Parent perceptions of a group telepractice communication intervention for autism

Background & Aims Estimates suggest that one in 59 children receive a diagnosis of autism and that early intervention can be effective if applied consistently and intensively. Parent implemented intervention can increase intervention consistency and intensity however, availability of providers, geographical factors, time constraints, and parental stress levels can all act as barriers to service access. Limitations in understanding elements that support family engagement can also impact participation in intervention. Telepractice can increase availability of intervention services and decrease the time and costs associated with face-to-face delivery. Research focused on children with autism has shown that telepractice is acceptable to parents. Despite positive findings for telepractice services with individual clients, limited research has been conducted on telepractice services for parent groups; parent perceptions and preferences regarding intervention; and service delivery methods. This research aimed to investigate parent perceptions of a group intervention programme for autism; the telepractice approach; parent and child outcomes; and parental stress. The purpose of the investigation was to build an understanding of parent's intervention preferences to inform future service offerings, increase choice, and support participation. Methods Eleven parents of preschool children with autism participated in a telepractice delivered group training programme called Hanen More Than Words (HMTW). The intervention is traditionally delivered face to face and teaches strategies to facilitate social-communication development in young children. Quantitative and qualitative measures were used to evaluate parent perceptions of the telepractice HMTW intervention. Data were collected via the Parenting Stress Index, HMTW programme evaluation forms, and online parent survey. Quantitative data was analysed using descriptive statistics. Pre- and post-intervention comparisons of parenting stress were conducted using paired T-Tests. Open comment field responses were analysed qualitatively using a directed content analysis. Results Parents reported high levels of satisfaction with telepractice delivered HMTW across intervention and post programme evaluations. Interactive learning opportunities, group participation, video coaching, individualisation of service, and programme facilitation were identified as key supports to learning. Parents perceived increased insight into the interaction, learning, and behaviour of themselves and their children. They reported positive changes in strategy implementation and confidence. Parents also perceived improvements in their children's communication, responsiveness, interaction, and play following intervention. Parental stress measurements from pre- to post intervention, were not significantly different. Conclusions Telepractice may reduce service barriers and improve access, particularly with the efficiency of a group delivery approach. Utilising technology to deliver group intervention was acceptable to parents and perceived to have positive outcomes for both parent and child. Further investigation into parent perceptions of intervention types and delivery approaches, could facilitate a broader understanding of family needs with respect to service access and engagement. Implications Expansion of telepractice offerings can increase efficiencies and service choice for families and providers. Limitations in service availability and barriers to service access and engagement, confirm the importance of pursuing ongoing service improvements and evaluating the preferences of service users. Development of standardised tools to measure and compare parent perceptions across intervention types and service delivery approaches would be beneficial.

Solitary symbolic play, object substitution and peer role play skills at age 3 predict different aspects of age 7 structural language abilities in a matched sample of autistic and non-autistic children

Backgrounds and aims Early symbolic play abilities are closely related to long-term language development for both autistic and non-autistic children, but few studies have explored these relations for different dimensions of pretence and of language. The current study explores carer-reported measures of solitary symbolic play, object substitution and peer role play abilities at age 3, and their respective relations with parent-reported semantics, syntax and narrative abilities at age 7 for both autistic and non-autistic children. Methods We conducted secondary data analyses exploring links between different aspects of pretence and of language on the Longitudinal Study of Australian Children population cohort. We identified 92 autistic children and used propensity score matching to match them with 92 non-autistic children based on demographic and developmental information such as non-verbal IQ and socioeconomic status. We explored concurrent and longitudinal relations using correlation and regression models. Results: Both correlational and hierarchical regression analyses confirmed the significant effects of age 3 symbolic play abilities in facilitating age 7 semantics, syntax and narrative abilities for autistic children. We found that object substitution held most prominent influence, followed by peer role play and solitary symbolic play. In contrast, for non-autistic children, none of the age 3 symbolic play abilities were significant predictors, whereas socioeconomic status at birth and age 3 language abilities held significant influences on their age 7 semantics, syntax and narrative abilities. Conclusion: We discuss the implications of our findings for play interventions targeting language outcomes.

Coconuts and curtain cakes: The production of wh-questions in ASD

Background and aims Children with autism spectrum disorders (ASD) have been found to exhibit difficulties in wh-question production. It is unclear whether these difficulties are pragmatic or syntactic in nature. The current study used a question elicitation task to assess the production of subject and object wh-questions of children with ASD in two different languages (Hebrew and French) wherein the syntactic structure of wh-questions is different, a fact that may contribute to better understanding of the underlying deficits affecting wh-question production. Crucially, beyond the general correct/error rate we also performed an in-depth analysis of error types, comparing syntactic to pragmatic errors and comparing the distribution of errors in the ASD group to that of children with typical development (TD) and children with Developmental Language Disorder (DLD). Results Correct production rates were found to be similar for the ASD and DLD groups, but error analysis revealed important differences between the ASD groups in the two languages and the DLD group. The Hebrew- and French ASD groups were found to produce pragmatic errors, which were not found in children with DLD. The pragmatic errors were similar in the two ASD groups. Syntactic errors were affected by the structure of each language. Conclusions Our results have shown that although the two ASD groups come from different countries and speak different languages, the correct production rates and more importantly, the error types were very similar in the two ASD groups, and very different compared to TD children and children with DLD. Implications: Our results highlight the importance of creating research tasks that test different linguistic functions independently and strengthen the need for conducting fine-grained error analysis to differentiate between groups and gain insights into the deficits underlying each of them.

A home-based longitudinal study of vocalization behaviors across infants at low and elevated risk of autism

Background and Aims: The purpose of this exploratory study was to expand existing literature on prelinguistic vocalizations by reporting results of the first home-based longitudinal study examining a wide variety of behaviors and characteristics, including early vocalizations, across infants at low and elevated risk of autism spectrum disorder (ASD). The study of vocalizations and vocalization changes across early developmental periods shows promise in reflecting early clinically significant differences across infants at low and elevated risk of ASD. Observations of early vocalizations and their differences during infancy could provide a reliable and essential component of an early developmental profile that would lower the average diagnostic age for ASD. However, studies employing observation of vocalization behaviors have been limited and often conducted in laboratory settings, reducing the external generalization of the findings. Methods: The present study was conducted to determine the consistency of previous findings with longitudinal data collected in home environments. Infants in the present study represented elevated risk from two etiological backgrounds, (a) infants born prematurely and with low birth weight and (b) infants who had an older sibling diagnosed with ASD. All data were collected in the infants’ homes and compared with data collected from infants with low likelihood of ASD. The study included 44 participants (31 in the low-risk sample, 13 in the high-risk sample) with vocalization behaviors observed at 6- and 12-months through 20-min semi-structured play interactions with caregivers. Observations were video-recorded and later coded for speech and non-speech vocalizations. Results: Differences in the 6-month vocalization behaviors were not statistically significant across risk levels of ASD. By 12 months; however, risk group differences were evident in the total number of vocalizations overall with specific differences across groups representing moderate to large, clinically relevant effects. Infants at low risk of ASD demonstrated significantly greater developmental change between 6- and 12-months than did the infants at high risk. Data were also reviewed for differences across high-risk group etiologies. Conclusions: The present study was unique and innovative in a number of ways as the first home-based longitudinal study examining infant vocal behaviors across low and high risk of ASD. Many of the present study findings were consistent with previous cross-sectional investigations of infants at elevated risk for ASD, indicating support for further home-based longitudinal study in this area. Findings also indicated some preliminary subgroup differences between high-risk etiologies of ASD. Vocalization differences across high risk groups had not been previously addressed in the literature. Implications: Vocalization differences are notable by 12-months of age between infants at low and elevated risk of ASD and infants at high risk demonstrated reduced developmental changes between 6- and 12-months compared to the infants at low risk. Observation of early infant vocalization behaviors may reasonably occur in the home, providing early childhood professionals and researchers with empirical support for data collection of child-caregiver interactions in this setting. Potential differences across high-risk etiologies warrant further investigation.

Cognitive and linguistic effects of narrative-based language intervention in children with Developmental Language Disorder

Background and aims Narrative-based language intervention provides a naturalistic context for targeting overall story structure and specific syntactic goals in children with Developmental Language Disorder (DLD). Given the cognitive demands of narratives, narrative-based language intervention also has the potential to positively impact related abilities such as working memory and academic skills. Methods Ten children (8–11 years old) with DLD completed 15 sessions of narrative-based language intervention. Results Results of single subject data revealed gains in language for five participants, four of whom improved on a probe tapping working memory. An additional four participants improved on a working memory probe only. On standardized measures, clinically significant gains were noted for one additional participant on a language measure and one additional participant on a visuospatial working memory. Carry over to reading was noted for three participants and to math for one participant. Across measures, gains in both verbal and visuospatial working memory were common. A responder analysis revealed that improvement in language may be associated with higher verbal short-term memory and receptive language at baseline. Those with working memory impairments were among those showing the fewest improvements across measures. Conclusions Narrative-based language intervention impacted verbal skills in different ways across individual children with DLD. Implications: Further research is needed to gain an understanding of who benefits most from narrative-based language intervention.

Speaking like a scientist: A multiple case study on sketch and speak intervention to improve expository discourse

Purpose This descriptive multiple case study examined the effects of a contextualized expository strategy intervention on supported and independent note-taking, verbal rehearsal, and reporting skills for three elementary students with language disorders. Method Two 9-year-old fourth grade students and one 11-year-old sixth grade student with language disorders participated. The intervention was delivered as sixteen individual 20-minute sessions across nine weeks by the school speech-language pathologist. Students learned to take written and pictographic notes from expository texts and use verbal formulation and rehearsal of individual sentences and whole reports in varied learning contexts. To explore both emergent and independent accomplishments, performance was examined in final intervention session presentations and pre/post intervention testing. Results Following the intervention, all three students effectively used notes and verbal rehearsal to prepare and present fluent, organized, accurate, confident oral reports to an audience. From pre- to post-test, the students showed a range of improvements in the quality of notes, use of verbal rehearsal, holistic quality of oral and written reporting, and strategy awareness. Conclusions Sketch and Speak shows potential as an expository intervention for students who struggle with academic language learning. The results support further examination of this intervention for supported strategy use by younger students and independent use by older students.

Play-based interventions to support social and communication development in autistic children aged 2–8 years: A scoping review

Background and aims Play is used by practitioners from across disciplinary backgrounds as a natural and enjoyable context for providing intervention and support in early childhood. In the case of autism interventions, many therapies are based on the association between social play and the development of social skills, language development, and communication skills, as these are often particular areas of challenge for autistic children. However, play is a wide-ranging concept and the extant literature on play-based interventions is large and heterogeneous. This means it is challenging for practitioners and families to navigate the evidence base and make choices about differing intervention strategies. This review aims to provide a comprehensive map of the research on this topic and to develop a conceptual framework to inform clinical decision-making. Methods An initial stakeholder consultation confirmed the relevance of the topic to practitioners and autistic people. A scoping review methodology (preregistered) was used to identify relevant literature. We systematically searched seven databases to find peer-reviewed primary intervention studies of play-based approaches targeting language, social and communication outcomes for autistic children aged 2-8 years. We then summarised the literature using narrative synthesis and Evidence Gap Maps (EGMs). The literature was summarised according to a range of characteristics, including study design, population characteristics, agent of intervention and outcomes measured, among others. These summaries were then used to develop a framework for some key considerations for practitioners appraising play-based approaches. Results 388 studies met inclusion criteria. Approximately 21% of studies were RCTs, and over 50% had ≤10 participants. Over 45% of studies reported multiple relevant outcomes, with social play skills being the most common single intervention target. Girls and minority background groups are under-represented. A range of intervention types were identified, and some high-level categorisations are proposed. Main contribution: On the basis of the evidence synthesis we suggest important dimensions for appraisal of play-based interventions, including the role of play within an intervention (as a context, a key developmental mechanism, or a component of a larger approach), the underpinning philosophy (e.g. behaviourist or developmental), and the role of the practitioner (providing parent feedback, 1:1 intervention, group facilitation). Conclusions The wide range of approaches uncovered by this review is a testament to the wonderful diversity inherent to both play and autism. However, research could usefully focus on consolidating the evidence base for existing approaches, rather than aiming for further diversification. Implications: The conceptual framework proposed in this review can help practitioners appraise the literature and aid their advice to families when making shared intervention decisions.

The complexity of early diagnostic decision making: A follow-up study of young children with language difficulties

Background & aims Due to the complexity of early diagnostic decision making, we examined the predictive value of an early diagnostic classification and early abilities on later best estimate diagnosis for 22 clinically referred children with language difficulties. Methods and procedures Four years after initial evaluation (Time 1), the clinical files of these children were reviewed. A best-estimate (BE) diagnosis of language disorder (LD), intellectual disability (ID), or autism spectrum disorder (ASD) was established, with ASD being most common. Outcomes and results Early clinical classifications were relatively unstable or difficult to establish at a young age. The magnitude of children’s cognitive and receptive language delay was a significant predictor of a later BE diagnosis of ID and LD respectively. A BE diagnosis of ASD, by contrast, could not be predicted from children’s early social communication problems nor the presence of restricted and repetitive behaviors and interests. Conclusions Taken together, the results of this study suggest that language difficulties can be an early marker of a neurodevelopmental disorder which is often not identified at the age of first referral. Implications Eligibility for treatment should, therefore, be based on biopsychosocial case formulation rather than DSM or ICD diagnostic classification. What this paper adds? In this study a dimensional approach was used to characterize the abilities of young children referred with mild to profound receptive and/or expressive language difficulties. Later on, a categorical approach was adopted to establish best estimate diagnoses. Our clinical, broadly defined sample reflects the heterogeneous intake of young children referred for diagnostic assessment. Other studies on diagnostic stability often only focus on one diagnostic category (and are explicitly excluding children with specific other diagnoses), not taking into account the difficulties of early differential diagnostic decision making and stability across different categories over time. Investigations of differential diagnosis within a clinical group, instead of only differentiating children with a specific diagnosis from typically developing children, may be more informative for clinicians.

Sleep problem screening of young children by speech-language pathologists: A mixed-methods feasibility study

Background & Aims Poor sleep in young children imperils language learning and use. Both sleep and language problems are prevalent in early childhood. Speech-language pathologists are in a unique position to expand surveillance of sleep problems, which in turn may contribute to communication difficulties. We conducted a feasibility study of speech-language pathologist screening for behavioral sleep problems and sleep-disordered breathing symptoms at a multidisciplinary evaluation and treatment center. Methods Speech-language pathologists administered screeners to parents of 2–6-year-olds: the Short Form-Children's Sleep Habits Questionnaire (for behavioral sleep problems) which includes an item asking if the child has a sleep problem (yes/no), and the pediatric sleep questionnaire (for sleep-disordered breathing). Speech-language pathologists participated in pre- and post-screening focus groups. Pre-screening topics included professional preparation and clinical experience regarding pediatric sleep issues. Post-screening, speech-language pathologists provided feedback about the screening experience and feasibility of incorporating such screening into practice. Results Among 51 children, 31% (16/51) screened positive for sleep-disordered breathing, 78% for behavioral sleep problems (40/51), and 43% (12/28) per parent report. Parent-reported problems were associated with sleep-disordered breathing ( p = 0.00) but not behavioral sleep problems ( p = 0.24). During focus groups, speech-language pathologists reported no formal pediatric sleep training, high parent concern about sleep, and agreed that screening fit their professional mandate. Speech-language pathologists affirmed that the ≤15 min screenings integrated seamlessly into practice but that additional training, particularly for sleep-disordered breathing, was needed. Conclusions The prevalence of sleep problems in 2–6-year-olds presenting to speech-language pathologists was higher than in community samples, but consistent with data from young children with developmental disabilities. Speech-language pathologists endorsed the utility and feasibility of sleep problem screening and education in their clinical practice. Implications Integrating sleep problem screening and education into speech-language pathologist practice is feasible and could widen surveillance of both sleep problems and risk factors for developmental language disorders. Further research should include larger samples and other settings, e.g. home or school.