A Systematic Review of Generalization and Maintenance Outcomes of Social Skills Intervention for Preschool Children with Autism Spectrum Disorder

Effects of an Augmentative and Alternative Communication Intervention Package on Socio-Communicative Behaviors Between Minimally Speaking Autistic Children and Their Peers

PURPOSE

The purpose of this study is to investigate the effectiveness of an augmentative and alternative communication (AAC) intervention package consisting of systematic instruction and aided modeling with speech-output technologies on the acquisition, maintenance, and generalization of socio-communicative behaviors-initiating a request for a turn, answering questions, and commenting-in four, minimally speaking (MS) autistic children between the ages of 6 and 9 years.

METHOD

A multiple-probe design across behaviors replicated across participants was implemented to evaluate the effects of systematic instruction and aided modeling on initiating requests for a turn, answering questions, and commenting behaviors. Additionally, a pre- and posttreatment multiple-generalization-probes design was used to assess generalization across peers.

RESULTS

Visual analyses demonstrated experimental control for two participants (i.e., Derek, Ajay) showing a functional relationship between the intervention and outcomes across all social communicative behavior. For one participant (i.e., Matthew), experimental control could not be established because he did not reach the learning criterion for commenting. The fourth participant (i.e., John) transferred to a different school after making some progress on requesting. Effect size indicator analyses corroborated these findings, indicating medium-to-strong effects for initiating requests for a turn strong effects for answering questions, and medium-to-strong effects for commenting. Generalization of socio-communicative behaviors from researcher to a typically developing peer was variable across participants. Participants maintained socio-communicative behaviors 3 weeks after the last intervention session with varying degrees of success.

CONCLUSION

The outcomes of this study suggest that aided modeling and systematic instruction using speech-output technologies may lead to gains in socio-communicative behaviors in some MS autistic children.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25799935.

Word meaning is complex: Language-related generalization differences in autistic adults

The current study marries two important observations. First, there is a growing recognition that word meanings need to be flexibly extended in new ways as new contexts arise. Second, as evidenced primarily within the perceptual domain, autistic individuals tend to find generalization more challenging while showing stronger veridical memory in comparison to their neurotypical peers. Here we report that a group of 80 autistic adults finds it more challenging to flexibly extend the meanings of familiar words in new ways than a group of 80 neurotypical peers, while the autistic individuals outperform the neurotypicals on a novel word-learning task that does not require flexible extension. Results indicate that recognized differences in generalization present an ongoing challenge for autistic adults in the domain of language, separate from social cognition, executive function, or the ability to assign single fixed meanings to new words.

Perceived Parent Needs for Improving Parent Participation in School-Based Therapies for Children with Disabilities Using the Parent-Therapist Partnership Survey

Rehabilitative and habilitative therapies can help children with disabilities increase independence and overall wellbeing. However, children and their caregivers face many barriers to accessing these therapies and often rely on the school for therapy access. Given the limited resources available within the special education system, increasing parent involvement in special education therapies could improve service delivery. However, providers must first understand what parents need to participate in therapies before attempting to engage families. 217 parents completed an online survey consisting of the Parent-Therapist Partnership Survey and demographic questionnaires about theirfamiliesand their child[ren] with disabilities. The percentage of needs parents endorsed as important and thepercentageofimportantneedsendorsedasunmetwere calculated. Differences across demographic variables were assessed. Overall, parents reported an average of 75% of needs as important with significantly more needs endorsed as important regarding being an informed, engaged member of the child's care team (M = 83%) than needs related to support and guidance (M = 65%, p < 0.001). Furthermore, parentsreportedan average of 58% of important needs as unmet, with no significant differences in subscale averages. Significant associations were found for race/ethnicity, education, income, partner availability, number of children with disabilities in the household, transportation access, neighborhood opportunities, parent efficacy and social, emotional, and behavioral concerns. Parents reported a high percentage of needs as important, but a large percentage of these important needs were considered unmet. Significant disparities based on racial/ethnic identities and access to resources were found. In order to successfully engage parents in special education therapy activities, providers must work to understand and address parents' engagement needs, paying special attention to each family's unique circumstances to optimize engagement.

Parent perspectives on treatment: A mixed methods analysis of PEERS® for Preschoolers

LAY ABSTRACT

Autistic children have social communication differences that can contribute to difficulties making and keeping friends, as well as poor mental health (e.g. anxiety, depression). Social skills training programs for preschoolers on the spectrum have been shown to increase social functioning and improve outcomes. Parent involvement in these programs is essential, as parents are able to use the intervention strategies outside of sessions. Teaching parents skills to help their children is also thought to reduce parenting stress through empowerment, knowledge, and social support. However, we still do not know much about how parents experience social skills treatments and whether there are specific parts that are especially helpful to them. This study examined parent perspectives on the University of California, Los Angeles Program for the Education and Enrichment of Relational Skills (PEERS®) for Preschoolers, an evidence-based, group social skills intervention for autistic young children who are struggling socially. Twenty-four parents reported on their child's progress through questionnaires and participated in semi-structured interviews that asked about their experiences and perspectives 1-5 years after completing (PEERS®) for Preschoolers. Parents reported that their children displayed increased social skills and confidence after (PEERS®) for Preschoolers, while parents described feeling more positive, supported, and having greater understanding of their child and their development. Those parents who continued to use strategies taught in (PEERS®) for Preschoolers, particularly priming and preparing their child for social activities, showed greater improvements in long-term child outcomes and parenting stress. Overall, findings show that parents had a positive experience during and after PEERS® for Preschoolers, finding the program helpful in multiple ways to both their child and to themselves as a parent.

PEERS® for Preschoolers preliminary outcomes and predictors of treatment response

PEERS® for Preschoolers (P4P) is a social skills group program for young autistic children and their caregivers, which provides everyday tools for interacting and communicating with others. Twenty-two caregiver-child dyads participated and completed pre-treatment, post-treatment, and follow-up measures (4-16 weeks after). Using single-subject analyses to examine social skills, 60% demonstrated post-treatment improvement, and 53.85% demonstrated follow-up improvement. Regarding a secondary outcome of behavioral difficulties, 33.33% demonstrated post-treatment reduction, and 7.69% demonstrated follow-up reduction. Using regressions, autistic traits predicted outcomes; fewer social communication difficulties predicted both greater social skills and fewer behavioral difficulties at post-treatment, while fewer repetitive behaviors predicted fewer post-treatment and follow-up behavioral difficulties. These results preliminarily demonstrate the benefits of P4P and how autistic traits may impact P4P outcomes.

Increasing linguistic and prelinguistic communication for social closeness during naturalistic AAC instruction with young children on the autism spectrum

This study examined the effects of an intervention package using high-tech augmentative and alternative communication (AAC) with Naturalistic Instruction (NI), time delay, and prompting during social routines for preschoolers on the autism spectrum. The AAC was a communication application on a tablet programmed with color photo representations of participants and communication partners engaged in social routines. The primary dependent measure was a linguistic communication turn on the AAC device completing the instructor's cloze phrase related to the routine. A secondary dependent measure was prelinguistic communication -nonspecific vocalizations and smiling - within each turn of the routine. Results indicated that all communication types increased and maintained for all three participants with two participants meeting mastery criteria within the minimal number of sessions. These results are significant in providing additional evidence for the effectiveness of AAC intervention beyond teaching simple object requests and in teaching more socially meaningful communication to children on the autism spectrum. Additionally, this study supports the use of color photo representations to promote social interaction. Future research should continue to evaluate such interventions on a larger scale and include naturally occurring communication partners, such as siblings and peers.

Play brick therapy to aid the social skills of children and young people with autism spectrum disorder: the I-SOCIALISE cluster RCT

Background

Social skills interventions are commonly recommended to help children and young people with autism spectrum disorder develop social skills, but some struggle to engage in these interventions. LEGO® (LEGO System A/S, Billund, Denmark) based therapy, a group social skills intervention, aims to be more interesting and engaging.

Objective

To evaluate the clinical effectiveness of LEGO® based therapy on the social and emotional skills of children and young people with autism spectrum disorder in school settings compared with usual support. Secondary objectives included evaluations of cost-effectiveness, acceptability and treatment fidelity.

Design

A cluster randomised controlled trial randomly allocating participating schools to either LEGO® based therapy and usual support or usual support only.

Setting

Mainstream schools in the north of England.

Participants

Children and young people (aged 7-15 years) with autism spectrum disorder, their parent/guardian, an associated teacher/teaching assistant and a facilitator teacher/teaching assistant (intervention schools only).

Intervention

Schools randomised to the intervention arm delivered 12 weekly sessions of LEGO® based therapy, which promotes collaborative play and encourages social problem-solving in groups of three children and young people with a facilitator (trained teacher or teaching assistant). Participants received usual support from school and community services. Participants in the control arm received usual support only. Research assistants and statisticians were blind to treatment allocation.

Main outcome measure

The social skills subscale of the Social Skills Improvement System (SSIS), completed by the children and young people's unblinded teacher pre randomisation and 20 weeks post randomisation. The SSIS social skills subscale measures social skills including social communication, co-operation, empathy, assertion, responsibility and self-control. Participants completed a number of other pre- and post-randomisation measures of emotional health, quality of life, loneliness, problem behaviours, academic competence, service resource utilisation and adverse events.

Results

A total of 250 children and young people from 98 schools were randomised: 127 to the intervention arm and 123 to the control arm. Intention-to-treat analysis of the main outcome measure showed a modest positive difference of 3.74 points (95% confidence interval -0.16 to 7.63 points, standardised effect size 0.18; p = 0.06) in favour of the intervention arm. Statistical significance increased in per-protocol analysis, with a modest positive difference (standardised effect size 0.21; p = 0.036). Cost-effectiveness of the intervention was found in reduced service use costs and a small increase in quality-adjusted life-years. Intervention fidelity and acceptability were positive. No intervention-related adverse events or effects were reported.

Conclusions

The primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes of between 0.15 and 0.21. There were positive health economics and qualitative findings, corroborated by the difference between arms for the majority of secondary outcomes, which were not statistically significant but favoured the intervention arm. Post hoc additional analysis was exploratory and was not used in drawing this conclusion. Given the small positive change, LEGO® based therapy for children and young people with autism spectrum disorder in schools should be considered.

Limitations

The primary outcome measure was completed by an unblinded teacher (rather than by the facilitator).

Future work

The study team recommends future research into LEGO® based therapy, particularly in school environments.

Trial registration

This trial is registered as ISRCTN64852382.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information.

Interventions for Young Children's Mental Health: A Review of Reviews

To determine the efficacy of intervention programs for young children (4-9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4-9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4-9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4-9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

Peer-Mediated Interventions for Students with Intellectual and Developmental Disabilities: A Systematic Review of Reviews of Social and Behavioral Outcomes

Peer-mediated interventions (PMIs) have been firmly established as evidence-based approaches for facilitating peer relationships among students with and without disabilities. We conducted a review of reviews evaluating PMI studies to support social skills and positive behavioral outcomes for children, adolescents, and young adults with intellectual and developmental disabilities (IDD). A total of 4,254 individuals with IDD were participants across 43 reviews of the literature, reflecting 357 unique studies. This review includes coding related to participant demographic information, intervention characteristics, implementation fidelity, social validity, and social outcomes addressed by PMIs across reviews. Our findings suggest that PMIs yield positive social and behavioral outcomes for individuals with IDD, mostly in the areas of peer engagement and initiating social interactions. Specific skills, motor behaviors, and challenging as well as prosocial behaviors were less likely to be examined across studies. Implications for research and practice to support the implementation of PMIs will be discussed.

Parent-Implemented Telepractice Autism Intervention: A Case Study of Maintenance and Generalization

The extent to which people maintain new skills and generalize those skills to new contexts without support are two aspects of intervention research that can be difficult to examine, especially over a sustained period of time and across a variety of contexts. In past research, we have explored teaching parents and caregivers to implement evidence-based communication strategies with their young children with autism who are minimally verbal. When a former research participant contacted us with a request to participate in our project again, four years later and with a different son, we used this as an opportunity to ask questions about her maintenance of the skills in using the targeted strategies, and her generalization of those skills to a different child. Using the data collected with her older son, Ali, and new data collected four years later with her younger son, Rami, we present a case study of this mother. We discuss the implications of the findings on interpreting the efficacy of the telepractice intervention's programming for generalization, identifying opportunities for refining the intervention, and insights useful for other intervention research.

A Systematic Review of Maintenance Measurement in Early Childhood Autism Spectrum Disorder Research

Single case research designs (SCRDs) are integral to identifying evidence-based practices (EBPs) for young children with autism spectrum disorder (ASD); however, the field lacks guidance on measuring response maintenance within SCRDs. We identified 103 studies in which researchers used SCRD to investigate the maintenance of behavioral intervention outcomes for children with ASD ages 0-5. Findings include: (a) maintenance conditions across most EBP categories, (b) limited within-case replication of maintenance assessment, (c) inconsistent use of maintenance terminology, (d) varying frequencies of maintenance assessment, and (e) wide range in latency to first and last maintenance probe. Results indicate a pressing need for the regular inclusion of maintenance conditions in behavioral research to increase our understanding of programming for and assessing maintenance.

Perceived parent needs in engaging with therapeutic supports for children with disabilities in school settings: An exploratory study

BACKGROUND

Parent engagement in therapeutic services for children with disabilities could optimize service delivery while addressing service disparities. However, service providers must first understand parents' needs to effectively involve parents.

AIMS

This study examines what needs parents identify as important when engaging with school-based therapies and how well these needs are being met.

METHODS AND PROCEDURES

Parents of children with Individualized Education Plans rated statements related to their needs for trust, information, support and guidance, and personal needs when engaging with their child's therapies. Parents also provided demographic information on them and their child[ren] with a disability.

OUTCOMES AND RESULTS

Parents endorsed an average of 83 % of needs as important but 51 % of needs as unmet. On average, 65 % of needs related to feeling trusted by service providers were met. In contrast, needs related to receivings upport and guidance (M = 58 %), information (M = 55 %), and addressing parent's own needs (M = 53 %) were frequently unmet. Parents indicated that needs related to feeling trusted by service providers were most frequently met. In contrast, needs related to receiving information were most frequently unmet. Race/ethnicity and number of children with a disability influenced the number of needs endorsed as important and unmet.

CONCLUSION

This feasibility study suggests that parents find a variety of needs regarding their interactions with school-based providers as important to them. However, given the high proportion of needs indicated being unmet, significant gaps likely exist in effectively engaging parents, especially for Parents of Color and parents with multiple children with disabilities.

IMPLICATIONS

This study provides a list of tangible needs school-based providers can use to improve parent engagement with school-based therapies. School-based providers and administrators can use the needs identified as important and unmet in this study to create actionable steps that aim to improve parent engagement in school-based services.

Teaching Safety Skills to Children: A Discussion of Critical Features and Practice Recommendations

Children may encounter safety threats from the physical environment (e.g., firearms or poisonous substances) or from the behaviors of others (e.g., abduction or sexual abuse lures). Such encounters may result in injury or death if children do not learn skills to respond safely. Research over the last 40 years has investigated approaches to assessing and training safety skills. This article discusses critical features that have emerged in the research related to best practice for assessing and training safety skills. We emphasize the importance of in situ assessments, effective training approaches, the need for data-based decision making, strategies for enhancing generalization and maintenance, the accessibility of training programs, and approaches to training individuals with disabilities. Following a discussion of each critical feature presented in this article, we provide recommendations for practicing behavior analysts.

Remote PEERS® for preschoolers: A pilot parent-mediated social skills intervention for young children with social challenges over telehealth

INTRODUCTION

Social differences characteristic of autism spectrum disorder (ASD) and other developmental disabilities are evident in early childhood and are associated with later difficulties. Unfortunately, there is a paucity of evidence-based interventions explicitly targeting social skills development for young children, few actively integrate parents and caregivers, and even fewer have remote models. The importance of providing accessible, tailored services for families in the wake of the COVID-19 pandemic, prompted the creation of a parent-mediated telehealth version of Program for the Education and Enrichment of Relational Skills (PEERS^®) for Preschoolers (P4P), a pre-existing, evidence-based social skills intervention for children 4-6 years focused on making and keeping friends.

METHOD

This methodological paper documents the implementation, feasibility, and satisfaction of a novel telehealth group-based delivery of P4P.

RESULTS

Qualitative results indicate acceptable feasibility and satisfaction. Additionally, following completion there was an increase in parental confidence in social coaching and increased use of child social skills.

DISCUSSION

Future work will evaluate quantitative outcomes and comparisons between delivery methods (e.g., telehealth vs. in-person).

Guidelines for Facilitating Direct Instruction of Generalized Social Behavior: Teaching the General Case

Social deficits are a common feature in individuals with low incidence disabilities. Current solutions used to teach social skills are not always effective, especially when it comes to generalizing these skills to novel contexts. General case programming (GCP) is an instructional methodology founded on the science-based tenets of Direct Instruction, designed to clearly communicate the multiple contexts and response variations a learner is likely to encounter in their complex social environments. The purpose of this article is to describe how GCP can be utilized to help program for generalization of social skills.

Long-Term Treatment Outcomes of PEERS® for Preschoolers: A Parent-Mediated Social Skills Training Program for Children with Autism Spectrum Disorder

Although parent-assisted social skills interventions may reduce early social challenges in preschool-aged children with autism spectrum disorder (ASD), limited research has explored whether intervention gains maintain several years after treatment. This study examined the durability of PEERS^® for Preschoolers, a parent-mediated social skills training program for preschool-aged children with ASD and other social challenges. Twenty-nine parents reported on child and family outcomes 1–5 years following treatment. Results demonstrated maintenance of treatment gains on measures of ASD-related social impairments including social communication, social responsiveness, social motivation, and peer engagement. Post-treatment improvements in problem behaviors and parenting stress were not maintained at long-term follow-up. Implications of these results are discussed.

A Systematic Review of Family-Mediated Social Communication Interventions for Young Children with Autism

Social communication deficits are a core symptom of autism spectrum disorder (ASD). The present paper reviews 54 studies evaluating social communication interventions delivered by parents and siblings to children with ASD under 6 years old. Fifty studies evaluated parent-mediated intervention, and four studies evaluated sibling-mediated intervention. Fourteen studies evaluated interventions using telehealth. Treatment effects and research strength were variable across studies. Treatment modality, setting, and dosage had inconclusive impact on treatment effect. Parent-implemented intervention packages, Pivotal Response Treatment (PRT), Early Start Denver Model (ESDM), and Joint Attention, Symbolic Play, Engagement & Regulation (JASPER), qualified as established evidence-based practice for this population. Most studies reported successful generalization of skills for some, but not all, children. Telehealth and sibling-mediated intervention are promising areas of further research and clinical practice.

Can I join in? Multiple case study investigation of play performance generalisation for children with autism spectrum disorder from dyad to triad

INTRODUCTION

Children with autism spectrum disorder (ASD) have difficulties with play, social interaction with peers and generalisation of intervention outcomes. The Ultimate Guide to Play, Language and Friendship (PLF) has demonstrated effectiveness in improving play performance of children with ASD and their typically developing (TD) peers. The aim of this investigation was to examine the changes in play performance when an additional TD child is added to an existing dyad of a child with ASD and a TD playmate to inform future delivery and adaptations of the intervention.

METHODS

Participants in this multiple case study design were five children with ASD and their TD peer who completed a dyad intervention as part of a randomised control trial investigation of the PLF and an additional TD peer who joined the play dyad. A trained occupational therapist delivered an adapted version of the PLF to the triad over four clinic sessions. An independent rater scored each child (N = 15) on The Test of Playfulness at pre- and post-triad intervention. Line graphs were used to examine case data and compare to dyad play performance and patterns of interaction.

RESULTS

Four of the five children with ASD generalised their play performance from the dyad to the triad social environment. However, the triad intervention did not demonstrate improvements in play performance. The play performance scores for the children with ASD and their TD peers were variable and demonstrated changes in their play pattern from the dyad to the triad.

CONCLUSION

This investigation delivered preliminary evidence of play performance generalisation from a dyad to a triad with TD peers for children with ASD. Careful consideration of characteristics of all playmates is recommended for delivering the intervention to support play performance of children with ASD.