Defining intervention features to advance outcomes of high risk and delayed infants and toddlers Rebecca Landa, Ph.D., CCC-SLP Director Center for Autism and Related Disorders
Goal- pushing the envelope on optimizing child outcomes (1) Defining candidate pivotal and malleable behaviors/processes to serve as caregiver and/or child intervention targets (2) Determining how to efficiently maximize caregivers treatment implementation fidelity (3) Addressing implementation challenges associated with prodromal interventions (4) Translating intervention approaches across disabilities or risk factors 2
Thank you Families, children, teachers, administrators R21DC015846, R324A1602288, R01 MH059630, R40 MC 15594 3
Pivotal and Malleable Targets 4
Pivotal and Malleable Targets Deliberate targeting of a behavior Deliberate engineering of a moment Watchfully wait for the behavior that follows And consequate or shape a cascade of events 5
Pivotal and Malleable Targets Insights into the learner With the child, we are coconstructing brain wiring learning 6
Pivotal and Malleable Targets Yields a pivotal & malleable caregiver target: Insight into the child as a learner -Interpreting behavior -Allowing processing time -Scaffolding 7
Learning + = experience dependent neuroplasticity Neuroplasticity: Neuronal connections are created and organized, and learning occurs in response to a child s experiences with the environment (Kolb & Gibb, 2011). 8
But good news Child Caregiver Perceptual & attentional [IDS, gaze] biases Infant Directed Speech Sensory (pitch discrim; speech pref) Child contingent talk & play Motor Environmental arrangement IQ Modeling, prompting, reinforcing Child: Meaning construction Caregiver: Environmental Engineer 9
In children with delays, or at risk for delays Atypical attention biases? Inadequate multi-modal processing? Memory limitations? Complexity threshold lowered? Detect pattern but not connecting meaning? Reward value? 10
6 months HR = LR associative learning HR=LR responding to caregiver pointing HR<LR looking at caregiver Bhat, Galloway, Landa, 2010 11
Pivotal and malleable child learning targets ASD Core deficit areas are malleable: Joint attention (JA) Imitation (Kasari et al., 2006 [RJA]; Ingersoll et al., 2006; Landa et al., 2011 [IJA]) Follow-up study: JA group had most rapid growth in frequency of triadic gaze and showing behavior, and most significant expressive language gains (Gulsrud et al., 2014) Frequency of IJA at preschool-age was associated with degree of expressive language gains between ages 8 to 10 years (Gulsrud et al., 2014) 12
Pivotal targets Peer-mediated JA tx in natural setting (Hansen, 2016) Targeting JA has collateral effects on social initiation, positive affect, imitation, spontaneous speech (Whalen et al., 2006) Teaching imitation of gesture (3 of 5 children) led to increased spontaneous use of gesture (Ingersoll et al., 2006) Longitudinal study of predictors of language outcomes: IJA and immediate imitation was associated with concurrent language ability (age 3-4 years) but toy play & deferred imitation were the best predictors of rate of communication development from age 4 to 6.5 years (Toth et al., 2006) 13
Pivotal targets Predictors of IQ, adaptive functioning, ASD severity: actively seeking social engagement, joint attention, and imitation loaded onto a single factor = social engagement variable. (Smith et al., 2015) Higher baseline social engagement scores predicted better IQ and adaptive functioning outcomes one and two years later (Smith et al., 2015) 14
In summary: Social engagement overall IJA Imitation Toy play Peers Early language functioning 15
Need to frontload treatment to foster learning in these key areas? 16
Targeted Child Outcomes: 2-year-olds Language Interpersonal synchrony Meaning construction 17
Are Interpersonal Synchrony targets pivotal & malleable in toddlers with ASD? Non-IS and IS groups: Comprehensive developmental curriculum 6 months 10 hours per week Parent training & education IS condition: Interpersonal Synchrony supplemental curriculum Socially engaged imitation Initiation of joint attention (and RJA) Shared positive affect (and face and emotion recognition) Landa et al. (2011) JCPP 18
Participants Baseline Class+IS N=24 Class Only N=25 CA 28.6 m (2.6m) 28.9 m (2.8m) Mullen EL T score* 23.92 (5.60) 25.92 (8.12) Mullen VR T score 27.5 (8.27) 31.12 (9.86) *Mullen subscale mean=50, sd=10 19
Instructional Approach NDBIs DTT TEACCH Nexus: Book Nursery School Schedule 20
Socially Engaged Imitation (generalized) p=0.01; d=0.86 Landa et al., 2011 JCPP 21
IJA frequency (CSBS DP) generalized p=.07, d=1.56 Landa et al., 2011 JCPP 22
Mullen Visual Reception T score change IS > growth during tx period than non-is p=.02 23
Pivotal and malleable child targets Translating EA for use in public preschool classrooms: ASD 24
Teachers/children (Early Achievements) Pivotal/Malleable targets JA (RJA- social anticipation, concept development, attention, visual search for relevant information; IJA- social initiation, intention, reward of getting others focused on your interest) Socially engaged imitation (synchrony, social attention, motor planning, observational learning, gesture & communication) Language (RL, EL, gesture) Peer-to-peer (social: anticipation, initiation, responsivity, followthrough, theory of mind, sharing/giving) Object knowledge/relations (concept formation, play, language) JA Peer-topeer Language Imitation Objects 25
Public preschool classrooms: 3 contexts Art Book? Snack 26
Seeing a breakthrough moment Teacher: Strategically designed placemats; duplicate (relevance, extending) Children: RJA Gesture Commenting Imitation Generalized 27
Pivotal together? JA Peer-topeer Language Imitation Objects -Day in and day out (potenitation) -With strategically selected exemplars (consolidation/generalization) -In multiple instructional contexts (generalization) -In ecologically valid contexts (meaningful engagement) 28
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Prodromal period: Greater opportunity to shape the learner & brain wiring? 30
Prodromal intervention for infants (8 to 12 months): communication &/or social delay 31
ASD-related prodrome 6 m: Self-generated social looking (Bhat, Galloway, Landa, 2010) 6 m: Visual-motor integration (Landa, Haworth, Nebel, 2016) 3 and 6 m: Postural control (Flanagan, Landa, Bhat, & Bauman, 2012) 6 and 10 m: Grasping (Libertus, Sheperd, Ross, Landa, 2014) 10 m: Communication frequency & diversity 32
Siblings of children with ASD ~20% are later diagnosed with ASD ~30% have other developmental concerns (social and/or language) 33
Apart from ASD risk, Motor delays in children with language delay 50% have gross motor delay 62% have fine motor delay (Chuang et al., 2011) 34
Literature: Intervention targets Development of novel behaviors is dependent on multiple subsystems and can be similarly advanced by addressing a variety of these subsystems (Lobo & Galloway, 2008) Past experiences with active object exploration can facilitate early information processing and the development of early knowledge (Lobo & Galloway, 2008) Enhancing language development: increase experiences to advance early object banging or gesturing (Iverson & Fagan, 2004; Iverson & Goldin-Meadow, 2005) Later problem-solving ability: Increase experiences to broaden the ranges of exploratory behaviors on various objects (Caruso, 1993) (exemplars) 35
Pivotal and malleable infant targets: Improve language learning Meaning construction via one s own body In synchrony with another person Engagement Self-generated experiences Person, object, coordinated Object exploration (toy play) Imitation Joint attention Communication 36
Determining how to efficiently maximize caregivers treatment implementation fidelity Toy affordances 37
In summary, (1) Pivotal and malleable targets Multiple domains across object use, social (imitation, JA), communication (2) Efficiently maximize caregivers treatment implementation fidelity -Early successes via engineering & scaffolding dyadic/triadic experiences - Playbook -Environmental supports (e.g., placemats, object affordances) -Opportunity to generalize: Implementation in multiple contexts (3) Addressing implementation challenges associated with prodromal interventions -Easing implementation challenges (engineer the context) -Promote understanding of child behavior 38