While the background noise of daily life includes a stream of fascinating new findings concerning the neurobiology of autism, parents of children with ASD face the urgent, present-day challenge of enhancing their children’s social, cognitive, linguistic, and adaptive development in every possible way. There is no time to lose. Two clear needs in this regard are early intervention, which has been repeatedly demonstrated to be a central feature of better outcomes in ASD, and methods for reducing non-compliant and other maladaptive behaviors that interfere with learning.
We profile two evidenced-based, parent-implemented behavioral intervention programs that address these needs. Early Social Interaction (ESI) is an early intervention program developed specifically for toddlers at risk for ASD. ESI aims to maximize the development of social communication by offering intervention during the earliest years of life. Parent Child Interaction Training (PCIT) was originally developed for young, non-autistic children to treat non-compliance, and other maladaptive behaviors that interfere with learning. PCIT is a potentially promising intervention in young children with milder forms of ASD.
While behavioral interventions for autistic children have always included parent training, the past fifteen years has witnessed a growing trend to increase the involvement of family members and other non-clinicians and to embed teaching in naturalistic environments. PCIT and ESI go far beyond merely involving parents as partners or collaborators by teaching them the skills to independently implement treatment in the naturalistic environment of the home and community.
Early Social Interaction Project
The Early Social Interaction (ESI) Project, developed by Wetherby and Woods, was designed to apply the 2001 recommendations of the National Research Council (NRC) of the National Academy of Sciences to toddlers with ASD. The project’s aim is to develop a parent-implemented intervention that embeds naturalistic teaching strategies in everyday routines and is compatible with the mandate of the 2004 Individual with Disabilities Education Improvement Act (IDEIA), Part C. ESI treatment focuses on the core deficits of ASD, in joint attention, shared affect, communication, and play.
In ESI, parents are taught a repertoire of skills in the domains of communication, language, play, and social skills through coaching. Coaching occurs in both home and clinic settings. Parents are taught to integrate strategies into everyday routines. Based on the longstanding finding that intensity of treatment matters in early intervention, parents are taught to use the skills twenty-five hours per week in everyday predictable routines. ESI uses a developmental sequence for goal setting and emphasizes teaching and learning in daily routines and activities. ESI uses evidence-based practices driven by data collection and outcome measures, yet goals are formed based on individual and family needs. Interventions are embedded in naturalistic situations, and treatment goals are strategically planned within typical contexts. Some areas that ESI addresses are: Social Communication, Joint Attention, Symbol Use, Emotion Regulation, Active Engagement, Arousal States, Pretend Play, Social Engagement, Flexibility, and Reciprocity.
While research into the efficacy of ESI and other parent-implemented programs is in its infancy, there is growing evidence of the generic value of teaching parent responsiveness in any intervention program. Siller and Sigman (2002) compared samples of children with ASD with parents showing low- and high-level synchronization skills (defined as following the child’s focus of attention and engagement) during an initial sample of play behavior. They found that children of parents with high-level synchronization skills had better joint attention skills a year later and better language outcomes a full ten and sixteen years later.
A preliminary study of ESI using a sample of young toddlers at risk for ASD indicated significant improvement on eleven of thirteen social communication measures. For example, gains were evident in the areas of joint attention (i.e., gaze shifts, shared positive affect, gaze/point follow, and communicating for joint attention) for toddlers who entered treatment at two years of age (Wetherby and Woods, 2006). These preliminary results suggest that for families who are successful at learning and can provide this intervention at adequate intensity, ESI is a cost-effective and naturalistic means of delivering appropriate early intervention to very young children with ASD. While the long-term impact is yet unknown, the efficacy of ESI is currently being evaluated in a large, multi-site randomized control trials (RCT) study funded by Autism Speaks.
Parent-Child Interaction Training
Parent-Child Interaction Therapy (PCIT) is an empirically-based, time-limited parent training program that was originally developed to treat disruptive and oppositional behavior in non-autistic young children. Children with ASD were historically excluded from PCIT because it was assumed that they would not respond to a program that relied on social contingencies. Recently, however, children with milder forms of ASD who are motivated by social attention have been referred in increasing numbers for PCIT due to the growing recognition that it may be effective in reducing problematic behaviors.
PCIT is conducted in weekly, clinic-based, one-hour sessions attended by parent and child together. PCIT differs from many other parent training programs in that it involves live coaching, treats parents and children together, and is data-driven. During sessions, parents are invited to play and interact with their children. They are provided with a “bug-in-the-ear” microphone device with which a trained clinician coaches them from a one-way observation room.
PCIT has two phases of treatment. The first phase is Child Directed Interaction or “CDI.” CDI includes teaching parents specific communication skills to use in playtime routines that have been found to improve the parent-child interaction through the systematic use of skills involving labeled praise, imitation, and others during play. When a parent masters CDI skills, they then begin learning the second phase of PCIT, Parent Directed Interaction or “PDI.” PDI includes teaching parents how to give effective, developmentally-appropriate instructions or directives. In PDI, parents learn how to use visual cues, simple, clear language, and a set of specific steps in response to compliance and non-compliance. The goals of PDI are individualized based on target behaviors identified for each child. Parents’ use of CDI and PDI skills is coded during each session, and results guide further coaching. Data including the coding of parent skills, the child’s behavior, and the frequency of skill practicing outside of sessions is collected each week and reviewed with parents at the end of each session. The data is analyzed and used to monitor treatment progress. Once PDI skills are met, the family graduates from PCIT and is deemed independent with this method.
PCIT blends many therapeutic techniques that are recognizable features of well-established therapies for children with ASD. For example, the emphasis on compliance training in the PDI phase of PCIT is similar to ABA-based methods. PCIT’s stress on parent-child interaction and the quality of the parent-child bond is similar to central aspects of two, well-known methods of teaching children with autistic disorder, Greenspan and Wieder’s Floortime approach and the TEACCH model. Like pivotal response training (PRT), another time-honored, empirically-based approach, PCIT stresses the importance of using familiar play materials in a comfortable environment. Thus PCIT is a natural and familiar-feeling choice of treatment for young children with milder forms of ASD.
PCIT has strong empirical support with non-autistic groups. Controlled studies have found PCIT to be effective in reducing disruptive behavior. Other studies have found that gains are maintained over time. There is to date only one controlled study of PCIT for autistic children. This pilot study found improvements in parents’ perceptions of their child and increases in shared positive affect and parent positive affect (Solomon et al., 2008). Clinician-researchers at West Virginia University report success in the use of PCIT in building language and conversation, reducing stereotyped, repetitive behaviors, and increasing compliance, flexibility, and attention span in children with milder forms of ASD (Masse et al., 2008). They have found that PCIT was ineffective in more severely affected children whose language was developmentally below the age of two years or who were not motivated by social attention. With less affected children, however, PCIT showed signs of promise as a possible “gateway” treatment that can prepare children with milder forms of ASD to cooperate with other learning therapies.
Conclusion
Parents of autistic children are confronted with an array of treatment programs. Interventions for young children with ASD that are implemented entirely by parents are a new trend but one that occurs in the context of a growing interest in increased parent involvement. When parents are successful at learning and can offer the required degree of intensity of therapy, these approaches may offer a more cost-effective and naturalistic method of teaching skills and reducing problem behaviors than those that rely on service delivery by professionals. For these families, ESI and PCIT are two potentially valuable ways to help their children.
Dana Levy, PsyD, is Clinical Psychologist and Elizabeth Roberts, PsyD, is Neuropsychologist at the Child Study Center, at NYU Langone Medical Center.
References
Masse, JJ, McNeil, CB, Wagner, SM, Corney, DB (2008). Parent-Child Interaction Therapy and High Functioning Autism: A Conceptual Overview J Early and Intensive Behavioral Intervention, 4(4), 714-735.
Siller, M & Sigman, M (2002). The behaviors of parents of children with autism predict the subsequent development of their children’s communication. J Autism and Dev Dis, 32, 77-89.
Solomon, M, Ono, M, Timmer, S, Goodlin-Jones, B (2008). The effectiveness of parent-child interaction therapy for families of children on the autism spectrum. J Aut Dev Dis, 38, 1767-1776.
Wetherby, AM, Woods, JJ (2006). Early Social Interaction project for children with autism spectrum disorders beginning in the second year of life: A preliminary study. Topics in Early Childhood Special Educ, 26:2, 67-82.
