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Effects of Parent Training on the Active Engagement of Children with Autism Spectrum Disorder

Permanent Link: http://ufdc.ufl.edu/UFE0024300/00001

Material Information

Title: Effects of Parent Training on the Active Engagement of Children with Autism Spectrum Disorder
Physical Description: 1 online resource (62 p.)
Language: english
Creator: Ginsburg, Jordan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: autism, communication, engagement, parent, training
Communication Sciences and Disorders -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to examine the effectiveness of an 11-week intervention targeting parents of children with autism. Specifically, this single-subject design study attempted to define the construct of active engagement, and determine whether facilitation of parents' roles as primary interaction partners would result in increased child engagement for three children at different stages of communication. Through an intensive schedule of small group sessions and individualized in-home coaching and feedback visits, parents received training in naturalistic strategies to draw out communication and social interaction from their children. Research data consisting of 20-minute samples of parent-child interactions was collected prior to the onset of the program, following each small group session, and in the 3 months following the program's conclusion. Samples were analyzed and time stamped to indicate engagement or lack thereof. Outcomes were then measured as the percentage of the interaction during which the child was engaged. Variability of change across communication stages was observed, with the greatest improvement in magnitude and stability of active engagement seen in the child at the earliest stage. This research suggests that parents are able to successfully learn and apply strategies to facilitate child engagement. It also suggests the need for more descriptive measures of engagement for children with more advanced communication skills. As the importance of fostering engagement early on in the development of children with ASD is well established in the literature (National Research Council, 2001), clinicians should be aware of the potential that parent training has as a tool within their scope of practice.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Jordan Ginsburg.
Thesis: Thesis (M.A.)--University of Florida, 2009.
Local: Adviser: Johnson, Bonnie W.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024300:00001

Permanent Link: http://ufdc.ufl.edu/UFE0024300/00001

Material Information

Title: Effects of Parent Training on the Active Engagement of Children with Autism Spectrum Disorder
Physical Description: 1 online resource (62 p.)
Language: english
Creator: Ginsburg, Jordan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: autism, communication, engagement, parent, training
Communication Sciences and Disorders -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to examine the effectiveness of an 11-week intervention targeting parents of children with autism. Specifically, this single-subject design study attempted to define the construct of active engagement, and determine whether facilitation of parents' roles as primary interaction partners would result in increased child engagement for three children at different stages of communication. Through an intensive schedule of small group sessions and individualized in-home coaching and feedback visits, parents received training in naturalistic strategies to draw out communication and social interaction from their children. Research data consisting of 20-minute samples of parent-child interactions was collected prior to the onset of the program, following each small group session, and in the 3 months following the program's conclusion. Samples were analyzed and time stamped to indicate engagement or lack thereof. Outcomes were then measured as the percentage of the interaction during which the child was engaged. Variability of change across communication stages was observed, with the greatest improvement in magnitude and stability of active engagement seen in the child at the earliest stage. This research suggests that parents are able to successfully learn and apply strategies to facilitate child engagement. It also suggests the need for more descriptive measures of engagement for children with more advanced communication skills. As the importance of fostering engagement early on in the development of children with ASD is well established in the literature (National Research Council, 2001), clinicians should be aware of the potential that parent training has as a tool within their scope of practice.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Jordan Ginsburg.
Thesis: Thesis (M.A.)--University of Florida, 2009.
Local: Adviser: Johnson, Bonnie W.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024300:00001


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EFFECT S OF PARENT TRAINING ON THE ACTIVE ENGAGEMENT OF CHILDREN WITH AUTISM SPECTRUM DISORDER By JORDAN GINSBURG A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2009 1

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2009 Jordan Ginsburg 2

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To all who encouraged m e to ask why, then challenged me to seek my own answers 3

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ACKNOWLEDGMENTS First, I extend my gratitude to the families w ho so graciously allowed us into their lives, dedicating themselves to the intensive nature of both the program and research, that other families might benefit from the outcomes. I thank my mentor and supervisory chair, Dr. Bonnie Wyora Johnson, for her faith in my capabilities as a novice researcher and her facilita tion of my independence. I would like to thank Dr. Lori Altma nn for nurturing my early interest in research and her continued support as a member of my supervisory committee. My utmost appreciation is extended to Cathy Zenko, the speech-language pathologist who organized and implemented More Than WordsThe Hanen Program for Parent s of Children with Autism Spectrum Disorder at the University of Florida Center for Autism and Related Disabilities (UF-CARD). She is an inspiration in her clinical brilliance and crusade for cognitive clarity, and I am eternally grateful for her support and guidance. I w ould like to thank the entire sta ff of UF-CARD for their tireless devotion to all those affected by autism, and for allowing us to take over their facilities on a weekly basis. I also acknowledge Stacey Herl ofsky, Elizabeth Duda, Aubry Alvarez, Kami Walters, Cecelia Kolstad, Jaclyn McInnis, Al yson Yates, Lauren Hudson, Carolyn Brown, Suzanne Hayes, Nicole Mullin, Kelsey Wallace, Rachel Hogue, and Marcelline Beresheski for their involvement in the arduous process of co llecting, organizing, transcribing, and coding data. Lastly, I thank my family for th eir endless patience a nd support in all my lifes endeavors, and without whom none of this would be possible. 4

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TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4LIST OF TABLES................................................................................................................. ..........7LIST OF FIGURES.........................................................................................................................8LIST OF ABBREVIATIONS.......................................................................................................... 9ABSTRACT...................................................................................................................................10 CHAPTER 1 INTRODUCTION................................................................................................................. .12What is Autism Spectrum Disorder?......................................................................................12Active Engagement.................................................................................................................14Parent Training/Family-Centered Treatment..........................................................................19Research Questions............................................................................................................. ....262 METHODS...................................................................................................................... .......28Subjects...................................................................................................................................28Selection..........................................................................................................................28Participants......................................................................................................................29Michael.....................................................................................................................30Adam........................................................................................................................31Joe.............................................................................................................................32Procedures..................................................................................................................... ..........33Intervention......................................................................................................................33Data Collection................................................................................................................34Research visits..........................................................................................................34Transcription and coding..........................................................................................35Reliability.................................................................................................................363 RESULTS...................................................................................................................... .........434 DISCUSSION................................................................................................................... ......50Limitations.................................................................................................................... ..........53Summary.................................................................................................................................54Treatment Implications....................................................................................................56Conclusion.......................................................................................................................57 5

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LIST OF REFERENCES ...............................................................................................................58BIOGRAPHICAL SKETCH.........................................................................................................62 6

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LIST OF TABLES Table page 2-1 Participant characteristics................................................................................................ ..37 2-2 Adam, Michael, and Joe characteristics.............................................................................38 2-3 Adam, Michael, and Joe family characteristics.................................................................38 2-4 Michael CSBS-DP results..................................................................................................39 2-5 Adam CSBS-DP results.....................................................................................................40 2-6 The Hanen More Than Words program session outline....................................................41 2-7 Conversational partners in research tapings......................................................................42 3-1 Raw data of percentage of time engaged and length of each session................................49 7

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LIST OF FIGURES Figure page 1-1 A model of decision-ma king for active engagement.........................................................27 3-1 Graphed representation of Michaels activ e engagement data for a parent training intervention........................................................................................................................46 3-2 Graphed representation of Joes active engagement data for a parent training intervention........................................................................................................................47 3-3 Graphed representation of Adams activ e engagement data fo r a parent training intervention........................................................................................................................48 8

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LIST OF ABBREVIATIONS ASD Autism Spectrum Disorder MTW More Than WordsThe Hanen Pr ogram for Parents of Children with Autism Spectrum Disorder CARD Center for Autism and Related Disabilities SCERTS Social-Communication, Emoti onal Regulation, and Transactional Supports 9

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Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts EFFECTS OF PARENT TRAINING ON THE ACTIVE ENGAGEMENT OF CHILDREN WITH AUTISM SPECTRUM DISORDER By Jordan Ginsburg May 2009 Chair: Bonnie Wyora Johnson Major: Communication Sciences and Disorders The purpose of this study was to examine the effectiveness of an 11-week intervention targeting parents of children with autism. Specifically, this single-subject design study attempted to define the construct of active engagement, and determine whether facilitation of parents roles as primary interaction partners would result in increased child engagement for three children at different stages of communication. Through an intensive schedule of small group sessions and individualized in-home coaching and feedback visits, parents received tr aining in naturalistic st rategies to draw out communication and social interact ion from their children. Research data consisting of 20-minute samples of parent-child interactions was collect ed prior to the onset of the program, following each small group session, and in the 3 months following the programs conclusion. Samples were analyzed and time stamped to indicate engageme nt or lack thereof. Outcomes were then measured as the percentage of the intera ction during which the child was engaged. Variability of change across communicati on stages was observed, with the greatest improvement in magnitude and stability of active engagement seen in the child at the earliest stage. 10

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11 This research suggests that parents are able to successfully learn a nd apply strategies to facilitate child engagement. It also suggests the need for more descriptive measures of engagement for children with more advanced communication skills. As the importance of fostering engagement early on in the developmen t of children with ASD is well established in the literature (Na tional Research Council, 2001), clinicians should be aware of the potential that parent training has as a tool w ithin their scope of practice.

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CHAP TER 1 INTRODUCTION What is Autism Spectrum Disorder? Autism spectrum disorder (ASD) is a group of neurobiological devel opmental disabilities consisting of autism, Aspergers syndrome, and pervasive developmental disorder-not otherwise specified (PDD-NOS). Autism spectrum disorder s, along with Retts syndrome and childhood disintegrative disorder, fall under the umbrella term of pervasive developmental disorders (American Psychiatric Association, 2000). As the precise etiology and mechanistic implications of autism are still largely unknown, its identifica tion relies on commonalities in developmental and behavioral characteristics. The defining features of autism spectrum disorders are differences in communication, social interaction, and restricted and/or repetitive intere sts or behaviors. Each of these three core areas is a spectrum in itself, meaning that mani festations characteristic of the impairment may vary in extent and manner of presentation within an individual and across the population. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), a diagnosis of autism requires that a person evidence abnormalities in each area, with onset prior to 3 years of age, and failure to meet criteria for Retts syndrome or childhood disintegrative disorder (American Psychiatric Association, 2000). Communicative differences may present as a dela y or failure to develop verbal language or other communication modalities, difficulty or in ability to initiate a nd sustain conversation, echolalic or idiosyncratic use of language, and limited pretend play. Early red flags for deficits in communication include little or absent joint attention, or shifting gaze between objects and persons or pointing to share interest or en joyment and seek recipr ocity, and limited cooing, babbling, and other speech-language m ilestones (Wetherby et al., 2004). 12

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Social interaction m ay be characterized by limited use and understa nding of rules and behaviors that govern social interactions, such as nonverbal cues (eye contact, faci al expressions, gestures, and postures). Persons with autism sp ectrum disorders may struggle with aspects of relationships that require theory of mind skills and reciprocity, including sharing enjoyment or interests, understandi ng others emotions, and social prag matics (see White, Keonig, & Scahill, 2007 for review). Restrictive and repetitive be haviors can range from intense, unusual interests to preoccupation with routines, fixation on smaller parts of a whole object, or stereotypic motor movements (Rapin, 1991). Many of the behaviors displayed by people w ith autism can be classified as sensoryseeking behaviors. Although sensory needs ar e not a core trait of ASD, hyper or hyposensitivities in visual, olfactory, auditory, taste, tactile, kinest hetic, or vestibular systems are common. Arm-flapping, walking on toes, looking at things from unusual angles, and clapping hands over ears are just a few examples of behavior s that may be attempts to raise or lower ones internal arousal level to a state consistent w ith social and environmental demands (Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006). Prizant et al. (2006) contend that this may also be reflected in a strong preference for routines, whic h provide external struct ure and predictability, lessening the contribution of environmental input to the sensory system and simplifying internal emotional regulation. Janzen (2003) argues that lear ning style differences are inhe rent in autism. People with autism are generally considered Gestalt learners, but not Gestalt thinkers (Janzen, 2003). Gestalt learners absorb experiences in large chunks, without necessarily filtering details based on relevance or meaning. Gestalt thi nkers automatically analyze, sequence, and attribute meaning to 13

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inform ation from experiences, then store it w ith other relevant knowledge to form a more complete idea. Although it is unclear whether th ese differences in expe riential processing and acquisition of knowledge are causally linked to other deficits, the effects are synergistic, compounding the difficulty with more implicit or advanced social and co mmunication skills. For example, impairments in attend ing to people or the parts of stimuli deemed important may manifest in the development of speech or another language form wit hout the knowledge needed to use it effectively in a two-way communicativ e exchange. Overly literal interpretations may result from difficulty understa nding nonverbal and suprasegmental cues. Thus, gestalt processing and an atypical pattern of early social development limit the drawing of meaning and generalization beyond a specific frame of reference to more complex skills such as perspectivetaking, adapting responses, and social judgment (J anzen, 2003). This en masse absorption also relates to the sensory system and the concept of sensory overload. Whereas a typically developing person may ignore the feel of the carpet, the hum of the air conditioner, or the smell of the trash can, a person with autism may attend to each of these details as much if not more than the task at hand. The overwhelming environm ental sensory input coupl ed with a heightened internal state may lead to extreme disregula tion (Liss, Saulnier, Fe in, & Kinsbourne, 2006). Addressing areas of impairment with respect to these differe nces in learning styles is central to developing an effective treatment pla n. Goals should also have a basis in chronological and age-appropriate developmental skills as well as functional skills needed for independence (Janzen, 2003). Active Engagement Active engagem ent is an essent ial component in effective in tervention for children with autism. The National Research Council (NRC, 2001) recommends a minimum of 25 hours a week of intervention where the person with ASD is engaged in intensive, goal-directed activities. 14

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The NRC (2001) defined engagem ent as sustained attention to an activity or person (p.160). A comprehensive definition of engagement, howev er, must acknowledge that time present in an activity is not necessarily equivalent to time engaged (Ruble & Robson, 2007). It is here that some researchers consider the shared mean ing and intent of an interaction between communicative partners. Known as congruent enga gement, this concept is consistent with developmental approaches, with respect given to both the internal stat e of the child and the external environment (Ruble & Robson, 2007). Prel iminary data from Ruble and Robson (2007) identified congruent engagement as a particular weakness for children with autism compared to children with Down Syndrome, and suggested its inclusion as a target for all children with disabilities. Definitions of engagement vary widely across th e literature. The problem exists in the lack of a definition used with any consistency that is observable, measurable, and replicable for use in research experiments. The operationalization of active engagement would allow more accurate interpretation of treatment outco mes relative to the am ount of time the partic ipant was available to benefit from intervention and total time of intervention. Similarly, the advantages and disadvantages of different methods could be co mpared based on those variables. Other related research could explore the interaction of mo tivational factors and active engagement. Active engagement is crucial for people with ASD because it allows a child to shift attention and apply social knowle dge, communicate with a partner, and learn from experiences (Prizant et al., 2006), all of which are critical areas of im pairment. According to the SCERTS Model (Prizant et al., 2006), active engagement occu rs when ones emotional state is in tune with environmental demands. This is the only time at which a child is available for learning. As the fluent social communicator, the adult must put the appropriate transactional supports in place 15

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to foster engagem ent. In their ongoing study of the Early Social Interaction Project, Wetherby and Lord (as cited in Lord, 2008), state that th e adult should structure the environment, shift attention to the childs focus, balance conversa tional turns, use multiple modalities to bolster comprehension, and continuously reassess the childs emotional regulation and adjust expectations. The child, in turn, must be in a ba lanced state of arousal, participating in a goaloriented activity, and demonstrati ng reciprocal social interaction in order for engagement to be achieved. Others have taken a more disc rete behavioral approach to engagement. In their study using video self-modeling to in crease engagement in children with autism, Bellini, Akullian, and Hopf (2007) termed participation in an activity involving reci procal exchanges with a peer as social engagement. Examples of social engagement included reciprocal play, joint play, and turntaking. Parallel play, negative interactions, a nd avoidance behaviors were counted as nonengagement. They further operationalized their definition with a series of qualifying social initiations and responses. For the purposes of this study, the SCERTS mo del (Prizant et al., 2006 ) and the work of Wetherby and Lord (as cited in Lord, 2008) provid ed a framework for observing the state of the child and environment and determining whethe r the child was available for learning. The behaviors specified by Bellini et al (2007) were used as parameters to objectify reciprocal social interaction, or active engagement. It is importa nt to note that, although Bellini et al. (2007) did not code prompted social interactions as social engagement, they were recorded as active engagement in this study based on their inclusion in the SCERTS and Early Social Interaction Project definition under r esponding to verbal bids for social interaction. A model of all factors influencing whether or not a chil d was considered actively engaged is depicted in Figure 1-1. 16

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There are several hypotheses as to why people with autism ha ve difficulty engaging with others. One such hypothesis involves suspected differences in attention mechanisms. Joint attention, an early milestone in typical child deve lopment, may be demonstrated through gestures or vocalizations and eye gaze intended to draw anot her persons attention to an object or event of interest and establish join t reference (Mundy, Sigman, & Kasari, 1990). Children on the spectrum may fail to demonstrate th is capability to engage others in a shared experience as well as respond to others bids for joint attention. Rath er, they may be fully absorbed and perseverate on the object of interest. Landry and Bryson (2004) provided evid ence of the general difficulty young children with autism have in visually disengaging from an object of focus and shifting attention to competing stimuli, a lthough neither stimulus in their experiment was social in nature. Compared to typically developing children and children with Down Syndrome, Dawson, Meltzoff, Osterling, Rinaldi, and Brown (1998) found that children with autism were less likely to orient to stimuli overall, with the largest di screpancy occurring in the presence of social stimuli. They hypothesized that the difficulty with shared attention in autism is the consequence of a more basic failure to selec tively attend to social stimuli, su ch as another persons eyes or facial expression (p.484). In another study (Swettenham et al ., 1998), infants with autism demonstrated a higher incidence a nd duration of attention towards objects than people. Attention shifting was characterized by more frequent sh ifts between objects than between nonsocial and social or two social stimuli; a pattern opposite of that which was found in the developmental delay and normal groups. Thus, it may be that people with autism avoid stimuli which require processing of or engagement in social complexiti es; they are object rather than people-oriented. Neuro-imaging research, which attempts to a ccount for differences in the processing of social information based on concrete measur ements of brain activity, may offer a more 17

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com prehensive explanation of problems engaging. Active engagement requires a number of interpersonal behaviors that are less prevalent in people with ASD (for example, eye contact, sharing of emotions, and reading nonverbal cues). These interper sonal behaviors are at the crux of social cognition. Social cognition relies on one s ability to perceive the interpersonal behaviors of others, or social stimuli in the en vironment, and adapt ones own social behavior accordingly (Adolphs, 2001, as cited in Pelphrey, Adolphs, & Morris, 2004). It is possible that neurological deficits in soci al cognition are due to reduced overall functional connectivity between systems as well as abnormal activation of the amygdala, superior temporal sulcus, and fusiform gyrus areas involved in recognition and attribution of m eaning to social stimuli (see Pelphrey et al., 2004 for review). Tw o theories arise: 1) people w ith autism actively avoid social stimuli, or 2) they fail to understand significance in social stimuli. Either way, social attention demands complex, rapid processi ng and integration of informa tion in these areas and other systems that control spee ch and language processing. Motivation and Theory of Mind (ToM) developm ent may also be factors influencing active engagement. People with ASD may lack awaren ess that knowledge, experiences, and interests are not a shared collective (Janzen, 2003). Internal and external motivation to communicate and interact socially is derived from this individu ality, not only in what, but also in the way we experience. A ToM deficit may prevent them from implicitly understandi ng people as something of value, and deserving of atte ntion. Interestingly, Mundy (2003) suggested that joint attention and ToM skills overlap in their activation of dorsal medial-frontal cortex and anterior cingulate, along with other ventral social areas. These ear ly and later developing components of social cognition contribute to enga gement at progressing levels of social complexity. 18

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People with ASD have been hypot hesized to have a narrower range of optim al arousal (Klinger & Dawson, 1992), or ideal m ode for learning. It may be difficult or impossible for them to filter out or modulate internal and environmental sensory stimuli, so this bombardment of background information is muddled in with re levant information (Janzen, 2003). Engagement can be affected by a childs sensory regulation be cause of the competition for resources. If the child is focusing too much effort on dealing with the more pressing need for regulation, decreasing or seeking out sensory stimuli, fewer f aculties are available to deal with interactions outside him or herself. Parent Training/Family-Centered Treatment Currently, th ere exists a push for intensive earl y intervention with the inclusion of family as a part of the intervention team. Research ha s shown that treatments with successful outcomes are consistent in that interv ention is intensive with a str ong family component (Dawson & Osterling, 1997). At this early st age, it is likely that family members are the most frequent, familiar presence in a childs life, and thus have the most potential to influence their development. One popular method of involving parents in inte rvention is parent tr aining and education. Parent-administered intervention is naturalistic; it automatically occurs in the childs daily environment, in the course of daily life (Oglet ree, Oren, & Fischer, 2007). This is especially beneficial for this population because children with autism frequently have problems applying skills outside the learned context (NRC, 2001). Work ing within natural interactions eliminates much of the generalization phase of skill acquisition. Parent training programs generally promote increased spontaneous communication, communi cative forms and functions, and adults awareness of childs focus and interactive oppo rtunities (Prizant, Wetherby, & Rydell, 2000). 19

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The literature also supports pa rent training as an evidence based practice. Studies have proved that, with education, fathers of child ren with ASD can adm inister communication intervention strategies effectiv ely (Seung, Ashwell, J. Elder, & Valcante, 2006; J. Elder, Valcante, Yarandi, White, & T. Elder, 2005). The re searchers chose to trai n fathers specifically in their protocol due to the general trend in pare nt training of mothers as the primary target. The in-home training focused on teaching fathers to employ expectant waiting and imitation with animation strategies. Participants were able to ap ply skills in interactions with their children, and create a more balanced conversation. Child outcomes included positive gains in quantity and variety of single word utterances. Additionally, similar parent and child outcome measures in father-child and mother-child interactions showed that fathers were able to teach learned skills to a spouse. Many parent training programs have been developed and investigated for parents of children on the autism spectrum (NRC, 2001). One parent training program operated through the Center for Autism and Related Disabilities (CARD) at the University of Florida was More Than WordsThe Hanen Program for Parents of Childre n with Autism Spectrum Disorder (Sussman, 1999). This particular program was selected fo r its emerging research base, parent-friendly lesson plans, family-centered philosophy, and the pr esence of a program certified-SLP on staff at CARD. The program itself is naturalistic, promoti ng parents identification and capitalization on teachable moments in daily interactions with their children. Children do not receive direct intervention through the program; ra ther, intervention is administ ered by parents based on what theyve learned. The intervention format of More Than Words consists of an orientation and preprogram consultation, 8 small group parent sessi ons, and 3 individualized in-home feedback sessions. Specific strategies emphasized in sm all group trainings include providing motivating 20

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opportunities to comm unicate, waiting expectantly, allowing focus of the in teraction to be childdirected, modeling language, embedding goals wi thin routines, and breaking down language to ensure comprehension (Sussman, 1999). Two studies have been published to date on More Than WordsThe Hanen Program for Parents of Children with Autism Spectrum Di sorder. The first study (McConachie, Randle, Hammal, & Le Couteur, 2005) found that parents were indeed able to learn the facilitative strategies. Data also revealed significant gains in vocabulary for the group of children whose parent received training versus the control group. They failed, how ever, to detect any significant change in childrens social interaction skills vi a the social-communicatio n algorithm score of the Autism Diagnostic Observation Schedule (Lord et al., 2000) or problem behaviors related to intervention. Girolametto, Weitzman, and Sussman (2007) atte mpted to fill the gap of information on the programs effect on social interaction. Th eir multiple case study first looked at parent responsivity to a childs comm unicative act to measure the ex tent to which adults were capitalizing on opportunities and using strategies to promote conversation. Responsivity was calculated based on parents questions and comments intended to generate additional child responses. Instances of responsivity were subdi vided based on context, whether comments immediately followed a childs communicative act or unengaged behavior. Results showed that all parents increased responsiven ess, although parents varied in the context in which they improved. This responsiveness was viewed as th e mechanism through which the child variables were influenced. Novel child-related dependent variables examined by Girolametto et al.(2007) included the rate of communicative acts, social reciprocity in communica tion, and initiation of social interaction. Social reci procity was judged based on length and frequency of turn taking 21

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inte ractions. All three child subj ects demonstrated gains in the fi rst two areas, with mixed results in the latter. The researchers were also able to replicate the previous find ings (McConachie et al., 2005) of accelerated vocabulary growth. Strategies within the program are packaged and presented through language devices such as acronyms, rhymes, and alliteration. In this way, the program provides a framework to aid parents acquisition, storage, and retrieval of knowledge. Though the professional jargon is minimized, the individual strategies comprisi ng More Than Words are well-supported by the speech-language literature and practice (The Hanen Centre, 2007). Parents are taught to offer communicative temptations (Wetherby & Prizant, 1989), which are motivating opportunities for their chil d to communicate. Examples of communicative temptations include arranging the environment by putting preferred items in view but out of reach, providing desired stimuli in small incr ements, offering choi ces, and sabotaging known routines. When an opportunity is presented, the child must express what he or she wants in order to obtain it. Thus, these strategi es encourage the child to request, comment, show, protest, and repair communication breakdowns. Although exp ectant waiting could be considered a communicative temptation, it is presen ted in the program as a vital st ep in the effective execution of any temptation. A form of time-delay, expectant waiting is discussed as it relates to giving the child with autism the opportunity to respond to the issued temptation. It supports spontaneous communication by allowing extra time to proce ss, understand, and formulate an appropriate response. As execution of expectant waiting involv es pausing and employing natural cues such as facial expression, intonation, and eye gaze, th e child also gains expe rience with nonverbal cues that allude to the expectation of co mmunicative reciprocity. Waiting is an important technique particularly for this population, as parents of children w ith autism may compensate for 22

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lapses in interactions by increa sing their utterances, which furthe r lim its the child s opportunities to respond (Siller & Sigman, 2002). By reducing th eir own speech and increasing their childs opportunities through communicative temptations and waiting, the adult promotes a more appropriate balance of conversati onal turns. More regimented time delay procedures have been used in studies of children with ASD to target spontaneous speech specific to a particular situation or stimulus (Charlop, Schreibman, & Thibodeau, 1985; Charlop & Trasowech, 1991; Taylor & Harris, 1995). A baselin e opportunity to spontaneously produce the desired behavior (e.g., Taylor & Harris, 1995) or expectant waiting was implemented first, followed by a model with a graduated time delay between stimulus presentation or opportunity and cue. This procedure proved effective in teaching responding (Charlop et al., 1985), spontaneous speech in natural daily environments (Charlop & Trasow ech, 1991), and requesting information (Whats that?) (Taylor & Harris, 1995). One of the core concepts of the MTW program is allowing the childs focus to direct the interaction. By being sensitive to the childs interests parents may reduce demand involved in shifting attention, identify an intrinsically motivati ng activity, and maximi ze joint attention by converging on the object or event on which the child is already attending. Research shows it also results in the best communication outcomes (Siller & Sigman, 2002). More Than Words incorporates imitation, modeling, recast, and expansion techniques to establish interaction, and th en advance communication. Dawson and Adams (1984) suggested that children with autism still developing imitati on are most socially resp onsive to imitations of their own actions. Imitation likely em phasizes to these children the pow er of his or her actions. It also reinforces reciprocity as the child begins to anticipate and react to adult imitations and learns to switch roles. From imitation, expansion is an important step to build on the childs 23

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existing language form s and concept knowledge. Go als that are below ones capabilities limit learning opportunities, but high demand without support can cause extr eme frustration and similarly stall skill development (Janzen, 2003). Learning requires that the adult continuously reassess a childs progress, adjust goals to create challenges, and scaffold supports to facilitate success. Scaffolding language for this population may involve providing a model or recast for the gestalt learner to understa nd the appropriate communicative be havior. Research by Scherer and Olswang (1989) reported that adult use of modeling and expansion furthered growth in language of the child with autism. In their st udy, children were successful in imitation of the initial model and the expanded form, and then progressed into spontaneous productions of expansions. Literature also shows that childr en can acquire new forms of language syntax through maternal recasts (Baker & Nelson, 1984). Schuler (1995) noted central differences in information processing in autism, with strengths in visuo-spatial and rote memory skill s. Interventions may capita lize on the strengths of people with ASD by utilizing routines and visual supports to bolster lear ning (Ogletree et al., 2007). Visual supports can be used to foster literacy a nd comprehension of concepts, ease transitions, and reduce anxiety and behavioral displays by pr oviding predictability (Hodgdon, 1995). Visual supports act as a concrete, permanent reference; a rule-based system to attribute meaning and limit the need to abstract. Routines have a similar appeal in that they follow an established procedure, relying heavily on ro te memory. Opportunities are predictable and sequence is defined for active participation in exchanges. This enhances knowledge of communicative reciprocity (Prizan t et al., 2006). Moreover, rou tines can be manipulated to expand goals though role exchange, sabotage, ch ild initiation, inclusion of new people and objects, etc. 24

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Methods of ensuring a childs co mprehension of language are broken down into two modalities. Verbal output is simplified to highlight key words, and visual references are provided to help the child link language to meaning (Harris, Jones, Brookes, & Grant, 1986). The coaching and video self-modeling compone nt of the MTW program is designed to ensure parents are successful in creating opportunities and applying the above strategies in their natural environment to increas e reciprocal interactions. Video self-modeling involves reviewing video of oneself performing an adaptive behavior in order to learn skills or modify behaviors to reflect goals (Dowrick, 1999). With the coaching element, parents receive positive reinforcement from the speech-language pathologist. Coaching also allows for pre-planned and real-time development of feedforward mode ling opportunities (Dowrick, 1999), in which new combinations or contexts for fragments of attained skills are orchestrated to display novel skills slightly above their current abilities. In hi s summation of video self-modeling applications, Dowrick (1999) concluded that, in self-obser vation, learning occurs from ones own successes and adaptive behaviors. It is pos sible that this in turn increases the probability of the behavior being displayed again. Positive outcomes of video modeling and self-modeling interventions for children and adolescents with ASD have contributed to its consid eration as an evidence-based practice (Bellini & Akullian, 2007). Video self-m odeling has been previously utilized as a component of parent training as well. A study in corporating video self-modeling and feedback into an intervention for first-time fathers result ed in improved interaction skills (Magill-Evans, Harrison, Benzies, Gierl, & Ki mak, 2007), and provided evidence to support the use of this technique in the parent training domain. J. Elder et al. (2005) also used video self-modeling to support fathers acquisition of social reciprocity-promoting skills. 25

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Research Questions While prior studies on More Than WordsThe Hanen Program for Parents of Children with Autism Spectrum Disorder have provided valu able information on parents ability to alter interaction styles and the subs equent vocabulary growth of ch ildren, they fail to address the child-related goal emphasized across strategic elements of the pr ogram, and underlying all child achievements. Although the majority of goals are i ndividualized, and the program is not a direct intervention for children, it is hypothesized that all subjects would show improvement along the active engagement variable based on the assumptions that (1) parents alter interaction styles and implement strategies learned dur ing parent training (Girolametto et al., 2007) and (2) teaching strategies through parent training enables pa rents to act as a transactional support. Engagement is a central component to all learning. Prioritizing this critical goal that is a deficit in the learning style of autism (Janzen, 2003) paves the way for teaching and development of other meaningful skills. To determine whethe r parents were able to address this goal, the following question was posed: Did the proportion of time a child was actively engaged with partners change over time with the implementation of parent training? To investigate these questions, a single-s ubject design was employed. The experimental design was selected to most accurately depict the heterogeneity of this population by looking at individual differences. It was im portant to acknowledge as well th e variability characteristic of ASD that occurs within an indivi dual over time and across situations. 26

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27 Figure 1-1. A model of decisi on-making for active engagement

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CHAP TER 2 METHODS Subjects Selection Fam ilies were identified from the constituent base of the University of Florida Center for Autism and Related Disabilities (UF-CARD) and given the opportunity to participate in the program based on staff recommendations. These potenti al participants were required to meet the following criteria to be consider ed eligible for the program. Children must be between the ages of 2.5 years and 5 years old. A latitude of plus or minus 6 months was exercised. Children must have a diagnosis from a physicia n or clinical psychologist as being on the autism spectrum. Families must be CARD constituents. Families must commit to attend and participate in the entirety of the program, including the 8 group sessions on-site at the CARD office, an in-home pre-program consultation, and the 3 scheduled home feedback visits. Following an orientation on program format, participant investment, and goals, families were admitted to the program based on the order in which they committed. Once admitted, families were given the opportunity to participate in the research protocol. As stated in the Internal Review Board Inform ed Consent, participati on in the research was voluntary and did not influence inclusion in the parent training program. Families reserved the right to withdraw at any time. The sole per ceived risk to subjects was the additional time demands, and the only known benefit was that families would be provided with copies of research videotapes for their personal archives. 28

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Participants Seven families elected to participate in the re search component of the program. They are a subset of the eight families who participated in the inaugural MTW at CARD. Of those who participated in the research, a minimum of 10 tapings, including baseline, treatment, generalization, and maintenance data, was collec ted on four subjects. This minimum was the amount deemed sufficient for the chosen analyti cal method and interpreta tion. One of the four subjects was excluded from the current analysis due to a diagnosis of co-occurring apraxia of speech that he received post study onset. Cancellations of research tapings were due to illnesses, pre-existing travel arrangements, and family emergencies. Attrition of 1 family from the research occurred during the course of the research protocol due to the frequenc y of research tapings compounding the programs already intensiv e time commitment; however, all 8 families completed the More Than Words program. See Table 2-1 for research participant characteristics and the amount of data collected on each. Three subjects, Adam, Michael, and Joe (pseudonyms), completed the research protocol and met criteria for this study. Further informa tion on Adam, Michael, and Joe and their family characteristics is available in Table 2-2 and 23. Histories were obtained via parent report during CARD intake, professional repo rts provided to CARD by parents, and caregiver questionnaire. The Communicative and Symbolic Behavior ScalesDevelopmental Profile (CSBS-DP) Caregiver Questionnaire (Wetherby & Prizant, 2002) was issued to parents during the preprogram consultation to gain in formation on current abilities in social, speech, and symbolic domains. The questionnaire was completed by 2 of the 3 families (those of Michael and Adam). The third family (that of Joe) did not complete the questionnaire because the child seemed too developmentally advanced for this measure. Re sults are summarized in Table 2-4 and 2-5. The CSBS-DP is norm-referenced for ages 6 to 24 months, but may be used with children up to 6 29

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years of age whose delay s place them in that age range developmentally. Because subjects exceed the age for which normative data is availa ble, results should be interpreted with great caution. Percentile ranks provided correspond to those of the highe st age group (23-24 months), but cannot be accurately ascribed to abilities comm ensurate with chronological age. The tables also contain the age in months at which a given score is equal to the 50th percentile. Information on subjects present levels was also used to determine their MTW Hanen stages of communication. The programs division of stages based on interaction, communicative forms and functions, and comprehension served as a sort of initial ev aluation, and a guide to identifying skill areas of need and selecting goals. The first communication stage is own agenda, where a child demonstrates minimal interest in others. General goals for children in the own agenda stage are to send intentional messa ges, understand routines, and use sounds and gestures to interact (Sussma n, 1999, p. 59). At the next stage, requester, a child is displaying more intentional gestures and simple language to communicate wants. Goals include longer interactions, parallel play, join t attention, and using means of communication for social purposes (Sussman, 1999, p.61). Children at the third stage, early communicators, are requesting and using some social communication and joint atte ntion towards adults. Goals may be to extend interaction length, communicate for a wider variety of social purposes, and interact with other children (Sussman, 1999, p. 62). The fourth and highest stage is that of partner At this point, a child communicates for many reasons in l onger sequences, but may be challenged to communicate more spontaneously and take on new roles in play (Sussman, 1999, p. 66). Michael Michael was a 4 year old male. His medical hist ory is significant for some seizure activity. Although motor development was typical, his pa rents noted limited cooing and babbling. Michael was delayed on all verbal m ilestones, and demonstrated little to no joint attention or use 30

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of gestures to communicate. At 2 years of ag e, he still showed lit tle eye co ntact, shared enjoyment, or reciprocal engagement during pl ay activities. Expressive vocabulary hovered around 5 to 10 words. His parents also noticed difficulty following directions and transitioning between activities. On the CSBS-DP caregiver questionnaire, Michae ls parents reported his strength in visual learning and interest in letters and numbers. Ability to share thoughts and feelings and understand how to interact social ly were listed as specific areas of concern. Upon entry in the MTW program, Michael was classified as posse ssing characteristics of both own agenda and requester Hanen stages of communication. Adam Ada m was a 4 years, 11 month old male. Adams medical history is significant for static encephalopathy. The family had previously partic ipated in a father-training study as well as another study involving teaching imitation and pr omoting spontaneous utterances through the University of Florida. Speech-language evaluation two months prior to the start of the program revealed ageequivalent receptive and expressive language scores of 3 years, 8 months and 2 years, 9 months respectively on the Preschool Language Scale, Fourth Edition (Zimmerman, Steiner, & Pond, 2002). His standard score was 79 for receptive and 65 for expressive language. Age-equivalent for total language was 3 years, 2 months. The Go ldman-Fristoe Test of Articulation (Goldman & Fristoe, 2000) was significant for articulation and phonological errors co nsistent with stopping, liquid simplification, backing, nasa lization, deaffrication, devoici ng, and distorted vowels. Adam demonstrated reading abilities w ithout formal instruction suggestive of hyperlexia. Behavior was notable for impulsivity and inattent ion, but he responded well to verbal, tactile, and visual cues. 31

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On the CSBS-DP caregiver question naire, Adams parents reported his strengths in visual learning, reading, and fine and gr oss motor skills. Areas of c oncern included awareness of danger and attending to safety-related instruct ions, unusual sensory processing, and long-term educational issues. Upon entry in the MTW program, Adam was clas sified as being in the early communicator Hanen stage of communication. This determination was based on his ability to use language to request and occasionally share with adults, typically through echolalic means. Spontaneous speech and initiations were rare. Joe Joe was a 4 year old m ale. Joes parents reported normal speech-language development and achievement of milestones unt il 2 years of age. At age 3 y ears, 1 month, he was diagnosed with delayed receptive and expressive language a nd delayed speech intelligibility. He completed 22 sessions of speech-language tr eatment, after which he was referred for ASD screening and diagnosis. A speech-language evaluation 3 months prior to the start of this pr ogram indicated Joes difficulty with verbalizing for joint attention, reciprocal pla y, and conversation. Rigidity in routines was also noted. An additional evaluation one month later suggested some articulation impairments as well as overall delays in social communication and receptive and expressive language. No formal testing could be completed on either date due to disinterest in stimuli and inattention. Upon entry in the MTW program, Joe wa s classified as being in the partner Hanen stage of communication based on his ability to use spontaneous language for many reasons and participate in an extended interaction with adul ts. Interactive roles and play sequences were rigid, however, and Joe struggled with initiations. 32

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Procedures Intervention The inte rvention utilized for this study was MTW, an intensive parent education program developed at The Hanen Centre. Intervention was administered by a program-certified speechlanguage pathologist over 11 w eeks, during which parents atte nded eight 2.5 hour lessons in a small group format at the CARD-UF office and received three 2 hour individualized in-home sessions. The program divides children into four differe nt language stages (own agenda, requester, early communicator, and partner) based on forms of communication used for various contexts and intents. During the pre-progra m consultation, parents received a worksheet to assist them and the speech-language pathologist in determin ing their childs stage of communication and selecting goals. Goals targeted throughout the program are ba sed on language stage and the individual child; however, broad ai ms of the program include (a) in creased joint interactions, (b) more advanced and typical methods of communication, (c) improved social communication skills, and (d) a better understa nding of language (Sussman, 1999). In small group sessions, parents were taught to employ several co re strategies in order to facilitate progress toward and achievement of broad and indivi dualized goals. Core strategies include offering communicative temptati ons and expectant waiting, modeling and expanding/recasting language in child-directed in teractions, using routines and scripts, and promoting comprehension through the use of visual aids and other altered input. For example, during the first session, parents were encouraged to analyze their childs sensory preferences and determine the types of activities that might enhance motivation. Capitalizing on these highly preferred sensory activities, parent s were taught to incorporate temp tations in order to draw out communication. To maximize parents transfer of knowledge from class to everyday situations 33

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with their children, sessions 3, 6, 7, and 8 specifica lly addressed targeting goals in the context of playing people gam es (e.g., hi de-and-go-seek), singing songs, reading books, playing with toys, and peer interactions, resp ectively. See Table 2-6 for a comp lete list of session topics. Scheduled individual sessions involved visi ting the home of each family, helping to develop a series of planned activities in whic h to accomplish goals over a 20 minute parent-child interaction, and providing on-line coaching throughout the interac tion. Visits concluded with a form of video self-modeling, whereby parents view ed the videotaped events with the speechpathologist, self-critiqued, and we re offered feedback. Interactions were recorded via two video cameras manned by student volunteers. When the parent-child interact ion was complete, one videotape was used for viewing with the family, while the other was left running to record the feedback segment of the home visit. Individu alized home sessions occurred in the week following the third, fifth, and seventh small group lessons. Activities varied across the three tapings based on the lessons taught during the pr ior weeks. Video self-modeling and coaching highlighted parents use of interaction-promo ting strategies taught during small group sessions. Through coaching, the speech-language pathologist wa s able to offer real-time suggestions and alternatives when an activity or strategy was inef fective, as well as verb al praise and possible modifications and expansions of achieved goals. In this way, home sessions were designed to facilitate successes. Video se lf-modeling allowed parents to analyze their own successes and challenges. They were able to see what worke d, what didnt, and why by reviewing antecedents, resulting behaviors, consequences, and adju stments they made by employing strategies. Data Collection Research visits Volunteers f rom the Child Language Lab in the Communication Sciences and Disorders department at the University of Florida were as signed to families participating in the research. 34

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Research visits involved a 20 m inute in-home vi deotaping of an intera ction between the child and one or more parents during five categories of activities. Categories were as follows: A physical game without toys (e.g., Peek-aboo, Ring around the Rosie, chasing games, tickle games) Singing a song together. A daily routine (e.g., snack, washing hands, l unch, getting dressed). The routine will depend on the time of day of the appointment. Looking at a book together. Playing with a favorite toy together. Parents were allowed to select the order of activit ies as well as the specific activity within each category. Recording was stopped or paused at any time during the re search visit in accordance with parents requests. Volunteers attempted to collect 3 baselines pr ior to the start of the program, one taping during the week following each of the 8 sessions, and 2 follow-ups after the program concluded. Although tapings were specified as a 20 minute even t, lengths of research recordings varied. Table 2-7 displays the conversati onal partners for resear ch tapings of each of the 3 subjects. Transcription and coding Af ter the samples were collected, volunteer research assistants transcribed the video recordings to reflect all parent and child utterances produced ove r the course of each research visit. Second pass transcriptions were performe d by pairs of research assistants who had not participated in the primary transcription of the samples assigned. All but 4 samples were independently analy zed and coded for behaviors by a research assistant uninvolved in program planning and implementation, data collection, or utterance transcription. The coding process consisted of recording and time stamping each behavior the child exhibited, and coding whether or not a beha vior signified the childs active engagement. 35

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Review of the prim ary coders first three beha vioral transcriptions by one of this studys investigators confirmed that beha viors coded as active engagement could be classified within the broader initiating and responding behaviors indicative of active participation described by Bellini et al. (2007). Behaviors coded as not enga ged failed to meet those criteria; these were frequently classified as avoi dance behaviors. Baseline and week 1 samples for Michael were coded by an investigator of the study. Reliability Reliability of active engagem ent was not completed at this time for this study. 36

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Table 2-1. Participan t characteristics Child name* Age at study onset Sex Total research tapings Attrition Diagnosis Michael 4;0 M 3 baseline, 7 w eekly, 2 follow-up N PDD-NOS Bob 2;8 M 3 baseline, 5 weekly, 2 follow-up N Autism Joe 4;0 M 3 baseline, 6 weekly, 2 follow-up N Autism John 3;5 M 3 baseline, 2 weekly, 2 follow-up N Autism Adam 4;11 M 3 baseline, 6 weekly, 1 follow-up N Autism Sam 5;7 M 1 baseline, 7 weekly, 1 follow-up N PDD-NOS Jane 3;10 F 3 baseline, 1 weekly 0 follow-up Y (Research) PDD-NOS *Names are pseudonyms. 37

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Table 2-2. Adam, Michael, and Joe characteristics Child Age Age at diagnosis (in months) Diagnosis Hanen stage Education Other services received Adam 4;11 36 Autism Early communicator Attending preschool Speech-language therapy Michael 4;0 PDD 27 Autism 31 Autism Own agenda/ Requester Attending preschool Speech-language therapy 3 times per week. Occupational therapy 3 times per week Joe 4;0 47 Autism Partner Attending preschool Speech-language therapy 2 times per week Occupational therapy 2 times per week Table 2-3. Adam, Michael, and Joe family characteristics Subject Parent education Ethnicity Sibling sex/age Adam FatherMasters degree MotherAssociates degree Caucasian None Michael FatherMedical doctorate degree MotherMasters degree Arabic / Caucasian Female: 6;4 Male: 5;0 Female: 2;0 Joe FatherMasters degree MotherMasters degree Caucasian Female: 6;3 38

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Table 2-4. Michael CSBS-DP results Weighted raw score Percentile aAge equivalent (mos.) b Emotion and eye gaze 7 1 Communication 9 2 Gestures 6 1 Sounds 14 50 Words 13 37 Understanding 13.5 9 Object use 19 25 Social composite 22 1 8-9 Speech composite 27 37 19-20 Symbolic composite 32.5 9 15-16 Total 81.5 7-8 ~14 Social composite is comprised of emotion a nd eye gaze, communication, and gesture cluster scores. Speech composite is comprised of sounds and words cluster scores. Symbolic composite is comprised of understanding and object use clus ter scores. The total is the sum of the three composite weighted raw scores. a Calculated based on the top age ra nge of the test, 23-24 months. b Age equivalents are not provide d by the CSBS-DP manual, but were calculated based on the age in months at which the given scor e was equal to the 50th percentile. 39

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Table 2-5. Ada m CSBS-DP results Weighted raw score Percentile aAge equivalent (mos.) b Emotion and eye gaze 14 63 Communication 14 9 Gestures 10 9 Sounds 16 99 Words 23 75 Understanding 23 50 Object use 18.5 25 Social composite 38 16 13-14 Speech composite 39 84 Not available cSymbolic composite 41.5 37 19-20 Total 118.5 ~47-50 ~23 Social composite is comprised of emotion a nd eye gaze, communication, and gesture cluster scores. Speech composite is comprised of sounds and words cluster scores. Symbolic composite is comprised of understanding and object use clus ter scores. The total is the sum of the three composite weighted raw scores. a Calculated based on the top age ra nge of the test, 23-24 months. b Age equivalents are not provided by the CSBS-DP manual, but we re calculated for composite and total scores based on the age in months at which the gi ven score was equal to the 50th percentile. c Age equivalent could not be calc ulated because subject exceeded 50th percentile at all ages for which normative data is available. 40

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Table 2-6. The Hanen More Than Words program session outline Session Topic Phase 1 Understanding the way your child communicates and his or her sensory systems Communicative temptations 2 Child-directed strategies modeling language at an appropriate level expanding on and recasting childs communicative attempts 3 People games Singing songs 4 Promoting comprehension altering language complexity Using routines and scripts Treatment 5 Visual supports alternate modalities of comprehension and expression 6 Reading books 7 Playing with toys 8 Peer interactions Generalization 41

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42 Table 2-7. Conversational part ners in research tapings Michael Joe Adam Baseline 1 Father/Mother Mother Mother Baseline 2 Mother Mother Father/Mother Baseline 3 Father Mother Father/Mother Week 1 Father Mother Mother Week 2 Mother Mother Father/Mother Week 3 Father --------Week 4 Father Mother Mother Week 5 Father ----Mother Week 6 Mother Mother Mother Week 7 Mother Mother Mother Week 8 ----Mother ----Follow-up 1 Father Mother Mother Follow-up 2 Father Mother ----

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CHAP TER 3 RESULTS To test the hypothesis that the proportion of tim e a child was actively engaged with partners would change over time with the implem entation of parent traini ng, visual inspection of graphed data was performed. Gra phs and raw data are provided for each subject of the proportion of time actively engaged during each session ove r the course of the baseline, treatment, generalization, and maintenance phases of the program (see Figure 3-1, 3-2, 3-3; Table 3-1). Parents were trained in the co re strategies of More Than Words during the first 4 small group parent sessions. This period of time was cla ssified as the treatment phase. Rather than isolate a generalization phase, this experiment employed an additional follow-up, or maintenance phase, after all other program elem ents had ceased. The generalization phase was defined as that in which the focus of remaining educational small group sessions and home visits shifted from the teaching of core interaction-pr omoting strategies to support of situational application of strategies and skills in songs, books, toys, and involving peers. This studys division of data into what was perceived as a separate generalization phase created a smoother continuum along which to analyze efficacy based on incremental removal of program supports. It more closely reflects the natural transitions and expectations in all ski ll learning and acquisition, and lends itself to a more compre hensive interpretation. In the in terest of full disclosure, the consideration of all potentially re levant segments avoids presenting only those which conform to hypotheses or might falsely inflat e treatment effects. Thus, each of these outcome phases and their combination are analyzed with respect to baseline measures to maximize information. On visual inspection, changes can be seen in the proportion of each session for which Michael was actively engaged over the course of this investigation (F igure 3-1). The graph indicates that a high percentage of time was spent engaged in th e first baseline, but engagement 43

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dropped off dram atically over the remaining baselin es. The lowest levels of engagement (one percentage point below the lowest baseline) occurred during week 1 of the treatment phase, 8 days after the last baseline wa s collected. From week 1 to week 2, the data exhibited a marked increase, nearly equivalent in magnitude to the negative change over the th ree baseline points. At no time did the slope between consecutive weeks appr oach that of the thre e baselines or week 1to-week 2. Percentage of time actively engaged fluc tuated in the remaining weeks, resulting in a step-like pattern with a generally positive trend over the latter three phases. Furthermore, a positive directional change was evident between the first and last points of treatment, generalization, and maintenance phases individu ally, with the overall highest proportion of engagement occurring during the last maintena nce session. Two of three generalization and all maintenance points exceeded baseline range. Only the first generalization point demonstrated overlap. Joe began with a high percentage of active enga gement, as shown in his baseline measures. A fairly low amount of variability was also de monstrated in baseline, with all observations falling within ten percentage points of each other. Visual inspection of graphed data (Figure 3-2) shows no obvious trend. On generalization, however there were two data points above and one overlapping the high baseline range, suggesting some improvement. The highest recorded engagement overall was week 8, immediately following the last prog ram session. A declining slope was evident between the two maintenance points, with one falling within and one below the range of baselines, demonstr ating a decline in engagement in the months following program termination. Visual inspection of Adams graph (Figure 33) shows no apparent pattern in the data. Similar to Joe, Adam experienced a fairly stab le baseline, with no more than ten percentage 44

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points between observations. Engagem ent dropped dr amatically in the firs t treatment week, but returned to near base line the following session. Two of the three generalizations and the sole maintenance point somewhat exceeded the range of baseline data, but no consistent trend was evident as the one generalization point which overlapped was the final generalization sample. This generalization point also demonstrated a dr op of over ten percentage points from the prior sessions data. 45

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Figure 3-1. Graphed representati on of Michaels active engagement data for a parent training intervention. 46

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Figure 3-2. Graphed representation of Joes active engagement data for a parent training intervention. 47

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Figure 3-3. Graphed representati on of Adams active engagement data for a parent training intervention. 48

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49 Table 3-1. Raw data of percentage of time engaged and length of each session Michael Joe Adam % Time Engaged Session length % Time Engaged Session Length % Time Engaged Session Length B1 74.1 14:42 85.5 23:28 73.6 16:21 B2 53.0 21:00 90.1 20:02 81.0 23:17 B3 40.7 12:17 82.2 20:08 80.9 33:53 W1 39.7 19:27 85.0 22:13 50.1 20:06 W2 72.3 19:57 94.2 23:18 77.0 21:59 W3 61.5 12:15 W4 65.1 18:03 92.0 20:05 82.4 20:07 W5 63.8 15:46 81.7 18:47 W6 86.7 19:59 91.3 21:46 94.9 25:07 W7 84.7 18:12 89.1 20:30 77.4 24:05 W8 96.5 20:37 F1 83.0 19:33 86.5 20:42 89.6 31:23 F2 87.6 18:29 79.4 18:34

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CHAP TER 4 DISCUSSION This study investigated whethe r the proportion of tim e a child was actively engaged with partners changed over time with the implementati on of parent training. Outcomes varied across children in different communication stages, with data trends more difficult to detect in the higher stages. Overall, the only subjec t at the lowest communication stage experienced a large change over both generalization and maintenance. Michaels positive trend across all potentia l pre and post program measurement groupings demonstrates his significant magnitude of change over the course of th e parent training, and suggests a sizeable treatment effect of pa rent-implemented intervention on his active engagement. One threat to the interpretation of this subjects data particularly is the short time over which baselines were collected. This occurre d because time available to collect this data was limited to the period between a familys pr e-program consultation an d the first session (a maximum gap of 2.5 weeks), and only 4 weeks sepa rated the orientation and program onset. It is unclear whether the lack of st ability in Michaels baseline is a consequence of the limited number of data points and time period over which they were collected or th e large variability in skills and behaviors that is commonly characteri stic of ASD. It is also possible that the participation of both Michaels mother and father in the first baseline research taping (the only sample in which both were included) resulted in a false inflation of his levels of social interaction with respect to the other samples. Failure to obtain a stable baseline makes it more difficult to definitively attribute changes to the treatment effects. However, the downward trend in successive baseline points, along with the overall positive slope of the data through the treatment, generalization, and maintenance phases, still lend support to the conclusion that Michaels active engagement increased over the c ourse of the parent training program. Future 50

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researchers into More Than W ords should be aw are of the time period between orientation, preprogram consultation, and the first group sessi on and plan baseline collection accordingly. Compensation could be made through a larger ga p between the consultation and program onset and/or conducting orientations once per every few program cy cles. The latter would require extension of invitations to more families per or ientation, and the institu tion of a waiting list whereby additional baseline data are gathered during the waiting period. While it is possible that over a larger amount of time Michaels baseline levels of active engagement would have stabilize d, the pattern demonstrated in t hose few data points relative to that of the post-strategy instruction phases ma y also provide information of value. Michael achieved greater stability on the measure during treatment generalization and maintenance, as shown by the change in the range of scores of generalization and main tenance (23.8) as opposed to baseline (33.4). Further, on the last four data points the pr oportion of the session for which Michael was engaged consistently fell in the eighties, with the highest and lowest scores separated by only 4.6 percentage points (83.0-87.6%). The amount of time between the program conclusion and collection of maintenance data provides addi tional support for the increase in stability. Follow up visits were conducted ove r approximately 2.5 months following the program at fairly equivalent intervals. Michael was able to maintain achi eved levels over this period. His steady, step-wise improvements over the course of the protocol add support that changes were not random or a result of outside factors. Thes e results may suggest that the introduction of a naturalistic, child-centered inte rvention provided on a daily basis by his primary caretakers helped Michael attain higher and more consistent le vels of presence in an actively engaged state. It is contended here that stab ility of Michaels performance is as crucial as the magnitude of his change, if not more so, because it repres ents the level of accessibility, application, and 51

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genera lization of skill sets and behaviors, and whether the function and value of a behavior is truly understood. This finding of improved consis tency, albeit unintention al, is an important outcome for a population that exhibits such discrepancies in behaviors day to day. On visual inspection of his data, Joe did not appear to demonstrate many changes, significant or otherwise, on the dependent measur e as defined for the purpose of this study. No true trend is evident in his gr aph (Figure 3-2). Although Joes gene ralization level does appear to exceed that of baseline somewhat, based on the declining slope of the maintenance points no long-term active engagement effect can be attrib uted to treatment. Parent report and clinician observation led to Joes classification as the most advanced communicative stage addressed by the program (partner). Hi s high, stable levels of active engage ment during baseline suggest that he already learned, generalized, and valued e ngagement. The remaining proportion may indicate that the subject has hit a ceiling and reached th e maximum allocation of his engaged resources, or it may be beyond what can be reasonably expected for any child this age. Either way, it appears that once a child is capab le of high, stable measures of engagement and is consistently available to learn, the measurement itself loses its significance as a pre-le arning tool. It is also possible that program strategies targeting engage ment are more suited to a lower developmental level, as increasing engagement is not a true goal at the partner stage. In their exit survey, Joes pa rents anecdotally reported the emergence of more complex, interactive play behaviors and communication. They noted dramatic differences in his interest in engaging in pretend play in partic ular and his spontaneous initiati ons of such play. Thus, future research may choose to bypass discrete yes or no coding of engagement and instead provide more descriptive measures of the complexity of social engagement behaviors, consistent with the goals of children using higher le vels of communicative forms and f unctions at program outset. It 52

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m ay also be interesting to examine the frequenc y and complexity of social behaviors exhibited by children at various stages with respect to levels of engageme nt. This would benefit from a longitudinal sample of parent-child interactions in a group of typically developing children matched for age or language against which to compare patterns of engagement and the interactions between engagement and social ski ll development. Normative data would allow for improved understanding of whether a ceiling exists for engagement, as well as whether a lower proportion of time engaged precludes the emerge nce of more complex social behaviors or whether overlap commonly occurs. Ultimately, th is may help to answer more of parents questions about expected outcomes. Adam demonstrated no true change in active engagement on visual in spection of his data. Despite the presence of 3 data points in generalization and ma intenance above baselines, the apparent lack of any trend suppor ts the likelihood that these are random variations. The fact that Adams final (and sole) maintenance sample was near the ninetieth percentile and his initial baseline was around the seventy-fi fth adds a cautionary note to th e risk inherent in comparing only pre and post program measures to document change, as they would have likely supported the determination of a large treatment effect in this case. It also suggests the importance of monitoring post treatment change for maintenance of improvement. As an early communicator, it is probable that Adams high, stable baseline in dicate that was already capable of engaging, and similar to Joe, no longer required additional focus on this skill area. Limitations There are several threats to th e validity of this experim ent. One potential confound is the participation of both parents in data collection tapings. Although some families remained consistent in which parent wa s involved, Michaels parents reque sted and were permitted to alternate or participate jointly in tapings as they had both atte nded group lessons and home video 53

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feedback sessions. Adams fam ily also chose to have both parents particip ate in research visits, though for them the mother brought home informa tion and practice assignments from the small group sessions to share w ith the father. This variability in interaction partners is likely more representative of daily lives a nd the naturalistic intervention pr ogram, but especially with the small number of data samples, it may have advers ely affected research va lidity. Future studies may wish to exercise stricter c onsistency with this aspect of data collection. Both parents may still be able to partic ipate if a larger amount of data is collected, particularly an extended baseline, and random assignment of mother and fa ther to each taping is employed. Other threats to validity include lack of controls for maturatio n and other therapies. In addition to the lack of inter-rater reliability checks, be havioral coding of Michaels ba selines and first week samples was completed by a person other than the primar y coder. Efforts were made to eliminate potential introduction of bias through time stamping both engage d and unengaged behaviors and calculating time totals only at the end. Correct classification of behaviors by the primary coder observed in the first three samples was confirme d, although videos were not viewed to confirm accuracy of time stamps or specific observations. Summary Differences in subject outcom es underscore th e importance of looking within the group at individual differences when setting goals a nd implementing interventi on. The children involved in this study were all at diffe rent Hanen stages of communicati on. If active engagement had been sole target of intervention, it is likely that this intervention would have been wasted on Joe, a partner. However, because goals were conti nuously reassessed and expanded upon during home visits, the program was able to be tailored to th e strengths and weaknesses of each child. This is particularly important in a popul ation that exhibits such vari ability between individuals and splintered skill profiles within individuals. The coaching and video self-modeling sessions also 54

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allowed the program to address in dividual differences in parent in teraction styles and adaptation and implementation of specific strategies relative to their childs needs, furthering their success as communication facilitators. For example, Mich aels parents were advised to use a prolonged period of expectant waiting to accommodate for the extra pr ocessing time their son required rather than repeating the request or statemen t. Michael was then able to respond to their questions or express a request of his own. Early on, Joe was part icipating and communicating in all segments of the taping session as laid out on a visual schedule. When he expressed curiosity toward his fathers use of puppets, the father wa s encouraged to follow this interest and add a new challenge by having each member of the family, child included, take on the role of the puppet. They incorporated this pretend play in to several aspects of the interaction (singing, playing with toys, referring back to the schedul e during transitions, an activity of daily living), and remained in character as long as possible. Shif ting to Joes focus facili tated his initiation of a topic and maintenance over an extended peri od of time and number of turns as well as his understanding and expression of abstract concepts of pretend and others feelings and thoughts, all of which are goals at the partner stage. From the pre-program consultation, one of Michaels goals at the own agenda/requester stage was reciprocating interacti on (a component of active engageme nt). At the partner stage, Joe already had this piece, and through the strategies his parents empl oyed, he was able to expand his repertoire of communicative knowledge and skil ls. It is crucial that goals are matched appropriately to communicative abilities dur ing pre-screening. This study indicates the importance of tailoring outcome measures to stag es in order to assess progress toward stagespecific goals, and also to gather research da ta that will enable future MTW providers to elaborate on expected program outcomes. Wh ile measuring active engagement may not be 55

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beneficial for all children of this age, it is the foundation of all social and comm unicational learning, and merits further explor ation, especially as it pertains to naturalistic, family-centered early interventions. This offering of the More Than Words program appeared to be most effective in increasing active engagement for th e children at the own agenda/requester Hanen stages of communication. Treatment Implications More Than W ords providers may consider grouping families based on Hanen stages of communication. Separate iterations of the program for parents a nd children with similar goals may promote discourse, observation and exchange of ideas, and the intim ate bonding that occurs between parents in the intensive shared experien ce of small group sessions, as well as facilitate scheduling of peer play opportuni ties. In this format, small group training sessions could also be augmented with more extensive and advanced discussion and counseli ng on other issues and parental concerns that are likely shared by those with children at a similar developmental level. A counseling component is also recommended because, as this program is intended to be an early intervention, diagnoses are likely recent, and parents may be experiencing the onset of the grieving cycle. This is the ideal time to disc uss positive coping strategies that will most effectively support parent mental health and fa mily relationships and lower parental stress (Hastings et al., 2005). One of the most common requests coordinators of this particular program received was for more extensive input on how parents could faci litate social skills and peer interactions. Therefore, it is believed that the program may al so benefit from inclusion of sibling or peer workshops and in-home coaching to supplemen t parent training. Having a speech-language pathologist demonstrate ways to enhance play interactions can help siblings and peers gain confidence and feel involved. 56

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57 Conclusion In conclusion, the results of this study suggest the im por tance of examining a childs ability to actively engage when sett ing goals, and its prioritization as a critical goal if not present. Clinicians wishing to address th ese deficits should be aware of indirect intervention opportunities in their scope of practice, and the potential of these interventions to facilitate more complete skill learning. Teaching parents of child ren with ASD strategies to he lp their childre n establish and learn to value engagement may be especially re levant for children who use lower rates and less variety of communicative forms and functions.

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LIST OF REFERENCES American Psychiatric Association. (2000). Diagnostic and statistica l manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Baker, N.D., & Nelson, K.E. (1984). Recasting and related conversational techniques for triggering syntactic advances by young children. First Language, 5, 3-22. Bellini, S., & Akullian, J. (2007). A meta-analysis of vide o modeling and video self-modeling interventions for children and adolescen ts with autism spectrum disorders. Exceptional Children, 73, 264-287. Bellini, S., Akullian, J., & Hopf, A. (2007) Increasing social engagement in young children with autism spectrum disord ers using video self-modeling. School Psychology Review, 36, 80-90. Charlop, M.H., Schreibman, L., & Thibodeau, M.G. (1985). Increasing spontaneous verbal responding in autistic children using a time delay procedure. Journal of Applied Behavior Analysis, 19, 307-314. Charlop, M.H., & Trasowech, J.E. (1991). Increasing autistic ch ildrens daily spontaneous speech. Journal of Applied Behavior Analysis, 24, 747-761. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates. Dawson, G., & Adams, A. (1984). Imitation and social resp onsiveness in autistic children. Journal of Abnormal Child Psychology, 12, 209-226. Dawson, G., Meltzoff, A., Osterling, J., Rinaldi, J., & Brown, E. (1998). Children with autism fail to orient to naturally occurring social stimuli. Journal of Autism and Developmental Disorders, 28, 479-485. Dawson, G., & Osterling, J. (1997). Early intervention in au tism. In M. Guralnick (Ed.), The effectiveness of early intervention (pp. 307). Baltimore: Brookes. Dowrick, P. (1999). A review of self mode ling and related interventions. Applied & Preventive Psychology, 8, 23-39. Elder, J. H., Valcante, G., Yarandi, H., White, D., & Elder, T. H. (2005). Evaluating in-home training for fathers of children with autism using single-subject e xperimentation and group analysis methods Nursing Research, 54, 22-32. Girolametto, L., Sussman, F., & Weitzman, E. (2007). Using case study methods to investigate the effects of in teractive intervention for ch ildren with autism spectrum disorders. Journal of Communica tion Disorders, 40, 470-492. 58

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Goldman, R., & Fristo e, M. (2000). Goldman-Fristoe Test of Articulation (2nd ed.). Circle Pines, MN: American Guidance Services. Harris, M., Jones, D., Brookes, S., & Grant, J. (1986). Relations between the non-verbal context of maternal speech and rate of language development. British Journal of Developmental Psychology, 4, 261. Hastings, R.P., Kovshoff, H., Brown, T., Ward, N.J., Espinosa, F.D., & Remington, B. (2005). Coping strategies in mothers and father s of preschool and school age children with autism. Autism, 9, 377-391. Hodgdon, L.A. (1995). Visual Strategies for Improving Communication. Troy, MI: QuirkRoberts Publishing. Janzen, J.E. (2003). Understanding the nature of autism: A guide to the autism spectrum disorders (2nd ed.). San Antonio, TX: Therapy Skill Builders. Klinger, L.G., & Dawson, G. (1992). Facilitating early social and communicative development in children with autism. In S. F. Warren & J. Reichle (Eds.), Causes and effects in communication and language intervention (pp.157-186). Baltimore: Brookes. Landry, R., & Bryson, S. (2004). Impaired disengagement of attention in young children with autism. Journal of Child Psychology and Psychiatry, 45, 1115-1122. Liss, M., Saulnier, C., Fein, D., & Kinsbourne, M. (2006). Sensory and attention abnormalities in autistic spectrum disorders. Autism, 10, 155-172. doi: 10.1177/1362361306062021 Lord, C. (2008, September). Part 1: Evidence-based tr eatment for toddlers with ASD: What we know now and new research directions. Presentation at The Help Group Summit. Retrieved February 18, 2009, from http://www.thehelpgroup.org/pdf/LORD_PART%201_2.pdf Lord, C., Risi, S., Lambrecht, L., Cook, E.H ., Leventhal, B. L., DiLavore, P., et al. (2000). The Autism Diagnostic Observatio n ScheduleGeneric: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30, 205-223. Magill-Evans, J., Harrison, M.J., Benz ies, K., Gierl, M., & Kimak, C. (2007). Effects of parenting education on first-time fathers skills in interactions with their infants. Fathering, 5, 42-57. McConachie, H., Randle, V., Hammal, D., & Le Couteur, A. (2005). A controlled trial of a training course for parents of children with suspected autism spectrum disorder. Journal of Pediatrics, 147, 335. Mundy, P. (2003). Annotation: The neural basis of soci al impairments in autism: the role of the dorsal medial-frontal cortex a nd anterior cingulated system. Journal of Child Psychology and Psychiatry, 44, 793-809. 59

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Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study of joint attention and language developm ent in autistic children. Journal of Autism and Developmental Disorders, 20, 115-128. National Research Council. (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism, Divisi on of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press. Ogletree, B.T., Oren, T., & Fischer, M.A. (2007). Examining effective intervention practices for communication in autism spectrum disorder. Exceptionality, 15, 233-247. Pelphrey, K., Adolphs, R., & Morris, J.P. (2004). Neuroanatomical substrates of social cognition dysfunction in autism. Mental Retardation and Developmental Disabilities Research Reviews, 10, 259-271. Prizant, B.M., Wetherby, A.M., Rubi n, E., Laurent, A.C., & Rydell, P. (2006). The SCERTS model: A comprehensive educational appr oach for children with autism spectrum disorders. Baltimore: Brookes. Prizant, B.M., Wetherby, A.M., & Rydell, P. (2000). Communication in tervention issues for children with autism spectrum disorders. In A. Wetherby & B. Prizant (Eds.), Autism spectrum disorders: A transactional developmental perspective (pp. 193). Baltimore: Brookes. Rapin, I. (1991). Autistic children: Dia gnosis and clinical features. Pediatrics, 87, 751-760. Ruble, L.A., & Robson, D.M. (2007). Individual and environmental determinants of engagement in autism. Journal of Autism and Developmental Disorders, 37, 1457-1468. Scherer, N., & Olswang, L. (1989). Using structured discourse as a language intervention technique with autistic children. Journal of Speech and Hearing Disorders, 54, 383-394. Schuler, A. (1995). Thinking in autism: Differences in learning and development. In K. A. Quill (Ed.), Teaching children with autism: St rategies to enhance communication and socialization (pp. 105). New York: Delmar. Seung, H.K., Ashwell, S., Elder, J.H., & Valcante, G. (2006). Verbal communication outcomes in children with autism after in-home father training. Journal of Intellectual Disability Research, 50, 139-150. Siller, M., & Sigman, M. (2002). The behaviors of parents of children with autism predict the subsequent development of th eir childrens communication. Journal of Autism and Developmental Disorders, 32, 77-89. Sussman, F. (1999). More than words: Helping parents promote communication and social skills in children with autism spectrum disorder. Toronto, Ontario: The Hanen Centre. 60

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61 Swettenham, J., Baron-Cohen, S., Charman, T., Cox, A., Baird, G., Drew, A., et al. (1998). The frequency and distribution of spontane ous attention shifts between social and nonsocial stimuli in autistic, t ypically developing, and nonautis tic developmentally delayed infants. Journal of Child Psychology and Psychiatry, 39, 747-753. Taylor, B.A., & Harris, S.L. (1995). Teaching children with autism to seek information: acquisition of novel information a nd generalization of responding. Journal of Applied Behavior Analysis, 28, 3-14. The Hanen Centre. (2007). More Than Words: The Hanen program for parents of children with autism spectrum disorder: Research summary [Brochure]. Toronto, Ontario: Author. Wetherby, A.M., & Prizant, B.M. (1989). The expression of communicative intent: Assessment guidelines. Seminars in Speech and Language, 10, 77-91. Wetherby, A.M., & Prizant, B.M. (2002). Communication and Symbolic Behavior Scales Developmental ProfileFirst normed edition. Baltimore: Brookes. Wetherby, A.M., Woods, J., Allen, L., Cleary, J., Dickinson, H., & Lord, C. (2004). Early indicators of autism spectrum disord ers in the second year of life. Journal of Autism and Developmental Disorders, 34, 473-493. White, S.W., Keonig, K., & Scahill, L. (2007). Social skills deve lopment in children with autism spectrum disorders: A review of the intervention research. Journal of Autism and Developmental Disorders, 37, 1858-1868.

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BIOGRAPHICAL SKETCH Jordan Ginsburg was born and raised in Miami, Florida. She graduated from Miami Palmetto Senior High School in 2003. She earne d her B.A. in Communication Sciences and Disorders from the University of Florida in 2007, followed by her M.A. in the spring of 2009. As an undergraduate and graduate student at the Univer sity of Florida, Jordan was fortunate to work in the laboratories of Lori Altmann, Ph.D ., CCC-SLP, Hye-Kyeung Seung, Ph.D., CCC-SLP, and Bonnie W. Johnson, Ph.D., CCC-SLP. She al so attained part-time employment at the University of Florida Center for Autism and Rela ted Disabilities (UF-CARD). It is here that Jordan was afforded the opportunity to particip ate in the development and implementation of their inaugural More Than Word s program. Additional graduate student clinical practica at UFCARD, as well as in the developm ental disabilities and craniofaci al units of the University of Florida Speech and Hearing Clinic and Shands Rehab for Kids at Magnolia Parke, allowed Jordan to focus on the provision of speech and language services to pediatric populations. Through UF-CARD, Jordan was also able to explor e collaborative, interdisciplinary, team-based models of intervention, including parent a nd teacher training and classroom and home consultation. Jordan is pursuing a career in clinical speech-language pathology, and hopes to specialize in the population on the autism spectrum. 62