Early Social Interaction Project · RCT of Early Social Interaction (ESI) Project Wetherby,...

AmyM.Wetherby,Ph.D.DistinguishedResearchProfessor

LaurelSchendelProfessorofCommunicationDisordersDirector,AutismInstitute

CollegeofMedicine,FloridaStateUniversity

EarlySocialInteractionProject:ImprovingDevelopmentalTrajectoriesofToddlerswithAutismSpectrumDisorder

PresentationattheNationalAutismConferenceAugust2,2016 StateCollege,PA

Outline1. WhatdoestheresearchtellusaboutearlyinterventionfortoddlerswithASD?

2. CanwechangedevelopmentaltrajectoriesoftoddlerswithASD?

• FindingsfromtheEarlySocialInteractionProject

3. Howdowebridgetheresearch-to-practicegap?• LessonsfromImplementationScience—Strategic

PlanningforSustainedFidelityofImplementation• RollingoutAutismNavigatorinPennsylvania

Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- of 33

August 2, 2016 National Autism Conference State College, PA

Financial&NonfinancialDisclosures

l AmyWetherbyisemployedbyFSUandhasreceivedgrantfundingtosupportresearchonearlydetectionandearlyinterventionfromNIH,USDOE,&theCDC.

l AmyWetherbyisauthoroftheCommunicationandSymbolicBehaviorScales(CSBS)andtheSCERTSModelpublishedbyBrookesPublishingandreceivesroyalties

l AmyWetherbyisanownerofAutismNavigator,LLC.Nosalaryisearnedand100%oftheprofitsaredonatedtoanonprofittosupportthecourses&tools.

• Consensusstatementdevelopedbyagroupofautismresearchersonnaturalisticdevelopmentalbehaviorinterventions(NDBIs)

• TheincreasedabilitytoidentifyanddiagnoseASDearlierhasledtodesigninginterventionsforveryyoungchildren

• Empiricaldataontheefficacyoftoddlerinterventionshasemergedbasedonbehavioralinterventionsthatutilizenaturalisticapproachesanddevelopmentalorientations.



CommonFeaturesofEvidence-BasedNDBIs

• Three Part Contingency• Manualized Practice• Fidelity of Implementation• Individualized Treatment Goals• Ongoing Measurement of Progress• Child-Initiated Teaching Episodes• Environmental Arrangement• Natural Reinforcement to Enhance Motivation• Use of Prompting and Prompt Fading• Balanced Turns within Play Routines• Modeling• Adult Imitation of Child’s Behavior• Broadening Attentional Focus of the Child

Schreibman, Dawson, Stahmer, Landa, Rogers, McGee, Kasari, Ingersoll, Kaiser, Bruinsma, McNerney, Wetherby, & Halladay, 2014

Whatdoweknowabouttoddlertreatments?

Clinician-ImplementedInterventions• RCTsofclinician-implementedinterventionshavehadpromisingeffectsonchild

outcomesofdevelopmentallevel&adaptivebehaviorbutmodesteffectsonautismsymptoms

• Requireconsiderableamountofprofessionaltime,rangingfromto20hours/weekover2yearsto10hours/weekfor6months

Dawsonetal.,2010;Landa etal,2011

Parent-ImplementedInterventions• RCTsofparent-implementedinterventionshaveincreasedparentresponsivity,

synchronization,andinteractionskillsbuthavenotfoundsignificanteffectsonchildoutcomes.

• Verylowintensityrangingfrom11-24sessionsover3to12months

Carteretal.,2011;Greenetal.,2010;Rogersetal.,2012;Siller etal.,2012;Solomonetal.,2014



Background: Parent Implemented RCTsN Age

(months)Duration Intensity Proximal

EffectsDistalEffects

Carteretal.,2010

62 20 3.5months 8group/3ind sessions

X

Greenetal.,2010

152 24-59 12months 18sessions X

Kasari etal.,2010

42 30 2months 3Xweek X NA

Rogersetal.,2012

98 21 3months 1Xweek

Solomonetal.,2014

128 30-71 12months 1Xmonth X ADOS%Δ in

ASD/Autism

Intensitymatters…

…sohowdoweachieve25hoursperweekinwhichthechildisengagedactively andproductively inmeaningfulactivities?

(NationalResearchCouncil,2001)



RecommendationsoftheAmericanAcademyofPediatrics(2007)l Developmentalsurveillanceateverywell-childvisitfrom9to30months

l ScreenallchildrenforASDat18and24months

✔ Autismcanbediagnosedby18-24months,yetthemedianageofdiagnosisofis4-5years

✔ Childrenofminority,lowincome,andruralfamiliesarediagnosedayearandahalflater.

FundedbyNICHD,CDC,&NIDCD

www.FirstWordsProject.comPI:AmyM.Wetherby,Ph.D.FloridaStateUniversity



www.FirstWordsProject.com

§ ExaminedtheutilityoftheSORFasanobservationallevel-twoscreeningmeasureusingtheCSBSbehaviorsample

§ Psychometricpropertieswereexaminedin27416-24montholds:130withASD,61withdevelopmentaldelay,&56withtypicaldevelopment.

§ ResultsindicatedsignificantgroupdifferenceswithlargeeffectsfortheComposite,bothDomainscoresandthetotalnumberofredflags

§ ThesefindingsprovidesupportfortheSORFasanobservationalscreeningmeasurefortoddlerswithgooddiscrimination,sensitivity,andspecificity

Dow,D.,Guthrie,W.,Stronach,S.T.,&Wetherby,A.M.(inpress).PsychometricanalysisoftheSystematicObservationofRedFlags(SORF)forautismspectrumdisorderintoddlers.

Autism:InternationalJournalofResearchandPractice



esi.fsu.edu

Community-viable intervention model for toddlers with ASD & their families

Teach parents how to use supports and strategies in everyday activities at home and in the community

Funded byNIMH

ESITheoreticalPrinciples1. Afamily-centeredapproachtomeetthefamily’sneeds,

concerns,andprioritiesthroughouttheassessmentandinterventionprocess

2. Embeddedinterventioninnaturalenvironmentstoenhancegeneralizationforthechildandfamily

3. Parent-implemented,activity-basedintervention4. Intensityofprogrammingforatleast25hoursofactive

engagementperweek5. Systematicinstructionusingindividualizedandevidence-

basedstrategieswithmonitoring6. Developmentalapproachtargetingcoredeficitsofautism—

socialinteraction,communication,play,andemotionalregulationusingtheSCERTS curriculum



SCERTS Intervention Curriculum

S- SOCIALC- COMMUNICATIONE- EMOTIONALR- REGULATIONT- TRANSACTIONALS- SUPPORT

Barry Prizant, Amy Wetherby, Emily Rubin, & Amy Laurent

Brookes Publishing © 2006www.scerts.com

RCTofEarlySocialInteraction(ESI)ProjectWetherby,Guthrie,Woods,Schatschneider,Holland,Morgan,&Lord,2014

IndividualESIHighIntensity3individualsessionsperweek(2athomeand1inclinicplayroom);reducedto2sessionsperweekinlast3months

GroupESILowIntensity1groupsessionperweek(1educationmeetingand3playgroupsessionspermonth)

82childrenenteredstudyat18monthswithdiagnosisofASD

Comparedeffectsof2parent-implementedinterventionconditions(9months)

Employedacrossoverdesignsothatallfamiliesreceivedbothtreatments.



MeasuringTreatmentOutcomesChildActiveEngagement

• Isthechildwellregulated?• Isthechildactively

participatinginaproductiverole?

• Isthechildengaginginreciprocalsocialinteraction?Ø sociallyconnectedØ shiftinggazetofaceØ respondingtoverbalbidsforinteractionØ initiatingcommunication

• Isthechild’sbehaviorflexible&generative?

The3LayerCake:Teachingstrategies&supportstoparentstopromote

childactiveengagementineverydayactivities

Supports for better skillswModel and build language, play & interactionwExtend activity, child’s roles, & transitions

wAdjust expectations & supportswBalance of interaction and independence

Supports for a common agendawMotivating activity wProductive roles wPredictability

wPositioning wFollow child’s attentional focus

Supports for social reciprocitywPromoting initiation wBalance of turns wNatural reinforcers

wClear message to ensure comprehension

Copyright©2014.TheFloridaStateUniversity.Allrightsreserved.



“EverydayActivityCategories”topromotelearninginthenaturalenvironment

Play with PeopleSocial Games like Peek-a-boo, Rough

and Tumble, Songs & Rhymes

Play with ToysBlocks, Puzzles, Sand box, Playdough,

Cars and Trucks, Ball Games, Baby Dolls

Meals and SnacksPreparation, Eating, Cleanup

CaregivingDressing, Diaper Change, Bath,

Washing Hands, Brushing Teeth

Book Sharing Family Chores Mailbox, Laundry, Care for Pets, Plants




Support Learning in Everyday Activities and Multiple Contexts to Promote Generalization

SummaryofRCTFindingsWetherby,Guthrie,Woods,Schatschneider,Holland,Morgan,&Lord,2014

Significanttime-by-conditioninteractioneffectswithchildreninindividual-ESIshowingsignificantlygreaterimprovementon:§ SocialCommunication- CSBSSocialComposite§ AdaptiveBehavior- VinelandComm,Social&DailyLiving§ DevelopmentalLevel- MullenReceptiveLanguageand

significanttimeeffectsonothermeasuresSignificantmaineffectsoftime(nointeraction)withchildreninbothESIconditionsshowingsimilarratesofimprovement:§ Improvement on:CSBSSpeech&Symbolic;ADOSSocialAffect;

MullenExpressiveLanguage§ Worsening on:ADOSRRB,VinelandMotor,&MullenFineMotor



esi.fsu.edu

Measure of Active Engagement and Transactional Support (MAETS)

Parent Transactional Supports1. Promote Participation &ProductiveRole

2. MakeActivityPredictable3. Follow Child’s FocusofAttention4. PromoteChild Initiations5. Provide BalanceofTurns6. Support ChildComprehension7. ProvideVerbalandNonverbal Models8. AdjustExpectations&Demands



(IMFAR, 2016)

• Evaluated the effects of timing of intervention and is the firststudy of its kind to truly test whether ‘earlier is better’

• 82 children with ASD were enrolled at 16-20 months of age• Randomized to start with ESI Individual or Group then crossover• ESI Individual led to better gains when started at 18 vs 27

months for Receptive Language (MSEL), Expressive Language(VABS), Social Composite of CSBS and VABS Daily Living Skills

• Earlier was better, regardless of condition for ExpressiveLanguage (MSEL) and Symbolic skills (CSBS)

• Findings highlight the importance of early screening and referralto autism-specific interventions by 18 months and counter theUSPSTF recommendation

NextStepsSortingoutactiveingredientsoftreatmentandtreatmentresponders

CollaboratingwithDr.AmiKlin,PIoftheEmoryACE,tostudytheeffectsofESIwithyoungersibsstartingat12monthsComparingmobilecoachingwithface-to-facecoachingandcombinationsofthetwo.

Developingtreatmentsthatarefeasibleforfamiliesofdiverseculturesandcommunitiesofmodestresources

Studyingcommunityimplementationstrategiestobridgegapbetweenresearchandcommonpracticeinbothearlydetectionandearlyintervention



KeepinganEyeTowardCommunityUptakeEmbeddedinterventioninnaturalenvironmenttominimizecliniciantimeandmaximizeparentrole,consistentwithPartCEIservicesFeasibleforfamiliesofdiverseculturesandcommunitiesofmodestresourcesDevelopingweb-basedprofessionalcoursesandfamilytoolstosupportcommunityimplementationstrategiestobridgegapbetweenresearchandpractice

EarlydetectionEarlyintervention



CourseIntroduction

1. CoreDiagnosticFeatures

2. PrevalenceandCause

3. EarlyDetection

4. CollaboratingwithFamilies

5. Screening&Referral

6. EarlyInterventionBasics

for Primary Care

This7-hourcourselaunchedinSummer,2015.




www.FirstWordsProject.com




Language Learning 16 Gestures by 16 Months Imagination16 Actions with Objects by 16 MonthsSocial Connectedness 16 Ideas to Communicate by 16 Months Cooperation 16 Ways to Manage Emotions by 16 MonthsCritical Thinking 16 Messages to Understand by 16 Months



SocialCommunicationDevelopmentinInfantsandToddlers(SC•DIT)

Copyright©2016byFloridaStateUniversity.Allrightsreserved.

KnowledgeandSkillsLevelØ ExploreFunction

• 5DevelopmentalDomains• HundredsofVideosclips

illustrating80SCmilestonesØ Study-GuideFunction

• 15Self-GuidedLessons• 5LearningAssessments

MasteryLevelØ HomeVisitorsGuidetosupportfamiliesinthe

SCGrowthCharts

www.AutismNavigator.com



CourseIntroduction

1. ImprovingEarlyDetection

2. CollaboratingwithFamilies

3. DevelopmentalPerspectives

4. Evidence-basedInterventionStrategies

5. AddressingChallengingBehavior

for Early Intervention Providers




EmbeddingIncludes:

Interventiontarget(s)

Interventioncontext(s)

Transactionalsupports

OpportunitiesforPractice

Embedding intervention strategies into everyday activities provides the context for deliberate practice… for the parent and child



TheLensofActiveEngagement:




The3LayerCake:Teachingstrategies&supportstoparentstopromote

childactiveengagementineverydayactivities

Supports for better skillswModel and build language, play & interactionwExtend activity, child’s roles, & transitions

wAdjust expectations & supportswBalance of interaction and independence

Supports for a common agendawMotivating activity wProductive roles wPredictability

wPositioning wFollow child’s attentional focus

Supports for social reciprocitywPromoting initiation wBalance of turns wNatural reinforcers

wClear message to ensure comprehension




MasteryIntroduction

1. LibraryofEverydayActivities

2. LibraryofTransactionalSupports

3. LibraryofActiveEngagement

4. LibraryofChildrenandFamilies

5. LibraryofCoachingPractices





Successful implementation requires purposeful matching of “STAGES OF IMPLEMENTATION”:1. Exploration: identify need and determine innovation2. Installation: acquire resources/ prepare implementation3. Initial Implementation: put new practices in place at

selected sites with feedback loops and improvementcycles

4. Full Implementation: assure practices are used with highfidelity and achieving expected outcomes at all initial sitesand begin scale up and sustainability activities

5. Expansion and Scale-Up: increase number of sites

ECTA Center: Smith, Hurth, Pletcher, Shaw, Whaley, Peters, & Dunlap, 2014

for Early Intervention ProvidersLessons from Implementation Science



Strategies for Sustainable System Change1. Regional Team Supports and Strategies to Engage Users

§ Establish peer partners in your region§ Encourage intentional discussion groups§ Identify “Autism Navigator Specialists” to complete Mastery level§ Support feeling successful

2. Autism Navigator Learner Community§ Webinars on 1st & 3rd Tuesday of each month to focus on topics

identified by users and application of content§ Annual face-to-face meetings to engage users

3. E-Coaching to Support Fidelity of Implementation§ Autism Navigator LLC will offer e-coaching to provide feedback

and support to teams of Autism Navigator Specialists§ Video review and feedback on SORF, MAETS, fidelity of

implementation, and problem solving on specific cases

for Early Intervention ProvidersLessons from Implementation Science

Tiered Structure for Professional Development of Autism Navigator Specialists

Tier1:CompleteK&SCourse&JoinLearnerCommunity

Tier2: LocalTeamLeadershipRolesinMasteryCourse

Tier3:CertificationtoDocumentImplementationFidelity

Tier4:CertificationasanAN Regional Specialist

Tier5:CertificationasaMasterCoach/GlobalTrainer




www.AutismNavigator.com

RollingoutAutismNavigatorinPennsylvania



Early Social Interaction Project · RCT of Early Social Interaction (ESI) Project Wetherby,...

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