early social interaction project · rct of early social interaction (esi) project wetherby,...
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AmyM.Wetherby,Ph.D.DistinguishedResearchProfessor
LaurelSchendelProfessorofCommunicationDisordersDirector,AutismInstitute
CollegeofMedicine,FloridaStateUniversity
EarlySocialInteractionProject:ImprovingDevelopmentalTrajectoriesofToddlerswithAutismSpectrumDisorder
PresentationattheNationalAutismConferenceAugust2,2016 StateCollege,PA
Outline1. WhatdoestheresearchtellusaboutearlyinterventionfortoddlerswithASD?
2. CanwechangedevelopmentaltrajectoriesoftoddlerswithASD?
• FindingsfromtheEarlySocialInteractionProject
3. Howdowebridgetheresearch-to-practicegap?• LessonsfromImplementationScience—Strategic
PlanningforSustainedFidelityofImplementation• RollingoutAutismNavigatorinPennsylvania
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 1 of 33
August 2, 2016 National Autism Conference State College, PA
Financial&NonfinancialDisclosures
l AmyWetherbyisemployedbyFSUandhasreceivedgrantfundingtosupportresearchonearlydetectionandearlyinterventionfromNIH,USDOE,&theCDC.
l AmyWetherbyisauthoroftheCommunicationandSymbolicBehaviorScales(CSBS)andtheSCERTSModelpublishedbyBrookesPublishingandreceivesroyalties
l AmyWetherbyisanownerofAutismNavigator,LLC.Nosalaryisearnedand100%oftheprofitsaredonatedtoanonprofittosupportthecourses&tools.
• Consensusstatementdevelopedbyagroupofautismresearchersonnaturalisticdevelopmentalbehaviorinterventions(NDBIs)
• TheincreasedabilitytoidentifyanddiagnoseASDearlierhasledtodesigninginterventionsforveryyoungchildren
• Empiricaldataontheefficacyoftoddlerinterventionshasemergedbasedonbehavioralinterventionsthatutilizenaturalisticapproachesanddevelopmentalorientations.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 2 of 33
August 2, 2016 National Autism Conference State College, PA
CommonFeaturesofEvidence-BasedNDBIs
• Three Part Contingency• Manualized Practice• Fidelity of Implementation• Individualized Treatment Goals• Ongoing Measurement of Progress• Child-Initiated Teaching Episodes• Environmental Arrangement• Natural Reinforcement to Enhance Motivation• Use of Prompting and Prompt Fading• Balanced Turns within Play Routines• Modeling• Adult Imitation of Child’s Behavior• Broadening Attentional Focus of the Child
Schreibman, Dawson, Stahmer, Landa, Rogers, McGee, Kasari, Ingersoll, Kaiser, Bruinsma, McNerney, Wetherby, & Halladay, 2014
Whatdoweknowabouttoddlertreatments?
Clinician-ImplementedInterventions• RCTsofclinician-implementedinterventionshavehadpromisingeffectsonchild
outcomesofdevelopmentallevel&adaptivebehaviorbutmodesteffectsonautismsymptoms
• Requireconsiderableamountofprofessionaltime,rangingfromto20hours/weekover2yearsto10hours/weekfor6months
Dawsonetal.,2010;Landa etal,2011
Parent-ImplementedInterventions• RCTsofparent-implementedinterventionshaveincreasedparentresponsivity,
synchronization,andinteractionskillsbuthavenotfoundsignificanteffectsonchildoutcomes.
• Verylowintensityrangingfrom11-24sessionsover3to12months
Carteretal.,2011;Greenetal.,2010;Rogersetal.,2012;Siller etal.,2012;Solomonetal.,2014
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 3 of 33
August 2, 2016 National Autism Conference State College, PA
Background: Parent Implemented RCTsN Age
(months)Duration Intensity Proximal
EffectsDistalEffects
Carteretal.,2010
62 20 3.5months 8group/3ind sessions
X
Greenetal.,2010
152 24-59 12months 18sessions X
Kasari etal.,2010
42 30 2months 3Xweek X NA
Rogersetal.,2012
98 21 3months 1Xweek
Solomonetal.,2014
128 30-71 12months 1Xmonth X ADOS%Δ in
ASD/Autism
Intensitymatters…
…sohowdoweachieve25hoursperweekinwhichthechildisengagedactively andproductively inmeaningfulactivities?
(NationalResearchCouncil,2001)
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 4 of 33
August 2, 2016 National Autism Conference State College, PA
RecommendationsoftheAmericanAcademyofPediatrics(2007)l Developmentalsurveillanceateverywell-childvisitfrom9to30months
l ScreenallchildrenforASDat18and24months
✔ Autismcanbediagnosedby18-24months,yetthemedianageofdiagnosisofis4-5years
✔ Childrenofminority,lowincome,andruralfamiliesarediagnosedayearandahalflater.
FundedbyNICHD,CDC,&NIDCD
www.FirstWordsProject.comPI:AmyM.Wetherby,Ph.D.FloridaStateUniversity
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 5 of 33
August 2, 2016 National Autism Conference State College, PA
www.FirstWordsProject.com
§ ExaminedtheutilityoftheSORFasanobservationallevel-twoscreeningmeasureusingtheCSBSbehaviorsample
§ Psychometricpropertieswereexaminedin27416-24montholds:130withASD,61withdevelopmentaldelay,&56withtypicaldevelopment.
§ ResultsindicatedsignificantgroupdifferenceswithlargeeffectsfortheComposite,bothDomainscoresandthetotalnumberofredflags
§ ThesefindingsprovidesupportfortheSORFasanobservationalscreeningmeasurefortoddlerswithgooddiscrimination,sensitivity,andspecificity
Dow,D.,Guthrie,W.,Stronach,S.T.,&Wetherby,A.M.(inpress).PsychometricanalysisoftheSystematicObservationofRedFlags(SORF)forautismspectrumdisorderintoddlers.
Autism:InternationalJournalofResearchandPractice
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 6 of 33
August 2, 2016 National Autism Conference State College, PA
esi.fsu.edu
Community-viable intervention model for toddlers with ASD & their families
Teach parents how to use supports and strategies in everyday activities at home and in the community
Funded byNIMH
ESITheoreticalPrinciples1. Afamily-centeredapproachtomeetthefamily’sneeds,
concerns,andprioritiesthroughouttheassessmentandinterventionprocess
2. Embeddedinterventioninnaturalenvironmentstoenhancegeneralizationforthechildandfamily
3. Parent-implemented,activity-basedintervention4. Intensityofprogrammingforatleast25hoursofactive
engagementperweek5. Systematicinstructionusingindividualizedandevidence-
basedstrategieswithmonitoring6. Developmentalapproachtargetingcoredeficitsofautism—
socialinteraction,communication,play,andemotionalregulationusingtheSCERTS curriculum
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 7 of 33
August 2, 2016 National Autism Conference State College, PA
SCERTS Intervention Curriculum
S- SOCIALC- COMMUNICATIONE- EMOTIONALR- REGULATIONT- TRANSACTIONALS- SUPPORT
Barry Prizant, Amy Wetherby, Emily Rubin, & Amy Laurent
Brookes Publishing © 2006www.scerts.com
RCTofEarlySocialInteraction(ESI)ProjectWetherby,Guthrie,Woods,Schatschneider,Holland,Morgan,&Lord,2014
IndividualESIHighIntensity3individualsessionsperweek(2athomeand1inclinicplayroom);reducedto2sessionsperweekinlast3months
GroupESILowIntensity1groupsessionperweek(1educationmeetingand3playgroupsessionspermonth)
82childrenenteredstudyat18monthswithdiagnosisofASD
Comparedeffectsof2parent-implementedinterventionconditions(9months)
Employedacrossoverdesignsothatallfamiliesreceivedbothtreatments.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 8 of 33
August 2, 2016 National Autism Conference State College, PA
MeasuringTreatmentOutcomesChildActiveEngagement
• Isthechildwellregulated?• Isthechildactively
participatinginaproductiverole?
• Isthechildengaginginreciprocalsocialinteraction?Ø sociallyconnectedØ shiftinggazetofaceØ respondingtoverbalbidsforinteractionØ initiatingcommunication
• Isthechild’sbehaviorflexible&generative?
The3LayerCake:Teachingstrategies&supportstoparentstopromote
childactiveengagementineverydayactivities
Supports for better skillswModel and build language, play & interactionwExtend activity, child’s roles, & transitions
wAdjust expectations & supportswBalance of interaction and independence
Supports for a common agendawMotivating activity wProductive roles wPredictability
wPositioning wFollow child’s attentional focus
Supports for social reciprocitywPromoting initiation wBalance of turns wNatural reinforcers
wClear message to ensure comprehension
Copyright©2014.TheFloridaStateUniversity.Allrightsreserved.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 9 of 33
August 2, 2016 National Autism Conference State College, PA
“EverydayActivityCategories”topromotelearninginthenaturalenvironment
Play with PeopleSocial Games like Peek-a-boo, Rough
and Tumble, Songs & Rhymes
Play with ToysBlocks, Puzzles, Sand box, Playdough,
Cars and Trucks, Ball Games, Baby Dolls
Meals and SnacksPreparation, Eating, Cleanup
CaregivingDressing, Diaper Change, Bath,
Washing Hands, Brushing Teeth
Book Sharing Family Chores Mailbox, Laundry, Care for Pets, Plants
Copyright©2014.TheFloridaStateUniversity.Allrightsreserved.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 10 of 33
August 2, 2016 National Autism Conference State College, PA
Support Learning in Everyday Activities and Multiple Contexts to Promote Generalization
SummaryofRCTFindingsWetherby,Guthrie,Woods,Schatschneider,Holland,Morgan,&Lord,2014
Significanttime-by-conditioninteractioneffectswithchildreninindividual-ESIshowingsignificantlygreaterimprovementon:§ SocialCommunication- CSBSSocialComposite§ AdaptiveBehavior- VinelandComm,Social&DailyLiving§ DevelopmentalLevel- MullenReceptiveLanguageand
significanttimeeffectsonothermeasuresSignificantmaineffectsoftime(nointeraction)withchildreninbothESIconditionsshowingsimilarratesofimprovement:§ Improvement on:CSBSSpeech&Symbolic;ADOSSocialAffect;
MullenExpressiveLanguage§ Worsening on:ADOSRRB,VinelandMotor,&MullenFineMotor
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 11 of 33
August 2, 2016 National Autism Conference State College, PA
esi.fsu.edu
Measure of Active Engagement and Transactional Support (MAETS)
Parent Transactional Supports1. Promote Participation &ProductiveRole
2. MakeActivityPredictable3. Follow Child’s FocusofAttention4. PromoteChild Initiations5. Provide BalanceofTurns6. Support ChildComprehension7. ProvideVerbalandNonverbal Models8. AdjustExpectations&Demands
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 12 of 33
August 2, 2016 National Autism Conference State College, PA
(IMFAR, 2016)
• Evaluated the effects of timing of intervention and is the firststudy of its kind to truly test whether ‘earlier is better’
• 82 children with ASD were enrolled at 16-20 months of age• Randomized to start with ESI Individual or Group then crossover• ESI Individual led to better gains when started at 18 vs 27
months for Receptive Language (MSEL), Expressive Language(VABS), Social Composite of CSBS and VABS Daily Living Skills
• Earlier was better, regardless of condition for ExpressiveLanguage (MSEL) and Symbolic skills (CSBS)
• Findings highlight the importance of early screening and referralto autism-specific interventions by 18 months and counter theUSPSTF recommendation
NextStepsSortingoutactiveingredientsoftreatmentandtreatmentresponders
CollaboratingwithDr.AmiKlin,PIoftheEmoryACE,tostudytheeffectsofESIwithyoungersibsstartingat12monthsComparingmobilecoachingwithface-to-facecoachingandcombinationsofthetwo.
Developingtreatmentsthatarefeasibleforfamiliesofdiverseculturesandcommunitiesofmodestresources
Studyingcommunityimplementationstrategiestobridgegapbetweenresearchandcommonpracticeinbothearlydetectionandearlyintervention
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 13 of 33
August 2, 2016 National Autism Conference State College, PA
KeepinganEyeTowardCommunityUptakeEmbeddedinterventioninnaturalenvironmenttominimizecliniciantimeandmaximizeparentrole,consistentwithPartCEIservicesFeasibleforfamiliesofdiverseculturesandcommunitiesofmodestresourcesDevelopingweb-basedprofessionalcoursesandfamilytoolstosupportcommunityimplementationstrategiestobridgegapbetweenresearchandpractice
EarlydetectionEarlyintervention
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 14 of 33
August 2, 2016 National Autism Conference State College, PA
CourseIntroduction
1. CoreDiagnosticFeatures
2. PrevalenceandCause
3. EarlyDetection
4. CollaboratingwithFamilies
5. Screening&Referral
6. EarlyInterventionBasics
for Primary Care
This7-hourcourselaunchedinSummer,2015.
Copyright©2016.TheFloridaStateUniversity.Allrightsreserved.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 15 of 33
August 2, 2016 National Autism Conference State College, PA
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 16 of 33
August 2, 2016 National Autism Conference State College, PA
www.FirstWordsProject.com
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 17 of 33
August 2, 2016 National Autism Conference State College, PA
Copyright©2016.TheFloridaStateUniversity.Allrightsreserved.
Language Learning 16 Gestures by 16 Months Imagination16 Actions with Objects by 16 MonthsSocial Connectedness 16 Ideas to Communicate by 16 Months Cooperation 16 Ways to Manage Emotions by 16 MonthsCritical Thinking 16 Messages to Understand by 16 Months
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 18 of 33
August 2, 2016 National Autism Conference State College, PA
Copyright©2016.TheFloridaStateUniversity.Allrightsreserved.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 19 of 33
August 2, 2016 National Autism Conference State College, PA
SocialCommunicationDevelopmentinInfantsandToddlers(SC•DIT)
Copyright©2016byFloridaStateUniversity.Allrightsreserved.
KnowledgeandSkillsLevelØ ExploreFunction
• 5DevelopmentalDomains• HundredsofVideosclips
illustrating80SCmilestonesØ Study-GuideFunction
• 15Self-GuidedLessons• 5LearningAssessments
MasteryLevelØ HomeVisitorsGuidetosupportfamiliesinthe
SCGrowthCharts
www.AutismNavigator.com
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 20 of 33
August 2, 2016 National Autism Conference State College, PA
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 21 of 33
August 2, 2016 National Autism Conference State College, PA
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 22 of 33
August 2, 2016 National Autism Conference State College, PA
CourseIntroduction
1. ImprovingEarlyDetection
2. CollaboratingwithFamilies
3. DevelopmentalPerspectives
4. Evidence-basedInterventionStrategies
5. AddressingChallengingBehavior
for Early Intervention Providers
Copyright©2015byFloridaStateUniversity.Allrightsreserved.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 23 of 33
August 2, 2016 National Autism Conference State College, PA
EmbeddingIncludes:
Interventiontarget(s)
Interventioncontext(s)
Transactionalsupports
OpportunitiesforPractice
Embedding intervention strategies into everyday activities provides the context for deliberate practice… for the parent and child
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 24 of 33
August 2, 2016 National Autism Conference State College, PA
TheLensofActiveEngagement:
Copyright©2014.TheFloridaStateUniversity.Allrightsreserved.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 25 of 33
August 2, 2016 National Autism Conference State College, PA
The3LayerCake:Teachingstrategies&supportstoparentstopromote
childactiveengagementineverydayactivities
Supports for better skillswModel and build language, play & interactionwExtend activity, child’s roles, & transitions
wAdjust expectations & supportswBalance of interaction and independence
Supports for a common agendawMotivating activity wProductive roles wPredictability
wPositioning wFollow child’s attentional focus
Supports for social reciprocitywPromoting initiation wBalance of turns wNatural reinforcers
wClear message to ensure comprehension
Copyright©2014.TheFloridaStateUniversity.Allrightsreserved.
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 26 of 33
August 2, 2016 National Autism Conference State College, PA
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 27 of 33
August 2, 2016 National Autism Conference State College, PA
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 28 of 33
August 2, 2016 National Autism Conference State College, PA
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 29 of 33
August 2, 2016 National Autism Conference State College, PA
MasteryIntroduction
1. LibraryofEverydayActivities
2. LibraryofTransactionalSupports
3. LibraryofActiveEngagement
4. LibraryofChildrenandFamilies
5. LibraryofCoachingPractices
Copyright©2016byFloridaStateUniversity.Allrightsreserved.
for Early Intervention Providers
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 30 of 33
August 2, 2016 National Autism Conference State College, PA
Successful implementation requires purposeful matching of “STAGES OF IMPLEMENTATION”:1. Exploration: identify need and determine innovation2. Installation: acquire resources/ prepare implementation3. Initial Implementation: put new practices in place at
selected sites with feedback loops and improvementcycles
4. Full Implementation: assure practices are used with highfidelity and achieving expected outcomes at all initial sitesand begin scale up and sustainability activities
5. Expansion and Scale-Up: increase number of sites
ECTA Center: Smith, Hurth, Pletcher, Shaw, Whaley, Peters, & Dunlap, 2014
for Early Intervention ProvidersLessons from Implementation Science
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 31 of 33
August 2, 2016 National Autism Conference State College, PA
Strategies for Sustainable System Change1. Regional Team Supports and Strategies to Engage Users
§ Establish peer partners in your region§ Encourage intentional discussion groups§ Identify “Autism Navigator Specialists” to complete Mastery level§ Support feeling successful
2. Autism Navigator Learner Community§ Webinars on 1st & 3rd Tuesday of each month to focus on topics
identified by users and application of content§ Annual face-to-face meetings to engage users
3. E-Coaching to Support Fidelity of Implementation§ Autism Navigator LLC will offer e-coaching to provide feedback
and support to teams of Autism Navigator Specialists§ Video review and feedback on SORF, MAETS, fidelity of
implementation, and problem solving on specific cases
for Early Intervention ProvidersLessons from Implementation Science
Tiered Structure for Professional Development of Autism Navigator Specialists
Tier1:CompleteK&SCourse&JoinLearnerCommunity
Tier2: LocalTeamLeadershipRolesinMasteryCourse
Tier3:CertificationtoDocumentImplementationFidelity
Tier4:CertificationasanAN Regional Specialist
Tier5:CertificationasaMasterCoach/GlobalTrainer
for Early Intervention Providers
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 32 of 33
August 2, 2016 National Autism Conference State College, PA
www.AutismNavigator.com
RollingoutAutismNavigatorinPennsylvania
Early Social Interaction Project: Improving Developmental Trajectories of Toddlers with ASD Amy M. Wetherby, PhD -- Page 33 of 33
August 2, 2016 National Autism Conference State College, PA