Home-Based Play Routines in Low-Resourced Families of Young Children with ASD: Parent Strategy Implementation

Background:

In recent years, there has been much discussion about bridging the research-to-practice gap in autism research. Dingfelder and Mandell (2011) propose that one of the best ways to examine whether interventions are effective is to examine how the intervention is implemented in real-life context. This is particularly critical for families who have limited access to resources. Many autism interventions with parent training components have demonstrated effectiveness in increasing child outcomes but rarely are data reported on parent implementation in contexts outside the training sessions (Green et al., 2010; Landa, Holman, O’Neill, & Stuart, 2012).

Objectives:

The current study will examine 1) group differences in caregivers’ generalized implementation of intervention strategies, and 2) change scores in strategy implementation within the caregiver mediated intervention group.

Methods:

Participants were 28 dyads of caregivers and young children with autism spectrum disorder (ASD), ages 2-5. The sample is a subset of a larger RCT that examined children’s social communication skills in a naturalistic developmental behavioral intervention (NDBI) targeting joint engagement, play, and joint attention (Kasari et al., 2014). Caregivers were randomized to receive either 3 months of group caregiver education (CEM) or individualized caregiver-mediated intervention (CMM).

The Mullen Scales of Early Learning (MSEL; Mullen, 1989) was used to determine children’s cognitive ability. The Mullen yields age-equivalent scores for visual reception, fine motor, receptive and expressive language skills.

Home Observation. The home observation is a 30-minute videotaped session that records everyday home routines, including play, that the child and his/ her caregiver spent time doing together without the presence of the interventionist. These home observations are videotaped by research assistant blind to treatment condition. Parent strategy implementation was coded during the 30-minute taping, specifically during play interactions. Strategies coded include: Basic strategies, Setting up the Environment, Following the Child’s Lead, Play Routines, Expanding Routines, Joint Attention, and Language.

Results:

Linear mixed models were used to model the change in strategies from baseline to exit. Caregivers in the CMM group improved significantly more in all strategies except for play routines compared the CEM group from baseline to exit (Basic Strategies: F(1,24)=11.23, p=0.003, Setting up the Environment: F(1,24)=21.50, p<0.001, Following the Child’s Lead: F(1,24)=29.07, p<0.001, Play Routines: F(1,24)=3.42, p=0.077, Expanding Routines: F(1,24)=6.25, p=0.02, Joint Attention: F(1,24)=14.33, p<0.001, Language F(1,24)=21.44, p<0.001 and overall strategies: F(1,24)=45.66, p<0.001). On average, the CMM group increased 40.2% in their overall strategy implementation at exit (fidelity score: 70.2%) compared to the CEM group who stayed relatively the same from entry to exit (fidelity score at exit: 33.4%).

Conclusions:

This study demonstrates generalization from training sessions with parents to naturalistic demonstration of skills when videotaped by a blinded videographer in their home. The two strategies that caregivers improved the most suggests that by end of treatment, they were allowing their children to initiate more and were also becoming more aware and responsive to their children’s communication. Future parent-mediated interventions should continue to focus on child outcomes, but also include parent fidelity implementation measures to assess the adoption, feasibility, and maintenance of these intervention strategies.