Treatment mechanism of the WHO caregiver skills training intervention for autism delivered in community settings

This study examined the mechanism of effect of the WHO Caregiver Skills Training (CST) through secondary analysis of a pilot RCT conducted in community settings. Participants were 86 caregivers (77% mothers) of children with ASD (78% male, mean age: 44.8 months) randomized to CST (n = 43) or treatment as usual (n = 43). The primary outcomes, measured at baseline (t1), immediately post-intervention (t2), and 3 months post-intervention (t3), were derived from the coding of caregiver-child free play interactions with the Brief Observation of Social-Communication Change (BOSCC) and the Joint Engagement Rating Inventory scale (JERI). At t3 positive treatment main effects had been observed for caregiver skills supportive of the interaction and for flow of the interaction (JERI), albeit only non-significant changes in the expected direction for child outcomes: autism phenotypic behaviors (BOSCC), joint engagement and availability to interact (JERI). This study tested the theory of change of CST, hypothesizing that the intervention would lead to an improvement on all child and dyad outcomes through an increase in the caregiver skills supportive of the interaction. Serial mediation analyses revealed that the effect of the intervention was significantly influenced by change in caregiver skills. Participation in the intervention led to notable increases in caregiver skills at t2 and t3, which subsequently contributed to improvements at t3 in flow of the interaction, autism phenotypic behavior, joint engagement, and availability to interact. We confirmed our a priori hypothesis showing that change in caregiver skills significantly mediated the effect of treatment on the dyad primary outcome, as well as on the other child outcomes that had shown non-significant changes in the expected direction. Implications for intervention design and policy making in the context of public health services are discussed.

A Longitudinal Study of Language Use During Early Mother-Child Interactions in Spanish-Speaking Families Experiencing Low Income

PURPOSE

This longitudinal study assessed continuity and stability of productive language (vocabulary and grammar) and discourse features (turn-taking; asking and responding to questions) during mother-child play.

METHOD

Parent-child language use in 119 Spanish-speaking, Mexican immigrant mothers and their children at two ages (M = 2.5 and 3.6 years) was evaluated from transcriptions of interactions.

RESULTS

Child productive language significantly increased over the year, whereas mothers showed commensurate increases in vocabulary diversity but very little change in grammatical complexity. Mother-child discourse was characterized by discontinuity: Mothers decreased their turn length and asked fewer questions while children increased on both measures. Rates of responding to questions remained high for both mothers and children even as children increased and mothers decreased over time. Mothers and children showed significant rank-order stability in productive language and measures of discourse. Mothers' rate of asking questions and children's responses to questions during the first interaction predicted children's receptive vocabulary a year later.

CONCLUSIONS

As children become more sophisticated communicators, language input remains important, with discourse features growing in relevance. Children's early opportunities to respond to parents' questions in the context of play benefit their language skills. This work extends the evidence base from monolingual English-speaking families and is interpreted in the context of prior research on parenting practices in U.S. families of Mexican origin.

Symptoms of autism spectrum disorder and developmental delay in children with low mental age

Objective: Autism spectrum disorder (ASD) in very young children with significant cognitive impairment is difficult to diagnose, depriving them of the earliest opportunities for autism-specific intervention. This study delineated specific symptoms in this group, compared to symptoms in children with Global Developmental Delay (GDD) and in ASD with milder developmental delays.Method: Autism Diagnostic Observation Schedule, 2nd Edition, Toddler Module revealed symptoms in three groups of toddlers, with mean ages of 17-20 months: (1) ASD and cognitive/language functioning below the 12-month level (ASD-MA < 12 mos; n = 28), (2) GDD (n = 27), and (3) ASD and cognitive/language functioning at or above the 12-month level (ASD-MA ≥ 12 mos; n = 29). Logistic regression models were fit to control for developmental level. Results: Items in all domains (social interaction, communication, repetitive movements) discriminated ASD-MA < 12 mos from GDD. The two ASD groups, matched for age but differing on developmental level, showed strikingly similar ASD symptomatology. Conclusion: ADOS-2 symptoms differentiated ASD-MA < 12 mos from GDD, after controlling for cognitive impairment. Symptoms in the two ASD groups were minimally related to developmental level. The ADOS-2 Toddler Module successfully captured ASD symptomatology even in children whose developmental level was below the recommended ADOS-2 cutoff of 12 months, which may increase their access to early ASD-specific intervention.

Pilot Randomized Controlled Trial of the WHO Caregiver Skills Training in Public Health Services in Italy

Parents of children with ASD (N = 86; mean age 44.8 months; 67 boys) were randomized to either WHO Caregiver Skills Training (CST) delivered in public health settings in Italy or enhanced treatment-as-usual. Primary blinded outcomes were 3-months post-intervention change scores of autism severity and engagement during caregiver-child interaction. CST was highly acceptable to caregivers and feasibly delivered by trained local clinicians. Intention-to-treat analysis showed a large and significant effect on parent skills supporting joint engagement and a smaller significant effect on flow of interaction. Expected changes in child autism severity and joint engagement did not meet statistical significance. Analysis of secondary outcomes showed a significant effect on parenting stress, self-efficacy, and child gestures. Strategies to improve the effectiveness of CST are discussed.

Effect of Brief Training to Identify Autism Spectrum Disorder During Toddler Well-Child Care Visits

OBJECTIVE

To examine the effect of a brief Enhanced training using the information-motivation-behavior (IMB) change model on improving providers' surveillance rates and accuracy of autism spectrum disorder (ASD) detection.

METHOD

Toddlers (n = 5,672) were screened for ASD during their pediatric well-child visits. Pediatric providers (n = 120) were randomized to receive Enhanced (incorporating components of the IMB model) or Control training. Providers indicated whether they had an ASD concern at each well-child visit. Toddlers who were positive on any screener and/or whose provider indicated ASD concern were invited for a diagnostic evaluation. Differences in provider-indicated ASD concerns before and after training were evaluated using log-linear analyses.

RESULTS

The Enhanced training did not have a significant effect on provider-endorsed ASD concerns (p = 0.615) or accuracy of endorsing concerns (p = 0.619). Providers in the Control training showed a significant reduction in indicating whether or not they had concerns after the training (from 71.9% to 64.3%), which did not occur in the Enhanced group. The Enhanced training led to more frequent endorsements of language (χ2 = 8.772, p = 0.003) and restricted and repetitive behavior (χ2 = 7.918, p = 0.005) concerns for children seen after training.

CONCLUSION

Provider training had limited impact on ASD surveillance, indicating the importance of using formal screening instruments that rely on parent report during well-child visits to complement developmental surveillance. Future research should examine whether providers who indicate specific concerns are more likely to accurately refer children for ASD evaluations.

The first five minutes: Initial impressions during autism spectrum disorder diagnostic evaluations in young children

Diagnosticians report that autism spectrum disorder (ASD) is immediately apparent in some, but not all, children ultimately diagnosed. Clinicians' initial diagnostic impressions have implications for ASD early detection, yet the literature raises questions about their accuracy. This study explores diagnostic impressions of ASD specialists made within the first 5 minutes of meeting a young child and investigates factors associated with the match between initial impressions and final diagnoses. Participants were children (n = 294, aged 12-53 months) referred for an ASD evaluation as part of multi-site ASD screening studies. After 5 minutes observing each child, clinicians with expertise diagnosing ASD recorded if they thought the child would meet criteria for ASD following a complete evaluation, and recorded their confidence in this impression. Clinicians' initial impressions matched the final diagnosis in 81% of cases. Ninety-two percent of cases initially thought to have ASD met criteria following a full evaluation; however, 24% of cases initially thought not to have ASD also met criteria, suggesting a high miss rate. Clinicians were generally confident in their initial impressions, reporting highest confidence for children initially thought correctly not to have ASD. ASD behavioral presentation, but not demographic characteristics or developmental level, were associated with matching initial impression and final diagnosis, and confidence. Brief observations indicating ASD should trigger referral to intervention services, but are likely to under-detect positive cases and should not be used to rule out ASD, highlighting the need to incorporate information beyond initial clinical impression. LAY SUMMARY: When children come in for an autism evaluation, clinicians often form early impressions-before doing any formal testing-about whether the child has autism. We studied how often these early impressions match the final diagnosis, and found that clinicians could not easily rule out autism (many children who initially appeared not to have autism were ultimately diagnosed), but were generally accurate ruling in autism (when a child appeared to have autism within 5 minutes, they were almost always so diagnosed).

Early and Repeated Screening Detects Autism Spectrum Disorder

OBJECTIVE

To evaluate timing and accuracy of early and repeated screening for autism spectrum disorder (ASD) during well-child visits.

STUDY DESIGN

Using a longitudinal study design, toddlers (n = 5784) were initially screened at 12 (n = 1504), 15 (n = 1228), or 18 (n = 3052) months during well-child visits, and rescreened at 18, 24, and 36 months. Of those screened, 368 toddlers attended an ASD evaluation after a positive screen and/or a provider concern for ASD at any visit.

RESULTS

Screens initiated at 12 months yielded an ASD diagnosis significantly earlier than at 15 months (P = .003, d = 0.99) and 18 months (P < .001, d = 0.97). Cross-group overall sensitivity of the initial screen was .715 and specificity was .959. Repeat screening improves sensitivity (82.1%), without notably decreasing specificity (all >93.5%). Screening at 18 months resulted in significantly higher positive predictive value than at 12 months (X² (1, n = 221) = 9.87, P = .002, OR = 2.60) and 15 months (X² (1, n = 208) = 14.57, P < .001, OR = 3.67). With repeat screening, positive predictive value increased for all screen groups, but the increase was not significant.

CONCLUSIONS

Screening as early as 12 months effectively identifies many children at risk for ASD. Children screened at 12 months receive a diagnosis of ASD significantly earlier than peers who are first screened at later ages, facilitating earlier intervention. However, as the sensitivity is lower for a single screen, screening needs to be repeated.

Culture, parenting, and language: Respeto in Latine mother-child interactions

The cultural value of respeto (respect) is central to Latine parenting. Yet, how respeto manifests in the interactions of Latine parents and their young children remains unexamined. Low-income Mexican immigrant Spanish-speaking mothers and their 2.5-year-old toddlers (N = 128) were video-recorded during play (M _age = 30.2 months, SD = 0.52), and two culturally informed items of respeto were coded: parent calm authority and child affiliative obedience. Respeto related to standard ratings of mother and child interactions (e.g., maternal sensitivity and child engagement) but also captured unique features of parent-child interactions. Respeto related to mothers' and toddlers' language production and discourse during the interaction, and explained unique variance in language variables above standard ratings of mother-child interaction. This is the first effort to document a culturally salient aspect of dyadic interaction in Mexican immigrant mothers and young children and to show that respeto relates to language use during mother- child interactions.

Auditory joint attention skills: Development and diagnostic differences during infancy

To date, joint attention skill assessments have focused on children's responses to multimodal bids (RJA) and their initiation of bids (IJA) to multimodal spectacles. Here we gain a systematic view of auditory joint attention skills using a novel assessment that measures both auditory and multimodal RJA and IJA. In Study 1, 47 typically developing (TD) children were tested 5 times from 12 to 30 months to document auditory joint attention skill development. In Study 2, 113 toddlers (39 TD, 33 autism spectrum disorder [ASD], and 41 non-ASD developmental disorders [DD]; average age 22.4 months) were tested to discern the effects of ASD. Our findings fit well within the established depiction of joint attention skills with one important caveat: auditory items were far more difficult to execute than multimodal ones. By 24 months, TD children passed multimodal RJA items at the near-ceiling level, an accomplishment not reached even by 30 months for auditory RJA items. Intentional communicative IJA bids also emerged more slowly to auditory spectacles than to multimodal spectacles. Toddlers with DD outperformed toddlers with ASD on multimodal RJA items but toddlers in both groups rarely passed any auditory RJA items. Toddlers with ASD often monitored their partner's attention during IJA items, albeit less often than toddlers with DD and TD toddlers, but they essentially never produced higher-level IJA bids, regardless of modality. Future studies should investigate further how variations in bids and targets affect auditory joint attention skills and probe the relation between these skills and language development.

The Quality of Mother-Toddler Communication Predicts Language and Early Literacy in Mexican-American Children from Low-Income Households

This longitudinal study documents the key role of early joint engagement in the language and early literacy development of Mexican-American children from low-income households. This rapidly growing population often faces challenges as sequential Spanish-English language learners. Videos of 121 mothers and their 2.5-year-old children interacting in Spanish for 15 min were recorded in 2009-2011 in the Dallas-Fort Worth metropolitan area. Researchers reliably rated general dyadic features of joint engagement-symbol-infused joint engagement, shared routines and rituals, and fluency and connectedness-that have been found to facilitate language development in young English-speaking children. The construct respeto, a valued aspect of traditional Latino parenting, was also rated using two culturally specific items-the parent's calm authority and the child's affiliative obedience. In addition, three individual contributions-maternal sensitivity, quality of maternal language input, and quality of child language production-were assessed. General features of joint engagement at 2.5 years predicted expressive and receptive language at 3.6 years and receptive language and early literacy at 7.3 years, accounting for unique variance over and above individual contributions at 2.5 years, with some effects being stronger in girls than boys. The level of culturally specific joint engagement did not alter predictions made by general features of joint engagement. These findings highlight the importance of the quality of early communication for language and literacy success of Mexican-American children from low-income households and demonstrate that culturally specific aspects of early interactions can align well with general features of joint engagement.

Autism Adversely Affects Auditory Joint Engagement During Parent-toddler Interactions

This study documents the early adverse effects of autism spectrum disorder (ASD) on auditory joint engagement-the sharing of sounds during interactions. A total of 141 toddlers (49 typically developing [TD], 46 with ASD, and 46 with non-ASD developmental disorders [DD]; average age 22.6 months) were observed during a semi-naturalistic play session with a parent. Reactions to four types of sounds-speech about the child, instrumental music, animal calls, and mechanical noises-were observed before and as parents tried to scaffold joint engagement with the sound. Toddlers with ASD usually appeared aware of a new sound, often alerting to and orienting toward it. But compared to TD toddlers and toddlers with DD, they alerted and oriented less often to speech, a difference not found with the other sounds. Furthermore, toddlers with ASD were far less likely to spontaneously try to share the sound with the parents and to engage with the parent and the sound when parents tried to share it with them. These findings reveal how ASD can have significant effects on shared experiences with nonvisible targets in the environment that attract toddlers' attention. Future studies should address the association between auditory joint engagement difficulties and variations in multimodal joint engagement, sensory profiles, and ASD severity and the reciprocal influence over time of auditory joint engagement experience and language development. LAY SUMMARY: Like most toddlers, toddlers with autism spectrum disorder often alert when they hear sounds like a cat's meow or a train's rumble. But they are less likely to alert when they hear their own name, and they are far less likely to share new sounds with their parents. These findings raise important questions about how toddlers with autism spectrum disorder experience their everyday auditory world, including how they share it with parents who can enrich this experience.

Intervention focus moderates the association between initial receptive language and language outcomes for toddlers with developmental delay

This ex-post facto study reanalyzed data from Romski et al. to examine whether intervention focus moderated the relationship between pre-intervention standardized measures of receptive language and post-intervention standardized measures of receptive and expressive language age and observations of expressive target vocabulary size. In all, 62 toddlers with developmental delay were randomly assigned to augmented communication-input (AC-I), augmented communication-output (AC-O), or spoken communication (SC) interventions. AC-I provided augmented language input via spoken language and a speech-generating device (SGD); AC-O encouraged the production of augmented output via an SGD; and SC provided spoken input and encouraged spoken output without using an SGD. Intervention focus moderated the impact of initial receptive language on expressive language age and expressive target vocabulary size. Participants in AC-I, when compared to those in the other two interventions, had a significantly stronger relationship between initial receptive language and post-intervention expressive language age. For expressive target vocabulary size, participants in AC-O showed a strong relationship and those in AC-I a slightly weaker relationship between initial receptive language and expressive target vocabulary size; no significant relationship was found in the SC group. Results emphasize that different interventions may have distinct outcomes for children with higher or lower initial receptive language.

Sharing sounds: The development of auditory joint engagement during early parent-child interaction

Joint engagement-the sharing of events during social interactions-is an important context for early learning. To date, sharing topics that are only heard has not been systematically documented. To describe the development of auditory joint engagement, 48 child-parent dyads were observed 5 times from 12 to 30 months during seminaturalistic play. Reactions to 4 types of sounds-overheard speech about the child, instrumental music, animal calls, and mechanical noises-were observed before and as parents scaffolded shared listening and after the sound ceased. Before parents reacted, even 12-month-old infants readily alerted and oriented to the sounds; over time they increasingly tried to share new sounds with their parents. When parents then joined in sharing a sound, periods of auditory joint engagement often ensued, increasing from two thirds of 12-month observations to almost ceiling level at the 18- through 30-month observations. Overall, the developmental course and structure of auditory joint engagement and joint engagement with multimodal objects and events are remarkably similar. Symbol-infused auditory joint engagement occurred rarely at first but increased steadily. Children's labeling of the sound and parents' language scaffolding also increased linearly while child pointing toward it rose until 18 months and then declined. Future studies should address variations in the development of auditory joint engagement, whether autism spectrum disorder affects how toddlers share sounds, and the role auditory joint engagement may play in gestural and language development. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Brief Report: Sex Differences in Parental Concerns for Toddlers with Autism Risk

Research on sex differences in autism spectrum disorder (ASD) suggests both higher prevalence and a more easily observable presentation of core ASD symptomology in males, which may lead to sex differences in parental concerns. The current study examined whether sex and diagnosis relate to the timing, number, and types of pre-diagnosis concerns for 669 (N_male = 468) toddlers who screened at risk for ASD. No sex differences in parents' concerns emerged for toddlers diagnosed with ASD; however, in the overall at-risk sample, parents of boys endorsed ASD symptoms, including restricted and repetitive behaviors, more than parents of girls. Future research should examine why sex differences in pre-diagnosis concerns emerge and how they might impact early diagnosis for at-risk boys versus girls.

Do Verbal Children with Autism Comprehend Gesture as Readily as Typically Developing Children?

Gesture comprehension remains understudied, particularly in children with autism spectrum disorder (ASD) who have difficulties in gesture production. Using a novel gesture comprehension task, Study 1 examined how 2- to 4-year-old typically-developing (TD) children comprehend types of gestures and gesture-speech combinations, and showed better comprehension of deictic gestures and reinforcing gesture-speech combinations than iconic/conventional gestures and supplementary gesture-speech combinations at each age. Study 2 compared verbal children with ASD to TD children, comparable in receptive language ability, and showed similar patterns of comprehension in each group. Our results suggest that children comprehend deictic gestures and reinforcing gesture-speech combinations better than iconic/conventional gestures and supplementary combinations-a pattern that remains robust across different ages within TD children and children with ASD.

Do Parents Model Gestures Differently When Children's Gestures Differ?

Children with autism spectrum disorder (ASD) or with Down syndrome (DS) show diagnosis-specific differences from typically developing (TD) children in gesture production. We asked whether these differences reflect the differences in parental gesture input. Our systematic observations of 23 children with ASD and 23 with DS (Mages = 2;6)-compared to 23 TD children (Mage = 1;6) similar in expressive vocabulary-showed that across groups children and parents produced similar types of gestures and gesture-speech combinations. However, only children-but not their parents-showed diagnosis-specific variability in how often they produced each type of gesture and gesture-speech combination. These findings suggest that, even though parents model gestures similarly, the amount with which children produce each type largely reflects diagnosis-specific abilities.

After Early Autism Diagnosis: Changes in Intervention and Parent-Child Interaction

This study documents the relation between an autism spectrum disorder (ASD) diagnosis, increases in intervention, and changes in parent-child interaction quality. Information about intervention and observations of interaction were collected before diagnosis and a half year after diagnosis for 79 low-risk toddlers who had screened positive for ASD risk during a well-baby checkup. Children diagnosed with ASD (n = 44) were 2.69 times more likely to increase intervention hours. After ASD diagnosis, the relation between intervention and interaction quality was complex: although increases in intervention and interaction quality were only modestly related, the overall amount of intervention after diagnosis was associated with higher quality interactions. Moreover, lower quality interactions before diagnosis significantly increased the likelihood that intervention would increase post-diagnosis.

An Expanded View of Joint Attention: Skill, Engagement, and Language in Typical Development and Autism

This study provides an expanded view of joint attention and its relation to expressive language development. A total of 144 toddlers (40 typically developing, 58 with autism spectrum disorder [ASD], 46 with developmental delay [DD]) participated at 24 and 31 months. Toddlers who screened positive for ASD risk, especially those subsequently diagnosed with ASD, had poorer joint attention skills, joint engagement during parent-toddler interaction, and expressive language. Findings highlight the dynamic relation between joint attention and language development. In the ASD and DD groups, joint engagement predicted later expressive vocabulary, significantly more than predictions based on joint attention skills. Joint engagement was most severely impacted when toddlers did not talk initially and improved markedly if they subsequently began to speak.

Utilizing two-tiered screening for early detection of autism spectrum disorder

Despite advances in autism screening practices, challenges persist, including barriers to implementing universal screening in primary care and difficulty accessing services. The high false positive rate of Level 1 screening methods presents especially daunting difficulties because it increases the need for comprehensive autism evaluations. This study explored whether two-tiered screening-combining Level 1 (Modified Checklist for Autism in Toddlers, Revised with Follow-Up) and Level 2 (Screening Tool for Autism in Toddlers and Young Children) measures-improves the early detection of autism. This study examined a sample of 109 toddlers who screened positive on Level 1 screening and completed a Level 2 screening measure prior to a diagnostic evaluation. Results indicated that two-tiered screening reduced the false positive rate using published Screening Tool for Autism in Toddlers and Young Children cutoffs compared to Level 1 screening alone, although at a cost to sensitivity. However, alternative Screening Tool for Autism in Toddlers and Young Children scoring in the two-tiered screening improved both positive predictive value and sensitivity. Exploratory analyses were conducted, including comparison of autism symptoms and clinical profiles across screening subsamples. Recommendations regarding clinical implications of two-tiered screening and future areas of research are presented.

Early gesture provides a helping hand to spoken vocabulary development for children with autism, Down syndrome and typical development

Typically developing (TD) children refer to objects uniquely in gesture (e.g., point at cat) before they produce verbal labels for these objects ("cat"; Bates et al., 1979). The onset of such gestures predicts the onset of similar spoken words, showing a strong positive relation between early gestures and early words (Iverson & Goldin-Meadow, 2005). We ask whether gesture plays the same door-opening role in word learning for children with autism spectrum disorder (ASD) and Down syndrome (DS), who show delayed vocabulary development and who differ in the strength of gesture production. To answer this question, we observed 23 18-month-old TD children, 23 30-month-old children with ASD and 23 30-month-old children with DS five times over a year during parent-child interactions. Children in all three groups initially expressed a greater proportion of referents uniquely in gesture than in speech. Many of these unique gestures subsequently entered children's spoken vocabularies within a year-a pattern that was slightly less robust for children with DS, whose word production was the most markedly delayed. These results indicate that gesture is as fundamental to vocabulary development for children with developmental disorders as it is for TD children.

The Communication Play Protocol: Capturing Variations in Language Development

The Communication Play Protocol (CPP) is a semi-naturalistic, lab-based observational procedure that showcases parent-child interactions. This article reflects on how the CPP has matured since we described it over 25 years ago in the May 1999 issue of Perspectives. We emphasize how the CPP has provided us with a stable frame to observe both typically developing children and children with developmental challenges including autism spectrum disorder as they communicate with caregivers in a range of contexts. We also describe three versions of the CPP that have been designed to address different research questions and several methods including engagement state coding and rating items that have been used to extract data from video records of the CPP. We conclude that the CPP can provide both researchers and clinicians with a valuable way to systematically capture variations in language development.

Parents' Translations of Child Gesture Facilitate Word Learning in Children with Autism, Down Syndrome and Typical Development

Typically-developing (TD) children frequently refer to objects uniquely in gesture. Parents translate these gestures into words, facilitating children's acquisition of these words (Goldin-Meadow et al. in Dev Sci 10(6):778-785, 2007). We ask whether this pattern holds for children with autism (AU) and with Down syndrome (DS) who show delayed vocabulary development. We observed 23 children with AU, 23 with DS, and 23 TD children with their parents over a year. Children used gestures to indicate objects before labeling them and parents translated their gestures into words. Importantly, children benefited from this input, acquiring more words for the translated gestures than the not translated ones. Results highlight the role contingent parental input to child gesture plays in language development of children with developmental disorders.

Early deictic but not other gestures predict later vocabulary in both typical development and autism

Research with typically developing children suggests a strong positive relation between early gesture use and subsequent vocabulary development. In this study, we ask whether gesture production plays a similar role for children with autism spectrum disorder. We observed 23 18-month-old typically developing children and 23 30-month-old children with autism spectrum disorder interact with their caregivers (Communication Play Protocol) and coded types of gestures children produced (deictic, give, conventional, and iconic) in two communicative contexts (commenting and requesting). One year later, we assessed children's expressive vocabulary, using Expressive Vocabulary Test. Children with autism spectrum disorder showed significant deficits in gesture production, particularly in deictic gestures (i.e. gestures that indicate objects by pointing at them or by holding them up). Importantly, deictic gestures-but not other gestures-predicted children's vocabulary 1 year later regardless of communicative context, a pattern also found in typical development. We conclude that the production of deictic gestures serves as a stepping-stone for vocabulary development.

Baby sign but not spontaneous gesture predicts later vocabulary in children with Down Syndrome

Early spontaneous gesture, specifically deictic gesture, predicts subsequent vocabulary development in typically developing (TD) children. Here, we ask whether deictic gesture plays a similar role in predicting later vocabulary size in children with Down Syndrome (DS), who have been shown to have difficulties in speech production, but strengths in spontaneous gesture and baby sign use. We compared the gestures and baby signs produced by twenty-three children with DS (Mage = 2;6) and twenty-three TD children (Mage = 1;6), in relation to their expressive spoken vocabulary size one year later. Children with DS showed significant deficits in gesture production, particularly for deictic gestures, but strengths in baby sign production, compared to their typically developing peers. More importantly, it was the baby signs produced by children with DS, but not deictic gestures, that predicted their spoken vocabulary size one year later. Our results further highlight the important role baby signs can play in language development in children with developmental disorders.

The Contribution of Early Communication Quality to Low-Income Children's Language Success

The disparity in the amount and quality of language that low-income children hear relative to their more-affluent peers is often referred to as the 30-million-word gap. Here, we expand the literature about this disparity by reporting the relative contributions of the quality of early parent-child communication and the quantity of language input in 60 low-income families. Including both successful and struggling language learners from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, we noted wide variation in the quality of nonverbal and verbal interactions (symbol-infused joint engagement, routines and rituals, fluent and connected communication) at 24 months, which accounted for 27% of the variance in expressive language 1 year later. These indicators of quality were considerably more potent predictors of later language ability than was the quantity of mothers' words during the interaction or sensitive parenting. Bridging the word gap requires attention to how caregivers and children establish a communication foundation within low-income families.

How parents introduce new words to young children: The influence of development and developmental disorders

This study documents how parents weave new words into on-going interactions with children who are just beginning to speak. Dyads with typically developing toddlers and with young children with autism spectrum disorder and Down syndrome (n=56, 23, and 29) were observed using a Communication Play Protocol during which parents could use novel words to refer to novel objects. Parents readily introduced both labels and sound words even when their child did not respond expressively or produce the words. Results highlight both how parents act in ways that may facilitate their child's appreciation of the relation between a new word and its referent and how they subtly adjust their actions to suit their child's level of word learning and specific learning challenges.

Parent Stress and Perceptions of Language Development: Comparing Down Syndrome and Other Developmental Disabilities

This study extended research on the Down syndrome advantage by examining differences in parent stress and parent perceptions of language development between 29 parents of young children with Down syndrome and 82 parents of children with other developmental disabilities. Parents of children with Down syndrome reported lower levels of total stress, child-related stress, and stress surrounding the parent-child interaction. Parents of children in both groups reported that they felt successful in their ability to impact their children's communication development but did differ on perceptions of difficulty such that parents of children with Down syndrome perceived their children's communication difficulties as less severe despite the children exhibiting similar language skills. Finally, after accounting for potential explanatory confounding variables, child diagnosis remained a significant predictor of parent stress and perceptions of language development. Results highlight the importance of considering etiology when assisting families raising a child with a disability.

From interactions to conversations: the development of joint engagement during early childhood

This research traces the development of symbol-infused joint engagement during mother-child interactions into the preschool years. Forty-nine children, who had been previously observed as toddlers (L. B. Adamson, R. Bakeman, & D. F. Deckner, ), were systematically observed during interactions with their mothers at ages 3½, 4½, and 5½ during activities related to the past and future, internal states, and graphic systems. Although the amount of symbol-infused joint engagement reached a ceiling by 3½, its focus continued to become more complex and its form more balanced. Individual differences in children's symbol-infused joint engagement were stable across 4 years. These findings highlight both how joint engagement is transformed as conversational skills develop and how it remains rooted in earlier interactions and supported by caregiver's actions.

Effect of congenital heart defects on language development in toddlers with Down syndrome

BACKGROUND

Down syndrome (DS, OMIM #190685) is the most commonly identified genetic form of intellectual disability with congenital heart defect (CHD) occurring in 50% of cases. With advances in surgical techniques and an increasing lifespan, this has necessitated a greater understanding of the neurodevelopmental consequences of CHDs. Herein, we explore the impact of CHD on language development in children with DS.

METHODS

Twenty-nine children with DS were observed systematically in parent-child interactions using the Communication Play Protocol to evaluate their language use; they also completed the Mullen Scales of Early Learning and MacArthur Communication Development Inventory. Mean ages were 31.2 months for children with DS and CHD (DS + CHD, n = 12) and 32.1 months for children with DS and a structurally normal heart (DS - CHD, n = 17).

RESULTS

Compared with the DS - CHD controls, the DS + CHD group revealed lower scores in multiple areas, including fine motor skills and expressive and receptive vocabulary. Whereas most differences were not statistically significant, the Communication Development Inventory word count and symbol-infused joint engagement differed significantly (P < 0.01) and marginally (P = 0.09) between groups.

CONCLUSIONS

Finding that CHDs may account for part of the variation in language delay allows us to consider the specific mechanisms underlying the impact of CHDs on language acquisition in children with DS. Conclusions from this first study on early language outcomes of children with DS + CHD may be useful for clinicians in providing developmental surveillance and early intervention programmes with specific emphasis on language therapy as part of long-term follow-up for children with DS + CHD.

Rating parent-child interactions: joint engagement, communication dynamics, and shared topics in autism, Down syndrome, and typical development

A battery of 17 rating items were applied to video records of typically-developing toddlers and young children with autism and Down syndrome interacting with their parents during the Communication Play Protocol. This battery provided a reliable and broad view of the joint engagement triad of child, partner, and shared topic. Ratings of the child's joint engagement correlated very strongly with state coding of joint engagement and replicated the finding that coordinated joint engagement was less likely in children with autism. Ratings of other child actions, of parent contributions, and of shared topics and communicative dynamics also documented pervasive variations related to diagnosis, language facility, and communicative context.

Support for a dimensional view of autism spectrum disorders in toddlers

We examined whether clinically distinct subgroups can be derived from a sample of toddlers (n = 186) who failed the Modified Checklist for Autism in Toddlers, received a comprehensive clinical evaluation, and were diagnosed with an autism spectrum disorder (ASD). Three subgroups emerged from cluster analysis distinguished by (a) social, communication, and intellectual skills and (b) the rate and intensity of repetitive behaviors and abnormal sensory response. Preoccupations, compulsions, and rituals did not distinguish resultant subgroups. These results support a dimensional diagnostic view of ASDs in toddlers since subgroup differences were based on symptom severity rather than different symptom profiles. Results also identify specific types and levels of behavioral deficit relevant to toddler populations. Implications for early diagnosis are discussed.

The Developmental Progression of Understanding of Mind during a Hiding Game

In this longitudinal study, 52 typically developing preschoolers engaged in a hiding game with their mothers when children were 42-, 54-, and 66-months old. Children's understanding of mind, positive affect, and engagement with the task were rated, and mothers' utterances were coded for role and content. Analyses confirmed that some facets of children's understanding of mind developed sequentially; specifically, they expressed an understanding of knowledge access before an understanding of deception and false beliefs, and expressed an understanding of deception before an understanding of false beliefs. Children's understanding of mind increased across visits and positively correlated with false belief task performance. Results suggest that mothers may tailor the content of their utterances to the child's growing expertise, but the role of mothers' utterances did not change. Observing preschoolers engaged in a playful hiding game revealed that children's understanding of mind not only increased with age but also developed sequentially.

Parent perceptions of the language development of toddlers with developmental delays before and after participation in parent-coached language interventions

PURPOSE

This study examined parent perception of early communication development before and after participation in language intervention.

METHOD

Fifty-three parents of toddlers with developmental delays and fewer than 10 spoken words completed the Parent Perception of Language Development, an experimental measure, before and after the children were randomly assigned to a language intervention, 2 of which focused on augmented communication with a speech-generating device, and 1 of which focused exclusively on speech.

RESULTS

After intervention, the parents' perceptions of success became more positive. Their perceptions of the severity of the child's language difficulties decreased for the augmented interventions but increased for the spoken intervention. Child outcome correlated positively with success and negatively with difficulty, but only the correlation between number of spoken words and difficulty was statistically significant.

CONCLUSIONS

Augmented language intervention may not only help the child communicate but also have a positive impact on parent perception of language development.

Augmented language intervention and the emergence of symbol-infused joint engagement

PURPOSE

This study sought to determine whether the effects of 3 parent-coached language interventions--2 focused on augmented communication using a speech-generating device and 1 focused only on speech--for toddlers with developmental delays and fewer than 10 words (M. A. Romski et al., 2010) generalized to children's joint engagement during interactions with parents that took place outside the intervention context.

METHOD

Fifty-seven toddlers who participated in one of three parent-coached language interventions were observed both pre- and post-intervention interacting with their parents using a Communication Play Protocol that produced samples of communication related to social interacting, requesting, and commenting. Their engagement states were reliably coded from the videorecords of these interactions.

RESULTS

Symbol-infused joint engagement of children in all 3 intervention groups increased significantly from pre- to post-intervention. The amount of symbol-infused joint engagement observed post-intervention was significantly associated with whether or not the child produced spoken words and, for children in the 2 augmented conditions, the number of augmented words used during the last intervention session.

CONCLUSIONS

The effects of parent-coached augmented language interventions generalize to children's engagement in child-parent interactions outside the intervention context in ways that may facilitate additional language acquisition.

Early interests and joint engagement in typical development, autism, and Down syndrome

This study examines how spontaneous interests in people and in objects relate to joint engagement in typically developing toddlers and young children with autism or Down syndrome. Ratings of interests were made repeatedly during intermissions in a laboratory-based protocol focused on caregiver-child interactions. Interests were moderated by diagnosis and relatively stable across intermissions. In autism, interest in people tended to be low and to decline rapidly, and the balance of interests favored familiar objects over people. Lower interest in people and in unfamiliar objects was associated with less coordinated joint engagement and with less steep developmental trajectories for symbol-infused joint engagement. These findings suggest that variations in interests may contribute to differences in the child's engagement during social interactions that facilitate the acquisition of language.

Randomized comparison of augmented and nonaugmented language interventions for toddlers with developmental delays and their parents

PURPOSE

This study compared the language performance of young children with developmental delays who were randomly assigned to 1 of 3 parent-coached language interventions. Differences in performance on augmented and spoken word size and use, vocabulary size, and communication interaction skills were examined.

METHOD

Sixty-eight toddlers with fewer than 10 spoken words were randomly assigned to augmented communication input (AC-I), augmented communication output (AC-O), or spoken communication (SC) interventions; 62 children completed the intervention. This trial assessed the children's symbolic language performance using communication measures from the language transcripts of the 18th and 24th intervention sessions and coding of target vocabulary use.

RESULTS

All children in the AC-O and AC-I intervention groups used augmented and spoken words for the target vocabulary items, whereas children in the SC intervention produced a very small number of spoken words. Vocabulary size was substantially larger for AC-O and AC-I than for SC groups.

CONCLUSIONS

This study found that augmented language interventions that include parent coaching have a positive communication effect on young children with developmental delays who begin with fewer than 10 spoken words. Clinical implications suggest that augmented communication does not hinder, and actually aids, speech production abilities in young children with developmental delays.

Toddlers' joint engagement experience facilitates preschoolers' acquisition of theory of mind

Forty-two children participated in a longitudinal study that investigated the relationship between their joint engagement experience when toddlers and their development of theory of mind when preschoolers. Controlling for language comprehension at 30 months, higher preschool false belief scores were associated with more time in coordinated joint engagement earlier (18-21 mo, beta= .34) and in symbol-infused joint engagement later (27-30 mo, beta= .35) in toddlerhood. Findings suggest that the early foundation of theory of mind development is laid as toddlers attend to both social-emotional and symbolic aspects of shared events.

Research directions in augmentative and alternative communication for preschool children

PURPOSE

To review issues related to the use of augmentative systems with young children and present a case study of one child and family's experience with the System for Augmenting Language (SAL).

METHOD

The case involved a preschool child with severe developmental delays who had little functional speech. Acquisition and use of graphic symbols on a speech-output communication device was studied in home and clinical settings. Language and communication behaviours of the child and his communication partners were observed and language assessment measures were collected.

RESULTS

Child engagement state varied across the two settings with a stable profile seen in the therapy setting and a clear increase at home. Child communicative attempts increased following the introduction of the augmented system. Parents reported successful use of the SAL.

CONCLUSION

SAL is a viable communication intervention approach for young children.

Brief report: sensory abnormalities as distinguishing symptoms of autism spectrum disorders in young children

The purpose of this study was to explore the sensory profile of young children with ASD compared to young children with other developmental delays (DD) at first ASD assessment. Results found that young children with ASD had more tactile and taste/smell sensitivities and difficulties with auditory filtering than young children with other DD. Moreover, sensory scores were significantly correlated with stereotyped interests and behaviors. These findings support the hypotheses that young children with ASD show more sensory impairments than young children with other DD and that sensory symptoms are significantly related to stereotyped interests and behaviors. Results also suggest that sensory abnormalities are distinguishing symptoms of ASD that should be considered in diagnostic algorithms for younger cohorts.

Joint engagement and the emergence of language in children with autism and Down syndrome

Systematic longitudinal observations were made as typically developing toddlers and young children with autism and with Down syndrome interacted with their caregivers in order to document how joint engagement developed over a year-long period and how variations in joint engagement experiences predicted language outcome. Children with autism displayed a persistent deficit in coordinated joint attention; children with Down syndrome were significantly less able to infuse symbols into joint engagement. For all groups, variations in amount of symbol-infused supported joint engagement, a state in which the child attended to a shared object and to language but not actively to the partner, contributed to differences in expressive and receptive language outcome, over and above initial language capacity.

Development of displaced speech in early mother-child conversations

This study documents the development of symbolic, spatial, and temporal displacement of toddler's speech. Fifty-six children and their mothers were observed longitudinally 5 times from 18 to 30 months of age during a staged communication play while they engaged in scenes that encouraged interacting, requesting, and commenting and scenes that explicitly focused on the past and the future. Reliably coded transcripts revealed that toddlers highlighted symbols at a high and stable rate and that over time they became less focused on the here and now and more focused on internal states. The greatest expansion was into the near future. Only in scenes designed to discuss the past and future did conversations turn to the past and expand spatially beyond here.

Communication patterns of individuals with moderate or severe cognitive disabilities: interactions with unfamiliar partners

Interactions between youth with cognitive disabilities and unfamiliar adult partners were observed during a "standard partner" condition to discern the effects of the use of an augmentative and alternative communication system on communication patterns. Thirteen individuals who used the System for Augmenting Language (SAL) were compared to individuals who do not speak and who do not have SAL experience and individuals who speak. In general, the SAL users fell in the middle of the range, communicating better than the symbol-naive nonspeakers, yet not quite as well as the natural speakers with cognitive disabilities. These findings highlight the distinct contributions symbol experience makes to communication interactions with unfamiliar partners.

The Development of Symbol-Infused Joint Engagement

Fifty-six children were observed longitudinally from 18 to 30 months of age interacting with their mothers during a Communication Play that contained 8 scenes designed to encourage interacting, requesting, commenting, and narrating. Of primary concern was how often symbols infused the child's states of engagement with people and objects and how experience in such symbol-infused states related to language acquisition. Findings indicate that symbols increasingly infuse joint engagement, and that both the timing and the trajectory vary widely among typically developing toddlers, especially during the last half of the 2nd year. Moreover, variations in amount of symbol-infused supported joint engagement may both be influenced by variations in the onset of language and contribute to differences in language facility at 30 months.