Enhanced Milieu Teaching in resource-constrained settings: Stakeholder-informed adaptation guidelines.

BACKGROUND:  Enhanced Milieu Teaching (EMT) is an evidence-based naturalistic developmental behavioural intervention (NDBI) for children with developmental disabilities. Little is known about the EMT's fit or what adaptations might be needed to improve its applicability within a resource-constrained setting. OBJECTIVES:  To explore stakeholders' perceptions of the contextual fit of EMT for young children with developmental disabilities in a resource-constrained context and to identify adaptations to improve EMT's contextual fit. METHOD:  We conducted a descriptive qualitative study using semi-structured interviews and focus groups. Participants included 5 speech and language therapists and 11 caregivers of children with developmental disabilities who speak English and Afrikaans or isiXhosa. Using thematic analysis, data were coded into 10 subthemes and grouped according to the Adaptome framework components. RESULTS:  Overall, stakeholders view EMT as an appropriate intervention in the South African context. They indicated that certain intervention components may need to be modified. Specifically, clinicians may need to adapt intervention materials and activities to be sensitive to families' available resources, preferred activity routines and priorities. From these data, we provide guidelines to improve the fit of EMT in South Africa. CONCLUSION:  Enhanced Milieu Teaching is an appropriate intervention in the South African context, although some adaptations can enhance its fit.Contribution: This article highlights the importance of engaging with stakeholders to determine the fit of NDBIs, like EMT, as they are implemented in new contexts. Based on these insights, stakeholder-informed adaptation guidelines are provided for improving the contextual fit of EMT in resource-constrained settings.

Guidance for Increasing Primary Study Inclusion and the Usability of Data in Meta-Analysis: A Reporting Tutorial.

Meta-analyses can be used to comprehensively summarize the state of a given literature base, understand development and relations between constructs, and synthesize intervention effects to identify "what works for whom," all of which can directly inform research, practice, and policy. In this tutorial, we first argue that data reporting in primary studies can meaningfully affect the results of meta-analyses and, most importantly, the subsequent interpretations and use of the findings in research, practice, and policy in speech, language, and hearing sciences. Though reporting guidelines have been well established for the results of meta-analyses, there is limited focus on the essentials for primary study reporting that allow for inclusion in meta-analyses. To this end, we provide guidance for primary study authors to ensure their studies can maximize their contributions to research syntheses and, specifically, to meta-analyses. We discuss current and ongoing issues related to reporting, provide data-based examples of instances where lack of reporting or transparency has rendered a study ineligible from inclusion in a meta-analysis, encourage editorial teams and peer reviewers to be flexible in the inclusion of supplemental data reporting based on journal requirements and limits, and suggest being explicit and earnest about why these requests are important to advancing the field. Supplemental Material: https://doi.org/10.23641/asha.23117996.

Training Culturally Diverse Caregivers to Decrease Their Child's Challenging Behaviors: A Systematic Review and Meta-analysis.

Parents are the primary source of support for their children and can become principal interventionists for preventing and treating their child's challenging behavior. Yet, providing adequate and adapted training for culturally diverse families can be difficult due to the increase of international migration and the diversity of languages spoken worldwide. This systematic review and meta-analysis evaluated 13 studies that implemented training for caregivers with limited proficiency in the majority language. Overall, the results suggested a moderate-small treatment effects on positive and negative parenting practices. The results also indicated moderate-small treatment effects on challenging behaviors exhibited by both individuals with developmental disabilities and typically developmental. Findings are discussed in terms of strategies used and recommendations for future research and practice.

Screening for Autism in 2-Year-Old Children: The Application of the Systematic Observation of Red Flags to the Screening Tool for Autism in Toddlers and Young Children.

PURPOSE: A multimeasure approach was developed to capitalize on the strengths of two screening measures: the Screening Tool for Autism in Toddlers and Young Children (STAT), an observational measure of social communication, and the Systematic Observation of Red Flags (SORF), a checklist including restricted and repetitive behavior (RRB) items. This approach offers a novel method of identifying autism in toddlers. METHOD: This was a retrospective study of data collected from a multidisciplinary diagnostic program for 24- to 36-month-olds with developmental delays. Raters with autism expertise but naïve to diagnoses applied the SORF to STAT videos. Psychometrics were derived for the SORF on STAT observations and a multiple-measure approach that used a Least Absolute Shrinkage and Selection Operator modeling framework to construct a STAT-SORF RRB Hybrid, retaining SORF RRB items based on individual predictive abilities. RESULTS: The SORF alone correctly classified 84% of the sample (84% sensitivity and 86% specificity). The STAT-SORF RRB Hybrid model, which retained four SORF RRB items, correctly classified 90% of a validation sample (95% sensitivity and 75% specificity). CONCLUSION: These findings highlight the potential utility of using multiple autism identification tools and regression-based scoring to establish presumptive eligibility and facilitate early access to autism interventions.

Parent-Implemented Positive Behavior Support Strategies for Young Children on the Autism Spectrum: A Pilot Investigation.

PURPOSE: Parents of children on the autism spectrum enrolled in early intervention often receive coaching to address both social communication and disruptive behavior, which are the two most frequently reported concerns by parents. Intervention techniques for both are often recommended to be implemented across daily routines and require the parents to learn new ways of interacting with their child. A sequential approach to instructing parents in these key intervention targets may reduce burden and increase adherence. METHOD: This multiple-baseline design pilot study included three mother-child dyads who received instruction in a disruptive behavior intervention immediately following a social communication intervention. Maternal maintenance of social communication strategies and child disruptive behaviors were measured during probes throughout the study. RESULTS: Results indicate that although mothers readily learned to implement the techniques, fidelity of implementing social communication strategies declined after introduction of the positive behavior support strategies. CONCLUSIONS: A sequenced approach to parent-mediated intervention is feasible and acceptable. Clinical implications and future directions are discussed. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19528978.

Keeping up with the evidence base: Survey of behavior professionals about Naturalistic Developmental Behavioral Interventions.

LAY ABSTRACT: Primary service providers for young children on the autism spectrum and developmentally delayed children use many strategies under the umbrella of applied behavior analysis therapy. The evidence supporting interventions for children on the autism spectrum has changed last decade, and powerful research supports the relative effectiveness of Naturalistic Developmental Behavior Interventions, yet a few professionals serving young children on the autism spectrum receive training in this category of interventions. Board Certified Behavior Analysts and related professionals are the primary service providers for this population. The purpose of this survey study is to describe and understand the knowledge and beliefs that Behavior Analyst Certification Board certificants have around Naturalistic Developmental Behavior Interventions. The survey was completed by 901 respondents. Respondents indicated, on average, little to no knowledge of Naturalistic Developmental Behavior Intervention practices and few believe that these practices are effective or appropriate for the field. Recommendations include increasing training opportunities for related professionals, and changing certification requirements to match the current evidence.

Preemptive interventions for infants and toddlers with a high likelihood for autism: A systematic review and meta-analysis.

LAY ABSTRACT: Interventions to address core symptoms for young children on the autism spectrum have a strong and growing evidence base. Adapting and delivering evidence-based interventions to infants and toddlers with a high likelihood for autism is a logical next step. This systematic review and meta-analysis summarize the association between infant and toddler interventions and developmental and family outcomes. Results indicate that these early interventions are effective for improving parent implementation of core strategies, yet the effects do not readily translate to child outcomes. However, key studies demonstrate conditional results that indicate that parent implementation is associated with child outcome. Implications for research and practice toward building adaptive interventions that respond to parent implementation and changing child characteristics are discussed.

Generalized Effects of Naturalistic Social Communication Intervention for Minimally Verbal Children with Autism.

JASP-EMT, the combined Enhanced Milieu Teaching (EMT) and Joint Attention, Structured Play, and Emotion Regulation (JASPER) interventions, has been found to be effective for promoting social communication in young children with autism (Kasari et al. in J Am Acad Child Adolesc Psychiatry 53(6):635-646, https://doi.org/10.1016/j.jaac.2014.01.019 , 2014). The current study examined the effects of this naturalistic intervention on social language use in three children with autism who were in the early stages of language acquisition. Generalization to communication partners who did not utilize the intervention strategies was systematically examined using a multiple-baseline design. The results from this study indicate that this blended intervention is effective in increasing target social language for young children with autism, however, generalization to communication partners does not readily occur. Implications for practice and future research are discussed.

Brief Report: What Diagnostic Observation Can Teach Us About Disruptive Behavior in Young Children with Autism.

ABSTRACT: Objective: Approximately 50% of children with autism exhibit severe tantrums, defiance, and/or aggression. We propose that the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS)-a standardized clinical observation modeled after, and complementary to, the Autism Diagnostic Observation Schedule (ADOS)-could enhance earlier identification of disruptive behavior (DB) in autism populations and inform treatment planning. Methods: We adapted the DB-DOS for children with autism based on expert input and preliminary feasibility testing to accommodate varying cognitive and social communication capacities and increase the likelihood of observing DB in this population. Thereafter, we concurrently administered the modified DB-DOS and the ADOS to 12 children with autism aged 36 to 50 months. Results: Overall, children exhibited greater DB, especially behavioral regulation challenges, during the DB-DOS than during the ADOS. Conclusion: The use of a developmentally sensitive standardized observation tool that presses for DB to complement standardized observations such as the ADOS shows promise for enabling more precise research on targeted DB interventions. Such a tool holds promise as a reliable and efficient method of identifying comorbid DB disorders in the autism population.

Multi-component communication intervention for children with autism: A randomized controlled trial.

LAY ABSTRACT: This study reports the results of a randomized trial for preverbal preschoolers with autism that demonstrates the effects of multiple intervention strategies including caregiver training. About 50% of children with autism are not talking by age 3 and up to 30% of children with autism will remain minimally verbal past age 5. Interventions delivered by clinicians and caregivers have the greatest effects on spoken language and may reduce the rate of those who remain minimally verbal. Sixty-eight children ages 3-5 with autism and their caregivers participated in this randomized trial comparing the communication intervention to a comparison group. A brief, multi-component, communication intervention (including a speech-generating device) for children with autism that addresses core deficits may be effective in improving joint attention skills immediately following intervention and social communication skills 4 months following intervention. Future research is needed to understand for whom and under what conditions this intervention is most effective.

Improving Pediatric Hearing Testing for Children with Developmental Delays: The Effects of Video Modeling on Child Compliance and Caregiver Stress.

BACKGROUND: For children with developmental delays (DDs) of any kind (e.g., global DDs, autism spectrum disorder, and Down syndrome), it is essential to understand if a hearing loss may be contributing to these delays. However, toddlers with DDs may have difficulty understanding directions, may be uncomfortable with a new situation, or may simply not want to complete the hearing testing tasks. Regardless of the reasons, noncompliant behaviors have a negative impact on hearing testing, which requires reliable behavioral responses from the child. PURPOSE: The purpose of this study was to test a video intervention to improve hearing testing compliance in toddlers with developmental disabilities. RESEARCH DESIGN: Double-blind randomized clinical trial. STUDY SAMPLE: Twenty-four children with DDs between 24 and 36 months of age. INTERVENTION: Video model of the hearing testing procedures. DATA COLLECTION AND ANALYSIS: The primary child outcome measure was the number of hearing tests completed by the audiologist. Caregiver outcome included a parent survey of perceived stress level before and after the evaluation. RESULTS: There was no significant difference between treatment and control groups regarding the number of hearing tests that were completed. Parents in the treatment group reported less stress following the evaluation as compared with parents of children in the control group. CONCLUSIONS: Pre-exposure to the hearing testing procedures did not significantly improve patient compliance but may reduce caregiver stress. Given the high rates of noncompliance in toddlers with DDs, audiologists may benefit from multiple strategies to help improve testing compliance.

Association of Parent Training With Child Language Development: A Systematic Review and Meta-analysis.

Importance: Training parents to implement strategies to support child language development is crucial to support long-term outcomes, given that as many as 2 of 5 children younger than 5 years have difficulty learning language. Objective: To examine the association between parent training and language and communication outcomes in young children. Data Sources: Searches of ERIC, Academic Search Complete, PsycINFO, and PsycARTICLES were conducted on August 11, 2014; August 18, 2016; January 23, 2018; and October 30, 2018. Study Selection: Studies included in this review and meta-analysis were randomized or nonrandomized clinical trials that evaluated a language intervention that included parent training with children with a mean age of less than 6 years. Studies were excluded if the parent was not the primary implementer of the intervention, the study included fewer than 10 participants, or the study did not report outcomes related to language or communication. Data Extraction and Synthesis: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were applied to a total of 31 778 articles identified for screening, with the full text of 723 articles reviewed and 76 total studies ultimately included. Main Outcomes and Measures: Main outcomes included language and communication skills in children with primary or secondary language impairment and children at risk for language impairment. Results: This meta-analysis included 59 randomized clinical trials and 17 nonrandomized clinical trials including 5848 total participants (36.4 female [20.8%]; mean [SD] age, 3.5 [3.9] years). The intervention approach in 63 studies was a naturalistic teaching approach, and 16 studies used a primarily dialogic reading approach. There was a significant moderate association between parent training and child communication, engagement, and language outcomes (mean [SE] Hedges g, -0.33 [0.06]; P < .001). The association between parent training and parent use of language support strategies was large (mean [SE] Hedges g, 0.55 [0.11], P < .001). Children with developmental language disorder had the largest social communication outcomes (mean [SE] Hedges g, 0.37 [0.17]); large and significant associations were observed for receptive (mean [SE] Hedges g, 0.92 [0.30]) and expressive language (mean [SE] Hedges g, 0.83 [0.20]). Children at risk for language impairments had moderate effect sizes across receptive language (mean [SE] Hedges g, 0.28 [0.15]) and engagement outcomes (mean [SE] Hedges g, 0.36 [0.17]). Conclusions and Relevance: The findings suggest that training parents to implement language and communication intervention techniques is associated with improved outcomes for children and increased parent use of support strategies. These findings may have direct implications on intervention and prevention.

Enhanced milieu teaching for children with autism spectrum disorder in South Africa.

Purpose: Efficient and effective interventions are required to meet the communication needs of children with autism spectrum disorders (ASDs). However, most children with ASD living in South Africa do not receive individualised interventions.Method: This multiple baseline study examined the effects of therapist-implemented enhanced milieu teaching (EMT) on the diversity and frequency of spoken language of three children with ASD in South Africa.Result: A moderate functional relation was demonstrated between the introduction of EMT and increases in (1) the number of different words and (2) the number of spontaneous utterances used by each participant. Some evidence of generalisation to novel partners and contexts was observed.Conclusion: Results indicated that EMT may be effective for improving communication in South African children with ASD. Implications for clinical practice and cultural and linguistic adaptations are discussed.

Beyond pass-fail: Examining the potential utility of two thresholds in the autism screening process.

Access to early intervention as early in development as possible is critical to maximizing long-term outcomes for children with autism spectrum disorders (ASD). However, despite the fact that ASD can be reliably diagnosed by 24 months, the average age of diagnosis is 2 years later. Waitlists for specialized developmental evaluations are one barrier to early diagnosis. The purpose of this study was to examine one potential approach to reducing wait time for an ASD diagnostic evaluation by examining the utility of using more than one threshold for an autism screening tool, the Screening Tool for Autism in Toddlers and Young Children (STAT). Participants included 171 children between 24 and 36 months of age who received a medical diagnostic evaluation through Illinois' Early Intervention Program. This study directly compared the performance of the STAT when scored: (a) using the original single threshold, (b) using seven equally weighted items using a single threshold, and (c) using all items differentially weighted based on how strongly that item predicts a later ASD diagnosis. In addition, this study explored the potential utility of using two thresholds rather than a single threshold for each scoring method. Results of this study suggest that using a two-threshold logistic regression method has potential psychometric advantages over a single threshold and categorical scoring. Using this approach may reduce the wait time for specialty ASD diagnostic evaluations by maximizing true negatives and true positives, such that specialty evaluations may be reserved for those cases that are more ambiguous or more complex. Autism Research 2019, 12: 112-122. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examined the benefits of using two versus one cutoff score when screening for autism. Results indicate that having two scores and weighting test items based on predictive association with an autism diagnosis is better than using a single score and weighting each item equally. Using such an approach may reduce the wait time for specialty autism diagnostic evaluations, such that specialty evaluations may be reserved for those cases that are more ambiguous or more complex.

Autism at a glance: A pilot study optimizing thin-slice observations.

Borrowing from a clinical psychology observational methodology, thin-slice observations were used to assess autism characteristics in toddlers. Thin-slices are short observations taken from a longer behavior stream which are assigned ratings by multiple raters using a 5-point scale. The raters' observations are averaged together to assign a "thin-slice" value for each observation. In this study, a total of 60 toddlers were selected from a video archive: 20 children with typical development, 20 children with developmental language disorder, and 20 children with autism. In the first part of this study, 20 raters observed small play segments between toddlers and an assessor. Raters assigned scores to each of the 60 toddlers on items related to autism symptomatology. Item analysis and generalizability and decision studies were conducted to determine the factor structure and optimal number of raters to achieve a stable estimate of autism characteristics. In the second part of the study, generalizability and decision studies were conducted to determine the most efficient and optimal combination of raters and naturalistic contexts. This pilot study provides recommendations for optimizing the utility of thin-slice observations for measuring autism symptomatology in young children.

Language Disorders and Problem Behaviors: A Meta-analysis.

CONTEXT: A large number of studies have shown a relationship between language disorders and problem behaviors; however, methodological differences have made it difficult to draw conclusions from this literature. OBJECTIVE: To determine the overall impact of language disorders on problem behaviors in children and adolescents between the ages of birth and 18 years and to investigate the role of informant type, age, and type of problem behavior on this relationship. DATA SOURCES: We searched PubMed, EBSCO, and ProQuest. STUDY SELECTION: Studies were included when a group of children with language disorders was compared with a group of typically developing children by using at least 1 measure of problem behavior. DATA EXTRACTION: Effect sizes were derived from all included measures of problem behaviors from each study. RESULTS: We included 47 articles (63 153 participants). Meta-analysis of these studies revealed a difference in ratings of problem behaviors between children with language disorders and typically developing children of moderate size (g = 0.43; 95% confidence interval 0.34 to 0.53; P < .001). Age was entered as a moderator variable, and results showed that the difference in problem behavior ratings increases with child age (increase in g for each additional year in age = 0.06; 95% confidence interval 0.02 to 0.11; P = .004). LIMITATIONS: There was considerable heterogeneity in the measures of problem behaviors used across studies. CONCLUSIONS: Children with language disorders display greater rates of problem behaviors compared with their typically developing peers, and this difference is more pronounced in older children.

Exploring Cascading Effects of Multimodal Communication Skills in Infants With Hearing Loss.

Infants and toddlers with hearing loss (HL) are at risk for developing communicative delays that can have a substantial lasting effect. Understanding child characteristics that may be targeted in early intervention is essential to maximizing communicative outcomes in children with HL. Among the most malleable predictors of communication skills include maternal responsivity, gestures, and vocalizations. The purpose of this study was to examine the relationship among maternal responsivity, prelinguistic communication skills and expressive vocabulary in children with HL. Based upon the results we propose a theoretical cascading model of communicative outcomes for children with HL such that gesture use may be associated with future vocalizations which may in turn be related to long-term spoken language outcomes. This exploratory model may be supported by the underlying transactional model of bidirectional language development that occurs through maternal sensitivity in the first two years of life. Additionally, parents of children with HL may be less likely to respond to a single mode of communication than to a combination of modes. This exploratory study provides a theoretical framework by which multimodal communication development in infants and toddlers with HL may be better understood, and suggests hypotheses for future research and implications for intervention practice.

One-Year Language Outcomes in Toddlers With Language Delays: An RCT Follow-up.

OBJECTIVES: The current study is a 1-year follow-up analysis of data from a randomized controlled trial of Enhanced Milieu Teaching (EMT) for toddlers with language delays. Outcomes and predictors of child language and parent intervention implementation were examined 6 and 12 months after the end of the intervention. METHODS: Toddlers with language delays were recruited from the community, and 97 toddlers and parents were randomly assigned to receive usual community treatments or a 3-month EMT intervention with parent training. Multiple regression analyses were used to estimate the differences between groups at the 6- and 12-month follow-up periods. A subgroup of participants with receptive and expressive language delays was used in a post hoc moderator analysis of treatment outcomes. RESULTS: Children in the treatment arm did not differ from children in the control arm at 6- and 12-month follow-ups. However, post hoc analyses revealed that children with receptive-expressive language delays were persistently delayed relative to normative performance throughout the follow-up period. CONCLUSIONS: The immediate effects of the brief delivery of EMT were not sustained over the 1-year follow-up period. However, the short-term intervention may not have been sufficient for children with receptive-expressive delays to develop typical language abilities, suggesting they may need more intensive early intervention. Although this intervention may not be necessary for all children with primary language delays, future research should determine the extent to which children with receptive-expressive delays may benefit from more intensive intervention.