Child Directed Interaction Training for Young Children with Autism Spectrum Disorders

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Child Directed Interaction Training for Young Children with Autism Spectrum Disorders The Impact on Child Language, Social Skills, Adaptive Skills, and Problematic Behaviors
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1 online resource (106 p.)
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english
Creator:
Clionsky, Leah N
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University of Florida
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Gainesville, Fla.
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Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Psychology, Clinical and Health Psychology
Committee Chair:
Eyberg, Sheila M
Committee Members:
Bussing, Regina
Boggs, Stephen R
Waxenberg, Lori B
Elder, Jennifer H

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Subjects / Keywords:
autism -- behavior -- developmental -- parent -- pcit
Clinical and Health Psychology -- Dissertations, Academic -- UF
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Psychology thesis, Ph.D.
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theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
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Abstract:
This study examines an application of an evidence-based treatment that teaches parents specific skills to produce language, behavioral, and social gains in young children with Autism Spectrum Disorders (ASDs). Parent-Child Interaction Therapy (PCIT) integrates concepts from social learning theory, traditional play therapy, and attachment theory to treat a range of externalizing and internalizing problems.  The evidence base for applications of the Child Directed Interaction Training (CDIT) component of PCIT has shown promise as a powerful focal treatment for ASD to address the multifaceted symptoms of the disorder through the mechanism of the parent-child relationship. The specific aims of this study are to determine whether CDIT improves verbal, adaptive, and behavioral functioning in children with ASD at immediate post-treatment assessment (Aim 1) and 6-week follow-up assessment (Aim 2), as well as overall improvement across assessments (Aim 3). Thirty children between the ages of 3 and 7 years who met diagnostic criteria for a DSM-IV diagnosis of an ASD participated with their caregivers. Assessments included observational measures of ASD symptomatology, language and adaptive skills, parent-report measures of social behaviors, and observations of total child verbalizations during a child-led play situation with mother-child dyads. Families were randomized to an immediate treatment (IT) condition or a waitlist (WL) condition. Treatment included 8 weekly sessions of manualized CDIT. Families completed their second assessment at Week 12 (for the IT group this occurred one week following the conclusion of treatment) as well as a 6-week follow-up assessment following treatment. Primary outcomes at post-treatment (Assessment 2) were compared to WL families using analysis of covariance strategies. The results indicate that caregiver implementation of CDIT skills improves disruptive behavior and social awareness compared to the waitlist control. The gains made during treatment were maintained from post-treatment to 6-week follow-up. Implications include access to a time-limited and minimally time-constraining intervention for improving the disruptive behavior and social awareness of  children with ASD that may improve future intervention outcomes with this vulnerable population of young children.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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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 Leah N Clionsky.
Thesis:
Thesis (Ph.D.)--University of Florida, 2012.
Local:
Adviser: Eyberg, Sheila M.
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RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-08-31

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UFE0044561:00001


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1 CHILD DIRECTED INTERACTION TRAINING FOR YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDERS: THE IMPACT ON CHILD LANGUAGE, SOCIAL SKILLS, ADAPTIVE SKILLS, AND PROBLEMATIC BEHAVIORS By LEAH NEWLOVE CLIONSKY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2012

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2 2012 Leah Newlove Clionsky

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3 To my parents, who have provided so much support and guidance during this process

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4 ACKNOWLEDGMENTS I thank Sheila Eyberg, Ph.D., ABPP, my dissertation committee chair and research advisor, for her mentorship, encouragement, and editorial support as I worked on this research. I would like to thank Stephen Boggs, Ph.D. ABPP, Regina Bussing, M.D., Jennifer Elder, Ph.D., RN, FAAN, and Lori Waxenberg, Ph.D. ABPP members of dissertation committee, for the time and energy they have devoted to providing thoughtful feedback and support. In addition, I would like to thank Krestin Radonovich, Ph.D., for her helpful advice regarding assessment and treatment children on the autism spectrum and her help with recruitment. I would like to thank JohnPaul Abner, Ph.D. and Christina Warner Metzger for inspiring and helping to conceptualize both the theoretical and practical aspects of this work. I thank the Child Study Lab and the students who gave their time as therapists, assessors, and research assistants during this process and other graduate students in the D epartment of Clinical Psychology who also participated as clinicians in this s t udy In particular, I would like to thank the following students: Nicole Ginn, Nadia Bhuiyan, Kaitllyn Powers, Daniel Gering, Amanda Nzi, Ryan Fussell, Carmen Edwards, Jessi ca Spigner, Eileen Matias Davis, Jennifer Munoz Olivia Soutello, Katie Polston, and Stephanie Hernandez Finally, I would like to acknowledge the Center for Pediatric Psychology and Family Studies for funding this research.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES ............................................................................................................ 8 LIST OF FIGURES .......................................................................................................... 9 LIST OF ABBREVIATIONS ........................................................................................... 10 ABSTRACT ................................................................................................................... 11 CHAPTER 1 BACKGROUND ...................................................................................................... 13 Description of Autism Spectrum Disorders ............................................................. 13 Treatments for Autism Spectrum Disorders ............................................................ 13 Naturalistic Teaching Strategies ............................................................................. 15 Parent Child Interaction Therapy ............................................................................ 19 Theoretical Underpinnings of the Use of Child Directed Interaction Component for Children with Autism Spectrum Disorders ...................................................... 21 Maintenance of Treatment Gains and PCIT ............................................................ 22 Study Objectives and Hypotheses .......................................................................... 23 Aim 1 ................................................................................................................ 23 Hypothesis 1.1 ........................................................................................... 23 Hypothesis 1.2 ........................................................................................... 24 Hypothesis 1.3 ........................................................................................... 24 Hypothesis 1.4 ........................................................................................... 24 Aim 2 ................................................................................................................ 24 Hypothesis 2.1 ........................................................................................... 24 Hypothesis 2.2 ........................................................................................... 24 Hypothesis 2.3 ........................................................................................... 24 Hypothesis 2.4 ........................................................................................... 24 Aim 3 ................................................................................................................ 24 Hypothesis 3.1 ........................................................................................... 24 Hypothesis 3.2 ........................................................................................... 25 Hypothesis 3.3 ........................................................................................... 25 Hypothesis 3.4 ........................................................................................... 25 2 METHOD ............................................................................................................... 26 Participants ............................................................................................................. 26 Attrition ............................................................................................................. 27 Measures ................................................................................................................ 29 Demographic and Background Q uestionnaire .................................................. 29

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6 Phone S creener ............................................................................................... 29 Semi structured I nterview ................................................................................. 29 The Childhood Autism Rating Scale ,Second Edition (CARS2; Schopler, Reichler, & Renner, 1988; Schopler, Bourgondien, Wellman,.& Love, 2010) ............................................................................................................. 29 Peabody Picture Vocabulary Test Third Edition (PPVT III: Dunn, 1997) .......... 30 Vineland Adaptive Behavior Scales, Second Edition (VinelandII; Sparrow, Balla, & Cicc hetti, 1984; Sparrow Cicchetti,, & Balla, 2005). ......................... 31 Differential Abilities Scale, Second Edition (DAS II; Elliott, 2007). ................... 31 Social Responsiveness Scale (SRS: Constantino & Gruber, 2005; Constantino et al., 2000) ............................................................................... 32 Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999). ................... 33 Dyadic Parent Child Interaction Coding System (DPICS; Eyberg, Nelson, Duke, & Boggs, 2004). .................................................................................. 34 Word Count (Abner, 2008) ............................................................................... 34 Treatment Integrity ..................................................................................... 35 Experimental Design ............................................................................................... 35 Procedure ............................................................................................................... 36 Phone S creening .............................................................................................. 36 The Major Assessments ................................................................................... 36 Time 1 ass essment .................................................................................... 36 Time 2 and time 3 assessments and 6week follow up assessments ........ 38 Randomization ................................................................................................. 3 9 Treatment ......................................................................................................... 40 Core features of PCIT ................................................................................ 40 Application of PCIT .................................................................................... 40 Adaptation of PCIT for the purposes of this research ................................ 41 Statistical Analysis ............................................................................................ 42 3 RESULTS .............................................................................................................. 48 Demographic Information ........................................................................................ 48 Comparison of the Immediate Treatment and Waitlist Control Groups at Immediate Post Treatment Assessment .............................................................. 48 Disruptive b ehavior ........................................................................................... 49 Receptive and expressive l anguage ................................................................. 49 Social s kills ....................................................................................................... 50 Adaptive f unctioning ......................................................................................... 50 Maintenance of Treatment Gains from Post Treatment (Time 2) to 6Week Follow Up ............................................................................................................ 50 Changes from Pretreatment to 6 week Follow Up ................................................. 51 4 DISCUSSION ......................................................................................................... 64 General Findings .................................................................................................... 64 Comparison of th e Immediate Treatment and Waitlist Control Groups at Immediate Post Treatment Assessment .............................................................. 65

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7 Disruptive Behavior .......................................................................................... 65 Receptive and Expressive Language ............................................................... 66 Social Skills ...................................................................................................... 67 Adaptive Functioni ng ........................................................................................ 68 Maintenance of Treatment Gains from Post Treatment (Time 2) to 6Week Follow Up ............................................................................................................ 68 Changes from Pretreatment to 6 week Follow Up ................................................. 68 Limitations, Strengths and Future Directions .......................................................... 69 APPENDIX A TREATMENT DIAGRAMS ...................................................................................... 75 B CDIT PHONE SCREENER ..................................................................................... 79 C DEMOGRAPHIC AND BACKGROUND QUESTIONNAIRE ................................... 81 D SEMI STRUCTURED INTERVIEW ........................................................................ 85 LIST OF REFERENCES ............................................................................................... 95 BIOGRAPHICAL SKETCH .......................................................................................... 106

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8 LIST OF TABLES Table page 2 1 Demographic characteristics of immediate treatment and waitlist g roups .......... 45 2 2 Demographic characteristics of time 2 completers and dropouts before t ime 2 ......................................................................................................................... 46 3 1 Mean scores for measures at time 1 and time 2 assessments .......................... 53 3 2 Mean scores for measures at time 2 and time 3 assessments .......................... 54 3 3 Mean scores for measures at time 1 and time 3 ssessments ............................ 55

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9 LIST OF FIGURES Figure page 2 1 Sampling and flow of participants throughout c hild directed interaction training. ............................................................................................................. 47 3 1 Caregiver ratings of the ECBI Intensity raw scores from pre to post treatment for the IT and WL groups.. .................................................................................. 56 3 2 Caregiver ratings of the ECBI Pr oblem scores from preto post t reatment the IT and WL groups. .............................................................................................. 57 3 3 Caregiver ratings of the Social Responsiveness Scale Awareness scores from pre to post treatment the IT and WL groups. ............................................. 58 3 4 Observed number of total child verbalizations during a 5minute child led play situation of the DPICS from pre to post treatment in the IT and WL groups. ..... 59 3 5 Caregiver ratings of the ECBI Intensity raw scores from pretreatment to 6 week follow up assessments for the IT group. ................................................... 60 3 6 Caregiver ratings of th e ECBI Problem scores from pret reatment to 6week follow up assessments for the IT group. ............................................................. 61 3 7 Caregiver ratings of the VinelandII Maladaptive Behavior Index scores from pre treatment to 6week follow up assessments for the IT group.. ..................... 62 3 8 Caregiver ratings of the VinelandII Composite scores from pretreatment to 6 week follow up assessment for the IT group. .................................................. 63

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10 LIST OF ABBREVIATION S ASD Autism Spectrum Disorder CDIT Child Directed Interaction Training I T Immediate Treatment Condition PCIT Parent Child Interaction Therapy PDI Parent Directed Interaction WL Waitlist Control Condition

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11 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy CHILD DIRECTED INTERACTION TRAINING FOR YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDERS: THE IMPACT ON CHILD LANGUAGE, SOCIAL SKILLS, ADAPTIVE SKILLS, AND PROBLEMATIC BEHAVIORS By Leah Newlove Clionsky August 2012 Chair: Sheila Eyberg Major: Psychology This study examines an application of an evidencebased treatment that teaches parents specific skills to produce language, behavioral, and social gains in young children with Autism Spectrum Disorders (ASDs). Parent Child Interaction Therapy (PCIT) integrates concepts from social learning theory, traditional play therapy, and attachment theory to treat a range of externalizing and internalizing problems. The evidence base for applications of the Child Directed Interaction Training (CDIT ) component of PCIT has shown promise as a powerful focal treatment for ASD to address the multifaceted symptoms of the disorder through the mechanism of the parent child relationship. The specific aims of this study are to determine whether CDIT improves verbal, adaptive, and behavioral functioning in children with ASD at immediate post treatment assessment (Aim 1) and 6week follow up assessment (Aim 2) as well as overall improvement across assessments (Aim 3) Thirty children between the ages of 3 and 7 years who met diagnostic criteria for a DSM IV diagnosis of an ASD participated with their caregivers. Assessments included observational measures of ASD symptomatology, language and adaptive skills, parent -

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12 report measures of social behaviors and observ ations of total child verbalizations during a childled play situation with mother child dyads. Families were randomized to an immediate treatment (IT) condition or a waitlist (WL) condition. Treatment included 8 weekly sessions of manualized CDIT. Families completed their second assessment at Week 12 (for the IT group this occurred one week following the conclusion o f treatment) as well as a 6week follow up assessment following treatment. Primary outcomes at post treatment (Assessment 2) were compared to WL families using analysis of covariance strategies. The results indicate that caregiver implementation of CDIT skills improves disruptive behavior and social awareness compared to the waitlist control. The gains made during treatment were maintained from post treatment to 6 week follow up. Implications include access to a timelimited and minimally time constraining intervention for improving the disruptive behavior and social awareness of children with ASD that may improve future intervention outcomes wi th this vulnerable population of young children.

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13 CHAPTER 1 BACKGROUND Description of Autism Spectrum Disorders The definition of Autism Spectrum Disorders (ASDs) commonly includes Autistic Disorder, Asperger Syndrome, and Pervasive Developmental Disorder, Not Otherwise Specified (PDD NOS) (Bishop, Luyster, Richler, & Lord, 2008). Core symptoms of ASDs, as defined by the American Psychiatric Association (APA, 2000, p. 69) include severe and pervasive impairment in several areas of development: reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests, and activit ies with symptoms evident prior to age 3 years and often comorbid with Intellectual Disorders (ID; also know n as Mental Retardation). Associated social deficits are present in attachment, social imitation, joint attention, orienting to social stimuli, fac e perception, and emotional perception and expression, while language delays are marked by echolalia, atypical prosody, pragmatic impairments (understanding the semantic aspects of language), and few gestures (Klinger, Dawson, & Renner, 2003). Within the D SM diagnostic criteria, Autism Spectrum Disorders (ASDs) have a complex presentation of social skills deficits, communication delays, and restricted interests that often manifest in disruptive behavior and relational problems. Because of this high degree o f complexity in the presenting symptoms of ASD, it is important that treatments for ASD target the multifaceted nature of the disorder. Treatments for Autism Spectrum Disorders To date, Lovaas s Applied Behavior Analysis (ABA; Dunlap, KernDunlap, Clark, & Robbins, 1991) or Discrete Trial Training (DTT; Maurice, Green, & Luce, 1996) is the only psychosocial treatment that has been classified as evidencebased for the

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14 treatment of Autism Spectrum Disorders (Rogers & Vismara, 2008). ABA treatment stresses the importance of applying behavioral principles to increase appropriate social and communicative behaviors with reward and to decrease maladaptive behaviors (such as aggressive or self stimulatory behaviors) with ignoring, punishment, and shaping (Lovaas, 19 87). Involvement in Lovaas s Young Autism Project (YAP; Lovaas, 2003) begins with one year of highly structured, manualized Discrete Trial Training followed by a gradual emphasis on naturalist instruction. Discrete Trial Training occurs in a oneon one interaction that is directed by a trained therapist. The therapist gives the child short and clear instructions and follows through with carefully planned procedures to prompt the child to follow instructions or to provide immediate reinforcement of a correct response (Lovaas, 2003; Campbell, Herzinger, & James, 2008). Lovaas s (1987) initial research findings have been replicated by a variety of researchers using well designed randomized controlled trials (Lovaas & Smith, 2003; Eldevik, Eiseth, Jahr & Smi th, 2006; Rogers & Vismara, 2008) that support ABAs efficacy in improving intelligence in children with autism. Although ABA is the only evidencebased treatment for children with Autism Spectrum Disorders, ABA may not be suitable for all children and f amilies. Traditional ABA treatment is extremely time intensive, with time requirements that range from a 12 hours a week to 40 or more hours a week, with a duration ranging from a few months to 2 years, across several environments via collaborative efforts from parents and professionals (Rogers & Vismara, 2008). Access to treatment at this time is limited for families with low parental education, racial or ethnic minority status, or residence in

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15 nonmetropolitan areas (Thomas, McLaurin, & Morrissey, 2007). F amilies may lack the funding or time availability to provide this treatment to their children. In addition, there are not enough professionals with sufficient training and experience to provide highquality, intensively supervised treatment to children a nd families who do not have access to an autism research center. Parents have tried to remedy this problem in the past by recruiting paraprofessional therapists to be trained to provide the intervention (Lovaas & Smith, 2003). Unfortunately, research findi ngs have indicated that child outcomes were much less favorable in a parent initiated intervention, with child intelligence demonstrating no notable improvement during treatment (Bibby, Eikseth, Martin, Mudoford, & Reeves, 2001). Even if a child were able to receive sufficient ABA treatment by a professional, the current research supports ABA as evidencebased only for improving child intelligence. Research has not supported ABA as evidencebased for addressing the other challenges faced by child ren with AS D including elements of autistic symptomatology (particularly difficulties with social and communicative functioning), comorbid psychological and psychiatric difficulties, difficulties with adaptive functioning and higher than average disruptive behavior s. Parents may prefer a treatment that targets these other areas of functioning. Naturalistic Teaching Strategies Other treatment approaches have been developed to integrate behavioral mechanisms into naturalistic teaching strategies that draw from developmental theories. Naturalistic teaching refers to providing an opportunity for a child to learn or use a skill in a natural setting (like playtime) so that it can be generalized more easily to other contexts (Boutot, 2009). Because children with ASDs have difficulty generalizing skills that they have learned, they benefit from learning a skill in the context that is most often

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16 used. For example, children with ASD may benefit from learning play or communication skills in a play or interpersonal environment with caregivers and friends. Unfortunately, children with ASD are unmotivated to respond to complex social and environmental stimuli (Rogers & Vismara, 2008) and therefore are unlikely to engage spontaneously in play activities with caregivers or peers. As a result, they may miss out on opportunities to learn language and social skills and to generalize these abilities to other environments. Naturalistic strategies focus on making play interactions more rewarding for children with ASD by incorporating behavioral reinforcement and rewards (positive parenting strategies) into childled play interactions. Allowing the child to lead the interaction with little parent interference or correction is considered instrumental to optimizing the learning experience (Boutot, 2009). Pivotal Response Treatment (PRT; Koegal et al., 1999) is a childled, naturalistic teaching strategy designed for children with ASD that uses a developmental framework and behavioral principles to increase a childs motivation to partic ipate in communicativ e and social situations. In contrast to treatments aimed at teaching specific focal skills, PRT focuses on addressing pivotal areas which are believed to produce improvement in areas other than those specifically targeted (Koegal, K oegal, Harrower, & Carter, 1999). These pivotal areas include responsivity to multiple cues, child motivation, child self management, and child self initiations (Baker Ericzen, Stahmer, & Burns, 2007). For example, if child motivation to interact with caregivers is increased, the child may independently increase his or her own learning opportunities. PRT encourages children to initiate learning events and to benefit from naturally occurring rewards and consequences (Baker Ericzen, Stahmer, & Burns 2007). It has been shown that

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17 t reatment responders to PRT exhibited a greater interest in toys, are more tolerant of social proximity to others, engaged in lower rates of nonver bal self stimulation, and display higher rates of verbal self stimulation ( Rogers & Vismara, 2008). In general, PRT has demonstrated improved language, social, adaptive functioning, and play skills in children with ASD (Koegal, Koegal, Harrower, & Carter, 1999; Koegal, Koegal, Shoshan, & McNerney, 1999), as well as decreased levels of disruptive behaviors. Other popular models that maintain an emphasis on naturalistic strategies include Floortime or Developmental, Individual difference, Relationshipbased model (DIR; Greenspan, 1992; Greenspan & Wieder, 1999; Wieder & Greenspa n, 2006) and Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH; Mesibov, 1994; Schopler, 1994; Schopler & Reichler, 1971). All of these treatments focus on enhancing child motivation to engage in socialization and using behavioral principles within the context of the caregiver child interaction. Despite anecdotal evidence that existing naturalistic treatment strategies do lead to improvements in language and social interactions, sufficient research has not been cond ucted to establish these treatments as evidencebased. Reviews of various behavioral interventions for children with ASDs point to limitations in methodology and statistical design (Levy, Kim, & Olive, 2006; Wheeler, Blaggett, Fox, & Blevins, 2006; Na ti onal Research Council, 2001). Suggested guidelines for researching psychosocial inte rventions for children with ASD were developed in 2007 (Smith et al.), and included four distinct recommended phases of program development: (a) formulation and systematic application of a new intervention technique; (b) developing a manual and research plan for evaluation o f the intervention across sites; (c) randomized clinical

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18 trials (RCTs); and (d) community effectiveness studies. H owever, the number of true experimental design studies remains limited (Howlin, Magiati, & Charman, 2009). The lack of strong designs, independent replications, or peer reviewed data keeps many well known autism treatments from meeting criteria as evidencebased. For example, PRT in particular appears to have a relatively strong research backing based on singlesubject designs but the lack of randomized controlled trials prevents this treatments efficacy from being adequately evaluated (Rogers & Vismara, 2008). In addition, many treatments for ASD are not manualized (such as TEACCH) and the implementation of these treatments varies in replicability and quality at different sites (Helt, M., Kelley, E., Kinsbourne, M., Pandey, J., Boorstein, H., Herbert, M., et al., 2008). A review of studies that implemented naturalistic developmental intervention approaches (Wetherby & Woods, 2008) distinguished only five studies (Aldred, Green, & Adams, 2004; Drew et al., 2002; Kasari, Freeman, & Paparella, 2006; McConachie, Randle, Hammal, & LeCoureur, 2005; Yoder & Stone, 2006) that met the Smith et al. (2007) criteria for using a randomized controlled experimental group design, included children age 3 years or younger, and used social communication as a measure of outcome. Despite t he limited nature of the research on naturalistic strat egies, promising findings suggest ed that developmental interventions with low intensity (sometimes as little as an hour a week) and that include cliniciandelivered and parent training programs can improve social communication outcomes relatively quickly (in as few as 6 weeks) (Wetherby & Woods, 2008). In addition to the possibility that helping children improve social, communicative, and adaptive functioni ng, naturalistic strategies could also help caregivers to reduce child disruptive behaviors in young children with ASD.

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19 Parental positive attention to appropriate behaviors that are incompatible with negative behaviors has been shown to result in decreased negative behaviors and increased in targeted desired behavior (Boggs & Eyberg, 2008) Helping parents to use operant conditioning strategies outside of the clinical environment is instrumental to generalizing and maintaining child behavior changes (BrookmanFrazee, Stahmer, Baker Ericzen, & Tsai, 2006). However, very few st udies of treatments for children with ASD have explicitly targeted parenting practices with regard to externalizing behavior problems; instead, clinicians have taught parents to search systematically for the functions of disruptive behaviors without drawing attention to the parent child dynamic (BrookmanFrazee, Stahmer, Baker Ericzen, & Tsai, 2006). Future studies need to explore accessible early intervention treatments for ASDs that include parent implemented components, especially for families of low soc ioeconomic status and diverse cultural background. An intervention designed to improve the communicative, social, behavioral, and adaptive functioning of children through a sociobehavioral mechanism such as the parent child relationship may be key to affec ting change for children with ASD. Parent Child Interaction Therapy Parent Child Interaction Therapy (PCIT) is an evidencebased treatment for young children with disruptive behavior. PCIT has also been found effective for treating parent child dyads in other diagnostic populations (e.g., child abuse, separation anxiety di sorder, disruptive behaviors of children with intellectual delays) (Chaffin et al., 2004; Bagner & Eyberg, 2007; Pincus, Choate, Eyberg, & Barlow, 2005). The Child Directed Interaction (CDI) phase of PCIT allows parents to teach appropriate social behavior s (communication, sharing) through the behavioral principle of operant conditioning (Harwood & Eyberg, 2006). During CDI, parents learn to follow the childs play by

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20 providing positive attention for appropriate behaviors and ignoring inappropriate behavior s (Harwood & Eyberg, 2006) while at the same time fostering a close and rewarding parent child relationship. This use of differential social attention teaches children to increase behaviors that are more likely to receive positive parental attention (Boggs & Eyberg, 2008) In CDI Training, therapists observe and coach parents, via digital audiovisual transmission from the observation room, to use the CDI skills while interacting with their child in a playroom. This method of real time cueing and reinforcing caregivers skill in the application of differential social attention with their child leads to rapid skill acquisition and child behavior change (Shanley & Niec, 2010). The CDI component of PCIT has been found effective in increasing parent child attachment (Neary & Eyberg, 2002) and decreasing child disruptive behaviors (Harwood & Eyberg, 2006) in populations of children without developmental delay. PCIT research efforts initially focused on children with oppositional defiant disorder; children wit h ASDs were routinely screened from the studies and referred to other treatment. However, PCIT components may be therapeutic for young children with ASD because the conceptual foundation of PCIT emphasizes naturalistic strategies and incorporates both the parent child relationship and behavior analytic conceptualizations of change. In recent years, PCIT has shown potential promise as a focal treatment for ASD by increasing compliant behaviors and decreasing aggressive behaviors of children with ASDs (Masse, McNeil, Wagner, & Chorney, 2008). Like the PRT approach previously described, PCIT identifies caregivers as having an important role in implementing their childs tr eatment. Additionally, PCIT combines naturalistic and behavioral approaches by using childled activities to improve the parent child

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21 relationship and enhance social and communicative learning. This treatment involves parents as providers of differential reinforcement, imitation, and natural motivators to encourage desired behaviors in children with ASDs, such as increased verbalizations and social reciprocity. Theoretical Underpinnings of the Use of Child Directed Interaction Component for Children with Autism Spectrum Disorders The Child Directed Interaction component of PCIT may be effective as an intervention for young children with ASDs. Because the emphasis of CDI is to build attachment between caregiver and child and the CDI can be tailored to support appropriate child speech and play behaviors with praise, reflection, imitation, description and the expression of enjoyment (Eyberg, 1982), children may increase their language skills and repertoire of play behaviors. Due to deficits in social and communicative abilities, children with ASD often interact less frequently with parents and peer s than typically developing children and therefore miss out on important experiences that lead to the acquisition of social and communicative skills (Greenspan & Wieder, 1999; Mesibov, Shea, & Schoper, 2004). The results of a 16year longitudinal study dem onstrated that children of parents who synchronized their behavior to their childs behaviors and interests (essentially allowing the child to lead the play and following along with positive attention) had children with significantly better communication skills than children of parents who did not engage as actively with the children during play (Siller & Sigman, 2002). CDI Training, which similarly encourages and trains caregivers to follow their childs lead and make play enjoyable for the child, may have correspondingly positive outcomes. Studies of other parent implemented treatments for young children with ASD have found improved child communicative behavior and

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22 enhanced parent child interaction (McConachie & Diggle, 2005). For example, parent impleme ntation of naturalistic strategies was correlated with a significant increase in functional child verbalizations at post treatment assessment compared to a control group (Nefdt, Koegel, Singer, & Gerber, 2010). The combination of a rewarding, childcentere d social interaction and the use of the consistent behavioral principles seen in CDI would be expected to result in prosocial, language, adaptive and behavioral improvements following treatment. The effect of CDI Training (CDIT) alone on children with ASD has not been extensively studied. An adaptation of PCIT examining the effect of treatment among 19 children with highfunctioning ASD demonstrated a significant prepost increase in shared positive affect in the parent child relationship after the CDI phase of PCIT (Solomon, Ono, Timmer, & GoodlinJones, 2008). CDI training was also examined in a pilot study of 11 children with ASD designed to evaluate verbal language acquisition and prosocial interactions following treatment (Abner, 2008). Children showed decreased externalizing behavior as well as increased frequency of prosocial verbalizations and overall frequency of words spoken. Maintenance of Treatment Gains and PCIT Parent Child I nteraction T herapy has been associated with long term gains in childr en with disruptive behavior disorders. In a study examining child outcomes 3 to 6 years post PCIT, Hood and Eyberg (2003) found that children not only maintained their behavioral gains but also improved their behavior over time. In a study evaluating Tripl e P Positive Parenting Program, another widely disseminated program for children with disruptive behaviors, young children with Autism Spectrum Disorders maintained significantly reduced behavior problems at 6months post treatment (Whittingham, K.,

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23 Sofronoff, K., Sheffield, J., & Sanders, M., 2008). The maintenance of gains in PCIT and other parenting programs may be due to parental adherence to behavioral skills learned in treatment; without continued parental adherence, children might return to previous maladaptive behaviors. Moore and Symons (2009) evaluated patterns of parental adherence to treatment recommendations in the population of children with ASDs and found that parents were significantly more likely to adhere to behavioral treatment recommendat ions that asked them to reinforce their childs positive behaviors as opposed to those that asked them to punish negative behaviors (Moore & Symons, 2009). These results suggest that CDIT, which focuses on reinforcing appropriate behaviors, may also promot e adherence. Study Objectives and Hypotheses This study examines the effects of CDI Training (CDIT) on the verbal, social, adaptive and behavioral functioning in children with ASD. Child skill acquisition was assessed through direct observation of parent child interactions using a standardized laboratory situation and multiple measures to evaluate child functioning. Study objectives and aims are as follows: Aim 1 To determine whether CDIT improves verbal, adaptive, prosocial and behavioral functioning in c hildren with ASD at immediate post treatment assessment (Time 2 Assessment) when compared to a Waitlist control group. Hypothesis 1.1 Children in the immediate treatment (IT) group will demonstrate significantly fewer behavior problems than the WL control group at the Time 2 Assessment.

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24 Hypothesis 1.2 Children in the IT group will demonstrate significantly greater improvements in receptive and expressive language as com pared to the WL control group at the Time 2 Assessment. Hypothesis 1.3 Children in the I T group will demonstrate significantly greater improvements in prosocial behavior as compared to the WL control group at the Time 2 Assessment. Hypothesis 1.4 Children in the IT group will demonstrate significantly greater improvements in adaptive functio ning as compared to the WL control group at the Time 2 Assessment. Aim 2 To determine whether the expected gains from CDIT continue to be present at 6week follow up to treatment. Hypothesis 2.1 Six weeks following CDI Training completion, children will maintain behavioral outcomes from post treatment. Hypothesis 2.2 Six weeks following CDI Training completion, children will maintain receptive and expressive language outcomes from post treatment. Hypothesis 2.3 Six weeks following CDI Training completion, children will maintain prosocial behavior outcomes from post treatment. Hypothesis 2.4 Six weeks following CDI Training completion, children will maintain adaptive functioning outcomes from post treatment. Aim 3 To determine whether CDIT training improves verbal, adaptive, prosocial and behavioral functioning in children with ASD from pretreatment to the 6 week follow up. Hypothesis 3.1 Children will demonstrate significantly reduced behavior problems from the pr e treatment assessment to the six week Time 3 Assessment.

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25 Hypothesis 3.2 Children will demonstrate significant improvements in receptive and expressive language from the pretreatment assessment to the six week Time 3 Assessment. Hypothesis 3.3 Children w ill demonstrate significant improvements in prosocial behavior from the pre treatment assessment to the six week Time 3 Assessment. Hypothesis 3.4 Children will demonstrate significant improvements in adaptive functioning from the pretreatment assessment to the six week Time 3 Assessment.

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26 CHAPTER 2 METHOD Participants Participants were 30 families of children with ASDs, with 15 families in the Immediate Treatment Condition and 15 families in the Waitlist Control Condition. Children in the study w ere mostly boys (80%), with a mean age of 5 years, 11 months ( SD = 1.34). Participants were recruited from the University of Florida Psychology Clinic (33%), the University of Florida Psychiatry Clinic (17%), other research studies (10%), pediatricians (10%), recruitment materials (7%), tutors (3%), speech therapists (7%), occupational therapists (3%), schools (3%), and other (7% ). Racialethnic composition was 87% Caucasian, 0% African American, 7% multiracial, 0% Asian and 7% Hispanic Primary caregivers were all mothers. Primary caregivers education level was as follows: 3% did not complete high school, 13% graduated high school, 33% attended some college or technical school, 23% graduated college, and 28% completed some graduate education. Child ASD dia gnoses were 40 % Autistic Disorder, 7% Aspergers Syndrome, and 53% Pervasive Developmental Delay, Not Otherwise Specified (PDD NOS) Of the 15 families in the Immediate Treatment Condition who completed the 8 sessions of CDIT, 43% of primary caregivers met CDI graduation criteria. Seventy percent of assigned homework was completed by primary caregivers. Secondary caregivers were involved in 72% of treatment cases and participated in treatment in 45% of sessions. Of secondary caregivers who participated, 67% were fathers and 33% were stepfathers See Table 2 1 for child and family demographic information.

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27 The following criteria for child participants was required for study inclusion: (a) Diagnosis of ASD based on a previous diagnosis by a healthcare professional confirmed by the administration of the CARS2 at the Time 1 pretreatment assessment; (b ) Cognitive functioning at the 3year old level on tests of nonverbal functioning ; (c) Ability to speak 3 intelligible words or word approximations (incomplete/incorrectly spoken words that have the meaning of words); (d) Age between 3 years 0 months and 7 years 11 months; (e) Stability on their medications or other interventions one month prior to treatment and throughout the duration of their study partici pation. Due to the high comorbidity of ASD and Intellectual Disorder (ID) diagnoses, in combination with the known effectiveness of PCIT with children diagnosed ID (Bagner & Eyberg, 2007), children with dual diagnoses of ASD and ID wer e not excluded from t he study. The self selected Primary Caregiver was required to have unimpaired intellectual functioning (a cognit ive functioning equivalent standard score of at least 75) and to attend all sessions (one CDIT Teach Session and 7 CDIT Coaching Sessions) and assessments. Primary caregivers were required to have unimpaired cognitive functioning so that they would be able to learn the skills presented and generalize them to novel situations. Families were considered dropouts if they did not attend the 8 requir ed treatment sessions and the assessments. Children with a history of severe sensory impairment (e.g., deafness), or families with suspected abuse or crisis requiring out of home placement during the study were excluded from study participation. Inclusion and exclusion cri teria can be found in Diagram 1. Attrition Nine families who met inclusion criteria and were randomized to a treatment condition did not attend their Time 2 assessment and were considered dropouts. Of

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28 those 9 families, only 2 families had completed 1 or mor e treatment sessions; the rest of these families stopped participation before their first session. Of the 9 families that did not return for their Time 2 assessment, five families had been randomized to the WL condition and 4 were rand omized to the IT condition. Children of this subset were mostly boys (67%), with a mean age of 6 years, 11 months ( SD = .94). Racial ethnic composition was 56% Caucasian, 11% African American, 11% Asian and 22% Hispanic. ASD composition was 33% Autistic Di sorder and 68% Pervasive Developmental Delay, Not Otherwise Specified (PDD NOS). Primary caregivers education level was as follows: 11% did not complete high school, 11 % graduated high school, 44% attended some college or technical school, 22 % graduated c ollege, and 11% completed some graduate education. Participants were recruited from the University of Florida Psychology Clinic (44%), the University of Florida Psychiatry Clinic (22%), other research studies (11%), and schools (22%). Among the 7 participants who did not return after completing their pretreatment assessment but before receiving treatment, reported reasons for dropout included the following: starting a new medication or treatment (22%), family dynamic changes (22%), financial difficulties ( 11% ) and unknown (44%). Only 2 families in the Immediate Treatment group dropped out of the study after initiating treatment. In one case, a primary caregiver was in the midst of a difficult divorce. In the other case, the child demonstrated improvements i n school and the family decided that tr eatment was no longer necessary. See Table 22 for child and family demographic information. A chart of treatment flow is also provided to show the flow of participants throughout the study See Figure 21

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29 Measures A list of all measures and a chart of when each measure was collected can be found in Diagram A 2 Demographic and Background Questionnaire A parent questionnaire provided descriptive information about the child and family including sex, age, race/ethnicit y, occupation, education level, and medical history. See Figure C 1 for the Demographic and Background Questionnaire. Phone Screen er Initial phone screening occurred during the first phone contact that potentially interested participants made to us. If car egivers indicate d interest in participating, specific i nclusion/exclusion criteria were also be evaluated by the screener, including symptoms of ASD from the DSM IV TR (APA, 2000) Caregivers verbally presented with a checklist of symptoms of ASD and were asked to answer yes/no to whether their child met specific criteria. Children were required to meet criteria for ASD based on this checklist to be scheduled for a pretreatment assessment. See Figure B 1 for the Phone Screener. Semi structured I nterview A semi structured clinical interview was conducted with the caregiver at the pretreatment Time 1 Assessment to gather information on the childs sociobehavioral, family, and tr eatment history. See Figure D 1 for the Semi structured interview. The Childhood Autism Rating Scale ,Second Edition (CARS2; Schopler, Reichler, & Renner, 1988; Schopler, Bour gondien, Wellman,.& Love, 2010) The CARS is a 15 item observational screener developed to identify children with ASDs while distinguishing them from children w ith developmental disabilities without a

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30 cormorbid ASD. Assessors observe the child and then rate the child on 15 items of behavior. Internal consistency of .94 and 1year test retest reliability of .88 have been reported (Schopler et al., 1988). Inter rat er reliability ranged from a correlation coefficient of .55 (Level and Consistency of Intellectual Response) to .93 (Relation to People), with an average inter rater reliability of .71. The second edition of the CARS (the CARS2) keeps the original format o f the CARS and adds a form for evaluating children with High Functioning Autism and a parent report questionnaire to aide diagnosis. The Standard Version is equivalent to the original CARS and appropriate for children younger than 6 years old and those wit h communication difficulties or below average estimated IQs. The High Functioning Version is appropriate for verbally fluent children 6 years of age and older, with IQ scores above 80. The assessor selects which survey to complete based on child characteri stics. The CARS2 was used as an observational measure at the Time 1 Assessment to confirm ASD diagnosis. Peabody Picture Vocabulary Test Third Edition (PPVTIII: Dunn, 1997) The PPVT III is a well standardized measure of receptive language in individuals age 2.6 years and older. This instrument is offered in two parallel forms IIIA and IIIB for reliable testing and retesting. Reliability coefficients are as follows: Internal consistency (Alpha: .92 to .98), Split half: (.86 to .97), Alternateform (.88 to .96), and Test retest (.91 to .94). The PPVT III has an average correlation of .69 with the OWLS Listening Comprehension scale and .74 with the OWLS Oral Expression scale. It s correlations with measures of verbal ability are: .91 (WISC III VIQ), .89 (KAIT Crystallized IQ), and .81 (K BIT Vocabulary). The PPVT III was used to assess childrens level of receptive language and to track childrens receptive language development at all assessments. The child was randomly be assigned either form A or

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31 form B at the Time 1 Assessment. At the Time 2 Assessment, the child was tested using the other form. At the Time 3 Assessment, children were tested with the first form again. For the c hilds primary caregiver, a standard score of 75 or higher on form A was also required for study inclusion for someone who has not obtained the equivalent of a 2 year college degree. Vineland Adaptive Behavior Scales, Second Edition (VinelandII; Sparrow, Balla, & Cicchetti, 1984; Sparrow Cicchetti,, & Balla, 2005). The Vineland II is comprised of a semi structured interview that assesses personal and social skills in children from birth through 18 years, 11 months. The Parent/Caregiver form covers the sam e content as the Survey Interview, but uses a rating scale format. The VinelandII covers 5 domains: Communication, Daily Living Skills, Socialization, Motor Skills, and a Maladaptive Behaviors Index. Internal consistency coefficients for the Survey Form r anged from .83.94. Test retest reliability for domains was .83 to .90; with an Adaptive Behavior Composite of .88. The VinelandII also demonstrated strong construct and concurrent validity. It can be used to track progress after treatment completion. The VinelandII Parent/Caregiver form was administered at all major time points to track progress in adaptive behaviors across time points. Differential Abilities Scale, Second Edition (DAS II; Elliott, 2007). The DAS II is a brief, comprehensive measure of ability that is designed to measure the cognitive strengths and weaknesses in individuals between the ages of 2 years 6 months and 17 years 11 months across a broad range of developmental levels. A non verbal cognitive functioning score can be attained for children with very little language, thus making it appropriate for children with ASD who may not have sufficient

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32 expressive abilities to complete other measures of cognitive functioning. The DAS II is divided into two main testing batteries: The Early Year s battery and the School Age battery. All children were tested with the Early Years battery. The Early Years core battery includes verbal, nonverbal, and spatial reasoning subtests appropriate for ages 2:6 through 6:11. The battery is divided into two levels: children ages 2:6 3:5 and 3:6 6:11. The children were administered four core subtests to obtain the General Cognitive Abilities (GCA) composite score and children ages 3:6 6:11 take six core subtests which contribute to the GCA composite score. Although these subtests focus on ages 2:66:11, the DAS II can also be used to assess children ages 7:0 8:11 who are suspected of having cognitive delay. Testing usually takes 2030 minutes and the subtests can be given in any order to enhance child cooperation The DAS II was conducted at pretreatment to assess the childs level of intellectual functioning and to contribute to a screener of comorbid ID. Children were required to complete two tests of nonverbal reasoning at the 3year old level to be included in the study. Children with cognitive functioning below the 3year old level as measured by the DAS II were excluded from the study. Social Responsiveness Scale (SRS: Constantino & Gruber, 2005; Constantino et al., 2000) The SRS is a 65 item rating scale t hat measures the severity of autism spectrum symptoms as they occur in natural social settings, such as interactions with parents or peers, for children 4 to 18 years old. The items are rated on a 4point Likert scale ranging from not true to always true and informants are asked to consider the last 6 months. This parent completed measure takes approximately 15 to 20 minutes and provides a clear picture of a child's social impairments, assessing social awareness,

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33 social information processing, capacity for reciprocal social communication, social anxiety/avoidance, and autistic preoccupations and traits. In addition to a Total Score reflecting severity of social deficits in the autism spectrum, the SRS generates scores for five Treatment Subscales: Social Awareness, Social Cognition, Social Communication, Social Motivation, and Autistic Mannerisms. The SRS standardization sample was composed of more than 1,600 children from the general population. Norms are separated by rater (i.e., parent, teacher) and by the rated child's gender. Test retest stability ranged from .77 to .85 for parent ratings; mother father interrater reliability was .91.Validity was examined for the SRS in terms of discriminant validity, concurrent validity, structural validation, and factor analytic studies. The SRS was administered to the parents of all children over 4 years old at each of the three assessments. Cronbachs Alpha at pretreatment for this sample was 0.84. Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999). The ECBI is a 36 item parenting scale of disruptive behavior. The ECBI Intensity Scale measures the frequency with which disruptive behavior occurs, and the Problem Scale measures how problematic the childs behavior is for the parent. The Intensity and Proble m scales yield test retest reliability coefficients of .80 and.85 across 12 weeks and .75 and .75 across 10 months, respectively (Funderburk, Eyberg, Rich, & Behar, 2003). Psychometric examination of the ECBI with children with MR referred for treatment of behavior problems found these children received lower scores on both scales than nondelayed children referred for treatment of behavior problems (Cone & Casper Beliveau, 1997). Their scores were significantly above normative means, however, supporting the use of these scales for measuring outcome in this population. In our study, the ECBI was completed weekly by the primary caregiver to assess

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34 treatment progress and was used as a measure of treatment outcome. Cronbachs Alpha at pre treatment for this samp le was 0.91 for the Frequency scale and 0.83 for the Problem scale. Dyadic Parent Child Interaction Coding System (DPICS; Eyberg, Nelson, Duke, & Boggs, 2004). The DPICS is a behavioral observation coding system that measures the quality of parent child so cial interaction during three 5minute standard situations that vary in the degree of parental control (i.e., childled play, parent led play, and cleanup). The convergent and discriminative validity of the DPICS categories have been extensively documente d, and the psychometric data are summarized in the DPICS manual (Eyberg et al., 2004). The DPICS were administered to all caregivers and children at all major assessments, as well as during the first 5minutes of the parent child interaction of CDIT sessi ons. The total verbalizations of the child as measured by DPICS categories was calculated by summing all child codes across DPICS categories DPICS coding sessions were videotaped to ensure reliability of coding and coding reliability observations is in progress Kappa = 0.66. Word Count (Abner, 2008) Word Count was defined as the number of intelligible words spoken by the child in a 5minute period during the childled play DPICS situation to measure expressive language. To be included in the frequency count, words had to be distinct and separate from one another, b ut could be repeated words. In a previous study, 92% inter rater reliability was obtained. Samples of the childs Word Count were coded from the same 5 minute DPICS coding sessions as indicate d in the DPICS description in the above section. Thus, Word Count sessions were also videotaped to ensure reliability of

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35 coding. Coding reliability observations is in progress Inter rater reliability will be calculated when reliability coding is complete. Kappa=0.13. Treatment Integrity PCIT All therapy sessions were videotaped, and 30% of the session tapes from each family were randomly selected and checked for integrity using the treatment manual sess ion integrity checklists. Twenty seven percent of the checked tapes were again randomly selected and checked independently by a second coder to provide an interobserver reliability estimate. Integrity coding is still in progress, and treatment sessions for 11 of the 15 families have been coded. For these 11 families, accuracy was 98% with treatment protocol, and percent agreement interrater reliability was 97% (range = 90100%). Experimental Design Half of the 30 family sample (n=15) was randomized to immediate treatment (IT) condition and started CDIT treatm ent at Week 2 (1 week after the initial assessment). The other 15 families were randomized to the waitlist (WL) condition, and began CDIT treatment at Week 13 (12 weeks after the initial assessment; see Diagram A 3 ). Major assessments were conducted at three time points for participants in both the IT and WL conditions. The Time 3 Assessment for the IT condition served as their 6week follow up assessment and it served as the post treatment assessment for the WL condition ( see Diagram A 3 ). Each individually conducted assessment included a measure of language skills (receptive and expressive); parent report measures of child and family functioning, child adaptive functioning, child disruptive behaviors; and observations of child social behaviors within the context o f parent child interactions with the self identified primary caregiver. The Time 1 assessment also included interviews

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36 with the caregiver(s), parent report demographic form, ASD symptom screener (CARS2), and intelligence assessment for children and caregivers (DAS II and PPVT III). During treatment, weekly parent ratings of child behavior, child Word Count, and observations of parent child interaction were collected to guide treatment. The Assessment and Treatment Timeline is presented in Diagram A 3 Procedure Phone Screening Initial phone screening occurred during the first phone contact that potentially interested participants made to us. This prescreening was used to collect basic identifying information including name, contact information, age, and whether the child has previously received a diagnosis of ASD by a mental health professional. The family was informed of study procedures, time requirements, wait list design, and inclusion and exclusion criteria. If caregivers indicated interest in participating, specific i nclusion/exclusion criteria were also be evaluated by the screener, including symptoms of ASD from the DSM IV TR. Eligible families were scheduled for a Time 1 Assessment during this phone conversation. The Major Assessments T ime 1 assessment The Time 1 assessment is the first of the major assessmen ts and was completed prior to treatment. The Time 1 assessment visit was devoted to completing the informed consent process determining if the family met all study inclusion criteri a, and then obtaining baseline information. Informed c onsent A trained assessor met each family to complete the informed consent process. During this process, the assessor reviewed the limits of confidentiality

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37 and the purposes of the study, its methods and procedures, risks and benefits, treatment options outside the study, requirements of participation, and remuneration available. The assessor also review ed parental expectations, experience, and knowledge related to ASD and provided a summary of available evidence regarding ASD treatments for preschoolers and reviewed community treatment standards, covering risks, side effects and potential benefits, treatment options outside the study, requirements of participation, random assignment to treatment or wai tlist group, remuneration available to study participants, and the right to withdraw at any time wit hout penalty. The assessor explained that some families would not begin treatment for 12 weeks. All participants in the study were told during the informed consent process that if they or their child report ed child abuse to the researchers, or if the researchers observed evidence of child abuse or abusive behavior at any time during t his study, the researchers would be required by law to report this informati on to the appropriate agents and agencies. Key personn el and research assistants answer ed a ny questions the caregivers had, and informed consent was documented by written signature of the caregiver participant and the signature of the personnel obtaining t he c onsent before any measures were collected. For families with secondary caregivers participating, secondary caregivers signed a separate informed consent doc ument. Child assent was not obtained due to the childrens age and likely inability to underst and what is involved in the research, as well as potential benefits to participants, other children with ASD, or society as a whole. Parents were asked to sign the consent form indicating their willingness to participate. Parents were provided with a copy of the informed consent to take home with them to

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38 examine at their leisure. If the parents did not wish to postpone tr eatment for 12 weeks if they were randomized t o the WL condition, they were excluded from the study and referred elsewhere for treatment. If the family wished to complete PCIT, they were referred to PCIT providers in the Psychology Clinic or the community. Other information obtained Following the informed consent process, parents complete d the Demographic Questionnaire. They participated in a semi structured interview with the assessor to evaluate specific questions and concerns and treatment goals The assessor administer ed the PPVT III and the DAS II to the child while the parents completed the ECBI, the VinelandII, the Social Responsi veness Scale and other forms The parents also complete d the DPICS parent child interaction observations for CDI (requiring 10 minutes per parent), at which time child wordcount was obtained. Primary caregivers that had not obtained a 2year college deg ree complete d the PPVT III. When all the measures were complete, the assessor review ed with the parent any missing or incorrectly completed items. The assessor discuss ed the results w ith the family. Families that did not meet study criteria were referred els ewhere as appropriate. Families did not receive monetary reimbursement for the first major assessment. Time 2 and time 3 assessments and 6week follow up a ssessments Time 2 Assessments were completed by both the IT and the WL group after the IT group has completed treatmen t. The Time 3 Assessment was completed by the IT group 6 weeks after the Time 2 Assessment. The Time 3 Assessment was completed by the WL group after this group completed treatment. These assessments are identical to one another and simi lar to the pretreatment assessment except that the interview,

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39 PPVT III for parents and DAS II were no t administered. Families were paid $10 for each of the post treatment assessments. Randomization After 2 families had completed the Time 1 assessments, they were randomly assigned to one of two treatment conditions: (a) Immediate Treatment (IT) or (b) Waitlist (WL). A stratified approach was used to ensure that both treatment conditions were similar in terms of the severity of autistic symptomatology with equivalent numbers of children with Autistic Disorder, Aspergers Disorder, and PDD NOS in the IT and the WL groups. A stratified approach was used as follows: There were three different lis ts of ID numbers. Each list corresponded with an ASD Diagnosis: A utistic Disorder, Aspergers Syndrome, and PDD NOS. Prior to treatment, three ID numbers were randomly preassigned to either the WL or the IT condition. After the child received an A SD diagnosis, the family was randomly assigned an ID number from the list specific to that diagnosis. The child was placed in the treatment group that has been preselected to correspond with the ID number. For example, if a child received a diagnosis of Aspergers Disorder, his family would be randomly assigned an ID number fr om the Asperger Disorder list. This number would already be associated with a treatment condition No random number was us ed more than once. Assignment was always made in the order participants signed their informed consent form, thus controlling for lag time in t he two treatment conditions. The families were informed by the project coordinator by telephone of their treatment group assignment, therapists names, and approximate treatment start date.

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40 Treatment Core features of PCIT PCIT has similarities t o other parent training approaches for children with externalizing behavior, but may be distinguished by five core features. First, both the child and parents are involved in treatment, and treatment progress is determined by changes in their interactions. The second core feature is extensive in vivo coaching of parents during parent child play situations, enabling shaping of parents behaviors directly, and the childs behaviors via the parent. The third core feature of PCIT is its emphasis on responsive parenting by shaping nurturant parenting and related nonverbal communication skills in the early phase of treatment. A fourth core feature is in vivo training of the discipline procedure in clinic sessions until parents achieve competency and are able to use the procedures independently. Finally, PCIT is assessment driven, and treatment continues until the treatment goal criteria are met. Sessions are guided by observational data collected in the first 5 minutes of the parent child interaction, and the fam ily reviews a summary sheet of these weekly data at the end of each session to evaluate their progress toward the mastery criteria, determine targets for homework practice, when to move from one treatment phase to the next, and provide one of the criteria for termination. Application of PCIT The application of PCIT in this study was in many ways unchanged from traditional PCIT. Individual PCIT sessions were conducted once a week and were approximately 75 minutes in length. The first session was devoted to building rapport and orienting the family to the therapy process. Typically, the ChildDirected Interaction phase is the first phase of treatment preceding the Parent Directed Interaction discipline phase. The

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41 principles and skills of the interactions were presented in the first teaching session to the parents alone, using modeling and roleplay. Coaching sessions followed in which parents took turns being coached interacting with their child or observing and coding skills of their spouse. Parents were ask ed to practice the skills during daily home play sessions with their child (5 minutes each day). Coaching focused on helping the parents to obtain mastery of the specific CDI skills during the 5min coding interval at the start of the session (i.e., 10 be havioral descriptions; 10 reflections; 10 labeled praises; and fewer than 3 commands, questions, or criticisms). Adaptation of PCIT for the purposes of this research In this specific sample, coaching was tailored to focus on helping parents to implement the skills to address to the needs of their specific child in an effort to improve language, adaptive, and prosocial functioning and to decrease disruptive behaviors. Further, the study investigated the potency of CDI Training (CDIT) alone as it impacts th e parent child relationship and level of ASD symptomotology (e.g., stereotypic behaviors, imitative skills, eye contact, etc.). Because the focus of this research is on CDIT skill acquisition, the second phase of treatment, the Parent Directed Interaction (PD I) phase was not taught. Seven coaching sessions of CDIT were completed whether or not the parent obtained mastery of skills within the seven sessions. In standard PCIT, parents move on the second phase of treatment when they obtain CDIT Mastery Criteri a, as CDIT skills continue to be coached and honed within PDI. However, clinical experience has demonstrated that some families may reach mastery criteria for CDIT in the first or second session of treatment. We did not want to penalize parents who learn t he skills more quickly by denying them important sessions of coaching and learning to tailor this skill set to their

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42 specific ASD child. For this reason, although CDIT mastery was encouraged and not all parents reached this standard, all parents received the same number of treatment sessions. Statistical Analysis Data analysis was conducted using the Statistical Package for the Social Sciences 17.0 (SPSS). Preliminary statistical analyses and specific analyses for each hypothesis are detailed below. Dat a was screened to ensure univariate normal distribution prior to statistical analyses using a number of indicators. Normality assumptions were first assessed with descriptive statistics and boxplots. Values of kurtosis and skewness were also considered, and z score values at or above 2.58 were selected as cut points to indicate a significantly nonnormal distribution. Finally, Kolmogorov Smirnov and ShapiroWilk tests were used (Field, 2005). Using these multiple indicators, significantly nonnormal distrib utions were analyzed using nonparametric statistical tests to preserve integrity of data points in a small sample. Descriptive statistics, including means and standard deviations of the DPICS total child verbalizations ECBI (Intensity and Problem scales ) PPVT III, Wordcount, VinelandII (Composite, Social, and Maladaptive Behavior Index Scales) and the Social Responsiveness Scale, and demographic variables were reported. The Outcome Measures Breakdown is presented in Diagram 4 in Appendix A. For hypot heses 1.1 to 1.4, assessing the within and between group differences following CDI training, a mixed betweenwithin subjects analyses of covariance (ANCOVA), with pre treatment scores as covariates, was conducted to determine

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43 training effects from pretrai ning to post training on each measure. ANCOVA was chosen to control for any incidental pretreatment discrepancies between groups. For hypotheses 2.1 to 2.4, assessing the maintenance of changes in child behavior, child receptive and expressive language, child prosocial behavior, and child adaptive functioning, paired samples t tests were conducted to assess for significant changes in parent report of child externalizing behavior problems, adaptive functioning, and child prosocial behaviors, and observed s ignificant changes in child language. However, due to the small sample size of groups that completed the Time 3 assessments in the current study, related low power for analyses, and potential for inaccuracy in results, transformations were not conducted on these variables to correct for significant skewness for analyses. Instead, the Wilcoxin Signed Ranks Test, a nonparam etric repeatedmeasures analysis was used to evaluate significance on data that was not normally distributed. For hypotheses 3.1 to 3.4, assessing the changes from pretreatment to 6 week follow upin child behavior, child receptive and expressive language, child prosocial behavior, and child adaptive functioning, paired samples t tests were conducted to assess for significant changes in parent report of child externalizing behavior problems, adaptive functioning, and child prosocial behaviors, and observed significant changes in child language. However, due to the small sample size of groups that completed the Time 3 assessments in the cur rent study, related low power for analyses, and potential for inaccuracy in results, transformations were not conducted on these variables to correct for significant skewness for analyses. Instead, the Wilcoxin Signed Ranks Test, a nonpara metric repeatedmeasures analysi s, was used to evaluate significance on

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44 data that was not normally distributed.

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45 Table 2 1. Demographic characteristics of i mmediate treatment and waitlist groups I mmediate Treatment W aitlist Control Characteristic M SD M a SD t (28) X 2 p Child age (m onths) 57.00 13.87 65.87 17.27 1.55 -0.13 CARS II severity 49.67 7.16 48.40 6.80 0.49 -0.62 Child s ex (% male) 80.00 --80.00 --0.00 1.00 Child e thnicity (% Caucasian) 86.70 -86.70 --0.00 1.00 Receiving other treatments during participation (%) Occupational therapy 33.30 -60.00 --2.80 0.09 Speech t herapy 73.30 -53.30 --0.42 0.52 P sychiatric m edication 28.6 0 -28.60 --0.00 1.00 Diagnosis (%) Autistic Disorder 46.70 -33.30 --0.56 0.46 Aspergers Syndrome 6.70 -6.70 --0.00 1.00 PDD NOS 46.70 -60.00 --0.54 0.46 Mate rnal a ge (years) 34.93 8.86 38.93 7.11 1.36 -0.18 Maternal e ducation (% completed 2 years college) 80.00 -86.70 --0.24 0.62 Note: PDD NOS = Pervasive Developmental Delay, Not Otherwise Specified an = 15. b n = 15.

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46 Table 2 2 Demographic c haracteristics of time 2 completers and dropo uts befo re t ime 2 Completers a Drop Outs b Characteristic M SD M a SD t (37) X 2 p Child age (m onths) 61.43 16.04 73.33 11.45 2.07 -<0.05 Child s ex (% male) 80.00 -66.70 --0.69 0.41 CARS II severity 49.03 6.89 49.33 8.32 0.12 -0.91 Child ethnicity (% Caucasian) 86.70 -55.60 --4.11 <0.05 Receiving other treatments during participation (%) Occupational t herapy 46.70 -55.60 --0.22 0.64 Speech t herapy 63.30 -66.70 --0.03 0.86 Psychiatric m edication 20.00 -22.20 --0.02 0.89 Diagnosis (%) Autistic Disorder 40.00 -33.33 --0.13 0.72 Aspergers Syndrome 3.33 -0.00 --0.31 0.58 P DD NOS 53.33 -66.67 --0.50 0.48 Maternal Age (years) 36.93 8.15 37.56 9.14 0.20 -0.81 Maternal Education (% completed 2 years college) 83.30 -77.70 --0.15 0.70 Note: Completers= completed time 2 a ssessme nt, Drop Outs= did not complete time 2 assessment PDDNOS = Pervasive Developmental Delay, Not Otherwise Specified an = 30. b n = 9.

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47 Phone Screened for eligibility ( n = 63) Completed Pre Treatment (Time 1) Assessment and Randomized ( n = 39) Excluded ( n = 24): Did not meet criteria ( n =16) Refused to participate ( n = 2) Did not attend Time 1 assessment ( n = 6) Completed Post Treatment (Time 2) Assessment ( n = 15) Completed Post Treatment (Time 2) Assessment ( n = 15) Assigned to IT ( n = 19) Completed intervention ( n = 15) Dropped before intervention ( n = 2) Dropped during intervention ( n = 2) Assigned to WL ( n = 20) Completed wait ( n = 15) Dropped during wait ( n = 5) 6 Week Follow Up (Time 3) Completed ( n = 8) Chose not to attend Time 3 ( n = 3) Waiting to complete ( n = 4) Figure 2 1 Sampling and f low of p articipants t hroughout Child Directed Interaction Training IT = Imm ediate Training Group; WL= Waitl ist Control. Participant flow chart from phone screening through the final assessment for Child Directed Interaction Training.

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48 CHAPTER 3 RESULTS Demographic Information Independent samples t tests and chi square analyses were conducted to determine whether significant differences existed between the Immediate Treatment and Waitlist Control groups at pretreatment. The results were not significant, indicating no significant differences in child age, mother age, severity of ASD symptoms, breakdown of ASD diagnoses, mother education, child ethnic diversity, or gender between groups at pre treatment ( see Table 21 ). In additio n, participants who completed the Time 2 evaluations were compared to participants who dropped out of the study before their Time 2 assessment. A dditional independent samples t tests and chi square analyses were conducted to determine whether significant differences existed between Time 2 completers and study dropouts at pretreatment. The results were not significant for child gender, use of other treatments or services, breakdown of ASD diagnoses severity of ASD symptoms, or maternal education, indicating no significant differences i n these domains between groups at pretreatment. However, there were significant differences in child age, indicating that children who completed their Time 2 assessment were significantly younger than children who dropped out before their Time 2 assessment t (37)= 2.07, p < .05 Children in families who dropped out were also significantly more ethnically diverse than children in families that completed their Time 2 assessments x2= 4.11, p < .05 (see Table 2 2 ). Comparison of the Immediate Treatment and Waitlist Control Groups at Immediate Post Treatment Assessment Results were analyzed to determine whether CDIT improves verbal, adaptive, prosocial and behavioral functioning in children with ASD at immediate post treatment

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49 assessment (Time 2 Assessmen t) when compared to a Waitlist C ontrol group. Mixed betweenwithin subjects analyses of covariance (ANCOVA), with pretreatment scores as covariates, were conducted. At Time 2 assessment, differences between the IT and WL groups were examined for the following outcome variables: (a) child disruptive behavior as measured by the ECBI and the Maladaptive Behaviors Index on the VinelandII, (b) child receptive language as measured by the PPVT III, (d) child expressive language as measured by total child verbalizations during DPICS and W ordcount measures, (e) child social behaviors as measured by the SCS ad the VinelandII Socialization Domain, and (d) child adaptive functioning as measured by the VinelandII Composite Score. Mean scores for IT and WL groups on outcome measures are shown on Table 3 1 More specific findings for domains of functioning are outlined below. Disruptive Behavior On the ECBI Intensity Scale, the parents of children in the IT group reported significantly fewer disruptive behaviors at Time 2 than caregivers in the WL group, F (1,27)= 16.50, p < .001 and parents reported significantly lower problem scores associated with their childs behavior, F (1,27)= 8.95, p < 0.05. These r esults are consistent with decreased ECBI frequency and severity scores obtained in a previous study evaluating CDIT in an ASD population (Abner et al., 2008). Group differences were not significant on the Maladaptive Behaviors Index of the VinelandII, in dicating that parents did not perceive children as improving significantly on this measure, F (1,27)= 1.86, p = 0.19. Receptive and Expressive Language On the PPVT III, an objective measure of child receptive language, group

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50 differences were not significant at Time 2, F (1,27)= 0.01, p = 0.91. On objective measures of expressive language, children in the IT condition did not demonstrate increased vocalizations as measured words spoken (Wordcount ) F (1,27)= 0.58 p = 0.81, or by the DPICS ; conversely they demons trated significantly reduced social vocalizations compared to children who had yet to receive treatment as measured by DPICS, F (1,27 )= 5.83 p < .0 5. Social Skills Group differences on the Social Responsiveness Scale were not significant for Social Motivation F (1,27)= 0.93, p = 0.34, Autistic Mannerisms F (1,27)=1.14, p = 0.30, Social Communication F (1,27)=0.13, p = 0.72, Social Cognition F (1,27)=1.33, p = 0.26, on t he SRS overall Composite Score F (1,27)=2.43, p = 0.13, or on the Socialization subscale of the VinelandII, F (1, 27 )=2.80, p = 0.11. However, on the Social Awareness scale, children in the IT group demonstrated significant gains when compared to children i n the WL group at the Time 2 post treatment assessment F (1,27)= 6.82, p < .05. This outcome suggests that children did improve in their social understanding following CDI training, particularly in the domain of awareness of social cues Adaptive Functioni ng Group differences for the overall Composite score of the VinelandII were not significant, F (1,27)= 0.08, p = 0.79. Maintenance of Treatment Gains from Post Treatment (Time 2) to 6Week Follow Up Paired samples t tests were conducted to assess for significant changes in parent report of child externalizing behavior problems, adaptive functioning, and child prosocial behaviors, and observed significant changes in child language from Time 2 to

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51 Time 3 assessments. Wh en data was not normally distributed, a Wilcoxon signedrank test, a non parametric test, was calculated. All results were nonsignificant; indicating that the childrens functioning did not significantly improve or worsen between the post treatment assess ment and 6week follow up (see Table 3 2 ). Changes from Pre treatment to 6 week Follow Up In order to assess the changes from pretreatment to 6 week follow up in child behavior, child receptive and expressive language, child prosocial behavior, and child adaptive functioning, paired samples t tests were conducted. When data was not normally distributed, a Wilcoxon signedrank test, a nonparametric test, was calculated. Analyses indicated significant improvements from pretreatment to 6 week follow up in disruptive behavior as measured by the ECBI Intensity Scale, t (7)=3.47, p < .05, the ECBI Problem Scale, t (7)= 4.30, p < .05, and the VinelandII Maladaptive Behavior Index Scale, t (7)= 2.49, p< .05 General adaptive functioning, as measured by the VinelandII Composite score also improved during study participation, t (7)= 3.11, p< .05 (see Table 33 ). It is important to note that the subset of participants in the Immediate Treatment group who retur ned for their 6week follow up assessment demonstrated lower severity on some domains of functioning at the pretreatment assessment than children that had not yet completed their 6week follow up. The result s of an independent samples t test indicated t hat at pretreatment, children who later completed their 6week follow up assessment demonstrated significantly less symptom severity on the SRS Social Motivation Scale ( M= 81.14 SE= 4.70) than children who had not yet completed their 6week follow up asses sment ( M= 88.38, SE= 3.46), t (7)= 1.59, p< .05. In addition, children who completed their 6week follow up assessment demonstrated significantly

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52 lower symptom severity on the SRS Composite Scale ( M= 75.86, SE= 5.37) than children who had not yet completed th eir 6 week follow up assessment ( M= 86.00, SE= 2.27), t (7)= 1.82, p< .05

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53 Table 31. Mean scores for measures at time 1 and time 2 assessments Time 1 Time 2 Measure Group n M SD M SD F (1,27) p d a Eyberg Child Behavior In ventory Intensity IT 15 134.67 31.09 101.20 37.19 16.50 <.001 1.12 WL 15 135.93 24.24 134.27 19.35 Problem IT 11 17.85 5.16 7.00 6.32 8.95 <.05 0.92 WL 14 15.00 7.89 13.36 7.52 Vineland A daptive Behavior Scales, 2 nd Ed Maladaptive Behavior Index IT 12 20.47 1.81 19.67 2.27 1.86 0 .19 0.36 WL 10 20.50 1.78 20.36 1.55 Composite IT 12 74.27 11.40 75.75 11.87 0.08 0 .79 0.18 WL 10 75.40 9.31 77.64 8.48 Socialization IT 12 70.40 9.45 73.75 13.55 2.80 0 .11 0.24 WL 10 71.00 10.15 70.79 10.45 Social Responsiveness Scale Awareness IT 15 75.07 12.03 67.47 14.22 6.82 <.05 1.03 WL 15 78.26 8.46 78.53 5.42 Cognition IT 15 81.07 10.10 80.60 9.34 1.33 0 .26 0.18 WL 15 77.33 9.84 82.13 7.24 Communication IT 15 81.33 15.13 78.73 12.53 0.13 0 .72 0.10 WL 15 81.13 8.54 79.80 8.57 Motivation IT 15 81.27 11.60 75.27 12.33 0.93 0 .34 0.17 WL 15 71.93 14.52 73.00 13.92 Autistic Mannerisms IT 15 83.60 9.82 79.60 11.54 1.14 0 .30 0.12 WL 15 80.33 10.80 81.00 11.19 Composite IT 15 85.00 9.28 80.27 11.97 2.43 0 .13 0.17 WL 15 82.13 9.00 82.00 8.56 Peabody Picture Vocabulary Test, 3 rd Ed. IT 15 82.60 26.72 84.00 22.25 0.01 0 .91 0.42 WL 15 98.10 24.11 93.87 24.62 Dyadic Parent Child Interaction Coding System Total child v erbalizations IT 14 64.20 32.27 37.79 19.23 5.83 <.05 0.80 WL 15 59.87 17.03 53.07 18.84 Wordcount IT 14 132.27 88.93 166.33 73.58 0.58 0 .81 0.10 WL 15 185.33 91.56 157.14 100.03 Note: IT= immediate treatment, WL= waitlist control a Cohens d = effect si ze between IT and WL groups at t ime 2

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54 Table 32. Mean scores for measures at time 2 and t ime 3 a ssessments Time 2 Time 3 Measure n M SD n M SD t (7) z a p d b Eyberg Child Behavior Inventory Intensity 8 88.0 28.4 8 100.63 27.62 2.34 -0.52 0.45 Problem 4 4.25 4.79 4 7.25 3.40 2.04 -0.13 0.72 Vineland Adaptive Behavior Scales, 2 nd Ed. Maladaptive Behavior Index 6 18.83 1.17 6 19.50 1.22 1.35 -0.24 0.56 Composite 6 81.83 11.96 6 86.50 13.87 1.65 -0.16 0.36 Socialization 6 80.17 13.41 6 85.50 18.40 1.07 -0.33 0.33 Social Responsiveness Scale Awareness 8 61.75 15.76 8 68.62 8.09 2.08 -0.08 0.55 Cognition 8 79.63 10.64 8 79.00 9.90 0.28 -0.79 0.06 Communication 8 76.50 16.17 8 74.75 13.19 -0.95 0.34 0.12 Motivation 8 72.75 15.12 8 73.63 10.88 0.26 -0.80 0.07 Autistic Mannerisms 8 78.00 13.62 8 79.88 9.82 -0.68 0.50 0.15 Composite 8 77.00 14.79 8 79.88 10.92 -1.26 0.21 0.22 Peabody Picture Vocabulary Test, 3 rd Ed. 8 92.00 18.52 8 90.13 18.92 0.26 -0.80 0.10 Dyadic Parent Child Interaction Coding System Total child v erbalizations 8 33.37 14.02 8 39.38 24.71 -0.53 0.59 0.30 Wordcount 8 113.00 65.60 8 112.67 83.90 -0.63 0.53 0.00 Note: Analyses from immediate treatment condition aCohens d = effect size between Time 2 and Time 3. b Wilcoxin Signed Ranks Test= non parametric test for non normal data

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55 Table 33. Mean scores for m easures at time 1 and time 3 assessments Time 1 Time 3 Measure n M SD n M SD t (7) z a p d b Eyberg Child Behavior Inventory Intensity 8 129.75 25.89 8 100.63 27.62 3.47 -<0.05 1.09 Problem 6 18.33 2.80 6 8.67 6.38 4.30 -<0.05 1.96 Vineland Adaptive Behavior Scales, 2 nd Ed. Maladaptive Behavior 7 20.71 1.38 7 19.57 1.13 2.49 -<0.05 0.90 Composite 7 78.71 10.40 7 85.43 12.97 3.11 -<0.05 0.57 Socialization 7 75.00 10.30 7 85.57 16.80 1.52 -0.18 0.76 Social Responsiveness Scale Awareness 8 72.50 14.26 8 68.62 8.09 1.20 -0.27 0.33 Cognition 8 78.63 12.40 8 79.00 9.90 0.18 0.87 0.03 Communication 8 81.50 11.23 8 74.75 13.19 -1.90 0.06 0.55 Motivation 8 77.63 14.08 8 73.63 10.88 -1.10 0.27 0.32 Autistic Mannerisms 8 82.63 11.26 8 79.88 9.82 -1.15 0.25 0.25 Composite 8 82.13 11.84 8 79.88 10.92 -0.85 0.40 0.20 Peabody Picture Vocabulary Test, 3 rd Ed. 8 82.75 29.91 8 90.13 18.92 -1.08 0.32 0.94 Dyadic Parent Child Interaction Coding System Total child verbalizations 8 62.63 34.70 8 39.38 24.71 -1.26 0.21 0.77 Wordcount 8 128.33 58.23 8 112.67 83.90 -0.84 0.40 0.22 Note: Analyses from immediate treatment condition aCohens d = effect size between Time 2 and Time 3. b Wilcoxin Signed Ranks Test= non parametric test for non normal data

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56 Figur e 31. Caregiver ratings of the ECBI Intensity raw scores from preto post t reatment for the IT and WL groups. ECBI = Eyberg Child Behavior Inventory ; IT = Immediate Treatment Group, WL = Waitlist Control Group. The scores presented in this graph are the means from the 15 Immediate Treatment and 15 Waitlist Control Participants at preand post treatment.

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57 Figure 32. Caregiver ratings of the ECBI Problem scores from pre to p ost Treatment the IT and WL groups. ECBI = Eyberg Child Behavior Inventory ; IT = Immediate Treatment Group, WL = Waitlist Control Group. The scores presented in this graph are the means from the 15 Immediate Treatment and 15 Waitlist Control Participants at preand post treatment.

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58 Figure 33. Caregiver ratings of the Social Responsiveness Scale Awareness scores from pre to p ost t reatment the IT and WL groups. S RS= Social Responsiveness Scale ; IT = Immediate Treatment Group, WL = Waitlist Control Group. The scores presented in this graph are the means from the 15 Immed iate Treatment and 15 Waitlist Control Participants at preand post treatment.

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59 Figure 34. Observed number of total child verbalizations during a 5minute child led play situation of the DPICS from preto post t reatment in the IT and WL groups. DPICS = Dyadic Parent Child Interaction Coding System ; I T = Immediate Treatment Group, WL = Waitlist Control Group. The scores presented in this graph are the means from the 15 Immediate Treatment and 15 Waitlist Control Participants at preand post treatment.

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60 Figure 35. Caregiv er ratings of the ECBI Intensity raw scores from pre treatment to 6week follow u p assessments for the IT group. ECBI = Eyberg Child Behavior Inventory ; IT = Immediate Treatment Group. The scores presented in this graph are the means from the 8 Immediate Treatment p articipants at pretreatment and 6week follow u p.

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61 Figure 36. Caregiver ratings of the ECBI Problem scores from pre Treatment to 6week follow u p assessments for the IT group. ECBI = Eyberg Child Behavior Inventory ; IT = Immediate Treatment Group. The scores presented in this graph are the means from the 6 Immediate Treatment Participants at pretreatment and 6week follow u p.

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62 Figure 37. Caregiver ratings of the Vineland II Maladaptive Behavior Index scores from pre treatment to 6week follow u p assessments for the IT group. VinelandII = Vineland Adaptive Behavior Scales ; IT = Immediate Treatment Group. The scores presented in this graph are the means from the 7 Immediate Treatme nt p ar ticipants at pretreatment and 6week follow u p.

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63 Figure 38. Caregiver ratings of the Vineland II Composite scores from pretreatment to 6 week follow u p assessment for the IT group. Vineland II = Vineland Adaptive Behavior Scales ; IT = Immediate Treatment Group. The scores presented in thi s graph are the means from the 7 Immediate Treatment p ar ticipants at pretreatment and 6week follow u p.

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64 CHAPTER 4 DISCUSSION General Findings Overall, the results of the study indicate that caregiver implementation of CDIT skills improves disruptive behavior and social awareness compared to children in the waitlist control condition. Results also indicate that gains are maintained from post treatment to 6 week follow up. The significant improvements in disruptive behavior and social awareness reported after only 8 1 hour sessions establish the power of this intervention in changing behavior in a short timeperiod; how ever other treatments may be needed to address areas of functioning that were not improved by CDIT. CDIT may be useful as an initial or adjunct treatment to prepare children for eng agement in other therapies such as occupational and speech therapy diff erent behavioral interventions and even medical procedures. W hen a child engages in disruptive behaviors, such as noncompliant or oppositional behaviors, treatment providers may have difficulty teaching the child and making progress on target goals If a child is misbehaving at home, parents may have difficulty completing any homework assignments required to supplement treatment. In addition, many children with ASD avoid social interactions, including thos e with teachers and therapists; this difficulty bui lding rapport may also interfere with skill acquisition and treatment adherence. However, after a child has been treated with CDIT, a child may be more compliant and cooperative with other treatment modalities. In addition, improved social awareness may be the first step to helping a child to form closer and more appropriate relationships with other people, including treatment providers. Improved child cooperation may in turn lead to better progress in other treatment modalities and overall better services

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65 received by children and families. The treatment outcome results following CDIT are o utlined in greater detail below. Comparison of the Immediate Treatment and Waitlist Control Groups at Immediate Post Treatment Assessment Disruptive Behavior Children d emonstrated significant parent reported decreases in the frequency and intensity of problem behaviors on the ECBI Intensity Scale a measure of the frequency of child disruptive behavior. Disruptive behaviors are prevalent and problematic for families of c hildren with ASD (Greene et al. 2004; Mandell et al ., 2005a). Although children in the study were not selected for disruptive behavior problems and children were not required to demonstrate problematic behaviors to be eligible for study participation, sixtythree percent of children in our sample had clinically elevated behavior problems (ECBI Intensity score Reducing disruptive behavior in children with ASD is important because disruptive behaviors ( as opposed to behaviors associa ted with poor adaptive functioning ) are strongly associated with parent stress (Lescavalier, Leone, &Wiltz, 2006). Considering the dramatic improvement in disruptive behavior reported on the ECBI, it raises the question as to why similar improvements w ere not reported on the VinelandII Maladaptive Behavior Index. On average, childrens scores on this measure were in the Elevated Range at the pretreatment assessment and were not significantly reduced post treatment. This measure differs from the ECBI, which asks for the parent to report the frequency and intensity of clear, observable disruptive behaviors. Items on the Maladaptive Behavior Index are worded more subjectively and include internalizing problems (i.e. sadness and anxiety) and critical items (i.e. inappropriate sexual

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66 behavior) as well as externalizing symptoms into the total score. It is possible that the scale is less sensitive to sp ecific behavior changes or that children did not significantly change other components of maladaptive behavior, such as internalizing behaviors, following treatment. Receptive and Expressive Language The treated children did not display any significant increases in receptive or expressive language following CDIT. In fact, children spoke significantly fewer parent directed statements following treatment compared to waitli st controls as measured by total child verbalizations during the DPICS observation. Although these results appear problematic, the lack of observed language acquisition may be related to the fact that children in this sample had generally good or advanced language abilities t o begin with. In the domain of receptive language, it is possible that children did not have r oom for significant improvement due to a ceiling effect. For example, 63% of ch ildren had a receptive language standard score on the PPVT III in the av erage range or higher, and 23% of children had a receptive language score on the PPVT III in the above average to superior range at their pretreatment assessment. To understand whether CDIT may positively affect receptive vocabulary, it may be necessary to sampl e a group of children with impaired or less advanced language abilities at pretreatment. In the domain of expressive language, it appears that children generally had a good gr asp of language and worduse at the pretreatment assessment based on their receptive language scores and an average of 60 to 64 social statements made in the five minute child led play situation. Neither DPICS categories nor Wordcount evaluates the qualit y of child verbalizations as they pertain to children with ASD; only the quantity of child talk is measured by these instruments. Although the DPICS categories measure

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67 prosocial verbalizations, critical statements, commands, and questions directed at the p a rent, they do not measure the specific kinds of maladaptive speech most characteristic of ASD such as echolalia, repetitive or stereotyped phrasing, or excessive questionasking. Clinically, it appeared that this maladaptive use of language was reduced in children over treatment, but neither Wordcount n or the DPICS system are designed specifically for or are sensitive to verbal patt erns related specifically to ASD; improvements in the quality of child social talk would be missed on these measures It is possible that the decrease in child statements as measured by the DPICS demonstrates a reduction in maladaptive language (for example, repetitious statements about stereotyped interests) and may represent a more meaningful inter action overall. I nvestigators need to add the verbalization categories that are most typical of the kinds of language deficits seen in children with ASD. Social Skills Parents reported improvements on the Social Awareness domain of the Social Responsiveness scale compared to waitlis t controls, but not on other domains of social behavior as measured by the SRS or on the social domain of a measure of adaptive functioning. Evaluating child social changes is important because the ability to read and understand other people facilitates building close interpersonal relationships in the future and may create opportunities for learning in the context of social situations. One of the core features of ASD is a lack of ageappropriate social skills and understanding (APA, 2000). After completing CDIT, parent report measures indicated that children improved significantly in their ability to pick up on social cues and the sensory aspects of reciprocal social behavior. At pre treatment, all children were in the clinical range of social awareness and although children remained in the cli nical range of difficulties,

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68 their degree of change after just 8 weeks is promising It is possible that additional treatment sessions or practice over time is necessary to result in changes to other social behaviors. Adaptive Functioning Children showed no significant improvements in adaptive functioning compared to waitlist controls. It is possible that 8 weeks of treatment was not sufficient to result in significant adaptive changes especially when one considers that t reatments that focus on specific skill acquisition such as ABA, are extremely timeintensive with a duration ranging from a few months to 2 years (Rogers & Vismara, 2008). CDIT did not target many core areas assessed by the VinelandII, such as fine and gross motor functioning, skills of daily living in the community and at home, and academic goals Maintenance of Treatment Gains from Post Treatment (Time 2) to 6Week Follow Up The results indicated that childrens functioning did not significantly improve or worsen between the post treatment assessment and 6week follow up. Treatment gains in disruptive behavior and social awareness did not significantly dissipate over time. However, it is important to note that the small sample sizes used for thes e analyses may have resulted in a loss of necessary power to see changes that did occur. Changes from Pre treatment to 6 week Follow Up Analyses indicated significant improvements from pretreatment to 6 week follow up in disruptive behavior, strengthening the evidence that childrens improvements were more than socially desirable questionnaire responses by parents made to please their trainers. Children also improved in adaptive functioning, which potentially highlights the adaptive changes that we would expect to take place over time naturally as children

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69 develop. Changes in receptive and expressive language were not significant, which is consistent with the lack of gains from preto post treatment. Changes in social behavior wer e not significant in the group of 8 children who returned for their 6week follow up assessment ; however, it is important to note that at pretreatment, these 8 children demonstrated significantly better social skills than the 7 children who had not completed their 6week follow up assessment. It is possible that this subset of the Immediate Treatment group did not make as many social changes as the rest of the treatment group or that the limitation of a small sample size may have resulted in a loss of necessary power to see changes that did occur Limitations, Strengths and Future Directions Some limitations of this research should be noted. The study was conducted with a relatively small sample size of only 30 participating families (15 in each condit ion). O nly data from 8 families was available to be analyzed for the second and third aim s of this study, limiting the power and generalizability of the findings for these analyses; f ive of the remaining 7 participants did not attend their 6 week fol low up assessments in time for the authors dissertation defense and 2 participants chose not to attend their 6week follow up assessments. In addition, the subset of 8 families evaluated was significantly less severe in social domains at preassessment th an the other 7 families that had yet to complete their 6week follow up assessments. Along with sample size concerns, all families were living in central Florida within one hour driving distance from the University of Florida, creating an unavoidable geog raphic limitation. Children participating in the study were mostly Caucasian and male, with female children and ethnic minorities largely unrepresented. In addition, 44% of the families that dropped out of treatment before their Time 2 Post Treatment

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70 Assessment were not Caucasian such that dropouts were significantly more ethnically diverse than families that remained in the study. Despite limited ethnic diversity in treatment completers, the sample of completers is representative of the lack of diversity found in children receiving treatment for ASD in the community (Mandell et al., 2009; Thomas, Ellis, McLaurin, Daniels, & Morrissey, 2007). However, future studies need to be conducted with a more ethnically diverse sample to examine the outcomes of CDIT with nonwhite children and families. Another study limitation is related to diagnosis of child ASD in our sample. Children were diagnosed by an outside healthcare professional with their diagnosis confirmed by the administration of the CARS2 at pretreatm ent assessment; the use of a goldstandard diagnostic measure was not required for treatment eligibility due to the lack of assessors trained in these measures Diagnostic practices in the communi ty varied, but we know that 27% of study participants were diagnosed with the Autism Diagnostic Observation Scale (ADOS; Lord et al., 2000), the goldstandard observational measure for assessing ASD, in the University of Florida Psychology Clinic. Although the use of a goldstandard diagnostic measure would have been ideal, the assessment practices used in the study were representative or superior to those commonly seen in the community, where many diagnosing professionals do not use any formal diagnostic measures (Wiggins, Baio, & Rice, 2006). Future studies should evaluate CDIT in a sample that has been uniformly diagnosed with gol d standard instruments to increase the probability that all children participants are accurately diagnosed. Length of treatment also created a study limitation. In traditional PCIT, famil ies

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71 remain in the Child Directed Interaction phase of treatment until they reach mastery criteria, ensuring that they are expert in implementing CDI skills with their child. However, clinical experience has demonstrated that some families may reach mastery criteria for CDIT in the first or second session of treatment and we did not want to penalize parents who learn the skills more quickly by denying them important sessions of coaching and learning to tailor this skill set to their specific ASD child. Due to this study design, families ended treatment after 8 sessions whether or not they were considered to be competent in using CDI strategies. In our sample, only 47% of parents met CDI mastery, meaning that over half the sample would not be considered suffi ciently trained in their use of treatment strategies and whose lack of skill have affected their ability to implement CDIT effectively during their 5 minute practice sessions at home. Families might have benefited from additional sessions of CDI, either to improve skills in families that had not reached mastery or to provide an additional opportunity to tailor treatment for parents who were expert in their skills. It is possible that additional changes would have been seen if treatment had lasted longer. F uture research should evaluate whether length of participation in CDIT and parental mastery of the skills are related to improvements in c hild functioning over and above what was seen in this study. Important strengths of thi s research can also be noted, I n an article evaluating psychosoci al treatments for ASD, researchers asserted that Traditional 1 h a week treatments for language or social skills or behavior used in the US mental health system are rarely suffi cient to produce generalizable improvement s in core areas of ASD (696, Lord et al., 2005). However, children who completed 8 weekly sessions of

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72 Child Directed Interaction Training demonstrated significant improvements in the areas of disruptive behaviors and social awareness compared to Waitlist Controls at post treatment. In addition, children maintained these gains at 6week follow up. These improvements are clinically relevant especially when evaluating time limited, manualized, psychosocial interventions with children on the spectrum. CDIT i s practical and increasingly available: any trained PCIT therapist can follow the manualized sessions and most parents are likely able to dedicate an hour to treatment and 5 minutes per day to practice of the skills they learned in treatment In addition, our clinical observations suggest that parents enjoy treatment and find it helpful. Only two families that began treatment dropped out during CDIT one because of a divorce and caregiver changes and the other because the parents felt that their child had al ready made sufficient improvements. Identifying short term psychosocial treatments that can reduce disruptive behaviors is essential to improving child functioning and helping children to be compliant with other commonly used treatments for ASD, including speech and occupational therapy. In addition, using a psychosocial treatment to reduce disruptive behaviors could avoid the use of antipsychotic medications, which although often effective, can result in adverse effects, including weight gain, fatigue, dr owsiness, increased appetite, dizziness, drooling, constipation, and tremor (Shea, Turgay, Carroll, Schulz, Orlik, Smith, & Dunbar, 2004) and the results of long term use are unknown (McCracken et al. 2002). This study touches on some concerns in the PCI T literature about implementation of PCIT with children on the spectrum. There has been some

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73 controversy regarding whether the Parent Directed Interaction phase of PCIT, which specifically addresses noncompliant behaviors, should be implemented in children with ASD (Masse, McNeil, Wagner, Chorney, 2007). The evidence suggests that the use of aversive stimuli or even verbal correctives or directives may be unnecessary in many families It appears that the use of differential social attention and CDI skills alone can result in significant decreases in problem behaviors. Together, these results suggest that PDI may not be necessary for some children with comorbid ASD and disruptive behavior Parents may also be more adherent to CDI alone than to a treatment that includes a punishment component because CDI may be less stressful to implement (Moore & Symons, 2009). Some researchers had also hypothesized that only children with highfunctioning ASD would respond to a treatment that depends significantly on the use of differential social attention (Masse, McNeil, Wagner, Chorney, 2007) However, participants in this study ranged widely in ASD severity and included both children who would be identified as highfunctioning and those who would be labeled low functioning by treatment providers. The results indicate that even for children with relatively severe ASD symptoms, significant i mprovements were observed after CDIT. Future randomized controlled trials evaluating CDIT in ASD need to be conducted t o address the limitations in this rese arch by increasing sample size and geographic limitations. Also, additions to the coding system t argeting specific ASD symptoms need to be developed to improve behavior observations of child social and language behaviors that are tailored to the specific needs of children with ASD. Many of the improvements in caregiver child attachment and conversatio n that were observed

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74 clinically were not detected with our current outcome measures. However, the significant changes seen in these preliminary findings indicate a need to continue to examine this practical and replicable treatment for children on the auti sm spectrum.

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75 APPENDIX A TREATMENT DIAGRAM S Diagram 1: Inclusion and Exclusion Criteria Inclusion Criteria Exclusion Criteria Child Diagnosis of ASD (based on the CARS2 + previous diagnosis by a Mental Health Professional) Cognitive functioning years 0 months on nonverbal tasks Speaks 3 intelligible words Age 3 years 0 months to 7 years 11 months Stable on their medications or other interventions one month prior to treatment and throughout the duration of their study participation History of severe sensory impairment (e.g., deafness) Primary Caregiver Cognitive functioning education Attendance at all sessions and assessments Suspected abuse Crisis requiring out of home placement during the study.

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76 Diagram 2 Instruments Instrument Informant Weekly During Tx Time 1 Time 2 Ti me 3 Demographic and Background Questionnaire PrimP SecondC Semi Structured Interview PrimP SecondC Social Responsiveness Scale PrimP CARS2 O/PrimP DAS II O Vineland II O/PrimP PPVT III O Word Count O DPICS O Eyberg Child Behavior Inventory Intensity Scale PrimP SecondC Note. PrimC = Primary caregiver; SecondC=Secondary caregiver if participating; O = Observer.

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77 Diagram 3. Assessment and Treatment Timeline for IT and WL Conditions Week 1 Weeks 2 11 Week 12 Weeks 1317 Week 18 Week 1922 Week 23 IT Time 1 Assessment Weekly CDIT Tx Time 2 Assessment No Tx Time 3 Assessment No Tx WL Time 1 Assessment No Tx Time 2 Assessment Weekly CDIT Tx Time 3 Assessment Note. IT = Immediate Treatment condition; WL = Waitlist condition; Tx = Treatment.

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78 Diagram 4. Outcome Measures Breakdown Outcome Outcome Measure(s) Behavior problems Eyberg Child Behavior Inventory Vineland II: Maladaptive Behaviors Domain Language PPVT III Dyadic Parent Child Interaction Coding (child verbalizations) Word Count Prosocial Behavior Vineland II: Socialization Domain Social Responsiveness Scale Adaptive Functioning Vineland II Composite Score

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79 APPENDIX B CDIT PHONE SCREENER CDIT Phone S creener: Confirm the following information: Screening date: Child Name: Parent Name: Child DOB/Age: Address: Between the ages of 3 and 7 ? __No__Yes City/Zip: Male/Female?: Email: Referral Source: 1 or 2 parent family? Child resides in your home?: __ No __ Yes Phone 1: OK to leave message? __No__Yes Phone2: OK to leave message? __No__Yes Major concerns regarding [childs name] : Provide the following information about the study (check the small box when done): For children ages 3 7 w/ a previous diagnosis of ASD You may be assigned to immediate or wait list groups CDI training is at no cost Attend a 3 hour pre assessment Primary c aregiver is required to participate but other caregivers can also participate May be a 10 week wait before training starts Child must reside in the primary caregivers home Training is weekly for 8 weeks Child can not have history of severe sensory impairment (i.e. deafness) You will be paid for assessment 2 and 3 Child must be stable on other medication or interventions throughout the duration of their study participation PHI will be secure if participate or destroyed if not eligible Ask parent to rate the child on the following behaviors: where Yes (Y) = Behavior is a problem for me, No (N) = Not a pro blem for me Dawdles in getting dressed Dawdles or lingers at mealtime Has poor table manners Refuses to eat food presented Refuses to do chores when asked Slow in getting ready for bed on time Refuses to go to bed on time Does not obey house rules on own Refuses to obey until threatened with punishment Acts defiant when told to do something Argues with parents about rules Gets angry when doesnt get own way Has temper tantrums Sasses adults Whines Cries easily Yells or screams Hits parents Destroys toys and other objects Is careless with toys or other objects Steals Lies Teases or provokes other children Verbally fights with friend own age Verbally fights with sisters or brothers Physically fights with friend own age Physically fights with sisters or brothers Constantly seeks attention

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80 Interrupts Is easily distracted Has short attention span Fails to finish tasks or projects Has difficulty entertaining self alone Has difficulty concentrating on one thing Is overactive or restless Wets the bed Once Screener is complete: If scheduled for Pretreatment Assessment visit: File completed screener in confidential participant folder. If not meeting inclusion/exclusion criteria: Shred screener and note screen failure in referral tracking.

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81 APPENDIX C DEMOGRAPHIC AND BACK GROUND QUESTIONNAIRE Date: ___/___/_____ Childs LAST Name: ___________________________Childs FIRST Name:_______________ Childs Date of Birth: ___/___/_______ Childs Age: _____ year Childs Sex (circle one): Male Female Childs Ethnicity: (check one) ____ Caucasian ____ Hispanic ____ AfricanAmerican ____ Native American ____ AsianAmerican ____ Bi racial (please specify) _________________ ____ Other (please specify) __________________ Who referred your child for treatment: (please check one) ___Outpatient or clinic at Shands ___ Another Agency, clinic, or hospital referred ___School or teacher ___Another physician or doctor ___ Another psychologist ___ I decided to seek treatment for him/her ___Other (please specify)________________________ Is your child currently in school? ___No ___Daycare ___Preschool ___Kindergarten ___Elementary School ___Home school Is your child in a special classroom? (circle one) Yes No Who diagnosed your child with an Autism Spectrum Disorder: (please check one) ___ Pediatrician ___ Psychologist ___Psychiatrist ___School psychologist

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82 ___Other (please specify) ___________________ How old was your child when he/she was officially diagnosed: ________years old What kinds of assessments have been done to evaluate your childs functioning: (please check all that apply) ___Intelligence Testing ___Full psychological battery ___Language testing ___Occupational therapy evaluation ___P arent questionnaires ___Special tests ordered by a physician Which Autism Spectrum Disorder diagnosis describes your child: (please check one) ___Autistic Disorder ___Aspergers Syndrome ___Pervasive Developmental Delay, Not Otherwise Specified (PDD NOS) ___ Unsure (please describe) _________________________ Has your child been diagnosed with any other health or psychological difficulties: Yes No If Yes, please describe: ______________________________________________________ _____________________ _________________________________________________ ___ ______________________________________________________________________ ___ Is your child currently receiving services related to ASD symptoms (circle one): Yes No Where are you receiving services for your childs ASD symptoms (please check all that apply): ___School ___Psychologists office ___Pediatricians office ___Psychiatrists office ___Speech/language therapists office ___Occupational therapists office What tre atments for ASD is your child currently receiving (please check all that apply): ___Behavioral treatment ___Special services at school ___Social skills group

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83 ___ Speech/language therapy ___ Occupational therapy ___ Special diet ___ Medication ___Play therapy ___Other (please specify)________________________ What treatments for ASD has your child received in the past (please check all that apply): ___Behavioral treatment ___Special services at school ___Social skills group ___ Speech/language therapy ___ Occupational therapy ___ Special diet ___ Medication ___Play therapy ___Other (please specify)________________________ Please list your childs current medications, the reason he or she takes them, and how long he or she has been on them: Medication #1 Name:____________________________________ Dosage________________ How long (months) _______ Reason:_______________________________________________________________ _______ Medication #2 Name:____________________________________ Dosage________________ H ow long (months) _______ Reason:_______________________________________________________________ _______ Medication #3 Name:____________________________________

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84 Dosage________________ How long (months) _______ Reason:_______________________________________________________________ _______ Medication #4 Name:____________________________________ Dosage________________ How long (months) _______ Reason:_____________________________________________________________ __ _______

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85 APPENDIX D SEMI STRUCTURED INTERVIEW Parent Interview I. Primary Concerns: What do they want from the evaluation? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ _______________________________________________________ ________________________________________________________________ II. Developmental information: A. Pregnancy: Illness, medication, accidents, problems, complications; Length of Pregnancy, birthweight ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ __________________________________________________________ B. Labor & Delivery: Length of labor; problems or complications (medication, anoxia, jaundice, forceps) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________

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86 C. Temperament as an infant: (e.g., crying, sleep, or feeding problems) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________ ________________________________________________________ ____________________________________________________ D. ASD Diagnosis 1. When did you first notice your child displaying behaviors that concerned you? Please describe in detail. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________ 2. How was your child diagnosed? (At what age/ by whom/ details) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

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87 ______________________________________________________________________ ____________________________________________________ 3. What treatments have you tried/are currently using (frequency/effectiveness) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______ ________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ __________________________________ E. Developmental Milestones: 1. Walking: (age began) ______________________________________________________________________ ________________________________________________________________ 2. Talking : (age of first words; age of first 2word sentences)

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88 ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________ 3. Toilet Training: (age bladder trained; bowel trained; problems) _________________________________________________________________ _____ ______________________________________________________________________ _____________________________________________________________ F. Family Information: 1. Who is in the family now: Name Age Relationship to Child ASD diagnosis ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _________________________________________________ 2. Parent(s) involvement with child during early years: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

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89 ___________________________________ ___________________________________ _______________________________________________________ 3. Relationship with parents & siblings: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________ G. Medical History of Child 1. Accidents: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ __________________________________________________________ 2. Illnesses/ Hospitalizations/ Surgery: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _______________________________________________________ 3. Head Injury (ever been in a car accident or knocked unconscious)

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90 ______________________________________________________________________ ________________________________________________________________ 4. Seizures, tics, or unusual staring spells: ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________ 5. Sensitivities (food/ textures/sounds/lights) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________ 6. Medications (current and past) effective/problems/dose: (If relevant, is child on medication today ) ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________ ______________________________________________________ ________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

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91 ______________________________________________________________________ ______________________________________________________________________ _________________________________________________ H. School: 1. Day Care (type of day care or child care arrangement) Behavior, Learning, Peer relationships: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _______________________________________ ___________________ 2. Preschool (ages; type of school or child care arrangements) Behavior, Learning, Peer relationships: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _______________________________________________________ 3. Kindergarten (Type of School; Behavior, Learning, Friends): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ __________________________________________ ____________________________ _______________________________________________________ 4. First Grade (Behavior, Learning, Friends):

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92 ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ __________________________________________________________ 5. Second Grade (Behavior, Learning, Friends): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _______________________________________________________ 6. Other Relevant Grades (e.g., grades in which behavior, learning, or social relationships changed): ______________________________________________________________________ ______________________________________________________________________ _________ _____________________________________________________________ ______________________________________________________________________ _______________________________________________________ 7. Special Education Classes: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________ 8. Repeated or Skipped Grades:

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93 ___________________________________________________________________ I. Current ASD Behaviors/ Behavior Problems (Problem, Current frequency, When it began, What usually sets it off, what usually stops it): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ___________________________________ ___________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ___________ ___________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _________________________________________________________ _____________ _________________________ III. Discipline: A. Who disciplines: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _______________________________________________________ B. What is used? (What else? What else?) For each, how often; how effective: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

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94 ______________________________________________________________________ ________________________________ ______________________________________ ______________________________________________________________________ ____________________________ C. Spanking: (If parents havent mentioned spanking, ask specifically how often (per day/wk/or month, and make note o f their attitudes about it): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _________________ _____________________________________________________ _______________________________________________________ D. Other Concerns/ Problems Not Yet Addressed: ______________________________________________________________________ ________________________________ ______________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________ ________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _________________________

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95 LIST OF REFERENCES Abner, J.P., Bonney, E., Dugger, J., Lingerfelt, A., Michalk, E., & Suggs, J. (2008, October). CDI: An effective brief intervention for children with autism spectrum disorders? Paper presented at: National Parent Child Interaction Therapy Conference, Sacramento, CA. Aldred C., Green J., & Adams, C. (2004). A new social communication interventions for children with autism: Pilot randomized controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45, 14201430. doi:10.1111/j.14697610.2004.00338.x American Psychiatric Association. ( 2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, DC: Author. Bagner, D.M., Eyberg, S.M. (2007). Parent Child Interaction Therapy for disruptive behavior in children with Mental Retardation: A randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 36 418 429. doi: 10.1080/15374410701448448 Baumrind, D. (1976). Child care practices anteceding three patterns of preschool behavior. Genetic Psychology Monographs, 75, 4388. Baumrind, D. (1991). The influence of parenting style on adolescent competence and substance use. Journal of Early Adolescence, 11, 5695. doi:10.1177/0272431691111004 Boggs, S.R., & Eyberg, S.M. (2008). Positive attention. In W. ODonohue, & J.D. Fisher (Eds.). Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed) (pp 396401) New York: Wiley. Boggs, S.R., Eyberg, S.M., Edwards D.L., Rayfield, A., Jacobs, J., Bagner, D., & Hood, K.K. (2005). Outcomes of Parent Child In teraction Therapy: A comparison of treatment completers and study dropouts one to three years later. Child & Family Behavior Therapy, 26( 4), 1 22. doi:10.1300/J019v26n04_01 Boggs, S.R., McDiarmid, M., & Eyberg, S.M.(2004). Efficacy of Parent Child Interaction Therapy Paper presented at: American Psychological Association Conference, Honolulu, HI. Boutot, A. (2009). Using naturalistic instruction for children with autism. In: Boutot, Amanda (Ed); Tincani, Matt (Ed); Autism encyclopedia: The complete guide to autism spectrum disorders (pp. 275 280). Waco, TX: Prufrock Press. Brestan, E.V., Eyberg, S.M., Boggs, S.R.,& Algina, J.(1997). Parent child interaction therapy: Parents' perceptions of untreated siblings. Child & Family Behavior Therapy, 19 (3), 13 28. doi:10.1300/J019v19n03_02

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96 BrookmanFrazee, L., Stahmer, A., Baker Ericzenn, & M.J., Tsai, K. (2006). Parenting interventions for children with autism spectrum and disruptive behavior disorders: Opportunities for cross fertilization. Clinical C hild and Family Psychology Review, 9 (3), 181 200. doi:10.1007/s10567006 00104. Bruininks, R.H., Woodcock, R.W., Weatherman, R.F., & Hill, B.K. (1996). SIB R: Scales of Independent Behavior Revised, comprehensive manual Itasca, Illinois: Riverside Publishing. Burrell, T. (2009, October). Part I: Research update: Evidence supporting usage of PCIT with families of children with Autism Spectrum Disorders (ASD). Paper presented at: National Parent Child Interaction Therapy Conference, Traverse City, MI Capaldi, D., & Patterson, G.R. (1987). An approach to the problem of recruitment and retention rates for longitudinal research. Behavioral Assessment, 9(2), 169 177. Retrieved from http://psycnet.apa.org Chaffin, M., Silovsky, J.F., Funderburk, B.W., Valle, L.A., Brestan, E., Balachova, T., Jackson, S., Lensgraf, J., & Bonner, B. (2004). Parent child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72(3), 50 0 510. doi:10.1037/0022006X.72.3.500 Chase, R. M., & Eyberg, S.M. (2008). Clinical presentation and treatment outcome for children with comorbid externalizing and internalizing symptoms. Journal of Anxiety Disorders, 22 (2), 273 282. doi:10.1016/j.janxdi s.2007.03.006 Centers for Disease Control and Prevention.(2007). A report from the Autism and Developmental Disabilities Monitoring (ADDM) Network. Retrieved from http://www.cdc.gov/media/pressrel/2007/f070208.htm Chronis, A.M., Chacko, A., Fabiano, G.A. Wymbs, B.T., & Pelham, W.E. (2004). Enhancements to the behavioral parent training paradigm for families of children with ADHD: Review and future directions. Clinical Child & Family Psychology Review. 7 (1), 1 27. doi:10.1023/B:CCFP.0000020190.60808.a4 Cone, J. D. & Casper Beliveau, S. (1997, November). The Eyberg Child Behavior Inventory: Psychometric properties when used with children with developmental disabilities. Paper presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Miami, FL. Constantino, J.N.,& Gruber, C. P. (2005) The Social Responsiveness Scale Manual. Los Angeles: Western Psychological Services

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97 Cunningham, C.E, Bremner, R., & Boyle, M. (1995). Large group community based parenting programs for families of preschoolers at risk for disruptive behaviour disorders: Utilization, cost effectiveness, and outcome. Journal of Child Psychology & Psychiatry & Allied Disciplines, 36 (7), 11411159. doi:10.1111/j.14697610.1995.tb01362.x Curran, P.J., & Mu thn, B.O. (1999). The application of latent curve analysis to testing developmental theories in intervention research. American Journal of Community Psychology, 27, 567595. doi:10.1023/A:1022137429115 Dawson G, & Osterling J. (1997). Early intervention in Autism. In: M.J. Guralnick (Ed.). The effectiveness of early intervention (pp. 307 326). Baltimore: Brookes. Dodrill, C.B. (1981). An economic method for the evaluation of general intelligence in adults. Journal of Consulting and Clinical Psychology, 49 668 673. doi:10.1037/0022006X.49.5.668 Drew, A., Baird, G., Baron Cohen, S., Cox, A., Slonims, V. Wheelright, S., et al. (2002). A pilot randomized control trial of a parent training intervention for preschool children with autism: Preliminary fin dings and methodological challenges. European Child and Adolescent Psychiatry, 11, 266272. doi:10.1007/s0078700202996 Dunlap, G., KernDunlap, L., Clark, S., & Robbins, F. (1991). Functional assessment, curricular revision, and severe problem behaviors. Journal of Applied Behavior Analysis, 4, 387 397. doi:10.1901/jaba.1991.24387 Dunn, L. M., & Dunn, L. M. (1997). Examiners manual for the PPVT III: Peabody Pi cture Vocabulary Test Third Edition Circle Pines, MN: American Guidance Service. Eisenstadt, T.H., Eyberg, S. M., McNeil, C.B., & Newcomb, K. (1993). Parent child interaction therapy with behavior problem children: Relative effectiveness of two stages and overall treatment outcome. Journal of Clinical Child Psychology, 22(1), 42 51. doi:10.1207/s15374424jccp2201_4 Elliott, C. D. (2 007). Differential Ability Scales Second Edition (DAS II) San Antonio, TX: Psychological Corporation. Eyberg, S.M. (2005). Tailoring and adapting parent child interaction therapy for new populations. Education and Treatment of Children, 28, 197 201. Retr ieved from: http://pcit.org/literature.php Eyeberg, S.M., & Child Study Lab. (1999). Parent Child Interaction Therapy manual, Version 2.09 Retrieved from http://www.pcit.org.

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98 Eyberg, S.M., Funderburk, B.W., HembreeKigin, T.L., McNeil, C.B., Querido, J .G., & Hood, K.K. (2001). Parent child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child & Family Behavior Therapy, 23(4), 1 20. doi: 10.1300/J019v23n04_01 Eyberg, S.M., & Matarazzo, R.G. (1980). Training parents as therapists: A comparison between individual parent child interaction training and parent group didactic training. Journal of Clinical Psychology, 36(2):492499. Retrieved from: http://psycnet.apa.org Eyberg, S.M., Nelson M.M., Duke, M., & Boggs, S.R. (2004). Manual for the Parent Child Interaction coding system (3rd ed.). Retrieved from http://www.pcit.org. Eyberg, S.M., & Pincus, D. (1999). ECBI & SESBI R: Eyberg Child Behavior Inventory and Sutter Eyberg Student Behavior Inventory, Revised, professional manual. Lutz, FL: Psychological Assessment Resources. Eyberg, S.M., & Robinson, EA. (1982). Parent child interaction training: Effects on family functioning. Journal of Clinical Child Psychology, 11(2), 130137. doi:1 0.1080/15374418209533076 Fombonne, E. (2003). Epidemiological studies of pervasive developmental disorders. In: Volkmar F, Paul R, Klin A, Cohen D (Eds.). Handbook of Autism and Pervasive Developmental Disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed.) (pp.4249). Hoboken, NJ: Wiley. Funderburk, B. (2008, October). PCIT with children on the autism spectrum. Paper presented at: National Parent Child Interaction Therapy Conference, Sacramento, CA. Funderburk, B. W., Eyberg, S.M., Newcomb, K., McNeil, C.B., Hembree Kigin, T., & Capage, L.(1998). Parent child interaction therapy with behavior problem children: Maintenance of treatment effects in the school setting. Child & Family Behavior Therapy, 20(2), 1738. doi:10.1300/J019v20n02_02 Greenspan, S.I. (1992). Infancy and early childhood: The practice of clinical assessment and intervention with emotional and developmental challenges Madison, CT: International University Press Greenspan, S.I., & Wieder, S. (1999). Engaging Autism: Using the Floortime approach to help children relate, communicate, and think Cambridge, MA: DaCapo Press. Harwood, M.D., & Eyberg S.M. (2006). Child Directed Interaction: Prediction of change in impaired mother child functioning. Journal of Abnormal Child Psychology, 34, 335347. doi:10.1007/s10802006 9025z

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99 Hood, K.K., & Eyberg, S.M. (2003). Outcomes of Parent Child Interaction Therapy: mothers' reports of maintenance three to six years after treatment. Journal of Clinical Child & Adolescent Psychology, 32(3), 419429. doi:10.1207/S15374424JCCP3203_10 Houck, P., Mazumdar, S., Liu, K., & Reynolds, C. (2000). A pragmatic intent to treat analysis using SAS. Northeast SAS Users Group. Retrieved from www.nesug.org Howlin, P., Magiati, I., & Charman, T. (2009). Systematic review of early intensive behavioral interventions for children with autism. American Journal on Intellectual and Developmental Disabilities, 114(1): 23 41. doi:10.1352/2009.114:2341 Jaccard, J. (1998). Interaction effects in factorial analysis of variance. Newbury Park: Sage. Jaccard, J., & Guilamo Ramos, V. (2002). Analysis of variance frameworks in clinical child and adolescent psychology: Basic issues and recommendations. Journal of Clinical Child and Adolescent Psychology, 31, 130146. doi:10.1207/153744202753441747 Jamison, T.R.(2008, October). The effects of parent child interaction therapy on problem behavi ors in three children with autistic disorder. Paper presented at: National Parent Child Interaction Therapy Conference, Sacramento, CA. Kasari,C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young children with autism: A rand omized controlled intervention study. Journal of Child Psychology and Psychiatry, 47, 611 620. doi:10.1111/j.14697610.2005.01567.x Kasari, C., Paparella, T., Freeman, S., & Jahromi, L.B. (2008). Language outcome in autism: Randomized comparison of joint attention and play interventions. Journal of Consulting and Clinical Psychology, 76( 1), 125137. doi:10.1037/0022006X.76.1.125 Klinger, L.G., Dawson, G., & Renner, P. (2003). Autistic Disorder. In: E. J. Mash & E.J. Barkley RA (Eds.). Child psychopathol ogy (2nd ed.) (pp.409454). New York, NY: Guilford Press. Klinger, L., OKelley, S., Mussey, J. (2009). Assessment of Intellectual Functioning in Autism Spectrum Disorders. In: Goldstein, Sam (Ed.); Naglieri, Jack A. (Ed.); Ozonoff, Sally (Ed.); Assessment of autism spectrum disorders (pp. 209 252). New York, NY: Guilford Press. Koegel, L., Koegel, R., Harrower, J., Carter, C. (1999). Pivotal response intervention I: Overview and Approach. Journal of the Association for Persons with Severe Handicaps, 24 (3), 174 185. doi: 10.2511/rpsd.24.3.174

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100 Koegel, L., Koegel, R., Shosan, Y., McNerney, E. (1999). Pivotal response intervention II: Preliminary long term outcome data. Journal of the Association for Persons with Severe Handicaps,24(8), 186198 doi: 10.2511/rpsd.24.3.186 Koegel, R., Schreffirnan, L., Good, A., Cerniglia, L.,Murphy, C., Koegel, L. (2003). How to Teach Pivotal Behaviors to Children with Autism: A Training Manual. Retrieved June 3, 2009, from the University of California, Santa Bar bara: http://www.users.qwest.net/%7Etbharris/prt.htm Kogan, M.D., Blumberg, S. J., Schieve, L.A., Boyle, C., Perrin, J., Ghandour, R., Singh, G., Strickland, B., Trevathan., E., & Van Dyke, P. (2009). Prevalence of parent reported diagnosis of Autism Spec trum Disorder among children in the US, 2007 Pediatrics,124(4), 1 10. doi:10.1542/peds.20091522 Lescavalier, L., Leone, S., Wiltz, J. (2006). The impact of behaviour problems on caregiver stress in young people with autism spectrum disorders. Journal of Intellectual Disability Research, 50(3), 172 183. doi: 10.1111/j.13652788.2005.00732.x Levy, S., Kim, A.H., & Olive, M. (2006). Interventions for young children with autism: A synthesis of the literature. Focus on Autism and Other Developmental Disabilities, 21 55 62. doi:10.1177/10883576060210010701 Little, R.J., & Yau, L.H.Y. (1998). Statistical techniques for analyzing data from prevention trials: Treatment of noshows using Rubin's causal model. Psychological Methods, 3(2), 147 159. doi:10.1037/1082 989X.3.2.147 Lord, C., Rutter, M., DiLavore, P., & Risi, S. (2002). Autism Diagnostic Observation Schedule (ADOS) manual. Los Angeles, CA: Western Psychological Services. Lord, C., Risi, S., Lambrecht, L., Cook, E.H., Leventhal, B.L., DiLavore, P.C. Pickles, A., Rutter, M. (2000). The autism diagnostic observation schedulegeneric: a standard measure of social and communication deficits associated with the spectrum of autism, Journal of Autism and Developmental Disorders, 3 205 223. Lord, C., Wagner, A., Rogers, S., Szatmari, P., Aman, M., Charman, M., Dawson, G., Durand, V.M., Grossman, L., Guthrie, D., Harris, S., Kasari, C., Marcus, L., Murphy, S., Odom, S., Pickles, A., Scahill, L., Shaw, E., Siegel, B., Sigman, M., Stone, W., Smith, T., Yoder, P. (2005). Challenges in evaluating psychosocial interventions for autistic spectrum disorders. Journal of Autism and Developmental Disorders, 35(6) 696 708. doi: 10.1007/s10803005 00176 Lovaas, O.I. (1977). T he autistic child: Lang uage development through behavior modification. New York: Irvington Press.

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101 Lovaas, O.I. (1981). Teaching developmentally disabled children. The Me book Baltimore: University Park Press Lovaas O.I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting & Clinical Psychology, 55 3 9. doi:10.1037/0022006X.55.1.3 Lovaas, O.I., & Smith, T.A. (1989). Comprehensive behavi oral theory of autistic children: Paradigm for research and treatment. Journal of Behavioral Therapy and Experimental Psychiatry, 20, 17 29. doi:10.1016/00057916(89)900049 Maccoby, E.E., & Martin, J.A. (1983). Socialization in the context of the family: Parent child interaction. In: P.H. Mussen (Ed.), E.M. Hetherington (Vol. Ed.) Handbook of child psychology: Vol. 4. Socialization, personality, and social development ( pp. 1101). New York: Wiley. Mandell, D., Wiggins, L.D., Carpenter, L.A., Daniels, J., DiGuiseppi, C., Durkin, M.S., Giarelli, E., Morrier, M.J., Nicholas, J.S., Pinto Martin, J.A., Shattuck, P.T., Thomas, K.C., Yeargin Allsopp, M. and Kirby, R.S. (2009). Racial/ethnic disparities in the identification of children with autism spectrum disorders. American Journal of Public Health 99(3), 493 498. doi:10.2105/AJPH.2007.131243 Masse, J.J., McNeil, C.B., Wagner, S.M., & Chorney, D.B. (2007). Parent Child Interaction Therapy and high functioning Autism: A conceptual overview. Journal of Ea rly & Intensive Behavioral Intervention, 4 714 735. doi: 10.1007/9780 387 886398_12 Masse, J. Part III.(2009, October). Research update: Evidence supporting usage of PCIT with families of children with Autism Spectrum Disorders (ASD). Paper presented at: National Parent Child Interaction Therapy Conference, Traverse City, MI. Maurice, C., Green, G., & Luce, S.C. (1996). Behavioral intervention for young children with Autism: A manual for parents and professionals Austin, TX: Pro Ed, Inc. McCracken, J. T., McGough, J. H., Shah, B., Cronin, P., Hong, D., Aman, H. G., et al. (2002). Risperidone in children with autism and serious behavioral problems. New England Journal of Medicine, 347, 314 321. McConachie H, Randle V, Hammal D, & LeCouteur A. (2005). A controlled trial of a training course for parents of children with suspected autism spectrum disorders. Journal of Pediatrics, 147, 335340. doi:10.1016/j.jpeds.2005.03.056

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106 BIOGRAPHICAL SKETCH Leah Newlove Clionsky was born in Springfield, Massachusetts on September 18, 1984. The daughter of two psychologists, she was raised in Springfield and graduated from the Loomis Chaffee School in 2003. She earned her B.A. in psychology and French and graduated with honors from Vassar College in 2007. In August of 2007, she enrolled in a dual Master of Science and Doctor of Philosophy program at the University of Floridas Department of Clinical and Health Psychology. Leah completed her Master of Science in 2009 under the mentorship of Sheila Eyberg, Ph.D., ABPP. She participated in a research assistantship in the Child Study Laboratory for 4 years, until she began her predoctoral internship at Baylor College of Medicine in Houston, Texas in 2011. Leah completed the final months of this internship onsite at Ben Taub General Hospital. She received her Ph.D. from the University of Florida in the summer of 2012 and is currently working as a postdoctoral fellow at Baylor College of Medicine.