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Evidence-Based Practice for Very Young Children with Autism: Delivering Family-Centered Services within a Community Programs

Evidence from randomized controlled trials supports the efficacy of naturalistic developmental behavioral interventions (NDBIs; Schreibman et al., 2015) for young children with autism spectrum disorder (ASD). The Early Start Denver Model (ESDM; Rogers & Dawson, 2010) and Early Social Interaction model (ESI; Wetherby et al., 2014) are two examples of NDBIs. The ESDM is delivered through both one to one intervention and parent coaching, and ESI is a parent-implemented intervention.

NDBI-based models of intervention fuse the teaching principles of applied behavior analysis (ABA) with a developmental, relationship-based approach that is appropriate for very young children with ASD. Hallmarks of NDBIs include intervention delivered in settings that are typical of early childhood (e.g., home, playground, preschool), incorporation of child choice and following the child’s motivation, and the use of behavioral teaching principles. Interventions that combine both developmental and behavioral elements may be effective for a broad range of children with ASD (Stahmer, 2014). Despite this evidence, access to treatment based on these models of intervention is largely restricted to university-based research programs and is not typically available within the local community.

Program Information

The Center for Autism and the Developing Brain (CADB) offers an early intervention program to parents and children in a community setting, at NewYork-Presbyterian Hospital. The program is publically available and uses a NDBI approach. These services are provided free of charge through the New York State Early Intervention Program (EIP), and delivered within a focused 6 month period. This is to allow the maximum number of families a chance to participate in the program.

In the local region, the majority of available community programs are based on structured discrete trial (DT) interventions with limited parent involvement. The goal of the CADB program is to create a combined parent and child approach to empower parents while providing evidence-based practice to the child. This intervention takes place in group and individual settings at both the clinic and the child’s home with the goal of improving the child’s social communication, imitation, play skills, motor skills, personal independence, and behavior.

Components of the Intervention

Group classroom setting – Intervention is provided at CADB in a group setting of 6 children, for 6 hours per week. This is in an effort to replicate and extend research published on the effectiveness of ESDM in group preschool settings with peers (e.g., Vivanti, Dissanyake, Zierhut, Rogers, & Victorian ASELCC Team, 2013; Vivanti, et al., 2014). Children follow a program of small and large group activities including art, gym, snack, and toy play. Each child’s individualized objectives are embedded into the teaching within these developmentally appropriate activities, and teaching is carried out by a team including psychologists, educators, speech-language pathologists, occupational therapists, and interns/externs. Parents observe the classroom sessions through a one-way mirror to learn strategies to carry forward outside of the classroom setting.

 

Individual intervention – Individual child and family sessions are also provided to improve the child’s skills across all domains of development. In this way, parents are supported in carrying out embedded teaching within their family’s daily routines. Parents and caregivers spend 3 hours per week in parent coaching sessions with a therapist and their child, observing and practicing naturalistic teaching strategies. These sessions take place weekly in both the clinic and the home settings. The goal of this time together is for the clinician to work alongside parents and caregivers to teach strategies that they can embed in their child’s natural daily routines in the home and community, such as mealtime, book reading, and playing outdoors. For example, during a bath time routine, the therapist might show Allison’s parents how to get Allison to look at them and make sounds to request before pouring warm water from a cup onto her open hands, which she enjoys. During this same bath routine, the therapist may also work with Allison’s parents to teach Allison how to take off her own socks before bath time, and to tolerate nail cutting.

Related services such as speech and occupational therapy are also part of the CADB program, if a child qualifies for these services through the EIP.

 

Family components – Parents of children in the program also participate in a weekly support group and a weekly psychoeducational group session. Psychoeducational sessions led by a psychologist are used to share information with parents including about ASD symptoms, intervention options, use of visual supports, and how to manage challenging behavior. Psychoeducational sessions are also aimed at increasing parent competence in supporting their child’s continued development and in advocating for services to further their child’s growth.

Support group meetings focus on discussion topics of importance to the families and are facilitated by a psychologist or social worker.

Transitions and Maintenance

As children and families complete the 6-month program, they are provided with assistance in transitioning to other local services, whether they are continuing in the EIP or transitioning to a special education preschool setting through the Committees on Preschool Special Education (CPSE).

Following their 6-month participation in the intensive EIP, families are invited to attend weekly hour-long parent and child groups that are held simultaneously in order to continue to provide psychoeducation and support to parents, and group-based intervention to the children.

Future Directions

We are currently developing a research study to examine the feasibility and effectiveness of this community intervention program. Pilot data have shown treatment effects in all child developmental domains, with largest gains in the areas of language, play, and behavioral regulation.

 

Jamie Winter, PhD, BCBA-D, and Cynthia Martin, PsyD, are both Assistant Professors of Psychology in Psychiatry, Department of Psychiatry, Weill Cornell Medical College. Catherine Lord, PhD, is Professor of Psychology and Pediatrics in Psychiatry, DeWitt Wallace Senior Scholar, and Director of the Center for Autism and the Developing Brain, Weill Cornell Medical College, New York-Presbyterian Hospital, Teachers College, and Columbia University. For more information, contact Jamie Winter at jaw9089@med.cornell.edu or 914-997-4073.

References

Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement. New York, NY: The Guilford Press.

Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., … Halladay, A. (2015). Naturalistic developmental behavioral interventions: Empirically validated treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 1-18. doi: 10.1007/s10803-015-2407-8

Stahmer, A. C. (2014). Effective strategies by any other name. Autism, 18(3), 211-212.

Vivanti, G., Dissanyake, C., Zierhut, C., Rogers, S. J., & the Victorian ASELCC Team (2013). Brief report: Predictors of outcomes in the Early Start Denver Model delivered in a group setting. Journal of Autism and Developmental Disorders, 43(7), 1717-1724.

Vivanti, G., Paynter, J., Duncan, E., Fothergill, H., Dissanayake, C., Rogers, S. J., & the Victorian ASELCC Team (2014). Effectiveness and feasibility of the Early Start Denver Model implemented in a group-based community childcare setting. Journal of Autism and Developmental Disorders, 44(12), 3140-3153.

Wetherby, A. M., Guthrie, W., Woods, J., Schatschneider, C., Holland, R. D., Morgan, L., & Lord, C. (2014). Parent-implemented social intervention for toddlers with autism: An RCT. Pediatrics, 134, 1084-1093.

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