Title: Experimental evaluation of a parent-implemented AAC intervention protocol for children with severe autism

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1 Title: Experimental evaluation of a parent-implemented AAC intervention protocol for children with severe autism 60min interactive workshop Long Abstract Declaration of Interest Statement The authors disclose they have no financial or other interest in objects or entities mentioned in this paper. Aim Two popular interventions in augmentative and alternative communication (AAC) for prelinguistic children with autism are the picture exchange communication system (PECS) and speech-generating devices (SGDs). Recent research demonstrated positive effects on functional communication when these two strategies were combined in a modified PECS protocol (Boesch, Wendt, Hsu, Subramanian, & Johnston, 2013a,b). Furthermore, AAC interventions can be carried out by a variety of caretakers including clinicians as well as parents. Parent-implemented interventions have proven to be beneficial, and parent involvement is considered crucial in autism intervention (National Research Council, 2001). The research underlying this project sought to answer: (a) what effects does a parent-implemented intervention have on developing functional communication skills and natural speech development; (b) to what extent can parents implement AAC intervention with high fidelity; and (c) to what extent are parents satisfied with intervention procedures and effectiveness? Drawing from our ongoing experimental research into parent-implemented AAC, this interactive workshop will provide clinicians and applied researchers with an introduction on how to (a) construct a modified PECS protocol, (b) train parents to teach requesting and facilitate speech production, and (c) assess effectiveness and integrity of treatment implementation by parents. Method A parent-implemented training program can be a very cost-efficient, yet effective intervention option. In our project, parent-training consisted of (a) modeling by an experienced clinician followed by role-playing, (b) composing of video resources for parent review, (c) written instructions ( cheat sheets ), and (d) review of video-taped sessions with feedback. Throughout the workshop we will present a single-subject, multiple-baseline design across participants that evaluates the effectiveness of the parent-training along with the modified protocol. This design allows assessing mastery of newly taught skills and their generalization. Such research represents a rigorous approach to evaluating intervention efficacy and is the preferred method in

2 heterogeneous populations such as autism, where group designs are difficult to conduct (Schlosser & Raghavendra, 2004). Three children between 5-7 years with a diagnosis of severe autism and little to no functional speech participated in this study. Their diagnoses were verified based on the Autism Diagnostic Observation Schedule (ADOS) and the Childhood Autism Rating Scale (CARS). The intervention protocol contained the first five phases of the PECS approach, followed by generalization and maintenance phases. This protocol was modified by selecting symbols on an ipad display instead of exchanging picture cards. Dependent measures were: (a) The number of correct requests during a 20-trials session; and (b) the numbers of non-intentional utterances versus intentional vocalizations or word approximations. Intervention phases targeted requesting for food items; generalization probes were taken during baseline and after intervention for requesting different toys. Materials included an ipad equipped with an autism-specific and free AAC application specifically designed to mimic PECS. Inter-observer agreement (IOA) for dependent measures and treatment implementation was established by re-scoring 40% of all sessions. Mean IOA was 99% for requesting, and 92% for emerging speech. Treatment integrity ranged from 80-98% across parents. The audience will be presented with data tracking approaches to assess the number of PECS steps correctly implemented by the parent. Common difficulties for parents (e.g., error correction procedures, preference assessments) will be highlighted along with recommendations how to increase implementation fidelity (e.g., self-monitoring checklist). Data were graphed using Excel and visually inspected for changes in level (mean) and trend. Effect sizes were estimated using the Percentage of Nonoverlapping Data (PND) and the Non-overlap of All Pairs index (NAP). Results Children 1 and 2 mastered all five phases of the parent-implemented training, whereas child 3 only achieved phase 3. Acquisition rates varied across subjects, with children 1 and 2 needing on average 6 sessions to master each phase, and child 3 needing 7 sessions. The largest gain appeared when requesting was targeted: For child 1, requesting improved from a baseline mean of 0.25 to a maintenance mean of 17.75; for child 2 from 1.1 to 17.5; and for child 3 from 0.6 to All three participants showed generalization to untrained items. PND and NAP scores indicated a highly effective intervention. Results differed for the emerging speech measure: whereas child 1 made noticeable gains from a baseline mean of 16 to a maintenance mean of 24 word utterances, moderate gains were observed for children 2 and 3. PND and NAP scores were highly effective for child 1, fairly effective for child 2, and ineffective for child 3. Participating families completed social validity questionnaires. Parents appreciated the clear structure of the modified PECS protocol; difficulties were reported with error-correction and fading interest of the child in reinforcer items.

3 Conclusion Results suggest that parents can implement an ipad-based AAC intervention with sufficient fidelity. Children may not be able to complete all stages of the protocol, and performance may vary with the level of intellectual impairment. Treatment effects are most noticeable for requesting skills. A facilitative effect on natural speech development is possible, but cannot necessarily be expected for all clients. Although these speech effects are moderate in extent, such patterns are consistent with previous research on the PECS protocol. Overall, these results underscore the potential of including parents for maximizing benefits of AAC intervention in autism. Practitioners should recognize the value of joint parent-professional partnerships, and develop expertise for parent training. References Boesch, M., Wendt, O., Subramanian, A., & Hsu, N. (2013a). Comparative efficacy of the Picture Exchange Communication System (PECS) versus a speech-generating device: Effects on requesting skills. Research in Autism Spectrum Disorders, 7, Boesch, M., Wendt, O., Subramanian, A., & Hsu, N. (2013b). Comparative efficacy of the Picture Exchange Communication System (PECS) versus a speech-generating device: Effects on social-communicative skills and speech development. Augmentative and Alternative Communication, 29, Flores, et al. (2012). A comparison of communication using the Apple ipad and a picture-based system. Augmentative and Alternative Communication, 28, National Research Council (2001). Educating children with autism. Washington, DC: National Academy Press. Schlosser, R. W., & Raghavendra, P. (2004). Evidence-based practice in augmentative and alternative communication. Augmentative and Alternative Communication, 20(1), 1-21.

4 Program Planner/Instructional Personnel Relationship Disclosure Form In compliance with American Speech-Language Hearing Association s Continuing Education Board s Requirements, ISAAC Conference 2016 requires program planners and instructional personnel to disclose information regarding any relevant financial and non-financial relationships related to course content prior to and during course planning. Based on the information provided, ISAAC Conference 2016 will engage the program planner /instructional personnel in a guided interview process which seeks to understand how the relevant financial or nonfinancial relationship may influence the content of the course. Program Planner/Instructional Personnel s Name: Oliver Wendt Course Title: Experimental evalua2on of a parent- implemented AAC interven2on protocol for children with severe au2sm HIPAA REQUIREMENTS To comply with the Health Insurance Portability and Accountability Act (HIPAA), we ask that all program planners and instructional personnel insure the privacy of their patients/clients by refraining from using names, photographs, or other patient/client identifiers in course materials without the patient s/client s knowledge and written authorization. I am in compliance with these policies: OW (INITIAL HERE) Relevant financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, gift, speaking fee, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial relationships can also include contracted research where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. Do you have relevant financial relationships to disclose? No Yes (if yes complete Financial Relationship Disclosure Form) Relevant non-financial relationships are those relationships that might bias an individual including any personal, professional, political, institutional, religious or other relationship. May also include personal interest or cultural bias. Do you have relevant non-financial relationships to disclose? No Yes (if yes complete Non-Financial Relationship Disclosure Form) I attest that the information in this disclosure is accurate at the time of completion and I agree to notify ISAAC Conference 2016 (conference2016@isaac-online.org) of any changes to this information between now and the scheduled presentation date. I also understand that all completed Disclosure Forms must be incorporated within my paper proposal, as part of my Long or Extended abstract upload to the ISAAC Conference 2016 paper submission system. Signature Date ISAAC Conference 2016 Page 1 of 3 conference2016@isaac-online.org

5 Financial Relationship Disclosure Form Copy this page as many times as you need to complete information regarding each of your relevant financial relationships. Program Planners/Instructional personnel have a relevant financial relationship if that relationship could influence the information presented in the course and could be perceived as a conflict of interest by learners. Planner/Presenter name: Oliver Wendt Financial relationship with (name of Company/Organization): SPEAK MODalities, LLC Date form completed: What was received? (Check all that apply) Salary In kind Consulting fee Grants Intellectual property rights Gift Speaking fee Royalty Honoraria Hold patent on equipment Ownership interest (e.g., stocks, stock options or other ownership interest excluding diversified mutual funds) Other financial benefit (please describe): For what role? (Check all that apply) Employment Management position Teaching and speaking Board membership Ownership Consulting Membership on advisory committee or review panels Independent contractor (including contracted research) Other activities (please describe): ISAAC Conference 2016 Page 2 of 3 conference2016@isaac-online.org

6 Non-Financial Relationship Disclosure Form Copy this page as many times as you need to complete information regarding each of your relevant non-financial relationships. Program Planners/instructional personnel have a relevant non-financial relationship if that relationship could influence the information presented in the course and could be perceived as a conflict of interest by learners. Planner/Presenter name: Non-financial relationship with (name of Company/Organization/Institution): Date form completed: What is the nature of the non-financial relationship? (Check and complete all that apply) Personal, please describe: Professional, please describe: Political, please describe: Institutional, please describe: Religious, please describe: Personal interest, please describe: Bias, please describe: Other relationship, please describe: For what role? Volunteer employment Volunteer teaching and speaking Board membership Volunteer consulting Volunteer membership on advisory committee or review panels Other volunteer activities (please describe): ISAAC Conference 2016 Page 3 of 3 conference2016@isaac-online.org

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