ERIC ED581896: Integrating a Parent-Implemented Blend of Developmental and Behavioral Intervention Strategies into Speech-Language Treatment for Toddlers at Risk for Autism Spectrum Disorder

2018·0.31 MB·English

by  ERIC

Integrating a Parent-Implemented Blend of
Developmental and Behavioral Intervention
Strategies into Speech-Language Treatment
for Toddlers at Risk for Autism Spectrum
Disorder
Sarah R. Rieth, Ph.D., BCBA-D,1,2 Rachel Haine-Schlagel, Ph.D.,1,2
Marilee Burgeson, M.A., CCC-SLP,3,9 Karyn Searcy, M.A., CCC-SLP,4,8
Kelsey S. Dickson, Ph.D.,1,5 and Aubyn C. Stahmer, Ph.D, BCBA-D1,6,7
ABSTRACT
Naturalisticdevelopmentalbehavioralinterventionsincludean
explicit focus on coaching parents to use therapy techniques in daily
routinesandareconsideredbestpracticeforyoungchildrenwithautism.
Unfortunately, these approaches are not widely used in community
settings,possiblyduetotheclinicalexpertiseandtrainingrequired.This
article presents the work of the Bond, Regulate, Interact, Develop,
Guide,Engage(BRIDGECollaborative),amultidisciplinarygroupof
service providers (including speech-language pathologists), parents,
fundingagencyrepresentatives,andresearchersdedicatedtoimproving
the lives of young children with autism spectrum disorder and their
families.Thegroupselectedandadaptedaparentcoachingnaturalistic
developmentalbehavioralinterventionspecificallyforusewithtoddlers
andtheirfamiliesforcommunityimplementation.Lessonslearnedfrom
the implementation process include the importance of therapist back-
ground knowledge, the complexity of working with parents of young
children, and needed supports for those working closely with parents,
including specific engagement strategies and the incorporation of
reflective practice.
1Child and Adolescent Services Research Center, San EnhancingCommunicationandSocialInteractionSkillsof
Diego; 2Department of Child and Family Development; Children with Autism Spectrum Disorders and Their
SanDiegoStateUniversity;3MBSpeechTherapy;4TERI CommunicationPartners;GuestEditor,AmyL.Donald-
CrimsonCenterforSpeechandLanguage;5Departmentof son,Ph.D.,CCC-SLP.
Psychiatry,UniversityofCalifornia,SanDiego;6UCDavis Semin Speech Lang 2018;39:114–124. Copyright
MINDInstitute;7DepartmentofPsychiatryandBehavio- #2018byThiemeMedicalPublishers,Inc.,333Seventh
ral Sciences, University of California, Davis; 8Speech, Avenue, New York, NY 10001, USA. Tel: [phone]-
Language,andHearingSciences,SanDiegoStateUniver- 4662.
sity;9ProfectumAcademy,Mendham,NewJersey. DOI:https://doi.org/10.1055/s-0038-1627483.
Address for correspondence: Sarah R. Rieth, Ph.D., ISSN0734-0478.
BCBA-D,5500CampanileDrive,SanDiego,CA92180-
4502(e-mail:[email protected]).
114
INTERVENTIONSTRATEGIESFORTODDLERSATRISKFORASD/RIETHETAL 115
KEYWORDS:Naturalistic developmental behavioral intervention,
parent coaching, early intervention, reflective practice
LearningOutcomes:Asaresultofthisactivity,thereaderwillbeableto(1)summarizetherationalefor
blendeddevelopmentalandbehavioralapproachestoautismintervention;(2)discusstheimportanceand
impactofparentcoachingininterventionforyoungchildrenwithautism;(3)identifythechallengesofworking
withparentsofyoungandnewlydiagnosedchildrenwithautism;and(4)evaluatetheinfluenceoftheoretical
orientationonimplementationofblendedapproachesandavailablesupportforworkingwithparents.
NATURALISTIC DEVELOPMENTAL tosupportachild’scommunicationskills,inclu-
BEHAVIORAL INTERVENTIONS ding expressive speech and language, receptive
Recentworkfromleadingexpertsinthefieldof language, gesture production, and pragmatic
autism intervention has identified naturalistic skills. Different branded approaches implement
developmental behavioral interventions this collection of elements slightly differently
(NDBIs) as empirically and theoretically sup- (e.g.,EarlyStartDenverModel,5,6PivotalRes-
ported approaches for young children with ponseTraining,7,8ProjectImPACT[Improving
autism spectrum disorders (ASD).1 Although Parents as Communication Teachers]9), but all
behavioral and developmental treatments have focusontheuseofinterventionstrategiesinthe
traditionally come from highly diverse fields, context of the play and daily routines that are
current best practice acknowledges that there is centraltothelivesofyoungchildren.
muchtolearnfrombothapproachesandthatkey
ingredientsacrossmethodologiescanbesuccess-
fullyintegrated.Thisintegrationallowschildren BENEFITS OF PARENT-
who receive NDBIs to benefit from consistent IMPLEMENTED INTERVENTION
skillacquisitionguidedbymorestructuredbeha- In synthesizing theory and reviewing empirical
vioraltechniqueswithinthecontextofengaging evidence regarding earlyintervention outcomes,
interactions that build on the richness of the it is clear that best practice recommendations
developmental process. Ensuring that interven- emphasizetheinvolvementofparentsandcare-
tionisrootedinourknowledgeofdevelopmentis giversininterventiondeliveredtoyoungchildren
especiallyimportantnow,assignsofautismare withASD.10Tothatend,NDBIsoftenfocuson
beingidentifiedatincreasinglyyoungeragesand parentcoaching,inwhichinterventioniststeach
children may be receiving specialized treatment the parents of a child with ASD how to use
asearlyastheirfirstbirthday.2 treatmentstrategiestoincreasethequantity(time
Although not designed specifically for per day) and quality (in the context of a mea-
speech-language pathology, the framework of ningful relationship) of the intervention a child
NDBIsisconsistentwithbestpracticesforyoung receives.Aspartofbestpractice,parentinvolve-
childrenandwithpracticesoftenusedinspeech- mentininterventionincludescollaboratingwith
language pathology services.3,4 Common featu- clinicians to set goals and priorities for inter-
res of NDBIs include individualized treatment vention as well as acquiring the tools and stra-
goals,child-initiatedteachingepisodes,ongoing tegiestotargetthosegoalsinthecontextofhome
measurement of progress, environmental arran- and daily routines. This approach can promote
gementtopromoteinteraction,useofbehavioral children’ssuccessfuluseofskillsacrossenviron-
learning principles (including prompting and mentsandovertimewhentheyaregivenrepeated
reinforcement), modeling desired behaviors opportunitiestopracticenewskillsinthevariety
aroundthechild’sfocusofinterest,andimitating of contexts they encounter with their parents.11
the child’s language and gestures, among other In addition to the positive impacts of parent-
components.Eachoftheseelementscanbeused implemented intervention on children,5,10,12
116 SEMINARSINSPEECHANDLANGUAGE/VOLUME39,NUMBER2 2018
research consistently demonstrates positive ASDtreatment,stressandmentalhealthprob-
impacts of parent-implemented intervention on lemshavebeenlinkedexplicitlytopoorerchild
parents,includingreducedparentalstress,impro- outcomesinotherpopulations.22Furthermore,
vedparentresponsiveness, andenhancedparent one study found that high parent stress was
competency in promoting child learning,13–15 linked to compromised decision making by
amongotherbenefits. therapists regarding appropriate behavior tar-
Despite broad endorsement of blended, getsinabehavioralintervention.23Thus,parent
parent-implemented developmental behavioral stresscanimpact parents’engagement through
interventionsforyoungchildrenasbestpractice, the delivery of the actual intervention itself.
these approaches remain severely underutilized Logistically,parentsmayhavemultiplechildren
incommunitysettings.16,17Amaincontributor to care for, which can make it challenging to
tothisunderutilizationmaybethechallengesof fullyparticipateininterventionsessions.Fami-
adequatelypreparingthebroadrangeofservice lies may come from a culture where playful
providers who span the multiple disciplines interactionwithchildrenisnottypical,making
involved in early intervention to deliver and itdifficultoruncomfortableforthemtoengage
sustain high-quality, parent-mediated treat- inanimatedplaywiththeirchild.Furthermore,
ments. To successfully use these approaches, bythetimechildrenreceiveaccesstotreatment,
serviceprovidersnotonlyneedtobecomeadept parents may appear flat or have difficulty
at the intervention techniques themselves, but playing with their child, because they may
mustalsolearntoeffectivelyengageandsupport have been trying for 9, 12, or even 24 months
parents in learning to use the strategies. Too to engage with them with limited child res-
often, professionals trained in early childhood ponse. Together, these issues require interven-
intervention,includingspeech-languagepatho- tioniststobeskilledatunderstandingwhatmay
logists, overlook the importance of working affect parents’ participation in intervention
closelywithparentstopromotechildren’sskills. while discovering ways to increase parent
Additionally, they may lack the necessary trai- engagement.
ningtounderstandhowtosuccessfullyintegrate Parents’ perceptions of the efficacy of the
parents into the intervention process in a mea- interventioncanalsocontributetotheirengage-
ningfulway. ment in ASD treatment.24,25 When families
believetheinterventioncanresultinmeaningful
changeintheirchild’sfunctioning,theyaremore
CHALLENGES IN PARENT likelytobemotivatedtoengageintheservice.In
COACHING AND ENGAGEMENT addition, there is some evidence that higher
Though parent involvement is central to pro- perceived burden of the intervention on the
moting progress for young children with an family may reduce treatment engagement.26
array of challenges, parents vary in their moti- Parents’ perceptions about themselves can also
vation,skills,abilities,andcapacitytoengagein impact treatment engagement. For example,
parent-implemented interventions for children when parents believe that their involvement is
with ASD. Working with newly diagnosed beneficial andthey areequal decision makers in
children with ASD and their parents presents treatment, they are more likely to be active
several unique challenges for parent engage- participantsinservices.27Relatedly,whenparents
mentandcoaching.Forexample,theprocessof feel effective in their involvement in the treat-
receivingadiagnosisofautismordevelopmen- ment,theyaremorelikelytobeinvolvedinit.28
tal delay may be similar to the experience of
bereavement,18,19andparents’responsesmaybe
similartothosefollowingatraumaorcrisis.20,21 THE BRIDGE COLLABORATIVE
This may make it challenging for them to Studieshavesuggestedthatapproachingparent
engage in treatment and learn new skills. Alt- coaching as a provider-parent collaboration,
houghnoresearchhasspecificallyexaminedthe engaging in shared decision making and enab-
links between parental stress/mental health lingcollaborativeproblemsolvingcanfacilitate
problems and engagement in their children’s parent engagement in parent coaching
INTERVENTIONSTRATEGIESFORTODDLERSATRISKFORASD/RIETHETAL 117
interventions and improve treatment outco- in the context of on-going parent-child inter-
mes.23,29,30Supportinginterventionistsinbuil- actionsindailyroutines,andtheoverallfitwith
ding effective relationships with parents to sharedvaluesacrosscommunitystakeholders.33
promote their child’s development has been a Through pilot testing, expert and clinician
primary goal of a multidisciplinary group of feedback, and consultation with Project
interventionists,parents,researchers,andfund- ImPACT developers, the BRIDGE Collabo-
ingagencyrepresentatives,calledtheBRIDGE rative created a toddler-specific adaptation of
Collaborative, over the past 10 years. The the approach that included a new parent coa-
BRIDGE Collaborative is a community-aca- chingmanualaswellasinterventionisttraining
demic partnership dedicated to improving the materials. This adapted package is called Pro-
lives of young children with ASD and their ject ImPACT for Toddlers, and specifically
families by building capacity for families to addressestheneedsofchildren12to36months
receive a particular NDBI in the commu- forwhomtherearesocialcommunicationcon-
nity.31,32 The following sections highlight key cerns, as well as their families. Though the
pointsanddatafromtheworkofthecollabora- individual elements of Project ImPACT for
tive to inform the delivery of effective inter- Toddlers may seem highly similar to other
vention with young children with ASD, interventionapproaches(e.g.,followthechild’s
including providing best-practice training that lead,arrangetheenvironmenttocreatenatural
accounts for interventionists’ background opportunities to respond), it also focuses spe-
knowledge and theoretical orientation, integ- cifically on equipping professionals to work
rating reflective practice to support the inter- closely and collaboratively with parents, which
vention process and utilizing specific strategies is emphasized throughout the materials and in
to explicitly engage parents in the process of the training that interventionists receive. Fur-
treatment. thermore,theBRIDGECollaborativeintegra-
tedreflectivepracticeintothetrainingmodelto
optimally support providers as they engage in
PROJECT IMPACT FOR TODDLERS the challenging work of working with families
TheinitialworkoftheBRIDGECollaborative of young children with ASD.
involved reviewing an extensive survey of exis-
tingapproachestoearlyinterventiontosupport
young children and their families, including TRAINING MODEL
boththosesupportedintheliteratureandthose Project ImPACT for Toddlers involves an
widely in use in the community. After consi- explicit focus on coaching parents as well as
derableexaminationandaniterativeprocessof blending key ingredients from differing theo-
communityinput(e.g.,publicconferenceswith retical approaches (i.e., developmental and
intervention developers, surveys, focus groups behavioral). Although this approach is consis-
ofparentsandproviders),thegroupselectedthe tent with best-practice recommendations,10
NDBIProjectImPACTforcommunityimple- many providers and community members
mentation.33,34 Project ImPACT is a parent- expressedconcernsabouteffectivelycombining
mediatedinterventionthatfocusesontargeting strategies from the disparate theoretical orien-
children’s communication, play, social engage- tations as well as challenges in fully embracing
ment, and imitation skills in the natural envi- the parent coaching model. To address these
ronment of daily routines. The effectiveness of issues, a training program integrating best
Project ImPACT is empirically supported for practices from the adult learning and health
both in-person and distance parent-training/ care provider behavior change literature was
delivery models.9,35–37 Primary reasons for the createdwiththegoalofmaximizingimpacton
selectionofthismodelwerethebroadapplica- providers’ clinical practice, including parent
bility to early intervention professionals across coachingskills.TheProjectImPACTforTod-
multipledisciplines(includingspeech-language dlers training model alternates brief didactic
pathology),theparent-implementedapproach, information sessions and hands-on practice
the framework of targeting specific child goals with feedback. This allows therapists to learn
118 SEMINARSINSPEECHANDLANGUAGE/VOLUME39,NUMBER2 2018
a small chunk of the intervention content each ludedinthesession,fromparentsobservingthe
week and quickly provides the opportunity to therapist providing intervention only to full
practice implementing that same content the parent implementation of the techniques with
following week. This process repeats six times, didactic explanations and explicit coaching
for a total of 12 sessions (six didactic and six from the interventionist. Sessions were recor-
coaching).Thetrainingcontentdoesnotfocus dedacross25therapists,includingspeech-lang-
exclusively on the intervention strategies, but uagepathologistsinboththeProjectImPACT
alsoontherequisitebackgroundandaccompa- forToddlersgroupandusualcaregroup.Nearly
nying skills to use the intervention effectively 80% of the sessions (n 39) from Project
¼
(e.g.,knowledgeofearlysocial-communication ImPACTforToddlers–trainedtherapistscon-
development and effective parent coaching tained parent coaching, while less than 20% of
techniques). In a parallel process to the inter- the usual care recordings contained coaching
vention’s approach to teaching parents, the (n 51;seeFig.1,parentcoachingconsidered
¼
hands-on practice sessions provide the oppor- as types 4 to 6). Importantly, almost 50% of
tunityfortraineestoseethetrainerdemonstrate sessions by Project ImPACT for Toddlers–
thestrategiescoveredthepreviousweekwitha trained interventionists involved the highest
child and then try the strategies themselves quality parent coaching (defined as coaching
while receiving feedback from the trainer. with feedback and didactic instruction regar-
This dynamic and interactive training and dinginterventionstrategies)comparedwith0%
chunking of new information is consistent of sessions from providers in usual care. Fig. 1
with best practice in the field.38 containsthefullcomparisonofparentcoaching
Following the initial 12-week training present across the intervention sessions from
(alternating didactic and coaching sessions), both groups (as well as definitions of parent
the training model recommends an additional coachingtypes).Thesedatasupportthepositive
3-monthperiodofpracticeofthestrategiesand influenceoftheProjectImPACTforToddlers
bimonthlycoachingfromasupervisortoprovide training model on the therapists’ use of parent
continuedsupportandskilldevelopmentinusing coaching strategies.
theintervention.Duringthistime,attendanceat One interesting facet of interventionists’
reflective practice meetings is also encouraged. ability to use Project ImPACT for Toddlers is
Dependingontheneedsofthetrainees,coaching the influence that background knowledge has
sessionscanbeconductedwithinthecontextof on use of specific techniques. In an early pilot
ongoing care or can be scheduled explicitly for study of Project ImPACT for Toddlers in
the purpose of coaching (either individually or community settings, service providers from a
with a group). The extended training time variety of backgrounds in multiple disciplines
providesanopportunityforthetrainertoobserve received training in the intervention and then
the therapist implementing the strategies over returned to their service settings to use the
timeasconfidenceandskillsdevelop. approach with families. As part of training,
providers completed a demographics survey
that included information about their prior
USE OF THE INTERVENTION training and theoretical background. Providers
Initial data demonstrate a promising influence fell into three groups or orientations: behavio-
on the ability of the Project ImPACT for ral, developmental, or general family systems.
Toddlerstrainingtopromotetheuseofparent Behavioralprovidersreportedthatthemajority
coachingincommunityearlyinterventionpro- of their prior training was based in applied
grams.Inasmallcomparisontrial,intervention behavior analysis (n 3), whereas those who
¼
sessions for therapists whohad beentrained in reporteddevelopmentalbackgroundshadmore
ProjectImPACTforToddlers aswellasthose experience with relationship-based techniques
who were delivering usual care were recorded (n 4). Individuals endorsing general family
¼
conductingtherapyonceamonthforaperiodof systemsreportedcounseling andmentalhealth
4 months. Recordings were categorized by the therapy backgrounds (n 3). Providers also
¼
level of parent involvement and coaching inc- came from a range of primary disciplines,
INTERVENTIONSTRATEGIESFORTODDLERSATRISKFORASD/RIETHETAL 119
Figure1 ParentinvolvementininterventionsessionsacrossusualcareandProjectImPACTforToddlers
(PIforT).Note:TherapiststrainedinPIforThaveagreaterproportionofsessionswherebest-practiceparent
coachingispresentversusthosetherapistsdeliveringusualcareintervention.Parentinvolvementtypes:
1 parentobservationofsessiononly;2 parent-childinteractionduringsession,nocoachingfrom
¼ ¼
therapist;3 therapistmodelsandlabelstherapytechniqueswhileparentobserves;4 didacticexplanation
¼ ¼
oftechniquestoparent;5 parent-childinteractionduringsession,withcoachingandfeedbackfrom
¼
therapistonhowtousetechniques;6 parent-childinteractionduringsession,withcoachingandfeedback
¼
fromtherapistonhowtousetechniquesanddidacticinstructionontechniquestoparent.
including speech-language pathology (n 4, and play behaviors, which was an area of diffi-
¼
twobehavioral andtwodevelopmental).Video cultyforbehaviorallytrained therapists.Strate-
recorded sessions where providers practiced giessuchaslettingthechildchoosetheactivity,
implementing Project ImPACT for Toddlers stayingfacetofacewiththechildduringinter-
were scored for intervention fidelity, which is action, imitating child behavior, and modeling
the therapist’s use of each of the individual languagearoundthechild’sfocusofattentionto
components that makes up the model. Each give meaning totheir actions were used appro-
component was scored on a 1 to 5 scale where priatelybyalltherapists.39Thisinformationwas
1 doesnotusethecomponentand5 uses incorporatedintosubsequenttrainingsforPro-
¼ ¼
consistently and competently. ject ImPACT for Toddlers to help therapists
Careful examination of the fidelity data fromvaryingbackgroundslearnunfamiliarstra-
(Fig. 2) revealed that though there were some tegies.Additionally,thisinformationhighlights
common areas of strength across all interven- thefactthatself-knowledgeofpreexistingtheo-
tionists,thestrategiesthattherapistshadtrouble retical biases in conjunction with systematic
usingcorrectlyvariedsystematicallyaccordingto measurement of strategy can support interven-
their theoretical orientation. That is, therapists tionistsastheylearnblendedinterventions.
who self-reported their training as primarily
behavioral had different areas of weakness
thanthosetherapistswhoreportedtheirtraining USING REFLECTIVE PRACTICE TO
as predominantly developmental. For example, SUPPORT EARLY INTERVENTION
behavioral therapists, on average, consistently PROVIDERS
adjusted the level of prompting in accordance During the course of the development of Pro-
with the child’s responding to best promote ject ImPACT for Toddlers, early childhood
spontaneous use of skills, but developmentally practiceguidelinesbegantoemphasizetheneed
trained therapists did not. On the other hand, for reflective practice to support early inter-
developmentally trained therapists were better vention professionals in their work with com-
able to provide developmentally appropriate plex families. Expanding on more traditional
expansions on children’s subtle communication models of supervision, reflective practice is
120 SEMINARSINSPEECHANDLANGUAGE/VOLUME39,NUMBER2 2018
Figure2 Averagefidelityscorebytherapistbackground.Note:Individualfidelityitemsarescoredona1to5
scalewhere1 doesnotimplementand5 implementsconsistentlyandcompetently.Fidelityitemsare
¼ ¼
groupedbysimilarity/purposeofthetechniques.Thepatternoffidelityscoresindicatesdifferential
implementationacrosstypesoftherapisttheoreticalbackgrounds.
definedbyZerotoThreeasrelationship-based tivity).41 Many of the community members in
learning occurring between providers and theBRIDGECollaborativehadusedreflective
supervisors.40 This relationship builds profes- practice and understood the value for suppor-
sional growth and development within one’s tingthepracticeofparentcoaching,particularly
own discipline by attending to the emotional withfamiliesofyoungchildrenwhomaystillbe
contentandimpactontheproviderofthework processing the information that their children
as well as how provider’s reactions affect the havechallenges.Additionally,theteamfeltthat
work. This model of mentoring mobilizes a the incorporation of reflective practice in Pro-
powerful dynamic relationship between super- ject ImPACTfor Toddlers might further sup-
visor and staff that goes far beyond directional porttherapistswhowerenotcomfortableorhad
guidance. There is an important qualitative limited training in engaging parents in the
differenceinthementorrelationshipthatparal- intervention sessions.
lelsthetherapeuticprocess,requiringtheability As part of reflective practice, therapists
tolistenandwaitwhileallowingthesupervisee learntouseaparallelprocesstocreatereflective
todiscoversolutions,concepts,andperceptions partnershipswithparents,whichcanassistwith
independently.Thefoundationalunderpinning the collaborative relationship, thereby impro-
ofreflectivepracticeinvolvesasupportive rela- vingchildoutcomes.Thepracticefostersempa-
tionship between a more seasoned professional thy by allowing therapists to step back and
andaninterventionistthatisresponsive(invol- broaden their perspective beyond speech-lang-
vesattunementtothesuperviseeandnonverbal uage therapy and improve the quality of inter-
and affective signals), reliable (holds regular vention through examination of beliefs and
meetingtimeasapriority),andrespectful(seeks emotions about themselves and others within
to understand one another at a deeper level an interaction and in reflecting about difficult
through openness, active listening, and sensi- cases. Within this supervision process,
INTERVENTIONSTRATEGIESFORTODDLERSATRISKFORASD/RIETHETAL 121
therapistsbuildcompetencyinaddressingpro- ImPACT for Toddlers training and answered
fessional challenges in the workplace, cultivate several questions specifically about their per-
resilience, self-reflect, and clarify thinking to spectivesonreflectivepractice.Atotalof84%of
reduce stress and prevent burnout, a key issue interventionists agreed that reflective practice
impacting community-based services. If the meetings were valuable and 92% reported that
conceptualization of the context of speech- the meetings supported their learning and use
language therapy is broadened to include of Project ImPACT for Toddlers strategies.
parents, therapists are mobilizing child deve- Unfortunately,lessthan30%ofinterventionists
lopment by holding in mind the parent and reported that reflective practice meetings were
child relationship. ongoingwithintheiragencies,indicatinganeed
for focus on sustainment of this important
practice and a method by which to support
BENEFITS OF REFLECTIVE feasibility. Therapists reported several reasons
PRACTICE FOR SPEECH- for not continuing reflective practice meetings,
LANGUAGE PATHOLOGISTS with the majority focusing on the limited time
Reflective practice for speech-language patho- andschedulingdifficulties(therapists)aswellas
logistshasthepotentialtopromoteaqualitative the cost of providing additional supervision
differenceinpracticethatbuildscompetencyin time for direct service providers (agency
processing emotions that arise in this challen- leaders).
gingwork.Reflectivepracticeallowstherapists
to build a collaborative relationship with the
supervisor,tosupportthenavigationofclinical FURTHER PROMOTION OF PARENT
challenges, and to cultivate a deeper under- ENGAGEMENT IN INTERVENTION
standing of the relational framework in the The use of parent-coaching models and the
parent-child relationship. motivation to involve parents in intervention is
not unique to ASD. Researchers and clinicians
across multiple children’s service sectors have
REFLECTIVE PRACTICE IN workedtoidentifystrategiesthatcanbestengage
PROJECT IMPACT FOR TODDLERS parents.Someofthesestrategieswereintegrated
Because of the benefits of reflective practice in into Project ImPACT for Toddlers from a
early intervention, regular meetings based on toolkit designed for children’s mental health
thephilosophyandstrategiesofreflectiveprac- treatment.42,43 Examples of these strategies, as
tice were incorporated into a recent Project well as example language to implement the
ImPACT for Toddlers training. Reflective strategies, include: (1) listening actively to the
practice sessions began after the conclusion of parent(e.g.,“Itsoundslike...”or“LetmeseeifI
training on the primary material. These mee- gotthisright...”);(2)approachingtheparentas
tings provided an opportunity for therapists a partner, for example by making suggestions
whowereusingProjectImPACTforToddlers rather than giving directions (e.g., “One thing
tocometogetheranddiscusstheirsuccessesand I’veseen work for others is. . .”or “You might
challenges in implementing the approach with wanttothinkabout...”)orbytalkingexplicitly
families, as well as explore their own reactions aboutpartnership(e.g.,“Let’sworktogetherto..
and experiences with the approach. Formal .”or“YouandIarepartners...”);(3)seekingand
monthly meetings were held for 3 months utilizing parent input in service delivery, parti-
with agency leaders, and then leaders were cularly around planning for practice between
encouraged to return to their own agencies sessions (e.g., “What do you think about what
and incorporate the process of reflection with I said?” or “We covered x and y today; which
their therapists, either formally (through rou- would you like to focus on at home?”); (4)
tine meetings) or informally (through casual attending to parents’ strengths and efforts
conversations). Agency leaders and therapists (e.g., “I’m so glad you shared that.” or “That is
(n 32) completed a survey approximately suchagreatideato...”);and(5)workingwith
¼
3 months after the end of their Project the parent to identify and address barriers to
122 SEMINARSINSPEECHANDLANGUAGE/VOLUME39,NUMBER2 2018
practice between sessions (e.g., “What will be retical biases, integration of reflective practice,
hardabouttryingx...?”or“Let’sthinkabouta and use of explicit parent engagement techni-
solutiontothatchallenge together.”). Ourpre- ques, interventionists can learn to build a rela-
liminary qualitative results indicate that provi- tionship with the parents and caregivers of
ders find these strategies helpful in promoting childrentheytreattoultimatelyimprovechild-
parent engagement in the intervention and are ren’s communication and developmental
abletousethemsuccessfullyinsessions.43 outcomes.
The specific challenges with social com-
municationforchildrenwithASDmayresultin
DISCLOSURES
parentswhoappeartohave“givenup”tryingto
Financial: This research was supported in part
engage their child, because their past attempts
by grants from the Institute of Education
have been met with little success. Additional
Science (R324A130145) and Autism Speaks
strategies to address such challenges are expli-
(8136).
citly taught in Project ImPACT for Toddlers.
Nonfinancial: All authors are members of
Thesetoolsincludeastrategyaimingtofindan
theBRIDGECollaborative.Theauthorshave
activity the child responds well to with the
no additional nonfinancial interests to disclose
interventionist and then providing specific
related to this work.
and careful guidance to the parent to replicate
thatactivity.Forexample,ifthechildresponds
to peekaboo by pulling a towel off the inter-
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