Evidence-Based Research

The aim of this study was to examine how severity of autism affects children’s interactions (relatedness) and relationships with their parents. Participants were 25 parent-child dyads that included offspring who were children with autism aged from 4 to 14 years. The severity of the children’s autism was assessed using the calibrated severity metric of the Autism Diagnostic Observation Schedule (Gotham et al. in “J Autism Dev Disord: 39:693-705, 2009). Parent-child dyads were videotaped in 10-min semi-structured play interactions, and qualities of interpersonal relatedness were rated with the Dyadic Coding Scales (Humber and Moss in “Am J Orthopsychiatr” 75(1):128-141, 2005). Quality of relationships between parents and children were evaluated with a parent self-report measure, the Parent Child Relationship Inventory (Gerard in “Parent-Child Relationship Inventory (PCRI) manual.” WPS, Los Angeles, 1994). Multivariate regression analysis revealed that severity of autism was inversely related to patterns of parent-child interaction but not to reported quality of parent-child relationship. We consider the implications for thinking about relatedness and relationships among children with autism, and opportunities for intervention.

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Preliminary Efficacy of Relationship Development Intervention® and Parent-Implemented Applied Behavior Analysis/Verbal Behavior on Joint Attention and Communication of Preschool Children with Autism

Background:
Acquiring joint attention (JA) and functional spoken language by the time a child with autism enters school around the age of 5 years old are critical. Involving parents in treatment maximizes the child’s opportunities to learn. Relationship Development Intervention® (RDI) is a relationship-based intervention focusing on recreating developmental milestones through meaningful interactions with parents with a primary goal of increasing JA. However, little research has evaluated the efficacy of this intervention. In contrast, a model based on Skinner’s Analysis of Verbal Behavior (ABA/VB) increases spoken language directly when implemented by therapist and teachers; however, this approach has not been evaluated when implemented by parents. RDI and ABA/VB have different primary targets for intervention; however, both approaches assume that language and JA, respectively, will emerge as a corollary effect of the intervention.

Objectives:
The purpose of this pilot study is to compare the efficacy of two parent-implemented adjunctive interventions, RDI and ABA/VB, against Services As Usual (SAU) on JA and language in children 2-6 year old with ASD.

Methods:
Participants were 36 children diagnosed with autism spectrum disorder (ASD) by community providers and the Autism Diagnostic Observation Schedule-2™. Participants were randomly assigned to RDI, parent-implemented ABA/VB, or SAU conditions. All parents, regardless of assigned condition, reported weekly on the type and extent of services delivered. The intervention consisted of 16 sessions over 14 weeks delivered in the home. Assessments were conducted pre-treatment and end of treatment (3 months). The primary outcome measure was direct observation of parents and children interacting under different scenarios designed to implement conditions most likely to produce the behavior targeted by the interventions (e.g., joint attention, specific language skills) including prompts that involved having the child ask the parent for preferred items and engaging the child in a conversation about family photographs. The direct observations were coded by research assistants blind to treatment condition and trained to interobserver reliability levels of 80% or above on a coding taxonomy that included an array of parent and child behavior related to joint attention, language, and problem behavior. In addition, two standardized assessments were also administered (Mullen Scales of Early Learning and Communication and Symbolic Behavior Scales).

Results:
All participants for the study have been recruited and 29 children have completed the treatment and post-assessment. Preliminary results indicate that both RDI and ABA/VB produced gains in the child’s following of bids for joint attention, three-point gazes, and initiating verbalizations while SAU did not result in any gains for any of these behaviors.

Conclusions:
This pilot study examines the efficacy of parent-implemented RDI and ABA/VB against SAU on social and emotional communication and language via direct observation and standardized measures. Preliminary results indicate that both interventions are able of producing gains in joint attention and verbal behavior, even though the two interventions differ in primary intervention targets. Furthermore, children in SAU condition did not show evidence of change. These results support that parents can serve as effective agents of change in the implementation of empirically supported early interventions for ASD.

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BACKGROUND:
Relationship Development Intervention (RDI) is a program designed to empower and guide parents of children, adolescents and young adults with autism spectrum disorders (ASD) and similar developmental disorders to function as facilitators for their children’s mental development. RDI teaches parents to play an important role in improving critical emotional, social, and metacognitive abilities through carefully graduated, guided interaction in daily activities.

METHODS:
The paper reviews RDI’s theoretical underpinnings, current methodology and preliminary research results. The clinical utilization of RDI is discussed as an important part of the biopsychosocial management of ASD.

RESULTS:
Although a controlled, blinded study of RDI has yet to be done, preliminary research suggests that parents, through the RDI curriculum and consultation process, have the potential to exert a powerful impact on their ASD children’s experience-sharing communication, social interaction, and adaptive functioning.

CONCLUSIONS:
RDI should be considered as part of a comprehensive treatment regimen, in which the physician plays a clinical management role, providing medical and psychiatric consultation. The RDI clinician can function as a remediation specialist, providing accurate feedback to the physician, along with individualized training and guidance to family members.

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This study is the second in a series evaluating the effectiveness of Relationship Development Intervention (RDI) to address unique deficits inherent in autism spectrum disorders. RDI is a parent-based, cognitive-developmental approach, in which primary caregivers are trained to provide daily opportunities for successful functioning in increasingly challenging dynamic systems. This study reviewed the progress of 16 children who participated in RDI between 2000 and 2005. Changes in the Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnostic Interview-Revised (ADI-R), flexibility, and school placement were compared prior to treatment and at a minimum 30 month follow-up period. While all children met ADOS/ADI-R criteria for autism prior to treatment, no child met criteria at follow-up. Similar positive results were found in relation to flexibility and educational placement. Generalizability of current findings is limited by the lack of a control or comparison group, constraints on age and IQ of treated children, parent self-selection, and parent education conducted through a single clinic setting.

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The aim of this project was to replicate and extend findings from two recent studies on parent-child relatedness in autism (Beurkens, Hobson, & Hobson, 2013; Hobson, Tarver, Beurkens, & Hobson, 2013, under review) by adapting an observational assessment and coding schemes of parent-child relatedness for the clinical context and examining their validity and reliability. The coding schemes focussed on three aspects of relatedness: joint attentional focus (Adamson, Bakeman, & Deckner, 2004), the capacity to co-regulate an interaction and the capacity to share emotional experiences. The participants were 40 children (20 with autism, 20 without autism) aged 6-14, and their parents. Parent-child dyads took part in the observational assessment and were coded on these schemes. Comparisons were made with standardised measures of autism severity (Autism Diagnostic Observation Schedule, ADOS: Lord, Rutter, DiLavore, & Risi, 2001; Social Responsiveness Scale, SRS: Constantino & Gruber, 2005), relationship quality (Parent Child Relationship Inventory, PCRI: Gerard, 1994) and quality of parent-child interaction (Dyadic Coding Scales, DCS: Humber & Moss, 2005). Inter-rater reliability was very good and, as predicted, codes both diverged from the measure of parent-child relationship and converged with a separate measure of parent-child interaction quality. A detailed profile review revealed nuanced areas of group and individual differences which may be specific to verbally-able school-age children. The results support the utility of the Relationship Development Assessment – Research Version for clinical practice.

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A new social communication intervention for children with autism: pilot randomized controlled treatment study suggesting effectiveness. Journal of Child Psychology & Psychiatry, 45(8), 1420-1430.

Caregiver-child relatedness in autism, what changes with intervention? Poster presented at the meeting of the International Meeting For Autism Research (IMFAR), April 2008, London, UK.

Can children with autism spectrum disorders be helped to acquire a “theory of mind”? Revista de Logopediay Audiologia, Vol. 28(7), 74-89.