Can training parents in play improve communication skills in children with ASD? Can parents become the interventionists? Can parents successfully implement techniques that positively affect communication skills in their children with ASD? These are questions that have been asked for decades. Dr. Stanley Greenspan, developer of the DIR/Floortime Model of therapy intervention, not only believed this was possible but went so far as to create a therapy model whose integral part was parental training, education, and intervention.
Over the years researchers and therapists have been asking themselves if this approach to intervention works. Dr. Richard Solomon and colleagues attempt to answer that question in their research study titled Pilot study of a parent training program for young children with autism (2007). Yes this is an older article and I will be looking for more recent studies but I found this article interesting and wanted to share it with you today.
Citation: Solomon, R., J. Necheles, C. Ferch, and D. Bruckman. “Pilot study of a parent training program for young children with autism: The P.L.A.Y. Project Home Consultation program.” Autism, 2007, Vol 11 ( 3) 205-224.
Purpose: Purpose of this study was to determine if parent training and education using the PLAY Project Home Consultation program resulted in positive improvements in children with ASD.
Participants: There were originally 74 participants selected for this study however, only 68 children completed the 8-12 month program due to parental choice. Participants were between 2-6 years of age with the average age being 3.7 years. Participants had to obtain an outside diagnosis of ASD (mild (18 participants), moderate (22 participants), severe (10 participants)), PDD-NOS (14 participants) or Aspergers Syndrome (3 participants). The sample was representative of the total population at the time with 70% of participants being male. At least 70% of mothers and fathers has a bachelor’s degree or above and most families had one caregiver who did not work outside the home. Only 3 children in this study were African-American, and there were no children who were Latino/Hispanic. One child was also dx’d with Down Syndrome and two children dx’d with seizure disorders in addition to ASD. Twelve children under age 3 participated in an early intervention program for 2 hours a week, and the remaining 56 children older than 3 were enrolled in special education PK programs for 4-5 hours a week. No intensive therapies (25 hours or more) or interventions were received by any participants. All participants were from southeast Michigan.
Methods: Methodological process in this study: Assessment/Evalution, PLAY Project Home Consultation, Clinical Ratings, Client satisfaction survey, Results/Statistical Analysis
Assessment/Pre-Post: All participants had an outside dx of ASD, PDD-NOS, or Aspergers. They participated in a pre/post design evaluation at the start and end of the first year of the PLAY project’s home consultation program. Evaluations were completed using the FEAS (Functional Emotional Assessment Scale) ratings for both the participant and the parents to determine if behavior by either changed or improved over time. The higher the score on this test the more functional the child’s behavior and higher the child’s developmental level. Scores on this test were used on the primary measures of progress for participants. Inter-rater reliability was determined by comparing data from videotapes of 20 randomly selected subjects (no training tapes were used for this measure), and reported a paired t-tests.
PLAY project home consultation: Three trained home consultants (HCs) (one MSW, two recreational therapists, all with degrees in child development fields), received structured, supervised, and intensive training on DIR theory and PLAY project model for 1 month prior to beginning work with families. Half-day (3-4 hrs) home consultations were then made monthly within family homes where parents were taught how to provide, intensive, 1:1, play-based services to their children with ASD with the use of modeling, coaching and video assessment from HCs. First parents were taught the principles of play-based intervention and how to apply them for their individual child. Then they learned how to assess their child’s “unique profile” using the principles. A list of activities were created to engage the child. Parents were then taught methods of observing a child’s cues, following their lead, and “reading interactions in order to increase reciprocal interaction”. Finally, video assessments were used to provide immediate feedback to parents. Home consultants also participated in regular supervision visits with program’s medical director. During every session HCs also rated the child’s progress.
Clinical Ratings: HCs rated participants subjectively using a six-point scale, with .5 increments, related to Dr. Greenspan’s six functional developmental levels. These rates were used to track participants’ progress during HC visits.
Client Satisfaction Survey: Parents were given a satisfaction survey at 3 months and 1 year addressing their satisfaction level with the PLAY project’s HC program.
FEAS: FEAS scores for parents did not change over time, suggesting parents did not improve or change their behavior when implementing floortime techniques and strategies. However the FEAS scores for 45.5% of participants exhibited “good to very good” progress (e.g. improved by at least one FDL (functional emotional developmental level) which in some instances was equal to or more than 6 months to 1 years worth of growth). Also there was no statistical significance between progress and initial severity of ASD.
Intensity: Data suggested an association between number of hours a week of intervention (less than 15 hrs) and lower outcome scores however not statistically significant.
Reliability: High inter-rater reliability (p < .05, two-tailed t-test) was observed when measuring both the parent and child’s behavior on FEAS at pre- and post-intervention.
Clinical Ratings: Clinical ratings of HC were consistently higher than the FEAS scores suggesting 66% of participants made good or very good progress. Ratings demonstrated very good progress ( increase in 1.5+ FDLs) in 52% of children and good progress (improvement in 1 FDL) in 14% of students. Again, no statistical significance was observed between severity of initial level of ASD and clinical scores.
Satisfaction Survey: parental satisfaction was exactly the same at 3 and 12 months post beginning of HC program; 70% of those who completed the survey were very satified by the PLAY project, 10% were satisfied and 20% were somewhat satisfied.
Limitations: There are a number of limitations I feel that are important to address regarding this study. I want to add that the authors of this study were very clear and shared all of these limitations in this study as well.
1. Lack of control group: the participants themselves were used as the control in this study by comparing a pre- and post-intervention assessment. However, without a control group, authors cannot control for extranneous variables and cannot definitively say the PLAY project HC created the positive improvements in children.
2. Well educated parents and lack of diversity: Most of the parents in this study were well-educated with one stay-at-home parent. There is no control to determine if this particular method will work for other populations.
3. Simultaneous enrollment in other programs: Participants were already enrolled in 2-5 hours of intervention either via early intervention or PK programs prior to the beginning of this study. Therefore, it is difficult to determine what effect, if any, these programs had on participant progress. In addition, there was no information presented from other programs regarding participants behavior.
4. Intensity not well recorded: Levels of intensity of this program were not well tracked by parents on daily logs. Many times parents estimated the time in which they spent providing intervention and likely over-estimated that total time. In addition, authors also agree that parental stress should be added into analysis to determine if this role is effective.
Thoughts and Implications for Future Research: As this study was completed in 2007 and was a pilot study, it was the first step in determining if parental training/intervention could be an effective means of treated young children with ASD. It does appear from these results there is a positive effect with parental training and intervention for children with ASD. However teh extent to which this particular program or parent education in general affects changes in communication has yet to be fully determined. With that said there is a need for additional studies in this area to determine repetition and validity of the PLAY project (I do believe there has been a randomized-control study on the PLAY project that has been completed and will blog about it once I find it in publication). In addition, studies that compare various treatment programs/techniques/models with a control group would be a great way to determine effectiveness among various techniques. Also studies which measure improvements on other objective measures such as language tests, IQ tests, other developmentally appropriate measures, etc. would be able to demonstrate if improvements on FEAS also translates to improvements in other tested areas.