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Brief Report: Mediation of Treatment Effect in a Communication Intervention for Pre-School Children with Autism

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Abstract

Tests of mediation in treatment trials can illuminate processes of change and suggest causal influences in development. We conducted a mediation analysis of a previously published randomised controlled trial of parent-mediated communication-focused treatment for autism against ordinary care, with 28 children aged 2–5 years (Aldred et al. in J Child Psychol Psychiatr 45:1–11, 2004). The hypothesised mediating process, targeted by the intervention, was an increase in parental synchronous response within parent–child interaction. The results showed partial mediation, with change in synchrony accounting for 34% of the positive intervention effect on autism symptomatology (Autism Diagnostic Observation Schedule communication and social domain algorithm); the result was confirmed by bootstrap estimation. Improved parental synchronous response to child communication can alter short-term autism symptom outcome with targeted therapy.

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Fig. 1
Fig. 2

Abbreviations

ADOS:

Autism diagnostic observation schedule

RCT:

Randomised controlled trial

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Acknowledgments

The original intervention trial was made possible by a grant from the Shirley Foundation. Development, initial validation and study coding of the PCI (parent child interaction) coding formed part of Catherine Aldred’s doctoral dissertation for the University of Manchester. The authors gratefully acknowledge Eileen Davey’s contribution to the pilot PCI coding.

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Corresponding author

Correspondence to Jonathan Green.

Appendices

Appendix 1. Measurement and Reliability of PCI Codes

Method

Standardised event sampling was carried out recording the frequency of parent synchrony/asynchrony and parent/child communication acts.

Code Definitions

 

 

Description

Definition of parent codes

Synchronous communication acts

Verbal non-directive communication acts: comments, statements or acknowledgement of the child’s focus of attention

Asynchronous communication acts

Verbal acts used for the purpose of directing or to control the behaviour of another; commands, directing or seeking attention; questions or negation

Definition of child and parent code

Communication acts (CA)

Verbal or non-verbal acts used with intent or to influence the responses of the other person including requesting, seeking attention, directing, acknowledging, questions, demands, comments or statements

Inter-rater Reliability

For the Parent–Child interaction measure, two raters independently reviewed the 10-min parent–child interaction videos along with their transcripts in 7/28 (25%) of study cases. Each parent-spoken utterance identified on the transcript was coded for synchrony. Agreement on synchrony between these independently rated codes was 95.6% (kappa = .92). Subsequently, codes with inter-rater disagreement on original scores were resolved by conference, reviewing the utterance on question on video and transcript and agreeing a consensus code to be used in the analysis. A training programme and manual is available for the dyadic measure of communication.

Note on Codes

Echolalia is defined as child responses that repeat back precisely the adult’s utterance with an identical intonation pattern and do not form part of a communication function. Imitation is defined as the child’s imitation of words with appropriate intonation, and is coded for communication intent. Synchronous carer responses comment on the child’s focus and respond to the child’s topic of talk. Details of synchrony coding are illustrated in the following transcript. The pre-treatment sample shows predominant asynchrony coding. The post treatment sample shows increased parental synchronous codes with language that expands and builds on the child’s vocabulary and grammatical structures. With this there is associated increase in child communication initiation and language. Parent and child are playing with a selection of toys (plastic food, tea set, cutlery, puppet, figures, animals, garage and vehicles).

 

Pre treatment (baseline)

Mum: have some dinner now (Asynchronous)

D: Uh? Mum: have some dinner? (Asynchronous)

Mum: there’s your plate to have some dinner, there’s daddy’s, there’s mummy’s (Asynchronous)

Mum: have you got your knife and fork? (Asynchronous)

D: fork (echolalia not coded as communication)

Mum: I’m going to have my dinner now. There you are, there’s your plate. What do you want to eat? (Asynchronous)

D: eat? (Echolalia not coded as communication)

Mum: what do you want to eat? (Asynchronous)

D: eat; fork (Echolalia not coded as communication)

Post treatment (12 month follow-up)

D: wash little girl (holding small figure near toy sink) (Communication initiation)

Mum: washing hair little girl (Synchronous)

D: shampoo (showing small bottle to mum) (Communication initiation)

Mum: shampoo? (Synchronous)

Mum: put shampoo on, nice and clean (Synchronous)

D: freezing cold (Communication initiation)

Mum: yes she’s freezing cold (Synchronous)

D: need a toilet, need a wee (pointing to miniature toilet) (Communication initiation)

Mum: she needs the toilet; she needs a wee, (Synchronous)

Mum: here you are, here’s the toilet. (Synchronous)

Mum: She needs to wash her hands now. (Synchronous)

D: wash hands… good girl…(Communication initiation)

D: tap off…(Communication initiation)

D: pull the chain…wash her hands (Communication initiation)

Mum: wash hands little girl, (Synchronous)

Mum: turn the tap off (Synchronous)

D: need a toothbrush (showing small stick representing tooth brush) (Communication initiation)

Mum: let’s find a toothbrush (Synchronous)

Mum: this can be a toothbrush (Synchronous)

Mum: there she’s wiping her mouth now (Synchronous)

Appendix 2. Intervention Procedures

This parent mediated intervention trained parental communication responses adapted to the individual child’s communication skills. The treatment is mannualised with 6 stages to reflect the developmental progression of pre-linguistic skills. Child meaningful communication responses were enhanced, reducing echolalia or scripted speech. The intervention trains parents in adapted communication using video-aided feedback of parent–child play. Parents attend monthly 3 h clinic sessions for 6 months and 3 maintenance session for 6 months. The therapists use a reflective style to elicit heightened parent observation, understanding and progress whilst framing the focus of the observations within the stages of the manual. Parents undertake to spend 30 min daily between clinic sessions practising strategies recorded in the written home programme. The pace of work is individualised to the parents’ style and progress and the child’s accomplishment of developmental goals at each stage. Not all children progressed to stage 6.

The intervention goals firstly aim to and increase parental synchrony and sensitivity by increasing timely reciprocal responses matched to the child’s observed communication. Shared attention is elicited by the parental observing the child’s focus and intent. Incremental development of child communication is facilitated through the stages of the manual and the treatment gains are generalised into everyday routines. Parent–child video observation established the level of accomplishment at each of the stages in the manual.

Stages of the treatment programme:

  • Eliciting shared attention, communication, enjoyment

    • Parents observing the child’s focus, inferring intentions

  • Enhancing parental synchronous response

    • Parents using timely reciprocal comments, acknowledging the child’s focus, avoiding asynchronous responses that re-direct, question or make demands on child responses.

  • Adapted communication strategies for parents

    • Parent matching language use to child understanding, semantically contingent on child play

  • Eliciting child anticipation initiation and participation

    • Predictable sequences, routines, repetition, rehearsed play, imitation

  • Developing child communication initiation/pragmatic functions

    • Communication teasers

  • Elaborating child communication

    • Language extensions/elaboration

    • Conversational reciprocity

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Aldred, C., Green, J., Emsley, R. et al. Brief Report: Mediation of Treatment Effect in a Communication Intervention for Pre-School Children with Autism. J Autism Dev Disord 42, 447–454 (2012). https://doi.org/10.1007/s10803-011-1248-3

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