Teaching First Words, Expanding Friendship Opportunities and Building Family Resilience
Grace W. Gengoux, PhD, BCBA-D Clinical Associate Professor, Child and Adolescent Psychiatry
Director, Autism Intervention Clinic, and Well-Being Director, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine
with Jessica M. Schwartzman, MS
The world of Autism Spectrum Disorder (ASD) is a unique blend of bright moments and diverse obstacles, all shared by parents and family members. Over the years, many interventions have been developed for youth with ASD to help their caregivers cultivate areas of strength and tackle areas of challenge. To boost an intervention’s success, parent training has been added to many interventions to generalize skills outside of sessions and equip parents with tools for long-lasting success. At the same time, parents wear many hats outside of a treatment partner and have much to keep track of, which limits their free time. With this in mind, many families are left to wonder what to prioritize and parents want to know if intervention power can be increased by selecting pivotal treatment targets. In other words, can we do more with less by focusing on specific behaviors that will make the biggest difference or have the highest return on investment?
Critical Communication Skills
At the Stanford Autism and Developmental Disorders Research Program (ADDRP), we have aimed to answer these questions by studying a type of therapy called Pivotal Response Treatment (PRT). “Pivotal” refers to a class of behaviors, interactions, or skills which, when improved, can lead to cascading gains in other untargeted areas of behavior, communication, language, and social interaction. In our latest study of PRT, which was recently published in the journal Pediatrics, 48 young children (ages 2-5 years old) with ASD and their parents were randomized to either PRT or a control group. Children in the PRT group received up to 10 hrs per week of clinician-delivered PRT at home and parents received training on how to target the pivotal area of motivation to improve their child’s communication skills. Participating children exhibited significant improvements over time in functional speech, vocabulary, and social communication. Additionally, the majority of children were rated as “improved” by clinician raters and 91% of parents exhibited PRT skills meeting established implementation criteria. These findings suggest that participation in PRT not only equips parents with important intervention tools to use in the future, but also leads to cascading improvements for children in areas that were not targeted in session. Furthermore, results from this study lend support to the idea that interventions focusing on pivotal areas may be highly effective with a high return on parent investment of time and energy.
Telehealth Parent Training During Covid-19 Pandemic
As many clinical services have had to transition to telehealth delivery models during the Covid-19 pandemic, our team at Stanford has launched a new randomized controlled trial of PRT parent training to better understand how young children with ASD and their families may be able to learn PRT via video-based coaching and how much the child’s communication skills can improve from this guided practice in the home environment. For instance, parents will receive tips for how to take advantage of each child’s unique interests and how to turn these into opportunities for strengthening communication skills. For nonverbal children, the first goal is typically to increase the number of meaningful words the child is able to say during everyday activities. For children with some speech, the focus is on motivating the child to use complex descriptive language and make independent comments. With help from a trained therapist, family members can practice during everyday activities and learn how to make learning more efficient and more fun. Parents interested in more information about this or other research studies at Stanford can visit https://med.stanford.edu/autism/studies.html.
Social Engagement with Peers
Given that youth with ASD exhibit difficulty in social interactions, focusing on pivotal social skills in interventions may also alleviate some social challenges. In fact, research has shown that social initiations, communicative bids to peers to start an interaction, are a pivotal behavior that fosters social learning and independent interaction. To capitalize on this, we conducted a pilot study which aims to increase the number of social initiation attempts made by children with ASD to their peers in a cooperative, naturally-reinforcing play group environment. Preliminary data indicate that when children with ASD practice initiating under motivating conditions (i.e., to request items of interest), they may also start to make other types of initiations (e.g., joint attention, social interaction) not taught in intervention. This suggests that targeting pivotal areas in social skills treatment can lead to robust improvements in other important areas, such as social initiations and interactions. Given the added benefit of parent training in many interventions, the next phase of this research includes evaluating a parent training program to teach parents how to encourage positive peer interactions at home and in community settings.
As mentioned, parent participation is key to successful interventions for children with ASD. However, many parents experience unique parenting challenges and elevated stress that are barriers to treatment participation and personal well-being. Considering the potency of pivotal treatment targets in our previous studies, it appears that parent interventions targeting pivotal areas may also be beneficial, especially to maximize the limited free time available to parents. With this in mind, a new parent intervention targeting resilience (well-known to be effective for combating stress and improving longevity) was designed specifically for parents of children with ASD, called the AMOR (Acceptance, Mindfulness, Optimism, Resilience) Method. Over the past year, 34 parents of children with ASD participated in our pilot research study on the AMOR Method and learned a variety of resilience techniques in a brief 8-week intervention. Our preliminary data indicate that, by targeting resilience in intervention, parents not only demonstrated increases in resilience and stress management, but also cascading improvements in other areas not targeted in the intervention including decreased anxiety, increased self-efficacy, and more positive perceptions of family, marital quality, and children with ASD. Results suggest that resilience may be a powerful target to focus on in parent interventions.
Across these diverse domains – communication, peer interaction, and family resilience – it appears that a little bit of the right thing can go a long way for both children with ASD and their parents. By developing interventions focused on pivotal areas, children and parents alike may gain critical skills and benefit from improvements in other, unexpected areas. Our research group looks forward to continuing these lines of work, with the hope that more clarity about what to prioritize in treatment can lead to better quality of life for individuals with ASD and their families.
Grace Gengoux, PhD, BCBA-D is a Clinical Associate Professor, Director of the Autism Intervention Clinic, and the Well-being Director within Stanford University’s Department of Psychiatry and Behavioral Sciences. Dr. Gengoux is a licensed clinical psychologist and clinical researcher with expertise in training parents to promote the healthy development of social skills in their children and manage challenging behavior using positive behavioral approaches.
Jessica Schwartzman, M.S. is a clinical psychology intern at the Vanderbilt University Medical Center in the Autism and Lifespan Development track and finishing the final year of her doctoral program at Palo Alto University. Throughout her graduate career, Jessica has received training in several evidence-based early interventions and developed a strong interest in understanding and fostering resilience in parents of children with autism.