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Speech-Language Pathology Interventions and Ingredients that

Support Social Communication and Language of Preschoolers
with Autism
Amanda Binns, The University of Western Ontario

Supervisor: Dr. Janis Oram Cardy, The University of Western Ontario

A thesis submitted in partial fulfillment of the requirements for the Doctor of Philosophy degree
in Health and Rehabilitation Sciences
© Amanda Binns 2021

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Part of the Speech and Hearing Science Commons, and the Speech Pathology and Audiology
Commons

Recommended Citation
Binns, Amanda, "Speech-Language Pathology Interventions and Ingredients that Support Social
Communication and Language of Preschoolers with Autism" (2021). Electronic Thesis and Dissertation
Repository. 7663.
https://ir.lib.uwo.ca/etd/7663

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 Abstract

One of the best predictors of long-term outcomes for autistic children is development

of language and social communication skills. Therefore, it’s not surprising that speech and

language therapy is one of the most frequently accessed interventions for children with

suspected or diagnosed autism. From a public health and family well-being perspective,

identifying effective social communication interventions and better understanding the

specific components that contribute to their effectiveness is critical. However, there is a lack

of clarity about the most effective interventions. This dissertation addressed this important

topic through three studies.

Study 1 examined the literature on interventions provided by speech-language

pathologists (SLPs) to autistic preschool children through a scoping review. Findings

indicated that current research captures the versatility of SLPs’ roles in supporting autistic

children, and has markedly increased over the past decade. However, research with strong

methodological rigor that captures the complex and individualized nature of interventions is

needed, as are studies aligned with community practice.

Study 2 systematically reviewed and critically appraised research evaluating one type

of intervention used by SLPs – developmental social pragmatic (DSP) interventions. Results

revealed that DSP interventions positively impact autistic children’s social communication,

but evidence for impact on children’s language was inconsistent.

Study 3 focused on better understanding one support built into DSP interventions and

other programs – environmental modification – by exploring the relationship between

children’s unstructured (symbolic and gross-motor) play environments and their social

communication behaviours using linear mixed effect models. Results revealed that young

autistic children were more likely to socially attend to caregivers in gross motor play and to

ii
focus their attention solely on objects during symbolic play. This study confirmed the

importance of continued research focused on understanding the impact of unstructured play

environments on children’s social attention and communication.

Together, this dissertation contributes to a broader understanding of SLP-delivered

interventions for preschoolers with autism, begins the work of examining how specific

ingredients included within in early interventions might interact with social communication

behaviours, and provides suggestions for future lines of inquiry.

Keywords: Autism, Speech-Language Pathology, Social Communication, Language, Social

Attention, Intervention, Therapy, Children, Preschool, Play, Systematic Review, Scoping

Review

iii
 Summary for Lay Audience
This thesis aims to enhance our understanding of intervention programs offered by

speech-language pathologists (SLPs) to children with autism. One of the best predictors of

long-term outcomes for children with autism is development of language. Therefore, it is not

surprising that speech-language pathology services are one of the most frequently sought-

after services after children receive a diagnosis of autism. Three studies were conducted to

better understand therapies offered by SLPs, their effectiveness, and specific ingredients

within these interventions that might play an important role in supporting autistic children

and their families. The first study involved searching all research published between 1980-

2019 that investigated SLP-delivered therapies provided to preschool autistic children. This

was done to identify how much research has been conducted, what types of therapies have

been researched and to provide guidance for what kind of research needs to be done in the

future. The second study evaluated the quality of the research on one particular type of

therapy often use by SLPs when working with young children with autism. The third study

investigated how symbolic and gross motor play environments impacted autistic children’s

attention to their caregivers and their toys, how much they used language, and the complexity

of the language they used. Together these studies contribute to a broader understanding of

SLP-delivered therapies for preschoolers with autism and provide suggestions for future

research.

iv
 Co-Authorship Statement
This dissertation is composed of original work conducted by me in fulfilment of a

PhD under the supervision of Dr. Janis Oram Cardy, from the School of Communication

Disorders at University of Western Ontario. No part of this dissertation has been submitted

for any other degree or diploma.

This thesis includes three original papers presented in chapters 2, 3, and 4, one of

which has been published in a peer-reviewed journal and another that has been submitted for

publication. Publishers have granted permission to include the articles in this dissertation. All

three studies were designed and conducted by me along with collaborators. Co-author

contributions have been clearly outlined below. My primary supervisor, Dr. Janis Oram

Cardy, provided input into the design, analysis, and interpretation of results and editing of all

chapters in this dissertation.

Chapter 2: Binns, A. V., Andres, A., Smyth, R., Lam, J., & Oram Cardy, J. (2020). Looking
Back and Moving Forward: A Scoping Review of Research on Preschool Autism
Interventions in the Field of Speech-Language Pathology. Under review. Autism and
Developmental Language Impairments.

Author Contributions: Amanda Binns: Conceptualization (Lead), Investigation (Equal),

Methodology (Lead), Supervision (Lead), Writing - review & editing (Lead). Allison Andres:

Conceptualization (Supporting), Investigation (Equal), Project administration (Supporting);

Review & editing (Supporting). Rachael Smyth: Conceptualization (Supporting),

Methodology (Supporting), Investigation (Supporting), Review & editing (Supporting),

Formal analysis (Supporting). Joyce Lam: Investigation (Equal), Project administration

(Supporting); Review & editing (Supporting). Janis Oram Cardy: Funding acquisition (Lead),

Resources (Lead), Conceptualization (Supporting); Methodology (Supporting); Writing -

review & editing (Supporting).

v
Chapter 3: Binns, A., & Oram Cardy., J. (2019). Developmental social pragmatic
interventions for children with autism spectrum disorder: A systematic review. Autism and
Developmental Language Impairments, 4, 1-8. doi:10.1177/2396941518824497

Author Contributions: Amanda Binns: Conceptualization (Lead), Investigation (Lead),

Methodology (Lead), Supervision (Lead), Formal Analysis (Lead), Writing - review &

editing (Lead). Janis Oram Cardy: Resources (Lead); Conceptualization (Supporting);

Methodology (Supporting), Investigation (Supporting), Writing - review & editing

(Supporting).

Chapter 4: Unpublished manuscript

Author Contributions: Amanda Binns: Conceptualization (Lead), Methodology (Equal),

Investigation (Lead), Supervision (Lead), Writing - review & editing (Lead). Devin

Casenhiser: Conceptualization (Supporting), Methodology (Supporting), Formal Analysis

(Supporting), Review & Editing (Supporting). Stuart Shanker: Funding Acquisition (Lead),

Review & editing (Supporting). Janis Oram Cardy: Resources (Lead), Conceptualization

(Supporting), Methodology (Supporting), Investigation (Supporting), Writing - review &

editing (Supporting).

vi
 Acknowledgments
I first and foremost want to thank my supervisor Dr. Janis Oram Cardy for selflessly

sharing her knowledge, expertise and advice with me to help me grow, and for believing in,

and supporting me each step of this journey.

Thank you to my committee members Dr. Lisa Archibald, Dr. Sheila Moodie and Dr.

Betsy Skarakis Doyle for your thoughtful suggestions and input on my projects. Past and

present members of the Autism Spectrum and Language Disorders Lab, I’ve appreciated

your friendship and academic support over the years.

Thank you to the children and families who inspire me each day, and made this work

possible. I am grateful for the funding provided to me by the Ontario Mental Health

Foundation (Doctoral Award) and the Council of Ontario Universities (Autism Scholars

Doctoral Award).

I must also thank the following people who have played key roles in my pursuit of

this work. Dr. Devin Casenhiser, thank you for encouraging me to pursue this work, for

always pushing my thinking and for your mentorship. Dr. Stuart Shanker, from day one you

have always been one of my biggest supporters. Your passion and leadership inspired me to

continue the work we started at York University. To my colleagues and friends, Eunice, Fay,

Janine, Jessica, Kerry-Anne, you have continued to encourage and cheer me on during the

highs and lows - thank you.

Most importantly, I never would have been able to do this without the love and

support from my family. Each step of this process, in so many different ways, you have made

this possible. Thank you, Mom, Dad, Cristian, Cassia and Caius.

vii
 Table of Contents
Abstract.............................................................................................................................. ii
Summary for Lay Audience ............................................................................................ iv
Co-Authorship Statement ................................................................................................ v
Acknowledgments ........................................................................................................... vii
List of Tables ..................................................................................................................... x
List of Figures................................................................................................................... xi
List of Appendices ........................................................................................................... xii
Chapter 1: Introduction ................................................................................................... 1
1.1 Research Problem .................................................................................................. 1
1.2 Topic Selection........................................................................................................ 2
1.3 Autism Overview .................................................................................................... 2
1.3.1 A Word About Terminology ....................................................................... 3
1.3.2 Prevalence ..................................................................................................... 4
1.3.3 Diagnostic Criteria ...................................................................................... 4
1.3.4 Diagnostic Process........................................................................................ 7
1.3.5 Heterogeneity................................................................................................ 8
1.4 Supports and Interventions for Autistic Children and Their Families............. 9
1.4.1 A Note on Terminology ............................................................................... 9
1.4.2 The Importance of Providing Supports as Early as Possible................. 10
1.4.3 Parent Involvement.................................................................................... 11
1.4.4 Individualization of Treatment Programs ............................................... 12
1.4.5 Use of Natural Environments/Integrated Learning Targets ................. 12
1.5 Objectives .............................................................................................................. 13
Chapter 2 ......................................................................................................................... 24
Looking Back and Moving Forward: A Scoping Review of SLP-delivered Autism
Interventions for Preschool Children with Autism ................................................. 24
2.1 Introduction .......................................................................................................... 24
2.1.1 A Note on SLP Interventions and Programs .......... Error! Bookmark not
defined.
2.1.2 The Current Study ..................................................................................... 26
2.2 Methods ................................................................................................................. 27
2.2.1 Phase 1: Articulating the Research Question .......................................... 28
2.2.2 Phase 2: Identifying Relevant Studies ...................................................... 28
2.2.3 Phase 3: Selecting Studies ......................................................................... 29
2.2.4 Phase 4: Charting Data ............................................................................. 30
2.2.5 Phase 5: Collating, Summarizing and Reporting Results ...................... 33
2.3 Results ................................................................................................................... 33
2.3.1 Extent of Research ..................................................................................... 33
2.3.2 Range of Skill Development Areas Targeted........................................... 37
2.3.3 The Nature of Interventions Delivered by SLPs ..................................... 40
2.4 Discussion .............................................................................................................. 44
2.4.1 Extent of Research Specific to Speech-Language Pathology ................. 44
2.4.4 SLP Roles in Delivering Intervention ...................................................... 48
2.4.5 Range of Skill Development Areas Targeted........................................... 50
2.4.6 Nature of SLP-delivered Interventions .................................................... 51
2.4.7 Future Directions ....................................................................................... 53
2.4.8 Limitations .................................................................................................. 55

viii
 2.5 Conclusion............................................................................................................. 56
Chapter 3 ......................................................................................................................... 68
Developmental Social Pragmatic Interventions for Preschoolers with Autism
Spectrum Disorder: A Systematic Review ............................................................... 68
3.1 Background and Aims ......................................................................................... 68
3.2 Methods ................................................................................................................. 70
3.2.1 Search Procedures .................................................................................... 70
3.2.2 Selection criteria........................................................................................ 71
3.2.3 Data collection ........................................................................................... 75
3.2.4 Assessment of evidence-based quality ...................................................... 75
3.3 Results ................................................................................................................... 77
3.3.1 Systematically Identifying DSP Interventions......................................... 77
3.3.2 Description of Studies ................................................................................ 78
3.2.3 Description of Intervention ....................................................................... 83
3.2.4 Intervention Impact .................................................................................. 88
3.2.5 Factors influencing DSP intervention effects .......................................... 92
3.4 Discussion .............................................................................................................. 94
3.4.1 Limitations and future research ............................................................... 98
3.5 Conclusions ........................................................................................................ 100
Chapter 4 ....................................................................................................................... 109
Trampolines and Crash Mats or Pretend Food and Toy Cars? How Play Contexts
Impact the Engagement and Language of Preschool Autistic Children ............. 109
4.1 Introduction ........................................................................................................ 109
4.1.1 Considering the Role of the Environment ............................................. 112
4.1.2 The Current Study ................................................................................... 115
4.2 Method ............................................................................................................... 116
4.2.1 Participants.............................................................................................. 116
4.2.2 Overview of Design and Procedures ...................................................... 117
4.2.3 Coding and Reliability ............................................................................. 117
4.2.4 Analytic Methods ..................................................................................... 119
4.3 Results ................................................................................................................ 122
4.3.1 The Impact of Play Context on Social Attention/Engagement ............ 122
4.3.2 The Impact of Play Context on Language ............................................. 125
4.4 Discussion ............................................................................................................ 126
4.4.1 Engagement Differences Across Play Contexts .................................... 126
4.4.2 Language Differences Across Play Contexts ......................................... 129
4.2.3 Limitations ................................................................................................ 130
4.2.4 Clinical Implications and Significance ................................................... 132
4.5 Conclusions ......................................................................................................... 133
Chapter 5: General Discussion .................................................................................... 143
5.1 Foundational Knowledge: Mapping the SLP Autism Intervention Literature
............................................................................................................................. 144
5.2 Identifying and Evaluating Interventions using a Developmental Social
Pragmatic (DSP) Model .................................................................................... 146
5.3 The Relationship Between Play Contexts and Children’s Social
Communication ................................................................................................. 148
5.4 Future Directions ............................................................................................... 149
5.5 Conclusions ......................................................................................................... 152
Appendices ..................................................................................................................... 154
Curriculum Vitae .......................................................................................................... 173
ix
 List of Tables
Table 1. Range of Skill Development Areas Targeted Within the Included Studies ............. 38
Table 2. Interventions proposed to be DSP and evaluation of how they incorporate core
features of DSP interventions ................................................................................................. 71
Table 3. Summary of included studies ................................................................................... 81
Table 4. Summary of included studies outcomes and certainty of evidence ......................... 84
Table 5. Demographic information of participants .............................................................. 118
Table 6. Descriptions and examples of engagement variables based on Adamson et al., 2000
............................................................................................................................................... 120
Table 7. Random and Fixed Effects Parameters for All Five Mixed Models ...................... 124
Table 8. Pairwise Contrasts for LME Models ...................................................................... 125

x
 List of Figures
Figure 1. Number of studies by (a) decade published, (b) continent of origin, (c) participant
diagnostic information, and (d) study design. ......................................................................... 34
Figure 2. Theoretical models underpinning interventions targeting the nine skill development
areas, and comprehensive interventions. ................................................................................ 41
Figure 3. Number of times service delivery models were used across interventions targeting
specific skill development areas. ............................................................................................ 42
Figure 4. Prisma flow diagram ............................................................................................... 79
Figure 5. Pirateplots of descriptive data (group means, 95% confidence intervals) for
engagement and language performance (dependent variables) in participants across symbolic
and gross motor play contexts............................................................................................... 123

xi
 List of Appendices
Appendix A: Scoping Review Search Strategies and Limits ............................................. 154
Appendix B: References of Articles Included Within the Scoping Review ....................... 156
Appendix C: CASP Systematic review tool ....................................................................... 166
Appendix D: DSP Systematic Review: Inclusion of Reliability, Generalization and
Maintenance, Social Validity and Fidelity Measures ........................................................... 172

xii
 1

Chapter 1: Introduction

In this first chapter, I introduce the research problem and articulate the rationale

for selecting the topic of preschool autism interventions for my dissertation. Then, to

provide context for my research topic, I present an overview of autism, and broadly

discuss supports and interventions for autistic children and their families. Finally, I

outline the three studies included within this dissertation.

1.1 Research Problem

Speech and language therapy is one of the most frequently accessed early

interventions for children with suspected or diagnosed autism (Denne et al., 2018;

Salomone et al., 2016; Volden et al., 2015). This is not surprising given that parents

consistently identify both the communication and social domains as treatment

priorities for their children with autism (Pituch et al., 2011). Additionally, language

and social communication skills are among the most important contributors to long-

term outcomes in children with autism (Tidmarsh & Volkmar, 2003). Therefore,

identifying and implementing effective supports to improve these capacities in autistic

children is essential for enhancing quality of life for both children and their parents.

However, this is not an easy task. Autistic children present with complex and highly

heterogenous profiles (Masi et al., 2017), making it illogical to think that a single

intervention, or even a specific set of interventions, is likely to support all individuals

with autism. Speech-language pathologists (SLPs) are in a prime position to support

children with autism as they receive diversified trainings and can provide therapy to

support a range of different skill development areas. However, we (as SLPs) need to

better understand how to identify, select, and deliver these interventions to this

heterogeneous population of children. In order to do this, we need a more complete

 2

understanding of SLP-delivered interventions, their effectiveness, and the specific

supports built into the interventions that might act as mechanisms for positive change.

The primary purpose of my doctoral research was to enhance our understanding of

intervention programs offered by SLPs to children with autism and to contribute to our

knowledge about how to best support their social communication and language

development.

1.2 Topic Selection

As a SLP who practiced for seven years before pursuing a doctoral degree, I

have worked extensively with young children with autism and their families. My

front-line clinical experiences led me to reflect critically on what it means to provide

good treatment, for both the child and the family. These clinical experiences also

exposed clinical practice challenges and gaps in the current knowledge. For example,

there was (and remains) insufficient evidence to support the interventions that SLPs

use within their clinical practice, and there is little information guiding SLPs’

decisions in selecting interventions specifically suited for the specific needs of each

client and their family. Both my curiosity and desire to generate knowledge that could

have the potential to positively impact SLPs’ clinical service delivery, and the lives of

autistic children and their families, motivated me to focus on examining preschool

autism interventions for my dissertation.

1.3 Autism Overview

In this section, I provide context for this dissertation by reviewing research and

clinical literature relevant to preschool social communication interventions for autistic

children. I begin by considering the language used throughout this dissertation to describe

autism. Subsequently, I consider the prevalence of autism and explore the criteria and
 3

processes used to identify autism in children. Finally, I discuss the heterogeneity of

autism and consider the implications on the broader context of social communication. I

draw on the literature to develop the rationale for the work in this dissertation, illustrating

the importance of better understanding and contributing to the literature on social

communication interventions for preschool children with autism.

1.3.1 A Word About Terminology

Within this document, I use a mixture of terminology when referring to autism

and individuals identified as autistic. This is because autism is thought of as “both a

medical condition that gives rise to disability and an example of human variation that

is characterised by neurological and cognitive differences” (Lai et al., 2020). Autism is

thought to be a condition when an individual’s autistic traits do not cause impairment

for that person. However, when a person’s autistic traits lead to distress or dysfunction

for that person, autism is thought of as a disorder. Many autistic adults have expressed

frustration with the use of medical- and deficit-focused terminology referring to

autism as a disorder (see Kenny et al., 2016). They have advocated for use of language

that represents autism as a human variation - Autism Spectrum Condition (ASC) - and

identity-first language (e.g., autistic, or autistic person; Fletcher-Watson et al., 2017;

Fletcher-Watson & Happe, 2019). Other autistic adults have voiced a preference for

person-first language (e.g., child with autism), which was part of the disability rights

agenda and is required by many academic journals. For these reasons, I minimize the

use of medical and deficit focused terminology and use a combination of person-first

and identity-first language in this dissertation.

 4

1.3.2 Prevalence

Understanding the prevalence of autism is crucial for diagnostic and

intervention service planning and funding allocation. Autism is estimated to affect

over 1% of children globally (Baio et al., 2018) and 1 in 66 children in Canada (Public

Health Agency of Canada, 2018). Males are diagnosed with autism four times more

frequently than females (Baio et al., 2018; Guthrie et al., 2013). However, there is

growing recognition that females often present with more subtle signs of autism than

boys (Lai et al., 2015; Loomes et al., 2017). Because of this, it appears that females

who meet diagnostic criteria for an ASC are at disproportionate risk of not receiving a

diagnosis compared to their male counterparts (Loomes et al., 2017). As this disparity

becomes more widely recognized and accounted for within the diagnostic process, we

may see a narrowing of the male-to-female ratio in autism diagnoses in the future.

1.3.3 Diagnostic Criteria

“Diagnosis should be more than just a label, ideally, it’s about families working with

an expert team to understand the individual and make a plan for their future support

needs.” (Fletcher-Watson & Happe, 2019, pp. 61).

Autistic individuals have a range of abilities and talents, and many people with

autism achieve independence, develop lasting relationships, obtain higher education

degrees, and work in competitive jobs (Fletcher-Watson & Happe, 2019; Marriage et

al., 2009; Gentles et al., 2020). However, autistic persons and their families are also

faced with very real challenges. Autism is a life-long neurodevelopmental condition

arising from an interaction of genetic and environmental factors (Tick et al., 2016). As

defined by the fifth edition of the Diagnostic and Statistical Manual (DSM-5;

American Psychiatric Association, 2013), autism spectrum disorder is a diagnostic

 5

category that includes two core symptom domains: persistent social communication

atypicalities and the presence of repetitive behavior patterns or restricted range of

interests. Expression of characteristics within the core symptom domains and impact

on daily functioning is highly variable across individuals. Although the diagnosis of

autism does not always occur in childhood, presence of the core characteristics (social

communication challenges and repetitive behaviours) from early development must be

documented and must not be better explained by an intellectual disability or global

developmental delay.

1.3.3.1 Core Feature: Social Communication

In order to receive a diagnosis of autism, the DSM-5 (American Psychiatric

Association, 2013) specifies that atypicalities in social communication across three

areas must be present. The three areas are: social emotional reciprocity (e.g.,

difficulties in engaging in two-way back and forth communication exchanges, verbally

and non-verbally as in joint attention), non-verbal communication (e.g., difficulties

using and integrating gestures, affective facial expressions or social referencing when

communicating with others), and relationships (e.g., difficulties adjusting behavior to

suit context, or challenges developing and maintaining friendships).

1.3.3.2 Core Feature: Repetitive Behaviours

Repetitive behaviours are assessed across four areas within the DSM-5. In

order to receive a diagnosis of autism, the person must present with at least two of the

following four classifications: stereotyped or repetitive motor movements, use of

objects, or speech (e.g., use of scripted language or repeatedly lining up objects);

insistence on sameness (e.g., extreme distress with seemingly small changes, or

difficulty with transitions, or rigid rituals etc.); highly restricted interests (e.g., strong
 6

attachment to seemingly unusual item, or perseverative interests such as interest in

train schedules); and hyper- or hypo-reactivity to sensory input or unusual interests in

sensory aspects of the environment (e.g., using peripheral vision to watch spinning

items, or adverse reaction to specific visual, auditory, or tactile input).

1.3.3.3 Language Considerations

While not specific to autism, many children with autism also have a language

impairment (Levy et al., 2010; Kim et al., 2014). This is not surprising, with

neurocognitive research suggesting language and social communication processes as

distinct yet intertwined systems (e.g., Willems & Varley, 2010). Indicators of differences

in children’s language use (pragmatics) are captured within the DSM-5 descriptions of

the core social communication atypicalities. However, differences in language form

(morphology and syntax) and content (semantics) are not accounted for within the core

diagnostic criteria for autism. Instead, they are viewed as “factors that influence clinical

symptoms of ASD rather than defining the ASD diagnosis” (American Speech and

Hearing Association, 2012; pp. 11). Currently, language disorders are thought to be a

condition that co-occurs with autism, rather than a trait of autism itself. This has not been

biologically validated and is a current topic of debate (Mody & Belliveau, 2013). Even

though language impairment is not a core characteristic of autism, for young children

later diagnosed with autism, late onset of early language milestones is among the first

concerns most commonly reported by parents (Matheis et al., 2017). For this reason, it is

not surprising that SLPs are one of the most frequently accessed interventionists after

children receive an autism diagnosis (Denne et al., 2018; Salomone et al., 2016; Volden

et al., 2015).
 7

1.3.4 Diagnostic Process

The process of diagnosing autism has evolved significantly since the mid-

twentieth century, when doctors simply assigned diagnoses to patients (Fischer, 2012).

Today, the recommended process of diagnosing young children with autism is more

comprehensive and inclusive of the person receiving the diagnosis and their

caregivers. This includes (a) interviewing parents and other caregivers to gather a

complete developmental, medical and education/early intervention history; (b)

reviewing records (e.g., medical, speech-language and occupational therapy

assessments, educator observations); and (c) using standardized protocols to guide

clinical observations (ideally across different contexts; Brian et al., 2019; Chawarska

et al., 2008). Within Canada, physicians and psychologists primarily diagnose autism.

SLPs may be part of a diagnostic team, however, it is not within the SLPs’ scope of

practice to diagnose autism.

A number of tools are available for diagnosing autism in children. Today, the

most widely used standardized assessment for diagnosing autism is the Autism

Diagnostic Schedule – second edition (ADOS-2; Lord et al., 2012). It is considered to

be a gold standard diagnostic tool because of its high rates of sensitivity and

specificity (Kamp-Becker et al., 2018) and it includes a toddler version, which allows

for diagnosis in children as young as 12 months (Lord et al., 2012).

1.3.4.1 Early Identification

In recent years, there has been a rapid increase in the number of young children

referred for diagnostic evaluation of autism (Chawarska et al., 2008; Shaw et al.,

2020). The increase in early referrals for autism diagnosis is likely due to a number of

factors including the development of reliable diagnostic tools, the rise in public
 8

awareness of the early signs of autism, and ongoing monitoring of infants who have

genetic predisposition to autism (Johnson et al., 2007). The impetus for early

identification is also driven by recognition that early diagnosis of autism allows for

earlier access to supports and interventions for children and their families.

Currently, the mean age of diagnosis is 4 to 5 years of age (Daniels & Mandell,

2014; Salomone et al., 2016), despite accumulating evidence supporting the reliable

diagnosis of autism as early as 18 months in some children (Ozonoff et al., 2015;

Zwaigenbaum et al., 2016). For children from racial or ethnic minority groups, and

children living in remote or rural communities, diagnosis is likely to be later than

peers in the general population (Mandell et al., 2002; 2005). Similarly, children with

better verbal language skills are likely to be diagnosed later (Solomone et al., 2016),

and females (who are more likely than males to present with subtle symptoms of

autism) are often diagnosed later than males (Begeer et al., 2013). Delays in

identification of autism for these groups of children may have significant clinical

implications with respect to referral to early intervention programs and access to

supports.

1.3.5 Heterogeneity

Another factor of importance is the considerable heterogeneity among people

diagnosed with autism (Wing & Gould, 1979; Masi et al., 2017). The idea that autism

is heterogeneous was first brought forth in 1979 by Wing and Gould. Specific areas of

strength and impairment can vary widely across individuals, as can the severity of the

impairments. Some autistic individuals remain minimally communicative even after

receiving intensive supports, while others attain language abilities similar to same-

aged peers (Tager-Flusberg & Kasari, 2013; Tek et al., 2014). Autistic individuals’
 9

intellectual abilities can also span from profoundly impaired to abilities that are

superior to neuro-typical peers (Munson et al., 2008). This variability across strengths

and skill levels can pose challenges for diagnosis of autism and for the development

and selection of effective interventions. For example, it has been proposed that tools

used to diagnose autism might not be sensitive to subtle symptoms often presented by

females. Similarly, if there is a great deal of variability in skill development areas,

one-size-fits-all autism interventions are unlikely to be the most efficient way of

supporting this population.

1.4 Supports and Interventions for Autistic Children and Their Families

This section broadly explores the topic of preschool interventions for children

with autism. I begin by considering the language used throughout this dissertation to

describe the supports provided to autistic children. Subsequently, I review the

importance of providing intervention at a young age and discuss three components

commonly incorporated within interventions for young autistic children.

1.4.1 A Note on Terminology

The idea that autistic people require intervention or treatment has become

controversial. This is because use of the terms treatment or intervention can be

interpreted to imply that supports are being used in attempt to “cure” or “normalize”

the autistic child (Fletcher-Watson et al., 2017). It is important to articulate that this is

not my intended meaning. The goals of therapy are to enhance or amplify children’s

skills to support them to experience the world as fully as possible, and to decrease

barriers that impede their learning and well-being. Recognizing and respecting the

views of autistic advocates, I have attempted to adopt use of the term supports in this

dissertation where possible, however, the terms treatment and intervention are also
 10

used. This is because, regardless of a child’s diagnosis, a primary role of SLPs is to

deliver treatment and interventions to children who present with challenges in the

domains of speech, language, and communication development. When SLPs are

searching for information to inform their clinical practice, terms such as therapy and

intervention are likely to be used. Therefore, in order to ensure this research aligns

with the services SLPs deliver, and is easily searchable within databases, I have

included these terms within my work.

1.4.2 The Importance of Providing Supports as Early as Possible

With a growing emphasis on early diagnosis of autism comes a need for

interventions designed to support young children and their families. It is widely

believed that providing supports at the earliest age possible capitalizes on the brain’s

neuroplasticity and period rapid of growth that occurs in children at a young age (e.g.

Dawson, 2008; Sullivan, et al., 2014; Wallace & Rogers, 2010). We know that autistic

children who receive intervention at younger ages make greater gains than those who

enter programs at older ages (Harris & Handleman, 2000; Sheinkopf & Siegel, 1998).

Research has also shown that the ways autistic children interact with their

environment when they are young can impact neurodevelopment, potentially yielding

effects that extend beyond childhood (see Sullivan et al., 2014).

Many intervention programs have been developed to support young children

with autism and their families. Most of the research on these programs has been

conducted with preschool-aged children, although recently there has been an increase

in research examining interventions specifically developed for use with infants and

toddlers with suspected or diagnosed autism (e.g., Brian et al., 2017; Green et al.,

2017; Wetherby et al., 2014). Given the heterogeneity of autism, it is advantageous to

 11

have a diversity of program options, but it also makes it difficult for clinicians and

families to select the best fit for their child and family as a whole. Each program may

support unique skill development areas and evolve from different theoretical models

of child development, but despite theoretical differences, there are likely to also be

common elements shared across these programs.

Generally speaking, the elements shared across intervention programs for

young autistic children are thought to include: (a) parent involvement, (b)

individualization of the treatment program to fit each child’s developmental profile,

and (c) a focus on using natural environments so as to include a range of integrated

learning targets (Sullivan et al., 2014; Wallace & Rogers, 2010). These key elements

constitute recurring themes throughout this dissertation, and thus warrant a brief

introduction here.

1.4.3 Parent Involvement

Parents play a prominent role in their children’s social communication

development (Hart & Risley, 1995; Smith, Landry, & Swank, 2000; Tamis-LeMonda

et al., 2001). Therefore, involving families within early intervention is considered best

practice (Zwaigenbaum et al., 2019). A variety of terms are used across the literature

to capture the inclusion of parents within intervention processes (e.g., parent coaching,

parent training, parent-mediated interventions, parent support groups, reviewing

therapy progress with parents; Bearss et al., 2015). Each of these terms reflects a

qualitatively different approach to how parents are included within the interventions.

Nonetheless, interventions that include parent involvement principally focus on

building caregivers’ capacity to support their child within the context of their everyday

activities and routines. They are considered triadic treatment models where (a)
 12

clinicians use direct coaching, reflective practice, and/or teaching to help parents learn

communication facilitation strategies, (b) parents learn strategies during sessions, and

(c) the child receives intervention directly from their parent during sessions and in-

home. Interventions that include parents within the therapeutic process are thought to

align with the transactional theory of development, which considers the bidirectional

nature of child development (Sammeroff, 2000).

1.4.4 Individualization of Treatment Programs

As was previously mentioned in section 1.3.5, the vast heterogeneity of autism

requires personalized interventions (Massi et al., 2017). Autistic children’s response to

treatment can be variable, with some children making substantial gains, and others

seeing only modest gains (Howlin & Charman, 2011). However, we know little about

the factors related to children’s variability in treatment response (Kilner & Dudley,

2020; Sherer & Schreibman, 2005). This leaves caregivers with little guidance for how

to pick services and programs tailored to their child’s needs, and clinicians with little

evidence for selecting supports tailored to each child’s individual differences.

Furthermore, for young children, interventions need to be tailored not only to each

child, but also to their family’s strengths and areas of challenge. Thus, it seems our

pursuit of identifying effective interventions is relative, and consideration of how to

identify and align the right supports with the right child and family profile needs to be

further explored.

1.4.5 Use of Natural Environments/Integrated Learning Targets

The importance of embedding opportunities for language learning within social

interactions has been documented in typical development (Kuhl et al., 2003) and in

children with various challenges (e.g., Smyke et al., 2009). Interventions that embed
 13

learning within children’s real-world interactions and daily routines are thought to

promote cross-domain integration of skill development (Schribeman et al., 2015) and

generalization of skill acquisition (Kashinath et al., 2006). At a biological level, it is

thought that children’s neural connections are strengthened through social interactions

with familiar caregivers, and repeated experiences within their social and physical worlds

(Carter et al., 2005). For young children, one essential natural environment is their play

environment. For this reason, many interventions that embed their programs within

young children’s everyday interactions are referred to as play-based interventions. The

concept of embedding intervention within children’s daily routines and play aligns with

both ecological systems and transactional theories of development, as they promote

integrated learning within bi-directional social interactions (Bronfenbrenner, 1979;

Sameroff, 2000).

1.5 Objectives

With speech-language pathology services among the most frequently accessed

early interventions after children receive an autism diagnosis (Denne et al., 2018;

Salomone et al., 2016; Volden et al., 2015), research focused on understanding SLP-

delivered interventions is imperative. The overarching purpose of the research in this

dissertation was to enhance our understanding of intervention programs offered by SLPs

to children with autism, and to contribute to the research considering how to best support

social communication and language of children with autism. The next three chapters

continue the discussion introduced within this chapter, through: examining the extent,

range, and nature of research on interventions provided by SLPs to autistic preschoolers

(Chapter 2); systematically reviewing the research on one type of intervention commonly

used by SLPs (Chapter 3); and, finally, examining the impact one support strategy
 14

(environmental modification) may have on children’s social communication (Chapter 3).

These are described in further detail below.

The first study, described in Chapter 2, used a scoping review methodology to

look broadly at the state of research in the field of speech-language pathology and

preschool autism interventions. We examined the extent of research conducted within

the field, identified the range of skill development areas targeted within the research,

and explored characteristics of the interventions.

The second study, described in Chapter 3, was a systematic review of one

treatment option available to young children with suspected or diagnosed autism for

supporting their social communication and language skills, namely, developmental

social pragmatic interventions. We examined the impact of developmental social

pragmatic interventions in supporting (a) foundational social communication and

language skills of preschool children with autism spectrum disorder and (b) caregiver

interaction style. Additionally, we reviewed results exploring mediators and potential

factors influencing children’s response to developmental social pragmatic

interventions.

The third study, described in Chapter 4, used data collected from a previous

research study conducted at York University (where I worked as a research SLP) to

retrospectively examine the impact of the play environment on preschool autistic

children’s social communication and language skills, to explore the impact of one key

ingredient used in preschool autism programs. As a member of the group that

collaborated on the York University MEHRIT research study (Casenhiser et al., 2013;

2015), I was granted access to videotapes collected as a part of this study for

retrospective analysis in my dissertation work.

 15

Collectively, these three studies aimed to contribute to a broader understanding

of SLP-delivered interventions for preschoolers with autism, and to begin the work of

examining how specific ingredients included within in early interventions might

interact with social communication behaviours.

 16

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 23

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 24

Chapter 2
Looking Back and Moving Forward: A Scoping Review of
Research on Preschool Autism Interventions in the Field of
Speech-Language Pathology

2.1 Introduction

Variations or challenges in social communication and social interactions are core

behavioural features of autism spectrum disorder (ASD) or autism spectrum conditions,

referred to here as autism (American Psychological Association, 2013; Fletcher &

Watson, 2019). The extent and range of communication and social interaction challenges

often faced by autistic individuals varies from person to person and the degree of these

difficulties can impact long-term outcomes and overall quality of life (Tidmarsh &

Volkmar, 2003). Some autistic individuals achieve independent living, develop lasting

relationships, obtain higher education degrees, and work in competitive jobs. However,

many do not and for these individuals, their social and communication challenges can

negatively impact community involvement, health, and overall quality of life (Marriage

et al., 2009; Gentles et al., 2020).

There is evidence to support better outcomes for children with autism who receive

early intervention (e.g., Beaudoin et al., 2014; Hampton & Kaiser, 2016), and one of the

best predictors of long-term outcomes in individuals with autism is functional use of

language and social communication skills by 5-6 years of age (Szatmari et al., 1989;

Taylor & Seltzer, 2011; Tidmarsh & Volkmar, 2003). Therefore, it is not surprising that

that speech-language pathology services are the most frequently accessed interventions

after children receive an autism diagnosis (Denne et al., 2018; Jabery et al., 2014;

Salomone et al., 2016; Volden et al., 2015) and that parents of autistic children have
 25

consistently identified communication and social domains as treatment priorities for their

children (Pituch et al., 2011). Thus, from a public health and family well-being

perspective, services from speech-language pathologists (SLPs) are an especially critical

component of efforts to support autistic children and their families and research focused

on understanding the services provided by SLPs is imperative.

The aim of this article is to look broadly at the state of research in the field of

speech-language pathology and preschool autism interventions, in order to reveal the

types of intervention studies that could be used to address and inform the practices of

SLPs, and to identify knowledge gaps. Many reviews have evaluated the efficacy of

interventions that aim to support autistic children’s communication and language

development (e.g., Hampton & Kaiser, 2016; Smith & Iadarola, 2015; Wetherby &

Woods, 2008; Sandbank et al., 2020). However, isolating the studies that examined

interventions delivered (at least in part) by SLPs was not the focus of these reviews.

Identifying and examining research that represents the roles served by SLPs within

preschool autism intervention delivery can be used to identify research gaps in the field

so they can be addressed in future research and, ultimately, be used to strengthen clinical

practice and policy development related to the services provided by SLPs.

2.1.1 A Note on SLP Interventions and Programs

Autism is thought of as both a “medical condition that gives rise to disability…

and an example of human variation that is characterised by neurological and cognitive

differences” (Lai et al., 2020, pp. 4). Because of this, the idea that autistic people require

intervention or treatment has become controversial. This is because use of the terms

treatment or intervention can be interpreted to imply that autism itself is something that

needs to be “treated” or “cured”. SLP services do not aim to “cure” or “treat” autism;
 26

instead their intervention services focus on enhancing the wellbeing of both the autistic

child and their family through supporting communication development and alleviating

distress that a child or caregiver might be experiencing due to breakdowns in

communication.

SLPs receive specialized training in how to support a range of skill development

areas such as use of augmentative communication, speech production, language

comprehension, language use, social communication, play, and feeding and swallowing.

This variety is echoed in reports examining the intervention practices of SLPs working

with autistic preschoolers in real-world settings (Hsieh et al., 2018; Gillon et al., 2017).

The diversified training and breadth of SLPs’ scope of practice enhances their ability to

tailor the selection of treatment goals and strategies to each individual child, which is

imperative given the heterogeneity of autism. However, the wide range of treatment

options available to SLPs and interest in providing flexible individualized intervention

programs also poses challenges, making it difficult to select the single or combination of

evidence-based early interventions(s) that are ‘just right’ for a given individual with

autism.

2.1.2 The Current Study

To gain a comprehensive understanding of the state of research on preschool

autism interventions provided by SLPs, this review aimed to answer the broad question:

What is the extent, range, and nature of the research conducted on preschool autism

interventions delivered at least in part by SLPs? In answering this question, we would be

able to map the existing literature base on SLP interventions provided to preschool

children with autism, provide insight into the types of intervention characteristics used

across research studies, identify research gaps and needs, highlight pathways for future
 27

research and policy development, and inform future funding initiatives and resource

allocation.

We elected to focus on preschool aged children because of the important role that

early intervention plays in autistic children’s long-term outcomes (e.g., Hampton &

Kaiser, 2016), the specific importance of achieving functional communication by the end

of the preschool period for maximizing long-term outcomes (e.g., Tidmarsh & Volkmar,

2003), and the fact that families frequently seek out the services of SLPs following their

preschooler’s diagnosis (e.g., Volden et al., 2015). We chose to use a scoping review

because this method is particularly useful for mapping a specific area of research that has

not been comprehensively reviewed before and examining ‘what’ and ‘how’ research has

been conducted within a particular field (Arksey & O’Malley, 2005; Munn et al., 2018).

A scoping review involves broadly searching the available literature and extracting

relevant information, and is often a pre-cursor to more detailed systematic reviews

focused on examining the effectiveness and meaningfulness of particular practices (Munn

et al., 2018). Five key phases are involved in conducting a scoping review: (1)

articulating the research question; (2) identifying relevant studies; (3) selecting studies;

(4) charting the data; and (5) collating, summarizing, and reporting results, and an

optional sixth phase - consulting with stakeholders (Arksey & O’Malley, 2005; Levac et

al., 2010). The optional sixth phase was not formally conducted in this study. However,

stakeholders (i.e., practicing SLPs and SLP-researchers) were well represented on our

team and thus were able to provide insight about the clinical relevance of the review.

2.2 Methods

Methodology for this scoping review was in accordance with the guidelines

outlined by Arksey and O'Malley (2005). Our review included articles published since
 28

1980, when autism was first included as a diagnosis in the Diagnostic and Statistical

Manual of Mental Disorders (American Psychological Association, 2013).

2.2.1 Phase 1: Articulating the Research Question

The central question guiding our scoping review was: What is the extent, range,

and nature of published experimental literature on preschool autism interventions

implemented – in part or in whole – by SLPs? In order to reflect the range of real-world

SLP-delivered services, we included studies examining interventions delivered solely by

SLPs, and those examining interventions where the SLP was one of the professionals

within a group of non-SLPs delivering the intervention. Specifically, we were interested

in identifying: (a) the extent of research conducted to date on interventions delivered to

autistic preschool children by SLPs, including information about the progression of

research over time, the study characteristics (i.e., study design, location, participant

diagnostic information), and the role of SLPs in delivering intervention, (b) the range of

intervention targets examined within the literature, and (c) the nature of these

interventions including theoretical underpinnings of the interventions researched, service

delivery models, and treatment dosage.

2.2.2 Phase 2: Identifying Relevant Studies

In consultation with an expert health sciences librarian at Western University, we

developed a concept map and search queries for seven electronic databases: Scopus,

ERIC, PsycINFO, EMBASE, AMED, PubMed and CINAHL using a combination of

relevant keywords and controlled vocabularies such as MeSH terms. Search strategies

were adjusted to each database to identify relevant articles published between January

1980 and December 2019. Our search strategy was intentionally designed to be

comprehensive to include all relevant articles. All searches included at least one identifier
 29

for ASD (e.g., autism, PDD-NOS, etc.) linked to at least one identifier for intervention

(e.g., therapy, treatment, intervention) and one identifier for SLP (e.g., clinician,

therapist, speech-language therapist). Search results were imported into an Excel

document and duplicates were identified and removed using the sorting feature. Search

strategies and limits for all databases are provided within Appendix A.

2.2.3 Phase 3: Selecting Studies

After removing duplicates, articles were reviewed in three steps: titles, abstracts,

and full text review. Five reviewers (2 SLPs and 3 graduate students training to become

SLPs) participated in the selection of studies. Prior to independently reviewing titles and

abstracts, 25% of the articles were double coded to establish a minimum of 95%

reliability between coders for kept articles. During full text review, two reviewers

independently assessed the full text of all potentially relevant articles for eligibility.

During both the abstract and full text reviewing steps, at least one of the reviewers was a

certified SLP. Discrepancies between reviewers were resolved through consensus with

the first author. Reference lists of all included articles were also reviewed to identify

additional studies to be assessed for eligibility. Inter-rater reliability was calculated for

full text screening.

For articles to be included in this review, they had to meet the following pre-

determined criteria: (1) participants were between 1 month and 5;11 years old, or the

mean age was below 6 years; (2) children were diagnosed with autism (inclusive of past

diagnostic labels PDD-NOS or Asperger syndrome) or were suspected to have autism; (3)

the study evaluated a treatment provided or supervised by a SLP; (4) articles were written

in English. We included children suspected to have autism, but not yet diagnosed because

many children do not receive an autism diagnosis until they are 4 years old (Christensen
 30

et al., 2016). For single subject studies that included subjects outside of our pre-

determined age range, only data for subjects who fell below 6 years of age were included.

Community based studies that included over 90% of subjects with autism or suspected of

having autism were also included. For the purposes of this article, suspected of having

autism was defined as showing documented challenges in social communication skills

and restricted or repetitive behaviours. Treatments provided by a SLP were defined as

services directly provided by a SLP or SLP graduate student, supervised by a certified

SLP, or provided in collaboration with a SLP. Articles were accessed electronically or

authors were contacted to obtain a reprint.

2.2.4 Phase 4: Charting Data

A table for extracting information from the included articles was developed a

priori and inter-rater reliability between reviewers was calculated for data extracted.

Information extracted from each article included: author names, year of publication,

article title, study design, sample size, the SLP’s role within the program (e.g.,

supervision, team, direct service), participant characteristics(i.e., age, autism diagnosis or

suspected autism), type of speech-language intervention (i.e., skill development area(s)

targeted), brand name of treatment program, theoretical approaches underlying

intervention, service delivery model (i.e., group, 1:1 intervention, parent/caregiver

training, remote therapy), intervention dosage (intensity, frequency, duration), location of

service (e.g., home, clinic, daycare), country where intervention was delivered, and notes

or questions for future reference.

 31

2.2.4.1 Participant Characteristics

For each participant meeting criteria for this review, we recorded the child’s age

and whether there was a diagnosis of autism or if the child was suspected of having

autism but did not have a formal diagnosis.

2.2.4.2 Type(s) of Speech-Language Intervention

For each included study, we identified primary skill area(s) that each intervention

aimed to support. We pre-defined social communication interventions as programs that

targeted foundational communication skills including engagement, synchronous

communication, joint attention, reciprocal interaction, use of affect, and regulation (Binns

et al., 2019; 2020). Language focused interventions were classified within three different

categories: general language (including both language production and comprehension),

programs that specifically targeted language production, and programs that focused on

language comprehension skills. Studies where augmentative alternative communication

(AAC) systems were sometimes used by children, but use of the system was not the focus

of the intervention, were not identified as AAC interventions. Instead they were classified

according to the distinct skill area(s) addressed by the intervention (e.g., social

communication and targeted behaviour; Smith et al., 2015). Interventions where

clinicians supported children’s use of AAC systems were identified separately. We

defined speech-based interventions as those that targeted one of articulation, oral-motor

production of speech sounds, voice, or fluency. Interventions that focused on skills such

as imitation, flexibility, and adaptive behaviour were identified as interventions for

targeted behaviours. Feeding interventions were distinct from other behaviour focused

treatments. Finally, we pre-defined play interventions as those that aimed to support

 32

children’s development of play skills or use of social dialogue specific to play scenarios

(e.g., peer play, use of social scripts).

2.2.4.3 Theoretical Approaches Underpinning Interventions

Each intervention was classified using one of the three common approaches in

which SLPs receive training: clinician-directed, child-centred, and hybrid (Paul et al.,

2018). Theoretical models underpinning interventions were identified using information

provided within the article (e.g., authors self-identified the theoretical model influencing

the intervention, intervention descriptions), and searching supplemental material

describing intervention approaches (i.e., therapy manuals, therapy brand websites). The

following definitions were used to guide classification of theoretical models informing

intervention programs. Clinician-directed interventions were defined as using a high level

of structure, drill, explicit prompting, error shaping, reinforcement of correct responses,

clinician-directed modelling, or principles of applied behaviour analysis to support

communication and language. Child-centred interventions (also known as developmental

social pragmatic or naturalistic approaches) were identified as treatment approaches that

created communication and language learning opportunities within natural settings and

used strategies such as following the child’s lead, recasting, expanding, extending,

modeling, and language mapping (Binns & Oram Cardy, 2019; Ingersoll, 2010). The

classification of a hybrid approach was assigned to interventions that included a balanced

use of both clinician-directed and naturalistic elements to support communication and

language development. When a single study examined two different interventions with

different theoretical models underlying each intervention, we documented both of the

theoretical models used (e.g., Paul et al., 2013).

 33

2.2.5 Phase 5: Collating, Summarizing and Reporting Results

Following data extraction, we used frequency analysis and narrative synthesis

involving extraction of themes around treatment characteristics to summarize our

findings.

2.3 Results

2.3.1 Extent of Research

Our initial search of seven databases yielded 23753 potentially relevant citations.

After removing duplicates (n=3442) and completing title (n=19796) and abstract

screening (n=4506), 1026 citations remained for full text review. Following full text

review, a total of 108 articles, reporting on 104 treatment studies met inclusion criteria

and remained for data extraction. When study results were reported within more than one

article, information from each of the articles was included and collapsed into one entry

(e.g., Casehniser et al., 2013; 2015). An additional 10 studies were included after

searching reference lists of all articles meeting inclusion criteria, resulting in a total of

114 studies included within this scoping review.

Interrater agreement during title and abstract screening was 97% based on double

coding of 25% of the articles, and interrater reliability was k=0.90. For full text review,

agreement between reviewers double coding all articles was 96%, with interrater

reliability k=0.88. There was 94% interrater agreement for the data extraction phase after

double coding of all articles meeting inclusion criteria. References for the 118 included

articles, reporting on 114 studies, are available within Appendix B

2.3.1.1 Study Characteristics

Publication dates of the selected studies ranged from 1980 to 2019. There was a

marked increase in SLP-delivered autism intervention publications since 2010, with 67%
 34

of the articles (n=76) in this review having been published since 2010. Another 23% of

the articles (n=26) were published between 2000 and 2009. Studies were conducted

across 6 continents within 21 unique countries, with the majority of studies occurring

within North America. See Figure 1 for a breakdown of the number of articles published

over the last four decades and study locations.

2.3.1.2 Study Designs

As outlined in Figure 1, case study or single subject study designs were the most

frequently documented within the literature (51%; n=58), followed by pre-post single

group designs (18%; n=21), randomized control trials (RCTs; 18%; n=21), and quasi

experimental group study designs (12%; n=14). All RCTs were conducted within the last

10 years. Data analysis techniques used within the studies varied greatly and included

descriptive analysis, measures of central tendency (means, median, mode) and variation

(Standard Deviations), changes in raw scores, percentage correct, and inferential analysis

(paired T-test, ANOVA/ANCOVA, linear regression).

2.3.1.3 Participants

Sample sizes varied from 1 to 210. Within the included studies, 3095 children

who ranged in age from 7 months to 5;11 participated. Overwhelmingly, the treatment

programs were provided to children who had received a diagnosis of autism (90%;

n=103). See Figure 1.

2.3.1.4 SLP Involvement in Intervention Programs

A variety of terminology was used within publications to identify clinicians as SLPs (e.g.,

speech language clinician, speech language therapist, speech therapist, specially trained

language clinician, clinician with familiarity with developmental psycholinguistics, and

communication interventionists). When clinicians were not explicitly identified as SLPs

 35

Figure 1. Number of studies by (a) decade published, (b) continent of origin, (c)
participant diagnostic information, and (d) study design.
 36

(e.g., clinician with familiarity with developmental psycholingistics), the professional

background of the therapists was verified with the authors of the publications. Also

prevalent were non-specific references to the professional background of the clinicians

delivering intervention (e.g., clinician, therapist, the second author, the researcher). Of

the 114 studies included in this review, 21% (n=24) did not report the professional

background of the therapists within the publication. When publications reported that ‘the

authors’ delivered interventions, we searched their professional background using Google

to determine if the interventionists providing therapy in these studies included SLPs. We

were also able to obtain information about the professional background of

interventionists from the authors via email. Notably, an additional 23 articles within the

full text review phase of study selection also had missing information about the

professional background of clinicians delivering the intervention studied in their article.

We were not able to obtain information about the professional background of the

clinicians for these articles therefore they were excluded. This resulted in a total of 47 of

the articles reviewed during the full text inclusion/exclusion phase requiring reviewers to

search for additional information about the professional background of clinicians.

Almost half of the treatment programs were provided by SLPs or SLP graduate

students alone (45%; n=51), while 63 programs (55%) were provided by a range of

professionals (that in some way included SLPs) – referred to within this article as multi-

professional delivery. Of the 76 articles published within the last 10 years, 63% involved

interventions delivered by multi-professionals (n=48). When interventions were delivered

by multi-professionals, the SLP’s role varied greatly across studies. Within the group of

interventions classified as multi-professional, some programs had SLPs providing direct

1:1 therapy to some of the participants, while the other participants did not receive SLP
 37

services, rather therapists from other professional backgrounds serviced them (e.g.,

Weatherby & Woods, 2006; Yu et al., 2010). Other intervention programs classified as

being delivered by multi-professionals, had each participant receiving 1:1 direct therapy

from SLPs, and 1:1 direct therapy from other professionals on the team (e.g.,

Occupational Therapists; Casenhiser et al., 2013; 2015). Within other programs, SLPs

played the role of supervising educators or behaviour therapists providing 1:1 therapy

(e.g., Dyer, 2008; Friedman & Woods, 2015; Muldoon et al., 2018). The extent of

supervision varied across the studies, ranging from SLPs supervising each session (e.g.,

Koegel et al., 1996) to SLPs supervising a program every 3 months (i.e., Dawson et al.,

2010).

2.3.2 Range of Skill Development Areas Targeted

We identified 9 skill development areas targeted within the 114 included studies:

social communication, language, AAC, targeted behaviours, play, speech, feeding,

auditory processing, and social emotional skills. Some programs targeted multiple skill

development areas (32%; n=36). We identified programs as comprehensive interventions

when they were delivered by multiple professionals who did not examine specific skill

development areas within the outcome measures (i.e., instead only used autism rating

scales or diagnostic assessment tools as outcome measures) (4%; n=4; e.g., Hojati, 2014;

Papavasiliou et al., 2011). See Table 1 for a list of skill development areas targeted and

examples of specific skills falling within each identified area.

2.3.2.1 Social Communication and Language Interventions

The majority of programs targeted social communication (n=63). Almost half of

these interventions (48%; n=30) also targeted other skill development areas within the

program (e.g., language, play, AAC, targeted behaviours). Interventions targeting autistic

Table 1. Range of Skill Development Areas Targeted Within the Included Studies
Skill development Examples of specific skills
area targeted
Social Communication Engagement, gestural
communication, reciprocal
interactions, use of affect, joint
attention, synchronous
communication and initiation of
communication
Language Production: language use,
question asking, expanding use
of commenting, vocabulary use,
verbal language
Comprehension: response to
question probes
AAC Use of low or high tech devices,
PECS, sign language
Targeted Behaviour Imitation, escape behaviours,
flexibility in routines, academic
performance
Play Peer play behaviours, play
dialogue, play steps, occurrence
of novel play
Speech Articulation, oral motor
production
Feeding Level of food acceptance,
mealtime behaviours
Auditory Processing Auditory perception (in children
with cochlear implants and
autism)
Social Emotional Regulation of emotions, social
emotional functioning
38
Examples of articles
Green et al., 2010;
Mcduffie et al., 2015;
Rogers et al., 2012; Smith
et al., 2015; Venker et al.
2012
Brown & Woods, 2015;
Casenhiser et al., 2015;
Hampton et al., 2019; Salt
et al., 2001; Summers et
al., 2017
Tan et al., 2014;
Thiemann-Bourque et al.,
2018; Yoder & Stone,
2006
Koegel et al., 2003;
Dawson et al., 2010; Shire
et al., 2017
Barbar et al., 2016;
Murdock et al., 2013;
Shire et al., 2017
Chenausky et al., 2017;
Dyer, 2008; Rogers et al.,
2006
Muldoon & Cosby, 2018
Mikic et al., 2016
Mahoney & Perales, 2003;
Yu & Zhu, 2018
 39

preschoolers’ language development were also prevalent within the studies in this review

(n=39). Language production skills were most frequently targeted (n=19), followed by

studies targeting both language comprehension and production (n=18). Two studies

(Grela & McLaughlin, 2006; Yorke et al., 2018) targeted language comprehension alone

(n=2).

2.3.2.2 AAC Interventions

AAC was another predominant skill development area targeted within the SLP-

delivered interventions (n=20). Both low (n=13) and high tech (n=7) communication

systems were included within this category. Three additional studies reported that

participants receiving treatment were provided access to AAC supports when it was

determined to be appropriate (i.e., Paynter et al., 2018; Reis et al., 2018; Smith et al.,

2015). However, we did not classify these interventions as targeting AAC specifically as

we could not identify how often this support was used across participants and supporting

use of AAC was not the primary focus of the intervention.

2.3.2.3 Targeted Behaviours and Other Areas

Targeted behaviours were also addressed within the interventions included within

this review (n=13). Targeted behaviours included interventions focused on supporting

imitation skills (e.g., Cardon et al., 2012), non-contingent escape (e.g., Coleman et al.,

1998), developing flexibility within routines (e.g., Ivey et al., 2004), reducing problem

behaviours (Koegel et al., 2003), and adaptive functioning (e.g., Smith et al., 2015). Over

half of the studies that addressed targeted behaviours also focused on supporting other

skill development areas (64%; n=9; i.e., language, social communication or play). The

remaining skill development areas targeted within the included studies were play (n=9),

speech (n=3), social emotional (n=2) auditory processing (n=1), and feeding (n=1).
 40

2.3.3 The Nature of Interventions Delivered by SLPs

2.3.3.1 Theoretical Models

The most frequently reported theoretical models underlying intervention programs

were child-centred, developmental-naturalistic models (38%; n=45), followed by

clinician-directed interventions based on applied behaviour principles (30%; n=36) and

hybrid approaches that combine aspects of both behaviour and developmental-naturalistic

models (22%; n=26).

Five studies compared two different treatments aligned with different theoretical

models (i.e., Hilton & Seal, 2007; Koegel et al., 1996; Koegel et al., 1992; Paul et al.,

2013; Prelock et al., 2011). For these studies we extracted information about both

intervention programs, thus we examined a total of 119 different programs. We were not

able to determine the theoretical models underlying 12 of the interventions (10%).

We also examined the theoretical models underpinning the interventions that

targeted specific skill development areas. For programs that targeted multiple skills, we

accounted for each skill area separately within our calculations. For the 5 studies that

examined two different interventions that aligned with different theoretical models, each

intervention was accounted for separately within the analysis. See Figure 2 for an

examination of the theoretical models used to underpin each of the targeted skill

development areas.

2.3.3.2 Service Delivery Models

Across the included 114 studies, we identified 9 unique service models used to

deliver the interventions. The majority of studies used a single service model (61%;

n=70), while 38% (n=43) used a combination of service delivery models (e.g., parent

coaching + direct therapy), and 1% (n=1) was unknown.

 41

Direct Therapy. Direct therapy, where a clinician worked 1:1 with a child, was

the prominent model (n=63) and was used in conjunction with other service delivery

models within 24 of the interventions. Proportionally, interventions targeting speech

(75%), AAC (52%) and play (50%) were most likely to use a direct service delivery

model. Direct 1:1 therapy models were also frequently used when targeting behaviours

(47%) and language skills (42%).

Parent Coaching. Delivering intervention programs using parent coaching was

also prevalent (n=36). We defined parent coaching as an intervention that involved

clinicians providing direct 1:1 guidance and support to parents as they were interacting

with their child. Some interventions exclusively used parent coaching (n=18), while the

others combined parent coaching with other service delivery models (e.g., direct therapy,

group therapy). Social communication was the most common skill area targeted using

parent coaching.

Figure 2. Theoretical models underpinning interventions targeting the nine skill

development areas, and comprehensive interventions.
 42

Caregiver Education. We differentiated treatment programs that used parent

coaching from those that provided caregiver education (n=22; i.e., workshops, webinars,

clinician parent review meetings not in the presence of the child). Exclusive use of

caregiver education was rare (n=2). Most programs used caregiver education in addition

to other service delivery models (e.g., direct 1:1, parent coaching).

Other. Other service delivery models identified included educator coaching

(n=6); educator training (n=4); classroom delivered interventions (n=4); small group

therapy (n=13); peer mediated interventions (n=7); and remote (virtual) services (n=3).

For a breakdown of service delivery models used across the different skill development

areas targeted, see Figure 3.

Figure 3. Number of times service delivery models were used across interventions
targeting specific skill development areas.

Note: Some interventions used multiple service delivery models and each was accounted
for within this graph. No service delivery model was identified for the single intervention
targeting auditory processing skills.
 43

2.3.3.3 Dosage
Treatment dosage varied greatly across the included studies. Session length

ranged from 10 minutes to 3 hours. Frequency of sessions ranged from 1 session monthly

to 7 times/week and the duration of the intervention programs ranged from 3 weeks to 2

years. Reporting details of treatment dosage also varied vastly across studies. Generally,

articles published since 2000 provided more information about treatment dosage than

those published before 2000, with some even sharing the number of trials with which a

child was presented during treatment (e.g., Al-dawaideh & Al-Amayreh, 2013; Reichle et

al., 2018).

It is expected that the treatment dosage of interventions delivered by SLPs

independently would differ from interventions provided by multi-professionals, and that

different service delivery models would also differ in treatment dosage (e.g., caregiver

education vs direct 1:1 services). Furthermore, with many of the studies that examined

interventions delivered by multi-professionals not specifying the breakdown of treatment

dosage across service providers, we decided to examine patterns in treatment dosage only

for interventions delivered solely by SLPs. We were able to examine treatment dosage

patterns in the two most frequent service delivery models delivered by SLPs alone (direct

1:1 and parent coaching), but there was not an adequate number of studies delivered

solely by SLPs using other service delivery models to comment on patterns of treatment

dosage within them.

Direct 1:1 Services. For interventions delivered solely by SLPs using a direct 1:1:

service delivery model, the session length (intensity) ranged from 15-60 minutes, with

30-45 minutes being the most frequently reported length. Session frequency ranged from

1/week to 7/week, with 3/week being the most common. Duration of the programs
 44

delivered with 1:1 SLP sessions ranged from 3 weeks to 10 months and varied across

studies.

Parent Coaching. For parent coaching sessions delivered solely by SLPs, the

intensity of treatment ranged from 30 minutes to 2 hours. The frequency of sessions

ranged from daily to monthly, and the duration of the program ranged from 10 weeks to

12 months.

2.4 Discussion

This scoping review provided important insights into the literature on

interventions delivered to autistic children via SLPs. We mapped the literature base to

identify: the extent and location of research conducted on interventions delivered by

SLPs, the progression of research over time, the study designs used, and the skill

development areas targeted. Additionally, we examined the nature of the interventions

studied to date, including the SLP’s role in delivering the intervention, the theoretical

models guiding the intervention program, service delivery models, and treatment dosage.

2.4.1 Extent of Research Specific to Speech-Language Pathology

We identified a total of 114 studies examining interventions delivered, at least in

part, by SLPs to autistic children under the age of 6 years. Single Subject Designs were

the most prevalent research design, followed by pre-post single group designs, RCTs, and

quasi experimental group study designs. Most studies involved children who had already

received a diagnosis of autism and were conducted within North America. Given that

78% of SLPs in the United States report servicing autistic children (Plumb & Plexico,

2013), the frequent use of SLP services by families of young children diagnosed with

ASD (e.g., Volden et al., 2015), and the range of skill development areas that fall within

SLPs’ scope of practice, the quantity of studies examining SLP-delivered preschool

 45

interventions is relatively small. However, it is consistent with the general need for more

intervention studies in the field of speech-language pathology (Justice et al., 2008).

Although the total number of studies examining preschool autism interventions

over the past 40 years is relatively small, there has been an upsurge in these publications

over the past 10 years. Over half of the studies and all of the RCTs included in this

review were conducted between 2010-2019. This increase in publications on autism

interventions and investment in larger scale RCT studies mirrors the continued increase

in the number of children diagnosed with autism and the progressively earlier age of

diagnosis (Baio et al., 2018). Nonetheless, the extent of research examining interventions

provided by SLPs to autistic preschool children continues to lag behind research

conducted on other approaches for autism intervention (e.g. behavioural interventions;

see Sandbank et al., 2020).

Notably, two-thirds of the studies conducted since 2010 were delivered by multi-

professionals (inclusive of at least one SLP) working either alongside or in collaboration

with one another. Timing of the shift toward conducting research examining interventions

delivered by a variety of professionals aligns with clinical practice recommendations for

more holistic, comprehensive service provision within early interventions (American

Speech-Language Hearing Association, 2008; Wallace & Rogers, 2010). This shift also

mirrors common real-world practices reported by SLPs (in the United States) and family

reports of multidisciplinary care (Green et al., 2006; Plumb & Plexico, 2013).

2.4.1.1 Potential Factors Impacting the Extent of Research

The relatively small number of studies on SLP-delivered preschool autism

interventions, and the smaller proportion examining interventions delivered solely by

SLPs, could be due to a variety of factors. First, there may be less opportunity to conduct
 46

research within our field in general. Training in research foundations and participation in

research labs during SLP graduate training appear to occur proportionally less often than

seen in other fields (e.g., psychology, audiology, and medicine; Roberts et al., 2020).

This is an important consideration for future curriculum and course development within

graduate level SLP academic programs. Additionally, a subset of the articles we

examined within our broad search of the literature did not mention the professional

background of those delivering the interventions. Some studies indicated that “the first

author” or “the researchers” provided the intervention, however, others categorized all

professionals delivering the intervention as “interventionists” or “clinicians”. For these

articles, we only learned that SLPs had a role in delivering the intervention after we did a

significant amount of investigating (e.g., emailing, Google searches, examining

university department websites). We were not able to determine the role of the therapists

delivering the interventions for an additional 23 articles from the full text review phase,

thus prohibiting their inclusion within this review. This lack of clear reporting of the

professional designation of the professionals delivering the interventions within the

autism intervention literature may have contributed to the relatively small literature base

we were able to identify that examined SLP-delivered preschool autism interventions.

The absence of explicit information about the professional training of clinicians

delivering the interventions is problematic for a number of reasons. First, this is

considered to be a key quality indicator when evaluating the methodological rigor of

interventions studies (Reichow, 2011), thus its absence reduces the quality of studies.

Second, not mentioning speech-language pathology or speech-language therapy within

the publication hinders the ability of researchers, policy makers, clinicians, and families

to search for and meaningfully use the information published within these studies.
 47

Finally, studies that generically referred to the people delivering the interventions as

clinicians or therapists fail to acknowledge that practitioners with different educational

backgrounds are likely to approach service delivery differently. Therefore, the unique

skill set that SLPs bring to their clients’ communication challenges are not recognized.

Moving forward, researchers need to make a concerted effort to clearly document the

professional designation of clinicians delivering the interventions.

2.4.1.2 Study Designs

Another important finding to consider is the predominance of single subject

designs across the literature in this review. Single subject designs are widely used within

the field of speech-language pathology, and communication sciences and disorders at

large. Historically, single subject designs have not been considered methodologically

rigorous or generalizable to the larger population due to the small sample size. They are

often excluded from reviews evaluating treatment effectiveness and study quality and are

frequently overlooked within health systems when considering evidence-based

practice (Byiers et al., 2012). However, well-designed, single subject study designs can

produce valuable information for clinicians, families, and policy makers. They allow

for systematic evaluation of the effects of a treatment at an individual level rather

than examining the average impact of an intervention across patients, which is important

when considering the heterogeneity of autism. Single subject designs are also well suited

to allow researchers and clinicians to ask complex questions that may not be feasible to

answer within traditional group or RCT designs (Byiers et al., 2012). Additionally, these

study designs are usually more accessible because they are not as expensive to conduct as

larger scale group or RCT designs. Within the field of autism intervention, there is

precedent for using outcomes from single case experiments to inform policy
 48

development. For example, the widespread global adoption of ABA intervention

programs and public policy changes including state level mandated insurance coverage

for ABA treatment (e.g., Steven’s Law, Arizona House Bill 2487), were predominantly

supported by several hundred single case experiments (Matson et al., 1996).

Although single subject designs occurred most often across the studies included in

this review, the variety of study designs used to examine preschool autism interventions

have diversified over the past 10 years. Still, within our field there remains a need for

additional research using differentiated study designs in addition to methodologically

strong single subject designs. Of particular interest would be exploratory and pragmatic

RCT study designs. RCTs are considered gold standard for treatment effectiveness

research. They allow for examination of active therapeutic ingredients and subgroup

variation in treatment response (e.g., comparative efficacy trials, adaptive treatment

designs, mediation and moderation analysis), and results would provide SLPs with

evidence that could be used to guide selection of intervention(s) or combining of supports

to tailor SLP services to children and families’ needs. Pragmatic RCT designs are

especially desirable as the interventions being investigated are administered in a way that

captures real-world SLP service delivery. Thus, there is a strong focus on external

validity (i.e. generalizability of the results to real-world clinical practice).

2.4.4 SLP Roles in Delivering Intervention

Interventions delivered solely by SLPs and in part by SLPs were relatively

equally represented in this review. Interventions delivered in part by SLPs included

programs delivered by multi-professionals (including SLPs) working either alongside or

in collaboration with one another. The heterogeneity and complexity inherit in autism
 49

make multi-professional delivered collaborative services a logical choice, but also pose

problems for research.

When intervention programs are delivered by multi-professionals, each therapist

comes to the team with their own educational background and professional views,

potentially adding to the complexity of the intervention. As interventions become

increasingly complex, the risk for variation in intervention delivery increases (Santacroce

et al., 2004) and the need for examination of the potential impact of intervention

components is underscored. Within the interventions that were delivered in part by SLPs,

we found variability in the professional background of team members, access to services

from members of the team (i.e., each participant did not always receive treatment from

each professional on the team), the service delivery models used, and treatment dosage.

Even the SLPs’ roles within teams differed across studies (i.e., supervision of non-

SLPs vs direct 1:1 service provided by SLPs).

With autism intervention research shifting toward use of multi-professional

interventions that are susceptible to variability, there is the opportunity to use evidence

from these studies to inform development of evidence-informed care pathways for

preschool children with autism. To support development of care pathways, future

research focused on improving our understanding of processes, structures, and

components used within interventions delivered by multi-professionals is essential (e.g.,

embedding process evaluations within RCTs), as are more studies using adaptive

treatment designs and examining mediators and moderators of effective multi-

professional interventions (e.g., dosage, service delivery models, child’s language level,

caregiver stress). This work would also provide guidance for SLPs aspiring to providing

flexible individualized intervention programs.

 50

2.4.5 Range of Skill Development Areas Targeted

The literature map generated by this scoping review revealed that research activity

reflects the breadth of SLPs’ scope of practice in terms of the range of skill development

areas targeted. However, the research across different skill development areas was not

evenly distributed. A total of nine skill development areas were targeted within the

included studies, but interventions targeting three skill development areas made up the

vast majority of the research.

Most widely researched were interventions that focused on supporting autistic

children’s social communication skills, language, or use of AAC. This is not surprising

given that autism affects how a person communicates with and socially relates to other

people. Furthermore, SLPs report that they frequently target these skill development

areas when working with young autistic children in real world clinical practice (Gillion et

al., 2017). Nonetheless, further research efforts are needed to examine the impact of SLP

interventions covering a wider range of skill development areas, including play, motor-

speech production, feeding, and social emotional development.

To address these gaps, it would be useful to focus future research efforts on

treatments for skill development areas that SLPs report they frequently target in sessions.

For example, studies on interventions targeting play were few, despite play being a

common skill development area targeted by SLPs working with autistic preschool

children (Gillion et al., 2017). Another focus to future research could be interventions

targeting skill development areas that SLPs are uniquely trained to support (e.g., motor-

speech production), since it is less likely that research from other disciplines are

contributing to the advancement of these types of interventions. Additionally, conducting

practice-based research that examines interventions used in the delivery of real-world

 51

SLP services would provide opportunity to capture information about, and generate more

research aligned with, the range of skill development areas targeted by SLPs.

2.4.6 Nature of SLP-delivered Interventions

2.4.6.1 Theoretical Models Underpinning Interventions

Interventions underpinned by child-centred, clinician-directed, and hybrid models

were relatively evenly represented in the studies included in this review. Those using

child-centred models were most prevalent across the included studies and were

predominantly used to target social communication and language skills. Child-centred

models align with recommended early intervention practice (American Speech-

Language-Hearing Association, 2008; Division for Early Childhood, 2014) and there is

accumulating evidence supporting the use of these models for targeting social

communication outcomes (Binns & Oram Cardy, 2019; Sandbank et al., 2020).

Interventions influenced by hybrid theoretical models were most likely to target social

communication skills. Evidence for the effectiveness of treatments developed using

hybrid models is also accumulating for both social communication and language

outcomes (Sandbank et al., 2020).

Interventions targeting AAC were likely to use clinician-directed models. Because

many of the AAC interventions examined in this review used the Picture Exchange

Communication System (PECS; e.g., Lerna et al., 2012; Min & Wah, 2011; Reichle et al.,

2018) and PECS is a program rooted in applied behaviour analysis, it is logical that most

AAC interventions were classified as being clinician-directed. Only a few interventions

appeared to deliver AAC interventions guided by child-centred or hybrid models of

intervention (i.e., Barton-Hulsey et al., 2017; Min & Wah, 2011; Tan et al., 2014). More
 52

research examining SLP-delivered AAC interventions using child-led and hybrid models

to guide treatment programs is needed.

Despite theoretical differences between child centred, hybrid and clinician

directed intervention programs, there are likely to also be common elements shared

across these programs. Therefore, working toward gaining a clear understanding of the

unique and shared elements of interventions guided by child centred, hybrid and

clinician directed theoretical models is an important direction for future research in the

field. This work would support efforts to: improve the consistency of assigning

theoretical categories to interventions, identify which ingredients from child-centred

models and clinician-directed models are being combined within hybrid interventions,

and guide the analysis of how different intervention features mediate children’s

response to treatment. Access to such information would support clinical decision

making and development of evidence-informed policies.

2.4.6.2 Service Delivery Models and Treatment Dosage

Variability across treatment dosage and the service delivery models used within

the interventions included in this review was pervasive across the studies. Given the

range of skill development areas targeted by SLPs, the varying roles SLPs play within

intervention delivery, and SLPs’ focus on individualizing intervention programs to fit

each child’s unique needs, a certain degree of variability was to be expected. Variability

is not inherently bad. It poses complexities for researchers but can also be a positive

discovery when broadly examining a literature base within any given field. Variability

within the literature means we have access to information about a variety of

interventions, targeting different skill development areas, in different ways. This is

meaningful given the heterogeneity of autism and SLPs intentions to provide flexible,
 53

individualized supports. Nonetheless, we need research focused on understanding the

impact of different service delivery models or treatment dosages (i.e., intensity,

frequency, duration) on child outcomes, parent acceptability and stress levels, and the

accessibility and feasibility of implementation within community programs.

Related to the accessibility of services for families and feasibility of

implementation of treatment programs, the most predominant service delivery model

used across the research was a direct 1:1 therapy model, and almost half of these

programs used direct 1:1 therapy in combination with other models. Few studies used

group-based service delivery models, which have been reported to be a cost-effective

model within other speech-language services (e.g. Gibbard et al., 2004). Even fewer

examined the use of remote (virtual) therapy services. Given the high prevalence of

autism diagnoses globally, and the limited resources of many countries and health

systems, a focus on conducting research examining potentially accessible and scalable

service delivery models (e.g. peer, group, classroom, remote) within a range of real-

world, community contexts, is also warranted.

2.4.7 Future Directions

Overall, it is clear that more research is needed examining interventions delivered

by SLPs to autistic preschool children. A number of gaps and needs for future research

were identified while conducting this scoping review and have been previously discussed.

Beyond these, attention to broad methodological improvements is also warranted.

2.4.7.1 Evaluation of Efficacy, Effectiveness, and Study Quality

Quality appraisal of research and examination of treatment effectiveness falls

outside the purview of scoping reviews (Arksey & O'Malley, 2005), but future efforts

should be made to further examine the methodological quality and treatment

 54

effectiveness of sub-groups of interventions delivered to preschool autistic children by

SLPs (e.g., AAC interventions, play interventions, parent-coaching studies). With the

high percentage of single subject studies examining SLP-delivered interventions, and the

previously mentioned impact that well designed single subject designs can have on

clinical decision making and policy development within the field of autism, examination

of treatment effectiveness and study quality of preschool autism interventions delivered

by SLPs – inclusive of single subject designs - is warranted. This suggestion is supported

by the Oxford Centre for evidence-based medicine where single subject designs are

ranked as Level 1 evidence, which means that single subject studies can be used to

inform decisions about treatment for individual clients when they are used alongside

systematic reviews of RCTs (http://www.cebm.net/).

2.4.7.2 Improving the Reporting of Intervention Components

Some of the studies included in this review provided complete information about

the professional background of clinicians, service delivery, treatment dosage, and

implementation of interventions (or referenced treatment manuals used to guide

intervention delivery). However, many studies did not provide comprehensive and

systematic information about the interventions delivered. The scarcity of such

information is a significant shortcoming. First of all, it does not allow for study

replication. It also makes it difficult to gain a clear understanding of the unique and

shared theoretical underpinnings across interventions (e.g., child-led vs directive models)

and does not cultivate examination of treatment mechanisms underlying change in

children’s outcomes. Furthermore, without this information, clinicians are unable to use

the information within the research articles to guide implementation of the interventions

within real-world practice with autistic preschool children. As such, improving the
 55

reporting of intervention characteristics through systematic presentation of the processes,

structures and components used within interventions is necessary within future research

studies.

One tool that could be useful for improving reporting quality is the Template for

Intervention Description and Replication (TIDieR; T. C. Hoffmann et al., 2014), a 12-

item checklist developed to address widespread poor reporting of clinical interventions

within research articles (Hoffmann et al., 2014) that has been recommended for use

within the field of speech-language pathology (Ludemann et al., 2017). The first two

items provide background information about the intervention (Brief name & Why -

Rationale/Theory). Procedural elements of the intervention are also accounted for within

items 3-9 (What – materials; What – procedures; Who provided – drawing on what

knowledge/training, how, where, when and how much; and Tailoring – what, when, why

how). The final three items examine issues relevant to treatment fidelity (Modifications –

what, when, why, how; How well – planned; and How well – actual). The checklist and

further explanation, elaboration, and examples for each item, can be found at

https://doi.org/10.1136/bmj.g1687.

2.4.8 Strengths and Limitations

This review offers a comprehensive picture of the state of research on

interventions delivered by SLPs to autistic preschoolers and clearly demonstrates existing

gaps. Findings can be used to guide future research within the field of speech-language

pathology and can be used to support efforts advocating for the versatile role of the SLP

within preschool autism services and for the need for more research in the area of

preschool autism interventions delivered by SLPs. Although this review was an important

first step, it has certain limitations. First, some relevant studies may not have been
 56

identified despite our use of comprehensive and systematic search methods. Despite our

best efforts to contact the authors of the publications that did not report the clinical

training of the interventionists delivering therapy, we were not able to identify the

interventionists within all of the studies and therefore these publications were not

included in the review. Another limitation is that only citations that provided full texts in

English were included (because of limited financial resources to translate); therefore,

there is a chance that relevant studies, written in other languages, were left out.

Additionally, only peer-reviewed articles were included within this review, leaving the

possibility that publication bias might have impacted our dataset. We decided to only

include peer-reviewed articles because we wanted to capture the literature base that was

most likely to be accessible to clinicians and policy makers when developing plans.

Finally, we did not pre-register the protocol for the scoping review, which would have

added transparency and more rigor to the review process (Munn et al., 2018).

2.5 Conclusion

The current study sheds light on the status of research within the field of SLP and

preschool autism interventions. Our findings captured the versatility of the SLP’s role

within preschool intervention and revealed that research in the area of autism

interventions delivered, at least in part, by SLPs has markedly increased over the past ten

years. With this, there is still certain need for more research within our field. Future

efforts focused on capturing the complex and individualized nature of interventions

through improving reporting, increasing the sophistication of intervention study

methodology (e.g., RCTs, comparative efficacy trials, adaptive treatment designs,

mediation and moderation analysis), and aligning research and clinical practice through
 57

community practice research would further the development of effective, evidence-

informed policy and practice in the field of speech-language pathology.

 58

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Chapter 3
Developmental Social Pragmatic Interventions for
Preschoolers with Autism Spectrum Disorder: A Systematic
Review

3.1 Background and Aims

Developmental social pragmatic (DSP) treatment models have been cited as one

of the primary treatment approaches used to address the social communication and

language challenges characteristic of children with autism spectrum disorder (ASD)

(Ingersoll et al., 2005; Prizant & Wetherby, 1998; Smith & Iadarola, 2015). These models

are based on an integration of developmental psychology (Piaget, 1936), transactional

models of development (Sameroff & Fiese, 2000), and the social pragmatic model of

language acquisition (Bates, 1976; Bruner, 1975, 1983; Prutting, 1982). Like other

interventions that are considered developmental, DSP interventions use the

developmental sequences observed in typical development to inform assessment and

treatment, with the assumption that the overarching principles of development are

applicable to all children regardless of diagnosis (NRC, 2001). In alignment with social

pragmatic theory, DSP interventions direct their emphasis away from focusing on the

content and form of spoken language, and instead emphasize the importance of social

engagement, communicative intent, and the flexible use of symbols within meaningful

contexts (Gerber, 2003). Influenced by both transactional and social pragmatic models of

development, DSP interventions also underscore the interpersonal aspects of

communication and language development. They draw from the assumption that both

social communication and language are learned within the context of affective social

engagement with caregivers during natural interactions. Therefore, caregiver

involvement—via training, coaching, and reflective practice—is a key component of DSP

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interventions. Some inherent features of DSP interventions include encouragement of

caregivers to join in with children’s ideas rather than promoting their own agenda during

play, attunement, responsiveness, and natural reinforcement to all forms of children’s

communication and arrangement of the environment to support communication

(Ingersoll, 2010). These interventions align with recommendations by the National

Research Council that ASD interventions (a) emphasize the inclusion of developmentally

appropriate activities and individualized goals, (b) include ongoing assessment of the

child’s developmental progress, (c) occur in inclusive settings, (d) include caregivers and

family (e.g. parent training or coaching), and (e) are intensive (25 or more hours per

week, when we consider both direct therapy and the amount of time parents implement

the learned strategies at home) (NRC, 2001).

Previous reviews of interventions for children with ASD have included treatments

classified as DSP within their evaluation (e.g. McConachie & Diggle, 2007; Odom et al.,

2010; Oono et al., 2013; Smith & Iadarola, 2015; Vismara & Rogers, 2010; Wagner, et

al., 2014; Warren; Wetherby & Woods, 2008). However, we still do not clearly

understand the effectiveness of this approach to intervention. One of the barriers to

progress is that previous reviews have not used consistent or explicit criteria to

differentiate interventions claiming to be using a DSP model from other developmental or

naturalistic behavioral approaches. This leads to inconsistency within the current

literature regarding which treatments are classified as DSP. Ensuring that treatments

share not only the self-identified title of DSP intervention, but more specifically share

DSP theoretical principles and practice elements, is important for ensuring more

homogeneity among the DSP treatment studies being examined. Additionally, having a

set of core common features among the interventions under evaluation can provide the
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advantage of examining potential mechanisms of action for efficacious DSP treatment

models.

The aim of this systematic review was to build on the current literature, and add a

level of specificity, in identifying DSP interventions used with children with ASD. Our

first step was to develop a clear approach to classifying DSP interventions. With this in

hand, we were then able to systematically evaluate whether DSP interventions are

effective in (a) improving children’s foundational social communication skills (e.g.

regulation, attention, engagement, joint attention, reciprocity), (b) improving children’s

language, and (c) changing caregivers’ interaction style or communication. Additionally,

we were able to explore which (if any) participant characteristics or intervention variables

may impact the effectiveness of DSP-based interventions.

3.2 Methods

3.2.1 Search Procedures

Phase one search strategy. With the aim of being comprehensive in our scan of

the literature, a multistep search strategy was used. The first phase involved identifying

treatment interventions that either self-identified as a DSP intervention or were identified

as DSP within peer-reviewed journals. Two independent reviewers explored previously

published articles discussing DSP theory or DSP-branded interventions (e.g. Brunner &

Seung, 2009; Ingersoll, 2010; Smith & Iadarola, 2015) and compiled a list of those

treatments referred to as DSP.

Phase two search strategy. Following the identification of brand named DSP

treatment approaches, we conducted systematic searches for each treatment approach

using the name of the treatment (e.g. “DIR” OR “developmental, individual difference,

relationship” OR “Floortime”; “Responsive Teaching”) and the key words (“Autism” OR

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“ASD”) AND (“Intervention” OR “Treatment”). The searches were completed between

November 2017 and April 2018 within five electronic databases: PsychINFO, SCOPUS,

ERIC, CINAHL, and PUBMED. Publication dates were unrestricted in our search;

however, only articles published in English in peer-reviewed journals were included. This

initial search limited us to only studies that had been conducted after the treatment had

formally received a name and would not have identified new DSP treatment approaches

or DSP treatments not given one of the aforementioned brand names. Therefore, we also

elected to conduct a broader search of the literature.

Phase three search strategy. To cast a wider net, we entered the following key

words into the search databases: (“Developmental Social Pragmatic” OR “Relationship-

based” OR “Transactional” OR “Social-Developmental”) AND (“Autis*” OR “ASD”)

AND (“Intervention” OR “Treatment”) AND (“Communication” OR “Language”) AND

(“RCT” OR “Randomized Control Trial”). Publication dates were unrestricted but the

search was limited to articles on children from 0 to 5 years published in English in peer-

reviewed journals. When available (i.e. PUBMED), a randomized trial filter was applied

to the search in lieu of RCT search terms. Because terms related to DSP-based treatments

may not appear in the title, abstract, or keywords, search parameters were set to “open

field.” Google Scholar and reference lists of articles that met inclusion criteria were also

examined to identify any articles that might have been missed.

3.2.2 Selection criteria

Phase one selection criteria. The compiled list of self-identified and previously

identified DSP interventions was independently screened by two speech-language

pathologists (SLPs) to determine whether (a) the intervention targeted social

communication or language development and (b) the intervention aligned with our DSP
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criteria (described below). Reviewers were asked to answer either yes, no or unknown for

each of the DSP criteria outlined in Table 2.

Interventions that received yes responses for each of the DSP criteria were

classified as DSP and those that met only some of the criteria were classified as non-DSP.

Inter-rater agreement was substantial, k = 0.886. Based on recommendations from the

Cochrane Collaboration, the disagreement was resolved by discussion between the

authors (Higgins & Green, 2011).

An adaptation of Ingersoll’s (2010) classification of DSP interventions was used

to decide if a treatment was DSP or non-DSP. This classification system was selected

because it included intervention elements that aligned with core elements of

developmental and social pragmatic theories. We extended Ingersoll’s (2010) DSP

criteria by including an additional core feature within our classification system that is

integral to social pragmatic theory. In order for a treatment to be considered a DSP

intervention, the treatment had to meet the following criteria: (a) describe itself as based

on developmental principles; (b) use a natural play-based setting; (c) ensure that teaching

episodes are child initiated; (d) include child-selected teaching materials and activities;

(e) target general social communication skills that are foundational to verbal

communication; (f) use facilitation strategies (e.g. adult responsiveness, contingent

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Table 2. Interventions proposed to be DSP and evaluation of how they incorporate core features of DSP interventions
Intervention Previously Natural Child Child Targets general Adult Arrange Reinforce Reinforce all Only Decision
identified as setting initiated selected social responsiveness environment naturally attempts indirect
DSP episodes materials communication as key strategy prompts
Autism 123 YES YES NO YES NO YES YES NO NO NO Non DSP
Project1
DIR2 YES YES YES YES YES YES YES YES YES YES DSP
Enhanced YES YES YES YES YES YES YES YES YES NO Non DSP
Milieu Training3
Focused YES YES YES YES YES YES YES YES YES YES DSP
Playtime
Intervention4
Focus Parent YES YES YES NO YES YES YES NO NO NO Non DSP
Training5
IMPACT6 YES YES YES YES YES YES YES NO NO NO Non DSP
JAML7 YES YES YES YES YES YES YES YES YES YES DSP
JASPER8 YES YES YES YES YES YES YES NO YES NO Non DSP
MEHRIT9 YES YES YES YES YES YES YES YES YES YES DSP
More than YES YES YES YES YES YES YES YES YES YES DSP
Words10
PACT11 YES YES YES YES YES YES YES YES YES YES DSP
Play Project12 YES YES YES YES YES YES YES YES YES YES DSP
RDI13 YES YES NO NO YES YES YES YES YES NO Non DSP
Responsive YES YES YES YES YES YES YES YES YES YES DSP
Teaching14
Son-rise15 YES YES YES YES YES YES YES NO NO NO Non DSP
SCERTS16 YES YES YES YES YES YES YES YES YES YES DSP
The Denver YES YES YES YES YES YES YES YES YES YES DSP
Model17
The Scottish YES NO NO NO NO YES YES YES YES YES Non DSP
Centre
Program18
Stronger YES YES YES UN UN UN UN UN UN UN Non DSP
Families
Project19

Note. DSP = Developmental Social Pragmatic. UN = unknown

1Wong & Kwan, 2010; 2Greenspan & Wieder, 2006; 3Ingersoll, Meyer, Bonter & Jelinek, 2012; 4Siller, Hutman, & Sigman, 2013; 5Oosterling et al., 2010;
6Ingersoll & Wainer, 2013; 7 Schertz, Odom, Baggett & Sideris, 2013; 8 Kasari, Freeman & Paparella, 2006; 9Casenhiser, Shanker & Stieben, 2013; 10 Sussman,

Drake, Lowry & Honeyman, 2016; 11Green et al., 2010; 13RDI Connect, 2017; 14 Mahoney & Perales, 2003; 15Kaufman, 1994; 16 Prisant, Wetherby, Rubin,
Laurent, & Rydell, 2005; 17Rogers & DiLalla, 1991; 18 Salt, Shemilt, Sellars, Boyd, Coulson & McCool, 2002; 19 Keen, Roger, Doussin & Braithwaite, 2007.
 74

imitation, indirect language stimulation, affective attunement); (g) use environmental

arrangement to support communication and language (e.g. communicative temptations,

playful obstruction, wait time); (h) reinforce communication using natural properties; (i)

use reinforcement contingencies that reinforce all communicative behavior (treating all

behavior as intentional); and (j) avoid use of explicit prompts that does not consider the

child’s intent (e.g. “Say ______”).

We elected to include avoidance of explicit prompts for communication as a core

feature of DSP interventions in our classification. This differentiation between DSP and

non-DSP interventions was mentioned by Ingersoll (2010) but not included within her

table comparing DSP and naturalistic developmental behavioral intervention (NDBI)

techniques. We decided to include this in our categorization because use of prompts to

elicit expressive language without consideration of speaker intent is explicitly avoided in

DSP interventions (Gerber, 2003). Prompting for expected verbal outcomes rather than

providing scaffolding to support children’s spontaneous generation of speech is

fundamentally different. This feature can differentiate DSP and NDBI interventions and

thus should be included in DSP criteria when looking at mechanisms of change in DSP

interventions. Treatment approaches that met all 10 criteria mentioned above were

screened by two independent reviewers for phase two selection criteria.

Phases two selection criteria. To be included in phase two of this review, studies

had to (a) be peer reviewed, (b) be published in English, (c) be a randomized control trial

(RCT), (d) evaluate social communication and/or language treatment effects of DSP-

based treatment for children or for caregivers, (e) report effects using quantitative data,

and (f) include preschool children (0–5 years) with a diagnosis of ASD. We excluded

studies where only a minority of the participants fell within the age range of 0–5 years or
 75

when diagnostic groups (those without ASD, or those with co-occurring diagnosis such

as untreated seizure disorder and ASD or Cerebral Palsy and ASD) were combined in the

data reporting (e.g. Siller et al., 2013).

3.2.3 Data collection

The first author developed a coding manual for extracting and analyzing data

from the articles meeting inclusion criteria. After completion of data collection, a

graduate SLP student independently verified 30% of the included studies and perfect

inter-rater agreement was attained k = 1.0. When two studies reported intervention

outcomes for the same group of participants, data for both studies were consolidated and

reported as a single entry in the table (e.g. Casenhiser et al., 2015, 2013). If a study

contained more than one experiment, only the experiments meeting inclusion criteria

were incorporated into our analysis (e.g. Green et al., 2020).

The following information was extracted from each study: (a) participant

characteristics (number, sex, and age), (b) research design, (c) intervention characteristics

(setting, practitioners, dosage), (d) dependent variables and intervention outcomes for

children (i.e. foundational social communication outcomes involving regulation,

attention, joint attention, engagement, reciprocity, and child language outcomes), (e)

dependent variables and intervention outcomes for parent language, (f) effect size

estimates, and (g) measurement tools. Where effect size was not reported, Cohen’s d was

calculated for each variable using means and SDs (Cohen, 1988).

3.2.4 Assessment of evidence-based quality

An integration of the Critical Appraisal Skills Programme tool (CASP, 2018) and

Dollaghan’s (2007) scale for appraising communication treatment evidence was used to

determine whether each article met one of three levels of evidence-based quality. CASP
 76

tools provide a framework for assessing the study quality through considering a series of

appraisal criteria designed to collectively answer three broad questions: (a) Is the study

valid? (b) What are the results? and (c) Will the results help locally? Some of the

appraisal criteria require a simple binary judgment; however, other ratings are more

subjective. As several criteria were used to assess these CASP questions, they were then

weighed and graded to derive both validity and importance (e.g. substantial effect size,

social validity, maintenance) scores using a three-point scale. A score of compelling was

assigned if all CASP questions on the topic being scored (i.e. validity or importance)

received a response of yes. If a low risk of bias was noted or only minor details were

questionable, a score of suggestive was provided. If there was a high risk of bias (a rating

of no or unknown response to more than two questions on the topic), a score

of equivocal was provided. These validity and importance ratings were then used to

derive overall assessments of the quality of the evidence using Dollaghan’s (2007) three-

point scale:

1. Compelling: The evidence is such that unbiased experts would find little or

nothing about the information to debate. Both the validity and importance of

results are rated compelling. Altering one’s current clinical approach should be

seriously considered.

2. Suggestive: A rating of suggestive could be indicative of inconsistent quality

open to debate on a few criteria. It requires at least a suggestive level of validity

and certainty of results. Clinicians might reach different decisions about whether

to use the information to support altering their current clinical practice.

3. Equivocal: An equivocal rating suggests low validity and questionable certainty

of results. No change to clinical practice needs to be considered.

 77

Methodological quality, risk of bias, and importance of results were independently

assessed by two SLPs (one of whom was blind to the authors and dates of publications).

Initial inter-rater agreement for overall quality ratings was k = 0.78 and 100% agreement

was attained through item-by-item discussion between the reviewers (Higgins & Green,

2011).

3.3 Results

3.3.1 Systematically Identifying DSP Interventions

Eighteen treatment approaches were either self-identified as being a DSP-based

intervention or identified in other literature as being DSP, and were examined during

phase one of our search. A total of 10 brand named treatments met all of the DSP criteria,

and thus were included in phase two of our search. See Table 3 for a list of all the

treatments referred to as DSP and our analysis of their alignment with the DSP

intervention components that we based on Ingersoll (2010).

We do not intend to imply that interventions receiving a response of no in any

DSP category mean that the treatment never incorporates the DSP feature into their

model, but rather that it is not a core feature of the intervention. For example, RDI

focuses on establishing shared partnerships (RDIConnect, 2017). Therefore, having

children select materials or initiate the teaching episodes is not a defining feature of the

intervention. Similarly, JASPER is a treatment that incorporates having children initiate

teaching episodes and selecting activities, but this is reportedly only done after children

have been primed to provide appropriate responses using discrete trial training (Kasari et

al., 2006). Additionally, interventions such as Enhanced Milieu Training and IMPACT

incorporate many DSP features that align with cognitive developmental psychology, but

were missing core features that align with social pragmatic theory (e.g. treating all forms
 78

of communication as intentional and avoiding explicit prompting for communication).

For example, Enhanced Milieu Training reports use of elicited modeling and manding to

target social communication and language, and IMPACT promotes having clinicians only

respond to correct communication attempts and withholding objects from the child until a

correct response is attained. Similarly, although the Denver Model meets DSP criteria,

the Early Start Denver Model, which evolved from the original Denver Model, did not

because it incorporates behavioral principles in how challenges in language production

are addressed (e.g. Picture Exchange Communication System; Rogers, 2017). Although

these treatments might meet the criteria for DSP interventions aligned with cognitive

developmental psychology, their failure to incorporate key social pragmatic aspects

classified them as non-DSP within this review.

3.3.2 Description of Studies

Consolidation of phase two and three of our search yielded a total of 289 abstracts

for review. Reference list and Google Scholar searches resulted in identification of an

additional four articles. After removing duplicates, 151 articles were screened for

inclusion. In order for a study to be definitively excluded, the title and/or abstract had to

undoubtedly fail to meet one of the predetermined inclusion criteria. Full text reviews

were conducted on 30 articles. A total of 10 studies (14 articles) examining 6 identified

DSP treatments met inclusion criteria. See Figure 4 for the PRISMA flow diagram

outlining our search and screening results.

Sample characteristics. A summary of participant characteristics for the included

articles is presented in Table 3. The 10 studies reported on outcomes for 716 children

diagnosed with ASD who ranged in age from 1:3 to 6:0 years with a mean of 37.8
 79

months. Sex was reported for 546 of the children; of these, 443 of participants were male

and 103 were female. Sample size across all studies ranged from 23 to 152 participants.

Studies were conducted across four countries, and thus included participants from a

variety of socioeconomic and cultural backgrounds.

Research design and rigor. All of the RCTs included at least one natural parent–

child observation measure that evaluated generalization of skills learned in intervention

during play interactions and all but one study (Schertez et al., 2013) reported adequate

measures of inter-rater reliability for the observational scales they used.Nine studies

included a social validity measure (Carter et al., 2011; Pajareya & Nopmaneejumruslers,

2011; Schertz et al., 2013, 2018; Venker et al., 2012; Wetherby et al., 2014), which

included parent satisfaction questionnaires, a parent stress index, and a clinician

experience questionnaire. Implementation of some form of fidelity measure was included

in six studies. Most of these studies evaluated clinician implementation of the

intervention (Carter et al., 2011; Green et al., 2010; Schertz et al., 2013, 2018; Solomon

et al., 2014; Venker et al., 2012; Wetherby et al., 2014), while only a few examined

parent implementation of strategies (Casenhiser et al., 2013; Schertz et al., 2013, 2018).

Evidence was assessed to be compelling for four of the studies, suggestive for one

and equivocal for five (see Table 4). Notably, one of the studies rated as equivocal was

conducted in Thailand, a country where access to intervention services and resources is

limited (Pajareya & Nopmaneejumruslers, 2011). Factors identified as recurring

challenges in study design included small sample size (under powered), participant

attrition, variable blinding of assessors (i.e. use of parent report outcome measures when

parents were not blind to group allocation), lack of clarity in the identification of the
 80

active ingredients used with caregivers and children within the treatment, and lack of

comprehensive fidelity measurement.

Figure 4. Prisma flow diagram

 81

Table 3. Summary of included studies

Articles N Age Rangea Treatment Condition Intervention Setting; Practitioner;

(n females) (mean ageb) (Control Condition) Frequency; Duration Practitioner Training

Aldred, Green & Adams (2004) 28 2:0-5:11 Child Talk Clinic; 1 session/month for Unknown; Unknown
(3 f) (48) (Routine Care) 6months, then “less
frequent” follow-ups for
6months; 12months
Carter, Messinger, Stone, Celimli, 62 1:3-2:1 More Than Words Clinic & Home; 8 parent SLP; Hanen certified
Allison, Nahmias & Yoder (2011) (11 f) (20) (No treatment) only sessions, 3 in home
sessions; 3.5months
Casenhiser et al. (2012; 2014) 51 2:11–4:11 MEHRIT, DIR based Clinic; 2hour/week; SLP, OT; DIR certification
(44) (Community 12months
treatment)
Green, Charman, McConachie et al. 152 2:0-4:11 PACT Clinic & Home; Biweekly SLP; “Specially trained,”
(2010); (28 f) (Treatment as usual) sessions for 6 months, supervised by senior SLP
Pickles (2016) monthly follow ups, 18 with clinical autism
sessions total; 12 months experience
Pajaraya & Nopmaneejumruslers 32 2:0–6:0 DIR Home; 1.5hours first Rehabilitation Therapist;
(2011) (9 f) (54) (Community standard session, no specified time Reading books, viewing
care) for remainder of sessions; training videos
3months
Schertz, Odom, Baggett, & Sideris 23 (26) Joint Attention Home; at least 15sessions; Early Childhood
(2013) Mediated Learning 4-12months with a mean Educators, Counsellor;
(Community treatment time of 7months “Prior training”
treatment)
Schertz, Odom, Baggett, & Sideris 144 1:4-2:6 Joint Attention Home; 1hour/week; Unknown; Unknown
(2018) (29 f) (24) Mediated Learning 32weeks
(Community
treatment)
Soloman (2014) 128 2:8–5:11 Play Project – DIR Home; 1, 3hour OT, SLP, Special
(23 f) (50) based session/month; 12months Educator; 4 day Play
 82

(Community standard Project Training, 12-

care) 18months of supervision
Venker, McDuffie, Weisemer & 14 2:4-5:8 Adapted More than Clinic; 5, 2hour parent SLP, Graduate student
Abbeduto (2011) (41) Words education sessions, 2, SLP; Hanen certified
(Delayed treatment 45minute individual
group) sessions, twice weekly
60minute group sessions;
7weeks
Wetherby, Guthrie, Woods, 82 1:4-1:8 SCERTS individual Clinic & Home; Unknown; Unknown
Schatschneider, Holland, Morgan, & (20) treatment 3sessions/week for
Lord (2014) (SCERTS group 6months, then
treatment) 2sessions/week for
3months; 9months
Note. f = female; RCT = Randomized Control Trial; SLP = Speech-Language Pathologist; MEHRIT = Milton and Ethel Harris Research Initiative Treatment;
DIR = Developmental, Individual Difference, Relationship Based Intervention; OT = Occupational Therapist; PACT = Preschool Autism Communication
Treatment; SCERTS = Social Communication, Emotional Regulation, Transactional Support Intervention;
aYears:months
bMonths
 83

3.2.3 Description of Intervention

Setting and intensity. Characteristics of the interventions are presented in Table

4. It was most common for therapy sessions to be provided within the child’s home

setting at least some of the time (n = 7). Only three studies conducted sessions solely in a

clinic setting. The range of treatment intensity was extensive, from an unspecified

amount of treatment over 3 months, to a hybrid of individual and group sessions over 7

weeks, to 2 hours weekly over 12 months.

Service delivery. The trainers implementing the DSP interventions varied across

studies. SLPs were the most frequently noted professionals (n = 5). Other professional

backgrounds included occupational therapists, a social worker, a psychologist,

rehabilitation therapists, recreation therapists, and educators, and three studies did not

report the professional background of the clinicians. The level of training of the therapists

was diverse and ranged from therapists who had undergone four years of training (e.g.

Casenhiser et al., 2013), to students reading a book and watching videos on the

intervention (e.g. Pajareya & Nopmaneejumruslers, 2011), to having no mention of

specific training (e.g. Schertz et al., 2018).

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Table 4. Summary of included studies outcomes and certainty of evidence

Citation Outcome Social Communication Language Variable, p-value Parent Outcome CASP
Measures used Variable, p-value (Effect size) (Effect size) Variable, p-value (Effect Certainty
size) of Evidence
Aldred, Green & ADOS social Social Interaction, p=.004 Expressive Language, p< .001 Increase in parent Equivocal
Adams (2004) interaction (d=.85) (d=.01) synchrony, p=0.16 (d=.93)
domain; Parent- Child communication acts, Language Comprehension, Decrease in parent
Child video p=.041 (d=.73) p=.10 (d=.00) asynchrony, p=.009
analysis; VABS Child shared attention, Communication, p=.121 (d=1.07)
Communication p=.204 (d=.57) (d=.43) Parent shared attention,
domain; MCDI Communication, p>.05 (unable p=.176 (d=.37)
to calculate effect size due to Parent communication
insufficient data) acts, p=.293 (d=.54)
Carter, ESCS; PCFP; Initiating joint attention, p>.05 - Parent responsivity, Equivocal
Messinger, Stone, Non-verbal (d=.00) p=.08 (d=.71)
Celimli, Allison, communication Initiating behavior requests,
Nahmias & Yoder of PIA-NV p>.05 (d=.00)
(2011) Frequency of intentional
communication, p>.05 (d=.00)
Casenhiser, CBRS; PLS & Initiation of Joint Attention, Total Language, p=.214 Fidelity Parent co- Suggestive
Shanker & CASL; Language p<.001 (d=1.02) (d=.63) regulation, p<0.001
Stieben (2012); Sample Enjoyment, p<.05 (d=.63) Number of utterances, (d=.996)
Casenhiser, Binns, Analysis; Parent Attention, p<.05 (d=.69) p=.002 (η2p=.191) Fidelity Parent joining,
McGill, Morderer Fidelity to Involvement, p<.01 (d=.87) MLUm, p=.015 (η2p=.123) p<0.01 (d=.92)
& Shanker (2015) Treatment Number of Different Fidelity Supporting
Communication Acts, p<.001 Reciprocity, p<0.01
(η2p=.208) (d=.86)
Contingent Responses, Fidelity Use of affect
p=0.28 (η2p=.138) (facial expressions,
 85

Commenting, p=.012 gestures, intonation

,(η2p=.239) changes etc.), p<0.001
Labeling, p=.021, (η2p=.104) (d=.96)
Responding, p=.147,
(η2p=.161)
Directing, p=.132, (η2p=.001)
Sharing, p=.005 (η2p=.234)
Obtaining Information,
p=.005 (η2p=.151)
Rejecting/protesting, p=.015
(η2p=.160)
Social Conventions, p=.57,
(η2p=.024)
Spontaneous Social
Expressions, p=.05,
(η2p=.075)
Green, Charman, Parent-Child Child Initiations, p=.009 PLS Receptive Language, n.s., Parental Synchrony, Compelling
McConachie et al. Video Analysis; (d=.44) no p-value reported (d=1.09) p>.00, (d=1.09)
(2010) CSBS-DP Social Social Composite, n.s., no p- PLS Expressive Language, Shared Attention, n.s., no
Composite; value reported (log- n.s., no p-value reported p-value reported (d=.38)
ADOS Social odds=2.49) (d=.00)
Communication Social Communication, n.s., no MCDI Receptive, n.s., no p-
Modified p-value reported (log-odds=- value reported (log-
Algorithm Total; 0.64) odds=2.49)
PLS; MCDI; MCDI Expressive, n.s., no p-
VABS value reported (log-
Communication odds=1.63)
domain Vineland Communication,
n.s., no p-value reported
(d=.17 )
 86

Pajareya & FEAS; FEDQ Functional emotional - - Equivocal

Nopmaneejumrus capacities, p=.031 (d=.82)
lers (2011) Emotional development,
p=.006 (d=1.18)
Schertz, Odom, PJAM; VABS Focusing on Faces p< .01 Receptive Language, p<.05 - Equivocal
Baggett & Sideris Communication (d=1.24) (d=.34)
(2013) domain; MSEL Responding to Joint Attention Expressive Language, p>.05
p< .001 (d=1.39) (d=.45)
Turn Taking p>.05 (d=.55) Communication, p< .05
Initiated Joint attention p>.05 (d=.59)
(d=.70)
Schertz, Odom, PJAM Focusing on Faces, p< .001 - - Compelling
Baggett & Sideris (d=1.20)
(2018) Responding to Joint Attention,
p< .001 (d=2.80)
Turn Taking, p< .001 (d=0.85)
Initiated Joint Attention,
p=.003 (d=.90)
Soloman, Van CBRS; SCQ; Attention, p<.01, n2=.07 Vocabulary understood, Maternal Behavior, p<.01 Compelling
Egeren, MBRS; MSEL; Initiation, p<.001, n2=.14 p>.05 (n2=.00) (n2=.30)
Mahoney, Quon MCDI-Words Social communication, p>.05, Phrases understood, p>.05 Maternal Responsiveness,
Huber & Gestures; MCDI- n2=.01 (n2=.00) p<.001 (n2=.15)
Zimmerman Words Gestures, p>.05, n2=.00 Vocabulary produced (words Maternal Affect, p<.001
(2014) Sentences Functional emotional and gestures), p>.05 (n2=.01) (n2=.20)
capacities, p<.05 (n2=.05) Vocabulary produced (words Maternal Achievement
and sentences), p>.05 orientation, p<.001
(n2=.02) (n2=.10)
Complexity, p>.05 (n2=.00) Maternal Directiveness,
Receptive, p>.05 (n2=.00) p<.001 (n2=.08)
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Expressive Language, p>.05

(n2=.01)
Venker, McDuffie, Parent-Child Spontaneous non-verbal Prompted communication Follow in comments, Equivocal
Weisemer & video communication acts, p=.320 acts, p=.007 (d=.74) p=.029 (d=.06)
Abbeduto (2011) transcription (d=.09) Spontaneous communication Linguistic mapping,
acts, p=.196 (d=.54) p=.025 (d=1.12)
Prompting, p=.002
(d=1.39)
Redirects, p=.004 (d=.89)
Wetherby, CSBS; VABS Social, p=.04 (g=.48) Receptive Language, - Compelling
Guthrie, Woods, Communication Socialization, p=.04 (g=.66) p=.008 (g=.58)
Schatschneider, & Socialization Expressive language, p=.61
Holland, Morgan domains; MSEL (g=.18)
& Lord (2014) Speech, p=.81 (g=.05)
Symbolic, p=.72 (g=.13)
Communication, p=.004
(g=.69)
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3.2.4 Intervention Impact

Foundational social communication skills. All of the RCTs examined the

impact of DSP intervention on social communication outcomes (see Table 5). The most

common social communication capacities targeted were overall social interaction or

communication (n = 4), attention (n = 3), joint attention (n = 4), and initiation (n = 3).

Studies also examined children’s focusing on faces (n = 1), involvement (n = 1),

engagement (n = 1), reciprocal interactions (n = 1), gesture use (n = 1), nonverbal

communication (n = 1), and intentional communication (n = 1).

Social interaction or social communication. Each of the four studies evaluating

social interaction capacities or overall social communication reported positive results,

with moderate (Solomon et al., 2014; Wetherby et al., 2014) to large effects (Aldred et

al., 2004; Green et al., 2010; Pajareya & Nopmaneejumruslers, 2011). Aldred et al.

(2004) included both social interaction and communication outcome measures, and

reported positive results in the social interaction domain of the ADOS, but no significant

change on the communication domain.

Attention, interest, engagement, and involvement. Children’s overall attention

was considered in three studies. Results were mixed. Positive results were reported in two

studies (Casenhiser et al., 2013; Solomon et al., 2014). The other study reported no

significant changes in children’s attention posttreatment (Aldred et al., 2004), but found

small to moderate effects, possibly related to small sample size (i.e. N = 28). A more

specific form of attention, focusing on faces, was also positively impacted for children

who had received DSP intervention (Schertz et al., 2013, 2018). Joint attention (including

initiating and responding to bids for joint attention) was examined in four studies. Large

positive effects postintervention were reported in studies rated suggestive and compelling
 89

(Casenhiser et al., 2013; Schertz et al., 2013, 2018) and no effects were reported in one

study that was underpowered (Carter et al., 2011). Children’s involvement in interactions

with caregivers and overall engagement were also found to be positively impacted

postintervention with large to moderate effects (Casenhiser et al., 2013).

Initiations. Moderate to large positive effects for children’s initiation were found

in two studies (Green et al., 2010; Solomon et al., 2014). However, Carter et al.

(2011) found no significant improvements in initiations of behavior requests.

Reciprocity. Only one study examined children’s reciprocity skills. Schertz et al.

(2018) found large positive effects on children’s turn taking post-DSP treatment.

Gestures, nonverbal, and intentional communication. No effects were found for

children’s use of gestures (Solomon et al., 2014), spontaneous use of nonverbal

communication (Venker et al., 2012), or frequency of intentional communication (Carter

et al., 2011).

Language capacities. Children’s posttreatment language skills were considered

within seven studies (see Table 3). Outcome measures used to assess language varied

across studies. Six studies used standardized language tests as outcome measures (e.g.

Preschool Language Scale; Zimmerman et al., 2006). Of these, three reported mixed

results across different language tests (Green et al., 2010; Schertz et al., 2013; Wetherby

et al., 2014) and three reported no effects (Aldred et al., 2004; Casenhiser et al., 2013;

Solomon et al., 2014). Two of the studies that reported mixed results found small to

moderate positive effects in children’s receptive language, but not in expressive language

(Schertz et al., 2013; Wetherby et al., 2014). Green et al. (2010) found no effects using

assessor-rated measures of language. However, parent ratings showed large positive

effects on both children’s expressive and receptive language. Casenhiser et al. (2013) and
 90

Aldred et al. (2004) found no significant differences for children’s receptive, expressive,

or total language scores using standardized language tests; however, moderate to large

positive effects on children’s language use were found when language skills were

analyzed during naturalistic videotaped interactions (Casenhiser et al., 2015). Venker et

al. (2012) also used naturalistic observation tools to evaluate language. They found mixed

results, with no changes observed in children’s use of spontaneous communication acts,

but large positive effects on children’s use of prompted communication acts, following

DSP intervention.

Short-term follow-up. Four studies reported on outcomes from follow-up

assessments that were conducted between 1–2 months and 1 year postintervention (Carter

et al., 2011; Pajareya & Nopmaneejumruslers, 2011; Schertz et al., 2013, 2018). One

study did not find significant treatment effects posttreatment or at follow-up (Carter et al.,

2011). However, Schertz et al. (2013) found significant improvements in their DSP

intervention group relative to a community intervention group that were maintained 4–8

weeks’ postintervention for following faces of communication partners (d = .84) and

responding to joint attention (d = 1.18). Schertz et al. (2018) reported similar maintenance

of skill improvements in the DSP group six-month postintervention (p = .007, d = .77), in

addition to improvements in reciprocal turn taking (p < .001, d = .78). However,

improvements in initiating joint attention were not maintained (p = .082, d = .69). Another

study found children’s overall socioemotional skills (e.g. attention, reciprocity, use of

affect) continued to significantly improve one-year postintervention relative to a

community treatment group (p < .001; Pajareya & Nopmaneejumruslers, 2012).

Long-term follow-up. A 5.75-year follow-up of children who received PACT

intervention revealed a smaller group difference for child initiations at follow-up (d = .29,
 91

95% CI: −0.02 to 0.57) than directly postintervention (Pickles et al., 2015). However, the

mean treatment effect from baseline to follow-up was stronger (d = 0.33, 95% CI: 0.1–

0.6, p = 0.004). Similarly, parent synchrony did not maintain treatment effects at follow-

up (d = .02, 95% CI: −0.30 to 0.36) but when the overall study duration was taken into

account, the effects of the intervention were significant (d = .61, 95% CI: 0.38–

0.86, p < 0.0001). Postintervention differences between groups in language were no

longer present at follow-up (d = .15, 95% CI: –0.23 to 0.53).

Caregiver interaction outcomes. Pre–post social communication or language

outcomes of caregivers were examined within six studies. Parent outcomes most

commonly reported related to parent responsiveness and parental control.

Responsiveness. Parental responsiveness significantly increased for parents who

had participated in DSP intervention, with two studies reporting large positive effects

(Casenhiser et al., 2013; Solomon et al., 2014). By contrast, Carter et al. (2011) reported

no changes in parental responsiveness with moderate effects noted, which may have

related to small sample size (n = 28).

Parental control/directiveness. Within DSP interventions, parental directiveness

is not thought to support spontaneous communication or language and is therefore

discouraged. Three studies reported reductions in directiveness with moderate (Solomon

et al., 2014) to large effects (Aldred et al., 2004; Venker et al., 2012).

Synchrony/joining and shared attention. Parent’s synchrony with their children

showed significant positive improvements in two studies (Aldred et al., 2004; Green et

al., 2010). Similarly, Casenhiser et al. (2013) reported large positive effects

postintervention for parents joining their children’s ideas. Parents’ use of comments that

followed the children’s interests also improved with moderate effects (Venker et al.,
 92

2012). Green et al. (2010) found positive changes in parent–child shared attention post-

DSP intervention but Aldred et al. (2004) did not.

Affect and coregulation. Both studies evaluating parents’ use of affect to engage

their children found large positive effects with DSP intervention (Casenhiser et al., 2013;

Solomon et al., 2014). Parents’ coregulatory strategies also had large positive changes

(Casenhiser et al., 2013).

Parent communication acts, linguistic mapping, and indirect prompting. Aldred

et al. (2004) reported no changes in the frequency of parent communication acts post-

DSP intervention; however, moderate effects were noted. Large positive changes in

parents’ use of linguistic mapping and indirect prompting to encourage communication

were also observed post-DSP treatment (Venker et al., 2012).

3.2.5 Factors influencing DSP intervention effects

Four studies examined child or intervention features that may have influenced

children’s response to DSP treatment (Carter et al., 2011; Casenhiser et al., 2013;

Pajareya & Nopmaneejumruslers, 2012; Schertz et al., 2018). Formal mediation analysis

examining the relationship between treatment elements and children’s response to

treatment was only conduced for two studies (Mahoney & Solomon, 2016; Pickles et al.,

2015). The following themes emerged.

Child’s pre-treatment object interest. Carter et al. (2011) reported that children’s

object interest prior to treatment influenced the treatment effect on the residualized gain

for several communication variables. Children who played with fewer than three toys

during the pre-treatment assessment demonstrated greater gains in initiating joint

attention and initiating requests if they were assigned to the DSP intervention. However,

children who played with five or more toys during the initial assessment showed fewer
 93

gains in initiating joint attention, initiating requests, and the weighted frequency of

intentional communication if they were assigned to the DSP treatment group. This

suggests that children’s level of object interest at the time they entered the study had an

impact on how they responded to the DSP intervention.

Autism severity and overall development. Two studies examined how a child’s

autism severity influenced treatment effects, and results were conflicting. Pajareya et al.

(2012) found that the less severe the impairments or the higher the level of overall

performance of the child prior to intervention, the more likely they were to have positive

gains from the DSP intervention. In contrast, Schertz et al. (2018) found that more

positive changes in responding to joint attention occurred for the children with more

severe autism. However, treatment effects for following faces, turn taking, and initiating

joint attention were not influenced by autism severity.

Expression of enjoyment of the child, joining, support of reciprocity, and

support of independent thinking. Casenhiser et al. (2013) found that parent fidelity to

treatment predicted both language and social communication outcomes in children

following DSP intervention. Specifically, positive child outcomes were predicted by

parent fidelity on expression of enjoyment during interactions with the child, joining,

support of reciprocity, and support of independent thinking. However, caregiver

behaviors before treatment were not significantly associated with any of the changes in

child outcomes.

Amount of treatment. Pajareya and Nopmaneejumruslers (2014) found that the

more hours per week of intervention, the better the gain in functional emotional

capacities. However, fidelity to treatment was not considered, so it is unknown whether

therapists or parents were implementing DIR therapy as it was intended. Therefore, it is

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unclear whether gains were related to time in the intervention per se or time spent

interacting with a parent.

Caregiver responsiveness and use of affect. Mahoney and Solomon (2016)

conducted a secondary analysis of data from Solomon et al. (2014) to examine potential

mediators of their DSP treatment. Intervention effects on children’s social engagement

were mediated by increases in parental responsiveness. Similarly, intervention effects on

children’s social affect were mediated by increases in parental responsiveness and use of

social affect. A large portion of the gains in children’s social engagement and functional

emotional capacities following DSP intervention was explained by change in caregiver

responsiveness and use of social affect.

Caregiver synchronous behavior. A follow-up study examining the treatment

mechanisms of PACT intervention found that children’s improvements in communication

initiations were mediated by an increase in caregivers’ synchronous behaviors. Repeated

measures reliability models and a two-mediator reliability mode indicated that

approximately 70–90% of the changes in the children’s improvement in communication

were attributed to improvements in parent synchronous behavior (Pickles et al., 2015).

3.4 Discussion

This systematic review examined the impact of six different DSP interventions on

children’s or caregivers’ social communication across 10 studies. Consolidation of results

from the studies identified as being compelling reveal consistent empirical support for the

effectiveness of DSP interventions for enhancing foundational social communication

capacities, namely positive changes in children’s attention, focusing on faces, responding

to bids for joint attention, use of affect, engaging in reciprocal interactions, and initiating

communication. It is critical to identify interventions that support the development of

 95

these foundational communication skills given that they can have a tremendous positive

impact on children’s social interactions and language development, yet these skills can be

particularly challenging for children with ASD (Watt et al., 2006). Within the few (n = 4)

studies that included maintenance measures, positive gains in social communication

remained, further supporting the effectiveness of DSP.

The effect of DSP interventions on children’s language is less clear. Positive

findings in some studies are tempered by null findings in others. Notably, of the studies

rated compelling, none revealed lasting, large effects on children’s language

posttreatment. In light of these findings, we should consider factors that may have

impacted children’s response to treatment. First, given the young age at which some of

the children began treatment, and the marked improvements in children’s social

communication but not language, we might consider the possibility that some of the

children included in the studies were not developmentally ready to use symbolic

language. Therefore, it would have been developmentally appropriate to solidify these

foundational communication skills prior to targeting specific language goals, and this

might be reflected within the results. Future studies should consider examining the

impact of children’s pretreatment language level on their response to DSP interventions.

Additionally, the heterogeneity in both the language capacities assessed and the

tools used to measure change may have played a role in the inconsistent language results

across studies. Children’s social communication and functional language use are

particularly difficult to evaluate using standardized or parent report measures (Teger-

Flusberg et al., 2009) and yet standardized language testing was the most frequent tool

used to evaluate children’s language outcomes. In alignment with social pragmatic

theory, DSP interventions focus on developing children’s communicative intent and

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communication functions, rather than language form. Natural play interactions create an

environment to more effectively evaluate these skills. Only two studies included in this

review evaluated language within natural contexts and found positive results (Casenhiser

et al., 2015; Venker et al., 2012). The inclusion of such natural outcome measures aligns

with previous recommendations and underscores the importance of including tools that

examine language within natural contexts as outcome measures to ensure that the data

gathered have the highest degree of validity possible (Tager-Flusberg et al., 2009).

Variability in the professional background and experience of the treating

clinicians, combined with the limited use of fidelity measures within the studies included

in this review also raises questions about the effective implementation of treatment

designed to support children’s language. A comprehensive evaluation of treatment

fidelity may help to resolve these issues. DSP interventions are considered triadic

treatment models where there is (a) a therapist providing treatment to a child and

coaching caregivers, (b) caregivers receiving training and then implementing strategies

learned during interactions with their child, and (c) a child receiving intervention directly

from both the therapist and the caregiver. When working within a triadic treatment

model, researchers would be wise to measure fidelity of treatment implementation at each

level of the intervention (e.g. therapist’s fidelity to delivering treatment, fidelity of parent

training, and fidelity of parent use of DSP strategies; Roberts & Kaiser, 2011). Within

our review, although many studies reported use of fidelity measures, only one Schertz et

al., 2018) looked at fidelity at more than one level of implementation (i.e. clinician and

caregiver).

Despite the importance DSP places on including caregivers in the treatment

process and previous research outlining the relationship between parent interaction and
 97

communication styles and children’s communication outcomes (Siller & Sigman, 2002,

2008), only three studies included outcome measures evaluating caregiver

communication. Access to both parent and child data will bolster further exploration of

the mediating effects of specific parent interaction styles on children’s communication

and language and vice versa.

Of the studies that included caregiver outcomes, increases in parent synchrony,

responsiveness, and use of affect were observed post-DSP intervention, as was a decrease

in the amount of directiveness. Uptake of these strategies aligns with a number of the

core features of DSP interventions, namely: (a) allowing children to initiate activities and

select materials, that is joining in with their ideas rather than directing the interactions

and (b) adult responsiveness. However, these changes were not universal across all

studies or all parent behaviors. To better understand why some studies found changes in

caregiver behavior and others did not, future research should examine not only parent

behaviors, but also the mechanics and techniques used in parent coaching. This

information would also allow for study replication and analysis of the relations between

coaching/training strategies and parents’ effective use of DSP techniques.

Two specific mediating effects of DSP treatments were revealed in our review:

caregiver responsiveness and caregiver synchronous behavior. Both positively predicted

children’s communication development and response to DSP interventions (Mahoney &

Solomon, 2016; Pickles et al., 2015). These findings align with previous research

demonstrating that parental responsiveness supports children’s cognitive,

communication, and socioemotional development (e.g. Kochanska et al., 1999; Mahoney

& Perales, 2003, 2005; Tamis-LeMonda et al., 1996; Wolff & Ijzendoorn, 1997). Both

responsiveness and synchronous behavior (joining in with ideas children have initiated)
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are specifically targeted within DSP interventions and were included within the

framework we used for identifying DSP-based interventions. Caregiver responsiveness in

particular is one of the critical differences in how DSP and some NDBI interventions are

implemented (with responsiveness not being a core defining feature of NDBI treatment

models; Ingersoll, 2010). It is possible that this feature influences interventions’

effectiveness for social communication and language development (Ingersoll, 2010).

Given the movement toward integrating developmental principles within behavioral

intervention models (Lord et al., 2005; Schreibman et al., 2015), it will be important to

understand which features of DSP interventions best predict positive treatment response.

Including analysis of potential treatment mediators in future research should be a priority.

This could help clinicians better tailor interventions to each child’s individual profile and

enhance the decision-making process about which treatment characteristics to integrate

when combining the two treatment models.

3.4.1 Limitations and future research

Within the studies that met inclusion criteria, there was sizable heterogeneity

specifically with respect to (a) study design; (b) methodological quality; (c) duration,

intensity, and implementation of treatment programs; (d) professional background of

professionals delivering the treatment; (e) fidelity to treatment; (f) level of training of

therapists; and (g) outcome measures used. Consequently, a meta-analysis was not

conduced (Sterne et al., 2011). There is need for additional RCTs that are adequately

powered and that employ greater consistency in the frequency, duration, and delivery of

the intervention provided to both the treatment and control groups. Consensus on

outcome measures used across studies will also help researchers draw more definitive

conclusions about DSP interventions. Although treatment effects were significant in

 99

many cases, wide confidence intervals demonstrating the variability of outcomes were

also common across studies. Within future research, it might be advantageous to look at

how DSP interventions impact more homogeneous groups of children with ASD (e.g.

smaller age range, similar pretreatment language level).

Inclusion of measures of generalization and maintenance when evaluating

treatment effectiveness is important (Dollaghan, 2007) and was scarce within the studies

included in this review. The necessity of these kinds of measures is underscored when

assessing interventions that include a parent training component. One goal of including

parents in intervention is to increase the child’s treatment dosage through having parents

generalize the strategies learned during intervention to their interactions with their child

outside of intervention. Without generalization measures, it is difficult to determine what

might be driving change within the intervention. For parent coaching interventions,

different levels of generalization that researchers should include: (a) whether the

caregiver and child, as a dyad, are able to generalize skills learned in treatment to natural

interactions that are outside of the treatment setting, and (b) whether the child is able to

maintain communication and language gains when interacting with someone who has not

received the intervention, and who therefore may not be providing scaffolds to enhance

the child’s communication or language. Examining generalization at these two levels can

help researchers to answer the question: Did the child’s language change because the

caregiver learned to effectively scaffold the child’s language, or was it specifically the

child’s language that changed, thus enabling the child to maintain changes across

different partners? In future research, it is imperative that measures of generalization are

included and that consideration is given to the tools used to evaluate

generalization. Kazdin (2008) explored opportunities to bridge clinical research and

 100

practice, reporting that “even changes on well-established rating scales are often difficult

to translate into every-day life” (p. 148). None of the studies included in this review

assessed generalization or maintenance of social communication or language gains by

removing the familiar caregiver during interactions. However, all studies employed at

least one outcome measure that evaluated children with caregivers or therapists in natural

play contexts. Including more extensive measures at multiple levels of generalization in

future research would support evaluation of real-world generalization.

Finally, including detailed information about service delivery factors (e.g.

intervention duration and frequency, clinician training) and how specific capacities are

targeted during intervention would be a valuable addition to this body of research.

Including this information would allow for analysis of how service delivery factors or use

of specific treatment strategies might relate to children’s response to treatment and

inform service delivery. Within the studies we reviewed, specific capacities targeted

during intervention were often described vaguely, and many of the DSP programs were

not manualized. This may be due to the concern that manuals do not always allow for

enough flexibility and customization of intervention to meet the diverse needs for the

children and families (Smith, 2012). However, a manual that provides guidance on how

to consider implementation of the intervention in a way that allows for flexibility and

individualized adaptation would help to make DSP intervention studies more replicable.

3.5 Conclusions

As far as we are aware, this is the first systematic review to identify a group of

interventions that met clearly defined DSP intervention criteria. Our review examined the

effectiveness of DSP treatments on the social communication and language of young

children with ASD. It also investigated how parents’ interaction and communication
 101

styles were impacted by these interventions. Our review suggests that DSP treatments

positively impact children’s foundational social communication capacities such as

attention, focusing on faces, joint attention, initiation, and reciprocity, but do not

consistently improve children’s language skills. These interventions have the capacity to

enhance the interaction styles of caregivers, optimizing them for supporting children’s

communication development. The two studies that examined mediating factors impacting

children’s response to DSP interventions suggest that caregiver responsiveness and

synchronous behavior positively predict response to treatment, and thus inclusion of these

intervention features should be strongly considered when working with preschool

children with ASD. Future research efforts should aim to isolate and test potential active

ingredients unique to DSP interventions to enhance understanding of how to most

effectively combine evidenced, effective treatment mechanisms and personalize and

adapt them to children’s unique profiles and communication needs.

 102

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Chapter 4
Trampolines and Crash Mats or Pretend Food and Toy Cars?
How Play Contexts Impact the Engagement and Language of
Preschool Autistic Children

4.1 Introduction

Social communication challenges or variations are considered a core feature of

autism. However, the extent and range of these differences are variable across autistic

individuals (American Psychological Association, 2013; Masi et al., 2017; Tager-

Flusberg, 2005). Some autistic individuals remain minimally communicative even after

receiving intensive supports, while others attain language abilities similar to same aged

peers (Tager-Flusberg & Kasari, 2013; Tek et al., 2014). Autistic children’s early

development of social communication skills is among one of the most important

contributors to long-term outcomes (Tidmarsh & Volkmar, 2003; Venter et al., 1992).

Specifically, preschool aged children who communicate often, are reciprocal and

referential with their communication partners, and use language in a semantically diverse

manner are more likely to attain positive social and vocational outcomes later in life

(Billstedt et al., 2005; Howlen et al., 2000; Howlen et al., 2004; Tidmarsh & Volkmar,

2003; Venter et al., 1992). Furthermore, parents have consistently identified the

communication and social domains as treatment priorities for their children with autism

(Pituch et al., 2011). Therefore, identifying and implementing effective supports to

strengthen social communication capacities in children with autism is crucial for

enhancing quality of life for both the child and parent.

Social attention abilities are thought to be critical for early social communication

and language development (Adamson, 1995; Mundy, 2016). This is because children’s

capacity to socially attend facilitates their ability to link behaviours, experiences, or

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words with meaning, and develop social interaction competencies (Bottema-Beutel et al.,

2020; Mundy & Jarrold, 2010; Nelson, 2007). Conceptually, social attention can be

viewed as a broad construct inclusive of social orienting, attending, and joint attention

behaviours (Mundy, 2016). At its most basic form, social orienting is thought of as

directing our sensory organs toward sources of social stimuli (Mundy, 2016).

Neurotypically developing children show a tendency to autonomically align their

attention with social stimuli, rather than attending to non-social stimuli within the same

context (e.g., Scaife & Bruner, 1975; Farroni et al., 2004). Social orienting is necessary

for, but different from attention, which is thought of as an active process whereby

information processing occurs after having oriented toward the stimuli (Mundy, 2016).

Joint attention is more complex, involving social orienting, attending, referential

processing, and signal sending. It consists of a triadic pattern of social attention that

involves coordinating attention with another person to attend to, and ultimately share, a

common point of reference (i.e., objects, events, ideas; Mundy et al., 2009; Tomasello &

Farrar, 1986). Within clinical practice, the term engagement is often used in reference to

social attention behaviours (e.g., Greenspan & Wieder, 2009; Solomon et al., 2014).

Rather than parsimoniously identifying social attention behaviours as discrete child skills

(Adamson & Bakeman 1984; Bottema-Beutel et al., 2020), examination of engagement

states (Adamson et al., 2010) is thought to capture the dyadic and interactive nature of

social attention behaviours. Both the terms social attention and engagement will be used

within this document.

Young autistic children consistently display different social orienting, joint

attention, and social engagement patterns than their non-autistic and typically developing

peers (e.g., Dawson et al., 2004; Jones et al., 2008; McArthur & Adamson, 1996). For
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example, Jones and Klin (2013) found that autistic children displayed an increase in

attending to objects compared to their non-autistic peers. Swettenham et al. (1998)

examined children’s attention shifting during free play and found that autistic children

spent less time looking at people than age-matched peers. Furthermore, the autistic

children in this study were more likely than both their non-autistic and typically

developing peers to shift attention from one object to another object, and were less likely

to shift attention from person to person, or from person to object. Differences in social

attention have been documented across different environments in autistic children

including home settings (e.g., Baranek, 1999; Werner & Dawson, 2005) and clinical

laboratory settings (e.g., Mcarthur & Adamson, 1996; Signman & Ruskin, 1999). Autistic

children also tend to engage in and initiate joint attention less frequently than age

matched peers (e.g., Dawson et al., 2004; Werner & Dawson, 2005). In the most recent

version of the DSM (American Psychiatric Association, 2013), it is suggested that

“impaired joint attention manifested by a lack of pointing, showing or bringing objects to

share interest with others, or failure to follow someone’s pointing or eye gaze” (p. 54) is

one of the earliest identifiable features of autism.

Social attention is an important construct to consider when working with autistic

children, since evidence suggests that it is positively linked to social cognition (i.e.,

perspective taking, theory of mind, use of mental state vocabulary; Nelson et al., 2007;

Brooks & Meltzoof, 2015; Kuhn-Popp et al., 2015). Additionally, the amount of time

children spend in social interactions is positively associated with language development

(e.g., Kasari et al., 2008) and social behaviour including social initiations and joint

attention (e.g., Patterson et al., 2014). Thus, identifying supports to help autistic children

maximize their opportunities to socially attend to their caregivers and access language
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that facilitates interactions is critical given the challenges autistic children already

experience in the social communication domain.

4.1.1 Considering the Role of the Environment

According to transactional and systems theories of development (Thelen & Smith,

1994; Sameroff & Fiese, 2000), children’s social attention and communication manifest

differently depending on the social context, which can include the environment, materials

available, and familiarity of play partners (e.g. Abbeduto et al., 1995; Miles et al., 2006;

Kover et al., 2014; O’Brian & Bi, 1995). This has implications for professionals

supporting the development of social communication skills and for assessing social

communication capacities in autistic children. Adjustment of the environment is a key

support strategy used in both Developmental Social Pragmatic and Naturalistic

Developmental Behavioural Interventions (Binns & Cardy, 2019). However, specific

information regarding when, why, and how environments should be adjusted is often not

clearly specified or well understood.

When providing supports for preschool aged children, one essential

environmental factor to consider is the play environment, specifically, the materials

available in the children’s play context. This may be particularly important for autistic

children given their sensory processing differences (Robertson & Baron-Cohen, 2017),

differences in motor skill development (Flanagan et al., 2012), and reported differences

in choice and interaction with toys. Dominguez et al. (2006) found that autistic children

engaged in more exploratory, sensorimotor, and relational types of play than their

neurotypical peers. Additionally, they used gross motor toys and figurines of popular

characters in the media more than their neurotypical peers. Taking into consideration

autistic children’s tendency to gravitate toward sensory motor play with gross motor toys,
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the goal of this study was to examine and describe patterns of preschool autistic

children’s social attention and communication skills in two different play environments,

namely, a gross motor play environment and a symbolic play environment.

A substantial amount of research has examined the impact of play environments on

the social communication of neurotypically developing children. During play with other

people, 2-year-old children generate more complex language and more talking overall as

compared to when they play independently (Bornstein et al., 2002). For neurotypical

children under 3 years, free play environments are better for increasing their social

engagement and vocabulary diversity, as compared to structured play environments

(Kwon et al., 2013). At 5 years old, they speak more during free play contexts, but use

more complex language during more structured contexts such as conversations and story

generation (Southwood & Russell, 2004). O’Brian and Bi (1995) revealed that different

types of play (i.e., symbolic vs gross motor) can yield very different language output

from young children. Children in their study spoke more often and used more complex

language during symbolic play as compared to gross motor play. They even found that

different toys within the same type of play (i.e. symbolic play with blocks vs with dolls

and food) can yield different language from children across the different contexts, with

children using more statements and fewer labels during symbolic play contexts with open

ended toys such as blocks and toy cars, as compared to symbolic play with play with

dolls and a play house. For children with language impairments, we see similar results on

the impact of play context on social communication to those reported for neurotypical

children (e.g., Sealey & Gilmore, 2008).

Few studies, however, have empirically examined the impact of unstructured play

environments on young autistic children’s social attention and communication skills, and
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even fewer have looked at the relationship between gross motor play contexts and

children’s attention and social communication. One study examined differences between

autistic children’s language samples taken across three different contexts: parent-child

free-play, during administration of the ADOS, and examiner-child free-play (Kover et al.,

2014). They reported autistic children spoke more often, had higher intelligibility,

requested more often, participated in turn-taking more often, and had a higher diversity of

vocabulary when interacting with parents, as compared to the ADOS and examiner child-

play contexts. The children’s language complexity (as measured by mean length

utterance in morphemes; MLUm) was highest in the play context with the examiner.

Another study by MacDonald et al. (2017) compared autistic and non-autistic children’s

engagement, sustained attention, and connectedness with their caregiver across two

parent-child play sessions: a traditional social play setting and a motor behaviour-based

setting (i.e., fine and gross motor tasks). Results revealed significantly lower engagement,

sustained attention, and level of connectedness with their parent in the motor behaviour-

based play setting for the autistic children as compared to their neurotypical peers. Within

the social play setting, autistic children and their peers performed similarly, with the

exception of engagement, which remained significantly lower for autistic children

compared to their peers. This suggested that children with autism have less engagement

with their parent or caregiver than their typically developing peers across both motor and

social play settings, although fewer group differences were observed in the latter.

Swettenham and colleagues (1998) and Adamson and colleagues (2016) also found that

autistic children were more likely than their age matched peers to spend longer durations

attending to objects, and less time attending to people in their play environments.
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4.1.2 The Current Study

With the long-term goal of contributing to the literature used to develop effective,

adaptable assessment and intervention processes for autistic preschoolers, our study

examined and described patterns of children’s language use and engagement in two

different play environments (e.g., gross motor, symbolic). This study had two main aims.

Aim 1: To examine whether preschool-aged autistic children engaged with their

caregiver differently in unstructured symbolic vs gross motor play environments. Social

cognitive theories of development suggest environments can impact children’s social

attention, and past research (e.g., O’Brian & Bi, 1995; MacDonald et al., 2017) has

suggested there will be differences in how well children engage with adults in symbolic

play environments and gross motor play environments. Specifically, children

demonstrated less social engagement in the gross motor play environment than in the

symbolic play environment. However, because autistic children display different social

attention patterns and interactions with toys than their non-autistic and typically

developing peers (e.g., Dawson et al., 2004; Domingez et al., 2006; Jones et al., 2008),

and because the toys used in our motor context differ from those used in MacDonald’s

(2017) study, we expected to see different patterns of engagement than other studies have

found observing non-autistic children in symbolic and gross motor play (e.g., O’Brian &

Bi, 1995). Namely, we predicted that the children in our study would demonstrate more

social engagement in the gross motor play environments than in the symbolic play

environments, and more engagement with objects and time spent unengaged with objects

or people in the symbolic play environment.

Aim 2: To examine whether preschool-aged autistic children use language

differently in unstructured symbolic and gross motor play contexts. Social cognitive
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theories of development that suggest environments can impact children’s use of language,

and past research with neurotypical children and children with language impairment (e.g.

O’Brian & Bi, 1995; Sealey & Gilmore, 2008) has suggested that children speak more

often and use more complex language during free play, and play with symbolic toys.

Therefore, we expected autistic children would also speak more often and use more

complex language in a symbolic play environment versus a gross motor environment. We

expected autistic children to follow similar patterns to neurotypical and non-autistic peers

for language, due to the nature of gross motor-based play, namely, because gross motor

play makes fewer language demands than symbolic play.

4.2 Method

4.2.1 Participants

Participants included 70 children (and parents) who were recruited through

diagnosing physicians, public service agencies, and newspaper advertisements in the

Greater Toronto Area, and participated in a previously reported randomized control trial

(Casenhiser et al., 2013). Children met the following criteria prior to entry into the

treatment study: (a) clinical diagnosis of autism spectrum disorder, confirmed by the

Autism Diagnostic Observation Scale and Autism Diagnostic Interview, (b)

chronological age between 2 years 0 months and 4 years 11 months, and (c) no secondary

neurological or developmental diagnoses (e.g., seizure disorder, global developmental

delay; Casenhiser et al., 2015). Parents who enrolled in Casenhiser and colleagues’ study

committed to attend a 2-hour session weekly for a period of 12months, and spend an

additional 10-13 hours per week implementing therapy strategies at home. Demographic

information is presented in Table 5.

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4.2.2 Overview of Design and Procedures

Institutional review board approval was obtained prior to enrollment of

participants. A repeated measures design was used for this study. To collect data on

children’s engagement states and language across two play contexts, we used a set of pre-

treatment, videotaped, caregiver-child interactions. Videos were collected at in a research

laboratory setting at York University in Toronto, Canada. The entire caregiver-child,

free-play interaction was 25 minutes and consisted of 15 minutes of access to symbolic

toys, 5 minutes of access to tactile toys, and 5 minutes of access to gross motor toys,

presented in this same order for all participants. For the purpose of the present analysis,

we elected to examine the first 5 minutes of the symbolic toy section and the 5-minute

gross motor toy section. We used only 5 minutes of the symbolic section so that the

amount of time was the same across both play contexts. Prior to being videotaped,

caregivers were instructed to play with their child as they would at home. They were then

presented with the different sets of toys. The symbolic toys included toy food, a shopping

cart, a cash register, a toy house, toy cars, and puppets. Gross motor toys included a crash

mat, small trampoline, exercise ball, and spinning desk chair.

4.2.3 Coding and Reliability

4.2.3.1 Social Attention/Engagement State Variables

Time-tagged video coding of the children’s engagement states was conducted using

Datavyu software (Datavyu Team, 2014) and was informed by Adamson and colleagues’

(2010) engagement state coding system. Three distinct variables were examined: active

engagement with caregiver (attending to social stimuli), engagement with objects only,
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Table 5. Demographic information of participants

Demographic Variables Overall (N=70)

Chronological Age Child (months)

Mean 42.5
Median 44.0
Range 25.0 – 57.0

Sex, n (%)
Female 5 (7%)
Male 65 (93%)

Parent sex, n (%)

Female 54 (77%)
Male 16 (23%)

Family income*
51% (over 100 000)
22% (50 000-100 000)
27% (less than 50 000)

Mother’s education level**

16% (advanced degree)
52% (bachelors degree)
8% (associates degree)
22% (some university/college)
4% (high school)

Language most often spoken at home

English 62
Other 8

*Incomes are reported for 46 families and are in Canadian dollars. Six families elected
not to provide information on their income, and family income was not available for 18 of
the families. Statistics Canada reports the 2008 median gross income in Canada is
approximately $76,000 (2010).
**Mother’s education level was reported for 52 families and was not available for 18
families.
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and no engagement with objects or people (non-social attention). The variable

engagement with caregiver is inclusive of both children’s social orienting and joint

attention behaviours because evidence supports these behaviours are highly correlated,

suggesting that they measure a common construct (Dawson et al., 2004). Moments in

which the child was crying or the child’s body was offscreen were considered uncodable.

Descriptions and examples of each of the engagement codes appear in Table 6. To

calculate internal reliability of coding engagement states, 40% of the videos across both

play contexts were double coded by AB and two graduate students in speech-language

pathology. Reliability was good: Cronbach’s α = .840.

4.2.3.2 Language Variables

Videos were transcribed in the Child Language Data Exchange System

(CHILDES) and utterances were coded for morphemes using the % mor tier in

CHILDES. The kidEVAL program was used to calculate number of utterances and mean

length of utterance in morphemes. Children’s reciting of songs or poems and exact

repetitions of previous utterances were excluded when calculating both MLUm and total

number of utterances produced. Transcription reliability between trained graduate

students in speech-language pathology and trained undergraduate research assistants was

computed for 25% of the participants and internal reliability was 96%.

4.2.4 Analytic Methods

To address our research questions, the relationship between play context

(symbolic vs gross motor) and child language and engagement variables was examined

with linear mixed effects modeling using R (R Core Team, 2012) and the lme4

Table 6. Descriptions and examples of engagement variables based on Adamson et
al. (2000)
Engagement Explanation
Variables
Engaged with Engagement with caregivers
Caregiver was defined as children’s time
spent: watching/observing
caregiver, engaged with a
caregiver (with only minimal
involvement of toys), engaged
in social referencing
(responding to, and initiating,
using social referencing and/or
verbal referencing).
Engaged with The child is visually attending to
Object (not an object, exploring or playing
socially with it independently. The
attending) caregiver may attempt to engage
the child, but the child ignores
them. Segments in which the
child is merely in contact with
an object, as when they hold a
small toy while scanning the
room (not visually or auditorily
attending to the toy) are not
included.
Not Engaged No apparent engagement with a
with Object or specific person, object, or
Caregiver symbols. The child may be
(unengaged) unoccupied, may be scanning
the environment as though
looking for something with
which to be engaged, or may be
flitting between foci without
committing to any.
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Examples
• Child watching parent jump on the
trampoline while waiting for a turn
• People play, such as the child and
caregiver making a game of the child
jumping into the caregiver’s arms
• Caregiver demonstrates how to use a
toy, child watches then
spontaneously imitates actions to use
toy
• The child bangs their hand onto the
same toy that the caregiver is
manipulating it, and then looks at the
caregiver, bangs the toy, and then
looks back at the caregiver, smiling
• Child focuses attention on spinning
wheels on a chair
• Child visually explores the lines on
the side of a doll house.
• Child walking the perimeter of the
room
• Child sitting independently and using
self-talk without directing it to
caregiver or shifting gaze toward
caregiver.
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package (Bates, Maechler & Bolker, 2012). This method was selected because linear

mixed effect models are relatively robust against violations of the assumptions of

normality (Gellman & Hill, 2007), and they allow for the resolution of non-

independencies in our data (Winter, 2013). Using liner mixed effect models, we are able

to depict the relationships between play context and the engagement and language

variables while properly accounting for the within-subject factor. That is, by including

participant as a random effect in the linear mixed effects model, the idiosyncratic

variation due to individual differences across participants is characterized. The

assumption is that each participant has a unique intercept for each variable. Given the

heterogeneity across autistic children, it is particularly advantageous to control for this

individual variation among participants.

We ran separate models for each of our dependent variables. Within our models,

play context (gross motor or symbolic) was entered into the model as a fixed effect, and

all models were built with participants entered as a random effect (random intercept).

Statistical significance of the fixed effect was obtained by testing the full model with the

effect in question against the null model (without the effect in question) using the Akaike

Information Criterion. This allowed for arbitrating the explanatory power of the models.

Systematic visual inspection was used to examine homoscedasticity and normality of the

residuals. Significant interaction effects were further explored using post-hoc pair-wise

comparisons across participants and context, provided by the emmeans package (Lenth,

2018), with Holm- Bonferroni adjustment for family-wise error. Effect size (eta-squared)

for each model was calculated using the anova_stats function, provided by the sjstats

package (Lüdecke, 2020).

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4.3 Results

Figure 5 presents visualization of the descriptive statistics for all dependent

variables. The impact of context on children’s engagement and language variables was

examined using linear mixed effect models, with context entered as a fixed effect and

participant entered as a random effect. Separate models were created for each dependent

variable. Table 7 presents random and fixed effects parameters for all five models.

Systematic visual inspection of residual plots for each model did not reveal any obvious

deviations from homoscedasticity or normality.

4.3.1 The Impact of Play Context on Social Attention/Engagement

Examination of the impact of play context (gross motor vs symbolic) on

children’s overall social attention directed toward their caregiver revealed significant

main effect, F(1-69) = 9.36, p = 0.003, with a moderate effect (η2 = 0.095). Within the

symbolic toy context, there was a decrease in time children spent engaged with their

caregiver by 26.69s ± 8.72 (SE), as compared to the gross motor context. In other words,

when in a symbolic play environment for 5 minutes, children spent roughly 9% less time

attending to their caregiver than they did during the gross motor play environment. Play

context also had an impact on children’s focus of attention solely on objects F(1-69) =

24.10, p = 0.001, with a large effect (η2 = 0.186). During the 5 minutes
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Figure 5. Pirateplots of descriptive data (group means, 95% confidence intervals)

for engagement and language performance (dependent variables) in participants
across symbolic and gross motor play contexts.

Note: Gross = Gross Motor Context; Sym = Symbolic Context; MLUm = Mean Length Utterance in
morphemes.
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Table 7. Random and Fixed Effects Parameters for All Five Mixed Models

Model Fixed Random Estimate SE t Variance SD

Effects Effects
Engagement Models
Time (seconds) Intercept 182.84 9.12 20.05
engaged with
caregiver
Context -26.69 8.72 -3.06
Subject 3206 56.62
Time (seconds) Intercept 55.1 7.23 7.61
engaged with
objects only
Context 42.12 8.55 4.909

Subject 1121 33.48

Time (seconds) Intercept 48.11 5.15 9.34
not engaged
with objects or
people
Context -17.51 6.94 -2.52

Subject 171.6 13.10

Language Models

Total Utterances Intercept 21.784 2.572 8.471

Context -1.224 1.535 -0.798
Subject 81.45 9.025
MLUmor Intercept 1.56773 0.11835 13.25
-
Context 0.15955 0.07745 -2.06

Subject 0.4339 0.6587

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of play within the symbolic play environment, we saw children’s attention solely on

objects increase by about 41.95s ±8.55 (SE) compared to their attention to objects in the

5-minute gross motor play context. This is an increase of about 14% in time spent

engaged with objects only during the symbolic play. Finally, a significant main effect

was also revealed for the relationship between play context and children’s focus of

attention on neither objects nor people F(1-69) = 24.01, p = 0.01, with a small effect (η2

= 0.048). On average, children decreased their time spent unengaged by 17.50s ±6.936

(SE) when in the symbolic play context as compared to the gross motor play context.

Table 8 outlines pairwise contrasts for the LME models.

Table 8. Pairwise Contrasts for LME Models

Model Contrast Estimate SE df t ratio p value

Total utterances Gross-sym 1.22 1.53 68.5 0.798 0.4279
MLUm Gross-sym 0.16 0.0775 68.8 2.060 0.0432*
Time actively engaged Gross-sym 26.7 8.72 69.2 3.059 0.0032*
with caregiver
Time engaged with Gross-sym -42 8.55 69.2 -4.909 <.0001*
objects only
Time not engaged with Gross-sym 17.5 6.94 69.8 2.524 0.0139*
objects or caregiver
Note: Holm-Bonferroni method was used to adjust P-values for family-wise error

4.3.2 The Impact of Play Context on Language

No impact of play context on the total number of utterances spoken by children

was found F(1-68) = 0.636, p > 0.5. However, a significant main effect between play

context and children’s MLUm was revealed F(1-69)= 4.24, p=0.04, η2 = 0.053, with

children’s MLUm decreased by 0.16 ± 0.08 (SE) in the symbolic play context vs the

gross motor play context. With the participants’ combined MLUm (inclusive of symbolic

and gross motor contexts) ranging from 0 – 3.696, with a mean of 1.498, a change in 0.16
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represents an 11% difference in children’s MLUm across contexts. See table 8 for

pairwise contrasts.

4.4 Discussion

Our study examined autistic preschool children’s engagement and spoken

language within two different play contexts, with the goal of identifying potential

interactions between the contexts and children’s engagement or language. This is the first

study of its kind to specifically examine the interaction between unstructured gross motor

and symbolic play contexts and the engagement and spoken language use of autistic

preschool children. Findings supported our general hypothesis as significant interactions

between play context and autistic children’s engagement and language were revealed.

Our findings were consistent with results from previous studies of autistic, neurotypical,

and non-autistic preschool children, which suggested that a child’s play environment can

influence their interaction patterns (e.g., Kover et al., 2014; Sealy & Gilmore, 2008).

4.4.1 Engagement Differences Across Play Contexts

Our specific prediction for the impact of play environment on children’s social

attention was that the autistic children in our study would demonstrate more social

engagement in the gross motor play environment than in the symbolic play environment,

and more time engaged with objects in the symbolic play environment. In alignment with

our hypothesis, children in our study directed their attention socially toward caregivers

more often, spent less time focusing on objects only, and spent slightly more time

unengaged with objects or people in their environment, during the gross motor play

context relative to the symbolic play context. Our findings may be related to a number of

factors that have yet to be tested but are worthy of consideration. One possibility is that

this was merely an artefact of the order in which the contexts were presented, that is,
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children may have engaged more with caregivers in the gross motor play context because

this context was always presented to the child after the symbolic context. It is plausible

that children were warming up during the symbolic context, and the increase in

engagement with caregivers in the gross motor context could be attributed to their

becoming more comfortable with the environment over time. However, the data from our

symbolic play context is closely aligned with data on young autistic children’s

engagement states within semi-natural play interactions from Adamson et al. (2012). This

suggests that although it is possible that children may have interacted differently in the

symbolic play context as a function of the order in which the two contexts were filmed,

the patterns of children’s engagement observed in our symbolic play context appear to be

representative of young autistic children’s engagement in symbolic contexts.

It could also be the case that the properties of the toys provided in each of the play

environments, rather than the nature of the toys (symbolic vs gross motor), contributed to

our findings of systematic differences in children’s engagement across play contexts.

Within the context of the toys used in this study, these properties include how they are

used, their size, and the degree of visual detail within them. Differences in the properties

of toys used in our study compared to those in MacDonald (2017) may also account for

conflicting results between the studies. MacDonald used both fine and gross motor toys

in their motor context and the toys in our motor play environment were solely gross

motor toys.

Generally, symbolic and gross motor toys are designed to be used very

differently. For young children, the gross motor toys may be more likely to require a

partner’s assistance for use than the symbolic toys. For example, in the gross motor

context a child could jump on a crash mat and might require caregivers to hold their
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hands for stabilization, while in the symbolic context they could explore a toy car and

figurine independently. It could be the case that the built in need for caregiver’s

assistance to use many of the gross motor toys in our study contributed to children’s

increase in attention directed toward caregivers in the gross motor context. Additionally,

there was a distinct difference in the size of the toys provided in the symbolic vs the gross

motor play context. Toys in the gross motor play context were much larger (i.e., personal

trampoline, crash mat, large yoga ball, spinning chair) than the toys provided in the gross

motor play context (i.e., action figures, small toy cars, play food items). For some

children with autism, disengaging and then shifting attention is slower, and perhaps a

more effortful process than that experienced by non-autistic peers (Burack et al., 1997;

Elison et al., 2013; Waas, et al., 2015). It is possible that when children are playing with

larger toys, their visual field is likely to be expanded, potentially making it less effortful

for them to shift their focus of attention toward their play partners. Moreover, the toys in

the gross motor environment also tended to have less visual detail than the toys presented

in the symbolic play environment. For example, a large yoga ball has less complex visual

details than a cat figurine. Thus, when children were in the symbolic play context, they

could have been more focused on the objects in their environment because they tended to

be more visually detailed. This viewpoint aligns with research by Remington et al. (2009)

suggesting that autism maybe characterized by increased perceptual capacity. They

propose that this perceptual difference may lead autistic individuals to be more detail

focused and distracted by visual details of objects, which may also make it harder for

them to shift attention to social stimuli (social orienting). Systematic testing of the impact

of the aforementioned toy properties on children’s engagement should be explored in

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future work, to form a more detailed understanding of the impact of play environments

on young autistic children’s engagement.

The final factor to consider when interpreting the engagement results revealed in

our study relates to the impact gross motor play activities can have on children’s arousal

level. We know from listening to the lived experiences of autistic self-advocates and

empirical research that autistic children have sensory-regulatory differences that can

impact arousal (e.g., Fletcher-Watson & Happe, 2019; Baranek et al., 2007; Baranek et

al., 2013; Cascio et al., 2016; Welch et al., 2019). In addition, there is evidence indicating

a relationship between arousal and social attention behaviours such as attention shifting

and re-orienting (e.g. Marrocco et al., 1998; Orekhova & Stroganova, 2014).

Furthermore, gross motor play requires physical exertion and thus is likely to increase

children’s arousal levels more so than symbolic play. Therefore, the toys provided to

children during gross motor play could have been upregulating children’s arousal level,

potentially making it easier (less effortful) for them to shift attention. In future work,

adding a measure to examine children’s arousal during play interactions, and examining

the relationships between arousal, engagement, and play environment would be of value

and could be used to inform development of engagement supports.

4.4.2 Language Differences Across Play Contexts

Although there was a clear impact of play environment on our participants’

engagement, the impact of play environment on children’s spoken language was less

robust. We had predicted that the preschool autistic children in our study would follow

similar patterns to those revealed in neurotypical children and children with language

impairments, that is, speaking more and using more complex language in the symbolic

play environment than in the gross motor play environment. However, our findings
 130

revealed there was no meaningful difference in how often children used spoken language

across the symbolic and gross motor play contexts, and that children used more complex

language in the gross motor play context. When considering the clinical significance of

these results, it is important to note that although the children’s difference in MLUm

across contexts was statistically significant, in absolute value, the difference in MLUm

between the symbolic and gross motor play contexts is quite small (an increase of 0.16).

Nonetheless, the fact that there was little difference in children’s spoken language across

the two different contexts is meaningful, as this pattern of language use across symbolic

and gross motor environments differs from the patterns observed in neurotypical children.

Therefore, our findings, although preliminary, should expand consideration of how play

contexts might be used in clinical settings when evaluating and working with young

autistic children.

Increase in children’s MLUm in the gross motor play context could be related to

their increase in social engagement in this same context, as the correlation between social

attention and language is well documented (e.g. Charman, 2003; Poon et al., 2012).

Furthermore, aligned with the transactional model of development, previous research has

suggested that autistic children’s MLUm is significantly associated with their caregivers’

communication (Fusaroli et al., 2019). We have yet to explore if there were differences in

how the parents used language across the two play environments, but we acknowledge

that this could have impacted our findings.

4.2.3 Limitations

Although informative, this study is characterized by a number of limitations that

should be considered. First, because we used previously collected videos, we were not

able to alternate the order in which symbolic and gross motor toys were presented to the
 131

children. As such, our analysis is subject to bias in that the order of presentation could

have impacted children’s overall stronger performance within the gross motor context. In

future work, this could be addressed by randomizing order of the play contexts.

It should also be noted that our data was extracted from 5-minute samples for each

play context. This duration is consistent with recommendations for engagement language

samples (Miller, 1981). However, we do not know if this pattern would be sustained over

a longer period of time (e.g. a 30-minute therapy session). This should be taken into

account when considering how to apply this information clinically. Future work could

examine longer samples of play interactions to establish scalability.

Additionally, although efforts were made to avoid bias in the sample selection

when participants were recruited for the original study, self-selection bias was present.

Parents who signed up for the original study from which the data was obtained had to

make a considerable time commitment (17-hours/week for 12months). Thus, participants

might not be representative of the general population and thus limit generalizability of

our findings.

Finally, and perhaps most importantly, this study did not explicitly consider the

dyadic, bidirectional nature of social attention and communication, the impact that the

play contexts may have had on caregiver language or interaction styles, and how these

factors might interact with child outcomes. We know that children’s engagement and

social communication is inextricably intertwined and dependent on their partner’s

communication and actions. For example, caregiver quality of language and

responsiveness have been shown to predict early language learning in neurotypical

children (e.g., Tamis-LeMonda et al., 2001; Hirsh-Pasek et al., 2015) and autistic

children (e.g., Haebig et al., 2013). Further, caregiver responsivity has been linked to the
 132

amount of time children jointly engage with their interaction partners (Patterson et al.,

2014; Ruble et al. 2008). Although our engagement coding system (Adamson et al.,

2010) took into consideration the actions of both the caregiver and child, without

systematic examination of caregivers’ contribution to this bidirectional interaction

process, we only have a partial understanding of the impact of play contexts on autistic

preschool children’s engagement and communication. Future work examining the impact

of play contexts on caregiver’s language and interaction styles and examination of how

they mediate children’s engagement and communication is needed to gain a more

complete picture.

4.2.4 Clinical Implications and Significance

Although our results warrant replication and expansion before concluding that one

particular play context is better than another for autistic preschoolers, our findings

suggest there is value in clinicians differentiating play contexts when assessing and

supporting the language and engagement capacities of young autistic children. It may be

that specific elements within gross motor play environments provide some autistic

children with important sensory-regulatory supports that positively impact their social

engagement and communication. Thus, clinicians don’t need to feel confined to using

symbolic play environments when supporting children’s social communication. If a child

is having difficulty socially attending to their play partners in an environment with

symbolic toys, the clinician may want to explore where positive changes can be made in

the child’s social engagement within a gross motor play environment. Furthermore, the

recognition that play context can influence preschool autistic children’s engagement and

use of language can help in the design of supports for autistic preschoolers, and may

encourage more interdisciplinary work between professionals who support social

 133

communication and sensory-motor domains (e.g., speech-language pathologists with

occupational therapists, physical therapists, and recreation therapists). Research exploring

why and for whom play contexts impact social communication behaviours is needed to

be able to more accurately guide clinical practice.

4.5 Conclusions

While our findings are preliminary, they support the idea that preschool aged

autistic children’s play environments can influence their social attention and spoken

language use. They also contribute to the literature helping clinicians better understand

the impact the play environment can have on autistic preschool children’s social attention

and language. Future work in this area should investigate the factors that predict the

impact of play environment on children’s social attention and communication, which

could be used to inform development of supports for autistic preschoolers. Moreover, the

findings encourage us to continue to study the impact of children’s play environments on

their engagement and language, using a broader cross disciplinary lens, in hopes of better

understanding how to support autistic children’s social attention and communication.

 134

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Chapter 5: General Discussion

Approaching this dissertation research from the viewpoint of both a speech-

language pathologist (SLP) and a researcher, the primary purpose of my doctoral research

has been to enhance our understanding of intervention programs offered by SLPs to

children with autism, and to contribute to our knowledge about how to best support their

social communication and language. As a clinician, I wanted to produce research that was

meaningful to clinicians working within real-world community settings, and respectful of

the values of parents and autistic individuals. As a researcher, I aimed to contribute to the

limited literature base on SLP approaches to intervention for autistic preschool children.

This integrated article dissertation began with a scoping review that broadly explored the

literature on autism interventions within the field of speech-language pathology (Chapter

2). The aim of this review was to gain a comprehensive understanding of the state of

research on preschool autism interventions provided by SLPs. Additionally, we wanted to

identify the range of skill development areas targeted within the studies and to explore

characteristics of the interventions (i.e., theoretical models underlying the programs,

service delivery models, treatment dosage). The systematic review reported in Chapter 3

focused on one particular type of intervention frequently offered by SLPs, and examined

the effectiveness of these interventions in supporting communication and language

outcomes for autistic preschool children. Specifically, we aimed to differentiate

interventions using a developmental social pragmatic model from other developmental or

naturalistic behavioral approaches and examine the impact of developmental social

pragmatic interventions in supporting (a) foundational social communication and

language skills of preschool children with autism spectrum disorder and (b) caregiver

interaction style. Finally, the study reported in Chapter 4 explored the impact of one
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specific support strategy built into many preschool interventions, environmental

modification, on autistic children’s social communication and language. Specifically, we

examined whether preschool aged autistic children socially attended or used language

differently in unstructured symbolic versus gross motor play environments.

In this final chapter, I discuss the main findings across the three studies included

in this dissertation and highlight the contribution of these studies to the field, for both

research and clinical practice. The chapter concludes with considering the ways in which

this work provides directions for future research.

5.1 Foundational Knowledge: Mapping the SLP Autism Intervention Literature

In order to gain a better understanding of the available research examining

preschool autism interventions in speech-language pathology, it was necessary to conduct

a study broadly scoping the literature (Chapter 2). With speech and language therapy

being one of the most frequently accessed early interventions for children with suspected

or diagnosed Autism (Denne et al., 2018; Salomone et al., 2016; Volden et al., 2015), we

were surprised to find that such a review had not already been done. A total of 114

studies met inclusion criteria with most published within the last decade. Case studies or

single subject designs were predominant across the SLP intervention literature,

underscoring the need for more methodologically rigorous and differentiated study

designs. Nine skill development areas were targeted within the studies included in this

review, but interventions targeting social communication, language, and augmentative

communication skills made up the vast majority of the research. There was a great deal of

variability across intervention characteristics (i.e., service delivery models and treatment

dosage) and about half of the studies were delivered by SLPs working on multi-

professional teams, however, very little information was provided regarding the nature of
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the teams, how or if they worked collaboratively, roles of team members, etc. With

regard to the theoretical underpinnings of interventions offered by SLPs, there was

relatively even distribution of research on interventions informed by child-centred,

clinician-directed, and hybrid models. Together, the results from this study shed light on

the status of research within the field of SLP and preschool autism interventions, called

attention to the versatility of the SLP’s role within preschool intervention, and reminded

us of the limits of the evidence that we have to support the approaches used by SLPs in

clinical practice. Although there has been an increase in research in our field over the last

decade, the discipline of speech-language pathology still needs a stronger evidence-base

to strengthen advocacy and policy development. The findings presented in this scoping

review can be used as a rationale for conducting systematic reviews and research on SLP-

delivered autism interventions and can be cited when applying for funding for such

research..

The work done for this scoping review enabled me to broadly review the breadth

of available literature related to preschool autism interventions, highlighted gaps in our

current knowledge, and provided me with directions for future research. The gaps in the

literature limit the ability of SLPs, organizational leadership, and policy makers to make

evidence informed decisions when deciding on and developing social communication and

language supports for young children and their families (e.g., service delivery, type of

parental training, process for collaboration with multidisciplinary teams, program

selection, etc.). Embedded within the scoping review article are several suggestions for

future research. One idea that has particularly important implications for clinical practice

is producing research that supports efforts in gaining a clear understanding of the unique

and shared theoretical underpinnings informing intervention models. With SLP

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interventions generally classified into one of three models, child-centred, clinician-

directed, or hybrid models, identifying which therapeutic strategies or ingredients are

used within each model, and which ingredient(s) from the child-centred and clinician

directed models are being combined within hybrid models, would support efforts to

conduct research to understand which combination of supports mediate children’s

response to treatment. Many of the studies included in the scoping review did not provide

comprehensive and systematic information about the interventions delivered. The scarcity

of such information is a significant shortcoming for research and hinders clinicians’

abilities to implement findings within real world service delivery. In our next study

(Chapter 3), I focused on beginning to address this challenge.

5.2 Identifying and Evaluating Interventions using a Developmental Social

Pragmatic (DSP) Model

The second study was narrower in focus, and systematically identified one type of

parent-mediated intervention commonly used by SLPs that aligned with child-centred

interventions, namely, developmental social pragmatic interventions (DSP). Ten studies

of varying methodological rigor evaluated DSP programs and were included in this

review. All of the studies examined foundational communication outcomes (e.g., shared

social affect, reciprocity, joint attention) and all but one reported positive outcomes for at

least one of the measures. Fewer studies (n=7) examined language outcomes and while

results were positive for language use within natural contexts, they were mixed for

overall, receptive, and expressive language. In addition, parents’ interaction styles

significantly changed postintervention, namely in terms of increased responsiveness,

synchronous behavior, use of affect, and decreased directiveness. Only two studies

conducted formal mediation analysis and found that parent responsiveness and
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synchronous behavior were related to children’s positive response to treatment. Together

the evidence suggested that these interventions positively impact autistic children’s

foundational communication capacities (i.e., attention, social referencing, joint attention,

initiation, reciprocity); however, there is need for more methodologically rigorous studies

and research exploring components of DSP treatments that might mediate response to

treatment is needed. The findings presented in this systematic review can be used as a

rationale for conducting more DSP and parent-mediated intervention research, can be

cited when applying for funding, and can be used to inform preschool autism intervention

policy development.

In this article we took a unique approach to identifying DSP intervention studies

to include in this review, which lead to important contributions to research and clinical

practice. The unique element included in our study identification process involved using

Ingersoll’s (2010) DSP criteria (which explain similarities and differences between DSP

and hybrid therapy models) as a guide to clearly specify criteria each intervention being

studied needed to meet in order to be classified a DSP intervention and included in our

review. Only 55% of the articles that self-identified as being DSP actually incorporated

all elements required to meet DSP criteria. From a research perspective, inclusion of this

step in our systematic review supported efforts to assess a more homogenous group of

interventions, and ensured our results genuinely reflected an evaluation of DSP

intervention studies. Clinically, by undertaking this step, it allowed us to include

information in our publication evaluating how each intervention self-reporting use of a

DSP model incorporated core features within their information. This information can be

used by SLPs to guide their responses to parents or colleagues inquiring about similarities

and differences between different intervention models.

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5.3 The Relationship Between Play Contexts and Children’s Social Communication

To address limitations within the current literature surrounding the understanding

of specific ingredients that may be used in SLP-delivered interventions, the final study in

this dissertation examined one specific ingredient commonly used in SLP-delivered

interventions – environmental modification. Specifically, we examined the relationship

between play context (symbolic vs gross motor) and child language and engagement

during free-play interactions between 70 autistic children aged 2-4 years and their parent.

Although preliminary, our findings support the idea that preschool-aged autistic

children’s play environments can influence their social attention and spoken language

use. The most significant finding was that young autistic children were more likely to

socially attend to caregivers in gross motor play contexts than in symbolic play contexts,

and they were more likely to focus their attention solely on objects during symbolic play

contexts as compared to gross motor contexts. Small effects were also found for

children’s increase in MLUm and time spent unengaged with objects or caregivers,

during the gross motor play contexts. The findings have potential to inform how SLPs

use environmental modification during assessment and intervention and encourage

continued exploration of the impact of children’s play environments on their engagement

and language, using a broader cross-disciplinary lens.

This study stemmed from my clinical work, and observations of differences in

children’s engagement and language production during SLP sessions using symbolic toys

as compared to SLP-Occupational Therapist (OT) co-treatment sessions. When

consulting the literature, little research was found examining the impact of gross motor

play environments on children’s engagement and language. In addition, with so much

work in the field of autism focused on supporting the ability of autistic children to adapt
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to, or fit into, a neuro-typical world, I felt that we should also consider whether there are

changes that we (as clinicians) could make to tailor the environment to better support the

child. For these reasons, I aimed to contribute to the body of research focused on better

understanding the impact of children’s environments (specifically play environments) on

preschool autistic children’s social attention and language. By examining both gross

motor and symbolic play contexts, it expanded my thinking about factors that might be

impacting children’s engagement and language play (i.e., sensory-motor, regulation).

More research is needed to further explore child factors (e.g., language level, play level)

that might be impacting engagement and language use in different play contexts, and

specific elements or changes in caregiver behaviors that may contribute to differences in

their child’s engagement and use of language across symbolic and gross motor contexts

(e.g., use of directives, language demands, affective interactions, use of routines in

interactions). Nonetheless, our findings can still inform clinical practice, and encourage

clinicians not to feel confined to using symbolic play environments when supporting

children’s social communication. I am eager to continue this program of research,

crossing disciplinary silos, and exploring why and for whom certain play contexts impact

social communication behaviours.

5.4 Future Directions

Taken together, this research has uncovered exciting opportunities for new lines

of inquiry about preschool social communication supports for autistic children. We

identified many areas in need of further investigation in order to continue moving this

work forward (e.g., systematic reviews of SLP interventions targeting specific skill

development areas). However, foundational to this work is better understanding the

complexities and nuances of the SLP-delivered programs offered in research studies, the
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process involved in delivering the interventions, and the service delivery models used.

One important suggestion for moving this work forward entails improving our reporting

of speech-language pathology intervention components, processes of collaboration, and

clinical decisions by sharing treatment manuals, making use of mixed methodologies, or

using tools such as the Template for Intervention Description and Replication (TIDieR;

T. C. Hoffmann et al., 2014). Following this recommendation alone would strengthen the

precision of the research and enable service providers working in community settings to

better relate to and apply the findings within their practice.

As I reviewed much of the literature on SLP-delivered interventions for

preschool autistic children for the reviews, I noticed a tension or paradox between

viewing the work through the lens of a researcher and a service provider. As a researcher,

I recognize the need to conduct clean research that is consistent, with as few confounding

variables as possible. However, as a clinician, I am well aware of the real-world need to

embrace the complexity and messiness of delivering interventions in the community. I

found myself asking questions such as: (a) are the interventions being examined in

research studies aligned with the services and programs SLPs use in their day-to-day

work? (i.e., are we measuring the interventions SLPs truly care about or already use?), (b)

do the service delivery models being examined within the research align with what

community programs are able to offer within real-world settings (e.g., duration, level of

multi-disciplinary integration, cost)?, (c) what is the process involved in coaching or

training the agent of intervention within parent-mediated or educator-training

interventions?, (d) are the tools being used to measure outcomes within research studies

in alignment with the tools SLPs use in clinical practice, or in alignment with outcomes

that are important to families? I believe that in answering these questions, through mixed
 151

methodological studies, we will be able to better align the design of future research

studies with the values, needs and goals of the knowledge users (i.e. clinicians, parents,

educators). This is important if our ultimate goal is real-world community adoption and

implementation of the supports or interventions.

Another piece of working toward a more complete understanding of SLP-

delivered autism interventions is understanding active therapeutic ingredients and

subgroup variation in treatment response. This work can be done using comparative

efficacy trials, adaptive treatment designs, and RCTs with adequate power to allow for

mediation and moderation analysis. Once mediators and moderators are identified, they

can be taken into account when developing interventions, and can then be further tested

and refined through a series of experimental studies. Given the heterogeneity of autism,

and the focus on individualizing treatment programs for each child within SLP services,

this information would be immensely meaningful to clinicians and could be used to guide

their selection and provision of services.

Finally, the findings from our third study (Chapter 4) led me to a new line of

inquiry focused on investigating factors that predict the impact of play environment on

children’s social attention and communication using a broader cross disciplinary lens.

Currently, I am in the process of conducting a follow up study (to chapter 4), examining

the transactional nature of interactions within different play contexts, specifically

examining the impact of play environments (gross motor or symbolic) on parent

interaction style, and the interaction between play context, parent interaction and child

variables. The findings from such work could be used to inform development of supports,

and inform clinical decision making for SLPs working with autistic preschoolers and

their parents.
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5.5 Conclusions

This dissertation set out to enhance the understanding of interventions offered by

SLPs to children with autism and contribute to our knowledge about how to best support

social communication and language of children with autism. The research took the form

of three studies, each one informed by my experience working as a clinician. The first

study shed light on the status of research within the field of SLP and preschool autism

interventions, called attention to the versatility of the SLP’s role within preschool

intervention, and reminded us of the limits of the evidence that we have to support the

approaches used by SLPs in clinical practice. The second study revealed DSP

interventions positively impact autistic children’s foundational communication capacities

(i.e., attention, social referencing, joint attention, initiation, reciprocity), and identified

that further inquiry is needed to better understand the inconsistent results found for the

impact of these interventions on language. Findings from the final study support the idea

that preschool autistic children’s play environment can influence their social attention

and spoken language use and confirm the importance of considering their impact on

clinical assessment and intervention and continuing to investigate the impact of

unstructured play environments on children’s social attention and communication.

Collectively, the findings from the studies included in this dissertation provide several

directions for future research and have opened important questions to consider in an

effort to better align research with real-world clinical practice. Taken together, these

works set a foundation for the speech-language pathology field to move forward with a

focus on autism intervention research that is meaningful to the children, and families, and

the clinicians who serve them.

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References

Denne, L. D., Hastings, R. P., & Hughes, C. J. (2018). Common approaches to

intervention for the support and education of children with autism in the UK: An
internet-based parent survey. International Journal of Developmental
Disabilities, 64(2), 105-112. https://doi.org/10.1080/20473869.2016.1275439

Hoffmann, T. C., Glasziou, P. P., Boutron, I., Milne, R., Perera, R., Moher, D., Altman,
D., Barbour, V., Macdonald, H., Johnston, M., Lamb, S., Dixon-Woods, M.,
McCulloch, P., Wyatt, J., Chan, A. W., & Michie, S. (2014). Better reporting of
interventions: Template for intervention description and replication (TIDieR) checklist
and guide. BMJ, 348. https://doi.org/10.1136/bmj.g1687

Ingersoll, B. R. (2010). Teaching social communication: A comparison of naturalistic

behavioral and development, social pragmatic approaches for children with autism
spectrum disorders. Journal of Positive Behavior Interventions, 12(1), 33-43.
https://doi-org/10.1177/1098300709334797

Salomone, E., Beranová, Š., Bonnet-Brilhault, F., Briciet Lauritsen, M., Budisteanu, M.,
Buitelaar, J., ... & Fuentes, J. (2016). Use of early intervention for young children with
autism spectrum disorder across Europe. Autism, 20(2), 233-249.
https://doi.org/10.1177/1362361315577218

Volkmar, F, Lord, C., Bailey, A., Schultz, R. T., Klin, A. (2004). Autism and pervasive
developmental disorders. Journal Child Psychology and Psychiatry, 45, 135-170.
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Appendices
Appendix A: Scoping Review Search Strategies and Limits
Based on our research question, four key criteria were used and combined to search
databases for relevant articles. Studies were only included if they 1) included children
with ASD, 2) involved services delivered at least in part by a SLP, 3) Included children
aged birth to 5-11 years of age, 4) outlined intervention practices with child outcomes. To
extract articles most likely to fit the above criteria, the following search terms were used.

Keyword search terms used for SCOPUS, AMED, ERIC, PsycInfo, EMBASE,
CINAHL:
1. ASD: “Autis*” OR “Asperger*” OR "Pervasive Developmental Disorder*" OR
"Pervasive-Developmental Disorder*"
2. SLP/ CDA: “Speech-Language Patholog*” OR “Speech-Language Therap*” OR
“Speech Patholog*” OR “language patholog*” OR “Communicative Disorders
Assistant*” OR “Communication Disorders Assistant*” OR “Speech Therap*”
OR “Language Therap*” OR “supportive personnel*” OR “support personnel*”
OR “speech teach*” OR “language teach*” OR “clinician*” (Note: In AMED,
EMBASE, and CINAHL, the keyword “Speech-language pathology assistant”
was also added. Due to an oversight, “speech patholog*” was not included in the
search of the EMBASE database.)
3. Preschool Age: “Child*” OR “Preschool*” OR “Pre-school*” OR “Infant*” OR
“Toddler*” OR “Boy*” OR “Girl*”
4. Intervention: “Intervention*” OR “Therap*” OR “Program*” OR “Treat*” OR
“Train*”

Subject Heading searches for AMED, PsycInfo, EMBASE, CINAHL:

Where applicable in a given database, relevant subject headings were also searched.
Subject headings included in each database are outlined below.
AMED Subject Headings: “autism”, “Asperger syndrome”, “speech-language
pathologist”, “speech therapy”, “language therapy”, “preschool child”, “infant”,
“toddler”, “child”, “boy”, “girl”, “early intervention”
PsycInfo Subject Headings: “Autism Spectrum Disorders”, “Speech-Language
Pathology”, “Preschool students”, “Infant development”, “Early Intervention”,
“Intervention”, “Treatment”, “Training”
EMBASE Subject Headings: “autism”, “Asperger syndrome”, “speech-language
pathologist”, “speech therapy”, “language therapy”, “preschool child”, “infant”,
“toddler”, “child”, “boy”, “girl”, “early intervention”
CINAHL Subject Headings: “Autistic Disorder”, “Asperger Syndrome”, “Pervasive
Developmental Disorder – Not Otherwise Specified”, “Speech-Language Pathology”,
“Speech Therapy”, “Language Therapy”, “Communicative Disorders”, “Speech-
Language Pathology Assistants”, “Child, preschool”, “Infant”, “Child”, “Early Childhood
Intervention”, “Treatment Outcomes”, “Communication Skills Training”, “Models,
Educational”, “Social Skills Training”, “Early Intervention”
 155

The PubMed database was also searched, using the following keywords and MeSH
terms:
PubMed MeSH Terms: “Asperger syndrome”, “autistic disorder”, “child development
disorders, pervasive”, “speech-language pathology”, “communication disorders”,
“therapy”(Subheading), “therapeutics”
The following keywords were searched in PubMed:
1. “Asperger AND syndrome” OR “Asperger syndrome” OR “Asperger” OR
“Asperger’s AND syndrome” OR “Asperger’s syndrome” OR “Asperger’s” OR
“Autistic AND disorder” OR “autistic disorder” OR “autism” OR “autistic” OR
“autistics” OR “Child AND development AND disorders AND pervasive” OR
“pervasive child development disorders” OR “pervasive AND developmental
AND disorder” OR “pervasive developmental disorder”
2. “speech-language AND pathology” OR “speech-language pathology” OR “speech
AND language AND pathology” OR “speech language pathology” OR “speech-
language pathologist*” OR “speech language pathologist*” OR “speech
therapist*” OR “language therapist*” OR “clinician” OR “communication AND
disorders” OR “communication disorders” OR “communicative AND disorders”
or “communicative disorders AND assistant”
3. “therapy” OR “treatment” OR “therapeutics”, OR “intervention” OR
“interventions” OR “therapies” OR “treatments” OR “program” OR “programs”
OR “training” or “trainings”
This search yielded only 370 results, so further limiting by preschool age was not deemed
necessary and all articles were included to be screened for inclusion.
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Appendix B: References of Articles Included Within the Scoping

Review

1. Al-dawaideh, A. M., & Al-Amayreh, M. M. (2013). The effectiveness of Picture

Exchange Communication System on learning request skills and the development
of speech in Arabic-Speaking children with autism. Life Science Journal, 10(2),
2139-2148. http://www.lifesciencesite.com
2. Aldred, C., Green, J., & Adams, C. (2004). A new social communication
intervention for children with autism: Pilot randomised controlled treatment study
suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45(8), 1420-
1430. https://doi.org/10.1111/j.1469-7610.2004.00338.x
3. Baharav, E., & Reiser, C. (2010). Using tele-practice in parent training in early
autism. Telemedicine and e-Health, 16(6), 727-731.
https://doi.org/10.1089/tmj.2010.0029
4. Barber, A. B., Saffo, R. W., Gilpin, A. T., Craft, L. D., & Goldstein, H. (2016).
Peers as clinicians: Examining the impact of Stay Play Talk on social
communication in young preschoolers with autism. Journal of Communication
Disorders, 59, 1-15. https://doi.org/10.1016/j.jcomdis.2015.06.009
5. Barton-Hulsey, A., Wegner, J., Brady, N. C., Bunce, B. H., & Sevcik, R. A. (2017).
Comparing the effects of speech-generating device display organization on symbol
comprehension and use by three children with developmental delays. American
Journal of Speech-Language Pathology, 26(2), 227-240.
https://doi.org/10.1044/2016_AJSLP-15-0166
6. Beilinson, J. S., & Olswang, L. B. (2003). Facilitating peer-group entry in
kindergartners with impairments in social communication. Language, Speech, and
Hearing Services in Schools, 34(2), 154-166. https://doi.org/10.1044/0161-
1461(2003/013)
7. Bellon, M. L., Ogletree, B. T., & Harn, W. E. (2000). Repeated storybook reading
as a language intervention for children with autism: A case study on the application
of scaffolding. Focus on Autism and Other Developmental Disabilities, 15(1), 52-
58. https://doi.org/10.1177/108835760001500107
8. Boyd, B. A., Watson, L. R., Reszka, S. S., Sideris, J., Alessandri, M., Baranek, G.
T., Crais, E. R., Donaldson, A., Gutierrez, A., Johnson, L., & Belardi, K. (2018).
Efficacy of the ASAP intervention for preschoolers with ASD: A cluster
randomized controlled trial. Journal of Autism and Developmental
Disorders, 48(9), 3144-3162. https://doi.org/10.1007/s10803-018-3584-z
9. Braddock, B. A., & Armbrecht, E. S. (2016). Symbolic communication forms in
young children with autism spectrum disorder. Communication Disorders
Quarterly, 37(2), 67-76. https://doi.org/10.1177/1525740114558255
10. Brown, J. A., & Woods, J. J. (2015). Effects of a triadic parent-implemented home-
based communication intervention for toddlers. Journal of Early
Intervention, 37(1), 44-68. https://doi.org/10.1177/1053815115589350
11. Carbone, V. J., O'Brien, L., Sweeney-Kerwin, E. J., & Albert, K. M. (2013).
Teaching eye contact to children with autism: A conceptual analysis and single case
study. Education and Treatment of Children, 36(2), 139-159.
https://doi.org/10.1353/etc.2013.0013
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12. Cardon, T. A. (2012). Teaching caregivers to implement video modeling imitation

training via iPad for their children with autism. Research in Autism Spectrum
Disorders, 6(4), 1389-1400. https://doi.org/10.1016/j.rasd.2012.06.002
13. Cardon, T. A., & Wilcox, M. J. (2011). Promoting imitation in young children with
autism: A comparison of reciprocal imitation training and video modeling. Journal
of Autism and Developmental Disorders, 41(5), 654-666.
https://doi.org/10.1007/s10803-010-1086-8
14. Cardon, T. (2013). Video modeling imitation training to support gestural imitation
acquisition in young children with autism spectrum disorder. Speech, Language
and Hearing, 16(4), 227-238. https://doi.org/10.1179/2050572813Y.0000000018
15. Carson, L., Moosa, T., Theurer, J., & Oram Cardy, J. (2012). The Collateral Effects
of PECS Training on Speech Development in Children with Autism. Canadian
Journal of Speech-Language Pathology & Audiology, 36(3), 182-195.
https://cjslpa.ca/files/2012_CJSLPA_Vol_36/No_03_176_263/Carson_Moosa_The
urer_Cardy_CJSLPA.pdf
16. Carter, A. S., Messinger, D. S., Stone, W. L., Celimli, S., Nahmias, A. S., & Yoder,
P. (2011). A randomized controlled trial of Hanen’s ‘More Than Words’ in toddlers
with early autism symptoms. Journal of Child Psychology and Psychiatry, 52(7),
741-752. https://doi.org/10.1111/j.1469-7610.2011.02395.x
17. Casenhiser, D. M., Binns, A., McGill, F., Morderer, O., & Shanker, S. G. (2015).
Measuring and supporting language function for children with autism: Evidence
from a randomized control trial of a social-interaction-based therapy. Journal of
Autism and Developmental Disorders, 45(3), 846-857.
https://doi.org/10.1007/s10803-014-2242-3
18. Casenhiser, D. M., Shanker, S. G., & Stieben, J. (2013). Learning through
interaction in children with autism: preliminary data from asocial-communication-
based intervention. Autism, 17(2), 220-241.
https://doi.org/10.1177/1362361311422052
19. Chenausky, K. V., Norton, A. C., & Schlaug, G. (2017). Auditory-motor mapping
training in a more verbal child with autism. Frontiers in Human Neuroscience, 11,
426. https://doi.org/10.3389/fnhum.2017.00426
20. Coleman, C. L., & Holmes, P. A. (1998). The use of noncontingent escape to
reduce disruptive behaviors in children with speech delays. Journal of Applied
Behavior Analysis, 31(4), 687-690. https://doi.org/10.1901/jaba.1998.31-687
21. Colombi, C., Narzisi, A., Ruta, L., Cigala, V., Gagliano, A., Pioggia, G.,
Siracusano, R., Rogers, S. J., Muratori, F., & Prima Pietra Team. (2018).
Implementation of the Early Start Denver model in an Italian
community. Autism, 22(2), 126-133. https://doi.org/10.1177/1362361316665792
22. Copple, K., Koul, R., Banda, D., & Frye, E. (2015). An examination of the
effectiveness of video modelling intervention using a speech-generating device in
preschool children at risk for autism. Developmental Neurorehabilitation, 18(2),
104-112. https://doi.org/10.3109/17518423.2014.880079
23. Couper, L., van der Meer, L., Schäfer, M. C., McKenzie, E., McLay, L., O’Reilly,
M. F., Lancioni, G. E., Marschik, P. B., Sigafoos, J., & Sutherland, D. (2014).
Comparing acquisition of and preference for manual signs, picture exchange, and
speech-generating devices in nine children with autism spectrum
disorder. Developmental Neurorehabilitation, 17(2), 99-109.
https://doi.org/10.3109/17518423.2013.870244
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24. Dalwai, S. H., Modak, D. K., Bondre, A. P., Ansari, S., Siddiqui, D., & Gajria, D.
(2017). Effect of multidisciplinary intervention on clinical outcomes of children
with autism spectrum disorder in Mumbai, India. Disability, CBR & Inclusive
Development, 28(2), 95-116. https://doi.org/10.5463/DCID.v28i2.508
25. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J.,
Donaldson, A., & Varley, J. (2010). Randomized, controlled trial of an intervention
for toddlers with autism: The Early Start Denver Model. Pediatrics, 125(1), e17-
e23. https://doi.org/10.1542/peds.2009-0958
26. Devlin, S. D., & Harber, M. M. (2004). Collaboration among parents and
professionals with discrete trial training in the treatment for autism. Education and
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prelinguistic communication interventions on the acquisition of spoken
communication in preschoolers with ASD. Journal of Speech, Language, and
Hearing Research. https://doi.org/10.1044/1092-4388(2006/051)
115. Yoder, P., & Stone, W. L. (2006). Randomized comparison of two communication
interventions for preschoolers with autism spectrum disorders. Journal of
Consulting and Clinical Psychology, 74(3), 426. https://doi.org/10.1037/0022-
006X.74.3.426
116. Yoder, P. J., & Layton, T. L. (1988). Speech following sign language training in
autistic children with minimal verbal language. Journal of Autism and
Developmental Disorders, 18(2), 217-229.
117. Yorke, A. M., Light, J. C., Gosnell Caron, J., McNaughton, D. B., & Drager, K. D.
(2018). The effects of explicit instruction in academic vocabulary during shared
book reading on the receptive vocabulary of children with complex communication
needs. Augmentative and Alternative Communication, 34(4), 288-300.
https://doi.org/10.1080/07434618.2018.1506823
118. Yu, L., & Zhu, X. (2018). Effectiveness of a SCERTS model-based intervention for
children with autism spectrum disorder (ASD) in Hong Kong: A pilot
study. Journal of Autism and Developmental Disorders, 48(11), 3794-3807.
https://doi.org/10.1007/s10803-018-3849-6.
 166

Appendix C: CASP Systematic review tool

VALIDITY IMPORTANCE

Are the results of the trial Valid? What are the Results? Will the results help locally?
Can the results
Were all the patients be applied in
Was the who entered the trial your context
assignment properly accounted (or to the local Were all
of patients to for at its conclusion? How large was the population)? clinically
treatments Consider: Was the treatment effect? Consider: Do important
randomized? trial stopped early? Were the groups Aside from the Consider: What you think that outcomes
Consider: Were patients similar at the start of experimental outcomes were How precise the patients considered
How was this analyzed in the groups the trial? Consider: intervention, measured? Is the was the covered by the ? (See
carried out? to which they were Also look at other were the groups primary outcome estimate of the trial are similar fidelity &
Was the randomized? Was factors that might treated equally? clearly specified? treatment enough to generalizati Are the benefits
allocation there a high attrition affect the outcome... Consider: did What tools were effect? patients to on chart for worth the harms and Certainty of
sequence rate? Was attrition rate age, sex, social class both groups used for Consider: What whom you will additional costs? Even if this is Evidence
concealed noted? Was there a etc. (was there a big receive same measurement? What are the apply this? if info on not addressed by the (Equivocal,
from valid reason for difference between assessments? at results were found confidence not how do they these trial what is your Suggestive,
Article researchers? attrition rate? groups?) same timing? for each outcome? limits? differ? measures) opinion? Compelling)
No effect sizes
reported but was
able to calculate d
using mean & SD

Social
communication:
Mixed - no effect, Y - no real
moderate effect, harm as the
CT large effect children who
– for the most part did not undergo
N yes, but amount Language: Mixed - experimental
-matched according of intervention no effect, small intervention Validity:
to amount of routine after the first 6 positive, moderate received the Equivocal
treatment received – months was not positive intervention
Y but not matched on clearly defined they would've Importance:
Randomized -no dropouts from important measures (e.g. “less Parent Interaction: received in their Suggestive
Aldred, active treatment such as age, frequent”) Mixed - no effect, CT community
Green, & But very small once treatment language or severity therefore difficult moderate positive, - no CIs were Maybe – small settings Overall:
Adams, 2004 sample size started of ASD to replicate large positive reported N Y otherwise Equivocal
Carter, Y Y Overall – no Wide CI Validity:
Messinger, Allocation N - No differences in positive statistical particularly for Y Suggestive
Stone, et al, concealment - (89% retention), socio-demographic significance for standardized Hanen MTW is
2011 unknown but small sample characteristics or on Y treatment group– language a common Y Y (as above) Importance:
 167

to begin with thus any Time 1 measures although some testing – VABS intervention in Equivocal
some risk of bias of the experimental moderate effect & Mullen (but SLP
- partial intent to or clinical child sizes (possibly due notably wide Overall:
treat (5 variables to small sample across both Equivocal
participants were size). treatment and
included in control groups)
analyses when -additionally
their outcome data Confidence
were available intervals
straddled zero
- some
measures
parental report
(and parents not
blind to
treatment group
so some risk of
assessment
bias)
N (risk of bias)
- 9 families
withdrawing from
the MEHRIT Social
treatment group interaction/commun
and 13 ication:
withdrawing from Positive - significant
the CT group. “We improvements made
cannot be sure of (mCBRS: Large
the effect of this effect)
attrition on the
outcomes. We Language:
decided not to Standardized
continue to collect language testing- no Maybe
measurements statistical -culturally
from these significance (small diverse
children because –medium positive) - but majority
the different were from 2
methods used by Language Sample: parent
the several Positive (MLU, household
government total number of - depending on
treatment centers, utterances, diversity structure of Validity:
and the variance in of functions & intervention Suggestive
the amount of time responsiveness could be
individuals were Y (large positive difficult to Importance:
receiving -matched based on effects) Relatively wide deliver 1 year Suggestive
Casenhiser, et treatment through age, baseline CI; Language of intervention
al., 2011; our program, language level and Parent Interaction: CI straddling with both OT Overall:
2014 Y would have cognitive function Y Large positive zero and SLP Y Y (as above) Suggestive
 168

effectively erased
any homogeneity
in treatment
among the
individuals who
withdrew, and the
20–30 hours of
treatment these
individuals were
receiving was not
comparable to the
3.9 hours (on
average) being
received by the
rest of the CT
group.”
- These children
were not
accounted for
statistically.
Y Social
For the most part - Communication: CI’s do straddle
the two treatment Large positive zero; but are
groups were well effects relatively
matched for narrow.
demographic Language: moderate -some measures
variables to large positive parental report
-Except that effects but were not
socioeconomic status primary Maybe
and proportion of Parent Interaction: outcome -intervention
parents with Large positive measures and was 2 hours
Y (low risk) qualifications gained data was not biweekly for 6
- attrition to after age 16 years However, no extracted as no months and Validity:
endpoint was low were higher in the differences were p values were then monthly Compelling
(6 [4%] of 152 for group given PACT noted with the reported, nor booster sessions
primary endpoint -Baseline child teacher Vineland were we able to for 6 months. Importance:
Green, and 101 [7%] of measures were well Communication and obtain the effect Depends on Compelling
Charman, 1520 for all balanced across Adaptive Behavior size program if this
McConachie, secondary treatment groups & Composite standard measurement would be Overall:
et al, 2010 Y endpoints). trial sites. Y scores. used by authors feasible.. Y Y (as above) Compelling
(risk of bias) Validity:
- 31 out of the Y Y Equivocal
initial 34 families -Four strata were No effect sizes -conducted in
Pajareya & remained in the generated within reported but developing Importance:
Nopmaneeju study. One family both treatments to calculated d using country Suggestive
mruslers refused to do the guarantee baseline mean & SD Moderately (Thailand) with
(2011) CT intervention, two similarity Y wide CI few resources Y Y (as above) Overall:
 169

families who were Social Equivocal

in the control communication:
groups decided to Large Positive
seek FloorTime
intervention from
friends.
- Not included in
statistical analysis
Social Y
Not entirely – but Communication: – but small
accounted for in Moderate to large sample size –
statistical positive effects (one higher number
analysis. with moderate of parents not
effects but no CT working but
- No statistically statistical - no confidence staying home
significant significance – intervals were with children
difference in the initiating JA) reported (almost half of
amount of time - SD were the group)
spent in treatment. Language: Mixed - smaller than -positive,
- Assessment No statistical mean children were
times varied but significance- -some measures recruited across Validity:
CT researchers took expressive (but parental report various cites Equivocal
Random sequence this into account moderate effect); (and parents not across US
Schertz, generation or and treated positive with small blind to - but parents Importance:
Odom, allocation CT Y different to moderate effects treatment group were primarily Equivocal
Baggett & concealment - but no mention – No significant assessments as – receptive language so some risk of Caucasian from
Sideris of participants difference on pre-test categorical and parent reported assessment 2 parent Overall:
(2013) Small sample size dropping out. measures. variables. language bias) household Y Y (as above) Equivocal
Y
-9 dropped
out/withdrew in
treatment group –
and 4 dropped out
in control group Y
(13 total) -children from
- another 9 lost at metropolitan
Randomly follow up for and rural areas Validity:
assigned but no treatment group across 3 states Compelling
allocation and 8 lost at Social - but primarily
Schertz, concealment follow up for communication: Caucasian and Importance:
Odom, (“assigned to control group Large positive 83% of parents Compelling
Baggett & group as they were - Accounted for in effects. Gains received post
Sideris determined analysis (intent to maintained at follow high-school Overall:
(2018) eligible”) treat) Y Y - same up. Acceptable CI education Y Y (as above) Compelling
Y Y Y Social social Y - no real Validity:
Solomon, -although - retention rate -Did not differ communication: communication harm as the Compelling
Van Egeren, randomization was 89% of PLAY significantly on any Y Mixed - no change Cis realtively Y Y children who
 170

Mahoney, et occurred within families and demographic or – to positive changenarrow; and - ¼ of did not undergo Importance:
al, 2014 sites 85.9% of control outcome variables. with moderate to language CI’s participants non experimental Compelling
families large effects larger, and Caucasian intervention
- intent to treat (attention, initiation)
straddling zero. - most from 2 received the Overall:
analysis used for -some measures parent home intervention Compelling
most measures Language: No effect relied on parent - more than half they would've
(not video report and reported family received in their
observations) Parent interaction: parents aware incomes less community
positive effects – of treatment than 60,000 settings
moderate - large (US median otherwise.
was 51 000 at
the time)
- but 12 months
may not be
feasible for all
public systems.
No effect sizes
reported but
calculated d using
mean & SD

-groups did not Social CT

differ in ADOS communication: no - Wide CI’s
severity, PLS-4 statistical straddling zero
Auditory significance ranges were
Comprehension, reported and Y - no real
Mullen Visual Language: Large ranges from harm as the
reception, parent positive effects – some measures parents in the Validity:
report of vocabulary prompted were very wide 'delayed- Equivocal
or chronological age communication acts indicating treatment'
Y (low risk of - But delayed variability group were to Importance:
Venker, Randomized bias) treatment group was Parent among the Y – treatment receive training Equivocal
McDuffie, - no children significantly higher interaction/language group (occurred conducted in if they wished
Weismer, But very small dropped out of the in PLS-4 expressive : Large positive for both groups real world once post data Overall:
Abbeduto sample size study early language. Y effects at times) clinical setting Y was collected. Equivocal
Y Y Y - both groups
- Attrition was - baseline Social of children
16% (13/82) equivalency for all communication: no Maybe received
overall, 19% groups on baseline effects – parent –Interventions intervention.
(8/42) in measures report – positive could be hard to Although the Validity:
individual-ESI, -did not differ on with moderate do in local pop individuals in Compelling
and 13% (5/40) in demographic observational due to length (9 the group-ESI
group-ESI. variables or hours of months), received less Importance:
Wetherby, Attrition was other intervention. Language: Mixed – Wider Cis for especially the intervention Compelling
Guthrie, comparable -FSU site had higher no effect some – CSBS individual-ESI, time per week,
Woods, et al, between scores on MSEL moderate positive (socialization which was 2-3 this type of Overall:
2014 Y conditions (P = Visual Reception & Y effect others. and speech) times per week. Y intervention is Compelling
 171

.42) and sites (P = Fine Motor but not similar to other

.91). Receptive or group parent
- intent to treat Expressive Language interventions
analysis used available.
 172

Appendix D: DSP Systematic Review: Inclusion of Reliability,

Generalization and Maintenance, Social Validity and Fidelity Measures
Citation Reliability Generalization (other Social Fidelity
than natural video Validity
interaction) or
Maintenance
Aldred et al. Yes No No No
Carter, Messinger, Yes Yes Yes Yes
Stone, Celimli, Allison, (clinician)
Nahmias & Yoder,
2011
Casenhiser et al., 2012 Yes No No Yes
Green, Charman, Yes Yes No Yes
McConachie et al.
2010
Pajareya & Yes Yes Yes No
Nopmaneejumruslers,
2011
Schertz, Odom, No Yes Yes Yes (2 levels –
Baggett & Sideris, (4 & 8 weeks) clinician
2013 implementation &
parent
implementation
Schertz, Odom, Yes Yes Yes Yes (2 levels clinician
Baggett & Sideris, & parent)
2018
Soloman, 2014 Yes No Yes Yes
Venker, McDuffie, Yes No Yes Yes (2 levels clinician
Weisemer & implementation &
Abbeduto (2011) clinician coaching)
Wetherby, Guthrie, Yes No Yes Yes (clinicians)
Woods,
Schatschneider,
Holland, Morgan, and
Lord (2014)
 173

Curriculum Vitae

Name: Amanda Binns

Post-secondary University of Western Ontario

Education and London, Ontario, Canada
Degrees: In Progress, PhD. Health and Rehabilitation Sciences
Note: Maternity leaves of absence 2015-2016 (12 months) and
2018-2019 (18months)

University at Buffalo
Buffalo, New York, United States
M.A., Speech–Language Pathology

Brock University
St. Catharines, Ontario, Canada
B.A. Communication Sciences and Disorders

Honours and Autism Scholar’s Doctoral Award

Awards: 2019-2020

Autism Research Training Award

Training Tuition and Travel
2016-2018

Ontario Mental Health Foundation 3-year Studentship

Doctoral Award
2014-2018

CCHCSP Rising Researcher Symposium Training Award

Training, Tuition and Travel
2015

Council of Canadian Child Health Research Training Award

Training, Tuition and Travel
2014

Related Work Research Assistant/SLP Clinician

Experience Milton and Ethel Harris Research Initiative, York University
Toronto, Ontario, Canada
2006-2013

Peer Reviewed Publications:

 174

1. Binns, A. V., Andres, A., Smyth, R., Lam, J., & Oram Cardy, J. (2020). Looking
back and moving forward: A scoping review of research on speech-language
intervention for preschool children with autism. Under review. Autism and
Developmental Language Impairments.

2. Binns, A. V., & Oram Cardy, J. (2019). Developmental social pragmatic

interventions for preschoolers with autism spectrum disorder: A systematic
review. Autism and Developmental Language Impairments, 4(1), 1-18.
https://doi.org/10.1177/2396941518824497.

3. Binns, A. (2019). Applying a self-regulation and communication framework to

autism intervention. Autism and Developmental Disorders Journal (Russia),
17(2), 34-45. doi: 10.17759/autdd.2019170203.

4. Binns, A. V., Hutchinson, L. R., & Oram Cardy, J. (2018). The speech-language
pathologist’s role in supporting the development of self-regulation: A review and
tutorial. Journal of Communication Disorders, 78, 1-17.
https://doi.org/10.1016/j.jcomdis.2018.12.005.

5. Cunningham, B. J., Washington, K. N., Binns, A., Rolfe, K., Robertson, B. &
Rosenbaum, P. (2017). Current methods of evaluating speech-language outcomes
for preschoolers with communication disorders: A scoping review. Journal of
Speech-Language and Hearing Research, 60(2), 447-464.
https://doi.org/10.1044/2016_JSLHR-L-15-0329.

6. Casenhiser, D, Binns, A., McGill, F., Morderer, O. M., Shanker, S. (2015).

Measuring and supporting language function for children with autism: Evidence
from a RCT of social-interaction-based therapy. Journal of Autism and
Developmental Disorders, 45(3), 846-857. doi: 10.1007/s10803-014-2242-3.

Other Publications

1. Oram Cardy, J., Binns, A., Cunningham, B. J., Sinos, J., Kwok, E., & Coughler,
C. (2019). Scientific Support for the OSLA’s government submission: Supporting
the success of the Ontario Autism Program. 6 pages. Prepared for the Ontario
Association of Speech Language Pathologists and Audiologists.

2. Ontario Ministry of Education. Draft of the: Kindergarten STEP Framework of

Observable Language Behaviours. 2018.

3. Casenhiser, D. M., Binns, A., Lee, E., McGill, F. & Robinson, C. (2010).
MEHRIT Fidelity Scale. Unpublished manuscript.

Presentations and Special Lectures

1. International
 175

Abstracts and Other Papers

2019 Jun Does the play environment impact parent’s communication or style of
interaction with their autistic child? Poster presented at the Symposium on
Research in Child Language Disorders, Madison, WI, USA. Presenter(s):
Binns, A., Casenhiser, D., Shanker, S., & Oram Cardy, J. (Poster
Presentation).
2019 May Do play contexts impact engagement states in preschool children with
autism spectrum disorder? The International Society for Autism Research
Annual Meeting, Montreal, QC, Canada. Presenter(s): Binns, A.,
Casenhiser, D., Forsyth, K., Shanker, S., & Oram Cardy, J. (Poster
Presentation).
2018 May. Do play contexts impact language production in preschool children with
autism spectrum disorder? Poster presented at The International Society
for Autism Research Annual Meeting, Rotterdam, Netherlands.
Presenter(s): Binns, A., Casenhiser, D., Shanker, S., & Oram Cardy, J.
(Poster Presentation).
2017 Jun Trampolines and crash mats or pretend food and toy cars? How play
contexts impact language production in children with ASD. Oral
presentation at the Symposium on Research in Child Language Disorders,
Madison, WI. Presenter(s): Binns, A., Casenhiser, D., Shanker, S., &
Oram Cardy, J. (Submitted Oral Presentation).
2017 May Developmental social pragmatic parent coaching intervention increases
language-promoting utterances in parents of children with ASD. The
International Society for Autism Research Annual Meeting, San
Francisco, CA, USA. Presenter(s): Binns, A., Wang, M., Casenhiser, D.,
Shanker, S. Oram-Cardy, J. (Poster Presentation).
2016 Sep Recent research session: Two researchers in the area of communication
disorders in children with Autism will present their most recent studies.
The Interdisciplinary Council of Developmental Learning Disorders
annual conference. Orlando, FL. Presenter(s): Binns, A. & Grosvenor, M.
(Submitted Oral Presentation).
2016 Jun Does developmental social pragmatic intervention for children with
Autism Spectrum Disorder influence parent language use? Oral
presentation at the Symposium on Research in Child Language Disorders,
Madison, WI. Presenter(s): Wang, M., Oram Cardy, J., Casehniser, D.,
Shanker, S., & Binns, A. (Submitted Oral Presentations).
2016, Jun DIR/Floortime: Does getting down on the floor promote social
communication and language development in children with autism
spectrum disorder? Poster session presented at the Symposium on
Research in Child Language Disorders, Madison, WI, USA. Presenter(s):
Binns, A., & Oram-Cardy, J. (Poster Presentation).
2014 Nov Measuring and supporting language function for children with autism. The
2014 American Speech Language and Hearing Association Convention,
Orlando, FL. Presenter(s): Binns, A., & Casenhiser, D. C. (Submitted Oral
Presentation).
2012 Nov Re-framing play & behavior: Coaching parents from a multicultural
perspective. Oral presentation at ICDL Annual International Conference:
 176

The Power of Affect, Montclair, NJ., U.S.A. Presenter(s): Binns, A., &
Lee, E. (Submitted Oral Presentation).
2011 Nov The clinical practice behind the research. The Interdisciplinary Council of
Developmental Learning Disorders Annual International Conference,
Bridging the Divide: Mental Health and Developmental Disorders,
Rockville, MD. Presenter(s): Binns, A., & Lee, E. (Submitted Oral
Presentation).

Invited Lectures and Presentations

2019 Apr Invited Keynote Speaker. Setting the stage for communication to flourish:
The role of regulation. The International Scientific-Practical Conference:
Innovations in Autism Interventions, Moscow, Russia. Presenter(s):
Binns, A.
2016 Nov Invited Speaker. DIR/Floortime therapy: Engaging parents. DIR/Floortime
Centre Korea Parent and Professional Conference, Seoul, South Korea.
Presenter(s): Binns, A.
2016 Nov Invited Speaker. Developmental individual difference relationship based
therapy: Coaching parents and professionals. Daejeon Centre for Child
Development Professional Development Conference Daejeon, South
Korea. Presenter(s): Binns, A.
2016 Nov Invited Speaker. Developmental individual difference relationship based
therapy: Supporting children with complex language. Love Tree Childcare
Centre Conference. Changwon, South Korea. Presenter(s): Binns, A.
2016 Apr Invited Keynote Speaker. Supporting parents as partners in
communication. JISH Annual Scientific Symposium XVII of
Communicative Disorders, Jeddah, Saudi Arabia. Presenter(s): Binns, A.
2015 Nov Invited Speaker. DIR/Floortime therapy: An introduction for parents and
professionals. Love Tree Childcare Centre Conference for Parents and
Professionals. Changwon, South Korea. Presenter(s): Binns, A.
2015 Nov Invited Speaker. Developmental individual difference relationship based
therapy: An introduction. The Daejeon Centre for Child Development:
Parent and Professionals Conference. Daejeon, South Korea. Presenter(s):
Binns, A.
2014 Jul Invited Speaker. Developmental individual difference relationship based
therapy: An introduction. Love Tree Childcare Centre Conference. Busan,
South Korea. Presenter(s): Binns, A.
2013 Dec Invited Speaker. Supporting language development through play: Working
with children with autism spectrum disorder. Alia Intervention Centre,
Kingdom of Bahrain. Presenter(s): Binns, A.
2013 Oct Invited Speaker. Developmental, individual difference, relationship based
intervention and functional changes in language use. The Interdisciplinary
Council of Development and Learning Annual International Conference:
Developmental perspectives on Autism, Inclusion and Education,
Montclair, NJ. Presenter(s): Binns, A.
2013 Oct Invited Speaker. DIR/Floortime, inclusive education, and the cultural
frame: A model for full human development. The Interdisciplinary
Council of Development and Learning Annual International Conference:
Developmental perspectives on Autism, Inclusion and Education,
 177

Montclair, NJ. Presenter(s): Shahmoon-Shanook, R., Binns, A., Cordero,

M., Ehlers-Flint, L., Janert, S., Lalvani, P., & White, R.
2013 Oct Invited Speaker. Parents and professionals working together as a team.
Invited Presentation at Growing Tree Centre for children with Autism.
Busan, South Korea. Presenter(s): Binns, A.
2013 Feb Invited Speaker. Using play-based therapy to target communication and
language development: Assessment and clinical applications. Alia
Intervention Centre, Kingdom of Bahrain. Presenter(s): Binns, A.
2013 Jan Invited Speaker. DIR/Floortime therapy: Parents and professionals
working together as a team. Care Oyun Akademisi, Istanbul, Turkey.
Presenter(s): Binns, A.
2011 Sep Invited Keynote Speaker. The importance of self-regulation in child
development. Confinalco Conference, Medellin, Colombia. Presenter(s):
Binns, A., & Lee, E.
2010 Nov Invited Speaker. Milton and Ethel Harris Research Initiative Treatment
(MEHRIT) fidelity measure. The Interdisciplinary Council of
Development and Learning Annual International Conference, Bethesda,
MD. Presenter(s): Casenhiser, D., Binns, A., Lee, E., McGill, K. F. &
Robinson, C.

2. National

Invited Lectures and Presentations

2014 Feb Invited Speaker. Self-regulation: Theory to practice. Literate Beginnings,

Literate Lives: Canadian Institute of Reading Recovery National Reading
Recovery & Early Literacy Learning Conference, Toronto, ON.
Presenter(s): Binns, A.

Media Appearances

2012 May York University's Milton & Ethel Harris Research Initiative: Autism
Treatment Study. CBC The National, Television Broadcast. Canadian
Broadcast. Participant(s): Binns, A., Lee, E., McGill, K., F., Robinson, C.,
Steiben, J., & Shanker, S.
 178

3. Provincial/ Regional

Invited Lectures and Presentations

2019 Nov Invited Speaker. Looking back and moving forward: Uncovering the state
of autism intervention research in the field of speech-language pathology.
Ontario Association of Speech-Language Pathologists and Audiologists
Autism Educational Event, Markham, ON. Presenter(s): Oram Cardy, J.,
Binns, A.
2017 May Invited Keynote Speaker. Better together: Strategies for supporting self-
regulation and communication. The Hamilton Wentworth Catholic District
School Board SLP department bi-annual conference, Hamilton, ON.
Presenter(s): Binns, A.
2016 Apr Invited Keynote Speaker. Making the connection: Self-regulation
communication & language. The York Region District School Board
Speech-Language Pathology Department annual conference, Toronto, ON.
Presenter(s): Binns, A.
2015 Sep Invited Keynote Speaker. Self-Regulation: Music for Young Children.
Music for Young Children Annual Conference. Woodstock, ON.
Presenter(s): Binns, A.
2015 May Invited Keynote Speaker. Developing self-regulation in young children.
Keynote at the Speech Language and Hearing Association of
Peterborough Annual Conference, Peterborough, ON. Presenter(s): Binns,
A.
2014 Aug Invited Speaker. Self-regulation, Communication and Language
Development. The Canadian Self-Regulation Initiative Summer Institute.
Vancouver, BC. Presenter(s): Binns, A.
2013 Nov Invited Speaker. Supporting Self-Regulation in Children with
Developmental Disabilities. Ontario Association of Children’s
Rehabilitation Services, Toronto, ON. Presenter(s): Binns, A.
2013 Nov Invited Speaker. What is our role as an SLP in Supporting Self-
Regulation? Yukon Ministry of Education: Self-Regulation Summer
Institute, Whitehorse, YT. Presenter(s): Binns, A.
2013 Aug Invited Speaker. What we learned from our work: Milton & Ethel Harris
research initiative. The Yukon Ministry of Education: Self-Regulation
Summer Institute, Whitehorse, YT. Presenter(s): Binns, A., Robinson, C.
& Shanker, S.
2012 Oct Invited Speaker. The central role of parents within the MEHRI treatment
model. Invited presentation at Ontario association for infant and child
development, Toronto, ON. Presenter(s): Binns, A., Lee, E., & McGill, K.
F.
2012 Sep Invited Speaker. Self-Regulation project. Invited presentation for the BC
schools First Wave self-regulation project, Victoria, Vancouver &
Smithers, BC. Presenter(s): Binns, A., Lee, E., McGill, K. F., Robinson,
C., & Shanker, S.
2012 Jun Invited Speaker. Theoretical and clinical perspectives on the importance of
play and interaction for young children. The ninth annual summer institute
 179

on early childhood development, Toronto ON. Presenter(s): Binns, A.,

Lee, E., McGill, K. F., & Robinson, C.
2012 Feb Invited Speaker. York University: An introduction to our research and
clinical work. Autism Ontario conference, Toronto, ON. Presenter(s):
Binns, A., Lee, E. & McGill, K. F.

Presented Abstracts
2013 Apr An integrated multidisciplinary approach to working with children and
their families. Expanding Horizons for the Early Years Conference:
Fostering Shared Frameworks, Toronto, ON. Presenter(s): Lee, E., Binns,
A., & McGill, K. F. (Submitted Oral Presentation).

4. Local

Invited Lectures and Presentations

2019 Oct Invited Speaker. Supporting clinicians to use a self-regulation framework

to support young children with communication challenges. Invited
presentation to George Hull Ontario Preschool Speech and Language
Program Site. Toronto, ON. Presenter(s): Binns, A.
2015 Nov Invited Speaker. The brain empathy and self-regulation. Invited
presentation to Hope 24/7. Brampton, ON. Presenter(s): Binns, A.
2015 Aug Invited Speaker. Self-regulation: What is it and why should we care?
Invited presentation for George Brown College Student Mentor
Workshop. Toronto, ON. Presenter(s): Binns, A.
2015 Jul Invited Speaker. Fostering co-regulation en-route to self-regulation: In
home and early learning settings. Invited presentation for The MEHRIT
Centre & Trent University Summer Institute. Peterborough, ON.
Presenter(s): Binns, A.
2015 May Invited Speaker. Self-regulation parent evening Durham Catholic District
School Board. Invited presentation to educators and parents. Oshawa,
Ontario. Presenter(s): Binns, A.
2014 Jun Invited Speaker. Self-Regulation. Toronto Catholic District School Board
parent night. Toronto, ON. Presenter(s): Binns, A.
2013 Nov Invited Speaker. DIR/Floortime based therapy: Parents and professionals
working together as a team. Toronto District School Board, Toronto,
ON. Presenter(s): Binns, A.
2013 May Invited Speaker. Supporting language development during all classroom
interactions. KidsCAN Oakwood Academy Professional Development
Day, Mississauga, ON. Presenter(s): Binns, A.
2013 Apr Invited Speaker. Assessment, goal setting and treatment: Supporting
parents to be part of the process. Toronto Pre-School Speech-Language
Services professional development day, Toronto, ON. Presenter(s): Binns,
A., Lee, E. & McGill, K. F.
2012 Apr Invited Speaker. Goal setting using a DIR/Floortime framework. Invited
presentation at Kids Can Oakwood Academy, Mississauga ON.
Presenter(s): Binns, A., Lee, E., & McGill, K. F.
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2012 Apr Invited Speaker. The role of self-regulation in working with children and
families. Invited presentation at George Brown College early childhood
education training, Toronto ON. Presenter(s): Binns, A., Lee, E., &
McGill, K. F.
2011 Sep Invited Speaker. Supporting foundational capacities for language
development. Interdisciplinary Council on Development and Learning
online training program. Presenter(s): Binns, A.

Presented Abstracts
2016 Jul As we speak: Preliminary results from the MEHRIT study on how a parent
coaching treatment model rooted in DIR and Self-Reg impacts how
parents communicate with their child. Oral presentation at The MEHRIT
Centre (TMC) self-regulation symposium, Peterborough, ON.
Presenter(s): Binns, A. (Submitted Oral Presentation).

Other Presentations
2011 Dec Self-regulation case review. Presentation at infant mental health
promotion rounds Sick Kids Hospital, Toronto ON. Presenter(s): Binns,
A., Lee, E. & McGill, K. F.