The “Commission’s Report to the Governor” on autism in California lists 12 major “overarching gaps”. These gaps are summarized on page 2 of the report, and examined in depth in the body of the report. You are to select one of the 12 gaps and research it (Academic Journal). Is this still a current issue? Has there been any change in the “gap” since the report was written in 2007? If so, please explain in detail how this has happened. If you find there are no changes, please research to determine why. Your paper needs to follow APA style guidelines and needs to be 5-7 pages in length. I included 2 academic journals. You can choose from either one or if you can find a better one than that’ll work too. Thank you. California Current Issue Paper Rubric This paper is worth 50 points and will be scored using the rubric below Criteria Topic analysis Response to questions Research Exemplary (10 points) Adequate (7 points) The paper provides a cogent, clear understanding of the topic as it specifically relates to California All questions/instructions listed are addressed clearly, completely and effectively The paper is exemplary in the use of recent research on the selected “gap”. The paper provides an adequate understanding of the topic as it specifically relates to California All questions/instructions listed are addressed adequately Leadership The paper demonstrates an understanding of exemplary leadership skills in special education as they relate to the topic Writing mechanics The paper fully adheres to APA guidelines and contains no errors TOTAL Developing (4 points) The paper provides a developing understanding of the topic as it specifically relates to California All questions/instructions listed are addressed partially The paper is adequate in The paper is developing the use of recent research in the use of recent on the selected “gap”. research on the selected “gap”. The paper demonstrates The paper an adequate demonstrates a understanding of developing leadership skills in special understanding of education as they relate leadership skills in to the topic special education as they relate to the topic The paper adequately The paper partially adheres to APA guidelines adheres to APA and contains minimal guidelines and contains errors several errors Insufficient (1 point) The paper demonstrates a limited or no understanding of the topic All questions/criteria listed are not addressed The paper does not use recent research The paper demonstrates insufficient leadership skills in special education as they relate to the topic The paper does not adhere to APA guidelines and contains numerous errors Total EDITORS’ NOTE: The Forum section of the Journal of Positive Behavior Interventions is presented to encourage communication among readers and provide for an exchange of opinions, perspectives, ideas, and informative personal accounts. We welcome brief articles from family members, professionals, friends, advocates, administrators, researchers, and other individuals who are concerned with behavioral support issues. The purpose of the Forum is to facilitate a constructive dialogue among many stakeholders regarding important issues in practice, research, training, program development, and policy. Submissions to the Forum undergo an expedited review and may be submitted to either editor. Positive behavior support focuses on strategies for producing comprehensive and durable improvement in the lives of children and their families. This forum article outlines an innovative model for helping families build the skills to establish and sustain communication gains for young children with autism. The emphasis is on a “whole family” intervention approach, and the changes that occur are not just with specific child skills but with the ability of the whole family to be more successful. The message of this forum article will be of particular value for JPBI readers. First S.T.E.P.: A Model for the Early Identification of Children With Autism Spectrum Disorders
Lynn Kern Koegel, Robert L. Koegel, Nicolette Nefdt, Rosy Fredeen, Eileen F. Klein, Yvonne E. M. Bruinsma University of California, Santa Barbara Even though children with autism spectrum disorder (ASD) can be reliably identified by autism experts at 18 months (Baron-Cohen, Allen, & Gillberg, 1992), and the majority of parents report symptoms before age 2 (Baghdadli, Picot, Pascal, Pry, & Aussilloux, 2003), the average age of diagnosis for children with autism in the United States is 3 to 4 years of age (Filipek et al., 1999). Early identification is especially vital given the growing amount of research documenting the significant positive effects of early intervention (Connor, 1998; Koegel, Koegel, Frea, & Smith, 1995; Lovaas, 1987; Rogers, 1998). In particular, research suggests the likelihood of a more positive developmental trajectory the earlier intervention begins (Koegel, Bruinsma, & Koegel, in press). The Autism Research and Training Center (ARTC) has developed a model, Project First S.T.E.P. (First Screening, Training, Education, Project), which is funded by First 5 of Santa Barbara County and is designed to address the apparent delays in identification of children at risk for ASD. The project is part of a larger initiative to increase services (e.g., early mental health, dental, school readiness) for families of young children. Our goal is to increase the early identification of children with ASD by raising awareness and providing access to services, in addition to assuring that identified children and their families receive early intervention and support services. First S.T.E.P. has developed a three-part package to accomplish these goals. These three components—Outreach, Screening, and Family support—will be discussed in more detail in this article. Outreach The goal of the outreach component of the program is to increase the knowledge and awareness among pediatricians, health-care workers, educators, parents, and community members of the early behavioral symptoms of ASD to ensure early identification of children at risk for ASD so they can receive specialized services. This outreach is done through community presentations, advertising campaigns, and participation in family-oriented community events. Journal of Positive Behavior Interventions Volume 7, Number 4, Fall 2005, pages 247–252 247 248 Journal of Positive Behavior Interventions PEDIATRICIAN PRESENTATIONS Pediatricians and their staff are targeted as primary outreach recipients due to their frequent access to infants and toddlers. Research has noted that most parents who have concerns about their child’s development first take their child to their pediatrician. In the past, however, pediatricians have been reluctant to refer children for evaluations due to concerns about misdiagnosis, creating unnecessary anxiety, and a lack of information about behavioral symptoms of concern and/or available services (Woods & Wetherby, 2003). With the goal of increasing referrals from the pediatric community, specific presentations for this population are developed to target variables that potentially contribute to the overall reluctance of referring children with developmental delays. Furthermore, to facilitate access to pediatricians, who tend to be very busy, presentations are scheduled during pre-existing training times and complimentary lunches are provided. To update pediatricians’ training regarding atypical child development, current research on the early characteristics of autism and a review of typical development is organized into the three affected areas: social, communication, and behavior. To facilitate the organization of the presentation and the saliency of the information, video examples of each affected area of autism are presented. Doing so enables us to accomplish two objectives: first, we are able to emphasize the range of symptoms exhibited by very young children at risk for ASD; second, we are able to stress the importance of the absence of specific typical behaviors. That is, rather than showing children with classic symptoms such as hand flapping or spinning objects, we include video examples of children who exhibit a severe lack of typical social and communicative behaviors. For example, there may be a video clip of a parent trying to engage their child who is playing with a toy. During the video clips, we point out how the child does not respond to his or her name being called, does not point or babble, and does not use eye gaze appropriately to share enjoyment as a typically developing child would do at that same age. The presentations also attend to the reluctance of pediatricians to address developmental concerns, in case they are mistaken about considering autism, which could unnecessarily alarm parents. Specifically, we take into account that there may be tremendous anxiety about providing potentially incorrect diagnostic information about a child. Therefore, we work to assure pediatricians that they can refer a child without making a formal decision of whether autism is present or not and that they can suggest the project to families as a screening to assess their child’s developmental level and to determine if further evaluations would be warranted. Last, it is particularly important to inform pediatricians of the availability of intervention services and the impact of such services on treatment outcomes for chil- dren with autism. This is accomplished by describing research-based outcomes for children with autism who have had intervention. Additionally, intervention data demonstrating changes in communication scores toward a more typical developmental trajectory are presented. This is done to emphasize that children with ASD who are provided with early intervention have the potential of making significant improvements in the symptoms of the disability. Since specifically targeting outreach to the pediatric community, in only 1 year we have seen a dramatic increase in the number of referrals from pediatricians and a clear reduction in the average age of the children referred to Project First S.T.E.P., with the youngest child being 10 months old (see Figures 1 & 2). Targeting pediatricians and related health-care professionals, such as office staff and nurses, appears to be vital in decreasing the age of referral for very young children with ASD. ADVERTISEMENT CAMPAIGN Additional methods of outreach that are successful include the use of media outlets (e.g., radio announcements, newspaper ads, slides in movie theaters), mass mailings of posters and brochures (to pediatrician offices, preschools, daycares, and mental health organizations), and attendance at family-oriented community events. It is important to note that delays in communication are the focus of the advertisement campaign. Specifically, all newspaper ads, movie slides, posters, and brochures state, “If your child is 18 months or older and not talking, call for a free screening.” The presence of a communication delay was selected as the targeted symptom, because parents and practitioners can easily determine if a child is not verbally communicating by the typical age of onset for spoken language (approximately 12–18 months). In addition to traditional advertising, First S.T.E.P also conducts outreach by attending community fairs and festivals to provide information for families and to network with other community agencies that serve young children. Screenings The following section highlights the screening component of the program, including basic operations and assessment procedures. The screening process begins when a family contacts us, following a referral from a pediatrician, teacher, community agency, or self-referral. During this first phone contact, parents are asked about demographics for and concerns about their child. This is followed by a clear description of the screening process, and the parent is informed that there will be no “formal” testing and that their child will not be required to participate in any undesired activity. This is done to prevent any potential anxiety Percentage of Referrals That Were From Pediatricians 249 2003 ASD 2004 2003 2004 Other Disability Months Figure 1. The number of referrals from pediatricians for both children with autism spectrum disorders and children with other disabilities increased between 2003 and 2004. 2003 ASD 2004 2003 2004 Other Disability Figure 2. The average age of children with autism spectrum disorders and children with other disabilities who were referred to Project First S.T.E.P. decreased between 2003 and 2004, with the youngest child being 10 months old. 250 Journal of Positive Behavior Interventions about participating in the screening process. Finally, an attempt is made to schedule an appointment no later than a week from the initial phone call. Again, this is done to relieve any anxiety the parent may be experiencing (Siegel, Pliner, Eschler, & Elliot, 1988) and to reduce the length of time before the child can access services. Once the initial contact has been made and an appointment scheduled, the actual screenings are conducted at the ARTC and are attended by the primary caregiver, the child of concern, and, sometimes, additional family members. To accommodate families who are unable to travel to the ARTC, screenings are also conducted at the homes of families or at community agencies and clinics. Such off-site screenings are particularly helpful for many families from remote farming areas or without means of transportation, families often most under-reached and under-served. Regardless of the screening site, screenings are conducted by two advanced doctoral students studying either special education or clinical psychology. Both have advanced training in applied behavioral analysis, several years of experience providing education to parents of children with autism, several years of experience in testing and diagnosis of autism and related disabilities, and an indepth knowledge of the literature regarding early characteristics of ASD. In addition, all sessions are videotaped, and the tapes are reviewed by two PhD-level supervisors specializing in autism. The screening appointment begins with an introduction to the child (e.g., playing with the child, identifying preferred objects and activities) and the completion of paperwork (e.g., consent forms, grant agency forms, an initial intake form) by the parent. The intake form inquires about parent concerns in the areas of socialization, communication, and behavior and also includes other more general questions about their child’s development, their child’s first symptoms, and their referral process. Consistent with the literature, the majority of the parents report that the first symptom they noticed was a lack of, or abnormal, speech development (Siegel et al., 1988). Upon completion of necessary paperwork, parents are asked to play with their child for 10 minutes as they would typically do so at home. This play interaction is videotaped and is helpful in observing specific parent– child interactions and assessing the child’s communicative and social behaviors. Following this initial play interaction, parents are interviewed about their child’s development and concerns using the Vineland Adaptive Behavior Scales (Sparrow et al., 1984). Then, behavioral observations and direct behavioral presses of the child are conducted using a protocol that incorporates items from the Modified Checklist for Autism in Toddlers (M-CHAT; Robins et al., 2001), the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989), and the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition–Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). Behavioral observations and presses are conducted by the advanced doctoral students. In particular, the aforementioned behavioral-assessment protocol is composed of items that assess behaviors from each of the three diagnostic areas: (a) qualitative impairments in reciprocal social interaction, (b) qualitative impairments in communication, and (c) restricted, repetitive, and stereotyped patterns of behavior, interest, or activity (DSM-IV-TR). In addition to probes designed to assess the three diagnostic areas of autism, the protocol focuses on areas known to be predictive of autism spectrum disorders, such as a lack of appropriate joint attention behaviors (e.g., eye gaze alternation between a communicative partner and an object/activity of interest, showing, pointing), which has consistently been related to the development of ASD (Mundy, Sigman, Ungerer, & Sherman, 1986). Consequently, one of the probes administered during the screening is a task in which the clinician blows bubbles for the child, periodically pausing before resuming blowing to provide the child with opportunities to engage in joint attention behaviors to comment or request (e.g., gaze alternation, pointing; Lord et al., 1989). Once all observational and reported data are collected, the clinicians decide if the child demonstrates symptoms that may put him or her at risk for ASD. The clinicians then provide the family with specific clinical impressions of the child’s strengths and weaknesses as applicable to the three areas associated with ASD and in regard to any other developmental delay. The clinicians specifically emphasize the strengths and potential of the child in an effort to provide hope for the family. Based on this information, the family is referred to an appropriate agency for intervention if the child exhibits risk factors for ASD or other developmental delays. Subsequent to the screening, the family is given a follow-up call approximately 1 week later. This is done to further help the parent access appropriate services. In addition, a letter is sent to relevant state agencies to help speed up the process of beginning intervention, and a letter is sent to the referring pediatrician or agency regarding the results of the screening. Family Support Because families coping with autism or developmental delays undergo considerable stress, especially at the time of diagnosis, another important component of the project is the family support package. This includes helping children and their families access early appropriate intervention. As discussed above, family support begins during the first phone conversation when a substantial effort is made to assure that the family feels welcomed and at ease with the process. In addition, the parent is provided with an opportunity to describe their concerns in detail, and all questions and concerns are answered empathetically and honestly. There is also a clear message to parents that they 251 Volume 7, Number 4, Fall 2005 are the expert on their child and that the project staff are there to help them access services and to improve upon the excellent care that they were already providing for their child. Information that is gathered via parent report is, in fact, considered important and valid because research shows that parents are very keen evaluators of their children’s development (Glascoe, 1998; Glascoe & Dworkin, 1995). REFERRAL AND RECOMMENDATIONS After the screening, all data and information are reviewed with the directors of the program. Once this is done, the child’s parents are given a follow-up call and provided with any additional feedback. All feedback is provided with extreme sensitivity and awareness of potential parental concerns and time is taken to again answer questions. During this follow-up call, we also assure that the parent has all necessary referral information. Most parents are usually successful at connecting with an intake coordinator to schedule an evaluation appointment. However, in cases where parents are having difficulty connecting with the referral agency and obtaining appropriate appointments, we directly contact the agency chosen by the parent to help facilitate the process. Furthermore, a brief screening report is written for all referred children and sent to the agency to which we refer them. This report is also given to the parent. CASE MANAGEMENT To assure that children and families receive appropriate access to intervention services in the community, their cases are followed for a period of time. To ease the entry into the service delivery system, families are also encouraged to call with any questions or updates about their child. Consistent with research, this is an important step in reducing anxiety and depression in parents dealing with the initial stages of learning that their child may have a severe disability (Randall & Parker, 1999). It is important to note that many families maintain contact until their child begins receiving services, and some continue to call with specific questions for years after the screening. WORKSHOPS An important component of our support package is the 2-hr parent education workshop, which is offered (at no cost to the family) to all children who exhibit a developmental delay. Workshops are scheduled immediately, usually occur within a month of the screening, and are typically conducted in the child’s home. The workshops have two objectives: to teach parents procedures to accelerate their child’s communicative development and to bridge the time between initial identification of a developmental delay and the start of specialized support services. Preliminary data suggest that even such short workshops can produce substantial improvements in both parent and child. For example, data suggest that parents are able to learn strategies for teaching language and children are able to make progress in their communication development. During each workshop, the parents are provided with manuals that describe the specific techniques of pivotal response treatment (PRT; Koegel, Koegel, Bruinsma, Brookman, & Fredeen, 2003; Koegel et al., 1989) to teach first words, and the PRT principles are reviewed. Modeling and specific feedback are used to teach efficient implementation of PRT. As mentioned above, these brief workshops appear to be a helpful way to start teaching parents strategies for improving expressive communication use in their children, in that most of the children begin to show improvement during the first 2 hours and continue to show increases in both total number and diversity of functional verbalizations at follow-up. These workshops are an essential and critical component of the family-support package because they empower parents with immediate strategies to address their child’s challenges. More important, parents are given an opportunity to see their child learning and succeeding, providing renewed hope for their child’s future. Conclusion The primary focus of this project is to decrease the age at which children with ASD are identified and receive early intervention. To accomplish this goal it is vital to raise community awareness of the early signs of autism. Specifically, we have found that targeting pediatricians is an effective means of reaching the desired goal of identifying very young children with ASD (see Figure 1). Prior to First S.T.E.P., data for the state of California suggested children did not receive services until age 4 or 5 (M.I.N.D. Institute, 2002). However, with the creation of First S.T.E.P, the average age of children screened at the ARTC and later diagnosed as having autism has been reduced to 29 months (range, 16 months–55 months; see Figure 2). Further, families are receiving the family support package to target their stress and increase their skills in working with their children. Last, the families are connected with established community-based interventions and support agencies. As we look to the future, it is hoped that similar models can be replicated nationwide to decrease the average age of diagnosis at a national level so that more and more children with ASD receive early intervention services as soon as possible. ABOUT THE AUTHORS Lynn Kern Koegel, PhD, is the clinic director of the Autism Research and Training Center at the Gevirtz Graduate 252 Journal of Positive Behavior Interventions School of Education, University of California, Santa Barbara. Robert L. Koegel, PhD, is the director of the Autism Research and Training Center and professor in the Counseling/ Clinical School Psychology Program and Special Education, Disability, and Risk Studies Emphasis at Gevirtz Graduate School of Education, University of California, Santa Barbara. Nicolette Nefdt, MA, is a graduate student in the Special Education, Disability, and Risk Studies Emphasis at the University of California, Santa Barbara. Rosy Fredeen, PhD, is a head supervisor at the Autism Research and Training Center at the Gevirtz Graduate School of Education, University of California, Santa Barbara. Eileen F. Klein, MA, is a doctoral candidate in the Counseling/Clinical/School Psychology Program at the University of California, Santa Barbara. Yvonne E. M. Bruinsma, PhD, is a psychologist and researcher at the Autism Center in Oegstgeest, the Netherlands. Her major research interests include early diagnoses and intervention for children with autism, parent education, positive behavior support, and social skills interventions for children with autism in community inclusion settings. Address: Lynn Kern Koegel, Autism Research & Training Center, Graduate School of Education, University of California, Santa Barbara, 93106; e-mail: lynnk@education.ucsb.edu AUTHORS’ NOTE Preparation of this article was supported in part by research grant MH028210 (R. Koegel, P.I. ) from the National Institute of Mental Health and a project development grant from First 5 Santa Barbara County: Children and Families Commission. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders–Fourth edition–Text revision. Washington, DC: Author. Baghdadli, A., Picot, M., Pascal, C., Pry, R., & Aussilloux, C. (2003). Relationship between age of recognition of first disturbances and severity in young children with autism. European Child & Adolescent Psychiatry, 12, 122–127. Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can autism be detected at 18 months? The needle, the haystack, and the CHAT. British Journal of Psychiatry, 161, 839–843. Connor, M. (1998). A review of behavioural early intervention programmes for children with autism. Educational Psychology in Practice, 14(2), 109– 117. Filipek, P. A., Accardo, P. J., Baranek, G. T., Cook, E. H., Dawson, G., Gordon, B., et al. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism and Developmental Disorders, 29(6), 439–484. Glascoe, F. (1998). Collaborating with parents: Using Parents’ Evaluation of Developmental Status to detect and address developmental and behavioral problems. Nashville, TN: Ellsworth & Vandermeer Press. Glascoe, F., & Dworkin, P. (1995). The role of parents in the detection of developmental and behavioral problems. Pediatrics, 95(6), 829–836. Koegel, R. L., Bruinsma, Y., & Koegel, L. K. (in press). Developmental trajectories with early interventions. In R. L. Koegel & L. K. Koegel (Eds.), Pivotal Response Treatments for autism: Communication, social, and academic development. Baltimore: Brookes. Koegel, R., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. (1989). How to teach pivotal behaviors to children with autism: A training manual. Santa Barbara, CA: University of California. Koegel, R., Koegel, L., Frea, W., & Smith, A. (1995). Emerging interventions for children with autism. In R. L. Koegel & L. K. Koegel (Eds.), Teaching children with autism: Strategies for initiating positive interactions and improving learning opportunities (pp. 1–15). Baltimore: Brookes. Koegel, R. L. Koegel. L. K., Bruinsma, Y., Brookman, L., & Fredeen, R. (2003). Teaching first words. Santa Barbara, CA: University of California. Lord, C., Rutter, M., Goode, S., Heemsbergen, J., Jordan, H., Mawhood, L., et al. (1989). Autism diagnostic observation schedule: A standardized observation of communicative and social behavior. Journal of Autism and Developmental Disorders, 19, 185–212. Lovaas, I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55(1), 3–9. M.I.N.D. Institute. (2002). Report to the legislature on the principal findings from the epidemiology of autism in California: A comprehensive pilot study. Davis, CA: University of California. Mundy, S., Sigman, M. D., Ungerer, J., & Sherman, T. (1986). Defining the social deficits of autism: The contribution of non-verbal communication measures. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 27(5), 657–669. Randall,P., & Parker, J. (1999). Supporting the families of children with autism. New York: Wiley & Sons. Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31(2), 131–144. Rogers, S. (1998). Empirically supported comprehensive treatments for young children with autism. Special empirically supported psychosocial interventions for children. Journal of Clinical Child Psychology, 27(2), 168– 179. Siegel, B., Pliner, C., Eschler, J., & Elliot, G. (1988). How children with autism are diagnosed: Difficulties in identification of children with multiple developmental delays. Journal of Developmental and Behavioral Pediatrics, 9(4), 199–204. Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vineland Adaptive Behavior Scales: Survey form manual. Circle Pines, MN: American Guidance Service. Woods, J. J., & Wetherby, A. M. (2003). Early identification of and intervention for infants and toddlers who are at risk for autism spectrum disorder. Language, Speech & Hearing Services in Schools, 34(3), 180–193. Action Editor: Robert H. Horner EDITORS’ NOTE: The Forum section of the Journal of Positive Behavior Interventions is presented to encourage communication among readers and provide for an exchange of opinions, perspectives, ideas, and informative personal accounts. We welcome brief articles from family members, professionals, friends, advocates, administrators, researchers, and other individuals who are concerned with behavioral support issues. The purpose of the Forum is to facilitate a constructive dialogue among many stakeholders regarding important issues in practice, research, training, program development, and policy. Submissions to the Forum undergo an expedited review and may be submitted to either editor. Positive behavior support focuses on strategies for producing comprehensive and durable improvement in the lives of children and their families. This forum article outlines an innovative model for helping families build the skills to establish and sustain communication gains for young children with autism. The emphasis is on a “whole family” intervention approach, and the changes that occur are not just with specific child skills but with the ability of the whole family to be more successful. The message of this forum article will be of particular value for JPBI readers. First S.T.E.P.: A Model for the Early Identification of Children With Autism Spectrum Disorders
Lynn Kern Koegel, Robert L. Koegel, Nicolette Nefdt, Rosy Fredeen, Eileen F. Klein, Yvonne E. M. Bruinsma University of California, Santa Barbara Even though children with autism spectrum disorder (ASD) can be reliably identified by autism experts at 18 months (Baron-Cohen, Allen, & Gillberg, 1992), and the majority of parents report symptoms before age 2 (Baghdadli, Picot, Pascal, Pry, & Aussilloux, 2003), the average age of diagnosis for children with autism in the United States is 3 to 4 years of age (Filipek et al., 1999). Early identification is especially vital given the growing amount of research documenting the significant positive effects of early intervention (Connor, 1998; Koegel, Koegel, Frea, & Smith, 1995; Lovaas, 1987; Rogers, 1998). In particular, research suggests the likelihood of a more positive developmental trajectory the earlier intervention begins (Koegel, Bruinsma, & Koegel, in press). The Autism Research and Training Center (ARTC) has developed a model, Project First S.T.E.P. (First Screening, Training, Education, Project), which is funded by First 5 of Santa Barbara County and is designed to address the apparent delays in identification of children at risk for ASD. The project is part of a larger initiative to increase services (e.g., early mental health, dental, school readiness) for families of young children. Our goal is to increase the early identification of children with ASD by raising awareness and providing access to services, in addition to assuring that identified children and their families receive early intervention and support services. First S.T.E.P. has developed a three-part package to accomplish these goals. These three components—Outreach, Screening, and Family support—will be discussed in more detail in this article. Outreach The goal of the outreach component of the program is to increase the knowledge and awareness among pediatricians, health-care workers, educators, parents, and community members of the early behavioral symptoms of ASD to ensure early identification of children at risk for ASD so they can receive specialized services. This outreach is done through community presentations, advertising campaigns, and participation in family-oriented community events. Journal of Positive Behavior Interventions Volume 7, Number 4, Fall 2005, pages 247–252 247 248 Journal of Positive Behavior Interventions PEDIATRICIAN PRESENTATIONS Pediatricians and their staff are targeted as primary outreach recipients due to their frequent access to infants and toddlers. Research has noted that most parents who have concerns about their child’s development first take their child to their pediatrician. In the past, however, pediatricians have been reluctant to refer children for evaluations due to concerns about misdiagnosis, creating unnecessary anxiety, and a lack of information about behavioral symptoms of concern and/or available services (Woods & Wetherby, 2003). With the goal of increasing referrals from the pediatric community, specific presentations for this population are developed to target variables that potentially contribute to the overall reluctance of referring children with developmental delays. Furthermore, to facilitate access to pediatricians, who tend to be very busy, presentations are scheduled during pre-existing training times and complimentary lunches are provided. To update pediatricians’ training regarding atypical child development, current research on the early characteristics of autism and a review of typical development is organized into the three affected areas: social, communication, and behavior. To facilitate the organization of the presentation and the saliency of the information, video examples of each affected area of autism are presented. Doing so enables us to accomplish two objectives: first, we are able to emphasize the range of symptoms exhibited by very young children at risk for ASD; second, we are able to stress the importance of the absence of specific typical behaviors. That is, rather than showing children with classic symptoms such as hand flapping or spinning objects, we include video examples of children who exhibit a severe lack of typical social and communicative behaviors. For example, there may be a video clip of a parent trying to engage their child who is playing with a toy. During the video clips, we point out how the child does not respond to his or her name being called, does not point or babble, and does not use eye gaze appropriately to share enjoyment as a typically developing child would do at that same age. The presentations also attend to the reluctance of pediatricians to address developmental concerns, in case they are mistaken about considering autism, which could unnecessarily alarm parents. Specifically, we take into account that there may be tremendous anxiety about providing potentially incorrect diagnostic information about a child. Therefore, we work to assure pediatricians that they can refer a child without making a formal decision of whether autism is present or not and that they can suggest the project to families as a screening to assess their child’s developmental level and to determine if further evaluations would be warranted. Last, it is particularly important to inform pediatricians of the availability of intervention services and the impact of such services on treatment outcomes for chil- dren with autism. This is accomplished by describing research-based outcomes for children with autism who have had intervention. Additionally, intervention data demonstrating changes in communication scores toward a more typical developmental trajectory are presented. This is done to emphasize that children with ASD who are provided with early intervention have the potential of making significant improvements in the symptoms of the disability. Since specifically targeting outreach to the pediatric community, in only 1 year we have seen a dramatic increase in the number of referrals from pediatricians and a clear reduction in the average age of the children referred to Project First S.T.E.P., with the youngest child being 10 months old (see Figures 1 & 2). Targeting pediatricians and related health-care professionals, such as office staff and nurses, appears to be vital in decreasing the age of referral for very young children with ASD. ADVERTISEMENT CAMPAIGN Additional methods of outreach that are successful include the use of media outlets (e.g., radio announcements, newspaper ads, slides in movie theaters), mass mailings of posters and brochures (to pediatrician offices, preschools, daycares, and mental health organizations), and attendance at family-oriented community events. It is important to note that delays in communication are the focus of the advertisement campaign. Specifically, all newspaper ads, movie slides, posters, and brochures state, “If your child is 18 months or older and not talking, call for a free screening.” The presence of a communication delay was selected as the targeted symptom, because parents and practitioners can easily determine if a child is not verbally communicating by the typical age of onset for spoken language (approximately 12–18 months). In addition to traditional advertising, First S.T.E.P also conducts outreach by attending community fairs and festivals to provide information for families and to network with other community agencies that serve young children. Screenings The following section highlights the screening component of the program, including basic operations and assessment procedures. The screening process begins when a family contacts us, following a referral from a pediatrician, teacher, community agency, or self-referral. During this first phone contact, parents are asked about demographics for and concerns about their child. This is followed by a clear description of the screening process, and the parent is informed that there will be no “formal” testing and that their child will not be required to participate in any undesired activity. This is done to prevent any potential anxiety Percentage of Referrals That Were From Pediatricians 249 2003 ASD 2004 2003 2004 Other Disability Months Figure 1. The number of referrals from pediatricians for both children with autism spectrum disorders and children with other disabilities increased between 2003 and 2004. 2003 ASD 2004 2003 2004 Other Disability Figure 2. The average age of children with autism spectrum disorders and children with other disabilities who were referred to Project First S.T.E.P. decreased between 2003 and 2004, with the youngest child being 10 months old. 250 Journal of Positive Behavior Interventions about participating in the screening process. Finally, an attempt is made to schedule an appointment no later than a week from the initial phone call. Again, this is done to relieve any anxiety the parent may be experiencing (Siegel, Pliner, Eschler, & Elliot, 1988) and to reduce the length of time before the child can access services. Once the initial contact has been made and an appointment scheduled, the actual screenings are conducted at the ARTC and are attended by the primary caregiver, the child of concern, and, sometimes, additional family members. To accommodate families who are unable to travel to the ARTC, screenings are also conducted at the homes of families or at community agencies and clinics. Such off-site screenings are particularly helpful for many families from remote farming areas or without means of transportation, families often most under-reached and under-served. Regardless of the screening site, screenings are conducted by two advanced doctoral students studying either special education or clinical psychology. Both have advanced training in applied behavioral analysis, several years of experience providing education to parents of children with autism, several years of experience in testing and diagnosis of autism and related disabilities, and an indepth knowledge of the literature regarding early characteristics of ASD. In addition, all sessions are videotaped, and the tapes are reviewed by two PhD-level supervisors specializing in autism. The screening appointment begins with an introduction to the child (e.g., playing with the child, identifying preferred objects and activities) and the completion of paperwork (e.g., consent forms, grant agency forms, an initial intake form) by the parent. The intake form inquires about parent concerns in the areas of socialization, communication, and behavior and also includes other more general questions about their child’s development, their child’s first symptoms, and their referral process. Consistent with the literature, the majority of the parents report that the first symptom they noticed was a lack of, or abnormal, speech development (Siegel et al., 1988). Upon completion of necessary paperwork, parents are asked to play with their child for 10 minutes as they would typically do so at home. This play interaction is videotaped and is helpful in observing specific parent– child interactions and assessing the child’s communicative and social behaviors. Following this initial play interaction, parents are interviewed about their child’s development and concerns using the Vineland Adaptive Behavior Scales (Sparrow et al., 1984). Then, behavioral observations and direct behavioral presses of the child are conducted using a protocol that incorporates items from the Modified Checklist for Autism in Toddlers (M-CHAT; Robins et al., 2001), the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989), and the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition–Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). Behavioral observations and presses are conducted by the advanced doctoral students. In particular, the aforementioned behavioral-assessment protocol is composed of items that assess behaviors from each of the three diagnostic areas: (a) qualitative impairments in reciprocal social interaction, (b) qualitative impairments in communication, and (c) restricted, repetitive, and stereotyped patterns of behavior, interest, or activity (DSM-IV-TR). In addition to probes designed to assess the three diagnostic areas of autism, the protocol focuses on areas known to be predictive of autism spectrum disorders, such as a lack of appropriate joint attention behaviors (e.g., eye gaze alternation between a communicative partner and an object/activity of interest, showing, pointing), which has consistently been related to the development of ASD (Mundy, Sigman, Ungerer, & Sherman, 1986). Consequently, one of the probes administered during the screening is a task in which the clinician blows bubbles for the child, periodically pausing before resuming blowing to provide the child with opportunities to engage in joint attention behaviors to comment or request (e.g., gaze alternation, pointing; Lord et al., 1989). Once all observational and reported data are collected, the clinicians decide if the child demonstrates symptoms that may put him or her at risk for ASD. The clinicians then provide the family with specific clinical impressions of the child’s strengths and weaknesses as applicable to the three areas associated with ASD and in regard to any other developmental delay. The clinicians specifically emphasize the strengths and potential of the child in an effort to provide hope for the family. Based on this information, the family is referred to an appropriate agency for intervention if the child exhibits risk factors for ASD or other developmental delays. Subsequent to the screening, the family is given a follow-up call approximately 1 week later. This is done to further help the parent access appropriate services. In addition, a letter is sent to relevant state agencies to help speed up the process of beginning intervention, and a letter is sent to the referring pediatrician or agency regarding the results of the screening. Family Support Because families coping with autism or developmental delays undergo considerable stress, especially at the time of diagnosis, another important component of the project is the family support package. This includes helping children and their families access early appropriate intervention. As discussed above, family support begins during the first phone conversation when a substantial effort is made to assure that the family feels welcomed and at ease with the process. In addition, the parent is provided with an opportunity to describe their concerns in detail, and all questions and concerns are answered empathetically and honestly. There is also a clear message to parents that they 251 Volume 7, Number 4, Fall 2005 are the expert on their child and that the project staff are there to help them access services and to improve upon the excellent care that they were already providing for their child. Information that is gathered via parent report is, in fact, considered important and valid because research shows that parents are very keen evaluators of their children’s development (Glascoe, 1998; Glascoe & Dworkin, 1995). REFERRAL AND RECOMMENDATIONS After the screening, all data and information are reviewed with the directors of the program. Once this is done, the child’s parents are given a follow-up call and provided with any additional feedback. All feedback is provided with extreme sensitivity and awareness of potential parental concerns and time is taken to again answer questions. During this follow-up call, we also assure that the parent has all necessary referral information. Most parents are usually successful at connecting with an intake coordinator to schedule an evaluation appointment. However, in cases where parents are having difficulty connecting with the referral agency and obtaining appropriate appointments, we directly contact the agency chosen by the parent to help facilitate the process. Furthermore, a brief screening report is written for all referred children and sent to the agency to which we refer them. This report is also given to the parent. CASE MANAGEMENT To assure that children and families receive appropriate access to intervention services in the community, their cases are followed for a period of time. To ease the entry into the service delivery system, families are also encouraged to call with any questions or updates about their child. Consistent with research, this is an important step in reducing anxiety and depression in parents dealing with the initial stages of learning that their child may have a severe disability (Randall & Parker, 1999). It is important to note that many families maintain contact until their child begins receiving services, and some continue to call with specific questions for years after the screening. WORKSHOPS An important component of our support package is the 2-hr parent education workshop, which is offered (at no cost to the family) to all children who exhibit a developmental delay. Workshops are scheduled immediately, usually occur within a month of the screening, and are typically conducted in the child’s home. The workshops have two objectives: to teach parents procedures to accelerate their child’s communicative development and to bridge the time between initial identification of a developmental delay and the start of specialized support services. Preliminary data suggest that even such short workshops can produce substantial improvements in both parent and child. For example, data suggest that parents are able to learn strategies for teaching language and children are able to make progress in their communication development. During each workshop, the parents are provided with manuals that describe the specific techniques of pivotal response treatment (PRT; Koegel, Koegel, Bruinsma, Brookman, & Fredeen, 2003; Koegel et al., 1989) to teach first words, and the PRT principles are reviewed. Modeling and specific feedback are used to teach efficient implementation of PRT. As mentioned above, these brief workshops appear to be a helpful way to start teaching parents strategies for improving expressive communication use in their children, in that most of the children begin to show improvement during the first 2 hours and continue to show increases in both total number and diversity of functional verbalizations at follow-up. These workshops are an essential and critical component of the family-support package because they empower parents with immediate strategies to address their child’s challenges. More important, parents are given an opportunity to see their child learning and succeeding, providing renewed hope for their child’s future. Conclusion The primary focus of this project is to decrease the age at which children with ASD are identified and receive early intervention. To accomplish this goal it is vital to raise community awareness of the early signs of autism. Specifically, we have found that targeting pediatricians is an effective means of reaching the desired goal of identifying very young children with ASD (see Figure 1). Prior to First S.T.E.P., data for the state of California suggested children did not receive services until age 4 or 5 (M.I.N.D. Institute, 2002). However, with the creation of First S.T.E.P, the average age of children screened at the ARTC and later diagnosed as having autism has been reduced to 29 months (range, 16 months–55 months; see Figure 2). Further, families are receiving the family support package to target their stress and increase their skills in working with their children. Last, the families are connected with established community-based interventions and support agencies. As we look to the future, it is hoped that similar models can be replicated nationwide to decrease the average age of diagnosis at a national level so that more and more children with ASD receive early intervention services as soon as possible. ABOUT THE AUTHORS Lynn Kern Koegel, PhD, is the clinic director of the Autism Research and Training Center at the Gevirtz Graduate 252 Journal of Positive Behavior Interventions School of Education, University of California, Santa Barbara. Robert L. Koegel, PhD, is the director of the Autism Research and Training Center and professor in the Counseling/ Clinical School Psychology Program and Special Education, Disability, and Risk Studies Emphasis at Gevirtz Graduate School of Education, University of California, Santa Barbara. Nicolette Nefdt, MA, is a graduate student in the Special Education, Disability, and Risk Studies Emphasis at the University of California, Santa Barbara. Rosy Fredeen, PhD, is a head supervisor at the Autism Research and Training Center at the Gevirtz Graduate School of Education, University of California, Santa Barbara. Eileen F. Klein, MA, is a doctoral candidate in the Counseling/Clinical/School Psychology Program at the University of California, Santa Barbara. Yvonne E. M. Bruinsma, PhD, is a psychologist and researcher at the Autism Center in Oegstgeest, the Netherlands. Her major research interests include early diagnoses and intervention for children with autism, parent education, positive behavior support, and social skills interventions for children with autism in community inclusion settings. Address: Lynn Kern Koegel, Autism Research & Training Center, Graduate School of Education, University of California, Santa Barbara, 93106; e-mail: lynnk@education.ucsb.edu AUTHORS’ NOTE Preparation of this article was supported in part by research grant MH028210 (R. Koegel, P.I. ) from the National Institute of Mental Health and a project development grant from First 5 Santa Barbara County: Children and Families Commission. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders–Fourth edition–Text revision. Washington, DC: Author. Baghdadli, A., Picot, M., Pascal, C., Pry, R., & Aussilloux, C. (2003). Relationship between age of recognition of first disturbances and severity in young children with autism. European Child & Adolescent Psychiatry, 12, 122–127. Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can autism be detected at 18 months? The needle, the haystack, and the CHAT. British Journal of Psychiatry, 161, 839–843. Connor, M. (1998). A review of behavioural early intervention programmes for children with autism. Educational Psychology in Practice, 14(2), 109– 117. Filipek, P. A., Accardo, P. J., Baranek, G. T., Cook, E. H., Dawson, G., Gordon, B., et al. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism and Developmental Disorders, 29(6), 439–484. Glascoe, F. (1998). Collaborating with parents: Using Parents’ Evaluation of Developmental Status to detect and address developmental and behavioral problems. Nashville, TN: Ellsworth & Vandermeer Press. Glascoe, F., & Dworkin, P. (1995). The role of parents in the detection of developmental and behavioral problems. Pediatrics, 95(6), 829–836. Koegel, R. L., Bruinsma, Y., & Koegel, L. K. (in press). Developmental trajectories with early interventions. In R. L. Koegel & L. K. Koegel (Eds.), Pivotal Response Treatments for autism: Communication, social, and academic development. Baltimore: Brookes. Koegel, R., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. (1989). How to teach pivotal behaviors to children with autism: A training manual. Santa Barbara, CA: University of California. Koegel, R., Koegel, L., Frea, W., & Smith, A. (1995). Emerging interventions for children with autism. In R. L. Koegel & L. K. Koegel (Eds.), Teaching children with autism: Strategies for initiating positive interactions and improving learning opportunities (pp. 1–15). Baltimore: Brookes. Koegel, R. L. Koegel. L. K., Bruinsma, Y., Brookman, L., & Fredeen, R. (2003). Teaching first words. Santa Barbara, CA: University of California. Lord, C., Rutter, M., Goode, S., Heemsbergen, J., Jordan, H., Mawhood, L., et al. (1989). Autism diagnostic observation schedule: A standardized observation of communicative and social behavior. Journal of Autism and Developmental Disorders, 19, 185–212. Lovaas, I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55(1), 3–9. M.I.N.D. Institute. (2002). Report to the legislature on the principal findings from the epidemiology of autism in California: A comprehensive pilot study. Davis, CA: University of California. Mundy, S., Sigman, M. D., Ungerer, J., & Sherman, T. (1986). Defining the social deficits of autism: The contribution of non-verbal communication measures. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 27(5), 657–669. Randall,P., & Parker, J. (1999). Supporting the families of children with autism. New York: Wiley & Sons. Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31(2), 131–144. Rogers, S. (1998). Empirically supported comprehensive treatments for young children with autism. Special empirically supported psychosocial interventions for children. Journal of Clinical Child Psychology, 27(2), 168– 179. Siegel, B., Pliner, C., Eschler, J., & Elliot, G. (1988). How children with autism are diagnosed: Difficulties in identification of children with multiple developmental delays. Journal of Developmental and Behavioral Pediatrics, 9(4), 199–204. Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vineland Adaptive Behavior Scales: Survey form manual. Circle Pines, MN: American Guidance Service. Woods, J. J., & Wetherby, A. M. (2003). Early identification of and intervention for infants and toddlers who are at risk for autism spectrum disorder. Language, Speech & Hearing Services in Schools, 34(3), 180–193. Action Editor: Robert H. Horner J Autism Dev Disord (2015) 45:2092–2104 DOI 10.1007/s10803-015-2376-y ORIGINAL PAPER Preliminary Effectiveness of Project ImPACT: A ParentMediated Intervention for Children with Autism Spectrum Disorder Delivered in a Community Program Nicole A. Stadnick • Aubyn Stahmer Lauren Brookman-Frazee • Published online: 30 January 2015 Ó Springer Science+Business Media New York 2015 Abstract This is a pilot study of the effectiveness of Project ImPACT, a parent-mediated intervention for ASD delivered in a community program. The primary aim was to compare child and parent outcomes between the intervention group and a community comparison for 30 young children with ASD at baseline and 12 weeks. The secondary aim was to identify parent factors associated with changes in child outcomes. Results indicated significant improvement in child communication skills and a strong trend for parent intervention adherence for the intervention group from baseline to 12 weeks. Higher baseline parenting stress was negatively related to child social gains from baseline to 12 weeks. Findings provide further support for delivering parent-mediated interventions in community settings to children with ASD. Keywords ASD
Community-based services
Implementation
Parent-mediated interventions Introduction While several research-based parent-mediated intervention methods for children with autism spectrum disorder (ASD) have been tested in controlled research settings (Brookman-Frazee et al. 2009; National Research Council 2001; N. A. Stadnick (&)
A. Stahmer
L. Brookman-Frazee Department of Psychiatry, University of California, San Diego, San Diego, CA, USA e-mail: nstadnic@ucsd.edu Present Address: A. Stahmer Department of Psychiatry and Behavioral Health, MIND Institute at the University of California, Davis, Davis, CA, USA 123 Dawson and Burner 2011; Rogers and Vismara 2008), limited information is known about the effectiveness of such methods in ‘‘usual care,’’ community-based service settings. Over the past decade, there have been increasing recommendations for translational research to address the need for implementation of efficacious interventions for children with ASD (Guralnick 2005; Interagency Autism Coordinating Committee 2011; National Standards Report 2009). To address this need, the goal of the current study was to examine the initial effectiveness of a specific parentmediated intervention targeting social-communication and delivered in a community-based setting to children with ASD and their caregivers. Reviews of the literature and best practice guidelines consistently identify active parent participation and education as an important component of intervention for children with ASD (National Research Council 2001; Oono et al. 2012). Several intervention approaches that include a parent training component have documented efficacy in research settings (Brookman-Frazee et al. 2009; National Research Council 2001; National Standards Report 2009). Growing support exists for blended parent-implemented naturalistic developmental behavioral interventions (NDBIs) to address core issues of ASD and deficits in communication and cognition at early developmental stages (Ingersoll and Wainer 2013; Rogers et al. 2012; Wallace and Rogers 2010). These methods use behavioral strategies (e.g., direct prompting, contingency reinforcement) to teach specific social-communication skills along with emphasizing strategies derived from developmental science designed to facilitate reciprocity, social engagement, and shared affect during adult–child interactions. Child progress across several domains has been documented in two randomized trials (Rogers and Dawson 2009; Yoder and Stone 2006) and controlled single-subject J Autism Dev Disord (2015) 45:2092–2104 and quasi-experimental studies of systematic blending of behavioral/developmental methods (Ingersoll and Dvortcsak 2010; Ingersoll et al. 2005; Ingersoll and Wainer 2013). Given this empirical support, parent-mediated NDBIs are increasingly recommended as state-of-the-art treatment options for children at risk for developing ASD (Dawson et al. 2010; Ingersoll 2009; Rogers et al. 2012; Stahmer et al. 2011). Despite well-documented efficacy data, less is known about the effectiveness of these parent-mediated approaches in community-based service settings, a critical service site for children with ASD. The limited research that has examined community-based early intervention and mental health services for children with ASD suggests that discrepancies exist between care provided in these routine services and that delivered in controlled research studies (Brookman-Frazee et al. 2010; Stahmer et al. 2005). To mitigate discrepancies, there are increasing calls to implement research-based interventions in routine care settings serving children with ASD (Lord and Bishop 2010). Research suggests that community-based ASD providers can successfully be trained and subsequently deliver specific research-based interventions for children with ASD with strong treatment fidelity (Brookman-Frazee et al. 2012; Vismara et al. 2009, 2013; Wainer and Ingersoll 2013). Further, a growing body of research has also reported that positive child and parent outcomes, similar to those in efficacy studies, can be obtained when parent interventions are delivered in community settings. Two quasi-experimental studies reported improvements in child adaptive behavior and communication skills following participation in a brief, naturalistic behavioral parent training program delivered in a similar community setting as in the current study (Baker-Ericzén et al. 2007; Stahmer and Gist 2001). The earlier of these two studies (Stahmer and Gist 2001) also reported that over half of parents who participated in the program met criteria for intervention skill mastery (i.e., appropriate use of intervention techniques during 75 % of scored videotaped intervals). Studies outside of the US examining community-based ASD services have reported similar positive findings across a range of child outcomes including cognitive, communication, and adaptive behavior skills, autism severity, rate of development, and disruptive behavior problems (Freeman and Perry 2010; Perry et al. 2008; Smith et al. 2010; Valenti et al. 2010). Taken together, these studies suggest that researchbased parent-mediated NDBIs for children with ASD delivered by community ASD providers are associated with positive child developmental outcomes. However, these studies have a number of limitations that the current study attempts to address. These limitations include the general lack of a control comparison group, assessment of parent 2093 intervention adherence, and examination of the impact of parent psychosocial factors on child outcomes. To address these limitations, the current pilot study examined the effectiveness of a specific parent-mediated NDBI, Project ImPACT (Improving Parents As Communication Teachers; Ingersoll and Dvortcsak 2010), delivered in one community-based program that serves children with ASD and their families. The primary study aim was to compare child and parent outcomes in the intervention group to a community comparison group from baseline to 12 weeks. The secondary aim was to examine baseline parent stress, depression symptoms, and intervention adherence as predictors of child outcomes for all dyads at 12 weeks. Methods The current pilot study examined the effectiveness of the Project ImPACT intervention (Ingersoll and Dvortcsak 2010) delivered between 2010 and 2012 in one community-based service center that routinely serves children with ASD and their families. This service center is affiliated with a local children’s hospital and provides a variety of services including individual and group parent training programs, social skills groups, psychodiagnostic assessment, inclusion services, and cognitive behavioral therapy. The current study focused on the individual parent training program that is provided, which uses the Project ImPACT intervention as its standard treatment protocol. Children who participate in the parent training program have historically been between the ages of 18 months and 8 years. Participants Participants included 30 children and their parent. Each parent–child dyad was either in the intervention group or the community comparison group. A total of 16 parent– child dyads were in the intervention group and 14 parent– child dyads comprised the community comparison group. Inclusion criteria for all children included: (1) child between 18 months and 8 years, (2) child had a documented ASD diagnosis or was considered ‘‘at risk’’ for ASD, and (3) both parent and child were English-speaking. For dyads in the intervention group, each parent–child dyad had to be newly enrolled in the parent training program at the participating service center and had attended fewer than three sessions. For families in the comparison group, the child needed to be currently receiving community-based ASD services (outside of the service center) and parent– child dyads needed to have never received services at the service center where the study was conducted, the Project ImPACT intervention, or services that used similar intervention methods. 123 2094 Regarding sociodemographics and diagnostic information, the mean age of the total sample was 54.83 months (SD = 25.44) and 80 % were boys. Parents reported that children were 47 % Multiracial, 30 % White, 10 % Hispanic/Latino, 7 % Asian, 3 % African American, and 3 % Other. All children had a current ASD diagnosis according to the DSM-IV (APA 2000) or were considered ‘‘at risk’’ for ASD (a provisional diagnosis for children under age 3) based on a community professional’s diagnosis (87 % were diagnosed by a psychologist) and verified by two of three ASD screening measures (described below) and a review of the most recent evaluation report documenting the ASD or ‘‘at risk’’ diagnosis. The child’s biological mother was the respondent for 97 % of the sample. Table 1 characterizes the sample. There were no statistically significant differences between study groups related to sociodemographics, service use, or ASD diagnostic type. Procedures Intervention Group The recruitment process for intervention group dyads consisted of contacting parents who were recently enrolled in the program delivering Project ImPACT, and who provided permission to be contacted to receive study information. A total of 29 families were contacted. A phone screen was conducted with each family to confirm eligibility. Of these families, 13 were ineligible primarily because the child was outside of the study age range or the child did not have a documented ASD or ‘‘at risk’’ diagnosis. The remaining eligible 16 families agreed to participate in the study for approximately 6 months. All intervention group dyads completed the parent training program. The Project ImPACT intervention (Ingersoll and Dvortcsak 2010) consists of a prescribed set of naturalistic behavioral and developmental teaching strategies to facilitate child communication and social skills throughout daily activities and routines in young children (ages 18 months to 8 years). Project ImPACT uses NBDI methods that emphasize fostering the child’s relationship with others involved in intervention to focus on developing reciprocity, social engagement, and shared affect during adult–child interactions while integrating behavioral strategies (e.g., direct prompting, contingency reinforcement) in the context of a highly engaged interaction to teach specific social-communication skills. Four core socialcommunication skills are addressed: (1) social engagement, (2) language, (3) imitation, and (4) play. The original protocol includes 24 sessions that can be delivered in an individual or group format. At the service center used for this study, the curriculum was condensed (in consultation 123 J Autism Dev Disord (2015) 45:2092–2104 with the intervention developer) into 12 sessions, due to constraints of the organization’s funding source. In this service setting, Project ImPACT was delivered in an individual format over 12, 1 h per week sessions. In each session, parents received didactic instruction in intervention strategies, modeling of the intervention strategies by the clinician with the child, and in vivo feedback on their in-session practice of intervention strategies. Parents were provided with homework assignments to practice use of the intervention strategies throughout their child’s daily activities. Table 2 describes the typical order that sessions were delivered. The intervention can be flexibly implemented to best meet the needs of the child and their family. Project ImPACT was delivered by three clinicians in the community program. Clinicians were three full-time female clinicians who routinely delivered Project ImPACT at the service center used for this study. Clinicians had received formal training in Project ImPACT by the intervention developers and had met intervention adherence according to standard fidelity measures provided by the developers. Two clinicians held a master’s degree in Psychology and one clinician held a doctoral degree in Clinical Psychology. All clinicians specialized in working with children with ASD. Community Comparison Group Families in the community comparison group were recruited from a variety of local and national community organizations and providers that serve or provide resources to families of children with ASD including: providers at local school districts, the local California Regional Center, community agencies that serve children with developmental disabilities, private practitioners who routinely serve children with ASD but do not deliver Project ImPACT, and departments at the local children’s hospital that serve children with ASD. Study information was also posted on several high traffic websites and in a weekly email newsletter for families of children with ASD. A total of 37 families were referred and contacted. A phone screen was conducted with each family to confirm eligibility. Of these families, 23 were ineligible. Reasons that children were ineligible included: the child was already enrolled in the Project ImPACT intervention or had previously received similar intervention methods, the child was outside of the study age range or the child did not have a documented ASD or ‘‘at risk’’ diagnosis. Assessment Procedures For both the intervention and community comparison groups, dyads were assessed at: (1) baseline (pre- J Autism Dev Disord (2015) 45:2092–2104 2095 Table 1 Baseline characteristics of the sample Intervention (n = 16) Comparison (n = 14) Child age M = 46.75 months (SD = 25.88; range = 20–108) M = 64.07 months (SD = 22.32; range = 18–104) Child sex 81 % boys 79 % boys Caucasian/White 31 29 Hispanic/Latino 6 14 Asian/Pacific Islander 13 – African American Multiracial 6 44 – 50 Child race/ethnicity (%) Other 7 Family income (%) 0–$25,000 14 7 $25–50,000 36 21 $50–75,000 14 7 $75–$100,000 29 57 [$100,000 7 7 M = 34.80 years (SD = 6.81; range = 23–45) (n = 15) M = 36.50 (SD = 6.56; range = 27–50) (n = 14) 6 38 21 21 Maternal agea Maternal education (%) High school/GED Associate’s degree Bachelor’s degree 31 36 Master’s degree 19 21 Doctoral degree 6 – Married 60 79 Separated/divorced 7 14 Single 33 7 Regional center 56 57 Private pay 6 14 Commercial insurance 13 21 Private pay and regional center 6 7 Private pay and insurance 13 – Medicaid 6 – 53 70 Marital status (%) Primary services funder (%) ASD diagnosis (%) Autistic disorder PDD-NOS 7 10 At-risk for ASD 40 20 Psychologist 100 71 Psychiatrist – 14 School psychologist – 14 Diagnosing provider (%) a SRS total score (%) n=5 n = 12 Severe range 100 91 Mild to moderate range – 9 Normal range – MCHATa a SCQ total score (%) 57 % failed (n = 7) 100 % failed (n = 2) (n = 14) (n = 14) 123 2096 J Autism Dev Disord (2015) 45:2092–2104 Table 1 continued Intervention (n = 16) Comparison (n = 14) ASD 71 93 Non-ASD 29 7 M = 4.50 (SD = 1.55; range = 2–7) M = 4.07 (SD = 1.69; range = 1–6) Number of concurrent services (%) a Parent training – 71 In-home ABA 75 64 Occupational therapy 81 71 Speech therapy 94 71 Physical therapy 31 14 Social skills group 25 36 Special education 44 64 Other 14 21 Data were not available for all participants Table 2 Typical sequence of sessions for Project ImPACT (Ingersoll and Dvortcsak 2010) Session 1 Therapists administer the intake assessments. Overview and goals of the program, intervention techniques (interactive and directive), and social-communication are discussed Session 2 Therapists begin with teaching the interactive techniques. They first discuss how to set up the home environment for practicing intervention techniques (e.g., scheduling predictable routines, setting up a defined space, limiting distractions, toy rotation) and following the child’s lead Session 3 Therapists and parents develop specific goals for the child. Topics covered include how to use animation using direct language stimulation (e.g., self-talk and parallel talk) to make play and daily activities more interactive Session 4 Therapists teach parents how to model and expand their child’s language and use playful obstruction to create opportunities for communication and increase social engagement Session 5 Therapists teach parents how to use communicative temptations (e.g., have a desired toy in the child’s sight but out of reach) and taking turns during play Session 6 Therapists begin teaching the directive techniques, which require the parent to use prompting and reinforcement to increase the complexity of their child’s response Session 7 Therapists teach parents how to use eight specific language prompts coordinated with reinforcement to enhance their child’s expressive language Session 8 Therapists teach parents how to use four specific prompts coordinated with reinforcement to enhance the child’s ability to understand and follow directions Session 9 Session 10 Therapists review previously taught interactive techniques and new directive techniques to teach the child social imitation Therapists teach parents how to use six specific play prompts coordinated with reinforcement to increase the complexity of the child’s play Session 11 Therapists review the use of interactive and directive techniques and update developmental and behavioral child goals Session 12 Therapists administer the post assessments and develop a plan for continued implementation of intervention techniques. This sequence was adapted, per routine care, for the site in which the intervention was delivered for this study intervention) and (2) 12 weeks from baseline (typical length of intervention). The primary caregiver completed a set of standardized questionnaires (described below) and was video recorded playing naturally with his or her child for 10 min at each assessment. Each assessment lasted approximately 1–2 h and parents received $20 (up to $40 total) and their child received a small gift (up to two total) at each assessment period. 123 Eligibility and Sample Characteristics Measures Family Sociodemographics and Service Use Parent-report data were collected at the initial assessment regarding child and parent age, child gender, child race/ ethnicity, parent level of education, family income, parent marital status, child comorbidity, and child history of J Autism Dev Disord (2015) 45:2092–2104 current and past services. Parents reported concurrent services received at the 12-weeks assessment. Social Communication Questionnaire (SCQ) (Rutter et al. 2003) The SCQ is a 40-item parent-report measure that examines the presence of ASD symptoms in children. The SCQ has strong evidence for its use as a screening instrument and in identifying children at risk for ASD (Berument et al. 1999; Bishop and Norbury 2002; Chandler et al. 2007; Charman et al. 2007). A Total Score is derived. A cutoff score of 15 is applied to the Total Score to divide the results into ASD versus Non-ASD. The SCQ was used to confirm ASD diagnoses and it was administered at baseline to all parents. This measure was used in combination with the Social Responsiveness Scale or Modified Checklist for Autism in Toddlers (described below) depending on the child’s age to confirm concordance of the child’s ASD diagnosis. Social Responsiveness Scale (SRS) (Constantino and Gruber 2005) The SRS is a 65-item parent-report measure that examines the severity of autistic symptoms for children ages 4–18. The SRS has robust reliability and validity (Charman et al. 2007; Constantino et al. 2000, 2003). Five subscales and a Total Score are calculated. The Total Score is converted into a T-score that is classified into: (1) the Severe range, (2) the Mild to Moderate range, and (3) the Normal range. The SRS was used to help confirm ASD diagnoses and was administered at baseline to parents of children who were 4 years and older. Modified Checklist for Autism in Toddlers (M-CHAT) (Robins et al. 1999) The M-CHAT is a 23-item parent-report ASD screening assessment for children 16–30 months. The M-CHAT has strong psychometric properties (Chlebowski et al. 2013; Kleinman et al. 2008; Robins et al. 2001; Robins 2008). A Total Score is derived and classifies the results into ‘‘passing’’ or ‘‘failing.’’ A ‘‘failing’’ classification, suggests a risk for ASD and a recommendation for follow-up. The M-CHAT was administered at baseline to confirm ASD diagnoses for children younger than 4 years. Evaluation Report Documenting ASD Diagnosis The child’s most recent psychological, neuropsychological, school, or medical evaluation documenting a formal ASD diagnosis or ‘‘at risk’’ classification (for children under 3 years old) was reviewed at the baseline assessment. 2097 Child Outcomes Measure Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) (Sparrow et al. 2005) The Vineland-II is a standardized interview completed by parents that assesses child adaptive functioning in four domains: Communication, Daily Living Skills, Socialization, and Motor Skills. Only the Communication and Socialization domains were administered, per routine care at the service center used for this study. The Communication domain measures the child’s verbal, receptive, and written language abilities while the Socialization domain assesses interpersonal, play and leisure, and coping skills. Each domain yields a standard score with a mean of 100 and a standard deviation of 15. The Vineland-II has strong internal consistency and concurrent validity (Sparrow et al. 2005). The PI administered the Vineland-II to all families in the comparison group and the clinician delivering the Project ImPACT to those in the intervention group administered the Vineland-II at baseline and 12 weeks, per routine care. Parent Measures Center for Epidemiological Studies-Depression Scale (CES-D) (Radloff 1977) The CES-D is a 20-item self-report scale that assesses the frequency of depression symptoms. The CES-D has strong reliability, with alpha coefficients ranging from 0.85 to 0.90, and validity for use in the general adult population (Radloff 1977). Parenting Stress Index-Short Form (PSI-SF) (Abidin 1995) The PSI/SF is a 36-item parent-report scale derived from the full-length PSI. Each item is rated on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). The PSI-SF contains three sub-scales, each with 12 items: (1) Parental Distress, (2) Parent–Child Dysfunctional Interaction, and (3) Difficult Child. A Total Stress score is computed by summing the three subscales. Subscale scores range from 12 to 60 and the Total score ranges from 36 to 180, with higher scores indicating a greater level of stress. The PSI-SF has strong psychometric properties (Abidin 1995). Parent Intervention Adherence Video recorded observations of natural parent–child interactions lasting 10 min occurred at each assessment to 123 2098 examine changes in intervention adherence (i.e., degree to which the parent correctly uses the required intervention techniques during interactions with her child). Parents and children were asked to play or interact as they would typically at home. An established observation coding form that was created (Ingersoll and Dvortcsak 2010) by the intervention developers was used to evaluate the parent–child interactions. The measure requires a trained coder to rate each intervention technique taught to parents on a 5-point scale from ‘‘1’’ (parent does not implement or never implemented appropriately) to ‘‘5’’ (parent implements competently throughout segment). Coders rated each of the six component summary scores: (1) Parent Uses Follow Your Child’s Lead, (2) Parent models and expands child’s language or play, (3) Parent creates opportunities for the child to initiate, (4) Parent helps child increase complexity of language, imitation or play, (5) Parent paces interaction to keep child engaged and learning, and (6) Parent targets child’s social-communication goals. The mean of the six component summary scores was calculated for each video. Intervention adherence was defined as the mean of the summary scores at or greater than a rating of 4. Five undergraduate or bachelor’s-level research assistants, who were blind to study condition and had achieved reliability to independently code videos (i.e., correctly rated 80 % of codes on two consecutive training videos), scored each 10-min parent–child interaction. Approximately 30 % (n = 22) of video observations were double coded. Inter-rater reliability was calculated in two ways. First, the intraclass correlation coefficient (ICC) was computed on the mean of the six component summary scores of each rater and was 0.66, which is within the acceptable range (Cicchetti 1994). Second, percent agreement was computed. Percent agreement is method of determining interrater reliability for observational data that is often used in the developmental disability literature (e.g., Galensky et al. 2001; Koegel et al. 2012). Agreement was defined as both coders assigning a rating for each of the six summary scores that was within one point. Percent agreement was the quotient of the sum of the total number of agreements and the sum of the total number of agreements and disagreements, multiplied by 100. The average percent agreement was 96 % (range 86–100 %). J Autism Dev Disord (2015) 45:2092–2104 Communication and Socialization standard scores, raw scores from the PSI-SF and CES-D and the parent intervention adherence mean. The second aim of the study was to examine parent factors as predictors of child outcomes for all families at 12 weeks. Multiple linear regression analyses were performed with Vineland-II Communication and Socialization baseline to 12 weeks difference scores as the outcome variables. Data from families in both groups were pooled for these analyses. Study condition and baseline child standard scores on the Vineland-II were entered as covariates. Results Descriptive statistics are graphically depicted in Figs. 1, 2, 3, 4 and 5. Baseline Groups Equivalence Differences in sociodemographic and service use variables between the intervention and comparison groups were examined using one-way ANOVAs and Chi square analyses. There were no baseline differences between study groups for relevant child or parent sociodemographics, primary funding source, ASD diagnosis type, professional who provided the ASD diagnosis, or the number of services that the child was receiving (all p values[0.05). To further assess the degree of association between categorical sociodemographic and service use variables, Cramer’s V was calculated. No statistically significant associations were identified. Differences in baseline child and parent outcome variables were next examined using one-way ANOVAs. There were no baseline differences between the intervention and comparison group on the Vineland-II, PSI-SF, CESD-D, and the intervention adherence mean (all p values [0.05). Data Analysis To examine the first study aim, repeated measures mixed analyses of variance (ANOVA) were used to compare child and parent outcomes between the intervention and comparison groups. Individual models were performed for each child and parent outcome as measured by the Vineland-II 123 Fig. 1 Child communication skills. Data displayed are standard scores from the Vineland-II (Sparrow et al. 2005) J Autism Dev Disord (2015) 45:2092–2104 Fig. 2 Child social skills. Data displayed are standard scores from the Vineland-II (Sparrow et al. 2005) 2099 Fig. 5 Parent intervention adherence. Data displayed are the mean of the six summary intervention component scores on which parents were rated for child communication skills, F(1, 27) = 5.70, p \ 0.05, g2 = 0.17. There was a strong positive trend for parent intervention adherence, F(1, 22) = 4.14, p = 0.05, g2 = 0.16. There was not a significant interaction between study group and time for child social skills, F(1, 27) = 1.43, p = 0.24, g2 = 0.05, parent stress, F(1, 24) = 1.62, p = 0.22, g2 = 0.06 or parent depression symptoms, F(1, 27) = 0.83, p = 0.37, g2 = 0.03. Full model results are reported in Table 3. Fig. 3 Parent stress. Data displayed are raw scores from the Parenting Stress Index/Short Form (Abidin, 1995). A score of 86 or greater on the Parenting Stress Index/Short Form is suggestive of clinically significant stress Fig. 4 Parent depression symptoms. Data displayed are raw scores from the Center for Epidemiological Studies-Depression Scale (Radloff 1977). Scores between 16 and 26 on the Center for Epidemiological Studies-Depression Scale are suggestive of mild depression symptomatology Child and Parent Outcomes Comparison Repeated measures mixed ANOVA were performed to compare child and parent outcomes between groups. There was a significant interaction between study group and time Parent Characteristics Predicting Child Outcomes To examine the secondary study aim examining the role of baseline parent factors on child skills changes, bivariate correlations between parent stress, depression, and intervention adherence at baseline and 12 weeks, and child difference scores in communication and social skills were first performed to guide selection of subsequent regression analyses. Parent stress at baseline demonstrated a statistically significant (at p \ 0.10 level), negative correlation with changes in child social skills from baseline to 12 weeks (r = -0.34; p = 0.09). As a result, two multiple linear regression analyses were conducted with parenting stress (PSI-SF Total score) at baseline as the predictor variable, and changes in child communication and social skills between baseline and 12 weeks (change scores) as the dependent variables. Study group and the most proximal assessment child score (e.g., baseline child scores for the model predicting child changes from baseline to 12 weeks) were entered as covariates in the regression models. Of these models, baseline parenting stress emerged as a statistically significant predictor of changes in child social skills from baseline to 12 weeks, b = -0.17, SE = 0.07, p \ 0.05, after controlling for study group and baseline child social skills. Specifically, there was a negative association between baseline parenting stress and child social skills changes with higher baseline parenting 123 2100 J Autism Dev Disord (2015) 45:2092–2104 Table 3 Repeated measures analysis of variance Effect MS df 2 F p g Child communication skills Time 458.94 1 13.64 0.001 0.34 Time 9 study group 191.76 1 5.70 0.02 0.17 33.66 27 Error Child social skills Time 151.52 1 2.99 0.10 0.10 Time 9 study group 72.62 1 1.43 0.24 0.05 Error 50.67 27 Time 495.24 1 2.46 0.13 0.09 Time 9 study group Error 326.16 201.71 1 24 1.62 0.22 0.06 45.39 1 1.22 0.28 0.04 0.83 0.37 0.03 Parent stress Parent depression symptoms Time Time 9 study group 31.05 1 Error 37.22 27 Time 0.13 1 0.33 0.57 0.02 Time 9 study group 1.59 1 4.14 0.05 0.16 Error 0.38 22 Parent intervention adherence stress related to smaller improvements in child social skills from baseline to 12 weeks. Discussion This study examined the initial effectiveness of the Project ImPACT intervention, a parent-mediated NDBI intervention for children with ASD served in a community-based program. Findings from the first study aim indicated that children in the intervention group demonstrated significantly greater gains in communication skills relative to comparison group children from baseline to 12 weeks. In addition, a strong positive trend was identified for parents in the intervention group demonstrating higher treatment adherence compared to comparison group parents from baseline to 12 weeks. Results from the second aim of the study indicated that higher baseline parenting stress was associated with less change in child social skills from baseline to 12 weeks (commensurate with the duration of the intervention), independent of study group. Results of this first study aim are generally consistent with the small but growing literature that has examined outcomes from parent-mediated interventions delivered in community settings for families of children with ASD (e.g., Baker-Ericzén et al. 2007; Stahmer and Gist 2001; Vismara 123 et al. 2009). Specifically, these findings support the available literature that has documented significant child improvements in social-communication skills and parent behavior change following participation in parent-mediated interventions. However, while the findings indicating greater improvement in specific child and parent skills for the intervention group are promising, it is important to note that not all child and parent outcomes examined improved. There are a number of possibilities that may explain these results. One possibility may be that the study groups differed on measured variables that were related to outcomes but were not detected due to the study’s small sample size and the non-randomized design of the study. Related, the study groups may have differed on unmeasured variables that were related to study outcomes. Another possibility is that the concurrent services reported by parents impacted outcomes. Information on the intensity (i.e., frequency and duration) of and specific nature of concurrent service use throughout the study was not collected. Therefore, it is not known whether the intensity of services received differed between the study groups and what impact this may have had on study outcomes. Another consideration is that the original design of the Project ImPACT intervention includes 24 sessions delivered twice weekly rather than the 12 session, once-per-week model used in the current study. There is the possibility that the higher intensity format of the intervention may have yielded stronger intervention effects. It was beyond the scope of this study to examine the relation between treatment dosage and outcomes. However, a recent study that examined the efficacy of Project ImPACT (Ingersoll and Wainer 2013) reported similar positive outcomes regarding parent intervention adherence and child language acquistion with both the 12 session and 24 session service delivery models. Results from the second study aim are also somewhat consistent with the limited research that has examined caregiver functioning of children with ASD. Specifically, study findings confirm previous literature that has documented the high parenting stress levels that caregivers of children with ASD experience (Baker-Ericzen et al. 2005; Hayes and Watson 2013; Osborne et al. 2008; Plienis et al. 1988; Robbins et al. 1991). Specifically, parents in this sample generally reported clinical levels of parenting stress across 12 weeks. In addition, study findings support the limited literature that has demonstrated the negative relationship between parenting stress and child skill acquisition (Robbins et al. 1991). Given that this study had increased methodological rigor, relative to the existing literature that has assessed parent-mediated interventions delivered in community settings, findings from this study are important in advancing empirical pursuits aimed at examining effectiveness for the ASD population. J Autism Dev Disord (2015) 45:2092–2104 This study adds to the available literature in several respects. Most importantly, the increased methodological rigor of the study provides more definitive support for the utility and positive impact on communication skills and parent behavior that the Project ImPACT intervention may provide for children with ASD and their caregivers. While the small sample size significantly impacted the statistical power of the effects examined, descriptive data on the other child and parent outcomes paralleled the positive trends in improvement that were identified for child communication skills and parent intervention adherence from baseline to 12 weeks. Further, this study facilitates clarification of the previously mixed results regarding the impact of parenting stress, in particular, on child skills. Due to the finding that greater baseline parenting stress levels were related to less change in child social skills from baseline to 12 weeks, an important clinical consideration in services planning is the addition of parent stress assessment upon entry into parentmediated services for children with ASD. The deleterious effects of high parenting stress on child skill acquisition underscore the need for assessment of parenting stress in parent training. Related, study findings suggest the need for adapting parent-mediated interventions for caregivers with high levels of parenting stress. There is a growing interest in understanding how to best tailor ASD interventions based on child and family characteristics (Stahmer et al. 2011). This research has suggested that caregivers who present with high stress levels may be poor candidates for parent training services. Children and their caregivers in this circumstance may fare better in intervention that requires less parent involvement. Additionally, examining interventions to address high levels of parent stress will be important as parent stress may directly affect child outcomes. Future research is greatly needed, particularly with access to a larger sample size of families. It may also be important to assess additional aspects of parent functioning that may be not only an outcome of intervention, but may also facilitate the effects of intervention on their children. It should be noted that there was little movement in parent depression symptoms across study groups. The average depression scores across 12 weeks were well below the clinical range so the limited variability in scores may have impacted findings. This may suggest that assessing depression symptoms does not provide the best representation of psychosocial functioning for caregivers of children with ASD or that the depression scale used was insufficiently sensitive. Further, it suggests the need to assess a broader range of parent functioning constructs. For example, parent confidence in managing child behaviors, therapeutic alliance, and parental sense of social support may represent both naturally occurring outcomes of parent- 2101 focused intervention and mediators or moderators of child skill acquisition. The significance of these parent constructs in parent-mediated interventions have been reported in recent studies (Rogers et al. 2012; Stahmer and Gist 2001). Finally, as mentioned earlier, future research should also examine the utility of ‘‘booster’’ sessions in maintaining or augmenting child and parent skills. Strengths and Limitations The primary strength of this study is its strong ecological validity. Specifically, this study examined the effectiveness of research-based practices in community settings for children with ASD. Another strength is the focus on parent factors to further understand the impact of a research-based parent training intervention on parent functioning and skills. Related, this study examined parent factors as predictors of child clinical outcomes. There is limited research examining predictors of child clinical outcomes beyond child age and IQ (Rogers, and Vismara 2008). Study findings suggest the importance of systematically assessing parenting stress upon entry in ASD services that include a parent-involvement component. In addition, the inclusion of a community comparison condition was a methodological strength of this study. While the comparison condition is a strength, it is also associated with inherent methodological limitations. Specifically, families were not randomly assigned to study group. Random assignment was not feasible for this study due to ethical constraints related to withholding treatment from families and because the purpose of the study was to compare Project ImPACT to usual care. While random assignment may facilitate examining intervention effectiveness and mitigate the influence of endogeneity biases (Duncan et al. 2004), research suggests that random assignment may negatively impact the flexibility required when initially testing an intervention. This is particularly true for ASD intervention research within community settings that naturally involve funding, ethical, and sociopolitical factors that can be challenges to random assignment (Rogers and Vismara 2008). Given that this study aimed to provide initial results on the effectiveness of Project ImPACT, the methodological design of this study was appropriate, added methodological rigor to existing research, and provided the flexibility required to be tested ...
Purchase answer to see full attachment