COMBINING SINGLE CASE DESIGN AND GROUP EXPERIMENTAL DESIGN RESEARCH

Transcription

1 COMBINING SINGLE CASE DESIGN AND GROUP EXPERIMENTAL DESIGN RESEARCH Ann P. Kaiser, PhD Vanderbilt University IES SCD June

2 Today s Talk Overview of research on Enhanced Milieu Teaching (EMT) Illustrate how single case and group experimental designs have been used to build an evidence base Discuss the advantages and limitations Guidelines for developing research program drawing on both single case and group design methods Part 1 now and Part 2 on Thursday IES SCD June

3 Background: Young Children with Language Impairment Language development is one of the strongest predictors of children s long term academic and social outcomes Primary language delays: Young children with typical cognitive development but significant delays in receptive and expressive language at age 2 are at-risk for later social and academic development. These risks increase when children live in low resourced homes and communities Secondary language delays: Young children with intellectual disabilities, Down syndrome, autism spectrum disorders, cleft lip and/or palate are likely to have significant deficits in vocabulary, syntax and social language use that impact overall development, social engagement, behavior and academic performance IES SCD June

4 Enhanced Milieu Teaching IES SCD June 2018

5 What is Enhanced Milieu Teaching? EMT is a naturalistic, conversation-based intervention that uses child interests and initiations as opportunities to model and prompt language in everyday contexts. EMT can be used throughout the day as part of the everyday interactions. EMT is an evidence-based intervention with 20 years of research. EMT is an effective intervention. IES SCD June

6 Enhanced Milieu Teaching Program of research Funded by a ranges of agencies model NICHD program project on children with intellectual disabilities; IES Goal 3 projects, Autism Speaks, OSERS project, HRSA, John Merck Foundation Broad population of children across ID, DS, ASD, language delayed, children at-risk due to poverty, children with CLP, children with language delays Spanish and English Multiple methods group experimental, RCT, single case designs, descriptive group analyses Goals: Improving generalized communication outcomes for children Understanding the conditions in which communication and language are learned IES SCD June

7 EMT Principles and Strategies 1. Promote adult-child communication in immediate interactions Notice and respond Follow the child s lead 2. Increase child engagement with objects and activities Child preferred activities Join the child in play and activity Teach play and participation 3. Expand the social basis of communicative interactions Arrange environment to increase engagement Teach joint attention strategies Balance turns (mirror and map) Increase person engagement 4. Teach child communication target forms to advance language Respond Model Expand Prompt IES SCD June

8 Evidence For Child Outcomes Increases child use of language targets Vocabulary (Kaiser et al, l993*; Scherer & Kaiser, 2010*; Roberts & Kaiser, 2012; Kaiser & Roberts, 2013; Roberts & Kaiser, 2015; Kaiser, Scherer, Frey & Roberts, 2017) Early syntactic forms (Kaiser & Hester, 1994*) Moderately complex syntax (Warren & Kaiser, l986*) Increases child frequency of communication (Warren et al., l994*; Kaiser et al, l993*; Kasari et al., 2016; Curtis, et al.,2017) Generalization across settings, people, and language concepts (Warren & Bambara, l989; Goldstein & Mousetis, l989; Kaiser & Roberts, 2013) Maintenance of newly learned targets (Warren & Kaiser, l986; Kaiser & Roberts, 2012; Roberts et al., 2013*) More effective than drill-practice methods (Yoder, Kaiser, & Alpert, l991*; Kaiser, Yoder, et al., 1996*) IES SCD June

9 Training communication partners as interventionists is an essential component of EMT Interventionists Key Skills Therapists Environmental Arrangement Parents Notice and Respond Siblings Balance Turns Teachers and assistants Model/ Expand Target Talk Time Delay Milieu Prompting Sequence Mode: Signs, SGD, Speech IES SCD June

10 A Cascading Intervention Model How to Teach Interventionists? Interventionist Training Interventionists Use of Strategies What to Teach Interventionists? Child Language IES SCD June

11 Maximizing Intervention Effects Interventionist Training Interventionist Use of Strategies Child Language Teach-Model-Coach-Review First 10 minutes of each Training session Re-stated the strategy, gave example Teach (Parent Intervention) Role played Discussed ways to use the strategy Based on 6 15 adult minutes learning of each strategies session (Dunst & Model Trivette, 2009). Modeled the language support strategy Simultaneous Highlighted use of different strategy methods use has the largest effect (d=1.25). 15 minutes of each intervention session Coach Coached the caregiver while she practiced the strategy with the child Review Last 10 minutes of each session Discussed the session Linked parent and child behaviors Made a plan for home use of strategies IES SCD June

12 Evidence for Training Parents Parents learn a range of strategies to criterion levels. Environmental arrangement (Alpert & Kaiser, 1992*; Hemmeter & Kaiser 1990*) Responsive interaction strategies (Hancock & Kaiser, 2002*; Kaiser et al., 1996*, Kaiser & Roberts, 2012; Roberts, Kaiser, et al submitted) Modeling language targets (Hancock & Kaiser, 2002*; Roberts & Kaiser,2015) Prompting target production using MT techniques (Kaiser, Hancock & Nietfeld*, 2001; Roberts et al, 2015; Wright & Kaiser, 2013*) Parents generalize these strategies to home interactions with their children (Hancock & Kaiser, 2002; Kaiser & Roberts, 2012; Roberts et al, 2015*Wright & Kaiser, 2013*; Peredo, et al., 2017*). Parents maintain their newly-learned skills over 6-18 months (Kaiser, et al 2001*; Kaiser & Roberts, 2012;Roberts & Kaiser, 2015; Hampton et al.,2018). IES SCD June

13 EMT Modifications to Child Characteristics Provide alternative mode Signs SGD Teach partners mode Mode Engagement Strategies Teach play Increase person engagement Teach coordinated joint attention Baseline Communication Learning Strategies Teach joint attention skills Support partner comprehension Teach imitation Add discrete trials Increase dosage IES SCD June

14 JASPER + EMT [J-EMT] Teaches joint attention, symbolic play, regulation Modifications of EMT JASPER + EMT + AAC [J-EMT+ SGD ; Words + Signs] Teaches joint attention, symbolic play, regulation Includes speech generating device or signs for input and output Phonological Emphasis + EMT [PE-EMT] Models speech targets Recasts for speech + Discrete trial training [Rescue protocol] - Reduce prompt complexity, number of prompts [Simplify] + Increase Dosage [Dosage] + Support Partners to use mode and EMT [Partner] IES SCD June

15 Phenotypic Specific Modifications Population Modifications Mode Engagement Learning Strategy Support Baseline Communication Toddlers with Receptive/ Expressive Delay No No Support partner as teacher Down syndrome + Sign or SGD Teach play +Dosage Support partner comprehension Cleft Lip +/or Palate + Speech targets No +Recast + Speech practice Increase rate of child talk Minimally Verbal ASD + SGD Teach play, engagement +Dosage +Rescue Protocol: imitation, receptive language Teach joint attention skills IES SCD June

16 EMT Active Ingredient Play and engage Modification EMT Type Population Study Teach play, Use person engaged activity to reinforce social engagement J-EMT ASD Minimally verbal ASD Kasari, et al., 2006 Kasari, Kaiser et al 2014 Kasari et al in progress Follow child s lead in play and activity Teach play Provide more motivating materials, choices J-EMT ASD Minimally verbal ASD Kasari, et al., 2006 Kasari, Kaiser et al 2014 Respond to child communication Modify mode Train partners to recognize communication Target simple rate increases first Words & Signs J-EMT +SGD DS ASD Wright, Kaiser, Roberts & Reikowsky 2012*; Kasari, Kaiser et al 2014; Model language in context Teach imitation skills Modify modeling to fit speech or mode characteristics Rescue protocol PE-EMT Words + Signs J-EMT +SGD Minimally verbal ASD Cleft toddlers DS Kasari, et al in progress Scherer & Kaiser, 2011* Kaiser, Scherer,& Frey, 2017 Expand child communication Teach prelinguistic skills ( point, show, give) Increase intelligibility Make mode more transparent to partner J-EMT+ SGD Words + Signs Minimally verbal ASD DS Kasari et al 2006 Kasari, Kaiser et al, 2014; Kaiser Hampton, & Fuller, in progress Wright et al 2012* Use time delay to prompt requests or initiations Modify time delay (lessen production demand) until child regularly responds Choose highly preferred objects EMT Words + Signs/SGD Simplify to accept gesture Toddlers with receptive/expressive delay DS ASD toddlers Roberts & Kaiser 2012; 2015 Wright et al 2012*; 2015* Use Milieu teaching prompts to Teach responding to prompts and EMT Toddlers with Wright et al 2012* promote practice least to most support sequence, Words + Signs receptive/expressive delay Roberts & Kaiser, 2015 Increase reinforcement for DS Kasari, Kaiser, 2014 responding Simplify Minimally verbal ASD Scherer & Kaiser, 2011*; Cleft toddlers Kaiser, Scherer & Frey, in press IES SCD June

17 Using Single Case Designs Foundations Primary demonstrations of components of EMT Demonstration of new combinations Training Interventionists Demonstrating parent training, sibling training, teacher training Developing Teach-Model-Coach-Review Training parent trainers Examining generalization and maintenance By intervention agents By children Differentiating intervention Child population demonstrations Adding mode: sign, SGD Adding components: JASPER (Kasari et al 2006), positive behavior supports, direct instruction Modifications for intervention context: Spanish speaking, siblings, classroom IES SCD June

18 Single Case Design Studies Foundational Demonstrations Design and Demonstrate Systems Train Implementers Differentiate for Implementation Context Differentiate for Child Population IES SCD June

19 Single Case Design Studies: Measurement Measurement of Key Components Primary, Generalized, Maintained Measures of System Environmental support Implementation in context Measurement of Implementation.; develop criteria for implementers, for training implementers Differentiated components of implementation to fit culture, language, child needs, setting Differentiated components, dosage, mode, combination treatments IES SCD June

20 Measurement Development Based on SCD Observational measures of EMT components Definitions, reliability standards and protocols, observer training protocols, Specified to population s baseline communication, target skills, mode, language Criteria for primary EMT implementation E.g., percent responsiveness, percent talk at target level, number and percentage correct use of prompts Used for therapist implementation fidelity and parent implementation fidelity Child proximal targets # of social communicative utterances (word, gesture, sign, SGD) # of different words or unique multiword targets # of uses of specific target classes % responsiveness to obligatory and non obligatory partner communication Secondary target measures Use of SCD, problem behavior, generalization, maintenance, general linguistic development IES SCD June

21 Preparation for RCTs Estimating relationship between proximal gains and global or distal gains Therapist implemented produces more rapid gains in proximal targets for children with ID, DS and language impairment Parent implemented produces slightly more rapid gains and better global gains for children with ASD ( See Kaiser, 2012) Amount of gain in intervention (Words Observed) needed for 1 point gain on a standardized assessment varies by population Development of fidelity measures and standards Estimating dosage of interventions Acquisition of EMT at criterion Mastery of EMT sufficient for generalization and maintenance: training across routines Child dosage to demonstrate global gains varies by population Could we have done this better with statistical ES estimates? IES SCD June

22 Two Examples of Blending SCD and RCT Toddlers with delayed language Single case MBL with 4 families Dosage based on proximal outcomes Tested TMCR training protocol Developed training modules Estimated power for distal outcomes RCT Treatment vs Control Longitudinal follow-up Examined relation of parent fidelity to outcomes Examined mediation of behavior and language outcomes Examined predictors of response to treatment RCT multisite clinical trial ( beginning July 2018) Toddlers with delayed language from Spanish-speaking low resourced homes Planning: acceptability, feasibility, adaptions Reviewed data from Spanish speaking families in our previous studies Interviewed families, providers; validated adapted EMT and TMCR procedures Single case MBL with 3 families with generalization, social validity, maintenance Made further adaptations in EMT and TMCR Small RCT ( ongoing) powered for parent outcomes, Medium scale RCT powered for child outcomes (proposed, not funded, revised) Single Case MBL with children with ASD (planned) IES SCD June

23 Group Experimental Studies Parent vs Therapist (ID)+ SCD embedded Parent + Therapist ( Toddlers) Design and Demonstrate Systems Differentiate for Implementation Context Foundational Demonstrations Train Implementers Differentiate for Child Population Minimally verbal ASD w/aac Minimally verbal ASD DT VS JEMT Minimally verbal ASD DT+JEMT ASD Toddlers JEMT Cleft Lip+/-Palate EMT+PE DS Preschoolers w/aac Spanish Speaking Parents IES SCD June

24 Strengths of SCD Developing intervention Demonstrating package interventions Testing individual components of interventions Developing fidelity measures and criterion standards Examine dosage in relation to proximal outcomes Flexible design could allow modification of treatment, adjustment of dosage Thorough examination of generalization and maintenance Examine individual differences in response to treatment on proximal primary and secondary measures IES SCD June

25 Limitations Focus in on proximal, malleable outcomes: construct validity and relation to global measures may be a limitation The nature of the intervention is influenced by the design of treatment delivery Continuous monitoring Feedback for performance, fidelity Some behaviors limit the types of flexible SCD that can be used May not be clear what characteristics of individuals are related to differences in responding Challenges in estimating effects; Not how ES estimates for proximal outcomes translate from SCD to RCT Measures used in RCTs are usually not the same proximal measures in context of intervention Replications would be useful to increase confidence at each step of development, but rarely conducted IES SCD June

26 Suggested Guidelines Determine your long term goal(s) for your research Theory of change Indigenous implementers Naturalistic context Analyze what you need to know, have and measure Participant characteristics Treatment protocols, training materials, Fidelity protocols Measures of dependent variables Dosage, intensity Determine what questions can be asked using SCD Determine the optimal, strongest contemporary design SCD for the question Determine if designing the SCD for statistical analysis is possible Determine iwhat SCD replications are needed Pilot global measures that will be used in RCT IES SCD June

27 Thanks for your time and attention! More information about EMT research can be found at : Complete List of Published Work : MyBibliography: v/sites/myncbi/1busdkbkcgaq6/bibliogra phy/ /public/?sort=date&directi on=ascending me: Ann.Kaiser@Vanderbilt.edu IES January