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ORIGINALPAPER In-HomeTrainingforFathersofChildrenwithAutism:AFollow upStudyandEvaluationofFourIndividualTrainingComponents JenniferH.Elder € SusanO.Donaldson € JohnKairalla € GregoryValcante € RoxannaBendixen € RichardFerdig € EricaSelf € JeffreyWalker € ChristinaPalau € MicheleSerrano TheAuthor(s)2010.ThisarticleispublishedwithopenaccessatSpringerlink.com Abstract Literatureregardingfathersofchildrenwith autismremainssparse,andbecausemothersarethemore commoninterveningparent,fewtrainingmethodshave focusedonfathers.Thus,wesoughttoevaluateeffectsof in-hometrainingdirectedatfathersandtheirabilitytotrain mothersinthesamemannerinwhichtheyweretrained. Fathersweretaughtfourskillscommonlyassociatedwith in-hometraininginterventionsforparentsofchildrenwith autism:followingthechild’slead,imitationwithanimation,commentingonthechild,andexpectantwaiting. Fatherskillswereevaluatedtwiceaweekfor12weeks duringvideotapedin-homefather–childplaysessions. Analysesincludedvisualinspectionofgrapheddataand statisticalanalysesoffatherskillacquisition,motherskill acquisition,andchildbehaviorswithbothparents.A multivariaterepeatedmeasuresanalysisof18dyads revealedsignicantincreasesinfrequenciesoffathers’ imitationwithanimation,expectantwaiting,andcommentingonthechild.Childinitiatingratesincreasedsignicantlyasdidfrequenciesofchildnon-speech vocalizations.Analysisofmothersrevealedsignicant increasesinfrequenciesofimitationwithanimation, expectantwaiting,andfollowingthechild’slead.Child behaviorshadsimilarresultsforfatherandmothersessions.Findingsareconsistentwiththosefromourrst studyindicatingthatfatherscaneffectivelyimplement skillsthatpromotefather–childsocialinteractionsandthat childrenrespondpositivelytothisapproach. Keywords Autism Fathers Parenttraining Introduction RecentestimatesfromCentersforDiseaseControland Prevention(CDC)indicatethatasmanyas1in110US childrenarediagnosedwithautismoranautismspectrum disorder(ASD)(CDC2009).Whiledebatecontinuesasto whetherthisreectsmorepublicawarenessand/orbetter diagnosticmeasures,a57%increasefrom2002to2006, anda600%increaseinthelast20yearswarrantsintensiedeffortstoaddressthispopulation’sneeds(CDCMorbidityandMortalityWeeklyReport[MMWR],2009). Particularlyimportantisdeterminingwaystoeffectively treatchildrenwithautismandimprovequalityoflifefor themandtheirfamilies,nowoneofthetopprioritieslisted byNIHandcongressionallymandatedresearchprograms (NIHretrievedOctober5,2009). Amongthevariousprofessionalswhoworkwithchildrenwithautism,ithaslongbeenthoughtthattraining parentstoeducateandmanagetheirchildrencanbean effective,cost-efcientmeasure.Costsavingisparticularly importantasthesefamiliesareoftenfacedwithenormous nancialburdensassociatedwithavarietyofspecialist evaluationsandautism-relatedtreatments.Interestingly, literatureregardingfathersofchildrenwithautismremains sparse,andbecausemothersarethemorecommoninterveningparent,fewtrainingmethodshavefocusedon fathers.Ourclinicalexperiencehasalsoshownthatwhen parentsaretrainedsimultaneously,mothersoftentakelead roleswhilefathersassumebackgroundpositionsorbecome absent,leavingtrainingprimarilytomothers.Thiscan resultininconsistentinterventionimplementation,which maybeveryconfusingtochildrenwithautismwhohave J.H.Elder( & ) S.O.Donaldson J.Kairalla G.Valcante R.Bendixen R.Ferdig E.Self J.Walker C.Palau M.Serrano UniversityofFlorida,101S.NewellRd.,Box100187, Gainesville,FL32610-0187,USA e-mail:elderjh@u.edu 123 JChildFamStud DOI10.1007/s10826-010-9387-2

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difcultygeneralizingacrossdifferentindividualsorsettings.Moreover,motherswhoareprimarycaretakersoften reportextremestressandadesireformoreinvolvement fromthefather. Resultsfromourrstfathertrainingstudyrevealedthat fatherscouldbetrainedtousetwotheoretically-derived childtrainingskills, imitatingwithanimation and expectant waiting ,andthatthey,inturn,wereempoweredinthisrole andcouldeffectivelytrainmotherstousetheseskills (Elderetal. 2005 ).Wealsomadeseveralimportant methodologicaldiscoveriesthatwereincorporatedintoour recentlycompletedfollow-upstudy,which,inadditionto replicatingourprotocolwith18additionalfamilies,evaluatedeffectsoftwonewtrainingcomponents, following thechild’slead and commentingonthechild .Bothofthese newcomponents,derivedfromsocialinteractiontheory andresearch(DawsonandGalpert 1990 ;Duchan 1989 ; Donnellanetal. 1984 ;Stahmer 1995 ),aredesignedto promoteparent–childsocialreciprocity. TheoreticalFramework First,andstillmostoftenusedtodescribethebi-directionalityofmother-infantinteractions, socialreciprocity is describedastheongoinginteractionalprocessbetweentwo individuals(Calhounetal. 1991 ).Maternalresponsiveness hasbeenexaminedoverseveraldecadesbyanumberof researchers(Ainsworthetal. 1978 ;Barnard 1983 ;Belsky etal. 1984 ;Brazeltonetal. 1974 ;Mundyetal. 1994 ;Siller andSigman 2008 ),andfoundbyalltocorrelatesignicantly withpositivechildoutcomes(e.g.,languagedevelopment, cognitiveandsocialcompetence).Parent–childturn-taking, anothercomponentofsocialreciprocity,isdescribedin severalclassicworksasessentialinchildlanguagedevelopment(Bruner 1973 ;Furrowetal. 1979 ;Snow 1983 ),andit maybeparticularlyimportantforchildrenwithautism,who typicallyhaveseverelanguagedelays(WetherbyandPrizant 2000 ).Othershypothesizedthatparentsofchildrenwith autismmaynotengageinparent–childturn-takingbecause thechilddoesnotrespond(takehisturn)andthus,theparent isnotreinforcedtocontinuetheinteraction(Cunningham etal. 1981 ).Researchersnotethattrainingprogramsfor childrenwithautismaremosteffectivewhentheyaretailoredfortheparticularchild,addresscommunicativeintent ofchildbehaviors,andpromotesocialreciprocitybetween childrenandindividualswithwhomtheyhaveregularcontact(Elder 2002 ;Schopler 1996 ;Koegeletal. 1987 ;Mudfordetal. 2001 ;Mundyetal. 1994 ). ParentTrainingInterventions Overthepast30years,trainingparentstointervenewith theirchildrenwithautismhasbecomeanintegralpartof mosteffectivecomprehensiveinterventionplans.Parents, onceviewedasthecauseoftheirchildren’sproblems,are nowrecognizedforthekeyrolestheycanplayinongoing childtrainingandskillgeneralizationovertime(Elder 2002 ;Marcusetal. 1997;Schreibman 1997 ).Interventions targetingpivotalskillslikejointattentionmayproduce positive,sustaineddevelopmentaleffects(Mundyetal. 1990 ),anditmaybepossibletotrainparentstoeffectively teachtheseimportantskills(Koegeletal. 1999 )during everydayinteractions.Inourworkwecloselyexamined fourindividualparent-traininginterventioncomponents thoughttobelinkedwiththesecoreconstructs:imitating withanimation,expectantwaiting,followingthechild’s lead,andcommentingonthechild. Inareviewofparent-trainingliterature,wefoundfew empiricalstudiesevaluatingparent-trainingmethodsthat addressedtheoretically-linkedpivotalskillsdescribed above.WiththeexceptionofLovaas’( 1987 )work,there wasalsolittlesystematicreplicationofin-homeparenttrainingapproaches.Clearly,aneedexistsforwelldesignedparent-trainingstudiesthatemployappropriate data-collectionstrategies.Manystudiesusecomplicated proceduresthatdiscouragereplicationand‘‘intervention packages’’thatmakeitdifculttoassesseffectsofspecic interventioncomponentsontargetbehaviors.Sincemost studiesreportedareprofessional-directedinterventions, thesearecostly,timeconsuming,intermittentandtake placeoutsidethehome.Theinterventionwedevelopedand replicatedaddressestheseproblems.Itisparent-directed andcanbecontinuouslyimplementedinthehomesetting. FathersasIn-HomeTrainersandGeneralization ofTrainingwithinFamilies Interestinthefather’sroleinchilddevelopmenthas markedlyincreasedoverthepasttwodecades,with researchexpandingonLamb’sseminalwork( 1987 ). TiedgeandDarling-Fisher( 1996 )reportedthathealthy father–childinteractionspositivelyaffectedchilddevelopment.However,BoothandCrouter( 1998 )andDamon ( 1998 )notedthatwhilesomestudiessupportedthispositiveview,othersshowednoclearlydiscerniblepaternal effectsonchilddevelopment.Theseconictingndings arefurthercomplicatedinthecaseoffathersofautistic children,aboutwhomevenlessisknown(Elderetal. 2003 ).Thus,thepurposeofourpriorandrecentlycompletedstudieswastoevaluateeffectsofin-hometraining directedatfathersandtheirabilitytotrainmothersinthe samemannerinwhichtheyweretrained.Inoursecond study,reportedhere,weenrolled18additionalfamilies, andexaminedinmoredetailtwopreviouslytestedandtwo newinterventioncomponentsthoughttopromoteparent– childsocialreciprocity.Specicresearchquestionswere: JChildFamStud123

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1.Canfathersbetaughttoeffectivelyusefourskill components(imitatingwithanimation,expectant waiting,followingthechild’slead,andcommenting onthechild)duringin-homeplaysessions? 2.Doesfatherimplementationoftheseskillcomponents resultinsignicantdifferencesinthefrequencyof childinitiating,childresponding,childnon-speech vocal,andchildintelligiblewordsduringplay sessions? 3.Canfatherseffectivelytrainmotherstousetheseskill componentsanddoesimplementationoftheseskillsby mothersresultinsignicantdifferencesinthedesignatedchildbehaviors? Methods ParticipantsandSetting Childrenwereincludediftheymetthefollowingcriteria: (a)adiagnosisof‘‘autisticdisorder’’accordingtoDSMIV TRcriteria(AmericanPsychiatricAssociation 2000 ),(b) scoresabovecut-offineachsubscaleoftheAutism DiagnosticInterviewRevised(ADI-R)andAutismDiagnosticObservationSchedule(ADOS),and(c)residence within150milesoftheUniversityofFlorida.Children wereexcludediftheirmedicalhistoriesand/orphysical examinationsindicatedtheyhadphysicalorsensory impairmentsorsignicantmedicalproblems(e.g.,seizure disorders,chronicotitismedia).Afterwritteninformed consentwasprovidedbyparents,children( N = 24)were randomlyassignedtoeitherthestandardinterventionora 6-weekwaitlistcontrolgroup.Eighteenchildren(nineper group)completedtheentireprotocol.Childrenrangedin ageatenrollmentfrom3.07to7.07(mean4.41 1.36) years,andtherewere17malesand1female.Thirteen (72%)wereCaucasian,2(11%)wereAfricanAmerican, and1(6%)eachLatinAmerican,Hispanic,andAsian, reectiveofdemographicsofthenorthcentralFlorida region.Fathersandmothersalsoprovidedinformedconsentforthemselvesandwereincludediftheyexpressed willingnesstobevideotapedwiththeirchildrenandto engageinthetrainingprocess.Exclusioncriteriaforparentsconsistedofanyphysical,majorpsychiatric,orsensoryproblems(e.g.,speechandlanguagedisorders,hearing loss),asnotedintheintakeevaluationthatmightaffect theirabilitytoconducttrainingand/orinteractwith children. Alltrainingandvideotapingsessionstookplacein participants’homes.Videotapingofthechildandone participatingparentoccurredinaroomwherechildren weremostoftenexposedtoinformalfamilyinteractions. Videographersfollowedproceduresdevelopedinourpreviousstudiestominimizeobtrusivenessandparticipant reactivity.Ifchildorparentlefttheplayarea,videotaping andtimingceasedandresumedaftertheyreturned.Ifthey didnotreturn,datawereconsideredunusableandalater sessionwasscheduled.Whilethisdidoccur,itwasrareand usuallyassociatedwiththechildbeingill.Asinourearlier work,studyparticipationwasgenerallywellmaintainedin homesettings.Participantsweremorelikelytokeep scheduledappointmentsandparticipateregularlyathome (comparedtoaclinic)becauseitwasconvenientand requiredlessexpenditureoffamilyresources.Home-based trainingandobservationsalsoprovidedessentialin-depth dataaboutindividualparticipantsinnaturalisticsettings. Instruments Afterobtainingparentconsent,eachchildwasscreened withtheAutismDiagnosticInterview-Revised(ADI-R) andAutismDiagnosticObservationSchedule(ADOS).If initialcriteriaweremet,additionalchilddatawere obtainedwiththeVinelandAdaptiveBehaviorScales. Informationregardingfamilyincomeandparentaleducationwasalsogatheredtodescribeoverallfamilysocioeconomicstatus. AutismDiagnosticInterview-Revised TheADI-R(Lordetal. 1994 )isastandardizedparent interviewforassessingpresenceandseverityofsymptoms. Adiagnosisofautismisestablishedifanindividualscores atorabovethecutoffscoreinthethreeICD-10symptom domains.Atrainedcertiedmemberoftheresearchteam administeredtheADI-Rtotheprimarycaregiver(parent whoreportedspendingthemosttimewiththechild). AutismDiagnosticObservationSchedule TheADOS(Lordetal. 2002 )isasemi-structuredobservationalassessmentadministereddirectlytothechild.Like theADI-R,instrumentvalidityisbasedondiagnosticcriteriaforautismintheDiagnosticandStatisticalManualof MentalDisorders(DSM-IV-R1994)andICD-10symptom domains.ADOSmoduleswereadministeredbyteam memberstrainedandcertiedinitsuse. VinelandAdaptiveBehaviorScales-SurveyForm (Vineland) TheVineland(Sparrowetal. 1984 )isawidelyused measureofadaptivebehaviorsfrombirthtoage18.This semi-structuredinterviewwithaparentoracaregiver JChildFamStud123

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assessesadaptive(reallife)skillsincommunication,daily living,maladaptivebehavior,andsocialization.Itiscommonlyusedinautismresearchbecauseitoffersoverall areasofdecitsinindividualswithautismanddimensional metricationofahallmarkdecit,socialization(social competence;Volkmaretal. 1997 ).Allinstruments describedabovehavewell-establishedpsychometric properties. MeasurementofDependentVariables DirectObservationofParentandChildBehavior ResearchAssistants(RAs),whosuccessfullycompleted extensivebehavioralcodingtraining,videotaped15min eachoffather–childandmother–childin-homeplaysessions.Therst5minwere‘‘settlingin’’andnotcoded;in thefollowing10min,codersvideotapedoccurrencesof parentandchildreciprocitybehaviors.Codersworked independentlyandbehavioralfrequencycountswere determinedbynumberofoccurrencescountedduringthe 10-minsession.Codingandanalysisoftargetbehaviors werefacilitatedwiththewidelyusedcomputerized ObserverProgram,whichalloweddatatobeenteredinto computers,labeledandorganized,andstoredinalarger desktopcomputerwithnetworkaccess.Throughoutthe researchprotocolthePI,whotaughttheinterventions,was notinvolvedinthecodingprocess,andcoderswerenot toldwhichinterventionswerebeingtaught.Toevaluatefor possibleraterdrift,asecondratercoded20%ofrandomly selectedvideotapedsessions.Interraterscoresrangedfrom 0.71to1.0,withameanof0.83.First,theteamcoded frequenciesofthefourfatherskillcomponents:imitating withanimation,expectantwaiting,followingthechild’s lead,andcommentingonthechild.Theteamalsocoded frequencyofthesameskillcomponentsforthemothers. Childinitiating,childresponding,childnon-speech vocalizations,andintelligiblewordswerealsocodedfor boththefather–childandmother–childsession. DescriptionofIndependentVariable(Father-Training Intervention) RationaleforSpecicTrainingComponents Inearlierresearchandclinicalwork,manyparentsverbalizedtheydidnotknowhowtoplaywiththeirchildrenduring playsessions.Parentseithersatpassivelyoraggressively triedtodirectinteractions,notallowingchildrensufcienttimetorespond(Elder 1995 ).Therstintervention, ‘‘imitating/animating,’’wasdesignedtoaddresstheseconcernsbypromotingbasicturn-takingplayinteractions. Enhancedwithspecicvideotapedexamplesandwritten directionsaboutfollowingthechild’sleadinplay,fathers wereinstructedtoattendtoandimitatetheirchildren’s vocalizationsand/oractionsinananimatedmanner.Asin ourearlierwork,parentsreportedthatimitatingthechildren was‘‘fun’’andhelpedthemrelaxduringplaysessions. ‘‘Expectantwaiting’’continuedtobemoredifcultto employ,asitrequireswaitingforchildresponses.Thus,we continuedtoteach‘‘imitating/animating’’rst,followedby ‘‘expectantwaiting.’’Inourpriorstudywealsoobservedthat evenwithinstructionemphasizingwaitingforthechildto initiate,fatherandmotherinitiatingdidnotdecreasesignicantlyacrossconditionsandthatmanyparentsreliedon directivequestioning.Toaddressthisinthecurrentstudy,we addedanothercomponenttospecicallyteachfathersto commentonthechild’sverbalizationsandactions,rather thanquestion. Figure 1 providesanoverviewofPI-fathertraining sessions,father-conductedtrainingsessions,andvideotapingdatacollectionsequence.Asnoted,therewerethree PI-fathertrainingsessions:introducingandteaching ‘‘imitating/animating’’and‘‘followingthechild’slead’’in playinterventions(Session1),introducingandteaching ‘‘expectantwaiting’’and‘‘commentingonthechild’’ (Session2),andcombiningthefourstrategies(Session3). FollowingPI-fathertraining,fathersimplementedwhat theylearned.Eachtimeaninterventionwasintroducedby fathers,anewconditionwasestablished(I-III). ConditionI:FathersUseInterventionItoTeachImitating/ Animating Oncepre-evaluationdatawereanalyzedforfather–child dyads,therstauthor(PI)usedfather–childvideotaped Enrolled and randomly assigned to standard intervention or wait list control group  Videotaped baseline sessions until stable  4-6 sessions for standard intervention group 16-18 sessions for wait list control group Condition I: Imitating/Animating and Following Child’s Lead (1) PI trained father, (2) 2 father-child sessions videotaped, (3) computer feedback session,* (4) 2 father-child sessions videotaped, (5) father instructed to train mother in Intervention I. Condition II: Expectant Waiting and Commenting vs. Questioning (1) PI trained father, (2) 2 father-child sessions videotaped (3) computer feedback session,* (4) 2 father-child sessions videotaped, and (5) father instructed to train mother in Intervention II. Condition III: Combining All Strategies (1) PI trained father, (2) 2 father-child sessions videotaped, (3) computer feedback session,* (4) 2 father-child sessions videotaped, and (5) father instructed to train mother in Intervention III. Fig.1 Sequenceofexperimentalconditions* JChildFamStud123

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baselinesessionstoteachfatherstorecognizechildinitiations,followchild’sleadinplay,andapplytheintervention‘‘imitating/animating.’’Motherswerenotpresent duringfathertraining.Aftertraining,fatherswere instructedtoimmediatelybeginusingInterventionIin everydayinteractionswiththeirautisticchildren.Skill acquisitionwasassessedviavideotapeduringfather–child playsessionstwotimesaweekfortwoconsecutiveweeks. Fatherswereinstructedtousetheinterventioncomponent withtheirchildfor3–4daysbeforebeingvideotaped again.Theresearchteamuseddatafromthesesessionsto determinenumberofopportunitiesforusingtheinterventionandhowoftenfathersrespondedtotheseopportunities.ThePIdiscussedthesendingswithfathersand determinediftheywerereadytoadvancetothenext conditionorifremediationwasindicated.Motherswere videotapedduringeachhomevisitaswell.Father–child andmother–childsessionsremainedseparate,andorderof videotapingwascounterbalancedacrosssessions.Asinthe baselinephase,childrenweregivenbreaksbetweenall sessions. Attheendofeachinterventioncondition,fatherswere instructedtoteachmothersinthesamemannertheywere taught.Thisincludeduseofwrittenmaterialsandvideotapedparent–childsessions.ThePI wasnot directly involvedinthemothertrainingprocessbutremained availabletofathersfortelephoneand/orweb-basedconsultation.Eachparentwasgivenaccesstoaweb-based discussionforumforprivateconsultationwitharesearcher asneeded. ConditionII:FathersUseInterventionIItoTeach CommentingandExpectantWaiting PriortocollectingdatainConditionII,fatherswereasked totrainmothersinInterventionIandtobeginusing InterventionII,themselves.Datacollectionmethodsof child/parentbehaviorswereidenticaltoConditionI.PIfathertrainingofInterventionIIinvolvedtwostrategies: ‘‘expectantwaiting’’(signalingchildforadesiredactionor wordandwaitingexpectantlyaminimumof3-sfora response)and‘‘commentingonthechild,’’insteadof askingquestions,amorecommonparentalbehavior.From ourpreviousworkwenotedthatevenwheninstructedto discontinueInterventionI,somefathershadalready incorporateditintotheirdailyfather–childinteractions, anditwasunrealistictoexpectthemto‘‘unlearn’’theskills set.Therefore,inthecurrentstudyfathersdecidedwhether tocontinueusingInterventionIwithoutovertinstruction, andInterventionIusewasdocumentedthroughoutall conditions.AsinConditionI,theresearchteamuseddata obtainedfromthersttwovideotapedsessionsinConditionIItodeterminenumberofopportunitiesforusingthe interventionandhowoftenfathersrespondedtothese opportunities.Theparenttrainer(PI)discussedndings withfatherstodetermineiftheywerereadytoadvanceto thenextconditionorifboostertrainingwasindicated.If videotapesshowedafatherwasnotusingthestrategiesas instructed,ateammembermadeonesubsequenthomevisit toprovideadditionalinstructionandencouragement,andto answerquestions.Atleasttwomorevideosessionswere thenconductedtoensurethefatherwasusingthestrategies beforeaskinghimtoinstructthemotherandmovetothe nextintervention. ConditionIII:FathersUseCombinedInterventionsIandII Inthistrainingsessionfathersviewedfather–childvideotapesanddata,andreceivedadditionalinstructionregardingcombiningbothpreviouslylearnedstrategies.Training wasindividualized,basedonassessmentdata,thechild’s progress,andexpressedneedsoffathers.Datacollection wasidenticaltoConditionsIandII. Insummary,eachfamilywasvideotapedtwiceaweek for8–12weeks.Therangeinweeksreectseachfamily’s uniquenessregardingneedfortraining,familyillness,and/ orlast-minutelmingsessioncancellations.Variationwas accountedforinstatisticalanalysisofgroupeddata. DataAnalysis Twotypesofanalyseswereused.Therstinvolvedvisuallyanalyzingindividualparent–childgraphstodetermine ifbaselinedatawerestablepriortoimplementinginterventioncomponents.Thisisacustomaryapproachusedin single-subjectexperimentalresearchdesigns(Hersenand Barlow 1987 ).Baselinesofstandardinterventionandwait listcontrolgroupswereevaluatedtodetermineifthere werechangesinlevelsandtrendsthatcouldbeattributable tofactorsotherthanspecictraininginterventions.The secondandmainanalysisinvolvedrepeatedmeasures ANOVAtostudypotentialgroupwisechangesinbehaviorsovertheconditionsofinterest;SASversion9.1.3(SAS Institute,Cary,NC)wasused.Toreducevariability,individualsessionfrequencieswererstaggregatedbycondition,withaggregatevaluesusedintheanalysis.Thesingle groupapproachusestheparticipant’smeanbaseline behaviorscoresashis/herowncontrolsanddetermines whether,onaverage,thereisachangeoverthechronologicalconditionsofinterest.Advantagesofthedesignare thatissuessuchasparticipantselectionandmatching becomeirrelevant,andeveryparticipatingfamilyreceives theintervention. AtConditionI,fathersweretaught‘‘imitating/animating’’and‘‘followingthechild’slead.’’Themultivariatetest JChildFamStud123

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ofinterestwaswhethertherewasachangefrombaseline, onaverage,atanyfollow-upperiod(allConditions).At ConditionII,fathersweretaught‘‘expectantwaiting’’and ‘‘commentingonchild.’’Hence,themultivariatetestof interestwaswhethertherewasachangefrombaseline,on average,atIIorIII.Testsformotherbehaviormirrored thoseusedforfathers.Multivariatetestsforchildresponses lookedforachangefrombaselinetoanyfollow-upperiod inthestudy.Inordertofurtherexaminelocationsand magnitudesofchange,follow-up t -testsexaminingchange frombaselinetospecicconditionswerealsoperformed. Results Visualanalysesofbaselinedataforboththestandard intervention( n = 9)andwaitlistcontrolgroups( n = 9) revealednodiscernabletrendsindicatingtheinuenceof confounds(e.g.,participantreactivitytodatacollectors, environmentalfactors)priortotheintervention. Themainanalysisinvolvedgroupeddataacross18 childrenandtheirparents.RepeatedmeasuresANOVA resultsforfathersessionsarepresentedinTable 1 and visuallydepictedinFig. 2 ;resultsformothersessionsare presentedinTable 2 andvisuallydepictedinFig. 3 FatherBehaviors Signicantchangesinfather imitating/animating rates werefoundfrombaselinetothethreeconditions(overall p \ 0.001).Follow-upanalysisconrmedthemeanratefor imitating/animating increasedfrombaselinetoeachfollow-upcondition( p \ 0.001ateachcondition).Nosignicantoverallchangeoccurredfrombaselinefor followingthechild’slead (overall p = 0.089);however, follow-upexploratoryanalysisshowedapossibleincrease frombaselinetoConditionI( p = 0.015).Signicant changesinfathers’ expectantwaiting rateswerefound frombaselinetothenaltwoconditions(overall p = 0.013).Follow-upanalysisconrmedthemeanrate Table1 Father–childdyadfrequencies( n = 18) BehaviorVariablesBaselineConditionIConditionIIConditionIII Fp ImitatewithanimationM1.921.421.319.519.72 \ 0.001 SD0.43.82.72.6 Followchild’sleadM1.32.52.22.32.620.089 SD0.30.50.40.6 ExpectantwaitingM0.50.57.57.55.740.013 SD0.30.22.42.0 CommentonchildM24.027.631.728.54.900.022 SD2.72.93.03.2 ChildinitiatingM16.022.728.129.84.150.025 SD2.23.55.55.5 ChildrespondingM21.218.521.721.50.33 [ 0.2 SD4.45.35.14.5 Childnon-speechvocalsM23.429.833.330.54.240.023 SD2.33.73.22.4 ChildintelligiblewordsM40.951.846.844.50.65 [ 0.2 SD11.015.211.312.6 ImitatewithAnimation,FollowChild’sLead,andchildbehaviorfrequenciesweretestedaschangefromBaselinetoanyofthethreeConditions; ExpectantWaitingandCommentingonChildweretestedaschangefromBaselinetoeitherConditionIIorConditionIII 0 5 10 15 20 25 30 35Behavior frequenciesBaselineCondition ICondition IICondition IIICondition Father SkillsImitate/Animate Follow Lead Expectant Waiting Comment on Child Fig.2 Fatherskillacquisitionandchildbehaviorsfrombaseline throughconditionIII JChildFamStud123

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for expectantwaitingi ncreasesfrombaselinetoeachofthe twonalconditions( p = 0.011and p = 0.003,forIIand III,respectively).Signicantchangeswerealsofoundfor fathers’ commentingonthechild ratesfrombaselinetothe naltwoconditions(overall p = 0.022).Follow-upanalysisconrmedthatthemeanratefor commentingonthe child increasesfrombaselinetoConditionII( p = 0.005) andthattheeffectispossiblydiminishedinConditionIII ( p = 0.11). MotherBehaviors Signicantchangesinmother imitating/animating rates werefoundfrombaselinetothethreeconditions(overall p \ 0.001).Follow-upanalysisconrmedthatthemean ratefor imitating/animating increasedfrombaselineto eachoftheconditions( p \ 0.001ateach).Therewasalso asignicantoverallchangefrombaselinefor followingthe child’slead (overall p = 0.006).Follow-upanalysis showedasignicantincreasefrombaselinetoConditionII ( p = 0.034)butdidnotshowsignicantchangestothe othertwoconditions( p [ 0.2and p = 0.068forIandIII, respectively).Signicantchangesinmothers’ expectant waiting rateswerefoundfrombaselinetothenaltwo conditions(overall p = 0.005).Follow-upanalysisconrmedthemeanratefor expectantwaiting increasedfrom baselinetoeachofthetwonalconditions( p = 0.007and p = 0.008forIIandIII,respectively).Signicantchanges werenotfoundformothers’ commentingonthechild rates frombaselinetothenaltwoconditions(overall p [ 0.2). Follow-upexploratoryanalysisdidnotndpotentiallysignicantchangesfrombaselinetoeitherConditionIIorIII. ChildBehaviors,FatherandMotherSessions Childbehaviorfrequencieswereanalyzedforbothfather andmothersessions,withsimilarresults.Signicant overallchangesfrombaselinewerefoundin childinitiating (overall p = 0.025forfathersessionsand p = 0.009 Table2 Mother-childdyadfrequencies( n = 18) ResponseVariablesBaselineConditionIConditionIIConditionIII Fp ImitatewithanimationM3.59.813.713.211.77 \ 0.001 SD0.91.61.51.6 FollowleadM1.51.32.33.96.170.006 SD0.30.20.30.5 ExpectantwaitingM1.00.92.33.97.700.005 SD0.40.30.71.1 CommentonchildM26.228.532.332.50.91 [ 0.2 SD3.52.83.34.5 ChildinitiatingM16.322.026.727.55.620.009 SD2.43.74.24.3 ChildrespondingM20.320.315.817.22.140.107 SD3.33.03.03.2 Childnon-speechvocalsM22.731.031.428.25.430.010 SD2.22.52.93.1 ChildintelligiblewordsM45.154.251.348.61.35 [ 0.2 SD12.813.514.813.6 ImitatewithAnimation,FollowChild’sLead,andchildbehaviorfrequenciesweretestedaschangefromBaselinetoanyofthethreeConditions; ExpectantWaitingandCommentingonChildweretestedaschangefromBaselinetoeitherConditionIIorConditionIII 0 5 10 15 20 25 30 35Behavior frequenciesBaselineCondition ICondition IICondition IIICondition Mother SkillsImitate/Animate Follow Lead Expectant Waiting Comment on Child Fig.3 Motherskillacquisitionandchildbehaviorsfrombaseline throughconditionIII JChildFamStud123

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formothersessions)and childnon speechvocalizations (overall p = 0.023forfathersessionsand p = 0.010for mothers).Follow-upanalysisforchildinitiatingshowed signicantincreasesfrombaselinetoallthreeconditions forfather/mothersessions(all p \ 0.03).Follow-upanalysisfor non speechvocalizations showedsignicant increasesfrombaselinetoeachofthethreeconditionsfor fathersessions(all p \ 0.03)andthersttwoconditions formothersessions(both p \ 0.01forIandII, p = 0.08 forIII).Overallchangesfrombaselinewerenotsignicant forchildresponse( p [ 0.2forfathers; p = 0.11for mothers)orfor intelligiblewords (both p [ 0.2).Exploratoryfollow-upanalysisfoundonlyonepotentialchange frombaselineforthesetwomeasuresacrossmother/father sessions:childuseofintelligiblewordsfrombaselineto ConditionIincreasedby9.2onaverage( p = 0.047)in mothersessions. Discussion Asdiscussedintheintroductorysection,thefourindividual trainingcomponentsarelinkedtosocialinteractiontheory anddesignedtopromotesocialreciprocitybetweenparents andchildrenwithautism.Asinourpreviouswork,we notedthatpriortoin-hometraining,fathersandmothers infrequently,andinsomecasesnever,usedstrategiesof imitatingthechildwithanimation and expectantlywaiting forachildresponse.AfterfathersweretrainedbythePI andmothersweretrainedbyfathers,bothgroupseffectivelyusedthesestrategiesanddemonstratedsignicant increasesinfrequency.Anecdotalreportsindicatedthat parentsviewedtherststrategyas‘‘fun’’andwereableto incorporateitintotheirdailyparent–childinteractions. Whileparentswereabletolearnandusethe expectant waiting strategy,theyreporteditwassometimesdifcultto waitforchildresponsesfortheinstructedminimumof3s. Differencesoccurredinhowoftenfathersandmothersused theothertwostrategies, followingthechild’slead and commentingonthechild .Mothersused commentingonthe child moreoftenthanfathersduringbaseline,andperhaps thatiswhytheydidnotdemonstratethesamesignicant increasesasfathersfollowingtraining.Mothersdid,however,showasignicantincreaseinuseof thechild’slead whilefathersdidnot.Reasonsforthisndingareuncertain.Childresponsesweresimilarforbothparentsinthat sessionswitheachshowedsignicantincreasesinboth initiating and non speechvocalizations .Thisndingis particularlyimportantsinceahallmarkfeatureofautismis impairedsocialinitiating,andnon-speechvocalizations (pre-speech‘‘babble’’)oftenprecedeintelligiblespeech. FathersinthisstudyweretrainedbythePIand instructedtotrainmothers,whohadnotrainingotherthan this.Toourknowledge,oursaretherststudiestotestthis approach.Inbothstudiesfathersdemonstratedtheycould learnthestrategiesandtrainmothers.Mothers,inturn, effectivelylearnedfromfathersasdemonstratedbytheir abilitytoimplementthesestrategies.Furtherstudyis neededtodetermineifthisapproachisanefcaciousmeansofsolicitingandmaintainingfatherinvolvement. Resultsofthisandourpriorstudyindicatethatidentifyingandimplementingstrategiesdesignedtopromote socialreciprocityinparentsandchildrenwithautismisa valuableapproachandwell-acceptedbyparticipating families.Afthaimofthisstudy,notdiscussedinthis article,wasthedevelopmentofawebsitetoinformfamiliesandreinforcetraining(Ferdigetal. 2009 ).Awebassistedapproachalsoshowspromiseandwillbeempiricallyevaluatedinfutureresearch.Wehaveprovidedevidenceindicatingthatfather-directedtrainingiseffective andaddressesavarietyoffamilyandchildneeds.Although labor-intensive,wealsonotedthatcollectingvideotaped dataovernumeroussessionsratherthansinglepreand post-interventionisveryimportantbecausebehavioral variabilityinchildrenwithautismoftenoccurs.Visually analyzingbaselinedatafromthewaitlistcontrolgroup alsohelpeddiscernthattreatmenteffectswerefromthe interventions,notmerelyfromattentionto,orpresenceof, investigators.Asineverynewareaofinquiry,more researchisneededtofurthervalidatefamily-focused,inhomeinterventionsinchildrenwithautismaswellasother relateddisorders.Acknowledgments Wewishtoacknowledgetheparticipating familiesandchildrenwhohavegainedouradmirationandtheeditorialassistanceprovidedbyPamelaSelby,M.S.,M.A.Theresearch wasfundedbyaR01fromtheNationalInstituteofNursingResearch. RichardFerdigisnowatKentStateUniversity. OpenAccess Thisarticleisdistributedunderthetermsofthe CreativeCommonsAttributionNoncommercialLicensewhichpermitsanynoncommercialuse,distribution,andreproductioninany medium,providedtheoriginalauthor(s)andsourcearecredited.ReferencesAinsworth,M.,Blehar,M.,Waters,E.,&Wall,S.(1978). Patternsof attachment:Apsychologicalstudyofthestrangesituation (5th ed.).HillSDale,NJ:Erbaum. AmericanPsychiatricAssociation.(2000). Diagnosticandstatistical manualofmentaldisorders (Revised4thed.).Washington,DC: Author. Barnard,K.(1983).Thecasestudymethod:Aresearchtool. Journal ofMaternalChildNursing,8 (1),36. Belsky,J.,Rovine,M.,&Taylor,D.G.(1984).ThePennsylvania infantandfamilydevelopmentproject,III:Theoriginsof individualdifferencesininfant-motherattachment:Maternaland infantcontributions.[Article]. ChildDevelopment,55 (3),718– 728.doi: 10.1111/1467-8624.ep12422856 JChildFamStud123

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Booth,A.,&Crouter,A.C.(Eds.).(1998). Meninfamilies:Whendo theygetinvolved?Whatdifferencedoesitmake? Mawhaw,NJ: LawrenceErlbaumAssociates. Brazelton,T.,Koslowski,B.,&Main,M.(1974).Theoriginsof reciprocity.Theearlymother-infantinteraction.InM.Lewis& L.Rosenblum(Eds.), Theeffectoftheinfantonthecaregivervol 1 (pp.49–76).NewYork:Wiley. Bruner,J.S.(1973).Fromcommunicationtolanguage:Apsychologicalperspective. Cognition,3 ,255–287. Calhoun,M.,Rose,T.,Hanft,B.,&Sturky,C.(1991).Social reciprocityinterventions:Implicationsfordevelopmentaltherapists. PhysicalandOccupationalTherapyinPediatrics,11 ,45– 56. Cunningham,C.E.,Reuler,E.,Blackwell,J.,&Deck,J.(1981). Behavioralandlinguisticdevelopmentsintheinteractionsof normalandhandicappedchildrenandtheirmothers. Child Development,52 ,62–70. Damon,W.,&Eisenberg,N.(1998). Handbookofchildpsychology: Social,emotional,andpersonalitydevelopment (5thed.).New York:Wiley. Dawson,G.,&Galpert,L.(1990).Mothers’useofimitativeplayfor facilitatingsocialresponsivenessandtoyplayinyoungautistic children. DevelopmentandPsychopathology,2 ,151–162. Donnellan,A.,Mirenda,P.,Mesaros,R.,&Fassbender,L.(1984). Analyzingthecommunicativefunctionofaberrantbehavior. JournaloftheAssociationfortheSeverelyHandicapped,9 ,201– 212. Duchan,J.(1989).Evaluatingadults’talktochildren:Assessingadult attunement. SeminarsinSpeechandLanguage,10 ,17–27. Elder,J.H.(1995).In-homecommunicationinterventiontrainingfor parentsofmultiplyhandicappedchildren. ScholarlyInquiryfor NursingPractice,9 ,71–92. Elder,J.H.(2002).Currenttreatmentsinautism:examiningscientic evidenceandclinicalimplications. JournalofNeuroscience Nursing,34 (2),67–73. Elder,J.H.,Valcante,G.,Won,D.,&Zylis,R.(2003).Effectsofinhometrainingforculturallydiversefathersofchildrenwith autism. IssuesinMentalHealthNursing,24 (3),273–295. Elder,J.H.,Valcante,G.,Yarandi,H.,White,D.,&Elder,T.H. (2005).Evaluatingin-hometrainingforfathersofchildrenwith autismusingsingle-subjectexperimentationandgroupanalysis methods. NursingResearch,54 (1),22–32. Ferdig,R.E.,Amberg,H.G.,Elder,J.H.,Donaldson,S.A., Valcante,G.,&Bendixen,R.(2009).Autismandfamily interventions:TheuseoftheInternettotrainfathersofautistic children. InternationalJournalofWeb-basedLearningand TeachingTechnologies,4 (3),55–69. Furrow,D.,Nelson,K.,&Benedict,H.(1979).Mothers’speechto childrenandsyntacticdevelopment:Somesimplerelationships. JournalofChildLanguage,6 (3),423–442.doi: 10.1017/ S0305000900002464 Hersen,M.,&Barlow,D.(1987). Single-caseexperimentaldesign: Strategiesforstudyingbehaviorchange .NewYork:Pergamon Press. Koegel,L.,Koegel,R.,&Dunlap,G.(1999). Positivebehavioral support .York,PA:TheMaplePress. Koegel,R.L.,O’Dell,M.,&Koegel,L.K.(1987).Anatural languageparadigmfornonverbalautisticchildren. Journalof AutismandDevelopmentalDisorders,17 (2),187–200. Lamb,M.E.(1987). Thefather’srole:Cross-culturalperspectives HillSDale,NJ:LawrenceErlbaumAssociates. Lord,C.,Rutter,M.,DiLavore,P.C.,&Risi,S.(2002). Autism diagnosticobservationschedulemanual .LosAngeles:Western PsychologicalServices. Lord,C.,Rutter,M.,&LeCouteur,A.(1994).Autismdiagnostic interview-revised:Arevisedversionofadiagnosticinterviewfor caregiversofindividualswithpossiblepervasivedevelopmental disorders. JournalofAutismandDevelopmentalDisorders, 24(5),659–685.doi: 10.1007/BF02172145 Lovaas,O.(1987).Behavioraltreatmentandnormaleducationalan intellectualfunctioninginyoungautisticchildren. Journalof ConsultingandClinicalPsychology,55 (1),3–9. Marcus,L.,Kunce,I.,&Schopler,E.(1997).Workingwithfamilies. InD.J.Cohen&F.R.Volkmar(Eds.), Handbookofautismand pervasivedevelopmentaldisorders (2nded.,pp.631–649).New York:Wiley. Mudford,O.C.,Martin,N.T.,Eikeseth,S.,&Bibby,P.(2001). Parent-managedbehavioraltreatmentforpreschoolchildrenwith autism:SomecharacteristicsofUKprograms. Researchin DevelopmentalDisabilities,22 (3),173–182. Mundy,P.,Sigman,M.,&Kasari,C.(1990).Alongitudinalstudyof jointattentionandlanguagedevelopmentinautisticchildren. JournalofAutismandDevelopmentalDisorders,20 (1),115– 128.doi: 10.1007/BF02206861 Mundy,P.,Sigman,M.,&Kasari,C.(1994).Jointattention, developmentallevel,andsymptompresentationinyoung childrenwithautism. DevelopmentandPsychopathology,6 389–401.doi: 10.1017/S0954579400006003 Schopler,E.(1996). Parents’survivalmanual:Aguidetocrisis resolutioninautismandrelateddevelopmentaldisorders .New York:Plenum. Schreibman,L.(1997).Theoreticalperspectivesonbehavioral interventionforindividualswithautism.InD.J.Cohen&F. R.Volkmar(Eds.), Handbookofautismandpervasivedevelopmentaldisorders (2nded.,pp.920–933).NewYork:JohnWiley &Sons. Siller,M.,&Sigman,M.(2008).Modelinglongitudinalchangeinthe languageabilitiesofchildrenwithautism:Parentbehaviorsand childcharacteristicsaspredictorsofchange. Developmental Psychology,44 ,1691–1704. Snow,C.E.(1983).Sayingitagain:Theroleofexpandedand deferredimitationsinlanguageacquisition.InK.E.Nelson (Ed.), Children’slanguage (Vol.4,pp.29–58).HillSDale,NJ: LawrenceErlbaumAssociates. Sparrow,S.,Balla,D.,&Cicchetti,D.(1984). Vinelandadaptive behaviorscales .CircleInes,MN:AmericanGuidanceService. Stahmer,A.C.(1995).Teachingsymbolicplaytochildrenwith autismusingpivotalresponsetraining. JournalofAutismand DevelopmentalDisorders,25 ,123–141. Tiedge,L.B.,&Darling-Fisher,C.(1996).Fatherhoodreconsidered: Acriticalreview. ResearchinNursingandHealth,19 (4),471– 484. Volkmar,F.,Klin,A.,&Cohen,D.(1997).Diagnosisandclassicationofautismandrelatedconditions:Consensusandissues.In D.J.Cohen&F.R.Volkmar(Eds.), Handbookofautismand pervasivedevelopmentaldisorders (2nded.,pp.5–40).New York:Wiley. Wetherby,A.M.,&Prizant,B.M.(2000). Autismspectrum disorders:Atransactionaldevelopmentalperspective .Baltimore,MD:Brookes. JChildFamStud123