Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning [1 ed.] 1462545718, 9781462545711

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Coaching Parents of Young Children with Autism

Also Available FOR PROFESSIONALS

Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement Sally J. Rogers and Geraldine Dawson Early Start Denver Model Curriculum Checklist for Young Children with Autism Sally J. Rogers and Geraldine Dawson Human Behavior, Learning, and the Developing Brain: Atypical Development Edited by Donna Coch, Geraldine Dawson, and Kurt W. Fischer Human Behavior, Learning, and the Developing Brain: Typical Development Edited by Donna Coch, Kurt W. Fischer, and Geraldine Dawson Imitation and the Social Mind: Autism and Typical Development Edited by Sally J. Rogers and Justin H. G. Williams FOR GENERAL READERS

A Parent’s Guide to High-­Functioning Autism Spectrum Disorder: How to Meet the Challenges and Help Your Child Thrive, Second Edition Sally Ozonoff, Geraldine Dawson, and James C. McPartland An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn Sally J. Rogers, Geraldine Dawson, and Laurie A. Vismara What Science Tells Us about Autism Spectrum Disorder: Making the Right Choices for Your Child Raphael A. Bernier, Geraldine Dawson, and Joel T. Nigg

Coaching Parents of Young Children with Autism Promoting Connection, Communication, and Learning

Sally J. Rogers Laurie A. Vismara Geraldine Dawson

THE GUILFORD PRESS New York  London

Copyright © 2021 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:  9 8 7 6 5 4 3 2 1

LIMITED DUPLICATION LICENSE These materials are intended for use only by qualified mental health professionals. The publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which permission is specifically granted in a footnote. This license is limited to you, the individual purchaser, for personal use or use with clients. This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video or audio recordings, blogs, file-­sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, or webinars, whether or not a fee is charged). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications.

The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the authors, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources.

Library of Congress Cataloging-in-­Publication Data is available from the publisher. ISBN 978-1-4625-4571-1 (paperback) — ISBN 978-1-4625-4572-8 (hardcover)

Contents

Chapter 1

Helping Parents Help Their Young Children with Autism: An Introduction

1

Why Has This Model Emerged?, 3 Defining Coaching within Parent-­Implemented Early Intervention Approaches, 4 Where Do These Ideas Come From?, 9 Who Are We Writing For?, 9 What Lies Ahead?, 10 Chapter 2

Key Practices in Coaching Parents in Parent-­Implemented Interventions

12

Key Practice: Parents Working with Their Children at Home, 12 Key Practice: Attending to the Positive Parent–Child Relationship in Young Children with ASD, 14 Key Practice: Building Language Interventions Based on Developmental Communication Science, 16 Key Practice: Interdisciplinary Teams, 18 Key Practice: Parent Coaching and Family-­Centered Care, 19 Conclusion, 21 Chapter 3

Becoming a Coach: Knowledge, Characteristics, and Supports What Coaches Need to Know, 24 Coaching Characteristics: The Relationship between Coach and Parent, 30 Supports for Coaches, 34 Understanding What Motivates Parents, 37 Conclusion, 40

ix

23

About the Authors

Sally J. Rogers, PhD, is Distinguished Professor Emeritus of Psychiatry and Behavioral Sciences at the MIND Institute at the University of California, Davis. She has served as president of the International Society for Autism Research and is a Fellow of the American Psychological Association, the Association for Psychological Science, and the International Society for Autism Research. With Geraldine Dawson, Dr. Rogers developed the Early Start Denver Model (ESDM), the first empirically validated comprehensive intervention for toddlers with autism, now used by parents and professionals around the world. She is coauthor of books including An Early Start for Your Child with Autism (for parents) and Early Start Denver Model for Young Children with Autism (for professionals). Dr. Rogers has published over 200 papers, chapters, and books, and ranks in the top 1% of Clarivate Analytics Highly Cited Researchers. Laurie A. Vismara, PhD, BCBA-D, LBA, has spent her research career working closely with families with autism and contributing to the science and program development of ESDM. She is coauthor of An Early Start for Your Child with Autism (for parents). Dr. Vismara uses telehealth platforms and travels throughout the United States and internationally to help families, publicly funded programs, and universities develop ESDM in their communities. Geraldine Dawson, PhD, is the William Cleland Distinguished Professor of Psychiatry and Behavioral Sciences at Duke University. She directs the Duke Institute for Brain Sciences and the Duke Center for Autism and Brain Development. With Sally J. Rogers, Dr. Dawson developed ESDM, the first empirically validated comprehensive intervention for toddlers with autism. Dr. Dawson is coauthor of the parent resources What Science Tells Us about Autism Spectrum Disorder, An Early Start for Your Child with Autism, and A Parent’s Guide to High-­Functioning v

vi

About the Authors

Autism Spectrum Disorder, Second Edition. Her books for professionals include Early Start Denver Model for Young Children with Autism. She is an elected member of the American Academy of Arts and Sciences; received the Distinguished Career Award from the Society of Clinical Child and Adolescent Psychology (Division 53 of the American Psychological Association) and the Lifetime Achievement Award from the Association for Psychological Science; and ranks in the top 1% of Clarivate Analytics Highly Cited Researchers.

Acknowledgments

The concepts and materials provided here for readers result from our many years of discussion, collaboration, research activities, and clinical work. All three of us have a long history of parent coaching, from the beginnings of our professional careers. Efforts to coach parents in Early Start Denver Model (ESDM) concepts began as early as 2001–2002, as Geri and Sally were building the main procedures and tools that became ESDM in the initial randomized controlled trial led by Geri at the University of Washington. The model grew conceptually as Laurie and Sally began to work together, and each new parent coaching study tested additional concepts, techniques, and tools. The power of the model to affect children’s behavior was demonstrated most effectively in the Rogers et al. paper published in 2019 (Rogers, Estes, Vismara, et al., 2019), which demonstrated for the first time a direct positive relationship between parent fidelity of implementation and child growth. We need to acknowledge the parents and families who spent so much time teaching us and working with us in these projects and sharing their data so that we could learn and understand the effects of our efforts. Many, many colleagues have contributed to the work represented here. We want to recognize especially Annette Estes, Jessica Greenson, Meagan Talbott, Gregory Young, Jamie Winter, Cynthia Zierhut, and Carolyn McCormick, who have shared their expertise, their time, and their talents over the years as these studies were designed and carried out. We thank the many members of Sally’s lab at the MIND Institute, and Geri’s lab at the University of Washington, whose support and ongoing efforts made the work possible. And finally, we need to acknowledge our funding sources, both the National Institutes of Health and Autism Speaks, for making the work possible.

vii

Contents

x

Chapter 4

The Coach’s Tools

41

Clipboard and Pencil, 41 Session Plan, 41 Clock, 43 Tablet of Paper, 43 Parent Manual, 44 Copies of Topic Summary (Refrigerator) Lists, 45 Three Data Checklists, 45 Wide-Angle Perspective, 47 Emotional Thermometer, 47 Reflective Mirror (Supervision), 48 Other Tools, 48 Problem Solving, 54 Conclusion, 57 Chapter 5

Assessment, Goal Setting, and Treatment Planning

59

From Diagnosis to Treatment Planning, 59 Conclusion, 72 Chapter 6

Parent Coaching Sessions

73

The First Coaching Session, 73 Subsequent Coaching Sessions, 75 Coaching Session Routines, 77 Unfinished Business, 95 Conclusion, 100 Chapter 7

Guides for Introducing Intervention Topics and Strategies to Caregivers Topic I: Gaining Child Attention as a Precursor to Child Learning, 102 Topic II: Why It Is So Important That Parent–Child Interactions Are Fun for All, 107 Topic III: Why Back-and-Forth Interactions (Turn Taking) Are So Important for Learning, 112 Form 7.1: Joint Activity Template, 116 Topic IV: Why Nonverbal Communication (Body Language) Is a Critical Tool for Young Children, 125 Form 7.2: Activities That Encourage Nonverbal Communication, 128 Topic V: Imitation Is a Critical Learning Tool—for Everyone!, 138 Topic VI: Understanding the ABCs of Children’s Behavior, 147 Form 7.3: ABC Action Plan Template, 150

102



Contents xi

Topic VII: Why It Is So Important That Children Learn to Share Interests and Attention with Others (Joint Attention), 164 Topic VIII: Developing Flexible, Creative Object Play for Learning, 173 Topic IX: Why Pretend Play Is So Important for Young Children’s Learning, 187 Topic X: Helping Young Children Develop Speech, 200 Form 7.4: Action Plan Template for Parent Follow-­Through, 215 Closing, 218 Chapter 8

Variations in Coaching Practices

220

Variations in Family Stories, 221 Coaching Adaptations, 233 Coaching Parents in Groups, 235 Form 8.1: First Group Session Plan, 237 Some Final Notes, 240 Chapter 9

Looking to the Future: Challenges and Opportunities

242

Children with ASD Who Have Co-­Occurring Conditions: Treating the Whole Child, 242 Children and Families in Low-­Resource Communities, 248 Parent-­Implemented Interventions for Infants at Risk for ASD, 250 Looking Ahead, 251 Conclusion, 254

Appendix A

Handouts and Checklists Used Routinely in Parent Coaching Sessions Appendix A.1: Coach’s Clipboard List, 257 Appendix A.2: Coach’s Session Planning Sheet, 258 Appendix A.3: Parent Daily Practice Chart, 259 Appendix A.4: Activity Categories, 261 Appendix A.5: Refrigerator List, 262 Appendix A.6: Parent–ESDM Fidelity Coding Sheet, 263 Appendix A.7: Parent Skills Checklist, 264 Appendix A.8: Parent Self-­Monitoring Checklist, 267 Appendix A.9: Coach’s Fidelity of Implementation Brief Checklist, 269 Appendix A.10: ESDM Coaching Fidelity Rating Tool, 271 Appendix A.11: Stages of Change and Possible Coaching Techniques, 279

255

xii

Appendix B

Contents

P-ESDM Infant–Toddler Curriculum Checklist

287

sally J. rogers, geraldine dawson, laurie Vismara, meagan talbott, Cynthia Zierhut, Jamie winter, Carolyn mcCormick, marie rocha, and emily holly Appendix C

Parent-Friendly Data-Tracking Tools

301

Appendix C.1: Simple Tally System, 303 Appendix C.2: Days of the Week Tracking Chart, 304 Appendix C.3: Activities Data Tracker, 305 Appendix C.4: Goals and Activities Bar Chart, 306 References

307

Index

316

Chapter 1

Helping Parents Help Their Young Children with Autism An Introduction

Receiving a diagnosis of autism is one of the most devastating events that can happen to parents of young children. The profound sense of loss and grief for an imagined future, the fear and anguish about their child’s life, the guilt and blame about possible contributors the parents* might have avoided—it is a defining moment in family life that changes them forever. And somewhere in the near future, during this critical time, most such families in the United States will develop a relationship with a person who signifies help—an early interventionist—whose role it is to work closely with them to help their children engage and learn. This relationship typically follows one of two models. In the first model, one or more well-­trained adults deliver a clinician-­generated treatment plan directly to the child and provide advice and guidance to the family to incorporate at home. The family relies on the interventionists as experts in the child’s treatment needs. When the family asks questions, the interventionist gives answers. As new learning needs develop, the interventionist defines or revises the intervention plan and carries it out. In the best situations, the interventionist uses skills, knowledge, and experience to support and guide the family, particularly the primary caregiver, in areas where the caregiver needs help. In publicly funded services, early intervention tends to be low-­intensity intervention, ranging from two to three hourly visits per week to 1 hour or less per month, although a few communities provide much greater intensity. *Throughout this book we use the terms parent and parents generically to refer to any person or any partnership or group of people raising a child. We also use case examples throughout, with all names and other identifiers disguised. 1

2

Coaching Parents of Young Children with Autism

Potential problems with this model reveal themselves quickly. One is that, for low-­intensity delivery, there is no evidence from high-­quality* studies that this model results in either the parent’s overall adoption of the guidance provided, or benefit to the child. Second, the family’s dependence on the interventionist for determining what the child needs and how to meet those needs is not well supported with infrequent contacts. Third, this model is built on the assumptions that parents are not competent enough to discern their children’s needs or to support their children’s progress without the interventionist’s help. Fourth, multiple providers are often involved, each providing advice and guidance to the family from a limited perspective, leaving them to integrate and act on differing and sometimes conflicting advice. Fifth, interventionists come and go throughout the child’s early years, providing discontinuous relationships with the family, who as the constant figures in the child’s life from birth hold the only comprehensive view of the child’s developmental course, skills, and need, and of the family’s status, structure, strengths, and needs. Yet, with all these drawbacks, our experience tells us that this is the most prevalent model of care for young children with autism spectrum disorders (ASD), in our nation and in others. A second model exists, one described in multiple high-­quality research studies and websites, embraced by many states’ early intervention philosophies, and widely discussed. In this family-­centered model, the interventionist focuses on the child as embedded in a family with strengths and needs, with its members mobilized to help their child. The interventionists’ focus is supporting the key adults in the child’s life to support the child’s learning needs within their daily routines with the child. The interventionist steps away from the role of the authority figure with all the answers and toward the role of partner who understands that early intervention contacts are opportunities to pass on skills and knowledge to caregivers so that they can support their child’s growth during their ongoing interactions. The shift from expert to partner, and from direct intervention to guidance and support for the family, requires a relationship with the parents different from that of teacher and learner, with its inherent hierarchy. A relationship that better captures the transfer of knowledge and skills from one competent person to another is the coaching relationship. In our early childhood work, coaching refers to “an adult-­learning strategy that is used to build the capacity of a parent or colleague to improve existing, abilities, develop new skills, or gain a deeper understanding of practices for use in current and future situations” (Rush & Shelden, 2008, p. 1). Thus, a coach is a person whom another requests to pass on his or her skills and knowledge. When parents make this request, the coach begins the relationship by asking about the family’s goals, assessing initial skills and needs, *Throughout this text, the term high-­quality refers to well-­designed studies using either single-­subject or group designs in which the research design clearly controls for all sources of potential effect on change other than the treatment being studied (e.g., randomized group studies that are appropriately powered and analyzed as time-by-group interactions, and single-­subject designs using multiple-­subject multiple-­baseline designs).



An Introduction 3

and then working with the family to form action plans based on family goals, values, and priorities. The plans are put into practice through regular contacts in which the family member demonstrates and continues his or her learning as the coach supports parent and child learning, while seeking and sharing reflections and plans for the next steps (see Figure 1.1). Why Has This Model Emerged? Young children spend most of their waking hours (75 or so per week) with caregivers in everyday activities and everyday contexts. Those interactions offer the learning opportunities that build cognitive, motor, social, and communicative repertoires for all young children. Harnessing those daily, hourly interactive experiences to meet the learning needs of young children with ASD can provide more opportunities for practice and learning than can any external provider. Working this way maximizes the interventionist’s impact on child learning. Most interventionists with whom we have interacted want to transfer their skills and knowledge to parents and to support them in their use of the learning opportunities inherent in everyday activities but have found it difficult to do. In our own Early Start Denver Model (ESDM)–based work with families and with early childhood practitioners, we have encountered many early interventionists who wish to adopt this second model of family-­centered parent-­implemented intervention, but who struggle to find ways to shift out of traditional provider-­ directed intervention. The interventionist who wants to change approaches often feels uncertain about what behaviors actually constitute coaching and how

Figure 1.1.  Key components of the practice-based coaching (PBC) framework. From Snyder,

Hemmeter, and Fox (2015). Copyright © 2015 Sage Publishing. Reprinted by permission.

Coaching Parents of Young Children with Autism

4

a collaborative practice should look and feel (Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005). Shifting from authority to partner and coach necessitates a new way of thinking about knowledge transfer and skill building. This book was written to help professional and paraprofessional interventionists who treat early autism and other developmental disorders in public and private settings make the transition from a one-on-one delivery model to a caregiver-based delivery model through their coaching and partnering relationship with families. Defining Coaching within Parent-­Implemented Early Intervention Approaches

Purpose For us, the goal of coaching parents to implement intervention with their children at home is to increase the learning opportunities available to children in their everyday, moment-by-­moment life with their caregivers. This involves infusing needed learning opportunities into all the environments and interactions that a young child daily experiences. In this context, a learning opportunity is an event in which the child acquires a new skill or strengthens an existing skill. In order to be a learning opportunity, the experience requires the child’s active attention, effortful goal-­directed action, and success. There are learning opportunities already present in each child’s daily environments, and the products of this learning are evident in the skills the child has developed. However, parents often embed learning opportunities in an unintentional way into ongoing activities and are frequently unaware of the specific learning needs of their young children as influenced by the disability of the child with ASD. In order to increase a child’s learning opportunities, a caregiver needs to know (1) the child’s current learning needs, (2) how to create learning opportunities that will support the child’s learning, and (3) how to infuse these throughout the routines and environments of daily life. These are our goals in parent coaching—to help parents understand their child’s immediate learning needs in all areas that are not progressing well, and to help parents learn how to embed learning opportunities into their interactions with their child in daily activities.

Distinctive Features The content of parent coaching includes (1) the current learning needs and goals for the child intervention and (2) methods for creating needed learning opportunities within the daily routines and interactions that occur between the child and other family members. The coaching relationship supports parents to build this skill and knowledge base by developing a partnership whereby both parties pool



An Introduction 5

their existing skills and knowledge. The result of this process is increasing child learning opportunities to enhance child’s development. The coach shares knowledge and skills about early autism, child learning, child development, specific intervention techniques, and principles and behavior management strategies. Caregivers share knowledge of the child’s unique abilities, vulnerabilities, preferences, interests, and typical skills and behavior in many environments and with many different people. Caregivers bring knowledge of their extended support network, the community, their lifestyle, resources, culture, values, philosophies about parenting and ideal parent–child relationships. They bring their ideas and priorities with regard to the goals they have established for themselves as parents and for their child. And, they bring to the table what they have learned through thousands of hours of interaction with their child. The parent–coach partnership thus involves a balanced relationship among experts, each seeking to learn from the other and each seeking to share what they have of value with the other to achieve a common goal: supporting the child’s optimal development.

Unique Aspects of the Coaching Relationship The differences between the coaching relationship and relationships that occur between a parent and a professional in therapy, counseling, parent education, and parent training should now be clearer. Coaching differs from these on several dimensions: implicit hierarchy of expert and learner and one-way flow of information, from expert to learner. There are many different types of approaches for working with parents: Counseling, educating, training, and treatment are various styles of addressing parenting skills. While coaching shares certain characteristics with other approaches to help adults, like counseling or teaching, it differs from both in content and process. Main differences are the sense of a partnership and the resulting downplay of hierarchical structure. In coaching, both parent and coach are learners and both are experts. Coaching builds from the existing values, knowledge, and interaction skills of the parent vis-à-vis the child, adding to the parent’s existing repertoire of interactive skills and child knowledge in ways that the parent actively seeks to learn. The interactive process involving parent, coach, and child involves a co-­ construction of child learning activities in the ongoing moments of parent–child interaction during their typical routines. With partners, interaction and communication flow in both directions. Idea sharing, comments, and questions surface on both sides. In a partnership, moments of didactic instruction are very rare and occur when requested. Feedback is goal-­focused, rather than evaluative. The coach facilitates the parent’s capacity to gather information, identify strategies, develop new skills, problem-solve, and

6

CoAChing PArents of Young Children with Autism

ultimately promote self-discovery. Goal accomplishment is the result of the efforts and abilities of the three people in the room. All families and all children bring strengths and challenges to the early intervention relationship, and each family works with their children in the ways that best fit them; individual differences among families are as dramatic as those among children. For some children and families, a very young child’s needs can be well met with a parent-implemented approach. For other children and families, parent coaching provides one arm of multifaceted early intervention services. However, given that young children spend the majority of their waking hours with caregivers, we cannot optimize outcomes for young children with developmental difficulties such as ASD without ensuring that their learning needs are being addressed within everyday life with their caregivers. Coaching is a way of being with people to help them enact change to attain their own goals, as well as to resolve barriers to growth. It involves understanding the principles and characteristics of adult learning and how to support adults on a course of change from the outset of intervention. Coaching requires a solid understanding of how adults learn and change, and of the tools to manage the barriers that arise. As the parents master the skills and knowledge they are seeking, the tools and solutions they learn provide a powerful sense of competency and empowerment for managing future needs and goals as well. A competent coach thus knows how to balance sharing knowledge and skills with promoting parents’ selfdiscovery and developing a sense of self-efficacy. We have evolved this role because of the beneficial results of this type of relationship expressed by the people we have worked with and evidenced in the data that we and many other researchers have collected on the child with ASD’s growth, fidelity of implementation among parents, and parents’ evaluation of the coaching experience. Setting aside the role of expert and assuming the role of a coaching partner present a wealth of opportunities to engage in an open, honest dialogue with parents; to listen to their beliefs, priorities, worries, and challenges; to share in the everyday pleasure and pain of raising young children with disabilities; and to offer support and empathy as a partner in the process. Table 1.1 summarizes some of the differences in roles and behavior between a coach and a child interventionist.

Challenges to Coaching This view of coaching often runs counter to how professionals who work in early intervention were trained to deliver treatment. We were taught that our direct treatment was vital to improving child outcomes. We still see such thinking in



An Introduction 7

Table 1.1.  Role Differences: Coach versus Interventionist

Therapist

Coach

Identify the child’s needs as you have defined them based on your assessment.

Identify the family’s goals for their child and their assessment of their child’s strengths and needs, as well as strengths and recommended areas of intervention focus from the individualized family service plan (IFSP) assessment process.

Develop a treatment plan to ameliorate the child’s difficulties that you will follow in your treatment sessions.

Work with the family to build a plan for parents/ caregivers to support the child’s strengths and address the child’s needs based on the family’s daily routines, family priorities and preferences, and materials at home.

Tell the parent how much treatment the child needs and when the sessions are scheduled.

Discuss with the parents how frequently they would like to meet, what times and days will work for them, and possible locations for sessions (home, other community settings, classroom or clinic, other caregiving environments).

Job requirement is to provide disciplinary expertise in assessment and intervention.

Job requirement is to bring interdisciplinary knowledge of early development and the child’s disability, provide disciplinary expertise when needed, form a partnership with parents, and support them in their goals of supporting their child’s development at home.

Deliver hands-on treatment directly to the child.

Support parent–child interactions in everyday activities as the therapeutic vehicle for child development.

Choose materials and activities that will challenge the child to develop new skills.

Plan with parents what daily routines and household materials will best support child learning and their goals for the coaching session.

Make a few suggestions that you would like the parent to work on over the week.

Support parents to incorporate child learning goals into learning activities in their everyday routines, to monitor child response and changing learning needs, to problem-solve when interactions go awry, and to organize their environment as needed to support their efforts at home.

Conceptualize treatment as that which occurs during direct professional interactions with the child.

Conceptualize intervention as child-­engaged learning opportunities that address specific child needs and occur with all partners in all environments.

Write a chart note and evaluate the success of the treatment based on clinical observations and session notes.

Evaluate child progress via behavioral data gathered during coaching sessions (and from parents’ weekly observations/data), written in a chart note, and shared with parents.

Decide length of treatment and need for consultation/referral based on agency rules and procedures, funding availability, child response and attendance.

Discuss length of treatment in terms of parent goals for treatment. Discuss periodically with family in light of continuing and changing needs, options available, and desire for additional professional input.

8

Coaching Parents of Young Children with Autism

action when observing therapists who ignore the parent sitting in the treatment room, or who leave the parent in the waiting room as they take the child into their therapy room to work alone as a solution to the difficulties that might ensue when the child wants to interact with his or her parents during the therapy session. This approach is clearly seen in the autism field where recommendations of 20–40 hours per week of one-on-one treatment for very young children are still made by many knowledgeable health professionals—as if no learning can occur outside of the therapy setting; as if learning occurring inside the therapy setting will magically transfer to everyday life and everyday relationships; as if it is beneficial for very young children to be in such intensive interactions for long periods; as if naps, mealtimes, diaper changes, and baths are not key learning activities for young children; as if there was any empirical evidence for the beneficial effects of such intensive treatment on outcomes of young children with autism; as if the evidence of the benefits of high-­quality parent-­implemented interventions at home did not exist. Having experienced the medical system of assessment and diagnosis, parents are also primed to seek an expert model of intensive interaction when they begin early intervention. Parents’ previous interactions with professionals and the advice they may have found in various media tools will likely have directed them to find professionals with the greatest expertise and do as they direct. Their hope for professionals who can “fix” their children’s delays and symptoms and prevent longterm disability is part of their coping strategy for managing the massive crisis in their lives that the ASD diagnosis has created. Yet, while these experiences of interventionists and parents initially move both to seek a more hierarchical expert-based direct intervention model, it is interesting to look at the backgrounds of the authors of some of the most well-­ supported (in terms of evidence) parent-­implemented models for ASD, all of whom were initially trained in direct treatment of children. We interventionists realize that children’s best outcomes cannot be supported unless everyday life provides children with needed learning and practice opportunities. Everyday life is where children spend most of their time, even for children who are spending 40 hours of their week in treatment. If everyday life does not provide the learning and practice opportunities that children need, then children will learn other skills and behavior that are adaptive in these out-of-­therapy environs—skills and behavior that may be just those that therapists are trying to replace. Furthermore, if parents do not know how to support their children’s new learning, they will not necessarily appreciate their child’s learning ability. And most unfortunately, if parents only become aware of their child’s new skills in the presence of a therapist, then they may assume that they themselves lack the skills to teach their child, with resulting feelings of inadequacy, and that their child no longer cares about cooperating with them, which may fuel feelings of anger and the attribution of manipulation or malicious intent to the child.



An Introduction 9

Where Do These Ideas Come From? The ideas, practices, and philosophy found in this book come from more than 20 years of learning from our colleagues and from our own research on early intervention and parent-­ implemented interventions for young children with ASD, as well as our direct experience as clinicians coaching families of children with developmental difficulties, especially autism and those at risk of autism. We have been heavily influenced by the work of Dunst and Trivette (2009a, 2009b); Dunst, Trivette, and Hamby (2007); Hanft, Rush, and Shelden (2004); Rush and Shelden (2011); and Snyder, Hemmeter, and Fox (2015), all hailing from the field of early intervention for children with developmental disabilities; by work in the field of infant mental health (Zeanah, Stafford, Nage, & Rice, 2005). Much of our clinical work has involved our intervention model, ESDM, and its related parent-­implemented version (P-ESDM). We have published many research papers concerning the efficacy of these approaches (Dawson, Rogers, et al., 2010; Jones, Dawson, Kelly, Estes, & Webb, 2017; Rogers, Estes, et al., 2012; Rogers, Estes, Vismara, et al., 2019; Rogers, Vismara, et al., 2014; Sullivan, Stone, & Dawson, 2014; Vismara, Colombi, & Rogers, 2009; Vismara, Young, & Rogers, 2012; Webb, Jones, Kelly, & Dawson, 2014). Who Are We Writing For? We are writing for readers whose intervention approach shares the characteristics of a naturalistic developmental–­behavioral early intervention model (NDBI; ­Schreibman et al., 2015) for young children with ASD or other developmental disorders. NDBI approaches share these characteristics: (1) a natural type of back-andforth communication between child and adult; (2) following child preferences and/ or choices for activities and materials; (3) child initiations of activities; (4) adult responses that are sensitive and responsive to the child’s verbal and nonverbal communications; (5) goals for learning that reflect the child’s developmental readiness and represent developmentally and culturally appropriate activities for the child; (6) teaching approaches derived from learning science as used in applied behavior analysis (ABA), including analysis of antecedents, behaviors, consequences, functions of behavior, prompting shaping, modeling, and graduated least-to-most guidance; (7) teaching trials, frequently initiated by child actions, are embedded in the flow of adult–child activities; and (8) rewards for the child’s learning response are typically the child’s ability to achieve his or her own goals—the child is able to do what the child intended to when he or she chose this activity. In short, the principles in this text can be used with any early intervention approach that embeds learning in the child’s preferred activities—it is about the process of working with parents as they interact with their children in everyday routines.

10

Coaching Parents of Young Children with Autism

What Lies Ahead? In the chapters that follow, we offer a more detailed definition of coaching and how it differs from direct intervention with the child. In Chapter 2, we outline the theoretical and empirical bases and key practices for our parent coaching model for early ASD. Our model draws on the adult learning and coaching literature; on cognitive–­behavioral therapy as well as ABA; on the science of developmental psychology and infant mental health as it has described the processes of relationship development, communication development, play, and cognitive development; and on infant learning research. In Chapter 3, we describe what a coach needs to know, coaching characteristics, the coaching process, and recommended supports. Chapter 4 outlines the key elements of the coach’s tool kit. Starting with Chapter 5 and continuing through Chapter 6, we take you through the coaching process beginning at the first point of contact with the family; the steps for identifying parent, child, and family learning needs across environments; and the collaborative intervention planning process. We share user-­friendly data tools that we have developed, both for our own use and for parents’ use, to assist us all to determine and address the child’s needs, to evaluate the child’s learning and response to the intervention, and to troubleshoot difficulties that arise and progress that is slower than expected. Chapter 5 walks the reader through an assessment and goal-­setting approach. In Chapter 6, we cover the initial parent coaching session and subsequent sessions, describing ways to work alongside families to introduce and practice various intervention practices by using the coaching skills of observing, giving feedback, problem solving, and, most importantly, listening and reflection. Chapter 7 provides the coach with technical guidance for sharing key intervention concepts with families and coaching families to implement key strategies. In Chapter 8, we discuss situations in which the core practices we have described need to be varied or adapted in order to meet specific family needs or characteristics. Chapter 9 offers several directions for future research on aspects of parent coaching and considerations that need to be made when working with parents whose children have additional psychiatric or medical problems, those whose infants are showing concerning symptoms, and those who live in low-­resource communities in the United States and elsewhere. Coaching stories accompany key topics to illustrate the qualities of relationships and interactions with families and to share important moments in our own learning as well. Throughout the book, we cite the empirical evidence that has influenced our learning and that documents the evolution of parent-­implemented early intervention practices. We hope that this book will provide some support to practitioners who are seeking additional ways of helping young children with ASD progress, those who desire to partner more successfully with families and to evolve a more family-­centered, parent-­implemented approach to delivery of early intervention for young children with or at risk for ASD. Most of all, we hope that this text will



An Introduction 11

enhance practitioners’ motivation and skills to support parents to embed intervention into everyday life to help their children advance. We have written this book because we know that such an approach to early intervention helps children learn. Experienced therapists and experienced parents understand the power of parallel expectations and parallel management strategies across environments and interactions to support optimal child progress. And the parent coaching literature demonstrates the power of the coaching relationship to support parent learning and confidence in providing for the unique needs of their young children with ASD. The parent coaching approach and techniques that we provide here, while developed from our work in P-ESDM, have extensive parallels with other NDBIs (Schreibman et al., 2015) referenced early in the chapter: those developed by Brooke Ingersoll, Amy Wetherby, Connie Kasari, Michael Siller, Laura Schreibman, Robert and Lynn Koegel, and other NDBI leaders publishing current research on parent-­implemented treatments. However, we also integrate concepts and practices from the field of infant mental health and two key practices that set ESDM apart from these other approaches: the seamless integration of ABA and developmental approaches, and intervention techniques that allow one to focus on multiple learning objectives inside adult–child learning-based interactions. We hope that this text will provide additional tools for interventionists working with parents to embed early intervention in everyday routines, will provide greater confidence and a sense of efficacy to the interventionists who use it and the parents they work with, and will provide the children in their care with additional opportunities for learning—­finding excitement in all the new learning opportunities in everyday life and the pleasure of interacting and learning from their family members.

Chapter 2

Key Practices in Coaching Parents in Parent-­Implemented Interventions

The current emphasis on parent-­implemented interventions for early ASD is fueled by (1) new findings from the studies of infant–­toddler development of ASD symptoms, (2) new tools for early diagnosis of autism, (3) and recent research funded by the National Institutes of Health and advocacy groups, especially Autism Speaks, on effective interventions for very young children with ASD. Key Practice: Parents Working with Their Children at Home Before the early 1970s, children with autism were very often treated in treatment centers, institutions, and psychiatric settings by therapists. The work of two men, Eric Schopler and Ivar Lovaas, had tremendous influence on the development of parent-­implemented intervention for ASD. Eric Schopler (1971), a student of Bruno Bettelheim’s, reacted strongly to Bettelheim’s destructive and inaccurate suggestions that autism was caused by rejecting parents. Convinced that autism was a biological condition, Schopler showed in his doctoral thesis (personal communication to G. Dawson, 1983) that children with ASD have unusual ways of processing information. Soon thereafter, he made a radical proposal: Parents can and should provide therapy directly to their children, at home. He led a pioneering effort to mobilize home- and community-based services for children with ASD and spearheaded an intervention called Treatment and Education of Autistic and Related Communication-­Handicapped Children (TEACCH; Mesibov, 2005), still in use today. He provided four completely 12

Key Practices in Parent-­Implemented Interventions 13



new ideas about how children and adults with ASD should be treated, ideas that have had lasting influence (Schopler, Reichler, & Lansing, 1980). The first idea involves a generalist approach: that autism therapists need to bring generalized knowledge of autism treatment to families and children, knowledge developed within an interdisciplinary team in which professionals from a wide range of disciplines learn from each other and pool their knowledge, with each taking on the role of primary therapist for children with ASD and their families. The second idea promotes working with parents and children in a home setting as a crucial part of intervention. Schopler’s third novel idea is the need for parents to have a strong voice in their child’s treatment and to work as partners with professionals in all aspects of assessment, diagnosis, and treatment of children with autism. Fourth, ASD interventions need to respect people with ASD, supporting their preferences, strengths, and needs rather than working to eliminate or hide their symptoms and individual differences. TEACCH achieves these goals by building on individual preferences and strengths as well as needs, delivering interventions whose methods and content best support an individual’s personal learning styles and needs, and simultaneously supporting the independence, comfort, and community participation of those with ASD (Mesibov, Shea, & Schopler, 2005). The influence of the TEACCH generalist model is clear in interventions such as ESDM, in which one member of an interdisciplinary team takes on the role of team leader, partnering with parents in the design, implementation, and oversight of their child’s intervention. Other professionals on the team serve as consultants to the team leader and parent, rather than as direct interventionists with the child. This model has three major effects on service delivery. First, responsibilities for team leadership and decision making are shared by parents and the team leader. Second, the generalist team leader helps integrate information from all available sources for parents to apply to the child’s intervention; in so doing, the generalist

The Generalist Model Developed by TEACCH 1. Various disciplinary therapists have unique knowledge of autism. 2. Generalists learn and use the core principles/practices from each discipline. 3. The interdisciplinary team knows the child and supports each generalist’s work. 4. A primary generalist helps parents work with their child at home. 5. Parents have a strong voice on the team and work as partners with professionals.

6. Intervention needs to respect the unique strengths and needs of each child

with ASD.

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Coaching Parents of Young Children with Autism

is in a position much like that of parents, who need to make decisions about their child based on information from many resources. Third, the generalist team leader uses the interdisciplinary intervention knowledge acquired to coach the parents and to help develop a practical and effective approach to their work at home. Lovaas, approached autism as a problem of learning. Lovaas, like Schopler, began his work with older children, 6- to 10-year-olds, since autism was not yet recognized or diagnosed in early childhood. Building on the work of his colleagues, the early leaders in ABA—Sidney Bijou, Donald Baer, Montrose Wolf, and Todd Risley, among others—­Lovaas commenced his independent work by creating a teaching environment based on the principles of operant learning in a hospital setting and taught his staff to work intensively with children with autism using the principles of ABA throughout the children’s waking hours. While these children made considerable progress, return to their previous settings after the study ended resulted in a loss of new skills and the resumption of their previous patterns of behaving. Learning from this experience, Lovaas and colleagues (1973) shifted their focus to beginning interventions as early as possible and carrying them out using trained interventionists at home, with the family and in the community. Parents were taught the same intervention strategies that the intervention team used. The curriculum itself was comprehensive (Lovaas, 1981, 2003), providing systematic teaching programs to address children’s behavioral deficits and excesses across developmental and behavioral domains and embedding needed supports in community activities to assure child participation and learning (Lovaas, Koegel, Simmons, & Long, 1993). Several aspects of Lovaas’s practices are apparent in many parent coaching approaches in ASD, including ESDM, today: (1) Young children with ASD need to engage with others in typical activities throughout their waking hours; (2) the home, family, and community provide optimum contexts for supporting the learning of young children with ASD; (3) children with ASD (and all of the rest of us) learn when the learning content is broken down into small steps and taught systematically; (4) intervention should begin as soon as possible; and (5) children with ASD are adaptable and need to learn within the everyday environments of family, typically developing peers, and community members. (Although these were the principles that Lovaas and his close colleagues espoused and demonstrated, it is often the case that they are not the aspects of his practice that we associate with some community discrete trial training [DTT] services.) Key Practice: Attending to the Positive Parent–Child Relationship in Young Children with ASD There was a long period of time in which professionals assumed that the attachment relationship in ASD was either disturbed or nonexistent. These assumptions



Key Practices in Parent-­Implemented Interventions 15

were eventually proven wrong. Beginning with the landmark contributions of Marian Sigman and her students and colleagues (Sigman & Ungerer, 1984; Capps, Sigman, & Mundy, 1994; Sigman & Mundy, 1989; Rogers, Ozonoff, & MaslinCole, 1991; Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2009), autism researchers demonstrated that young children with ASD can, in fact, form secure attachments with their caregivers. Evidence from these group studies showed that children with ASD experience their parents as secure bases, that they know and prefer familiar to unfamiliar people, and that they are negatively affected by separation from their parents and by interactions with strangers. These findings provided solid evidence for focusing on adults’ sensitive and responsive interactions (parent behaviors that mediate secure attachments in toddlers) with young children with ASD and focusing on supporting parental roles and competencies as key emotional figures and teachers in their young autistic children’s lives. In addition to the attachment studies in ASD, studies focused on parent–child patterns of interaction in ASD have demonstrated many similarities between parent–child interactions in ASD, those in other neurodevelopmental disorders, and those in typical development (Kasari, Sigman, Mundy, & Yirmiya, 1988; Meirs­ schaut, Warreyn, & Roeyers, 2011). They have also defined differences in key communication behaviors, such as the ability to share attention with others or joint attention (Mundy, Sigman, Ungerer, & Sherman, 1986; Sigman, Mundy, Sherman, & Ungerer, 1986; McEvoy, Rogers, & Pennington, 1993). Kasari reported that parents and children with ASD interact very similarly to children with other developmental delays, with the main differences arising from the need for increased parent support for the child’s attention to the parent (Kasari et al., 1988). Dawson and colleagues demonstrated that children with ASD readily increased their eye contact and joint attention behavior when the caregivers closely followed and responded contingently to the behavior of the child (Dawson & Adams, 1984b; Lewy & Dawson, 1992). We also learned that young children with ASD desire social interaction and respond more positively when social interactions are predictable and understandable. We saw that parents typically scaffolded their children’s learning in ways that supported positive parent–child interactions, while also supporting the child’s social attention and engagement in activities and interactions. Sadly, and against all evidence, there is still a tendency to question the skills of parents with children on the spectrum, fueled by layperson notions of autism as well as the topic of the broader autism phenotype. The latter leads some to question whether the ASD-related genetic backgrounds of parents may result in parenting differences. Very important studies recently examined this question by looking at parent–child interactions among a large group of infants who had an older sibling with ASD (Talbott, Nelson, & Tager-­Flusberg, 2016; Wan, Green, & Scott, 2019). Contrary to the hypothesis that parents of children with ASD may interact differently with their children due to the presence of autism risk genes, no significant differences were found between the group of parents who had a child with

16

Coaching Parents of Young Children with Autism

ASD (and thus were assumed to have more autism risk genes) and those who had children exhibiting typical development. Thus, 30-plus years of studying parent– child interactions in ASD have not reported significant parenting differences that might be responsible for any ASD symptom development in their children. Perhaps someday science and advocacy will be able to put this destructive idea to rest once and for all. The critical findings suggest the opposite: Children with ASD and parents generally develop close ties; children with ASD know and prefer their family members and caregivers and feel safe with them, although they may use different behaviors than other children to express these feelings (Rogers et al., 1991); and parents of children with ASD interact with them in ways that demonstrate their understanding and support for their children’s unique needs. Key Practice: Building Language Interventions Based on Developmental Communication Science Our understanding of the processes that young children use to develop spoken language has altered radically over the past few decades. Before the 1970s, the predominant theories of language development represented nativist and environmentalist viewpoints. The most well-known representative of the nativist position was Noam Chomsky; his hypothesized Language Acquisition Device (Chomsky, 1965, 1980) was a uniquely human brain mechanism that parsed language into its elemental parts and helped children acquire speech and language. The environmentalist view was best represented by B. F. Skinner’s operant learning model, which posited that speech and language evolved from the same learning processes seen in all other aspects of learned behavior (Skinner, 1957). The operant learning approach to language is still embraced by many and is highlighted in the Verbal Behavior method of intervention (Sundberg & Partington, 1998). In the 1970s, a new model of language development was articulated and began to be studied in infant developmental labs across the country. Known as the pragmatics approach and articulated by Jerome Bruner (1983), Elizabeth Bates (1976), Inge Bretherton and Bates (1979), and other key scientists, the pragmatic approach suggests that children decode and learn language by discerning the speaker’s intent (the goal of the communication). Is the speaker making a request, offering or asking for help, directing a partner to act, seeking a social response, directing a partner’s attention? Such intents are expressed by body language—­ gesture, posture, vocal tone, and facial expressions—as well as word meanings. Young children demonstrate their understanding of these intents toward the end of the first year of life, through their preverbal responses to partners and their own gestural production of these intents. A series of elegant experiments occurring across several decades have firmly supported the pragmatics foundation of

Key Practices in Parent-implemented interventions

17

infant speech and nonverbal communication. The experiments have changed the view of speech and language from behaviors learned via imitation and associative learning for the purpose of representing objects and actions in the world, to efforts to join a social partner in shared activities for the pleasure of social connectedness and social influence through shared meanings. Early on, Ratner and Bruner (1978) highlighted the key roles of infant–adult play routines in infants’ learning to anticipate and predict others’ behaviors and intentions. They pointed out that first words were very often the cue words in social games like peekaboo, “uh-oh,” “so big,” rather than need-fulfilling words like milk, food, or help. Their insights about the impact of emotionally salient and highly pleasurable routines with favored social partners on early word learning have stood the test of time and formed the basis for the ESDM intervention. The second contribution of pragmatics researchers was to examine what parents did that fostered word learning in their infants. In direct challenge to the operant learning theory of language learning, a large variety of studies have demonstrated that infants and toddlers benefited the most in the early stages of word learning from partners who used language to describe the focus of an infant’s attention or goals, rather than using it to direct the infant’s attention and to teach word labels. Many studies have found that young children with autism learn spoken language using the same processes as do typically developing children (Lord & Schopler, 1989; Sigman & Ruskin, 1999; Tager-Flusberg et al., 1990). A milestone study by Michael Siller and Marian Sigman (2002) demonstrated the effect on language development of parents who use language to follow their autistic children’s leads rather than to direct them, and this style positively affected their children’s language learning not only in early childhood, but also all the way through adolescence. Longitudinal findings by Mundy and colleagues and others demonstrated that a child’s early joint attention gestures were strong predictors of later language acquisition (Mundy, Sigman, & Kasari, 1990). Such findings indicate that language interventions for preverbal toddlers should focus first on developing use and understanding of communicative gestures, especially the joint attention gestures involving initiating and following a partner’s gaze, pointing, showing, and sharing/giving. These and many other research findings stress the importance of parents and other adults interacting with young autistic children by responding to and following such children’s focus of attention and goals, talking with them about their activities, and joining them as play partners.

18

Coaching Parents of Young Children with Autism

Key Practice: Interdisciplinary Teams On October 8, 1986, a federal law (Public Law 99-457) was passed that amended the 1975 Education for All Handicapped Children Act (Public Law 94-1142)— now known as the Individuals with Disabilities Education Act (IDEA)—to require public educational services be provided to children with disabilities from age 3 to 22. Public Law 99-457 also required that assessment, intervention, and family support for all infants and toddlers with or at risk of developmental delays be provided at little or no cost to families. This law cast a wide umbrella for infants and toddlers with difficulties in all spheres of development, including the social and behavioral domain. It called for interdisciplinary services from a wide range of disciplines, both educational and health-­related, as well as case management services, home visits, parent training, counseling, and the full range of allied health benefits and educational benefits. It also mandated that a family service plan be developed and carried out. The content required of the family service plan was specific, family- and strengths-­focused, completely individualized, and outcome-­oriented. It required objective demonstration of the child’s progress and benefit. It required specification of the nature, frequency, and method of each type of intervention provided. Finally, it required that parents receive the help and information needed to participate in the educational decision-­making processes, including the development of the child’s individualized educational program, as well as the right to obtain information about what programs, services, and resources were available to children with disabilities and the degree to which the programs, services, and resources were appropriate for their child. This family-­centered orientation was a drastic change from the medical model of therapy delivery for infants and toddlers that prevailed at the time. Parents were required to be at the table, fully informed on all available services and members of the decision-­making group establishing a service plan for their child—and for themselves. This focus on supporting the family set in place the idea of parents and professionals as partners in all aspects of infant–toddler identification assessment and intervention. It also reflected the importance of professionals learning about the challenges to families created by a young child’s delays or disabilities, and of supporting families and parenting in order to support children’s development. The focus on services at home and in typical community settings further emphasized the socioecological Bronfenbrenner model of child development (1986) and its grounding in the family, home, neighborhood, and community for supports. Working at home with parents to help them incorporate children’s intervention needs into everyday life developed during these years as a primary delivery model for children from birth to age 3 (Brown & Moersch, 1978). It is interesting that in 2021 these principles are often set aside for young children with ASD in favor of an intensive one-on-one therapy model, likely due



Key Practices in Parent-­Implemented Interventions 19

to the downward extension of what some consider a “best practices” model of service delivery for older children with ASD. One wonders what has been gained and what has been lost by replacing the family-­centered model of infant–toddler intervention described in Public Law 94-457 with a direct intensive service model. Key Practice: Parent Coaching and Family-­Centered Care Coaching approaches can be found within sports, business, education, humanistic psychology, behavioral and cognitive psychology (Allcorn, 2006). Grant (2006) suggests several common themes that unify the widely different contexts and practices in which coaching occurs: 1. Relationships are egalitarian and collaborative, rather than authoritarian. 2. The process begins with defining goals, constructing plans, and working

systematically toward goal attainment. 3. Goals involve personal growth or self-­directed learning rather than treatment, recovery, or diminished symptoms. 4. Goal setting is a collaborative process. 5. Coaches are not necessarily content experts, but they are process experts. These themes and values resonate with the kinds of relationships that we authors have maintained in parent coaching relationships with families and with the values that we hold as clinicians. The development of our parent coaching approach has been powerfully influenced by many voices. Two, in particular, require mention. Carl Dunst has provided an unwavering voice and key research in support of family-­centered care (Dunst & Trivette, 2009a, 2009b; Dunst, Trivette, & Hamby, 2007). His research findings and values have influenced an entire generation of early intervention practices. Ann Turnbull, a professor of special education and the parent of a child with disabilities, has powerfully voiced the necessity of parental advocacy and parent–professional partnerships in order to create a world of inclusive education, work, and supports for persons with developmental disabilities (Turnbull & Turnbull, 2015). Dunst’s and Turnbull’s visions, advocacy, and science have had major impacts on special education and early interventions’ transition to a more family-­centered focus on parent coaching and parent–professional partnerships. In 2004, a landmark publication by Hanft, Rush, and Shelden (2004) brought the practice of coaching into early childhood intervention front and center. It clearly articulated a radically different way of working with parents from that to be found in parent training models, like TEACCH and DTT, or the “show-andtell” or “magic hands” models that came from the health sciences and emphasized

20

Coaching Parents of Young Children with Autism

hands-on therapy practices. Deeply informed by research in infant–­toddler development, infant mental health, the science of adult learning, and communication science, these authors stressed the parent–child dyad as the necessary focus of attention for early intervention, and children’s interactions with caregivers within activities of daily life as the necessary source of learning opportunities supported by early intervention. Their work continues at this time with their collaboration in the Family, Infant and Preschool Program (FIPP) and a second coaching handbook (Rush & Shelden, 2011). Starting from the Hanft et al. (2004) text, the Rush and Shelden (2011) text, and the FIPP website materials (www.fipp.org), and also deeply influenced by the knowledge and practice base of infant mental health (Fraiberg, Adelson, & Shapiro, 1975; Stern, 1985; Zeanah, Berlin, & Boris, 2011), we constructed and tested a parent-­implemented ESDM model (P-ESDM) based on parent coaching practices. The framework, materials, and measurement tools that we developed and tested in our multiple P-ESDM studies and our clinical P-ESDM practices are all available in this text. Parent coaching (as contrasted to parent training or parent education) nests within the larger framework of family-­centered care. While the term family-­ centered care is used throughout service delivery systems, not all systems of care that describe themselves as family-­centered actually provide care that is centered on family needs, family strengths, family beliefs, family values, and family routines and practices. Two main factors in family-­centered care have to do with shared decision-­making and parent–professional communication styles. The concept of family-­centered care gained much of its momentum from the advocacy of parents of children with developmental and chronic health needs in the 1980s: In a system-­centered model, care processes are structured to facilitate the function of health care professionals to serve patients; patients must adapt to the constraints of the system. When a patient-­centered model is used, the opposite is true: The system accommodates the individual. In pediatrics, patient-­centered care is typically referred to as family-­centered care to acknowledge that children’s well-being is inextricably linked to that of their families. A family-­centered approach requires recognition that families have the most expertise about their child and, therefore, that they have the right and the responsibility to collaborate in medical decision making in behalf of their child. (McGuinn & Worley, 2008, p. 215)

Dunst and Trivette (2009a) proposed a framework for help-­giving relationships that empowers families by promoting family competency as it pertains to identifying and managing their child’s needs. Their model of empowerment requires specific conditions for both families and professionals: that families acquire (1) an increased understanding of their child’s needs, (2) the ability to deploy competencies to meet those needs, and (3) self-­efficacy (a belief that they are capable) to do so. Among the desired qualities of help-­givers (professionals) in this model are:



Key Practices in Parent-­Implemented Interventions 21

(1) that professionals have a proactive stance marked by a belief that help-­seekers are already competent or have the capacity to become competent; (2) that professionals create opportunities for competence to be displayed by providing enabling experiences to help-­seekers; and (3) that they allow help-­seekers to use their competencies to access resources and attribute success to their own actions, not the professional’s. In essence, Dunst and Trivette (2009a) suggested that viewing the relationship with help-­seekers from a strengths-based perspective rather than one of deficits is a more effective way to achieve desired outcomes for children with special needs and their families. Dunst and his colleagues have been leaders in advocating, defining, demonstrating, and examining family-­centered care for decades. Their work to transform early intervention practices from “a deficitbased, child-­focused early intervention to a strengths-based, family-­focused early childhood and family support program” (Dunst & Trivette, 2009a, p. 120) began in 1975 and continues to the present, influenced strongly by advanced in-­family systems theories, by the development of ecologically based frameworks for looking at child development (e.g., Bronfenbrenner, 1986), and by a productive program of research (Dunst & Trivette, 2009b) into every aspect of the model that has generated considerable support. Table 2.1 condenses descriptors of family-­centered care from McGuinn and Worley (2008) and coaching practices from Hanft, Rush, and Shelden (2004). Conclusion The importance of family interactions and routines as the context for children’s early learning was a compelling concept behind the 1975 creation of the Education for All Handicapped Children Act (Public Law 94-142). The concepts and law were extended to infants and toddlers with risks and disabilities (Part C of IDEA) to enhance infant–­toddler development and to provide support for families to meet the special needs of their young child, as well as to reduce the downstream governmental costs of treatment and education by intervening as soon as intervention needs were recognized and by emphasizing least-­restrictive environments. Both the law and findings from decades of research on infant–­toddler development of both typically and atypically developing young children over the past 4 decades emphasize the necessity of (1) supporting positive parent–child relationships fundamental to optimal early development, and (2) supporting caregivers in each child’s natural environments and activities, to understand and support the young child’s development—in order to optimize child and family outcomes.

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Coaching Parents of Young Children with Autism

Table 2.1.  Similarities and Differences in Family-­Centered Care and Parent

Coaching Concepts

Family-­centered models of care

Coaching in early childhood intervention

Parents are experts on their children.

Coach and parents pool their expertise.

Parents need to be part of the decisionmaking process.

Parents and coach make decisions together.

Identifying family strengths and needs.

Emphasis on assessment of family strengths and needs for support; parents’ goals, values, practices.

Relationship between medical personnel and parents should be collaborative.

Collaborative, partnership relations.

Importance of culturally sensitive care.

Importance of cultural sensitivity and learning from family.

Importance of community ties and community-based supports.

Community-based activities and supports.

Treat families with respect and support.

Mutually respectful partnership.

Optimal child functioning reflects supportive family and community.

Intervention focused on child participation in the family and community.

Needs of all family members must be considered.

Supporting family means supporting all its members.

Services need to be easy for parents to use.

Skills being coached need to be easy to learn and easy to implement in everyday contexts.

Providing honest, unbiased information to families.

Having honest reciprocal exchanges and sharing reflections and evaluations.

Honoring diversity in all its aspects within families.

Having honest reciprocal exchanges and sharing reflections and evaluations.

Respecting different methods of coping and use of supports.

Acknowledging and building on parents’ ways of coping and their use of their own supports.

Importance of parent–parent support and social support systems for the child and family well-being.

Attention to social network that supports parents and family, focus on community relations more than professional relations.

Services organized and designed based on child–family needs, not agency needs.

Coaching services designed based on family needs and preferences.

Interdisciplinary care and comprehensive services.

Coach functions in an interdisciplinary way— addresses all child’s treatment goals.

Note. Data from McGuinn and Worley (2008) and Hanft, Rush, and Shelden (2004).

Chapter 3

Becoming a Coach Knowledge, Characteristics, and Supports

Parent coaching adds additional skill sets to our early interventionist repertoires: new ways of thinking, new skills and knowledge, and new resources to tap. The more complex interactions and events that occur in coaching create needs for new supports and resources for coaches. This new tool kit supports parent-­implemented child intervention in all kinds of natural environments. It provides the interventionist with new ways to build working relationships with parents, based on partnership, collaboration, and adult learning principles. Very few parent-­mediated interventions discuss straightforwardly the fact that the primary goal of coaching parents is to change adult behavior. Child change is the secondary goal, and it is the hoped for effect of parent behavior changes. The learning process that parents begin as they enter parent coaching requires ongoing effort in learning, practicing, and generalizing new skills, as does any other adult goal of changing out old habits for new ones. This is not how our field has typically discussed parent-­mediated interventions. However, we have found it very helpful to recognize and embrace the behavior change of parents as the primary target of intervention in the P-ESDM model and the mediator of change in children (just as behavior change was our goal as we learned these skills and taught them to our students.) This conceptualization of parent coaching led us to a number of adult learning concepts, empirically based tools, and teaching and assessment procedures from other well-­established interventions that we found helpful as we coached and supported parents through a process of change. In this chapter, we describe the coaching approach we have developed to help parents turn their new learning into long-term cognitive, emotional, and action-­oriented habits. This chapter addresses what coaches need to know, some 23

24

Coaching Parents of Young Children with Autism

characteristics of an effective coach, and coaching strategies for addressing lapses in parent motivation and follow-­through. In addition, we provide the self-­ monitoring tools for parents to guide their own learning and their own behavior changes. After all, adult learning is about internal motivation, personal goal setting, and ongoing self-­evaluation; adults need to own their own learning in order for it to occur. What Coaches Need to Know

Know the Evidence The expectation that interventionists use evidence-based practices is written into laws, insurance reimbursement practices, and professional codes of ethics. Parent-­ implemented intervention is an evidence-based practice, as is the use of a coaching relationship to help adults change behavior. Knowing the concepts and the evidence base behind their parent-­implemented coaching model deepens coaches’ understanding and commitment to their work while helping them answer parents’ questions and problem-solve more successfully. How can interventionists learn the deeper aspects of their chosen model? Early intervention agencies with which we have worked use several strategies for building coaches’ knowledge base. They support motivating speakers who deliver the evidence in person using well-­filmed and well-­edited videos, and sometimes individual stories; visually clear data create energy and enthusiasm for learning and change. They provide staff retreats, and in-­service sessions offer new learning in environments that allocate the time, group support, and social rewards needed for acquiring new skills and knowledge. They share attractive self-­learning materials in the form of links to reliable websites and YouTube postings; the videos of other skilled coaches dealing with challenges and a wide range of families and children; visually compelling handouts and electronic materials; annotated bibliographies of key concept papers, review articles, book chapters; and studies that include articles and personal checklists for organizing and task-­analyzing learning. They encourage and support regular peer supervision groups focused on the sharing of videos and self-­measurement using fidelity of implementation measures; these provide necessary opportunities for the refinement, maintenance, and generalization of learning among supportive peers who share the same learning goals. Staff learning requires time, and agencies that set aside work time to be used for new learning deliver a powerful message about how much they value the quality of work their employees will provide. This, in turn, enhances interventionists’ self-­ esteem and confidence in their professional skills. Finally, knowing the evidence provides coaches with the base they need to answer parents’ questions about the evidence and concepts behind various approaches. Coaches who can answer such questions knowledgeably and share



Knowledge, Characteristics, and Supports 25

materials at parents’ request quickly demonstrate their preparedness and expertise, which increases parents’ buy-in and motivation for the work at hand.

Master the Practice Many evidence-based, low-­intensity parent-­implemented practices belong to the category of NDBIs (Schreibman et al., 2015). Numerous different brand-name interventions and professional disciplines use some type of naturalistic approach as a basis for treating young children, because these methods support child motivation and participation. NDBI approaches are built on principles that reflect what is known about how young children learn most readily: within familiar settings and routines, with people they know and feel comfortable with, with materials that they choose and prefer, in activities that fit a child’s current abilities and interests. What do we mean by naturalistic approaches? In general, adults using naturalistic approaches follow children’s interests, preferences, and skill readiness. They interact with the child as a play partner, rather than as an authority figure. They use reward strategies that are part and parcel of the activity, material, and interaction, rather than external reinforcers like food and drink (unless the activity is a meal!), tokens, points, stars, or a preferred object (phone or computer) that is not part of the activity. They capitalize on the child’s interest and pleasure to capture and hold his or her attention, and they use children’s own desires to repeat pleasurable activities to assure opportunities to practice the new skill. The most skilled naturalistic therapists also present learning challenges that are just beyond the child’s current skill set in order to stimulate mastery motivation in the child, with all the pleasure that accompanies it. Understanding that children cannot perform at their most skilled level every single time, they also assure the child has ample opportunity to enjoy the activity and receive those internal rewards using his or her current skill set. Naturalistic approaches can be found in developmentally based interventions, sensory-based interventions, and interventions derived from ABA. Pivotal response training (PRT; see Schreibman & Koegel, 1996, for an early review) and incidental teaching (McGee, Krantz, Mason, & McClannahan, 1983) were the first two ABA-based interventions for autism to publish treatment studies for children with ASD that used naturalistic ABA approaches. Interventionists from speech and language pathology, occupational therapy, and early childhood special education typically use naturalistic approaches for young children in their disciplinary work. The unique feature of NDBIs is the careful integration of developmental science and learning science (ABA) within a naturalistic teaching approach. In addition, NDBIs emphasize predetermined teaching goals, ongoing data collection, task analysis, and developmental sequencing of treatment objectives to determine the daily skills to be practiced and taught, and data-based decision making, and thus fit well into the legal requirements of individualized family service plans

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(IFSPs) and individualized education plans (IEPs) for preschoolers. For interventions grounded in ABA, NDBI adds developmental knowledge to decisions about goal development, communication-­stimulating interaction with an adult who is a reciprocal communicative partner in all activities, and the motivational benefits of child choice and child preferences. One unique aspect of ESDM within the NDBIs is the practice of teaching to multiple objectives with several repetitions inside a single ongoing activity, which adds many more learning opportunities in a time period than can be attained when only one objective is focused on at a time. In order to coach a parent to implement an intervention approach at home, a coach has to have extended mastery of the skills and concepts to be learned. It is far more difficult to coach someone else in a skill than to carry it out oneself, because coaching another person requires that the coach translate into words all that he or she knows, including knowledge held so deeply that the coach performs those actions without thinking about them. Bringing such “automatic” actions into one’s mind and one’s vocabulary; learning to articulate the why’s and wherefores behind such actions; being able to break down complex actions and ideas into very simple, quickly learned scripts (see Chapters 6 and 7 of this book for detailed how-to examples); and being able to deliver that learning at just the point and level that a parent needs to learn in order to use the skill in the moment and also generalize it—this requires additional learning and practice, both didactic and experiential, including self-­assessment, feedback, and supervision. Given all that goes into providing intervention for young children with ASD, how does a coach decide what parents need to learn in order to implement a practice at home? Most name-brand NDBI practices use an explicit assessment tool or approach that helps to define what the adult needs to do within a teaching interaction, and these are known as fidelity of implementation (FOI) or fidelity measures. The FOI measure explicitly describes each skill that a well-­trained practitioner uses and provides a means of measuring the accuracy of each skill, thus giving the coach a convenient way to assess what parents are learning within coaching and where additional coaching is needed. In addition to the brand-­specific fidelity tools, there is also a recently published NDBI FOI tool that coaches can use if their method of practice does not have an FOI associated with it (Vibert et al., 2020). We recommend that coaches assure their own fidelity of practice before coaching others, and this can be accomplished in a variety of ways, including formal training (with associated fees and associated professional continued education units [CEUs]), self-study or group study using Web-based and written materials and peer supervision, and inservice training efforts utilizing a consultant, among others. For parent coaching, we have created a public website, Help Is in Your Hands (www.helpisinyourhands.org), with many free materials for coaches and parents. Other branded interventions also have affiliated websites and offer a variety of training options. For busy early interventionists, taking the time to learn and perfect their skills



Knowledge, Characteristics, and Supports 27

may seem incredibly difficult, but most of us are accustomed to the expectation of continued learning in our professions, given our agency or licensing requirements for continued professional education. Ongoing inservice training at an agency level, the requirements of an agency’s annual review, and annual professional goal setting all provide structure and incentives from employers and professional associations for improving clinical practice. Joining a formal training program brings the benefit of externally structured learning and motivational enhancements. If you decide to take a self-­instructional approach, consider the following, and please remember that social support from peer learners will help you with consistency, motivation, and practice as well as objective feedback about your learning, all of which will help you learn more rapidly and more successfully. Try teaming up with a colleague or two to complete this process together by following these steps: 1. Set a year-long goal of attaining fidelity in the practice of your choice. 2. Develop a set of short-term objectives or benchmarks (over, say, a period of

12 weeks) that require no more than an hour or two of your time per week, and schedule your time slots for the year! 3. Break down each set of short-term objectives into six steps with mastery criteria for each, and create a data sheet for yourself. 4. Choose an FOI tool to define your long-term goals. 5. Videotape (with permission, of course) your work with several children to provide yourself with a baseline and progress data. 6. Code your partner’s work as well as your own, so you both have some objective scores. 7. Set up regular times to meet with your partner (we suggest every 2 weeks) to review and code sections of videos that demonstrate your current goals. 8. Keep yourself focused on just one skill at a time to boost your confidence and self-­esteem. 9. The fidelity scores of master therapists typically fall in the 85–90% range. Perfection is not a human attribute! So far, we have discussed the tools a coach needs in his or her tool kit in order to transition into a coaching role. We have additionally discussed interdisciplinary knowledge of the child’s needs and strengths (the generalist role), a back-up team of colleagues who also know the child and family and can provide advice and support, well-­developed skills in the intervention being applied, and a peer support and supervision group. We also assumed that the coach has kept the child’s goals in clear view and has broken down all related objectives into short-term learning goals. A final assumption is that the coach has had meaningful experience training others to carry out interventions—­students or other trainees, assistants, and colleagues who have asked for help with certain techniques. We will cover step-bystep skills in coaching a session in later chapters. Right now, we need to focus on

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Coaching Parents of Young Children with Autism

two more areas of skill: how to transition from direct therapy to coaching models, and how to develop the kind of relationship that is necessary with parents when one becomes a coach.

Shifting Intervention Sessions from Therapist–Child to Parent–Child with Coach Support It is very difficult to transition from direct intervention to parent coaching, and it is even more difficult to do this with families that have experienced you as a direct therapist. Remember the purpose of the shift—to increase children’s learning opportunities exponentially and to provide parents with the skills they want: to know how to help their kids, what to do and how, when, and where to do it. Parents want to get it right. It is our universal experience that when we first meet parents with their young children, the parents’ initial question is “What can we do?,” not “What will you do?” Therapists who tell us that the parents they work with are not motivated, that they sit on the sidelines, or text, or check their phones, or do housework, or nap during their home visits do not realize parents develop these habits in response to therapists providing direct therapy in the treatment hour. Interventionists who want to support parent-­implemented intervention will do well to look out for these intentional or unintentional therapist’s behaviors, which often signal that the parents are not integral to the intervention: • Working with the child, rather than supporting the parents to work with their child • Telling the parents what the intervention’s goals are, rather than asking them what they want their child to learn • Directing parents what to do at home, rather than asking them how the therapist can be of help in everyday life at home • Working only with materials and equipment that the therapist has brought to session, rather than items the parents have at home • Conducting activities that are far removed from the typical daily living routines these parents carry out with their child • Expecting that the parents will observe rather than interact, or asking the parents not to interact because it interferes with treatment For all these reasons, it is often easiest to begin your coaching practice with families that are new to you as an interventionist, so you can develop coaching interactions from the start. Chapters 5 and 6 describe how to begin the parent– child–coach interactive triangle from the very first contacts, in the initial assessment and treatment sessions. However, we have watched so many therapists shift their practice from direct therapy to coaching that we know this approach can be successful and that parents will be very appreciative of their new role once they



Knowledge, Characteristics, and Supports 29

have had the chance to learn it. For families that are accustomed to being on the periphery, the coach can set up a new plan for collaborating following these steps: 1. Discuss the new plan and the reasons for it at the beginning of a session.

Be ready to notice and address positive and negative emotional reactions to change. 2. Ask parents what their goals are for the session, and ask them to describe something that has gone well or not so well with their child over the past week (the initial observation activity). If the parents do not have a goal, you can share your list of treatment goals and let them choose one. 3. Ask the parents an open-ended question: how they felt about the activity and their child’s response, and share your own reflections about what occurred, emphasizing the parents’ successful actions and any positive reactions to the parents the child may have had. You have begun the plan– act–­reflect–evaluate format that will be laid out in Chapters 5 and 6. 4. It is critical that in this first encounter the parents have a positive experience working with their child, and it is the coach’s responsibility to make sure this happens. However, for adult learners, feelings of success and competence come not from adult praise, but rather from meeting their own goals, which in this situation are reflected in their child’s positive response to them, their child’s learning, the parents’ enjoyment of such interactions, and the parents’ sense of mastery and competence as expressed in the child’s learning and engagement. The coach who responds to parents’ efforts with their child by highlighting these observations has provided a much more powerful reinforcer than the coach who simply tells them how “great” they’re doing (which in itself is kind of judgmental and distancing for some parents).

Incorporating Principles of Adult Learning into Your Coaching Parents, like coaches, are adult learners of the intervention being used, and the principles of adult learning apply to both. As adult learners, parents have goals for their own learning based on their immediate interests, priorities, and needs. They expect to see immediate consequences for their efforts. If their goals are not met, they will not maintain a learning relationship with the coach. Parents need to feel respected for what they bring to the situation, and they evaluate the teaching–­ learning process as it unfolds. Adults (like children) are hands-on learners. If there is an action to be accomplished, they will learn it by doing it, seeing its effect, and assessing what occurred. This is where feedback about what just happened can be helpful. Watching and copying a more skilled person are less effective and much less satisfying than doing and assessing, which emphasizes independence, intention, and control. A beginner cannot learn a tennis swing (or how to play

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Coaching Parents of Young Children with Autism

a musical instrument, or a dance step) by being told how to do it, or by reading about it, or by watching someone else. One has to pick up the racket, hit the ball, see what happens, and then have a coach explain why the ball went where it did. Then one has to hit the ball again and again, and again, until the muscles and brain learn to do automatically what one aims to accomplish. Parents need to experience the same rewards that skilled therapists experience with children in intervention: the reward of seeing the child make small changes, the pleasure of interacting with a happy child, the excitement of seeing learning happen in the moment, and the sense of competence that comes from helping children reach new goals. These are the rewards that have fueled us as therapists, and these are the rewards that we, as coaches, need to hand over to parents to experience firsthand—to build their feelings of confidence and competence in themselves and in their children. Now that we have described the learning content that new coaches need to begin coaching the parents of young children with ASD in everyday activities with their child, it is time to examine the type of interpersonal relationship that marks a successful coaching relationship between adults and coaches. Coaching Characteristics: The Relationship between Coach and Parent Parents need to know (and feel) that the coach genuinely cares about them and their child in order to be open to the coaching process and willing to work together. Think back to the last time you tried to learn something completely new. Remember how inept you felt, how anxious you might have been, how embarrassing it was to make mistakes, how impossible it seemed that you would ever master the skill. With coaching, parents are not only trying something different but also doing so with the most important person in their life—their child—in front of an “expert” whom they do not know very well. Parents have to trust what the coach is teaching them, have to be motivated to keep practicing, have to feel safe enough to talk about their experiences, and have to be comfortable asking for help without feeling inept, ignorant, judged, or criticized. They must have the humility to make mistakes and demonstrate failures in front of the coach without becoming so discouraged that they give up trying. A competent coach shows a caring, compassionate attitude through encouragement, humor, acceptance, and the creation of a safe, supportive, and motivating environment in which parents can try out new approaches, ask for guidance, and make mistakes, accepting them as a necessary part of the learning process. The coach who empathizes and reflects on his or her own mistakes or misjudgments emphasizes a common learner stance. A coach who understands errors as markers of learning opportunities is providing the kind of emphatic reciprocal relationship that will support parent learning.

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Such a relationship is guided by a mutual understanding of the reason for engaging in coaching (to benefit child learning) and the roles involved (both have expertise and both are learning from each other via past experiences and current practice, reflections, and discussion). See the box for questions that will help parents reflect on the coaching relationship. Effective coaching depends on certain skills and certain qualities that the coach demonstrates to parents. The skill set includes a deep knowledge of the early intervention that the child needs. However, supporting parent learning of early intervention skills involves five key characteristics of a successful coach–parent relationship: being collaborative, reflective, nonjudgmental, conversational and reciprocal.

Being Collaborative A collaborative coach works with parents as partners to reach common goals, rather than deciding on the goal for the parents or leaving all responsibility to them. Collaboration means asking questions, deep listening, and summarizing or restating parents’ comments to show respect and a desire to understand their goals, topics, concerns, and point of view. Parents also ask questions, listen, reflect, and assess to establish and reach common goals. Each party shares expertise with the other and conveys recognition of the other’s knowledge and abilities.

Being Reflective Reflection promotes continuous improvement by considering in depth what has just occurred and sharing those reflections in ways that illuminate progress toward the goal at hand. Coaching calls for the sharing of reflections after each activity,

Questions to Help Parents Reflect on the Coaching Relationship • “What were the parts of today’s session that seemed most helpful for you? The least helpful for you?” • “Are you feeling more encouraged or more discouraged about our work together over the last couple of weeks? Why?” • “Have you had some ideas or thoughts about ways that this might go better for you or for your child?” • “We’ve been working together for a few weeks now. How is this going in terms of what you expected when we first met?”

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followed by the creation of a plan to take the next step toward the immediate goal. The intent of this reflective discussion is for parents to consider what has happened and to compare what they intended versus what occurred. For coaches, the purpose of reflection is to highlight the relationship between parents’ actions and the child’s actions given the goals on the table and the previous knowledge that the parent has attained. Reflection typically contains or is followed by evaluation and an action plan for the next activity generated at times by parents, or suggested by the coach if need be. This process of plan–act–­reflect–evaluate builds parents’ capacity to use the learning being gained via coaching to build more teachable moments into their everyday activities with their child. Rather than placing the entire burden of reflection and assessment on the parent or coach, the reciprocal nature of this process permits the coach to demonstrate the process of reflecting, assessing, and planning; allows the parent to learn to plan, self-­assess, and self-­correct when the coach is not present; and illustrates the kind of partnership needed between parents and interventionists to best support children’s learning.

Being Nonjudgmental A nonjudgmental stance involves acceptance of parent and child as he or she is. It is conveyed in the body language and spoken language that occur throughout a session. While we see many examples of praise used by people who work regularly with parents, we agree with Hanft and colleagues (2004) that words of praise like good, great, and perfect have associated drawbacks that can interfere with our goals as coaches. One limitation is that they do not actually convey any information. They are easy to use and ubiquitous in our work, but they don’t provide much feedback to the learner from which he or she might grow. Compare two statements made to a grandfather following a puzzle activity with his 2-year-old grandson. Scenario: Grandfather is working on the goal of following a child’s leads instead of directing; in prior sessions, his grandson would get easily frustrated and leave the activity. In the current activity, the child finds the correct place for a star-­shaped piece, but it’s not aligned properly and doesn’t drop in. He fusses with the piece and then begins to become very frustrated. Grandpa says, “You want it to go in! But it’s stuck! Want help?” The child asks “Help” and hands the piece to Grandpa, who immediately gives it back to the child, gently nudging him how to position it into place, while saying, “Turn it.” Statement 1 to the grandfather: “Wow, fantastic! You nailed that!” Statement 2: “It stood out to me how, when he couldn’t fit the piece in, you commented on his frustration and you offered help, and then he wanted to do it and you helped him turn it, so he could feel it slide in. He stayed with you the whole time! And, he was so pleased—­sharing that smile with you, like ‘I did it,’ like ‘We’re a good team!’ ”



Knowledge, Characteristics, and Supports 33

In Statement 1, the coach shares the pleasure in the moment and provides generic praise to the grandfather. But there is a subtle evaluative component to that praise: as if the expert is judging Grandpa’s behavior and finding it worthy. In Statement 2, the coach describes the key features of the interaction that align with the grandfather’s and child’s goals. The coach emphasizes the effect of the grandfather’s responsive action and words on the child’s frustration and motivation to complete the puzzle as well as his relationship with Grandpa. There are no evaluative words. When caregivers can evaluate the result of their efforts in terms of their effect on a child’s behavior, they are using the same feedback loop that interventionists use, one that is always present for them. It helps them develop the self-­sufficiency they will need when trying to follow interactive principles when alone. Although it is inevitable that we sometimes offer praise, we work hard to use descriptive language in most of our reflections and feedback to parents. We want to use language that describes what we saw in the relationship between parents’ actions and their child’s behavior. The parental actions we focus on are those that a parent has explicitly chosen for the interaction. Tying descriptions to a parent’s and child’s goals helps parents learn to think behaviorally and analytically about their interactions with their child—the source of all information about whether goals are being realized. Modeling and supporting this type of reflection in our shared reflections prepare parents for the job at hand.

Being Conversational and Reciprocal Given that we see the relationship as a partnership, we strive for a style that is conversational: friendly, warm, accepting, and grounded in confidence in the parent and child. We need to demonstrate the partnership in balanced exchanges, meaning that the coach and parents are each initiating and responding to the other and sharing the conversational floor. This requires that the coach be sensitive to the timing of conversation and staying on topic, while engaging in deep listening and turn-­taking in terms of questions and reflections. The coach should not interrupt the parent while he or she is talking unless it is necessary given time restraints or with permission, and in the service of understanding what the parent is conveying. There is an implicit challenge in trying to adhere to these practices while also understanding that the goal of coaching is to provide parents with an assortment of possible actions that will help their child, which necessitates learning through acting, not talking. We have solved this problem in the structure of the session by following each action activity with an opportunity for reflection–­evaluation and goal setting, and then offering a discussion period at the end of each session. This structure will be described in Chapter 6.

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Coaching Parents of Young Children with Autism

Supports for Coaches Shifting the focus of early intervention from direct treatment to parent coaching has major implications for early interventionists. Self-­identity and self-worth, personal sources of motivation for the work, professional competence, knowledge, and skills are all on the line. Addressing children’s specific intervention needs in natural environments rather than well-­stocked and well-­controlled clinical settings requires a new way of thinking and working with children and parents, and most therapists were never trained in such models.

Motivations for Learning and Adopting a Coaching Approach Interventionists who are contemplating a move into coaching often express some anticipated loss of the satisfaction they experience doing direct treatment. The one-on-one relationship developed with children and the pleasure in seeing them progress reflect the values of the people who choose this work as well as important rewards for doing it. However, we have found the rewards derived from the coaching relationship to be even more potent than those we experience in direct intervention. And, these rewards occur at several levels. In our conversations with interventionists who choose to make this transition, they frequently mention several aspects of coaching that motivate them to learn the processes. They convey their initial enthusiasm and optimism as they imagine the effects on child learning of caregivers who provide needed learning opportunities in everyday environments throughout the child’s routines and activities, throughout the child’s waking hours. That is what motivates therapists to become coaches. For those who are developing fidelity to evidence-based NDBI practices for the first time, they tell us that learning empirically supported parent-­implemented interventions provides a sense of security to them: that they will now have a set of tools they know will help the children they serve in measurable ways. They note a contrast between the clarity they experience with the specificity of practices and tools that they are learning to use, compared to the feelings of confusion, frustration, and sometimes failure that they experience in the face of a child’s poor progress within the low-­intensity interventions they have been using. A third source of satisfaction and reward comes from the coaching experience itself. When interventionists see parents and children constructively and happily engaged and learning, they experience a sense of competence in being able to impart critical skills to parents and, in turn, their children. Seeing the effects of a parent’s efforts at home on a child’s development week-by-week is a powerful reward, for both coach and parent alike. Watching parents build their skill set and competently manage difficult situations with their children speaks volumes about the coach. The changes in parents’ confidence, changes in parents’ views of



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their children’s competence, and changes in parents’ attitudes about their child’s future communicate powerfully to coaches about the efficacy and value of coaching as a means of intervention. We should not overlook the positive experiences that children have in these sessions, and their increasing pleasure in interacting and communicating with their parents in a variety of everyday activities. Happy children who are learning and progressing well may be the most potent reward and motivation of all. Motivation and reinforcement are critical sources of change, for coaches, as well as for children and parents.

Working Through Negative Reactions That Arise with Change “I don’t feel like I am doing my job!” Catherine led off with this comment as the discussion hour between her team and their coaching consultant began. “I feel like I am paid to provide the best intervention that I can in the limited time I have with this little boy. Just sitting on the sidelines and trying to help his mom learn how to get his attention and teach him language feels like I am wasting precious time and hurting his progress. It feels irresponsible!” There are also negative emotions that arise as one moves into unknown territory—fears of failure, of incompetence, and of losing one’s professional identity as an interventionist, clinician, therapist, or educator. For those who are in a position to choose a coaching role, such feelings are likely inevitable, but they are mitigated by the positive emotions that draw them into coaching practice. For those who have been assigned to, rather than choose, a coaching role, these negative reactions are not tempered or balanced by the positives that come from choosing to take on this role. There may be anger, sadness, worry, and doubt, a sense of being devalued for the work they have been doing and of losing their professional identity. For those who have doubts and hesitancy about learning the coaching process, we have found it helpful to work together in a peer group setting, where such worries and doubts can be expressed among supportive others. As the group shares their thoughts and feelings about their changed role, members find comfort in knowing that others also have doubts, and they also learn what motivated others to make the change—the anticipated rewards, emotional, behavioral, and cognitive, that can result from this new way of working. The shared positive emotion that results from this type of group conversation enhances motivation and positive feelings among all members. And, sharing the negatives in a group helps to normalize these feelings and realize that they do not need to hold one back. Sharing among other adult learners enhances both the learning process and emotional ties between group members. The motives shared by those seeking to transition to coaching can influence those who have not yet made this choice, because the professionals who opt to

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work with young children and their families have a similar value system. They want to help children; they wish for children to get the most assistance available; they want to feel competent when promoting changes; and they are rewarded by a child’s progress and positive relationships with his or her parents. Using group learning situations that emphasize group discussion and interpersonal sharing can stimulate the motivation to learn and showcase coaching approaches for those being asked to make this change. Leaders of a coaching group can embed opportunities for sharing individuals’ thoughts, feelings, and reactions into each of the learning activities themselves. Allowing ample time for discussion throughout learning activities and providing open-ended questions to the group stimulate reflections and sharing of personal reactions to new concepts and skills. The group can discuss the process of change itself and the positive and negative emotions that occur. Many interventionists will already be familiar with the ideas of people like Erik Erikson and Jean Piaget, who portray learning and development as a healthy process of resolving conflicts between old and new ways of doing, thinking, and feeling. Without conflict, we cannot grow.

Ongoing Interpersonal Support Both new and established coaches need ongoing peer support and supervision. Providing regular and frequent opportunities for these activities helps support coaches and maintains positive morale. They are easier to provide when several coaches all work at the same agency. Those who work independently can set up such activities via telecommunications. Regular peer supervision meetings with coaches and interventionists from other disciplines allow each coach to access the kind of transdisciplinary help that we need when working in a generalist role. We have found it important to include a team member who is a licensed mental health professional in these group meetings because of the questions or concerns about difficulties in interpersonal processes, adequacy of child care, difficulties with child or family progress, or child and family mental health concerns that frequently arise in this work. Additionally, those working in a hierarchical structure like an agency, hospital clinic, or school need to know that they have a champion, an advocate from within the power structure, to support their transition to a coaching and parent-implemented model of intervention. Program administrators who believe parent coaching is the best way to serve young children support the learning and communication needs of their team, and support the time needed to plan, reflect, review, and provide peer supervision. Does it cost more? Not necessarily. Does it accomplish more? Evidence suggests that the answer is “yes.”



Knowledge, Characteristics, and Supports 37

Generalized Knowledge about Development in ASD Parents have many questions about ASD at the start of intervention, and coaches need to have the answers. Thanks to the requirements of public early intervention laws, it is now the norm rather than the exception that interventionists work in multidisciplinary teams. The source of needed learning in this area may exist directly within the team. Each team member has disciplinary knowledge about treating ASD, so the team itself is the first source of knowledge about early ASD development and intervention in various affected domains. This leads to the challenges of role release and of dissolving disciplinary boundaries. For some, sharing expertise with others may feel as if they are being diminished or their role on the team is somehow less valued by the process; for others, it may seem as if they are being expected to do something they do not know how to provide. One of the easiest paths to role sharing between team members of different disciplines is working together simultaneously with children so that each has a chance to observe the other’s work and ask questions about what that individual is doing and why. It is common for professionals from various disciplines to visit the same child at different times, delivering different treatments. Working together with children in occasional joint sessions helps overcome communication barriers, allows specialized information to be shared, and strengthens a sense of collaboration among different disciplines. Inservice training opportunities, team sharing of data from professional conferences, circulation of key websites, reading materials, and self-study further general knowledge as well. Encourage team members to fulfill their requirements for continuing educational credits by learning more about early ASD, thereby addressing two goals at once. Sharing their new knowledge and new learning materials with the rest of the team via inservice training promotes maximum gain from the money spent on learning.

Understanding What Motivates Parents What motivates a caregiver to show up at the coaching session? What does he or she want to accomplish? What is the individual’s current skill set or knowledge base? These are questions the coach must be able to answer to ensure that the coaching process and learning experiences will address the caregiver’s goals and will result in immediate feedback and measurable progress. Constructive behavior change begins when adults are motivated by their intrinsic values, by something they consider important. Adults learn what they choose to learn. This concept was first identified by Knowles (1980), who was considered the “father of andragogy” (adult learning). When coaching in parent-­implemented interventions, parents’ motivation stems from the desire for growth and change in their children. It

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is in the coaching process that the parent realizes the change in his or her child’s behavior will result from changes in parental actions. Thus, in addition to parental skills, knowledge, and goals, the coach needs to learn about parental motivations, which will help define parental reinforcers. How does the coach assess not only parental motivation but also the motivations of each adult in the child’s familial care team? Here are some questions to help you start exploring family member motivation: • “What would you like to accomplish?” • “What motivates you to want to be here?” • “What motivates you to want to try to learn something new?” • “How is this current experience similar or different from other experiences you’ve had when learning a new skill?” We are accustomed to incorporating the principles of learning into our intervention strategies with children. We establish antecedents that elicit specific behaviors that are followed by consequences that can encourage or discourage such behavior. Adult learning is just as much about antecedents, behaviors, and consequences as is child learning, and in particular the coach needs to think carefully about the consequences a parent may experience. What motivates and is reinforcing to adults? Intuitively, we might assume that praise is reinforcing for the parent, but as we discussed earlier, this is not actually the case. Why? Because seeking approval of others is seldom the adult’s goal for participating in a learning activity. Parents enter into coaching to help their child achieve progress and to help their child learn. A child’s progress is a powerful reward. Knowing that it is the parent’s interactions that have fostered their child’s growth is another powerful reward for adults: providing a sense of personal efficacy, competence, and confidence. Parents often carry feelings of guilt and blame about their child’s autism, the sense that they did something that might have contributed to it. Parents’ desire to help their child, to do everything possible to limit the disabling effects of ASD, and to promote their child’s improvement is the driving force behind their contact with the coach. There is often another goal as well—stated or not—the desire to replace the feelings of parental incompetence that the diagnosis of ASD often creates with feelings of competence about parenting a child with ASD successfully. Knowing how to help their children counteracts feelings of guilt, blame, and helplessness. As the coaching relationship moves forward, parents become aware that their daily interactions are facilitating their child’s learning; the session data demonstrate this, as does their child, and this fuels their sense of parental competence and self-­efficacy. This confidence and knowledge base provide them with a strong foundation for the role of child advocate that they will often have to assume in



Knowledge, Characteristics, and Supports 39

choosing interventions, schools, classrooms, therapists, activities, and so much more of life’s moments for their child. Empowerment comes from confidence, and confidence comes from a sense of efficacy, capability, knowledge, and know-how. The more the coach knows about each of the parents in terms of his or her own motivation for coaching and his or her learning history, the more individualized the coaching can be. The following are some questions for identifying parents’ needs, history, and learning experiences that can help the coach during intervention sessions: • “What about the pace today for you? What worked well for you in this session?” • “What do you need to see to know that you are being successful? Who are the other caregivers that we need to engage?” • “When are other times you have successfully worked to change your own behavior? What was rewarding about that process?” • “Are you satisfied with your progress toward your goals? What seems to be working the best for you in terms of our work together? What has not been as helpful?”

Individualizing Adult Learning Strategies Adults differ in the tools they prefer to help them learn. They know what modalities and methods they typically use to learn something new, and what tools they never use. Some prefer reading, some prefer online videos and materials, and some are hands-on learners and prefer being shown how to do something and help repeating it. Some want immediate feedback from the coach, whereas others prefer to self-­evaluate. Some want to know the reasons behind the skills they are learning; others can’t be bothered with theory and explanation. The coach can discuss all these options, as well as any other approaches that help parents absorb and apply new information at the start of working together and also along the way. We want to provide parents with the learning tools they need in whatever medium they find most helpful. We ask family members how they learn new concepts or behaviors: what they look for, if they have ever tried to change one of their own behaviors, how successful they were, what worked and didn’t work. The answers provide the coach with leads about what kinds of learning media and materials may help the most. In our sessions, we incorporate a wide range of learning materials from the big and little sticky pads that Sally gives to families, to the refrigerator lists in our parent manual (Rogers, Dawson, & Vismara, 2012). Materials that help us individualize the experience for parents include: handwritten checklists, videos from the session, our Help Is in Your Hands narrated video series, schedules for home, journal pages, online resources of all types from various websites, a daily note to complete and return to us, suggested role playing, and the various parental

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Coaching Parents of Young Children with Autism

skill checklists and data sheets of all levels of complexity found in this current book as well as the parent manual (Rogers et al., 2012). Below are some questions to help coaches identify parents’ learning preferences: • “How do you like to learn? Do you prefer reading manuals or books, going online for advice, or watching a YouTube video?” • “Tell me about a learning experience you particularly liked, and one you disliked. What was it about those experiences that helped you learn or impeded your learning?” • “On a scale of 1–10, based on your best and worst learning experiences, how did today go?” If the number is low: “What can we do next time to help our work go more to your liking?” If the number is high: “What did we do today that made our work go so well, so we can hold onto that experience next time?” Conclusion The goal of parent coaching in early ASD is to help parents learn how to use their everyday activities to provide needed learning opportunities for their child. To do so requires that parents make changes in their interactions across daily life. Some resources for coaches to help support parents’ process of change have been described in this chapter: the collaborative, reflective, nonjudgmental, conversational and reciprocal style that the coach uses to engage and support parents; specific methods to support adults as learners, including the motivation to learn something new. Other factors that influence parents’ growth include a desire for self-­growth, the presence of a supportive environment, individual learning styles, prior learning experiences, ongoing support to put new skills into practice, and the positive consequences of new learning in everyday life. Effective coaching in a parent-­implemented intervention can give parents skills that may fit many life dilemmas: assessing situations; goal setting; building a short term, step-by-step plan for goal achievement, with ongoing evaluation to make changes as needed. Now that we have described some of the tools and resources that interventionists can use as they transition to the coaching role, we will address the actual management of coaching to support learning for parents and for the child.

Chapter 4

The Coach’s Tools

Making the shift from therapist to parent coach is helped by the contents of the tool kit that coaches bring to a session. The tools that we have found most helpful in a coach’s toolbox are not complex, but they are necessary for us to do the job well. Our toolbox contains a clipboard and pencil, a session schedule, a clock, a tablet of paper, the parent manual, topic summary (“refrigerator”) lists, three data checklists, a wide-angle perspective, an emotional thermometer, and a reflective mirror (supervision), along with other tools. Clipboard and Pencil The clipboard is a dual-­function tool. It holds and organizes all the pieces of paper that the coach needs to get through the session. Unlike a folder or notebook, it provides a surface on which to take notes or complete checklists anywhere in the room. Setting up the clipboard for a session organizes the coach for the session to come. Sequence the paper in the same sequence as the session activities and mentally review them during this process. See Appendix A.1 for a list of the order and content of Sally’s clipboard for parent coaching sessions. Session Plan Providing a session of parent coaching requires a session plan. This should include time to set goals at the start of the session, time for two to three parent–child activities, and time to reflect and plan again after each activity to generalize and consolidate both cognitive and behavioral learning. It should also include time to set up a home practice plan for the period until the next meeting. It needs a time 41

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Coaching Parents of Young Children with Autism

slot for parents to discuss the problems that weigh most on their minds. It needs 5 minutes for transitions in and out of the session. Finally, the therapist requires time to take notes, to schedule the next appointment, and to take data during the session. This is a lot of ground to cover in 60–90 minutes, and it is new territory for coaches who are accustomed to providing direct treatment to children. A plan and a schedule can be easily subverted by the tendency for coach and parents to want to talk. Discussions might pop up at any point and derail the rest of the session. In addition, pets, siblings, or other adults may walk in and out with their own agendas, interrupting the ongoing interaction and plan. A hungry child, a messy diaper, a child’s fall that requires parental comfort—these normal events can take over much of the planned session time. What is the coach to do? Over the years, we have created a specific session schedule that gives the coach a clear temporal organization and a clear content plan for the session. The plan includes time for an initial chat, for goal setting, for topic description, for parent–child coaching activities, and for the repeated cycles of plan–act–­reflect– evaluate. It includes time for parents’ open discussion on a topic they are most concerned about. This schedule can be briefly summarized by the coach before the first few sessions as part of the transition from greetings into the warm-up activity. Parents and child all learn the rhythm of the sessions over a few repetitions, which helps the sessions move along as planned. Here is how we think about the session structure. Each session begins with 5 minutes of settling in and sitting down, followed by about 5 minutes of parental update on what transpired since the last session. Any arising topics unrelated to the coaching topics are acknowledged but “parked” until the discussion period at the end of the session. The coach ends this brief update by transitioning into the parent–child work. The coach asks what material or issue from the last session the parents have focused on with their child over the past week; then the coach asks the parents to demonstrate what their “warm-up” activity to get the child ready for the session looked like. It is in this warm-up that the coach takes stock of parent fidelity and mentally notes the parents’ learning accomplishments and needs. A very brief reflection on the parents’ work follows the warm-up, with the topic of the day set, based on the parents’ readiness for new material as well as any need for addressing skills related to the warm-up activity. The principles of the topic of the day are reviewed with the parents using the related refrigerator list, and two ­parent–child activities involving differing target activities (in which we record data on the child’s progress) then follow, with coaching on the established topic during each activity, followed by reflection, evaluation, and planning for the next activity. Ten minutes at the end of the session are provided for discussion of any “parked” issues and how to generalize the topic of the session into other activity types that will occur for parent and child over the next week. Then a 5-minute closing and transition take place for the parents, child, and coach. Writing out the plan before each session and using it within each session have

the Coach’s tools

43

transformed our practice. It has allowed us to build more focused work into each session than we had believed was possible at the start of our coaching practice. It also allows us to preplan materials and activities so that child learning objectives are specifically taught (more on this below). Parents have indicated their satisfaction with this process in study after study, and we have documented the beneficial effects on children in our published papers. We take notes on the session planning sheet throughout the session and use the notated form to plan the next session (we often do this immediately after a session is finished). Appendix A.2 offers a copy of our “Coach’s Session Planning Sheet.” Clock Use a clock that can alert you to your schedule and help you maintain control of the session and the plan. The best-developed session plan is only helpful when the coach stays with the plan, and this is dependent on the coach’s constant attention to passing time. Managing time is most effective when the coach is facing a clock and can see the passage of time throughout the session. If this is not possible (carrying a travel clock and setting it up is an option anywhere!), then a programmable timer on a phone or watch is the next best option, but it requires setting time for each activity block to be of maximum help. Parent, child, and coach all need to experience a consistent routine in coaching sessions in order to maximize parent and child learning, and that routine is the session plan carried out within the time allotted, as dictated by the clock. Tablet of Paper Use texts, lists, drawings, or some other visual methods of supporting the parent in the session and for the week ahead. A plan for the session can be written down if it helps the parents during the initial conversational check-in and is referred to throughout the session. Parents need a plan for the week that concretizes the goals they have established with you (see the example “Parent Daily Practice Chart” in Appendix A.3). The Parent Daily Practice Chart helps parents remember the week’s targeted skills for parent and child, the activities and locations in which these can be practiced, checklists for noting which of these behaviors occurred in a given activity on a given day, and any other details from the session they want to remember and review at home. Some parents want to write down these facts themselves, and other parents will describe the

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Coaching Parents of Young Children with Autism

details as the coach records them. The “Activity Categories” cartoon in Appendix A.4 can help families identify the daily times and activities to carry out specific learning routines with their child. An activity plan for completing a specific activity like a meal may help parents remember what they are trying to do during an activity. Posting sticky notes in key locations at home can help parents remember key aspects of the four-step joint activity to use in various activities, or of the many ways to respond without directing or questioning, or levels of prompting, or the cues of a multistep task like handwashing. Refrigerator lists (like those in Rogers, Dawson, & Vismara, 2012; see Appendix A.5 for an example) help parents remember the main points of particular topics. Some parents want to write notes on refrigerator lists or in their parent manual during sessions. Certain parents desire detailed supports, and other parents may be best served by watching a cell phone video recorded during a session. Additional ideas for visual supports for parents include recording points on their phone during the summary, YouTube videos that parents have found (or the free video modules at www.helpisinyourhands.org), and visuals or notes that a parent may generate during a session. One way or another, parents, just like coaches, need ways to remember the plan that was generated from each session and what they planned to practice, so they feel well prepared at the end of each session and approach the next one with a personal plan and sense of readiness. Parent Manual Having a parent manual in hand provides ready access to the main points of each strategy that the coach and parent plan to cover in a session. Keeping the relevant chapter open during the brief topic discussion activity allows the coach to thumb through the manual and fixate visually on the main points (likely highlighted) of the topic. Our parent manual provides checklists and other organizers for parents that help to concretize the topic points and assist with topic review at the end of the session. The “refrigerator lists,” or other summary lists in treatment manuals, summarize previously covered topics and points when a tune-up is needed. Parents who cannot afford to purchase a parent manual for themselves (either used or new) may obtain one from the provider agency or through financial gifts or fund-­raising efforts made for the agency. Parents can access an ESDM-related parent website with publicly available materials (www.helpisinyourhands.org) as well as videos on YouTube and other websites. Coaches may help parents remember the content of a chapter in the manual or a session topic by recording videos on their cell phones during sessions for reference and for sharing with other parents, and child intervention providers (only with signed parental permission, of course). When the coach has a manual and clipboard in hand and uses it in sessions, this visually reminds the parent to have materials ready for sessions as well.



The Coach’s Tools 45

Copies of Topic Summary (Refrigerator) Lists Keep two copies of a topic summary (“refrigerator”) list focused on the day’s topic on your clipboard: one for yourself and one for parents. These give you a handy way of referring to the main points of the topic throughout the session. They allow you and the parents to take notes throughout the session that can be shared with others. They can also be used for review, planning, reflection, and evaluation. Referring to the refrigerator list is especially useful (1) following each activity reflection, as a way of tying each reflection to the teaching points; (2) as a concrete planning and goal-­setting tool for the parent before each activity begins; and (3) to plan follow-up activities for parents and their child throughout the week. In addition, keep one copy of the refrigerator lists you have already covered on your clipboard as a memory prompt to facilitate any brush-up of skills that may have slipped a little, and perhaps as part of your plan for the coming week’s focus. Three Data Checklists One checklist is for the child (child data sheet or goal sheet), one is for the parent (fidelity of implementation data sheet), and one is for yourself (fidelity of coaching implementation tool). These simple data-­keeping tools allow the coach to assess child and parent progress during parent–child activities. Focusing on parent and child learning targets assures that the coach concentrates on skill mastery for the parent and skill mastery for the child. Gathering objective observational data guards against sole reliance on a parent’s report or coach’s memory of change to document the parent and child’s progress. Parent data need involve nothing more than demonstration of the strategies being taught within the session parent–child activities. While coaches can certainly develop checklists for themselves, most evidence-based NDBI practices have a parent or therapist fidelity of implementation measure that can be used to quantify parent learning and performance over time. Taking data while a parent and child are interacting requires some practice, and we have found it easier to record data on one or the other, but not both, during a particular activity. Appendices A.6 and A.7 are examples of parent fidelity of implementation tools that we developed for different projects, both of which have resulted in appropriate interrater reliability data. However, even something as simple as the refrigerator lists or other topic lists that coaches create for parents (see Appendix A.8, “Parent Self-­Monitoring Checklist,” for an example) can be transformed into checklists that help both parents and the coach maintain their focus and assess progress. The second checklist or data sheet captures child progress data on the targeted

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skills that exist in the child’s IFSP, IEP, or other treatment plan. The ESDM child data systems (Rogers & Dawson, 2010) provide a checklist model for recording a child’s skills activity by activity and an example for coaches to use. When collaborating in a parent-­implemented intervention, we write up approximately 12 objectives for a 12-week period based on goals the parents and coach have agreed on, and we then break down each of those 12 objectives into five to six steps, with Step 1 representing the current baseline skill and the final step the fully mastered objective as written. Intermediate steps represent very small gains in progress sequenced from baseline to mastery. Note that steps are not changes only in the level of prompting; increasing independence and spontaneity are also typically involved. The number of child actions often increases as well, as skill refinements as immature performance becomes more mature. (For detailed descriptions of this process, see the ESDM manual [Rogers & Dawson, 2010].) However, any system the interventionist already uses for tracking a child’s daily progress on objectives suffices. Examining a child’s progress over a session requires that activities be chosen that will allow for those skills to be demonstrated and taught. The child data sheet guides the therapist in planning the content of the day’s activities: Pretend play? Three-piece or five-piece puzzles? Books with pictures that highlight animals (for animal sounds), or verbs, or body parts? Part of the planning process of the session includes planning the types of activities to be focused on, and the materials needed for them. While child progress is not as important a focus early on in coaching given the emphasis on parent learning, as parents approach mastery of their implementation skills, then child learning becomes a primary focus for them and the coach. However, it is highly motivating for parents to hear the coach point out gains the child has made as measured by the child data sheet. The parents’ greatest reward is their child’s progress, and that information is dependent on the coach recording child data and reporting them from time to time. The final checklist is the coach’s implementation checklist. We have provided two versions of this based on the approach laid out in this text (see Appendices A.9 and A.10). For a beginning coach, the list of coaching behaviors to be covered in each part of the session helps enormously, guiding him or her through the activities and to remember all the parts. For more experienced coaches, the tools that measure the coach’s skill levels generate progress data to help assess growing strengths and ongoing areas for further development. These are most useful when completed immediately after a session, while all materials are fresh in everyone’s mind. Some coaches even perform this task in their car as they leave family homes or child centers; others do it in the office after families leave. Taking intermittent data on oneself, and recording sessions here and there to share with another coach for his or her ratings, are part of the process of learning and mastery of coaching skills.



The Coach’s Tools 47

Wide-Angle Perspective A wide-angle perspective helps the coach maintain sight of all that happens during the session: the flow of time, the goals of the session, actions of the parents and child and their meanings, changes in the environment that are affecting each person and the flow of the session, and family events going on outside the session that are affecting parent and child inside it. The coach needs a binocular viewpoint, with one lens focused on the overall sequence of events taking place and the other on the target behaviors of the parents, child, and coach that are planned for the hour. The coach’s attention has to be flexibly moving and shifting across multiple environmental stimuli as well as inner thoughts and feelings occurring throughout the moving parts of the session. The other tools in our tool kit help with this task, especially the clock, the session plan, the clipboard, and the various checklists. The circular reflective processes of plan–act–­reflect–evaluate, laid out in the session plan, that occur throughout the parent coaching session allow the therapist to maintain this meta-­analytic perspective through the ebb and flow of the hour. Emotional Thermometer You need a thermometer so you can take your emotional temperature frequently across the session. Parent coaching is intense cognitive, attentional, social, and emotional work, and it generates many reactions in the coach, which if unrecognized can affect the work in unplanned and sometimes negative ways. An emotional thermometer keeps you in touch with your feelings as the hour transpires and helps you monitor and process any responses that might interfere with your work: growing frustration, irritation, pressure, hurriedness, overinvestment or attachment to others in the room, feelings of inadequacy, lack of control, or doubt. Some signs that your own reactions are getting in the way of the work are repeated feelings of anger, avoidance of a specific family or child, overinvolvement with a child or parent, evaluative descriptions of families to your colleagues (“great family,” “challenging family to work with,” “dread the sessions with this family”), and expressions of overly intense emotion, either positive or negative, when discussing your work with a particular family with a colleague. These are all clues that your own goals or motives may be interfering with your ability to listen, observe, and evaluate the interactions taking place in front of you. You are here to meet other people’s needs, not your own. You need to tune into those feelings, reorient yourself to the needs of your clients and the work at hand, and then revisit these feelings after the session. The thermometer readings can also help you recognize the need for consultation and/or supervision to understand and regulate your emotional responses to a client or topic that frequently triggers you.

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Reflective Mirror (Supervision) Working with parents and children together is intense work! The minutes fly by, and half of what you planned to cover is squeezed out by the clock. Moving through the session requires you to make decisions constantly, some of which you will realize were not the best judgments. Psychotherapists who treat adults typically seek out opportunities with a peer, supervisor, or therapist to review their own actions and feelings within the treatment they are providing, objectively as well as subjectively. Parent coaches need the same opportunities. One advantage of an interdisciplinary team approach is the ability to share with the team and grow from their observations and experiences. While many team meetings allow for brief descriptions to the team of what is happening with a family and child, coaches also need time for deep reflection on the emotional impact the work is having on them, and the interpersonal processes occurring during the treatment session. Reflective supervision provides a space in which to think through and share therapeutic decisions and reactions and to consider the listener’s thoughts and questions. Such reflective practice helps to prevent one from operating from blind spots or emotional reactions. It can provide a safe, supportive, listening environment for coaches to work through a challenging session; to consider and evaluate all the different relationships, motivations, and spoken and unspoken messages that occurred; to determine how these are helping or hurting the coaching process, and thereby helping or hurting the intervention process. The goal of reflective supervision is, first and foremost, insight into the inner processes occurring within each person in the session. When the coach understands each person’s feelings, strengths, and needs, as well as the established treatment goals and trajectory, then the coach has a firm base for making coherent decisions moment by moment about what to initiate and how to respond. Enlisting the mental health professional on the team to help the group learn the reflective peer supervision process provides an in-house solution to the needs that all parent coaches have for support for the interpersonal aspects of their work with families and children. Other Tools

Mindfulness Practices Coaching sessions take place within a context of at least three people’s lives: the caregiver’s, the child’s, and your own. It’s not uncommon for a coaching session to occur directly after a stressful or otherwise distracting activity that is part of one’s workday. Yet being a coach requires you to be fully present, maintaining an attitude of acceptance rather than control, with a focus that is outward rather than inward. Mindfulness is the ability to be fully present in the moment, focused



The Coach’s Tools 49

on the situation at hand, and what you are thinking, feeling, and doing moment by moment. It means not holding onto, reacting to, or becoming overwhelmed by your own or others’ emotions. Emotions are simply accepted for what they are, without judgment or an attempt to immediately change them. Being present means you are aware of your own feelings and how they may affect what you do; it also means being aware of the parents’ and child’s subtle emotional behaviors and being ready to reflect those with the parents in an accepting and nonjudgmental way. As coaches, we three authors have all learned to use mindfulness and centering practices to mentally prepare for starting a coaching session and to recenter after a session. A centering practice can be as simple as a few minutes of deep breathing before or after a session, during which the coach mentally lets go of the stresses of the day and focuses his or her attention on the work at hand. Taking a moment to calm your emotions, your mind, and your breathing before a session leaves you in a state of both alertness and calm. The benefits are many. First, you as the coach will experience less stress both during and after coaching sessions. Second, parents and the child will consciously or unconsciously be aware of your calmness, openness, and nonevaluative stance, allowing the parents to feel more comfortable expressing themselves and reducing any feelings of anxiety or embarrassment that some may experience when being observed, or when their child is upset or not “performing.” Third, because your mind is not filled with distracting or self-­judgmental thoughts, you will be more able to take in all that happens during the session and make better decisions moment by moment.

Motivational Carrots Skilled coaching supports increasingly skilled, motivated, confident parents and measurable progress in children. However, behavior change is not a steady process, regardless of the skill level of the person trying to change his or her behavior and the skill of the coach. As the literature and personal experience attest, adults involved in weight loss and fitness programs, changes in drinking or smoking patterns, and other behavior changes demonstrate greatly fluctuating motivation and behavioral transformation week by week and sometimes day by day. Motivation and goal attainment involve both emotional processes (reward seeking, pain avoidance) and cognitive processes (inhibition, planning, self-­monitoring, redirection), and they are affected by everything—sleep, hunger, illness, disruption in routines and schedules, visitors, relationships, and stressors of all kinds. Motivation problems arise in parent coaching just as they do in every other type of process involving adult behavioral change. However, a parent’s decreased motivation for incorporating intervention approaches into daily activities with his or her child results not only in parental lack of progress and learning, but also in the loss of learning opportunities for the child in everyday routines with caregivers—the

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child’s greatest learning platform. Young children’s progress is threatened when their parents lose the motivation to work with them at home. In virtually every parent coaching relationship, there will be times when parents express low motivation for following through on intervention plans. While it is tempting to use a cheerleading approach (recounting all their successes, praising their work, etc.) or to reassure parents that these feelings are normal, neither of these responses actually show that the coach has listened and heard what the parent has said. Empathic listening is the first step to take. The second is to turn to effective ways to address motivational challenges. One approach in psychology literature is motivational interviewing (MI; Miller & Rollnick, 2012), which offers a set of tools to help people move along the change process or resume that path if motivation has flagged. Just as a treatment fidelity tool helps coaches know how to address child learning, so, too, does MI help us support parents who experience decreases in motivation or a lack of motivation in the first place. MI provides coaches with the tools for both assessing motivation and for supporting increased motivation to move ahead. Writings in the MI literature and related work involving the stages of change (Prochaska, Redding, & Evers, 2002) give a helpful evidence-based approach for coaches to assess the nature of motivational difficulties and to tailor small and achievable steps that parents can take toward action. An ESDM coaching version follows the Prochaska et al. (2002) stages of change: beginning at or before the first contact (not ready to begin), to a point after the first contact (consideration), to when decision and preparation begin, to the initiation of active coaching in ESDM, to the mastery of fidelity and routines, to a point at which the techniques feel “natural” or “effortless.” Times of lowered motivation, competing priorities (e.g., holidays), changes of setting (e.g., vacation), and other disruptions (e.g., illness), with difficulty resuming embedded interventions, are marked as possible relapse points. At these times, coaching and intervention may resume at the point where they leave off, or major motivation lapses (not ready) may require beginning the entire cycle again. Since the adoption of ESDM in home routines represents a long-term lifestyle change for the family, relapse periods are a normal and expected part of the process until habits become so deeply ingrained that they feel like a natural part of everyday life and are easy to resume after any disruption. We have found MI tools to readily blend with parent coaching, particularly when families experience difficulty putting the intervention into action at home. Our team uses a transdisciplinary approach similar to what we describe in Chapter 6 for role sharing among interventionists of different disciplines working together to support families. One way to bring MI into a group’s skill set is to have a team member who represents the mental health profession share his or her knowledge of MI, or begin training in MI via workshops, webinars, supervision, and other training experiences, and initiate self-study and peer supervision of MI and the motivational cycles of change. In our own intervention group, we sought

The Coach’s Tools 51



Possible relapse/ recovery point

Not ready Considering

Preparing Embedded/ maintaining Beginning/ learning

Possible relapse/ recovery

Mastering

Possible relapse/ recovery

Figure 4.1.  An ESDM coaching version of the Prochaska et al. (2002) stages of change.

to learn the principles of MI using the above strategies and started to apply the techniques within our coaching sessions when needed. We used peer supervision and clinical review meetings to learn some of the strategies via videos, descriptions, and session data. Over time, all our team members’ skills in MI grew, and we eventually incorporated it into one of our research studies (Rogers et al., 2019) and our basic way of practicing. We use three sets of MI tools in our coaching process with families. First, we have found that the careful work done on indirect verbal and nonverbal expressions of motivation in adults has helped us listen for and “hear” parents’ motivational messages more clearly. It involves attending with our whole body; using direct eye contact, positive facial expressions, an open body posture; and maintaining awareness of our proximity to the parents—all to convey interest as we listen, to confirm the meaning of their words, and to prompt our next action. Sometimes this means encouraging periods of silence to allow parents to reflect and organize their thoughts. It is important to be comfortable with silence and to resist the urge to fill every moment with conversation. When parents feel heard and understood in the message they seek to communicate, they are more encouraged to continue sharing. Second, the dialogue process also sheds light on where parents fall in the stages of change or how ready, willing, and able they are to change their behavior. The stages of change are precontemplation (change on the back burner), contemplation (considering change), preparation (actively preparing for change), action

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(enacting change), maintenance (settling into change), and relapse and repair (when change falters; Prochaska et al., 1994). These stages have given us a very helpful tool for identifying where family members are at different points in the motivational cycle, especially useful when there is a mismatch among different family members concerning their views of the situation. One parent may be quite motivated to learn new ways of working with his or her child at home, whereas the other parent still wonders if the child’s development is problematic or not. When the coach aligns with the parent who is motivated to move ahead, the parent who has not yet reached that point tends to be left out of the process, or to feel unimportant, adding additional stress to the relationship. Knowing where parents fall on the stages of change coupled with MI techniques allows the coach to understand and accept each parent’s current position, while helping the various caregivers recognize their common ground and shared commitment to the child. Parents are less likely to withdraw from the intervention process when their points of view and interactive skills with their child are acknowledged, respected, and valued. As the child acquires skills over time, the difference in viewpoints between parents often lessens, particularly when the coach is careful to attribute a change in the child to both parents’ efforts and interactions. MI’s third very helpful contribution to coaching skills is the recognition that relapse is an expected part of the change process, not a signal of failure. People often cycle through different stages, from contemplation (being ready to move forward) to precontemplation (being on the back burner) or from action (doing) to relapse (a slip), before reaching their goals. When this happens, it is important to use the opportunity to reflect and regroup before moving forward. People often have ways of responding to relapse in other domains and a history of partial success to build from. The dialogues for recognizing and addressing relapse without casting it as failure are extremely helpful for both the coach and the parents.* Parents may feel vulnerable or shaken by the experience and unsure what to do next. They may need help making sense of what happened. The coach is there to listen and to help parents see this moment as an opportunity to learn something, rather than experience failure. The coach now needs to help parents renew or recommence the cycle of change. The cycles involved in identifying and setting goals, working to achieve them, making good progress, running out of steam, or getting ambushed by a different set of problems, taking a rest, picking up and starting again—these cycles require a set of tools and a body of knowledge that are great coping tools for all kinds of life situations.

*There are many workbooks, books, online and website materials, trainings, and chapters focused on MI for people receiving coaching for all kinds of behavior change goals. These tools are full of examples of such dialogues, which are generalizable to parent coaching situations. In addition, see Appendix A.11 for a chart that describes some motivational coaching tools tied to the stages of change that can provide help for interventionists working with families.



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Humility Being involved with families so closely leads easily to the coach’s sense of what underlies a child’s behavioral problems and how the parent’s omissions or commissions are supporting the unwanted behavior. But what might seem to be a simple change in parenting behavior from the coach’s point of view may be extremely difficult for the parent to carry out in the way the coach has suggested. When we observe in session that a parent knows how to implement a strategy effectively and correctly, and see in the data that the strategy is not being used, it is easy to begin placing blame on the parent’s shoulders. “If only the parent would . . . ” is the lead-in phrase that parent coaches have doubtless expressed hundreds of times. When these feeling arise, we need to quickly reflect on our own efforts to change our own behaviors involving our family members or ourselves, and to be humbled by the enormity of the task of altering an established pattern of interaction that has occurred hundreds or thousands of times. How often have we each tried and failed to change our interactions with people close to us? Any change in a child is the result of huge parental effort, and many efforts to change result in naught, as we all know from our personal lives. Keeping this in mind helps us to reign in our expectations, to focus on small steps, and to protect ourselves and the parents from the negative effects of our own hopes, disappointments, and negative appraisals with regard to the parents’ efforts.

Clear Boundaries Coaches’ entry into the life of a young family, and frequently entry into their homes, is a unique situation for people trained to carry out clinical practice. The structures that typically support the boundaries of clinical and intervention work—the office or classroom, the office staff, the billing, and the separation of the clinician from other types of relationships—are often challenged when you are working in people’s homes. Intimacy occurs when you sit at the family table during a family meal in order to observe a child and the child throws food at you, when you sit on the floor in a coaching session and the child comes over and kisses you, when you see the family in a messy house, with their pets needing attention, children in diapers, family members interrupting. You have to think carefully about your response to the social overtures that families may make—offers of food or drink, invitations to birthday parties or school graduations, gifts at holidays, parental hugs instead of handshakes. We have had to inhibit gestures of help or care that would be appropriate within another relationship but are not appropriate in a parent coaching relationship. When an unusual request or situation arises, it’s important to consult with other professionals from your same discipline, use peer supervision, and consult your own disciplinary ethical standards in order to determine the appropriate professional response. Many agencies also find the need

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to spell out clearly what agency staff members can and cannot do with families to assure that professional boundaries are maintained, and that we as professionals do not compromise the objectivity needed to make appropriate decisions for delivering care. We are professionals working in a paid relationship with clients, and all of our behaviors with family members must reflect this relationship.

Easy Laughter To quote the Scottish poet Robert Burns (from his 1785 poem “To a Mouse”), “The best-laid plans of mice and men go oft awry.” There is only so much control that the coach can wield in a treatment hour. Sometimes the doorbell rings, the dog throws up, the child falls asleep, the school bus arrives, and the hour is suddenly over. Providing treatment at home is great for generalization and tough for environmental control, and all we can do is laugh and say, “That’s life with little kids. How can I help?” Appreciating the complexities of everyday life for the parents eases potential feelings of guilt or demand they may have with regard to the coaching situation and helps the therapist relax about the planned session that is not going to happen, given all the degrees of freedom that exist when providing clinical treatment inside a family home with a young child. These unplanned and unexpected experiences occurring within one intervention hour should increase coach’s appreciation of, and respect for, what it takes for parents to apply intervention techniques in everyday life, especially when such techniques are new and require thought and planning. Problem Solving One of the primary tools of coaching is skilled problem solving. A coach needs to rapidly generate problem-­solving strategies with families and test them to find solution(s) to the problems that arise during a session. Below, we share these methods and some examples of their use.

Defining the Problem Behavior as the Best Solution to Helping the Child Reach His or Her Goal When we work with children with ASD to address a challenging, or less than desirable behavior, the first step is to identify and understand its function so that we can teach the child a more acceptable and efficient way to meet his or her goal. We need to take a similar approach with families, so they learn to think within this functional, adaptive framework. We help families become detectives to investigate, extract, and characterize the problem behavior and the child’s underlying goal before putting anything into action. Current behavior versus what behavior

The Coach’s Tools 55



the parents wish was happening, who is involved, where the unwanted behavior occurs, when it is likely to happen versus not happen. They need to understand the when, where, why, how, and with whom problem behaviors happen to develop a different plan of action. The parents describe to the coach that their daughter frequently screams and cries when they walk out of the house without her. The coach asks them to elaborate further. What leads up to the parents opening the front door? What is said, or not said, to the daughter? What is she doing when they leave? What happens after she becomes upset? As the parents discuss the behavior further with the coach, they agree that the child does not understand where the parents are going or why. The transition may feel abrupt and sudden, making it difficult in the moment for her to understand what is happening. The parents want to develop a plan to help the child through these transition moments and not feel guilty when they need to leave her at home.

Generate Ideas Once parents can define the unwanted behavior and the child’s goal, the coach and parents can together brainstorm about what behaviors the parents prefer the child use instead to communicate his or her goal, with this desired behavior eventually substituting for the unwanted behavior. Is the desired behavior as easy for the child as the unwanted behavior? As efficient for the child in terms of goal attainment? The coach uses skilled communication strategies (described in the coaching section) to listen and to help parents consider the desired substitute behavior, and how to bring it into the child’s repertoire in terms of possible steps to take before, during, and after the antecedent associated with the unwanted behavior. The coach asks the parents what actions they have tried before with their daughter when they attempt to leave the house. The parents explain that they always say goodbye to her and tell her where they are going and that they will be back. Usually, the daughter is doing something when they say goodbye, such as eating a meal, watching a video, or playing. When the coach asks the parents what they might change in their approach, the parents explore the idea of giving their daughter more notice and a fuller explanation of why they are leaving. Initially, they worried that telling her in advance might cause her more anxiety, but now they think it is important to give her more warning and prepare her for what will happen. They realize that trying to explain to her what will happen in the middle of an ongoing activity, especially when she gets upsets quickly, makes it difficult for her to listen, process, and understand because she is not in a calm, attentive state. The parents talk about different options and strategies to increase her attention and comprehension of their need to leave the house, as well as her coping skills to work through any agitation or upset.

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Decide on a Plan The coach and parents jointly consider the possible solution or combination of solutions. They evaluate the ideas according to the following criteria: how to implement the solution(s), how long each solution will take, and what constitutes a desired outcome(s). They then decide on the best course of action based on their evaluation. The parents and coach work out a plan to help the daughter understand and cope when her parents say goodbye. The parents pinpoint bedtime as the time when they have their daughter’s full attention to talk about what will happen when they leave the next day—where they need to go, what they will do, and when they will be back. The coach and parents explore the idea of using visuals to turn the explanation into a story that may improve the daughter’s interest, as well as her comprehension and coping. The parents decide to use pictures of where they will go and what they will be doing to make a book. Their daughter likes books, so she will perhaps be more likely to pay attention to her parents’ explanation and participate. The coach also encourages the parents to think about choices they can offer their daughter, such as what she wants to do while they are away and what she wants to do with them when they return. This may help to focus her attention on what she can control (i.e., activities to do with and without her parents) than what she cannot (i.e., her parents leaving). The parents think this idea will work, and they talk about different activities they could ask their daughter to choose between. They may also use pictures for the choice of activities if that will increase her excitement. The parents and coach decide to reevaluate the plan in 2 weeks. They define initial progress as the daughter making choices (with or without pictures) of what she will do while her parents are away from the house and when they return. They feel it is OK if their daughter exhibits some upset when they depart, but not to the point where they cannot console her or comfortably leave the house.

Implement the Plan The coach and parents decide who will do what by when and then carry out the agreed-upon actions. It will help the parents greatly for the coach to be present when they first implement the strategy to be sure it goes as planned and to tweak it as needed so that the parents have carried it out successfully and know exactly what to do before the coach leaves. Over the next 2 weeks, the parents try out their plan with their daughter. At bedtime, they tell her the story of what will happen the next morning when they say goodbye—where they will go, what they will do, and when they will be back. They show pictures on their phone of where they will be going, to engage her into talking about and understanding the day’s events. They discuss what activities she can do while they are away and show her pictures of those, as well as what she might like to do together with them when they come home. The parents also present her with

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a digital watch and explain how the numbers on the watch work to introduce the concept of time. They focus her attention on the numbers that represent the time they will be back home; they show her how an alarm will go off at that same time. In the morning, they remind the daughter of their impending departure while she gets dressed and again at the breakfast table. They emphasize the choice of daytime activity that she had made the night before, so her attention remains focused on what she gains (i.e., through the power of her choices) and not what she loses (i.e., her parents leaving). When the daughter fusses the first few mornings, her parents repeat what she will do while they are away; what numbers she needs to wait for on the watch, signaling when they will return home; and what they will do together once the parents get home. She calms down and is able to let her parents leave. When one or both parents arrive home, they are quick to greet their daughter and engage in her choice of activity. After the first few days of this routine, the parents take turns at night telling the story of what will happen the following morning and reiterate the rest of the plan.

Evaluate the Plan The coach needs to help the parents find ways to assess the effectiveness of the solution(s), since memory alone is such a faulty tool. Generating a very simple data system that parents can carry out, and having them practice it with the coach, is a necessary part of the behavior change plan. Parents need to stop the intervention if the data indicate that it is not effective, and the coach needs to remain involved so that ineffective strategies do not continue and parents do not become discouraged and abandon their efforts before the plan gets fixed and leads to progress. The coach and parents meet 2 weeks after the plan’s implementation to review how their daughter has responded so far. The parents see positive changes in their daughter’s development as a result of the plan. They describe her avid participation: helping to tell the story of what will happen the following day and using her watch during the day. She is able to cope and say goodbye to her parents without serious upset, and she welcomes them home with excitement so they might engage in her choice of activity. The parents feel confident that the plan is working. They do not foresee making any changes to the plan at this time and want to continue with the established strategies. They would also like to consider whether similar strategies may help their daughter cope with other difficult transitions, such as when she needs to go someplace new or her parents take a different route of travel to a familiar place. The coach and parents decide to finalize that new plan at the next session. Conclusion Coaching parents to help their young children with ASD is exhilarating, intense, demanding work. This chapter described a wide range of physical, cognitive,

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emotional, and social tools to help coaches maintain their motivation for doing this important work for the long haul. We also outlined how parents might apply the tool of effective problem-­solving methods with regard to their child. Finally, coaches need tools to replenish themselves so that the ongoing stress of caring for others who are in such need of care does not lead to distancing, devaluing, pessimism, and other defensive reactions to the pain that families experience and helping professionals feel.

Chapter 5

Assessment, Goal Setting, and Treatment Planning

It’s scary—the power of first impressions on the course of a new relationship. The first hour of a low-­intensity intervention can create energy and optimism for some families for the work to come, setting a trajectory that propels the coaching relationship forward for both the coach and the parents. Other families may find themselves unsure about the nature of the relationship or the course of action that the new professional has described. The first hour may also set off a difficult-to-­ change dynamic whereby one of the parents takes on the role of an observer while the professional steps in to do the intervention, which if it continues will result in relatively little progress in the child, the coach’s frustration, and parents’ sense of incompetence and disappointment. The expectations of the therapist with regard to the parents and of the observing parent are not realized, and the parents’ hopes for their child’s rapid progress are dashed and replaced by the fear that this is how things will always be: their child not progressing well and professionals who are well meaning not helping very much. If we want a different outcome, we can capitalize on the power of the first hour to set in motion a different type of relationship—the balanced partnership of parent and coach. From Diagnosis to Treatment Planning In some communities, families may be able to access direct one-on-one treatment services for their child with ASD for many hours per week as their first intervention. Other families find that their first intervention will involve a few hours per week (or less) with an early interventionist. This low-­intensity intervention approach has two sets of practices behind it: (1) the typical outpatient therapy 59

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delivered by allied health professionals, speech and language coaches, psychologists, occupational and physical therapists, and others, and (2) the publicly funded from birth to age 3 service delivery model resulting from Public Law 99-457, built on a model of parent and family guidance and support, discussed in Chapter 2. The science that led to the passage of this law involved either parent-­implemented interventions for young children with developmental disorders or an intensive professional delivery model (with both approaches using parent teaching and coaching; see Ramey & Ramey, 1998, for a review of this literature). For young children with or at risk for ASD, the only evidence of the effects of low-­intensity services comes from parent-­implemented interventions, a literature that is fairly new and not typically familiar to parents (Landa, 2018). Some families first meet their coach as part of their enrollment with a public intervention service agency. These families may receive a phone call or text to schedule a home visit with a coach who has been assigned to them. The family may or may not have met this person previously, and this may be their very first experience with an interventionist. Other families may be actively seeking out a coach, contacting professionals based on others’ recommendations or their own research, requesting an initial appointment, interviewing coaches, observing them work with their child, and deciding with which coach they want to work. In this scenario, parents actively choose their coach and might also pay them in a fee-for-­service model. Regardless of the route taken, parents most likely expect a traditional hierarchical relationship with this professional, a relationship in which the professional will instruct the parents and take responsibility for the intervention. Thus, in this initial contact, the parents’ expectations and the coach’s expectations are at odds, and the coach needs to let the parents know what working together will mean. The first meeting between a family and a coach provides a crucial opportunity for inspiring active parents and a supporting professional. Parents typically begin the intervention process after receiving a diagnosis of ASD or ASD risk for their child. According to parents, the period before and during a diagnosis is one of the most stressful and emotional time for them (Bonis & Sawin, 2016). Emotions may become more complex as parents search for services and adequate professional support and attempt to manage the many appointments and communications with providers (Neely-­Barnes, O’Hare, Powers, & Swick, 2012). The first contact with an interventionist is an intense experience for the family. Although the parents have requested treatment, they may still be grappling with their child’s diagnosis and all that the process of putting in place a treatment program entails. There likely has been a prolonged period of worry that precedes the diagnostic evaluation and motivates it, including the waiting period for their child to receive a diagnostic evaluation, the evaluation and feedback process itself, the financial impact of missed days of work, and concern about how each person in the immediate and extended families might react to the presence of autism in



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the family. Parents may have unanswered questions; they may have been given information that was not helpful or did not reconcile with what the family believes is true for their child. Such experiences raise doubts about professional helpfulness and expertise. Moving into treatment is a life-­changing transition for families: a transition from life as lived to life into the new and unpredictable world of autism and developmental disabilities. It can be isolating, confusing, and overwhelming as the family learns about and navigates many different treatment options that might help their child. There are many questions, many feelings, many ups and downs, and many changes and new demands on a young family. It is a period of sadness, worry, grief, and anxiety about what lies ahead for the child’s development and future. The family’s coach becomes part of their support system in this new world. Professionals sought out by the family after diagnosis hear about what has occurred from the family’s perspective and can support the family at the start by being ready to listen and to be present and accepting during a very emotional time. Sometimes the professional who will assume the coaching role was also part of the diagnostic process and may have previously provided feedback to the parents about the evaluation results and diagnosis. The parents already know this person in one role, but the diagnostic process and its relationships often vary greatly from the coaching process and its relationships. This shift from the authority figure that assessment entails to a coach and partner needs to occur so that a positive working partnership and alliance between coach and parents can be forged. In situations where it is clear that the evaluator will become the parents’ coach, the transition might go more smoothly if the evaluator uses a family-­centered approach and builds a partnership-of-­experts relationship with the family during the assessment process. Having the parents demonstrate their child’s skills and preferences in play interactions during the assessment; explicitly voicing the shared-­expertise roles; using a reciprocal style of engagement with parents; giving parents the lead; acknowledging in many ways that the parents know their child best by active listening, showing them respect, and incorporating the parents’ perspective and knowledge into the evaluation process and report—these are all methods for initiating a type of relationship that will aid the transition to coaching.

Getting to Know Each Other For some families, an intervention agency will select their coach. For other families, the family will take responsibility for choosing that person. Regardless of how the parent and the coach first come together, the coach needs to begin to foster this new partnering relationship by stepping away from an authority role and handing the parents the “floor,” while listening and gathering knowledge of their values and priorities, their aspirations for their child, their fears and their hopes for what lies ahead. It will help greatly if both parents or other primary caregivers

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are present at this first meeting. Important information is being shared on both sides and important decisions are being made, and those who will be partnering to raise the child need each other’s support. The coach also needs to meet the people directly involved in the child’s everyday life and begin to build relationships with the family. In this very first contact, the coach needs to obtain several kinds of information in order to know how to proceed: 1. The coach needs to hear from the parents about what they are seeking,

what they are most worried about, in what areas they most want to see change in their child, which other professionals they have already seen and what they have been told, and what the biggest day-to-day challenges are. 2. The coach needs to learn something about how the adult family members’ relationships are being affected, who the main players are in the child’s life, the child’s day-to-day care schedule, and the nature of family activities within and outside of the home. 3. The coach needs to see the child in action; know what the child likes to do; comprehend what the child understands about people, objects, and communication; learn how the child communicates wants and desires; and observe how the child responds socially. 4. The coach needs to see the parents and their child interacting together. How do they play together with toys? Without toys? How do they negotiate feeding? How do they respond to each other’s cues? What emotions are apparent and shared by each in their interactions? While the coach needs to gather this information in his or her first contact with the parents and their child in order to understand what the family is seeking, the parents also need to learn what the coach is offering:

Possible Questions the Coach Might Ask • “What do you hope to gain from our time together?” • “What skills would you like to see your child develop over the next 6 months?” • “What are the activities that you enjoy doing the most with your child? The least?” • “What are the most fun aspects of daily life with your child? The most frustrating?” • “What learning methods do you prefer? Dislike?” • “What worries do you have about beginning our work together?”



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1. The family needs to hear about the parent-­ implemented intervention

approach. They need to know the facts that demonstrate the power of this approach to help children progress in low-­intensity interventions (Sandbank et al., 2020; Fuller, Oliver, Vejnoska, & Rogers, 2020). 2. The parents need to hear about the role of parents as implementers in their everyday activities, with the coach primarily serving as a parent-­helper rather than providing direct intervention. The parents need to know how their time together with the coach will be spent; in what ways the coach will help the parents learn how to integrate their child’s intervention needs into everyday life; and that the basis of this approach is the knowledge that parents have the greatest capacity to help their children, given the amount of time they spend with their child, the nature of their relationship with the child, and the commitment they have to helping their child. 3. The parents need to learn how they and the coach will partner together to build a plan that will focus on those areas that the parents and coach have identified as the current primary needs. 4. The parents need to feel the coach’s confidence in this approach for their child. The coach develops this confidence by observing what the parents have already taught their child and that they thus have the ability to learn to implement this plan successfully, if it is the course they wish to follow. The parents also need to feel the coach’s confidence in their child’s ability to make progress on the goals the parents have named. If parents and coach both find that this approach is a good fit, then the coach will set up the next appointment to assess the child’s current performance in everyday activities, information needed in order to build an intervention plan. This intervention plan will define the skills to be targeted in the immediate future and also provide the basis for progress data that will document the success of the parent-­implemented practice. While parents generally react to the plan with disbelief that their child can learn these skills within the planned time period, the coach’s confidence and optimism buoy the parents and create initial motivation for the work ahead.

Assessing the Child’s Skills The process of establishing the child’s short-term goals together is the parents’ next experience of the active parent–coach partnership. For this, the coach typically needs some information about the child’s current skill levels and behavior patterns. In our own P-ESDM practice, this is achieved as part of the ESDM Curriculum assessment process and our “P-ESDM Infant–­Toddler Curriculum Checklist” (provided in Appendix B). Regardless of what type of assessment approach a coach uses, the assessment and goal-­setting process occurs within a reciprocal

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relationship between coach and parents. The coach demonstrates that parent– child interactions and parental knowledge form the foundation of the intervention by including the parents as partners in this assessment process; using an everyday activity framework to work through the assessment; having parents play with their child on the floor in various ways that illuminate the skills the coach needs to assess; asking the parents questions about what they observe at home; having them demonstrate eating, reading, and other routines as carried out there. This working together to capture the child’s current abilities in many areas illustrates to the family how the parent–coach partnership will work in the weeks and months to come. The treatment assessment may be completed during an office or home visit. If the assessment occurs at home, the family’s own materials can be used, but the coach needs to ensure that the needed materials will be available regardless of location. This activity takes at least 1.5 hours, with the child and parents allowed ample time for set-up, adult–child interactions, parent–coach interactions, annotation and scoring, discussion, and clean-up. If additional time is needed, it can be given during the next contact in the transition to treatment. However, unlike standardized assessment, this kind of curricular assessment is focused on identifying the next steps of learning—the child’s proximal zones of development in various domains, and this zone is marked by the transition from successes to failures in developmental sequences. This does not require that every single item be administered. Videotaping the assessment is not necessary, but for someone new to coaching, doing so will be very helpful for self-­assessing the quality of parent– coach interactions and checking scoring later on. Showing this same video at the end of parent coaching can be a thrilling experience for parents as it will document all that has been accomplished via coaching.

The Environment Because of the intervention’s focus on everyday activities, it helps if the assessment space has home-like characteristics so that interactions within various play and care activities can occur in a variety of places, as they do at home: on the floor, at a child-sized table, on the couch or the coffee table, in a high chair, atop cushions on the floor. The coach sets up various activities for the parents and child, and supports transitions between the various activities needed to probe assessment items.

The Assessment Process Coaches “coach” parents on the skills they want to see: Would you show me how you and your son play with these blocks? Would you show me how your son helps you put on and take off his shirt? Parents can often elicit skills that the coach



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cannot because they know their child’s habits and the situation or circumstances that the child is accustomed to for these activities. The parents and child have familiar ways of doing various activities, and this familiarity decreases the child’s stress and maximizes his or her participation. Young children, including those with ASD, prefer interacting with parents compared to strangers and are most comfortable and relaxed with their caregivers. As a parent and child play or carry out a task together (cleaning up, putting on socks and shoes), the coach is right there with them, guiding the parent as to what should be asked, handing over and positioning materials, perhaps probing something with the child during the parent–child interaction once rapport has been established, directly observing the different skills used by the child and the extent of teaching or support from the parent, asking how representative the child’s actions are, inquiring about skills that cannot be probed in this setting. After the coach has extracted as much information from an activity as possible (across all domains of the instrument, not just the most relevant one), he or she begins another activity to illuminate another set of skills, often involving a change of pace and a change of location, as well as providing breaks to meet the child’s needs or those of the adult!

Ending the Assessment Session A comfortable, reflective closing of the assessment session will help set up the next coaching session. Assessments often increase parents’ anxiety about their child’s future. Participating so directly in the assessment can leave parents feeling very exposed, observed, and evaluated. The coach can help allay parental worry by inviting parents to share with the coach what they saw and experienced, and for the coach to share and reflect on his or her own personal experiences as well. Parents need to hear from the coach about their child’s strengths and potential to learn; about the parents’ demonstrated understanding and skills with their child; and observations of the child’s enjoyment, security, and comfort with his or her parents. The coach’s ability to reflect and share his or her experiences, attention to expressed emotions of the child and parent, and strength-based orientation delivers a powerful message to parents about how their efforts will be understood and how their child will be seen. It also sets up the reciprocal observe–­reflect–share– plan pattern that will emerge throughout each session they spend together. The message of unconditional positive regard for parents and child helps ease parental worry about the treatment that is to come, both for themselves and for their child. The session should also end on time; that delivers an important message. Reserve the last few minutes of the session for scheduling the first coaching treatment session with the parents, provide any preparatory reading or viewing materials, and tell parents what the focus of the next session will be—­reviewing and finalizing the short-term (12-week) learning objectives and treatment plan, and beginning to focus on specific interactive techniques. It is often helpful to let

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parents know that coaching sessions will be similar to the assessment session. There will be several periods of parent–child interaction during which the coach supports the parents as they work with their child, followed by a short break in which the coach and parents discuss what just happened, and then a chance to talk more generally. Finally, the assessment session ends as the coach says goodbye to the parents and child before they depart.

Collaborating on Short-Term Goals At some point in the first contact or assessment session, the coach and parents need to discuss what short-term goals the parents have for their child—their most pressing needs. In stimulating this discussion, it helps to pick a milestone approximately 3 months into the future (the child’s birthday, a major holiday, the beginning or end of a season) and ask parents to imagine desired changes between now and then. This idea of short-term changes building toward a long-term goal helps parents look ahead positively, rather than feeling discouraged by the enormity of the task that lies ahead. It’s also a time to talk about the fact that children develop different skills at different rates and that some skills will develop more quickly than others. A third possibly useful concept is that the acquisition of various skills may occur in spurts interspersed with periods during which a child develops certain skills more slowly. This is often observed when a brand-new skill is being introduced. The first steps in a new objective frequently take much longer to acquire than its later steps; it’s as if the first steps build the base, and the later steps refine or differentiate the ability further. Some parents may know right away what they want to see their child learn to do. They may come to the first session with a list of behaviors or expectations already written down or mentally prepared to share. When parents share their goals and the coach writes them down verbatim without offering changes, suggestions, or modifications, it delivers the message that parents have authority: Their knowledge and priorities matter. Given that more than 80% of parents of children with ASD already feel “stressed beyond their personal limits” (Bitsika & Sharpley, 2009, p. 540), it is important that parents feel acknowledged and supported in their ideas about what should be addressed in treatment, rather than feeling discounted or mistaken. Other parents may be unsure of what skills or goals are appropriate to expect from their child and need help from the coach to get started. A parent and his or her partner may be in conflict about which needs to address, and a coach



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who listens, learns, and understands the differing viewpoints being expressed can help the family find common ground. Sometimes the parents’ goal is a long-term rather than short-term goal, in which case the coach helps the parents think about what earlier accomplishments will lead to that longer-term goal, with parents then identifying a more achievable short-term goal. Coaches should also offer ideas for goals that have arisen from their discussions with the parents or assessment of the child. On occasion coaches have heard parents describe particular behaviors, activities, or events in their child’s daily life that present difficulties, and the coach can raise these using the parents’ own words to suggest possible goals. If the parents want to address goals that concern needs that the coach has not yet been able to observe, the coach will have to gain some insight into these needs, perhaps through a video, or visit to a specific environment where the problem occurs, in order to develop goals and intervention strategies. Sometimes the parent and coach can use role playing to enact a scenario to develop goals and strategies for new learning. The time spent in collaboration around goal setting clearly illustrates the interpersonal process that lies ahead for families in this coaching relationship.

Writing Objectives and Learning Steps After the assessment session is finished and short-term goals have been set, the coach proceeds to build child objectives and teaching steps or milestones. For those using ESDM materials, this process is described in detail in the Rogers and Dawson (2010) manual. We have found that writing 10–12 objectives for a 3-month period during weekly parent-­implemented intervention sessions is ample for most children and families, although there are no absolute rules. After writing the treatment objectives, we break down each into five to six small steps that we expect the child to learn in a week or two of teaching. Following the ESDM procedures, Step 1 specifies the child’s baseline or initial abilities, and subsequent steps add new skills, new levels of independence, or increasing generalization to meet the full objective. When coaches write objectives and steps for parents, everyday language substitutes for jargon, technical terms, and scholarly words and phrases. The descriptions of child and parent behaviors, types of activities, materials, and mastery criteria need to speak clearly to the parents and their everyday life as a family. It’s best to use the same words that parents use whenever possible. Describe objectives as they will come up during everyday child–family routines and activities; this helps families learn when and how to practice skills with their children. For each objective, we describe the reason behind or purpose of a behavior, the situation or activity in which it will likely occur, and a way to measure the behavior’s progress within family-­oriented routines. We write objectives that will call for children to perform a skill independently and consistently in the final

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step. Some “probe” questions that may help parents think about learning goals are these: • What skill(s) will an objective address? • In what daily activities will the skill be used? • What will tell us that the child is learning the skill? • What materials will be needed to teach the skill? • What event(s) or situations will lead the child to use the skill once it is learned? Is this use similar to how other children of the same age would perform the skill? Below are some examples of “parent-­friendly” objectives and learning steps. Objective “When I look at books with my child and I touch a picture and name it, my child will look at and touch the picture and either name the image, make sound effects, or look at me as a cue for me to make sound effects. He or she will do this for four or more pictures almost every time we read a book, using one of three different books.” Learning Steps • Step 1: “Looks at five or more pictures when I touch and name them and add sound effects for one to two books.” (This is the child’s current skill level.) • Step 2: “Looks at and touches several pictures either spontaneously or in imitation of me, before I add sound effects for two books.” • Step 3: “After I touch and name a picture, he will touch or name the three to four pictures and then look at me as I wait before adding sound effects for one to two books.” • Step 4: “He will touch or name three to four pictures before I do, and then look at me as a cue for me to make sound effects in two to three books during the course of a week.” • Step 5: “Touches or names four pictures that I name and then looks at me for sound effects, and imitates several of them, in three books this week.” In this next example, the objective and steps teach the child how to play backand-forth with his or her parent no matter who initiates the play episode. The materials called for in the objective are those that the parent suggested. Objective “When my child and I are playing with art materials, she and I will take at least four back-and-forth turns putting in, taking out, or using three or more

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materials on paper (e.g., marker, stickers, glitter, scissors, glue), including cleaning up afterward, in 5 minutes of play in two separate art activities per week.” Learning Steps • Step 1: “Watches and stays in the activity for 5 minutes when I show her actions to do with the materials on paper.” • Step 2: “When I model one action and hand her materials, she will mark on the paper with some help, three times.” • Step 3: “When I hand her the materials, she will make a mark that I then copy, and we will take three to four back-and-forth turns.” • Step 4: “She will help me remove some markers from the container and then spontaneously pick up one and mark on the paper with it, and we take three back-and-forth turns.” • Step 5: “She will help me remove some materials from the container and then spontaneously pick up one and mark on the paper with it, and we will take three back-and-forth turns, and then she will help me put away the materials in the container.” • Step 6: “When I put the container on the table, she will remove several markers independently, mark independently, takes several turns with me, and then when I say it is time to finish and give her the container, she will initiate putting away some materials.” The last example below reflects a family goal: for the child to participate with the family at dinner time. This goal is appropriate for a child who is very motivated to eat but whose main difficulty is wanting to get down from his or her chair and wander the house with food. The steps list the strategies the parents will use to teach new behaviors and expectations to the child. Objective “When told that it is dinner time, my child will come on his own, get in his chair, and stay in his chair eating his food until he says, ‘All done’ five nights this week.” Learning Steps • Step 1: “Walks to the table, seats himself, eats preferred foods (may choose), and leaves his seat when he wishes.” • Step 2: “Walks to the table, seats himself, eats several bites of preferred foods, says, ‘All done’ when asked, and hands over plate and cup with help when asked, before he gets down.”

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• Step 3: “Comes to table on his own when called, seats himself, stays seated while he eats several bites of dinner food, says, ‘All done’ when asked or on his own, and hands over plate and cup when asked before he gets down.” • Step 4: “Comes to table when called, seats himself and stays seated while eating some of the family meal, says, ‘All done’ when asked or on his own, hands over plate and cup with gestural cue and gets down from his chair.” • Step 5: “Comes to the table when called, seats self and stays seated while eating, says, “All done’ and hands over cup or plate to parent spontaneously, and gets down.” The objectives reflect the family’s priorities, which they stated when first asked about their goals for the next 12 weeks, and reiterated when the coach offered draft objectives for the family to consider. Even though the objectives are family-­ chosen, challenges may emerge during their implementation that may require the alteration, elimination, or addition of other objectives during the treatment period. Coaches follow family leads here and adapt and update the objectives and steps as needed so that the written treatment plan always defines family priorities and actual practice.

Creating and Implementing a Transdisciplinary Treatment Plan In P-ESDM, the coach creates a treatment plan that addresses all areas of an individual child’s short-term learning needs. While some groups do this by having team members from each discipline write objectives, such a piecemeal approach can result in duplications, contradictions, and omissions. We have found it most efficient and effective to have the person who is the coach write all the objectives. Other team members who have interacted with the child in his or her evaluation or have the child’s quarterly treatment data available to them, and have seen samples of the child in treatment, live or on a videotape, review and edit objectives and steps that fall under that person’s disciplinary expertise. This process helps all team members develop a common way of writing objectives and steps. Standards that evolve from the group can be codified by the team to define a transdisciplinary team standard for writing the individual treatment plan. Using criterionbased assessment tools that cover all the developmental domains for young children in quarterly treatment progress assessments facilitate this transdisciplinary process greatly, since the tool covers all domains and the coach develops familiarity with the progression of skills across developmental domains. Once the plan is in place, the coach needs to know the teaching content and process behind each objective and step in order to best coach the parents. Partnering different disciplines together, such as the speech and language pathologist and the physical therapist, in an intervention session will allow each person to help the other learn how to elicit the skill and assess child performance



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via coaching, demonstration, and discussion. This kind of process allows for one team member to coach the parents in all the treatment objectives. Furthermore, listing all the objectives on a common data sheet makes it far more likely that most, if not all, will be addressed during one session. In a coaching model, this is critical in order for the parents to recognize that all the objectives are important and can be practiced daily in various activities across the day, without taking hours of time. This is what we aim for in parent coaching: that the parents will address all their child’s needs in his or her daily activities. The team members share disciplinary expertise across the team so that everyone develops a generalist knowledge of children’s intervention needs and can pass on this transdisciplinary knowledge to parents.

Coordinating Treatment Plans When There Are Multiple Coaches When a child is receiving treatment from multiple providers, child and family progress is maximized when goals and approaches align across providers. Any way that the coach can help bring together the various players with the family—­ through interdisciplinary meetings, Internet conferences, or phone calls—will help parent–­professional communication and the formation of unified treatment goals. If no direct communication is possible, gathering copies of other treatment plans from the family allows the coach to identify similarities and differences in approaches and priorities. When approaches and goals seem to conflict across different treatment providers on the interdisciplinary team, it’s important that the coach refrain from criticizing or openly disagreeing with the approach of another provider, which can put the parent in a challenging and defensive situation. Rather, parent and coach need to understand the other treatment giver’s rationale. The coach may help the parent sort through questions to then ask the other provider to better understand that individual’s rationale and perspective. The coach may also help the parent brainstorm how to integrate two therapy recommendations that might initially seem at odds. When parents are clearly getting contradictory messages from various coaches, the coach can support the parents in thinking through these conflicts and using their own knowledge of their child’s behavior and development to choose the route they wish to take, with the coach ready to support whatever decisions the family makes. At times, parents may ask the coach for help in conducting these dialogues, which fits the model of the parent–coach team as the decision makers. This is particularly fitting early on in an intervention. However, an important coaching goal is that parents develop the skills and confidence to have dialogues about conflicting ideas with professionals on their own, and to do so in a manner that results in mutual problem solving and respect. Coaches need to be aware of and manage their own wishes to be needed given the importance of supporting parental skills in self-­advocacy.

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Conclusion We have discussed the importance of the beginning of the coaching relationship when parents have first asked for help with their child. We have discussed how to demonstrate the parent–coach partnership through the process of identifying parents’ goals, the strengths and needs of both the family and child, evolving into a family-­friendly treatment plan of goals, steps, actions, and outcomes for learning based on everyday activities and learning opportunities, including all the people who are a part of the family context and potential sources for learning opportunities. Throughout, we have also discussed the strengths of this approach to low-­intensity intervention, as well as the challenges that can arise in developing family skills and routines that incorporate goals, activities, and practices, while additionally incorporating family values, cultural beliefs, and priorities. Finally, we discussed the coordination of the parent-­implemented intervention plan with other interventions that may be in place for the child and family. Family, home, and community contexts are far richer in learning opportunities for young children with ASD than are specialized settings. The parent–coach relationship can provide parents with the knowledge and skills to capitalize on these rich learning opportunities in everyday activities for their young child with ASD. Supporting parents in this way promotes parental confidence, positive expectations, and a sense of self-­efficacy and empowerment, all of which promote the parents’ mental health, family relationships, and optimal outcomes for the child.

Chapter 6

Parent Coaching Sessions

What exactly are we trying to create in a parent coaching session? What does it look like? What does it feel like? How does the coach manage it so that the overall experience feels satisfying and “whole,” rather than busy and scattered? What can we do to create an experience in which parents leave feeling better than when they walked in the door: better about themselves and better about their child, clear and confident about what they want to accomplish over the week, feeling like something important happened in the session? This chapter will focus on the temporal and physical organization, learning content, and interpersonal processes that occur in each coaching hour. And, it all begins in the first treatment session. This session moves the focus of sessions from parent–child interactions to parent– child learning. It transitions the work from planning to doing, sets parents’ expectations for what is to come, and deepens the developing relationship between the coach and family. The First Coaching Session The first coaching session represents a transition from what has occurred in past visits to this new way of working together that defines parent-­implemented interventions. There are two main topics addressed in this session. It begins by gaining closure on the past session and its focus on gathering the data needed to create an intervention plan. It starts off, as all sessions will, with a brief greeting period and time to share any residual content from the last session (briefly! There will be ample discussion time at the end for anything that requires processing). The greeting transitions into the daily activities via a planning moment in which the coach reminds the parents of the two main activities that will happen today: (1) getting agreement and closure on the intervention plan, and (2) moving into parent–child 73

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intervention work on the plan by doing an activity together. The session will end with discussion time as needed and then a goodbye time to transition parents and the child out the door. The greeting time in this session offers a challenge that will exist in every other session—­managing the child while the parents and coach talk. The coach needs to make materials available for the child that will occupy him or her with as little adult attention as possible. Some children will happily sit on a parent’s lap or become engaged with objects that will keep them occupied. If both parents are present and the child needs some tending, one might manage the child if needed so the other can engage fully with the coach. If only the parent and coach are present, then in this and every other session and reflection–­discussion activity, we have found it most helpful for the coach to settle and manage the child so that the parent can become fully engaged in the thought and discussion taking place. This can be part of the planning at the start of the session. Once everyone is seated, any residual issues from the last session have been shared, and the coach has described the two-part plan for the day, the coach provides each parent with a copy of the intervention plan—the objectives, written in family-­friendly style (examples occur later in the chapter). The coach introduces the objectives by reminding the parents that these derive from their previous discussions as well as any goals the coach may have discussed during the evaluation session. The coach then summarizes each objective in terms of its essence, as the parents read along, and confirms that this is a high priority for them. Once the review is completed and any questions are discussed and resolved, the coach typically tells the parents that he or she will be tracking their child’s progress on each objective at every session and is always happy to share such information, and that the parents should expect to see signs of progress on these goals at home. The topic then shifts to how everyone will work together on these objectives in the coaching sessions, beginning today. The coach typically describes how the session will go—a few minutes to greet and chat, a warm-up activity to help the child transition into action, a plan for the parents’ topic of the day, several chances for parents to practice as the coach supports their learning and the child’s learning, and then time to discuss any open topics before the session ends. The coach next introduces the parents to the materials that they will be using. This may include a manual for the parents, a notebook the coach has put together for them, or other general materials for the parents’ regular use. (The refrigerator list provided in Appendix A.5, subtitled “Stepping into the Spotlight,” is always a possible kickoff point for the activity of the day.) Now it’s time to get into the first activity/coaching experience! In a brief description (10 minutes maximum!), the coach reviews the main points of the topic for the parents, using the handout as a visual. (See Chapter 7 for pointers on how to introduce this, and many other topics, if you need some additional supports.) The coach talks about the techniques the parents can use to increase



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their child’s performance on the skill, and the coach may suggest or inquire about what techniques will be the focus today. Any suggestions from the coach should be based on previous observations of parent–child play—­techniques that could use some shoring up. The parent chooses a material for this first play activity (or uses materials the child is very engaged with already) and begins to join the child in play. The coach sits near the parent, generally in a kind of triangular configuration and equidistant from the child and parent and clearly outside of their play space, but close enough to be able to hand an object to the parent if needed. During this first coaching opportunity, the coach may restate the targeted technique as the activity begins. The coach’s two jobs are (1) to support the parent’s use of the new skill and (2) to not interrupt the ongoing interaction between the parent and child. In this 3- to 5-minute (maximum) play activity, the coach watches, comments when the parent uses the techniques that have previously been discussed (“right in front,” “you’re in his spotlight”), and offers any other brief prompts or supports as needed via gesture and brief comments, provided that these do not interrupt the ongoing interaction of child and parent, so the coach assures that the activity goes as planned. The coach finds the right time to close out the activity, so the opportunity exists for the parent and coach to reflect on what just occurred. Each share reflections on the established parental goals for the activity and actual events, with the coach being sure to link the parent’s planned actions and their effect on the child’s desired behaviors, and show how this addresses one of the objectives for the child. If there is time for another activity, it occurs in the same way—based on the reflection–­evaluation discussion that just occurred, using different materials but practicing the same goal for the parent, followed by reflection–­evaluation. The coach’s primary goal is parental mastery of the skill. The coach then moves the session to closure, moving each member of the group back to his or her seat if needed, tending to the child as needed, providing some time for parents to process this transition into active coaching sessions and any questions or comments in the final minutes. All agree on the time and place for the next session, the coach provides copies of any materials relevant to the session to the parents, advises parents on what they might bring to the next session (notebook, questions, parent manual, beverage and snack for the child, etc.), and says goodbye to the parents and child, introducing a brief routine for the child followed by departure. Subsequent Coaching Sessions The structure we are sharing is based on the writings of Hanft and colleagues (2004); it involves cycles of planning, observation, coaching, reflection, and evaluation. It includes the session structure and also the process contained in each activity block. The coaching process involves not only parent and child learning

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but also the opportunity to support parents through a process of self-­discovery: about what they already know, are doing, and have tried in relation to their needs and goals. At the same time, the activity blocks described next define one way for a coach to organize and manage a session developed with the parents with their priorities in mind. We arrived at this structure for coaching sessions in response to too many sessions spent in adult talk and too little practice and mastery of adult and child skills. The structure for ongoing coaching sessions (shown in the box below) begins with a greeting and check-in, followed by a warm-up parent–child activity that supports planning for the rest of the session; then proceeds through two to three rounds of coaching within a parent–child activity, each followed by reflection; then allows for discussion time for topics that fall outside of the immediate coaching topic and finally a closing that ends with departure. During each of these activities, the coach is gauging the skills of the parents and child to support their learning. The coach notes throughout each activity what skills the parents already

The Plan for Each Coaching Session • Greeting: Joining together, greeting, and transitioning into work • Progress: Listening to parent progress reports and their goals for the session • Warm-up activity: Observing parent interaction skills during this first activity • Reflecting/evaluating: Sharing reflections of parent and child actions together to help parents understand and evaluate the effectiveness of the strategies they used; deciding on goals and strategies for next activity coaching • Coaching Activity 1: Parents practice skills learned; coach supports their learning goals through on-the-spot coaching • Reflecting/evaluating: Asking questions and actively listening as parents evaluate the effectiveness of the strategies used; deciding on goals for the next activity • Coaching Activity 2: Parents practice skills learned; coach supports their learning goals through on-the-spot coaching • Reflecting/evaluating: Sharing and listening to the progress made toward the parents’ desired outcomes and the next steps toward improvement; developing a plan for the week using the target skills or concepts with a focus on practicing using a variety of environments, materials, and activity types • Discussion of parked topics (if any) • Closing: Transitioning out of the session with goodbyes to all



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know and use and what new learning is needed; the coach also considers what additional support, resources, or examples may extend progress or improve understanding of a topic, and how aligned the new information is with techniques the parents have learned and previously applied. Throughout each activity period, the coach creates balance in the interaction, with the parents and coach functioning as respectful partners participating equally in the discussion and activities that occur. The activity structure provides organization for the ongoing observation–­ planning–­ practice–­ reflection–­ evaluation cycle that supports parent and child learning. We prepare and use the “Coach’s Session Planning Sheet” in Appendix A.2 during all our sessions with families. It breaks down the session activities with a recommended time span for each activity based on a 90-minute session (coaches adjust as needed for shorter sessions). There are spaces to take notes on what has been observed and discussed with parents. We strongly recommend that coaches use a form like this that records the content, timing, and notation needed to structure their preparation, execution, and reflection surrounding each session. Coaching Session Routines This first session is a microcosm of all the remaining sessions, setting up the routines for the coach, parents, and child that will occur throughout the coaching intervention. Having walked through this experience, it’s time to step behind the curtain to look at the actual scripts, props, and tools that will make this process successful for all, measurable via the child’s progress, parents’ skill development, and parental satisfaction with the experience and the coaching relationship.

Coach Preparation Successful sessions flow from the coach’s preparation: knowing the parental skills covered in the last session, the child’s current performance goals, coaching skills the coach is keeping in mind, and topics from the previous session that need to be reexamined in the coming session. This is too much to keep in mind during a session, and codifying this information in a session plan (see Appendix A.2 for a model) is a critical preparatory step. Additional session materials the coach needs to keep on hand (or on a clipboard—Sally’s preferred way of organizing materials!) include the written session plan, child data sheet, parent tool for fidelity assessment, child objectives, parent manual, parent handouts on the new topic and techniques to be covered and on past topics and techniques (in case more work is needed on them), any parent checklists, or other materials on the topics relevant at the moment (both handwritten and from a website), and a coaching fidelity tool for the coach to review after the session.

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Greeting and Check-In The session begins with greetings all around and a transition into the session environment, where parents and coach are seated together and the child settles into an independent activity while the adults converse. Keep it brief! The goal of this period is to join together and quickly seat the parents and coach while occupying the child if necessary so that work can begin. There will be an initial social chat or greeting, asking how all are doing, as the group transitions to work. The seating area can be anywhere that the parents and coach may sit near each other and oversee the child. Joining in involves greeting the parents (first) and child (second). If the child is occupied, it is helpful not to interrupt, so planning can move forward with the parents. Sitting in the same place each session, either in the family’s home or at the center, helps the process of getting started. The initial chat allows for transition from social greetings to the work at hand. The coach’s action of sitting down and picking up pen and clipboard signal readiness to begin. Once the parents and coach are seated and child is occupied, “the greeting activity” is finished. Either the parents or coach then shift the topic to what the parents have focused on with the child since the last visit, based on the goals that were established then. The coach may need to initiate this shift by recalling the plan in place when they all said goodbye at the last session, and how that plan has evolved during the interval. Reviewing these goals activates each parent’s memory and mindset for the work that is to come. If the parents have planned to keep track of data, this is the time to ask for and review it, after a genuine thank-you for, and acknowledgment of, the effort required to keep data! This early attention to data actively demonstrates the importance of the information and the effort required to record it. The coach listens carefully to gather information that will help define the focus for this session. Parents may share excitement at the success they experienced, or concern, frustration, or uncertainty when asked about their progress since the last session. They may provide reasons for why they could not follow through. Robert’s father Michael tells the coach he feels confident using the toy trains with his son to imitate his actions. Michael comments that Robert’s distress and tendency to leave activities have reduced dramatically as a result of the imitation strategy. But it feels like he is not teaching him anything new by just imitating him, and he wants to know what other ways he can play with Robert besides imitating every action and still keep the play going. The coach remarks on the importance of this question and notes that they will return to it during the session. Andreas’s mother Maria shares her feelings of failure with her son, who held onto the toy cars instead of imitating the play actions she demonstrated. The coach asks that they do this activity together in this session so that the coach can have a better sense of how to help her.



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In both of these examples, the coach listens and follows up on the needs, questions, or experiences (implied or overtly stated) that the parent has shared by making these a priority to address in the session.

Potential Problems It is often the case that a parent will bring up a problem or concern unrelated to parent coaching topics in these first moments, or at other times during the session. These need to be responded to—we are here to help—but we also need to maintain the goal of the sessions: parents’ acquisition of the concepts and skills needed to problem-solve and support their child’s progress. In these situations, the coach learns of the concern, agrees to its importance, and suggests that it be returned to in the discussion time that will occur later in the session. Jot down the topic in your session planning sheet so it isn’t forgotten, but “park it” for now, so attention is solidly focused on parent–child learning.

The Warm-Up Activity: Initial Observation We have found it very helpful to transition out of talking into parent–child action by asking the parents to help the child get ready for the session, or show the coach what they worked on at home over the past week. “Would you help Aisha warm up for our session?” “Can you show me how your work went during the week?” Or in your own words, invite the parents to show you how they practiced last week’s concepts with their child, or how a problem they describe arose. This brief warm-up activity involves a parent- or child-chosen activity that provides the coach with a snapshot of the current situation—an opportunity to evaluate what the parent or child has mastered thus far. This is a time to observe the interaction very closely, through the lens of the parent fidelity rating tool (which should now be in the coach’s hands). In this activity only, the coach does not coach the parent or interrupt what is happening until the end of the activity. The coach stays physically separate from the dyad, attending to the fidelity sheet, not making eye contact with either partner. This period of uncoached parent– child interaction provides a picture of the parents’ current knowledge and skills, while giving the coach an opportunity to assess the progress of parent and child and to consider challenges or difficulties that need additional coaching. The coach watches until he or she has completed the observation—3 minutes is usually ample time. With any luck, there is a natural (positive) moment for the activity to end, but the coach can also suggest an ending and help as needed to end the activity. Alternatively, the coach may suggest that the parent break from the activity, leaving the child to play. As the parent transitions out of the activity, the coach makes sure the child is somehow occupied so that the two adults can talk. A transition phrase from the coach, something like “That’s a helpful picture

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for me. Let’s allow her to play while we discuss it,” helps move everyone from the activity to a couch or chair, or at least turn to each other and move away from the child, thus marking the transition and providing nonverbal communication to the child that the adults are not available right now and to begin the next activity: reflection and planning.

Potential Problems 1.  The play activity goes on too long, or one activity morphs into another and another. The activity has to be short to save time for coaching. The coach can suggest, “Let’s allow her to continue playing while we talk about it.” 2.  The first activity is very brief, and the dyad quickly moves from one activity to the next without stopping. The coach only needs to see 2–3 minutes of an activity once it starts, so again the coach needs to interrupt and end the activity. 3.  The parent begins to engage the coach instead of the child in the activity with questions, comments, and the like. A good response is “We’ll talk after you are done.” Sitting apart from the dyad, turning your body away, and focusing on your clipboard, the child, or the materials helps lessen the likelihood of this kind of parental behavior. 4.  The coach is tempted to interact with the child in response to the child’s initiations or through a sincere desire to help the child. Sitting apart helps curb this behavior as well. Focusing on an assessment of parental skills helps the coach remain quiet, separate from the interactions during this activity. Not making eye contact with the child helps considerably! 5.  The child continues to seek interaction with the parent and interrupt the initial adult discussion. In our practice it is the coach’s responsibility to occupy the child so that the parent can fully attend to the learning tasks at hand. The goal is for the child to be quietly focused on some activity, seated if possible, so that parents and coach can think, talk, and plan.

Reflection and Session Goal Setting This is the next activity and the end point of the discussion to establish the parental learning goals for the interactions to come. Once the child is occupied and the parent and coach are back in interaction, the coach begins a reflective discussion with the parent, as he or she will after every parent–child interaction. While in other reflective periods, the coach may sometimes initiate a reflection, in the warm-up activity reflection, we ask about the parent’s response to that activity. The more open-ended the coach’s question can be, the more the parent will be able to share. A question like “How did that go for you?” or “Did that go as you expected?” can elicit helpful information about what the parent’s goal was and



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how it was, or was not, met. We have found it very helpful to listen deeply, without interruptions, without questions, and without reassurances or praise, until the parent has finished talking. If the parent provides a closed answer (e.g., “It went fine”), the coach can ask for more information: “Tell me more” or “Tell me what you were thinking about” or “Tell me about [restate the parent’s original goal].” This is not a two-way discussion, but rather a chance for the coach to hear how the parent is conceptualizing the interactions and interpreting his or her child’s behavior. With that information and the information from the observation, the coach and parent now need to establish a session goal, and there are three choices: (1) to continue on the topic that was previously reviewed, (2) to move to a new topic, or (3) to use the next activity to further refine the previous topic’s skills and to then use the last activity(ies) to begin a new topic. The parent will have his or her own thoughts about whether to move on or whether to continue, and the coach will also have data to bring to this decision. If the goal is to continue with the same topic, then the coach needs to be certain of the skills to be mastered during the course of this session, and that needs to be verbalized and agreed to so all adults have the same goal in mind. Karla, who is very focused on helping her daughter Sofia learn to speak, begins a warm-up activity with a puzzle. The coach watches Karla hold out and name each puzzle piece for Sofia to repeat. Sometimes Sofia responds, and other times she does not but tries to take the piece from the mother. Even when Sofia responds, Karla holds onto the piece and asks Sofia another question to answer (e.g., “Do you want to put it in?” or “Where does it go?”). Sofia finally gets up from the table to leave, and Karla quickly gives her pieces to encourage her to return to the activity. She takes the pieces and the puzzle to a different location to play alone. The coach suggests that they let her play while they reflect on the activity. Karla agrees, and the coach asks how the activity went for her. Karla responds that the exchange is typical and expresses frustration that Sofia will not cooperate by naming the pieces. She says that Sofia is just stubborn and wants to do everything by herself, and she doesn’t know what to do when Sofia tries to take the pieces out of her hand. This provides an excellent point for the coach to shift to the parent coaching topic for the session, based on Karla’s learning need. The coach affirms that Karla’s concerns are an important topic for the day—how to play with puzzles and other activities in ways that encourage child communication. Inwardly, the coach plans to focus on the skills involved in following a child’s leads, taking turns, and elaborating from the child’s theme. If it is time to begin a new topic with the parent, the coach can use parent fidelity data to decide what the most useful next topic would be. We typically make sure that the parent has a core skill set: gaining his or her child’s attention, following the child’s leads, using the skills of narration, imitating the child, commenting,

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“admiring” to respond without directing, taking turns, and using theme and variations in play (the four-step joint activity routine in ESDM terminology), before we move to skills that actively address the child learning their treatment objectives (social communication, gesture, language, child imitation, constructive and pretend play, joint attention, etc.). The core skill set develops the kind of interactions that allow the parent to create many learning opportunities for his or her child—­ interactions that are marked by the child’s attention to the adult, the child’s motivation to continue the activity, the active reciprocal engagement of both child and adult, adult responsivity and sensitivity to the child, and a flow of activities including initiations and endings that are marked by continuous engagement. If the plan is to continue with the current parent topic instead of a new one, then the coach and parent identify the key skills to be focused on (based on what the coach learned from watching the warm-up activity), the coach helps the parent plan the next activity, which typically uses different materials and different activity theme (as suggested in the parent handout “Activity Categories” in Appendix A.4: books, constructive play with a toy, meals, sensory social routines, pretend play) and helps the parent transition into the next parent–child activity. If the plan is to move on to a new topic, then the learning targets of that topic need to be introduced. Here is the most didactic aspect of the whole session. The coach introduces the topic—what it is—why it is important for all children, why it is especially important for children with ASD, and the specific behaviors (refrigerator list!) that the parent will target, giving examples from parent–child activities already observed for this family. In Chapter 7, we provide ideas for ways to describe a variety of topics that are taught in NDBI, and these follow each of the chapters in our ESDM parent manual (Rogers, Dawson, & Vismara, 2012). The coach discusses the main points of the topic using the core strategies (refrigerator list) as a visual aid for both the coach and parents. It’s a careful balancing act: to present enough information for parents to understand but not get waded down in detail or too much talk. Parents need opportunities to comment on, give feedback on, and share their understanding of new information. Does this seem important to them? Does it raise concerns for them? What challenges do they anticipate, or have they already encountered? Once the coach and parent(s) have agreed on the parent learning goals for the session, the transition to a coaching activity occurs. Note 1: If more than one parent is actively involved, then each parent may have a different focus of learning, and each parent may do one of the remaining activities. Note 2: There is a lot to cover in this first reflection–­planning period and the coach has to keep it brief, because the key learning will occur in the parent–child interaction, not in talking about it. Hitting the high points is all that is needed in order to move to the parent–child interaction. The coach and parent discussion should not take longer than 10 minutes before the next practice activity occurs.

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At the end of this activity, the coach transitions everyone into the next parent– child interaction, now clearly focused on coaching the parents on a specific set of techniques to support new parental learning and positive responses in the child.

Potential Problems The biggest problem that can occur in this and all reflection periods is the need for child management. This is the child’s break. If possible, provide a toy or object that will occupy the child for 5 minutes without need of adult supervision. If there is another adult in the room, it will be very helpful if that person could silently occupy the child. If this is not possible, then we have found it beneficial for the coach to manage the child, so the parent can focus on reflection. Those who are managing the child need to be careful not to teach or interact with the child (which will distract the parent and therapist and prevent the child break that is intended), but rather to support the child’s independent play while looking at and listening to the parent. Another problem occurs when the parent and coach have differing opinions about the next parent skill to address. Sometimes a parent may be ready to move on to a new topic, whereas the coach believes that more practice of previously taught content would help better prepare the parent for the skills he or she wants to address. The coach acknowledges the parent’s desire or preference and explains how the recommended topic will support the parent’s movement toward that goal. Example phrasing from the coach might be something like this: “You and I both want your child to use more words. However, speech and language are built on children’s ability to communicate using gestures, facial expressions, and actions, as well as making sounds and words. She’s not using many gestures yet, and I’m thinking that spending this week on strengthening those would help her get to speech more quickly. We could focus next week on building more sounds. How does that plan sound?” With this kind of explanation, the coach has provided the parents with important information about language development, reiterated their common goal, voiced their priorities for speech, and put a plan in place, demonstrating careful listening, deference to their choices, and a working partnership.

Coaching Activity In all the parent–child coaching activities, the process is the same. As the parent moves toward developing an activity with the child, the coach moves with the dyad, near the parent and ready to coach through actions or comments. Avoid sitting between the child and parent, who should be facing each other. The coach

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needs to communicate with the parent, to support, prompt, and reinforce the parent, whose skill development is the target of the coach’s efforts. The parent begins to interact with the child, trying out the new strategies. This is an opportunity for the coach to quickly record the child’s progress data on the child data sheet before focusing on coaching the parent. The goal of coaching is to help the parent achieve the targeted skills discussed in the plan so that he or she experiences how it feels to use the technique successfully and how it helps the child learn. However, in order to succeed, coaching during an ongoing activity needs to occur in a way that does not interrupt the flow of the parent–child activity or take the parent’s mind off the interaction. This means that coaching during the activity has to be brief and directive. Examples are handing a different toy to the parent (one that will work better); pointing to a child behavior or an object that needs attention; naming successful targeted techniques that are being demonstrated; directing a head nod, comment, and/or smile to the parent after a successful action; verbally modeling what the parent could be saying, or providing a brief instruction: “Stop him.” “Get attention.” “Wait, offer it.” “Prompt him.” “Hold onto that toy.” “Praise her.” “Well done; that’s it, bravo.” No questions or comments to elicit parent responses are made at this point. They are reserved for the reflection and evaluation phase. This parent–child activity continues for 3–4 minutes, until a logical ending or transition point into the next reflection–evaluation activity, with its accompanying engagement of the child, change in position, and preparation for parent–coach dialogue. For Darius, who was working on following his son Jayden’s lead by imitating before introducing new ideas, and doing so only when it’s his own turn: During coaching about four-step joint activities, the coach watches Darius in play and makes quick affirmations or comments about Darius and Jayden in action together: “You’re following his trains around the track.” “Show him how you can set your animal on top of the train to ride around the track.” “He just looked at you when you made that engine sound.” For a mother, Asami, who wanted to work on child communication during the topic on nonverbal communication: As her son Hiro points to the hole for a puzzle piece of a fish and Asami names it, the coach prompts, “Hand him the fish to put in.” The coach reminds Asami to bring more words into the interaction: “Say what you’re doing right now,” and Asami responds with “in” or points and says “here” as she places the piece in the puzzle. The coach points out Hiro’s attention to his mother’s gestures. Hiro points to an empty place in the puzzle, and Asami starts to

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respond without speaking. The coach says, “Name it. Then give it to him.” As the interaction proceeds, Asami begins to add words to both her actions and her child’s. In both examples, the coach continues to support the parent’s learning within the parent–child interaction with brief, focused verbal or gestural comments or directions to assure a successful experience.

The Reflection–­Evaluation–­Planning  Cycle A brief opportunity for shared reflection follows each activity so that the parent has time to process what just occurred and consolidate his or her learning by discussing it, shown in Figure 6.1. A particular theme in the reflection–­evaluation–­ planning dialogue is the relationship between parents’ actions and strategies and their child’s behavior in response. The coach can facilitate a reflective process by using open-ended and nondirective questions or by a reflection to enable the parent to consider some aspect of the interaction. Open-ended questions may begin with what, when, where, who, and how. Questions may start with the reflection and become more focused as the conversation evolves—for example, “It seemed like your child became much more verbal

Observation

Continuation mastery

Check-in and warm-up Joint planning

Closing with an action plan

Topic

Reflection

Practice

Evaluation

Feedback

Figure 6.1.  The coaching process: Actions and interactions.

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after [some event] occurred. I wonder why?” “Your child got so interested in that activity. How did you do it?” “How did that activity compare to the goal you set?” “Based on what you just shared, how would you do this next time?” “Why” questions should be used cautiously to avoid a feeling of blame, although it may be possible to ask sensitively worded “why” questions without the parents feeling they have done something incorrectly—for example, “Why do you think she does not like the activity?” When the parent shares a reflection, the coach may restate or summarize the associated content, knowledge, or feelings to demonstrate active listening. This allows the coach to confirm or clarify his or her understanding and also gather further information if necessary—for example, “You feel comfortable using this strategy in toy play with your child but not in other routines that don’t involve toys. Hmm, I wonder what other types of activities we should try next. What do you think?” “I hear your concern about how other people react to her tantrums. What does it mean in terms of taking her out in public?” “You seem disappointed that your child did not follow through in the way you expected. What stood in the way?” The coach also needs to share a brief reflection about the interaction—­ thoughts you are pondering, feelings that arose, expectations that you had that were or were not met; statements (not questions) that begin with reflective phrases like “I noticed,” “I wondered,” “I was thinking about,” “It occurred to me while I watched”—focusing on the relationship between parent behavior and child response, or the parent’s goals for the interaction. Coach reflections can illuminate additional aspects of the interaction related to the goals of the interaction. Given the partnering relationships, coaches should sometimes reflect first so that the parent does not always have to lead this activity, and so that it does not seem rote. Try to balance who leads off reflecting across activities, so the parent is not always in the “hot seat,” right after leading an activity. The coach has to be comfortable with moments of silence that may occur when it is the parents’ turn to speak. It takes time to think and organize thoughts. Some thoughts or feelings may be uncomfortable for the parents to explore; taking time to process feelings may ease communication. A coach who always jumps in to fill the silence out of good intentions to help a family, or out of his or her own discomfort with silence, may inadvertently take away parents’ opportunity to process, reflect, or figure things out. Parents may feel rushed to say something or incapable of giving the “right” answer to appease the coach. It may harm rather than help the process of creating a safe and trusting coaching relationship. Coaches need to learn to be quiet after a question or statement is made, and not follow up with additional questions or suggestions. Quiet waiting from the coach demonstrates acceptance and respect toward the parents. It emphasizes how important the parents’ input is to the process and ongoing work. From the reflection emerges a summary from the coach or parent that



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evaluates the status of the parent’s goal and a plan for the goal in the next activity. The plan is typically either: (1) a further improvement to be made in the targeted parent skill in the same type of activity, or (2) generalizing the skill to a different type of activity. If the previous activity involved toys, then the next activity might be a sensory social activity, or a caretaking activity, or a book or art activity. The “Activity Categories” cartoon in Appendix A.4 provides a framework for generalization. In each coaching session, it helps a parent’s generalization to vary the activity types and to practice all of them over the course of a few sessions. If the reflection follows the final coaching activity of the session, then the plan involves parental interactions with the child in their daily home activities until the next session, which also involves some generalization. Although all of this sounds lengthy, the entire reflection–­evaluation planning activity is only 5–10 minutes maximum and requires careful time management on the part of the coach. The following illustrations of this process are helpful in conceptualizing such a dialogue. Let’s return to our two coaching vignettes to illustrate the coach’s use of reflective questions and active listening. We pick up first with the coaching conversation with the father of a 2-year-old son whose goal is to imitate and follow his child’s interests in play before introducing other play ideas to the activity. While the child continues playing with trains, the coach invites the father to self-­reflect on what happened compared to the goals he identified at the start of the activity. Coach: You went into the activity with two goals. You wanted it to be fun for Liam, but you also wanted to try to follow his lead. How did that go for you? Kyle: I realized that I can’t just start off with how I want to play with the trains. Otherwise, he cries and grabs for the trains, and then it becomes really hard to try to play with him at all. Coach: That didn’t happen today. Kyle: Yeah. I didn’t try to control or take all of the trains right from the beginning. I think he was expecting me to do that again, which is why he fussed at first when I sat down on the floor with him. But I let him take the whole bag of trains so he could start off the activity and get into it. And when he couldn’t open the bag, I waited for him to look at me or to say something. When he didn’t do this, I asked if he wanted help, and he gave me the bag and looked at me to open it. I was thrilled! I let him take the trains he likes the most, and then I just closed up the bag and set it in front of him. When he was ready to take out tracks from the bag, he gave it to me right away and said, “Open.” Coach: You gave him the lead, and he kept coming back to you. Seems like he wanted to include you in the play.

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Kyle: Yeah, I always thought he just wanted to play with them alone, and he could have, but he didn’t. He kept bringing me back in. Coach: One thing that stood out to me was how you worked in choices again and again. Kyle: I asked him if he wanted straight or curved tracks. I think I also gave him choices of which color train he wanted next and which order to connect the trains on the track. Coach: He had so many choices, and he was also OK with you making some choices. Kyle: I slowed myself down this time, compared to before when I tried to control everything and show him right away how to play with the trains. I paid more attention to what Liam likes about trains, and I copied him and these actions until I could tell that he liked it. Then I did something I wanted to do with them, like crash them! Coach: [Evaluative comment] It was like the more leads you gave him, the more Liam pays attention to you and wants you to keep going, and he can then handle you taking a turn to show him something new and different. Kyle: Yeah, that was really something! I never thought he wanted to play with me, and I never thought he would try to copy me! Coach: [Moving to the plan] So the next activity you have, what will you be focusing on? Kyle: That I could try to teach him something new in the activity, but only after he has a chance to get started, And it must still relate to something he likes to do or wants to do. Like last time that we talked, about adding one thing at time, instead of lots of ideas at once. Coach: We have time for one more activity. Want to give this a try with a different set of materials, maybe books or art? Kyle: Sure, that’s a good idea. But books seem too hard. I’ll do some drawing with him, following his leads and imitating him, and just add something different once in a while, only one new thing at a time. In this reflection, Kyle recognizes and names several strategies to become a part of Liam’s play. He comments on the fun he and Liam experience together in the activity, compared to his past attempts to control the trains. He is proud that he could demonstrate a new play concept to his son and that Liam liked the idea and wanted to continue repeating it in the same activity. The coach and Kyle discuss the skills he used to navigate new play ideas with his son and the different learning opportunities that resulted. Kyle expresses his confidence with some but not all of the strategies to extend Liam’s play. He opts for more practice in how to



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add new play actions and scenarios to activities. The coach and father decide to pursue this topic for the remainder of the session and to finalize a plan for Kyle to continue working toward his goal at their next session. In our second coaching vignette, Deborah wants her daughter Leah to speak more words during activities. She has tried to teach her how to ask for items or materials, but generally finds that Leah leaves the interaction or waits until Deborah leaves before doing the activity herself. Deborah identified and practiced new strategies to approach communication with Leah, and now the coach wants Deborah’s reflections from the last coaching activity. Coach: Let’s allow Leah to play for a few minutes while we revisit the puzzle activity. We talked about other ways to practice communication besides holding onto the materials at the start of the activity. What did you try, and how did it go? Deborah: It was very different than what I expected or had done in the past. Coach: Can you tell me more about that? Mother: Before I would take all of the pieces and make her ask me for each one. It was stressful and not fun for either of us. She cared more about the pieces than playing with me, and I felt like unless I had the pieces, then I didn’t know how to make myself important to her. Plus once she had all of the pieces, I never knew how to get them back without taking them, at which point she always gets up and walks away. Coach: How did this activity compare to what you have described? Deborah: It was easier. I focused my attention and ideas on how I could play with her or play in the activity instead of worrying about the pieces. It didn’t occur to me until we talked about it today that naming what I do in my turns would help her speak. I was really surprised when she said “fish” after I did. Leah is actually listening and learning from me and from what I say. Coach: We heard her say several words from watching what you did. She said “in” or “there” when she wanted to put in the puzzle piece. There was also a social purpose to her communication. Deborah: What do you mean? Coach: There were a few times when she said, “fish” after you put in the piece, but it had a different goal and feel to it than wanting to get the item from you. She said it with a tone of excitement and a smile. It’s like Leah is watching you and interested in what you’re doing, and saying “fish” in this context is a way of connecting with you, as if to say, “Hey, that’s a fish. I know that that’s called ‘fish’!” She’s commenting. Deborah: I didn’t think about it that way, but I see the difference.

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Coach: There were other types of communication you showed her besides spoken words. I saw her watch you demonstrate these and then try them herself. Deborah: Oh yeah, you mean when she pointed to where the pieces go or to the pictures on the board after I did it? Coach: Yes. What was she communicating to you in those moments? Deborah: Sometimes it seemed like she was asking for another piece, but other times it goes back to what you were just talking about. Where she was excited about the picture she saw on the board, and she wanted to share that excitement and show me the picture. Coach: She wanted to see if you saw what she saw. Deborah: What would I do if she didn’t respond right away to what I say or show her? Coach: Well, let’s think about that. There were times where she didn’t say “fish” or point to something in the activity. What did you do in those situations? Deborah: That’s true. I said the word or showed her the action again. Coach: She might need to hear the word or see you do something a few times, especially when it is a new word or action. What else could you do if she didn’t naturally respond after you repeated the word or action? Deborah : I can’t help her say the word, but I could help her do the action, or I could see if there is a gesture or a sign I might add to the word that will make it easier for her to tell me what she wants or is thinking. She could point to where my piece goes or hand me the next piece she wants me to put in, or she might like if I made a fish face or sang “Slippery Fish” after we put in all the pieces. Coach: You know a lot of strategies to help her communicate. Your ideas about her attention to gestures and playful body movements can support language when words may not come as easily. Should we practice this again? Deborah: Yes, and maybe with a different activity like when I have to change her clothes. She doesn’t like for me to do it, but she tolerates it more when I sing songs. Maybe we could practice communication instead of me singing a whole song. Coach: Let’s do that next. The coach assists the mother in her reflection on the activity and the next steps to take to continue supporting her daughter’s communication. The coach



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begins by asking Deborah to reflect on her use of other strategies to elicit communication from Leah and encourages the mother to elaborate with more information so the coach can better understand Deborah’s perspective. The coach acknowledges Deborah’s progress and provides further examples of her mastery of these skills. The conversation also includes open-ended questions from the coach to aid Deborah in imagining additional strategies to support Leah’s communication. The coach and Deborah decide to stay with the topic of communication so that she can practice supporting Leah’s communicative gestures and words within the context of a less preferred routine. In both coaching examples, the coach encourages the parent to explore his or her knowledge, skills, and experience related to the coaching topic, and to consider adjustments or next steps as necessary in the session plan. Also evident in both examples is the coach’s responses to the parent’s self-­reflections in ways that support, affirm, elaborate, and provide insight. The coach’s feedback first follows the parent’s reflection to assure an accurate understanding of his or her thoughts, ideas, and needs. The coach waits for a while before providing recommendations. Even when the coach knows other strategies the parents could use, the coach holds back and encourages them to generate their own solutions, adding examples from the coach’s observations to support their ideas. When the coach gives recommendations, ideas, or feedback, it is clear, concise, and relevant to the activities that occurred. It describes specific examples of parent–child behavior so that the parents can relate the content back to their actions and those of their children and know exactly what the coach means. Lastly, there is no critical or negative tone to the coach’s words. The coach does not point out any overlooked or incorrect actions. The conversations between each parent and coach build a relationship of trust, respect, and open communication. In both coaching examples, the sessions continue with further practice to build parental understanding and confidence in the targeted skill or topic. The box on the next page summarizes the key features of this reflective/evaluative process. The coach will continue to use observation, reflection, feedback, and practice at the end of the session to summarize and plan next steps (before the next session) and to review with the parents the effectiveness of the coaching process. The evaluation section following the last coaching activity needs to lead to a plan for the week, rather than for the next activity. The discussion often summarizes the skills practiced across the session and cements parents’ understanding before they go home to continue working toward their goals. It needs to focus on generalizing skills to other activities at home. In this planning process, the parent needs to visualize using the target skill or concept across many activities during the day and the week (what is meant when we say “generalization”). Appendix A.4, the “Activity Categories” chart, is an excellent visual aid for this discussion, as is Appendix A.3, “Parent Daily Practice Chart.” The coach might take notes for

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Supporting Parent Reflection • Coach solicits the parent’s reflection with an open question (or leads off with own reflection). • Coach restates the parent’s comments for accurate understanding. • Coach shares reflection that emphasizes the effects of targeted parental acts on child learning/behavior. • The two discuss the activity to evaluate parental mastery/need for practice. • Coach encourages parental problem solving when mastery has not yet been achieved. • Coach’s tone is thoughtful and accepting, not cheerleading, not critical.

the parent as he or she discusses plans for these different activities, perhaps on the daily chart. Any record keeping that the parents are going to do (e.g., sleep diary, food dairy, word list) should also be discussed at this juncture. This is also a good point at which to discuss the child’s progress, with the coach sharing data that have been gathered during the activity periods, pointing out areas of gain in skill, but also discussing any skills that are not improving. Here is the place to help the parent plan to target a specific child skill during the next week, making sure the parent knows how to elicit the skill, how to foster increased child mastery, and in what daily activities this skill can be practiced. Setting a specific goal for the child’s skill development that will be assessed at the next session and writing it down for the parents and coach (on the session planning sheet!) demonstrate the importance of child learning. The coach may offer to email or text the parent to check on skill progress, or ask the parent to text or email about it at specific times between now and the next session. Establishing both a specific target for the parent and a clear follow-up plan between sessions typically supports parental efforts and also assures that any problems in home teaching are revealed and addressed rapidly, so neither parent nor child experiences failure. If the skill is too difficult to teach at home at this stage in the coaching, then that can be prioritized as the first topic to be discussed at the next session. The coach can end the final reflection–­evaluation–­planning conversation by asking if something particularly helpful or not helpful took place in the session. This gives parents the opportunity to directly provide feedback about their experience with the coach. Spending time to review the whole session helps the coach and parents gauge the progress that they and the child are making. It also provides an opportunity



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for parent feedback on the usefulness and impact of the coaching relationship and session. The coach needs to know the parents’ true perspective on how helpful they find the session, what else they might need to facilitate their learning, and what changes could be made to improve the coaching process and relationship. Parent feedback assists the coach’s self-­evaluation of coaching skills and what styles, techniques, communication, and interactions are the best fit for these parents.

Potential Problem It is very common for coaches to assume the role of parent cheerleader following each activity, and sometimes during activities as well, with the goal of reinforcing parent efforts and adding to parental motivation. Following the guidance of Hanft et al. (2004), we have worked very hard to embrace a different style of coaching. Praise connotes evaluation and authority. While children often need this kind of feedback because they are not yet able to self-­evaluate, adult learners evaluate themselves. Parents need self-­evaluation skills for all the hours that they will spend with their child without the coach. The process of reflection shared between parent and coach fosters the self-­reflective process that the parent needs in order to work independently of the coach. It is modeled from the process that therapists use to evaluate their own treatment, session by session, and it is the process that skilled adults use routinely to self-­monitor and improve their work. Thus, we inhibit, as much as we can, the desire to praise the parent after activities so that parents can learn to evaluate the activities themselves, and thereby make corrections and identify success independently. This learning occurs through reflective activities, through active listening to parental reflections, through sharing personal reflections about observed parent and child goals, acts, and emotions, through attention to the effect of parent behavior on child behavior, and through reminders of topics and skills already mastered.

Discussion Time This is the time period for returning to any topics parents identified earlier as needing attention, or for asking if other topics exist that they want to discuss at today’s session. If there are none, then the session can continue through one more round of activity and reflections until closing. If topics do arise, given the brief time period (10 minutes), there will likely be no opportunity to discuss more than one problem (so the parents need to prioritize topics in advance), or to solve any large problems, but time is available to put a plan of action in place that will allow the coach and parents to develop an approach to the problem during the next visit. A child’s behavior problem may need to be described so that frequency data

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can be gathered at home. Then it can be prioritized in the next session’s discussion period, to consider the ABCs involved in the behavior, to consider follow-up with other adults in the family network about the problem, or to discuss a referral or consultation, either outside the treatment group or with a member of the treatment team with more expertise in this particular area than the coach has. An important part of the parent learning process is to go through the steps together of gathering the information needed and of identifying the tasks that have to be completed to lead to a behavior plan and behavior change—skills that will help parents to problem-solve independently in the future. At the end of the discussion, any plans or topics that must be carried over to the next session should be written down in the coach’s notes and targeted for the next session. If a check-in is needed concerning a new skill or problem before the next scheduled session, that should be planned for as well, as this phase transitions into the closing.

Closing The session closing is the transition into departure. It is a time to briefly confirm and record the action plans that have been set for the parents and coach, to confirm the date and time for the next scheduled session, and to say your goodbyes to the parents and child in a quick separation at the door. It is easy to get caught up in continued discussion during this phase, and the coach has to be intentional about the closure that has been established and the need to “park” any continuing topics until the next session. The coach’s bodily communications: standing up, gathering materials, moving to closure with the child—these are the actions that move the closing through to its conclusion.

Coach’s Reflection and Note After the door is closed and you are either in the treatment room alone or in your car, take 5 minutes to gather your thoughts. Finish your notes on the child’s progress; jot down needs and topics for the next session, action plans, successes, or concerns; or complete a data sheet or two. Keeping a new session planning sheet on your clipboard and using it during this moment of review will help you essentially plan some content for next session as you sort through your own thoughts. A review of the coaching fidelity checklist and rating tool (Appendix A.9 or A.10) will help your reflection on your coaching characteristics and session management, perhaps giving you new points to add to your planning for the next session. Focus for a moment on the emotions generated during the session. This aids your own reflection–­evaluation–­planning process before these thoughts dissolve in the press of the next client and another session. It also provides content for reflective peer supervision and for seeking additional help if coaching problems are creating discouragement, self-doubt, parent- or self-­blaming, anger, or hopelessness.



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Unfinished Business Thus far, we’ve been advancing the basic principles and practices that have allowed us to support the parents of young children with ASD as they embed intervention practices in everyday activities at home. Our research studies have demonstrated that parents have learned to do this with a high level of fidelity to the core practices. The approach already described has consistently demonstrated parents’ ability to learn those practices, transfer them to a home environment, and maintain them even when weekly sessions have ended. However, there is more to deal with in parent coaching than parent learning. Three additional topics will be the focus of the rest of this chapter. These are all aspects of coaching that occur “down the line,” after the first months of coaching have passed, and they all focus on how to assure that children are receiving what they need from the parent-­implemented intervention. The first of these topics is how to add the focus on child progress and child objectives to the coaching sessions without losing sight of the adult behavior within child-­focused interactions. The second topic has to do with ways of addressing difficulties in the coaching relationship with parents, and the third topic concerns termination of the coaching relationship.

Addressing Child Objectives within Coaching Sessions Thus far, we have focused exclusively on supporting parents’ learning of interactive skills that will support their children’s learning. However, children with autism have core difficulties that interfere with their ability to learn from other people. Their difficulties with social communication, joint attention, imitation, and pretend play, their reduced motivation for social interaction, and their engagement in repetitive and restrictive behaviors and interests present major challenges for parents in everyday situations. We see the results of their learning problems when we assess their skills in order to develop learning objectives for them. One difference between P-ESDM and some other parent-­implemented interventions is our belief that for most children, their learning needs will have to be directly addressed in a parent-­implemented intervention to stimulate progress in all areas. After all, this is the purpose of the intervention, to help children progress! How does the coach help this happen? It happens bit by bit, as parents become skilled in their new learning, beginning with the child data that the coach keeps for each session. Each week, the coach takes data on the child’s progress on the objectives that were developed at the start of the intervention. In order to track progress, the coach has to observe activities that will support child objectives. While some objectives, like language, imitation, or social engagement, can be addressed in any type of activity, other activities, like pretend play, self-care skills, and fine motor

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skills, require specific materials, actions, and themes for their practice. To monitor progress in these areas, the coach must see parents carry out the targeted activities in session. Thus, the data-­keeping process itself starts to shape activities, so attention is focused on child objectives. For activities that are not parent go-to’s (pretend play is often one of these), this requires that the coach ask the parents to do the activity with the props and actions that will elicit the targeted child behavior. This is an important didactic moment for parents, and they will likely need coaching support in order to learn how to conduct this activity in a way that addresses their child’s learning needs. Because this is a new activity focused on child learning rather than new parent techniques, the best place for it is as the last activity of the day. The coach supports the parents through the activity and points out what the child’s current skill level is and what the target skill is. Here is a natural point to ask the parents if they can practice this activity at home over the coming week and, when they agree, to then come back to it in the next session’s discussion time in order to help them develop a plan for mastering the activity. The data-­taking process itself has directly brought the targets of child learning into coaching. This is why we emphasize data keeping throughout the session. A second process fostered by data helps to shift attention to child learning targets, and this occurs when the coach begins to summarize the progress he or she has observed. We expect that children will show progress within a few weeks on many of their social, communication, and play objectives as the parents learn techniques that better support their attention, involvement, communication, and imitation, which now occur inside all activities. Sharing their child’s progress on specific objectives is very reinforcing to parents’ efforts, and it is a natural point of celebration. This can happen after any parent–child activity in the coach’s part of the reflection–­evaluation–­planning cycle. Showing parents the data sheets and the progress made further strengthens their efforts. However, it also draws the coach’s attention to what is not progressing, and the coach may begin to share this in the discussion time, as part of planning for the next week’s home activities or the next week’s session. Some skills involve a small refinement, like responding at first instruction. For parents who always gesture with instructions or always repeat the instruction several times, the child has not had the chance to demonstrate the skill. The coach may raise this issue and then ask the parent to be aware of such behaviors, to try and give an instruction once and then move to a prompt. The coach might even role-play this with the parent to be sure it is understood. That might be the parent’s “homework” for the week. Please see the materials provided in Appendix C for examples of simple self-­monitoring tools that parents can use at home to focus their attention on the new skills that they themselves are learning. It often happens that it is in the reflection time after the session ends that the coach becomes aware the child is not progressing on one or another target, in which case the need to support child learning on that skill can be prioritized in the planning activity at the start of the next session as one of its goals. Including



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a child learning target as part of a session plan often leads the coach to want to demonstrate “how to do it” to the parents and to then have them imitate what the coach has done. We personally do not use this approach for several reasons. We prefer to discuss the skill with the parent, get the parent and child interacting in an activity, and then point out an opportunity as it arises and coach the parent as needed to support the child’s target skill. In this way, the parent has the personal experience of helping his or her child learn something new, and this progress has come out of the child–parent activity that they have evolved and their own interactive style. We don’t model the skill because we want the parent to have the experience firsthand and to do it in his or her own way.* As the intervention moves along and the parents gain more and more skills, this attention to child progress continues—moving the initial focus on parent learning to a shared focus on parent learning and child learning. As parents begin to demonstrate mastery of the skills they are learning, the sessions become more and more focused on child learning. The warm-up always begins our sessions so that fidelity data can show us any areas that need parental review, covered typically in the first activity, and then the remaining activities may be focused on child learning targets within the parent–child activity, with parents using the skills they have learned. Our data have shown that parents, on average, master the techniques we have been helping them learn after eight sessions. At that point, the coach’s focus is on maintaining the parents’ skills while focusing on the child’s progress, and each activity is focused on child learning. The coach continues to take data on parent fidelity and child progress, but the coach and parent may shift into a co-­ intervention approach in which they alternate activities as partners in the intervention delivery, each focused on child learning, each attending to child progress and intervention skills, each working to embed this style of interaction into more and more of the child’s everyday routines within the family.

Difficulties in the Coaching Relationship The philosophy and approaches that we have discussed thus contribute mightily to building a positive working relationship that builds both the parents’ and child’s skills and ends with high levels of parental satisfaction. Our data show this! However, difficulties arise in every relationship of every type, and sometimes these are not fleeting. Long before the parents end the relationship by moving on to another provider, or by asking to end the coaching relationship and have the interventionist provide direct intervention instead, warning signs emerge. *Do we ever model? Yes, occasionally, most often to problem-solve a skill that parents are having difficulty supporting. In that situation, we imitate the parent’s approach and try to figure out a solution, and then reverse roles so the parent has a chance to perform the skill with our support. We might also model if a parent explicitly asks us to, so they can see the skill from the “sidelines.” This is rare but not off-­limits!

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Cancelled appointments, no shows, reports of no time to practice, desires to talk rather than work with the child, change in parent demeanor and behavior within sessions, no progress in parent or child data, requests that the interventionist do the sessions so the parents can learn by watching—all these are signs that things are not going well, and they need to be addressed. We have previously discussed the helpfulness of motivational interviewing approaches as tools for addressing motivational problems; they provide a very beneficial set of coaching tools for discussions that need to occur. The coach’s first step as warning signs are emerging is to seek guidance and support from peers or supervisors with experience in addressing conflict in this kind of treatment. Planning for this dialogue needs to be a part of the coach’s session planning activities so that the coach can enter a discussion of the subject with reflection and intention, rather than negative affect and defensive feelings. Once you as the coach are ready to raise the topic, discussion time is the appropriate opportunity to discuss the signs being observed and put your own concerns on the table. After commenting on what has gone well in the session that day—both for the child and parents—it’s time to talk about the signs you have seen and your question whether they reflect difficulties the parents may be experiencing in working in this way with you. Ask them directly about what difficulties they are experiencing, and then follow your question with silence and a readiness to listen deeply so that they as the parents have a chance to consider what to say and the space within which to think and respond. Parents may tell you what the problems are, which then allows you to take in that information, lower your own defenses, and respond calmly to whatever they have said. Perhaps they want to work through the problems and find solutions to them with you. Perhaps they want to change interventionists. Perhaps they want to try a different type of approach. Perhaps they want your style to be more directive style. The problem-­ solving dialogue you will have with them needs to lead to some possible solutions and an action plan that can be tried at the next session, with a commitment from both sides to find a way to work things out. In that commitment, all are expressing the value of the relationship and of the work that has gone on, and the shared priority of the child. Perhaps the parents will defer or deny that there is any problem. The coach can still follow up by scheduling the next session and then suggesting that the parents might like to do things a little differently at that point. Are there particular ideas or adjustments that they have in mind? If they so “no,” then the coach can proceed to end the session as usual, and return to this question again in the greeting period at the next session, before the warm-up. Having the chance to consider this issue over time may help the parents better form their thoughts and requests, and it is critical that the topic be returned to early in the next meeting, given the discomfort all must have experienced at the end of the last meeting. These situations are very difficult for the coach, who might need support



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through them from a peer supervision group, a supervisor with this kind of experience, or the mental health professional on the team. In most situations, opening dialogues about problems is the single most helpful action a coach can do, and most difficulties will be helped by the opportunity for discussion, even if the parents do not share the concern. The coach’s level of care and concern about the parents and child and about the coaching relationship have been clearly demonstrated, and this by itself can deepen the relationship and strengthen motivation on all parties to continue the work.

Ending the Coaching Relationship Parent coaching is often a short-term activity, filling the space for services prior to the time that children are old enough to be eligible for public school services at age 3. The ending of an intervention relationship is an ongoing part of an interventionist’s life, and the relationship may end in various ways. It may be that the coach and the family have previously decided on a set number of sessions, which was communicated from the onset of service. This is likely to happen in research studies, for example. Alternatively, sessions may end when the coach and parents mutually agree that the coaching process has met its goals, and parents feel able to use knowledge from the intervention, to self-­assess, and to self-­correct without the coach being present. Funding may end, or parents may begin another intervention that requires the time they allocated for parent coaching. Endings can also result in negative experiences for both the coach and parents. Coaches may believe that there is much unfinished business, or that relatively little was accomplished, resulting in feelings of failure, of “imposter syndrome,” or of anger toward systems that created the termination or families that appeared to do so little between sessions. They also may feel a great deal of guilt, knowing that the child received so little of the intervention that was very much needed, or sadness over the lost and unrecoverable time for child learning. Parents may also end the coaching relationship with negative feelings about the whole experience, believing that it was a waste of time, or that the interventionist “left” them unprepared and alone, or that no one will ever be able to do what this interventionist did for them. There are steps the coach can take before the coaching relationship ends to prepare everyone for the ending in a way that leads to positive closure, and this involves ongoing attention to the gains that the parents are making in helping their child learn and the gains in the child’s progress. The goal of increasing parental independence, problem solving, and decision making described throughout these chapters prepares the parents for the time ahead, after this coaching intervention ends. The final sessions should involve increased parental focus on child progress. The increased use of self-­monitoring tools and data tools that allow parents to assess gains and needs themselves, and an increased focus on parents’

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problem-­solving skills and the application of their new learning to decision making become critical, as the coach shifts from a leadership and coaching role to work on the sidelines, to function more as a sounding board for parents than as an initiator of content. Session content shifts to maintain the new learning that has occurred, continuing to build the child’s skills within home routines using objectives and steps and data systems—ranging from very simple to more complex according to the parents’ preferences. Given the amount of child progress that has occurred during the coaching sessions, the coach may offer to provide another set of child objectives for the parents to work from. This would be most helpful if the next intervention will not involve help for parents at home. Four weeks before the end-date for coaching, session planning can shift to the parents’ requests for choosing the topic of the day based on what they will need after sessions end, and such planning and doing can continue in each of the final sessions. Discussions of resources for additional parent coaching when the family needs it help reassure them that help will be available in the future. In some coaching relationships, the session schedule can purposely start to thin out, going from every week to every 2 weeks, to prepare parents. Some coaches may continue to make a monthly visit for a few months after the final session to support parental independence. If it is not possible for the coach to reinstate these periodic followup sessions, is there another colleague functioning in a coaching role or some other resource that might be able to assist? Exploring these options with parents provides some reassurance of help along the way. If follow-up sessions are planned, we have found it helpful to maintain the same familiar activity structure of the coaching process, with decisions about next steps being made during the discussion time. The final session is often a bittersweet experience, looking back and looking ahead. Using the same session structure, it is often the time to have each person in the room do a final activity with the child, for the pleasure of observing the child’s progress and for the pleasure of rewarding adult–child interactions. The discussion time is a moment to relish what has been accomplished and the amount of learning that has occurred. Parents and coach will each share how they have grown from the experience and how they have seen the child grow. Parents might bring a small gift, the coach may do an art activity with the child and ask to keep the result as a remembrance, or parents might ask for a picture of the coach and child posing together. These kinds of acts help parents realize that the coach will not forget them or the relationship that was forged in the room. Conclusion This chapter has walked coaches through a typical coaching session, piece by piece, to provide a template for a session that provides a considerable amount



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of time for parent–child interactions and coaching, while also allowing for the more general person-to-­person, family-­focused support that interventionists want to give and that parents of newly diagnosed young children very much need. We also addressed issues that come up after the working relationship and rhythm of the sessions have been established, and parent learning has been the topic of the sessions for enough weeks that children and parents are both demonstrating new learning in the sessions. These have included increasing attention to child learning, evolving into cotreatment sessions as parents master the intervention skills, and dealing with termination. We have also addressed ways to confront challenges that signal the potential failure of the coaching relationship, all of which need to include some ongoing support from others, given how painful an experience this is for coaches. Coaching relationships in early intervention birth to age 3 services are by definition short-term relationships, and termination of the coaching relationship is a bittersweet experience—a time to celebrate all that has been accomplished and a time to acknowledge the feelings of loss that come with the end of fruitful partnerships unified around children’s needs.

Chapter 7

Guides for Introducing Intervention Topics and Strategies to Caregivers

As we have worked with early interventionists making the shift from direct intervention to parent coaching, we have found that the introduction of new topics has often been a source of difficulty. Three core difficulties seem to occur. First, some report that it’s hard to take concepts from the early intervention research and practice literature, and present them to parents without sounding like a graduate school professor. Providing a didactic lecture makes the techniques sound foreign and complicated, while communicating the concepts in everyday vernacular puts parents at ease and helps them relate the new information to their current parenting styles. Second, interventionists often report that it’s difficult to condense the topic introductions into 5–10 minutes, and instead they find themselves going on for way too long so that the whole session loses its focus on doing, as opposed to talking. Third, interventionists report that it is difficult to convey to the families why the skills in the topic description really matter, and how they fit into everyday life. The purpose of this chapter is to provide coaches with some guidelines for introducing new topics. While the topics follow the ESDM parent manual (Rogers, Dawson, & Vismara, 2012), they are typical of those covered in many NDBI approaches for young children with ASD and may be helpful to a wide range of interventionists. Topic I: Gaining Child Attention as a Precursor to Child Learning

Rationale: Why Gaining Children’s Visual Attention Is So Important for Learning What to Share with Parents: Watching what others do—their actions, gestures, facial expressions—and listening to the language tied to these behaviors are how 102



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young children learn about the world, people, and objects around them. Babies and toddlers rely on this exposure to develop skills and language and to support their milestones. In fact, their brains are wired to watch, listen, and respond to people because those interactions are as biologically necessary as other wired responses like crying when hungry, tired, or scared. For Coaches: Highlight the developmental importance of young children’s attention to other people, not just their environment, for learning from what they see.

Justification: Why This Is Such an Important Issue for Children with ASD What to Share with Parents: There is a risk in autism for young children to not have as strong of an interest in watching, listening, and interacting with people as other children do. Instead, objects are easier or more interesting to play with than people. Objects are straightforward. There are only so many different actions one can perform with them and, generally, the same outcome can be expected from the object. Interacting with people is entirely opposite. More skills are involved (watch, listen, comprehend, speak, act, or move), they have to happen simultaneously, and you cannot predict or know what will occur in each interaction. When children with ASD spend more time with objects than people, they miss out on the learning opportunities available with people. They miss seeing and listening to what people do and say—their physical actions, body language, facial expressions, gestures, and words—in order to learn. Over time, these missed moments add up and slow down their learning and potential for skills to grow and become stronger. Supporting children’s attention to people’s faces, voices, and actions is the first and most important tool in helping children with ASD get the most social learning out of interactions. This is our first coaching topic together. For Coaches: Include examples of social actions, language, and/or emotions observed in children’s interactions with parents or in stories shared by the parents to highlight why more attention to others equals more opportunities to learn and strengthen their development.

Five Steps for Increasing Children’s Attention to Interacting Adults What to Share with Parents: Name and describe the step(s) that parents are to learn today. Help the parents select activities to practice those strategies with their children, and plan and problem-solve how to continue their practice of specific child goals they established until the next coaching session.

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For Coaches: Keep in mind what parent–child skills are already in use by parents. Also keep in mind how many steps need more practice to cover in a given session without overwhelming or confusing parents. Step 1: Identify the Spotlight of the Child’s Attention

What to Share with Parents: When we know what materials, activities, games, actions, sound effects, or other interests children like, we can create greater appeal or motivation for children to want to be a part of the interaction. Remember that children learn through watching, listening, and doing, and none of that can take place without an activity or interaction. Also, children who are motivated to participate in an activity generally want that interaction to continue, which means the more learning opportunities that are available, the longer the activity lasts. Let’s observe or discuss what your child likes. For Coaches: Share a few activity ideas for parents to offer to the child and reflect on the child’s behavior with the parents. Which material(s) does the child walk toward, look at, or touch? How does the child manipulate or play with the material(s)? Are there words or vocal sounds the child says or makes? Encourage parents to share their observations before sharing your ideas first. Step 2: Step onto the Stage and Take Your Position

What to Share with Parents: Children’s learning from interactions cannot go any further without paying attention to people’s voices, faces, and actions within those activities. We want to make children’s attention to people as easy as possible. This requires finding the positions that put people in children’s spotlight, meaning children will look at adults—their eyes and facial expressions, where they look, the movements their mouths make when they speak, the actions that they take with toys or objects—and finding positions or activities that support children’s bodies and arousal needs. Do children need to sit in a beanbag chair for better support for their back and feet when looking at a book with their parents? What about letting a child lean against a table if sitting for longer periods is difficult? Is lying on the ground an option when playing social games or singing songs? What about physical games to wake up a passive, quiet child or sensory activities to calm a child with higher energy? Let’s brainstorm for ideas to increase your child’s attention to you. For Coaches: Reference the activity ideas for this step to help the parents decide which positioning ideas to try with their child. Consider what you observed from the child in Step 1 to help parents brainstorm on positioning ideas. Resist the temptation to share your ideas first.



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Step 3: Eliminate the Competition

What to Share with Parents: We want to be aware of and manage distractions that can pull children’s attention away from people, the fun vibe of activities, and the learning opportunities inside those interactions. Distractions might be certain toys or materials; how much of something is available at once; how long a child has an object; electronic items like phones or tablets; background noise; or even the number of people in a given interaction. Once we know what are or could be distractions for your child, we can talk about ideas to work through them so that your child’s attention on you is maximized. For Coaches: Share activity ideas for this step to help parents identify real or potential distractions (if they are unsure) and the tools to manage them. Consider sharing observations in the form of questions or statements from earlier activities done with the child to support parents’ reflection. Help parents answer these questions if doing so assists their planning: • “What stood out to you when you tried to join your child with Play-Doh? How did you gradually shift your child’s attention away from the containers of Play-Doh on the table to the one you were holding?” • “I noticed how you and your wife did not take turns at the same time.” Step 4: Identify Your Child’s Social Comfort Zone

What to Share with Parents: Paying attention to how children with ASD respond to proximity or the physical closeness of another person helps to gauge their social comfort zone for interactions and learning. Leaning away or taking steps back from an adult who moves closer suggests a child is uncomfortable with close space. Looking at an adult, watching actions happen in an activity, or maybe even raised corners of the mouth to suggest a smile suggest that a child is at ease with the adult and the adult’s space. We want to read children’s cues, particularly their nonverbal reactions—their body language, facial expressions, movements—to understand their level of comfort and to make adjustments when necessary. What signals have you seen from your child in activities today or previously that suggest comfortable social zones? What about uncomfortable social zones? How could we respond going forward to try to change that experience? For Coaches: Offer activity ideas for this step to help parents share examples of comfortable and uncomfortable reactions from their child and how to respond to them. Consider sharing observations in the form of questions or statements from earlier activities done with the child to support parents’ reflection. Help parents answer these questions if doing so assists their planning:

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• “How would you describe your child’s comfort level during the song?” • “How did your child respond when you moved in closer to sing the song?” • “Where else could your body be in relation to hers?” Step 5: Join in by Following Your Child’s Lead

What to Share with Parents: Listening to children is a strategy crucial to learning. For children who are not yet active talkers or without conversational skills, we want to follow four strategies to give children the sense that parents are present in the moment, attentive, and ready to take in whatever their children want to share with them within interactions. Those strategies are showing interest, narrating, helping, and imitating to build relationships with children and to encourage their initiation of ideas and social interests, not just responding to ours. Showing interest is the least intrusive and a good place to start, especially for children who may leave activities or become upset when parents attempt to participate. Parents position themselves near enough for children to accept their presence, but distant enough so children will not leave the activity and facing children (or sitting sideways for very avoidant children, suggesting there will not be a lot of interaction just yet) to observe their actions and to make encouraging gestures (head nods, smiles) and simple, descriptive comments, vocalizing the child’s expressions to mark the parents’ presence and to show interest in the children’s focus of attention. This strategy is to nod, smile, and watch—to convey to children that parents are interested, attentive observers, friendly faces, and not here to change their children’s focus and make them do something. Narrating is like sportscasting or describing what children do in the moment (in short sentences!). It gives parents something to say or do timed to children’s actions and to their affect, energy, and animation. Narrating captures the emotional tone and tempo of children’s actions and movements and its synchrony to parents’ descriptions and their own affect, so the reciprocity becomes another way to be there for children and to tell them that the parents are on their wavelength. Helping children particularly before they need help is a way to join in the interaction and make it easier for children to attain their own goals. Helping children get the next toy or complete a more challenging task allows parents to start taking a slightly more active role in interaction without causing upset or frustration. Helping is not asking children to demonstrate a behavior, but making it easier for children to reach their goals. Imitating children is the most “intrusive” of the four strategies, but the next one to try for parents who have worked their way through the earlier strategies and for children who are comfortable with parents as helpers in activities. Imitating means picking up objects that are the same as what their children have, doing the same action, and handing the objects over to the children. Parents can also imitate children’s movements, sounds, facial expressions, or other cues.



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These four strategies do not dominate the activity, but instead tell children that their parents see them and what they are doing, so the children become more attentive to the parents and more comfortable with their presence. For Coaches: Reference the ideas and tips for this step to help prepare parents for practice with their child. Support parents one strategy at a time, instead of practicing all four in one interaction. Consider spending more than one coaching session on this step for parents and children who would benefit from more practice and support.

Topic II: Why It Is So Important That Parent–Child Interactions Are Fun for All What to Share with Parents: Helping children find the fun in activities with people is so important to their development. Fun means more opportunities, longer attention, and more drive to practice and learn skills, especially those harder to do at first. Fun entices children to take action in their behaviors with others through looks, smiles, movements (takes a step closer or swings arms), and to reach in excitement and anticipation for the activity to continue. They signal to the person, “I like this,” “I am having fun,” “Do this again.” These moments give way for families to teach children how to evolve signals into clear gestures, actions, or words. The exchange teaches and supports children to become active leaders in their communication, not just passive observers. For Coaches: We offer the following six points explaining why having fun is such an important part of helping your child learn: 1. More fun = faster learning. People want to continue activities they’re enjoying. So simple, but fun keeps you both at it, and for your child more practice leads to faster learning. 2. More fun = more learning opportunities. The longer the two of you interact, the more learning opportunities you will provide for your child. 3. Adding fun to a learning activity aids the learning and memory process. Pleasurable activities result in much faster and durable learning than carrying out activities that do not have any emotional meaning. 4. The desire to communicate that he or she wants to keep doing something is the basis for your child’s learning to communicate. Looking and anticipating, smiling, reaching, or bouncing and being excited can all be developed into clear gestures, words, and eventually sentences! This is one of your most powerful teaching opportunities as a caregiver. 5. A favorite activity is its own reward! Repeating an enjoyed activity after your child communicates wanting more provides a strong reward for your child’s

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communication. The power of teaching through play is built on this natural reward system. 6. Being a very frequent source of fun and pleasure increases your child’s attention to you at all times. As your child learns the cues that you use to begin an activity, he or she learns more about your communication. (Rogers & Dawson, 2010, p. 92)

These six points can always be turned into a handout to share with parents.

Why Not Having Fun Together Is a Problem What to Share with Parents: We learn skills and abilities from communication and language to critical thinking, reasoning, play, friendships, and all other aspects of our mental and emotional life—from the ebb and flow of interacting with others. Every day, we gain new and deeper practice, insights, and knowledge from these exchanges. When social interactions are constrained or limited, we miss out on the opportunities to watch, listen, act, and learn. This chapter talks about a kind of social play between people that aims for children with autism to find the fun and learning value in their interactions with others. The social play is called “sensory social routines” (SSRs): “sensory” because the routines often involve stimulating sensory experiences; “social” because the main agents of action are you and the people in your children’s lives, not the objects or sensory materials used in the routines; and “routines” because the activities or games become familiar and predictable so that learning is easier for children with ASD to take the lead in their gestures, actions, and words with others. We want children to be active learners in charge of their behaviors, not simply passive observers responding to the actions of others. We explore three steps next to help put children in the driver’s seat of their own engagement and learning. For Coaches: You can include in your explanation skills that parents have already shared with their child, or skills that parents would like their child to learn how to do within SSRs, to help parents see how SSRs may be used as learning opportunities to practice these goals. If parents do not volunteer this information, invite them to reflect and share examples. Help parents answer these questions if doing so assists their planning: • “What learning moments stand out to you in your sensory social routines with your child?” • “What learning moments could we add to your sensory social routines or create with new sensory social routines to help your child?” • “What concerns or worries do you have about sensory social routines?”



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Techniques for Increasing the Fun Quotient in Parent–Child Interactions Step 1: Find the Rhythm of SSRs

What to Share with Parents: There are two golden rules that separate SSRs from other types of activities. Unlike toy play or other activities involving materials, (1) parents and children engage face-to-face in SSRs to highlight the social attention and engagement we want to prioritize and attach to the fun inside the games, and (2) SSRs call for reciprocity or equal actions between parents and children. Neither is always the leader nor always the follower. Instead, parents and children take turns leading and following one another. They communicate with words, gesture, facial expressions, and movements or actions to keep the game going. Although parents often have to start the game to show their child how to participate, parents are quick to support a child’s lead when he or she pauses a game midaction or a song midverse, and to wait or encourage their child to gesture, say a word, look at them, or move his or her body to resume another round of the game. As rounds continue, the child becomes an expert in how to participate and in how to cue parents with words, gestures, actions, facial expressions, or other signs to continue the fun. There is a clear rhythm and balance to SSRs. It is an exchange between two partners. Parent starts, parent pauses, child cues, parent continues, parent pauses, child cues, parent continues, and so on. Talk with parents about what kinds of SSRs their child likes to do or might enjoy trying, and how they can start to practice back-and-forth rhythm. For Coaches: Reference the activity ideas and tips for this step to help generate SSRs and strategies that parents can practice with their child. Remember that parents may need to repeat an SSR two to three times before pausing to wait for or help their child cue to continue the game. When parents need to cue their child to respond, coach them through least-to-more prompting strategies—start to do the action or say the word and pause, add emphasis or exaggeration to the action or word, look at the child excitedly and expectantly, model or show the cue again to encourage the child’s imitation, or physically guide the child through the cue, mindful not to overdo the physical support and upset or rob him or her of the motor imprint necessary to learn how to independently do the cue the next time. Coach and support parents in a few SSRs with the back-and-forth rhythm and cues in place. Help parents answer these questions if doing so assists their planning: • “What sensory social routine do you want to try?” • “Let’s talk through the start, pause, cue, and continue rhythm or pattern so we have a plan on how to support your child through the routine.”

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Step 2: Build a Repertoire and Refine the Routines

What to Share with Parents: Anything done several times can start to lose its appeal. Also true is that every activity or routine naturally comes to an end. Sometimes it is children who cue parents through changes in their body language, attention, or excitement that they do not want to continue a game, and other times it is parents who are ready or need to end first. This step explores how to add more SSRs to a family’s repertoire and the cues to pay attention to as we introduce and transition between new routines so that the fun and learning opportunities these games bring to children continue. Below are three options to expand SSRs. There is no wrong choice about which option to use or to do first. Choose whichever you like, or try all three to help children find interactions with people fun and, through their participation, see, practice, and learn new skills. 1.  Parents can introduce brand-new routines to their children. Don’t be dis-

couraged if they take to some games right away, whereas others are not fan favorites. Some children need more than one go with a game to take part in the fun and to then want to participate themselves. Unless children clearly protest, repeat the routine or try it again another time. 2.  Parents can add variations, or new ideas, to familiar songs or games, such

as new movements, sound effects, or other people (“If You’re Happy and You Know It, Jump Up and Down,” pretending to be each animal while “Old McDonald” is sung, or cousins joining in “Ring-­Around-the-Rosy”). 3.  Parents can add props, or objects and materials, to new or existing SSRs.

Props are positioned between children and parents’ face-to-face interactions and generally managed by parents to maintain children’s attention on them. We want to avoid children taking and walking off with the props. Choosing props that children enjoy parents using or that require parents’ help to start and continue the game may prevent the objects from taking over the interaction and instead draw children’s attention to parents’ faces, bodies, and actions to see, understand, and respond to their cues for communication and interaction. With props, parents carry out the back-and-forth rhythm of SSRs the same way they do without props. Parent starts prop, parent pauses prop, child cues, parent continues prop, parent pauses prop, child cues, parent continues prop, and so on. Anything done several times can start to lose its appeal. Also true is that every activity or routine naturally comes to an end. Parents’ practice and success with SSRs rest not just on a repertoire of choices, but also on when and how to end and move from one game to the next. Changes in children’s body language, attention, or excitement may signal the end



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is approaching. Other times, parents may be ready to end or need to stop before children are. Trial-and-error is definitely permitted here. When it is time to be “all done,” prepare your child with a warning that the end is approaching, say when you are finished, and then start the next activity (whether it is another SSR, an activity with toys, or some other kind of activity) to help your child see the transition taking place and how to follow you into the next interaction. Let’s discuss what other routines with or without props come to mind. For Coaches: Reference the activity ideas and tips for this step to help parents practice new SSRs with and without pros and add variations to familiar SSRs. Remember that parents may need to repeat a new SSR two to three times before pausing to wait for or help their child cue to continue the game. When parents need to cue their child to respond, coach them through least-to-more prompting strategies—start to do the action or say the word and pause, add emphasis or exaggeration to the action or word, look at the child excitedly and expectantly, model or show the cue again to encourage the child’s imitation, or physically guide the child through the cue, mindful not to overdo the physical support and upset or rob him or her of the motor imprint necessary to learn how to independently do the cue the next time. Coach and support parents with each of the three options to expand SSRs to find a back-and-forth rhythm and cues in place before moving onto Step 3. This way we hold onto smiles for both parents and children. Help parents answer these questions if doing so assists their planning: • “What variation or prop with a sensory social routine would you like to try? Let’s talk through the start, pause, cue, and continue rhythm or pattern, so we have a plan on how to support your child through the new routine.” • “How did the transition go with your child? What should we keep the same, and what do we want to try differently?” Step 3: Optimize Your Child’s Energy Level for Learning

What to Share with Parents: Children, like adults, are in the best state to learn when they are attentive, alert, and engaged, not when they are distracted, anxious, agitated, overly excited, or tired. This last step seeks to help children find and hold onto their best energy or arousal level for finding activities to be fun, as well as interacting with and learning from others. We will continue with our practice of SSRs alternated with other activities as we watch children for signs of engagement and enjoyment versus overexcitement, fatigue, boredom, or other behaviors that may put a stop to our games and decide how to try and regain optimal states for learning. Sometimes this may be turning down the “dial” or intensity of the game to head off signs of overarousal—not listening or responding, running around, yelling, screaming, hitting, or exhibiting other concerning behaviors. Other times

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parents may need to turn up the dial or intensity of the game to energize an underaroused child—­sluggish, bored, unresponsive, uninterested, or displaying other passive behaviors. For Coaches: Reference the activity ideas and tips for this step to help parents think ahead to the behaviors that help versus hurt their child attend, participate, and learn within a familiar or new SSR, followed by adjustments they might need to make and recognizing when to do them during SSRs in response to the child’s attention, motivation, and arousal levels. Reflect with parents after each SSR on the adjustments made during a routine and how the child responded to these changes. It is important for the parent to see and understand the connection between his or her actions and their effect on the child’s behavior in order to know whether to take them again or try something else. Help parents answer these questions if doing so assists their planning: • “How would you describe your child’s attention and energy in the sensory social routine?” • “How did your child’s attention and energy shift in response to your change(s) in the sensory social routine?” • “What do you want to keep the same in that routine and what do you want to change?”

Topic III: Why Back-and-Forth Interactions (Turn Taking) Are So Important for Learning What to Share with Parents: Here, we focus on an interaction where the child and parent are jointly involved from start to finish, participating in an entire activity together. We call this a “joint activity,” and it can be used for any moment of interaction with children—from play with or without toys to looking at books, meals and snacks, diapering, dressing, bathtime, getting ready for bed, and other caretaking routines or exchanges that happen between young children and their families. The reason joint activities are important for young children’s development goes back again to the multitude of natural learning opportunities and skills ready to be unleashed inside these specific interactions. Children get to practice and learn concepts like patience and tolerance in the form of taking and waiting for turns with another person, sharing materials or toys, flexibility when seeing how someone else does something, problem solving through personal differences, and negotiation and conflict resolution. Unlike activities where parents initiate more of what unfolds, following their children’s interests and actions to ease into activities, joint activities aim to approach parent and child as equal (or more equal than before) play partners to find a better balance in their style of interaction. No



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one is the boss, and no one is the follower. Instead, the two partners take turns leading and following. One leads, and the other follows. Then the follower leads, and the leader now follows. Back-and-forth exchanges like this happen across selecting activities to do together, adding new play ideas to make activities last longer, sharing materials, and taking turns with toys, along with our actions, facial expressions, and words or sounds. For Coaches: Feel free to invite families to share examples of joint activities already in effect with their child or to acknowledge if none have been developed; then reflect on what joint activities they envision trying with their child. Help parents answer this question if doing so assists their planning: • “What joint activities happen now or that you see as important activities to introduce to your child’s development or family life?”

Why Not Taking Turns in Parent–Child Interactions Is a Problem What to Share with Parents: It’s important for children with ASD to see and respond to their parents’ turns or other communication signals so that they can build essential skills like play, imitation, sharing, alternating attention between people and objects, problem solving, flexibility, and so much more. We worry that without these and other skills, children with autism will continue to play mostly alone and become more removed over time, rather than draw parents or other children and play partners into their activities for engagement, enjoyment, and continued learning. The risk of these missed social learning moments in early childhood is as great to children’s brain development, during which their brain cell networks are particularly ready to absorb and process social and language information, as it is to their behavior. We want to turn up the volume of parents’ eyes, faces, bodies, and voices through joint activities to help children expect, see, and respond to these communicative messages and initiate on their own, without losing out on the fun of social interactions. We will next talk about and practice how to carry out joint activities. For Coaches: Parent–child communication includes the eyes, face, body, and voice, which means that messages are sent and received through any and all of these channels. Consider giving examples of the different communicative signals that parents have shared and their child already does, or skills that parents would like their child to develop within joint activities to help parents start thinking about how to do activities together so they can be used as learning opportunities to practice such goals. If parents do not volunteer this information, invite them to reflect and share examples. Help parents answer these questions if doing so assists their planning:

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• “What learning moments so far stand out to you when you practice or think about joint activities with your child?” • “What parts of your communication [remember, think eyes, face, body, and voice] could we turn up for your child to take more notice?” • “What parts of your child’s communication with their eyes, face, and body do we need to turn up to support (or help him or her find) his or her voice?” • “What concerns or worries do you have about trying joint activities?”

Techniques for Building Turn Taking and Theme and Variation in Play Step 1: Understand the Four-Part Framework of Joint Activities

for Taking Turns

What to Share with Parents: There are four parts that make up joint activities, and each part contributes learning opportunities and social values to the backand-forth interactions we want to create between parents and children with ASD. Think of joint activities as conversations that parents and children have together whereby their turns to play a game, sing a song, look at a book, eat a snack, get dressed for the day, and many more moments that happen throughout the day involve a set of turns to carry out the desired actions. The focus of joint activities is to share, or to take turns, doing those actions instead of parents performing all the actions for children or children performing all the actions by themselves. The framework involves four steps: 1. Parent or child choose a song or game to start and repeat it two to three

times to create momentum for the child to find fun in the activity and want to keep it going. This is called the “set-up.” 2. The other partner joins in to do the same activity so that each is watching, imitating, taking turns, or somehow going back-and-forth with the other to continue the same activity. This is called the “theme.” 3. At some point, doing the same thing becomes boring or unintentionally invites less desirable behaviors to develop, making the activity more difficult to stop. The parent reads the child’s body language to gauge when to add some changes to the activity. The parent and child continue to watch, imitate, take turns, or somehow go back-and-forth together to continue the same activity a little differently from the way it started. This is called the “variation” or “elaboration.” 4. At some point, the activity naturally comes to a conclusion. The parent is ready to end the activity or it needs to end. The child communicates to the parent his or her desire to end the activity. The parent reads the child’s body language suggesting that it is time to end the activity. Whichever way



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it happens, one partner communicates that it is time to end the activity and the other partner acknowledges the message. Toys or items if used are put away. The set-up, theme, variation, and closing continue in the next activity and the activity after that, and so forth. For Coaches: We want parents to understand the framework in order to contemplate what activities and routines in their daily interactions with their child they want to practice next. It may be helpful for that activity to be something a parent has already practiced in a coaching session with their child—a puzzle, book, blocks, Play-Doh, song, bubbles, or social game like tickles or peekaboo—so that you are aware of how he or she currently does the activity and can support the parent’s reflection of how to apply this framework to the same activity. Ask questions or share statements to help the parent think about what parts of the interaction already meet the back-and-forth or turn-­taking aspects of a joint activity, and what parts of the interaction or activity need to change to turn up the volume of the parent’s communication, so his or her child can “hear” and participate in the conversation. Use visual handouts to depict the four-part framework of a joint activity; include items for you and the parent to fill in together if that helps the parents visualize the steps in action. Form 7.1 is such a Joint Activity Template. See the leading questions below each step and an example of a joint activity responding to these questions to help guide your planning with the parent. Step 2: Start to Practice—­Beginning Involves Setting Up

the Joint Activity

What to Share with Parents: The set-up of how the joint activity starts between parents and children establishes the tone for the rest of the interaction to unfold and continue. The set-up begins with how parents “hook” their children’s attention and interest to watch, approach, and join the activity, and the options below present a few different scenarios of how parents and children might do this. Whichever way the set-up happens, good body positioning supports good communication, so children can see their parents’ eyes, facial expressions, gestures, body movements, and hear the words spoken to understand the theme and how to participate themselves. • Option 1: Parents choose the toy or SSR that they know from past experience their children like or a new activity (whether it is toy-based or an SSR) they think their children might like. They start the activity by demonstrating the theme of the language and actions of the activity they want the children to understand and imitate.

FORM 7.1

Joint Activity Template Activity

Set-Up

Theme

Who chooses the activity?

What action does What other ideas the parent and or changes can child do together? the parent and child add to the activity?

How does the activity start?

Variation

Closing When is it time to end the activity? How will the activity end? What is the next activity?

Play-Doh

Place Play-Doh bin on Imitate child’s table. action with my own Play-Doh. Offer two closed containers for child to choose between. Hold out hand for child to give selected container for you to open.

Add googly eyes and Hold out bin for pipe cleaners to make child to put away one insects out of Play- or more items. Doh. Offer “Hokey Pokey” Use rolling pin and or “We’re Going on a cookie cutters to Treasure Hunt” song make shapes out of next. Play-Doh.

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 116



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A mother knows her daughter likes water, but she has not tried water play with her daughter apart from bathtime. The mother takes a spray bottle of water to try a new SSR with her. The mother kneels in front of her daughter to set up good body positioning where they are face-to-face and then shows the bottle to her daughter. The mother holds out the water bottle for her daughter to touch the bottle and then sprays her own hand with water to show her daughter the water inside the bottle and to see how she is reacting to the game. The daughter looks at the bottle, and the mother sprays her hand again and then wipes some of the water on her daughter’s hand so that she can feel the water, too. As the mother is not yet sure whether her daughter likes this game, letting her feel the water gives the mother a chance to better read her reaction. The daughter puts her hand with the water to her mouth to taste it. The mother sprays her hand again and then holds out her hand for her daughter to touch the water. A theme is emerging to this routine. • Option 2: Parents offer a choice of activities to their children and demonstrate the theme they want them to understand and imitate. A child looks at the puzzle, not the book, when her father offers a choice between the two. The father interprets her look at the puzzle as her communicating that she wants to do that activity and sets it on the floor for them to do together. He picks up a piece to place in the puzzle, but his daughter does not see his action. She is looking elsewhere at the floor. He tries again, but his daughter misses that turn, too. The father sets couch cushions on the floor where his daughter’s attention seems to be and places the puzzle on top of the cushions so the activity will be closer to her eye level. This time when he picks up a piece, his daughter sees him put it in the puzzle. Then he hands her a piece to take and do the same. Father and daughter are now better connected to continue the theme together. • Option 3: Children choose the toy and set the theme for the activity. A child picks up a car and rolls it back and forth. His mother picks up another car to repeat the same action. • Option 4: Parents or children choose the toy or SSR and participate together in the physical set-up of the activity before starting the theme. For activities with toys, parents and children can take materials to wherever the activity will occur, open containers, and set out the materials together. For SSRs that involve props, parents and children can do the same steps. A mother carries a Ziploc bag of trains, while her son carries a bag of tracks to the table. Once at the table, the mother helps her son make choices on how to set up the trains—which bag should they open first, which track or train should they take out from the bag, who should take out the track or train, where does the track or train go, and so forth until the activity is set up. Now driving trains over the tracks can start as the theme to this activity.

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Each option and scenario show how parents and children are partners from the start of a joint activity. One partner chooses the toy or routine and shows the actions involved in the activity for the other to take turns and do the same. Sometimes with new activities, parents have to take a little more of the lead to repeat actions or encourage and help their children to participate until the activity and actions involved become more familiar to the children, so they can more easily understand them and experience the fun. At some point, parents, children, or both partners in the activity will lose interest in the theme, or the children become so experienced with the theme that parents will need to add other play ideas to keep the theme and fun going for more interactive learning to happen. This is the variation that we will practice in a later step. When children start to lose interest or parents run out of ideas to add to an activity, it’s time to clean up and end the activity altogether. For Coaches: Parents do not have to practice all four options to set up an activity with children. Instead help parents choose toys, objects, or SSRs that will be helpful in establishing the set-up and theme of play with their children. Consider choosing activities that you and parents may have “sketched out” in a Joint Activity Template (Form 7.1) if that would support the parents’ practice. The following goals of this step are important to reach with parents: 1. Parents have discovered activities with or without toys that embrace good

body positioning with their children. 2. Parents can follow or demonstrate play ideas that support their children’s interests, imitate their actions, and take turns with children as the basis for developing themes. 3. Parents are conscious of the four parts to joint activities even if those parts are not yet reflected in their activities. Help parents answer these questions if doing so assists their planning: • “How will you and your child set up the joint activity?” • “What is the theme of the joint activity?” Step 3: Set the Theme

What to Share with Parents: The theme is something that parents and children each take turns doing for the activity to become a shared interaction. The options and scenarios above show that the theme can be set by parents, children, or decided together. If children set the theme, parents follow their lead and take turns doing the same thing, either with their own toy or materials or taking turns with their children’s. When children don’t take the first turn or parents want to



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demonstrate new activities, they can show children what to do and then give them their own materials, so they can copy the theme or take turns with the same materials to continue a back-and-forth exchange in the activity. Whether parents or children set the theme, parents add the words to name the materials, add sound effects, and label the actions they and their children take in the activity. Because of the language barrier with ASD, we encourage parents to think about how much language they use to talk with their children based on how much their children speak by themselves. We will say more about this later on, but to give an example now for children who are not yet talking, parent language should hover around one to two words to name objects, actions, and sound effects. For children speaking their first words, parent language should be two, maybe three, words, depending on the rate at which the child’s communication grows and expands. Let’s go back to the earlier scenarios in the last step to illustrate how the parent and child develop a theme and the language used in the activity. Scenario 1: The mother says “water” each time she sprays water on her or her daughter’s hand. Later on, when the daughter reaches for the bottle, the mother adds “hand,” taking her daughter’s hand, then “water” as she sprays the water on her daughter’s hand. The mother’s words “hand” and “water” become a part of the theme each time she holds out her hand or takes her daughter’s hand and sprays water on one of their hands. Then when her daughter wants to hold the bottle to spray water, the mother adds “push” to help her daughter do so. The mother and daughter continue with this theme. For Coaches: Help parents and children develop and carry out themes together as equal partners. You can refer to other examples in our book An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn (Rogers, Dawson, & Vismara, 2012). The theme might feel a little repetitive in the first few turns for you and/or the parents. Some of that is necessary to help children learn what will happen next and how to wait for their turn. But we also need children to find fun in the theme, which means the idea has to be something they want to do and are given turns soon enough to try. Ask questions, share examples of previous activities that you have coached parents through with their children, or revisit activities planned out on the Joint Activity Template to help parents prepare themes they want to practice with the children. One other coaching thought is that some parents may not naturally add language right away to their activities or miss some opportunities in their exchanges with children to label objects and actions. Their attention may be more focused on their direct actions, as well as their children’s actions, to build themes, and in the process they might go inward and become quiet with their voice. In these situations, consider coaching parents on how to add their voice after they have

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developed some methods to build themes and experience positive turn-­taking interactions with their children. Help parents answer these questions if doing so assists their planning: • “What is the theme of the joint activity?” • “How do you and your child take turns with the theme?” • “How did your child respond to the theme?” • “How would you describe your child’s attention span and participation in the theme?” Step 4: Elaborate the Joint Activity and Add Variations

What to Share with Parents: With the theme, parents or children pick an idea and repeat the actions to play or interact together. At some point, though, that idea can start to become stale for parents, children, or both. It is only natural to do an action for so long before wanting to stop and do something else. This is where variations come into the picture. Parents or children add other ideas to the activity to keep the interaction, the fun, and the learning going strong. Variations—make-­believe, role play, using objects in other ways, and adding new steps to familiar routines—bring creativity to interactions. For children with ASD, variations help expand their imagination and flexibility to contribute or partake in ideas different than what they are accustomed to. There are three ways to vary themes: add new materials to the activity, add or change the actions within the activity, or add more steps to the actions happening in the activity. We return to the earlier scenario to show how variations were added to the activity. Scenario 1: Once the mother and daughter have turn taking down to spraying water on each other’s hands, the mother adds other actions to vary the game. She names and touches her daughter’s “toes” to spray water on them and then does the same thing on her own “toes.” That action makes her daughter laugh, so the mother says “toes” again before spraying both of their feet. At the next opportunity, the mother gives her daughter a choice: to either have her “toes” or “hand” sprayed. When her daughter looks at her foot, the mother says “water” and then “toes” when spraying them. The mother offers a few more choices between hands and toes before adding another body part to spray. This time, she names and touches her own “head” and sprays a mist of water above it. She then touches her daughter’s head and asks, “Head?” to see if she wants water sprayed on it. When her daughter touches her own head, the mother says “head” and sprays water over her daughter’s head. Now the mother and daughter have three body parts to choose from when next spraying. The mother has also thought of other variations to try another time: (1) asking who will spray from the bottle, (2) adding objects to spray with water (e.g., plastic animals or cars), or (3) moving the activity elsewhere to named locations or objects to spray with water (e.g., cups on the table or flowers



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in the yard). Lots of variations will bring more fun and learning opportunities to this game. For Coaches: Reference the activity ideas for this step to help parents vary activities. Remember that parents should also pay attention to their children’s actions for ideas of how activities could vary. A troubleshooting tip here (when variations do not stick) is to be sure that the theme is really well established first so that children understand the play concept and find it to be fun. Other issues could be whether parents follow children’s interests or actions enough times before changing their focus, or have the children’s attention in the first place before varying activities. If variations are just too difficult for children to do (no matter how long parents follow children or try to make the variations fun and enticing), parents can help children copy their variation, praise them, and then let them go back to the theme and join them for a few more times in it before trying the variation again. Just as with themes, parents may also want to practice variations within caretaking and family routines that happen daily, such as diaper changing, bathtime, dressing, and meals, and if not in coaching sessions then in action planning with you, encourage them to try on their own and to share updates at the next session. Use the Joint Activity Template format outlined in Step 1 if that helps parents’ planning. Parents may need reminders to name these new materials, actions, or steps added to activities. Just as in the last step, their attention may be more focused on their direct actions, as well as their children’s actions, to add variations than to name or label everything that happens during activities. You can coach parents to first develop some variations before bringing up this point or gradually support them to add language to their variations as their success and confidence grow. Help parents answer these questions if doing so assists their planning: • “How can you vary or expand the joint activity? How will you take turns in the variation?” • “What other materials, actions, or steps can you add to the theme?” • “How will [or did] you decide it is [or was] time to vary the activity?” • “How did your child respond to the variation?” • “What ideas could [or did] your child offer for variation?” • “How would you describe your child’s attention and participation in the variation?” Step 5: Close One Joint Activity and Transition to the Next

What to Share with Parents: It is time to end the joint activity when children lose interest, parents lose interest, or parents cannot think of anything else to do and the play has become repetitive or stale. When this happens, someone makes

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the move to signal it is time to end the activity. Children may say, “All done,” or start to put away the materials themselves to communicate they are done. Parents follow children’s lead to participate in the clean-up. Other times, parents have the opportunity to teach these skills to their children. Parents can ask them, “All done?” or “Should we stop?” and hold out containers to see if the children will put away the materials, parents can start to put away materials to show children how to do the same, or parents can set up the next activity, guiding their children through a change of activities. Any of these actions signal that both parents and children acknowledge the end of the activity, that together they put away the toys or materials used in the activity, and that together they transition to something else. This is the closing, and it marks the final part of joint activities. Let’s see how the mother and daughter in the earlier scenario closed their joint activity together. Scenario 1: The mother and daughter continue to take turns picking body parts to spray with water. Besides hands, toes, and heads, they now add the tummy, eyes, and arms to their routine. When the mother notices that her daughter does not seem as eager to take her turn or to pick where to spray the water, she asks, “All done?” and holds the bottle over the kitchen counter to gesture that she will place the bottle there if the game was finished. The daughter looks at her mother but does not reach for the bottle, so the mother interprets her eye contact as confirmation that she does not want the game to continue. The mother repeats, “All done,” this time as a statement, not a question, and places the bottle on the counter to signal the game is finished. The mother then picks up and holds out her daughter’s cup, asking, “Juice?” to see if she is thirsty. The daughter reaches for her cup to signal she is thirsty, so the mother helps her daughter into a seat at the kitchen table and then gives her some juice to drink. The mother also pours herself some water and sits down next to her daughter at the table. Now they have another joint activity to do together. For Coaches: Reference the activity ideas for this step to help parents close and transition to other activities. One of the activity ideas involves how parents decide whether to do an SSR or toy/object activity in their transition from one joint activity to the next. We share thoughts about how to discuss this question in the next step as a wrap-up to the whole chapter. You can wait until the next step to bring up that topic, or share it now in this step with parents—­whichever makes sense to you based on whatever information the parents have shared and what you have observed in their practice activities with their children. Consider revisiting previously practiced activities to help parents decide how to now add the closing and any transitions. Parents may also want to practice or talk about closings and transitions for activities other than play, such as caretaking and family routines. Adding closings and transitions to the Joint Activity Template columns may assist parents who are visual learners in deciding how to do those and other activities from start to finish with their children.



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Help parents answer these questions if doing so assists their planning: • “How will you and your child set up the joint activity?” • “What is the theme of the joint activity? How will you take turns with the theme?” • “How can you vary or expand the joint activity? How will you take turns in the variation?” • “How can you and your child end and transition to the next joint activity together?” • “How did you decide it was time to end the activity?” • “What cues could [or did] your child give you to indicate he or she was done with the activity? How will [or did] you respond?” • “How did your child respond to the closing and transition?” • “What will you keep the same about that closing and transition? What will you change or do differently the next time?” Step 6: Create Joint Activities during Other Daily Routines to Foster

Multiple Areas of Development

What to Share with Parents: All kinds of moments in families’ lives have a joint activity structure. Diapering has an initiation (a parent bringing his or her child to a changing table or laying the child on the floor and getting out the wipes, ointment, a clean diaper, and maybe a change of clean clothes); a theme (changing into a clean diaper and possibly new clothes!); one or more variations (singing songs, playing footsie games, or adding objects like stuffed animals, dolls, or action figures to tickle, sing to, or entertain the child in some way during the routine); and a closing (a parent holding out hands to lift up the child or to help the child pull him- or herself up). Meals, baths, brushing teeth and hair, books, doing chores, getting dressed or ready to leave the house, and many more care routines that happen every day can be turned into joint activities for new ways to carry out these interactions with children. Particularly when it is difficult to find the time to sit down and play with children, daily routines give plenty of practice for interaction and learning. Knowing the four parts to a joint activity, parents now have a “script” to think through, to transform any interaction into something they can do together with their children. Every encounter or exchange with parents and other family members or caregivers can now be filled with more learning. It is intervention all day long. Adults and children are also likely to find more fun in this approach because children’s smiles will be found within such interactions, and who can resist happy, excited children? In the last step, we talked about how to decide what type of activity to pursue in the transition. Up until this point, the options have been joint activities with toys/objects or SSRs, but now we have a third option: care routines. We

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recommend rotating across all three to keep joint activity routines fresh, different, and sensitive to children’s arousal and motivation for learning. Imagine that a parent and child have enjoyed a fun game of jumping off the couch into pillows. A mother and her daughter set up the pillows and take turns crashing into them. Mom gradually adds the actions of first rolling herself and then her child across the pillows and later squishing each other with the pillows. But then Mom observes that her child’s energy has gone too high, and she is running around the room and not paying attention to her mother’s efforts to get her back into the game. Mom realizes it is time to end this game and to transition to something else that will calm her daughter and quiet her body. At the same time, the child is too overaroused to transition to a still activity like looking at a book. Some movement needs to be involved, but with a purpose. Mom tells her daughter that she needs to give more water to the family dog Cooper, and she brings over an empty cup to build in extra steps to do this chore. Together, mother and child walk to the kitchen sink to fill up the plastic cup and to pour water in Cooper’s bowls, both inside the house and in the backyard. Next, the mother says, “Let’s show Cooper the water,” and they put on his leash to walk him over to the bowl in the house to see if he’s thirsty. He is not but that’s OK. His leash is now on, so Mom says, “Let’s take Cooper for a walk around the block and then he will be thirsty.” Mom brings a few treats in her pocket as a variation (to introduce during the walk), so her daughter can give them to Cooper. Soon the child is focused, settled, and engaged in a completely different joint activity from the last one. We consider families’ daily interactions to fall into six types of activities: 1. Toy or other object play 2. Social play (SSRs) 3. Meals (snacks included) 4. Caregiving (bathing, dressing, changing, bedtime, etc.) 5. Books 6. Household chores

Let’s think about how to start turning these interactions into joint activities for your family. For Coaches: Reference the activity ideas for this step to help parents choose and develop daily routines into joint activities. Coaching with parents and children may occur in this step to practice a routine not yet turned into a joint activity. But, the focus of this step is action planning through collaborative discussion to help parents identify the activities and routines in their day that would benefit from the joint activity framework. Which activities lack more structure or involve more challenging behavior? Which activities happen lots of times in the day, thus



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offering more opportunities for learning to take place? Which activities involve siblings or caretakers who would add to and gain from the joint interaction? Parents may choose joint activities across all six types to practice right away or only one or two types. Support parents with however many they choose. You can always revisit the six types later once the parents have had some success with their initial choices. Also make sure to discuss how to decide the type of activity parents and children transition to next if not covered in the last step. Help parents answer these questions if doing so assists their planning: • “How will you and your child set up the joint activity?” • “What is the theme of the joint activity? How will you take turns with the theme?” • “How can you vary or expand the joint activity? How will you take turns in the variation?” • “How can you and your child end and transition to the next joint activity together?”

Topic IV: Why Nonverbal Communication (Body Language) Is a Critical Tool for Young Children What to Share with Parents: A lot of communication skills develop before speech. Babies and toddlers use their eyes, facial expressions, hand gestures, body postures, and sounds to get across their messages. Their body language tells us way before speech develops what they like or do not want, or when they are excited, afraid, hungry, or tired. They also learn to understand and respond to their parents’ body language. Speech actually builds from nonverbal communication. This topic focuses on how children’s bodies “talk” to transmit needs, thoughts, and feelings to another, and to understand and receive back the needs, thoughts, and feelings of the other person. It is how nonverbal communication happens through reading, understanding, and reacting to each other’s cues. Body language is nonverbal communication, and its emergence is crucial to speech development. When children see people responding to their eyes, gestures, expressions, movements, and sounds, they understand that communication exists and that these actions have meaning. Speech becomes an additional communication system stemming from their body language or “talking bodies.” For Coaches: You can ask parents to share what this information means to them or cite examples of “talking” body communication you have already seen their child use if that helps to explain why body language is so important to speech development. Particularly when parents are focused on speech as the immediate

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outcome for nonverbal children, highlighting the talking body communication children already have may help parents see that communication is, in fact, already happening and understand the rationale behind why we want to continue to strengthen and support spoken words through talking bodies. Help parents answer these questions if doing so assists their planning: • “What body language does your child use now to communicate with you?” • “What body language do you use to communicate with your child?” • “What other talking body moments can we create between you and your child?”

Why Is Lack of Nonverbal Communication a Problem for Young Children? What to Share with Parents: When children communicate, they are in charge of their own voice. When children do not communicate or do so under limited conditions, they lose that ability to effectively say what they want or do not want, to share their thoughts and feelings, and to connect and engage with others. What also occurs is the tendency to take up that communication for children—to anticipate what they want or react to their distress, and to take care of those needs and do the things that we know they want or do not want. A fidget, a whine, an action on someone or something—these behaviors mean something, but as a reaction to what children want or feel, not a communication directed to or shared with another person. And when we respond to children by doing the thing that they want us to, then we send the message to them to keep using these less helpful behaviors instead of clearer and more meaningful communication. We want to break this well-­intentioned but limitless habit of acting for children and instead teach them how to use their first communication system, their talking bodies. We lay out five steps for teaching children and parents how to send and receive communication through their talking bodies. This way, we create a two-way system for communication to go back-and-forth between two people: child and parent or another play partner. For Coaches: Invite the parents to set goals with their talking bodies for themselves and their children. Consider referencing activities or moments within interactions to help parents generate ideas if they are unsure of how to proceed. Help parents answer these questions if doing so assists their planning: • “What talking bodies have you noticed so far in your child?” • “What talking bodies have you noticed so far in yourself?” • “What [other] talking body opportunities might be available in [name a specific joint activity like ‘shapes’ or a joint activity category like ‘toy play’]?”



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• “What parts of your communication [remember, think eyes, face, body, and voice] could we turn up for your child to take more notice of?” • “What parts to your child’s communication with eyes, face, and body do we need to turn up to support [or help him or her find] his or her voice?” • “What concerns or worries do you have about working on your and/or your child’s talking bodies?” Step 1: Do Less, So Your Child Does More

What to Share with Parents: Doing less means that parents still anticipate their children’s needs but help them use gestures, eye contact, expressions, and sounds to say what they want, to make choices, to refuse things they don’t want, and to share thoughts and feelings. This step is how to encourage children to communicate their needs and wants instead of you giving free access to everything. Refer to the six activity types below. What each activity type has in common is the joint activity framework: the set-up, theme, variation, and closing. How can we help children do more within each of these parts of the joint activity? 1. Toy or other object play 2. SSRs 3. Meals 4. Caregiving (bathing, dressing, changing, bedtime, etc.) 5. Books 6. Household chores

For Coaches: Reference the activity ideas for this step to help parents think about how children can do more within joint activities. Use the template in Form 7.2, “Activities That Encourage Nonverbal Communication,” to fill out with parents and plan activities that will encourage children’s nonverbal communication. You will see from the template that parents list different activities, followed by the materials and/or actions that children like about those activities; how parents can join children in their likes; the requests that children can make with their bodies to access those materials or actions; and the body language that parents wait for their children to use before they respond with the materials or actions the children want. This method plans out the opportunities that parents create around children’s likes and wants for them to communicate with their bodies—gaze, gestures, voice. You don’t have to fill out all five columns with the parents in this step if that seems like too much information to give to them at once, but rather concentrate on the column on how children can use their bodies to request the materials or actions they like about the activity. Help parents answer these questions if doing so assists their planning:

FORM 7.2

Activities That Encourage Nonverbal Communication

Activity Diapering

My child likes to: Get out of a dirty diaper. Be done with the routine.

Meal/Snack Eat Drink

I can join by:

My child can request with his or her body by:

The body language I am waiting to respond to is:

Holding out my arms to pick up my child and take them to the changing table. Handing toys that my child likes to hold or play with while being changed. Holding out my arms to pick up my child from the changing table.

R eaching or pointing to the item or toy they want to hold while I change them. Handing me a clean diaper to put on them. Lifting arms to be picked up.

Looking at me. Making a sound or saying a word. R eaching out arms. Walking or taking a step toward me to be picked up. Giving me the diaper.

Showing a drink with small amounts of liquid in the cup. Asking my child which cup to drink from. Asking my child if they want more to drink. Handing small portions of food at a time. Offering utensils for my child to use.

R eaching or pointing to the item they want. Giving me or holding out their cup, bowl, or food for more drink and food. Looking from me to one of the two items I have (or vice versa) to say, “I want that one.” Looking from me to the cup, bowl, or plate (or vice versa) to say, “Put the drink/food there.”

Looking at me. Looking at me and laughing/smiling at what I do. Looking at me and what I offer them. Making a sound or saying a word. Giving me items for more help, or when done. Pushing away or giving back items they don’t want. Nodding or shaking their head.

Asking my child if they want the food in a plate or bowl. Asking my child if they want more food. Helping my child open drink/ food containers for more of the item(s) they want. Asking my child to hand me their cup, bowl, or plate for more of the item(s) they want. Asking my child to give me a drink or bite. Drinking from my own cup or eating from my own bowl/ plate to make comments and add silly sounds.

Giving me containers for my help to open. Giving me their cup or food to have some, too. Watching me when I drink or eat and talk about what’s happening or make silly sounds. Giving me their cup, bowl, or plate when done.

(continued)

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 128

FORM 7.2.  Activities That Encourage Nonverbal Communication (p. 2 of 2)

Activity

My child likes to:

I can join by:

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My child can request with his or her body by:

The body language I am waiting to respond to is:

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• “How might your child become more involved in [name the set-up, theme, variation, or closing]?” • “What choices can you offer your child in [name the set-up, theme, variation, or closing]?” • “What opportunities can you create for your child to need help in [name the set-up, theme, variation, or closing]?” • “How can your child refuse items or actions in [name the set-up, theme, variation, or closing]?” • “How can your child comment about items or actions in [name the set-up, theme, variation, or closing]?” • “What materials can you and your child trade or share in [name the set-up, theme, variation, or closing]?” Step 2: Wait a Little

What to Share with Parents: One way for parents to do less is by waiting for children to cue them with their talking bodies for what they want, instead of knowing what they want and giving it to them right away. Items and activities may have to be arranged differently so that children cannot access them without their parents. Otherwise, why ask for something that children already have? Look for children’s eye contact, a gesture like an outstretched hand or a movement like taking a step forward, a vocalization, or some sound to say they want a particular item or activity. When parents see that talking body signal, they should then quickly give their children what they are requesting, with a simple communication naming what the children wanted. Respond to any talking body message children give, even if it is just one behavior, such as eye contact or a gesture, because children need to see the actions that will result from their behavior to understand they can communicate in this way. For Coaches: Reference the activity ideas and tips for this step to help parents think about how to wait for their children’s talking body cues. Also available is the Activities That Encourage Nonverbal Communication Template used with parents in the last step, where the body language that parents are waiting for their children to use to make requests can now be added (or highlighted if already included in the prior step). When parents need assistance on how to identify and create these moments, start with the opportunities in activities for children to request items/toys or actions, and how parents can rearrange or hold off on turning over those items or doing those actions until their children cue them. Keep in mind that sometimes children may not understand what their parents are waiting for them to do. All children see is that they do not get the usual item or action and they may become frustrated and upset. To instruct and guide their children, parents can model the talking body behavior to use—­holding up an item near



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their face to support the children’s eye contact with them or extending and naming the toy to see whether the children will reach for it. Go back over activity ideas that you and the parents developed using the Joint Activity Template to find those moments where parents can wait or pause activities for children’s talking bodies. Help parents answer these questions if doing so assists their planning: • “How can you wait for your child to ask for items or actions in the activity?” • “What talking body communication could or did your child demonstrate to ask for items or actions in the activity?” • “What you can do to help your child understand what you are waiting for him or her to do?” Step 3: Create Lots of Practice Opportunities

What to Share with Parents: Children need lots of practice to learn anything new. Here, we want parents to create many opportunities in the routines and activities already happening with children to show them how to use their bodies to communicate. Finding ways to hold back a little to help children communicate what they want does not mean ignoring their needs. Parents are best at knowing what their children need a lot of times, frequently before the children even do. We want parents to continue to tap into that knowledge of what they know their children need to show them how to use eye contact, sounds, reaches, directed smiles, and other simple, nonverbal body gestures to communicate those needs. The idea here is to create communication “temptations.” For Coaches: Reference the activity ideas and tips for this step to help parents think about how to create practice opportunities within existing routines/activities and potentially new interactions. Parents could offer items or actions they think their children will not like to help them politely refuse or decline those options. Parents could create opportunities for children to need their help to open or activate objects, to add silly sounds to games, to carry out favorite songs or other SSRs. Children can set up the materials for the activity, choose items or actions, ask for more, ask for help when they cannot open or make something work, give or trade materials, politely reject things they do not want, follow and share ideas for elaboration, and put away materials when the activity is done. Parents can try this with one part of the joint activity framework, such as the theme to increase children’s participation, and then as they feel more confident, add the other parts, like the set-up, variation, and closing, to have their children do more. Also important at some point to cover with parents before advancing to the next step is which communicative gestures parents should first teach their children. There are three main points to hold onto as you work with parents on this section: (1) Choose gestures that relate to the children’s requests for people and

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items/activities (we will address joint attention gestures for parents in Topic VII of this chapter); (2) choose gestures with lots of practice opportunities available to the children and parents or other caretakers; and (3) choose gestures that make sense for children their age. Later in this chapter, we will delve into how parents can teach and ask children for more elaborate communication, such as pointing instead of reaching for what they want; gesturing and making eye contact or combining other behaviors at the same time; and expanding simple, nonverbal communications into spoken words and across different communicative functions, like refusing or sharing items. For now, though, the goal is to help parents create as many moments as possible for children to use nonverbal communications such as eye contact, sounds, reaches, directed smiles, and other body gestures. Help parents answer these questions if doing so assists their planning: • “What communication temptations can you practice daily with your child?” • “What talking bodies will your child use to communicate with you?” • “What will be your response if your child does not use a talking body?” Step 4: Hang In There! Persist!

What to Share with Parents: Whenever parents try something new or different, all children naturally need a minute (or two) to understand what is happening, whether they like or dislike it, and what is being asked or expected of them in the interaction. Children with ASD need the same benefit, especially if parents have changed the way an activity or a routine previously occurred. But, they also need their parents to do three things to help them make it through new routines: (1) Keep new routines easy for children to understand and do with parents, (2) make practice opportunities easy (meaning straightforward and clear) so children can communicate and get what they want, and (3) persist with repeating the routines and the learning that occur within the interactions because, like anything else, practice makes perfect! For Coaches: Reference the activity ideas for this step to help parents create new routines that are approachable for their children, easy for them to communicate within. Refer back to the Activity Categories Template you may have completed with the parents to find out how they would describe the ease of use for children to understand and communicate in those practiced activities. Troubleshoot with parents when children fuss or resist during activities on how to make the interactions and/or talking body communications simpler for children to demonstrate, more directly related to what the children want, or on how the parents might embed more practice during the day, depending on what they describe. Remember that



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children’s agendas have to be supported and the new routine must be just as timely, effective, and easy in terms of talking bodies communication as whatever parents did before this concept was introduced; otherwise, the road to communication will take a lot longer and involve a lot more struggle. Help parents answer these questions if doing so assists their planning: • “What talking bodies communication can your child easily produce? If you’re not sure, then let’s start with what items/materials or actions your child will want included in the activity, and what communications make sense to teach him or her to ask for them.” • “How can you help your child complete the communication necessary to tell you what he or she wants in the activity?” • “Describe how you handed over the objects or actions your child wanted in the activity?” • “How can you continue your practice of this activity and the talking bodies communication within it until our next session?” Step 5: Position Yourself “Face-to-Face and Close Enough to Touch”

What to Share with Parents: Parents who position themselves face-to-face with (as opposed to behind) their children make communication easier to see, understand, and reciprocate. Children get the idea that the eyes, voices, and gestures they experience come from someone and that their own eyes, voices, and gestures go to someone. Acts of communication are not random but have a direction and purpose between child and adult. Recall that you have covered positioning options for parents and children to promote shared attention to and active communication with each other during activities (see Step 2 of Topic IV). This step reminds us to position desired objects or activities for children so they can see their parents form the words and use the gestures/actions that their parents want them to understand and learn how to say and do. For Coaches: Reference the activity ideas for this step to help parents position their bodies and the desired objects/activities between themselves and children. For a parent whose child is sitting on his or her lap to read a book, practice positioning the book between the parent and child as each names, describes, points to, and even acts out pictures on its pages. Help parents answer these questions if doing so assists their planning: • “How do you want to position yourself and your child in this activity?” • “How can materials be positioned between you and your child in this activity?”

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What Families Can Do to Increase Their Children’s Understanding of Other People’s Nonverbal Communication What to Share with Parents: It is just as important for children with ASD to understand the meaning of other people’s eye contact, facial expressions, and gestures as it is to communicate with their own body language. The next three steps attempt to teach children with ASD to pay attention to people and what they are doing to help them understand what their eyes, voice, and body mean. For Coaches: We want parents to have found ways to increase their child’s talking bodies (i.e., gestures, gaze, expressions, sounds) to communicate wants, feelings, and thoughts. Support parents to build those skills before continuing with this section for better learning outcomes. Step 1: Exaggerate Your Gestures

What to Share with Parents: Parents want to add simple gestures and the speech that goes with those actions to routines to grab children’s attention to do the same. Simple gestures are any hand or body movement that is relatively easy for children to imitate and that makes sense to do in the activities, such as reaches, points, gives, pushes away, picks up, or puts in objects/toys. For activities without objects or materials, like SSRs, add actions that can be a part of song verses, sound effects, or the physical actions happening in the game (e.g., claps, hops, peekaboo, tickle motion with fingers, animal motions). Parents model or demonstrate the gestures first in their turns and then encourage their children to do the same. Sometimes parents may need to repeat or show gestures more than once or make other adjustments to their body positioning or to the pace of the activity (e.g., speeding up or slowing down) to make sure that children hear and see their spoken words and gestures. Help children follow through with the gesture and be sure they reach the goal they wanted to achieve and there is lots of celebration (e.g., the parent helps her child clap his hands and sings the next verse of “If You’re Happy and You Know It, Clap Your Hands,” or the child touches a picture in her book and her parent makes a silly animal sound). Gestures can also be made during setting and cleaning up activities, caretaking routines, and chores whenever parents show or ask children to pick up, give, and put away items. A child’s gesturing shows his or her understanding and response to others’ language. All parent–child routines can include gestures for communication to occur. For Coaches: Reference the activity ideas for this step to help parents add gestures to their routines. Sometimes an easier opportunity for parents is getting their children to help in the routine, using the materials and actions they want them to, or completing a less preferred activity more quickly, like diapering or brushing teeth. Guide parents through how to name, or label, the materials and actions that



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relate to what their children want and then how to involve the children in practicing those gestures to get their needs met. We also want parents and children to practice gestures not only with toys but also with books, SSRs without props, and daily caretaking routines. Keep a coaching eye out for the possible adjustments mentioned above that parents may need to make to their actions or activities to support children’s understanding and abilities to carry out gestures. Help parents answer these questions if doing so assists their planning: • “What gestures can you model and teach your child to do in this activity?” • “How can you help your child follow through with the gesture when he or she needs to?” Step 2: Add Predictable Steps

What to Share with Parents: Repeating routines where parents do the same steps and sequences as in play and certain tasks helps children understand the actions and expectations involved so that they can participate with greater ease and independence. This does not mean that routines always stay the same. We still want to add variations or change up the ways in which activities unfold to teach a wider number of skills, as well as flexibility and creativity, to children. But carrying out activities or games in predictable steps a few times in a row teaches children to anticipate what’s coming next so that when parents pause at one of the steps and use an exaggerated gesture to cue children that something should happen, they can respond with their talking bodies—eyes, voice, gestures. The more steps that parents build into routines, the more opportunities there are to teach different skills to children, so they can see the skills in practice and do them on their own. For Coaches: Reference the activity ideas and the examples for this step to help parents add predictable steps to their routines and to encourage their children to respond. Remember that the joint activity framework parents already know and should be using from the previous topic is the same structure parents use here. If parents need a reminder, go back to that topic with them to review the four parts. If helpful, share the example below: how to add predictable steps to highlight a typical activity that parents do every day with their children. Notice there are at least 17 possible communicative steps in this one interaction. See the talking body examples given previously that parents could use throughout any of the six different activity types (i.e., play with a toy or other object, SSRs, meals, caregiving, books, and chores). How many could parents create within other daily routines like bathing and eating, or play activities that can become quite elaborative? Louise has built a predictable routine around dressing for her 24-month-old son Henry. She has worked earlier with Henry on how to participate in dressing—­pulling

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shirts over his head, putting his arms through the sleeves, sitting down to put his legs through his underwear and pants or shorts, and standing up to pull them up over his waist. Now she wants to add steps for Henry to open his dresser’s drawers and choose between clothing items to wear. Set-up: Step 1: Louise brings Henry into his room and kneels down in front of him to touch the onesie he wears for sleeping, and says, “Take off” as she unzips it. Step 2: Louise looks expectantly at Henry who looks elsewhere around the room. Louise tugs the onesie a little bit off Henry’s shoulder and waits again for him to respond. Her cue works, and Henry removes his arms from the onesie as Louise says, “Arms out.” Step 3: Louise waits to see if Henry continues to undress from the onesie. When he does not, she pulls a little on the bottom of the onesie, and that gesture reminds Henry to wiggle and pull the onesie down his legs. Step 4: Louise expects Henry to next sit on the floor and pull off the onesie from his feet, but instead he surprises her with his own variation when he tries to do it standing up and holding onto her shoulder. She tells him “off legs,” and he repeats the phrase, lifting up his legs for her to help him. Theme: Now it is time to get dressed. Step 5: Louise points to Henry’s dresser and says, “Open drawer.” When Henry does not respond, she exaggerates the action of trying to pull open the drawer and says, “Help me.” Henry finds this funny and helps her open the drawer. Step 6: Louise takes out two shirts—one blue and the other green, holds one in each hand, and asks Henry, “Which shirt?” Henry reaches for the green shirt. Step 7: Louise touches Henry’s head and says, “Put shirt on.” As Henry brings the shirt to his head, Louise scrunches the shirt to make it easier for him to find the hole and to pull it over his head himself. Step 8: Then Louise waits to see if Henry automatically puts his arms through the holes. Henry does for one arm and then gets distracted with a piece of fuzz he collects on his finger. Step 9: Louise holds out her hand and says, “I’ll help. Give me,” for Henry to let go of the fuzz. Step 10: She adjusts the shirt slightly to make the hole easier for Henry to find (for his arm that needs to go through it) and to remind him of what to do next, and Henry responds. Louise and Henry repeat the steps to pick out and put on a pair of pants (Steps 11 and 12) and socks (Steps 13 and 14). Variation: Steps 15 and 16: Louise touches the onesie that Henry took off and tells him to “pick up” and “put [it] in” the laundry basket that she holds out. Closing: Step 17: Dressing is done! Louise points to Henry’s door and asks, “Ready to go?” Henry lifts his hand in the direction of the door and Louise responds, “Yeah, let’s go!” Step 3: Provide Needed Help

What to Share with Parents: Parents teach their children to “ask” for help when they create opportunities where something is hard for the children to do alone. Items like Play-Doh, bubbles, pegs, or toys with multiple pieces that are in



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containers children may have trouble opening can be turned into gestures for children to give those items to their parents to open or to reach for those same items when their parents hand them back. SSRs that need another person to make them more fun, like hide-and-seek, chase, tumbling or other physical games, or songs, lead to different hand or body actions from children to request that the routines continue for another round. Toys that may also be difficult for children to work themselves, such as blowing bubbles from a wand, putting together a new puzzle or one with more pieces, or playing with a wind-up toy, might lead to looks or maybe even words from children saying what they want their parents to do. When children need help, parents get to show them how to use different nonverbal (talking bodies) communication to ask for that help. Parents can extend open hands toward children and ask them to give them the Play-Doh or a container they cannot open themselves. Parents can point to where the next puzzle piece on a board goes. Parents can place their hands in front of their face to cue children to do the same in another round of peekaboo. Parents can say, “I’m gonna get you” and take a step toward their children, anticipating that they will look and smile at them to continue the game. Children learn the relationships between the need for help and how to read and interpret the meaning of parents’ gestures, body movements, expressions, and words to provide that help: “If I give that item to Mom, she will open it to me. If I look at Dad when his hands are above my tummy, he will tickle me again. If I lean forward to take Grandma’s hands, we will dance to my favorite song.” For Coaches: Reference the activity ideas and tips for this step to plan when in activities children can “ask” for help. Help parents break down those opportunities into steps. Some parents find it helpful to talk through their day to identify when to practice this with children. Help parents create moments for children to ask for help within the joint activity framework: to open materials and set out materials during the set-up; to ask for more materials or routines to be used during the theme; to use a different material or try a different action that is hard to do without help during its elaboration; and to pack away materials with others when it is time to clean up. If necessary, take more than one coaching session to help parents dissect joint activities across the six different activity types, so they develop a strong framework for thinking through the different gestures, actions, expressions, and words that go with these steps inside any moment in the day with their children. Help parents answer these questions if doing so assists their planning: • “What opportunities have you found during the day to highlight nonverbal communication (or your talking bodies) to your child?” • “What moments [in the activity or throughout the day] does your child ask you [or others] for help?”

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• “What body language does your child use to ask you [or others] for help?” • “What happens after your child asks for help?” Topic V: Imitation Is a Critical Learning Tool—for Everyone! What to Share with Parents: Imitation is a built-in learning tool. Children naturally copy what they see their parents do. They copy the actions and gestures their parents make. They copy the sounds and words their parents say. Children do this because their brains, like adult brains, are naturally wired to resonate with other people’s actions, through the brain’s “mirror neuron system.” Brain cells called mirror neurons activate both when we act and also when we see others carrying out actions. The cells react to the behavior of the other person as though the observer was acting. Mirror neurons are what make it possible for children and adults to imitate a behavior immediately after someone else does it, or to hold onto that information even without practicing the behavior right away and to imitate it later on. Children’s natural capacity for imitation means that any play partner (adult, sibling, grandparent, teacher, day care provider) can pass on endless skills to observe, remember, and put into action: 1. How to interact socially with others through facial expressions, body lan-

guage, proximity, staying on topic, listening/speaking, and other social rules for conversation 2. How to empathize and feel the same emotion that another feels 3. How to string together sounds that turn into the spoken words we hear others say and to understand the meaning of those words through the actions that follow 4. How to convey emotion in those words through the gestures, actions, postures, and other nonverbal cues that we add to our speech 5. How things work, from objects to games and routines, when we carry out actions we see others doing 6. How we share a connection or identify with someone when we copy what that person does because we have that moment or experience in common Imitation is a powerful learning tool to teach so many different behaviors to children. For Coaches: You can ask parents to share what this information means to them or cite examples of imitation that you have seen children learn from their parents’ actions and language to encourage their reflection on this topic. Even though this is the first mention here of imitation of parents, every child has imitated something his or her parent has done in earlier sessions.



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You can ask these optional coaching questions of parents: • “What have you seen your child learn through imitation?” • “What are several examples where your child has imitated what you have said or done?”

Why Is Not Imitating Very Much a Problem for Young Children? What to Share with Parents: Imitation is one the easiest, most efficient tools we have for learning. We watch someone, and whether it is in the same moment or later on, we do what they did, too. Children who do not imitate miss out on this simple learning tool. Instead of observing what’s happening around them, they have to figure things out from scratch. That takes more time and doesn’t guarantee children will actually develop the skill. Plus, they have to repeat the process for each new skill they want to learn . . . exhausting! We already have the tools to step into children’s attention spotlight and create motivating activities to do together. Now we use those same tools to support children’s attention and motivate them to imitate what they see and hear their parents do in the play and caregiving routines already in motion. For Coaches: You can emphasize that children with ASD learn well and naturally when their own motivation and attention to imitate are increased. Reference back to earlier topics where parents imitated what their children did as a way of joining them in an interaction and gaining their attention. Reference particular moments when children paid attention and the exchange that happened when their parents followed their lead to imitate a sound, movement, or play action. You can ask these optional coaching questions of parents: • “How does your child respond when you imitate him or her?” • “What play activities or other routines seem easier to harder to imitate your child? Which behaviors or skills would you imitate [sounds, words, gestures, expressions, actions with objects or toys, body movements]?” • “What concerns or worries do you have about this topic?” Step 1: Imitate Children’s Sounds and Word Approximations

What to Share with Parents: When parents imitate children’s sounds, three events occur: (1) Children begin to notice their own vocalizations, (2) children hear more sounds and parents’ words that usually accompany those sounds, and (3) children have more opportunity to make sounds and vocalizations. We want these three things to happen because children need a large vocabulary of sounds to learn how to turn on their voice (i.e., that sounds happen intentionally, not by

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chance); to learn how to make specific sounds to express that they want something (e.g., “ba” for ball, or “ah” for up); and to become more proficient through practice at turning those sounds into spoken words. Even when parents are not sure what sound children make or what it means, imitate it to communicate to your children that you have heard them and that their vocalization matters. When parents do this, they say, “I heard you” to their children and give meaning and importance to the sound. Parents physically position themselves so the children can see their faces and imitate whatever vowel (e.g., “oh,” “ah,” “eee”), consonant sound (e.g., “geh,” “da,” “wa”), or other sound effects come forth, except for crying, screams, or whines that children make when playing with their voices. Then parents wait to see whether their children will make the sound again. If they do, parents repeat the sound and pause again for children to take their turn within this back-andforth game. If children do not repeat the sound, parents make the sound and wait again, trying to entice them into the game. For Coaches: Reference the activity ideas and parent–child example provided earlier to help parents and children imitate each other’s sounds and words. Go back to activities where parents have had this success beforehand but may not have realized what they did to accomplish this step. You can ask these optional coaching questions to help parents plan how to use this step: • “What sounds does your child make?” • “What songs, finger games, or other language activities does your child like, and what key word or phrase can you highlight in these activities for your child to imitate?” • “What modifications might need to happen in these activities [when children do not readily imitate parents]?” Step 2: Imitate Actions on Objects

What to Share with Parents: Children notice when parents imitate their actions with objects. They like that parents copy what they do. They listen to their parents name the objects and actions as they happen. They add more words to their growing vocabulary. They develop a sense of reciprocity, or this social coordination of “you” and “I” going back-and-forth to do something together. This back-and-forth helps children with ASD pay attention to not only the objects that parents hold but also more importantly what parents do with them in order for their children to learn new skills and build their repertoire of play ideas through the actions that parents show them. How do parents start? Go back to building the theme of a joint activity routine. Parents copy children’s actions with their own object and label what’s happening.



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When children hit a drum, parents hit the drum with their stick and say “bang,” or when children scribble on paper with their marker, parents do the same and say “color.” When children stop their action, parents stop, too, and look expectantly to cue their children to resume. For children who do not readily continue an action on their own, parents can say the action word (e.g., “bang,” “color”) or briefly start the action (e.g., tap the drum once or make a mark on the paper) to encourage children’s return to the activity. Parents continue their start-and-stop motions timed to children’s actions until they see eye contact, smiles, or other body language indicative of children’s awareness of the back-and-forth rhythm of the theme. For Coaches: The example above is a brief explanation of the teaching sequences presented earlier for how to use matching or multiple-piece toys to practice imitation during play activities and with objects beyond playtime (e.g., mealtimes, bathtime, household chores). Keep in mind that parents’ pace to imitate their children’s actions will likely change based on the children’s level of interest and arousal during activities. Sometimes parents may need to speed up their actions and other times slow down their actions. There is a lot of information and s­trategies packed in this and the previous step. Don’t hesitate to take more than one coaching session to help develop different interactive games for teaching c­ hildren to imitate sounds and actions with objects before moving onto the next step. You can ask these optional coaching questions to help parents plan how to use this step: • “What matching or multiple-piece objects or toys can you use with your child?” • “What actions does your child like to do with the object that you can imitate?” • “What other actions do you think your child would like to see you do with the object?” • “How can you encourage your child to continue the imitation?” • “What opportunities during the day do you have to imitate your child?” Step 3: Imitate Hand Gestures and Body/Facial Movements

What to Share with Parents: Now that parents and children have developed back-and-forth games to imitate sounds and actions with objects, the next step is to teach children how to attend to and imitate hand gestures and physical motions that occur during SSRs, like songs, finger games, nursery rhymes, and social games. Parents already know how to complete a large part of this step from their practice with topics we have previously covered:

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• Developing SSRs with fun movements, sound effects, and words • Introducing new actions or materials to routines that add more flexibility, learning potential, and fun to interactions • Pausing routines midverse or in action for children to cue with talking body communication that interactions should continue Now is the time to teach children how to imitate and associate their parents’ gestures, body movements, and physical actions with the words that are part of a song or game. Parents use the theme of a joint activity routine (just like they did in Steps 1 and 2) to start the song or game and show children how to do the gesture or movement. A mother sings, “You put your foot in. You put your foot out. You put your foot in and shake it all about . . . ” to the “Hokey Pokey,” or in another joint activity routine she says “blow” and puffs her cheeks to blow a raspberry on her daughter’s tummy. In the next round of the song or game, parents pause right before the gesture or movement and look expectantly at their children to cue them to do the gesture or movement now. Sometimes children need a stronger hint to understand that parents are waiting for them to do something. This is when parents can prompt, or give extra help, to teach children what they want them to do. Parents speed up or slow down the pace (depending on which helps children pay closer attention to the motion) to exaggerate and repeat the gesture or movement, encouraging their children to try the motion. Going back to our examples, the mother starts the verse, “You put your foot in . . . ” and lifts up her foot, holding it in the air, or puffs up her cheek and puts her lips together to start the raspberry motion while encouraging her daughter: “Haley, do too.” If extra help is needed, parents guide their child’s body through the action, careful to not overdo it with too much physical assistance lest the child not develop the skill on his or her own. The mother could touch or gently lift up her daughter’s foot before quickly letting it go, prompting her daughter to finish the motion herself. The mother encourages her daughter to move her foot by herself in the next round, even if not perfect or complete, because an objective is to celebrate any act that children try to imitate. Since children cannot be physically guided to imitate facial movements like blowing raspberries, the mother may add other sound effects or dramatic motions to encourage her daughter to imitate the raspberry. The mother slowly and loudly takes in air to puff up her cheeks and makes funny noises as she pretends to blow a raspberry on her daughter before pausing in the next round, with her cheeks puffed out, to encourage her child’s imitation. For Coaches: The examples above offer a brief explanation of the teaching sequences along with parent–child examples and activity ideas referenced in this step to help parents teach their children to imitate the gestures and movements within SSRs. Keep in mind the helpful tip about prompting: for parents to give the least amount of help possible for children to imitate their gesture or



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movement, and to give less and less help over time so that children learn how to make the motion without help. Coach parents through these strategies within SSRs before turning to the activity ideas of different gestures, movements, and sounds that parents can add to other daily routines, like diaper changing, dressing, or mealtimes. You can ask these optional coaching questions to help parents plan how to use this step: • “What sensory social routines does your child like to do with you?” • “How does your child signal you with talking body communication to continue sensory social routines?” • “What gesture or body movement can you add to each sensory social routine? When will you pause to cue your child to imitate it?” • “What facial expressions, sound effects, dramatic motions, or other exaggerations can you add to the routine to encourage your child to imitate your gesture or body movement?” • “How can you guide your child to imitate the gesture or body movement when extra help is needed?” • “To what other activities besides sensory social routines can you add gestures or body movements for your child to imitate?” Step 4: Imitate and Expand on Actions

What to Share with Parents: Parents changing up activities keep interactions fun, less repetitious, and full of imitative turn-­taking opportunities to show children how to use different materials and actions in a variety of ways. When children have more than one way to engage with toys and social games, this expands how they see and think about objects and actions. Also, whenever children imitate something new, their ability to imitate only grows stronger and subsequent actions, gestures, or facial/body movements only become easier and quicker to imitate. The other good news here is that parents already know how to expand on their actions by adding variations to joint activity routines practiced earlier! Let’s revisit. 1.  Parents start with a theme to teach children to imitate a specific sound, action with objects, hand gesture, or a facial/body movement. Parents label and repeat this action a few times to capture children’s attention and to build up the fun behind that action. Remember that we want children to find fun in the action to make them more likely to want to imitate it. 2.  Once the activity is fun to children, parents can now teach them to imi-

tate their actions. In the next round of the theme, parents pause midaction or

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midverse and look expectantly at children to imitate their action. Parents recognize any effort from children to do the imitation, even if not perfect, and then resume the theme. Remember, we want children to find the action relatively easy to do since it is a new skill; otherwise, they may be less likely to imitate the action again. If children do not readily imitate the action, then parents may need to speed it up or slow it down or add gestures or facial expressions (if not a part of the action already) to encourage children to try the imitation. Parents physically guiding children through a motion is used only when the other prompts do not elicit imitation. 3. When children imitate the action with ease and consistency, parents replace the theme with a variation (also called an elaboration) to the activity. Parents follow the same teaching sequence to show, label, and help children that is needed for them to imitate a different sound, action with an object, hand gesture, or facial/body movement. Parents continue to teach one new action at a time to expand the children’s imitation skills. Parents celebrate any and all efforts that children make with imitation, especially with regard to behaviors that are more difficult for children to initially imitate. As children develop different actions, parents ask them to choose which to do next (e.g., “Clap hands or stomp feet?” “Roll dough or poke dough?” “Woof, woof or meow, meow?”). This lets children take turns leading activities and have a voice in the actions they would like to pursue with their parents.

For Coaches: Reference the activity ideas to help parents develop variations to the games they play with their children. Variations can be simple. Think about what materials, actions, or sequences parents can add to change up activities, one action at a time, and that children will find fun in and want to imitate. In addition, children may need extra reinforcement, or access, to desired materials/actions before parents’ next expectation to imitate another action. Help parents continue to read children’s talking bodies to know when to stick with the same action or switch to a new one. Remember the steps below to coach parents’ teaching sequence with regard to imitation: 1. Parents show, label, and repeat an interesting action that children will find

fun to imitate. 2. Parents pause and wait for children to imitate the action. Parents cheer if children do. 3. Or, parents exaggerate the action and encourage children to imitate the action with cheers if they do. 4. Or, parents physically guide children to start the motion or to do the entire action only if the extra help is necessary. Be sure that parents fade this prompt as soon as possible.



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You can ask these optional coaching questions to help parents plan how to use this step: • “What theme(s) and action(s) does your child like to imitate in this activity?” • “What other action(s) do you think your child will like and imitate in this activity?” • “How will you prompt your child to imitate the new action(s)?” • “How will you fade your prompt(s) for your child to imitate the new action(s) by him- or herself?” Step 5: Put Imitation Games into the Joint Activity Frame

What to Share with Parents: Let’s revisit the four parts of a joint activity routine: set-up, theme, variation, and closing/transition to see how different examples of imitation games fit into this framework. Using Double Sets or Multiple-Piece Objects and Toys 1.  Set-up. Parents position themselves and their objects in front of the children in order to be seen and heard. 2.  Theme. Parents copy children’s actions with their own object and label what’s happening. Parents continue their start-and-stop motions timed to children’s actions until they see eye contact, smiles, or other body language indicative of children’s awareness of the back-and-forth rhythm of the theme. 3.  Variation. Once a theme develops, parents show a different action with their object for children to imitate. Parents stick to showing (and teaching) one action at a time. The different action could be something that parents have seen their children do previously with objects (e.g., tap on the xylophone or draw circles on the paper) or something new that parents think children will like (e.g., tap on household objects, tickle each other with a stick, draw animals, or place stickers on paper and color over them). Parents label the new action and repeat it a few times before pausing and waiting expectantly for the children to copy their action. When children copy new actions, parents celebrate and join in to complete the actions, too. When children do not readily copy the new action, parents encourage them to try it again, and may need to change up the tempo or motion or add gestures, expressions, or sound effects as enticements to increase the children’s motivation to want to imitate the action. Parents and children go back-and-forth with the new action just like they did with the theme, or they can return to the prior theme if children find the new action harder or less interesting to do. Parents can always try another action to see whether children like that one better than the

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last. Children can also make choices between actions that parents ask (e.g., “Drum or pan?” or “Circle or star?”) to maintain high interest in the activity. 4.  Closing/transition. When new actions run their course and there are no other actions to think of or try, parents prepare children for the end of an activity. Remember that activities took time to start and build with children, so it only makes sense that activities take time to end, especially when children are not yet ready for the fun to stop. Parents can try several strategies to support children through closings and transitions. They can gradually put away objects to make fewer available to children. They can give warnings of how much time or turns are left before the game ends. They can tell children that they want to be done with the activity and start putting away some of their objects when double sets are used. They can set up and talk with excitement about the next activity. All these steps attempt to explain and ease children’s anxiety with the change and to focus children’s attention on what is coming next, not what is coming to an end. Parents can also use clean-up routines to teach children to imitate actions when they label and put back objects in containers or on shelves. Matching can be taught, too, when parents show children how objects of the same color (e.g., red pegs in one bag and blue pegs in another), same size (e.g., small blocks in one container and large blocks in another), or same appearance (e.g., markers in one box and crayons in another) can be put away together.

Using SSRs 1.  Set-up. Parents pick a movement or gesture that relates to a favorite song or game their children like and is relatively easy to imitate. 2.  Theme. Parents start the song or game to show children how to do the

gesture or movement. 3.  Variation. Parents teach one gesture or movement at a time before using

the same prompts to teach other gestures or movements. When Haley learns how to lift up and extend her foot in front of her body her clothing to the “Hokey Pokey” song, the mother shows her how to jump, listening to “Put her whole body in and her whole body out” in the next verse. 4.  Closing/transition. When parents or children tire of the gestures or facial/ body movements and there are no other actions to think of or try, parents prepare children to end the song or game. Parents give warnings of how much time or turns are left before the song or game ends. They can tell their children that they want to be done with the activity and to put away their props if used in the song or game. They can set up and talk with excitement about the next activity to highlight to children what is coming next, as opposed to what is ending. Again, parents’ language and actions help children understand and move ahead.



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For Coaches: Coach parents through the set-up, theme, variation, and closing/transition for any joint activity routine practiced thus far with imitation, to establish the full framework with children. Refer to the Joint Activity Template (Form 7.1) to help parents plan how imitation can be included within other child care routines, besides with toys, object play, or SSRs. The rest of the coaching chapters in this book rest on parent–child abilities to become play partners and to imitate one another’s actions. Stay with this chapter and revisit earlier chapters, if necessary, to help parents and children develop the steps. The more imitative games that you can help parents develop with children, the higher the number of learning opportunities the parents will create to strengthen not just their children’s imitation skills, but also their attention, play, communication, thinking, and engagement skills. You can ask these optional coaching questions to help parents plan how to use this step: • “What can your child imitate you doing during set-up?” • “How can you and your child imitate each other in the theme?” • “What other sounds, gestures, or facial and body movements can you and your child imitate?” • “When is it time to end the activity? How can you prepare your child for the transition?” • “What can your child imitate you doing during clean-up?” Topic VI: Understanding the ABCs of Children’s Behavior What to Share with Parents: Whenever a new behavior develops or an old one changes, learning takes place. This holds true for children as much as it does for parents or adults. Whether a person wants to eat healthier and exercise more often, or a parent wants her child to look at her and speak words more often, both examples require change on the part of the person to learn something new or to do something different in terms of his or her behavior. Earlier sections of this chapter have asked parents and children to do something different—to change something about their behavior—in order to create fun-­filled joint interactions for children to learn new skills. For parents, the expectation has been to adopt new strategies in how they approach, engage, and interact with children to capture their attention and motivation for learning to occur. For children, the expectation has been to develop or expand skills for interaction, communication, and play with their parents. In this topic, we give a name to the mechanics of learning that parents and children have been using: the ABCs of learning, or, more formally,

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applied behavior analysis (ABA), which refers to the science of how learning happens for people to change or develop new behavior. A common misperception is that ABA is one specific intervention approach. In fact, ABA is an entire knowledge base of how to understand, teach, and change behavior in people—adults and children alike! This topic goes over the important “rules” of how to increase parental awareness of: • Their own behavior • The meaning and purpose behind children’s behaviors (the Bs) • The events or actions that lead to children’s behavior (the As, antecedents) • The events or actions that follow children’s behavior and determine whether they are more or less likely to repeat that behavior again (the Cs, consequences) Once parents have mastered these concepts, additional teaching tools become available to encourage the development of positive behaviors in children and to show children new ways of behaving that are more age-­appropriate or functional to their development. Parents maximize their ability to help children learn and to benefit the most from the interactions that parents provide. For Coaches: You can ask parents to share what they understand or know thus far about ABA to encourage their reflection on this topic. Even though this may be the first mention of ABA to parents, the previous topics have taught parents: (1) to complete some action that cues a behavior in their child (antecedents) and (2) to respond to that behavior in some way either encouraging or discouraging it from happening again (consequences). Bring up at least one example (if parents do not) to help parents see the connection between their behavior and their children’s. You can ask these optional coaching questions of parents: • “What new behavior have you taught your child to do?” • “How did you teach your child to use the new behavior?” • “How did you respond when your child used the new behavior?” Step 1: Pay Attention to What Your Child Does—B Is for Behavior

What to Share with Parents: All behavior has a reason why it happens. This means that children (and adults) take actions or say the things they do to achieve a goal for that behavior. Behavior serves a purpose or function. Even unusual, infrequent, or random behavior has an underlying reason why children (or adults) do it. The first two rules to know about children’s behavior are the following:



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1. Observe what children do with their behavior, not what they seem to “know.” Children with autism have difficulty communicating and relating their feelings or emotions to others, as well as understanding them. Instead, parents can rely on what children do routinely with their actions to figure out what they understand and know how to do when it comes to a skill, routine, or learning moment asked of them. When we focus on what children with ASD actually do, not what we think they can do or how they respond if made to do something, we gain a clear picture of their vulnerabilities and the skills that they would benefit from learning. 2.  We already said that all behavior happens for a reason, but let’s define what those possible reasons are. Children (and adults) do what they do to: (1) get something they like or want or (2) avoid something they do not like or want. These patterns hold true over time, meaning that when a behavior results in something that people like, they are more than likely to repeat it. Similarly, when a behavior results in getting out of or avoiding something that people do not like, they are also more likely to do it again. Sometimes more than one reason or goal might be behind why the same behavior happens, such as a child screaming out of excitement when bubbles are blown or out of frustration when a favorite toy is taken away.

Let’s talk about how these two rules apply to your child’s behavior. For Coaches: Reference the activity idea and tips to help parents observe their children’s behavior and consider the goals or functions behind what they say and do. A plan for how parents can continue their observation of, and reflection on, the children’s behavior and function(s) at home should be developed before your session ends. Consider discussing examples of behavior that serve more than one purpose or function if applicable to what parents describe about their children. Consider encouraging parents to observe and define children’s behavior across more than one type of interactive activity (i.e., toy play, SSR, meals/snacks, caretaking, books, chores) to broaden their understanding. Begin to use the ABC Action Plan Template (see Form 7.3) to help parents learn to describe behaviors and all other aspects of ABC chains. You can ask these optional coaching questions to help parents plan how to use this step: • “What behavior have you observed your child using?” [Have parents include at least one positive example if undesirable behavior is initially described.] • “What does your child want to accomplish with that behavior?” [Have parents include at least one positive example if undesirable behavior is initially described.] • “How would you describe your comfort level, differentiating between an observable behavior from your child versus how your child feels?”

FORM 7.3

ABC Action Plan Template What is the activity?

What are What behaviors the learning are expected from How will I teach the opportunities? the child? behaviors to my child?

Meals

My child will sit at the table when she wants to eat and drink. My child will tell me what she wants to eat and drink. My child will use a napkin to wipe her face. My child will stay seated to eat and drink. My child will tell me she’s all done with her food and drink. My child will give me her cup, bowl, and napkin.

To come to the table and sit in her booster chair when told. To look at me and reach or make a sound for what she wants when I name and show food and drink items. To wipe her face with a napkin when told. To stay in her chair while eating and drinking. To look at me and gesture, make a vocal sound, or hand me her cup or bowl indicating that she’s done with her food and drink. To give me her cup, bowl, and napkin when told.

C all her name, show food or drink item that she likes, push out her chair, and tap it for her walk over and sit in it. Be face-to-face and name and hold out food and drink items. To give her a napkin for her to take and, while watching me wipe my face, for her to do the same on her face while I say, “Wipe face.” To watch for signs of her being restless, meaning she’s ready to get out of her chair, and to ask her, “All done?” To hold out my hand and say, “Give me,” with the option to put the cup, bowl, or napkin in my hand if she doesn’t pick them up herself.

What positive consequences follow my child’s behaviors? She eats and drinks plus my cheers! She eats and drinks plus my cheers! She eats and drinks plus my cheers! She eats and drinks plus my cheers! She does not have to eat or drink anymore. She leaves the table, and we do another activity.

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 150



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Step 2: Choose the Reward—C Is for Consequence

What to Share with Parents: We have already said that all behavior happens for a reason: to get something, or to avoid or stop something. Whether or not a behavior achieves its goal to get something or avoid/stop something is called the “consequence.” Consequences matter and are important for parents to understand because how people or the environment respond to behavior basically decides whether someone does that behavior again or not. Let’s go over the rules for how consequences work. Rule 1: Behavior that achieves its goal is likely to happen again. Consequences are actions or events that follow behavior, and when those actions or events help behavior achieve its goal, the technical name is “reinforcement.” • A parent who picks up her daughter (the consequence) after her child lifts up her arms (the behavior) teaches the child that lifting up her arms is how to get Mommy to pick her up when she wants to be carried (reinforcement). • A parent who starts a game of hide-and-seek (the consequence) after his child asks for another round of the game (the behavior) teaches the child that saying those words are how to continue doing something fun with Daddy (reinforcement). • A child repeatedly flicking the light switch on and off (the behavior) because he enjoys the visual stimulation (the consequence) also means that the behavior is likely to continue, assuming nothing is done about it (reinforcement). Rule 2: Behavior that achieves its goal to get something is likely to happen again, as will behavior that achieves its goal to avoid/stop something. There are two types of reinforcement: positive and negative. Both respond to behavior to help someone achieve a goal. The difference lies in the type of goal that is met as a result of that consequence or reinforcement. Consequences that help behavior get something are called “positive reinforcement.” Consequences that help behavior avoid/stop something are called “negative reinforcement.” • A parent who gives a toy (the consequence) in response to his son looking at him and reaching for the toy (the behavior) because the child wants the toy (the goal or purpose for the behavior) teaches the child that his use of eye contact and gesture are why he was given the toy and increase the likelihood that the child will engage in both behaviors the next time he wants something (positive reinforcement). Parent has toy → child looks at parent and reaches for toy → parent gives toy to child → child learns to look and reach to ask for an item

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• A parent who shows her child how to hand her a toy (Behavior 1) instead of crying (Behavior 2) because the child cannot make it work and needs help (the goal for the behavior), followed by the parent fixing the toy and giving it back to her child (the consequence), stops the child’s crying and teaches him or her that handing over an item, not crying about it, is how to ask for help (negative reinforcement). Child cannot fix toy and cries → parent shows child how to hand her the toy for help → child stops crying → parent fixes and gives toy back to child → child learns to give item to ask for help

• A parent who gives food or drinks (the consequence) while her child walks around the room while eating and drinking (the behavior) whenever the child is hungry or thirsty (the goal for her behavior) teaches the child that walking around a room, not sitting for meals, is OK and increases the likelihood the behavior will continue as is (positive reinforcement). Child shows signs of hunger or thirst → parent gives food or drink to child → child walks around the room while eating or drinking → child learns this routine is OK at mealtime

Rule 3: Positive and negative reinforcement can change or teach new behavior. Learning new behavior depends on what type of consequence follows the action. The more opportunities that children have to use a behavior—­whether it is a prosocial behavior like looking and reaching to communicate they want something, an unhelpful behavior like crying when upset because something does not work, or demonstrating no behavior and being given an item for doing nothing at all), the stronger those behavior become. • When parents give something (like a toy or their attention) to a behavior they want their child to keep using, the consequence they deliver, positive reinforcement, tells their child, “Yes! Do that behavior again.” • When parents give something (like a toy or their attention) to a behavior they do not want their child to keep using, the consequence they deliver, positive reinforcement, tells their child, “Yes! Do that behavior again,” even though parents, in fact, do not want their child to continue it. • When parents give something (in this case, a different behavior) to avoid or stop a behavior they want their child to use, the consequence they deliver, negative reinforcement, tells their child, “Use this behavior instead of that one to get your goal met.” • When parents give something (like a toy or their attention) to avoid or stop a behavior they do not want their child to use, the consequence they



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deliver, negative reinforcement, tells their child, “Yes! Do that behavior again,” even though parents, in fact, do not want their child to continue it. Rule 4: Behaviors that are not reinforced will decrease over time or not happen at all. A behavior that cannot achieve its goal has less reason to happen. The longer a behavior goes without achieving its goal, the weaker that behavior becomes until it does not occur at all. There are two types of consequences that can make this happen. A behavior that goes without positive reinforcement is called “extinction.” When used carefully and correctly, extinction can teach children to stop using less desirable behavior. But when used incorrectly or unintentionally, extinction can also teach children to stop using positive, prosocial behavior. • The parent who decides to no longer give food or drink to her child while she walks around a room teaches the child that her behavior will no longer get her the food or drink that she wants. The child still needs to be taught what behavior to do to eat or drink instead of walking around the room. Don’t worry! That step comes in the next section. • The parent who does not give toys or items when a child makes eye contact while reaching for an item teaches the child that his behavior will no longer get him what he wants. In this case of extinction, we risk stopping a communicative behavior that we actually want to promote and strengthen. A behavior that is followed by something unpleasant or unwanted to make that behavior less likely to happen again is a negative consequence and called “punishment.” Time-outs are one example of punishment, as are taking away a reward, stopping a favorite activity, or grounding a child when misbehavior happens. There is a lot to understand and think about when it comes to the actions and events that follow children’s behavior. But there’s good news here. First are the wide range of consequences at parents’ hands to teach children new behavior and to change existing ones. Second are the thousands of opportunities that already exist within parents’ interactions and routines with children. The wheel does not have to be re-­created. Third are coaching sessions to help parents observe children’s behavior and decide how to respond, and, in fact, that’s what will happen next. By observing children’s behavior and the type of consequence that currently follows, parents can determine the goal or reason behind the children’s behavior, whether the existing consequence helps the behavior meet or not meet its goal, and whether that pattern of behavior → consequence (or B → C) should be kept or replaced with another behavior and/or consequence chain. The last bit of, and the most important, good news here is that with these powerful tools, parents help children grow to their upmost potential!

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For Coaches: This information is detailed and will take anyone time to understand. Devote the necessary coaching time and session(s) to talk through the step’s activity ideas, parent–child scenarios, and templates to help parents observe and define the functions and relationships between children’s behavior and the consequences that follow. Although not discussed with parents in the examples above, keep in mind when consequences brought up or observed by parents may relate to the environment (e.g., the buzzing of fluorescent lights), to actions other than the parents’ (e.g., another person flushing the toilet or the elevator door opening as parent and child walk past it), as well as from children’s own responses (e.g., a child running around the room or sticking his hands in his ears because of the sensation produced by an action). The same rules for consequences apply, but parents may need guidance on how to identify the consequence that should follow. Overall, it is better not to advance to the next step until parents can generally identify: (1) whether the consequence that follows children’s behavior increases or decreases its occurrence, (2) how to support positive behavior–­consequence chains with learning opportunities throughout play and routines, and (3) how to change undesirable behavior–­consequence chains to encourage development and growth. You can ask these optional coaching questions to help parents plan how to use this step: • “What desirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What undesirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What consequence(s) follow your child’s desirable behavior?” • “What consequence(s) follow your child’s undesirable behavior?” • “What consequence(s) are important to keep giving your child? What consequence(s) would you like to change?” Step 3: Identify What Came First, Right before the Behavior

Occurred—A Is for Antecedent

What to Share with Parents: Step 1 of this chapter explained that behavior occurs to gain, or to avoid or stop, something. Step 2 explained that the consequences that follow behavior matter in terms of whether the behavior happens again or not. When consequences support behavior to meet its goal (i.e., to gain or avoid/ stop something), behavior strengthens and is likely to occur again. When consequences do not support behavior to meet its goal (i.e., behavior wanted to gain something or avoid/stop an experience and that didn’t happen), behavior weakens and is less likely to occur again. The last part to understanding and teaching or changing behavior focuses on the events right before behavior happens to cue or



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trigger its taking place. This is called the “antecedent,” or “stimulus.” Let’s review the rules for antecedents. Rule 1: Behavior occurs in response to antecedents. Remember, we said behavior happens to get or to avoid/stop something. That something is the antecedent. It can be something observable that the child sees and wants, such as a toy or piece of candy. It can be something observable that the child sees and does not want or wants to stop, such as medicine, broccoli, or brushing his or her teeth. Antecedents can be brought on by children’s other senses than sight, including sounds, tastes, smells, and touch. A child hears a vacuum running and starts to cry. A child smells cookies baking and comes into the kitchen. A child feels a tag on the back of a shirt and wants to take off the shirt. Or, antecedents can be something children feel, like hunger, thirst, sleepiness, fear, and happiness. A child reaches for the drink that Mom shows her because she is thirsty. A child hides behind Dad’s legs when a dog and its owner pass them on the sidewalk. A child may be hard to console because she did not sleep through the night. Lastly, antecedents can be events or situations that cue children to respond with certain behavior. Children see a park and want to run toward it. A set of elevator doors open and children walk in to go for a ride. Parents need to focus just as much attention on antecedents as they do consequences to understand the whole picture on what leads up to cueing behavior and what follows once behavior occurs to strengthen or weaken its ability to happen again. Rule 2: Antecedents can be nonverbal cues, verbal instructions, or events that trigger behavior to occur. In the last step, we touched on the different antecedents that children can see, hear, taste, touch, smell, feel, or experience to cause specific behavior to happen. But parents also have antecedents through their words and actions to teach, change, or encourage children’s behavior. Think back to every chapter before this one; each has shown parents how to say or do something to cue the behavior they want to see in their children. Parents have a wide range of antecedents: their language, gestures, facial expressions, sound effects, play, turn taking, and other actions to carry out games and routines with children. The examples below remind parents of different antecedents highlighted in previous chapters and the teaching that is already in effect with children. Now just give a technical name to parents’ actions and language that helps children learn. • A parent shows how to perform a new fun-­filled action with his toy (the antecedent), so his child will imitate him (the behavior). • A parent points to where a toy piece has fallen (the antecedent) to help the child find the piece and pick it up (the behavior). • A parent holds out a book in each hand and asks his child which book she

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would like to read (the antecedent), prompting her to look at him and point or say which one (the behavior). Rule 3: Use antecedents that other children use. When parents are unsure of what antecedent to use to cue their children’s behavior, they should think about what events cue this behavior for other children the same age. If parents cannot figure out what other children respond to, they could observe other children using the behavior to see what antecedents caused it to happen, ask friends or family members what their children respond to, or ask teachers or other caretakers what they see children doing. Using antecedents similar to what other children and adults use means children with ASD will have a greater chance of understanding cues that many different people use and strengthening their use of that behavior when done with multiple people. This is why we encourage parents’ use of language, gestures, expressions, body language, and other antecedents that happen in everyday situations and routines; they make it so much easier for children to learn antecedent–­behavior–­consequence patterns that others will also use. Children learn what they need to approach, engage with, and respond to many people, not just their immediate family, and in many situations, not just the “teaching” ones. For Coaches: Now we ask parents to see the relationship and function between the antecedents that precede and cue children’s behaviors. Just as in the last step, devote the necessary coaching time and session(s) to talk through this step’s activity ideas and parent–child scenarios on antecedents and behaviors. Guide parents to list the positive, or functional, relationships between the antecedents and child behaviors they want to maintain, as well as child behaviors that might benefit from other antecedents. We strongly encourage staying with this step until parents show confidence in thinking through antecedents and behaviors patterns, which is different than expecting parents to feel 100% confident in knowing how to change or teach new behaviors. Parents will struggle with the remaining steps if they cannot “see” the antecedents that cue children’s behavior in many situations (and the consequences that follow and will strengthen or weaken it). You can ask these optional coaching questions to help parents plan how to use this step: • “What desirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What undesirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What antecedent(s) happen before your child’s desirable behavior?” • “What antecedent(s) happen before your child’s undesirable behavior?” • “What behavior from your child is important to strengthen? What behavior from your child is important to change or teach him or her to do?”



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Step 4: Put Together the ABCs of Learning

What to Share with Parents: Now that parents know the ABC rules of learning, they can decide on the behaviors they want their children to keep using, the new behaviors they want to teach them, and the behaviors they want to change. Rule 1: Keep the ABCs for behavior you want to happen. Parents know what behavior they want their children to use. When parents see that behavior in the children, think about the antecedents that cued it to happen and the consequences that followed to support or discourage it from happening again. When parents know the ABCs, they have the power to help children practice that behavior again and again until it becomes an automatic action. Let’s go through an ABC example to demonstrate parents’ teaching power. • A child no longer wants to color (the antecedent) and walks away from the activity (the behavior) to take out other toys (the consequence). Her mother brings over the crayons and box (the antecedent), so the child will put them away (the behavior) before taking out other toys (the consequence). When the child does not respond (the behavior), the mother puts a few crayons in the box and says, “crayons in,” and “help me” as she hands crayons for the child to return to the box (the antecedent). The child puts the crayons in the box (the behavior), and the mother helps take out other toys the child wants (the consequence). Rule 2: Know the ABCs for unwanted behaviors. Parents know what behavior they want their children to not have. When children use behavior that parents do not want, parents should first think about the current antecedents and consequences that support or trigger the behavior to happen. Before parents change or teach new behavior, parents need to understand why children do the behavior in the first place and what events before and after its occurrence will give the behavior reason to re-occur. • A child hits his sister (the behavior) when she walks up to his train table (the antecedent) because the child thinks she will take his trains (the goal for the child’s behavior). The parent tells him “no” and picks up his sister to comfort her while the child continues to play with his trains (the consequence). Even though the parent is clear that hitting is not allowed, the child’s play with trains continues uninterrupted and he does not learn how to ask for help or tell his sister not to touch his trains the next time he thinks she will take his trains. Rule 3: Change the ABCs for behavior you want to change. Once parents understand why children do a certain behavior and what antecedents and

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consequences support that behavior to happen, parents can change the pattern. Now parents can think about other behavior they want their children to use in place of less desirable or challenging behavior and the new antecedents and consequences they need to provide in order to teach children to use more appropriate behavior and reinforce (i.e., strengthen) it. Let’s return to our last example to show new antecedent–­behavior–­consequences patterns. • The next time that Mom sees her daughter approaching her brother at his train table (the former antecedent), the mother intervenes before her son is able to hit his sister and asks him what he can give his sister to play with from the train table (the new antecedent). The son replies, “Nothing!” (the old behavior). The mother tries again: “The trains are yours. Can she put animals on the table or cars on the table?” (the new antecedent). The son yells again, “No! I don’t want to!” (the old behavior) The mother repeats her message, “The trains are yours. The trains are Sammy’s. Sissy gets animals or cars?” and holds up one of each to her son (the new antecedent). He points toward the animals in his mother’s hand and says, “That” (the new behavior). The mother places the toy animals on the table within his reach and tells him, “Give animals to your sister when you do not want her to touch your trains. Let’s do together” (the new antecedent). After the boy gives an animal to his sister, his mother gives him a big hug and tells him how proud she is of him. He also sees that his sister takes the animal to the floor instead of touching his trains and that makes him happy (the new consequence). The mother knows she still needs to help her son understand and use the new antecedent, behavior, and consequence pattern but she now thinks they are on the right track! Rule 4: Behavior takes time to develop and it takes time to undo. Behaviors generally do not develop overnight. While children might say or do something that parents have not heard or seen before, it’s the behavior that achieves its goal over time that becomes a habit and part of children’s repertoire. This means that when children engage in behavior that parents do not like and want to change, parents should intervene to change the ABC before the behavior becomes more difficult to undo and teach an alternative in its place. Rule 5: New behavior has to be relatively easy and make sense to use. Children use behavior to achieve a goal (remember, to get or to avoid or stop something). The easier and more obvious new behavior is for children to use and to achieve goals, the smoother the learning process goes for both children and parents. This rule doesn’t hold true forever. But for children learning a lot of rules at once on how to increase attention, interaction, communication, play, and other skills, this rule helps them see the relationship between the new behavior that



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parents want them to use and the familiar consequence children want to follow their action. New behavior that is within children’s developmental grasp, that leads to the goal achievement children want or do not want, or that helps them cope through upset when something cannot go their way is the most effective way to teach and change behavior. For Coaches: Now we ask parents to “connect all the dots” on the relationship and function between children’s behavior and the antecedents and consequences that surround their action. Refer to the exercises that you and parents went through in Steps 1–3 to help parents see the ABC sequences that underlie children’s current repertoire of desirable and undesirable behaviors. Help parents start with child behaviors and goals followed by consequences and then antecedents. (Hint: The “recency effect” in cognitive psychology says that people have an easier time recalling what happens last in a sequence, rather than what happens first.) Make sure parents include positive, or desirable, ABC sequences if the only ones they list focus on what they wish their children did not do. Once parents finish their list, guide them through a reflection on which ABC sequences they want to maintain, change, or add for new learning opportunities. The next step relies on parental understanding of ABC sequences to increase children’s learning for new skills and to allow existing behavior to flourish. The time and energy required for parents to develop this knowledge will not be wasted. You can ask these optional coaching questions to help parents plan how to use this step: • “What desirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What undesirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What antecedent(s) and consequence(s) happen before and after your child’s desirable behavior?” [You can ask this as a two-part question if that makes it easier for parents to think about and answer.] • “What antecedent(s) and consequence(s) happen before and after your child’s undesirable behavior?” [Again, you can ask this as a two-part question if that makes it easier for parents to think about and answer.] • “What behavior from your child is important to strengthen?” What behavior from your child is important to change or teach him or her to do?” Step 5: Use the ABCs to Increase Your Child’s Learning Opportunities and Teach Your Child New Skills or Behaviors

What to Share with Parents: Every moment with children is a potential learning opportunity. This statement can seem overwhelming, but that’s not our intention.

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Rather, it is to show how much parents can mobilize ABC sequences within existing interactions to help children learn. And to make the most of these opportunities, parents have to remember the following rules. Rule 1: Remember children’s goals. Know what children want or do not want. It does not mean parents give into children’s every whim. But, parents need to understand what children are trying to achieve with desirable and undesirable behavior before they can respond appropriately. Rule 2: Respond with antecedents and consequences for the behavior parents want to see in children. Parents provide the nonverbal language, verbal communication, or situational cues that will lead to the behavior they want to see in their children. Parents respond with the goal that children want when they use desirable behavior. Rule 3: Be aware of distractions. Parents cannot control or remove all distractions to children, especially when out in public places. Parents need to be aware of distractions that can be potential reinforcers for children, as in something they want or do not want, and have an ABC or two ready to help them navigate their way through that challenge. If it’s something children want, such as food, toys, or attention, what behavior can parents teach their children to ask for the item or person? If it’s something children do not want, such as unpleasant sounds, texture, or something that scares them, what behavior can parents teach their children to communicate or resolve the issue? If it’s something children want or do not want but parents cannot grant their request, are there alternatives parents can offer to redirect their children’s attention to, and interest in, what they do have and to help them cope with the upset? Rule 4: Teach (or aim for) more mature behavior in children. Parents asking themselves how children communicate what they want and do not want lets them reflect on the complexity of behavior observed in children. If their children’s behaviors are increasing and improving in frequency, clarity, and sophistication, then ABC sequences are serving their purpose to aid the children’s development. If children’s behaviors happen with ease, parents could add other ABC sequences to expand those behaviors across other skills, activities, people, or places. If children’s behaviors do not improve or start to and then stop, parents need to revisit and change ABC sequences so their children do not fall behind further in development. Besides observing or speaking with friends, family members, or teachers to see what other children the same age do, parents can go online to trusted institutions like the Centers for Disease and Control and Prevention and Autism Speaks to reference their checklists of the skills and developmental milestones children normally achieve by certain ages. Developmental pediatricians and psychologists can also share their knowledge about typical (and atypical) child behavior.



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Rule 5: Follow through on ABCs. When children do not respond the first, second, or even third time with behaviors parents want them to use, it can feel frustrating to parents, but, in fact, this is a real opportunity to help children achieve an “ah-ha” moment. Think back to when something didn’t make sense and then suddenly something clicked, and it did make sense. What a powerful experience that was! We want children to have that same awakening. To help children get there, parents need ABCs. First are antecedents to cue children’s behaviors. Whether that’s parents showing, saying, or doing something or children feeling something, antecedents are available but not yet given to children until the behavior happens. Parents hold back with antecedents until children communicate or complete one of the behaviors on the parents’ list that relate to the antecedent. When children use the behavior, parents deliver consequences or what children want or don’t want to happen, so they achieve their goal as a result of the behavior. When children do not respond or resort to unwanted behaviors like a tantrum, parents help children to respond or use behavior that is appropriate. If it is a word that parents want children to say, parents model the word or add enticement like gestures or actions if that helps to increase their children’s motivation or gives them alternative communications (think “talking bodies”) to respond. If it is gestures or actions that parents want children to do, parents can also repeat and slow down to help children see and process behaviors or speed up to motivate children to act. When extra help is needed, parents can physically guide children through behaviors they are trying to teach. After children act, parents deliver consequences. A full ABC sequence (antecedents cue behaviors parents want children to use to receive desired consequences) is the secret to learning. Now parents and children can both experience “ah-ha’s”! For Coaches: Using the exercises that you and parents have been conducting, now address the last step in the ABC sequences that reinforce children’s current repertoire of desirable and undesirable behaviors. Help parents identify the reinforcers that met children’s goals (i.e., parents gave something the children wanted or removed/stopped something they didn’t want) and what behaviors children did (whether verbal or nonverbal) to communicate their goal. These are the learning opportunities parents provided to children in those situations. If parents recall that their children offered no behavior but reinforcers happened anyway, those represent missed learning opportunities for parents to recognize and reconsider. Help parents continue this activity to: (1) reinforce their continued effort of learning opportunities perhaps across other behaviors, play materials or activities, items, caretaking routines, play partners, or locations; and (2) become more aware of potential missed opportunities to help children respond before consequences result. You can ask these optional coaching questions to help parents plan how to use this step (all questions but the last two are repeats from the previous step):

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• “What desirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What undesirable behavior have you observed your child using, and what does your child want to accomplish with that behavior?” • “What antecedent(s) and consequence(s) happen before and after your child’s desirable behavior?” [You can ask this as a two-part question if that makes it easier for parents to think about and answer.] • “What antecedent(s) and consequence(s) happen before and after your child’s undesirable behavior?” [Again, you can ask this as a two-part question if that makes it easier for parents to think about and answer.] • “What behavior from your child is important to strengthen? What behavior from your child is important to change or teach him or her to do?” • “What other learning opportunities are available during the day to strengthen behavior you want your child to keep using?” • “How can we turn missed moments into learning opportunities for your child?” Step 6: Change Unwanted Behavior

What to Share with Parents: We return to this topic for the very important reason that parents may have identified children’s behavior they are not happy with and would like to change in the templates filled out in previous steps. It’s not uncommon for children (and adults, too) to have less attractive or quirky habits, but we do not want children’s behavior to stand in their way of interaction and learning. When behaviors take more time and energy to control or manage, parents lose moments to teach and connect with their children, and children, in turn, miss opportunities to learn and grow stronger and more independent in their development. No one “wins” with challenging behaviors. Let’s revisit how ABC sequences work to strengthen the behavior parents want to see in children and to decrease and change unwanted behavior parents do not want to see in their children: Antecedent → Behavior → Consequence (child achieves goal) = Strengthens behavior and likely to happen again Antecedent → Behavior → Consequence (child does not achieve goal) = Decreases behavior and less likely to happen again

Now let’s consider when children use unwanted behaviors and the ABC sequences (1) maintain the challenging pattern or (2) change the pattern to teach more desirable behaviors. This ABC sequence maintains children’s unwanted behavior: Antecedent → Unwanted behavior → Consequence (child achieves goal) = Strengthens unwanted behavior and likely to happen again



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The next ABC sequence has two parts. The first teaches children that unwanted behavior no longer results in desired outcomes, and the second teaches children another behavior that is more appropriate to achieve the desired outcomes: Antecedent → Unwanted behavior → Consequence (child does not achieve goal) = Decreases behavior and less likely to happen again → Antecedent → Replacement behavior → Consequence (child achieves goal) = Strengthens wanted behavior and likely to happen again

Here’s how parents teach replacement behaviors to children: 1.  Identify ABC sequences and children’s goals for unwanted behaviors that occur often and disrupt interaction and learning. 2.  Think about what children could do differently to achieve their goals. These become replacement behaviors for children to learn how to use instead of unwanted behaviors to achieve their goals. Remember in Step 4 that we said the easier and more efficient new behaviors are for children to use, the more often they will do so and the stronger those behaviors become. The same rule applies with replacement behaviors: to be easy for children to use, or easy for parents to help children use, and quickly result in the same rewards children intended with unwanted behaviors. Replacement behaviors that are hard for children to use, even with parents’ help, or that take too long to achieve desired outcomes, or are only used some but not all of the time are not likely to work and unwanted behaviors will continue. 3.  Write out new ABC sequences to show how replacement behaviors will be

taught to children. Start with “B” or replacement behaviors, then “C” or consequences of desired outcomes that the children will receive for their use of replacement behaviors, and “A” or antecedents that cue and teach the children to use replacement behaviors. 4.  Practice! New behaviors only grow in strength from practice. And practice helps troubleshoot, refining and improving ABC sequences for maximal learning and behavior development to happen. Tiptoeing around situations or demands to lessen the likelihood of unwanted behaviors does not do children and families any good. Children continue with lesser behaviors that over time only become stronger and potentially more problematic. Parents continue with struggles. Siblings or other family members get caught in the middle. No one learns or benefits. 5.  A word of caution. The ABCs intend to help parents think about behav-

iors in order to promote and strengthen desirable behaviors in children. But, the ABCs cannot erase all unwanted behaviors from happening. Children feel disappointment, frustration, fatigue, fear, anger, sadness, pain, or other upset and

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sometimes need to cry or scream to release those emotions. If unwanted behaviors persist or intensify and parents are concerned, please consult a pediatrician or family doctor to make sure health-­related problems are not involved. If children’s health is not an issue, then parents can also discuss these ABC concepts with early intervention coaches or other professionals who have training in behavior management. For Coaches: Help parents do 1–4 above, using at least one of their examples of an ABC sequence that supports an unwanted behavior. Make sure that unwanted behaviors parents choose can be sufficiently addressed with replacement behaviors in your scope of practice; otherwise, referrals should be made to appropriate professionals. This step also includes a case example of unwanted behaviors addressed with ABC sequences to share with parents if that improves their understanding of these concepts. We want parents to know much more about why children do behaviors parents want them to keep using and why children do behaviors parents want them to stop using. With this knowledge and ABC tools, parents can support children’s desirable behaviors and replace unwanted behaviors with more functional alternatives. Equally important, parents will need these ABC tools to teach the social communication behaviors addressed in the remaining chapters. You can ask the following optional coaching questions to help parents plan how to use this step (all questions but the last two are repeats from the previous step). • “What desirable behaviors do you see your child using? When do they happen? How do you make them happen?” • “What undesirable behavior do you want your child to stop doing or to do less often? What is your child’s goal for using that undesirable behavior? What antecedent and consequence support that undesirable behavior to happen?” • “What replacement behavior is relatively easy for your child to learn and will still result in your child’s goal? What antecedent and consequence will support your child to use the replacement behavior? When will you use this new ABC sequence?” • “What could stand in your way of using the new ABC sequence to maintain the replacement behavior with your child?” Topic VII: Why It Is So Important That Children Learn to Share Interests and Attention with Others (Joint Attention) What to Share with Parents: Hopefully, by now it is no surprise that children’s attention to parents and others is important! In fact, not much can happen during



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interactions or be taught without children paying attention to us. This is why previous chapters focus on how parents encourage and support children’s attention to their faces, bodies, voice, and actions. This teaches children the power of two people (the parent or another adult and the child) doing things together. Children watch parents’ actions, listen to their language, try actions themselves, take turns, express and observe emotions, and communicate intentions. Through these different behaviors, parents and children share experiences that unlock the learning potential to gain new information and skills. Now we teach children how to share their attention between themselves, parents, and objects or events that happen. Like a triangle, this three-way interaction called “triadic or joint attention” teaches children how to shift their gaze and use gestures and language to share information, emotion, or meaning about something that interests them and to respond to those things that interest others. Joint attention supports a lot of learning and communication development both during infancy when these skills start to develop and later when language, social, and cognitive abilities grow as children age. We want to build joint attention skills and the related social, communication, cognition, and language learning that derive from these shared experiences. For Coaches: Share examples with parents on what joint attention looks like with children to start a reflection. Have parents tried these or similar experiences with children? Have you observed any joint attention behaviors in children? Or if not yet, what dyadic behaviors have parents seen or have you seen in children to focus attention on objects or people? Children need to learn these dyadic behaviors and to participate in joint attention, so we want to make sure parents see their value, too. You can ask these optional coaching questions of parents: • “How do you and your child share moments?” • “How does your child let you know when something excites him or her?” • “How does your child respond when you share something with him or her?”

Why Is It a Problem? What to Share with Parents: Without joint attention, children with ASD are less likely to share their excitement and thoughts about objects or events with parents and other important people in their lives. Also less likely to happen is children’s ability to read another person’s cues and understand their excitement and thoughts about objects or events that interest them. Children with ASD lose out on opportunities to develop the desire to seek out the attention and praise from others over something fun and enjoyable, and to talk about what happens and relate to the other person’s feelings or emotions about the experience when

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joint attention is limited. But joint attention and the multiple skills that are on display during these special moments do not have to be different for children with ASD. We will describe and practice steps for parents to help children with ASD understand and use joint attention and benefit from the same social, language, and critical thinking opportunities that happen during these exchanges. We start with strategies that parents have already used to strengthen children’s ability to shift eye contact or gaze between a person and an object or event: • Parents position themselves and objects in front of children for all activities to draw children’s attention to their faces and eyes. • Parents develop joint activities across the six different activity types (i.e., toy play, SSRs, books, meals, caretaking routines, and household chores) to do together with children. • Parents pause activities midaction to cue children to use their talking bodies of eye contact, gestures, actions, facial expressions, sounds, or words to communicate needs. Once parents increase their children’s skills, parents and children are ready for the three steps we cover next to develop joint attention skills. For Coaches: Include any example where children have responded to interactive strategies listed above to shift their gaze to communicate or to perhaps share excitement about an object or event with parents. Maybe it was parents pointing to or holding up a toy and then their children looking from parents to the object and back again. Or, perhaps the children made a sound out of excitement and smiled during an SSR with parents. If children have yet to shift their gaze or gesture for shared enjoyment (but have done one or both to request something), then help parents see children’s current skills as a stepping stone to now being ready to understand and use joint attention to share. If children are not yet shifting their gaze or gesturing to request, stay with previous chapters to troubleshoot with parents. You can ask these optional coaching questions of parents if not covered already: • “How do you and your child share moments?” • “How does your child let you know when something excites him or her?” • “How does your child respond when you share something with him or her?” Step 1: Teach Your Child to Give You Objects

What to Share with Parents: This step is easier for parents to teach when children are willing to hand over objects on request and know they will get them



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back. But, it is also OK if children do not yet possess or understand this skill. We can still teach children how to do this. Parents may recall the strategy of creating opportunities for children to need their help—to open a container, to get a toy to work, or to have more juice put in their cup to drink. Parents can take advantage of these opportunities when children need their help with toys or other items and to teach children how to give them the objects to receive help. To teach children how to give objects to parents, we start with the antecedent—­remember, that’s the cue parents provide children, so they understand a particular behavior is expected back from them. Parents put their own hands out, palms up, and ask children to give them the object. If the children do not respond, parents follow through and help them place the requested object in their parents’ hands. Now comes the consequence for parents to provide the help they told their children they would and to return the object right away to their children. We do not want parents holding onto the object, so the children must ask for it back. Children already demonstrated expectant behavior when they gave the object (even if parents had to help them do so) to parents. Recall that a desirable consequence is what “seals the deal” in an ABC sequence for children to want to repeat a behavior again. Children therefore quickly need to see the consequence of parents helping and giving back objects, to understand that giving objects leads to something desirable—in this case, help. The more quickly and more often children experience this ABC sequence, the faster they understand and respond to parents when asked to give something. And, the good news is that parents can practice teaching children to give in a variety of routines, such as meals, bathtime, dressing, and other opportunities throughout the day that involve objects. Parents can also ask children to hand them their shirt or a pair of pants before parents help dress them. If a child likes to be gently splashed with water during bathtime, his parents can ask him to give them toys to be squirted or even a washcloth or cup to pour water over his head or back, remembering to return the object right away to the child. When children want something more to eat or drink, they can give their plate, bowl, or cup for parents to refill. While children eat or drink, parents can add silly sounds, pretending to eat what their children have, or ask the children to give them a bite or sip. Let’s figure out other ideas to help children give objects to parents throughout their activities. For Coaches: See the other activity ideas and helpful tips in this step for parents to think of ways during play, caregiving routines, or other activity categories whereby children can share objects for help. Coach parents to experiment until they have devised some methods for children to share things for help. Then parents will be ready to turn to these other steps that teach children to show and point to objects to share their experiences with parents. You can ask these optional coaching questions to help parents plan how to use this step:

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• “What objects can your child give you for help?” • “How will you teach your child to give you objects he or she needs for help?” • “What happens after you help your child?” Step 2: Teach Your Child to Show You Objects

What to Share with Parents: With this step, parents teach children how to draw someone’s attention to objects of interest to share the experience. We want children to hold things in front of parents (or others) and to gradually make eye contact and comments that will draw parents’ attention to look at the object. Showing out of interest is a very important skill in children’s development because the action gets people to label and talk about the objects for children to listen to the words, connect those words to their meaning, and build their vocabulary. As children learn to show objects and watch others do it, too, they also learn to enjoy the social attention and praise that naturally comes with the action. That positive consequence increases children’s desire, or motivation, to want to share things with others. Parents start by holding out objects children like or may find interesting and by commenting to draw children’s attention to them. Be sure to name objects in comments (e.g., “Look at the X,” or “X”) and again when children look at them (e.g., “It’s an X!”). Parents can do this many times each day during play when it is their turn with an object and they can show what it’s called, how it works, or new actions that can be done with the object before returning it to the child. Parents can also show objects that are part of usual routines for children to look at before receiving what they want. Parents can say and hold out a “cup,” “spoon,” or other items during mealtimes for children to look at before receiving each object to drink or eat with. With any opportunity, parents show and name the objects for children to look at and when they do, parents rename the objects and hand them over quickly to their children. Children receiving objects after they look at them is the positive consequence or reward that motivates them to want to look at objects the next time and each time thereafter parents practice the skill. When children are quick to look at an object that parents name and hold out, they are now ready to be taught how to also look at parents before receiving the object. Parents do all the set-up steps the same to cue children to look at the object—they name the object enthusiastically and hold it out for children to see, but they do not hand over the object until the children look from the object to them. To help children get the hint to do this, parents can talk about the object, add gestures or sounds that relate to the object, and move it closer to their face to draw children’s attention to their eyes. Parents, however, should avoid touching or moving a child’s face to make him or her look at them; otherwise, we risk upsetting children with an invasive action they do not enjoy and it will, in fact, make them less likely to want to look at



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people. Any quick or subtle look that children give to parents counts and parents respond quickly and enthusiastically when giving the object to the children. Children receiving the object and with their parents’ cheers is what’s key to making them do the behavior. Once children consistently look at parents’ objects, parents can begin to teach children how to show the objects themselves. The gesture is similar to how parents taught children to give them objects. When children have an object, parents position themselves in front of their children and the object to say, “Show me X” (make sure to name the object), while parents hold out their hands as if they were asking the children to give them the object. Parents should emphasize the word show when they say it because that’s the antecedent to cue children what you are asking them to do and it has a different meaning than the word give previously taught to children. Children should be able to reach out with the object since the gesture was part of the focus in the last step. But if a child does not, parents repeat the request and touch the child’s wrist or even elbow to help him or her move the object up and outward. When children show either on their own or with parents’ help, parents do not take the object but instead admire it and respond enthusiastically (e.g., “Wow! You have a X,” “That’s a cool X!” “I see X!”). Parents can also touch, not take away, children’s objects that merit admiration and comments about them. After children routinely hold up objects in response to parents’ request, parents can stop offering their hands to see if the children will respond to their words alone. When children do, parents respond the same way as before—admire the object, make comments, and not take the object from children’s hands. If children do not respond, parents offer their hand partway but not all the way, as a partial cue to remind children of the right gesture to make. Parents offer their hand less and less as they continue this practice with the children until they respond right away to parents’ words. Children’s eye contact from objects to parents may need to be taught as an additional step, just as when parents had to show objects to children. Parents teach children to look at them only after children respond with ease and consistency to showing objects upon request by their parents. When this happens, parents ask children to show an object, but hold off naming or commenting about it until their children look at them. If children do not look, parents can ask them again to show the object, can say their name, or can add a gesture or sound to “lure” children’s attention to their face, but must hold back enthusiastic comments until eye contact has occurred. As soon as children look, even if very quickly or briefly, parents respond with admiration and comments. For Coaches: We want children to respond to parents showing objects and with eye contact before parents teach children how to show them objects. This step may take more than one coaching session depending on parent–child progress. Refer to the activity ideas and tips for each gesture to help parents think of the

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objects they use with their children and that they can show to one another during play, caregiving routines, or other types of activity. Coach parents to use the “look” and “show me” instructions but as parent–child showing skills strengthen, see if parents can use other words to cue children to look at their objects (“Come see!” “I have an X!”) and to show their objects to parents (“Let me see!” “You have an X!”). We want children to shift their gaze between objects and parents, but we may need to help parents manage their expectations if children are not able to do this every single time. We want to be careful that children do not lose or lessen their motivation to want to show objects to parents if and when eye contact is not paired with the gesture. If this starts to happen and the suggestions above on how parents draw children’s attentions to their faces do not work, then another tip is for parents to respond with some but not as much enthusiasm to children’s look at the objects and to reserve the big response for when children do look at them during some point in the exchange. We are applying differential reinforcement in how “big” parents go in their praise and attention to children—some praise and attention when children look at objects upon request, but more praise and attention when children shift their gaze from objects to parents. Lastly, make sure parents continue their use of “give me” throughout activities so that children do not forget how to use that skill. You can ask these optional coaching questions to help parents plan how to use this step: • “What objects can you show to your child?” • “How will you teach your child to look at what you show him or her?” • “What happens after your child looks at what you show him or her?” • “How can you support your child’s eye contact with you when you show an object?” • “What objects can your child show you?” • “How will you teach your child to show you an object?” • “What happens after your child shows you an object?” • “How can you support your child’s eye contact when he or she shows you an object?” • “During what other daytime activities can you and your child show each other objects?” Step 3: Teach Your Child How to Point to Objects to Share Experiences

What to Share with Parents: Pointing is just as important as giving and showing for parents and children to comment about, and share interest in, objects and events they see. Children typically learn to point after giving and showing, and that’s why we teach it once children know how to do the other two gestures. And



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just like giving and showing, it’s easiest for parents to teach children to first follow and understand their points and then to point themselves. Parents use their finger to point, or tap, and draw children’s attention to objects nearby that they may want or are looking at. The gesture is easy to understand. As parents point, they say the name of the object. When children follow parents’ point to look at the object, parents name the object again to affirm that the children found it and help them achieve their goal. If children do not look, parents may need to reposition themselves, the object, and/or their children and point again, or point to something closer that’s within the children’s line of sight. Keep pointing while children pick up the object to help them see the relationship between the point and the object itself. A lot of opportunities exist within play and other daily routines to help children practice pointing to objects. Parents can point to and name the next toy for children to take out and where to place it. Parents can point to a toy before activating it or initiating the action children will enjoy. Parents can point to and name the juice inside a container before pouring more of it into the children’s cups; they can do the same with another item of food children want to eat before giving it to them. Parents can point to the next clothing item they want a child to put on and where the child can place her dirty clothes. In these and other moments, parents first wait for children to look at the named item or help them look, and then respond with an action. Children need a few skills before they are ready to learn how to point by themselves. First is what we just described—­following parents’ pointing to objects— and second is reaching with their hand consistently toward objects to indicate what they want and making their choices known without having to touch the objects. To begin to teach pointing, parents hold the object that children want slightly away to stimulate the child to reach for that item. When the child does, parents quickly mold the child’s hand into a point while giving the instruction (e.g., “Point to X”) and help the child touch the tip of his or her index, or first, finger to touch the object wanted. Then parents immediately name and give the object to the child (e.g., “Here’s X”). Teaching children how to point is easier for parents if they hold the object for children to touch in their less dominant hand and use their dominant hand to help children form their point. Or, parents can rest the object on a table, floor, or somewhere in front of children’s sight, so both of their hands will be free to help the children. Just as with the giving and showing gestures, parents teach children to point first without expecting eye contact. Children can start off by extending their index finger with or without their other fingers folded to touch the named object. With time and practice, children will learn to close their other fingers to make a point. Once children point easily and consistently to request an item, parents can begin to wait for children to look at them after they point before giving up the object. Parents’ positioning themselves in front of children makes it easier

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for children to look at them; they can also call a child’s name, move the object closer to his or her face, or add a gesture or sound to encourage the child’s eye contact. The good news is the number of opportunities throughout play and other routines for children and parents to practice pointing to objects up close (called “proximal points”) or to objects at a distance (called “distal points”) to communicate requests or to show and comment about them. Children can point to make a choice between two objects either close-up or far away. All of these are opportunities to let children practice pointing and showing to express different meanings (e.g., “I want,” “Give me that,” “Hey!,” “Look at that,” “What’s this?,” “I see it,” or “Show me this”), all of which adds words to their vocabulary. For Coaches: This step comes with a lot of activity ideas to help parents teach children how to follow and form a point. We strongly encourage guiding parents through this information in stages, as outlined in the step. Start with parents teaching children to follow their points to objects up close and then far away, before parents teach children to point to request objects and to show or comment. With each stage, parents should let children point first without eye contact to make the gesture easier to learn before expecting them to point with eye contact. Just as happens with the other two gestures of giving and showing, children may need time and practice to master pointing and to shift their gaze between objects and parents. And like before, we want to be careful that children’s motivation to show objects to parents is not lost or lessened if and when their gesture is not perfect or eye contact is not paired with the gesture. If this starts to happen and the suggestions above on how parents draw children’s attentions to their faces do not work, go back to the coaching tip of differential reinforcement for parents to respond with some but not as much enthusiasm to children’s look at the objects and to reserve the big response for when children do look at them before or after pointing. Lastly, parents and children should be able to incorporate all three gestures—giving, showing, and pointing—in back-and-forth exchanges before moving on. You can ask these optional coaching questions to help parents plan how to use this step: • “What objects can you point to for your child to take, pick up, or place?” • “What activities besides toy play can you point to, to show objects to your child?” • “How will you teach your child to follow your point and look at the object?” • “What happens after your child follows your point and looks at the object?” • “How can you support your child’s eye contact with you when you point to an object?” • “What objects can your child point to and request?”



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• “How will you teach your child to point to and ask for or show an object?” • “What happens after your child points to an object?” • “How can you support your child’s eye contact when he or she points to an object?” • “During what other daytime activities can you and your child point to show each other objects?”

Topic VIII: Developing Flexible, Creative Object Play for Learning What to Share with Parents: Playing is what young children do most apart from eating, sleeping, or completing other necessary routines (like bathing or dressing). Play matters to children’s development because the actions that children do during play help them build new skills, as well as practice and maintain skills already developed. Play encourages children to explore and imagine new ways to use their toys and objects. Anything and everything in children’s hands can turn into a creative plaything. Children get to practice social skills during playtime, too. When others participate, children watch actions, take turns, learn to share and problemsolve, communicate and listen to more words, and play expands to routines and actions they see others do in real life—­playing house or doctor, pretending to go to the zoo or to shop. Playtime becomes as much about learning as it does about having fun. For Coaches: Ask parents about children’s toy play and how the four reasons we’ve just outlined for why play is so important to learning compare to what they see in their own children. You can ask these optional coaching questions of parents: • “How does your child play with toys?” • “What toys are his or her most favorite? Least favorite?” • “What play actions does your child see others do?”

Why Is Play a Problem in Autism? What to Share with Parents: When children play alone or their actions are repetitive, simple, or limited in interests, they do not experience the same amount of learning as their peers: to watch others, to imitate what they see others do, to think of and try new ways of doing things, to practice and strengthen new skills, to share and cooperate, and to learn language. Over time, repetitive, simple, or restricted toy play remains just that for children with ASD and significantly reduces their chances to experience new learning opportunities for language,

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socialization, creativity, tolerance, and flexibility. Children with ASD need play skills with others and with toys so they get the same benefits to their development as other children their age do. This is why we encourage the type of interaction that parents have practiced with children to build attention, motivation, thinking, language, socialization, imitation, and communication. Now we turn to constructive toy play under this topic and then pretend play (also called “symbolic play”) in the next—so children with ASD learn to play and have fun with lots of different materials in lots of different ways with lots of different people. Both types of play are easier to teach children when they can watch and imitate parents’ play actions with toys or objects. Think about how any new idea parents show children requires that children watch what happens and copy the same action, too. If children struggle to imitate others’ actions with toys or objects, it is not a waste of time to go back to the activities and strategies on imitation before focusing on the strategies explained in this chapter. In fact, parents strengthening their children’s imitation skills will help them develop more mature and varied play. For Coaches: Ask parents for their feedback on how children’s toy play has improved, what’s helped to make that change possible, and what play skills with toys would children benefit from learning next. Parents need to know how to use imitation as their main tool for teaching play skills, as explained in the next section. Pull any part of the imitation strategies into your coaching if parents and children need the practice to carry out the next section. You can ask these optional coaching questions of parents: • “How has your child’s play with toys improved?” [Ask for positive examples if none are mentioned and share at least one example if the parent is unsure.] • “What strategies so far have helped to improve your child’s play with toys?” [Ask specifically about imitation teaching strategies if not mentioned by parents.] • “What about your child’s play with toys still concerns you?”

What Parents Can Do to Increase Variety, Flexibility, and Learning Opportunities in Parent–Child Toy Play What to Share with Parents: Parents teach play skills to children just like they taught children to imitate actions with toys or objects using the four-part joint activity framework. Here’s a refresher: 1.  Set-up. Parents choose toys or objects that children like and want to play with, and set up the activity to support children’s attention to themselves as well as the materials. Parents copy children’s actions with the materials to begin the play.



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2.  Theme. Most toys or objects have at least one main action in terms of how parents and children play with them. Balls are thrown, markers color paper, pots and pans are banged with a spoon. Parents and children use toys or objects in ways that other children would naturally play with them and take turns to find a fun action as the main theme they can do together. They only need that one action to create the theme for play. Sometimes the theme will come from parents watching and copying children’s actions, assuming those actions relate to how the toy or object should be used. Other times parents may demonstrate a play theme with the toy or object they think their children will like and want to do. Although themes can and should develop from parents following children’s play interests, we focus the teaching sequence below on how parents set up fun-­filled play themes to build children’s skill set with toys.

• Parents and children are seated or standing face-to-face when the toys or objects come out and are put between them. • Parents take a few pieces (not all) and show their children how to do something they think the children will like and find fun. They use simple words to name the toys or objects and actions involved. Parents may need to work quickly when showing children how something works and with sound effects or dramatic actions added if that captures children’s attention and interest to join in right away. If toys or objects do not have multiple pieces, parents and children have one of each (e.g., each has a ball, marker, or spoon to bang the pot) or take turns with the sole toy or object. Parents and children take turns doing the theme, with the parents taking faster or fewer turns in the beginning if that helps children see and experience the fun of the theme and want to join in. • Parents read children’s talking bodies (i.e., face, body language, voice) for how interested children are in the theme. Are children looking at the toy or object as parents show the action? Do they reach for the toy or object? Do their eyes widen out of curiosity? If children show these or other signs of interest, parents give the toy, object, or piece to them and see if they copy what the parents did. When children imitate, parents cheer, take another turn, and hand the toy, object, or piece back to the children to use again. When children seem disinterested or do not imitate the theme, parents repeat the action with something extra added to entice them to participate. Parents can exaggerate the effect of the toy or object, use sound effects or gestures with the toy or object, slow down or speed up the motion of the toy or object, or apply other ideas they think of that might encourage the children to try the theme. When those strategies do not work, parents physically guide children through the action to complete the theme, followed by cheers and another toy, object, or piece for more back-and-forth turns. • Sometimes children do not like, or take right away to, a particular theme no

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matter how much cheerleading and help parents provide. Parents should try a few times to encourage or help children complete the theme, but parents should also be careful not to force an idea onto children when their talking bodies remain unchanged or unconvinced of the fun. Most toys or objects have more than one action that parents can show as another theme. Balls can be rolled, not just thrown. Markers can draw lines or dots, not just scribbles on paper. Parents take turns to show another play theme, encourage or help children to imitate the action, label the objects and actions involved, and cheer and enjoy children’s efforts to learn. • We encourage parents to build themes and children’s play skills with various types of toys, some of which children may not be playing with yet: Books Art materials { Ball play { Puzzles, shape sorters, color sorters, pegboards { Building toys (blocks, Legos) and nesting toys { Stringing and lacing { Musical toys { Outdoor toy play (sand, water) { Bath play { {

3.  Variation. Only when children understand, like, and participate in the theme are they ready for parents to show them more than one thing they can do with a toy or object to expand their play skills. Variation teaches children play flexibility and complexity on how to use toys or objects and actions in different, fun ways. Variation exposes children to more language learning and skill building through the new toys or objects and actions that are added to play. Variation encourages children to pay attention and play longer, to think about the new things happening, and to use the skills to participate. Variation adds lots of benefit to children’s development, not just fun. There are three ways variation (along with play flexibility, play complexity, and language learning) can happen.

• Parents add other toys or objects to do the same play actions that started the theme. For example, for a theme of tossing balls into a bucket, parents and children can toss in other items, like beanbags, stuffed animals, or othersized or colored balls. • Parents add other actions with the same toys or objects that started the theme. For example, for a theme of tossing balls into a bucket, parents and children can do other actions with the balls, like rolling, catching, bouncing, kicking, or running them up and down arms, legs, backs, or even tummies to tickle one another. For a theme of using markers to scribble on



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paper, parents and children can draw other things on the paper, like shapes, numbers, letters, or animals. • Parents add other steps or phases (whether that involves new materials and actions) for children to complete the theme. For example, for a theme of throwing balls, parents and children can set up bowling pins to knock down and then restack them to repeat the action. • Whether parents add other play materials, actions, or steps to the theme, parents follow the same teaching sequence to build variation as they did to build the theme. Parents show the new play material, action, or step one idea at a time (e.g., Mom rolls the ball up and down her child’s legs) instead of multiple ideas back-to-back (e.g., Mom rolls the ball up and down her child’s legs, bounces the ball, sticks the ball inside her child’s shirt to tickle her tummy, adds a beanbag and throws it onto the child’s lap, rolls the ball across the table for her child to catch) for children to imitate. When children imitate and any attempt counts, parents make a big fuss (in a good way) to celebrate their achievement. When children do not readily imitate on their own, parents repeat their turns to encourage and entice children to do the same or help children to imitate that action. Children should imitate the variation at least once to plant a memory for the next time they come back to the activity with their parents. And parents should try the variation again even if the play idea is not a huge hit right off the bat with children. Sometimes children need more time and practice to like an idea, so parents should not just give up if something is not an immediate hit. In fact, repetition is key to all children learning new concepts. When parents demonstrate something more than once, children get to see and think about how that new idea works and whether they like the idea well enough to want to do it themselves. And when children are able to repeat actions, their practice builds and strengthens the skill into an automatic behavior that becomes a part of their routine and repertoire. They no longer need Mom or Dad’s encouragement or help because they know how to do it by themselves! Parents and children take turns to continue each variation that children like, and at any point they can return to the initial theme of the activity. 4.  Closing/transition. Parents watch for children’s interest, or their own, start-

ing to wane—­remember talking bodies—and prepare children when the end of an activity is approaching. Even with an alert, children may still need a little time to ease out of a fun activity. Parents can start to put away toys or objects, prompting their children to join them, or they can offer choices to children of which activities to do next, encouraging them to clean up before moving on. For Coaches: In this section, there are a lot of activity ideas, helpful tips, and overall coaching materials to go through with parents for increasing the number

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of typical toddler–­preschooler cause-and-­effect toys and the complexity of play with these toys. Focus parents’ attention on functional, or cause-and-­effect, play skills for this topic and save any discussion or goals on pretend play with toys for the next topic. Guide parents to think of the play theme as the “cause-and-­effect” actions the object presents and any variations should stay within that cause-and-­ effect theme. Ask or help parents to make a list of toys or objects children like to play with, even if not every day, and then characterize whether children’s play skills with each toy or object fall into the category of: (1) “simple play”—singlestep play skills that children have been doing for a long time with the toy (e.g., opening, closing, touching, watching something move back-and-forth) or (2) “mature play”—multistep or cause-and-­effect action (e.g., putting a piece into a puzzle, opening a shape sorter to dump out the shapes and put them back into the sorter, connecting trains and pushing on a track). We want parents and children to spend more time and practice with mature than simple, or basic, play skills. Now ask or help parents to mark the mature play skills that children know how to do without any physical help from others as their “maintenance” or “M” skills, whereas the other mature play skills left unmarked are children’s “acquisition” or “A” skills still emerging in development. Ask or help parents to select up to five “A” toys that children would like, could learn relatively easily (i.e., without frustration or challenging behavior), and would want to do with parents. If they wish, parents can also identify those toys with a “G,” because those will turn into “goal” toys for daily play with children. The next section covers how parents will do this. On their list, have parents also include a few “M” toys to make sure children continue their practice and fun with those mature, maintenance play skills already in their repertoire. Once children become consistent in their play with the five “G” toys, those play skills become a part of their repertoire, and parents can mark them with an “M” on their list. Parents can then choose the next set of “G” toys to practice with children. Stay with this topic to help parents and children develop various cause-and-­effect play routines before moving to the next section on independent play. You can ask these optional coaching questions to help parents plan how to use this step: • “What play skills with toys does your child like, or would like, if shown how to do with your help?” [Let’s pick one idea at a time as the main play action or theme for the activity and plan the teaching steps to build the set-up and theme with your child.] • “What cues or behaviors can your child give to say he or she likes or does not like the theme?” • “What happens if your child doesn’t immediately like a particular theme?” • “What cues or behaviors can your child demonstrate to say he or she is ready for a variation to be added to the theme?”



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• “What other materials, actions, or steps might your child like to see added to the theme?” [Let’s pick one idea at a time as the variation and plan the teaching steps to build it with your child.] • “What cues or behaviors can your child demonstrate to say he or she likes or does not like the variation?” • “What happens if a particular variation isn’t immediately liked by your child?” • “What other types of toys does your child play with that we can use to build themes and variations?” • “What other types of toys does your child play or not play with that we can use to build themes and variations?”

What Parents Can Do to Help Their Child Play Independently What to Share with Parents: Children need to be able to play alone constructively with their toys. Parents cannot always be with children to engage them in activities. Parents have to consider the needs of other children if there are siblings, their spouse or partner, and themselves besides meeting the daily responsibilities of work, the household, and whatever else life throws at them. There is nothing wrong with parents taking time throughout the day for other people or to do other things while children play appropriately by themselves. It is also important in development that children know how to come up with functional play ideas and actions on their own, without needing parents to always guide them. And there ought to be different play options available for how children can occupy themselves with toys or objects and strengthen their play skills and independence than only watching videos or television shows that do not encourage any of the above. A practical goal for parents to work toward with children is 10–15 minutes of independent play once children (1) can easily and frequently imitate actions that parents do (2) during set-ups, themes, variations, and closing/transitions (3) across a number of play routines with different toys. When children have these three skills down, they are ready for parents to teach them how to choose a toy or object, set it up, and play without parents taking any turns to play or model how to do something. This establishes a different role for parents, but parents take this approach deliberately because now the focus is on children’s spontaneous, independent (not joint) play. There are five steps parents follow to do this. For Coaches: Make sure that children can imitate variations whether they are other actions, toys or objects, and sequences of actions shown with toys or objects and without parents’ physical help. Parent repetition or encouragement to do the modeled action is OK, but we want children to develop the motivation and understanding to complete the action themselves. If it is unclear to you whether the children are at this stage, ask their parents to do the activities with them

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and to then share with you examples of when they saw them happening without incident. You can ask these optional coaching questions to help parents plan how to use this step: • “What themes and variations does your child readily imitate without any help?” • “I would love to see what that activity looks like. Would you share that with me now?” [You can ask this as a follow-up to the last question.] • “Would you show me what that looks like with your child?” [You can ask this as a follow-up to the first question.] • “How does your child currently keep him- or herself busy when you need to do other things?” Step 1: Organize for Independence

What to Share with Parents: How children’s toys are organized is important to how the teaching process begins. Too many toys out at once can make it harder for children to choose and focus on any one toy at a time, and instead lead to randomly picking up and dumping toys or trying a toy once or twice before going onto the next one. We want a few selected toys, no more than six, available for children to choose from at a time. We recommend cause-and-­effect toys that children like and that include a number of different actions children can do by themselves, like puzzles, shape sorters, building blocks, Play-Doh or other sensory materials like water play, drawing, painting, or pegs and a pegboard. Parents should also consider activities that other children this age play or look online for ideas, and follow the teaching sequences in the last section to show children how to do these new activities before offering them as an independent play choice. Parents should avoid toys that are electronic, that need someone’s help to operate, or that could turn into repetitive play because the goal is to promote children’s independent, constructive play skills. The selection of toys should also change every few days or weekly depending on children’s level of interest to keep playing with the toys and to strengthen and expand children’s play skills over many toys and many actions. Once parents have made their selection, organize the toy pieces in containers, bins, shelves, or baskets that children can carry and see and get to on their own. We recommend a low shelf with the containers (or whatever parents choose to hold the toys) arranged side by side, as opposed to stacked or arranged on the floor. Children will need to walk over to the area to look at their options, make a choice, pick up the toy, and take it in one trip to wherever they will begin their play. So where the toys are located and how they are organized are important to



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children’s ability to complete this step. If toys are difficult to identify or pieces fall out of a too small container or require multiple trips to carry, these or other setbacks could discourage the child’s focus and motivation to want to play with that toy. Let’s make the set-up and what we want children to be able to do as easy and clear as possible to help them succeed. For Coaches: If parent ideas seem too mature for children or not geared at independent play, is it possible for parents to scale back the play by one age level or change the focus of the play, so children will be able to participate and still like the activity (e.g., a child puts the pegs wherever she would like on the pegboard instead of by color)? Starting with play ideas that children can do by themselves can sometimes establish the attention span and interest needed so that parents can teach other concepts leading to children doing more actions by themselves (e.g., how to connect the pegs to build a tower or a rocket ship that blasts off). Children can also learn to do more for themselves during the setup and cleanup to start and end activities (e.g., to open and take off the lid to play with pegs or to pick up the box and put away in the closet). You can ask these optional coaching questions to help parents plan how to use this step: • “What toys do you think your child would like to play with, and can he or she do the play actions without help?” • “How can you organize and set out those toys to make choosing and the set-up relatively easy for your child?” • “What can we troubleshoot to make sure this plan works for your child?” Step 2: Ease Out of the Play Partner Role

What to Share with Parents: Once toys are selected and organized, parents want to begin to shift their role in activities from an active partner (who takes turns to play with children) to a passive observer (who supports children as they choose a toy, set it up, and begin to play without parental involvement). Parents can start to shift their role when playing with children who know how to easily use favorite toys without help. Once children begin their play, parents should scoot back a little and turn their body slightly to the side so they become less available in the activity. Parents do not narrate or draw attention to themselves when doing so, but rather watch their children to see how they respond or react to this initial change. Children who go on with their play are doing what we want them to without extra encouragement, reminders, or help. Parents let children continue their play for several minutes at a time before commenting on what they have done (e.g., “That’s right! The square goes there” “You made a snake . . . ssss”). By doing so, parental

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acknowledgment becomes the positive reinforcement to make children feel good about what they are doing and to want to continue to play constructively and independently with toys or objects. Children who stop their play or notice when parents physically move back from the activity may need that extra encouragement or enthusiasm from parents to continue their turn. Parents can narrate or talk about what their children will need to do when it’s their turn (e.g., “There’s a circle and a triangle. Which one do you want?” “Make another snake”) to try to motivate them to resume their interest in the activity. Parents can also move materials closer to children’s reach or start their turn and have children finish it as an effort to shift children’s attention on what to play with next, instead of their parents attempting to pull back again from the activity. Parents give children a few minutes at a time to play by themselves before commenting on their actions. Even if children only do something once in an activity and then want to stop, they still did it! When parents notice children’s play skills slowing down, parents can comment on other variations that children could try, for instance, adding other objects, actions, or steps to their play. Try not to take turns to show the ideas to children, but instead offer ideas or ask the children for their own so you stay to the side of the interaction not in it. As children practice, parents pay attention to and even jot down how long children are able to play by themselves and how many times, if any, they need help to stay on track. Over time, parents want children to be able to play by themselves for 10 to 15 minutes and for the number of times children need help to decrease as their play skills and interest grow. For now, we want children to engage in constructive theme and variation phases with toys or objects by themselves for a few minutes at a time. For Coaches: Coach parents through this teaching sequence in a few activities so that they learn how to shift from an active play partner who takes turns with children to a commentator on the side who supports children’s play. For now, focus mostly on parents’ ability to decrease their support during the theme and variation with toys or objects since the next step covers the set-up and closing/transition phases. You can ask these optional coaching questions to help parents plan how to use this step: • “What toys do you think your child would like to play with? And can he or she do the play actions without help?” • “What play actions and body language do you want your child to show before you start to pull back or turn your body away from the activity?” • “If your child notices what you do, how can you encourage your child to continue?”



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Step 3: Decrease Support for the Set-Up and Closing/Transition Phases

What to Share with Parents: Once children can do the last step, they are ready to carry out the set-up and closing/transitions of activities by themselves to add more independence to their play. Let’s look at how parents do this within the joint activity framework. 1.  Set-up. Parents have children walk over to where the toys are organized to

choose what they want to play with and to take that item to the table, floor, or other play space and get started. Parents position themselves next to children, but not right in front of them and not too close, so that gradually parents can move behind children as their focus turns more and more to their play. When children need help, parents should respond, but it is important to let them do as much of the action as possible by themselves to build their independence at problem solving, not only playing. Parents start by telling children what to do (e.g., “take off the lid”) followed by gesturing when saying isn’t enough (e.g., touching, mimicking how to open, or pointing to the lid) before physically starting the motion for children to finish (e.g., opening the lid from one corner instead of all four) or moving children’s bodies from behind or the side to learn how to do the action from their perspective (e.g., placing one hand to hold onto the box and the other hand on the lid to pull it off). Helping children from behind or beside their bodies, rather than in front of them, teaches children how to carry out actions on their own. This is the one time where parents are not face-to-face with children when we want them to maneuver the mechanics of an action by themselves, rather than participate in an activity and share the experience together. 2.  Theme. Parents follow Step 2: Wait for children to begin their play and

comment occasionally after every few minutes of children’s independent play on the actions that would keep them feeling encouraged and motivated. When children stop in their play, make suggestions or take very brief turns to keep the children going. 3.  Variation. Parents follow Step 2: Offer ideas for children to try with other

toys, actions, or steps added to their play. Comment occasionally after every few minutes of children’s independent play to acknowledge what they’re doing. When children need help, instruct them: offer, demonstrate, give, or point out what to do. A last resort is to initiate the motion yourself or help children from behind their bodies to finish the action. Do not take turns. Continue to observe and comment. 4.  Closing/transition. When play ideas have run their course and children

seem done with a toy (or tell you so), parents should encourage them to put the toy or pieces back into their container and to return it to the shelf or spot where other containers of toys are stored. If children need help, parents should help as

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commentators or from the sidelines, remaining less directly involved in the actual clean-up, such as pointing to or moving pieces closer to children’s reach, holding the container for children to put away pieces, or turning clean-up into a game of how fast children can do it by themselves. If children do not put the toy container back in the right spot, parents can point to it, or walk the children along with the container over to the storage area. They can also help the children from behind or the side to carry the container to the right spot and set it down. Then children get to pick the next toy to play with and practice the same sequence over again. For Coaches: Parents should practice the entire joint activity framework to decrease their support and role in children’s independent play. You can ask these optional coaching questions to help parents plan how to use this step (the first three questions are repeated from Step 2 in case they apply to parent–child practice with this step): • “What toys do you think your child would like to play with, and can he or she do the play actions without help?” • “What play actions and body language do you want your child to exhibit before you start to pull back or turn your body away from the activity?” • “If your child notices you pulling back, how can you encourage your child to continue the activity?” • “What signals is your child sending to suggest he or she is ready to end the activity?” • “How can you encourage your child to clean up without your help or help from the side?” Step 4: Change Toys Frequently

What to Share with Parents: Not all at once, parents change one or two of the toy choices, including children’s favorites, often enough and before children tire of their choices to widen children’s exposure to different toys, play ideas, and skills. For some children, the rotation might occur every other day, whereas other children may need more time to get the hang of how to play with something on their own or want to keep playing with it a little longer before switches are made. Toys that are new or less interesting choices can be included in the mix only after children and parents have played with them together (i.e., taking turns within the usual joint activity framework) and children understand how to play with them and have some motivation to do so. For Coaches: Although we want frequent toy rotation to benefit children’s play, parent input on how often they can actually make it happen, and stay consistent, is important to know. If parents cannot complete this task at least weekly, ask



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them to share what stands in their way and try to problem-solve with them. Also important for families to know is this: Do not go out and buy new toys as the only way for children to get more toy experience and play skills. You can go back to the lists that parents made earlier in this chapter for increasing children’s variety and flexibility across different toys. Or, you can help parents make another list of new toys or objects children might like to play with on their own once they know how to use materials with parents. You can ask these optional coaching questions to help parents plan how to use this step: • “What toys can you rotate across time for your child to play with by himself? Which toys does your child like to play with, and can he do the play actions without help? Which toys might your child like to play with on his own or after you show him how to do it?” • “How many toys should be available for your child to choose at a time? And how much time should elapse before you rotate in the next one or two toys?” • “Which starter toys from the list do you want your child to choose?” • “What can we troubleshoot to make sure this plan works for your child?” Step 5: Move Farther Away from Your Child

What to Share with Parents: Parents gradually move farther away and make themselves less available as children’s play increases with a toy or object. Parents can look at something else from their seat, maybe a book or their phone if not distracting to children, or get up to do something in another room with periodic checks and positive comments about their children’s independent play. When children cannot get something to work or their play stalls or stops, parents give the children a little time to problem-solve on their own before jumping in to help or offer an idea. Keep in mind that children’s play may not be as creative or elaborate as when they play with parents, but the goal here is children’s independence to do constructive, solitary play, not necessarily re-­creating every skill parents have taught them in previous chapters. As children’s independence improves and they can complete the entire independent play routine from set-up to clean-up and any transitions on their own, parents can add an electronic toy (one at a time) to the children’s choices to see what happens. If children tend to only play with that toy, or while playing with it, their play goes from functional to repetitive, parents can stop including electronic toys as an option. That rule should apply to any toy (electronic or not) when children “get stuck” and cannot move away from it. Repetitive play limits children’s learning opportunities to try new things. That’s why parents rotate different toys for children to choose from and increase their play repertoire and flexibility, as well as limit boredom.

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For Coaches: Observe and, as needed, coach parents to move farther away and make themselves less available while children play by themselves. Ask parents before they practice this step how they want to occupy themselves while children play independently. Parents could put unused items away, step outside the room to do something, talk with you about how to continue their practice of this step, or jot down ideas to share later in the session with you. Parents should select whichever option they believe will be less distracting or anxiety-­provoking to their children, and keep an eye out for how the children respond when their attention and in some cases bodies are elsewhere than in the same room. If parents decide to leave the room and the session is in your clinic (as opposed to their home), parents should tell children where they are going and that they will be back in a minute so as not to alarm the children in a setting that is not their home. Parents can decide if children need that same warning when they leave a room in their own home. When parents move away from children’s play or out of the room, we recommend that parents time how long children can play by themselves before asking for help, expressing their desire to be done, or demonstrating a behavior (positive or negative) to get their parents’ attention. Doing so gives parents a sense of how long they may have to accomplish something else before children are likely to want their attention. Parents can then return to the room where the children are, or if the parents haven’t left, they can share positive comments about the children’s play. This way, parents give children their attention for the thing we want them to do—to learn how to play on their own—and not for something else, like asking for help or an escape from boredom. Ask parents what other questions they might have to put, and to keep, this plan in action. Briefly, parents can practice this (and frankly any skill from this book) either when siblings are doing their own thing (e.g., napping, attending school, or spending time with another parent or caregiver), or they can teach children and siblings how to carry out an independent play routine together. When children don’t readily add to their own play, parents need to make sure children are interested in the toys or objects they have. Children need to like what they have to want to do things with them. If children’s interest is real, then parents can verbalize ideas for children to try with other materials, actions, or sequences in their play, or parents can take brief turns modeling new ideas while their children are watching. Parents repeat quick turns or introduce other strategies if children need more enticement to participate before physically helping children do the action. You can ask these optional coaching questions to help parents plan how to use this step: • “What cues or signs do you want to see in your child before you start to move away from an activity?” • “What other help besides physical assistance can you offer when your child needs help?”



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• “How does your child interact with the toy or object?” [Ask this question when you want to see if children are even interested in an activity, or parents share that the children have not added new actions to it.] • “In what other ways besides physical help can you demonstrate new actions for your child to do with the toy or object?” • “What can we troubleshoot to help you encourage and support your child to do the independent play routine on his or her own?”

Topic IX: Why Pretend Play Is So Important for Young Children’s Learning What to Share with Parents: The play skills practiced in the last topic taught children to think about and create constructive play ideas and actions with toys. A puzzle piece goes into the puzzle board, a ball is thrown or kicked, a block is stacked. Now we introduce pretend play (also called “symbolic play”) to expand children’s thinking abilities and play ideas from their imagination, instead of focusing only on concrete actions with physical materials. An animal puzzle piece can “walk” and make its animal sound before going into the puzzle board, a ball can have a happy face (or other face) drawn on it and come to life to “talk” to children, or a block can be “food” that children pretend to eat. We add to children’s play skills with more spontaneity, creativity, and flexibility, and in doing so, the creative thinking associated with pretend play is deeply rooted in language and other aspects of thought important to children’s development.

Why Is It a Problem? What to Share with Parents: Young children expand their knowledge about the social world when they play make-­believe (expressing what they see, think, and feel) and share those experiences with others. Pretend play opens up children’s mental world of imagination beyond the physical world, developing endless play ideas and using those play skills to join in and further such play with other children. Pretend play carries meaningful themes about people and their lives that we want children with ASD to also experience. We follow the next set of steps so children will receive the exposure, practice, and guidance they need to develop such skills. For Coaches: Ask parents to describe children’s pretend play or revisit that conversation, if asked in the section “Why Pretend Play Is So Important,” for a sense of children’s capabilities thus far versus needs that could become potential learning goals. Pretend play should be introduced after children are able to play with many different toys, combine objects in play, and carry out different actions with

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individual toys or objects. Children should also know how to imitate and engage in joint attention when playing with others before advancing to pretend play. Explain to parents how these skills will build more imaginative make-­believe play, particularly if children would benefit from more time and practice before moving forward with this section. If parents mention examples of children’s creative or make-­believe play, ask them what’s helped to make that development possible. We also list a question below about themes families experience that they may want to act out in pretend play with their children once you transition to the coaching steps with them. You can ask these optional coaching questions of parents (the first question is repeated from the earlier section “Why Pretend Play Is So Important”): • “How does your child imagine or pretend during play?” • “What strategies so far have helped your child show more flexibility or creativity in his or her play?” • “We talked about how children can act out themes from real life and actions they see others doing. What themes from your family’s daily life might your child like to make-­believe and re-­create in play?”

What Parents Can Do to Increase Their Child’s Symbolic Play Skills What to Share with Parents: Pretend play involves three types of skills that children typically develop. Parents teach these three skills in much the same way they taught other skills to children—­through joint activity routines. And similar to other long-term skills like language, socialization, or cognition, pretend play also takes time to develop and continue to grow over time. 1. Animate play. Involves using dolls, stuffed animals, or other objects as if

they were alive and could move, talk, or take turns in play themselves (e.g., a lion putting in a puzzle piece or a doll eating a goldfish cracker). 2. Symbolic substitution. Involves using objects as if they were something else (e.g., pretending that a block is a cell phone and putting it to our ear to talk, or a spoon is an airplane and flying it around the room). 3. Symbolic combinations. Involves doing several different pretend-play actions to create an event or theme (e.g., pretending to give a bath to a stuffed animal involves six different pretend-play actions: using a bowl as a bathtub, filling up the bowl with pretend water, putting the animal in the bowl, using a sponge to pretend wash the animal, pouring pretend water from a cup over the animal, and drying off the animal with a towel). For Coaches: Be aware that pretend-play skills and sequences may take considerable time for some children to develop. Toddlers typically develop these skills



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beginning at 12 months old and continue their advancement in abilities to 36 months old and beyond. Help parents manage their expectations, if needed, to think of pretend-play skills as a long-term activity that may take a year or two to complete, but that can still be started and practiced immediately. Start to gather parents’ ideas on how to facilitate play or other routines (think: meals, bathtime, reading books, household chores, diapering, getting dressed, or other caretaking routines) to practice the three different types of pretend-play skills. You can ask these optional coaching questions of parents: • “What play ideas could you try with any of these types of pretend play?” • “How could dolls, stuffed animals, or other objects take turns in your child’s favorite games or other routines?” • “What toys or objects could you pretend are something else to show your child how they work in play?” • “What events or themes could you act out in steps to show your child how to do?” Step 1: Teach Conventional, or Functional, Play Skills

What to Share with Parents: Make-­believe begins for children when they use toys or objects based on how other people use them. A child pretends to feed himself with a spoon, picks up a tissue and pretends to sneeze into it, or puts on Mom’s necklace. Conventional, or functional, play is defined by the social meaning of other people’s actions that children watch and copy themselves, instead of sticking with only the physical attributes or cause-and-­effect properties of a toy or object. It is an important step in children’s play development because children watch other people to learn how to do these pretend actions. Conventional play is social learning—­attending to what other people are doing and imitating what they do. Parents teach children to develop conventional play skills through the usual four steps of a joint activity routine. Let’s go through a play example with a hairbrush (or comb). 1.  Set-up. The parent brings out the object, or it could be a choice between

items (e.g., a hairbrush or comb) for the child to choose which to use in play. If the parent offers a choice, he or she goes with whichever item the child chooses or seems to like. The parent can keep the item not selected nearby to use later with the child, but not in a way that interferes with the theme developing with the chosen item. 2.  Theme. The parent takes a turn to name and do the conventional or social action with the item. The item can be shared with the child, or the parent and child can each have the same item to use on him- or herself. Using the hairbrush,

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the parent says, “Brush hair” while brushing her hair. After the parent takes her turn, the parent hands over the hairbrush (if shared) or encourages the child to do the same action. If the child does not readily imitate, the parent repeats her turn with exaggeration or enthusiasm, or helps the child start the brushing motion to finish him- or herself. The parent and child continue their turns with the theme. 3.  Variation. Once the child does the theme readily and without the parent’s

help, other play ideas involving the item can be added to the interaction. The parent and child can switch roles—the parent brushes the child’s hair and encourages or helps the child brush the parent’s hair, or dolls or stuffed animals can have their hair brushed, too. The parent uses her own name and the child’s to mark turns with the items and actions that make up the play (e.g., “Mom’s hair,” “Claire’s hair,” “Mom’s turn,” “Claire’s turn,” “Brush Dolly”). 4.  Closing/transition. When the parent and child are out of play ideas or inter-

est fades (for either play partner), parent and child acknowledge they are done and put away the materials to decide what activity to do next. Parents can introduce conventional objects and actions during other routines besides play that they do with their children. They can brush their teeth with their own toothbrush and encourage or help children do the same with their brush. If children do not take right away to a conventional action that parents demonstrate, parents can still take their turn to expose children to the idea of brushing one’s teeth. Parents can also shift to other social objects or actions involved in the routine to see if those ideas initially hold more interest for children. If children do not show much interest in parents feeding themselves with their fork, would children like feeding parents, a doll, or a stuffed animal from their fork? The goal is to stay creative and persist with play ideas, so children will become more interested in what parents show them with materials. Adding social moments to these everyday interactions helps children learn more about what people do and the words that go with the objects and actions in life’s daily routines. For Coaches: See the activity ideas and parent–child scenarios for this step to help parents adapt joint activity routines and teach conventional play skills to children. Coach parents through these steps in play and in at least one other routine (e.g., meals/snacks, getting dressed, books) that’s possible to do in a session. This will give parents some ideas of how to use real objects to teach children this first step of symbolic play. If you think parents are ready for such a suggestion, you can also start to discuss the speech and language techniques explained in the next topic, because the kinds of play parents do in this chapter will help children make progress in their speech as well. Either way, parents should continue to read or just practice this chapter with you to build pretend-play skills with their children.



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You can ask these optional coaching questions to help parents plan how to use this step: • “What real-life activities or routines can you use when playing with your child?” • “What actions with the materials can you show your child within these activities?” • “How can dolls or stuffed animals be used in these activities?” • “How can you teach your child to imitate these actions if he or she needs help?” • “What other routines that happen often can you do with your child [e.g., meals, bath, dressing, changing, outdoor play, books, social sensory routines, household chores, self-care activities, errands]?” Step 2: Animate Dolls and Animals

What to Share with Parents: Now that children use objects to carry out social actions on themselves and their parents, and maybe even dolls or stuffed animals, parents can show children how dolls or stuffed animals might come to life to represent people and their actions, too. Any action that parents and children do can be turned into an opportunity for the doll or stuffed animal to also do. Parents use the same four steps of joint activity routines to show children how to do this. Parents can animate dolls, stuffed animals, or other figurines to receive and complete actions across all kinds of daily routines. A child can wash a doll’s tummy, arms, and face and then have the doll do the same to the child. A stuffed animal can sit at the table and take bites from the child’s meal and the parent’s food; the child and parent can then reciprocate the action on the stuffed animal. A doll can have its diaper changed or go to the potty and wash its hands afterward with the child. A stuffed animal can get dressed and help the child dress to get ready for the day, and later undress to get ready for bed. A doll can take a turn to read from a book or act out a page from it, sing a verse from a song, or play chase to tag the parent or child. So many opportunities become available to children throughout the day to see, think about, and incorporate animate play actions. Parents only have to decide where to get started! For Coaches: Help parents develop object routines that dolls, stuffed animals, or other figures can act out on parents, on children, and on “themselves.” Coach parents through these steps in play and in at least one other routine (e.g., meals/snacks, getting dressed, books, SSR, outdoor game) that’s possible to do in a session. This will give parents some ideas of how to animate play actions into all kinds of daily routines. As children become more successful in imitating the actions that parents show them how to do, make sure that parents wait to see if children will make

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a figure act independently, either spontaneously or after their suggestion, before parents use physical prompts with children. When children imitate the action without parents’ physical prompts, parents can imitate the action on themselves and respond with enthusiasm to celebrate the child’s action. Finally, incorporate the speech and language techniques into reflective conversations with parents on how they should use the one-word-up rule to narrate each one’s turn (i.e., parent– child–figure) with objects and actions. You can ask these optional coaching questions to help parents plan how to use this step: • “What dolls, stuffed animals, or other figures would your child like to use in play?” • “What real-life actions can these figures do with you and your child?” • “How can you teach your child to make a figure act before you help him or her do the action?” • “What other routines that happen often can figures do with you and your child [e.g., meals, bath, dressing, changing, outdoor play, books, social sensory routines, household chores, self-care activities, errands]?” Step 3: Move from Imitation to Spontaneous Symbolic Play

What to Share with Parents: As parents and children pretend-play actions with different materials and figures across different routines, children’s play skills to pretend and imagine grow stronger. Children develop more initiative and ideas to play make-­believe with props and a doll or stuffed animal, and they instruct parents who to be and what to do and say in their roles. We want children with ASD to also move from watching and imitating parents’ play suggestions to coming up with their own play ideas for parents to now follow. Parents support this transition from imitation to spontaneous pretend play when they set up the props or materials in some kind of orderly way for children to see and choose which items they want to use. Materials related to a specific theme, for instance, giving a doll a pretend bath, could be laid out on a table or the floor (e.g., the doll, a plastic bathtub or bowl large enough for the doll to fit inside, a cup, a sponge or washcloth, pretend soap, a towel), or materials for more than one theme, such as giving the doll a pretend bath or pretend haircut, could be organized in separate boxes or bins for children to choose from. Then parents wait and look expectantly at children to choose a theme if a choice is offered and what play actions they will do first, instead of the parents leading off with their own play ideas for children to imitate. When children initiate a spontaneous play action (e.g., put the doll in the bowl for a bath or pick up a hairbrush), parents might first comment on it (e.g., “The doll is in the bathtub” or “Brush”) and then follow their children’s idea. Parents can imitate the same action if there is more than one of the same object to use,



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such as picking up a second brush, or parents can help to support the children’s play idea, such as holding the bowl steady or adjusting the doll to stay upright. If children do not lead off with a spontaneous play idea, parents can offer a choice between themes if more than one play idea is suggested (e.g., “Does Dolly want a bath or haircut?”), or point to or hold out two materials for a theme (e.g., “Bathtub or Dolly?”)—and see if the children then begin an action, rather than parents starting an action or giving a specific play idea for children to carry out. When children need more help beyond a choice to get started, parents want to give as little direct help as possible to encourage children’s independence and spontaneity with their play. Parents could make statements or ask questions out loud to hint at ideas (e.g., “I see a washcloth, soap, and a cup,” or “Hmm, where does Dolly sit for a bath?”), followed by more direct suggestions (e.g., “Dolly goes in the bathtub,” or “Dolly is dirty. Let’s wash her”) before taking turns or physically helping children do the play action. This sequence of providing gradual bits of help when children do not immediately respond and pausing after each opportunity for children to enact the desired behavior is called a “least-to-most prompting hierarchy.” Parents have been using least-to-more prompting all along when they first wait to see what children can do on their own before using their voice or gestures to cue children what to do or physically helping children complete the action. When children do respond or initiate a play idea, parents comment and imitate the action with enthusiasm and glee so that children get the most enjoyment out of the learning opportunity and interaction to want to come up with more of their own play ideas. This teaching sequence is the key to increasing children’s spontaneous play: • Provide familiar, interesting materials in a visually organized way and without other distractions to motivate children and help them think about play ideas to do. • Wait for children to offer their play ideas first, or give the least amount of help for them to come up with play ideas. • Comment and copy what children do with enthusiasm and enjoyment. • New play ideas can gradually be added to complement what children do or come up with, or to help children return to a theme when their play interests or actions become repetitive or “stuck.” For Coaches: Coach parents to stay with this step until: (1) children initiate play ideas at least during the activity if not selecting materials or the theme to lead off the activity; and (2) when parents help children come up with or carry out play ideas, they do so without physical prompts. Don’t forget to reflect on parent–child communication skills if you and parents are working on those strategies in addition to this topic. You can ask these optional coaching questions to help parents plan how to use this step:

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• “What objects and props can your child choose for pretend play with figures?” • “How will you set out the materials to help your child think of ideas and start to play?” • “How can you encourage your child’s spontaneous play actions with figures or characters?” [Help parents think about least-to-more teaching strategies to suggest play ideas when children do not immediately come up with them. The next question is another way to ask parents about this.] • “What teaching strategies can help your child create spontaneous play actions with figures when he or she is not sure what to do?” • “How can you respond to reinforce your child’s play actions [spontaneous or imitative]?” • “What do you need in order for you and your child to act out different play scenarios or routines with props and figures?” Step 4: Teach Symbolic Substitutions

What to Share with Parents: The next type of pretend play to teach children is make-­believe with objects. Children do this when they pretend that an object is something else, like looking through a paper tower roll as if it were a telescope or singing and making silly sounds through it as if it were a microphone, or they pretend and act out actions with invisible objects, such as holding their hand as if they had a bottle to feed a baby doll. Treating objects as other things or making them up “out of thin air” are huge milestones in children’s development. These skills show that children’s imagination can guide their actions and thoughts beyond the world of objects or their physical attributes and cause-and-­effect properties. Play becomes more abstract and less rule bound, which are important characteristics for children with ASD to understand and know how to do when it comes to the play of their age-mates and being able to participate, contribute, and keep up as capable play partners. We start with teaching children how to pretend that objects represent other real objects during play, before teaching children to pretend-play with invisible objects. Parents use the same joint activity format used to teach all the other play skills. Helping Children Learn about Ambiguous Objects 1.  Set-up. Parents use props or materials that children are familiar with from other pretend-play activities and include a few ambiguous objects or materials that are neutral or without a strong identity of their own to children and could serve as good substitutes to represent something else (e.g., a napkin becomes a parachute for the action hero to hold when it jumps off the table, a block becomes a rolling



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rock that crashes into a toy car, or a marker rubber-band-bound to each foot of the doll now lets her ski or skate across the floor). Parents select ambiguous objects that represent realistic objects based on some key physical feature, such as size, color, or material. Parents want to find one or two ambiguous objects to substitute for two key objects in each of their play themes with children with figures (dolls, stuffed animals, action heroes, etc.), and props related to each play theme are also included. When parents have arranged all the materials, children can pick out familiar objects and choose the theme for parents to follow, or parents can suggest a theme that their children might like, particularly when they need a little help to get started. 2.  Theme. Parents hold off on using ambiguous objects right away and instead

use real objects (or wait for the children to use real objects) to start the pretendplay theme on each other and the doll, stuffed animal, or other figure. When children do not respond right away, parents continue with the least-to-most prompting hierarchy to encourage children to come up with their own play ideas, or to do an action before offering hints, suggestions, or stepping in as the last-­resort physical help to complete an action. 3.  Variation. After parents and children have played out a theme with real

objects, parents now introduce ambiguous objects, one at a time, to represent real objects used in the theme (e.g., a fork becomes a hairbrush to brush hair, or flat circles of Play-Doh become cookies for everyone to pretend-eat). Parents take a few turns to model and label the actions with ambiguous objects and to name ambiguous objects as the real objects (e.g., “Look, here’s my hairbrush! Brush Dolly’s hair” or “Monkey is making a chocolate cookie. Now he’s going to eat it”). Hand over the materials to the children and encourage them to do the same actions with ambiguous objects. When children do, repeat those actions with ambiguous objects to join children in the fun and reinforce their learning. Gradually show how the other ambiguous object(s) can be included in the play theme with the same least-to-most prompting sequence, to help children understand and participate with independence. When children use ambiguous objects with excitement and ease, include real objects alongside the substitutions (e.g., an actual hairbrush and a fork, or real or plastic cookies and Play-Doh) to do play actions with both types of objects. 4.  Closing/transition. When interest or play ideas start to wane, help children

participate in an organized closing/transition: Clean up and put away materials and move on to another activity. Helping Children Learn about “Invisible” (Pantomimed) Objects Note: Make sure that children spontaneously use a number of ambiguous objects to represent real objects during play before starting these steps. The more

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that children really understand the concept that one object can substitute for another, the easier this concept of how to gesture or pantomime as if they are using an actual object will become for them. 1.  Set-up. Just like with the set-up for ambiguous objects, leave out one or two key objects that will become the invisible objects to pretend to have in the play theme (e.g., leaving out the hairbrush for one play theme or cookies for another play theme). 2.  Theme. Play out the familiar and enjoyable theme using the props and doll, stuffed animal, or figure that parents have arranged in the set-up. When it’s time to use the missing object, parents pretend to have it in their hands and do the associated motion or action while describing what they’re doing (e.g., parent runs her hand down the doll’s hair while saying, “Brush doll’s hair,” or parent holds out her hand to the monkey and says, “Here’s a cookie. Eat it, Monkey”). Parents repeat the action a few times and encourage or help children to do the same. After parents and children have gone back-and-forth a few times acting out with the invisible object, parents offer the real object and let the children use it on one of the figures, while parents do the invisible action without the object on the other figure. 3.  Variation. Parents wait until children can act out an invisible object with gestures before they repeat the process with another main object left out of a favorite play theme. They use the same language and actions to show how to represent the real object with gestures or movements for children to imitate. Go slowly from one routine to the next and use real objects intermixed with invisible ones whenever children seem confused or do not catch on right away. 4.  Closing/transition. As usual, when interest or play ideas wane, help children participate in an organized closing/transition: Clean up and put away materials and move on to another activity.

For Coaches: See the activity ideas and tips to help parents and children learn how to play with symbolic substitutes. Talk through with parents the fact that this phase of pretend play takes a long time for all young children to develop. In fact, it is important not to rush this process because all the different play themes, scenes, and props that parents and children use together only help children learn more and more about real life, how to participate, and become a part of life events through their ideas, language, and actions. The more that parents understand how this process works, hopefully the less stressed or worried they will feel about the amount of time children naturally take to develop these skills. Instead, parents can focus on the fun aspects of play, which will build up their children’s knowledge of how to pretend with ambiguous and invisible objects and learn more about the



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social world through their imagination and play interactions with others. But if at any point, these pretend-play skills do not become clearer to children, then coach the parents to go back to carrying out pretend-play actions using real objects with dolls or figures in their play themes for children to imitate. This should improve their consistency and understanding before trying again with ambiguous or invisible objects. You can ask these optional coaching questions to help parents plan how to use this step. When children are ready to learn about invisible objects, you can ask the same questions with “ambiguous objects” substituted for “invisible objects.” • “What ambiguous/invisible objects could you use in play with your child?” • “How will you first set up and use real objects on figures to develop the play theme before using ambiguous/invisible objects?” • “How will you show your child to use ambiguous/invisible objects as real objects on figures?” [Help parents think about least-to-more teaching strategies to suggest play ideas when children do not immediately come up with them. The next question is another way to ask parents about this.] • “What teaching strategies can help your child use ambiguous/invisible objects as real objects with figures when he or she is not sure what to do?” • “How can you respond to reinforce your child’s pretend-play actions with ambiguous/invisible objects?” • “What do you need in order for you and your child to carry out play actions with different ambiguous/invisible objects?” Step 5: Develop Symbolic Combinations

What to Share with Parents: The last type of pretend play involves teaching children to combine pretend-play actions to act out an entire scene (not just a few related actions) from some real-life routine or event. The scene could be something that children participate in daily, like waking up and all the different actions that make up this routine (e.g., go to the potty, wash hands, brush teeth, take off pajamas, choose clothes, get dressed, and walk to the kitchen for breakfast). Or, the scene to act out could be outings or errands that children do with parents or as a whole family, such as grocery shopping, mailing a package at the post office, driving through a car wash, playing at the park, or other events that children commonly observe and experience. Whatever the activity, each involves a number of actions that children can pretend to do with parents and figures, so their play becomes richer and more elaborate. To make this step easier for children to learn, they should be able to play out, without difficulty, several different themes where they can imitate and spontaneously come up with different pretend actions with objects to use on parents, figures, and themselves, even if replacing real objects

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with ambiguous or invisible objects to complete the same pretend action is still an emerging skill. Let’s go through the four-part joint activity framework to teach children to combine and act out pretend-play actions from real-life scenes. 1.  Set-up. Parents arrange props or objects for a few different themes that represent familiar routines or events so children can choose which to do (e.g., having a picnic, acting out the story “The Three Little Pigs,” or going to the doctor’s office) and which figures will participate as characters in the scene. To get started with the theme, parents involve children in setting out and naming props and figures. 2.  Theme. Parents wait for children to begin a pretend act with an object and/or figure, or encourage children with questions, statements, or hints to help them get started with the chosen theme (e.g., “What do we want to eat on our picnic?,” “I see lots of food to put in the picnic basket,” “Bear needs help”). Parents continue to let children take the lead to build and carry out the theme, encouraging and helping when needed. When children imitate or spontaneously produce pretend actions, parents’ comments and actions mirror children’s play. 3.  Variation. Once children start to act out the theme, parents add actions that support or relate to the real-life event or routine. They narrate and show the action, one idea at a time, in their turns (e.g., “The grass is wet. I want to sit on the blanket to eat our food. Help me set down the blanket” or “We need forks and napkins to eat our food”) and encourage or help children do the same, either with their own set of materials or by sharing items. Parents continue to demonstrate actions and prompt children through imitation. 4.  Closing/transition. When children’s interest or play slows down or starts to feel repetitive, or nothing else can be added to the scene, it is time to end the activity and for children to put items away in their bin or box. If children still want to continue playing, parents can indicate the other themes children could do next or let children continue practice with independent play as long as their actions are not repetitive.

Parents can follow the joint activity steps to play out any kind of scene from daily routines (e.g., making a sandwich, bathing, brushing teeth, getting ready for bed), family events, or the children’s favorite books, television shows, or movies. The more that children do this kind of play, the more they understand about real-life experiences. In fact, parents may find that daily routines that are difficult for children to do or not their most favorite may become easier or even fun as children learn and practice the steps and narration in play. Acting out real-life events can also prepare children for new experiences that might otherwise seem difficult or scary. When parents help children pretend their way through the steps of going to the doctor or the dentist’s office, getting a haircut, going to another



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child’s birthday party, or using a noisy piece of equipment like a blender to make a smoothie, parents create a “script” for what children can expect in a new experience and what skills and behaviors to use inside its sequence of events. Parents can use this strategy called “priming” to familiarize children through any life experience whether it’s new or repeated, to improve children’s understanding and ability to participate and to ease frustration or anxiety when a particular event causes more upset. Through this supportive exposure, children will come to know the whole script for each of these experiences, from beginning to end, and will be able to participate in acting them out with parents or other family members included in the play. For Coaches: When parents would like ideas about what to act out with their children, you and the parents can create a list of real-life experiences and routines their children have experienced many times. For upcoming activities that a child will experience for the first time (a visit to the dentist, family picnic, birthday party, etc.), playing out the experience with dolls, with animals, and/or with each other helps the child understand and cope with a new or stressful experience. Once parents and children have some familiarity with a script, siblings or other family members can play a role in the scene, too. You can ask these optional coaching questions to help parents plan how to use this step: • “What real-life events, routines, or familiar stories could you and your child act out?” [Guide parents to first pick ideas that children will find enjoyable before trying other events that may be more difficult or stressful for children to do.] • “What objects or props and figures do you need for you and your child to re-­create the event?” • “How will you set up the needed items to encourage your child to start the play?” • “How will you help your child combine pretend-play actions in a sequence?” [Help parents think about least-to-more teaching strategies to suggest play ideas when children do not immediately come up with them. The next question is another way to ask parents about this.] • “What teaching strategies can help your child understand and carry out ‘scripts’ from a real-life event?” [Ideas include visits to a location to see what actions happen there, making storybooks or taking pictures with smartphones or tablets to build scripts, creating puppet shows to act out events.] • “How can you respond to reinforce your child’s participation?” • “What do you need in order for you and your child to act out new or more stressful real-life events?”

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Topic X: Helping Young Children Develop Speech What to Share with Parents: Parents may wonder why parent coaching sessions wait so long to discuss children’s ability to speak. It’s because everything in the earlier topics is actually also building the foundations for speech development: attention, vocalization, imitation, play, sending messages to others via nonverbal gestures, and joint attention. When children have all these skills, learning to speak—­expressive language—and understand speech—­receptive language—are much easier. This topic aims to help parents support children to use and understand speech through the active social interaction strategies already in use with people and their facial expressions, gestures, and body language. For Coaches: Ask parents for their perspective about children’s current abilities with these prerequisites, especially if any seem to be in question from your observations. You can also ask parents about children’s status with expressive and receptive language to hear how they view their children’s communication compared to your observations. You can ask these optional coaching questions of parents: • “How would you describe your child’s skills with these milestones?” • “How does your child use words to express him- or herself?” • “What types of communication [e.g., requests, comments, affirmation, protests, asking for help, greetings] are easier and more difficult for your child to use?” • “How would you describe your child’s understanding of what you and others say to him or her?” • “What types of communication [e.g., requests, comments, affirmation, protests, asking for help, greetings] are easier and more difficult for your child to understand?” • “How would you describe your child’s communication [both use and understanding] with other people [e.g., family members or someone he or she meets for the first time]?”

Why Is It a Problem? What to Share with Parents: By now, parents likely see a pattern of why behaviors affected by ASD are problematic for young children and their development. When children’s social attention to others is lessened or decreased, so is their ability to initiate, engage, and connect with others, and fewer social interactions with others means fewer opportunities for children to listen, learn, and respond to language. Everything parents have practiced has focused on strategies to decrease the amount of time children with ASD spend unengaged with others, or on behaviors that isolate them and make it harder for others to approach and play with them. That’s why



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parents strive to interact face-to-face with children and with toys, objects, props, or just themselves to develop meaningful, shared experiences instead of resorting to electronic toys, devices, computer games, or items where children’s attention gets “stuck.” That’s also why parents label and talk about what they see and do with children and what children see and do with them. Because the key, and this remains true for any skill that we want to teach children, is that children learn from their interactions with people. Now given the demands of life for parents and families, we also know that filling all the hours in a child’s waking day is just not possible or always healthy. Parents deserve a break from parenting, too. But, the reason that we talk about practicing the strategies during play activities, caretaking, or other routines that families usually do with young children is to take advantage of the moments when parents and children are naturally together. So, let’s discuss the next set of strategies to continue working on children’s ability to use and understand language! We discuss expressive language (the ability to use language) first followed by receptive language (the ability to understand language). For Coaches: Help parents see the connection among behaviors affected by ASD, such as attention, social, or communication, and subsequent opportunities for social interaction and learning for children with ASD. You can ask how parents relate to this information, which routines are doable with children versus those to work toward, and what changes (hopefully positive) they have seen so far in their children’s abilities to interact and learn more often from meaningful social activities with others throughout the day. Check in with parents as well for how they fare with all of this change. For parents who may struggle to put the strategies into effect with children, are there other resources your practice or organization can offer to them? You can ask these optional coaching questions of parents: • “How do you relate to this information?” • “What does this information mean to you and your family?” • “How do you now see your child’s social attention to others [e.g., interest, initiative, responsivity, engagement], compared to when we first started sessions?” • “How has your child’s social attention changed? What’s helped?” • “What changes have you observed in yourself [e.g., parents’ behaviors, habits, routines, lifestyle] in doing all of this to help your child learn? How do you manage?”

What Parents Can Do to Build Their Child’s Expressive Speech and Language What to Share with Parents: We dive into strategies to help children turn on their voice by making sounds such as an animal, a car, a train, or other playful

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noises that they do back-and-forth during interactions with parents. Developing these skills paves the way to build speech. For Coaches: Parents can share examples of playful or other vocal sounds their children make. You can ask these optional coaching questions of parents: • “What sounds is your child prone to make?” • “What activities encourage your child to make sounds?” Step 1: Build Up Your Child’s Vocabulary of Sounds

What to Share with Parents: All children first make vowel sounds like “ah,” “oh,” and “ee” before consonant-vowel combinations like “ba,” “da,” or “ma.” We want children with ASD to make a lot of these vowel sounds and to make them frequently in response to parents and other people making similar sounds. Parents begin by responding to children’s sounds as if they were words. Parents can answer, imitate, or say something that sounds like what children said. Even when children make sounds to themselves, parents can go up to them and repeat their sounds. When children vocalize, so do parents and the turn taking becomes a little conversation that teaches children how to turn their voice on and off. These games show children how to control their voice. When children stop vocalizing, that’s OK, too. It doesn’t mean that something has gone wrong or that children have lost the sounds they made. Children may be ready to do or think about something else. For Coaches: The other steps help parents develop vocal games to encourage children to make sounds, whereas this step reminds parents about their positioning respective to their children and to respond (through one of the strategies mentioned above) to children’s sounds. Parents could do this in any joint activity routine that excites and encourages children to start to vocalize. Some parents like to keep a list of sounds children make to track their development and progression. You could offer this suggestion and a template for parents to use if they would like to do this. You can ask these optional coaching questions to help parents plan how to use this step (the first two questions are repeated from the last section): • “What sounds is your child prone to make?” • “What activities encourage your child to make sounds?” • “How can you respond to your child’s sounds to encourage him or her to repeat them?”



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Step 2: Develop Vocal Games with Your Child’s Sounds

What to Share with Parents: Once parents and children vocalize back-and-forth from sounds that children make, parents can start the vocal games themselves. Parents start off face-to-face with children—in a highchair for a meal, at the changing table, on their laps, facing adults, leaning up against a table, on the bed, on the floor, or in other positions—to support good attention. Parents look at children, make a sound they know children can, and wait expectantly for children to repeat back that sound. When children do, parents answer back with the same sound to carry out a conversation. When children make a sound but not the same one the parents did, parents can repeat the original sound (not the different sound the children made) to acknowledge children’s effort with a vocal response and to also give more exposure for children to try out the new sound. It’s also OK when children do not respond with any vocal sound. Sometimes children need to hear (or see) something more than once, and they are still listening and thinking about the sound each time parents make it. Parents persist and can change their tone, pitch, or speed, use songs or props, like toy microphones or an empty paper towel roll, to add emphasis to their sounds, as well as try mouth movement games, like patting children’s mouths or running their fingers over children’s lips, to see whether that may encourage a vocal response from children. Parents continue to practice these vocal games as both a leader (being first to make the various sounds that they have heard children do) and as a follower (imitating sounds when children make them first). Parents and children practicing both of these roles, as a speaker making sounds first and as a listener responding to others’ sounds, teaches children how to start, answer, and sustain conversations. And that’s a big step toward speech! For Coaches: See the helpful tips and parent–child story for how parents can practice this step. As mentioned in the last step, some parents like to keep a list of sounds children make to track their development and progression. If parents started this list in the last step, ask them to share it with you to help decide which sounds parents can start practicing with children. As practice progresses, parents can add new sounds to their list and even check off the sounds that children repeat after their parents first make them. Seeing the list grow and differentiating between sounds that children produce first and repeat when parents make them first may be very encouraging to families. You can ask these optional coaching questions to help parents plan how to use this step (the first two questions are repeated from the last section): • “Let’s start with sounds that the child already makes. Which could you try and within what activities to encourage your child to answer you [or repeat them] back?”

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• “How might you respond to your child’s sounds to encourage him or her to repeat them again?” • “What strategies that we’ve discussed might encourage your child to respond to your sound when he or she does not readily do so?” Step 3: Increase Opportunities for Listening and Responding to Sounds Made by Others

What to Share with Parents: Parents increase opportunities for children to hear and respond to sounds when they add playful sounds, songs, or chants to play and other routines. Ideas include the following: • Make sounds that relate to toys, props, or imaginary objects used in pretend play, like “ding” when the “timer” goes off while pretend-­baking, “ringgg” to pretend to answer a phone, “ssss” to pretend to wash items or iron clothes. • Make animal or vehicle sounds for toys, picture books, songs, puzzles, or other objects that involve these categories. • Make silly sounds like tongue clicks or lip smacks that children might find funny and can be added to play and caretaking routines such as diaper changes, mealtimes, bath play, or getting dressed. • Make rhythmic sounds to the fun actions in SSRs, like “whee” or “ooo” as children swing, jump, or bounce, or “uh oh” when children fall down in “Ring-­Around-the-Rosy” or other physical games. • Add carrier phrases like “One, two, three!” or “Ready, set go!” to cue children to vocalize a sound in anticipation of fun-­filled actions with SSRs. Just as in the last step, parents position themselves for good face-to-face attention with children, utter each sound, wait patiently for children to imitate or make a sound back. In addition, parents watch children’s reactions (think talking bodies) and repeat those sounds that get children to smile, look up and at them, or show their interest and attention. Whether or not children respond, parents take another turn to make the sound and do the related action (e.g., say “ding” and open the pretend oven, or “grrr” and put the bear puzzle piece into the puzzle board). Children’s repeated exposure to sounds, followed by the predictability of enjoyable actions that follow their sounds, encourages them to turn on their voice and make sounds. In addition, hearing all of parents’ sounds throughout the day helps children build up a reserve of more and more sounds and better understand the social aspects and meaning of those sounds in action. For Coaches: We want children to practice this and the other two steps to develop the sounds they will need for speech production. Parents also need to develop the skills from this and the other two steps to support children through their first



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language-­learning phase, which is how to build on sounds children can already produce, how to offer new sounds and words in different contexts, and how to help children expand sounds in socially meaningful activities and interactions. Stay with these steps to gauge parent–child progress with expressive language goals developed in your coaching sessions. We strongly encourage parents, or you with parents’ permission, to share children’s expressive language goals and data on their progress across goals with the children’s speech language pathologists. Although children may not fully achieve the expressive language goals you have developed, depending on how many coaching sessions focus on Steps 1–3, children ought to show advancement across teaching steps for expressive language goals. Speech and language pathologists should observe parents’ interactions with children for feedback or consultation if more than three of your consecutive coaching sessions do not show children advancement across teaching steps for expressive language goals and need other strategies than what we’ve prescribed to help children turn on and use their voices. You can ask these optional coaching questions to help parents plan how to use this step: • “What sounds does your child make regularly?” [Ask about vowels and consonants so that you have the full picture of children’s vocal development.] • “What strategies that we’ve discussed [e.g., body positioning, sounds that catch children’s attention and interest, ways to exaggerate or add emphasis to sounds if that helps children repeat them, giving children enough time to hear and try to make sounds] might help your child repeat sounds that you make first?” • “What can you do to not lose your child’s interest if he or she looks and/ or gestures, but does not make a sound when you pause the game?” [Keep in mind the strategy of differential reinforcement to help parents troubleshoot this potential scenario—­parents respond with some but not all of the desired item or action children want (i.e., reinforcement) to acknowledge the children’s attempted response so as not to extinguish or lessen their motivation to respond. But full reinforcement is reserved for the bigger behavior parents want children to use: in this case, vocal sounds. Examples could be a smaller amount or portion given of a favorite snack, a shorter turn with the toy or item, or a toned down enthusiastic response from parents.] Step 4: Talk to Your Child in a Way That Promotes

Language Development

What to Share with Parents: How parents talk to children influences children’s language development. That’s why coaching strategies encourage parents to talk

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frequently to children when they are face-to-face, using simple language about what they and the children do, see, and experience with objects and actions that make up their activities. Parents who use speech mostly to give instructions or corrections to children limit opportunities for their language learning, whereas parents who talk to children throughout the day during both play and nonplay activities help them develop larger vocabularies. The easiest way for parents to talk a lot to children is when they follow children’s focus of attention to describe the children’s own actions and objects. Parents may recall this strategy from earlier coaching on how to capture children’s attention and interest by talking about what they like and do. But, parents putting words to what children look at, play with, touch, or use also helps children connect parents’ words to the objects and actions children are attending to and thinking about. This is how children learn the meaning of words and encourages them to say those words, too. Parents can think of a simple vocabulary of the words they want their children to learn and then use those words frequently for children to get enough exposure and practice to learn them. Remember, everything needs a name—the objects and actions that children encounter; the SSRs children like to do; the food, drinks, toys, and people children want. Parents may want to focus on colors, counting, the names of shapes, or letters for children who are beginning language learners. Those concepts will come later as children learn the names of objects and actions, and their vocabularies grow and lay the foundation for them to learn these higher-­thinking concepts. For now, beginning language learners need to learn the names of objects and actions they experience to develop a base. Another consideration is how complex parents’ language should be when speaking to children. In general, parents’ language ought to be just a little more complex than their children’s. This way, parents’ language is clear and to the point (to help children learn the meaning of words) but also descriptive (to help children’s vocabulary grow). For children who are not yet talking or just beginning to use words, parents want to keep their language really brief, using one- or two-word phrases that capture children’s actions and objects. For children speaking in two- to three-word phrases, parents’ language can increase to four to five words. For Coaches: Consider listing language examples that parents can use with children based on the children’s language level. See the language phrases, helpful tips, and parent–child story for ideas to accomplish this with parents. If parents started a list of children’s sounds from earlier steps, adapt or add to that list the words that parents can say that relate to those sounds and the objects and actions of children. Parents may also need practice and feedback to avoid speaking in more words than their children’s language level permits and/or to focus on physical or cognitive attributes instead of the names of objects and actions. A list, chart, or some visual template to assist parents with recognizing children’s vocal growth from this and earlier steps may help them resist this temptation and stick with the



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one-word-up rule: parents add one more word to their own speech than their children typically use. Feel free to also use and explain that term if it helps parents remember what to do and how to use it. Ideally, we want parents to be able to help their children make or show progress in these three areas before moving onto the next step: (1) to turn on their voices, (2) to develop more sounds or words, and (3) to make sounds or words back-and-forth with parents and others in vocal play that supports the framework for conversations to happen. You can ask these optional coaching questions to help parents plan how to use this step (the first two questions are repeated from the last section): • “Let’s figure out your child’s language level to know how many words we should use to speak to him or her. What sounds or words does your child say regularly?” [Ask about vocal and consonant sounds for children not yet saying words so that you have the full picture of the children’s vocal development and only count words that children say spontaneously to gauge the one-word-up rule.] • “What can you talk to your child about as you and he or she do activities together?” [Encourage parents to include nonplay activities for more diversified practice with children. The question below is another way to ask parents whose language examples or ideas may exceed the one-word-up rule.] • “What objects and actions can you name in the activities that you do with your child?” [Encourage parents to include nonplay activities for more diversified practice with children.] Step 5: Add Sounds to Gestures

What to Share with Parents: For children who can turn on their voice to make sounds or words in back-and-forth “conversations” with parents and others, the next step is adding gestures to their sounds or words. Parents do this when they build up children’s talking bodies to communicate—­through eye contact, gestures, facial expressions, and body language. Now it’s time to put sounds to those gestures. Just like other skills taught to children, parents model, or show, children how to put sounds, words, or even wordlike sounds (we call this “word approximations” and they count, too) to gestures. There are three steps for parents to follow: 1.  Parents choose a gesture and a sound, word, or word approximation that their child uses frequently and model the two together. For children who make sounds (as opposed to words or approximations), parents can see whether any current sounds resemble words to select, like “ah” for that, cat,” or ball, or “da” for dad or down (it could also work for that). For the child who says words or approximations, parents follow the one-word-up rule to pair simple words with gestures.

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A child knows how to reach or point to make a choice or to show his mother what he wants. The mother decides that either gesture will work since the child reaches and points fairly equally. Next the mother thinks about which vocalization her child already uses that can be paired with a reach or point when she shows him how to do both. Currently, her son only makes sounds, not yet words or approximations. The mother looks over her list of sounds for the child and sees that “ah” is one he says often, so she decides to pair that sound with the word that when her son reaches or points to something he wants. The next time her son reaches for an object that his mother holds, she asks him, “That? You want that?” and pauses for him to say “ah,” that, or another sound that is his attempt to say the word. When her child does not respond, the mother tries one more time with “Do you want that?” and enunciates the word that to bring more attention to the word for her son. The child looks at her and reaches for the object without a sound. Rather than discourage her son from the talking body communication he does use—his eye contact and a reach—to tell her what he wants, she gives him the object while saying, “That. You wanted that.” While the mother would have liked her son to say a sound or even the word, she knows that she will have many more opportunities to model and practice the skill each time the child reaches or points for something he wants. And, the mother wants her son to continue feeling encouraged and capable of making requests to her whether it’s through his voice, eyes, gestures, or other body language. When her son does learn to add the sound or word to his reach or point, the mother also knows it will be important to quickly give him what he has asked for so that he makes the connection: that his vocalization and gesture led to him receiving what he wanted. 2.  Parents add sounds or simple words to children’s gestures or actions. We mentioned this idea beforehand when parents make animal, transportation-­ related, or other playful sounds that relate to the toys, social games, books, or songs they do with their children. Other examples include: parents saying “no, no” when children push away something they don’t want; “uh oh” when children accidentally drop something; “boom” when children tap or hit objects and toys; “boo” when children uncover their parents’ faces during a game of peekaboo; “hi” or “bye” depending on the context when children wave; and “wow” when children give, hold up, or point to something of interest. Parents follow the suggestions just laid about above to select a sound or simple word to pair with their children’s gesture, and then model the sound or word and gesture to try to get their children to imitate it. When children do, parents can demonstrate the sound or word and gesture to keep the interaction going. When children do not imitate, parents encourage children to imitate their sound or word with a gesture, or recognize children’s other talking body communication to “speak” and look for the next interactive opportunity to try the combination again. Let’s go back to the mother and son in the last example to see how they’re doing with this step.

The child loves when he runs out from behind the couch and into his mother’s



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arms, and she squeezes and tickles him. The mother thinks about what sound or word she can say when he runs out, and before she does the actions he likes. She was going to choose “boo” but wants to keep that sound for peekaboo, so comes up instead with another sound or word for this game so that her son practices with more than one sound or word. In looking over the child’s sound and word list, she sees that he says “ha” and decides the sound is doable for him to imitate. The child runs out from behind the couch, and the mother says “ha” as she scoops him up in her arms. The child laughs and squeals with delight, and they continue like this for a few more rounds, with him listening for the sounds or words his mother says that are tied to the fun actions he loves for her to do. On the fourth go, the mother changes her positioning; she is no longer seated, but now kneeling on the floor so the child cannot immediately run into her lap. This time the mother says “ha” with outstretched arms but waits for the child to imitate her before taking him in her arms. The child doesn’t respond, so she says it again, “ha,” and waits. He continues to look at her and makes a slight sound, though not quite a “ha,” as he wiggles his body. But, the mother recognizes the child’s attempt to say the sound and scoops him up while saying “ha” to reinforce his effort to try to imitate her. Mom and child continue to play the game with more “ha’s” coming from the child. 3.  This step is for children who respond to parents with gestures and sounds,

but not yet words. When children make a sound and gesture, parents add the real word as they hand over the object or do the action children are requesting. Remember that words need to be simple—think single words that are nouns or verbs—and ideally they contain some sounds the children can already make and imitate in games or routines with parents. We return to the mother and son in the example below. During bathtime, the child points to each bath toy he wants from the mother and says “dah.” The mother responds with her usual “That?” and now she names each bath toy as she hands it over to the child, “Duck, whale, fish.” The mother is careful to clearly articulate the first consonant of each word for her son to hear the “dah” in duck, the “wah” in whale, and the “f” in fish. Since this is the first time the child is hearing his mother name his bath toys, the mother focuses on that task for the moment, instead of worrying if her son will try to imitate these new words. She still takes turns with the bath toys so that she can hold them up one at a time to name the word for her son to hear, and before and after he says “dah” and points to ask for each one. She expects that he will start to say some of the words after they have done this new routine several more times, and she will make sure that she has his full attention when she speaks the words to help him understand what it is she now wants him to say. For Coaches: Parents and children should keep a number of vocal imitation games going and with at least a variety of sounds that children can imitate to ­support their ability to say words before moving onto the next section, on building

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children’s receptive language skills. Coach parents to accept any sound match that children make and support parents to remain patient with their children’s vocal journeys. It can be a long road from a vowel or consonant-vowel sound to the full word, but this is the way that all children learn to speak. Children learn to say what they can, and with practice and time, their abilities to move and position their mouths, to hear the sound differences and say something more precisely, as well as the development of their speech muscles to physically produce and form sounds, all help them come closer to saying the real word. And, that’s very encouraging when children with ASD have all the abilities to follow the same route! You can ask these optional coaching questions to help parents plan how to use this step: • “How can you talk to your child in play and nonplay activities?” • “What language level should you use to speak to your child? Remember, we want to use just a word or two more than what your child says on his or her own.” • “How can you position yourself for easy contact with your child while narrating what you and your child do together in activities?” • “How can you still participate in activities with your child so he or she hears your language for what you do, not just what he or she does?” • “What simple sounds can you add to your child’s gestures?” [Help parents select sounds they know their children can imitate.] • “How can you encourage your child to imitate your sounds?” • “When your child imitates or says sounds with gestures, what simple words can you say in response?” [Help parents use the one-word-up rule with nouns and verbs.] • “How can you encourage your child to imitate your words?”

What Parents Can Do to Help Their Child Understand Speech What to Share with Parents: A big part of the language difficulty for children with ASD is understanding the words that people around them use. Some children might seem to understand more than they actually do by compensating for their lack of language with other skills or abilities, like looking around a room or zeroing their attention in on a particular object or cue to make good guesses about what will happen next and based on their past experiences (e.g., parents getting out children’s shoes and socks or taking out their car keys are cues for children to understand they’re about to leave the house, instead of parents saying, “Let’s go to the store,” or “It’s time to get in the car”). Other times children with ASD seem to ignore everything all together, speech and cues alike. Parents could be practicing all the language strategies covered in the book—adding labels to objects and actions to children’s activities, using sounds and simple words, and providing lots



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of language models—and yet their children still seem not to “hear” their words. In these cases, children with ASD may not fully understand the importance of listening when people speak or of following through with a response or action to people’s words. But, parents can still teach their children to listen and to respond, and there are two pieces of good news here. The first is that the steps given earlier in this chapter build children’s expressive language skills and using those techniques also develops children’s receptive language skills, or their ability to listen, understand, and respond to what people say. And the more that parents practice such techniques, the more they help children understand the importance of speech—that children need to listen and attend to what is said, and that a response is expected when someone speaks to them—and develop both sets of skills. The second lies with the next set of steps that focus precisely on children’s understanding and responding to others’ speech. For Coaches: Parents may want to talk about how this information resonates with their understanding of ASD and/or experiences with children. Keep in mind the option to invite parents’ stories if doing so may deepen their understanding of what’s happening in ASD and/or with their child. You can ask these optional coaching questions of parents: • “What comes to mind as we talk about what happens in ASD?” • “What questions do you have about what happens in ASD?” • “What concerns or worries do you have about this topic?” Step 1: Expect a Response, Then Get It

What to Share with Parents: People may not always know what to do or how to respond when children with ASD seem to ignore their language. This can be worrisome for two reasons. Over time, people may stop expecting that child to respond. And, a child who isn’t expected to respond won’t learn the importance of speech. Thus, people’s expectations and follow-­through that children respond to their language are crucial. What’s involved in making that happen goes back to strategies parents are already using with children. First is the need to get children’s attention (think: positioning relative to your children’s, removing or managing distractions, including children’s likes or interests if applicable in the situation), followed by a simple instruction and brief wait for their response. If children do not respond, then parents quickly prompt children to do so, followed by a positive consequence related to what children were asked to do. The turn-­taking routines parents have been practicing are great examples of these moments already happening with children. Parents use their turns to teach something they want children to do (e.g., to turn over a toy or watch and try a new play idea). Parents initially wait for children to try to take that action themselves, or help children

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complete the request with least-to-most prompting before following through with the outcome children wanted (e.g., a parent fixes or creates fun with a toy that a child gave him, a child wants to keep building on a new play idea or to go back to the prior theme). Parents state gentle and easy but frequent requests, ideas, or instructions, and follow-­through teaches children the meaning of their words through children’s attention and responsiveness to adult speech. For Coaches: Guide parents to consider the types of requests or instructions they can add to existing play and other routines, as well the least-to-most prompts they may need to help children respond to their language. This step is an exception where parents may need to resort to physical, rather than verbal and gestural, prompts when the situation calls for a faster follow-­through with children. But like any skill taught with physical prompts, parents need to fade them as soon as possible to support children’s independence with requests or instructions. You can ask these optional coaching questions to help parents plan how to use this step: • “What request or instruction can you add to this activity?” • “How can you support your child to follow through with the request or instruction?” [Another way to ask this question comes next.] • “What strategies that we’ve discussed can help your child respond to your request or instruction?” • “What do you think would happen if you held back from using a physical prompt this time with your child?” • “What other requests or instructions could you ask or give your child to do at home?” Step 2: Remember the Natural Reinforcers of Your Child’s Speech,

and Be Sure to Use Them for Responding to Speech

What to Share with Parents: When parents pick reinforcers that work with children’s own goals and motivations for doing what was asked of them, children are more likely to respond and do the same thing again. When no reinforcer follows or one that does not matter much to children, they are less likely to respond and do the same thing again. This concept goes back to the ABCs, which say learning happens only when behaviors are followed by reinforcers or positive experiences like a favorite object, action, or activity. So, we revisit the ABCs where parents give children a request or instruction (the antecedent), wait or prompt children to respond if not on their own (the behavior), and follow through with a reinforcer that children find motivating and that, whenever possible, relates to the children’s behavior (the consequence). Here are some examples. The parent says,



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• “Sit down,” and the child sits to start a fun-­filled play activity. • “Open,” and the child takes off the lid of a container to eat some cereal. • “Come here,” and the child walks over to be picked up. • “Give me my glasses,” and the child hands them over for her dad to put on his face. • “Show me your tummy,” and the child touches his stomach for his mom to tickle him there. What if it’s difficult, though, to think of a reinforcer that relates to what parents want children to do or that children find motivating? When parents find that trying to work new skills into children’s interests or likes does not work, this is where the “first/then” rule (also called the “Premack principle”) may help children learn to tolerate and cooperate with the request or instruction. With it, parents think about something rewarding that can follow children’s completion of the request or instruction, and then follow through for children to go through the experience. Let’s look at some examples. A parent says, • “First socks and shoes, then outside.” • “First wash hands, then juice.” • “First clean up, then bubbles.” For Coaches: Coach parents to think about the request or instruction they want children to comply with and what natural reinforcer—or if not intrinsic, then something preferred—that can follow children’s cooperation with the request or instruction. If the question comes up of why should we have to reinforce, or “reward,” children for doing what’s asked of them, parents may see a conflict with this principle compared to their parenting, cultural, religious, or other personal beliefs. Or, parents may not think their children need the same amount or level of reinforcement to follow requests or instructions given all the learning they have accomplished. Whatever the issue may be, it is important to ask questions and listen to parents’ perspectives, as well as to find common ground with the reasons parents share since this is how children learn and how adults operate, too (e.g., we go to work to make a living, we plan to have dessert that night, we finish a term paper and treat ourselves to a pedicure!). We all live by and with incentives, and doing so does not usually make our actions any less sincere or less valuable. Once parents have formulated some requests or instructions and reinforcers, just as in the last step, they use least-to-most prompts to help children respond to their language and may need to resort sooner to physical rather than verbal and gestural prompts when the situation calls for a faster follow-­through with children. Parents ideally practice this within the context of play and nonplay activities before moving on to the next step.

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You can ask these optional coaching questions to help parents plan how to use this step (all questions but the two asking parents to think about reinforcement are repeated from the last step): • “What request or instruction can your child do in this activity?” • “What reinforcer will motivate your child to meet the request or instruction?” • “What is something preferred that can follow your child completing this less preferred request or instruction?” • “How can you support your child to follow through with the request or instruction?” [Another way to ask this question comes next.] • “What strategies that we’ve discussed can help your child respond to your request or instruction?” • “What do you think would happen if you held back from using a physical prompt this time with your child?” • “What other requests or instructions could you ask your child to do at home?” Step 3: Instruct Less and Follow Through More

What to Share with Parents: Parents following through to help children respond to their instructions, questions, ideas, comments, or other language opportunities teaches children that words have meaning. And, this carries responsibilities for parents: to be ready for the consequences of what they say and when they say it, to assure that children follow through with the expectation. When parents are in a rush or children are having a difficult moment or there are other interferences in the background, parents might hold off or be very selective in what they ask their children to do. For example, instructions can focus on the actions that parents know children can do or are capable of learning how to do—­sitting, standing, giving an item, showing where it goes, coming over when called, looking at what someone else wants to show them, putting something on, taking something off, or putting an item down or in or on top of something. Parents give the request and wait for children’s response; if none, they then walk children through how to meet the request, fading their supports as quickly as possible for children to become capable of completing the action by themselves. Fewer instructions, but with more follow-­through and not the other way around, are what will help children understand parents’ and others’ speech. For Coaches: Use Form 7.4, “Action Plan Template for Parent Follow-­Through,” with parents to select the play activities or other routines and the requests or other receptive language learning opportunities that children can do within these interactions. Parents also select the different responses children do to meet their

FORM 7.4

Action Plan Template for Parent Follow-­Through Activity/ routine

Parent follow-­through

Parent request

Child response

Reinforcer

Mr. Potato Head

—Give me the nose. —Put on the hat. —Where are his glasses? —I have an earring. It goes on her ear.

The child does the requested action (e.g., give, put on, pick up, point to, or look at the named piece) and receives the reinforcement.

The child participates in the parent’s turn (e.g., touch or point to where the piece goes or put in the piece for the parent), receives the next piece to continue the activity, or chooses what to do next in the activity.

The parent models the request, repeats the request, gestures (e.g., lifts a hand to cue the child giving the piece or shrugs shoulders upward for the child to look for the piece), moves the piece closer or puts it in the child’s hand to cue the child to do the action, or physically guides the child to do the action.

Mealtime

—Take out the mat and put it on the table.* —Open the drawer and take out a napkin. —Do you want a fork or spoon? —Where does your cup go? —Open the container of fruit. —Do you want goldfish in your bowl or on your plate? —Hand your sister a napkin, please. —I want a bite, too. —Look! I am going to take a big bite of carrot. —Put your napkin in the trash. —Take your cup to the counter. —Put your bowl in the sink. —Help me wipe the table.

The child does the requested action (e.g., take out, open, choose, give, or look at what the parent does) and receives the reinforcement.

The child receives the preferred food or drink.

The parent initiates each request and provides a prompt if needed. Prompts are graduated to provide only as much support for the child’s requested action as needed for the child to respond as requested. The adult provides no more than two repetitions of the request before moving into a gestural, partial physical, or full physical prompt.

(continued) *Instruction examples listed as back-to-back steps can always be separated into two requests for children to do.

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 215

FORM 7.4.  Action Plan Template for Parent Follow-­Through (p. 2 of 2)

Activity/ routine

Parent request

Child response

216

Reinforcer

Parent follow-­through



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expectations, the reinforcement that children receive for their responses, and the follow-­through to conduct when children do not respond on their own. When follow-­through is necessary, the strategies listed in the template’s last column reflect least-to-most prompting as reminders of how parents can ensure a response from children, while still promoting their independence to do as much of the behavior by themselves. The first two rows of the template are examples intended to help inspire ideas, but we encourage parents to select the requests and amount to ask of children for more (not less) follow-­through. You can ask these optional coaching questions to help parents plan how to use this step (some of the questions below are repeated from the last step): • “What play activity or other routine can you give instructions for your child to do?” [Ask the next question once parents select an activity or routine.] • “What request or instruction can your child do in this activity?” • “What reinforcer will motivate your child to meet the request or instruction?” • “What is something preferred that can follow your child doing this less preferred request or instruction?” • “How can you support your child to follow through with the request or instruction?” [Another way to ask this question comes next.] • “What strategies that we’ve discussed can help your child respond to your request or instruction?” • “What do you think would happen if you held back from using a physical prompt this time with your child?” • “What other requests or instructions could you ask your child to do at home?” Step 4: Teach Your Child to Understand Brand-New Words

and Instructions

What to Share with Parents: So far, parents’ instructions have taught children to do skills within their reach or capabilities. As children develop these skills, parents gradually add new instructions involving other skills they would like their children to learn to do in the activities or routines. For example, a mother wants her son to hang up his jacket or put it on the bench in the hall now that he knows how to take off his jacket by himself. Parents follow the same teaching process in giving children instructions and helping them follow through. The Teaching Process 1. Parents will select a play or nonplay activity and instructions for children

to do that fit within the scope of the activity. 2. Parents will figure out reinforcers or positive consequences that children care about and that relate to children’s behaviors (when possible).

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3. Parents give children the instructions and wait for them to respond or help

them follow the instructions if no response ensues. 4. Parents give reinforcers for children following instructions. For Coaches: Parents might like to use the “Action Plan Template for Parent Follow-­Through” to include other requests for children to do and some instructions may consist of two steps (e.g., “Pick up the toy and put it there,” or “Throw the napkin in the garbage and put your bowl in the sink”). For skills with lots of steps, with the parents, list the steps and prompts besides verbal instructions they can use to show children how to do the skills. Before parents’ last sessions with you, discussion should take place and a plan established for how they will continue to monitor their own learning and their children’s based on the strategies and skills you have helped them to develop. You can ask these optional coaching questions to help parents plan how to use this step: • “What other requests or instructions can your child do in this activity?” • “What back-to-back instructions could your child do in this activity, like pick something up and put it somewhere or bring it to you?” • “What other skills would you like your child to know how to do?” [Ask the next question once the parent selects a skill.] • “What are the steps for your child to learn how to do that skill?” • “Is the first or last step easier to show your child how to do?” • “What prompts besides verbal instruction can you use to show your child how to do that step?” • “What signs from your child tell you that he or she is learning how to do that step by him- or herself and you can fade your prompt(s)?” Closing In closing, this chapter has been more “technical” than any of the other chapters in this book, and we have written it this way in response to many requests for help that we receive from coaches in the field and from those taking our coaching workshops. Many experienced coaches will already have established ways of describing the various techniques they teach parents. However, we are holding in mind those interventionists working in public early intervention programs and those who are working as generalists and want to transfer their skills and knowledge to parents so that parents can integrate their interventions into a child’s everyday life. Changing from direct delivery to a parent coaching-­focused intervention requires a great deal of change in the interventionist’s moment-to-­moment actions within an intervention session, and this chapter is written to provide interventionists



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with topics and dialogue prompts that we have found to be quite helpful in transferring the reasons behind the intervention practices to parents. We assume that interventionists using this content will fit this material into their own personal styles of interaction and communication, as well as the learning styles and interaction styles that they have developed with each of the families they treat. We also recognize that these topics are focused on addressing the development of play, social communication, and interaction in young children with or at risk for ASD, and thus represent only a limited number of developmental domains that are affected in most of these children. However, these are the developmental domains most disrupted and delayed in early ASD, and these are the skills that are most predictive of better outcomes down the line. Focusing on these areas does not preclude including any additional targets in the coaching intervention that an individual child needs, but these areas are core components for all the NDBIs for early autism and are therefore essential to address.

Chapter 8

Variations in Coaching Practices

Thus far, we have been describing a scenario where the coach establishes a constructive, effective coaching relationship with families through which both parents and children progress well toward their goals. However, this typical scenario does not describe the day-to-day and week-to-week variations that arise in ongoing work with children with ASD, their families, or the life of the interventionist. As readers know, themes and variations, moving forward and stalling out, reward and frustration, elation and disappointment—all are part and parcel of this type of work. It is common to have to quickly redo a carefully thought-out coaching session plan in the moment because of what has been observed or shared by the family. Thus, the coach often has to let go of what he or she considered a great intervention idea because the family rejects it outright (“It’s OK with me if he sleeps in our bed with us forever!”). The following chapter describes some of the variations in our coaching practices in P-ESDM that we have experienced over the years. We want to give newer coaches ways to circle around, detour from, substitute, or accept obstacles to steady progress. We’ll consider innovative coaching approaches to increase access to intervention services and problem solving amidst challenging situations and diverse family needs. We will also explore coaching parents who vary considerably in their motivation, skills, abilities, and capacity to engage in intervention, and the coach’s need for cultural humility and ease with the learner role in the face of unfamiliar customs and beliefs. Significant variation in approach does not imply the inability to affect desired change. These examples describe coaching decisions to meet specific family and child needs while continuing efficacious intervention methods and a constructive learning environment. In so doing, we illustrate in more depth some of the necessary tools in each coach’s tool kit. We begin with the stories of three different families. 220



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Variations in Family Stories

Anna and Anthony Cabello The Cabellos’ 2-year-old son Gabriel had recently been diagnosed with ASD. The parents first became concerned when Gabriel was 18 months old and not yet speaking or babbling very often. They had always noted Gabriel’s easy-going nature and chalked his slow language progress to him being a boy, having two older sisters who did all the talking for him, and hearing a mixture of Spanish and English throughout his day. He was the baby of the family, the only boy, and everyone doted on him. It was not until the pediatrician became concerned about Gabriel’s development that she referred the family to a developmental pediatrician who made the diagnosis of ASD. Gabriel demonstrated limited eye contact, limited and unusual play interests and skills, and a lack of response to his name being called, coupled with delayed communication milestones. The Cabellos’ world turned upside down that day. They had risen thinking of Gabriel as their perfect baby boy and now only a few hours later, someone was telling them something was very wrong with him. They frantically researched ASD on the Internet to understand the symptoms, how to intervene, and what intervention approaches would help their son. However, no specialty programs for ASD were available in their rural area. The nearby public birth-to-3 services set up an intake appointment with them a month into the future and described the process of evaluation and early intervention. The Cabellos looked into better programs in the nearest cities, but both parents could not commit to a long commute given their full-time jobs, which the family needed to make ends meet. The parents did not want to delay help for Gabriel and felt consumed with grief and fear about what to do or how to get started with a program that could help their family. Their large extended family did not accept Gabriel’s diagnosis, would not discuss it, and suggested that the parents focus on prayer and the church as a source of comfort and help. What coaching issues stand out to you with regard to this family? Take a minute to jot them down. Does your list include these factors: a bilingual, bicultural family context, the family’s isolation in rural America, stigma concerns, lack of nearby professional supports, conflict between low-­intensity birth to 3 practices and high-­intensity treatment recommendations for young children with ASD, family conflicts about child status and needs, limited family financial resources and time, multiple caretakers and caretaking contexts (extended family homes)? Others? Here is how this situation played out. The agency social worker called to schedule an intake appointment, and in doing so asked Gabriel’s mother Anna to tell her about all that had taken

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place. Anna was so grateful for the opportunity to share that she told the whole story—the diagnosis, the information she had found on the Internet, the lack of ASD-specific services, the family conflicts, her limited time and inability to take time off from work. The social worker listened empathically, reviewed the detailed report from the pediatrician that she had been faxed, realized that the intake visit needed to occur at home and should cover all that was needed to qualify Gabriel for services in one visit, and set up an appointment with Anna for a visit at a time and date that would not interfere with her work schedule. In response to the conflicts with the extended family, the social worker asked whether discussing this with the parish priest was a possibility. Anna had a good relationship with her priest and eagerly followed up on this suggestion. Her priest listened attentively and encouraged the parents to proceed with the appointment, which would provide needed support for the parents with the extended family. The team visit involved the social worker, a speech and language pathologist, and an occupational therapist, given the pediatric report detailing language delays, ASD, hypotonia, and delayed motor milestones. Within the 2-hour window that Anna had secured from her boss, the team assessed Gabriel in all domains using a developmental profile. The social worker made friendly and respectful initiations in Spanish to the grandmother who was there taking care of the other children, complimenting her on her family, commenting positively on Gabriel and her daughter’s parenting ability with him, including her in discussions about his functioning at home, and looking for opportunities for shared points of view with her. The team then took a quick break to discuss their findings and what they could offer the family. The father Anthony was able to join in on his lunch break, and the team carried out a bilingual discussion with the family about the child’s needs and recommended services, including the family’s goals and its support needs. In response to the Cabellos’ requests for ASD-specific services, the team explained the benefits of a parent-­implemented approach and offered a combination of monthly visits and weekly telehealth contacts using an evidence-based practice, with the social worker as coach, given the very positive connections that she had established in this visit. The parents expressed concern that their child’s main need was speech therapy, and the speech therapist explained that she would be involved throughout Gabriel’s enrollment, viewing videos of the telehealth sessions, monitoring his progress, and detailing exactly what needed to happen. She also explained that children learn language best from the people in their lives, like grandparents and parents, and doing everyday activities. This was very satisfying to the grandmother, as was the therapist’s emphasis on the importance of Gabriel hearing both languages. Coaching consisted of contacts with the coach every 2 weeks via telehealth. The coach followed the session structure and data systems described in this book to coach the parents in an NDBI (Schreibman et al., 2015) and monitored both the child’s and parent’s progress. The Cabellos used a publicly available



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evidence-based telehealth coaching program (www.helpisinyourhands.org) which they watched weekly and incorporated into their everyday activities. The coach called during the parents’ lunch hour, which they had arranged with their employers, and Grandma joined in as she was so inclined. Gabriel responded quickly to the intervention, learning to play with his toys, began to imitate words (in both languages), and also started to respond to adult comments and instructions (again in both languages). While the grandmother maintained her position that there was nothing wrong with Gabriel, she was very supportive of her daughter and son-in law, was thrilled to see Gabriel learning, and she began to model what the parents were doing, just by watching them when all were together. His sisters also adopted the parent’s interaction style just from their exposure to it. When parents raised the question of his need for more treatment hours in the coaching session, the coach asked them to calculate how many hours in his day were spent on learning language, learning to play, learning to listen, and learning to do things for himself. Parents realized that he was getting as much intervention as the doctor had said he needed (20+ hours per week) and that he was making progress in all the areas they had expected, which helped them relax and look forward to their son’s continued progress. Are there additional supports that you might have provided? If you work in a setting similar to the one this intervention team did, it might be fruitful to discuss this scenario with your team; consider what might have occurred differently, and better, for this family and child. Additional resources that could have been provided include: tying the family into the statewide family support network and providing parent-to-­parent contact with the families of other children with ASD, preferably including parents with Latino roots. What else did you come up with?

Allie and Phil Warner Allie was a stay-at-home mother of two young children, a 1-year-old boy and a 3-year-old girl Ava, and the wife of a busy and successful businessman. She already had her hands full, managing her home and all the family’s needs, including supporting her husband at required social events. Her daughter had been diagnosed with ASD approximately 1 year ago. At the time of Ava’s diagnosis, Allie stayed up late at night to research, locate, and start intervention for Ava. Once services began, she enrolled her toddler in a full-day nursery school program and added all of Ava’s intervention needs to her daily schedule. Her husband supported her efforts but could not share either the physical or emotional burdens, given his demanding job and his own grief and anxiety. The two decided not to share Ava’s diagnosis with anyone just yet. Ava’s weekly interventions included intensive ABA intervention in the home, speech and occupational therapy sessions at a clinic, and a supported play group with two other children. Then there were

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the neurological and genetic exams to rule out epilepsy or other complications and routine pediatric visits to monitor Ava’s overall developmental growth and milestones. Ava’s team leader, the supervisor of her ABA team, observed Allie’s competence and commitment to Ava’s needs and complimented her frequently on her ability to support Ava, attributing the child’s rapid progress to Allie’s dedication and efforts. A comment that the team leader made frequently was “I wish all my parents could do what you do for their children.” Allie was, in fact, exhausted and felt very alone, but she thought all that mattered was Ava and getting her the help that she needed. Following a year of intervention, Ava’s gains in language, attention, social engagement, play, and self-care had moved her standard scores into the normal range in all areas, and her behavior had improved markedly. Her intervention team altered her intervention plan so she would now participate in an inclusive ABA preschool center program where all of her intervention needs were met at the center. Allie’s toddler had grown to love preschool and was thriving there, but the mother found herself at home, isolated and alone. None of the services that had been established or the hard work that Allie had done addressed any of her own emotions or personal needs in caring for her daughter. Allie felt a myriad of emotions—grief, fear, anger, blame, sadness, and loneliness. She had more and more trouble functioning during her day at home and found herself tearful, irritable, and tired all the time. She thought daily about what would happen to Ava as she became older and she noted each gain and each symptom, balancing her hope of a cure with her panic about a lifelong disability. Would Ava’s peers continue to accept her, or would they pull away or ostracize her? Would Ava fall in love? How would she support herself, and who would take care of her once Allie and her husband were gone? Would this responsibility fall to Ava’s younger brother, and would he grow to resent Ava? What if somehow Ava became hurt by someone she trusted? Would she know to tell someone or would the abuse continue? These fears plagued Allie, as did her knowledge that one day she would not be there to protect and care for Ava. She worried about her marriage and her inability to share any of these feelings with her husband. The gulf was widening, and she felt abandoned and alone. Both these parents needed help with their individual situations and a lifeline back to each other. In the IEP review meeting held at the center, the psychologist, speech pathologist, and team leader—a behavior analyst—met with Allie in a small, comfortable, carpeted room, sitting around a coffee table, to discuss Ava’s new treatment. The team leader began, “Now that we get to see Ava all day, we have a pretty good sense of how she is doing here, but we don’t have such a good sense of how things are going at home now. How are things at home now?” Allie sat silently, looking down, and started to cry. The team members felt her sadness, offered her a tissue box, and waited. Allie began to share: her loneliness, her fears, the emptiness of her daily life. When she paused, her team leader said empathically, “Things are



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so hard for you right now. I’m so sorry. Do you have someone you talk to about all this?” And then Allie revealed the estrangement between the couple, the depression, the silence. “It sounds like Ava’s needs have taken quite a toll on your family. I wonder if it would be helpful for us to meet together with you and your husband. We have not seen him in a long time, and it was an oversight on our part to not communicate with him directly. Would that be helpful, or if not, is there another way we can help? The experience of diagnosis and beginning intervention can be such a painful one for families, but things can get better.” Allie felt so supported by this dialogue—the careful listening, the reflection, the emotional support, the optimism conveyed in that last sentence. She thought a minute and decided that this idea would be a good next step, and said so. The team leader asked her whom she wanted in attendance, and Allie indicated that she thought it would be important to have the whole team there, to answer all her husband’s questions. After the meeting, the team reflected on their lack of inclusion of the father in meeting invitations. He had been so active in their initial meeting. They had handed over to Allie their own responsibility for communicating with both parents. They discussed how to approach the next meeting, the need to provide support for Allie, the signs of depression and anxiety they had seen and heard, the need for support for the couple. They decided that the clinical psychologist on the team should be actively involved in the next meeting given her skill set. They thought about Allie’s social isolation and wondered if parent-to-­parent contact might be helpful. There was a very active mother among their families, with family roles similar to Allie’s, who had started a parent support group. Mental health services including family counseling also seemed important interventions to raise. At their next peer supervision meeting, the team leader brought up the subject of Allie again, feeling very guilty that she had been in that home every 2 weeks for the entire year and had not tuned into any of these issues. She asked her team for help in reviewing her own work, and how she might have done things differently to try to avoid the current situation from developing again. What are your thoughts on this as a reader? This may be a helpful topic for your own team to discuss. What ideas that have been brought forward in this coaching book apply to the situation with Allie? The coach decided, with her team’s support, not to wait until the team meeting, but to raise the topic of the parent support group at her next coaching session with Allie, who was open to the idea and said she would consider it. The coach asked if she would like a phone call from the group leader, and Allie hesitantly agreed. The leader called her the next day and initiated a warm, comfortable conversation about the difficult situation they both now found themselves in, and how much it might help her to have other parents to talk to. She invited Allie to

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the next group coffee, later in the week. Allie agreed, although she was not sure how much she wanted to share in front of a group of people whom she did not know. At the same time, she appreciated the warmth and understanding communicated in that first phone call, and hoped that she might experience some of that connection in the group. Allie was grateful that she did not have to say much at her first meeting. The leader introduced her to the five women and one man in the room and shared a little about their group and the ground rules they had developed: the expectation of “acts of kindness” from each other, the agreements about confidentiality, about listening without interrupting, about not giving advice unless it was specifically requested, about the importance of “I” statements rather than cross-talk. As the members shared stories, thoughts, and experiences from their week, a lot of what was said resonated with Allie. Some group members expressed the pain and fear that Allie first felt when Ava was diagnosed. Others were exploring various intervention options. Some had been in the trenches for a few years and were thinking ahead to the future and what it might hold. All were sharing their lives in deeply personal ways—with humor, pain, loss, anger, and for some, acceptance, about their lives in ASD. The father in the group touched on the strain that his child’s needs placed on his marriage. He shared his feelings about his own struggles with how to take care of his son, whereas he saw his wife’s very natural instincts with their son. She understood what their son wanted when he took one of them by the hand, leading his mother or father to what he wanted, and how instead she taught him to touch or point to the item or thing he wanted, or how to lift up his arms and look at her to pick him up and attempt to say the word of the food that he was looking for when he stood in the pantry staring up at the shelves. As the son’s father, this group member felt that he should also know how to anticipate and read his son’s needs, how to provide for him, and keep him healthy and safe. Instead, he regarded himself as a failure as a father and husband, and his shame had gradually alienated him from his wife and left him unsure of how to approach her and explain these feelings. Allie took some comfort in listening to everyone share. She did not have to hide her feelings or pretend that everything was fine at home. Although she did not talk much in this session, when the group took turns speaking at closing, she thanked them and said it meant a lot to her to be there, and that she would return for the next meeting. While driving home, Allie wondered whether her husband ever felt the way that the father in the group had described. Allie thought about how she handled everything related to Ava’s intervention since she and Phil first became concerned about Ava not talking. From researching services to handling all appointments and sessions and learning how to use interactive techniques with Ava, Allie self-­ admittedly did not involve Phil. He was already busy with work and even more since Ava’s treatment. Allie realized how left out Phil might feel about Ava’s learning and development. She did not want Phil to feel unfit as a father to Ava and



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was glad about the team’s efforts to directly involve him. She also thought that Phil might get something out of attending the next support group meeting and planned to approach him with that very idea. Meanwhile, the coach sent out email messages to both Allie and Phil inviting them to a team meeting to review Ava’s last 12 weeks of progress and to consider goals for the coming year, since Ava was beginning her second year of treatment. She asked them to suggest days and times over the next 2 weeks when they might be available for a 2-hour meeting. Phil checked his schedule, found a window of time, and emailed the possibility to Allie, who then sent an email to the team, copying her husband, to set up the meeting. They arrived in separate cars to the meeting, which was again held in the comfortable space, with hot coffee, water, and cups available at the doorway. The coach greeted each and introduced them to the other group members. The meeting started exactly as the previous meeting had begun. In response to the question about how Ava was doing at home, directed to the couple, Allie looked at Phil and waited. He began, stating apologetically that his work was so demanding that he had little time at home, often leaving early and arriving late at night. He commented on how much he enjoyed seeing Ava’s steady progress on the weekends when he was not traveling, and expressed his appreciation to the team for their efforts. He also looked right at Allie and expressed his appreciation to her for all she was doing for Ava and for their family and home. As the group listened, he became reflective. “After she was diagnosed, the world turned pretty black for me, and it was all I could do to get to the office and do my job. I felt kind of numb, and alone, and far away from everything.” Allie put her hand on his, and he held it. “Now I see her chatting, watching movies, running around in her little pool in the yard, and she seems like a different child, like any other child, and it gives me hope. I see her curiosity, her humor, her personality. She makes me feel more alive.” Allie squeezed his hand and they looked at each other. “I want to do more to help Allie. I don’t want you to have to do this all alone.” Allie wiped away some tears, and the nearest team member passed over a tissue box. The team psychologist spoke up: “We are happy to help you both continue to help her. That’s our job. Shall we talk about some things that you see she still needs help with? How can we all help her learn those skills this year, with us working with her at school and you at home?” Both parents nodded, and the conversation moved to goals for the coming year. As plans for learning were made that involved home and family activities, the coach made a point of looking at both parents and directing questions about home learning to both. Allie answered first, describing what she could do in her time with Ava. The coach thanked her and then purposely looked at Phil, who had ideas of his own for his weekend time with Ava. When Allie asked him if that would really work out for him, he said, “I don’t feel like I know my own daughter

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very well, or my son either, for that matter. I want to feel like their dad. You know how to do so much with them. I want that, too.” In the pause that followed, the psychologist commented how difficult the year after diagnosis and treatment was for so many families, how deeply it affected mothers and fathers alike—the sadness, the worry, and how hard it could be on each parent and on the couple and family. People and families adjust, and find their ways forward, but they need help in the process, from each other, from other family members and friends, and from other professionals, including therapists and counselors. She added, “Knowing what kind of help you need to be the kind of parent you want to be with Allie is the biggest step toward achieving it, and our job is to help you find those supports. I’m so pleased that we could all meet together, and I apologize to you, Mr. Warner, for not including you in all our prior emails and communications. That was an error on our part, and we will not make that mistake again. We’ve covered a lot today, and our time is almost up. I imagine you will need some time at home to process all that we discussed today. Shall we meet again in a few weeks to check in and see how your home goals are going, and if there are other supports you have identified that we can help you find?” Phil answered, “I like that plan, and I’ll need some real concrete help with my own goals for my time with Ava, something written, something specific.” The coach immediately volunteered to build that plan with him at her next parent coaching session and asked him to set a date and time to work on that task. Take some time to reflect on this team meeting and discuss it with your own team. Are there other points you would have raised in this meeting? Are there interventions in it that you and your team members disagree with? Have you ever been in meetings like this? What would you find useful in your own practice in terms of how this team managed this session? The progress review meeting occurred a month later, with the psychologist and coach in the family’s home. The difference in the mood of both parents was clear. Both parents reported enthusiastically on progress with Ava with their own activities, and when the psychologist asked about whether they were finding it helpful to discuss their activities together, their descriptions of their problem-­ solving dialogues made it clear that the lines of communication had opened up. Allie also described the ideas and help that she and Phil were getting from the parent group (Phil attended when he could), and she reflected on how differently she felt now than a few months earlier, how much less alone, how much more optimistic. Phil’s nonverbals mirrored her statement. Think about the variations in typical intervention practice that were brought into play for this family. Are these variations that you have used before? Are there



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families in your own practice that resonated with you as you read Allie and Phil’s story?

Akio and Kumi Sato Akio and Kumi Sato and Kumi’s parents moved from Japan to the United States when their son Kaito, 2 years, 3 months old, was diagnosed with ASD. They did so to participate in a research study that would offer a 2-year home-based intensive intervention program to Kaito delivered by a well-­trained team in their home at no cost to the family. In addition, the team worked directly with the parents and grandparents to coach and support them in how to use the intervention techniques within their daily activities and family routines with Kaito. Within the first few weeks of intervention, the Satos noticed subtle but significant differences in Kaito. He appeared more curious in what his family did and would walk over to take a closer look, something he never did before intervention started. He sat longer to do certain activities with his family, such as looking at a picture book or putting pegs into a pegboard. He also smiled and laughed with others in activities he loved, such as his sister tickling and chasing him or his grandmother twisting water from a washcloth over his head during bathtime. These developments made his family ecstatic and hopeful for his prognosis to continue learning new skills. There was just one problem. His parents did not feel competent or confident in their ability to help Kaito learn. While the intervention team held regular meetings with the parents and the team leader had parent coaching visits with them every 2 weeks, the Satos did not understand everything said. Conversational English was not easy for them, and the rapid speech and amount of information provided during their team meetings required great concentration and attention on their part. They could not process the information fast enough to answer questions being asked of them. During parent coaching sessions at home, the coach included all the adults, which required that the parents act as translators between grandparents and coach. The coach worked hard to use the kind of parent-­ centered dialogues we have described here: open-ended questions, parental choice, and shared control of the goal and session planning processes. However, this was a different scenario than what the Satos were accustomed to with professionals in Japan. They expected that professionals would tell them what to do, and they were uncomfortable answering questions about their goals, their ideas, or their personal experiences or feelings. They were shy and embarrassed about their English skills. The grandparents found the process incomprehensible and questioned the expertise of the coach because why else would the coach ask for their ideas and input? The parents felt caught between the grandparents and the gratitude and pleasure they experienced as they watched the teamwork with Kaito. The parents did not want to work with Kaito in front of their coach and were not comfortable in their

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parent coaching sessions, and neither was their coach, who began to dread these sessions and found herself looking for reasons to cancel them. Take a few minutes to put yourself in the coach’s place. What might you be feeling about yourself, and about the Satos? What ideas would you have for varying your coaching practices? What steps would you take to increase parental comfort and involvement, and ease tension with the grandparents? What steps would you take to deal with your own feelings? The coach decided to ask for a reflective supervision session with her team. In this session, she first described the scenario, and her own feelings of frustration, inadequacy, failure, and powerlessness to help the family use the intervention techniques in everyday activities with them at home. She described her sense of hopelessness as she watched the grandparents feed him, cater to his every whim. “They undo everything we have done as soon as we walk out of the house! It feels like a waste of time and money, and I don’t know what to do. I’m not the right person for this family,” she shared tearfully. The team members listened carefully, and when she was finished, they began to ask open-ended follow-up questions. How did she wish the sessions would go? How would she change them if she could? How did she think the parents wished the sessions would go? How would they change them if they could? As the dialogue continued, helpful ideas bubbled up. One group member shared what she had learned about cultural differences in working with Asian families and colleagues in a previous job. She discussed the preference for some families to be in a learner role, especially early in the intervention. She also discussed working with families in which the culture itself expects less independence from young children than does American culture. Another considered the challenges of being in the interpreter role and wondered about other ways to support the grandparents’ needs and interests. A third asked the coach what would she like to do if she was to start again with a clean canvas. The speech and language therapist observed the language-based communication challenges embedded in every contact and wondered what effects those could be having for everyone. Stop here and consider other open-ended questions and reflections that you would offer in this session. The coach left the meeting with several ideas that she discussed at her next meeting with her supervisor. One involved an inservice session for the team from the local Asian-­Pacific Mental Health Center to increase their cultural awareness of typical professional–family relations in Japan. This occurred, with considerable discussion about the meaning of having a son with a significant disability and



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cultural processes related to grief and treatment. The center agreed to continue to support the team, and also suggested a translator from their team who might be of help. A second idea involved a meeting with the parents at the center with a translator present as well as the supervisor and team member with experience with Asian families. The purpose of the meeting was threefold: (1) to discuss how the parents most wanted to use the parent coaching meetings, (2) to discuss the cultural differences between life in Japan and life in the United States as it related to working with therapists as well as topics of child language learning and child independence, and (3) to consider how best to help with communication with the grandparents about Kaito’s needs and interventions. The meeting occurred with the translator, a therapist from the Asian-­Pacific Mental Health Center. In it, the parents were far more talkative and open than they had been previously. They expressed their gratitude to the coach and team members about their care for Kaito and the family, and their amazement at his rapid progress. They shared their astonishment at hearing him begin to say words in both languages, and their pride in his rapid response to toilet training, which had been a priority for them. In response to questions about what they most wanted during their coaching sessions, they answered that it was difficult to listen and respond with the grandparents present. When the coach asked whether the parents might like to meet at the center with the coach and Kaito, they enthusiastically agreed, and said that what they most wanted Kaito to learn was how the coach would help him play at home, go on walks to the park, and behave well within a Japanese-­language church service they wanted to attend. They thought this last goal in particular would matter very much to the grandparents and help them come on board with Kaito’s interventions. They expressed gratitude for the written and video materials the coach had provided, since written English was easier for them to absorb than conversational English alone. They were very pleased that he could eat with a fork and spoon, even though it was not something that they expected, and they shared their pride in the compliments they received at church family dinners about his eating skills and behavior at the table. They wanted to learn how to help him manage as well in other settings so that they would not be embarrassed by him. They also wanted to understand how American families explained their children’s autism to others and how they managed grandparents who denied any problems. The translator’s mental health expertise and cultural expertise were of tremendous help in this meeting, and she offered to continue to be a part of team meetings in the future. Several changes in intervention delivery resulted from this meeting. The coach and family began to meet at the center, and the coach comfortably took on a more educational orientation in her sessions with the parents. She went with them to a playground with Kaito, and also to a church service and the lunch that followed to learn about expectations and activities for toddlers. She developed a

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plan for Kaito in the next coaching session, writing out on a dry erase board the goals that the parents wanted Kaito to do in each of these settings, followed by the steps of how to help him learn each goal. The father then recorded this on his phone, and they went to the playground at the center to try out Steps 1 and 2. The father recorded the coach’s actions and then asked his wife to record him as he tried the same activity on the swing, with the coach’s help. He then asked his wife to try as well, as he recorded. Kaito responded well with both parents—­ requesting “go” for pushes (Step 2) and “down” (Step 1) when he wanted to get down to push the swing himself. The parents were very excited that he enjoyed this and chatted about the swing at the park that evening. Similar activities took place around church activities, with the coach modeling and writing out each intervention program for the parents, with the parents recording each activity. They later told the coach that they used the videos to cue themselves and also shared them with the grandparents. They also began to bring videos of Kaito to the coaching sessions, both to show how well he was doing and also to ask for help when activities broke down. For church activities, the coach developed a plan of how to increase his participation and made sure the intensive intervention team taught him the core skills in sessions, which she then practiced with the parents in coaching sessions. When the parents asked the coach if she would come to church with them the first time to show them how to support him, she did (all recorded by the father). As the parents became more and more comfortable with the new approach and more confident about Kaito’s learning and their own ability to teach him, they continued to bring videos and questions about problems that occurred, and by the next quarterly review, they were ready to set goals for coaching for the next quarter. Akio also became more comfortable sharing observations and reactions during sessions, though Kumi held back, until one day she brought Kaito alone, and surprised the coach with how much she wanted to talk about her son. At the next quarterly team meeting, the team members and translator listened with rapt attention as Akio explained (in English) how he and his wife had answered questions about Kaito that came up at a church lunch once Kaito began to attend the toddler group, and how much support the minister provided to them. He exclaimed in wonderment about his ability to use the term “autism,” and the supportive reactions of the other parents, many of whom knew about autism. He had provided links to a Japanese website about autism for some families who asked about it. His wife commented on how much Kaito had learned, that there was no reason for shame, that she thought he would do great things in his life. This family experience highlights cultural variations that may deviate from typical coaching practices used with Western families. How do your coaching practices recognize and respond to potential cultural stigmas associated with autism and mental health needs? Are there other coaching resources you would need to help a family like the Satos?



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The rest of this chapter discusses in more detail the adaptations used in the above examples as well as coaching parents in a group format. Coaching Adaptations

Mental Health and Counseling Services The process of observing child difficulties, referral, diagnosis, and beginning intervention raises deep and painful emotions for most parents. The grief and mourning after a child autism diagnosis have been well described in the clinical literature. The interpersonal processes that we have described in this text can provide considerable support for families and many opportunities to discuss these issues with a caring, listening coach. However, many parents need mental health services along the way. Recognizing the signs and symptoms of mental health difficulties is a critical skill within an early intervention team. Identify this skill set within your team; make sure that team members are aware of the signs and symptoms of such needs, and discuss how and when to bring these issues to the fore. This will help all team members listen better for such signs and bring their concerns to peer supervision so that the mental health difficulties of family members do not continue to worsen over time, as did Allie’s. Coaching techniques that we have discussed in this text can help to provide needed support and a two-way communication line that will help parents share their ongoing experiences, both positive and negative. These include checking in every week on how things are going, making time for parents to raise any topic in the coaching session, deep and careful listening, the use of the reflection process, and avoiding the cheerleader role with its general praise, compliments, and unmitigated enthusiasm.

Dealing with Conflicts It is necessary to speak directly with parents about conflicts that the coach feels pose a significant challenge to the success of the coaching sessions. The goal of the resulting conversation is always a collaborative, goal-­focused resolution with both parties satisfied with the outcome. Examples like those above illustrate the importance of deep listening and taking the time to rethink the coaching approach and tools being used. All kinds of variations can occur without compromising the integrity of the intervention. All kinds of support can be enlisted to help with the impasse. Particularly in challenging moments, how we respond can make the difference between families continuing with or ending sessions. Our response may ultimately determine whether the family achieves the goals and learning outcomes that all had hoped for. Parents can learn a wide range of intervention strategies, and they can support their child in ways they cannot yet

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imagine, but their learning depends on the coach’s creativity, flexibility, commitment, and humility.

Culturally Informed Practices Cultural differences involve far more than language, race, and ethnicity. They involve religious practices, community norms, social class and socioeconomic status, regional and local practices, and parenting philosophies and practices, among many other factors. These are transmitted to parents throughout their lives through their relationships with important others—family of origin, friends, classmates, church contacts, work colleagues, recreational groups, and community contacts, among many others. All of the families described here demonstrated specific sociocultural aspects of the challenges they were facing, aspects that were not part of their coach’s lives. Careful listening, peer supervision, consultation and learning from outside the group, thinking outside of the box, and a cultural framework were needed to help each of these families. Every family is part of one or more specific subcultures. Coaches need to be careful not to assume that physical similarities with their clients imply shared cultural understanding, or vice versa. Learn to ask many questions over time to understand the family’s practices, philosophies, challenges, preferences, fears, and hopes regarding parenting and raising their autistic child.

Telehealth Coaching The rise of the Internet has paved the way for telehealth as an alternative approach to coaching families with ASD (Hall & Bierman, 2015; Hall, Culler, & FrankWebb, 2016). Telehealth (also used interchangeably with the term “telemedicine”) is medical information exchanged from one site to another using electronic communications, such as two-way video, email, smartphones, tablets, and other wireless tools, to improve a person’s health status (American Telemedicine Association, 2014). Our own research has examined various technology platforms starting initially with DVDs and websites for parents to access written and video content to video conferencing, where parents can see, hear, and communicate in real time with a coach from their homes. Through these applications, families throughout the United States and in other countries have practiced, reflected, and evaluated their learning and their children’s progress with the P-ESDM (www.helpisinyourhands.org; Vismara, McCormick, Monlux, Nadhan, & Young, 2016; Vismara, McCormick, Shields, & Hessl, 2019; Vismara, McCormick, Young, Nadhan, & Monlux, 2013; Vismara, Young, & Rogers, 2012). More and more clinical settings now have the potential for delivering telehealth services to families. Both research evidence and clinical experiences have reassured us about the ability of this modality to deliver high-­quality parent coaching to families who need this service.



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However, each professional discipline has specific ethics and practices regarding Internet delivery of treatment, protection of confidential information, licensing, billing, record keeping, and other aspects of clinical care. Individual professionals who wish to use telehealth services need to consider their malpractice insurance, professional ethics, agency policies, and the security of Web-based communication before they begin to provide this service. However, we are confident that telehealth services will become more and more widely available, breaking down access barriers for many families and professionals alike, and resulting in more service delivery and more economical delivery in the years to come. There are many online courses for those wanting to understand more about the legal and practical use of telehealth within their professions. Coaching Parents in Groups Parent group coaching is increasing in use among families with ASD (Baker-Ericzén, Stahmer, & Burns, 2007; Gengoux et al., 2015; Hardan et al., 2015; Minjarez, Williams, Mercier, & Hardan, 2011). The synergistic experience of being part of a group and able to connect, support, and learn from each other while learning and practicing how to foster child learning is an important benefit of this experience. Comfort and insight may come from watching other families at work with their children as well as listening to other parents’ stories and experiences that have impacted their lives. Parents may develop new resources and connections through these exchanges for working with their children and for connecting with other parents, which help them feel less alone and more adjusted psychologically and emotionally (Minjarez et al., 2011). In our own initial efforts to figure out how to coach parent groups in P-ESDM, the focus remains on helping parents form and reach their goals through the use of planning, action, personal reflection, evaluation, and other adult education principles (Trivette, Dunst, Hamby, & O’Herin, 2009). We also use the family-­centered approach described in Part C of the IDEA. In group coaching, parents meet with the coach as a group without their children to identify goals that will serve as learning foci in sessions. They then practice with their children at home and in 15-minute one-on-one sessions with the coach, followed by a chance to reflect–­evaluate– plan in terms of the impact that intervention has on their parenting actions, their child’s behavior, and their daily life. The coach (and the group) listen, support, and process without imposing beliefs, values, or priorities onto parents. Resources and tools are provided just as they are in individual coaching, and coaching remains focused on the contextual, relationship, and behavioral variables important to parent–child–family dynamics, interactions, and learning (Vismara & Rogers, 2018). Coaching in all these formats involves preparation before and after each session to assure that it starts and ends on time, follows an agenda or plan, and

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addresses the actions and topics of the families. We use the same coaching session plan that we use in one-to-one coaching, although in group delivery, not all of the coaching activities outlined may be possible without children present in sessions (see Form 8.1). (We offer alternatives below.) Table 8.1 lists the similarities and differences in preparation between coaching individual families and groups. With groups, the first session may begin with the coach posing discussion questions for parents to answer together as an ice-­breaker to get to know each other and to find out common interests or needs for formulating connections. In addition, the coach and group may want to set ground rules with regard to their communication and behavior toward one another, for example, no interrupting, keep all that is shared confidential and limited to the people in the room, no telling each other what to do or criticizing what a parent has done. Moreover, emotions and stress may be high when talking about personal and difficult experiences. The group needs to be a safe conversation space that helps parents share, discuss, and resolve their differences of opinion in constructive ways so that it is always a place of support and encouragement for its members and members remain committed to one another’s success. Research tells us that parents who feel safe enough to openly communicate and describe their experiences in detail are more likely to benefit from coaching and engage in intervention practices important to children’s development, compared to those who feel less able to do so (Hutman, Siller, & Sigman, 2009; Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2012; Siller, Hutman, & Sigman, 2013). Table 8.2 lists the similarities and differences between the first session for coaching individual families and for groups.

Planning and Observation In group work, the initial check-in and planning set the stage for actions that will follow. In group coaching, each parent briefly describes what was practiced since

Table 8.1.  Group Coaching Preparation

Similarities to individual coaching

Differences from individual coaching

• Planning sheet outlines intervention topics and coaching activities to cover in sessions.

• Not all activities on planning sheet may be possible with groups.

• The coach is organized, prepared, and ready to start and end sessions on time. • The coach summarizes information and parent, child, and coaching data after each session.

• Planning sheet may address more than one topic or need with groups. • The meeting room is of adequate size and has visual or other coaching aids to accommodate learning. • Intervention toys and child care volunteers are available if children are included.

FORM 8.1

First Group Session Plan Coach:             Client:             Session Date: Topic/Goals from Last Session:

Check-in (updates/needs/tentative session plan)

Observation (reflection/evaluation/session plan)

Topic (strategies/goals)

Coaching Activity 1 (reflection/evaluation)

Coaching Activity 2 (reflection/evaluation)

Closing (action plan/questions/needs)

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 237

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Table 8.2.  Plan for the First Session

Similarities to individual coaching

Differences from individual coaching

• Explains the structure, organization, and coach versus family roles involved with sessions.

• “Ground rules” are recommended to go over positive communication practices with groups.

• Positive communication practices are modeled by coach to promote a safe, accepting environment.

• Group confidentiality is discussed and practiced.

• Goal setting follows parent priorities and defines the intervention content and behaviors taught in sessions. • Goals and teaching steps follow an ABC learning contingency in parent-­friendly language.

• Volunteers arranged if children participate in group sessions. • Test the Internet and audiovisual connection in rooms selected for video conferencing. • Find common ground in group goals to build peer connections and social support.

the last session. The coach and other members celebrate achievements, no matter how small. Challenges are asked about or acknowledged but not problem-­solved until the coach observes the parent and child in action. In group sessions where children are present, parents work with their child in a brief activity in front of the group, discussing the goal and providing some reflection afterward to share with the group. If children are not present, parents may opt to share video, or at least goal-­tracking sheets, of their practice at home. The coach takes parent fidelity and child performance data to track progress and to guide the reflective conversation that will take place next with parents. Data are not talked about as numbers or scores necessarily with parents, but rather as parent–child behaviors that relate to the learning strategies and goals parents strive to change. Constructing data into meaningful actions and constructive feedback parents can follow and feel good about doing is how the coach supports their learning. Below are two statements from a coach talking about data. What differences do you notice between the two statements? Which approach would resonate if you were the parent in the session? Coaching Statement 1 “I noticed the different ways you pulled Henry’s attention to you. When Henry looked past you, you followed his eyes to the musical instruments and moved them right in front of you. You gave him a moment to look at the instruments and named each one for him to notice. When his attention lingered on the drum, you picked it up and held it out for him to take. He looked at you while doing so. I saw other looks Henry gave you when you sang, ‘The Ants Go Marching’ and banged your drum. Henry’s attention seemed to lessen from

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you as other tools he could use to hit the drum were added to the activity. What could we try differently next time to introduce these new and creative ideas without Henry losing sight of you?” Coaching Statement 2 “I scored a ‘3’ for how you pulled Henry’s attention to you. This score means you had Henry’s attention on you some of the time but not all the time. The actions where you enticed Henry to look at you was following his interest to the instruments and moving them in front of you, as well as singing a favorite song while drumming. I also saw Henry’s attention slipping from you as more materials were added to the activity. What could we try differently next time to hold onto Henry’s attention and get your score to a ‘4’ or ‘5’?”

Topic of the Day and Coaching The coach explains the topic, briefly, with a variety of teaching aids (e.g., handouts, videos, visual anchor points, role play, journaling). This leads parents into the first coaching activity to practice the topic and related goals with their children. Without children present, discussion, video analysis, and role play are methods to help parents process the new skills being discussed. The Appendix A.4 “Activity Categories” cartoon handout helps parents see the different options and learning moments available, whether it is toy play, sensory social routines, caretaking activities, books, mealtime, child-­appropriate chores, or family outings. Table 8.3

Table 8.3.  Coaching Action in Groups

Similarities to individual P-ESDM

Differences from individual P-ESDM

• Defined by the topic and goals and supported with coaching.

• Multiple learning tools and coaching modalities to accommodate unique and different learning styles and when children cannot participate in sessions.

• Coaching in the moment is concise, positive, and improves parent–child skills. • Accomplishments (no matter the size) recognized. • At least two different coaching activities practiced per session. • Reflection and evaluation follow after each coaching activity. • Results in a plan of how information will be practiced, by whom, where, when, and measured.

• Group input to other parents’ action plans. • Increased attention to parents’ body language and nonverbal signs of discomfort or dissatisfaction. • Unobstructed view of parent–child interactions for telehealth coaching. • Parent–child videos as a substitute for live coaching if children cannot participate in groups.

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outlines the similarities and differences of coaching action for individual families and groups.

Reflection and Evaluation Reflections occur after each activity, and the evaluation ends the session. Evaluation goes hand-in-hand with reflection to support the coaching process. For parents, evaluation provides a platform for self-­assessment. Do parents see improvement in what they are doing? Are they achieving, or at least moving closer, toward desired goals? For the coach, parents’ evaluation coupled with their own evaluation of what happens in sessions informs the next steps for learning. Are parents ready to segue to another intervention topic and goals, or do they need more time to meet their expectations? The coach plans several moments inside telehealth and group sessions for evaluation to occur. The first takes place within the check-in conversation when parents describe what they have practiced since the last session and how those experiences compare to the goals they set to achieve. Parents share their goal-­ tracking sheets, or the coach asks for them. All efforts are recognized and validated by the coach and other parents if in groups. Sharing brief reflections with each member of the group at the closing of the group helps the coach develop a clear action plan for each parent to practice at home in order to progress toward the desired results. Please refer to progress-­tracking strategies for some examples of simple data-­tracking systems we have made for parents to evaluate their own progress. Tables 8.4 and 8.5 outline how reflections and the closing evaluation are conducted in groups, compared to individual families. Some Final Notes Consider the following lessons learned when varying coaching practices to meet specific family needs. These come directly from our own research and clinical

Table 8.4.  Reflection Phase

Similarities to regular P-ESDM

Differences from regular P-ESDM

• Share insight about practice and progress to make coaching decisions and before new content is introduced.

• Time management is central for everyone in the group to share.

• Goal tracking sheets, questions, or statements may help with time management or recall.

• Group contributions are important to bonding through success and struggles. • Anticipate how to use content at home if children do not participate in groups.



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Table 8.5.  Evaluation Phase

Similarities to regular P-ESDM

Differences from regular P-ESDM

• Assess progress toward desired outcomes after each practice.

• Invite group praise and support.

• Different options for goal tracking. • Adults decide which evaluation methods work best. • Informs coaching decisions and action plans.

• Parents need to feel encouraged and comfortable to ask for help when in groups or online. • Different evaluation methods may be used simultaneously with groups.

• Any and all progress are acknowledged. • Problems are addressed within a defined time frame set by coach and learner.

practice with families. Parent coaching and the adapted coaching modalities described in this chapter are not intended to substitute for intensive early intervention. We do not have data that compare the efficacy of each. However, data do demonstrate that parent-­implemented ASD-specific interventions help families and children when compared to generic interventions, or no interventions. Parents are first and foremost their child’s parents, not their therapists. We use parent coaching to equip parents with tools to help their interaction and communication with their child and to help their child learn how to grow and learn in everyday life at home. We believe in the importance of parent coaching even when children are receiving intensive early intervention from a skilled team, and all of our studies and clinical practices have used parent coaching to support parents’ involvement, knowledge, advocacy, and confidence in themselves and their children. The parents in the examples that started this chapter each faced a specific set of challenges, but they also had multiple commonalities: their love for and commitment to their children, their desire to teach their children and be involved in their care, and the insight and wisdom about their child’s abilities and needs parents hold. It is our role as coaches to be flexible and adapt to parents even when this means setting aside our own expectations, values, and preconceptions of how the intervention should unfold. Through this process of communicating, accepting, and adapting, trust builds between the parent and coach and forms a solid foundation for the coaching process and for parent and child learning and growth.

Chapter 9

Looking to the Future Challenges and Opportunities

In this chapter, we suggest several directions for future research on different aspects of parent coaching and discuss the broader impact of parent-­implemented intervention. These research directions include: (1) understanding how parent-­ delivered early interventions can be adapted for children with ASD who have co-­occurring psychiatric or medical conditions; (2) developing and implementing strategies for use with children and families in low-­resource communities within the United States and globally; and (3) creating and evaluating parent-­delivered intervention for infants at risk for ASD. Children with ASD Who Have Co-­Occurring Conditions: Treating the Whole Child Practitioners who serve as therapists or parent coaches for families with children with ASD have long recognized that ASD is not one condition, but rather represents a heterogeneous group of neurodevelopmental disorders characterized by difficulties in social interaction and engagement and the presence of restricted and repetitive behaviors. The fact that a core tenet of any ASD early intervention program is that it must be individualized reflects awareness of the tremendous heterogeneity found among children with ASD. Therapists help families establish individualized goals based on the unique needs and characteristics of each child and family. The specific strategies and sequence of activities also are specifically tailored for each child and family. The core principle is that treatment for ASD is not “one size fits all,” but rather a highly personalized endeavor. This is a tenet of all empirically validated early intervention programs (Schreibman et al., 2015). There is increasing recognition that ASD also overlaps with several psychiatric 242

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243

and medical conditions that need to be treated in their own right. This has led to a call for early intervention approaches that address more than one condition.

Psychiatric Conditions Two of the most prevalent psychiatric comorbidities are anxiety and attentiondeficit/hyperactivity disorder (ADHD); 40–60% of children with ASD meet diagnostic criteria for one or both of these disorders (Leyfer et al., 2006; Turygin, Matson, & Tureck, 2013), as illustrated in Figure 9.1. Research has shown that having both ASD and another condition, such as ADHD and/or anxiety, affects a child’s outcome (Magnusdottir, Saemundsen, Einarsson, Magnusson, & Njardvik, 2016; Sikora, Vora, Coury, & Rosenberg, 2012; Sprenger et al., 2013). Such children tend to have more severe deficits in social interaction and language, higher levels of sensory sensitivities, and more challenging behaviors, such as tantrums and aggression. In addition to these differences in behavior, having ASD in combination with ADHD and/or anxiety also affects a child’s physical well-being. The presence of these co-occurring diagnoses has been linked to increased gastrointestinal problems and difficulties with sleep (Johnson, Gliga, Jones, & Charman, 2015; Singh & Zimmerman, 2015). The presence of a co-occurring diagnosis, such as ADHD, is one of several family and child factors found to be associated with disparities in access to diagnostic assessments and early intervention. Other factors that lead to a delay in diagnosis include ethnic or racial minority background and lower parental education and socioeconomic status. One study found that children who received an initial diagnosis of ADHD before being diagnosed with ASD were nearly 30 times more likely to receive their ASD diagnosis after age 6 (Miodovnik, Harstad, Sideridis, & Huntington, 2015).

Autism

ADHD

Anxiety

Figure 9.1. Conditions that can co-occur with ASD. Forty to 60% of children with ASD

also meet diagnostic criteria for ADHD and/or anxiety.

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In addition, the presence of both co-­occurring anxiety and ADHD symptoms has been found to interfere with the ability to fully benefit from behavioral interventions (Antshel et al., 2011). This is one reason why current research is examining how early intervention approaches, including parent-­delivered interventions, should be adapted to better fit the needs of children with ASD who have a co-­occurring psychiatric condition. While this research is ongoing, there are a number of things that a parent coach can do to increase the likelihood that early intervention will be successful. First, become familiar with the symptoms of co-­occurring psychiatric conditions that commonly affect young children with ASD. Although the symptoms likely begin during infancy, these conditions are detectable as early as 3 years of age. Symptoms of ADHD include inattention (e.g., trouble holding attention on tasks or play activities, failure to complete a task, easily distracted) and hyperactivity/impulsivity (e.g., fidgets, squirms, leaves seat frequently, runs about and climbs on things, trouble waiting). Children with ADHD (and infants who are later diagnosed with it) tend to be more irritable and fussier (Sullivan et al., 2015). Interestingly, these problems are ones that are common for a young child with ASD, especially if they are just beginning a treatment program. Many children with ASD initially are unable to sustain their attention to a play routine and wander around the room or climb on furniture. Some children become fussy and irritable when they sense that some demands will be made of them. However, as the intervention proceeds, we expect to see that the child is increasingly able to focus his or her attention on a play activity when it is engaging and developmentally appropriate and start to readily approach the parent with an interest in playing together rather than running around the room. We also know from experience that children differ in terms of how quickly they are able to “learn to learn,” meaning that they become attuned to the play activities and engage in them for developmentally appropriate periods of time. When a child is on the extreme end of this continuum and is making very little progress despite the sustained efforts of both the parent coach and parent, it is time to consider whether the child might have ADHD. Similarly, children younger than age 3 are less likely to be diagnosed with an anxiety disorder, although the symptoms can begin to appear much earlier. Common symptoms of an anxiety disorder in a young child include frequent crying; extreme fears (e.g., of certain sounds or objects); reluctance to separate from the parent; extreme distress reactions when novel objects are introduced; frequent meltdowns and tantrums, especially in novel situations; avoidance of certain activities; refusal to speak; and specific phobias (e.g., of restrooms or dogs). Studies have shown that children with ASD who have higher levels of sensory over-­ responsivities are more likely to have an anxiety disorder (Mazurek et al., 2013). Specific phobias are especially common among children with ASD and might be related to negative sensory experiences (e.g., fear of the toilet after hearing loud

Looking to the Future 245



flushing) and difficulties shifting their attention away from the negative experience. If symptoms are affecting the child’s ability to make progress from a parent-­ mediated intervention or the parent mentions that anxiety or ADHD-like symptoms are interfering with family life, a referral to an appropriate specialist is warranted. Early intervention with young children with ASD and their families should always be conducted within the context of an interdisciplinary team. This means that either the parent coach is in a setting where other disciplines are part of the clinical care team or the parent coach is aware of the appropriate referrals for specialists, as needed. Consultation with a psychologist, psychiatrist, and sometimes a primary care pediatrician can be helpful. Regardless of the ultimate diagnosis of a co-­occurring condition, it will be important to adapt the intervention to consider the impact of the co-­occurring condition. Fortunately, best practices for treating ADHD and anxiety in young children involve the application of principles of applied behavior analysis, which is already part of P-ESDM. The strategies that focus on the principles of ABA (antecedent–­behavior–­consequence) will be especially relevant as you consider how to guide the child’s behavior to enhance social engagement and learning. Behavioral principles that you are already familiar with, such as slowly introducing novel activities (called “graded exposure”), encouraging the parent to reinforce approximations to the longer-term behavioral objective, and reinforcing increasingly long periods of appropriate engagement in activities, will go a long way in

Symptoms of ADHD and Anxiety in Young Children ADHD

Anxiety

• Trouble holding attention to play activities

• Crying often

• Failure to complete a task

• Reluctance to separate from parent

• Easily distracted • Fidgets and squirms

• Extreme distress reactions to novel objects

• Leaves seat frequently

• Frequent meltdowns and tantrums

• Runs about and climbs on things

• Avoidance of certain activities

• Trouble waiting

• Refusal to speak

• Irritable and fussy

• Specific fears (e.g., of restrooms or dogs)



• Having extreme fears

• Fears related to sensory sensitivities

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helping the child and parent. Ideally, the parent coach and a professional who is trained in the behavioral treatment of ADHD and/or anxiety will meet together with the parent to develop ways in which the parent coaching session can be adapted and to identify shared goals and strategies. This is not unlike how the parent coach might work collaboratively with the speech language therapist and occupational therapist who are working with the child and parent.

Medical Conditions A wide range of medical conditions frequently co-occur with ASD and can have an impact on the child’s ability to benefit from early intervention. Two very common medical conditions include sleep and gastrointestinal problems (Holingue, Newill, Lee, Pasricha, & Daniele Fallin, 2018; Mannion & Leader, 2014). Interestingly, these are more common in children who have ADHD and/or anxiety. Sleep problems are common in many young children. About half of parents of typically developing children report that the child has trouble sleeping. However, sleep problems are even more common in children with ASD. The majority of children with ASD have problems falling asleep. This increased rate of sleep problems in children with ASD has been shown to have a biological basis and is related to differences in genes that regulate sleep–wake cycles. Research over the past decade has demonstrated the importance of sleep for brain health. Sleep is important for memory consolidation, stress reduction, and the ability to sustain attention. Sleep appears to be especially important for the developing brain and the retention of new skills and self-­regulation. Clearly, these are key areas affecting the lives of all people, but can especially impact a young child with ASD who is engaged in an early intervention program. At the beginning of the intervention program when you are getting to know a child and his or her family, it’s a good idea to ask parents about the child’s sleep patterns. The most common problems in children with ASD include trouble falling asleep, sleepwalking, nightmares, and frequent nighttime awakenings requiring parental intervention. The parent coach should explain that the presence of sleep problems could affect how much the child benefits from early intervention and that there are now behavioral and medical treatments (e.g., melatonin and other medications) helpful for addressing sleep problems in most children with ASD. Simple behavioral interventions to promote good sleep hygiene include establishing a regular nighttime routine, limiting use of electronic media before bedtime, and using extinction to reduce bedtime demands. A referral to the child’s primary care pediatrician is warranted to address persistent sleep issues. What kinds of behaviors might lead you to suspect that the child is not getting adequate sleep? Children with sleep difficulties tend to have more difficulty sustaining their attention during play, are irritable, have more frequent tantrums, and have more difficulty retaining new skills.

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Signs of Inadequate Sleep in Children • Difficulty sustaining attention during play • Irritability, fussiness • Tantrums • Difficult retaining new skills • Daytime sleepiness

Research has found that children with ASD have gastrointestinal problems more frequently than other children. The most common problems are constipation, diarrhea, and abdominal pain. Studies have also shown that children with gastrointestinal problems are more likely to have trouble sleeping and exhibit more frequent irritability, tantrums, and aggression. Because of language delays and poor body awareness, some children with ASD are unlikely to tell their parent that their tummy is hurting. Instead, parents and the parent coach will need to look for signs that the child might have gastrointestinal distress. Signs of gastrointestinal discomfort can include whining, moaning, screaming, sobbing “for no reason at all,” grimacing, wincing, pushing on the abdomen, rotating the torso or trunk in a distorted way, agitation, self-­injurious behavior, sleep disturbance, and irritability. If the parent coach or parent notices these behaviors, especially if they have an abrupt onset, it is important to have the child evaluated by a physician. A referral to the child’s primary care pediatrician is appropriate. The child’s pediatrician might recommend that the child be evaluated by a pediatric gastroenterologist. Specific recommendations for treating gastrointestinal problems in children with ASD have

Signs of Gastrointestinal Distress in Children • Whining, moaning • Screaming, sobbing “for no reason at all” • Grimacing, wincing • Pushing on the abdomen • Rotating the torso or trunk in a distorted way • Agitation, irritability, fussiness • Self-­injurious behavior

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been developed and published (Furuta et al., 2012). Treating gastrointestinal distress will help the child benefit from parent-mediated interventions. Although this section has focused on the most common psychiatric and medical conditions that co-occur with ASD, many other conditions also can be present and affect a child’s and family’s ability to engage successfully in a parent-mediated intervention. Examples of other common conditions include eating and feeding problems, allergies, nutritional deficiencies, sensory deficits such as hearing and vision problems, specific genetic conditions (e.g., fragile X syndrome) that have unique effects on the child’s strengths and abilities, and epilepsy, among others. The parent coach should be familiar with these conditions and have a plan for interdisciplinary collaboration to ensure that the child can optimally benefit from early intervention. Children and Families in Low-Resource Communities Participating in parent-mediated ESDM typically assumes that parents will have the resources to travel frequently to see the parent coach; take regular time away from work or other daily activities to be part of parent coaching sessions; have access to materials such as toys, Play-Doh, dolls, and so on; and live in a home that is not so noisy, unsafe, crowded, or busy that it would be extremely difficult to have sustained periods of quality time focused on parent–child interaction (e.g., regular meal- and bathtimes). The majority of families worldwide live in conditions that make it difficult to meet most of these assumptions we often bring to the therapy session. It’s essential that the parent coach understand the home and family context in which the child and parent live and take these into account when discussing expectations for the parent and child. How often will they come for therapy? Who will be involved? When will therapy techniques be practiced at home? A major barrier for many families is living outside urban areas, making it difficult to travel to see a parent coach on a regular basis. Advances in technology have made it possible to deliver parent-mediated interventions remotely using telehealth methods (discussed in Chapter 7). Such methods can include the use of smartphone apps, DVDs, videoconferencing, and Web-based content to deliver the treatment remotely. Recently, a systematic review of nine studies that used telehealth to deliver a parent-mediated intervention was published, which included one study of P-ESDM led by Laurie Vismara (Parsons, Cordier, Vaz, & Lee, 2017). In all, this review included 197 parents from the United States, Canada, and Australia. The review concluded that telehealth approaches were



Looking to the Future 249

beneficial for improving parents’ knowledge and children’s social behavior and communication skills. Although still in its early stage, this line of research is very promising in offering hope for reaching more families who cannot engage in faceto-face interaction with a parent coach due to their geographic location. Over the past several years, there also has been increasing interest in addressing the tremendous treatment gap that exists in meeting the needs of young children with ASD in low- and middle-­income countries compared to wealthy Western countries. Indeed, the vast majority of children with ASD live in lower-­ income countries and have no access to any treatment before school age. Even after school age, the majority of these children cannot access specialized services for their ASD. This means that the majority of children with ASD will continue to have significant levels of disability including behavioral, communication and cognitive disabilities, placing a tremendous strain on their families. It is clear that this challenge cannot simply be addressed by training more professionals. More than 5 million children with ASD, ages 2–9 years, live in India alone (Arora et al., 2018). One approach currently being evaluated is training nonspecialist community health workers to become parent coaches for parent-­mediated interventions, referred to as “task-­shifting.” This approach has been successful in addressing the needs of populations with other challenges, such as depression, HIV-AIDS, and schizophrenia. This is a significant undertaking that requires substantial adaptation of current evidence-based parent-­mediated interventions to make them feasible and culturally appropriate for low-­resource settings. The process involves: (1) conducting focus groups and qualitative interviews with both parents and community workers to better understand the cultural context, attitudes, values, resources, and constraints, and (2) adaptation of the treatment manual to be more culturally relevant, appropriate for nonspecialists, and feasible. For example, parents may be encouraged to use water, sticks, leaves, and other common materials rather than toys during play routines. Lauren Franz, a child psychiatrist, has been working in Africa over the past several years to improve access to early intervention for young children with ASD (Franz et al., 2018). Noting the potential benefit of P-ESDM for families in Africa, she has been adapting the intervention to be culturally appropriate and feasible within sub-­Saharan Africa. She started out by systematically studying whether the use of joint activity routines, including play routines in which P-ESDM is embedded, are applicable in low-­resource, culturally diverse environments in South Africa. She worked closely with parents and other caregivers to understand whether joint activity routines would be feasible in the multicultural, multilingual South African context. She found that, in fact, parents in South Africa readily described many joint activity routines that they commonly use in their daily routines, suggesting that P-ESDM is a promising early intervention approach in this low-­resource country (Ramseur et al., 2019). Franz is currently conducting a trial assessing the benefits of P-ESDM when delivered by community workers for improving outcomes for young children with ASD and

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their families in South Africa. Franz’s work is one example of the exciting progress that offers hope for families in regions across the globe where access to trained professionals is limited or nonexistent. Recent studies have provided evidence of the positive benefits of parent-­delivered interventions for children with ASD in other regions of the world. One study involved the use of nonspecialized health workers in Goa, India, and Rawalpindi, Pakistan, and showed that adapting and task shifting an intervention initially used in a high-­income context were feasible and resulted in positive outcomes for improving parent–child interaction (Rahman et al., 2016). This work is inspiring and suggests that parent-­delivered interventions are likely to be a key element in addressing the treatment gap that exists for the large majority of young children with ASD and their families. Parent-­Implemented Interventions for Infants at Risk for ASD Studies of infants at genetic risk for autism, such as infant siblings of children with ASD, and home videotapes of infants later diagnosed with ASD have shed light on the earliest symptoms of ASD (Osterling & Dawson, 1994; Ozonoff et al., 2010). Whereas about a quarter of children with ASD develop normally and then lose skills during the second or third year of life, most children with ASD begin showing signs of ASD during the second half of the first year of life. Among the earliest symptoms are poor eye contact; reduced communicative babbling; failure to orient when their name is called; lack of use of gestures, especially pointing; and differences in temperament (overly fussy or quiet and passive). We have learned a lot about the early symptoms of ASD in infants by prospectively following cohorts of infants who have an older sibling with ASD since it is known that approximately one in five of these infants will develop ASD (Ozonoff et al., 2011). Such studies have shown, for example, that infants who later develop ASD are paying attention to the world in different ways beginning by 2–6 months of age (Jones & Klin, 2013). As we have become better at detecting ASD symptoms in infants, researchers have been developing interventions that can promote social and communication development in an infant at risk for ASD. Parent-­implemented interventions are particularly well suited for infants. Although the research is just beginning, three proof-of-­concept studies have been conducted that provide initial support for the efficacy of early interventions with infants at risk for ASD. The first study was conducted by Rogers and colleagues at University of California Davis (Rogers et al., 2014). Fourteen infants between 7 and 15 months of age who were exhibiting early behavioral symptoms of ASD took part in the study. Symptoms included lack of communicative babbling, being fixated on objects, repetitive behaviors, lack of gaze coordination between the parent and objects, and showing little interest in interacting with people. Seven of the 14 infants were provided with 12



Looking to the Future 251

weekly parent coaching sessions. The remaining seven infants, who had declined intervention, comprised the comparison group. The intervention was an infant version of ESDM, in which parents were coached to use interactive strategies that promoted social engagement and communication. At 18–36 months, the treated infants showed fewer autism symptoms than infants who were not provided with intervention (although they still showed some signs of ASD). Infants whose parents received coaching also had higher language scores on the Mullen Scales that were similar to those of typical infants, whereas the group that was not treated had significantly delayed language abilities. The second study was conducted by Green and colleagues in the United Kingdom (Green et al., 2015). This was a randomized controlled trial of fifty-four 7- to 10-month-old infants who had an older sibling with ASD, half of whom received parent coaching in a parent-­implemented intervention. Infants whose parents received coaching showed fewer ASD symptoms at the end of the intervention. Three years later, children in the parent-­delivered intervention group had milder autism symptoms and, during parent–child interaction, were more attentive and more likely to initiate interactions (Green et al., 2017). No effects of the intervention on overall developmental or language level were found at age 3. The third study was conducted by Dawson and colleagues (Jones, Dawson, Kelly, Estes, & Webb, 2017). At 6 months of age, 36 high-risk infant siblings were administered a task that assessed the infant’s ability to recall faces (a skill area that has been shown to be deficient in children with ASD). Brain activity was assessed by recording electroencephalography (EEG) while the infants watched videos of dynamic social and nonsocial stimuli, and an event-­related potential (ERP) task that assessed their brain responses to faces and objects. At 9 months, infants were randomly assigned to receive no intervention or a parent-­delivered intervention focused on promoting infant social engagement and communication. When infants were assessed at 12 and 18 months of age, treated infants were better at recalling faces and showed more normalized patterns of brain activity to social stimuli. These early studies are promising. Research with larger samples is needed to replicate these findings, understand the key elements that are responsible for effective treatment, and indicate for whom infant intervention is most effective. Looking Ahead In the research and evolving practices on intervention for early autism, it has become clear that parent-­implemented interventions supported through parent coaching have much to offer children and families and are an appropriate starting point for toddlers in the 12- to 30-month age range (Rogers et al., 2014). Looking ahead, the following recommendations will help improve our confidence and refine our approaches in working with very young children with ASD:

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Coaching Parents of Young Children with Autism

1.  We need more evidence for the developmental impact of parent-­implemented intervention, including understanding factors related to variation in developmental outcomes. Additional longitudinal data are needed that examine whether parent-­ implemented interventions based on parent coaching can have similar effects on children’s developmental quotients (i.e., IQ) and symptoms to those found for intensive, therapist-delivered interventions (Dawson et al., 2010; Lovaas, 1987). The work by Wetherby et al. (2014) suggests the potential power of parent-­implemented interventions for improving developmental outcomes, but additional research support is needed. There are reasonable arguments against considering improvements in language learning and overall developmental rates as the most important criteria for measuring whether an intervention is effective. However, we have few viable alternative outcome measures. Most measures, including those assessing adaptive behavior, are not independent of IQ gains. An outcome that focuses solely on ASD symptoms does not address the fact that longitudinal studies suggest that IQ and language learning, rather than ASD symptoms, are most predictive of long-term outcomes (although none of these is independent of the others). There are both humanistic and disability-­centered arguments that would argue against taking an outcomes orientation for an intervention in favor of a supported inclusion orientation, but these arguments and alternatives fit better when discussing adults with disabilities than discussing young children. It is the typical “role” for young children to be learners and to learn to communicate, play, and contribute to their families in ways defined by family values, culture, and community. Thus, outcomes for young children’s development typically assume increased development of communication, social interaction, play, family participation, and independence skills. Applying these same expectations to children with disabilities is not a focus based on their disabilities or deficits, but rather one based on their social roles as children, a focus that is important to many families. 2.  We need to master interdisciplinary practice. Interdisciplinary, collaborative models of early intervention are considered best practice. However, in truth, clinical practices are much more likely to be multidisciplinary than interdisciplinary. Families are often seeing many specialists who are addressing different needs of their child, but too often these specialists are not working closely together to develop a coherent, comprehensive intervention plan. Specialization continues largely due to health billing and reimbursement practices that reward disciplinary rather than interdisciplinary care. Treating the whole child by addressing family, contextual, medical, and behavioral (social, emotional, language, cognitive) needs will result in the best outcomes for children. Birth to 3 early intervention programs that do not rely on health reimbursement funding are, in theory, well positioned to practice interdisciplinary care, given their requisite staffing patterns. However, interdisciplinary practice takes time to learn, and it requires that teams practice intervention plans that are



Looking to the Future 253

created and implemented together in order to share roles, knowledge, and skills and foster interdisciplinary collaboration across the group. This kind of inter-­ interdisciplinary transmission works when a group of parents, their young children, and their interdisciplinary team are all together at one place and time. However, while home visiting has become the main method of delivery of early intervention due, in part, to the requirements of delivery in the least restrictive environments and in typical environments. Home visits are not a viable setting for interdisciplinary teamwork due to staffing costs. In the future, increased focus on innovative ways of facilitating interdisciplinary approaches will be important for achieving best outcomes for children. 3.  We need to transition from expert models toward family-­centered models of assessment and coaching intervention. Unlike delivery of early intervention for children with other types of developmental difficulties and their families, early intervention service delivery for ASD often relies on a professionally driven model of intervention for children and families (see Dunst & Trivette, 2009a, 2009b), for helpful descriptions of core differences in the models. A coaching relationship is consonant with family-­centered supports. It is a service model that uses family-­ centered practices from the very first contact with the family, through the initial contacts, assessment, feedback, and planning. Family-­centered care has already established the groundwork for coaching relationships between parents and providers. More importantly, family-­centered practices result in greater benefit for families and for children than expert-based models (see Dunst & Trivette, 2009b, for a review of multiple studies and meta-­analyses). For those who are still in their professional training programs or plan to work in pediatric settings, family-­centered care and parent coaching practices need to become part of the curriculum in the medical and allied health and early education fields. For those professionals already working in early intervention, inservice training workshops and credentialing packages in coaching and family-­centered care need to become far more accessible and affordable. 4.  We need to understand and define characteristics of helping relationships when

parents implement the intervention. In parent-­implemented studies that use a coaching model, both children and parents are recipients of the coaching intervention, while both coaches and parents are implementers of the intervention. How should these relationships look? Early intervention researchers have provided detailed descriptions of types of adult–child interactions that help children progress as captured in various fidelity of treatment measures. However, fidelity of implementation measures for interventionists, considered a necessity in child-­focused treatment studies, are just as necessary in parent-­implemented intervention studies. What are the actions and behaviors that coaches need to provide to be the most effective at supporting parents to implement interventions? How do we measure those skills? Such tools are needed for training, for research, and for personal

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practice. There are existing tools in the literature for parent coaching, but they come from the general disability literature that may not include autism. We don’t know whether existing tools are as helpful for parents of young children with autism as they are for parents of children with other disabilities. Parents of young children with autism have been found to experience higher levels of stress as compared to parents of children with typical development or other developmental disabilities (Hayes & Watson, 2013; Sanders & Morgan, 1997). It will be helpful to determine whether the coaching and family-centered models (as opposed to an expert model) that have been developed for children with other developmental disabilities are helpful for families who have children with ASD. Conclusion In this book, we have shared our knowledge and experience regarding coaching parents to help their children with ASD communicate, learn, and connect with them and other family members. We need to support and empower parents. This is best accomplished by moving away from the role of expert to a more family-­centered model with families as experts. Research in developmental science and early detection has had a substantial impact on our current models for parent-­focused interventions, as has research on understanding how adults learn. The latter informs our strategies for working with parents, including how to best promote their ability to adapt their own behavior through learning, practice, habit formation, and replacement of earlier behaviors. Research on adult learning has provided strong support for the therapist adopting the role of coach, rather than expert or trainer. We have described the natural course of parent-­focused intervention, which typically involves a phase focused on parent learning, followed by a second phase focused on achieving the child’s learning goals. As intervention inevitably involves challenges and setbacks, we have described strategies for how to make adjustments to the treatment plan and flexibly adapt to the unique needs of each family. Just as each child with ASD has unique strengths and challenges, each parent brings his or her own unique history, resources, expectations, cultural and family attitudes and values, and personal characteristics to the treatment sessions. An individualized approach to intervention is fostered by the flexibility and respect that coaches bring to their work with families. We have learned much about how to promote development and learning in young children with ASD and their families. Providing much more access to present knowledge for the world’s families and children will go a long way to improving the outcomes and meaningful participation in all aspects of community life as these children grow up—a challenge to all interventionists with these tools. Learning how to identify children as early as possible and provide feasible, accessible interventions at lower cost and with meaningful outcomes remains a challenge for ASD researchers and practitioners worldwide.

Appendix A

Handouts and Checklists Used Routinely in Parent Coaching Sessions

As you have already experienced in Chapters 4, 5, and 6, we use many simple paper and pencil tools to organize ourselves, prepare for sessions, take notes through sessions, track time, record data, rate our own skills, and manage the coaching sessions. Using these tools allows the coach to maintain fidelity to the model, conduct a considerable amount of teaching, keep data on all participants in the session, and still allow for the family-­ centered, reflective characteristics that are essential aspects of the ESDM. We have seen that the most experienced and skilled coaches are those that lean the most heavily on these tools; thus, we consider them essential for maintaining the quality and impact of this model. Contents Appendix A.1:   Coach’s Clipboard List

257

Appendix A.2:   Coach’s Session Planning Sheet

258

Appendix A.3:   Parent Daily Practice Chart

259

Appendix A.4:   Activity Categories

261

Appendix A.5:   Refrigerator List

262

Appendix A.6:   Parent–ESDM Fidelity Coding Sheet

263

Appendix A.7:   Parent Skills Checklist

264

Appendix A.8:   Parent Self-­Monitoring Checklist

267

Appendix A.9:   Coach’s Fidelity of Implementation Brief Checklist

269

Appendix A.10:  ESDM Coaching Fidelity Rating Tool

271

Appendix A.11:  Stages of Change and Possible Coaching Techniques

279

255

APPENDIX A.1

Coach’s Clipboard List

  1.  Coach’s Session Planning Sheet   2.  Post-it Notes   3.  Child Data Sheet   4.  Parent Fidelity of Implementation Data Sheet   5.  Child Objectives   6.  Activity Categories Cartoon   7.  Refrigerator List   8.  Parent Daily Practice Chart   9.  Coaching Fidelity of Implementation Brief Checklist 10.  Coaching Fidelity of Implementation Data Sheet

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 257

APPENDIX A.2

Coach’s Session Planning Sheet Therapist:              Date:        Child: Session No.:     Parent coaching topics covered in previous session: Discussion points from last session to return to: Time

Activity

  0–5 min.

Greetings: • Initial chat • Gather data and thank parent for it

Notes

Progress report: • Main focus last week?   5–10 min. • How did your work with [child] go? • What do you want to accomplish today? Activity 1: Warm-up 10–15 min. • Show me how your work on       went. Take parent fidelity data here. Reflection and discussion 15–20 min. • How was that for you? Note use of already taught topics. 20–30 min.

Discussion of readiness for new topic, or continued work with current topic (self-paced learning)

30–35 min.

Activity 2: Coaching—­different activity type Take child data here.

35–40 min. Reflection, evaluation, planning Activity 3: Coaching—­different activity type 40–45 min. • Parent practice of new skills Take child data here. 45–50 min. Reflection, evaluation, planning for week 50–60 min. Open discussion time or final activity 60–65 min. Review of plans for parents and child at home 65–75 min.

Transition to departure, packing up, and goodbyes all around

Notes: From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 258

259

Caregiving

Dressing, diaper changing, Social games—no bathing, washing toys: peekaboo, hands, hair, brushing rough/tumble, songs, rhymes, tickle; outdoor play teeth, bedtime

Sensory social routines Chores

Mail, laundry, caring for pets, watering plants, Books, dishwasher, wipe up, photo albums, pictures on iPad car washing

Book sharing

(continued)

Key: + Tried this today in this routine and it went well. – Tried this today in this routine but it didn’t go well. × Didn’t get a chance to work on this in this routine today.

Preparation, eating, and clean-up, wash-up

Meals and snacks

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents).

My plan for today:                             

Today’s date:             

6.

5.

4.

3.

2.

1.

Learning toys, dolls, bubbles, balloons, Parent focus for week noisemakers, balls

Joint object activities

Parent Daily Practice Chart

APPENDIX A.3

260

My plan for tomorrow:

What I needed more help with:

I felt competent about these successes:

What stood out about my time with my child today:

Parent Notes from Today

APPENDIX A.3.  Parent Daily Practice Chart (p. 2 of 2)

APPENDIX A.4

Activity Categories Bathing

Books

Dressing/diapering

Household tasks

Meals

Outdoor activities

Sensory/social routines

Toy play

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 261

APPENDIX A.5

Refrigerator List Stepping into the Spotlight Goal: To increase your child’s attention to you. Steps: • Identify your child’s attentional spotlight. • Find your position in that spotlight, face to face and close enough to touch! • Eliminate the competition for your child’s attention. • Find your child’s comfort zone and stay inside it. • Follow your child’s lead: Use active listening, narrating, helping, and imitating.

From An Early Start for Your Child with Autism by Sally J. Rogers, Geraldine Dawson, & Laurie A. Vismara. Copyright © 2012 The Guilford Press. Reprinted in Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning (Guilford Press, 2021). Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents).

262

APPENDIX A.6

Parent–ESDM Fidelity Coding Sheet Coach:              Parent and date: Child and session: Item

Activity 1

Activity 2

Activity 3

a. Management of child attention b. ABC format c. Instructional techniques d. Modulating child affect/ arousal e. Management of unwanted behavior f. Use of turn taking/ dyadic engagement g. Child motivation is optimized h. Adult use of positive affect i. Adult sensitivity and responsivity j. Multiple varied communicative functions k. Adult language l. Joint activity and elaboration m. Transition between activities Comment columns for note taking Scoring rules: View the entire activity before scoring. Read the full definition of each rating before assigning score. Give a single numerical score. Note reasons for score in boxes. See Rogers and Dawson (2010) for definitions. From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 263

APPENDIX A.7

Parent Skills Checklist Name:                   Rater: Activity 1 2 3

Skill Stepping into the Spotlight: Capturing the Child’s Attention Positions self with the child in front, close enough to touch, sitting or standing comfortably, well positioned for play. Notices what distracts the child and finds ways to manage them and reduce distraction. When others want to join in, they wait and take turns rather than interrupting and diverting the child’s focus. Finds appropriate distance so that the child is not averting gaze, turning away, or leaning back. Does best to help the child be engaged in objects and self, and to optimize child state for learning. Sets up materials and activities in an organized way to support child initiative.

Following the Child’s Lead Follows rather than redirects the child’s interest. If needed, offers good activities for the child to choose. Watches the child’s actions, admires, and narrates what the child is doing or looking at. Joins in by imitating the child’s goals, including sounds. Helps the child by making it easier for child to reach goals, by repeating the activity, by handing over desired objects, etc.

Using Sensory Social Routines to Increase the Child’s Pleasure and Social Engagement and Optimize the Child’s Arousal Uses sensory social routines (SSRs). Pauses to elicit child active communications to continue SSRs. Uses SSRs to create/improve/sustain optimal child arousal state for learning. Note. Use a plus sign (+) to indicate that the skill is used in most opportunities, +/– to indicate that the skill is used in roughly half of opportunities, minus sign (–) to indicate that the skill is used in few or no opportunities within the joint activity. If there were no opportunities to use it, code N/O.

(continued)

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 264

APPENDIX A.7.  Parent Skills Checklist (page 2 of 3)

Activity 1 2 3

Skill It Takes Two to Tango: Building Back-and-Forth Joint Activity Routines to Increase Engagement and Learning Opportunities Uses toys or objects appropriate for the child’s age, and for the child’s interest. Chooses objects that support turn taking and varied play. Uses four-step joint activity routine in both SSRs and object routines. Takes balanced turns with the child to create a theme. Length of adult turns is well fitted to the child’s attention. Recognizes when the child is losing interest or is over- or understimulated or if play is becoming too repetitive. Has the child help clean up some or all of the activity. Uses various strategies as needed to help child transition.

Talking Bodies: Helping the Child Learn to Use Body Language Creates many skillful gestural communication learning opportunities for the child. Recognizes subtle body language efforts/attempts for communication. Elicits and makes consequences for the child’s gestures appropriately. Waits for the child to communicate. Persists and helps so the child successfully communicates. Scaffolds the child to use body to communicate in many situations.

Do What I Do! Helping the Child Learn by Imitating Imitates and extends the child’s sounds when they occur. Uses double sets of toys or multiple objects for imitation. Frequently imitates the child’s actions with objects. Embeds at least one gesture or body movement to imitate in each SSR. Adds facial expression and sound effects to SSRs and daily routines. Follows the one-word-up rule for the child to imitate speech across target activities. Pauses and waits for the child to imitate the action before helping the child do so. Prompts child appropriately to imitate action. Provides repetitions and expansions on imitation that are appropriate for the child’s needs. (continued) 265

APPENDIX A.7.  Parent Skills Checklist (page 3 of 3)

Activity 1 2 3

Skill Uses the Basic Learning Principles for Helping the Child Engage, Communicate, and Learn New Skills Understands the goals, antecedents, and consequences underlying wanted and unwanted behaviors in target activities. Consistently uses As and Cs skillfully to build adaptive skills following both wanted and unwanted behaviors. Creates multiple high-­quality ABC learning opportunities throughout most target activities.

The Joint Attention Triangle: Sharing Interests in Objects and Activities with Others Provides multiple learning opportunities for joint attention: Help, give, show, point gestures. Skillfully uses language, gesture, and ABC teaching to develop or maintain joint attention gesture skills. Skillfully teaches pointing skills to attend to, place, choose, and pick up toys, food items, pictures in books, others. Skillfully supports the child to coordinate gaze and gesture in joint attention activities.

Teaches the Child to Play Flexibly and Independently Skillfully teaches new actions on objects via joint activity themes, expansions, and imitation skills in all target activities.

Developing Speech/Language: Supporting the Child to Use and Understand Speech through Active Social Engagement Imitates and expands child’s vocalizations appropriately. Carries out back-and-forth vocal routines with the child, using pause-and-wait strategies effectively to support the child’s turn. Uses lots of sound effects, single words, song routines, and “baby games” that combine action and simple words or sounds with the child. Skillfully elicits and consequates the child’s word productions to support speech/ language development. Supports the child to use speech/language for multiple pragmatic functions. Consistently helps the child follow through with instructions. Uses appropriate language levels in language learning activities.

266

APPENDIX A.8

Parent Self-­Monitoring Checklist Parent:              Date:        Activity: 1 2 3 a.  My child showed consistent interest in the activity and in Not often Sometimes Mostly true me throughout the activity.

Next time I will: 1 2 3 b.  My child’s attention was not distracted or if it was, I tried Not often Sometimes Mostly true my best to manage distractions and focus my child on me and the activity.

Next time I will: 1 2 3 c.  My child and I had frequent eye contact and face-to-face Not often Sometimes Mostly true interaction during the activity.

Next time I will: d.  My child and I had fun. We both smiled frequently and enjoyed ourselves.

1 2 3 Not often Sometimes Mostly true

Next time I will: e.  I followed my child’s attention in the activity rather than only trying to direct my child’s attention from one thing to another.

1 2 3 Not often Sometimes Mostly true

Next time I will: f.  In our activity there was lots of turn taking between me and my child, either in actions or social exchanges.

1 2 3 Not often Sometimes Mostly true

Next time I will: g.  My turns involved a mix of commenting, imitating, showing, and elaborating on my child’s activities.

1 2 3 Not often Sometimes Mostly true

Next time I will: 1 2 3 h.  In our activity I provided many opportunities for my child Not often Sometimes Mostly true to communicate with eyes, body, sounds.

Next time I will: (continued)

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 267

APPENDIX A.8.  Parent Self-­Monitoring Checklist (page 2 of 2)

i.  I consistently imitated my child’s sounds or expanded them into words with the same sounds.

1 2 3 Not often Sometimes Mostly true

Next time I will: j.  I consistently responded to my child’s looks, smiles, sounds, and actions by naming things and actions.

1 2 3 Not often Sometimes Mostly true

Next time I will: k.  I narrated my child’s activities and added sound effects.

1 2 3 Not often Sometimes Mostly true

Next time I will: l.  Our joint activity had all four parts: set-up, theme, variation, and closing.

1 2 3 Not often Sometimes Mostly true

Next time I will: m. I followed my child into play by helping, joining in, and imitating his or her actions.

1 2 3 Not often Sometimes Mostly true

Next time I will: n. When my child’s attention shifted, I followed the shift with appropriate language and action.

1 2 3 Not often Sometimes Mostly true

Next time I will: o.  I showed my child play actions that my child could do either independently or with just a little help.

1 2 3 Not often Sometimes Mostly true

Next time I will: p.  I showed my child a new play action two to three times and then waited for him or her to imitate, giving help if needed to imitate.

1 2 3 Not often Sometimes Mostly true

Next time I will: q.  If my child got stuck on an action or toy, I found a way to engage him or her in a new activity. Next time I will:

268

1 2 3 Not often Sometimes Mostly true

APPENDIX A.9

Coach’s Fidelity of Implementation Brief Checklist +/–

Set-up

Notes

Greets parent and child Parent reports some events of week Parent identifies focus with child for last week Parent identifies what is going well and not so well reflectively Parent identifies any problems with child or concerns or other points for discussion Therapist demonstrates active listening strategies during this period Any data are gathered and commented on Avoids lengthy discussions during this period There is a smooth flow into warm-up activity +/–

Warm-up and session planning

Notes

Parent–child play proceeds without interruptions Activity illustrates parent topic from past week Parent shares evaluative or reflective comments about the activity Therapist comments on parental techniques in action and parental focus Goal of and plan for the rest of the session emerge from the joint discussion Smooth transition into the first learning–­ coaching activity (continued) From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 269

APPENDIX A.9.  Coach’s Fidelity of Implementation Brief Checklist (page 2 of 2)

Activity +/– Coaching activities

1

2

3

Preparation occurs via review of points, tools, or concepts as needed for activity Parent conducts activity with sufficient coaching to achieve goal Coaching acts help parent not interrupt ongoing interactions between dyad Both parent and coach share reflection/evaluation/planning after activity Coach manages child to allow parent time to think without interrupting parent Coach’s comments are helpful to parent and lead to action planning Exchange is comfortable, not stilted, and constructive rather than judgmental Goal and plan for next activity emerge Repeated activities represent different home routines

Activity +/– Closing Balanced discussion occurs Generalization to other activities is discussed Open topics from opening are discussed Enough time has been allowed for an organized closing Goodbyes occur Plans for next session have been made: place, time There is a smooth transition out the door 270

1

2

3

APPENDIX A.10

ESDM Coaching Fidelity Rating Tool A. Greeting and checking in: The coach greets parent(s) and child. The parent(s) should provide a snapshot of the week and identify their focus with child for the past week, usually set at the previous session. The therapist gathers any data that parent(s) completed since previous session. The parent(s) may raise other questions or concerns, which the therapist acknowledges. This is a brief period that sets a base for quickly moving into action. 1. There is no invitation or opportunity for parent(s) to share their experiences since the last session. The coach either begins to interact with the child directly or begins the next topic, or asks the parent(s) to initiate a child interaction immediately. 2. The coach asks the parent(s) to summarize progress and challenges from the past session; however, the parental opportunity is not realized due to coaching problems. The coach may interrupt the parent(s) and take over the lead, or may begin the topic of the day without review, or child management needs may become the focus without an opportunity later to return to the topic of sharing and review. 3. The parent(s) may share progress and challenges from the past session. However, the therapist disregards one or more important elements: (a) reviewing parent(s) home data, (b) active listening without taking over the lead, (c) acknowledging the parent(s) efforts, (d) transitioning smoothly into parent(s)–child interaction; (e) finding a way to organize the parent(s) comments into the session’s activities. 4. The parent(s) may share progress and challenges since the past session. The therapist shows interests, listens actively, follows up as needed, and acknowledges their efforts over the week and on the data sheets that are collected. This opening transitions smoothly into parent–child activity. B. “Warm-up” parent–child joint activity: This phase allows the coach to observe and evaluate parent(s)–child progress based upon what was discussed and practiced in the last session. (1) The focus of the interaction emerges from the parent(s) sharing of the week’s activities and theme; (2) an uninterrupted parent–child activity occurs that allows parent(s) and child to move into action and allows the coach to gauge progress; (3) after the activity, the coach invites the parent(s) to reflect on the activity, to evaluate the extent to which the parent(s) goals were realized; (4) the coach then comments constructively in a way that reinforces parental use of learned techniques; and (5) there is a smooth transition into the next phase. 1. There is no warm-up parent(s)–child activity either because the coach does not set it up, or interrupts the parent(s) and child before an activity fully develops. 2. A warm-up activity begins, but no theme has been developed prior to the activity. In addition, several other parts are missing. The coach may provide general praise or criticism. Or, there is no feedback from coach to the parent(s). Or, the coach begins a long period of coaching, forgetting that this is a “warm-up.” The coach does not transition quickly into the theme for the day. (continued) From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 271

APPENDIX A.10.  ESDM Coaching Fidelity Rating Tool (page 2 of 8)

3. There is a warm-up activity and it has a theme. The coach may make an interrupting comment or two during the interaction but the parent(s) will complete the activity without being derailed. The coach provides feedback, but does not elicit parental feedback soon enough in the conversation and/or puts the parent(s) “on the spot” when asking for feedback. The activity moves into the next phase fairly smoothly. 4. The warm-up activity occurs in response to the previous session’s theme. All five parts are present. The coach allows the activity to occur without interruption, or with only the most minor comments that do not interrupt the play. The coach invites the parent(s) to provide some evaluation of the activity; the coach provides constructive comments concerning parent(s) behavior and child response afterward and there is a smooth transition to the next activity. C. Introduction of the topic of the day: This phase sets the main topic for the session and mentions the sequence of events that will happen in the session (if this has not occurred earlier). The coach (1) defines the topic from the manual: its goal, main parenting strategies, and effects on child behavior adjusted well for time; (2) ties the topic to parent(s) goals for the child; (3) ties the new topic into previous observations or discussions with the parent(s); (4) applies multimodal strategies (print materials, verbal explanation, visual demonstration) that best fit the parent(s) learning needs; (5) solicits parent(s) input to assess understanding; and (6) demonstrates sensitivity to parent(s) cultural and child-­ rearing beliefs. 1. There is no theme identified for the session. Interactions occur with the child and parent(s) without a previously stated plan. 2. The coach begins to identify the topic, but does not complete the main points of the topic. No other critical parts are addressed. No plan emerges for how this information will actually unfold during the session. Parent goals are not discussed or if so, do not relate to the topic and/or child goals. There is no discussion or not enough time set aside to check in with the parent(s) at the end of the session. This score can also be used when the topic is introduced but the main points are “lost” in a sea of talk. 3. The topic is presented. However, one or two of the critical parts are missing: (a) ties the topic to parent(s) goals for the child; (b) ties the new topic into previous observations or discussions with the parent(s); (c) lays out the sequence of events that will happen in the session (if this has not occurred earlier); (d) uses appropriate multimodal strategies for this family including language level and open-ended questions; (e) sensitivity to parental values and practices; or (f) time is not used well when explaining topic (too much or too little information). 4. The topic is clearly identified and a plan for the session is laid out. These are tied into parent goals for the child, and into previous observations or discussions with the parent(s). Parent buy-in is sought and gained. The presentation uses multimodal features and adequate talking time well fitted to this family’s learning style and needs. Assess understanding with open-ended questions. Parent values and priorities are addressed. D–E.  Coaching on the week’s topic: (Note: You will code this twice—once for each activity.) This phase focuses on the coach’s skills to support parent attention and success at using the topic skill. Coaching does not interfere with ongoing activity, improves parent(s) practice as 272

APPENDIX A.10.  ESDM Coaching Fidelity Rating Tool (page 3 of 8)

activity continues or from one activity to the next, and occurs across at least two activities during the session. By the end of the coaching, the parent(s) can state the main strategies and child goals to practice before the next session. Coaching strategies involve (1) tying the key teaching strategies to parent actions and child behavior and goals; (2) provision of enough support for the parent(s) to successfully carry out the new skill and achieve the child target; (3) invitation for parent(s) to reflect on experience and evaluate key interactions using open-ended questions and active listening; (4) another practice interaction using a different activity, with enough support for success; and (5) coaching practices (e.g., active listening, providing feedback, direct modeling) fit parent learning styles, understanding level, values. 1. Parent coaching does not occur. Coach is in an authority position, doing the skill, demonstrating it without role shift, or “telling” parent(s) how to do it rather than supporting parent(s) to do it. 2. Coaching occurs but is unsuccessful at supporting parent(s) to use the target skill independently by the end of the activity. Coach has not successfully used coaching techniques (e.g., prompt fading, shaping, differential reinforcement, multimodal approaches, or other teaching strategies) that would support parent learning style and skill acquisition. Or, parent(s) may be too anxious or distressed to continue due to too much criticism, evaluation, or directions. 3. Coaching occurs and provides enough support for parent(s) to partially perform target skill in the activity. However, parent(s) may not be independently using the skill and coaching lacks one or more elements: (a) Attention to the parent learning preference, understanding level, or child targets are missed; (b) the coach is too directive, provides feedback without eliciting parent reflection and evaluation; or may be too quiet, missing moments to encourage more practice; (c) generalization to another activity does not occur; or (d) information does not relate back to parent actions and/or child behavior and goals. 4. Coaching occurs and is successful at supporting parent use of target skill and elicitation of child skill. Coach adjusts techniques according to parent learning styles, understanding level, child goals, and increasing success. Strategies tie parent actions to child behavior and goals with practice across at least two activities. Parent(s) showed use of reflection and evaluation to build skills. Parent(s) can tie practice to child goals across different activities or settings at home. F. Closing: In the last 10 minutes or so of the session, the coach and parent(s) carry out a balanced discussion in which the coach: (1) makes time for any topics the parent(s) brought up for discussion earlier and addresses them; (2) elicits parent understanding of the topic, the parent and child skills involved; (3) supports parent(s) to consider use of the techniques in multiple activities and contexts of daily life; (4) invites parent reflection and evaluation of the utility of the session activities; (5) reviews the next meeting time; and (5) says goodbye to both parent(s) and child in a smooth transition out of the door. Parent(s) and child leave on a positive note. 1. There is no organized closing. Time runs out and the family leaves without a clear review, or there is no clear ending and conversation is still occurring all the way out the door and into the hall. There is no clear goodbye. 273

APPENDIX A.10.  ESDM Coaching Fidelity Rating Tool (page 4 of 8)

2. There is a closing but it is missing most of the above elements. Open topics are not addressed, generalization is not addressed, the discussion is not balanced, and reflection, evaluation, and planning for next session or goodbyes are missing. 3. A closing occurs, a plan is made for next time, and goodbyes are said. Parent(s) and coach have a balanced discussion. However, open topics are not addressed, and/or the session topic is not reviewed and generalized. 4. The closing addresses topics still open, generalization across daily activities, and ends the session smoothly. Conversation has been balanced, reflection and evaluation have occurred, details of next session addressed, clear goodbyes to all, and smooth transition out the door. Coaching characteristics: Across the whole session, to what extent was the coach . . .

G. Collaborative: The coach works with the parent(s) as a partner to reach common goals rather than deciding on the goal for the parent(s) to achieve or leaving all responsibility to the parent(s). It’s about the balance in the relationship. 1. The coach is not a collaborative partner in the process. The coach may be in an authority position, not acknowledging parent knowledge and abilities, not seeking parent input, reflection, evaluation, telling the parent(s) what to do. Or, the coach is in an onlooker role, giving all control to the parent(s) rather than sharing responsibility, knowledge, understanding, and skills with the parent(s). 2. The coach attempts to collaborate with the parent(s) to identify common goals and topics but misses openings and opportunities to draw out parent knowledge and expertise, taking more of an authority role than a collaborative one. Or, the coach listens and supports without expanding upon a topic, comment, or question, thereby not sharing their own knowledge with the parent(s). 3. The coach joins the parent(s) in common goals and acknowledges parent knowledge and abilities. However, there is not an easy flow of shared observations, reflections, evaluation, and ideas across the session. The collaborative roles do not seem well worked out yet, or moments of conflict or withdrawal occur. 4. The coach collaborates with the parent(s) to establish and reach common goals. Each shares expertise with the other, and conveys recognition and respect for the other’s knowledge and abilities. The coach asks questions, listens, and summarizes parent responses to identify goals, topics, and concerns. Parent(s) may also ask questions, listen, and reflect. The collaboration seems well worked out and comfortable for all. H. Reflective: Throughout the session the coach reflects on (1) what she has observed, (2) the relationship between the learning goals and observed actions, (3) effects of parent behavior on child behavior, and (4) emotional expressions that are occurring. These reflections proceed and lead to evaluations, ideas, and suggestions so that the coach’s line of thinking is transparent to the parent(s). The coach invites parallel reflections from the parent(s), and supports the parent(s) to use reflection to lead to evaluation and action plan. These reflections focus on child goals, emotions, motivations, and communications, and the relations among context, parent behavior, and child behavior. 1. The coach does not assume a reflective stance during the session. Instead, the coach 274

APPENDIX A.10.  ESDM Coaching Fidelity Rating Tool (page 5 of 8)

may invoke specific rules to evaluate and lead to action. Or, the coach may consistently ask parent(s) for reflection or feedback rather than offering it herself. 2. The coach provides one or two reflective comments during the session, but these do not lead transparently to ideas for actions so parent(s) cannot benefit from the line of thought involved. The coach invites parental reflection occasionally but then offers the action plan rather than assisting parent(s) to form one through the reflection/evaluation process. 3. The coach reflects on several of the areas and draws out some parental reflection as well. Some of the coach’s reflections lead to action plans, but this is not consistent, or transparent, to the parent(s). The coach attempts to support parent(s) to move from reflection to evaluation and action, but these are only partly successful. If topics of reflection do not end up with action plans, code here. 4. The coach reflects on most of the five areas, provides transparent lines of thought from reflection to action, and supports parent reflections and evaluative processes. There are enough relevant examples elicited from the session and from opportunities at home to enhance parent knowledge and practice on the targeted topics before the next session. Reflection/evaluation leads to action plans. I. Nonjudgmental: The coach uses descriptive rather than evaluative or judgmental language to point out relations between parent actions and child behavior. 1. The coach’s feedback across the session is generally judgmental and evaluative and does not address parent action and child response. The coach may praise the parent(s) in language that is vague or not tied to either specific parent actions or child behaviors (“that was great,” “good job,” “how fun,” “your child did so well”). Or, the coach’s tone and word choice appear harsh or critical of the parent(s) and/or child. 2. The coach’s feedback across the session uses evaluative, judgmental language that addresses either parent actions or child behavior but not the links between them (“I like how you did X,” “That was great how your child responded with X,” “You didn’t follow through”). 3. The coach’s feedback across the session mixes descriptive and evaluative language and frequently addresses links between parent actions and child behavior. 4. The coach’s feedback across the session is predominantly descriptive rather than evaluative and it consistently highlights relations between parent actions and child behavior (“I noticed that when you did X, your child typically responded with Y,” “It seemed like whenever X happened, Y followed”); with enough examples to support parent understanding and practice before the next session. J. Conversational and reciprocal: The interactions between the coach and therapist are balanced. The tone is conversational rather than didactic. The therapist listens well and responds to parent topics. The tone is friendly, warm, encouraging, and optimistic and maximizes child and parent enjoyment and success. 1. The coach dominates the interaction, leaving little time for parent input by talking at rather than with the parent(s). Or, the parent(s) may dominate the interaction and the coach does not exert appropriate strategies to become an active partner, with parental comments and questions left unanswered. 275

APPENDIX A.10.  ESDM Coaching Fidelity Rating Tool (page 6 of 8)

2. The coach makes some efforts to establish reciprocal exchanges, but is not generally successful and the balance is more often off than on between the partners. However, the coach’s efforts are clear, in use of questions to the parent(s), moments of active listening, and offering reflections. 3. The tone of the interaction is more often reciprocal than not, but the balance and reciprocity are not consistent. There are clear occurrences when it lapses and one or the other partner takes control without the coach re-­righting the balance. This could involve times in which the coach failed to follow up on a comment or question in which the parent(s) sought a response, or times in which the coach passes the lead to the parent(s), and then takes it back in the silence before the parent response. Or, the coach shifted back to a didactic, authoritative tone when explaining new information to the parent(s) without shifting to the parent(s) to restate, reflect, question, or comment. Multiple interruptions and lack of topic maintenance are other examples of coach gaffes. 4. The coach interacts with the parent(s) as partner(s), sensitive to the timing of conversation, staying on topic, and sharing control. The coach does not interrupt the parent(s) unless it is with permission and in the service of the communicative exchange (e.g., re-­righting digression, asking for clarification, answering a question that was asked but lost, restatement to check understanding). Turns are balanced, and partners command a fairly equal amount of “floor time.” K. Ethical conduct: The coach demonstrates appropriate professional behavior and does not talk about other patients or own children, criticizing other therapists or approaches, too much self-­disclosure, discouraging comments, jokes, crossing of professional boundaries, making a request for therapist benefit, coercing child or family. 1. The therapist violates ethical boundaries as described above. 2. There is no violation of ethics. However, the boundaries are not clear, as demonstrated by sharing of personal details, making a request for therapist benefit, using something in the home without permission, making inappropriately friendly comments to parent(s) or child, and so forth. 3. There is no violation of ethics and no crossing of boundaries. However, the therapist demonstrates an instance of over-­familiarity or other behavior that in retrospect gives one pause (initiating affectionate behavior like kissing the child, hugging the parent[s], commenting on the house décor, etc.). 4. The coach maintains appropriate professional behavior and ethical conduct throughout the session. Any self-­disclosure serves the purpose of supporting parent learning or parent experience. L. Organization and management of session: Data, materials and furniture, readiness, child is occupied, physical space is well organized, session follows protocol, space and structure fit family and child well, transitions smooth. 1. The session appears quite disorganized, both temporally and physically. There does not seem to be a temporal plan in place. The family and child do not seem to know what to expect. Needed materials are not available, or the materials are not organized in ways that facilitate the child and family. 276

APPENDIX A.10.  ESDM Coaching Fidelity Rating Tool (page 7 of 8)

2. One aspect of the session appears disorganized, either the timing or the physical set-up. Or, child is not adequately occupied and so consistently derails topics. 3. There is a temporal structure in place, and there is a physical organization in place at the start of the session. However, the organization of one of these falters at some point during the session in ways that adversely affect the work going on for the child, family, or therapist. 4. The session is well organized, both temporally and physically. The session’s activities flow according to the plan, or, if plan is derailed by child need, a new organization is developed and essential parts are not lost. The session ends on time, the room is well set up for the child and family, and materials and activities are managed so that the child and family are well organized by the therapist’s management of the setting and session. M. Managing parental implementation difficulties: Parent implementation difficulties often reveal themselves in (1) lack of follow-­through in interventions requested by the parent(s) (e.g., homework, sleep, eating); (2) habitual lateness, cancellation, or no show; (3) a great deal of discussion and explanations that interfere with time spent working with child; (4) many excuses for child behavior (e.g., being tired, ill); and (5) philosophies of parenting that are fundamentally contrary to the intervention (not wanting to reward child for appropriate behavior). 1. There is a clear conflict or negative exchange that arises related to an issue during the session. It is not successfully addressed or managed and the issue pervades the rest of the session, impairing the working alliance needed for the session to achieve its goals. 2. There is a clear conflict or negative tone that arises during the session. There is some effort by the therapist to address the difficulty, and there is some effort at repair, but some negative or uncomfortable effects continue afterward in the session. 3. There is a clear conflict or negative tone that arises during the session. The therapist works to address it and there is a repair of the breach and the shared work starts up again and allows for the session to achieve its goals. However, the underlying issue is not explored and addressed as such so that a full resolution is accomplished. 4. There is no conflict in the session. Or, in an exchange in which there is a conflict between therapist and parent(s), in the following interactions the therapist demonstrates awareness of underlying issues, invites parent(s) to share viewpoint and listens and acknowledges their views, finds a point of convergence that results in a resolution of the conflict and a new solution that all can embrace, and this process strengthens the parent–coach alliance and refocuses all on child intervention needs.

277

APPENDIX A.10.  ESDM Coaching Fidelity Rating Tool (page 8 of 8)

Early Start Denver Model Coaching Fidelity Coding Sheet Therapist:              Rater and date: Child and episode: Item

Code

Comments

a. Greeting and check-in b. Warm-up activity c. Introduction of the topic d. Coaching on the topic: Activity 1 e. Coaching: Activity 2 f. Closing g. Collaborative h. Reflective i. Nonjudgmental j. Conversational and reciprocal k. Ethical conduct l. Organization and management m. Managing conflict and implementation difficulties Comment columns for note taking From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 278

APPENDIX A.11

Stages of Change and Possible Coaching Techniques Phase

Activity

Pre-­ contemplation

Stage 1. Moving toward change: Listening and reflecting, motivational interviewing, cognitive, and experiential techniques primary

Therapist documentation column

Key question #4 I don’t really need to be doing this; my child will be fine. Behavioral characteristics

1. Parent has not initiated contact but has been referred by someone else. 2. Parent does not acknowledge child’s diagnosis or difficulties and/or rejects the proposed treatment approach. 3. Parent is reluctant to discuss child issues with others. 4. Most often seen in the non-­referring parent, key family members, or parent who referred based on urgings of others.

Therapeutic goal Parent moves toward acknowledgment of child difficulties or needs and openness for treatment to occur. Session activities

Delay enrollment. Provide information about study and answer parent questions. Provide project materials. Describe what would be involved. Perhaps show a parent–child video, session example, or pre–post video of parent–child interactions. A target activity handout to provide a sense of how this would go.

Some helpful questions

1. What motivated you to come in today? 2. What are you looking for, for your child? 3. What can I do to help? 4. How are you feeling about being here? 5. Try to categorize the parent’s state: a. Reluctant—­expresses reservations (e.g., “Am I going to be able to learn this model?” “The intervention seems too difficult to use every day.” “I don’t have the time to do this.”) b. Rebellious—­challenges, questions, or expresses hostility (e.g., “I don’t think your information is accurate.” “Does intervention really make a difference to my child’s outcome.” “I don’t appreciate being here.”) (continued)

From Table of Motivational Stages of Change and Related Therapist Activities by Sally J. Rogers and Laurie A. Vismara. Copyright © 2012 Sally J. Rogers and Laurie A. Vismara. Reprinted in Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning (Guilford Press, 2021). Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 279

APPENDIX A.11.  Stages of Change and Possible Coaching Techniques (page 2 of 8)

Phase Some helpful questions (continued)

Activity c. Resigned—­statements about self or others that are pessimistic, defeatist, hopeless, or negative in tone (e.g., “I’m not good at playing with my child.” “My child doesn’t like being around me.” “There are no activities my child enjoys doing with others.”) d. Rationalizing—­explaining away the problems. e. Ambivalence—giving mixed messages, both verbal and nonverbal, about desire for change and desire to pursue treatment, not paying attention or responding to therapist, changing the direction of the conversation that the therapist is pursuing

Key therapeutic techniques

1. Human relationship (HR) 2. Providing requested information 3. Active, reflective listening: open-ended questions, reflective statements, restatement 4. Developing discrepancy, rolling with resistance, increasing change talk

Contemplation

Stage 1. Moving toward change: Listening and reflecting, motivational interviewing, cognitive, and experiential techniques primary

Key question #5 I’m not sure if this will help my child but I am open to learning more. Behavioral characteristics

1. Parent acknowledges that child has difficulties. 2. Is considering doing something about child difficulties but is not yet ready or sure about what route to take. 3. Ambivalence is high. Pros and cons are equal.

Therapeutic goal Parent develops the motivation to begin to prepare for action. There is movement toward a commitment to act, demonstrated either by enrolling in project or by deciding to get services elsewhere. The therapist has helped “tip the balance toward change” (DiClemente & Velasquez, 2002, p. 208). Session activities

Family meeting is scheduled to (1) review information about proposed treatment approach, study consent, home procedures; (2) answer parent questions; (3) establish the family’s social support network; and (4) address barriers for implementation. Child evaluation also happens in this stage.

280

Therapist documentation column

APPENDIX A.11.  Stages of Change and Possible Coaching Techniques (page 3 of 8)

Phase

Activity

Some helpful questions

1. What kind of information do you need to begin? 2. What are your areas of concern about starting intervention? 3. What have you learned about the effects of early intervention on young children with ASD? (If no response:) What information would you like on the effects of early intervention on young children with ASD? 4. How do you think your life would be different if you and your child were doing this intervention? 5. What would you like to see your child learn after a year of intervention? 6. Would it be helpful to know how some other parents and children have responded to this intervention? 7. What do you see as the pros and cons of getting started in this intervention? (Make a table.) How might things change for you/your family/your child? 8. Have you ever tried to change one of your own patterns or behaviors before? How did it go?

Key therapeutic techniques

1. HR 2. Joint planning process to identify parent goals for self and child 3. Active, reflective listening: open-ended questions, reflective statements, restatement 4. Developing discrepancy, rolling with resistance, increasing change talk

Preparation

Stage 2. Ready for change: Behavior change processes are quite important

Key question #1 I am not really doing much at home yet but I want to and I’m working up to it. Behavioral characteristics

Has enrolled in project. Is ready for and committed to taking action in the near future.

Therapeutic goal Help parent to formulate goals for child and develop goals and a plan of action for self. Child plan is developed in this phase. Session activities

Home visit: Meet at parent home to prepare for sessions—set up learning spaces, select toy/learning materials, introduce website, review their availability and schedule sessions.

281

Therapist documentation column

APPENDIX A.11.  Stages of Change and Possible Coaching Techniques (page 4 of 8)

Phase

Activity

Session activities (continued)

Clinic visit: Observe parent implementation of materials from prior week; work together on parent and child learning goals.

Some helpful questions

  1. On a scale of 1–5, how motivated are you to get started?   2. What would need to happen in order to move from X to Y (lower to higher rating, if score is 3 or lower)?   3. What do you hope your child can learn in the next 3 months?   4. Which of these six parent–child activities do you think might be good learning formats for your child? Which not? Which do you enjoy the most?   5. What are your favorite ways to help yourself remember things and keep track of information?   6. How do you like to approach each day? As a blank slate or a to-do list?   7. How do you like to learn about something new?   8. Have you worked with any teachers or coaches in the last few years that were really great? What made them great?   9. Have you worked with any teachers or coaches in the last few years that were pretty bad? What made it bad? 10. What other resources may you or your family need to feel prepared to help your child?

Key therapeutic techniques

1. HR 2. Active, reflective listening: open-ended questions, reflective statements, restatement 3. Home checklists 4. Environmental evaluations for parent to become aware of people and things at home 5. Visual aids, multimodal treatment materials 6. Visit schedule may drop to once per week if parent prefers

282

Therapist documentation column

APPENDIX A.11.  Stages of Change and Possible Coaching Techniques (page 5 of 8)

Phase

Activity

Action

Stage 2. Ready for change: Coaching for behavior change processes is quite important

Key question #2 I’m working on things daily: I feel “full steam ahead” about this. Behavioral characteristics

Active parental behavior change is occurring seen in parent use of techniques and materials. Parent is actively involved in changing their parenting patterns. Parent is using materials and plan.

Therapeutic goal Help parental behavioral change plans be successful and reflected in data on parent behavior and child behavior change and learning. Teach parent each P-ESDM skill to mastery as quickly as possible. Order can be flexible— based on parent desires and skills, child needs, and parent fidelity data. Goal: parent at fidelity on P-ESDM skills and providing self-­monitoring data and child home data weekly. This is a difficult period for parent. Session activities

Two visits per week, one at home; following basic session schedule. Monitor parent learning via fidelity scores and parent home videos, parent self-­monitoring data and child change.

Some helpful questions

1. How did things go this week? 2. What parts of the plan were you most focused on? 3. What was most helpful this week? How did it help? 4. What problems came up that you didn’t expect? How did you deal with them? 5. May I see your data sheets? 6. What do you most want to focus on today?

Main therapeutic 1. HR techniques 2. Differential reinforcement of other behaviors 3. Self-­monitoring 4. Problem-­solving strategies 5. Reinforcers (emotional and tangible) 6. Attention to discriminative stimulus (antecedents) 7. Begin new skill as soon as parent has mastered last skill. If parent is already at fidelity on a skill, review it and move on.

283

Therapist documentation column

APPENDIX A.11.  Stages of Change and Possible Coaching Techniques (page 6 of 8)

Phase

Activity

Maintenance

Stage 2. Ready for change: Coaching for behavior change processes quite important

Key question #6 I work on things daily and it feels like a more natural part of my parenting routines now. Behavioral characteristics

Parent is using tools routinely and provides weekly self-­monitoring data and child home data. Verbalizes ESDM principles spontaneously and uses them to solve problems independently. Demonstrates comfort with many techniques. Is maintaining fidelity.

Therapeutic goal Help parent sustain changes, maintain motivation, and resist relapse. Help parent find reinforcers in new ways of behaving and in child growth. Some helpful questions

1. What motivates you now? Where are your rewards? 2. What problems came up this week? How did you address them? 3. How did things go this week? 4. What parts of the plan were you most focused on? 5. What are you finding most helpful? Least helpful at this stage? 6. What problems came up that you didn’t expect? How did you deal with them? 7. May I see your data sheets? 8. How do you want to use our time today?

Therapeutic techniques

1. HR 2. Self-­monitoring 3. Problem-­solving strategies 4. Reinforcement (emotional and tangible) 5. Attention to discriminative stimulus 6. Support self-­efficacy

Lapse and repair

Stage 1. Moving toward change: Motivational interviewing, cognitive, and experiential techniques primary

Key question #3 I’m kind of in a slump; I feel like my motivation to work on things at home is slipping. OR I’m kind of in a slump but I’m able to keep working on things at home/I’m working on things at home but I feel in a slump. 284

Therapist documentation column

APPENDIX A.11.  Stages of Change and Possible Coaching Techniques (page 7 of 8)

Phase

Activity

Behavioral characteristics

Parent demonstrates a lapse in adherence to behavior plan. Describes loss of motivation or lacking resources to address personal needs (stress, depression, loneliness). Expresses doubts about own ability or child ability to grow. Lack of daily data or drop in frequency of practice or cancels sessions. May explain via child illness, tiredness, visitors, etc. without use of problem-­solving efforts. Fidelity score may have dropped below criterion or other activities have lessened (reporting progress, using website, emailing updates, trying new experiences with child).

Therapeutic goal Assess current stage in addition to lapse. Recycle through stages. Shift to motivational interviewing strategies for increasing motivating for behavior change. Try to move to commitment for action and into preparation stage for how to resume. Try to end with parent having worked out some action plan for current week and a method for you to help monitor this. Goal is for the following session to be in action stage. Session activities

Resume twice weekly visits, focus on discussion with parent to determine current stage and to work on increasing motivation for change and change talk. Unlike the action and maintenance phases, there may be more talk than action during this stage.

Some helpful questions

1. Listen and reflect back on the parents’ feelings. 2. What do you think is going on? With yourself? With your child? 3. What do you want to do? 4. What is the best way for us to use our time today? 5. What needs to change or be in place?

Therapeutic techniques

1. Return to twice weekly visits if these have dropped off. 2. Develop a monitoring plan with parent for contacts during the coming week. 3. HR 4. Active, reflective listening: open-ended questions, reflective statements, restatement 5. Developing discrepancy, rolling with resistance, increasing change talk

285

Therapist documentation column

APPENDIX A.11.  Stages of Change and Possible Coaching Techniques (page 8 of 8)

Human relationship fidelity—all stages

Score of 1

Score of 2

Reflective listening

1.  Therapist presents roadblocks involving directing, interrupting, warning, disagreeing.

2.  Therapist presents roadblocks involving agreeing, praising, reassuring, changing the subject without permission, giving unasked for advice, too many questions, close-ended questions, or trying to persuade.

Affirmations

1.  Does not make any 2.  Makes compliments 3.  Observes client positive statements rather than observing strengths at least once about client. strengths. during the session.

Summaries

1.  Does not summarize at the end of discussions to organize what has gone on, to mark and organize topics, mark transitions, or link different topics together.

2. Occasionally summarizes but lacks appropriate frequency, brevity, or helpfulness in the summaries.

3.  Provides helpful brief summaries at key points in session to collect, link, or transition.

Empathic acceptance of client’s feelings and perspective

1.  Therapist denies client feelings or perspective or suggests that they are other than what they are.

2.  Therapist does not mark client feelings and perspective, either by not drawing out or by not restating when they are spoken.

3.  Therapist draws out feelings and perspectives if not offered, and restates with appropriate affect when they are offered.

Respect for client’s autonomy, self-­ efficacy, and decision-­making ability

1.  Therapist tells client what to do and how to do it.

2.  Therapist listens to client but does not mark client discussion of wishes, goals, or choices.

3.  Therapist elicits and respects client choices and goals, including no change (Rosengren, 2009).

Collaborative relationship

1.  The two seem to be working against each other (wrestling), or one is passive and the other active (out of sync). Therapist is more active than client.

2.  The two are talking but not much is happening (standing). Therapist may be underactive.

3.  The two are working as partners (dancing; Rosengren, 2009). Interactions are balanced. Therapist resists righting reflex.

Evocation

1.  Draws solutions and ideas and motivation from client. Therapist directs and argues for change.

2.  Therapist listens to whatever parent shares but does not bring it to change talk.

3.  Therapist draws out client’s views on change (Rosengren, 2009).

286

Score of 3 3.  Listens attentively without interrupting and restates with simple or complex restatements to test understanding. Questions are fewer than statements.

Appendix B

P-ESDM Infant–­Toddler Curriculum Checklist Sally J. Rogers, Geraldine Dawson, Laurie Vismara, Meagan Talbott, Cynthia Zierhut, Jamie Winter, Carolyn McCormick, Marie Rocha, and Emily Holly1

Child name or ID:                  Curriculum date: Child birthday and age:             Assessor: Parent(s) interviewed: Others interviewed: Instructions: Use the checklist to define the child’s most mature skills, those skills that are currently emerging, and those skills that are currently not in the child’s repertoire, in each domain. Consult the Infant–­Toddler Curriculum Item Descriptions for more detailed descriptions of each item and administration practices. Bolded items are scored from the Parent Report. No more than 10% of nonbolded items should be scored solely from Parent Report. (continued) 1The

Infant–­Toddler Version of the Curriculum Checklist used in the PATH and C-ESDM projects was adapted for the TEDI project. Items added in this revision are noted with an asterisk. The work on this instrument was partially supported by Grant No. 8089 from Autism Speaks and Grant No. NIH R21HD1003372 from the National Institutes of Health.

From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents). 287

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 2 of 13)

Use the following codes for behavior in each of these columns: Observed, Parent Report, and Other/Teacher Report:  + or P (pass) for consistent performance at appropriate times  +/– or P/F (pass/fail) for inconsistent performance   F (fail) when the behavior is difficult to elicit For the CODE column, use the following: A (acquired)—child clearly demonstrates skill and parent reports skill is used consistently. P (partial or prompted)—child is only able to demonstrate skill inconsistently or with additional prompting and parent/other reports the same, or child demonstrates some, but not all, of the steps of the skill. N—child is unable or unwilling to demonstrate the skill and parent/other reports difficulty. X—no opportunity, or not appropriate for this child. To rate each child, either start at the beginning of each section or establish the basal for each section. The basal is established when the child receives ratings of “A” in the CODE column for four items in a row for each section. Continue to rate each item sequentially in each section until the child reaches the ceiling of four “N” ratings in a row for that section, or you reach the last item in the section. It is important that the examiner feel confident about the basal and ceiling levels, so the examiner may choose to complete more items to establish the basal and ceiling levels for each section. Curriculum checklist items may also be scored from the parent’s interactions with the child, both during the curriculum administration and the PCI measure. For infants, parents should be heavily involved. The Infant–­Toddler Curriculum Checklist can be used to target teaching areas for each domain. The target area for teaching in each domain is the point where item ratings move from “A” to “N.”

288

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 3 of 13)

Receptive Communication: Understanding Early Gestures  1

When adult puts arms out to gesture “pick up” child leans in and/or puts arms up.

Self-­explanatory

 2

Comes in response to “hands out” gesture for come here.

Crawls, walks, or otherwise moves within arm’s reach of adult; may be accompanied by the adult saying, “come here.”

 3

Responds with anticipation to 3+ different gestures associated with familiar sensory social routines.

Examples include: smiling or beginning to laugh as parent holds up hands to tickle, kicking feet as parent starts “bicycle, bicycle” game with child.

 4

Puts indicated object in adult’s outstretched hand with or without verbal instruction (e.g., “give me”).

Responds to adult gesture by placing or attempting to place the object in hand. Adult may use other hand to point to open palm.

 5

Responds to adult point to open container during clean-up Places objects where you point with or without verbal instruction (e.g., “put routine by dropping/placing item in container, or places object in other desired location as indicated by adult’s point. in”).

 6

Follows 5+ different instructions (e.g., “give me,” “sit down,” “look,” and “come here”) with gestures.

Responds to adult’s gestural cue by performing action.

Receptive Communication: Understanding Speech  1* Responds to loud sounds.

Orients to loud sounds.

 2

Looks to playful sounds.

Demonstrates awareness of sound by turning eyes and head and looking at person.

 3

Looks to partner when name is called when unoccupied.

Turns eyes and head toward partner’s body when child is not engaged in another activity.

 4

Looks to or reaches to 2–3 familiar items when named (e.g., “blankie,” “ball”).

Self-­explanatory

 5

Looks to partner when name is called when occupied.

Turns eyes and head toward partner’s body when child is focused on something else or engaged in another activity (i.e., playing with a toy).

 6

Stops actions momentarily in response to inhibitory words “stop/no.”

Stops an ongoing activity when told “No, stop”, or demonstrates awareness by pausing temporarily, turning eyes and head toward adult, or showing distress (e.g., crying).

 7

Follows 5+ different verbal instructions Completes instruction by performing action without adult (e.g., “give me,” “sit down,” and “come gestures or physical guidance. Adult may repeat instructions a second time without gesture cue. here”) without gestures.

 8

Looks to/goes to 1–2 very familiar people when named.

 9

Responds to verbal instruction to give/ Self-­explanatory point/show for 8–10 specific objects in natural play, dressing, eating routines (e.g., baby, chair, car, block, bear).

Turns eyes and head toward named person who is in the same room or moves within arm’s reach when asked “Where’s Mommy?” or “Go to Daddy?,” etc.

289

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 4 of 13)

Receptive Communication: Understanding Speech (continued) 10

Identifies 3 named pictures in book by visually attending or touching when asked, “Where’s the    ” or told, “Show me    .”

Responds to “Where is . . . ?” or “Show me . . . ?” by looking at, touching, or pointing to the picture.

11

Looks to/touches/points to photos of 3–4 important people when named.

If the named person/pet is present, child clearly looks at the person or pet when named (may also point). If pictures, child looks at, touches, or points to picture when named.

12

Demonstrates understanding of 4–5 action verbs by making those actions with and without objects (e.g., shake, throw, go, dance, jump, clap).

Child responds to verbal instructions involving verbs (e.g., shakes maraca, bangs sticks, hugs baby, pokes Play-Doh, stands up, claps hands). Child has to follow both types— body actions and actions on objects.

13

Attends and joins with interest for 5–10 minutes as adult reads familiar book with simple sentences. 

Stays with adult, pays full attention, and participates in a story the adult is reading. Examples include: alternating eye contact between book pages and adult, pointing to pictures in book, turning book pages, vocalizing the names of pictures in book.

14

Follows novel one-step commands involving familiar objects/actions.

Completes instruction by looking at adult and performing action without adult gestures or physical guidance. Adult may repeat instructions a second time without gesture cue.

15

Identifies 5+ different actions in pictures and books.

Vocalizes and/or gestures (e.g., points) in response to adult’s questions. Examples are “Where’s baby sleeping?” or “Do you see the dog running?” Response need not be accompanied by eye contact.

16

Follows 2+ different, 2–3 part routine Child sequences 2–3 actions together on an object in instructions given in familiar situational response to verbal instruction. routines (e.g., “Get your shoes and bring them to me”).

17

Understands 3+ different prepositions describing spatial relationships involving objects (e.g., in, on, under).

Demonstrates understanding of prepositions by following verbal instructions using objects.

Expressive Communication: Communicative Gestures  1

Requests objects and social games by reaching or body movements (e.g., holds leg out for pat-a-feet).

Reaches toward desired object in adult’s hands to indicate request or uses motor prompt to initiate to or continue social games. Gesture need not be accompanied by eye contact or vocalizations/words. Does not include reaching just to grab.

 2

Returns affection gestures (e.g., hug, kiss, high five) to familiar others?

Child spontaneously and consistently hugs back familiar adults with arms and body; kisses back with pucker on cheek or lips.

 3

Responds correctly to a choice of 2 by reaching to preferred item.

Adult holds up and names two objects, one in each hand but out of reach of child. Child reaches toward desired object. Does not need to be accompanied by eye contact or vocalizations/words. Does not include reaching just to grab.

 4

Indicates “no” by pushing away or giving back.

Other conventional gestures (e.g., shaking head, sign “all done”) or words (“no”) are acceptable. Gestures need not be accompanied by eye contact or vocalizations/words.

290

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 5 of 13)

Expressive Communication: Communicative Gestures (continued)  5

Gives an object to ask for help.

Indicates help by placing object in adult’s hand, offering object to adult, verbalizing, or looking to adult. Gesture need not be accompanied by eye contact or vocalizations/words.

 6

Combines eye contact with gesture (e.g., reaching, grabbing, signing “all done”) for request, help, or protest.

Spontaneously turns head and eyes to adult and makes eye contact for 1–2 seconds to request object.

 7

Returns waves for greetings and departures (i.e., hi and bye).

Child responds to greetings with both words and gestures, without prompting.

 8

Uses proximal point to request.

Points to object within 6–12 inches with first or index finger (not open hand) to indicate request. Object may be in adult’s hand or in reach of the child.

 9

Uses distal point to request.

Uses first or index finger (not open hand) to point toward desired object, 3 feet or more away from child.

10

Spontaneously shakes head “no” to decline.

Self-­explanatory

11

Spontaneously nods head “yes” to assent.

Self-­explanatory

12

Use target signs or gestures with vocalization to express (request, all done, share, help, and protest).

Child combines specific gestures and vocalizations or word approximations to communicate all four of these functions.

Expressive Communication: Vocal/Verbal Communication  1* Produces vowel sounds.

Excludes crying or vegetative sounds.

 2* Makes sounds to show joy and displeasure.

Different sounds for each emotion.

 3* Makes vocalizations with varying intonation.

Vocalizations vary in pitch, not flat.

 4* Vocalizes back-and-forth with adult for at least 2 rounds (vowel).

Vocalizes (vowel only) with eye contact for at least 2 rounds. Vocalization can be initiated by either partner.

 5

Vocalizations occur with or without adult verbal models. Vocal play counts.

Produces 2–3 different consonants.

 6* Vocalizes back-and-forth with adult for at least 2 rounds (CV).

Babbles (with CV combination) with eye contact for at least 2 rounds. Vocalization can be initiated by either partner.

 7

Vocalizes to communicate.

Vocalizes in conjunction with eye contact and/or gesture (e.g., reaching) to request desired item or object.

 8

Makes eye contact to obtain a desired object when adult blocks access/ withholds desired object.

Turns head and eyes to adult and makes eye contact for 1–2 seconds with or without a gesture (e.g., reaching, grabbing) to request object. Eye contact and gesture need not be accompanied by vocalizations and words.

 9

Says name of one important person (e.g., “Mama”).

Either prompted or spontaneous.

10

Vocalizes with eye contact to request.

Turns head and eyes to adult and makes eye contact while vocalizing to request desired item. Vocalization may be an approximation (e.g., “aah” for ball or “ooh” for go).

11

Produces 4–6 different consonants.

Vocalizations occur with or without adult verbal models. Vocal play counts.

291

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 6 of 13)

Expressive Communication: Vocal/Verbal Communication (continued) 12

Imitates self-­initiated CVs 3 rounds with adult in context.

Child vocalizes a consonant-vowel sound, adult imitates it, and child vocalizes the sound again.

13

Imitates adult-­initiated familiar CVs 1–2 rounds.

Adult vocalizes a consonant-vowel sound and child imitates it.

14

Vocalizes with identical CVCV sequences (e.g., “ba-ba,” “di-di”; reduplicative babbling).

Vocalization need not be accompanied by eye contact or gesture.

15

Vocalizes with differing CVCV sequences (e.g., “ba-da,” “di-da”; variegated babbling).

Self-­explanatory

16

Imitates 5+ different sound effects or animal sounds in play (e.g., “zoom” and “woof woof”).

Self-­explanatory

17

Imitates 5+ different CV word approximations in a play activity (e.g., “ba” for “ball,” “ca” for “car”).

Produces 5 or more words or approximations within familiar routines. They can be spontaneous or spontaneously imitated but not prompted; must occur within the same joint activity.

18

Names 3+ different objects important to child (e.g., “bottle,” “blankie,” “doggy”).

Imitated or spontaneous

19

Imitated or spontaneous Produces 3+ different word approximations in a single joint activity (e.g., “uh” for “up,” “ca” for “car,” and “zooo” for “zoom”). 

20

Spontaneously requests 5+ different objects that are in sight.

Self-­explanatory

21

Spontaneously requests 3+ different actions (e.g., “up,” “down,” “go”). 

Self-­explanatory

22

Spontaneously uses 20 different words in a week. 

Self-­explanatory

23

Spontaneously labels 5+ different objects and 5+ different pictures to comment (not request).

Self-­explanatory

24

Says the names of 3 important people Child uses names to label people in pictures, mirror, and real life. Can be in response to question, “Who is that?” in photos and in person (including self).

25

Combines verbalization, wave, and eye contact to initiate and respond to greetings/departures.

Self-­explanatory

26

Says “no” to protest.

Says “no” when offered food or object.

27

Says “yes” to affirm.

Says “yes” when offered food or object.

28

Spontaneously uses 50 different words in a week.

Self-­explanatory

29

Combines several two-word phrases spontaneously (e.g., “more cookie,” “mama shoes,” “go door”).

Verbalization must include eye contact. Articulation need not be perfect.

292

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 7 of 13)

Expressive Communication: Vocal/Verbal Communication (continued) 30

Asks several questions with appropriate intonation (e.g., “go?” “all done?” “what’s that?”).

Questions may be one-word utterances with rising intonation. Verbalization must include eye contact.

31

Produces 2–3 word combinations for a variety of communicative functions (i.e., gaining attention, requesting, greeting, protesting).

Verbalizations must include eye contact. Examples: “want more juice,” “bye, Sally,” “help me open,” or “no ball.” Articulation need not be perfect.

32

Produces 2+ word utterances to comment to another person (e.g., “see cow,” “airplane go fast,” or “doggie”).

Verbalizations must include eye contact and are not related to requests for objects or actions. Articulation need not be perfect.

33

Labels actions words in pictures and books (e.g., “eating” or “bird flying”).

Verbalizations need not be accompanied by eye contact. Articulation need not be perfect.

34

Names 1–2 colors.

Verbalizations need not be accompanied by eye contact. Adult may ask, “What color is the car?” but child must initiate answer. Approximation may be accepted.

35

Responds to “who, what, where” questions.

Must answer one of each type of question for mastery. Verbalization need not be accompanied by eye contact. Adult may ask a second time.

36

Asks simple “yes, no” questions with rising intonation.

Verbalization must include eye contact. Questions may be one-word utterance with rising intonation. Examples include “Cookie?” or “Go bye-bye?”

37

Answers simple information questions (name, age, etc.).

Verbalizations must include eye contact.

Joint Attention  1

Makes eye contact 2–3 times with an adult during an activity.

Activities can be with or without objects.

 2

Smiles 2–3 times during an activity with adult.

Activities can be with or without objects.

 3

Looks at objects and pictures that you touch during play.

Follows adult touch with gaze or by touching object or picture.

 4

Looks at shown item (“Name, look”).

Turns eyes and head in direction of object held by adult.

 5

Looks at pictures or objects that you proximally point to without touching.

Child looks at picture or object when adult points within a few inches of a picture or an object.

 6

Follows distal point to object across the room.

Responds to distal point by looking at, approaching, and/or picking up the toy.

 7

Shifts gaze from object to person when Self-­explanatory requesting object or help.

 8

Gives and takes objects with coordinated eye contact.

 9

Self-­explanatory When holding an object, responds to “show me       ” by extending object to adult.

This involves a spontaneous give or take. If it is a take, the adult should not offer the object. The gaze communicates a “request.”

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APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 8 of 13)

Joint Attention (continued) 10

Shows objects spontaneously.

This involves routine acts of showing—positioning the toy toward the adult’s face, looking to the adult, and waiting for a comment. Pass if this is seen 3 times within the session.

11

Points to objects, pictures, and people to comment (or for naming).

This involves routine acts—at least 4 within the session. Child must point to target and look to adult and wait for comment. Point may be proximal or distal.

12

Gets adult attention (eye contact) using Self-­explanatory gesture (e.g., wave, show, turn face, pat, show object, tap) or name.

13

Shares smiles with adult when alternating gaze during an activity. 

This involves clear gaze shifts from object to adult eyes and back to object to share pleasure. Should be seen several times in a 10-minute period.

14

Initiates joint attention by shifting gaze from object to adult to comment on object or share experience.

This involves clear gaze shifts from object to adult eyes and back to object. Can also include vocalization and/or gesture (e.g., point, touch, or reach). Pass if this is seen a few times in a half hour of play.

Social Skills: Dyadic Engagement  1* Recognizes familiar faces vs. stranger.

Change in affect or engagement observed when child focuses gaze on familiar vs. unfamiliar adult, may be parent report item.

 2* Likes to look at self in mirror.

Change in affect observed when child focuses gaze on self in mirror, may try to pat or swipe at image. Take care to distinguish from interest in the mirror itself.

 3* Responds to others’ emotions.

Shows some social contagion or recognition—responds to smiles with smiles, anger with sadness or fear, etc.

 4* Wary or fearful of strangers.

Shows distinction between familiar and unfamiliar adults. May reach to parent, turn away from stranger, etc.

 5* Has favorite toys.

Parent report item.

 6* Plays peekaboo.

Looks for parent when hidden, some indication (through gaze or actions) that interest is more than in materials (blanket).

 7* Enjoys and engages socially in 2–3 sensory social games.

Parent report item.

 8

Accepts brief social activities and touch.

Child shows no avoidance, withdrawal, or negative affect.

 9

Maintains engagement in sensory social routines for 2 minutes.

Shows interest in sensory social routine by approaching, observing, or actively participating, and requesting continuation of the routine through eye contact, gestures (e.g., reaching, imitating adult’s movement), or vocalizations for 3 different sensory social routines.

10

Enjoys and engages socially in 5–10 different sensory social games. 

Participates in any action behavior (reaching, imitate, vocalize) in a game. Eye contact and smiles alone are not enough. Examples include rhymes/songs (“Itsy-Bitsy Spider,” “If You’re Happy and You Know It”), games (“Ring-­Around-the-Rosy,” “Patty-Cake”), bubbles, balloons, books, airplane.

294

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 9 of 13)

Social Skills: Dyadic Engagement (continued) Consistently participates throughout 4-part dyadic activities including the set-up, co-­construction of a theme, elaboration, and closing.

11

Engages consistently in 4-part dyadic joint activity routines with adult (with smooth transitions).

12

Verbally requests or physically initiates Child spontaneously initiates and cues social gazes through familiar social games.  body movements, gestures, or vocal patterns (e.g., adult’s name or an action word) that are specific to a familiar social game.

13

Chases another, hides and searches for Eye contact and smiles alone are not enough. Examples are others in hide and seek, and/or dances “Hide and Seek,” “Ring-­Around-the-Rosy,” playing ball, and chase (reciprocal). in circle games.

Imitation  1* Copies (or attempts) sounds or gestures.

Action occurs immediately following example. May be prompted or spontaneous. Does not have to be exact but should share some aspect of the model. Example: Vocalization may share intonation but not exact consonant.

 2* Imitates 1 action on object.

Partial credit for partial imitation or attempts.

 3

Watches adult in parallel play.

Shows interest in activity by observing adult play acts and continues the play schema being imitated.

 4

Imitates 2–3 different single actions on Imitates actions on object within 5 seconds of adult’s objects. model. Examples include banging two objects together, placing an object in its container, or rolling an object.

 5

Imitates 5+ different single actions on objects.

Imitates actions on object within 5 seconds of adult’s model. Examples include banging two objects together, placing an object in its container, or rolling an object.

 6

Imitates 3+ multiple-step actions on one object.

Imitates a sequence of 3 or more related actions on one toy (e.g., taking off the shape-­sorter cover, taking out the shapes, putting the lid on, and putting the shapes through).

 7

Imitates 3 different visible body movements inside songs/game routines.

Imitates actions that child can see him- or herself make (e.g., clapping, stomping feet).

 8

Imitates 3 different invisible body movements inside songs/game routines.

Imitates 3 different actions that child cannot see him- or herself make (e.g., hands on head, ears, or patting cheeks).

 9

Imitates 3+ different oral facial movements inside songs/game routines.

Imitates oral-­facial movement within 5 seconds of adult’s model (e.g., wiggling tongue, blowing raspberries, making “kissy lips,” or puffing cheeks).

10

Imitates 2–3 novel actions in unfamiliar songs/game routines.

Approximates novel actions during new song or game after adult models.

11

Imitates 2-step movement sequences in songs/game routines.

Child spontaneously imitates 2 or more actions in a row within a single song without any prompting or waiting.

Cognition  1* Watches objects as they move.

Focuses gaze on objects 1–3 feet away, gaze may be brief, and tracking may not be smooth across the midline.

 2* Coordinates gaze and reaching.

Uses hands and eyes together, like seeing a toy and reaching for it.

295

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 10 of 13)

Cognition (continued)  3* Tracks objects side to side.

Fixates gaze on object and follows it as it is moved through the midline in the majority of opportunities.

 4* Looks at things nearby.

Visually explores the environment by fixing gaze on multiple objects/people. Movement of head/eyes without fixating on objects does not count.

 5* Brings objects to mouth.

Self-­explanatory

 6* Tries to get objects out of reach.

Child attempts to grasp objects nearby. They do not necessarily have to be successful, but should indicate active interest in the objects in their environment. Reflexively grasping objects placed in their hand does not count.

 7* Passes things from one hand to another.

Without dropping

 8* Explores objects using 2–3 actions.

Interacts with objects in more than one motor pattern— banging, shaking, mouthing, waving, dropping, spinning.

 9* Watches the path of something as it falls.

Self-­explanatory

10* Looks for hidden objects.

After seeing object hidden by adult, pulls back blanket or washcloth to get to hidden object.

11

Acts according to the differential qualities of 5 different objects (e.g., shakes a maraca, stacks blocks).

Interacts with toys that match the characteristic of the toy.

12

Takes objects in and out of containers.

Release of objects into and grasping and pulling of objects out of container.

13

Matches 3 sets of identical objects.

One set of objects is 1 matched pair. May be in response to adult verbal (e.g., “Put here”) or physical cue (e.g., handover-hand) for first few trials, but child needs to complete matching/sorting independently. Examples include: matching/sorting trains and tracks, crayons and paper, or sticks and circles in separate containers.

14

Matches 3 sets of identical pictures.

One set of objects is 1 matched pair. May be in response to adult verbal (e.g., “Put here”) or physical cue (e.g., handover-hand) for first few trials, but child needs to complete matching/sorting independently. Puzzles do not count.

15

Matches 3 sets of objects to pictures.

One set of objects is 1 matched pair. May be in response to adult verbal (e.g., “Put here”) or physical cue (e.g., handover-hand) for first few trials, but child needs to complete matching/sorting independently.

16

Matches 3 objects by color.

One set of objects is 1 matched pair. May be in response to adult verbal (e.g., “Put here”) or physical cue (e.g., hand-over-hand) for first few trials, but child needs to complete matching/sorting independently. Examples include matching/sorting red versus blue blocks, orange versus green pegs, or yellow versus purple balls into separate containers.

17

Matches 3 objects by shape.

One set of objects is 1 matched pair. Self-­explanatory

296

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 11 of 13)

Cognition (continued) 18

Matches 3 objects by size.

One set of objects is 1 matched pair. Example: During clean-up, when adult puts little bear in one container and big bear in another, child correctly sorts 5 or more bears (big and little) in corresponding containers.

19

Sorts similar objects into like groups by Child matches and sorts non-­identical objects by identity 3 categories (e.g., cars, horses, balls). (e.g., cars, horses, balls, socks, shoes, cups).

20

Sorts related common objects into 3 categories by function (e.g., eating, clothing, toys).

Self-­explanatory

21

Recognizes objects are missing and looks for or asks for them (e.g., doll missing shoe, puzzle missing piece).

Child recognizes when 1 object out of a set is missing and asks for it or searches for it (e.g., a missing puzzle piece, a missing shoe, a missing cup).

22

Matches objects across 2 features (e.g., size and color, shape and color).

Child matches/sorts 5 objects by color and shape, or shape and size, etc.

23

Matches objects by quantity (1–3).

Child matches objects in quantity groups for 5 trials involving the quantities 1 to 3 (e.g., domino pieces, animal crackers on a plate).

Play  1

Acts on 3–5 single objects using undifferentiated schema.

Interacts with toys all in the same way (e.g., shakes every toy, bangs every toy, mouths every toy).

 2

Holds 1 object in each hand and acts on them using the same schema.

Holds 1 object in each hand and interacts with both toys in the same way (e.g., holds 1 block in each hand and mouths each 1, or holds a block in 1 hand and a ring in the other and shakes both blocks at the same time).

 3

Brings 2 objects together in play (e.g., bangs blocks together).

Connects 2 toys by physically bringing them together or by using 1 object to act on the other (e.g., bangs 2 blocks together, uses a drumstick to bang a drum).

 4

Makes repetitive actions that cause interesting results.

Makes an action on an object, observes the result, and then makes the action again (e.g., pushes button on cause-and-­ effect toys, squeezes squeaky toy, shakes rain stick).

 5

Orients materials appropriately (e.g., turns car or cup right side up).

Self-­explanatory

 6

Pushes car or train with model.

Intentionally pushes the car so it moves forward and/or backward so that all 4 wheels stay on the table/floor.

 7

Plays independently with 3+ different May be in response to adult cue to start routine but places toys requiring 3 repetitions of the same 3 or more pieces independently (e.g., places rings on a ring stacker, takes nesting cups in/out, stacks blocks, or places action. pegs in holes).

 8

Completes 3+ piece puzzle with wooden handles.

May be in response to adult cue to start routine but places 3 or more pieces independently.

 9

Completes 2+ different actions with 2–3 multistep toys.

Play involves independent completion of the object/activity but may be in response to adult cue to start routine. Pass with 2–3 toys. Examples include placing blocks in a block sorter, opening top, and dumping blocks out; putting balls in a ball maze, hitting the ball with the hammer.

297

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 12 of 13)

Play (continued) 10

Completes 2+ different actions with 5–10 more multistep toys.

Play is developmentally appropriate (i.e., not restricted or repetitive), relates to the object/activity, and involves two-step actions on objects (e.g., placing blocks in a block sorter, opening top, and dumping blocks out; putting balls in a ball maze, hitting the ball with the hammer). May be in response to adult cue to start routine.

11

Shows conventional actions with objects on self with a model.

Actions are socially conventional and direct toward self. Examples include: places phone to ear, brushes hair with hairbrush/comb, puts spoon/fork to mouth, wipes nose with a tissue, cup to lip, put beads on.

12

Shows conventional actions with objects on others with a model.

Actions are socially conventional and directed toward others. Examples include: feeds other with spoon, combs adult’s hair.

13

Self-­explanatory Shows conventional actions spontaneously with objects on self and others.

14

Combines related objects in play (e.g., fork on plate, spoon in dish).

Child demonstrates awareness of functional relations of multiple sets of objects in his or her play and in clean-up.

15

Acts on figures or dolls with props (e.g., feeds teddy bear with spoon).

Requires spontaneous action; do not pass for imitation only.

16

Pass if child routinely demonstrates trial-and-error problem Demonstrates a trial-and-error solving in object play. approach to problem solving with constructive toys; schemas are flexible, not repetitive.

17

Constructive play involves sequencing complex schemas with multiple coordinated objects (e.g., trucks on a road, blocks make building, beads make a necklace).

Construct 3 or more schemas. Multiple objects may be trucks on road, blocks make building, beads make necklace.

18

Links 3 or more related actions in a play sequence.

Examples are building track, pushing train, and crashing train or taking out Play-Doh, using shape cutter, taking out shape.

19

Physically places figures in appropriate Places figures in appropriate context during play. Examples include: seats figure in chair or puts figure in car. context (e.g., miniatures on furniture/ vehicles).

20

Arranges props for the theme.

Arranges 2 or more props in 3 or more different play schemas. Examples are seeking out a plate and fork to feed baby, putting hat on self and other to play dress-up.

21

Animates agents with actions (e.g., moves stuffed dog as if dog is running after a ball).

Self-­explanatory

22

Uses several placeholder objects as props (e.g., pretends a block is a cell phone).

Pretends that objects are something other than what they actually are.

23

Spontaneously combines 3+ related behaviors in pretend play.

Examples: gives a baby doll a bottle and then covers it with a blanket; pours water in pot, stirs food, and pours food in bowl; puts on firefighter hat, drives fire engine truck, and puts out fire.

298

APPENDIX B.  P-ESDM Infant–Toddler Curriculum Checklist (page 13 of 13)

Play (continued) 24

Directs partner in play.

Provides 3 or more relevant instructions directed to partner to carry out some aspect of play theme across 2 or more play activities.

25

Plays out several life events (e.g., birthday, McDonald’s, the doctor) including the use of verbal scripts.

Plays out 3 or more life events, each containing at least 3 embedded activities, interacting with partner through verbal scripts and object actions.

26

Plays out several story themes in play.

Plays out 3 or more story themes with partner using multiple actions and scripts as described in the item above. Examples: Little Red Riding Hood, The Three Little Pigs, and Three Billy Goats Gruff.

27

Takes on a character’s role and plays it out.

States role (e.g., “I’m the Mommy”) and plays out a life scene with verbal script, activities, and gestures appropriate to role with three or more exchanges to partner.

28

Follows another’s lead in play.

Follows partner’s play directives verbally or nonverbally, 5 or more times by imitating partner’s acts or responding to partner’s instructions.

299

Appendix C

Parent-­Friendly Data-­Tracking Tools

Appendix C contains a few simple templates that we have created for parents to use for self-­evaluation of their progress. In each of the data tools we have provided, parents only need to mark a check, “X,” or plus sign next to the goal(s) they practiced successfully, a minus sign when their efforts were not successful, or NP (“not practiced”) for goals they did not practice. We keep the templates easy to use and focus on what parents deem important to track so that they feel ownership of the forms’ contents. We learned an important lesson from parents who began to track data at home, either their own or their child’s. We learned to ask about data sheets at the very beginning of the session, to look at any data sheets as soon as parents provided them, and to comment on them, in order to convey the importance of data and to show our respect for the effort required to record this information at home. We learned that if we did not ask for the data and remark on it, there would be no data the next session. So, ask to see the data!

Contents Appendix C.1:  Simple Tally System

303

Appendix C.2:  Days of the Week Tracking Chart

304

Appendix C.3:  Activities Data Tracker

305

Appendix C.4:  Goals and Activities Bar Chart

306

301

APPENDIX C.1

Simple Tally System

Here, we offer a tally system to track how often a parent practices each goal. The Xs in each box indicate how frequently a goal has been practiced at the end of the day, week, or whatever amount of time the parent chooses, with the total number of times practiced summarized entered below each goal.

My child watches me try new play ideas without leaving the interaction.

XXXX Total Times Practiced:  4

My child makes or copies my sounds during play or caretaking routines.

My child copies My child takes gestures that I three or more turns show him how to do when I follow his in songs. ideas and encourage him to continue play with a toy, songs, or other games with me.

XXXXXXXX Total Times Practiced:  8

X Total Times Practiced:  1

303

XXXXXXXXXX Total Times Practiced:  10

APPENDIX C.2

Days of the Week Tracking Chart These two examples track goals or steps by days of the week. Parents can check off boxes in the top table or make tallies in the bottom table once a goal or step has been achieved. If a goal or step is attempted but not successful, a minus sign or a similar symbol to indicate lack of success should be marked. If a step was not practiced, then the parent needs to document that with “NP” or similar notation. This is important because documenting lack of success or lack of practice provides extremely important data to the coach, who can determine if there is a problem with the step or with the way it is being practiced. Additionally, using an NP code creates a little motivation to practice a skill the next day and it alerts the coach to the possible need for motivational strategies. Sums or totals can be added to the table, as shown in the second example, if helpful to the parents in order to track how often each goal or step has been reached throughout the week and at the end of each day.

Sunday

Monday

Tuesday

Wednesday Thursday

Friday

Saturday

Sunday

Monday

Tuesday

Wednesday Thursday

Friday

Saturday

Goal/Step Goal/Step Goal/Step Goal/Step

Total

Goal/Step

16

Goal/Step

15

Goal/Step

38

Goal/Step

19

Total

12

15

9

11

304

0

8

12

APPENDIX C.3

Activities Data Tracker

Here’s another type of table to track how often goals or steps are achieved across activities that families typically perform with their young children. The range of activities can always be decided by the family members, as can the type of goals chosen; parents can also add totals in the last column and row to summarize progress across activity type. Other variables could also be included in addition to, or in place of, the activities practiced, such as the intervention strategies used to achieve goals.

Toy Play

Sensory Social Routines

Goal/Step

2

2

Goal/Step

1

3

Goal/Step

4

Goal/Step

Meals

Books

Bathtime Diapering Dressing

4

1

2

3

1

3

4

5

1

8

7

6

7

1

4

6

8

305

5

Outdoor

APPENDIX C.4

Goals and Activities Bar Chart

The coach may also consider a template like the one shown below that summarizes parents’ evaluation data across sessions. We find that parents appreciate seeing progress over time charted as it validates their hard work and achievements. Laurie typically does this at the midpoint and in the 10th out of 12 sessions with families, although the frequency can be adjusted based on how many sessions are offered to families. The chart also illustrates how often four goals were practiced inside the three routines of play, meals, and bathtime (alternatively, teaching steps could be recorded instead of goals). A similar chart could be devised with the ESDM Curriculum Checklist to show the number of skills achieved per domain from one quarter to the next.

16 14 12 10 8 6 4 2 0 Goal 1

Goal 2 Play

Goal 3 Meals

306

Bath time

Goal 4

References

Allcorn, S. (2006). Psychoanalytically informed executive coaching. In D. R. Stober & A. M. Grant (Eds.), Evidence-based coaching handbook: Putting best practices to work for your clients. Hoboken, NJ: Wiley. American Telemedicine Association. (2014, May). Core operational guidelines for telehealth services involving provider-­patient interactions. Retrieved from www.uwyo. edu/wind/_files/docs/wytn-doc/toolkit-docs/ata_core_provider.pdf. Antshel, K. M., Polacek, C., McMahon, M., Dygert, K., Spenceley, L., Dygert, L., . . . Faisal, F. (2011). Comorbid ADHD and anxiety affect social skills group intervention treatment efficacy in children with autism spectrum disorders. Journal of Developmental and Behavioral Pediatrics, 32(6), 439–446. Arora, N. K., Nair, M. K. C., Gulati, S., Deshmukh, V., Mohapatra, A., Mishra, D., . . . Vajaratkar, V. (2018). Neurodevelopmental disorders in children aged 2–9 years: Population-based burden estimates across five regions in India. PLOS Medicine, 15(7), e1002615. Baker-Ericzén, M. J., Stahmer, A. C., & Burns, A. (2007). Child demographics associated with outcomes in a community-based pivotal response training program. Journal of Positive Behavior Interventions, 9, 52–60. Bates, E. (1976). Language and context: The acquisition of pragmatics. Cambridge, MA: Academic Press. Bettelheim, B. (1972). The empty fortress: Infantile autism and the birth of the self. New York: Free Press. Bitsika, V., & Sharpley, C. F. (2009). Stress, anxiety and depression among parents of children with autism spectrum disorders. Australian Journal of Guidance and Counseling, 14, 151–161. Bonis, S. A., & Sawin, K. J. (2016). Risks and protective factors for stress self-­management in parents of children with autism spectrum disorder: An integrated review of the literature. Journal of Pediatric Nursing, 31, 567–579. Bretherton, I., & Bates, E. (1979). The emergence of intentional communication. New Directions for Child and Adolescent Development, 1979(4), 81–100. 307

308

References

Bronfenbrenner, U. (1986). Ecology of the family as a context for human development: Research perspectives. Developmental Psychology, 22(6), 723–742. Brown, S., & Moersch, M. (Eds.). (1978). Parent on the team. Ann Arbor: University of Michigan Press. Bruner, J. (1983). Child’s talk; Learning to use language. Oxford, UK: Oxford University Press. Capps, L., Sigman, M., & Mundy, P. (1994). Attachment security in children with autism. Development and Psychopathology, 6(2), 249–261. Chomsky, N. (1965). Aspects of theory of syntax. Cambridge, MA: MIT Press. Chomsky, N. (1980). Rules and representations. Oxford, UK: Blackwell. Dawson, G., & Adams, A. (1984b). Imitation and social responsiveness in autistic children. Journal of Abnormal Child Psychology, 12(2), 209–225. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., . . . Varley, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125(1), e17–e23. DiClemente, C. C., & Velasquez, M. M. (2002). Motivational interviewing and the stages of change. In W. R. Miller & S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (2nd ed., pp. 201–216). New York: Guilford Press. Dunst, C. J., & Trivette, C. M. (2009a) Capacity-­building family-­systems intervention practices. Journal of Family Social Work, 12(2), 119–143. Dunst, C. J., & Trivette, C. M. (2009b). Meta-­analytic structural equation modelling of the influences of family-­centered care on parent and child psychological health. International Journal of Pediatrics, 2009, Article ID576840. Dunst, C. J., Trivette, C. M., & Hamby, D. W. (2007). Meta-­analysis of family-­centered helpgiving practices research. Mental Retardation and Developmental Disability Research Reviews, 13, 370–378. Fixsen, D. L., Naoom, S. F., Blasé, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature (FMHI Publication No. 231). Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network. Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant–mother relationships. Journal of the American Academy of Child and Adolescent Psychiatry, 14(3), 387–421. Franz, L., Adewumi, K., Chambers, N., Viljoen, M., Baumgartner, J. N., & de Vries, P. J. (2018). Providing early detection and early intervention for autism spectrum disorder in South Africa: Stakeholder perspectives from the Western Cape province. Journal of Child and Adolescent Mental Health, 30(3), 149–165. Fuller, E., Oliver, K., Vejnoska, S. F., & Rogers, S. J. (2020.) The effects of the Early Start Denver Model for children with autism spectrum disorder: A meta-analysis. Brain Sciences, 10, 368. Furuta, G. T., Williams, K., Kooros, K., Kaul, A., Panzer, R., Coury, D. L., & Fuchs, G. (2012). Management of constipation in children and adolescents with autism spectrum disorders. Pediatrics, 130(Suppl. 2), S98–S105. Gengoux, G. W., Berquist, K. L., Salzman, E., Schapp, S., Phillips, J. M., Frazier, T. W., . . . Hardan, A. Y. (2015). Pivotal response treatment parent training for autism:



References 309

Findings from a 3-month follow-up evaluation. Journal of Autism and Developmental Disorders, 45, 2889–2898. Grant, A. M. (2006). An integrative goal-­focused approach to executive coaching. In D. Stober & A. M. Grant (Eds.), Evidence-based coaching handbook. Hoboken, NJ: Wiley. Green, J., Charman, T., Pickles, A., Wan, M. W., Elsabbagh, M., Slonims, V., . . . Johnson, M. H. (2015). Parent-­mediated intervention versus no intervention for infants at high risk of autism: A parallel, single-blind, randomised trial. Lancet Psychiatry, 2(2), 133–140. Green, J., Pickles, A., Pasco, G., Bedford, R., Wan, M. W., Elsabbagh, M., . . . Johnson, M. (2017). Randomised trial of a parent-­mediated intervention for infants at high risk for autism: longitudinal outcomes to age 3 years. Journal of Child Psychology and Psychiatry, 58(12), 1330–1340. Hall, C. M., & Bierman, K. L. (2015). Technology-­assisted interventions for parents of young children: Emerging practices, current research, and future directions. Early Childhood Research Quarterly, 33, 21–32. Hall, C. M., Culler, E. D., & Frank-Webb, A. (2016). Online dissemination of resources and services for parents of children with Autism Spectrum Disorders (ASDs): A systematic review of evidence. Journal of Autism and Developmental Disorders, 3, 273–285. Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., & Minjarez, M. B. (2015). A randomized controlled trial of Pivotal Response Treatment Group for parents of children with autism. Journal of Child Psychology and Psychiatry and Allied Disciplines, 56(8), 884–892. Hanft, B. E., Rush, D. D., & Shelden, M. L. (2004). Coaching families and colleagues in early childhood. Baltimore: Brookes. Hayes, S. A., & Watson, S. L. (2013). The impact of parenting stress: A meta-­analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(3), 629–642. Holingue, C., Newill, C., Lee, L. C., Pasricha, P. J., & Daniele Fallin, M. (2018). Gastrointestinal symptoms in autism spectrum disorder: A review of the literature on ascertainment and prevalence. Autism Research, 11(1), 24–36. Hutman, T., Siller, M., & Sigman M. (2009). Mothers’ narratives regarding their child with autism predict maternal synchronous behavior during play. Journal of Child Psychology and Psychiatry, 50, 1255–1263. Johnson, M. H., Gliga, T., Jones, E., & Charman, T. (2015). Annual research review: Infant development, autism, and ADHD—Early pathways to emerging disorders. Journal of Child Psychology and Psychiatry, 56(3), 228–247. Jones, E. J. H., Dawson, G., Kelly, J., Estes, A., & Webb, S. J. (2017). Parent-­delivered early intervention in infants at risk for ASD: Effects on electrophysiological and habituation measures of social attention. Autism Research, 10(5), 961–972. Jones, W., & Klin, A. (2013). Attention to eyes is present but in decline in 2–6-month-old infants later diagnosed with autism. Nature, 504(7480), 427–431. Kasari, C., Sigman, M., Mundy, P., & Yirmiya, N. (1988). Caregiver interactions with autistic children. Journal of Abnormal Child Psychology, 16(1), 45–56.

310

References

Knowles, M. S. (1980). The modern practice of adult education: From pedagogy to andragogy (rev. ed.). Wilton, CT: Association Press. Landa, R. (2018). Efficacy of early interventions for infants and young children with, and at risk for, autism spectrum disorders. International Review of Psychiatry, 30(1), 25–39. Lewy, A. L., & Dawson, G. (1992). Social stimulation and joint attention in young autistic children. Journal of Abnormal Child Psychology, 20(6), 555–566. Leyfer, O. T., Folstein, S. E., Bacalman, S., Davis, N. O., Dinh, E., Morgan, J., . . . Lainhart, J. E. (2006). Comorbid psychiatric disorders in children with autism: Interview development and rates of disorders. Journal of Autism and Developmental Disorders, 36(7), 849–861. Lord, C., & Schopler, E. (1989). Stability of assessment results of autistic and non-­autistic language-­impaired children from preschool years to early school age. Journal of Child Psychology and Psychiatry, 30(4), 575–590. Lovaas, O. I. (1981). Teaching developmentally disabled children: The ME book. Austin, TX: PRO-ED. Lovaas, O. I. (2003). Teaching children with developmental delays: Basic intervention techniques. Austin, TX: PRO-ED. Lovaas, O. I., Koegel, R., Simmons, J. Q., & Long, J. S. (1973). Some generalization and follow-up measures on autistic children in behavior therapy. Journal of Applied Behavior Analysis, 6(1), 131–165. Magnusdottir, K., Saemundsen, E., Einarsson, B. L., Magnusson, P., & Njardvik, U. (2016). The impact of attention deficit/hyperactivity disorder on adaptive functioning in children diagnosed late with autism spectrum disorder: A comparative analysis. Research in Autism Spectrum Disorders, 23, 28–35. Mannion, A., & Leader, G. (2014). Sleep problems in autism spectrum disorder: A literature review. Journal of Autism and Developmental Disorders, 1(2), 101–109. Mazurek, M. O., Vasa, R. A., Kalb, L. G., Kanne, S. M., Rosenberg, D., Keefer, A., . . . Lowery, L. A. (2013). Anxiety, sensory over-­responsivity, and gastrointestinal problems in children with autism spectrum disorders. Journal of Abnormal Child Psychology, 41(1), 165–176. McEvoy, R. E., Rogers, S. J., & Pennington, B. F. (1993). Executive function and social communication deficits in young autistic children. Journal of Child Psychology and Psychiatry, 34, 563–578. McGee, G. G., Krantz, P. J., Mason, D., & McClannahan, L. E. (1983). A modified incidental-­teaching procedure for autistic youth: Acquisition and generalization of receptive object labels. Journal of Applied Behavior Analysis, 16(3), 329–338. McGuinn, L., & Worley, L. (2008). Treatment and management: Family centered care and the medical home. In M. Wolraich, P. Dworkin, D. Drotar, & E. Perrin (Eds.), Developmental–­behavioral pediatrics: Evidence and practice. St. Louis, MO: Mosby. Meirsschaut, M., Warreyn, P., & Roeyers, H. (2011). What is the impact of autism on mother–child interactions within families with a child with autism spectrum disorder? Autism Research, 4, 358–367. Mesibov, G. B. (2005). The origins and history of the TEACCH program. In G. B. Mesibov, V. Shea, & E. Schopler (Eds.), The TEACCH approach to autism spectrum disorders. Boston: Springer.



References 311

Mesibov, G. B., Shea, V., & Schopler, E. (2005). The TEACCH approach to autism spectrum disorders. New York: Springer. Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. New York: Guilford Press. Minjarez, M. B., Williams, S. E., Mercier, E. M., & Hardan, A. Y. (2011). Pivotal response group treatment program for parents of children with autism. Journal of Autism and Developmental Disorders, 41, 92–101. Miodovnik, A., Harstad, E., Sideridis, G., & Huntington, N. (2015). Timing of the diagnosis of attention-­deficit/hyperactivity disorder and autism spectrum disorder. Pediatrics, 136(4), e830–e837. Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study of joint attention and language development in autistic children. Journal of Autism and Developmental Disorders, 20(1), 115–128. Mundy, P., Sigman, M., Ungerer, J., & Sherman, T. (1986). Defining the social deficits of autism: The contribution of non-­verbal communication measures. Journal of Child Psychology and Psychiatry, 27(5), 657–669. Neely-­Barnes, C. E., O’Hare, L., Powers, J. D., & Swick, D. C. (2012). The impact of autism spectrum disorders on the family: A qualitative study of mother’s perspectives. Journal of Family Social Work, 15, 187–201. Oppenheim, D., Koren-Karie, N., Dolev, S., & Yirmiya, N. (2009). Maternal insightfulness and resolution of the diagnosis are associated with secure attachment in preschoolers with autism spectrum disorders. Child Development, 80(2), 519–527. Osterling, J., & Dawson, G. (1994). Early recognition of children with autism: A study of first birthday home videotapes. Journal of Autism and Developmental Disorders, 24(3), 247–257. Ozonoff, S., Iosif, A. M., Baguio, F., Cook, I. C., Hill, M. M., Hutman, T., . . . Young, G. S. (2010). A prospective study of the emergence of early behavioral signs of autism. Journal of the American Academy of Child and Adolescent Psychiatry, 49(3), 256–266. Ozonoff, S., Young, G. S., Carter, A., Messinger, D., Yirmiya, N., Zwaigenbaum, L., . . . Stone, W. L. (2011). Recurrence risk for autism spectrum disorders: A Baby Siblings Research Consortium study. Pediatrics, 128(3), e488–e495. Parsons, D., Cordier, R., Vaz, S., & Lee, H. C. (2017). Parent-­mediated intervention training delivered remotely for children with autism spectrum disorder living outside of urban areas: Systematic review. Journal of Medical Internet Research, 19(8), e198. Prochaska, J. O., Redding, C. A., & Evers, K. (2002). The transtheoretical model and stages of change. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed.). San Francisco: Jossey-Bass. Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H. Rakowski, W., . . . Rossi, S. R. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13(1), 39–46. Rahman, A., Divan, G., Hamdani, S. U., Vajaratkar, V., Taylor, C., Leadbitter, K., . . . Green, J. (2016). Effectiveness of the parent-­mediated intervention for children with autism spectrum disorder in south Asia in India and Pakistan (PASS): A randomised controlled trial. Lancet Psychiatry, 3(2), 128–136.

312

References

Ramey, C. T., & Ramey, S. L. (1998). Early intervention and early experience. American Psychologist, 53(2), 109–120. Ramseur, K., 2nd, de Vries, P. J., Guler, J., Shabalala, N., Seris, N., & Franz, L. (2019). Caregiver descriptions of joint activity routines with young children with autism spectrum disorder in South Africa. Pediatric Medicine, 2. Ratner, N., & Bruner, J. (1978). Games, social exchange, and the acquisition of language. Journal of Child Language, 5(3), 391–401. Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York: Guilford Press. Rogers, S. J., Dawson, G., & Vismara, L. (2012). An early start for your child with autism: Using everyday activities to help kids connect, communicate, and learn. New York: Guilford Press. Rogers, S. J., Estes, A., Lord, C., Munson, J., Rocha, M., Winter, J., . . . Talbott, M. R. (2019). A multisite randomized controlled two-phase trial of the Early Start Denver Model compared to treatment as usual. Journal of the American Academy of Child and Adolescent Psychiatry, 58(9), 853–865. Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., . . . Dawson, G. (2012). Effects of a brief Early Start Denver Model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 51(10), 1052–1065. Rogers, S. J., Estes, A., Vismara, L., Munson, J., Zierhut, C., Greenson, J., . . . Talbott, M. (2019). Enhancing low-­intensity coaching in parent implemented Early Start Denver Model intervention for early autism: A randomized comparison treatment trial. Journal of Autism and Developmental Disorders, 49(2), 632–646. Rogers, S. J., Ozonoff, S., & Maslin-Cole, C. (1991). A comparative study of attachment behavior in young children with autism or other psychiatric disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 30(3), 483–488. Rogers, S. J., Vismara, L., Wagner, A. L., McCormick, C., Young, G., & Ozonoff, S. (2014). Autism treatment in the first year of life: A pilot study of infant start, a parent-­implemented intervention for symptomatic infants. Journal of Autism and Developmental Disorders, 44(12), 2981–2995. Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. New York: Guilford Press. Rush, D. D., & Shelden, M. L. (2008). Coaching: Quick reference guide. Briefcase, 1(1), 1. Rush, D. D., & Shelden, M. L. (2011). The early childhood coaching handbook. Baltimore: Brookes. Sandbank, M., Bottema-­Beutel, K., Crowley, S., Cassidy, M., Dunham, K., Feldman, J. I., et al. (2020). Project AIM: Autism intervention meta-­analysis for studies of young children. Psychological Bulletin, 146(1), 1–29. Sanders, J. L., & Morgan, S. B. (1997). Family stress and adjustment as perceived by parents of children with autism or Down syndrome: Implications for intervention. Child and Family Behavior Therapy, 19(4), 15–32. Schopler, E. (1971). Parents of psychotic children as scapegoats. Journal of Contemporary Psychotherapy, 4, 17–22.



References 313

Schopler, E., Lansing, M. D., & Waters, L. (1982). Teaching activities for autistic children (Vol. III): Individualized assessment and treatment for autistic and developmentally disabled children. Baltimore: University Park Press. Schopler, E., Reichler, R., & Lansing, M. D. (1980). Teaching strategies for parents and professionals (Vol. II): Individualized assessment and treatment for autistic and developmentally disabled children. Baltimore: University Park Press. Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., . . . Halladay, A. (2015). Naturalistic developmental behavioral interventions: Empirically validated treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(8), 2411–2428. Schreibman, L., & Koegel, R. L. (1996). Fostering self-­management: Parent-­delivered pivotal response training for children with autistic disorder. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for children and adolescent disorders: Empirically-based strategies for clinical practice. Washington, DC: American Psychological Association. Sigman, M., & Mundy, P. (1989). Social attachments in autistic children. Journal of the American Academy of Child and Adolescent Psychiatry, 28(1), 74–81. Sigman, M., Mundy, P., Sherman, T., & Ungerer, J. (1986). Social interactions of autistic, mentally retarded and normal children and their caregivers. Journal of Child Psychology and Psychiatry, 27(5), 647–655. Sigman, M., & Ruskin, E. (1999). Continuity and change in the social competence of children with autism, down syndrome, and developmental delays. Monographs of the Society for Research in Child Development, 64(Serial No. 256). Sigman, M., & Ungerer, J. A. (1984). Attachment behaviors in autistic children. Journal of Autism and Developmental Disorders, 14(3), 231–244. Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-­deficit/hyperactivity disorder symptoms, adaptive functioning, and quality of life in children with autism spectrum disorder. Pediatrics, 130(Suppl. 2), S91–S97. Siller, M., Hutman, T., & Sigman, M. (2013). A parent-­mediated intervention to increase responsive parental behaviors and child communication in children with ASD: A randomized clinical trial. Journal of Autism and Developmental Disorders, 43, 540–555. Siller, M., Morgan, L., Turner-Brown, T., Baggett, K. M., Baranek, G. T., Brian, J., . . . Zwaigenbaum, L. (2013). Designing studies to evaluate parent-­mediated interventions for toddlers with autism spectrum disorder. Journal of Early Intervention, 35(4), 355–377. Siller, M., & Sigman, M. (2002). The behaviors of parents of children with autism predict the subsequent development of their children’s communication. Journal of Autism and Developmental Disorders, 32(7), 77–89. Singh, K., & Zimmerman, A. W. (2015). Sleep in autism spectrum disorder and attention deficit hyperactivity disorder. Seminars in Pediatric in Pediatric Neurology, 22(2), 113–125. Skinner, B. F. (1957). Verbal behavior. New York: Appleton-­Century-­Crofts. Snyder, P. A., Hemmeter, M. L., & Fox, L. (2015). Supporting implementation of evidence-based practices through practice-based coaching. Topics in Early Childhood Special Education, 35, 133–143. Sprenger, L., Buhler, E., Poustka, L., Bach, C., Heinzel-­Gutenbrunner, M., Kamp-­Becker,

314

References

I., & Bachmann, C. (2013). Impact of ADHD symptoms on autism spectrum disorder symptom severity. Research in Developmental Disabilities, 34(10), 3545–3552. Stern, D. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books. Sullivan, E. L., Holton, K. F., Nousen, E. K., Barling, A. N., Sullivan, C. A., Propper, C. B., & Nigg, J. T. (2015). Early identification of ADHD risk via infant temperament and emotion regulation: A pilot study. Journal of Child Psychology and Psychiatry, 56(9), 949–957. Sullivan, K., Stone, W. L., & Dawson, G. (2014). Potential neural mechanisms underlying the effectiveness of early intervention for children with autism spectrum disorder. Research in Developmental Disabilities, 35(11), 2921–2932. Sundberg, M. L., & Partington, J. W. (1998). Teaching language to children with autism or other developmental disabilities. Concord, CA: ABV Press. Tager-­Flusberg, H., Calkins, S., Nolin, T., Baumberger, T., Anderson, M., & ChadwickDias, A. (1990). A longitudinal study of language acquisition in autism and Down Syndrome children. Journal of Autism and Developmental Disorders, 20, 1–21. Talbott, M. R., Nelson, C. A., & Tager-­Flusberg, H. (2016). Maternal vocal feedback to 9-month-old infant siblings of children with ASD. Autism Research, 9, 460–470. Trivette, C. M., Dunst, C. J., Hamby, D. W., & O’Herin, C. E. (2009). Characteristics and consequences of adult learning methods and strategies. Research Brief, 3(1), 1–33. Turnbull, R., & Turnbull, A. (2015). Looking backward and framing the future for parents’ aspirations for their children with disabilities. Remedial and Special Education, 36(1), 52–57. Turygin, N., Matson, J. L., & Tureck, K. (2013). ADHD symptom prevalence and risk factors in a sample of toddlers with ASD or who are at risk for developmental delay. Research in Developmental Disabilities, 34(11), 4203–4209. Vibert, B. A., Dufek, S., Klein, C. B., Choi, Y. B., Winter, J., Lord, C., & Kim, S. H. (2020). Quantifying caregiver change across early autism interventions using the measure of NDBI strategy implementation: Caregiver change (MONSI-CC). Journal of Autism and Developmental Disorders, 50, 1364–1379. Vismara, L. A., Colombi, C., & Rogers, S. J. (2009). Can one hour per week of therapy lead to lasting changes in young children with autism? Autism, 13(1), 93–115. Vismara, L. A., McCormick, C., Monlux, K., Nadhan, A., & Young, G. S. (2016). Telehealth parent training in the Early Start Denver Model: Results from a randomized controlled study. Focus on Autism and Other Developmental Disabilities, 33(2), 67–79. Vismara, L. A., McCormick, C. E. B., Shields, R., & Hessl, D. (2019). Extending the parent-­delivered Early Start Denver Model to young children with fragile X syndrome. Journal of Autism and Developmental Disorders, 49, 1250–1266. Vismara, L. A., McCormick, C., Young, G. S., Nadhan, A., & Monlux, K. (2013). Preliminary findings of a telehealth approach to parent training in autism. Journal of Autism and Developmental Disorders, 43, 2953–2969. Vismara, L. A., & Rogers, S. J. (2018). Supporting parents to define and address goals for their children’s development in everyday activities. In M. Siller & L. Morgan (Eds.), Handbook of parent-­implemented interventions for very young children with autism. New York: Springer.



References 315

Vismara, L. A., Young, G. S., & Rogers, S. J. (2012, November 22). Telehealth for expanding the reach of early autism training to parents. Autism Research and Treatment, 2012(2–3), 121878. Wan, M. W., Green, J., & Scott, J. (2019). A systematic review of parent–infant interaction in infants at risk of autism. Autism, 23(4), 811–820. Webb, S. J., Jones, E. J., Kelly, J., & Dawson, G. (2014). The motivation for very early intervention for infants at high risk for autism spectrum disorders. International Journal of Speech–­Language Pathology, 16(1), 36–42. Wetherby, A. M., Guthrie, W., Woods, J., Schatschneider, C., Holland, R. D., Morgan, L., & Lord, C. (2014). Parent-­implemented social intervention for toddlers with ASD: An RCT. Pediatrics, 134(6), 1084–1093. Zeanah, C. H., Berlin, L. J., & Boris, N. W. (2011). Practitioner review: Clinical applications of attachment theory and research for infants and young children. Journal of Child Psychology and Psychiatry, 52(8), 819–833. Zeanah, P. D., Stafford, B. S., Nage, G. A., & Rice, T. (2005). Addressing social-­emotional development and infant mental health in early childhood systems. Los Angeles: National Center for Infant and Early Childhood Health Policy.

Index

Note. f or t following a page number indicates a figure or table. ABC Action Plan Template, 149 ABCs of behavior and learning ABC sequences of behavior intervention topic and, 147–164 helping young children develop speech intervention topic and, 212–214 Acceptance, 32–33, 48–49 Acquisition skills, 178–179 Action Plan Template for Parent Follow-Through form, 214–217, 218 Action stage of change, 51–52. See also Stages of change Activities Categories handout, 44, 91–92, 132–133, 261 Activities Data Tracker, 305 Activities That Encourage Nonverbal Communication form, 127, 128–129, 130–131 Activity plan, 44. See also Topics for coaching sessions Activity/coaching experience of the coaching session. See also Coaching session routines; Parent coaching sessions; Topics for coaching sessions in a group format, 239–240, 239t overview, 74–75, 76, 83–85 Stages of Change and Possible Coaching Techniques checklist, 279–286 Adaptations to coaching, 233–240, 236t, 238t, 239t, 240t, 241t. See also Parent coaching Adult learning principles, 29–30, 37–40. See also Learning Animate play, 188. See also Play; Pretend play; Toys Antecedents that lead to a behavior, 147–164. See also ABCs of behavior and learning Anxiety and anxiety disorders, 48–49, 243–246

Applied behavior analysis (ABA) ABC sequences of behavior intervention topic and, 147–164 early intervention and, 14 knowledge base needed by coaches and, 25–26 overview, 9, 10, 11 Asking for objects, 164–173 Assessment family-centered model of intervention and, 18 overview, 63–66 parents’ role in, 13 P-ESDM Infant–Toddler Curriculum Checklist, 63–64, 287–299 short-term goals and, 66–67 Attachment relationship, 14–16. See also Relationships Attending to others, 164–173 Attention, joint, 164–173, 293–294 Attention of child, 102–107 Attention-deficit/hyperactivity disorder (ADHD), 243–246, 243f

Behavior, 147–164. See also ABCs of behavior and

learning Blame, 38 Body language. See also Gestures; Nonverbal communication imitation as a learning tool intervention topic and, 141–143 nonverbal communication (body language) intervention topic and, 125–138 sharing interests and attention with others (joint attention) intervention topic and, 164–173 Boundaries, 53–54 Broader autism phenotype, 15–16

316



Caregiver coaching. See Parent coaching

Index 317

Caregiver-implemented intervention. See Parentimplemented early intervention approaches Centering practices, 48–49 Changing behavior ABC sequences of behavior intervention topic and, 162–164 stages of change and, 50–52, 51f, 279–286 Stages of Change and Possible Coaching Techniques checklist, 279–286 Check-in period of coaching sessions. See Coaching session routines; Greeting period of sessions Check-ins in between coaching sessions, 94 Checklists. See Handouts/forms/checklists Cleaning-up after an activity, 183–184, 185. See also Ending activities Clipboard as a coach’s tool, 41, 257 Clock as a coach’s tool, 43 Closing period of coaching sessions, 74, 75, 76, 94. See also Coaching session routines; Ending activities; Parent coaching sessions Coaches. See also Coaching relationship; Parent coaching assessment and, 65–66 boundaries and, 53–54 coach preparation, 77 coordinating treatment plans when there are multiple coaches, 71 emotional thermometer and, 47 first contact with parents and children and, 61–63 humility and, 53 knowledge base needed by, 24–30 overview, 40 relationship between coach and parent and, 30–34 role of, 2–3, 6–8, 7t, 93 support for, 34–37 wide-angle perspective and, 47 Coaching. See Parent coaching Coaching fidelity checklist. See Coach’s Fidelity of Implementation Brief Checklist Coaching fidelity rating tool. See ESDM Coaching Fidelity Rating Tool Coaching relationship. See also Coaches; Parent coaching; Relationships assessment and, 64 boundaries and, 53–54 difficulties within, 97–99 ending the coaching relationship, 99–100 establishing and building, 61–63 overview, 5–6, 59, 72, 101 parental motivation and, 38–39 relationship between coach and parent and, 30–34 supporting a coaching approach and, 34 Coaching session routines. See also Parent coaching sessions; Topics for coaching sessions closing, 94 coach preparation, 77

coaching activity and, 83–85 coach’s reflection and notes, 94 discussion time, 93–94 greetings and check-ins, 78–79 in a group format, 236–239, 236t, 238t, 239t, 240t, 241t overview, 77, 85f, 100–101 reflection and session goal setting, 80–83 reflection–evaluation–planning cycle and, 85–93, 85f warm-up activities, 79–80 Coaching time of sessions, 74–75. See also Coaching session routines; Parent coaching sessions Coach’s Clipboard List, 41, 257 Coach’s Fidelity of Implementation Brief Checklist, 94, 269–270 Coach’s Session Planning Sheet, 77, 258 Coach’s tools clipboard and pencil, 41 clock, 43 Coach’s Clipboard List, 257 Coach’s Session Planning Sheet, 41–43 data checklists, 45–46 emotional thermometer, 47 mindfulness as, 48–49 other tools to consider, 48–54, 51f overview, 41, 57–58 parent manual as, 44 problem solving, 54–57 reflective mirror (supervision) as, 48 Refrigerator List, 45, 262 wide-angle perspective as, 47 Collaboration coordinating treatment plans when there are multiple coaches, 71 dealing with conflicts and, 233–234 first contact with parents and children and, 61–63 knowledge base needed by coaches and, 37 relationship between coach and parent and, 31 short-term goals and, 66–67 Comfort zone of children, 105–106 Communication. See also Language back-and-forth interactions (turn taking) intervention topic and, 112–125 gaining children’s attention intervention topic and, 102–107 helping young children develop speech intervention topic and, 200–218 language interventions and, 16–17 nonverbal communication (body language) intervention topic and, 125–138 P-ESDM Infant–Toddler Curriculum Checklist, 63–64, 287–299 relationship between coach and parent and, 33 sharing interests and attention with others (joint attention) intervention topic and, 164–173 Community, 13, 248–250 Competencies, 20–21

318

Index

Conflicts, dealing with, 233–234 Consequences of behavior, 147–164. See also ABCs of behavior and learning; Reinforcement Constructive toy play, 173–187. See also Play Contemplation stage of change, 51–52. See also Stages of change Conventional play, 189–190. See also Play Co-occurring conditions, 242–248, 243f Copying. See Imitation Core skill set, 82. See also Topics for coaching sessions Counseling services, 233 Creative play, 173–187. See also Play Culturally informed practices, 234, 248–250

Data checklists, 45–46. See also Handouts/forms/

checklists Days of the Week Tracking Chart, 304 Developmental processes ABC sequences of behavior intervention topic and, 160 future research needs regarding, 252 helping young children develop speech intervention topic and, 200–218 infants at risk for ASD and, 250–251 knowledge base needed by coaches and, 37 language interventions and, 16–17 P-ESDM Infant–Toddler Curriculum Checklist, 63–64, 287–299 pretend play intervention topic and, 188–189 short-term goals and, 66 Diagnosis beginning coaching following, 59–61 co-occurring conditions and, 242–248, 243f feelings and reactions to, 1 parents’ role in, 13 process of, 61 Discussion time of sessions, 74, 76, 93–94. See also Coaching session routines; Parent coaching sessions; Reflection/evaluation during coaching sessions Distractions, 105, 160

Early intervention. See also Parent coaching;

Parent-implemented early intervention approaches clinician-driven, 1–2 coaching and, 4–8, 7t future research needs regarding, 252–254 language interventions and, 16–17 overview, 22t, 254 parent–child relationship and, 14–16 research regarding, 9 Early Start Denver Model Coaching Fidelity Coding Sheet, 278 Early Start Denver Model (ESDM). See also Parent-Implemented Early Start Denver Model (P-ESDM) assessment and, 63–64 data checklists and, 45–46

Early Start Denver Model Coaching Fidelity Coding Sheet, 278 ESDM Coaching Fidelity Rating Tool, 271–277 knowledge base needed by coaches and, 26 motivational interviewing (MI) and, 50–52, 51f overview, 3–4, 3f, 13–14 writing objectives and learning steps, 67 Education for All Handicapped Children Act (Public Law 94-142), 18, 21 Elaborations, 143–147 Emotions emotional thermometer tool, 47 ending the coaching relationship and, 99–100 mindfulness and, 48–49 negative emotions, 35–36, 99–100 positive emotions, 99–100 supporting coaches and, 35–36 Empowerment, 20–21, 38–39 Ending activities back-and-forth interactions (turn taking) intervention topic and, 121–124 flexible creative object play intervention topic and, 177, 183–184 imitation as a learning tool intervention topic and, 146 ESDM Coaching Fidelity Rating Tool, 94, 271–277 Ethical standards, 53–54 Evaluation stage of problem-solving, 57 Evidence-based practices, 24–25 Expand on actions, 143–147 Expertise, 24–30 Exposure to sounds, 204–205 Expressive language. See also Language helping young children develop speech intervention topic and, 200, 201–210 overview, 201 P-ESDM Infant–Toddler Curriculum Checklist, 290–293 Eye contact and gaze, 166, 169–173

Facial movements

imitation as a learning tool intervention topic and, 141–143 sharing interests and attention with others (joint attention) intervention topic and, 166 Families, 29–30 Family, Infant and Preschool Program (FIPP), 20 Family-centered model. See also Interventions; Parent-implemented early intervention approaches emergence of, 3–4, 3f future research needs regarding, 252–254 interdisciplinary teams and, 18–19 overview, 2–3, 20–21, 22t parent coaching and, 19–21 parent group coaching and, 235–240, 236t, 238t, 239t, 240t, 241t shifting to parent coaching and, 28–29 Feedback, 32–33



Index 319

Fidelity measures. See also Handouts/forms/ checklists Coach’s Fidelity of Implementation Brief Checklist, 94, 269–270 Early Start Denver Model Coaching Fidelity Coding Sheet, 278 ESDM Coaching Fidelity Rating Tool, 94, 271–277 Fidelity of Implementation (FOI) data sheet, 45–46 knowledge base needed by coaches and, 26–28 overview, 45–46 parent fidelity data, 45, 81 Parent–ESDM Fidelity Coding Sheet, 263 Fidelity of implementation (FOI) knowledge base needed by coaches and, 26–28 supporting a coaching approach and, 34 First Group Session Plan form, 236, 237 Flexibility, 54 Follow through ABC sequences of behavior intervention topic and, 161 helping young children develop speech intervention topic and, 214–217 Forms. See Handouts/forms/checklists Fun. See also Play flexible creative object play intervention topic and, 173–187 fun in parent–child interactions intervention topic and, 107–112 Future directions and research, 242–248, 243f, 252–254

G

eneralist approach, 13–14 Generating ideas stage of problem-solving, 55 Genetic factors, 15–16 Gestures. See also Body language helping young children develop speech intervention topic and, 207–210 imitation as a learning tool intervention topic and, 141–143 nonverbal communication (body language) intervention topic and, 125–138 P-ESDM Infant–Toddler Curriculum Checklist, 289, 290–291 sharing interests and attention with others (joint attention) intervention topic and, 164–173 Goals addressing within coaching sessions, 95–97 assessment and, 63–66 coaching and, 4–5 Coach’s Session Planning Sheet and, 41–43 ending the coaching relationship and, 99–100 flexible creative object play intervention topic and, 178–179 parental motivation and, 37–40, 49–52, 51f problem solving and, 54–55 reflection–evaluation–planning cycle and, 85–93, 85f

reviewing in first coaching session, 74 session routines and, 80–83 short-term goals and, 66–67 writing objectives and learning steps, 67–70 Goals and Activities Bar Chart, 306 Goodbye time of sessions. See Closing period of coaching sessions Greeting period of sessions, 73, 74, 76, 78–79. See also Coaching session routines; Parent coaching sessions Group parent coaching, 235–240, 236t, 238t, 239t, 240t, 241t

Hand gestures. See Gestures

Handouts/forms/checklists. See also Refrigerator lists ABC Action Plan Template, 149, 150 Action Plan Template for Parent FollowThrough, 214–217, 218 Activities Categories handout, 44, 91–92, 132–133, 261 Activities Data Tracker, 305 Activities That Encourage Nonverbal Communication form, 127, 128–129, 130–131 Coach’s Clipboard List, 257 Coach’s Fidelity of Implementation Brief Checklist, 269–270 coach’s reflection and notes, 94 Coach’s Session Planning Sheet, 77, 258 data checklists, 45–46 Days of the Week Tracking Chart, 304 Early Start Denver Model Coaching Fidelity Coding Sheet, 278 First Group Session Plan form, 236, 237 Goals and Activities Bar Chart, 306 Joint Activity Template, 115, 116, 118, 119, 121, 122–123 overview, 44, 74–75 Parent Daily Practice Chart, 43, 91–92, 259–260 parent manual and, 44 Parent Self-Monitoring Checklist, 45, 267–268 Parent Skills Checklist, 264–266 Parent–ESDM Fidelity Coding Sheet, 263 P-ESDM Infant–Toddler Curriculum Checklist, 63–64, 287–299 Refrigerator List, 44, 45, 262 Simple Tally System, 303 Stages of Change and Possible Coaching Techniques checklist, 279–286 Health concerns, 246–248 Help, asking for, 136–138 Help Is in Your Hands website, 26, 39–40, 44 Home practice plan, 41–42 Humility, 53

Imagination

flexible creative object play intervention topic and, 173–187 pretend play intervention topic and, 187–199

320

Index

Imitation flexible creative object play intervention topic and, 173–187 gaining children’s attention intervention topic and, 106 imitation as a learning tool intervention topic and, 138–147 P-ESDM Infant–Toddler Curriculum Checklist, 295 Implementation stage of problem-solving, 56–57 Incidental teaching, 25 Independence and independent play, 13, 179–187. See also Play Individualized education plans (IEPs), 26 Individualized family service plans (IFSPs), 25–26 Individualizing interventions, 39–40 Individuals with Disabilities Education Act (IDEA), 18, 21 Infant–adult interactions, 17. See also Parent–child interactions Infants at risk for ASD, 250–251 Interactions with others. See also Parent–child interactions back-and-forth interactions (turn taking) intervention topic and, 112–125 flexible creative object play intervention topic and, 173–187 gaining children’s attention intervention topic and, 102–107 helping young children develop speech intervention topic and, 200–218 sharing interests and attention with others (joint attention) intervention topic and, 164–173 Interdisciplinary models, 252–253 Interdisciplinary teams generalist model and, 12–14 knowledge base needed by coaches and, 37 motivational interviewing (MI) and, 50–52 overview, 13–14, 18–19 reflective supervision and, 48 Interests, sharing with others, 164–173 Internet-based coaching, 234–235 Interpersonal support, 36 Interventionists. See also Coaches generalist model and, 13 knowledge base needed by coaches and, 24–30 overview, 1–2 role of, 2–3, 6–8, 7t supporting a coaching approach and, 34–37 Interventions. See also Activity/coaching experience of the coaching session; Early intervention; Family-centered model; Parent coaching; Parent-implemented early intervention approaches; Topics for coaching sessions clinician-driven, 1–2 co-occurring conditions and, 242–248, 243f

generalist model and, 12–14 shifting from to parent coaching, 28–29 “Invisible” objects in play, 195–197. See also Play; Pretend play

Joint activities

back-and-forth interactions (turn taking) intervention topic and, 112–125 imitation as a learning tool intervention topic and, 140–141, 142–147 Joint Activity Template, 115, 116, 118, 119, 121, 122–123 Joint attention, 164–173, 293–294

Knowledge base needed by coaches, 24–30 Language. See also Communication

back-and-forth interactions (turn taking) intervention topic and, 118 flexible creative object play intervention topic and, 173–187 helping young children develop speech intervention topic and, 200–218 language interventions and, 16–17 P-ESDM Infant–Toddler Curriculum Checklist, 63–64, 287–299 pretend play intervention topic and, 187–199 sharing interests and attention with others (joint attention) intervention topic and, 164–173 Laughter, 54 Learning. See also Adult learning principles ABC sequences of behavior intervention topic and, 147–164 assessment and, 63–66 child objectives and, 95–97 data checklists and, 45–46 developing learning steps, 67–70 early intervention and, 14 flexible creative object play intervention topic and, 173–187 fun in parent–child interactions intervention topic and, 107–112 gaining children’s attention intervention topic and, 102–107 helping young children develop speech intervention topic and, 200–218 imitation as a learning tool intervention topic and, 138–147 incorporating adult learning principles into coaching, 29–30 interventions that support learning styles, 13 language interventions and, 16–17 opportunities for, 4–5, 8 parental motivation and, 37–40, 49–52, 51f pretend play intervention topic and, 187–199 sharing interests and attention with others (joint attention) intervention topic and, 164–173



Index 321

supporting a coaching approach and, 34–35 writing objectives and learning steps, 67–70 Limited resource availability to children and families, 248–250 Listening, 50, 106–107, 204–205. See also Communication Lists, refrigerator. See Refrigerator Lists Looking at objects, 166, 169–173 Low-resource communities, 248–250

Maintenance skills, 178–179

Maintenance stage of change, 51–52. See also Stages of change Make-believe play. See Play; Pretend play Medical conditions, 246–248 Medical model, 18 Mental health services, 233, 243–246, 243f Mindfulness, 48–49 Motivation parental motivation and, 37–40, 49–52, 51f Stages of Change and Possible Coaching Techniques checklist, 279–286 Motivational interviewing (MI), 50–52, 51f Multidisciplinary models, 252–253

Naturalistic approaches, 25–28. See also

Naturalistic developmental–behavioral early intervention model (NDBI) Naturalistic developmental–behavioral early intervention model (NDBI). See also Topics for coaching sessions data checklists and, 45 fidelity of implementation (FOI) tool and, 26 knowledge base needed by coaches and, 25–28 overview, 9, 11, 254 supporting a coaching approach and, 34–37 variations in family stories, 221–233 Needs, individual, 13, 20–21 Negative emotions and reactions, 35–36, 99–100. See also Emotions Negative reinforcement, 151–152. See also Consequences of behavior; Reinforcement Nonjudgmental stance, 32–33 Nonverbal communication. See also Body language; Gestures helping young children develop speech intervention topic and, 200–218 nonverbal communication (body language) intervention topic and, 125–138

Object play, 173–187. See also Play

Objects, attention to, 164–173. See also Joint attention Observation–planning–practice–reflection– evaluation cycle, 77 Observations ABC sequences of behavior intervention topic and, 148–149 coaching session routines and, 79–80

data from, 45, 75 parent group coaching and, 236–239, 238t One-on-one therapy model, 18–19 Operant learning model, 16–14

Pantomimed objects in play, 195–197. See also Play;

Pretend play Paper as a coach’s tool, 43–44 Parent coaching. See also Coaches; Coaching relationship; Coaching session routines; Parent coaching sessions; Topics for coaching sessions adaptations to, 233–235 assessment and, 63–66 beginning the process of, 59–61 with children and families in low-resource communities, 248–250 co-occurring conditions and, 242–248, 243f coordinating treatment plans when there are multiple coaches, 71 family-centered care and, 19–21 first contact with parents and children and, 61–63 future of, 252–254 in a group format, 235–240, 236t, 238t, 239t, 240t, 241t for infants at risk for ASD, 250–251 motivational interviewing (MI) and, 50–52, 51f overview, 4–8, 7t, 10–11, 22t, 23–24, 40, 57–58, 59–61, 72, 220, 240–241, 254 parental motivation and, 37–40, 49–52, 51f process of, 85, 85f relationship between coach and parent and, 30–34 session plan and, 41–42 shifting to, 28–29 short-term goals and, 66–67 Stages of Change and Possible Coaching Techniques checklist, 279–286 supporting interventions based on, 34–37 transdisciplinary treatment plan and, 70–71 variations in family stories, 221–233 writing objectives and learning steps, 67–70 Parent coaching sessions. See also Activity/ coaching experience of the coaching session; Coaching session routines; Parent coaching; Session plan addressing child objectives within, 95–97 assessment and, 65–66 difficulties within the coaching relationship and, 97–99 ending the coaching relationship, 99–100 first session, 73–75 overview, 73, 100–101 preparing for, 77 structure for, 75–77 Parent Daily Practice Chart, 43, 91–92, 259–260 Parent fidelity of implementation tools. See Fidelity measures

322

Index

Parent manual, 44. See also Handouts/forms/ checklists; Refrigerator lists Parent Self-Monitoring Checklist, 45, 267–268 Parent Skills Checklist, 264–266 Parent training models, 19–20 Parent–child interactions. See also Infant–adult interactions; Interactions with others; Parent– child relationship back-and-forth interactions (turn taking) intervention topic and, 112–125 fun in parent–child interactions intervention topic and, 107–112 helping young children develop speech intervention topic and, 205–207 overview, 15–16 planning the activity/coaching experience of the coaching session based on, 75 sharing interests and attention with others (joint attention) intervention topic and, 164–173 Parent–child relationship, 14–16. See also Relationships Parent–coach relationship. See Coaching relationship Parent–ESDM Fidelity Coding Sheet, 263 Parent-implemented early intervention approaches. See also Early intervention; Family-centered model; Interventions; Parent-Implemented Early Start Denver Model (P-ESDM) coaching within, 4–8, 7t for infants at risk for ASD, 250–251 overview, 12–14, 22t research regarding, 9 Parent-Implemented Early Start Denver Model (P-ESDM). See also Early Start Denver Model (ESDM) assessment and, 63–64 group format for, 235–240, 236t, 238t, 239t, 240t, 241t overview, 9, 11, 220 parent coaching and, 20 P-ESDM Infant–Toddler Curriculum Checklist, 63–64, 287–299 transdisciplinary treatment plan and, 70 Parents communication with, 20–21 incorporating adult learning principles into coaching, 29–30 motivation and, 37–40, 49–52, 51f overview, 15–16 relationship between coach and parent and, 30–34 Patience, 112–125 Peer support motivational interviewing (MI) and, 50–52 reflective supervision and, 48 supporting coaches and, 36 Pencil as a coach’s tool, 41 P-ESDM Infant–Toddler Curriculum Checklist, 63–64, 287–299

Plan for sessions. See Coach’s Session Planning Sheet Plan–act–reflect–evaluate process, 32, 42, 47 Planning moment of sessions, 73–74, 80–83, 85–93, 85f. See also Coaching session routines; Parent coaching sessions Planning stage of problem-solving, 56 Play back-and-forth interactions (turn taking) intervention topic and, 112–125 flexible creative object play intervention topic and, 173–187 fun in parent–child interactions intervention topic and, 107–112 imitation as a learning tool intervention topic and, 138 P-ESDM Infant–Toddler Curriculum Checklist, 297–299 pretend play intervention topic and, 187–199 Pointing to objects, 170–173. See also Gestures Positive emotions and reactions, 99–100. See also Emotions Positive reinforcement, 151–152. See also Consequences of behavior; Reinforcement Practice-based coaching (PBC) framework, 3–4, 3f Praise parental motivation and, 38 relationship between coach and parent and, 32–33 sharing interests and attention with others (joint attention) intervention topic and, 170 Precontemplation stage of change, 51–52. See also Stages of change Preferences, 13 Premack principle, 213 Preparation stage of change, 51–52. See also Stages of change Pretend play, 187–199. See also Play Proactive stance, 21 Problem definition stage of problem-solving, 54–57 Problem solving, 54–57 Progress monitoring, 45–46, 95–97 Proximal points, 172. See also Pointing to objects Proximal zones of development, 64 Psychiatric conditions, 243–246, 243f Punishment, 153

Receptive language. See also Language;

Understanding speech helping young children develop speech intervention topic and, 200, 210–218 overview, 201 P-ESDM Infant–Toddler Curriculum Checklist, 289–290 Reflection reflective supervision and, 48 relationship between coach and parent and, 31–32, 33



Index 323

Reflection/evaluation during coaching sessions. See also Coaching session routines; Discussion time of sessions; Parent coaching sessions in a group format, 240, 240t, 241t overview, 76 reflection and session goal setting and, 80–83 reflection–evaluation–planning cycle and, 85–93, 85f Reflection–evaluation–planning cycle, 85–93, 85f Reflective mirror (supervision), 48. See also Supervision Refrigerator Lists, 44, 45, 262. See also Checklists; Parent manual Reinforcement. See also Consequences of behavior ABC sequences of behavior intervention topic and, 151–154 helping young children develop speech intervention topic and, 212–214 parental motivation and, 37–38 sharing interests and attention with others (joint attention) intervention topic and, 170 Relapse and repair stage of change, 51–52. See also Stages of change Relationships. See also Coaching relationship back-and-forth interactions (turn taking) intervention topic and, 112–125 parent–child relationship, 14–16 relationship between coach and parent and, 30–34 sharing interests and attention with others (joint attention) intervention topic and, 164–173 Resources available to children and families, 248–250 Responding to sounds made by others, 204–205 Routines for sessions. See Coaching session routines

S

elf-care, 47 Self-efficacy, 20–21 Self-monitoring, 96–97, 99–100 Sensory social routines (SSRs) back-and-forth interactions (turn taking) intervention topic and, 115–125 fun in parent–child interactions intervention topic and, 108–112 imitation as a learning tool intervention topic and, 142–147 Session plan. See also Coaching session routines; Parent coaching sessions; Topics for coaching sessions overview, 41–43 parent group coaching and, 236–239, 238t preparing for coaching sessions and, 77 reflection–evaluation–planning cycle and, 85–93, 85f Stages of Change and Possible Coaching Techniques checklist, 279–286 using a clock as a tool and, 43 Session routines. See Coaching session routines

Sessions. See Coaching session routines; Parent coaching sessions Shared decision-making, 20–21 Sharing skills, 164–173. See also Turn taking Short-term goals, 66–67. See also Goals Showing objects to others, 164–173 Simple Tally System, 303 Social play. See also Play fun in parent–child interactions intervention topic and, 107–112 pretend play intervention topic and, 191 Solitary play. See Independence and independent play Sounds. See also Vocalizations helping young children develop speech intervention topic and, 201–210 imitation as a learning tool intervention topic and, 139–140 P-ESDM Infant–Toddler Curriculum Checklist, 291–293 responding to sounds made by others, 204–205 Speech. See also Vocalizations helping young children develop speech intervention topic and, 200–218 language interventions and, 16–17 nonverbal communication (body language) intervention topic and, 125–126 P-ESDM Infant–Toddler Curriculum Checklist, 289–290 Spontaneous play, 192–194. See also Play Stages of change motivational interviewing (MI) and, 50–52, 51f Stages of Change and Possible Coaching Techniques checklist, 279–286 Stimulus. See Antecedents that lead to a behavior Strengths, 13, 21 Summary “refrigerator” lists. See Refrigerator Lists Supervision. See also Reflective mirror (supervision) motivational interviewing (MI) and, 50–52 reflective supervision, 48 supporting coaches and, 36 Support, 34–37, 233–234 Symbolic combinations, 188, 197–199. See also Play; Pretend play Symbolic play. See Play; Pretend play Symbolic substitution, 188, 194–197. See also Play; Pretend play

Tablet of paper, 43–44

Talking to children, 205–207 Teams, interdisciplinary. See Interdisciplinary teams Techniques to teach during coaching sessions. See Topics for coaching sessions Technology, telehealth and, 234–235 Telehealth coaching, 234–235 Termination, 99–100 Therapist, 6–8, 7t. See also Coaches Therapist–child intervention sessions, 28–29

324

Index

Three-way interactions, 165. See also Joint attention Time-outs, 153 Tolerance, 112–125 Tools, coach’s. See Coach’s tools Topics for coaching sessions. See also Activity/ coaching experience of the coaching session; Coaching session routines; Core skill set; Session plan ABC sequences of behavior, 147–164 back-and-forth interactions (turn taking), 112–125 flexible creative object play, 173–187 fun in parent–child interactions, 107–112 gaining children’s attention, 102–107 in a group format, 239–240, 239t helping young children develop speech, 200–218 imitation as a learning tool, 138–147 nonverbal communication (body language), 125–138 overview, 82–83, 102, 218–219 pretend play, 187–199 sharing interests and attention with others (joint attention), 164–173 Stages of Change and Possible Coaching Techniques checklist, 279–286 Toys. See also Play flexible creative object play intervention topic and, 173–187 pretend play intervention topic and, 187–199 Training knowledge base needed by coaches and, 27–28 motivational interviewing (MI) and, 50–52 Transdisciplinary approach motivational interviewing (MI) and, 50–52 transdisciplinary treatment plan and, 70–71 Transitions back-and-forth interactions (turn taking) intervention topic and, 121–124 flexible creative object play intervention topic and, 177, 183–184 imitation as a learning tool intervention topic and, 146 Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH), 12–14, 19–20

Treatment plan. See also Topics for coaching sessions assessment and, 65–66 coordinating when there are multiple coaches, 71 reviewing in first coaching session, 74 short-term goals and, 66–67 transdisciplinary treatment plan and, 70–71 writing objectives and learning steps, 67–70 Triadic attention, 165. See also Joint attention Triggers of behavior. See Antecedents that lead to a behavior Turn taking back-and-forth interactions (turn taking) intervention topic and, 112–125 helping young children develop speech intervention topic and, 211–212 sharing skills and, 164–173

Understanding speech, 200, 210–218. See also

Receptive language Unwanted behavior, 162–164. See also Changing behavior; Topics for coaching sessions

Variations to activities

constructive toy play and, 176–177 flexible creative object play intervention topic and, 184–185 imitation as a learning tool intervention topic and, 143–147 Vocal games, 203–204, 209–210 Vocalizations. See also Sounds; Speech helping young children develop speech intervention topic and, 200–218 imitation as a learning tool intervention topic and, 139–140 P-ESDM Infant–Toddler Curriculum Checklist, 291–293 sharing interests and attention with others (joint attention) intervention topic and, 166

Warm-up activities in coaching sessions, 76,

79–80. See also Coaching session routines; Parent coaching sessions Week, plan for, 43–44 Wide-angle perspective, 47