Working with parentsWorking with parentsThe Early Start Denver ModelThe Early Start Denver Model

Costanza Colombi & Sally Costanza Colombi & Sally RogersRogers

M.I.N.D. Institute, UC DavisM.I.N.D. Institute, UC Davis

This work is based onThis work is based on

• Rogers & collaborators, University of Rogers & collaborators, University of Colorado DenverColorado Denver

• Dawson & Rogers, University of Dawson & Rogers, University of WashingtonWashington

• Rogers, Vismara, & Colombi, M.I.N.D. Rogers, Vismara, & Colombi, M.I.N.D. Institute at UC DavisInstitute at UC Davis

TopicsTopics

I.I. Parent Training, introduction and Parent Training, introduction and experimental evidenceexperimental evidence

II.II. The Early Start Denver Model The Early Start Denver Model (ESDM) Parent Training(ESDM) Parent Training

III.III. A single subject study of ESDMA single subject study of ESDM

Recommendations for the Education of Recommendations for the Education of Children with Autism (NRC, 2001)Children with Autism (NRC, 2001)

“…“…Across primarily preschool Across primarily preschool programs, there is a very strong programs, there is a very strong consensus that the following features consensus that the following features are critical: …Inclusion of a family are critical: …Inclusion of a family component, including component, including parent parent trainingtraining (p. 219)…” (p. 219)…”

Parents successfully Parents successfully learned:learned:

•Parent–child relationship (e.g., Koegel, 1996; Mahoney & Perales, 2003)

•Communication skills (e.g., Harris, 1986; Rogers et al., 2006)

•Decrease inappropriate behavior (Marcus et al., 1978)

Benefits of Parent TrainingBenefits of Parent Training

• Trained parents continuous gains in Trained parents continuous gains in children (Lovaas et al., 1973)children (Lovaas et al., 1973)

• Increased generalization and maintenance overtime (Koegel et al, 1982)

• Reduced stress • Increased quality of life in family (Koegel et al.,

1996)• More leisure time (Koegel et al., 1982)• More optimism about child’s development (Koegel

et al., 1982)

Procedures successfully Procedures successfully taughttaught

• Discrete Trial Training (DTT)Discrete Trial Training (DTT)

• Pivotal Response Training (PRT)Pivotal Response Training (PRT)

• Relationship Development Training Relationship Development Training (RDI) (RDI)

• Denver ModelDenver Model

A new intervention need: infants and A new intervention need: infants and toddlers with autismtoddlers with autism

• Are infants “special”? Where do we look Are infants “special”? Where do we look for models of infant therapy?for models of infant therapy?

• Are maternal relationships with infants Are maternal relationships with infants “special”? Parent training/parent support“special”? Parent training/parent support

• Who should deliver tx?Who should deliver tx?• Treatment intensity?Treatment intensity?• Delivery settings?Delivery settings?• Level of directiveness?Level of directiveness?

Partnerships with families in Partnerships with families in Denver Model Denver Model

• Parents are part of all activities and Parents are part of all activities and meetingsmeetings

• Parents help set goalsParents help set goals• Parents determine focus of home Parents determine focus of home

interventionsinterventions• Parent deliver intervention at homeParent deliver intervention at home• Parent/family needs are part of planParent/family needs are part of plan• Parent supports actively fosteredParent supports actively fostered

M.I.N.D. Parent-Toddler Intervention StudyM.I.N.D. Parent-Toddler Intervention Study(Vismara, Colombi, & Rogers, in press)(Vismara, Colombi, & Rogers, in press)

• Intervention right after diagnosis before intensive Intervention right after diagnosis before intensive treatmenttreatment

• Effective tools for helping child’s development in all Effective tools for helping child’s development in all areasareas

• A positive experience of self as teacher, child as A positive experience of self as teacher, child as learnerlearner

• To develop a manualized intervention for coaching parents in ESDM

• To examine parents’ acquisition of ESDM• To examine changes in children’s social

communication

Children Children Eight consecutive referrals, diagnosis of AD, no Eight consecutive referrals, diagnosis of AD, no

health or medical problems, interest in objectshealth or medical problems, interest in objects

ageage ethnicethnic Rec MARec MA Exp MAExp MA ADOSADOS

Child 1Child 1 26 m26 m CaucCauc 10 m10 m 11 m11 m 1414

Child 2Child 2 31 m31 m CaucCauc 9 m9 m 14 m14 m 1919Child 3Child 3 26 m26 m LatinoLatino 11 m11 m 13 m13 m 1818Child 4Child 4 27 m27 m CaucCauc 8 m8 m 9 m9 m 1717

Child 5Child 5 35 m35 m LatinoLatino 9 m9 m 10 m10 m 2222

Child 6Child 6 10 m10 m CaucCauc 6 m6 m 6 m6 m ----

Child 7Child 7 36 m36 m CaucCauc 13 m13 m 12 m12 m 1717

Child 8Child 8 29 m29 m CaucCauc 14 m14 m 17 m17 m 2222

Research DesignResearch Design

• Single subject design across 8 Single subject design across 8 subjectssubjects

• 17 1 hour contacts across a 26 week 17 1 hour contacts across a 26 week periodperiod

Weeks 1 and 2Evaluate

Gather baseline dataDevelop treatment plan

Weeks 3 – 15Provide 1 hr of parent-

Child treatment per weekGather behavior samples weekly

Weeks 16 – 264 follow-up visits

Gather maintenance and generalization data

Evaluate Treat Follow-up

What do we measure?What do we measure?

Fidelity to Fidelity to treatment treatment deliverydelivery

• Therapist – ChildTherapist – Child

• Parent – ChildParent – Child

• Therapist - ParentTherapist - Parent

Progress on Progress on ObjectivesObjectives

• % of % of objectives objectives masteredmastered

Dependent VariablesDependent Variables

• Standardized Standardized measures (e.g, measures (e.g, Mullens, Vineland, Mullens, Vineland, CARS, ADOS)CARS, ADOS)

• Frequency of target Frequency of target behaviors (words, behaviors (words, imitative acts, child imitative acts, child attention, child attention, child initiation)initiation)

Data gathered in two 10 min play samples per sessionData gathered in two 10 min play samples per sessionOne with parent, one with therapistOne with parent, one with therapistCoded from videos by coders blind to date and orderCoded from videos by coders blind to date and order

EVALUATIONEVALUATION

Step 1: Curriculum Step 1: Curriculum AssessmentAssessment

• Receptive Receptive languagelanguage

• Expressive Expressive languagelanguage

• Joint attentionJoint attention• Social interactionSocial interaction• Fine motorFine motor• Gross motorGross motor

• ImitationImitation• CognitionCognition• PlayPlay• Personal Personal

independenceindependence– EatingEating– DressingDressing– GroomingGrooming– choreschores

Autism affects all aspects of Autism affects all aspects of developmentdevelopment

Curriculum ChecklistLevel 1 Observed TA

ReportParent Report

Code

Receptive Communication

1 Localizes to sounds by turning toward sound source

2 Looks to playful vocal sounds (raspberry, whistle)

3 Responds to voice by turning toward person

4 Looks at indicated pictures as adult points to pictures in books

5 Follows a proximal point to place objects in containers, puzzle pieces, etc

6 Looks when shown an object and told, “Name, look”

7 Looks to partner when name is called

8 Follows proximal point to object or location

9 Follows distal point to retrieve toy

10 Looks, reaches, or smiles in response to adult gestures and voice in social games

Step 2: Writing Specific Step 2: Writing Specific Treatment ObjectivesTreatment Objectives

• 12 week objectives developed with 12 week objectives developed with parents; 2-3 per developmental areaparents; 2-3 per developmental area

• Objectives define interventions across Objectives define interventions across people and settingspeople and settings

• Objectives target functional, Objectives target functional,

adaptive actions-in-context adaptive actions-in-context

Treatment ObjectivesTreatment Objectives

• Objectives written in ABC format; Objectives written in ABC format; measurable, targeting generalization and measurable, targeting generalization and independent or spontaneous performanceindependent or spontaneous performance

• AA: What is the : What is the antecedentantecedent or stimulus that or stimulus that is to cue the behavior?is to cue the behavior?

• BB: What is the : What is the behaviorbehavior, defined , defined measurably?measurably?

• CC: What is the : What is the criterioncriterion for mastery of this for mastery of this objective?objective?

Objective - exampleObjective - example

• (A) In sensory social routines, when adult (A) In sensory social routines, when adult says the names of five different games says the names of five different games (e.g. so big, peekaboo, little piggies, here (e.g. so big, peekaboo, little piggies, here comes a mousey, pattycake) comes a mousey, pattycake) unaccompanied by gestures,unaccompanied by gestures, ( (B) the child B) the child will respond with an appropriate gesture or will respond with an appropriate gesture or body movementbody movement (C)75% of the first four (C)75% of the first four opportunities both in therapy and at home opportunities both in therapy and at home with parents over 3 consecutive days.with parents over 3 consecutive days.

Step 3: Developmental Task Step 3: Developmental Task Analysis of Each ObjectiveAnalysis of Each Objective

• Each objective is broken down into 4-Each objective is broken down into 4-6 teaching steps6 teaching steps

• First step: baseline level of skillFirst step: baseline level of skill

• Last step: mastery level of skillLast step: mastery level of skill

• Intermediate steps define Intermediate steps define

progress towards masteryprogress towards mastery

Step 4: Build the Data SheetStep 4: Build the Data Sheet• Daily data sheet constructed from Daily data sheet constructed from

task analysis for each objectivetask analysis for each objective

• Data collected at 15 minute intervalsData collected at 15 minute intervals

• Data used to adjust daily teaching Data used to adjust daily teaching practices practices

• Goal: measurable progress Goal: measurable progress

within three instructional sessionswithin three instructional sessions

Daily Data Sheet ExampleDaily Data Sheet ExampleRECEPTIVE COMMUNICATIONLooks to adult vocal. in 5 minutes of play : 1X 2X

3X

Stops activity, turns and looks to name : looks no distractions turns and looks looks while playing

turns and looks while playing from 5 feet across room

Responds to give gesture and verbal request: extends towards hand makes contact with hand places no release places and releases

Follows proximal point to retrieve object: looks at object touches object takes object

Follows proximal point to place object: looks at indicated target makes contact with indicated target inconsistently places on target consistently places on target

Conducting the parent-Conducting the parent-child sessionchild session

Parent Manual ChaptersParent Manual Chapters

• Attention and Attention and motivation motivation

• Sensory social Sensory social routinesroutines

• Taking turns during Taking turns during playplay

• Joint activity routinesJoint activity routines

• ImitationImitation

• Talking bodies Talking bodies

• Speech development Speech development

• ABC’s of learning ABC’s of learning

• Understanding and Understanding and managing unwanted managing unwanted behaviors behaviors

• Prompting, shaping, Prompting, shaping, fading, chainingfading, chaining

Intervention SessionIntervention Session

• 5-10 minutes – review of past week5-10 minutes – review of past week

• 5-10 minutes – play sample with parent5-10 minutes – play sample with parent

• 5-10 minutes – discuss new concept5-10 minutes – discuss new concept

• 5-10 minutes – demonstrate new concept5-10 minutes – demonstrate new concept

• 5-10 minutes – parent practices new 5-10 minutes – parent practices new concept with coaching until masteredconcept with coaching until mastered

• 5-10 minutes – review of objectives, 5-10 minutes – review of objectives, discussion of practice in varying environsdiscussion of practice in varying environs

• goodbyegoodbye

Play Assessment with ParentsPlay Assessment with Parents

Sensory routine with Dr Rogers – Sensory routine with Dr Rogers – wk 6wk 6

Joint activity with father – wk 6Joint activity with father – wk 6

Can parents learn to improve their Can parents learn to improve their teaching skills in short period of time?teaching skills in short period of time?

• Yes, mastery of ESDM by 6th intervention sessionYes, mastery of ESDM by 6th intervention session• Maintenance their skill level during program and 3 ms follow Maintenance their skill level during program and 3 ms follow

up.up.

Will parent skills increase child word Will parent skills increase child word acquisition ?acquisition ?

• Similar levels of child performance occur both with Similar levels of child performance occur both with parents and therapists.parents and therapists.

Average Number of Spontaneous Average Number of Spontaneous WordsWords

Will parent skills increase child Will parent skills increase child imitative behaviors?imitative behaviors?

Higher levels are maintained in follow up both with Higher levels are maintained in follow up both with parents and unfamiliar therapists compared to baseline parents and unfamiliar therapists compared to baseline levels.levels.

Average Number of Imitative BehaviorsAverage Number of Imitative Behaviors

Will parent skills improve child Will parent skills improve child engagement?engagement?

• Higher levels of child engagement to adult (i.e., Higher levels of child engagement to adult (i.e., attention, persistence, cooperation, interest) attention, persistence, cooperation, interest) compared to baseline levels.compared to baseline levels.

Gains are maintained during follow up with parentGains are maintained during follow up with parent

• Higher levels of initiation to adult (i.e., joint Higher levels of initiation to adult (i.e., joint attention, affect) compared to baseline levels.attention, affect) compared to baseline levels.

• Gains are maintained during follow up with parent Gains are maintained during follow up with parent and unfamiliar therapist.and unfamiliar therapist.

Will parent skills improve child Will parent skills improve child initiations?initiations?

ParticipantParticipant Post-Treatment Post-Treatment Mastered Mastered ObjectivesObjectives

Follow-Up Follow-Up Mastered Mastered ObjectivesObjectives

Child 1Child 1 73%73% 100%100%

Child 2Child 2 93%93% 100%100%

Child 3Child 3 87%87% 93%93%

Child 4Child 4 67%*67%* NANA

Child 5Child 5 56%*56%* NANA

Child 6Child 6 85%85% 98%98%

Child 7Child 7 64%64% 100%100%

Child 8Child 8 77%77% 100%100%

Developmental ObjectivesDevelopmental Objectives

Effects of the intervention:Effects of the intervention:ParentsParents• learned play based intervention learned play based intervention

strategies strategies

• learned principles of behavior change learned principles of behavior change and learned how to apply themand learned how to apply them

• used these skills in real-life contexts used these skills in real-life contexts and interactionsand interactions

• taught children their developmental taught children their developmental objectivesobjectives

• maintained skills for 12 weeks after maintained skills for 12 weeks after treatment endedtreatment ended

Effects of the intervention:Effects of the intervention:childrenchildren

• increased attention and engagement with increased attention and engagement with others others

• increased spontaneous social initiations and increased spontaneous social initiations and responsesresponses

• increased number of words more than 10 fold increased number of words more than 10 fold • increased number of imitations more than 10 increased number of imitations more than 10

foldfold• continued to develop and generalize skills 12 continued to develop and generalize skills 12

weeks after the end of treatmentweeks after the end of treatment

ConclusionsConclusions

• Short term parent based interventions Short term parent based interventions begun soon after diagnosis can:begun soon after diagnosis can:– Provide parents with powerful teaching skillsProvide parents with powerful teaching skills– Address their motivation to act immediately Address their motivation to act immediately

after diagnosisafter diagnosis– Stimulate changes in child developmentStimulate changes in child development– Provide an important intervention while Provide an important intervention while

waiting for other treatments to beginwaiting for other treatments to begin– Prepare children for participation in more Prepare children for participation in more

intensive therapist based interventionsintensive therapist based interventions

ThanksThanks

• To all the contributors To all the contributors

• To the participating familiesTo the participating families

• To YOU!To YOU!