicians wishing to

enhance parental responsiveness may want to differentiate communicative acts from

noncommunicative behaviour and help parents learn to respond to missed opportunities

in both contexts. This may be especially important for children who use low rates of

communicative acts.

A second measure of mothers’ responsive interaction, the JAFA rating scale, was

administered by an independent observer to validate changes in responsive behaviour. All

three mothers showed increases on the JAFA (2.0, 3.5, and 10.0 points) from pretest to

posttest. These increases equalled or exceeded the pre-established criterion (i.e., 2.0 scale

points) derived from previous work using this scale (McConachie et al., 2005). A third

measure, parents’ subjective responses on surveys administered during home visits,

provided some assurance for the ecological validity of these findings. All three mothers

reported that they adopted strategies consistent with the program’s focus on responsive

interaction. In summary, the gains in maternal responsiveness observed during videotaped

interaction and reported by mothers themselves are consistent with effects patterns


observed in previous work and also with the intervention model’s central tenet of

optimizing responsive interaction. Microanalytic techniques of measurement appear to be

a sensitive measure of parental responsiveness.

The second aim of this study was to replicate the previous findings of increased

vocabulary development for children with ASD following intervention. Children’s

vocabulary was measured in two ways—parent report (CDI) and videotaped interaction.

All three children made gains in vocabulary size as measured by the CDI. All three

children made vocabulary gains that exceeded those made by the experimental group in

the McConachie et al. study (2005). The children’s lexical diversity revealed that all

children increased the number of different words that they used during the posttest play

interaction, supporting parent report on the CDI. In addition, these findings were

supported by a third measure, mothers’subjective reports of increases in vocabulary on the

home visit surveys. Thus, all three case studies replicated the effects pattern for

vocabulary outcomes observed in prior studies of this intervention approach. Caution is

needed in interpreting Anthony’s lexical gains as he appeared not to use his vocabulary

spontaneously.

The final and most important aim of the study was to examine the children’s social

interaction skills following intervention, specifically their rate of communicative acts,

participation in social interaction sequences, and initiation of social interaction. All three

children made gains in the rate of communication acts, surpassing the gains made by the

experimental group in Aldred et al. (2004). Jackson, Ana, and Anthony also made

substantial increases in social interaction sequences. Their mothers’ subjective

comments, obtained during home visits, supported improvements in turn-taking and

social interaction skills for the children. In contrast, the results for social initiation skills

were mixed. Jackson and Ana increased the proportion of child-initiated sequences

substantially, whereas the data indicate that Anthony used fewer social initiations at

posttest. Therefore, the hypothesized effect on social initiations was supported by only

two of the three children. Future research investigating the efficacy of social-interactionist

intervention needs to investigate these social-pragmatic outcomes using similar

microanalytic techniques.

In general terms, the increases in communicative acts and social interaction episodes

experienced by all three children replicated the findings of two previous studies that

examined similar interactive behaviours using rating scales (Aldred et al., 2004; Mahoney

& Perales, 2003). Social-interactionist theory suggests that the more interactive practice

children obtain, the more they stimulate adults’ responsiveness and receive further

responsive feedback from which they can learn rules of engagement, discourse, and

language. Thus, the changes observed in the children’s interactive participation in this

study have the potential to bootstrap further developmental gains in their communication

development. Social-interactionist theory also suggests that parental responses to

children’s initiations are especially important for learning (Rocissano & Yatchmink,

1983; Tomasello & Farrar, 1986). Two of the three children appeared to make

improvements in social initiations, which is a core deficit in children with autism spectrum

disorder. Clinicians should monitor parent–child interaction closely to ensure that parents

appropriately scaffold opportunities for their children to initiate (e.g., making

environmental arrangements, pausing and waiting expectantly).


There are several important limitations to the present study. This study was conducted

in a clinical setting and was not designed with control groups or multiple data collection

points due to restrictions imposed by the clinical agency. Second, the lack of a control

group prevents any conclusions regarding the efficacy of this intervention approach as the

outcomes reported in this study may reflect children’s maturational changes. However, the

outcomes do point to the potential of measures for detecting change in this group of

children. Third, the number of children who participated in this study was small, and the

case study methodology necessitates more replications to corroborate the theoretical

direction of influence suggested by this intervention model (Yin, 2003). These

preliminary data suggest that children experience outcomes that are consistent with

the hypothesized intervention mechanisms. Fourth, multiple data points, in addition to

pretest and posttest filming, would have been helpful to help trace the development of

parental responsiveness and children’s interactional behaviour during the program period.

Case study methodology is strengthened when a series of data points is examined (Yin,

2003).

In conclusion, the data from this exploratory study are consistent with the theoretical

mechanisms of the social-interactionist intervention approach. They add to the

literature by revealing that an 11-week parent-administered program (i.e., More Than

Words) may be associated with positive changes in social interaction and initiation

skills in preschool children with ASD. Thus, this study extends the findings of

McConachie’s study (2005) which did not report gains in these important areas. Further

research using this intervention approach has the potential to confirm gains in social

interaction skills and investigate the program’s impact on social initiation skills. The

results of this study illustrate the importance of microanalytic coding methods to

investigate interaction gains. The clinical implications of this study for practitioners

include the value of (a) examining parent–child interactions for child initiations and (b)

distinguishing between communicative acts and noncommunicative events so that

parents learn to respond sensitively in both contexts to scaffold the child’s social

engagement.

Acknowledgements

Our appreciation is extended to the parents and children who participated in this

study and willingly opened up their homes to us so that we could assess and videotape

their progress in the More Than Words intervention program. We are indebted to Cheri

Rorabeck, Lauren Lowry, and Meggan Levson, the speech-language pathologists who

helped recruit, assess, and deliver the intervention program. Thanks to Rhonda

Schwartz for expediting ethics review and recruitment at the North York General

Hospital. We express our gratitude to Maureen O’Keefe, Nadia Abisaleh, Tara Davies,

and Sandra Hitchcock for transcribing and coding the videotapes of parent–child

interaction. Finally, we express our sincere gratitude to Maureen O’Keefe, research

officer, who oversaw every stage of this project. Funding for this research was obtained

from the Canadian Language and Literacy Network (Network of Centres of

Excellence).


Appendix A. Description of intervention program

Week 1 During the first group session, parents learn how to arrange their child’s environment

so that the child is motivated to attend and interact with them. For example, parents

may blow bubbles and then give the closed container to their child and wait for

the child to ask for more using the communicative mode appropriate for his stage

(e.g., alternating gaze between parent and object or echoing an adult model or

using a phrase)

Week 2 During the second group session, parents learn to follow their child’s lead in terms

of activities or interests with the aim of establishing reciprocal social interaction on a

shared topic. Parents learn to share the child’s interests by touching, pointing to,

or commenting on the child’s focus. Parents imitate their child’ actions and sounds

and interpret nonverbal communication and echolalia by giving the child a language

model (label or short phrase). Finally, for children who do not readily share joint

attention, parents are taught to join into their child’s play and structure a turn-taking

routine from it

Week 3 In the third group session parents learn how to create structured, predictable

‘‘people games’’ based on their child’s sensory preferences. Parents are

encouraged to set appropriate goals based on their child’s stage of communication

and keep the games highly structured in the beginning. Parents repeat their actions/

words, create opportunities for the child to take turns, provide explicit cues for the

child to take a turn if necessary (e.g., hand-over-hand physical help, complete

verbal models, wait, looking expectant, ask questions)

Week 4 First home visit—to monitor progress and coach interactions

Week 5 In the fourth group session, parents learn to adjust their language input by

shortening their utterances, emphasizing key words, speaking slowly,

but naturally, and supplementing speech with contextual cues (such

as gestures or objects). The most important information for parents is the

realization that their child might not understand as much as they had thought

and the importance of timing what they say to the immediate moment that

their child shows an interest in something

Week 6 In the fifth group session parents learn to improve their child’s comprehension by

using visual aids (e.g., photographs, pictures) to explain situations and contexts,

such as feelings, what’s going to happen next in an activity/situation, or how

to perform a sequence of actions

Week 7 Second home visit—to monitor progress and coach interactions

Weeks

8 and 9

In the sixth and seventh group sessions parents learn to integrate all of the

previously learned program strategies and apply them to situations such as

reading books and playing with toys

Week 10 Third home visit—to monitor progress and coach interactions

Week 11 In the eighth and final group session, parents learn how to prepare their child for interactions with

peers (siblings, relatives, playmates) by (a) rehearsing the games, songs, and play routines that the

child may use in interactions with other children, (b) practicing play with toys and activities that

may be shared with peers, and (c) coaching peer interactions from the sidelines to encourage

balanced turn-taking between the child and peers


Appendix B. Parent interaction coding system

Directives included:

1. [BC]—behaviour control: parent calls the child’s name to get attention; uses a

command to promote safety or reduce noncompliance (e.g., ‘‘Arpita,’’ ‘‘Don’t eat that,’’

‘‘Come here and play’’).

2. [CO]—command: parent requests an action response (e.g., ‘‘Put the wand in the

bottle’’).

3. [TQ]—test question: parent asks a question to elicit a known answer (e.g., ‘‘What colour

is this?’’).

4. [PC]—promote communication: parent prompts children to communicate by using

intonation cues or sentence completion (e.g., ‘‘This is a�.’’). The parent does not direct

the child what to say.

Responses included:

5. [WH]—Wh-question: parent asks an open-ended Wh-question (e.g., ‘‘What would you

like to do now?’’).

6. [YN]—yes/no question: parent asks a question requiring a yes/no response (e.g., ‘‘Do

you want more bubbles?’’)

7. [CH]—choice question: parent asks a choice question (e.g., ‘‘Do you want a cookie or a

banana?’’)

8. [CM]—comment: parent uses comments that (a) acknowledge the child’s behavior

(e.g., ‘‘Good boy’’, ‘‘Uhum’’); (b) imitates the child’s utterance; (c) provides a label

(e.g., ‘‘That’s a bus’’); (d) expands the child’s utterance; or (e) makes a general

comment or statement that is not a label, imitation, or expansion (e.g., ‘‘You’re popping

all the bubbles’’).

Uncodable utterances included:

9. [UN]—uncodable: adult’s utterance is incomplete (e.g., ‘‘Give me the . . .’’) or unclear

(e.g., ‘‘This is a X’’).

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