Transforming Everyday Moments

A “PARENTS EMPOWERING PARENTS” TRAINING EVENT

Kat Houghton, Relate to Autism
The Parents Empowering Parents project is an innovative approach to
providing evidence-based, high quality autism intervention services to
families at all socio-economic levels and from a variety of cultural
backgrounds. This series of research projects will explore how to transfer
the current, research-based, undestanding of autism into community
settings. We aim to bridge the gap between lab and home, making
cutting-edge autism intervention services accessable and available to
families across the US.

This paper provides an overview of the initial pilot work being undertaken
in 2011. The first parent curriculum to be rigorously tested is the
“Transforming Everyday Moments” program. This program aims to teach
parents how to promote joint attention in their children with autism in just
six 2-hour group sessions. Here we provide some theoretical back ground
for this work and an overview of the empirical work to test it.

Developmental Models of Autism

Current theoretical models view child development as a dynamic
process. It is through a continuous flow of interaction with the world and
others that a child develops the social, emotional, communicative and
cognitive capacities that form the basis of all other learning
(Bronfenbrenner, 1979; Bruner, 1983, Vygotsky, 1978, Rogoff, 1990; Howe &
Lewis, 2005).

This appears to be no less true for children “through a continuous

with autism. Dynamic, relational models of flow if interaction with
autism suggest that early subtle, others a child
differences in a child’s social-
develops the social,
communication behaviors can be
emotional and
amplified over time through iterative
cognitive capacities
feedback from interactions with
that form the basis of
caregivers (Mundy, 1995; Mundy and
all other learning”
Cowson, 1997).

While the initial triggering event responsible for autism remains illusive to

Transforming Everyday Moments 2

scientists it has become apparent that differences in social-
communication behaviors can be observed much earlier than prevously
thought. Children who are later diagnosed with autism have been shown
to prefer non-social over social stimuli as young as 6 months (Maestro et
al., 2001), to orient less to their own name and combine looking and
smiling less at 8 months (Osterling, e al., 2994; Werner, et al., 2000) and to
show decreased capacity for imitation, social smiling, social attention and
interaction, sharing facial expressions and initiating bouts of joint attention
at 12 months (Adrien, et al., 1991, 1993; Werner & Dawson, 2005;
Zwaigenbaum, et al., 2005).

Before 12 months of age these differences are often very subtle and not
picked up by parents and community service providors. Social-orienting
models of autism hold that the lower levels of attention paid to social
stimuli (e.g. looking at faces, orienting to name, smiling, sharing facial
expressions, imitating, sustaining social interaction and initiating joint
attention) result in gradually smaller amounts of time spent engaged in
social interaction. Over time the amunt of time spent engaged with
social partners learning about communication and social exchanges
becomes increasingly less compared to that of typically developing
children. Hence, the children with autism miss out on their “socal
education (Klin, et al., 1993). By the time most children receve a diagnosis
in the US (age 3 -4) these unusual patterns of social interaction are well
established.

The Importance of Early Intervention

Autism intervention strategies that have emerged from this

undersytanding target early social-communication capacitites in an
attempt to shift a child’s developmental trajectory towards that of a more
typically developing child (see Meindl & Canella-Malone, 2011 for a
review). The thinking is that the earlier in the developmental process
intervention can help increase the amount of time a child spends
engaged with others in social exchanges the more quickly that child will
“catch-up” to her typically developing peers. Researchers are now
developing autism interventions specifically for toddlers (e.g. Kasari, et al.,

Transforming Everyday Moments 3

2010; Dawson, et al., 2008; Schertz & Odem, 2005; Woods & Wetherby ,
2003).

These developmentally focused interventions, while proving to be

effective in the lab have yet to be tested in community-based settings.
For most families, access to these interventions is impossible. This is largely
due to the very limited number of trained interventionists. This results in
many families acorss the US being unable benefit from this research and
researchers being unable ot benefit from working with more diverse
populations. The Parents Empowering Parents project aims to accelerate
the translation of autism interventions from the lab to the community by
finding quicker ways to directly train parents.

Evidence-based Autism Interventions: From Lab to

Community
Parents as Primary Therapists

Traditionally new interventions, developed by researches, have been

gradually disseminated to children through the training of relevant
professionals. This model has two major problems. First, this has led to an
estimated lab-to-child lag time of about 20 years (Walker et al., cited in
Bagget et al., 2010). This can be short-circuited only by parents who can
afford to hire expensive private therapists. Second, parents are removed
from the therapeutic process as clinician-implemented service delivery
models have dominated the field.

Expert

Child

Traditional Dissemination of Evidence-Based Practices

Transforming Everyday Moments 4

Policy level thinking is now changing. The rising numbers of children being
diagnosed with developmental delays and the continued recognition of
the importance of early intervention is promoting a shift to greater
inclusion of parents in the therapeutic process.

Family-centered practices that not only include parents in interventions

but actively aim to strengthen the child-parent relationship and enhance
the parents’ ability to promote the child’s development, are
recommended by The Individuals with Disabilities Education Improvement
Act of 2004 (IDEIA, 2004) Part C, practice recommendations from the
Division for Early Childhood of the Council for Exceptional Children (DEC;
Sandall, Hemmeter, Smith & McLean, 2005) and the National Association
for the Education of Young Children (NAEYC; Copple & Bredekamp,
2009).

Parent

Child Expert

Family-Centered Dissemination of Evidence-Based Practices

Numerous studies have found that parents can readily learn the necessary
techniques to use with their child (e.g. Aldred, Green & Adams, 2004;
Ingersoll & Gergans, 2007; Kaiser, Hancock & Nietfeld, 2000; Koegel,
Bimbela & Schreibman, 1996; Mahoney & Perales, 2003; Solomon et al.,
2007; Solomon, 2008).

The parent-child relationship is primary to all future learning, a fact that is

undisputed when we consider typically developing children (e.g.
Trevarthan, 1993 Vygotsky, 1978). We know that parents influence the
outcome of their children’s therapy even when they are not specifically

Transforming Everyday Moments 5

included in the process (e.g. Estes, et al., 2009) yet still parents are often
not included in therapy for children with ASD.

Additionally, research has found that parents are very effective at

teaching their children to use more frequent verbalizations, spontaneous
speech (Laski, Charlop & Schreibman, 1988; Gilbert & LeBLanc, 2007), and
specific words (Kaiser et al., 2000). Parents have also been seen to
improve their children with autism’s social interaction (Aldred et al., 2004;
Mahoney & Perales, 2003) joint attention (Rocha, Schreibman & Stahmer,
2007), imitation skills (Ingersoll & Gergans, 2007) and play skills (Gillett &
LeBlanc, 2007).

One of the drawbacks of this body of research is its reliance on parent-

training models involving direct one-on-one coaching to parents. This
makes the process of parent training time consuming and thus expensive.
Additionally, this body of research has included mainly families from white,
middle-class backgrounds. Families from lower socio-economic and
minority ethnic groups are greatly under-represented in this literature.

The Parents Empowering Parents Project Aims

The Parents Empowering Parents project aims to develop a series of

training programs for parents that can be effectively delivered in
community settings by either local service providors or previously trainined
parents. Additionally, by targeting the training programs specifically to
families from lower socio-economic groups and diverse cultural
backgrounds the project will extend the current applicability of these
interventions.

The intentions are to:

1. Provide parents, regardless of economic status, with access to the
lastest evidence-based interventions for autism.
2. Empower parents to be the primary therapists for their youg children
with developmental disoders
3. Seed local parent-to-parent support networks for sustainable parent
learning and access to new interventions.

Transforming Everyday Moments 6

The Transforming Everyday Moments Curriculum
The Transforming Everyday Moments program is the first parent training
curriculum to be developed by the Parents Empowering Parents project.

The Transforming Everyday Moments curriculum follows the

recommendations of Part C, DEC and NAEYC by designing a program
that:

• Strengthens parent-child relationships

• Enhances parents’ ability to promote their child’s development
• Asks the child to take an active role in learning by increasing child
motivation and child-initiated learning
• Challenges children just beyond their mastery level to progressively
learn new, developmentally appropriate, skills.

The Transforming Everyday Moments program is designed for parents of

children with, or at risk for, a diagnosis of autism spectrum disorder (ASD)
under the age of 5 years.

The program teaches parents the importance of engaging their child in

frequent, reciprocal social interactions that emphasize child initiations of
specific social-communication behaviors found to be pivotal in the
remediation of autism symptomology.

Important Target Skills

• Looking at faces
• Sustaining joint engagement
• Imitation
• Using gestures to make requests
• Responding to bids for joint attention
• Initiating joint attention

Transforming Everyday Moments 7

The Pivotal Role of Joint Attention

The ultimate therapeutic goal is to facilitate the child’s spontaneous

initiation of joint attention. That is, the child actively seeks, without
prompting, to draw the attention of another to an object or event for the
purpose of sharing the experience of that event (not for imperative or
requesting purposes) (Bakeman & Adamson, 1984; Mundy, 1997).

This is known as triadic (adult/object/child) joint attention and “demands

that infants monitor other’s attention in relation to self” (Legerstee, 2009,
pp.34) something profoundly challenging for children with ASD (Charman,
2003). In fact, lack of triadic joint attention, especially bids for triadic joint
attention initiated by the child, has been identified as a key indicator of
autism (Leekam and Ramsden, 2006) and included in the “gold-standard”
diagnostic assessment for ASD (Lord, et al, 2000) which probes for triadic
joint attention behaviors such as gaze shifting between object and adult,
showing objects to adults and declarative pointing (points to share
interest in an object rather than to gain access to the object).

The social orienting impairments

“targeting joint
discussed earlier (e.g. looking at faces,
social smiling, imitation, etc.) are
attention … has been
precursors to triadic joint attention. The
found to have
Transforming Everyday Moments collateral effects on
program will help parents identify which untargeted expressive
skills their child requires help with in order language, cognitive
for that child to be developmentally and social
ready to learn how to initiate joint development”
attention.

Recent research has highlighted the importance of targeting joint

attention in autism intervention as this has been found to have collateral
effects on untargeted expressive language, cognitive and social
development (Kasari, et al., 2006, 2008; Jones, Cara and Feely, 2006;
Martins & Harris, 2006; Gulsrud et al., 2007; Whalen, Schreibman, and
Ingersoll, 2006). That is, when intervention was focused on a child’s joint

Transforming Everyday Moments 8

attention skills but not on that child’s ability to use expressive language,
improvements in both areas were observed. This empirical work underlines
the dynamic understanding of social development and autism holding
that the ability to use language emerges from the capacity to engage in
joint attention. Thus teaching expressive language to a child requires that
child to have a strong foundation in joint attention skills.

Research has shown that trained parents “teaching expressive

are able to promote the development of language to a child
joint attention (Schertz & Odem, 2005; requires that child to
Vismara & Lyons, 2007) in their young have a strong
children and in so doing help their children foundation in joint
learn language (Drew et al., 2002), attention”
nonverbal communication skills (Woods &
Wetherby, 2006), more joint engagement and play skills (Kasari, et al.,
2010).

Rigorous Evaluation
The Parents Empowering Parents project is taking two important steps:

1. Investigating the feasibility of training parents to required fidelity

levels in 6 x 2 hour sessions over 6 weeks.
2. Training parents to deliver group parent training.

We begin with a randomized controlled trial of the efficacy of the

Transforming Everyday Moments parent-training program in Bronx County,
NY from September 2011 through September 2012.

The trial will be open to any qualifying parent and we hope to attract a
group of parents of lower socio-economic status and of minority ethnic
backgrounds as these groups are almost entirely un-represented in the
current autism intervention research literature.

Transforming Everyday Moments 9

This study will be the first step in a series of similar trials designed to
produce a number of parent-training curricula and supporting multi-
media materials that can be used across the country to bring these new
autism interventions to local community-based settings.

Summary
The Transforming Everyday Moments parent-training curriculum is a first
attempt to transfer current research-based autism interventions to a
community setting. The program will directly teach parents how to
facilitate their child’s use of early social-communication skills shown to be
pivotal in autism including joint attention.

The curriculum will be tested with a randomized controlled trial with a

group of parents representative of the population in Bronx County, NY. This
study will be the first in a series designed to explore how to most
effectively bridge the gap between interventions developed in the lab
and practical support for families.

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