Even excellent developmental behavioral interventions are limited in their ability to help toddlers with autism spectrum disorder (ASD) communicate in everyday situations, as they are limited to a set number of hours each week. Coaching parents to use language-supportive activities in naturalistic settings can supplement formal interventions and fill some of the gap, research suggests.
A multidisciplinary group of speech-language pathologists and other service providers, parents, funding agency representatives, and researchers in San Diego, California, adapted a parent coaching naturalistic developmental behavioral intervention for toddlers to be implemented across the community. This BRIDGE Collaborative (Bond, Regulate, Interact, Develop, Guide, Engage) aims to support providers in building effective relationships with parents to promote their child’s development. Such relationships can increase use of parent-implemented interventions for toddlers with ASD.
“It’s really helping parents to use strategies rather than the interventionist working directly with the child because an interventionist only gets to see a child 1 or maybe 15 hours a week in intensive programs,” lead author Sarah R. Rieth, PhD, BCBA-D, from the Child and Adolescent Services Research Center and San Diego State University in California, told Psychiatry Advisor. “It’s being intentional about opportunities to communicate and target whatever challenges the child might be facing,” she said.
This type of strategy is called a naturalistic developmental behavioral intervention (NDBI).
“A[n] NDBI takes natural social settings as a jumping off point for teaching children social skills,” Victoria Chen, MD, a developmental-behavioral pediatrician at Cohen’s Children Medical Center in New Hyde Park, New York, told Psychiatry Advisor. Dr Chen was not involved with this program. “For example, asking a child to get his ‘shoes,’ and then telling him to show his ‘white shoes’ to his sister may be a natural way to build vocabulary,” Dr Chen said.
Gaining skills in these natural settings is more generalizable to other situations than showing the child a picture of a shoe and providing reinforcement when the child says “shoe,” Dr Chen explained.
Parent-Implemented Naturalistic Inventions Benefit Children
Research on early intervention outcomes has shown that best practices involve emphasizing caregiver involvement in the intervention a child with ASD receives, Dr Rieth and associates wrote in the April issue of Seminars in Speech and Language. NDBIs enhance the child’s learning by increasing the quantity of time the child is exposed to the intervention as well as the quality of that time, as it is part of the meaningful relationship between the child and another caregiver.
“This approach can promote children’s successful use of skills across environments and over time when they are given repeated opportunities to practice new skills in the variety of contexts they encounter with their parents,” the authors wrote. “In addition to the positive impacts of parent-implemented intervention on children, research consistently demonstrates positive impacts of parent-implemented intervention on parents, including reduced parental stress, improved parent responsiveness, and enhanced parent competency in promoting child learning, among other benefits,” they added.
According to Dr Chen, it is well established that children younger than 3 years will not progress well if they do not have their family’s external support. The current standard of care, she noted, is Applied Behavioral Analysis, a high-intensity behavioral intervention, but one of its flaws makes it less generalizable to everyday situations.
“It may seem rigid or robotic because it depends on prompts and repetition, which does not happen in the ‘real world,’ ” Dr Chen said. “This is in contrast to using relational elements of interaction in natural play sessions to help children develop social skills as described in this article.”
The success of this approach relies on forming an effective relationship with mutual trust between the practitioner and the child’s caregivers.
“This work is exciting because of its potential to make quality therapeutic services for autism spectrum disorder more accessible in the community,” Dr Chen told Psychiatry Advisor. “However, this study acknowledges the unique challenges parents of children with ASD face in being engaged with therapy, especially if their children have been very detached or difficult,” she said.
Challenges of Parent Coaching
Dr Rieth said one challenge in implementing NDBI strategies is lack of training among intervention specialists for working with parents. Parents themselves may also not realize how their involvement can help their child, so parents frequently get overlooked during children’s interventions.
“Some of it is just the parents feeling overwhelmed already,” Dr Rieth told Psychiatry Advisor. “There are some parents that are motivated and walk in the door and want to learn everything, and then there are some parents who are going through complex grief, maybe having their own mental health challenges, and are not in a place where they can learn yet.”
Even when parents are ready and eager to learn, however, it is up to the practitioner to help them learn how to be active participants in their child’s treatment, she added. Many interventionists tend to be entry-level or early-career practitioners who may not have full confidence in their own skills yet, she said.
“Learning how to do the intervention with the child is one thing, and they may still feel like they’re developing that skill, but then being able to coach adults to learn those same strategies is a whole other thing,” Dr Rieth told Psychiatry Advisor.
Interventionists may not have training in practice-based coaching, which comes more from the field of education, Dr Rieth said. But with support, they can learn to provide parents with didactic instruction, then model the intervention strategy for the parent, then watch the parent practice it, and finally provide the parent with feedback.
“Thinking about parent engagement strategies and how to help parents want to be involved in the session is also going to be very valuable,” Dr Rieth said. She said her group is working on developing online modules that may be able to help with this supplemental training.
Implementation in Clinical Practice
The specific program evaluated in this paper was called Project ImPACT (Improving Parents as Communication Teachers) for Toddlers, which “blended use of key ingredients from both developmental and behavioral approaches in the context of a parent-mediated intervention,” the authors wrote.
However, incorporating parent coaching into an intervention can be done with any program, Dr Rieth said. It is an additional strategy to be used with existing best practices. Most programs targeting language development or other skills in toddlers with ASD usually involve the same basic components.
“The meat and potatoes are not that different, and that’s a good thing, because it means we know what works,” Dr Rieth told Psychiatry Advisor. “The real difference here is thinking about helping the parent figure out how that strategy can work for them in their daily routines.”
For example, a staple of most effective programs is to follow the child’s lead in an activity that holds the child’s interest. Adding parent coaching would mean helping the parent learn to follow a child’s lead even when it seems odd or counterintuitive to the parent, she explained.
If the child is playing with a shape sorter toy, for example, a parent may be inclined to coax the child to put the shapes in their appropriate slots. But if the child is stacking the shapes or simply holding them and looking at them, that is the activity the parent should support, Dr Rieth said.
Parents are not expected to do everything an interventionist does, as they lack the knowledge and training and have other daily parenting priorities, but specialists can learn what a parent’s strengths are and then build on those.
“We know a lot about adult learning and behavior change and what helps people actually do things,” Dr Rieth told Psychiatry Advisor. “It’s marrying that body of knowledge with the child intervention body of knowledge.”
The program was funded by the Institute of Education Science and Autism Speaks.
Rieth S, Haine-Schlagel R, Burgeson M, Searcy K, Dickson KS, Stahmer AC. Integrating a parent-implemented blend of developmental and behavioral intervention strategies into speech-language treatment for toddlers at risk for autism spectrum disorder. Semin Speech Lang. 2018;39(2):114-124.