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Early Start Denver ModelParent Coaching

P-ESDM

ESDM Canada

Mary McKennaJanet Harder

Michaela Jelen

BCASLPA ConferenceOctober 22nd, 2016

ESDM

ESDM• ESDM draws on several different models as

its foundationo Denver Model (Rogers et al., 1981)o Model of Interpersonal Development

(Rogers & Pennington, 1991)o Model of Autism as a disorder of social

motivation (Dawson et al., 2004)o Pivotal Response Training - PRT

(Schreibman & Pierce, 1993; Koegel & Koegel, 1988)

ESDM• Criterion-referenced tool that provides a

developmental sequence of skills in 8 domains.

• 480 items organized across 4 levels.• Developed for toddlers with ASD ages 12 –

60 months.• Developed “specifically for young children

with ASD and reflects their typical developmental profile.” (p.58)

Goals of the ESDM• Reduce ASD symptomology • Bring the child back into the social loop• Teach the building blocks of social life:

o Imitationo Emotional communicationo Sharing experienceso Social and symbolic playo Language

• Fill in the learning gaps

ESDM Elements: Relationship-based

• Quality of relationships are central in intervention

• Naturalistic teaching strategies

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ESDM Elements:Developmental Framework

• All developmental areas affected by ASD are targeted.

• Curriculum follows a developmental sequence.

• The language intervention approach in ESDM:oComes from the science of

communication development rather than behaviour analysis

ESDM Elements:Applied Behaviour Analysis

• Prompting, fading, shaping, chaining• Management of motivation and attention• Clear ABC contingencies

oAntecedento BehaviouroConsequence

• Data-based decision making

Developmental Framework+ ABA

PRT  Principles

Denver Model

Principles

PRT Principles

ABA Principles

ESDM Elements: Multiple environments

community

home

preschool

ESDM Elements: Interdisciplinary Approach

OT

Behaviour  Analyst

Physician

Education

Child  Psych.

SLP

ParentTeam  Leader

ESDM: Delivery Settings• In home or clinic

o 20-hours-or-more per week – including time with parent

o 1:1 treatment delivery by supervised interventionists

o Sessions typically run 2 hours • Parent delivered ESDM (P-ESDM)

o Parent and child attend therapy 1.5 hours per week

oClinician coaches the parent to implement ESDM in natural household routines and parent child play activities through weekly sessions.

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ESDM: Fidelity Checklist• 13 key areas that are evaluated to ensure

fidelity of implementation.• Quantifies intervention

o 1(No strengths)o 5 (best possible Example)

• Used in the ESDM and in the P-ESDM

Parent Coaching

Parent-Delivered Intervention Programs

• Hanen More than Words• Early Start Denver Model (P-ESDM)• Pivotal Response Training• Responsive Teaching • Social Communication, Emotional

Regulation, Transactional Supports - SCERTS

ESDM Elements: Relationship-based

• P- ESDM: Parents are highly involved as decision makers and as ‘interventionists’

• Quality of relationships are central in intervention

• Naturalistic teaching strategies

Why do ESDM Parent Coaching?

• Parents spend the most time with their children

• Parents are highly motivated to implement goals and work on goals with their child

• Allows professionals to support families• Children supported across a wide range of

activities: Meals, play, dressing

• Knowledge is Power – Parent need to be able to understand and explain their child’s strength’s and needs to a variety of individuals

• Efficient use of funds

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P-ESDMWhat is it….? Parent Coaching

“Parent coaching, include(s) parent use of the interventions daily and therapist modeling of the

intervention to the parent… There is robust evidence that parents can effectively deliver interventions for

children with autism and effect desired child change.” (Rogers et al., 2014).

Coaching vs. TrainingCoaching • Parents ‘experts’ on

their children• Parents and coach are

equal partners• Parents drive the goals

for themselves and their child

• Coach supports parent/child interactions

• Feedback through self-reflection of parent

Training• ‘Expert’ model• Parents told how to

implement strategies• Parents are often

‘shown’ how to intervene

• ‘Expert’ knows ‘best’• Parents are often left to

‘try it out’ on their own• Parents watch videos

of others

Research in P-ESDM

Vismara, L.A., Colombi, C., & Rogers, S.J. (2009). Can one hour per week of therapy lead to lasting changes in young children with autism? Autism, the International Journal

Goals of the Pilot Study• Evaluate whether a 1-hour weekly visit

would result in real benefit.• Develop a generalist intervention that could

be delivered by a range of childhood professionals.

• Develop an intervention that could be delivered immediately after diagnosis.

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Summary• Piloted a manualized parent intervention using

a parent manual that highlighted 10 therapy strategies.

• Delivered brief 12 week, 1 hour per week, individualized parent-child education program to eight toddlers newly diagnosed with autism.

• The ESDM Fidelity Scale was used to assess 14 parent behaviours.

• Changes Social communication was assessed by:

o Number of spontaneous functional verbal utterance

o Number of imitative behaviours (action on objects, manual acts with no objects and vocalizations and words).

Results• For parents that completed the training, all

but one parent mastered the techniques (met fidelity) by the 5th to 6th hour of parent coaching.

• Parents maintained their skills 3 months following the end of treatment.

• Children demonstrated sustained change and growth in social communication behaviors measured by number of spontaneous functional verbal utterances and imitative behaviours across play activities.

Rogers, S.J., Vismara, L., Wagner, A.L., McCormick, C., Young, G., & Ozonoff, S. Autism treatment in the first year of life: A pilot study of Infant Start, a parent-implemented intervention for symptomatic infants. J of Autism and Developmental Disorders. 2014.

Summary• Pilot-tested a 12-week parent intervention• 7 infants ages 7-15 months, highly

symptomatic for ASD• 4 Comparison groups also at risk for ASD due

to sibling status and increased early symptoms.

• Intervention aimed to change (reduce) 6 target symptoms and developmental patterns of early ASD.

MeasuresParent Measures• Infant Start Parent Fidelity Measure (Rogers

et al. 2012c) – 19 items, Likert scale.• Parent Satisfaction Rating (Charlop-Christy

and Carpenter 2000)• Working Alliance Scale for Intervention with

Children (Davis et al. 2006) a social validity measure, used to describe families response to intervention.

Measures - continuedInfant Enrollment Measures• Infant Toddler Checklist (Wetherby and

Prizant 2002)• Autism Observation Scale for Infants (AOSI;

Bryson et al. 2008)Infant Treatment Curriculum Measures• The Carolina Curriculum for infants and

Toddlers with Special Needs, 2nd Edition (Johnson-Martin et al. 1991)

• ESDM Curriculum Checklist (Rogers and Dawson 2010)

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Measures - continuedInfant Outcomes Measures• ADOS, MSEL, Total Intervention Hours

(unpublished), Clinical Best Estimate Outcome classification, Infant Start Therapist Fidelity Measure (Rogers et al 2012c)

ResultsQuestions Addressed:1. Could symptomatic infants <15 months be identified and recruited for treatment? Yes, but…2. Can parents learn and deliver intervention with high fidelity and maintain it? Yes, 6/7 mastered at week 7 (<8 contact hours), all mastered and maintained 80% fidelity.

Results - continued3. Are parents satisfied with low intensity, short-term intervention? Yes, high parent satisfaction ratings.4. Are infants who received intervention less impaired in terms of ASD at age 3 compared to those who did not receive intervention? Yes, Infant Start group less impairment (ASD symptoms and dev. delays) at 36 months.

Estes, A., Vismara, L., Mercado, C., Fitzpatrick, A., Elder, L., Greenson, J., Lord, C., Munson, J., Winter, J., Young, G., Dawson, G., & Rogers, S.J. The impact of parent-delivered intervention on parents of very young children with autism. J of Autism and Developmental Disorders. 2014;44(2), 353-365.

Summary• Investigated the impact of how intervention

delivered through 3 months of parent coaching to very young children with ASD impacted parents level of satisfaction and stress.

• Hypothesis; P-ESDM would lead to improved level of parenting stress as well as increased sense of competency when compared to community interventions.

Summary• 98 Children with ASD and primary caregivers• Randomized into 2 intervention groups

oESDM 49 (mean 2.6 hrs/week intervention)

oCommunity 49 (mean 4.8 hrs/week intervention)

• ESDM – 1 hour session with consistent structure designed to teach interactive principals of ESDM

• 12-15 learning goals (not directly targeted)• Therapist fidelity of administration of P-ESDM

needed to be at 85%

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Results• No significant difference in Parent Sense of

Competence Scores between P-ESDM and Community groups.

• Parent Stress scores in the P-ESDM were significantly lower compared to the Community group, even after accounting for major life events

• Number of intervention hours had no effect on Parent stress or Parent sense of competence.

Parent Implemented ESDM(P-ESDM)

Parent Coaching Manual• Work through the

manual with the parent/caregivers.

• Chapters 1-3: focus on understanding and coping with diagnosis.

• Chapters 4-14: Strategies

1. Setting up their child’s program 2. The importance of parents taking care of

themselves both physically and mentally3. Challenges of siblings4. Hallmarks of good intervention program5. Dealing with extended family6. Unique learning challenges of ASD

Understanding and Coping with Diagnosis.

11 Chapters on Everyday Strategies

• Step into the Spotlight: Capturing your Child’s Attention

• Find the Smile!: Having Fun with Sensory Social Routines

• It Takes Two to Tango; Building Back–and-Forth Interactions

• Talking Bodies: The Importance of Nonverbal Communication

• “Do What I Do!”: Helping Your Child Learn by Imitating

• Let’s Get Technical: How Children Learn• The Joint attention Triangle: Sharing Interests

with Others• It’s Playtime!• Let’s Pretend• Moving into Speech• Putting it All Together.

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Chapter Features• What is happening in Autism?• Why is it a Problem?• Activity Checklist• Refrigerator List

Start with a Simplified Intervention Plan• See for 1-2 assessment sessions

o Score the curriculum checklistoWrite objectivesoDevelop a task analysis of teaching

steps• Build a data sheet for objectives to be

monitored by certified therapist (not the focus for the parents during initial part of parent training)

Format of Parent Coaching Session

1. Review past week focus2. Parent child activity3. Introduce new topic/concepts4. Parent-child activity with Coaching5. Reflect6. Parent-child activity with coaching 7. Reflect8. Other topics9. Plan for next session

Data collection

• Parent fidelity• Child data• Coaching fidelity

The goal of P-ESDM is to have parents meet

Fidelity across a variety of activities

Fidelity Rating Scale• 13 key areas that should be the focus of

intervention – coded 1(No strengths) - 5 (best possible Example)a) Management of Child Attentionb) ABC formatc) Instructional Techniquesd) Modulating child affect/arousale) Management of Unwanted Behavioursf) Quality of Dyadic Engagement

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Fidelity Rating Scaleg) Adult optimizes child motivationh) Adult use of positive affecti) Adult’s sensitivity and responsivityj) Multiple varied communicative

opportunitiesk) Adult’s language for the child’s levell) Joint Activity Elaborationm)Transition between activities

Child Data

During three or more familiar sensory social routines (e.g., peek a boo, ring around the rosy) when you model a gesture, Mathew will copy you for 6 or more different gestures (e.g., hands up, clapping, twinkle fingers, etc.).

1. Watches me do the routine (SSR).

2. Imitates 1 action in the activity with support

3. Imitates 2 actions, independently

4. Imitates 4 actions independently

5. Imitates 6 actions independently

Clinician records on data sheet while the child is interacting with his/her parent.

Coaching Fidelity• The clinician records on Coaching Fidelity

Rating scale after the session.

Parent-Delivered Intervention Programs

• P-ESDM compared with the Hanen More Than Words (MTW)oGoalso Featureso Theoretical Foundationso Research

More Information

http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/certification.html

Becoming Certified in ESDM Direct Delivery

• Masters degree or the academic equivalent from your country of origin (e.g., MA, Ph.D., MFT, SLP, OT)

• Work regularly with children with ASD Spectrum Disorder (ASD) aged 12-48 month

• Work as part of an interdisciplinary team• Complete Introductory online course and Advanced

Workshop “to equip professionals with the information, skills, and resources necessary to correctly implement the ESDM within their organization.”

• Submit training materials (after the workshop is complete) to center for fidelity review and certification.

• Complete Parent Coaching workshop at the MIND

http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/certification.html