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Using case study methods to investigate the
effects of interactive intervention for children
with autism spectrum disorders
Luigi Girolametto a,*, Fern Sussman b,Elaine Weitzman b
a Department of Speech-Language Pathology, University of Toronto,
#160-500 University Avenue,Toronto, Ontario, Canada M5G 1V7b The Hanen Centre, Toronto, Ontario, Canada
Received 30 May 2006; received in revised form 6 November 2006; accepted 8 November 2006
Abstract
Purpose: The purpose of this multiple case study was to describe outcomes for three parents and
their children following participation in a social interactive model of language intervention. More
specifically, this study sought to clarify if changes in children’s participation, engagement, and
initiation of social interaction could be observed following an 11-week intervention.
Method: Three preschool children with autism spectrum disorders and their mothers participated in
an 11-week intervention program. The intervention taught parents to follow the children’s lead,
promote children’s participation in routines, and model language at the children’s level. Outcome
measures included estimates of parents’ responsive language input, and measures of children’s rate of
communication, number of engagements in social interaction, and initiations.
Results: The results indicated that all three mothers increased their responsive comments during
play interactions and were rated as being more responsive on a rating scale. All three children
evidenced positive outcomes in vocabulary and the number of engagements in social interaction. In
addition, improvement was observed in social initiation skills for all three children.
Conclusions: Increases in mothers’ responsiveness and children’s engagement in social interactions
are consistent with the theoretical mechanisms of the social interaction model of language inter-
Journal of Communication Disorders 40 (2007) 470–492
* Corresponding author. Tel.: +1 416 978 3353; fax: +1 416 978 1596.
E-mail addresses: [email protected] (L. Girolametto), [email protected] (F. Sussman),
[email protected] (E. Weitzman).
0021-9924/$ – see front matter # 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jcomdis.2006.11.001
vention. The results suggest that further randomized control trials of this intervention approach are
warranted.
# 2006 Elsevier Inc. All rights reserved.
Keywords: Autism; Interactive intervention; Responsiveness; Case study; Parent–child interaction
1. Introduction
Autism is a developmental disorder characterized by pervasive deficits in social
communication behaviour, including language, joint attention, and pragmatics (American
Psychiatric Association, 2000). A commonly used method of providing language
intervention for young children with Autism Spectrum Disorder (ASD) is parent-focused
intervention (e.g., Drew et al., 2002; Howlin & Rutter, 1989; Jocelyn, Casiro, Beattie, Bow,
& Kneisz, 1998). Recently, there has been growing interest in naturalistic intervention
models that are based on social-interactionist theories of language acquisition. In programs
ascribing to these naturalistic approaches, parents are taught to use responsive interaction
strategies (e.g., follow the child’s lead, take turns, imitate) during naturally occurring
activities with their children (Tannock & Girolametto, 1992). Several parent-focused
programs that ascribe to social-interactionist theories have been developed for children
with ASD and include: Relationship-Focused Intervention (Mahoney & Perales, 2003),
Social Communication Intervention (formerly Child’s Talk Aldred, Green, & Adams,
2004; Aldred, Pollard, & Adams, 2001), More Than Words (Sussman, 1999), and the
Developmental, Social-Pragmatic Approach (Ingersoll, Dvortcsak, Whalen, & Sikora,
2005; Prizant & Wetherby, 1998).
In social-interactionist interventions, parents learn to encourage the child’s social
participation in interaction by interpreting and responding to the child’s communicative
attempts as if they were meaningful (Keen, Sigafoos, & Woodyatt, 2001; Mahoney &
Perales, 2003). Behavioural teaching strategies are not used to elicit targets and learning is
presumed to occur as a result of the adult’s responsive scaffolding (Ingersoll et al., 2005;
Vygotsky, 1978). Parents learn four major strategies to foster the development of two major
skills that are areas of core deficit in young children with autism, that is, joint attention
skills (Mundy, Sigman, Ungerer, & Sherman, 1986) and pragmatic communication skills
(Prizant & Meyer, 1993). First, parents learn to use child-oriented strategies (e.g., follow
the child’s lead) to create communicative interactions around the child’s interests or focus
of attention. Second, by waiting and arranging the environment (e.g., violating common
routines, omitting items necessary for an activity), parents motivate their children to attend,
initiate communication, or participate in ongoing interactions. Third, parents use
interaction-promoting strategies (e.g., use predictable routines, take one turn and wait) to
encourage extended sequences of joint attention on a shared topic. Fourth, parents are
encouraged to interpret and respond to all of the child’s communicative attempts as if they
were intentional. Parents’ responses include simplified language input (e.g., responsive
labels, comments) that matches the children’s plan-of-the-moment and models pragmatic
communication in naturalistic contexts. A small, but growing body of evidence supports
the usefulness of the social-interactionist intervention model for children with ASD and
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 471
their parents (Aldred et al., 2004; Ingersoll et al., 2005; Mahoney & Perales, 2003;
McConachie, Randle, Hammal, & Le Couteur, 2005).
The purpose of this multiple case study is to examine the outcomes of three mothers and
their children following participation in a social-interactionist model of intervention
entitled More Than Words: The Hanen Program for Parents of Children with Autism
Spectrum Disorders (Sussman, 1999). To date, only one published study has examined the
efficacy of this program (McConachie et al., 2005). While it revealed significant outcomes
for children’s vocabulary development, it failed to detect intervention gains in core areas of
deficit for children with ASD, such as social interaction and social initiation skills. One
criticism of the study is that it did not include microanalytic techniques to code videotapes
of mother–child interaction to examine these interactive behaviours. Consequently, the
current study was undertaken to examine whether hypothesized outcomes in social
interaction and initiation skills could be detected using microanalytic coding techniques.
A case study approach is a useful methodology when a holistic, in-depth investigation is
needed to explore a theoretical construct (Yin, 2003). There are multiple definitions and
understandings of the case study. Yin (2003) describes three types of case studies:
exploratory, descriptive, and explanatory. The exploratory case study design, selected for
this investigation, seeks to develop pertinent hypotheses for further study concerning the
relationship between an intervention mechanism (i.e., parental responsiveness) and
outcomes. In this case the outcomes include social interaction skills for children with ASD.
The case study approach was chosen for this study because characteristics of children with
ASD differ widely from each other and large groups of children with ASD who have
similar characteristics are difficult to recruit. Moreover, large group designs obscure
findings at the level of the individual unit, and fail to provide useful information about the
uptake of program strategies by individual parents or their impacts on the individual
children. Given this intervention model’s lack of findings for children’s social interaction
skills, case study methods afforded a desirable alternative to an experimental design for
examining hypothesized theoretical links between related events (i.e., intervention and
parent–child changes) over time (Yin, 2003). Consequently, one potential implication from
this current study is to suggest whether further large-scale experimental research using
microanalytic techniques for examining parent–child interaction is warranted.
1.1. The interactive model of language intervention
Theoretically, social-interactionist theories of language acquisition hypothesize that the
adult’s enhanced responsiveness supports the child’s motivation to engage in social
interaction while the accompanying linguistic input stimulates the acquisition of early
social communication skills, vocabulary, and syntax development (Bohannon &
Bonvillian, 1997). The premise that adults can influence children’s developmental
progress finds support in Vygotskian theory, which maintains that adult–child interactions
provide cultural and social guidance that mediates children’s development of
communication and learning (Rogoff, 1990; Vygotsky, 1978). Vygotsky (1981)
maintained that the social interactions occurring between young children and more
capable adults provide the context for a shared construction of knowledge and
understanding. Promoting children’s communication development within the context of
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492472
naturalistic conversations reflects the social and pragmatic nature of language learning.
Within Vygotsky’s perspective, the process of learning is facilitated without direct
instruction but through ongoing mediation and scaffolding (Jarvis & Robinson, 1997).
Integral to the concept of scaffolding is the notion of using language that is within the
child’s ‘‘zone of proximal development’’, which refers to the level of performance that is
between independence and frustration (Vygotsky, 1978).
While it appears that social-interactionist intervention may have a facilitatory effect on the
development of communication skills, the precise mechanisms that are responsible for child
change are unclear. It has been suggested that a key mechanism for promoting
communication development is the adult’s responsiveness. Responsive caregiving leads
to secure attachments between child and adult, thereby laying the foundations for positive
social adjustment and optimal communication development (Mahoney & Perales, 2003;
Richter, 2004). Complementary evidence from the field of neuroscience suggests that
children’s neurological development occurs in response to social and interpersonal processes
(Nelson & Bloom, 1997) and the brain’s development is dependent upon supportive
experiences with adults (Richter, 2004). The facilitatory effect of parental responsiveness
may reside in a match between the child’s processing mechanisms and the adult’s responsive
input. Language input that is responsive to the child’s plan-of-the-moment reduces
contextual ambiguities, provides redundancy, and increases the saliency of the input such that
more cognitive resources can be available for attending to language and the social-pragmatic
rules of communication (Harris, Jones, Brookes, & Grant, 1986; Tomasello & Todd, 1983;
Yoder, Kaiser, Alpert, & Fischer, 1993). Thus, responsive speech input (including imitating,
interpreting child’s vocalizations as words, labeling objects to which the child is attending,
and expanding the child’s words into phrases) models semantic and syntactic content that is
more easily understood and promotes both receptive and expressive language learning.
1.2. Empirical evidence of efficacy of interactive intervention
Because of its recent development, there is relatively little information to inform
clinicians about expected outcomes for parents and children with ASD following parent-
focused interactive intervention. Thus far, interactive intervention has been used
successfully with parents of late-talking toddlers (Girolametto, Pearce, & Weitzman,
1996) and parents of children with cognitive and language impairments, such as Down
syndrome (Girolametto, Weitzman, & Clements-Baartman, 1998). A small but growing
body of evidence from descriptive studies (Mahoney & Perales, 2003) and control group
designs (Aldred et al., 2004; McConachie et al., 2005) is suggestive of favorable outcomes
for children with ASD as well.
Mahoney and Perales (2003) used a pretest–posttest design to investigate the outcomes
of twenty mothers and their preschool children with ASD. Families participated in a year-
long study in which mothers were trained to use responsive interaction strategies, such as
reciprocity, contingency, shared control, affect, and match. Following intervention, the
authors reported that 80% of the mothers increased their level of responsiveness. This was
accompanied by improvements in ratings of children’s attention, persistence, initiation,
and joint attention. The data also suggest that mothers who made the greatest changes in
responsiveness had children who made the greatest improvement. Although there was no
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 473
experimental control for maturation effects, the results of this study suggest that
mechanisms involved in responsive interaction may play an important role in facilitating
social interactive behavior in children with ASD.
The first randomised control trial of a parent-administered social-interactionist
intervention model utilized a program called Social Communication Intervention (Aldred
et al., 2004). This study randomly assigned 28 children with ASD into experimental and
control groups. In the 12-month experimental program, parents were trained to respond
sensitively to the child, interpret the child’s actions as having meaning, use action routines, set
up repeated scripts, and pause to elicit the child’s interaction and communication. Following
intervention, the children in the experimental group demonstrated significant increases in
expressive vocabulary as measured by the MacArthur–Bates Communicative Developmental
Inventory (CDI) (Fenson et al., 2003). The experimental group increased their expressive
vocabulary from 28.0 to 199.4 words. An examination of videotaped play interaction
revealed significantly more responsive parent–child interaction and significantly more child
communication acts relative to the control group. The mothers in the treatment group
increased their frequency of responsive comments from 57.8 to 65.1 in 30 min of play
interaction. Their children increased their frequency of communicative acts from 30.8 to 37.6
in the same time frame. However, no group differences were found for shared attention during
the play interaction and social initiations were not measured in this context. These results
suggest that a year-long social-interactionist program may produce positive outcomes in the
vocabulary and social communication skills of children with ASD. However, the impact of
this intervention on social interaction sequences and social initiations was not supported.
The specific intervention utilized in this study, More Than Words, has been trialled in
one quasi-experimental study that assigned 51 preschool-aged children with ASD into
experimental and control groups according to the timing of their recruitment (McConachie
et al., 2005). Parents participated in an 11-week program, More Than Words (Sussman,
1999), and received 20 h of instruction in groups of eight families. Each family also
received three home visits (for parent and child) during the program to monitor their
progress and provide individualized coaching. Instruction focused on improving parents’
ability to follow the child’s lead, promote social interactions, and model language at the
child’s level. Following intervention, the authors reported significantly higher mean ratings
of the Joy and Fun Assessment (JAFA) relative to the control group. This scale assessed
parental interaction strategies, including use of fun words (e.g., ‘‘whee’’), simplified
language, expansions, fun physical contact (e.g., hugging child), pretend games, and turn-
taking routines. The mothers of children with autism who were in the experimental group
received higher ratings on the JAFA (i.e., from 11.2 to 13.9) based on a 5-min play
interaction. In addition, the study found significant gains in children’s vocabulary size as
measured by parental report on the CDI relative to the control group. In this study, the
children with autism increased their vocabulary size from 34.7 to 72.6 words from pretest
to posttest (in a 7-month period). However, social communication skills as measured by the
Autism Diagnostic Observation Schedule (ADOS) (Lord, Rutter, DiLavore, & Risi, 1999)
did not differentiate between the two groups of children at posttest. While this study
provides preliminary evidence that More Than Words may impact on parental interaction
style and children’s vocabulary, it did not use microanalytic techniques to examine
children’s social interaction or initiation skills within dyadic parent–child interaction.
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492474
The purpose of the present study was to investigate social interaction and social
initiation outcomes for three children with ASD following their mothers’ participation in
More than Words. This study improves on the procedures used by previous investigators
(Aldred et al., 2004; McConachie et al., 2005) by employing microanalytic coding
techniques to examine parent–child interactions. Parents also completed subjective surveys
in which they described changes they perceived in themselves and their children during the
intervention. The first aim of this study was to confirm that parents used responsive
interaction strategies following intervention. This study improved on previous work by
examining this aim in relation to the children’s antecedent behaviour, that is, how parents
responded when their children communicated versus when their children were unengaged
in the interaction. To improve the validity of results obtained using the coding system,
parental responsiveness was also examined using the same rating scale (i.e., JAFA)
employed by McConachie et al. (2005). Based on the results of previous studies of this
intervention model (Aldred et al., 2004; Mahoney & Perales, 2003; McConachie et al.,
2005), it was predicted that parents would increase their responsiveness as measured by (a)
the frequency of responsive interaction codes and (b) ratings on the JAFA. The second aim
of this study was to replicate the previous findings of increased vocabulary development for
children with ASD following intervention. It was hypothesized, that all three children
would demonstrate increases in vocabulary development on two different measures,
including (a) a parent report questionnaire and (b) the frequency of unique lexical items
used during the play interactions. Previous studies on children with autism spectrum
disorders (Aldred et al., 2004; McConachie et al., 2005) have demonstrated the impact of
this parent-focused intervention in facilitating vocabulary development using the CDI. A
lexical diversity measure was added to confirm parental perceptions. The third and most
important aim of the study was to examine the children’s social interaction skills following
intervention, specifically their rate of communicative acts, participation in social
interaction sequences, and initiation of social interaction. Although year-long interventions
employing social-interactionist approaches have reported positive outcomes in these areas
for children with ASD (Aldred et al., 2004; Mahoney & Perales, 2003), these important
outcomes have not been observed consistently by the three studies reviewed above. Based
on previous work, it was hypothesized that the children in this study would experience
gains in social interaction (i.e., communicative acts, frequency and length of interaction
sequences, social initiations) measured using microanalytic techniques during play
interactions with their mothers.
2. Method
2.1. Participants
Three families were recruited from waiting lists for parent-focused language
intervention programs offered by The Hanen Centre in Toronto. These families were
selected because the children (a) were close in age and language level, (b) had received a
confirmed diagnosis of ASD from a developmental pediatrician or a registered
psychologist, and (c) were not participating concurrently in intensive behavioral
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intervention (or applied behavioral analysis). The children were between 2.8 and 3.2 years
of age and used intentional communication acts at entry into the study (e.g., conventional
gestures, a few single words). Table 1 summarizes the intake characteristics of the children.
The characteristics of the children’s parents are summarized in Table 2. The mothers
ranged in age from 27 to 38 years of age. One mother had completed a 2-year
postsecondary diploma while two mothers had completed university degrees. One child
was raised in a single-parent family and two children were raised in two-parent families.
All mothers were employed outside the home on a full-time basis. Only two fathers were
involved in their children’s care and both were also employed full-time.
2.2. Procedure
2.2.1. Design
To address the study aims, a multiple case study methodology was employed. This
design is an alternative to traditional experimental designs for exploring theoretical
presuppositions (Yin, 2003). In this case, the study sought to determine whether the
intervention mechanism underlying the social-interactionist model (i.e., enhanced
responsiveness) was associated with hypothesized outcomes in social interaction skills.
According to Yin (2003) a case study design must emphasize the units of analysis,
determine of how the data are linked to the hypotheses, and state criteria for interpreting the
findings. In this study, the units of analysis were the play interactions of three mother–child
dyads. The data collection focused on parental responsiveness as the primary intervention
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492476
Table 1
Characteristics of the childrena
Jackson Ana Anthony
Diagnosis Autism PDD Autism
Age at diagnosis 1.11 2.10 2.11
Sex Male Female Male
Age at pretest 2.8 3.2 3.2
Communication SSb 62 60 63
Socialization SSb 72 64 68
Child care Day care (full-time) In home care (grandmother) Day care (full-time)
Siblings None Older brother Younger brother
a Names are pseudonyms.b Standard scores on the communication and socialization scales of the Vineland Adaptive Behavior Scales.
Table 2
Parental characteristics
Jackson Ana Anthony
Family status Single mother Both parents Both parents
Mother’s age (years) 27 38 25
Mother’s educationa University University Postsecondary
Father’s age (years) N/A 37 28
Father’s educationa N/A High school High school
a Highest level of schooling completed.
mechanism and concomitant changes in children’s vocabulary and social interaction
behaviours as outcomes. Criteria for interpreting findings were developed for four
measures that had yielded significant group differences in two previous experimental trials
(Aldred et al., 2004; McConachie et al., 2005), and included (a) the rate of parental
responsiveness, (b) ratings on the JAFA, (c) the rate of children’s communication acts, and
vocabulary size. The specific criteria are described in the results section.
2.2.2. Assessment sessions
All pretest and posttest sessions were completed immediately before and after an 11-
week intervention program and were conducted during home visits lasting approximately
1.5 h each. During the assessment sessions, each mother–child dyad was videotaped in
their homes in four 5-min activities that included storybook reading (with a familiar book),
a known social game, a daily routine (e.g., feeding, dressing), and play with bubbles.
Parents were encouraged to interact with their children as they normally would if there was
no observer in the home. Filming was discontinued if the child began to cry or fuss and
could not be re-engaged. Subsequently, the parents completed the MacArthur–Bates
Communicative Development Inventory (CDI) (Fenson et al., 2003) Words and Gestures.
At the pretest only, the examiner interviewed the parents using the Socialization and
Communication Domains of the Vineland Adaptive Behavior Scales: Interview Edition
(VABS) (Sparrow, Balla, & Cicchetti, 1984) to obtain developmental information.
2.2.3. Intervention program
The 11-week intervention program used in this study was More Than Words: The Hanen
ProgramTM for Parents of Children with Austism Spectrum Disorders (Sussman, 1999).
The families participated in eight group sessions and three home visits to learn responsive
interaction strategies. The weekly group sessions were held in the evening, lasted
approximately 2.5 h, and included a combination of interactive presentations, group
discussions, videotape analysis, and opportunities to practice. Parents used a guidebook
entitled, More Than Words (Sussman, 1999). Three home visits were conducted to monitor
the parents’ progress and children’s outcomes. The purpose of these visits was for parents
to (a) practice program strategies in real-life contexts, with coaching and feedback from the
speech-language pathologist, (b) review and revise the child’s goals, and (c) discuss any
concerns that may have arisen. Once the formal training program ended, families were
supported in their roles by community-based speech-language pathologists. The program
emphasized responsiveness to the child to promote reciprocal interactions and social
communication skills in children with ASD. The content of the intervention program
included child-oriented strategies (e.g., observe the child, follow the child’s lead, be face-
to-face), interaction-promoting strategies (e.g., use routines, take a turn and pause for a
response, cue your child to take a turn), and language-modelling strategies (e.g., interpret
your child’s actions, label, expand). Parents learned four ways to support children’s
initiations: (a) include the children’s interests by commenting or joining in, (b) interpret the
child’s actions or vocalizations as meaningful, (c) imitate the child’s actions or
vocalizations, and (d) intrude when children are unengaged or involved in repetitive
behaviours. In this latter case, parents initiated a topic, routine, or game and supported their
children’s engagement in interaction. To promote longer interactions, parents learned to
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 477
use structured and predictable routines as contexts for increasing the length of their
children’s engagement in interaction sequences. The content of the program is outlined in
Appendix A.
2.3. Measurement
Case study methodology is designed to highlight outcomes of individual participants by
using multiple sources of data (Yin, 2003). The data sources utilized in this study included
two primary sources (a) videotapes of parent–child interaction and (b) parent report on
questionnaires and surveys. Moreover, in order to increase validity of findings, the parent
interaction outcomes were examined by two different sets of observers, each using a
different methodology. One observer coded interactions at a microanalytic level while the
other independently used a rating scale (i.e., JAFA) to score the interactions holistically.
Interrater reliability estimates were calculated for all measures by research assistants who
were unaware of the questions of the study.
2.4. Transcription of parent–child interaction
A research assistant who was blind to the purpose and design of the study transcribed the
parents’ utterances using the Systematic Analysis of Language Transcripts (SALT) (Miller
& Chapman, 2002). In a second pass, the child’s communicative acts were transcribed.
Communicative acts included (a) vocalizations accompanied by eye gaze to the parent or to
the parent’s referent, (b) conventional gestures (e.g., pointing, nodding, shaking head,
offering, pushing away object to reject), and (c) words and word approximations. A second
research assistant who was blind to the study questions and design verified all
transcriptions of the parent–child interactions following a procedure used by Johnston
(2001). This research assistant read each transcript while listening to the videotape, and
noted any disagreements on the transcript. Disagreements were resolved through
discussions with the original transcriber. Where agreement could not be reached, an X was
entered on the transcript. This procedure, while time-consuming, assured that every
transcript was examined and corrected (as opposed to a randomly selected number of
transcripts). Consensus reliability was conducted on 100% of the transcripts (before they
were amended) using the formula: number of agreements/ (the number
agreements + disagreements) � 100. Consensus reliability for the mothers was 99.3%
for utterance boundaries (N = 2,762) and 98.4% for words (N = 6,911). Consensus
reliability for the children’s communicative acts was 90.8% for vocalizations accompanied
by eye gaze (N = 782), 89.8% for gestures (N = 490), and 97.1% for words (N = 1,017).
These reliability figures reflected the extent to which the second individual agreed with the
original transcription prior to making any corrections on the transcripts.
2.5. Outcome measures
2.5.1. Parent interaction coding
All parental utterances were coded using a system that classified utterances as attention
calls, commands, prompts, Wh-questions, yes/no questions, choice questions, test
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questions, and responsive comments (e.g., imitations, labels, expansions, comments,
acknowledgements). The codes were derived from a coding system previously used by
Girolametto and Weitzman (2002) and is described in Appendix B. For the purposes of this
study, responsive language input consisted of four codes (i.e., Wh-questions, yes–no
questions, choice questions, responsive comments). The inclusion of questions as
responsive input takes into account the use of questions to promote conversation as
opposed to directing the interaction (McDonald & Pien, 1982). All codes in Appendix B
were mutually exclusive and each maternal utterance received only one code. If a parent
code immediately followed a child’s communicative act, it was considered to be in
response to that communicative act. All other parent codes were considered to follow the
child’s unengagement in the interaction. The total length of the videotaping sessions varied
from 15.5 to 18.5 min at pretest and 16.2 to 20.1 min at posttest (due to variability in the
children’s attention spans and engagement in interaction). Consequently, the coded data
were expressed as rates per minute. Twenty-five percent of the transcripts were recoded
independently by the first author to provide reliability estimates. Interrater reliability
was calculated using the formula: number of agreements/(the number
agreements + disagreements) � 100 (Sackett, 1978). Reliability for the individual
responsive codes used in this study was: Wh-questions = 92% (N = 13), yes/no
questions = 96% (N = 131), choice questions = 100% (N = 1), and comments = 97%
(N = 425). The interrater reliability for all responsive codes combined was 94% (N = 954).
2.5.2. Parent Interaction rating
The Joy and Fun Assessment (JAFA) (McConachie et al., 2005) is an observational
checklist that assesses parents’ use of responsive interaction during play. Nine parental
strategies are rated: use of fun words (e.g., ‘‘whee’’), simplified language, musicality of
speech, fun physical contact, praise, pretend games, smiles and laughter, turn-taking
routines, imitations and expansions. The scale has a maximum of 36 points. The scale was
applied to two 5-min play interactions using toys and a storybook by an independent
observer (who was not involved in coding the parents’ utterances) and averaged. (The scale
could not be applied to the remaining 10 min of interaction because the scenarios varied
considerably across children for social play and daily routines.) Twenty-five percent of
the videotaped interactions were re-scored independently by a research assistant who
was blind to the group assignment and questions of the study. Interrater reliability
was calculated using the formula: number of agreements/(the number
agreements + disagreements) � 100 (Sackett, 1978). The overall scale reliability was
87.5% (N = 36).
2.5.3. Vocabulary size
Parent report of children’s vocabulary size was obtained by asking parents to complete
the CDI at all test times. A research assistant calculated frequency counts of expressive
vocabulary size.
2.5.4. Lexical diversity and rate of communication acts
The number of different (i.e., unique) words used by the children during the videotaped
interaction was calculated using SALT. Communicative acts, defined as a vocalization
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 479
accompanied by eye gaze to the parent or the parents referent, a gesture, or a word, were
transcribed in a separate pass through the transcript. Reliability for communicative acts and
words is reported above (see Section 2.4). Lexical diversity was automatically calculated
by SALT.
2.5.5. Engagement in social interaction sequences
A research assistant identified reciprocal social interaction sequences that were defined
as chains of parent-to-child turns. Turns consisted of verbal utterances or nonverbal
communicative acts (i.e., vocalizations or conventional gestures accompanied by eye
gaze). The end of a reciprocal social interaction sequence was marked by the absence of a
response from the mother or child. Measures include the number of sequences as well as
the average length of sequences. Interrater reliability of social interaction sequences was
conducted on 25% of the sample. Interrater reliability was calculated using the formula:
number of agreements/(the number agreements + disagreements) � 100 (Sackett, 1978).
The reliability for the correct identification of sequences (i.e., both initiation and
termination of the sequence) was 97% (N = 187).
2.5.6. Children’s initiations of social interaction
Children’s initiations were measured by counting all social interaction sequences that
were initiated by the children. The proportion of sequences initiated by the child was
calculated by dividing the number of child-initiated sequences by the total number of
sequences. Interrater reliability was calculated on 25% of the transcripts using the formula:
number of agreements/(the number agreements + disagreements) � 100 (Sackett, 1978).
Reliability for correct identification of child-initiated sequences was 97%.
2.5.7. Parent report of program progress
At the end of each home visit, parents completed a short subjective survey that asked
what changes they made as a result of their participation in the program and what changes
they had noticed in their children.
3. Results
This section provides a description of the intervention outcomes of three children and
their parents following an 11-week parent-focused program. All names are pseudonyms.
Yin (2003) suggests that effects pattern criteria for evaluating intervention gains in case
studies may be derived from previous experimental studies employing similar measures
and subjects. For the current study, criteria for two parent measures and two child
measures were derived from variables that significantly differentiated the experimental
and control groups in extant investigations of the social-interactionist model (i.e.,
Aldred et al., 2004; McConachie et al., 2005). The study by McConachie and colleagues
(2005) used the same intervention program, More Than Words, and provided data for
expressive vocabulary acquisition and maternal ratings on the JAFA scale. The study by
Aldred and colleagues (2004) used a similar intervention and supplied data derived from
videotaped play interactions, including the rate of mothers’ responsive comments and
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492480
children’s communication acts. All four effects pattern criteria represent treatment
effects that were experienced by experimental participants in published studies. A
criterion was met if the gain score experienced by the participants in the current study
equalled or exceeded the following values: rate of maternal responses = 0.24 responsive
comments per minute (Aldred et al., 2004), rating of maternal general responsive-
ness = 2.8 scale points on the JAFA (McConachie et al., 2005), rate of expressive
vocabulary growth = 5.4 words per month (McConachie et al., 2005), and rate of
children’s communication acts = 0.23 acts per minute (Aldred et al., 2004). No a priori
data were available to establish criteria for social interaction sequences or social
initiations.
3.1. Child 1: Jackson
3.1.1. Developmental and clinical history
Jackson, a male, was diagnosed as having ASD at 2.3 years of age by a
developmental pediatrician. He obtained a communication score of 6 and a socialization
score of 10 on Module 1 of the ADOS, for a total score of 16, which met the criteria for a
diagnosis of autism. His hearing was tested using visual reinforcement audiometry with
headphones. Responses were within the normal range bilaterally with normal middle ear
function.
Jackson’s mother enrolled in the parent-administered intervention program when he was
2.8 years of age. At the pretest, a case history form completed by his mother indicated that
early motor milestones were within normal limits (e.g., he walked at 13 months) and he
acquired his first words at 18 months of age. She reported that by 2.8 years of age he had
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 481
Table 3
Rates of parental responsiveness following children’s communicative acts and children’s unengaged behaviour
Variable Jackson’s mother Ana’s mother Anthony’s mother
Rate of conversational responsivenessa
Following the child’s communicative actsb
Pre 3.5 1.5 1.1
Post 6.1 2.8 1.4
Gain +2.6 +1.3 +0.3
Following the child’s unengaged behaviourc
Pre 3.5 1.7 2.4
Post 3.6 4.2 7.1
Gain +0.1 +2.5 +4.7
Total gain in responsiveness +2.7 +3.8 +5.0
Note: Rates are expressed as the frequency of units per minute of interaction. The duration of pretest/posttest
interactions was 18.5/16.2, 15.5/20.1, and 18.5/20.1 min for participants 1, 2, and 3, respectively.a Conversational responsiveness included all parents’ Wh-questions, yes/no questions, choice questions, and
comments.b Communicative acts include all vocalizations or words accompanied by gestures or eye gaze towards the
parent (including towards the parent’s referent).c Unengaged behaviour included all noncommunicative behaviour (e.g., passive watching, looking around the
room, wandering, touching or playing with objects; not accompanied by a communicative act).
acquired several single words and communicated primarily using nonverbal means (e.g.,
taking his mother’s hand and pulling her to what he wanted).
3.1.2. Participation in intervention
Jackson’s mother attended all eight evening sessions and all three home visits. On the
home visit surveys, Jackson’s mother reported that she was learning to encourage more
turn-taking in social interactions and to create more opportunities for Jackson to
communicate during play. During the third home visit (i.e., week 10), she reported that
Jackson had learned many new words and was starting to use short phrases (e.g., from
‘‘Go’’ to ‘‘Mommy go’’). In addition, she noted that Jackson’s functional play had
improved and that he engaged in more turn-taking activities since the program began.
3.1.3. Outcomes
Tables 3 and 4 display the parental interaction data. Jackson’s mother increased her rate
of responsiveness by 3.7 utterances per minute when he communicated (i.e., 60 additional
responses during the 16.2 min posttest interaction). In contrast, her responsiveness to
Jackson’s unengaged behaviour remained consistent over the intervention period.
Independent observation using the JAFA yielded a 2.0 increase in the average rating of
parental responsiveness.
As can be seen from Table 5, Jackson’s vocabulary increased from 30 to 74 words
during the intervention period (a rate of 14.7 per month). In the posttest play interaction, his
lexical diversity increased by sixteen words and his rate of communicative acts increased
by 5.1 acts per minute. In addition, Jackson’s overall participation in social interactions
increased from 53 to 74 sequences and the proportion of sequences that he initiated
increased from 5.6% to 20.7%.
3.1.4. Summary
The observed gains substantiated the mother’s report of progress that she made
during the home visits. Gains observed for two maternal and two child measures were in
excess of the four criteria derived from previous studies: the rate of maternal
responsiveness, ratings of maternal interaction on the JAFA, gains in child vocabulary,
and the rate of the child’s communication acts. Jackson’s social initiations tripled from
pretest to posttest. Gains in lexical diversity that were obtained from the videotaped
interactions supported this mother’s report of an increase in Jackson’s vocabulary size
on the M-BCDI.
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492482
Table 4
Pretest, posttest, and gain scores of parental responsive interaction on the Joy and Fun Assessment (JAFA)
Variable Jackson’s mother Ana’s mother Anthony’s mother
Mean JAFA scorea
Pre 13.0 13.0 9.0
Post 15.0 33.0 12.5
Gain +2.0 +10.0 +3.5
a The mean JAFA score is the average of ratings obtained in two 5-min activities (i.e., bubbles, storybook
reading). The maximum score obtainable is 36.
3.2. Child 2: Ana
3.2.1. Developmental and clinical history
Ana, a female, was diagnosed as having autism spectrum disorder at 2.10 years of age by
a developmental psychologist. On Module 1 of the ADOS, she obtained a communication
score of 2 and a socialization score of 4, yielding a total score of 6, which met the criteria
for a diagnosis of pervasive developmental disorder. An audiogram was completed using
behavioural testing and indicated a moderate reversely sloping loss for at least one ear.
Ana’s parents reported that she had numerous ear infections that were controlled using
antibiotics.
Ana’s parents enrolled in the parent-administered intervention program when she was
3.2 years of age. At intake, a case history form completed by Ana’s mother indicated that
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 483
Table 5
Pre- and postintervention scores (and gain scores) for children’s vocabulary, communication, and interaction
measures
Variable Jackson Ana Anthony
Vocabulary development
Vocabulary size (CDI)a
Pre 30 96 380
Post 74 133 589
Gain +44 +37 +209
Different words (video)
Pre 10 27 3
Post 26 54 15
Gain +16 +27 +12
Social interaction (video)
Rate of communicative actsb
Pre 7.0 5.4 2.2
Post 12.1 8.3 3.1
Gain +5.1 +2.9 +0.9
Sequencesc
Pre 53 31 18
Post 74 88 37
Gain +21 +57 +19
Initiationsd (video)
% Child-initiated sequences
Pre 5.6% 3.2% 11.1%
Post 20.7% 20.5% 0.0%
Gain +15.1 +17.3 �11.1
a Vocabulary size as estimated by the MacArthur–Bates Communicative Development Inventories (Fenson
et al., 2003).b Rates of communication acts are expressed as frequencies per minute of interaction.c Social interaction sequences are chains of parent and child communicative acts without interruption (a
communicative act consists of a vocalization accompanied by eye gaze to the parent, a conventional gesture, or a
verbalization).d The percentage of social interaction sequences that are initiated by the child.
her early motor milestones were within normal limits (e.g., she walked at 14 months) and
that she spoke her first words at 13 months of age. By 3.2 years of age, she used
approximately 96 single words and several short phrases. Ana did not receive any speech-
language pathology treatment prior to participating in the parent program.
3.2.2. Participation in intervention
Ana’s mother attended all eight evening sessions and all three home visits; her father
attended all evening sessions and participated in the first home visit. During the second
home visit (i.e., week 6), Ana’s mother reported that she was following Ana’s lead more
often, engaging her in more frequent turn-taking routines, and using simplified language
(specifically, more labels and short sentences). She also reported that Ana was beginning to
use more words in social routines and participate in longer social interactions.
3.2.3. Outcomes
An examination of the parent–child interaction data (see Tables 3 and 4) indicates that
Ana’s mother increased her rate of responsive comments following communicative acts as
well as following unengaged behaviors. The combined increase was 3.8 responsive
comments per minute. On the JAFA rating scale, the average rating increased by 10.0
points from pretest to posttest.
As can be seen from Table 5, Ana learned 37 new words from pretest to posttest (a rate
of 12.3 words per month). During the videotaped parent–child interaction, she used 27
different words and increased her rate of communicative acts by 2.9 per minute. Ana also
increased her participation in social interactions from 31 to 88 sequences and the
proportion of sequences that she initiated from 3.2% to 20.5%.
3.2.4. Summary
The observations made by Ana’s mother during the home visits were supported by the
observed outcomes. Gains in two maternal measures and two child measures equaled or
exceeded the effects pattern criteria: rate of maternal responsiveness, mean rating on the
JAFA, and the child’s rate of communication acts and acquisition of words. Ana’s social
interaction sequences and social initiations more than doubled from pretest to posttest.
Ana’s increase in vocabulary diversity supported her mother’s report of increased
vocabulary size on the M-BCDI.
3.3. Child 3: Anthony
3.3.1. Developmental and clinical history
Anthony, a male, was diagnosed as autistic at 2.11 years of age by a registered
psychologist. During a developmental assessment, he obtained a communication score of 6
and a socialization score of 9 on Module 1 of the ADOS, for a total score of 15, which met
the criteria for a diagnosis of autism. An audiogram conducted using sound field testing
indicated hearing within normal limits. Impedance testing revealed a slight conductive
hearing loss.
Anthony’s mother enrolled in the parent-administered intervention program when he
was 3.2 years of age. She reported that his motor milestones were within normal limits
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492484
(e.g., he walked at 11 months) and that he acquired his first words at 24 months of age. By
3.2 years of age Anthony was reported to have many single words but communicated
primarily using nonverbal means (e.g., taking his mother’s hand and pulling her to what he
wanted). Anthony had not received prior speech-language therapy.
3.3.2. Participation in intervention
Anthony’s mother attended seven of the eight evening sessions and all three home visits.
His father did not participate in the intervention program. In the first home visit survey,
Anthony’s mother reported that she was learning how to involve herself in her child’s
solitary play to create turn-taking games. She reported that Anthony started learning new
words by the first home visit and that word learning continued throughout the intervention
period. By the third home visit (i.e., week 10) she was following Anthony’s lead more often
and waiting longer for him to respond in familiar routines. In addition, Anthony was
starting to use two- and three-word utterances appropriately. She also noted that Anthony
had learned to say ‘‘more’’ to ask for recurrence during social routines and was starting to
engage in pretend play.
3.3.3. Outcomes
An examination of the parent–child interaction data in Tables 3 and 4 indicate that
Anthony’s mother increased her rate of total responsive comments by 5.0 per minute from
pretest to posttest. An examination of the child’s antecedent behavior revealed that she
made large gains in responsive comments following his unengaged behaviors but only
marginally increased her responsiveness following his communication acts. On the JAFA
rating scale, her average rating increased by 3.5 points.
The data in Table 5 indicate that Anthony’s vocabulary increased by 209 new words (a
rate of 69.6 words per month) and his lexical diversity, as measured in videotaped
interaction, increased by twelve words from pretest to posttest. Anthony’s rate of
communicative acts increased by almost 1.0 per minute and his participation in social
interaction sequences doubled from 18 to 37. In contrast, the proportion of sequences that
he initiated decreased from 11.1% to 0.0%, indicating that his communicative acts were
primarily responsive in nature.
3.3.4. Summary
The gains noted by Anthony’s mother during the home visits were supported by the
observed outcomes. Gains in two maternal measures and two child measures equaled or
exceeded the pre-established criteria: the rate of maternal responsiveness, responsiveness
ratings on the JAFA, the child’s vocabulary size and rate of communicative acts.
Additionally, Anthony’s vocabulary diversity and number of social interaction sequences
more than doubled from pretest to posttest. No gains in social initiation skills were noted.
4. Discussion
The data presented in this multiple case study permitted an investigation of parental
responsiveness and outcomes for three children with ASD following intervention. The
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 485
purpose of this study was to investigate the use of microanalytic techniques for detecting
outcomes in parent–child interaction following participation in a social-interactionist
intervention. It is important to note that the results of this study cannot be used to conclude
that there is a causal relationship between the intervention and the outcomes because there
was no experimental control to account for maturation effects. However, case study
methods are very useful for examining the theoretical links between an intervention
mechanism (i.e., responsiveness) and hypothesized outcomes. The results may be used to
propose justification for future research and methods of measurement that are sensitive to
change. Moreover, although the case study design precludes generalization of results to
other children with ASD, it does permit the generalization of a set of results to a broader
theory (Yin, 2003).
The first aim of this study was to examine changes in parental responsiveness before
and after an 11-week intervention. Microanalytic techniques were used to investigate
this outcome. Responsive comments were investigated in two contexts—when the child
communicated versus when the child was unengaged in interaction. Consistent with the
hypothesized outcomes, all three mothers increased their rate of responsive comments
during a play interaction and their gains exceeded those observed in a previous study
utilizing a similar coding system (Aldred et al., 2004). An examination of the
contextual data (i.e., whether the child communicated or was unengaged in interaction)
revealed that maternal gains were idiosyncratic. Only Ana’s mother made gains in both
contexts. Jackson’s mother made gains in responsiveness following communicative acts
whereas Anthony’s mother made gains in responsiveness following unengaged
behaviour. The children’s interactive behaviour may explain these findings. Jackson
was the most communicative of all three children and used twelve communicative acts
per minute at posttest, offering many opportunities for his mother to respond. In
contrast, Anthony communicated the least of all three children at postintervention, and
his mother appears to focus her energies on re-engaging him in interaction. Anthony’s
posttest data suggest that his mother missed opportunities to respond to his
communicative acts (he used 3.1 acts per minute but her response rate was 1.4 per
minute). These data indicate the importance of examining the child’s antecedent
behaviour when counselling parents to increase responsiveness. Clinicians wishing to
enhance parental responsiveness may want to differentiate communicative acts from
noncommunicative behaviour and help parents learn to respond to missed opportunities
in both contexts. This may be especially important for children who use low rates of
communicative acts.
A second measure of mothers’ responsive interaction, the JAFA rating scale, was
administered by an independent observer to validate changes in responsive behaviour. All
three mothers showed increases on the JAFA (2.0, 3.5, and 10.0 points) from pretest to
posttest. These increases equalled or exceeded the pre-established criterion (i.e., 2.0 scale
points) derived from previous work using this scale (McConachie et al., 2005). A third
measure, parents’ subjective responses on surveys administered during home visits,
provided some assurance for the ecological validity of these findings. All three mothers
reported that they adopted strategies consistent with the program’s focus on responsive
interaction. In summary, the gains in maternal responsiveness observed during videotaped
interaction and reported by mothers themselves are consistent with effects patterns
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492486
observed in previous work and also with the intervention model’s central tenet of
optimizing responsive interaction. Microanalytic techniques of measurement appear to be
a sensitive measure of parental responsiveness.
The second aim of this study was to replicate the previous findings of increased
vocabulary development for children with ASD following intervention. Children’s
vocabulary was measured in two ways—parent report (CDI) and videotaped interaction.
All three children made gains in vocabulary size as measured by the CDI. All three
children made vocabulary gains that exceeded those made by the experimental group in
the McConachie et al. study (2005). The children’s lexical diversity revealed that all
children increased the number of different words that they used during the posttest play
interaction, supporting parent report on the CDI. In addition, these findings were
supported by a third measure, mothers’subjective reports of increases in vocabulary on the
home visit surveys. Thus, all three case studies replicated the effects pattern for
vocabulary outcomes observed in prior studies of this intervention approach. Caution is
needed in interpreting Anthony’s lexical gains as he appeared not to use his vocabulary
spontaneously.
The final and most important aim of the study was to examine the children’s social
interaction skills following intervention, specifically their rate of communicative acts,
participation in social interaction sequences, and initiation of social interaction. All three
children made gains in the rate of communication acts, surpassing the gains made by the
experimental group in Aldred et al. (2004). Jackson, Ana, and Anthony also made
substantial increases in social interaction sequences. Their mothers’ subjective
comments, obtained during home visits, supported improvements in turn-taking and
social interaction skills for the children. In contrast, the results for social initiation skills
were mixed. Jackson and Ana increased the proportion of child-initiated sequences
substantially, whereas the data indicate that Anthony used fewer social initiations at
posttest. Therefore, the hypothesized effect on social initiations was supported by only
two of the three children. Future research investigating the efficacy of social-interactionist
intervention needs to investigate these social-pragmatic outcomes using similar
microanalytic techniques.
In general terms, the increases in communicative acts and social interaction episodes
experienced by all three children replicated the findings of two previous studies that
examined similar interactive behaviours using rating scales (Aldred et al., 2004; Mahoney
& Perales, 2003). Social-interactionist theory suggests that the more interactive practice
children obtain, the more they stimulate adults’ responsiveness and receive further
responsive feedback from which they can learn rules of engagement, discourse, and
language. Thus, the changes observed in the children’s interactive participation in this
study have the potential to bootstrap further developmental gains in their communication
development. Social-interactionist theory also suggests that parental responses to
children’s initiations are especially important for learning (Rocissano & Yatchmink,
1983; Tomasello & Farrar, 1986). Two of the three children appeared to make
improvements in social initiations, which is a core deficit in children with autism spectrum
disorder. Clinicians should monitor parent–child interaction closely to ensure that parents
appropriately scaffold opportunities for their children to initiate (e.g., making
environmental arrangements, pausing and waiting expectantly).
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 487
There are several important limitations to the present study. This study was conducted
in a clinical setting and was not designed with control groups or multiple data collection
points due to restrictions imposed by the clinical agency. Second, the lack of a control
group prevents any conclusions regarding the efficacy of this intervention approach as the
outcomes reported in this study may reflect children’s maturational changes. However, the
outcomes do point to the potential of measures for detecting change in this group of
children. Third, the number of children who participated in this study was small, and the
case study methodology necessitates more replications to corroborate the theoretical
direction of influence suggested by this intervention model (Yin, 2003). These
preliminary data suggest that children experience outcomes that are consistent with
the hypothesized intervention mechanisms. Fourth, multiple data points, in addition to
pretest and posttest filming, would have been helpful to help trace the development of
parental responsiveness and children’s interactional behaviour during the program period.
Case study methodology is strengthened when a series of data points is examined (Yin,
2003).
In conclusion, the data from this exploratory study are consistent with the theoretical
mechanisms of the social-interactionist intervention approach. They add to the
literature by revealing that an 11-week parent-administered program (i.e., More Than
Words) may be associated with positive changes in social interaction and initiation
skills in preschool children with ASD. Thus, this study extends the findings of
McConachie’s study (2005) which did not report gains in these important areas. Further
research using this intervention approach has the potential to confirm gains in social
interaction skills and investigate the program’s impact on social initiation skills. The
results of this study illustrate the importance of microanalytic coding methods to
investigate interaction gains. The clinical implications of this study for practitioners
include the value of (a) examining parent–child interactions for child initiations and (b)
distinguishing between communicative acts and noncommunicative events so that
parents learn to respond sensitively in both contexts to scaffold the child’s social
engagement.
Acknowledgements
Our appreciation is extended to the parents and children who participated in this
study and willingly opened up their homes to us so that we could assess and videotape
their progress in the More Than Words intervention program. We are indebted to Cheri
Rorabeck, Lauren Lowry, and Meggan Levson, the speech-language pathologists who
helped recruit, assess, and deliver the intervention program. Thanks to Rhonda
Schwartz for expediting ethics review and recruitment at the North York General
Hospital. We express our gratitude to Maureen O’Keefe, Nadia Abisaleh, Tara Davies,
and Sandra Hitchcock for transcribing and coding the videotapes of parent–child
interaction. Finally, we express our sincere gratitude to Maureen O’Keefe, research
officer, who oversaw every stage of this project. Funding for this research was obtained
from the Canadian Language and Literacy Network (Network of Centres of
Excellence).
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492488
Appendix A. Description of intervention program
Week 1 During the first group session, parents learn how to arrange their child’s environment
so that the child is motivated to attend and interact with them. For example, parents
may blow bubbles and then give the closed container to their child and wait for
the child to ask for more using the communicative mode appropriate for his stage
(e.g., alternating gaze between parent and object or echoing an adult model or
using a phrase)
Week 2 During the second group session, parents learn to follow their child’s lead in terms
of activities or interests with the aim of establishing reciprocal social interaction on a
shared topic. Parents learn to share the child’s interests by touching, pointing to,
or commenting on the child’s focus. Parents imitate their child’ actions and sounds
and interpret nonverbal communication and echolalia by giving the child a language
model (label or short phrase). Finally, for children who do not readily share joint
attention, parents are taught to join into their child’s play and structure a turn-taking
routine from it
Week 3 In the third group session parents learn how to create structured, predictable
‘‘people games’’ based on their child’s sensory preferences. Parents are
encouraged to set appropriate goals based on their child’s stage of communication
and keep the games highly structured in the beginning. Parents repeat their actions/
words, create opportunities for the child to take turns, provide explicit cues for the
child to take a turn if necessary (e.g., hand-over-hand physical help, complete
verbal models, wait, looking expectant, ask questions)
Week 4 First home visit—to monitor progress and coach interactions
Week 5 In the fourth group session, parents learn to adjust their language input by
shortening their utterances, emphasizing key words, speaking slowly,
but naturally, and supplementing speech with contextual cues (such
as gestures or objects). The most important information for parents is the
realization that their child might not understand as much as they had thought
and the importance of timing what they say to the immediate moment that
their child shows an interest in something
Week 6 In the fifth group session parents learn to improve their child’s comprehension by
using visual aids (e.g., photographs, pictures) to explain situations and contexts,
such as feelings, what’s going to happen next in an activity/situation, or how
to perform a sequence of actions
Week 7 Second home visit—to monitor progress and coach interactions
Weeks
8 and 9
In the sixth and seventh group sessions parents learn to integrate all of the
previously learned program strategies and apply them to situations such as
reading books and playing with toys
Week 10 Third home visit—to monitor progress and coach interactions
Week 11 In the eighth and final group session, parents learn how to prepare their child for interactions with
peers (siblings, relatives, playmates) by (a) rehearsing the games, songs, and play routines that the
child may use in interactions with other children, (b) practicing play with toys and activities that
may be shared with peers, and (c) coaching peer interactions from the sidelines to encourage
balanced turn-taking between the child and peers
L. Girolametto et al. / Journal of Communication Disorders 40 (2007) 470–492 489
Appendix B. Parent interaction coding system
Directives included:
1. [BC]—behaviour control: parent calls the child’s name to get attention; uses a
command to promote safety or reduce noncompliance (e.g., ‘‘Arpita,’’ ‘‘Don’t eat that,’’
‘‘Come here and play’’).
2. [CO]—command: parent requests an action response (e.g., ‘‘Put the wand in the
bottle’’).
3. [TQ]—test question: parent asks a question to elicit a known answer (e.g., ‘‘What colour
is this?’’).
4. [PC]—promote communication: parent prompts children to communicate by using
intonation cues or sentence completion (e.g., ‘‘This is a�.’’). The parent does not direct
the child what to say.
Responses included:
5. [WH]—Wh-question: parent asks an open-ended Wh-question (e.g., ‘‘What would you
like to do now?’’).
6. [YN]—yes/no question: parent asks a question requiring a yes/no response (e.g., ‘‘Do
you want more bubbles?’’)
7. [CH]—choice question: parent asks a choice question (e.g., ‘‘Do you want a cookie or a
banana?’’)
8. [CM]—comment: parent uses comments that (a) acknowledge the child’s behavior
(e.g., ‘‘Good boy’’, ‘‘Uhum’’); (b) imitates the child’s utterance; (c) provides a label
(e.g., ‘‘That’s a bus’’); (d) expands the child’s utterance; or (e) makes a general
comment or statement that is not a label, imitation, or expansion (e.g., ‘‘You’re popping
all the bubbles’’).
Uncodable utterances included:
9. [UN]—uncodable: adult’s utterance is incomplete (e.g., ‘‘Give me the . . .’’) or unclear
(e.g., ‘‘This is a X’’).
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