ESDM Early Start Denver Model Parent Coaching P-ESDM

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1 ESDM Early Start Denver Model Parent Coaching P-ESDM BCASLPA Conference October 22nd, 2016 ESDM Canada Mary McKenna Janet Harder Michaela Jelen ESDM ESDM draws on several different models as its foundation o Denver Model (Rogers et al., 1981) o Model of Interpersonal Development (Rogers & Pennington, 1991) o Model of Autism as a disorder of social motivation (Dawson et al., 2004) o Pivotal Response Training - PRT (Schreibman & Pierce, 1993; Koegel & Koegel, 1988) ESDM Criterion-referenced tool that provides a developmental sequence of skills in 8 domains. 480 items organized across 4 levels. Developed for toddlers with ASD ages months. Developed specifically for young children with ASD and reflects their typical developmental profile. (p.58) Goals of the ESDM Reduce ASD symptomology Bring the child back into the social loop Teach the building blocks of social life: o Imitation o Emotional communication o Sharing experiences o Social and symbolic play o Language Fill in the learning gaps Relationship-based Quality of relationships are central in intervention Naturalistic teaching strategies 1

2 Developmental Framework All developmental areas affected by ASD are targeted. Curriculum follows a developmental sequence. The language intervention approach in ESDM: o Comes from the science of communication development rather than behaviour analysis Applied Behaviour Analysis Prompting, fading, shaping, chaining Management of motivation and attention Clear ABC contingencies o Antecedent o Behaviour o Consequence Data-based decision making Developmental Framework + ABA Multiple environments Denver Model Principles PRT Principles PRT Principles ABA Principles community home preschool Interdisciplinary Approach OT Behaviour Analyst SLP Parent Team Leader Physician Education Child Psych. ESDM: Delivery Settings In home or clinic o 20-hours-or-more per week including time with parent o 1:1 treatment delivery by supervised interventionists o Sessions typically run 2 hours Parent delivered ESDM (P-ESDM) o Parent and child attend therapy 1.5 hours per week o Clinician coaches the parent to implement ESDM in natural household routines and parent child play activities through weekly sessions. 2

3 ESDM: Fidelity Checklist 13 key areas that are evaluated to ensure fidelity of implementation. Quantifies intervention o 1(No strengths) o 5 (best possible Example) Used in the ESDM and in the P-ESDM Parent Coaching Parent-Delivered Intervention Programs Hanen More than Words Early Start Denver Model (P-ESDM) Pivotal Response Training Responsive Teaching Social Communication, Emotional Regulation, Transactional Supports - SCERTS Relationship-based P- ESDM: Parents are highly involved as decision makers and as interventionists Quality of relationships are central in intervention Naturalistic teaching strategies Why do ESDM Parent Coaching? Parents spend the most time with their children Parents are highly motivated to implement goals and work on goals with their child Allows professionals to support families Children supported across a wide range of activities: Meals, play, dressing Knowledge is Power Parent need to be able to understand and explain their child s strength s and needs to a variety of individuals Efficient use of funds 3

4 P-ESDM What is it.? Parent Coaching Parent coaching, include(s) parent use of the interventions daily and therapist modeling of the intervention to the parent There is robust evidence that parents can effectively deliver interventions for children with autism and effect desired child change. (Rogers et al., 2014). Coaching vs. Training Training Expert model Parents told how to implement strategies Parents are often shown how to intervene Expert knows best Parents are often left to try it out on their own Parents watch videos of others Coaching Parents experts on their children Parents and coach are equal partners Parents drive the goals for themselves and their child Coach supports parent/child interactions Feedback through selfreflection of parent Research in P-ESDM Vismara, L.A., Colombi, C., & Rogers, S.J. (2009). Can one hour per week of therapy lead to lasting changes in young children with autism? Autism, the International Journal Goals of the Pilot Study Evaluate whether a 1-hour weekly visit would result in real benefit. Develop a generalist intervention that could be delivered by a range of childhood professionals. Develop an intervention that could be delivered immediately after diagnosis. 4

5 Summary Piloted a manualized parent intervention using a parent manual that highlighted 10 therapy strategies. Delivered brief 12 week, 1 hour per week, individualized parent-child education program to eight toddlers newly diagnosed with autism. The ESDM Fidelity Scale was used to assess 14 parent behaviours. Changes Social communication was assessed by: o Number of spontaneous functional verbal utterance o Number of imitative behaviours (action on objects, manual acts with no objects and vocalizations and words). Results For parents that completed the training, all but one parent mastered the techniques (met fidelity) by the 5 th to 6 th hour of parent coaching. Parents maintained their skills 3 months following the end of treatment. Children demonstrated sustained change and growth in social communication behaviors measured by number of spontaneous functional verbal utterances and imitative behaviours across play activities. Summary Rogers, S.J., Vismara, L., Wagner, A.L., McCormick, C., Young, G., & Ozonoff, S. Autism treatment in the first year of life: A pilot study of Infant Start, a parent-implemented intervention for symptomatic infants. J of Autism and Developmental Disorders Pilot-tested a 12-week parent intervention 7 infants ages 7-15 months, highly symptomatic for ASD 4 Comparison groups also at risk for ASD due to sibling status and increased early symptoms. Intervention aimed to change (reduce) 6 target symptoms and developmental patterns of early ASD. Measures Parent Measures Infant Start Parent Fidelity Measure (Rogers et al. 2012c) 19 items, Likert scale. Parent Satisfaction Rating (Charlop-Christy and Carpenter 2000) Working Alliance Scale for Intervention with Children (Davis et al. 2006) a social validity measure, used to describe families response to intervention. Measures - continued Infant Enrollment Measures Infant Toddler Checklist (Wetherby and Prizant 2002) Autism Observation Scale for Infants (AOSI; Bryson et al. 2008) Infant Treatment Curriculum Measures The Carolina Curriculum for infants and Toddlers with Special Needs, 2 nd Edition (Johnson-Martin et al. 1991) ESDM Curriculum Checklist (Rogers and Dawson 2010) 5

6 Measures - continued Infant Outcomes Measures ADOS, MSEL, Total Intervention Hours (unpublished), Clinical Best Estimate Outcome classification, Infant Start Therapist Fidelity Measure (Rogers et al 2012c) Results Questions Addressed: 1. Could symptomatic infants <15 months be identified and recruited for treatment? Yes, but 2. Can parents learn and deliver intervention with high fidelity and maintain it? Yes, 6/7 mastered at week 7 (<8 contact hours), all mastered and maintained 80% fidelity. Results - continued 3. Are parents satisfied with low intensity, shortterm intervention? Yes, high parent satisfaction ratings. 4. Are infants who received intervention less impaired in terms of ASD at age 3 compared to those who did not receive intervention? Yes, Infant Start group less impairment (ASD symptoms and dev. delays) at 36 months. Estes, A., Vismara, L., Mercado, C., Fitzpatrick, A., Elder, L., Greenson, J., Lord, C., Munson, J., Winter, J., Young, G., Dawson, G., & Rogers, S.J. The impact of parent-delivered intervention on parents of very young children with autism. J of Autism and Developmental Disorders. 2014;44(2), Summary Investigated the impact of how intervention delivered through 3 months of parent coaching to very young children with ASD impacted parents level of satisfaction and stress. Hypothesis; P-ESDM would lead to improved level of parenting stress as well as increased sense of competency when compared to community interventions. Summary 98 Children with ASD and primary caregivers Randomized into 2 intervention groups oesdm 49 (mean 2.6 hrs/week intervention) ocommunity 49 (mean 4.8 hrs/week intervention) ESDM 1 hour session with consistent structure designed to teach interactive principals of ESDM learning goals (not directly targeted) Therapist fidelity of administration of P-ESDM needed to be at 85% 6

7 Results No significant difference in Parent Sense of Competence Scores between P-ESDM and Community groups. Parent Stress scores in the P-ESDM were significantly lower compared to the Community group, even after accounting for major life events Number of intervention hours had no effect on Parent stress or Parent sense of competence. Parent Implemented ESDM (P-ESDM) Parent Coaching Manual Work through the manual with the parent/caregivers. Chapters 1-3: focus on understanding and coping with diagnosis. Chapters 4-14: Strategies Understanding and Coping with Diagnosis. 1. Setting up their child s program 2. The importance of parents taking care of themselves both physically and mentally 3. Challenges of siblings 4. Hallmarks of good intervention program 5. Dealing with extended family 6. Unique learning challenges of ASD 11 Chapters on Everyday Strategies Step into the Spotlight: Capturing your Child s Attention Find the Smile!: Having Fun with Sensory Social Routines It Takes Two to Tango; Building Back and- Forth Interactions Talking Bodies: The Importance of Nonverbal Communication Do What I Do! : Helping Your Child Learn by Imitating Let s Get Technical: How Children Learn The Joint attention Triangle: Sharing Interests with Others It s Playtime! Let s Pretend Moving into Speech Putting it All Together. 7

8 Chapter Features What is happening in Autism? Why is it a Problem? Activity Checklist Refrigerator List Start with a Simplified Intervention Plan See for 1-2 assessment sessions o Score the curriculum checklist o Write objectives o Develop a task analysis of teaching steps Build a data sheet for objectives to be monitored by certified therapist (not the focus for the parents during initial part of parent training) Format of Parent Coaching Session 1. Review past week focus 2. Parent child activity 3. Introduce new topic/concepts 4. Parent-child activity with Coaching 5. Reflect 6. Parent-child activity with coaching 7. Reflect 8. Other topics 9. Plan for next session Parent fidelity Child data Coaching fidelity Data collection The goal of P-ESDM is to have parents meet Fidelity across a variety of activities Fidelity Rating Scale 13 key areas that should be the focus of intervention coded 1(No strengths) - 5 (best possible Example) a) Management of Child Attention b) ABC format c) Instructional Techniques d) Modulating child affect/arousal e) Management of Unwanted Behaviours f) Quality of Dyadic Engagement 8

9 Fidelity Rating Scale g) Adult optimizes child motivation h) Adult use of positive affect i) Adult s sensitivity and responsivity j) Multiple varied communicative opportunities k) Adult s language for the child s level l) Joint Activity Elaboration m) Transition between activities Child Data Clinician records on data sheet while the child is interacting with his/her parent. During three or more familiar sensory social routines (e.g., peek a boo, ring around the rosy) when you model a gesture, Mathew will copy you for 6 or more different gestures (e.g., hands up, clapping, twinkle fingers, etc.). 1. Watches me do the routine (SSR). 2. Imitates 1 action in the activity with support 3. Imitates 2 actions, independently 4. Imitates 4 actions independently 5. Imitates 6 actions independently Coaching Fidelity The clinician records on Coaching Fidelity Rating scale after the session. Parent-Delivered Intervention Programs P-ESDM compared with the Hanen More Than Words (MTW) o Goals o Features o Theoretical Foundations o Research More Information earch/esdm/certification.html Becoming Certified in ESDM Direct Delivery Masters degree or the academic equivalent from your country of origin (e.g., MA, Ph.D., MFT, SLP, OT) Work regularly with children with ASD Spectrum Disorder (ASD) aged month Work as part of an interdisciplinary team Complete Introductory online course and Advanced Workshop to equip professionals with the information, skills, and resources necessary to correctly implement the ESDM within their organization. Submit training materials (after the workshop is complete) to center for fidelity review and certification. Complete Parent Coaching workshop at the MIND rtification.html 9