“Try this at home” isn’t enough

The effects of coaching on teaching parents reciprocal imitation training

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There is an ever-growing research base for parent-implemented interventions for children with ASD, and for good reason! We know that in order for children with autism to make progress, they need high treatment intensity. The most cost-effective, naturalistic way of reaching that treatment intensity is by teaching their parents how to use intervention strategies with their children on a daily basis. The other side of this coin, however, is that we also know that treatment fidelity is an important factor in child outcomes; how closely parents adhere to the intervention will impact their child’s progress.  

This study looked at how one-on-one coaching affected parents’ ability to implement an evidence-based intervention for their child with ASD, and how their use of the strategies impacted their child’s outcomes. The intervention taught to parents was reciprocal imitation training (RIT). RIT is a naturalistic developmental behavioral intervention (NDBI; Schreibman et al., 2015) that teaches young children with ASD to spontaneously imitate within a social interaction. It uses naturalistic behavioral strategies such as following the child’s lead, modeling, prompting, and reinforcement.  

Three parents and their children with ASD participated in this study. The parents attended a training where they learned all of the ins and outs of how to do the intervention. Then they went home and video recorded their attempts to use the strategies once per day. After a few weeks, a clinician came to their home and provided coaching on the strategies once per week for 6-7 weeks. The researchers then went through the recordings and measured both the parents’ use of the strategies over time and the children’s growth in imitation skills. They found that parents were able to implement RIT with high accuracy (yay!), but only after individualized coaching support. While some of the parents improved significantly after the initial training, they all needed a therapist to come to their house and coach them in order to master the strategies. The children in the study all increased their spontaneous imitation, but only after their parents became consistent and accurate with at least some of the components of the intervention.

This study extends our understanding of the importance of coaching parents on strategies rather than relying solely on verbal instruction or suggestions. Here we have data to show how these parents needed more than just verbal instruction; they needed live feedback and training in order to use the strategies accurately and consistently, and only then did child outcomes improve. Providing parents with active coaching provides parents with the tools needed in order to support their children’s social communication. 

Note: If you are interested in learning more about RIT, you can check out this article. And here is the measure that the researchers used to evaluate the parents’ use of the strategies.

 

Penney, A. & Schwartz, I. (2018). Effects of coaching on the fidelity of parent implementation of reciprocal imitation training. Autism. doi: 10.1177/1362361318816688.

Imitation: a simple and powerful strategy for parents of toddlers at-risk for ASD

While we all know that involving parents in early intervention for toddlers with ASD is important, knowing where to start can be another matter altogether. What if there was one simple and effective strategy that we could teach parents right off the bat--one they could master easily with a big impact? Imitation might fit that bill.

Imitation is a strategy you already have in your toolbox: it’s as simple as copying what a child says or does. It’s been researched in different forms for decades, and it belongs to a family of strategies called “responsive” language strategies. Other responsive strategies include following the child’s interests, avoiding questions and directions, and responding to his communication attempts.

The great thing about imitation as a strategy is that it naturally incorporates many components of other responsive strategies. If a parent is imitating his child, then he is probably following his child’s interests, reducing the number of questions he asks, and paying more attention to how his child is communicating. If we teach parents to imitate, maybe we won’t need to explicitly teach the other responsive strategies!

These researchers did a small study in which they taught three parents of toddlers with ASD* to imitate their children’s actions, gestures, and words (the format of the sessions is fully described in the article!) Generally speaking, the sessions had these components:

  1. The therapist reviewed the parent’s questions or concerns that had come up since the previous session.

  2. The therapist explicitly taught the parent about why imitation is important and how to use it.

  3. The therapist played with the child and pointed out when she imitated the child.

  4. The parent played with the child while the therapist provided the parent with constructive coaching and feedback.

  5. The therapist summarized the session and answered the parent’s questions.

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The results showed that all three of the parents were able to master the imitation strategy, and all three children made improvements in their social eye gaze. An extra cool bonus? As parents started imitating their children, the number of questions and directions they gave naturally decreased without the therapist explicitly instructing them to do so. Talk about getting some great bang for your buck! Imitation shows promise of being a simple and efficient “first strategy” to teach parents. 

*or suspected ASD

 

Killmeyer, S., Kaczmarek, L., Kostewicz, D., & Yelich, A. (2018). Contingent Imitation and Young Children At-Risk for Autism Spectrum Disorder. Journal of Early Intervention. doi:10.1177/1053815118819230.

Throwback (2011): Increasing sound production through imitation therapy

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Imitation is the sincerest form of flattery. However, every SLP has worked with a child who simply doesn’t imitate. No matter how many times we blow raspberries, make animal noises, or wave our arms wildly, we are met with blank stares. Yet imitation during early development is a crucial building block to successful communication. 

This study looked at a systematic method for teaching nonverbal toddlers the skill of imitation. All children in the study were 18–19 months old, showed minimal babbling, did not imitate sounds, and did not produce any phonetically consistent forms. All of the children scored lower than the 2nd percentile on the PLS-3 or PLS-4 scores. Sounds like your typical El late talker, right?

Back in 1972, Zedler developed a therapeutic technique referred to as Technique Imitation Therapy (IT) for use with young children who did not develop language as expected. He believed that a child’s language development is dependent on the child’s awareness that his or her own behavior can affect others. The idea is that providing opportunities for the child to direct an adult’s attention and actions, the child will realize that their own actions can influence others. With reinforcement (as always), the child should eventually be able to learn how to imitate.  

In the present-day study, clinicians implemented Imitation Therapy with 18–19-month-old toddlers 2–4 times per week in 50 minute sessions, until the child spontaneously imitated verbalizations at least eight times in two consecutive sessions. This took between 16–18 sessions for the group of children, or approximately 8 weeks.

Imitation Therapy consists of four steps, starting with the adult serving as the sole imitator of everything the child does and says, until the child realizes that the adult is imitating him/her. Next, when the child begins to do some basic imitation of the adult, he is positively reinforced. Then, the adult begins to only imitate the child’s oral movements or sounds produced. At the final stage, the adult and child imitate each other reciprocally, with the goal of the child imitating sounds consistently. At the end of the study, all children showed a significant increase in their sound production and repertoire of phonemes. Specifically, all children had at least 13 phonemes and produced 100+ sound productions per session. Talk about measureable progress! This article describes the procedure in great detail, so that any SLP could recreate IT at their next home visit.  

The authors do mention that small sample size and lack of a control group are limitations of this study. However, each of the children missed a week of therapy due to fall/spring break. During this break, they experienced a decrease in sound production, which subsequently increased when therapy was again initiated. This observation reinforces the evidence that IT may have been a factor in the children’s progress. At a minimum, imitation therapy appears to be a promising technique to try with nonverbal toddlers who struggle to imitate.   

 

Gill, C., Mehta, J., Fredenburg, K., Bartlett, K. (2011). Imitation therapy for non-verbal toddlers. Child Language Teaching and Therapy, 27(1), 97–108.

Throwback (2007): Helping parents develop joint attention skills

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So, we know that deficits in joint attention skills are one of the earlier-appearing red flags for autism. We also know that early intervention for the autistic population should include tasks to develop joint attention. And early intervention should involve parents. Schertz and Odom (2007) combined these concepts and found that when parents take the lead in designing and implementing activities (with a little help/guidance from a professional) to promote joint attention skills, magic can happen—all three toddlers in this study improved their joint attention skills.

The researchers stress that the parents did most of the work. The parents came up with activities and carried through with their plans in natural environments. The interventionist took a backseat role; however, he or she also served as a teacher of theory and best-practice for the parents.

What activities did the parents do with their children? (Or, what can we as SLPs teach caregivers to do to promote joint attention skills?)

  • focusing of faces: mirror play, imitating facial expressions, putting the parent’s face in the child’s line of sight

  • turn-taking: responding to child’s actions as if the child were actually interacting with them, building in some pause time after the parent’s utterance to wait for the child’s response, imitation of the child’s gestures, working the parent into the child’s isolated play

  • responding to joint attention: sharing attention to the same object through parent initiations (making the toy exciting, and practicing looking between the toy and the parent’s face)

  • initiating joint attention: parents expressed excitement about the toy, or giving the child surprise gifts to increase excitement.

 

Schertz, H.H. & Odom, S.L. (2007). Promoting joint attention in toddlers with autism: A parent-mediated developmental model. Journal of Autism and Developmental Disorders, 37, 1562–1575.

Review written by: Knothe, C., Cordia, R., Meuschke, H., & Brumbaugh, K.

Joint engagement predicts language scores, but which kind of joint engagement?

Joint engagement predicts language scores. Got it. But which kind? You lost me. There are different kinds? As it turns out, yes, and this paper offered some pretty good information on them. You have your good old, traditional joint engagement, which is when at least two people actively attend to the same thing at the same time, and each person knows they are attending to the same thing at the same time. But you can break that down even further, into supported and coordinated joint engagement. Supported joint engagement (SJE) is when the child focuses on a shared item, but the parent carries the communicative load, so to speak. The parent supports the rest of the interaction while the child only has to spend cognitive energy on that item. Coordinated joint engagement (CJE), on the other hand, is when the child splits focus between the object at hand and a communication partner. For example, consider a Jack-in-the-Box toy. In SJE, the parent might turn the handle, narrate what is happening, and react to the doll popping out of the box while the child watches, listens, and learns about the weird musical box. In CJE, the child might turn the handle as she otherwise divides her attention between the toy and her parent, commenting and sharing in the suspense and surprise. 

Conway, et al. recorded mothers playing with their two-year olds and administered language assessments at 2, 3, (PLS-4) and 4 years of age (CELF-P2). Mean language scores for the group fell within low average range. The idea was to rate the videos and compare time spent in supported and coordinated joint engagement with maternal responses and language scores. Check out Table 2 in the study for details on the coding and descriptions of joint engagement, and Table 3 for descriptions of maternal responses measured.

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It turned out that the more time a mother and child spent in supported joint engagement, the higher the receptive and expressive language scores at 2- and 3-years, but the association was not significant at the 4-year testing. Coordinated joint attention was not associated with language scores, and the authors suggest that coordinated joint attention could be associated with other language skills, like pragmatics. Looking at maternal responses, the authors found that expansion and imitation were associated with language scores when the children spent less time in supported joint attention. The authors suggested that “where SJE is less frequent or of lower quality, expanding or imitating a child’s utterance may be especially important.”

While the authors caution that more studies are needed before generalizing these results, encouraging supported joint engagement and using imitation and expansion in interactions may be a good choice for supporting language development in both typical and late-talking 2-year-olds.

 

Conway, L. J., Levickis, P. A., Mensah, F., Smith, J. A., Wake, M., & Reilly, S. (2018). The role of joint engagement in the development of language in a community-derived sample of slow-to-talk children. Journal of Child Language. Advance online publication. doi: 10.1017/S030500091800017X