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Rebecca Landa, Ph.D., CCC-SLP Center for Autism and Related Disorders Kennedy Krieger Institute (c) Rebecca Landa, Ph.D., CCC-SLP Slide 2 Agenda Part I:Big Picture EI Part II:Family-Centered Approach Part III:Classroom-Based EI (c) Rebecca Landa, Ph.D., CCC-SLP Slide 3 Part I: Big Picture - EI (c) Rebecca Landa, Ph.D., CCC-SLP Slide 4 Goal of EI Improve outcomes Maximize quality of life _______________ (c) Rebecca Landa, Ph.D., CCC-SLP Slide 5 Accomplished through good intervention Intervention is intentional creation of experiences that maximize learning Life is the practice field for learning (c) Rebecca Landa, Ph.D., CCC-SLP Slide 6 Introduction to Parts II and III Early Achievements Model Rebecca Landa, Ph.D., CCC-SLP Slide 7 Children with ASD need to build the infrastructure to do what you just did so effortlessly (c) Rebecca Landa, Ph.D., CCC-SLP Slide 8 Early Achievements What it is What it spawned Achievements for Little Learners Parent Mediated manualized approach IES grant (3-5 year olds in public schools) (Rebecca Landa, Ph.D., CCC-SLP Slide 9 What are your treatment priorities? Rebecca Landa, Ph.D., CCC-SLP Slide 10 Your objective 1. Improve child functioning and hence, improve outcomes 2. Ensure a developmental milieu that will cultivate change and sustain growth/maintenance of new skills Rebecca Landa, Ph.D., CCC-SLP Slide 11 The 4 Es: How they help Engagement with people: Reciprocity Event-based: Predict and contribute Maintaining meaningful, reciprocal engagement How to engage with others Imitation Joint attention Conversation Understanding and remembering sequences of actions and event components Forming representations and symbols Flexibility and generativity Reading comprehension Embodiment of experience: Motor planning and making sense Ecological validity (relevant to childs life experiences): Generalization Planning Motivation Initiation Multi-modal mapping Understanding others actions Difficulty with implicit learning Play Using learned forms (gestures, words) meaningfully Extracting relevant information (c) Rebecca Landa, Ph.D., CCC-SLP Slide 12 The world consists of representations: Of events Of objects Of people Rebecca Landa, Ph.D., CCC-SLP Slide 13 We have to be purposeful in Selection of treatment targets (curriculum and goal sequence) Selection of intervention materials Intervention strategies Planning ecologically valid experiences Helping parents learn to implement at home Selecting intervention contexts Rebecca Landa, Ph.D., CCC-SLP Slide 14 Families: Parent Mediated Rebecca Landa, Ph.D., CCC-SLP Slide 15 Myths What you want for the child is what the parent wants What you understand about the childs level of functioning is how the parent sees the childs developmental level (repetitive actions video) How you read the childs intended messages is how the parent reads them You utilize the tools of our trade and child will change Rebecca Landa, Ph.D., CCC-SLP Slide 16 Many factors contribute to change Child factors (temperament, cognition, social cognition, preferences, motor, language, past experiences, biology, regression or fluctuating plateau/regression?) Parent factors (expectations for child, expectations for self, how they were raised, time, stress, mental health, resources, etc) Cultural factors (macro, micro) ____________________ Rebecca Landa, Ph.D., CCC-SLP Slide 17 To achieve developmental gains Alter early experiences through Strategically designed early intervention Therapist-mediated (+peers) Parent-mediated (+parent education) Intervention is nourishment to the brain (embodied cognition) Rebecca Landa, Ph.D., CCC-SLP Slide 18 Part II: Family-Centered Approach Rebecca Landa, Ph.D., CCC-SLP Slide 19 When the expected doesnt happen in childs development Parents experience: Fear Lack of confidence Drawing at straws Strain in the family: disagreement about what to do Friends and family dont understand Feelings of isolation Fragility in connection with child Rebecca Landa, Ph.D., CCC-SLP Slide 20 Change Child Context Parents Rebecca Landa, Ph.D., CCC-SLP Slide 21 Change: Rebecca Landa, Ph.D., CCC-SLP Slide 22 Culture Each family is a culture Beliefs about the child Beliefs about autism (India) Spousal/partner/family roles Expectations for outcomes, child behavior, self, school Discipline Etc. Rebecca Landa, Ph.D., CCC-SLP Slide 23 Basics for getting started In delivery of parent-mediated intervention Rebecca Landa, Ph.D., CCC-SLP Slide 24 Helping parents feel acknowledged and understood Be a good teacher AND listener. Be ready to lay your paradigms aside. Cross cultural competency. What is the currency (eg do chores vs play) to get buy-in? (chores vs play; role of other family members) Cant arrive in the familys home with your goals. Process to jointly establish goals for child. Where do they see their child and what are their expectations? Their expectations may exceed what would be expected for TD kids. Observe the child AND parent (style, priorities, challenges, signatures). Permission to take time for themselves. Change is executed within the system. Not trying to change the system. Shape what needs shaping. Co-problem solving (enlist parents input). Want to feel validated. Acknowledge what they are doing right. Rebecca Landa, Ph.D., CCC-SLP Slide 25 Responsivity literature In DD, TD, ASD, parents can learn to engage in responsive interactions with their children (e.g., Backersmans- Kranenburg, van Ijzendoorn, & Juffer, 2003; McCollum & Hemmeter, 1997; Trivette, 2003) Responsivity: Parents respond to childrens verbal and nonverbal acts Recode these communicative acts Take a turn and wait Follow the childs lead Imitate the child Need relationship base, but also need to take steps to directly teach specific gestures, vocalizations, coordinated gaze, and communication (Fey et al., JSLHR, 2006) Rebecca Landa, Ph.D., CCC-SLP Slide 26 Adult learning What you teach parents must be directly relevant to their lives Need demonstrations and models of the skills being taught (Winton & McCollum, 1997) Need to teach to generalize As new knowledge is applied at home, parents will encounter challenges for which they must generate creative solutions Problem solving results in consolidation of recently gained knowledge (Kolb, 1984) Over time, parents begin to be able to problem solve in more and more complex situations Skills become automatized and flexible, with parents being able to utilize their knowledge in more and more challenging contexts to arrive at creative and effective solutions (Feldon, 2007) Rebecca Landa, Ph.D., CCC-SLP Slide 27 Mantra: Simplify, sensible, sensitive Rebecca Landa, Ph.D., CCC-SLP Slide 28 Embedded in Routines Social disengagement Imitate Motivate Sustain engagement Language learning Core vocabulary Model Communicative temptations Play Select toys Follow child lead Expand, persist Developmentally appropriate ChildAdult strategy Rebecca Landa, Ph.D., CCC-SLP Slide 29 Remember! The child has a language delay Possibly a cognitive delay The child has ASD Implications of ASD: Behavior Self regulation Resistance to change Perspective taking Social understanding and initiative etc Rebecca Landa, Ph.D., CCC-SLP Slide 30 Steps: 1. Know the child a. developmental levels (established, emerging, undeveloped abilities/skills/behaviors) b. preferences (activities, reinforcers) c. temperament and triggers 2. Know the parents perspectives and priorities, concerns, perceived barriers 3. Define child goals & parental goals/roles 4. Define activities & materials 5. Define schedule 6. Define data keeping system 7. Select a curriculum Rebecca Landa, Ph.D., CCC-SLP Slide 31 Goals Child Parent Communication Social & engagement Play Self-regulation Empowerment & paradigm shifting Scaffolding for positive behavior & self-regulation (predictability, consequences, defining what is okay & not okay) Environmental restructuring Strategies to foster child communication, social connection, play Rebecca Landa, Ph.D., CCC-SLP Slide 32 1. Insights into child Actions child does with the object Childs attempts to communicate What does child do when you play next to him or her and imitate? Toy 1 Toy 2 Toy 3 Toy 4 Rebecca Landa, Ph.D., CCC-SLP Slide 33 2. Build relationship with parents Affirming and validating the parents Decoding the childs behavior Helps them regulate childs behavior Helps them scaffold for increased child learning Understanding development Simplifying Relaxing and having fun during interaction Goals Realizing that their behavior affects child Developing insights into what they do, say, expect Parents have choices, these impact the child Realizing that they CAN optimize learning environment Toy and book selection Home arrangement Home schedule Parents reach consensus Rebecca Landa, Ph.D., CCC-SLP Slide 34 Getting metcognitive 3. Changing behavior, expectations Putting the strategies into the hands of the parents Let them experience, first hand, with the protection of your guidance and scaffolding, the bi-directional influences of parent-child interaction Imitate your child Getting routines established What to say and when Pitching it at the right level Rebecca Landa, Ph.D., CCC-SLP Slide 35 Predictability: Routines Rebecca Landa, Ph.D., CCC-SLP Slide 36 Types of Routines Social Song- gesture/action Toy -based Book sharing Daily life Rebecca Landa, Ph.D., CCC-SLP Slide 37 Classroom-based model (c) Rebecca Landa, Ph.D., CCC-SLP Slide 38 2-year-olds STAART (NIMH) HRSA Autism Speaks (c) Rebecca Landa, Ph.D., CCC-SLP Slide 39 STAART: RCT (c) Rebecca Landa, Ph.D., CCC-SLP Multi-modal Classroom + Interpersonal synchrony curriculum AEPS curriculum 2.5 hours/day; 4 days/week 6 months Parent education class twice per month Group and 1:1 work Theme-infused Interpersonal synchrony curriculum: imitation, affect sharing, joint attention Slide 40 Classroom segments Circle: Teacher leads Play: Child leads (extend from Circle) 1:1 (DTT priming new skills; automaticity of emerging skills; TEACCH-type activities) Art Snack Sensory-motor and motor circuit Outside End of session Music and Parting activities (c) Rebecca Landa, Ph.D., CCC-SLP Slide 41 STAART RCT: Participants 24 in IS condition, 25 in Non-IS condition Domain Non IS mean (sd) IS mean (sd) Age28 (2.7)27 (2.9) Visual Reception 31 (11.6)27 (8.8) Receptive Language 22 (7.2)24 (9.7) Expressive Language 24 (7.0)23 (6.1) (c) Rebecca Landa, Ph.D., CCC-SLP Slide 42 Active ingredients Curriculum and strategic selection of learner goals (dont try to teach an unreasonable amount) Instructional strategies Instructional activities guided by: The 4 Es Strategically engineered environmental components Rebecca Landa, Ph.D., CCC-SLP Slide 43 Major content areas Comprehensive curriculum (can use any- just use one!) Cognition Language and communication Social Play Motor Rebecca Landa, Ph.D., CCC-SLP Slide 44 Thinking (Cognitive) What can I do with this object? How can I make it go? How can I make it work? Does it still exist when I cant see it? What is the same/different about these things? (categories) What other things can I play with when I play with this toy? (ball, bucket; cup, spoon) What causes what to happen? What happens first, second, .? Rebecca Landa, Ph.D., CCC-SLP Slide 45 Language How are objects the same? And What group of objects go together? They are called the same thing (such as ball). What can I say about this? How do I communicate about it? Gestures Words Phrases Icons Facial expression Rebecca Landa, Ph.D., CCC-SLP Slide 46 Social What can we do together? Imitate Take turns Show and share Comment Laugh and be silly Rebecca Landa, Ph.D., CCC-SLP Slide 47 The Ingredients Rebecca Landa, Ph.D., CCC-SLP Slide 48 Your checklist Curriculum Does my intervention target goals that are Easy (at the childs level- maintenance and generalization) Harder but within reach Relevant to the childs life Building the skills needed in order to learn the next set of skills the child needs to develop Rebecca Landa, Ph.D., CCC-SLP Slide 49 Your checklist Instructional strategies Face to face Clear and appropriate cues Clear enough that s/he knows what I want him/her to do? Am I cueing something that is developmentally appropriate (refer to curriculum)? Imitate and expand Motivating activities Am I incorporating childs interests? Sufficient predictability? (Routines?) Prompting Am I scaffolding and prompting, as needed, to promote success? Strategic use of modeling Reinforcing Are the reinforcers relevant to the behavior? Did I deliver the reinforcement quickly enough for the child to know s/he was being reinforced? Rebecca Landa, Ph.D., CCC-SLP Slide 50 Your checklist Instructional activities Motivating? Theme-related? Tools related to skills you are trying to teach? Duplicates Location Steps to completion Developmentally appropriate Extenders Books Rebecca Landa, Ph.D., CCC-SLP Slide 51 Putting it into action: 4 Es Embodiment: Opportunities for child to experience the skill with his/her own body? Ecologically valid: Does the activity relate to anything the child will experience in real life? Event-based: Am I scaffolding a set of events that enable the child to learn how things happen in his/her life? Engagement: Are there opportunities for using the skill in interaction with adults and peers? Rebecca Landa, Ph.D., CCC-SLP Slide 52 Seeing the ingredients in action Play Circle Snack Rebecca Landa, Ph.D., CCC-SLP Slide 53 Concluding remarks Early intervention a must Context: need options (center-based, home-based; parent mediated) Parent-child interactions can be shaped changing perspectives and behaviors and dynamics Must be strategic in use of strategies and principles to effect change Need to play for sustainability of change Strategies will change with child change More to be done support systems, peers, community engagement (c) Rebecca Landa, Ph.D., CCC-SLP Slide 54 Questions? (c) Rebecca Landa, Ph.D., CCC-SLP