Parent-Mediated Intervention for Infants & Toddlers at

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different caregiver responses. • Test out “hypotheses” about effective strategies live with child. • Evaluate & generate ideas for different strategies if needed.
Parent-Mediated Intervention for Infants & Toddlers at-Risk for ASD Identified by Community Screening Linda R. Watson, EdD, CCC-SLP Division of Speech & Hearing Sciences/Department of Allied Health Sciences School of Medicine University of North Carolina at Chapel Hill (As part of a panel: Landa, R., Watson, L. & Kaiser, A. (2018, March). Defining intervention features to advance outcomes of high risk and delayed infants and toddlers. Conference on Research Innovations in Early Intervention, San Diego, CA )

Elizabeth Crais

Grace Baranek

Lauren Turner-Brown

Steven Reznick

Linda Watson

Funding: Autism Speaks (Baranek, Crais, Turner-Brown, Watson; Reznick); Ireland Family Foundation; IES R324A100305 (Watson & Crais); NICHD 1R21HD091547 (Watson & Baranek). The opinions expressed are those of the presenter and do not represent views of the funding agencies. Grateful acknowledgements: our collaborators, research staff, students, and families who have participated in this research.

PEARLS Research Agenda •  Development & validation of parent questionnaire screening tool to allow community screening of infants & young toddlers (IYTs) for risk of ASD •  Current age range = 8-16 months

•  Development & evaluation of interventions for identified IYTs •  Focus has been on parent-mediated interventions implemented based on risk status, not diagnosis

Research questions we cannot yet answer: •  Is parent implementation of EI for IYTs at-risk for ASD impacted by the way risk is identified – familial risk vs. community screening? •  Do the features of parent-mediated intervention need to be different for IYTs at familial risk vs. screened at-risk to achieve similar effect sizes? •  What are the mechanisms of change? à What are the most important/pivotal intervention targets for IYTs at risk for ASD and/ or for their caregivers? •  What is the importance of intensity in parent-mediated EI for this population? And how do we define and measure intensity? •  Is it cost-effective to implement EI for IYTs based on ASD risk, prior to the time that definitive diagnosis is possible? Or should we focus on the subset of this population that is otherwise eligible for EI (e.g., based on developmental delays)?

Community screening

First Year(s) Inventory (FYI) •  Parent report screening tool to identify infants at-risk for ASD •  FYI 2.0—63-item tool normed for 12-month-olds •  FYI 3.1b—25-item tool normed for 9- to 16month-olds •  Both versions: •  Social-communication domain •  Sensory-regulatory domain •  PPV ~30-35% for ASD across studies

Decision-making within context of ambiguity •  Risk markers ≠ diagnosis •  Early identification of risk markers can lead to prolonged period before definitive diagnosis can be made •  Confidence levels about ruling in or ruling out ASD in infants/ young toddlers will vary •  Should we monitor? Should we assess for EI eligibility? Should we intervene based on risk? Anonymous, 1888; Hill, 1915; Boring, 1930

Early (“prodromal”) intervention

Adapted Responsive Teaching (ART)

Adapted from: Mahoney, G.J. & MacDonald, J. (2007). Autism and Developmental Delays in Young Children: The Responsive Teaching Curriculum for Parents and Professionals Manual. Austin: PRO-ED, Inc.

Features of ART •  Content

•  Social-communication domain à pivotal behaviors •  Sensory-regulatory domain à pivotal behaviors

•  Coaching

•  FRED-R (Family Routines Exploration & Description-Revised; Wakeford et al., 2009) + parent & coach assessment of pivotal behaviors •  Coaching fidelity items were grouped under: •  •  •  •  • 

Rapport & review Purpose & rationale – discussion points Demonstration & practice of A.R.T. strategies Family action planning Documentation – session notes & parent rating form

•  Setting

•  In home (generally during caregiver-child play)

•  Intensity

•  30 one-hour coaching sessions over 6 months

Early Development Project (EDP) 1 and 2 Theoretical Model for Adapted Responsive Teaching (ART) Trials M Parent responsiveness

ART vs Control

X

•  RCTs of parent-mediated intervention •  Children identified with FYI2.0 •  EDP1 (Autism Speaks) n = 16 •  Effects on parent response strategies and multiple child outcomes •  Baranek et al. (2015), Autism Research & Treatment

•  EDP2 (Institute for Education Sciences) n = 87

Child outcomes Y

•  Moderate to large effects on parent responsiveness & affect, only one puzzling main effect on a child outcome •  HOWEVER, changes in parent responsiveness mediated the effect of group on multiple child outcomes •  Watson et al. (2017), JADD

Mediation models summary Significant

•  SPA Hyper-responsiveness •  ADOS total algorithm score •  MSEL Expressive Language •  MSEL Receptive Language •  MSEL Fine Motor •  VABS Communication •  VABS Social

Nonsignificant

•  CSBS Behavior Sample •  SPA Hypo-responsiveness •  MSEL Visual Reception •  VABS Motor •  VABS Daily Living

Given mediation effects, do we see main effects on child outcomes over time?

Reflections following EDP1 and EDP2 •  Caregiver-child interactions reflect transactional processes •  Many parent-mediated interventions across populations have targeted aspects of parent responsiveness (often with positive child effects) •  Parent responsiveness was implicated as a potential mechanism of change for IYTs at-risk for ASD •  Most parent-mediated interventions, including ART, address the parent à child direction of effects, but not (explicitly) the child à parent direction of effects

Would efficacy improve if we modified features of the intervention? •  Content •  •  •  • 

Reduce the number of child behavior constructs Explicitly focus on bidirectional effects: child behaviors ßà parent responses Balance attention to the two domains Overarching outcome/goal

•  Coaching

•  More collaborative •  Use video to enhance caregiver observation, reflection, & decision-making •  Identifying effective strategies caregivers are currently using

•  Setting

•  Coaching across varied family routines

•  Intensity

•  Greater density of coaching sessions? •  Longer period of coaching, or periodic “booster sessions” after core coaching? •  Addressing “intensity” in parent implementation?

Current Study (in recruitment phase) NICHD 1R21HD091547 (Watson & Baranek)

•  Proof-of-concept study of new intervention model, Parents & Infants Engaged (PIE)

Overall PIE coaching process •  1 domain at a time (6 wks each) •  Within domain, use video “moments” to:

Assumptions about responses promoting increased engagement (to be tested!)

•  Identify child behaviors reflecting •  Hyper-reactivity and Hypo-reactivity •  Up-regulating child in context of •  Intentional prelinguistic communication and hypo-reactivity & downindirect communication regulating child in context of •  Discuss ways caregiver responds differentially hyper-reactivity to these behaviors •  Observe child/dyad engagement subsequent to •  Using nonverbal responses (+ different caregiver responses

•  Test out “hypotheses” about effective strategies live with child •  Evaluate & generate ideas for different strategies if needed •  Family plan •  Video for next session



optional verbal) in context of indirect communication and verbal responses (+optional nonverbal) in context of intentional communication

For further consideration - •  Some evidence for parent responsiveness as a mechanism of change •  Follow-up assessments important to fully evaluate EI efficacy •  Challenging to identify “key ingredients” of a multi-faceted EI •  Intensity of high-fidelity implementation likely important •  Relatively easy to measure intensity & fidelity of the coaching •  Current strategies for measuring intensity & fidelity of parent implementation are inadequate •  What intervention features effectively promote intensity of parent implementation?

•  In parent-mediated interventions for IYTs at-risk for ASD, is it feasible to achieve the fidelity & intensity required for clinically significant impact on key child outcomes?

Questions?