Our Funder and Manager

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1 SPEECH AND HEARING BC CONFERENCE VICTORIA, BC OCTOBER 18, 2018 PRESENTERS: PAT MIRENDA, PAOLA COLOZZO, VERONICA SMITH, JANET HARDER, MICHAELA JELEN, AND MARY MCKENNA Our Funder and Manager Research and Training Team Sally Rogers (back): Mary McKenna, Paola Colozzo, Karen Kalynchuk, Michaela Jelen, Janet Harder (front): Laurie Vismara, Veronica Smith, Pat Mirenda Wendy Ungar 3 PLEASE DO NOT COPY OR DISTRIBUTE without permission 1

2 Ps and Qs Parent coaches Nominated for coach training by their respective agencies and consented to participate (39 to start, 30 currently) Infant development and Aboriginal infant development consultants, early childhood educators, speech-language pathologists, occupational therapists, family and community support workers, behaviour interventionists, and clinical social workers, depending on the site. Qualified clinical specialists in ASD the Qs 15 Qs across sites Graduate level speech-language pathologists, occupational therapists, counsellors, family support/social workers Current Advisory Committee Deborah Pugh (ACT-Autism Community Training) Dr. Suzanne Lewis (PAFN) Dr. Armansa Glodjo (BCAAN) Dr. Karen Bopp (CIRCA, UBC) Diana Elliott (AIDP) Jackie Watts (ASCD) Jason Gordon (BCACDI) Dr. Isabel Smith (Dalhousie) Dr. Jessica Brian (U. of Toronto) Purpose The aim of PACE Coaching is to develop, implement, and evaluate a Naturalistic Developmental Behavioural Intervention (NDBI) model for parent coaching, to support parents of toddlers who are at risk for autism spectrum disorder (ASD) PLEASE DO NOT COPY OR DISTRIBUTE without permission 2

3 Models of Early Intervention MODELS OF EARLY INTERVENTION 7 Three Types: Think Condiments! ABA NDBI Developmental 8 Developmental Brands ABA NDBI Developmental DIR/floor time Son Rise Relationship development intervention (RDI) More Than Words (Hanen) 9 PLEASE DO NOT COPY OR DISTRIBUTE without permission 3

4 Developmental Approaches Based on the principles of typical development and how typical children learn to interact Child-directed: adult responds to child s interests ( follow the child s lead ) Model slightly more mature ways for the child to interact/communicate Teach in the context of natural social routines ( teachable moments ) Emphasize reciprocity, turn-taking, and positive affective engagement 10 Applied Behaviour Analysis (ABA) Brands ABA NDBI Developmental UCLA/ Lovaas model Precision teaching Verbal behaviour 11 ABA Approaches Based on the application of behavioural learning principles that are used to change socially significant behaviour in meaningful ways Most behaviours, including social and language behaviours as well as many problem behaviours, are learned through interactions with the environment Behaviours that encounter reinforcing events occur more often Behaviours that encounter negative consequences occur less often New behaviours can be taught through the use of carefully planned, systematic instructional procedures 12 PLEASE DO NOT COPY OR DISTRIBUTE without permission 4

5 Naturalistic Developmental- Behavioural Brands ABA NDBI Developmental Early Start Denver Model (ESDM) Pivotal response treatment (PRT) Joint attention, symbolic play, emotional regulation (JASPER) Social communication, emotional regulation, transactional support (SCERTS) Reciprocal imitation Training (RIT) Early Achievements Enhanced milieu teaching (EMT) Incidental teaching 13 NDBI Approaches (Schreibman et al., 2015) ì Incorporate elements of BOTH ABA AND Developmental models ABA Systematic assessment, with specific, focused goals and mastery criteria Systematic instruction (modeling, prompting, shaping, contingent reinforcement, etc.) Systematic data collection and review/revision process Systematic therapist/parent training, with fidelity checks DEVELOPMENTAL Assessment and curricula are developmentally sequenced Intervention is delivered in natural contexts Follow the child s motivational lead/use naturally occurring reinforcers Provide child choice 14 The PACE Coaching Story Dec MCFD announces funding for a parent coaching research project February 2016 Researcher meeting in Victoria August 2016 Steering Committee releases RFA Nov Application deadline January 2017 MSFHR convenes a scientific review panel February 2017 UBC proposal accepted, pending revisions March 2017 Revision deadline April 1, 2017 PACE Coaching is officially born! PLEASE DO NOT COPY OR DISTRIBUTE without permission 5

6 Objective 1: Best/Promising Practices To identify best/promising practices that will optimize future implementation of a parent coaching model, particularly in relation to achieving and maintaining the quality of service delivery across diverse communities and settings Identify Partner Agencies Implementation Action Planning (IAP) Meetings #1 Identify Coaches and Qs IAPs #2 IAPs #3 IAP #1 Conducted on each site, with agency leadership, potential coaches and Qs, other community members 85 participants across 29 agencies Participants completed a demographic survey and Context Tool online Overview of the project Discussion, Q&As Visit to local Aboriginal agency, if available PLEASE DO NOT COPY OR DISTRIBUTE without permission 6

7 Context Tool Four constructs; higher scores are associated with better adoption of innovations (scale of 1-5) Culture the way things are done in the organization (e.g., My organization effectively balances best practice and productivity. ) M = 4.46 (SD.56) Min = 1.33 Max = 5.00 Connections Among People how well people feel connected in an organization around issues that serve clients (e.g., People in my group share information with others in the group. ) M = 5.39 (SD.52) Min = 4.17 Max = 6.00 Leadership how effective the leadership is perceived to be (e.g., The leader effectively resolves conflicts. ) M = 4.04 (SD. 84) Min = 1.33 Max = 5.00 Feedback achieving best practices is associated with effective feedback (e.g., My colleagues and routinely monitor our performance with respect to the action plans. ) M = 3.52 (SD.78) Min = 1.00 Max = 5.00 IAP #2 Summer-Fall 2018 Individual interviews with EDs or designated leaders Individual interviews with trainers Group interviews with Qs Group interviews with coaches General questions: what has worked so far? not worked? what do you need from us to move forward? Completion of a second survey (different questions) Coach Pods To support a community of practice, coach trainees meet online periodically in regional Pods with their trainer, via our online platform, Teleroo To provide mutual support To share information about coaching strategies that have been effective To brainstorm and troubleshoot To celebrate progress Both coach trainees and their trainers endorsed the utility of the Pods PLEASE DO NOT COPY OR DISTRIBUTE without permission 7

8 Objective 2: Coach Training To train individuals in CDCs and AIDPs across the province to coach parents of at-risk children in home and community settings, using PACE Coaching, a BC NDBI model based on the Early Start Denver Model (ESDM) PACE Coaching Model Focus is narrower than in standard ESDM (primarily social, communication, play skills) Aimed at community-based early childhood educators rather than graduate-level professionals Coach training is streamlined There is no certification process Coaches work with parents in community settings, not in clinic settings 26 Coach Training Intro Module (online) PACE1 Coach Training PACE1 Practice and Pods PACE2 Coach Training PACE2 Practice and Pods Learn to use the PACE Coaching model with toddlers Learn to use the PACE Coaching model to coach parents PLEASE DO NOT COPY OR DISTRIBUTE without permission 8

9 Intro Module Online quiz, 25 questions, 80% correct PACE 1 Tools 29 PLEASE DO NOT COPY OR DISTRIBUTE without permission 9

10 31 Checklist Domains Receptive communication Understanding early gestures Understanding speech Expressive communication Gestures Vocal/verbal communication Joint attention Social skills: Dyadic engagement Imitation Cognition (matching, sorting, object permanence) Play skills Three Uses of the Checklist 33 PLEASE DO NOT COPY OR DISTRIBUTE without permission 10

11 Core PACE Coaching Strategies Positioning Adult positions self within the child s cone of attention 35 Environmental Arrangement 36 PLEASE DO NOT COPY OR DISTRIBUTE without permission 11

12 Enhancing Child Motivation Adult plans sessions ahead of time to incorporate the child s enthusiasms / preferences Adult arranges toys and materials to enhance the child s motivation and increase communication For example, highly preferred toys may be placed out of reach so the child has opportunities to ask for them, using gestures or vocalizations 37 Child-Initiated Teaching Episodes Adult understands the child s comfort zone and adapts accordingly Adult follows the child s lead Uses child interests to create engaging activities and embed learning opportunities 38 A-B-Cs of Learning A-B-C: Antecedent Behaviour Consequence Learning episodes should have a clear A B C structure A learning exchange should occur on average every seconds, matched to the child s learning needs 39 PLEASE DO NOT COPY OR DISTRIBUTE without permission 12

13 Instructional Strategies Prompting and prompt fading Modeling Imitating the child s actions Contingent ( if-then ) reinforcement 40 Joint Activity Routines Adult provides intervention in the context of ongoing, daily routines and activities 41 Joint Activity Routines Follow child choice/interest Engage in the activity with the child Target multiple objectives within each activity Have FUN! 42 PLEASE DO NOT COPY OR DISTRIBUTE without permission 13

14 Object-Based Routines Child alternates attention between an object and the partner = joint attention Giving Sharing Showing Pointing Alternating gaze Sharing smiles, etc. Objectives: communication, cognition, imitation, social 43 Sensory-Social Routines Child focuses attention on the play partner, not on objects Aimed at building reciprocal social interaction: Turn taking Imitation Communication (words, gestures, facial expressions) Social reciprocity 44 Pace 1 Therapist Practice Checklist: 24 Items PLEASE DO NOT COPY OR DISTRIBUTE without permission 14

15 PACE 2 The aim of this phase was to teach trainees how to coach parents to use the model with their young child a two-way conversation 49 PACE 1 and PACE 2 PACE 2 PACE 1 Training vs. Coaching TRAINING Trainer is an expert Child deficits are the focus Cultural context may be secondary or ignored Parent focuses on trainer s priorities and goals Trainer primarily explains and models COACHING Coach is an equal partner Child s strengths/ competencies are the focus Cultural context is primary Coach focuses on parent s priorities and goals Coach supports the parent to practice during ongoing interactions with the child and provides feedback 51 PLEASE DO NOT COPY OR DISTRIBUTE without permission 15

16 Telling is Not Teaching! Modeling is Not Enough! Coach s lament: I ve been working with this parent for months and have modeled this skill for her many times; I don t know why she can t do it herself! But we KNOW that telling and modeling are not sufficient for learning to occur, from the research on behavioural skills training (BST) Guided practice and immediate, constructive feedback are also essential Coaches #1 Lesson! 54 Evaluation Initiation Action Observation Reflection Resolution From Hanft, Rush, & Shelden, 2004 PLEASE DO NOT COPY OR DISTRIBUTE without permission 16

17 Refrigerator Lists Session Structure PACE 2 Coaching Skills Checklist: 40 items PLEASE DO NOT COPY OR DISTRIBUTE without permission 17

18 Coaches Graduation Gift Objective 3: Screening To develop and implement a screening process utilizing the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) Eligibility and screening training for Qs Qs identify eligible children and invite parents for screening Qs screen eligible children and inform parents of results Qs provide info to parents of at-risk children re: BCAAN referral Qs invite/ consent parents of at-risk children to the RCT Community Outreach One-page intros and flyers were distributed to physicians, Health Unit professionals, other community agencies, to inform parents of screening availability PLEASE DO NOT COPY OR DISTRIBUTE without permission 18

19 Training the Qs An online Module was developed to teach the Qs how to Identify eligible children Invite and consent parents for screening Administer and score the M-CHAT-R/F Securely transmit consent forms and MCHAT score forms to UBC Included role play videos of the process and of potential scenarios Quiz at the end; 90% correct Objective 4: RCT To examine the effectiveness of parent coaching by conducting a randomized controlled trial (RCT) RCT Plan RCT BEGINS: Qs complete baseline assessments Parents are assigned at random to the PC or A&M group Parents receive PC or A&M intervention x 24 weeks Qs complete final assessment PLEASE DO NOT COPY OR DISTRIBUTE without permission 19

20 Assessment Distal Merrill-Palmer-Revised Scales, Cognitive Battery (Roid & Sampers, 2004) M-CHAT-R/F (Robins, Fein, & Barton, 2009) Proximal Macarthur-Bates Communicative Development Inventory (Fenson et al., 1993) Parent-child interaction videos, coded with a modified version of the Communication Play Protocol (Adamson et al., 2012) Family Family demographic survey (at start) Carer QOL (Brouwer, van Exel, van Gorp, & Redekop, 2006) Brief Family Distress Scale (Weiss & Lunsky, 2011) Parent Feedback Questionnaire (at completion) More Modules! Two Modules were developed to teach the Qs how to conduct the pre- and post-intervention assessments Module 3A: Overview and procedures for all assessments except the Merrill-Palmer-Revised Scales (M-P-R) Module 3B: M-P-R administration, with each subtest illustrated Quiz after each module, with 90% criterion for completion PC Group (n = 70) Parents receive coaching from parent coaches One, 60 min. face-to-face session + one, min. online or phone follow-up per week for 24 out of 30 weeks (+ An Early Start for Your Child with Autism book, + Help is in Your Hands modules) Child may receive concurrent services in motor (e.g., scribbling, walking), or daily living skill areas (e.g., feeding, dressing, toilet training, sleeping) but not in social, communication, or play areas Coach will complete a Curriculum Checklist at the start and end; and a session log, Coaching Skills Checklist, and Parent Skills Checklist periodically as well Parent will keep track of time spent in coaching activities and other therapies with an activity log PLEASE DO NOT COPY OR DISTRIBUTE without permission 20

21 A&M Group (n = 70) Parents and children receive the supports they would ordinarily receive through the partner agency and elsewhere (SLP, OT, PT, group, etc.), for 24 out of 30 weeks (+ An Early Start + Help is in Your Hands) Parents will keep track of time spent in therapies and other services with an activity log that they submit monthly In the spirit of the Truth and Reconciliation Commission report, and with the advice of our Aboriginal advisers, are committed to three main principles in this project: Adopt a relational orientation Recognize that there is no "Pan- Aboriginal" world view Join the existing Circle of Support Community of Practice Ongoing consultation with Aboriginal agency leaders, Advisory Committee members, coaches, Elders when possible All decisions are collaborative and individualized For example, the P-CC name and logo design were suggested by a coach and Advisory Board member Flexibility and choice are essential PLEASE DO NOT COPY OR DISTRIBUTE without permission 21

22 In most agencies, Aboriginal parents will be given a choice between the RCT and Parent- Child Connections The first few/several coaching sessions will be focused on building a relationship with the parent and co-designing a coaching plan: Frequency, length, and timeline for coaching Location of coaching (home, Centre, elsewhere) Who will participate in coaching sessions (e.g., parent, auntie, grandparent, etc.) How coaching sessions are structured Whether or not coaching sessions will be videotaped Example The parent of an 18-month-old might decide that: She prefers coaching in her home, every 2 weeks for one hour each time She does not want the An Early Start for Your Child with Autism book or Help is in Your Hands She is willing to try this for 2 months and then decide if she wants more, or if she wants a different arrangement She does not want to be videotaped and does not want her child videotaped She does not have many toys at home but instead wants to focus on bath time and mealtime activities, not toy play PLEASE DO NOT COPY OR DISTRIBUTE without permission 22

23 Objective 5 To conduct a cost effectiveness analysis that compares parent coaching to services that are ordinarily available to toddlers at risk for ASD in BC We are working with our partners at the University of Toronto on this portion of the project Website: Selected References Adamson, L., Bakeman, R., Deckner, D., & Nelson, P. B. (2012). Rating parent-child interactions: Joint engagement, communication dynamics, and share topics in autism, Down syndrome, and typical development. Journal of Autism and Developmental Disorders, 42, Hanft, B.E., Rush, D.D., & Shelden, M.L. (2004). Coaching families and colleagues in early childhood. Baltimore, MD: Paul H. Brookes Publishing Co. Rogers, S., Dawson, G., & Vismara, L. (2012). An early start for your child with autism: Using everyday activities to help kids connect, communicate, and learn. New York: Guilford. Schreibman, L., Dawson, G., Stahmer, A.C., Landa, R., Rogers, S.J., McGee, G.G., Halladay, A. (2015). Naturalistic developmental behavioural interventions: Empirically validated treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 45, PLEASE DO NOT COPY OR DISTRIBUTE without permission 23