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.
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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
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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
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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.
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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
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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)
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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.
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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.
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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
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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
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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
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