Sally J. Rogers, Laurie A. Vismara, Geraldine Dawson - Coaching Parents of Young Children With Autism - Promoting Connection, Communication, and Learning-The Guilford Press (2021)

Coaching Parents of Young Children with Autism
Also Available
FOR PROFESSIONALS
Early Start Denver Model for Young Children with Autism:

Promoting Language, Learning, and Engagement
Sally J. Rogers and Geraldine Dawson
Early Start Denver Model Curriculum Checklist

for Young Children with Autism
Sally J. Rogers and Geraldine Dawson
Human Behavior, Learning, and the Developing Brain:

Atypical Development
Edited by Donna Coch, Geraldine Dawson, and Kurt W. Fischer
Human Behavior, Learning, and the Developing Brain:

Typical Development
Edited by Donna Coch, Kurt W. Fischer, and Geraldine Dawson
Imitation and the Social Mind: Autism and Typical Development

Edited by Sally J. Rogers and Justin H. G. Williams
FOR GENERAL READERS
A Parent’s Guide to High-Functioning Autism Spectrum Disorder:

How to Meet the Challenges and Help Your Child Thrive, Second Edition
Sally Ozonoff, Geraldine Dawson, and James C. McPartland
An Early Start for Your Child with Autism: Using Everyday Activities
to Help Kids Connect, Communicate, and Learn
Sally J. Rogers, Geraldine Dawson, and Laurie A. Vismara
What Science Tells Us about Autism Spectrum Disorder:

Making the Right Choices for Your Child
Raphael A. Bernier, Geraldine Dawson, and Joel T. Nigg
Coaching Parents
of Young Children
with Autism
Promoting Connection,
Communication, and Learning
Sally J. Rogers
Laurie A. Vismara
Geraldine Dawson
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Contents
Chapter 1 Helping Parents Help Their Young Children with Autism: 1

An Introduction
Why Has This Model Emerged?, 3
Defining Coaching within Parent-Implemented
Early Intervention Approaches, 4
Where Do These Ideas Come From?, 9
Who Are We Writing For?, 9
What Lies Ahead?, 10
Chapter 2 Key Practices in Coaching Parents 12

in Parent-Implemented Interventions
Key Practice: Parents Working with Their Children at Home, 12
Key Practice: Attending to the Positive Parent–Child Relationship
in Young Children with ASD, 14
Key Practice: Building Language Interventions Based
on Developmental Communication Science, 16
Key Practice: Interdisciplinary Teams, 18
Key Practice: Parent Coaching and Family-Centered Care, 19
Conclusion, 21
Chapter 3 Becoming a Coach: Knowledge, Characteristics, 23

and Supports
What Coaches Need to Know, 24
Coaching Characteristics: The Relationship between Coach
and Parent, 30
Supports for Coaches, 34
Understanding What Motivates Parents, 37
Conclusion, 40
ix
About the Authors
Sally J. Rogers, PhD, is Distinguished Professor Emeritus of Psychiatry and

Behavioral Sciences at the MIND Institute at the University of California, Davis.
She has served as president of the International Society for Autism Research and
is a Fellow of the American Psychological Association, the Association for Psycho-
logical Science, and the International Society for Autism Research. With Geral-
dine Dawson, Dr. Rogers developed the Early Start Denver Model (ESDM), the
first empirically validated comprehensive intervention for toddlers with autism,
now used by parents and professionals around the world. She is coauthor of books
including An Early Start for Your Child with Autism (for parents) and Early Start
Denver Model for Young Children with Autism (for professionals). Dr. Rogers has
published over 200 papers, chapters, and books, and ranks in the top 1% of Clari-
vate Analytics Highly Cited Researchers.
Laurie A. Vismara, PhD, BCBA-D, LBA, has spent her research career work-
ing closely with families with autism and contributing to the science and pro-
gram development of ESDM. She is coauthor of An Early Start for Your Child with
Autism (for parents). Dr. Vismara uses telehealth platforms and travels throughout
the United States and internationally to help families, publicly funded programs,
and universities develop ESDM in their communities.
Geraldine Dawson, PhD, is the William Cleland Distinguished Professor of Psy-

chiatry and Behavioral Sciences at Duke University. She directs the Duke Insti-
tute for Brain Sciences and the Duke Center for Autism and Brain Development.
With Sally J. Rogers, Dr. Dawson developed ESDM, the first empirically validated
comprehensive intervention for toddlers with autism. Dr. Dawson is coauthor of
the parent resources What Science Tells Us about Autism Spectrum Disorder, An
Early Start for Your Child with Autism, and A Parent’s Guide to High-Functioning
v
vi About the Authors
Autism Spectrum Disorder, Second Edition. Her books for professionals include Early
Start Denver Model for Young Children with Autism. She is an elected member of
the American Academy of Arts and Sciences; received the Distinguished Career
Award from the Society of Clinical Child and Adolescent Psychology (Division
53 of the American Psychological Association) and the Lifetime Achievement
Award from the Association for Psychological Science; and ranks in the top 1% of
Clarivate Analytics Highly Cited Researchers.
Acknowledgments
The concepts and materials provided here for readers result from our many years
of discussion, collaboration, research activities, and clinical work. All three of us
have a long history of parent coaching, from the beginnings of our professional
careers. Efforts to coach parents in Early Start Denver Model (ESDM) concepts
began as early as 2001–2002, as Geri and Sally were building the main procedures
and tools that became ESDM in the initial randomized controlled trial led by
Geri at the University of Washington. The model grew conceptually as Laurie and
Sally began to work together, and each new parent coaching study tested addi-
tional concepts, techniques, and tools. The power of the model to affect children’s
behavior was demonstrated most effectively in the Rogers et al. paper published in
2019 (Rogers, Estes, Vismara, et al., 2019), which demonstrated for the first time
a direct positive relationship between parent fidelity of implementation and child
growth. We need to acknowledge the parents and families who spent so much
time teaching us and working with us in these projects and sharing their data so
that we could learn and understand the effects of our efforts.
Many, many colleagues have contributed to the work represented here. We
want to recognize especially Annette Estes, Jessica Greenson, Meagan Talbott,
Gregory Young, Jamie Winter, Cynthia Zierhut, and Carolyn McCormick, who
have shared their expertise, their time, and their talents over the years as these
studies were designed and carried out. We thank the many members of Sally’s lab
at the MIND Institute, and Geri’s lab at the University of Washington, whose sup-
port and ongoing efforts made the work possible. And finally, we need to acknowl-
edge our funding sources, both the National Institutes of Health and Autism
Speaks, for making the work possible.
vii
x Contents
Chapter 4 The Coach’s Tools 41
Clipboard and Pencil, 41

Session Plan, 41
Clock, 43
Tablet of Paper, 43
Parent Manual, 44
Copies of Topic Summary (Refrigerator) Lists, 45
Three Data Checklists, 45
Wide-Angle Perspective, 47
Emotional Thermometer, 47
Reflective Mirror (Supervision), 48
Other Tools, 48
Problem Solving, 54
Conclusion, 57
Chapter 5 Assessment, Goal Setting, and Treatment Planning 59
From Diagnosis to Treatment Planning, 59

Conclusion, 72
Chapter 6 Parent Coaching Sessions 73
The First Coaching Session, 73

Subsequent Coaching Sessions, 75
Coaching Session Routines, 77
Unfinished Business, 95
Conclusion, 100
Chapter 7 Guides for Introducing Intervention Topics and Strategies 102

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

Interests and Attention with Others (Joint Attention), 164
Topic VIII: Developing Flexible, Creative Object Play
for Learning, 173
Topic IX: Why Pretend Play Is So Important for Young
Children’s Learning, 187
Topic X: Helping Young Children Develop Speech, 200
Form 7.4: Action Plan Template for Parent Follow-Through, 215
Closing, 218
Chapter 8 Variations in Coaching Practices 220
Variations in Family Stories, 221

Coaching Adaptations, 233
Coaching Parents in Groups, 235
Form 8.1: First Group Session Plan, 237
Some Final Notes, 240
Chapter 9 Looking to the Future: Challenges and Opportunities 242
Children with ASD Who Have Co-Occurring Conditions:

Treating the Whole Child, 242
Children and Families in Low-Resource Communities, 248
Parent-Implemented Interventions for Infants at Risk for ASD, 250
Looking Ahead, 251
Conclusion, 254
Appendix A Handouts and Checklists Used Routinely in Parent 255

Coaching Sessions
Appendix A.1: Coach’s Clipboard List, 257
Appendix A.2: Coach’s Session Planning Sheet, 258
Appendix A.3: Parent Daily Practice Chart, 259
Appendix A.4: Activity Categories, 261
Appendix A.5: Refrigerator List, 262
Appendix A.6: Parent–ESDM Fidelity Coding Sheet, 263
Appendix A.7: Parent Skills Checklist, 264
Appendix A.8: Parent Self-Monitoring Checklist, 267
Appendix A.9: Coach’s Fidelity of Implementation
Brief Checklist, 269
Appendix A.10: ESDM Coaching Fidelity Rating Tool, 271
Appendix A.11: Stages of Change and Possible
Coaching Techniques, 279
xii Contents
Appendix B P-ESDM Infant–Toddler Curriculum Checklist 287

sally J. rogers, geraldine dawson, laurie Vismara, meagan talbott,
Cynthia Zierhut, Jamie winter, Carolyn mcCormick, marie rocha,
and emily holly
Appendix C Parent-Friendly Data-Tracking Tools 301
Appendix C.1: Simple Tally System, 303

Appendix C.2: Days of the Week Tracking Chart, 304
Appendix C.3: Activities Data Tracker, 305
Appendix C.4: Goals and Activities Bar Chart, 306
References 307
Index 316
Chapter 1
Helping Parents Help Their Young

Children with Autism
An Introduction
Receiving a diagnosis of autism is one of the most devastating events that can hap-
pen to parents of young children. The profound sense of loss and grief for an imag-
ined future, the fear and anguish about their child’s life, the guilt and blame about
possible contributors the parents* might have avoided—it is a defining moment in
family life that changes them forever. And somewhere in the near future, during
this critical time, most such families in the United States will develop a relation-
ship with a person who signifies help—an early interventionist—whose role it is
to work closely with them to help their children engage and learn.
This relationship typically follows one of two models. In the first model, one
or more well-trained adults deliver a clinician-generated treatment plan directly to
the child and provide advice and guidance to the family to incorporate at home.
The family relies on the interventionists as experts in the child’s treatment needs.
When the family asks questions, the interventionist gives answers. As new learn-
ing needs develop, the interventionist defines or revises the intervention plan and
carries it out. In the best situations, the interventionist uses skills, knowledge, and
experience to support and guide the family, particularly the primary caregiver, in
areas where the caregiver needs help. In publicly funded services, early interven-
tion tends to be low-intensity intervention, ranging from two to three hourly visits
per week to 1 hour or less per month, although a few communities provide much
greater intensity.
*Throughout this book we use the terms parent and parents generically to refer to any person or any part-
nership or group of people raising a child. We also use case examples throughout, with all names and other
identifiers disguised.
1
2 Coaching Parents of Young Children with Autism
Potential problems with this model reveal themselves quickly. One is that,
for low-intensity delivery, there is no evidence from high-quality* studies that this
model results in either the parent’s overall adoption of the guidance provided, or
benefit to the child. Second, the family’s dependence on the interventionist for
determining what the child needs and how to meet those needs is not well sup-
ported with infrequent contacts. Third, this model is built on the assumptions
that parents are not competent enough to discern their children’s needs or to sup-
port their children’s progress without the interventionist’s help. Fourth, multiple
providers are often involved, each providing advice and guidance to the family
from a limited perspective, leaving them to integrate and act on differing and
sometimes conflicting advice. Fifth, interventionists come and go throughout the
child’s early years, providing discontinuous relationships with the family, who as
the constant figures in the child’s life from birth hold the only comprehensive
view of the child’s developmental course, skills, and need, and of the family’s sta-
tus, structure, strengths, and needs. Yet, with all these drawbacks, our experience
tells us that this is the most prevalent model of care for young children with autism
spectrum disorders (ASD), in our nation and in others.
A second model exists, one described in multiple high-quality research stud-
ies and websites, embraced by many states’ early intervention philosophies, and
widely discussed. In this family-centered model, the interventionist focuses on the
child as embedded in a family with strengths and needs, with its members mobi-
lized to help their child. The interventionists’ focus is supporting the key adults
in the child’s life to support the child’s learning needs within their daily routines
with the child. The interventionist steps away from the role of the authority figure
with all the answers and toward the role of partner who understands that early
intervention contacts are opportunities to pass on skills and knowledge to caregiv-
ers so that they can support their child’s growth during their ongoing interactions.
The shift from expert to partner, and from direct intervention to guidance
and support for the family, requires a relationship with the parents different from
that of teacher and learner, with its inherent hierarchy. A relationship that bet-
ter captures the transfer of knowledge and skills from one competent person to
another is the coaching relationship. In our early childhood work, coaching refers
to “an adult-learning strategy that is used to build the capacity of a parent or col-
league to improve existing, abilities, develop new skills, or gain a deeper under-
standing of practices for use in current and future situations” (Rush & Shelden,
2008, p. 1). Thus, a coach is a person whom another requests to pass on his or
her skills and knowledge. When parents make this request, the coach begins the
relationship by asking about the family’s goals, assessing initial skills and needs,
*Throughout this text, the term high-quality refers to well-designed studies using either single-subject or
group designs in which the research design clearly controls for all sources of potential effect on change other
than the treatment being studied (e.g., randomized group studies that are appropriately powered and analyzed
as time-by-group interactions, and single-subject designs using multiple-subject multiple-baseline designs).
An Introduction 3
and then working with the family to form action plans based on family goals,
values, and priorities. The plans are put into practice through regular contacts in
which the family member demonstrates and continues his or her learning as the
coach supports parent and child learning, while seeking and sharing reflections
and plans for the next steps (see Figure 1.1).
Why Has This Model Emerged?
Young children spend most of their waking hours (75 or so per week) with care-
givers in everyday activities and everyday contexts. Those interactions offer the
learning opportunities that build cognitive, motor, social, and communicative rep-
ertoires for all young children. Harnessing those daily, hourly interactive experi-
ences to meet the learning needs of young children with ASD can provide more
opportunities for practice and learning than can any external provider. Working
this way maximizes the interventionist’s impact on child learning. Most interven-
tionists with whom we have interacted want to transfer their skills and knowledge
to parents and to support them in their use of the learning opportunities inherent
in everyday activities but have found it difficult to do.
In our own Early Start Denver Model (ESDM)–based work with families and
with early childhood practitioners, we have encountered many early intervention-
ists who wish to adopt this second model of family-centered parent-implemented
intervention, but who struggle to find ways to shift out of traditional provider-
directed intervention. The interventionist who wants to change approaches
often feels uncertain about what behaviors actually constitute coaching and how
Figure 1.1. Key components of the practice-based coaching (PBC) framework. From Snyder,
Hemmeter, and Fox (2015). Copyright © 2015 Sage Publishing. Reprinted by permission.
a collaborative practice should look and feel (Fixsen, Naoom, Blasé, Friedman,
& Wallace, 2005). Shifting from authority to partner and coach necessitates a
new way of thinking about knowledge transfer and skill building. This book was
written to help professional and paraprofessional interventionists who treat early
autism and other developmental disorders in public and private settings make the
transition from a one-on-one delivery model to a caregiver-based delivery model
through their coaching and partnering relationship with families.
Defining Coaching within Parent-Implemented

Early Intervention Approaches
Purpose
For us, the goal of coaching parents to implement intervention with their children
at home is to increase the learning opportunities available to children in their
everyday, moment-by-moment life with their caregivers. This involves infusing
needed learning opportunities into all the environments and interactions that a
young child daily experiences. In this context, a learning opportunity is an event
in which the child acquires a new skill or strengthens an existing skill. In order
to be a learning opportunity, the experience requires the child’s active attention,
effortful goal-directed action, and success.
There are learning opportunities already present in each child’s daily envi-
ronments, and the products of this learning are evident in the skills the child
has developed. However, parents often embed learning opportunities in an unin-
tentional way into ongoing activities and are frequently unaware of the specific
learning needs of their young children as influenced by the disability of the child
with ASD. In order to increase a child’s learning opportunities, a caregiver needs
to know (1) the child’s current learning needs, (2) how to create learning opportu-
nities that will support the child’s learning, and (3) how to infuse these through-
out the routines and environments of daily life. These are our goals in parent
coaching—to help parents understand their child’s immediate learning needs in
all areas that are not progressing well, and to help parents learn how to embed
learning opportunities into their interactions with their child in daily activities.
Distinctive Features
The content of parent coaching includes (1) the current learning needs and goals
for the child intervention and (2) methods for creating needed learning opportu-
nities within the daily routines and interactions that occur between the child and
other family members. The coaching relationship supports parents to build this
skill and knowledge base by developing a partnership whereby both parties pool
An Introduction 5
their existing skills and knowledge. The result of this process is increasing child
learning opportunities to enhance child’s development.
The coach shares knowledge and skills about early autism, child learning,
child development, specific intervention techniques, and principles and behavior
management strategies. Caregivers share knowledge of the child’s unique abili-
ties, vulnerabilities, preferences, interests, and typical skills and behavior in many
environments and with many different people. Caregivers bring knowledge of
their extended support network, the community, their lifestyle, resources, culture,
values, philosophies about parenting and ideal parent–child relationships. They
bring their ideas and priorities with regard to the goals they have established for
themselves as parents and for their child. And, they bring to the table what they
have learned through thousands of hours of interaction with their child. The par-
ent–coach partnership thus involves a balanced relationship among experts, each
seeking to learn from the other and each seeking to share what they have of value
with the other to achieve a common goal: supporting the child’s optimal develop-
ment.
Unique Aspects of the Coaching Relationship

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

and abilities of the three people in the room.
All families and all children bring strengths and challenges to the early inter-
vention relationship, and each family works with their children in the ways that
best fit them; individual differences among families are as dramatic as those among
children. For some children and families, a very young child’s needs can be well
met with a parent-implemented approach. For other children and families, parent
coaching provides one arm of multifaceted early intervention services. However,
given that young children spend the majority of their waking hours with caregiv-
ers, we cannot optimize outcomes for young children with developmental difficul-
ties such as ASD without ensuring that their learning needs are being addressed
within everyday life with their caregivers.
Coaching is a way of being with people to help them enact change to attain
their own goals, as well as to resolve barriers to growth. It involves understanding
the principles and characteristics of adult learning and how to support adults on a
course of change from the outset of intervention. Coaching requires a solid under-
standing of how adults learn and change, and of the tools to manage the barriers
that arise. As the parents master the skills and knowledge they are seeking, the
tools and solutions they learn provide a powerful sense of competency and empow-
erment for managing future needs and goals as well. A competent coach thus
knows how to balance sharing knowledge and skills with promoting parents’ self-
discovery and developing a sense of self-efficacy.
We have evolved this role because of the beneficial results of this type of rela-
tionship expressed by the people we have worked with and evidenced in the data
that we and many other researchers have col-
lected on the child with ASD’s growth, fidelity
of implementation among parents, and parents’
evaluation of the coaching experience. Setting
aside the role of expert and assuming the role of
a coaching partner present a wealth of oppor-
tunities to engage in an open, honest dialogue
with parents; to listen to their beliefs, priori-
ties, worries, and challenges; to share in the everyday pleasure and pain of raising
young children with disabilities; and to offer support and empathy as a partner in
the process. Table 1.1 summarizes some of the differences in roles and behavior
between a coach and a child interventionist.
Challenges to Coaching
This view of coaching often runs counter to how professionals who work in early
intervention were trained to deliver treatment. We were taught that our direct
treatment was vital to improving child outcomes. We still see such thinking in
An Introduction 7
Table 1.1.Role Differences: Coach versus Interventionist

Therapist Coach
Identify the child’s needs as you Identify the family’s goals for their child and their
have defined them based on assessment of their child’s strengths and needs, as well
your assessment. as strengths and recommended areas of intervention
focus from the individualized family service plan (IFSP)
assessment process.
Develop a treatment plan Work with the family to build a plan for parents/
to ameliorate the child’s caregivers to support the child’s strengths and address
difficulties that you will follow the child’s needs based on the family’s daily routines,
in your treatment sessions. family priorities and preferences, and materials at home.
Tell the parent how much Discuss with the parents how frequently they would like
treatment the child needs to meet, what times and days will work for them, and
and when the sessions are possible locations for sessions (home, other community
scheduled. settings, classroom or clinic, other caregiving
environments).
Job requirement is to provide Job requirement is to bring interdisciplinary knowledge
disciplinary expertise in of early development and the child’s disability, provide
assessment and intervention. disciplinary expertise when needed, form a partnership
with parents, and support them in their goals of
supporting their child’s development at home.
Deliver hands-on treatment Support parent–child interactions in everyday activities
directly to the child. as the therapeutic vehicle for child development.
Choose materials and activities Plan with parents what daily routines and household
that will challenge the child to materials will best support child learning and their goals
develop new skills. for the coaching session.
Make a few suggestions that you Support parents to incorporate child learning goals
would like the parent to work into learning activities in their everyday routines, to
on over the week. monitor child response and changing learning needs,
to problem-solve when interactions go awry, and to
organize their environment as needed to support their
efforts at home.
Conceptualize treatment as Conceptualize intervention as child-engaged learning
that which occurs during direct opportunities that address specific child needs and
professional interactions with occur with all partners in all environments.
the child.
Write a chart note and evaluate Evaluate child progress via behavioral data gathered
the success of the treatment during coaching sessions (and from parents’ weekly
based on clinical observations observations/data), written in a chart note, and shared
and session notes. with parents.
Decide length of treatment and Discuss length of treatment in terms of parent goals for
need for consultation/referral treatment. Discuss periodically with family in light of
based on agency rules and continuing and changing needs, options available, and
procedures, funding availability, desire for additional professional input.
child response and attendance.
action when observing therapists who ignore the parent sitting in the treatment
room, or who leave the parent in the waiting room as they take the child into
their therapy room to work alone as a solution to the difficulties that might ensue
when the child wants to interact with his or her parents during the therapy ses-
sion. This approach is clearly seen in the autism field where recommendations of
20–40 hours per week of one-on-one treatment for very young children are still
made by many knowledgeable health professionals—as if no learning can occur
outside of the therapy setting; as if learning occurring inside the therapy setting
will magically transfer to everyday life and everyday relationships; as if it is benefi-
cial for very young children to be in such intensive interactions for long periods;
as if naps, mealtimes, diaper changes, and baths are not key learning activities for
young children; as if there was any empirical evidence for the beneficial effects of
such intensive treatment on outcomes of young children with autism; as if the evi-
dence of the benefits of high-quality parent-implemented interventions at home
did not exist.
Having experienced the medical system of assessment and diagnosis, parents
are also primed to seek an expert model of intensive interaction when they begin
early intervention. Parents’ previous interactions with professionals and the advice
they may have found in various media tools will likely have directed them to find
professionals with the greatest expertise and do as they direct. Their hope for
professionals who can “fix” their children’s delays and symptoms and prevent long-
term disability is part of their coping strategy for managing the massive crisis in
their lives that the ASD diagnosis has created.
Yet, while these experiences of interventionists and parents initially move
both to seek a more hierarchical expert-based direct intervention model, it is
interesting to look at the backgrounds of the authors of some of the most well-
supported (in terms of evidence) parent-implemented models for ASD, all of whom
were initially trained in direct treatment of children. We interventionists realize
that children’s best outcomes cannot be supported unless everyday life provides
children with needed learning and practice opportunities. Everyday life is where
children spend most of their time, even for children who are spending 40 hours of
their week in treatment. If everyday life does not provide the learning and practice
opportunities that children need, then children will learn other skills and behav-
ior that are adaptive in these out-of-therapy environs—skills and behavior that
may be just those that therapists are trying to replace. Furthermore, if parents do
not know how to support their children’s new learning, they will not necessarily
appreciate their child’s learning ability. And most unfortunately, if parents only
become aware of their child’s new skills in the presence of a therapist, then they
may assume that they themselves lack the skills to teach their child, with result-
ing feelings of inadequacy, and that their child no longer cares about cooperating
with them, which may fuel feelings of anger and the attribution of manipulation
or malicious intent to the child.
An Introduction 9
Where Do These Ideas Come From?
The ideas, practices, and philosophy found in this book come from more than
20 years of learning from our colleagues and from our own research on early
intervention and parent- implemented interventions for young children with
ASD, as well as our direct experience as clinicians coaching families of children
with developmental difficulties, especially autism and those at risk of autism. We
have been heavily influenced by the work of Dunst and Trivette (2009a, 2009b);
Dunst, Trivette, and Hamby (2007); Hanft, Rush, and Shelden (2004); Rush and
Shelden (2011); and Snyder, Hemmeter, and Fox (2015), all hailing from the field
of early intervention for children with developmental disabilities; by work in the
field of infant mental health (Zeanah, Stafford, Nage, & Rice, 2005). Much of
our clinical work has involved our intervention model, ESDM, and its related
parent-implemented version (P-ESDM). We have published many research papers
concerning the efficacy of these approaches (Dawson, Rogers, et al., 2010; Jones,
Dawson, Kelly, Estes, & Webb, 2017; Rogers, Estes, et al., 2012; Rogers, Estes,
Vismara, et al., 2019; Rogers, Vismara, et al., 2014; Sullivan, Stone, & Dawson,
2014; Vismara, Colombi, & Rogers, 2009; Vismara, Young, & Rogers, 2012; Webb,
Jones, Kelly, & Dawson, 2014).
Who Are We Writing For?
We are writing for readers whose intervention approach shares the characteris-
tics of a naturalistic developmental–behavioral early intervention model (NDBI;
Schreibman et al., 2015) for young children with ASD or other developmental dis-
orders. NDBI approaches share these characteristics: (1) a natural type of back-and-
forth communication between child and adult; (2) following child preferences and/
or choices for activities and materials; (3) child initiations of activities; (4) adult
responses that are sensitive and responsive to the child’s verbal and nonverbal com-
munications; (5) goals for learning that reflect the child’s developmental readiness
and represent developmentally and culturally appropriate activities for the child;
(6) teaching approaches derived from learning science as used in applied behavior
analysis (ABA), including analysis of antecedents, behaviors, consequences, func-
tions of behavior, prompting shaping, modeling, and graduated least-to-most guid-
ance; (7) teaching trials, frequently initiated by child actions, are embedded in the
flow of adult–child activities; and (8) rewards for the child’s learning response are
typically the child’s ability to achieve his or her own goals—the child is able to do
what the child intended to when he or she chose this activity. In short, the prin-
ciples in this text can be used with any early intervention approach that embeds
learning in the child’s preferred activities—it is about the process of working with
parents as they interact with their children in everyday routines.
What Lies Ahead?
In the chapters that follow, we offer a more detailed definition of coaching and
how it differs from direct intervention with the child. In Chapter 2, we outline the
theoretical and empirical bases and key practices for our parent coaching model
for early ASD. Our model draws on the adult learning and coaching literature; on
cognitive–behavioral therapy as well as ABA; on the science of developmental
psychology and infant mental health as it has described the processes of relation-
ship development, communication development, play, and cognitive development;
and on infant learning research. In Chapter 3, we describe what a coach needs
to know, coaching characteristics, the coaching process, and recommended sup-
ports. Chapter 4 outlines the key elements of the coach’s tool kit. Starting with
Chapter 5 and continuing through Chapter 6, we take you through the coach-
ing process beginning at the first point of contact with the family; the steps for
identifying parent, child, and family learning needs across environments; and the
collaborative intervention planning process. We share user-friendly data tools
that we have developed, both for our own use and for parents’ use, to assist us all
to determine and address the child’s needs, to evaluate the child’s learning and
response to the intervention, and to troubleshoot difficulties that arise and prog-
ress that is slower than expected. Chapter 5 walks the reader through an assess-
ment and goal-setting approach. In Chapter 6, we cover the initial parent coach-
ing session and subsequent sessions, describing ways to work alongside families to
introduce and practice various intervention practices by using the coaching skills
of observing, giving feedback, problem solving, and, most importantly, listening
and reflection. Chapter 7 provides the coach with technical guidance for sharing
key intervention concepts with families and coaching families to implement key
strategies. In Chapter 8, we discuss situations in which the core practices we have
described need to be varied or adapted in order to meet specific family needs or
characteristics. Chapter 9 offers several directions for future research on aspects of
parent coaching and considerations that need to be made when working with par-
ents whose children have additional psychiatric or medical problems, those whose
infants are showing concerning symptoms, and those who live in low-resource
communities in the United States and elsewhere. Coaching stories accompany key
topics to illustrate the qualities of relationships and interactions with families and
to share important moments in our own learning as well.
Throughout the book, we cite the empirical evidence that has influenced our
learning and that documents the evolution of parent-implemented early interven-
tion practices. We hope that this book will provide some support to practitioners
who are seeking additional ways of helping young children with ASD progress,
those who desire to partner more successfully with families and to evolve a more
family-centered, parent-implemented approach to delivery of early intervention for
young children with or at risk for ASD. Most of all, we hope that this text will
An Introduction 11
enhance practitioners’ motivation and skills to support parents to embed interven-

tion into everyday life to help their children advance. We have written this book
because we know that such an approach to early intervention helps children learn.
Experienced therapists and experienced parents understand the power of par-
allel expectations and parallel management strategies across environments and
interactions to support optimal child progress. And the parent coaching litera-
ture demonstrates the power of the coaching relationship to support parent learn-
ing and confidence in providing for the unique needs of their young children
with ASD. The parent coaching approach and techniques that we provide here,
while developed from our work in P-ESDM, have extensive parallels with other
NDBIs (Schreibman et al., 2015) referenced early in the chapter: those developed
by Brooke Ingersoll, Amy Wetherby, Connie Kasari, Michael Siller, Laura Sch-
reibman, Robert and Lynn Koegel, and other NDBI leaders publishing current
research on parent-implemented treatments. However, we also integrate concepts
and practices from the field of infant mental health and two key practices that set
ESDM apart from these other approaches: the seamless integration of ABA and
developmental approaches, and intervention techniques that allow one to focus
on multiple learning objectives inside adult–child learning-based interactions. We
hope that this text will provide additional tools for interventionists working with
parents to embed early intervention in everyday routines, will provide greater con-
fidence and a sense of efficacy to the interventionists who use it and the parents
they work with, and will provide the children in their care with additional oppor-
tunities for learning—finding excitement in all the new learning opportunities
in everyday life and the pleasure of interacting and learning from their family
members.
Chapter 2
Key Practices in Coaching

Parents in Parent-Implemented
Interventions
The current emphasis on parent-implemented interventions for early ASD is fueled

by (1) new findings from the studies of infant–toddler development of ASD symp-
toms, (2) new tools for early diagnosis of autism, (3) and recent research funded by
the National Institutes of Health and advocacy groups, especially Autism Speaks,
on effective interventions for very young children with ASD.
Key Practice:
Parents Working with Their Children at Home
Before the early 1970s, children with autism were very often treated in treatment
centers, institutions, and psychiatric settings by therapists. The work of two men,
Eric Schopler and Ivar Lovaas, had tremendous influence on the development of
parent-implemented intervention for ASD.
Eric Schopler (1971), a student of Bruno Bettelheim’s, reacted strongly to Bet-
telheim’s destructive and inaccurate suggestions that autism was caused by reject-
ing parents. Convinced that autism was a biological condition, Schopler showed
in his doctoral thesis (personal communication to G. Dawson, 1983) that children
with ASD have unusual ways of processing information. Soon thereafter, he made
a radical proposal: Parents can and should provide therapy directly to their chil-
dren, at home. He led a pioneering effort to mobilize home- and community-based
services for children with ASD and spearheaded an intervention called Treat-
ment and Education of Autistic and Related Communication-Handicapped Chil-
dren (TEACCH; Mesibov, 2005), still in use today. He provided four completely
12
Key Practices in Parent-Implemented Interventions 13
new ideas about how children and adults with ASD should be treated, ideas that
have had lasting influence (Schopler, Reichler, & Lansing, 1980). The first idea
involves a generalist approach: that autism therapists need to bring generalized
knowledge of autism treatment to families and children, knowledge developed
within an interdisciplinary team in which professionals from a wide range of dis-
ciplines learn from each other and pool their knowledge, with each taking on the
role of primary therapist for children with ASD and their families. The second
idea promotes working with parents and children in a home setting as a crucial
part of intervention. Schopler’s third novel idea is the need for parents to have a
strong voice in their child’s treatment and to work as partners with professionals
in all aspects of assessment, diagnosis, and treatment of children with autism.
Fourth, ASD interventions need to respect people with ASD, supporting their
preferences, strengths, and needs rather than working to eliminate or hide their
symptoms and individual differences. TEACCH achieves these goals by building
on individual preferences and strengths as well as needs, delivering interventions
whose methods and content best support an individual’s personal learning styles
and needs, and simultaneously supporting the independence, comfort, and com-
munity participation of those with ASD (Mesibov, Shea, & Schopler, 2005).
The influence of the TEACCH generalist model is clear in interventions such
as ESDM, in which one member of an interdisciplinary team takes on the role of
team leader, partnering with parents in the design, implementation, and oversight
of their child’s intervention. Other professionals on the team serve as consultants
to the team leader and parent, rather than as direct interventionists with the child.
This model has three major effects on service delivery. First, responsibilities for
team leadership and decision making are shared by parents and the team leader.
Second, the generalist team leader helps integrate information from all available
sources for parents to apply to the child’s intervention; in so doing, the generalist
The Generalist Model Developed by TEACCH

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

Relationship in Young Children with ASD
There was a long period of time in which professionals assumed that the attach-
ment relationship in ASD was either disturbed or nonexistent. These assumptions
were eventually proven wrong. Beginning with the landmark contributions of

Marian Sigman and her students and colleagues (Sigman & Ungerer, 1984; Capps,
Sigman, & Mundy, 1994; Sigman & Mundy, 1989; Rogers, Ozonoff, & Maslin-
Cole, 1991; Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2009), autism researchers
demonstrated that young children with ASD can, in fact, form secure attachments
with their caregivers. Evidence from these group studies showed that children with
ASD experience their parents as secure bases, that they know and prefer familiar
to unfamiliar people, and that they are negatively affected by separation from their
parents and by interactions with strangers. These findings provided solid evidence
for focusing on adults’ sensitive and responsive interactions (parent behaviors that
mediate secure attachments in toddlers) with young children with ASD and focus-
ing on supporting parental roles and competencies as key emotional figures and
teachers in their young autistic children’s lives.
In addition to the attachment studies in ASD, studies focused on parent–child
patterns of interaction in ASD have demonstrated many similarities between par-
ent–child interactions in ASD, those in other neurodevelopmental disorders, and
those in typical development (Kasari, Sigman, Mundy, & Yirmiya, 1988; Meirs
schaut, Warreyn, & Roeyers, 2011). They have also defined differences in key com-
munication behaviors, such as the ability to share attention with others or joint
attention (Mundy, Sigman, Ungerer, & Sherman, 1986; Sigman, Mundy, Sherman,
& Ungerer, 1986; McEvoy, Rogers, & Pennington, 1993). Kasari reported that par-
ents and children with ASD interact very similarly to children with other devel-
opmental delays, with the main differences arising from the need for increased
parent support for the child’s attention to the parent (Kasari et al., 1988). Dawson
and colleagues demonstrated that children with ASD readily increased their eye
contact and joint attention behavior when the caregivers closely followed and
responded contingently to the behavior of the child (Dawson & Adams, 1984b;
Lewy & Dawson, 1992). We also learned that young children with ASD desire
social interaction and respond more positively when social interactions are predict-
able and understandable. We saw that parents typically scaffolded their children’s
learning in ways that supported positive parent–child interactions, while also sup-
porting the child’s social attention and engagement in activities and interactions.
Sadly, and against all evidence, there is still a tendency to question the skills
of parents with children on the spectrum, fueled by layperson notions of autism as
well as the topic of the broader autism phenotype. The latter leads some to question
whether the ASD-related genetic backgrounds of parents may result in parenting
differences. Very important studies recently examined this question by looking at
parent–child interactions among a large group of infants who had an older sibling
with ASD (Talbott, Nelson, & Tager-Flusberg, 2016; Wan, Green, & Scott, 2019).
Contrary to the hypothesis that parents of children with ASD may interact dif-
ferently with their children due to the presence of autism risk genes, no signifi-
cant differences were found between the group of parents who had a child with
ASD (and thus were assumed to have more autism risk genes) and those who had
children exhibiting typical development. Thus, 30-plus years of studying parent–
child interactions in ASD have not reported significant parenting differences that
might be responsible for any ASD symptom development in their children.
Perhaps someday science and advocacy will be able to put this destructive idea
to rest once and for all. The critical findings suggest the opposite: Children with
ASD and parents generally develop close ties; children with ASD know and prefer
their family members and caregivers and feel safe with them, although they may
use different behaviors than other children to express these feelings (Rogers et al.,
1991); and parents of children with ASD interact with them in ways that demon-
strate their understanding and support for their children’s unique needs.
Key Practice: Building Language Interventions Based

on Developmental Communication Science
Our understanding of the processes that young children use to develop spoken
language has altered radically over the past few decades. Before the 1970s, the
predominant theories of language development represented nativist and environ-
mentalist viewpoints. The most well-known representative of the nativist position
was Noam Chomsky; his hypothesized Language Acquisition Device (Chomsky,
1965, 1980) was a uniquely human brain mechanism that parsed language into
its elemental parts and helped children acquire speech and language. The envi-
ronmentalist view was best represented by B. F. Skinner’s operant learning model,
which posited that speech and language evolved from the same learning processes
seen in all other aspects of learned behavior (Skinner, 1957). The operant learn-
ing approach to language is still embraced by many and is highlighted in the Ver-
bal Behavior method of intervention (Sundberg & Partington, 1998).
In the 1970s, a new model of language development was articulated and
began to be studied in infant developmental labs across the country. Known as
the pragmatics approach and articulated by Jerome Bruner (1983), Elizabeth Bates
(1976), Inge Bretherton and Bates (1979), and other key scientists, the pragmatic
approach suggests that children decode and learn language by discerning the
speaker’s intent (the goal of the communication). Is the speaker making a request,
offering or asking for help, directing a partner to act, seeking a social response,
directing a partner’s attention? Such intents are expressed by body language—
gesture, posture, vocal tone, and facial expressions—as well as word meanings.
Young children demonstrate their understanding of these intents toward the end
of the first year of life, through their preverbal responses to partners and their
own gestural production of these intents. A series of elegant experiments occur-
ring across several decades have firmly supported the pragmatics foundation of
Key Practices in Parent-implemented interventions 17
infant speech and nonverbal communication. The experiments have changed the
view of speech and language from behaviors learned via imitation and associative
learning for the purpose of representing objects and actions in the world, to efforts
to join a social partner in shared activities for the pleasure of social connectedness
and social influence through shared meanings.
Early on, Ratner and Bruner (1978) highlighted the key roles of infant–adult
play routines in infants’ learning to anticipate and predict others’ behaviors and
intentions. They pointed out that first words were very often the cue words in
social games like peekaboo, “uh-oh,” “so big,” rather than need-fulfilling words
like milk, food, or help. Their insights about the impact of emotionally salient and
highly pleasurable routines with favored social partners on early word learning
have stood the test of time and formed the basis for the ESDM intervention.
The second contribution of pragmatics researchers was to examine what par-
ents did that fostered word learning in their infants. In direct challenge to the
operant learning theory of language learning, a large variety of studies have dem-
onstrated that infants and toddlers benefited the most in the early stages of word
learning from partners who used language to describe the focus of an infant’s
attention or goals, rather than using it to direct the infant’s attention and to teach
word labels.
Many studies have found that young children with autism learn spoken lan-
guage using the same processes as do typically developing children (Lord & Scho-
pler, 1989; Sigman & Ruskin, 1999; Tager-Flusberg et al., 1990). A milestone study
by Michael Siller and Marian Sigman (2002) demonstrated the effect on language
development of parents who use language to follow their autistic children’s leads
rather than to direct them, and this style positively affected their children’s lan-
guage learning not only in early childhood, but also all the way through adoles-
cence.
Longitudinal findings by Mundy and colleagues and others demonstrated that
a child’s early joint attention gestures were strong predictors of later language acqui-
sition (Mundy, Sigman, & Kasari, 1990). Such findings indicate that language
interventions for preverbal toddlers should
focus first on developing use and understand-
ing of communicative gestures, especially
the joint attention gestures involving initiat-
ing and following a partner’s gaze, pointing,
showing, and sharing/giving. These and many
other research findings stress the importance
of parents and other adults interacting with
young autistic children by responding to and
following such children’s focus of attention and goals, talking with them about
their activities, and joining them as play partners.
Key Practice: Interdisciplinary Teams
On October 8, 1986, a federal law (Public Law 99-457) was passed that amended
the 1975 Education for All Handicapped Children Act (Public Law 94-1142)—
now known as the Individuals with Disabilities Education Act (IDEA)—to
require public educational services be provided to children with disabilities from
age 3 to 22. Public Law 99-457 also required that assessment, intervention, and
family support for all infants and toddlers with or at risk of developmental delays
be provided at little or no cost to families. This law cast a wide umbrella for infants
and toddlers with difficulties in all spheres of development, including the social
and behavioral domain. It called for interdisciplinary services from a wide range of
disciplines, both educational and health-related, as well as case management ser-
vices, home visits, parent training, counseling, and the full range of allied health
benefits and educational benefits. It also mandated that a family service plan be
developed and carried out.
The content required of the family service plan was specific, family- and
strengths-focused, completely individualized, and outcome-oriented. It required
objective demonstration of the child’s progress and benefit. It required specifica-
tion of the nature, frequency, and method of each type of intervention provided.
Finally, it required that parents receive the help and information needed to partic-
ipate in the educational decision-making processes, including the development of
the child’s individualized educational program, as well as the right to obtain infor-
mation about what programs, services, and resources were available to children
with disabilities and the degree to which the programs, services, and resources
were appropriate for their child.
This family-centered orientation was a drastic change from the medical model
of therapy delivery for infants and toddlers that prevailed at the time. Parents were
required to be at the table, fully informed on all available services and members
of the decision-making group establishing a service plan for their child—and for
themselves. This focus on supporting the family set in place the idea of parents
and professionals as partners in all aspects of infant–toddler identification assess-
ment and intervention. It also reflected the importance of professionals learning
about the challenges to families created by a young child’s delays or disabilities, and
of supporting families and parenting in order to support children’s development.
The focus on services at home and in typical community settings further empha-
sized the socioecological Bronfenbrenner model of child development (1986) and
its grounding in the family, home, neighborhood, and community for supports.
Working at home with parents to help them incorporate children’s intervention
needs into everyday life developed during these years as a primary delivery model
for children from birth to age 3 (Brown & Moersch, 1978).
It is interesting that in 2021 these principles are often set aside for young
children with ASD in favor of an intensive one-on-one therapy model, likely due
to the downward extension of what some consider a “best practices” model of

service delivery for older children with ASD. One wonders what has been gained
and what has been lost by replacing the family-centered model of infant–toddler
intervention described in Public Law 94-457 with a direct intensive service model.
Key Practice: Parent Coaching

and Family-Centered Care
Coaching approaches can be found within sports, business, education, humanistic

psychology, behavioral and cognitive psychology (Allcorn, 2006). Grant (2006)
suggests several common themes that unify the widely different contexts and prac-
tices in which coaching occurs:
1. Relationships are egalitarian and collaborative, rather than authoritarian.

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

opment, infant mental health, the science of adult learning, and communication
science, these authors stressed the parent–child dyad as the necessary focus of
attention for early intervention, and children’s interactions with caregivers within
activities of daily life as the necessary source of learning opportunities supported
by early intervention. Their work continues at this time with their collaboration
in the Family, Infant and Preschool Program (FIPP) and a second coaching hand-
book (Rush & Shelden, 2011). Starting from the Hanft et al. (2004) text, the Rush
and Shelden (2011) text, and the FIPP website materials (www.fipp.org), and also
deeply influenced by the knowledge and practice base of infant mental health
(Fraiberg, Adelson, & Shapiro, 1975; Stern, 1985; Zeanah, Berlin, & Boris, 2011),
we constructed and tested a parent-implemented ESDM model (P-ESDM) based
on parent coaching practices. The framework, materials, and measurement tools
that we developed and tested in our multiple P-ESDM studies and our clinical
P-ESDM practices are all available in this text.
Parent coaching (as contrasted to parent training or parent education) nests
within the larger framework of family-centered care. While the term family-
centered care is used throughout service delivery systems, not all systems of care
that describe themselves as family-centered actually provide care that is centered
on family needs, family strengths, family beliefs, family values, and family routines
and practices. Two main factors in family-centered care have to do with shared
decision-making and parent–professional communication styles. The concept of
family-centered care gained much of its momentum from the advocacy of parents
of children with developmental and chronic health needs in the 1980s:
In a system-centered model, care processes are structured to facilitate the function

of health care professionals to serve patients; patients must adapt to the constraints
of the system. When a patient-centered model is used, the opposite is true: The
system accommodates the individual. In pediatrics, patient-centered care is typically
referred to as family-centered care to acknowledge that children’s well-being is inex-
tricably linked to that of their families. A family-centered approach requires recogni-
tion that families have the most expertise about their child and, therefore, that they
have the right and the responsibility to collaborate in medical decision making in
behalf of their child. (McGuinn & Worley, 2008, p. 215)
Dunst and Trivette (2009a) proposed a framework for help-giving relationships

that empowers families by promoting family competency as it pertains to identi-
fying and managing their child’s needs. Their model of empowerment requires
specific conditions for both families and professionals: that families acquire (1) an
increased understanding of their child’s needs, (2) the ability to deploy competen-
cies to meet those needs, and (3) self-efficacy (a belief that they are capable) to
do so. Among the desired qualities of help-givers (professionals) in this model are:
(1) that professionals have a proactive stance marked by a belief that help-seekers
are already competent or have the capacity to become competent; (2) that profes-
sionals create opportunities for competence to be displayed by providing enabling
experiences to help-seekers; and (3) that they allow help-seekers to use their
competencies to access resources and attribute success to their own actions, not
the professional’s. In essence, Dunst and Trivette (2009a) suggested that viewing
the relationship with help-seekers from a strengths-based perspective rather than
one of deficits is a more effective way to achieve desired outcomes for children
with special needs and their families. Dunst and his colleagues have been lead-
ers in advocating, defining, demonstrating, and examining family-centered care
for decades. Their work to transform early intervention practices from “a deficit-
based, child-focused early intervention to a strengths-based, family-focused early
childhood and family support program” (Dunst & Trivette, 2009a, p. 120) began
in 1975 and continues to the present, influenced strongly by advanced in-family
systems theories, by the development of ecologically based frameworks for looking
at child development (e.g., Bronfenbrenner, 1986), and by a productive program of
research (Dunst & Trivette, 2009b) into every aspect of the model that has gener-
ated considerable support. Table 2.1 condenses descriptors of family-centered care
from McGuinn and Worley (2008) and coaching practices from Hanft, Rush, and
Shelden (2004).
Conclusion
The importance of family interactions and routines as the context for children’s
early learning was a compelling concept behind the 1975 creation of the Educa-
tion for All Handicapped Children Act (Public Law 94-142). The concepts and
law were extended to infants and toddlers with risks and disabilities (Part C of
IDEA) to enhance infant–toddler development and to provide support for families
to meet the special needs of their young child, as well as to reduce the downstream
governmental costs of treatment and education by intervening as soon as inter-
vention needs were recognized and by emphasizing least-restrictive environments.
Both the law and findings from decades of research on infant–toddler develop-
ment of both typically and atypically developing young children over the past 4
decades emphasize the necessity of (1) supporting positive parent–child relation-
ships fundamental to optimal early development, and (2) supporting caregivers in
each child’s natural environments and activities, to understand and support the
young child’s development—in order to optimize child and family outcomes.
Table 2.1.Similarities and Differences in Family-Centered Care and Parent

Coaching Concepts
Family-centered models of care Coaching in early childhood intervention
Parents are experts on their children. Coach and parents pool their expertise.
Parents need to be part of the decision- Parents and coach make decisions together.
making process.
Identifying family strengths and needs. Emphasis on assessment of family strengths

and needs for support; parents’ goals, values,
practices.
Relationship between medical personnel Collaborative, partnership relations.

and parents should be collaborative.
Importance of culturally sensitive care. Importance of cultural sensitivity and learning

from family.
Importance of community ties and Community-based activities and supports.

community-based supports.
Treat families with respect and support. Mutually respectful partnership.
Optimal child functioning reflects Intervention focused on child participation in

supportive family and community. the family and community.
Needs of all family members must be Supporting family means supporting all its
considered. members.
Services need to be easy for parents to Skills being coached need to be easy to learn
use. and easy to implement in everyday contexts.
Providing honest, unbiased information to Having honest reciprocal exchanges and

families. sharing reflections and evaluations.
Honoring diversity in all its aspects Having honest reciprocal exchanges and
within families. sharing reflections and evaluations.
Respecting different methods of coping Acknowledging and building on parents’ ways

and use of supports. of coping and their use of their own supports.
Importance of parent–parent support and Attention to social network that supports

social support systems for the child and parents and family, focus on community
family well-being. relations more than professional relations.
Services organized and designed based on Coaching services designed based on family
child–family needs, not agency needs. needs and preferences.
Interdisciplinary care and comprehensive Coach functions in an interdisciplinary way—

services. addresses all child’s treatment goals.
Note. Data from McGuinn and Worley (2008) and Hanft, Rush, and Shelden (2004).
Chapter 3
Becoming a Coach
Knowledge, Characteristics,
and Supports
Parent coaching adds additional skill sets to our early interventionist repertoires:
new ways of thinking, new skills and knowledge, and new resources to tap. The
more complex interactions and events that occur in coaching create needs for new
supports and resources for coaches. This new tool kit supports parent-implemented
child intervention in all kinds of natural environments. It provides the interven-
tionist with new ways to build working relationships with parents, based on part-
nership, collaboration, and adult learning principles.
Very few parent-mediated interventions discuss straightforwardly the fact that
the primary goal of coaching parents is to change adult behavior. Child change is
the secondary goal, and it is the hoped for effect of parent behavior changes. The
learning process that parents begin as they enter parent coaching requires ongoing
effort in learning, practicing, and generalizing new skills, as does any other adult
goal of changing out old habits for new ones. This is not how our field has typically
discussed parent-mediated interventions. However, we have found it very helpful
to recognize and embrace the behavior change of parents as the primary target
of intervention in the P-ESDM model and the mediator of change in children
(just as behavior change was our goal as we learned these skills and taught them
to our students.) This conceptualization of parent coaching led us to a number
of adult learning concepts, empirically based tools, and teaching and assessment
procedures from other well-established interventions that we found helpful as we
coached and supported parents through a process of change.
In this chapter, we describe the coaching approach we have developed to
help parents turn their new learning into long-term cognitive, emotional, and
action-oriented habits. This chapter addresses what coaches need to know, some
23
characteristics of an effective coach, and coaching strategies for addressing

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

Know the Evidence
The expectation that interventionists use evidence-based practices is written into
laws, insurance reimbursement practices, and professional codes of ethics. Parent-
implemented intervention is an evidence-based practice, as is the use of a coach-
ing relationship to help adults change behavior. Knowing the concepts and the
evidence base behind their parent-implemented coaching model deepens coaches’
understanding and commitment to their work while helping them answer parents’
questions and problem-solve more successfully. How can interventionists learn the
deeper aspects of their chosen model?
Early intervention agencies with which we have worked use several strate-
gies for building coaches’ knowledge base. They support motivating speakers
who deliver the evidence in person using well-filmed and well-edited videos, and
sometimes individual stories; visually clear data create energy and enthusiasm for
learning and change. They provide staff retreats, and in-service sessions offer new
learning in environments that allocate the time, group support, and social rewards
needed for acquiring new skills and knowledge. They share attractive self-learning
materials in the form of links to reliable websites and YouTube postings; the videos
of other skilled coaches dealing with challenges and a wide range of families and
children; visually compelling handouts and electronic materials; annotated bibli-
ographies of key concept papers, review articles, book chapters; and studies that
include articles and personal checklists for organizing and task-analyzing learn-
ing. They encourage and support regular peer supervision groups focused on the
sharing of videos and self-measurement using fidelity of implementation measures;
these provide necessary opportunities for the refinement, maintenance, and gen-
eralization of learning among supportive peers who share the same learning goals.
Staff learning requires time, and agencies that set aside work time to be used for
new learning deliver a powerful message about how much they value the quality of
work their employees will provide. This, in turn, enhances interventionists’ self-
esteem and confidence in their professional skills.
Finally, knowing the evidence provides coaches with the base they need
to answer parents’ questions about the evidence and concepts behind various
approaches. Coaches who can answer such questions knowledgeably and share
Knowledge, Characteristics, and Supports 25
materials at parents’ request quickly demonstrate their preparedness and expertise,

which increases parents’ buy-in and motivation for the work at hand.
Master the Practice

Many evidence-based, low-intensity parent-implemented practices belong to the
category of NDBIs (Schreibman et al., 2015). Numerous different brand-name
interventions and professional disciplines use some type of naturalistic approach
as a basis for treating young children, because these methods support child motiva-
tion and participation. NDBI approaches are built on principles that reflect what is
known about how young children learn most readily: within familiar settings and
routines, with people they know and feel comfortable with, with materials that
they choose and prefer, in activities that fit a child’s current abilities and interests.
What do we mean by naturalistic approaches? In general, adults using natural-
istic approaches follow children’s interests, preferences, and skill readiness. They
interact with the child as a play partner, rather than as an authority figure. They
use reward strategies that are part and parcel of the activity, material, and inter-
action, rather than external reinforcers like food and drink (unless the activity
is a meal!), tokens, points, stars, or a preferred object (phone or computer) that
is not part of the activity. They capitalize on the child’s interest and pleasure to
capture and hold his or her attention, and they use children’s own desires to repeat
pleasurable activities to assure opportunities to practice the new skill. The most
skilled naturalistic therapists also present learning challenges that are just beyond
the child’s current skill set in order to stimulate mastery motivation in the child,
with all the pleasure that accompanies it. Understanding that children cannot
perform at their most skilled level every single time, they also assure the child has
ample opportunity to enjoy the activity and receive those internal rewards using
his or her current skill set. Naturalistic approaches can be found in developmen-
tally based interventions, sensory-based interventions, and interventions derived
from ABA. Pivotal response training (PRT; see Schreibman & Koegel, 1996, for
an early review) and incidental teaching (McGee, Krantz, Mason, & McClan-
nahan, 1983) were the first two ABA-based interventions for autism to publish
treatment studies for children with ASD that used naturalistic ABA approaches.
Interventionists from speech and language pathology, occupational therapy, and
early childhood special education typically use naturalistic approaches for young
children in their disciplinary work.
The unique feature of NDBIs is the careful integration of developmental sci-
ence and learning science (ABA) within a naturalistic teaching approach. In
addition, NDBIs emphasize predetermined teaching goals, ongoing data collec-
tion, task analysis, and developmental sequencing of treatment objectives to deter-
mine the daily skills to be practiced and taught, and data-based decision making,
and thus fit well into the legal requirements of individualized family service plans
(IFSPs) and individualized education plans (IEPs) for preschoolers. For interven-
tions grounded in ABA, NDBI adds developmental knowledge to decisions about
goal development, communication-stimulating interaction with an adult who is a
reciprocal communicative partner in all activities, and the motivational benefits
of child choice and child preferences. One unique aspect of ESDM within the
NDBIs is the practice of teaching to multiple objectives with several repetitions
inside a single ongoing activity, which adds many more learning opportunities in a
time period than can be attained when only one objective is focused on at a time.
In order to coach a parent to implement an intervention approach at home,
a coach has to have extended mastery of the skills and concepts to be learned. It
is far more difficult to coach someone else in a skill than to carry it out oneself,
because coaching another person requires that the coach translate into words all
that he or she knows, including knowledge held so deeply that the coach performs
those actions without thinking about them. Bringing such “automatic” actions
into one’s mind and one’s vocabulary; learning to articulate the why’s and where-
fores behind such actions; being able to break down complex actions and ideas
into very simple, quickly learned scripts (see Chapters 6 and 7 of this book for
detailed how-to examples); and being able to deliver that learning at just the point
and level that a parent needs to learn in order to use the skill in the moment and
also generalize it—this requires additional learning and practice, both didactic
and experiential, including self-assessment, feedback, and supervision.
Given all that goes into providing intervention for young children with ASD,
how does a coach decide what parents need to learn in order to implement a prac-
tice at home? Most name-brand NDBI practices use an explicit assessment tool or
approach that helps to define what the adult needs to do within a teaching inter-
action, and these are known as fidelity of implementation (FOI) or fidelity measures.
The FOI measure explicitly describes each skill that a well-trained practitioner
uses and provides a means of measuring the accuracy of each skill, thus giving
the coach a convenient way to assess what parents are learning within coaching
and where additional coaching is needed. In addition to the brand-specific fidelity
tools, there is also a recently published NDBI FOI tool that coaches can use if their
method of practice does not have an FOI associated with it (Vibert et al., 2020).
We recommend that coaches assure their own fidelity of practice before coaching
others, and this can be accomplished in a variety of ways, including formal train-
ing (with associated fees and associated professional continued education units
[CEUs]), self-study or group study using Web-based and written materials and peer
supervision, and inservice training efforts utilizing a consultant, among others.
For parent coaching, we have created a public website, Help Is in Your Hands
(www.helpisinyourhands.org), with many free materials for coaches and parents.
Other branded interventions also have affiliated websites and offer a variety of
training options.
For busy early interventionists, taking the time to learn and perfect their skills
may seem incredibly difficult, but most of us are accustomed to the expectation of
continued learning in our professions, given our agency or licensing requirements
for continued professional education. Ongoing inservice training at an agency
level, the requirements of an agency’s annual review, and annual professional goal
setting all provide structure and incentives from employers and professional asso-
ciations for improving clinical practice. Joining a formal training program brings
the benefit of externally structured learning and motivational enhancements. If
you decide to take a self-instructional approach, consider the following, and please
remember that social support from peer learners will help you with consistency,
motivation, and practice as well as objective feedback about your learning, all of
which will help you learn more rapidly and more successfully. Try teaming up with
a colleague or two to complete this process together by following these steps:
1. Set a year-long goal of attaining fidelity in the practice of your choice.

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

to Parent–Child with Coach Support
It is very difficult to transition from direct intervention to parent coaching, and
it is even more difficult to do this with families that have experienced you as a
direct therapist. Remember the purpose of the shift—to increase children’s learn-
ing opportunities exponentially and to provide parents with the skills they want:
to know how to help their kids, what to do and how, when, and where to do it. Par-
ents want to get it right. It is our universal experience that when we first meet par-
ents with their young children, the parents’ initial question is “What can we do?,”
not “What will you do?” Therapists who tell us that the parents they work with
are not motivated, that they sit on the sidelines, or text, or check their phones, or
do housework, or nap during their home visits do not realize parents develop these
habits in response to therapists providing direct therapy in the treatment hour.
Interventionists who want to support parent-implemented intervention will do
well to look out for these intentional or unintentional therapist’s behaviors, which
often signal that the parents are not integral to the intervention:
• Working with the child, rather than supporting the parents to work with
their child
• Telling the parents what the intervention’s goals are, rather than asking
them what they want their child to learn
• Directing parents what to do at home, rather than asking them how the
therapist can be of help in everyday life at home
• Working only with materials and equipment that the therapist has brought
to session, rather than items the parents have at home
• Conducting activities that are far removed from the typical daily living
routines these parents carry out with their child
• Expecting that the parents will observe rather than interact, or asking the
parents not to interact because it interferes with treatment
For all these reasons, it is often easiest to begin your coaching practice with
families that are new to you as an interventionist, so you can develop coaching
interactions from the start. Chapters 5 and 6 describe how to begin the parent–
child–coach interactive triangle from the very first contacts, in the initial assess-
ment and treatment sessions. However, we have watched so many therapists shift
their practice from direct therapy to coaching that we know this approach can be
successful and that parents will be very appreciative of their new role once they
have had the chance to learn it. For families that are accustomed to being on the
periphery, the coach can set up a new plan for collaborating following these steps:
1. Discuss the new plan and the reasons for it at the beginning of a session.
Be ready to notice and address positive and negative emotional reactions
to change.
2. Ask parents what their goals are for the session, and ask them to describe
something that has gone well or not so well with their child over the past
week (the initial observation activity). If the parents do not have a goal,
you can share your list of treatment goals and let them choose one.
3. Ask the parents an open-ended question: how they felt about the activ-
ity and their child’s response, and share your own reflections about what
occurred, emphasizing the parents’ successful actions and any positive
reactions to the parents the child may have had. You have begun the plan–
act–reflect–evaluate format that will be laid out in Chapters 5 and 6.
4. It is critical that in this first encounter the parents have a positive experi-
ence working with their child, and it is the coach’s responsibility to make
sure this happens. However, for adult learners, feelings of success and com-
petence come not from adult praise, but rather from meeting their own
goals, which in this situation are reflected in their child’s positive response
to them, their child’s learning, the parents’ enjoyment of such interac-
tions, and the parents’ sense of mastery and competence as expressed in
the child’s learning and engagement. The coach who responds to parents’
efforts with their child by highlighting these observations has provided a
much more powerful reinforcer than the coach who simply tells them how
“great” they’re doing (which in itself is kind of judgmental and distancing
for some parents).
Incorporating Principles of Adult Learning into Your Coaching

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

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

in coaching (to benefit child learning) and the roles involved (both have expertise
and both are learning from each other via past experiences and current prac-
tice, reflections, and discussion). See the box for questions that will help parents
reflect on the coaching relationship.
Effective coaching depends on certain skills and certain qualities that the
coach demonstrates to parents. The skill set includes a deep knowledge of the early
intervention that the child needs. However, supporting parent learning of early
intervention skills involves five key characteristics of a successful coach–parent
relationship: being collaborative, reflective, nonjudgmental, conversational and
reciprocal.
Being Collaborative
A collaborative coach works with parents as partners to reach common goals,
rather than deciding on the goal for the parents or leaving all responsibility to
them. Collaboration means asking questions, deep listening, and summarizing or
restating parents’ comments to show respect and a desire to understand their goals,
topics, concerns, and point of view. Parents also ask questions, listen, reflect, and
assess to establish and reach common goals. Each party shares expertise with the
other and conveys recognition of the other’s knowledge and abilities.
Being Reflective
Reflection promotes continuous improvement by considering in depth what has
just occurred and sharing those reflections in ways that illuminate progress toward
the goal at hand. Coaching calls for the sharing of reflections after each activity,
Questions to Help Parents Reflect

on the Coaching Relationship
• “What were the parts of today’s session that seemed most helpful for you? The
least helpful for you?”
• “Are you feeling more encouraged or more discouraged about our work together
over the last couple of weeks? Why?”
• “Have you had some ideas or thoughts about ways that this might go better for
you or for your child?”
• “We’ve been working together for a few weeks now. How is this going in terms of
what you expected when we first met?”
followed by the creation of a plan to take the next step toward the immediate goal.
The intent of this reflective discussion is for parents to consider what has hap-
pened and to compare what they intended versus what occurred. For coaches, the
purpose of reflection is to highlight the relationship between parents’ actions and
the child’s actions given the goals on the table and the previous knowledge that
the parent has attained. Reflection typically contains or is followed by evaluation
and an action plan for the next activity generated at times by parents, or suggested
by the coach if need be. This process of plan–act–reflect–evaluate builds parents’
capacity to use the learning being gained via coaching to build more teachable
moments into their everyday activities with their child. Rather than placing the
entire burden of reflection and assessment on the parent or coach, the reciprocal
nature of this process permits the coach to demonstrate the process of reflect-
ing, assessing, and planning; allows the parent to learn to plan, self-assess, and
self-correct when the coach is not present; and illustrates the kind of partnership
needed between parents and interventionists to best support children’s learning.
Being Nonjudgmental
A nonjudgmental stance involves acceptance of parent and child as he or she is.
It is conveyed in the body language and spoken language that occur throughout a
session. While we see many examples of praise used by people who work regularly
with parents, we agree with Hanft and colleagues (2004) that words of praise like
good, great, and perfect have associated drawbacks that can interfere with our goals
as coaches. One limitation is that they do not actually convey any information.
They are easy to use and ubiquitous in our work, but they don’t provide much
feedback to the learner from which he or she might grow. Compare two statements
made to a grandfather following a puzzle activity with his 2-year-old grandson.
Scenario: Grandfather is working on the goal of following a child’s leads instead of
directing; in prior sessions, his grandson would get easily frustrated and leave the
activity. In the current activity, the child finds the correct place for a star-shaped
piece, but it’s not aligned properly and doesn’t drop in. He fusses with the piece
and then begins to become very frustrated. Grandpa says, “You want it to go in!
But it’s stuck! Want help?” The child asks “Help” and hands the piece to Grandpa,
who immediately gives it back to the child, gently nudging him how to position it
into place, while saying, “Turn it.” Statement 1 to the grandfather: “Wow, fantastic!
You nailed that!” Statement 2: “It stood out to me how, when he couldn’t fit the
piece in, you commented on his frustration and you offered help, and then he
wanted to do it and you helped him turn it, so he could feel it slide in. He stayed
with you the whole time! And, he was so pleased—sharing that smile with you,
like ‘I did it,’ like ‘We’re a good team!’ ”
In Statement 1, the coach shares the pleasure in the moment and provides
generic praise to the grandfather. But there is a subtle evaluative component to
that praise: as if the expert is judging Grandpa’s behavior and finding it worthy.
In Statement 2, the coach describes the key features of the interaction that align
with the grandfather’s and child’s goals. The coach emphasizes the effect of the
grandfather’s responsive action and words on the child’s frustration and motiva-
tion to complete the puzzle as well as his relationship with Grandpa. There are no
evaluative words. When caregivers can evaluate the result of their efforts in terms
of their effect on a child’s behavior, they are using the same feedback loop that
interventionists use, one that is always present for them. It helps them develop the
self-sufficiency they will need when trying to follow interactive principles when
alone.
Although it is inevitable that we sometimes offer praise, we work hard to use
descriptive language in most of our reflections and feedback to parents. We want
to use language that describes what we saw in the relationship between parents’
actions and their child’s behavior. The parental actions we focus on are those that
a parent has explicitly chosen for the interaction. Tying descriptions to a parent’s
and child’s goals helps parents learn to think behaviorally and analytically about
their interactions with their child—the source of all information about whether
goals are being realized. Modeling and supporting this type of reflection in our
shared reflections prepare parents for the job at hand.
Being Conversational and Reciprocal

Given that we see the relationship as a partnership, we strive for a style that is con-
versational: friendly, warm, accepting, and grounded in confidence in the parent
and child. We need to demonstrate the partnership in balanced exchanges, mean-
ing that the coach and parents are each initiating and responding to the other and
sharing the conversational floor. This requires that the coach be sensitive to the
timing of conversation and staying on topic, while engaging in deep listening and
turn-taking in terms of questions and reflections. The coach should not interrupt
the parent while he or she is talking unless it is necessary given time restraints or
with permission, and in the service of understanding what the parent is convey-
ing. There is an implicit challenge in trying to adhere to these practices while also
understanding that the goal of coaching is to provide parents with an assortment
of possible actions that will help their child, which necessitates learning through
acting, not talking. We have solved this problem in the structure of the session by
following each action activity with an opportunity for reflection–evaluation and
goal setting, and then offering a discussion period at the end of each session. This
structure will be described in Chapter 6.
Supports for Coaches
Shifting the focus of early intervention from direct treatment to parent coach-
ing has major implications for early interventionists. Self-identity and self-worth,
personal sources of motivation for the work, professional competence, knowledge,
and skills are all on the line. Addressing children’s specific intervention needs in
natural environments rather than well-stocked and well-controlled clinical set-
tings requires a new way of thinking and working with children and parents, and
most therapists were never trained in such models.
Motivations for Learning and Adopting a Coaching Approach

Interventionists who are contemplating a move into coaching often express some
anticipated loss of the satisfaction they experience doing direct treatment. The
one-on-one relationship developed with children and the pleasure in seeing them
progress reflect the values of the people who choose this work as well as impor-
tant rewards for doing it. However, we have found the rewards derived from the
coaching relationship to be even more potent than those we experience in direct
intervention. And, these rewards occur at several levels.
In our conversations with interventionists who choose to make this transi-
tion, they frequently mention several aspects of coaching that motivate them to
learn the processes. They convey their initial enthusiasm and optimism as they
imagine the effects on child learning of caregivers who provide needed learn-
ing opportunities in everyday environments throughout the child’s routines and
activities, throughout the child’s waking hours. That is what motivates therapists
to become coaches.
For those who are developing fidelity to evidence-based NDBI practices for
the first time, they tell us that learning empirically supported parent-implemented
interventions provides a sense of security to them: that they will now have a set of
tools they know will help the children they serve in measurable ways. They note
a contrast between the clarity they experience with the specificity of practices
and tools that they are learning to use, compared to the feelings of confusion,
frustration, and sometimes failure that they experience in the face of a child’s poor
progress within the low-intensity interventions they have been using.
A third source of satisfaction and reward comes from the coaching experience
itself. When interventionists see parents and children constructively and happily
engaged and learning, they experience a sense of competence in being able to
impart critical skills to parents and, in turn, their children. Seeing the effects of
a parent’s efforts at home on a child’s development week-by-week is a powerful
reward, for both coach and parent alike. Watching parents build their skill set
and competently manage difficult situations with their children speaks volumes
about the coach. The changes in parents’ confidence, changes in parents’ views of
their children’s competence, and changes in parents’ attitudes about their child’s
future communicate powerfully to coaches about the efficacy and value of coach-
ing as a means of intervention. We should not overlook the positive experiences
that children have in these sessions, and their increasing pleasure in interacting
and communicating with their parents in a variety of everyday activities. Happy
children who are learning and progressing well may be the most potent reward and
motivation of all. Motivation and reinforcement are critical sources of change, for
coaches, as well as for children and parents.
Working Through Negative Reactions That Arise with Change
“I don’t feel like I am doing my job!” Catherine led off with this comment as the
discussion hour between her team and their coaching consultant began. “I feel like
I am paid to provide the best intervention that I can in the limited time I have with
this little boy. Just sitting on the sidelines and trying to help his mom learn how to
get his attention and teach him language feels like I am wasting precious time and
hurting his progress. It feels irresponsible!”
There are also negative emotions that arise as one moves into unknown terri-
tory—fears of failure, of incompetence, and of losing one’s professional identity as
an interventionist, clinician, therapist, or educator. For those who are in a position
to choose a coaching role, such feelings are likely inevitable, but they are mitigated
by the positive emotions that draw them into coaching practice. For those who
have been assigned to, rather than choose, a coaching role, these negative reac-
tions are not tempered or balanced by the positives that come from choosing to
take on this role. There may be anger, sadness, worry, and doubt, a sense of being
devalued for the work they have been doing and of losing their professional iden-
tity.
For those who have doubts and hesitancy about learning the coaching pro-
cess, we have found it helpful to work together in a peer group setting, where such
worries and doubts can be expressed among supportive others. As the group shares
their thoughts and feelings about their changed role, members find comfort in
knowing that others also have doubts, and they also learn what motivated others
to make the change—the anticipated rewards, emotional, behavioral, and cogni-
tive, that can result from this new way of working. The shared positive emotion
that results from this type of group conversation enhances motivation and positive
feelings among all members. And, sharing the negatives in a group helps to nor-
malize these feelings and realize that they do not need to hold one back. Sharing
among other adult learners enhances both the learning process and emotional ties
between group members.
The motives shared by those seeking to transition to coaching can influence
those who have not yet made this choice, because the professionals who opt to
work with young children and their families have a similar value system. They
want to help children; they wish for children to get the most assistance available;
they want to feel competent when promoting changes; and they are rewarded by
a child’s progress and positive relationships with his or her parents. Using group
learning situations that emphasize group discussion and interpersonal sharing can
stimulate the motivation to learn and showcase coaching approaches for those
being asked to make this change.
Leaders of a coaching group can embed opportunities for sharing individuals’
thoughts, feelings, and reactions into each of the learning activities themselves.
Allowing ample time for discussion throughout learning activities and providing
open-ended questions to the group stimulate reflections and sharing of personal
reactions to new concepts and skills. The group can discuss the process of change
itself and the positive and negative emotions that occur. Many interventionists
will already be familiar with the ideas of people like Erik Erikson and Jean Piaget,
who portray learning and development as a healthy process of resolving conflicts
between old and new ways of doing, thinking, and feeling. Without conflict, we
cannot grow.
Ongoing Interpersonal Support

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

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

she want to accomplish? What is the individual’s current skill set or knowledge
base? These are questions the coach must be able to answer to ensure that the
coaching process and learning experiences will address the caregiver’s goals and
will result in immediate feedback and measurable progress. Constructive behavior
change begins when adults are motivated by their intrinsic values, by something
they consider important. Adults learn what they choose to learn. This concept
was first identified by Knowles (1980), who was considered the “father of andra-
gogy” (adult learning). When coaching in parent-implemented interventions, par-
ents’ motivation stems from the desire for growth and change in their children. It
is in the coaching process that the parent realizes the change in his or her child’s
behavior will result from changes in parental actions. Thus, in addition to parental
skills, knowledge, and goals, the coach needs to learn about parental motivations,
which will help define parental reinforcers. How does the coach assess not only
parental motivation but also the motivations of each adult in the child’s familial
care team? Here are some questions to help you start exploring family member
motivation:
• “What would you like to accomplish?”

• “What motivates you to want to be here?”
• “What motivates you to want to try to learn something new?”
• “How is this current experience similar or different from other experiences
you’ve had when learning a new skill?”
We are accustomed to incorporating the principles of learning into our inter-

vention strategies with children. We establish antecedents that elicit specific
behaviors that are followed by consequences that can encourage or discourage
such behavior. Adult learning is just as much about antecedents, behaviors, and
consequences as is child learning, and in particular the coach needs to think
carefully about the consequences a parent may experience. What motivates and
is reinforcing to adults? Intuitively, we might assume that praise is reinforcing for
the parent, but as we discussed earlier, this is not actually the case. Why? Because
seeking approval of others is seldom the adult’s goal for participating in a learning
activity. Parents enter into coaching to help their child achieve progress and to
help their child learn. A child’s progress is a powerful reward. Knowing that it is
the parent’s interactions that have fostered their child’s growth is another pow-
erful reward for adults: providing a sense of personal efficacy, competence, and
confidence.
Parents often carry feelings of guilt and blame about their child’s autism, the
sense that they did something that might have contributed to it. Parents’ desire
to help their child, to do everything possible to limit the disabling effects of ASD,
and to promote their child’s improvement is the driving force behind their contact
with the coach. There is often another goal as well—stated or not—the desire
to replace the feelings of parental incompetence that the diagnosis of ASD often
creates with feelings of competence about parenting a child with ASD success-
fully. Knowing how to help their children counteracts feelings of guilt, blame, and
helplessness.
As the coaching relationship moves forward, parents become aware that their
daily interactions are facilitating their child’s learning; the session data demon-
strate this, as does their child, and this fuels their sense of parental competence
and self-efficacy. This confidence and knowledge base provide them with a strong
foundation for the role of child advocate that they will often have to assume in
choosing interventions, schools, classrooms, therapists, activities, and so much

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

Adults differ in the tools they prefer to help them learn. They know what modali-
ties and methods they typically use to learn something new, and what tools they
never use. Some prefer reading, some prefer online videos and materials, and
some are hands-on learners and prefer being shown how to do something and
help repeating it. Some want immediate feedback from the coach, whereas others
prefer to self-evaluate. Some want to know the reasons behind the skills they are
learning; others can’t be bothered with theory and explanation. The coach can
discuss all these options, as well as any other approaches that help parents absorb
and apply new information at the start of working together and also along the way.
We want to provide parents with the learning tools they need in whatever medium
they find most helpful. We ask family members how they learn new concepts or
behaviors: what they look for, if they have ever tried to change one of their own
behaviors, how successful they were, what worked and didn’t work. The answers
provide the coach with leads about what kinds of learning media and materials
may help the most. In our sessions, we incorporate a wide range of learning mate-
rials from the big and little sticky pads that Sally gives to families, to the refrigera-
tor lists in our parent manual (Rogers, Dawson, & Vismara, 2012). Materials that
help us individualize the experience for parents include: handwritten checklists,
videos from the session, our Help Is in Your Hands narrated video series, schedules
for home, journal pages, online resources of all types from various websites, a daily
note to complete and return to us, suggested role playing, and the various parental
skill checklists and data sheets of all levels of complexity found in this current
book as well as the parent manual (Rogers et al., 2012). Below are some questions
to help coaches identify parents’ learning preferences:
• “How do you like to learn? Do you prefer reading manuals or books, going
online for advice, or watching a YouTube video?”
• “Tell me about a learning experience you particularly liked, and one you
disliked. What was it about those experiences that helped you learn or
impeded your learning?”
• “On a scale of 1–10, based on your best and worst learning experiences, how
did today go?” If the number is low: “What can we do next time to help
our work go more to your liking?” If the number is high: “What did we do
today that made our work go so well, so we can hold onto that experience
next time?”
Conclusion
The goal of parent coaching in early ASD is to help parents learn how to use
their everyday activities to provide needed learning opportunities for their child.
To do so requires that parents make changes in their interactions across daily life.
Some resources for coaches to help support parents’ process of change have been
described in this chapter: the collaborative, reflective, nonjudgmental, conver-
sational and reciprocal style that the coach uses to engage and support parents;
specific methods to support adults as learners, including the motivation to learn
something new. Other factors that influence parents’ growth include a desire for
self-growth, the presence of a supportive environment, individual learning styles,
prior learning experiences, ongoing support to put new skills into practice, and
the positive consequences of new learning in everyday life. Effective coaching
in a parent-implemented intervention can give parents skills that may fit many
life dilemmas: assessing situations; goal setting; building a short term, step-by-step
plan for goal achievement, with ongoing evaluation to make changes as needed.
Now that we have described some of the tools and resources that interven-
tionists can use as they transition to the coaching role, we will address the actual
management of coaching to support learning for parents and for the child.
Chapter 4
The Coach’s Tools
Making the shift from therapist to parent coach is helped by the contents of the
tool kit that coaches bring to a session. The tools that we have found most helpful
in a coach’s toolbox are not complex, but they are necessary for us to do the job
well. Our toolbox contains a clipboard and pencil, a session schedule, a clock, a
tablet of paper, the parent manual, topic summary (“refrigerator”) lists, three data
checklists, a wide-angle perspective, an emotional thermometer, and a reflective
mirror (supervision), along with other tools.
Clipboard and Pencil
The clipboard is a dual-function tool. It holds and organizes all the pieces of paper
that the coach needs to get through the session. Unlike a folder or notebook, it
provides a surface on which to take notes or complete checklists anywhere in the
room. Setting up the clipboard for a session organizes the coach for the session
to come. Sequence the paper in the same sequence as the session activities and
mentally review them during this process. See Appendix A.1 for a list of the order
and content of Sally’s clipboard for parent coaching sessions.
Session Plan
Providing a session of parent coaching requires a session plan. This should include
time to set goals at the start of the session, time for two to three parent–child
activities, and time to reflect and plan again after each activity to generalize and
consolidate both cognitive and behavioral learning. It should also include time to
set up a home practice plan for the period until the next meeting. It needs a time
41
slot for parents to discuss the problems that weigh most on their minds. It needs
5 minutes for transitions in and out of the session. Finally, the therapist requires
time to take notes, to schedule the next appointment, and to take data during the
session. This is a lot of ground to cover in 60–90 minutes, and it is new territory
for coaches who are accustomed to providing direct treatment to children.
A plan and a schedule can be easily subverted by the tendency for coach and
parents to want to talk. Discussions might pop up at any point and derail the rest
of the session. In addition, pets, siblings, or other adults may walk in and out with
their own agendas, interrupting the ongoing interaction and plan. A hungry child,
a messy diaper, a child’s fall that requires parental comfort—these normal events
can take over much of the planned session time. What is the coach to do?
Over the years, we have created a specific session schedule that gives the
coach a clear temporal organization and a clear content plan for the session. The
plan includes time for an initial chat, for goal setting, for topic description, for
parent–child coaching activities, and for the repeated cycles of plan–act–reflect–
evaluate. It includes time for parents’ open discussion on a topic they are most con-
cerned about. This schedule can be briefly summarized by the coach before the
first few sessions as part of the transition from greetings into the warm-up activity.
Parents and child all learn the rhythm of the sessions over a few repetitions, which
helps the sessions move along as planned.
Here is how we think about the session structure. Each session begins with 5
minutes of settling in and sitting down, followed by about 5 minutes of parental
update on what transpired since the last session. Any arising topics unrelated to
the coaching topics are acknowledged but “parked” until the discussion period at
the end of the session. The coach ends this brief update by transitioning into the
parent–child work. The coach asks what material or issue from the last session the
parents have focused on with their child over the past week; then the coach asks
the parents to demonstrate what their “warm-up” activity to get the child ready for
the session looked like. It is in this warm-up that the coach takes stock of parent
fidelity and mentally notes the parents’ learning accomplishments and needs. A
very brief reflection on the parents’ work follows the warm-up, with the topic of
the day set, based on the parents’ readiness for new material as well as any need
for addressing skills related to the warm-up activity. The principles of the topic of
the day are reviewed with the parents using the related refrigerator list, and two
parent–child activities involving differing target activities (in which we record
data on the child’s progress) then follow, with coaching on the established topic
during each activity, followed by reflection, evaluation, and planning for the next
activity. Ten minutes at the end of the session are provided for discussion of any
“parked” issues and how to generalize the topic of the session into other activity
types that will occur for parent and child over the next week. Then a 5-minute
closing and transition take place for the parents, child, and coach.
Writing out the plan before each session and using it within each session have
the Coach’s tools 43
transformed our practice. It has allowed us to build more focused work into each
session than we had believed was possible at the start of our coaching practice. It
also allows us to preplan materials and activities so that child learning objectives
are specifically taught (more on this below). Parents have indicated their satisfac-
tion with this process in study after study, and we have documented the beneficial
effects on children in our published papers. We take notes on the session planning
sheet throughout the session and use the notated form to plan the next session (we
often do this immediately after a session is finished). Appendix A.2 offers a copy
of our “Coach’s Session Planning Sheet.”
Clock
Use a clock that can alert you to your schedule and help you maintain control of
the session and the plan. The best-developed session plan is only helpful when the
coach stays with the plan, and this is dependent on the coach’s constant atten-
tion to passing time. Managing time is most effective when the coach is facing a
clock and can see the passage of time throughout the session. If this is not possible
(carrying a travel clock and setting it up is an option anywhere!), then a program-
mable timer on a phone or watch is the next best option, but it requires setting
time for each activity block to be of maximum help. Parent, child, and coach all
need to experience a consistent routine in coaching sessions in order to maximize
parent and child learning, and that routine is the session plan carried out within
the time allotted, as dictated by the clock.
Tablet of Paper
Use texts, lists, drawings, or some other visual methods of supporting the parent
in the session and for the week ahead. A plan for the session can be written down
if it helps the parents during the initial conversational check-in and is referred to
throughout the session. Parents need a plan for the week that concretizes the goals
they have established with you (see the example “Parent Daily Practice Chart” in
Appendix A.3). The Parent Daily Practice Chart helps parents remember the
week’s targeted skills for parent and child, the
activities and locations in which these can be
practiced, checklists for noting which of these
behaviors occurred in a given activity on a given
day, and any other details from the session they
want to remember and review at home.
Some parents want to write down these facts
themselves, and other parents will describe the
details as the coach records them. The “Activity Categories” cartoon in Appendix
A.4 can help families identify the daily times and activities to carry out specific
learning routines with their child. An activity plan for completing a specific activity
like a meal may help parents remember what they are trying to do during an activ-
ity. Posting sticky notes in key locations at home can help parents remember key
aspects of the four-step joint activity to use in various activities, or of the many ways
to respond without directing or questioning, or levels of prompting, or the cues of
a multistep task like handwashing. Refrigerator lists (like those in Rogers, Dawson,
& Vismara, 2012; see Appendix A.5 for an example) help parents remember the
main points of particular topics. Some parents want to write notes on refrigera-
tor lists or in their parent manual during sessions. Certain parents desire detailed
supports, and other parents may be best served by watching a cell phone video
recorded during a session. Additional ideas for visual supports for parents include
recording points on their phone during the summary, YouTube videos that parents
have found (or the free video modules at www.helpisinyourhands.org), and visuals or
notes that a parent may generate during a session. One way or another, parents, just
like coaches, need ways to remember the plan that was generated from each session
and what they planned to practice, so they feel well prepared at the end of each ses-
sion and approach the next one with a personal plan and sense of readiness.
Parent Manual
Having a parent manual in hand provides ready access to the main points of each
strategy that the coach and parent plan to cover in a session. Keeping the relevant
chapter open during the brief topic discussion activity allows the coach to thumb
through the manual and fixate visually on the main points (likely highlighted) of
the topic. Our parent manual provides checklists and other organizers for parents
that help to concretize the topic points and assist with topic review at the end of
the session. The “refrigerator lists,” or other summary lists in treatment manuals,
summarize previously covered topics and points when a tune-up is needed. Par-
ents who cannot afford to purchase a parent manual for themselves (either used
or new) may obtain one from the provider agency or through financial gifts or
fund-raising efforts made for the agency. Parents can access an ESDM-related par-
ent website with publicly available materials (www.helpisinyourhands.org) as well
as videos on YouTube and other websites. Coaches may help parents remember
the content of a chapter in the manual or a session topic by recording videos on
their cell phones during sessions for reference and for sharing with other parents,
and child intervention providers (only with signed parental permission, of course).
When the coach has a manual and clipboard in hand and uses it in sessions, this
visually reminds the parent to have materials ready for sessions as well.
The Coach’s Tools 45
Copies of Topic Summary (Refrigerator) Lists
Keep two copies of a topic summary (“refrigerator”) list focused on the day’s topic
on your clipboard: one for yourself and one for parents. These give you a handy
way of referring to the main points of the topic throughout the session. They
allow you and the parents to take notes throughout the session that can be shared
with others. They can also be used for review, planning, reflection, and evalua-
tion. Referring to the refrigerator list is especially useful (1) following each activ-
ity reflection, as a way of tying each reflection to the teaching points; (2) as a
concrete planning and goal-setting tool for the parent before each activity begins;
and (3) to plan follow-up activities for parents and their child throughout the
week. In addition, keep one copy of the refrigerator lists you have already covered
on your clipboard as a memory prompt to facilitate any brush-up of skills that
may have slipped a little, and perhaps as part of your plan for the coming week’s
focus.
Three Data Checklists
One checklist is for the child (child data sheet or goal sheet), one is for the parent
(fidelity of implementation data sheet), and one is for yourself (fidelity of coaching
implementation tool). These simple data-keeping tools allow the coach to assess
child and parent progress during parent–child activities. Focusing on parent and
child learning targets assures that the coach concentrates on skill mastery for
the parent and skill mastery for the child. Gathering objective observational data
guards against sole reliance on a parent’s report or coach’s memory of change to
document the parent and child’s progress. Parent data need involve nothing more
than demonstration of the strategies being taught within the session parent–child
activities. While coaches can certainly develop checklists for themselves, most
evidence-based NDBI practices have a parent or therapist fidelity of implementa-
tion measure that can be used to quantify parent learning and performance over
time. Taking data while a parent and child are interacting requires some practice,
and we have found it easier to record data on one or the other, but not both, dur-
ing a particular activity. Appendices A.6 and A.7 are examples of parent fidelity
of implementation tools that we developed for different projects, both of which
have resulted in appropriate interrater reliability data. However, even something
as simple as the refrigerator lists or other topic lists that coaches create for parents
(see Appendix A.8, “Parent Self-Monitoring Checklist,” for an example) can be
transformed into checklists that help both parents and the coach maintain their
focus and assess progress.
The second checklist or data sheet captures child progress data on the targeted
skills that exist in the child’s IFSP, IEP, or other treatment plan. The ESDM child
data systems (Rogers & Dawson, 2010) provide a checklist model for recording
a child’s skills activity by activity and an example for coaches to use. When col-
laborating in a parent-implemented intervention, we write up approximately 12
objectives for a 12-week period based on goals the parents and coach have agreed
on, and we then break down each of those 12 objectives into five to six steps, with
Step 1 representing the current baseline skill and the final step the fully mas-
tered objective as written. Intermediate steps represent very small gains in progress
sequenced from baseline to mastery. Note that steps are not changes only in the
level of prompting; increasing independence and spontaneity are also typically
involved. The number of child actions often increases as well, as skill refinements
as immature performance becomes more mature. (For detailed descriptions of this
process, see the ESDM manual [Rogers & Dawson, 2010].) However, any system
the interventionist already uses for tracking a child’s daily progress on objectives
suffices.
Examining a child’s progress over a session requires that activities be chosen
that will allow for those skills to be demonstrated and taught. The child data
sheet guides the therapist in planning the content of the day’s activities: Pretend
play? Three-piece or five-piece puzzles? Books with pictures that highlight animals
(for animal sounds), or verbs, or body parts? Part of the planning process of the
session includes planning the types of activities to be focused on, and the materi-
als needed for them. While child progress is not as important a focus early on in
coaching given the emphasis on parent learning, as parents approach mastery of
their implementation skills, then child learning becomes a primary focus for them
and the coach. However, it is highly motivating for parents to hear the coach point
out gains the child has made as measured by the child data sheet. The parents’
greatest reward is their child’s progress, and that information is dependent on the
coach recording child data and reporting them from time to time.
The final checklist is the coach’s implementation checklist. We have provided
two versions of this based on the approach laid out in this text (see Appendices
A.9 and A.10). For a beginning coach, the list of coaching behaviors to be cov-
ered in each part of the session helps enormously, guiding him or her through the
activities and to remember all the parts. For more experienced coaches, the tools
that measure the coach’s skill levels generate progress data to help assess growing
strengths and ongoing areas for further development. These are most useful when
completed immediately after a session, while all materials are fresh in everyone’s
mind. Some coaches even perform this task in their car as they leave family homes
or child centers; others do it in the office after families leave. Taking intermittent
data on oneself, and recording sessions here and there to share with another coach
for his or her ratings, are part of the process of learning and mastery of coaching
skills.
Wide-Angle Perspective
A wide-angle perspective helps the coach maintain sight of all that happens during
the session: the flow of time, the goals of the session, actions of the parents and
child and their meanings, changes in the environment that are affecting each per-
son and the flow of the session, and family events going on outside the session that
are affecting parent and child inside it. The coach needs a binocular viewpoint,
with one lens focused on the overall sequence of events taking place and the other
on the target behaviors of the parents, child, and coach that are planned for the
hour. The coach’s attention has to be flexibly moving and shifting across multiple
environmental stimuli as well as inner thoughts and feelings occurring throughout
the moving parts of the session. The other tools in our tool kit help with this task,
especially the clock, the session plan, the clipboard, and the various checklists.
The circular reflective processes of plan–act–reflect–evaluate, laid out in the ses-
sion plan, that occur throughout the parent coaching session allow the therapist
to maintain this meta-analytic perspective through the ebb and flow of the hour.
Emotional Thermometer
You need a thermometer so you can take your emotional temperature frequently
across the session. Parent coaching is intense cognitive, attentional, social, and
emotional work, and it generates many reactions in the coach, which if unrecog-
nized can affect the work in unplanned and sometimes negative ways. An emo-
tional thermometer keeps you in touch with your feelings as the hour transpires
and helps you monitor and process any responses that might interfere with your
work: growing frustration, irritation, pressure, hurriedness, overinvestment or
attachment to others in the room, feelings of inadequacy, lack of control, or doubt.
Some signs that your own reactions are getting in the way of the work are repeated
feelings of anger, avoidance of a specific family or child, overinvolvement with a
child or parent, evaluative descriptions of families to your colleagues (“great fam-
ily,” “challenging family to work with,” “dread the sessions with this family”), and
expressions of overly intense emotion, either positive or negative, when discuss-
ing your work with a particular family with a colleague. These are all clues that
your own goals or motives may be interfering with your ability to listen, observe,
and evaluate the interactions taking place in front of you. You are here to meet
other people’s needs, not your own. You need to tune into those feelings, reorient
yourself to the needs of your clients and the work at hand, and then revisit these
feelings after the session. The thermometer readings can also help you recognize
the need for consultation and/or supervision to understand and regulate your emo-
tional responses to a client or topic that frequently triggers you.
Reflective Mirror (Supervision)
Working with parents and children together is intense work! The minutes fly
by, and half of what you planned to cover is squeezed out by the clock. Moving
through the session requires you to make decisions constantly, some of which you
will realize were not the best judgments. Psychotherapists who treat adults typi-
cally seek out opportunities with a peer, supervisor, or therapist to review their
own actions and feelings within the treatment they are providing, objectively as
well as subjectively. Parent coaches need the same opportunities. One advantage
of an interdisciplinary team approach is the ability to share with the team and
grow from their observations and experiences. While many team meetings allow
for brief descriptions to the team of what is happening with a family and child,
coaches also need time for deep reflection on the emotional impact the work is
having on them, and the interpersonal processes occurring during the treatment
session.
Reflective supervision provides a space in which to think through and share
therapeutic decisions and reactions and to consider the listener’s thoughts and
questions. Such reflective practice helps to prevent one from operating from blind
spots or emotional reactions. It can provide a safe, supportive, listening environ-
ment for coaches to work through a challenging session; to consider and evaluate
all the different relationships, motivations, and spoken and unspoken messages
that occurred; to determine how these are helping or hurting the coaching pro-
cess, and thereby helping or hurting the intervention process. The goal of reflec-
tive supervision is, first and foremost, insight into the inner processes occurring
within each person in the session. When the coach understands each person’s
feelings, strengths, and needs, as well as the established treatment goals and tra-
jectory, then the coach has a firm base for making coherent decisions moment by
moment about what to initiate and how to respond. Enlisting the mental health
professional on the team to help the group learn the reflective peer supervision
process provides an in-house solution to the needs that all parent coaches have
for support for the interpersonal aspects of their work with families and children.
Other Tools
Mindfulness Practices
Coaching sessions take place within a context of at least three people’s lives: the
caregiver’s, the child’s, and your own. It’s not uncommon for a coaching session
to occur directly after a stressful or otherwise distracting activity that is part of
one’s workday. Yet being a coach requires you to be fully present, maintaining an
attitude of acceptance rather than control, with a focus that is outward rather
than inward. Mindfulness is the ability to be fully present in the moment, focused
on the situation at hand, and what you are thinking, feeling, and doing moment
by moment. It means not holding onto, reacting to, or becoming overwhelmed
by your own or others’ emotions. Emotions are simply accepted for what they
are, without judgment or an attempt to immediately change them. Being present
means you are aware of your own feelings and how they may affect what you do; it
also means being aware of the parents’ and child’s subtle emotional behaviors and
being ready to reflect those with the parents in an accepting and nonjudgmental
way.
As coaches, we three authors have all learned to use mindfulness and center-
ing practices to mentally prepare for starting a coaching session and to recenter
after a session. A centering practice can be as simple as a few minutes of deep
breathing before or after a session, during which the coach mentally lets go of the
stresses of the day and focuses his or her attention on the work at hand. Taking
a moment to calm your emotions, your mind, and your breathing before a session
leaves you in a state of both alertness and calm. The benefits are many. First, you
as the coach will experience less stress both during and after coaching sessions.
Second, parents and the child will consciously or unconsciously be aware of your
calmness, openness, and nonevaluative stance, allowing the parents to feel more
comfortable expressing themselves and reducing any feelings of anxiety or embar-
rassment that some may experience when being observed, or when their child is
upset or not “performing.” Third, because your mind is not filled with distracting
or self-judgmental thoughts, you will be more able to take in all that happens dur-
ing the session and make better decisions moment by moment.
Motivational Carrots
Skilled coaching supports increasingly skilled, motivated, confident parents and
measurable progress in children. However, behavior change is not a steady process,
regardless of the skill level of the person trying to change his or her behavior and
the skill of the coach. As the literature and personal experience attest, adults
involved in weight loss and fitness programs, changes in drinking or smoking pat-
terns, and other behavior changes demonstrate greatly fluctuating motivation
and behavioral transformation week by week and sometimes day by day. Moti-
vation and goal attainment involve both emotional processes (reward seeking,
pain avoidance) and cognitive processes (inhibition, planning, self-monitoring,
redirection), and they are affected by everything—sleep, hunger, illness, disrup-
tion in routines and schedules, visitors, relationships, and stressors of all kinds.
Motivation problems arise in parent coaching just as they do in every other type of
process involving adult behavioral change. However, a parent’s decreased motiva-
tion for incorporating intervention approaches into daily activities with his or her
child results not only in parental lack of progress and learning, but also in the loss
of learning opportunities for the child in everyday routines with caregivers—the
child’s greatest learning platform. Young children’s progress is threatened when

their parents lose the motivation to work with them at home.
In virtually every parent coaching relationship, there will be times when par-
ents express low motivation for following through on intervention plans. While it
is tempting to use a cheerleading approach (recounting all their successes, prais-
ing their work, etc.) or to reassure parents that these feelings are normal, neither
of these responses actually show that the coach has listened and heard what the
parent has said. Empathic listening is the first step to take. The second is to turn
to effective ways to address motivational challenges. One approach in psychology
literature is motivational interviewing (MI; Miller & Rollnick, 2012), which offers
a set of tools to help people move along the change process or resume that path if
motivation has flagged. Just as a treatment fidelity tool helps coaches know how
to address child learning, so, too, does MI help us support parents who experience
decreases in motivation or a lack of motivation in the first place. MI provides
coaches with the tools for both assessing motivation and for supporting increased
motivation to move ahead.
Writings in the MI literature and related work involving the stages of change
(Prochaska, Redding, & Evers, 2002) give a helpful evidence-based approach for
coaches to assess the nature of motivational difficulties and to tailor small and
achievable steps that parents can take toward action. An ESDM coaching version
follows the Prochaska et al. (2002) stages of change: beginning at or before the
first contact (not ready to begin), to a point after the first contact (consideration),
to when decision and preparation begin, to the initiation of active coaching in
ESDM, to the mastery of fidelity and routines, to a point at which the techniques
feel “natural” or “effortless.” Times of lowered motivation, competing priorities
(e.g., holidays), changes of setting (e.g., vacation), and other disruptions (e.g., ill-
ness), with difficulty resuming embedded interventions, are marked as possible
relapse points. At these times, coaching and intervention may resume at the point
where they leave off, or major motivation lapses (not ready) may require begin-
ning the entire cycle again. Since the adoption of ESDM in home routines repre-
sents a long-term lifestyle change for the family, relapse periods are a normal and
expected part of the process until habits become so deeply ingrained that they
feel like a natural part of everyday life and are easy to resume after any disruption.
We have found MI tools to readily blend with parent coaching, particu-
larly when families experience difficulty putting the intervention into action at
home. Our team uses a transdisciplinary approach similar to what we describe in
Chapter 6 for role sharing among interventionists of different disciplines work-
ing together to support families. One way to bring MI into a group’s skill set is to
have a team member who represents the mental health profession share his or her
knowledge of MI, or begin training in MI via workshops, webinars, supervision,
and other training experiences, and initiate self-study and peer supervision of MI
and the motivational cycles of change. In our own intervention group, we sought
Possible
relapse/
recovery Not ready
point
Considering
Preparing
Embedded/
maintaining
Beginning/
learning
Possible
relapse/ Mastering
Possible
recovery relapse/
recovery
Figure 4.1. An ESDM coaching version of the Prochaska et al. (2002) stages of change.
to learn the principles of MI using the above strategies and started to apply the
techniques within our coaching sessions when needed. We used peer supervision
and clinical review meetings to learn some of the strategies via videos, descrip-
tions, and session data. Over time, all our team members’ skills in MI grew, and
we eventually incorporated it into one of our research studies (Rogers et al., 2019)
and our basic way of practicing.
We use three sets of MI tools in our coaching process with families. First, we
have found that the careful work done on indirect verbal and nonverbal expres-
sions of motivation in adults has helped us listen for and “hear” parents’ motiva-
tional messages more clearly. It involves attending with our whole body; using
direct eye contact, positive facial expressions, an open body posture; and main-
taining awareness of our proximity to the parents—all to convey interest as we
listen, to confirm the meaning of their words, and to prompt our next action.
Sometimes this means encouraging periods of silence to allow parents to reflect
and organize their thoughts. It is important to be comfortable with silence and to
resist the urge to fill every moment with conversation. When parents feel heard
and understood in the message they seek to communicate, they are more encour-
aged to continue sharing.
Second, the dialogue process also sheds light on where parents fall in the
stages of change or how ready, willing, and able they are to change their behavior.
The stages of change are precontemplation (change on the back burner), contem-
plation (considering change), preparation (actively preparing for change), action
(enacting change), maintenance (settling into change), and relapse and repair
(when change falters; Prochaska et al., 1994). These stages have given us a very
helpful tool for identifying where family members are at different points in the
motivational cycle, especially useful when there is a mismatch among different
family members concerning their views of the situation. One parent may be quite
motivated to learn new ways of working with his or her child at home, whereas the
other parent still wonders if the child’s development is problematic or not. When
the coach aligns with the parent who is motivated to move ahead, the parent who
has not yet reached that point tends to be left out of the process, or to feel unim-
portant, adding additional stress to the relationship. Knowing where parents fall
on the stages of change coupled with MI techniques allows the coach to under-
stand and accept each parent’s current position, while helping the various caregiv-
ers recognize their common ground and shared commitment to the child. Parents
are less likely to withdraw from the intervention process when their points of view
and interactive skills with their child are acknowledged, respected, and valued. As
the child acquires skills over time, the difference in viewpoints between parents
often lessens, particularly when the coach is careful to attribute a change in the
child to both parents’ efforts and interactions.
MI’s third very helpful contribution to coaching skills is the recognition that
relapse is an expected part of the change process, not a signal of failure. People often
cycle through different stages, from contemplation (being ready to move forward)
to precontemplation (being on the back burner) or from action (doing) to relapse
(a slip), before reaching their goals. When this happens, it is important to use the
opportunity to reflect and regroup before moving forward. People often have ways
of responding to relapse in other domains and a history of partial success to build
from. The dialogues for recognizing and addressing relapse without casting it as
failure are extremely helpful for both the coach and the parents.* Parents may feel
vulnerable or shaken by the experience and unsure what to do next. They may
need help making sense of what happened. The coach is there to listen and to help
parents see this moment as an opportunity to learn something, rather than expe-
rience failure. The coach now needs to help parents renew or recommence the
cycle of change. The cycles involved in identifying and setting goals, working to
achieve them, making good progress, running out of steam, or getting ambushed
by a different set of problems, taking a rest, picking up and starting again—these
cycles require a set of tools and a body of knowledge that are great coping tools for
all kinds of life situations.
*There are many workbooks, books, online and website materials, trainings, and chapters focused on MI for
people receiving coaching for all kinds of behavior change goals. These tools are full of examples of such
dialogues, which are generalizable to parent coaching situations. In addition, see Appendix A.11 for a chart
that describes some motivational coaching tools tied to the stages of change that can provide help for inter-
ventionists working with families.
Humility
Being involved with families so closely leads easily to the coach’s sense of what
underlies a child’s behavioral problems and how the parent’s omissions or commis-
sions are supporting the unwanted behavior. But what might seem to be a simple
change in parenting behavior from the coach’s point of view may be extremely
difficult for the parent to carry out in the way the coach has suggested. When we
observe in session that a parent knows how to implement a strategy effectively
and correctly, and see in the data that the strategy is not being used, it is easy to
begin placing blame on the parent’s shoulders. “If only the parent would . . . ” is the
lead-in phrase that parent coaches have doubtless expressed hundreds of times.
When these feeling arise, we need to quickly reflect on our own efforts to change
our own behaviors involving our family members or ourselves, and to be humbled
by the enormity of the task of altering an established pattern of interaction that
has occurred hundreds or thousands of times. How often have we each tried and
failed to change our interactions with people close to us? Any change in a child is
the result of huge parental effort, and many efforts to change result in naught, as
we all know from our personal lives. Keeping this in mind helps us to reign in our
expectations, to focus on small steps, and to protect ourselves and the parents from
the negative effects of our own hopes, disappointments, and negative appraisals
with regard to the parents’ efforts.
Clear Boundaries
Coaches’ entry into the life of a young family, and frequently entry into their
homes, is a unique situation for people trained to carry out clinical practice.
The structures that typically support the boundaries of clinical and intervention
work—the office or classroom, the office staff, the billing, and the separation of
the clinician from other types of relationships—are often challenged when you
are working in people’s homes. Intimacy occurs when you sit at the family table
during a family meal in order to observe a child and the child throws food at you,
when you sit on the floor in a coaching session and the child comes over and kisses
you, when you see the family in a messy house, with their pets needing atten-
tion, children in diapers, family members interrupting. You have to think carefully
about your response to the social overtures that families may make—offers of food
or drink, invitations to birthday parties or school graduations, gifts at holidays,
parental hugs instead of handshakes. We have had to inhibit gestures of help or
care that would be appropriate within another relationship but are not appropri-
ate in a parent coaching relationship. When an unusual request or situation arises,
it’s important to consult with other professionals from your same discipline, use
peer supervision, and consult your own disciplinary ethical standards in order to
determine the appropriate professional response. Many agencies also find the need
to spell out clearly what agency staff members can and cannot do with families to
assure that professional boundaries are maintained, and that we as professionals do
not compromise the objectivity needed to make appropriate decisions for deliver-
ing care. We are professionals working in a paid relationship with clients, and all
of our behaviors with family members must reflect this relationship.
Easy Laughter
To quote the Scottish poet Robert Burns (from his 1785 poem “To a Mouse”),
“The best-laid plans of mice and men go oft awry.” There is only so much control
that the coach can wield in a treatment hour. Sometimes the doorbell rings, the
dog throws up, the child falls asleep, the school bus arrives, and the hour is sud-
denly over. Providing treatment at home is great for generalization and tough for
environmental control, and all we can do is laugh and say, “That’s life with little
kids. How can I help?” Appreciating the complexities of everyday life for the par-
ents eases potential feelings of guilt or demand they may have with regard to the
coaching situation and helps the therapist relax about the planned session that is
not going to happen, given all the degrees of freedom that exist when providing
clinical treatment inside a family home with a young child. These unplanned and
unexpected experiences occurring within one intervention hour should increase
coach’s appreciation of, and respect for, what it takes for parents to apply interven-
tion techniques in everyday life, especially when such techniques are new and
require thought and planning.
Problem Solving
One of the primary tools of coaching is skilled problem solving. A coach needs
to rapidly generate problem-solving strategies with families and test them to find
solution(s) to the problems that arise during a session. Below, we share these meth-
ods and some examples of their use.
Defining the Problem Behavior as the Best Solution to Helping

the Child Reach His or Her Goal
When we work with children with ASD to address a challenging, or less than
desirable behavior, the first step is to identify and understand its function so that
we can teach the child a more acceptable and efficient way to meet his or her goal.
We need to take a similar approach with families, so they learn to think within
this functional, adaptive framework. We help families become detectives to inves-
tigate, extract, and characterize the problem behavior and the child’s underlying
goal before putting anything into action. Current behavior versus what behavior
the parents wish was happening, who is involved, where the unwanted behavior
occurs, when it is likely to happen versus not happen. They need to understand
the when, where, why, how, and with whom problem behaviors happen to develop
a different plan of action.
The parents describe to the coach that their daughter frequently screams and cries
when they walk out of the house without her. The coach asks them to elaborate
further. What leads up to the parents opening the front door? What is said, or not
said, to the daughter? What is she doing when they leave? What happens after she
becomes upset? As the parents discuss the behavior further with the coach, they
agree that the child does not understand where the parents are going or why. The
transition may feel abrupt and sudden, making it difficult in the moment for her
to understand what is happening. The parents want to develop a plan to help the
child through these transition moments and not feel guilty when they need to leave
her at home.
Generate Ideas
Once parents can define the unwanted behavior and the child’s goal, the coach
and parents can together brainstorm about what behaviors the parents prefer the
child use instead to communicate his or her goal, with this desired behavior even-
tually substituting for the unwanted behavior. Is the desired behavior as easy for the
child as the unwanted behavior? As efficient for the child in terms of goal attain-
ment? The coach uses skilled communication strategies (described in the coaching
section) to listen and to help parents consider the desired substitute behavior, and
how to bring it into the child’s repertoire in terms of possible steps to take before,
during, and after the antecedent associated with the unwanted behavior.
The coach asks the parents what actions they have tried before with their daughter
when they attempt to leave the house. The parents explain that they always say
goodbye to her and tell her where they are going and that they will be back. Usu-
ally, the daughter is doing something when they say goodbye, such as eating a meal,
watching a video, or playing. When the coach asks the parents what they might
change in their approach, the parents explore the idea of giving their daughter more
notice and a fuller explanation of why they are leaving. Initially, they worried that
telling her in advance might cause her more anxiety, but now they think it is impor-
tant to give her more warning and prepare her for what will happen. They realize
that trying to explain to her what will happen in the middle of an ongoing activity,
especially when she gets upsets quickly, makes it difficult for her to listen, process,
and understand because she is not in a calm, attentive state. The parents talk about
different options and strategies to increase her attention and comprehension of their
need to leave the house, as well as her coping skills to work through any agitation
or upset.
Decide on a Plan
The coach and parents jointly consider the possible solution or combination of
solutions. They evaluate the ideas according to the following criteria: how to
implement the solution(s), how long each solution will take, and what constitutes
a desired outcome(s). They then decide on the best course of action based on their
evaluation.
The parents and coach work out a plan to help the daughter understand and cope
when her parents say goodbye. The parents pinpoint bedtime as the time when
they have their daughter’s full attention to talk about what will happen when they
leave the next day—where they need to go, what they will do, and when they
will be back. The coach and parents explore the idea of using visuals to turn the
explanation into a story that may improve the daughter’s interest, as well as her
comprehension and coping. The parents decide to use pictures of where they will go
and what they will be doing to make a book. Their daughter likes books, so she will
perhaps be more likely to pay attention to her parents’ explanation and participate.
The coach also encourages the parents to think about choices they can offer their
daughter, such as what she wants to do while they are away and what she wants
to do with them when they return. This may help to focus her attention on what
she can control (i.e., activities to do with and without her parents) than what she
cannot (i.e., her parents leaving). The parents think this idea will work, and they
talk about different activities they could ask their daughter to choose between. They
may also use pictures for the choice of activities if that will increase her excitement.
The parents and coach decide to reevaluate the plan in 2 weeks. They define initial
progress as the daughter making choices (with or without pictures) of what she will
do while her parents are away from the house and when they return. They feel it
is OK if their daughter exhibits some upset when they depart, but not to the point
where they cannot console her or comfortably leave the house.
Implement the Plan

The coach and parents decide who will do what by when and then carry out the
agreed-upon actions. It will help the parents greatly for the coach to be present
when they first implement the strategy to be sure it goes as planned and to tweak
it as needed so that the parents have carried it out successfully and know exactly
what to do before the coach leaves.
Over the next 2 weeks, the parents try out their plan with their daughter. At bed-
time, they tell her the story of what will happen the next morning when they say
goodbye—where they will go, what they will do, and when they will be back. They
show pictures on their phone of where they will be going, to engage her into talking
about and understanding the day’s events. They discuss what activities she can do
while they are away and show her pictures of those, as well as what she might like
to do together with them when they come home. The parents also present her with
a digital watch and explain how the numbers on the watch work to introduce the
concept of time. They focus her attention on the numbers that represent the time
they will be back home; they show her how an alarm will go off at that same time.
In the morning, they remind the daughter of their impending departure while she
gets dressed and again at the breakfast table. They emphasize the choice of daytime
activity that she had made the night before, so her attention remains focused on
what she gains (i.e., through the power of her choices) and not what she loses (i.e.,
her parents leaving). When the daughter fusses the first few mornings, her parents
repeat what she will do while they are away; what numbers she needs to wait for
on the watch, signaling when they will return home; and what they will do together
once the parents get home. She calms down and is able to let her parents leave.
When one or both parents arrive home, they are quick to greet their daughter and
engage in her choice of activity. After the first few days of this routine, the parents
take turns at night telling the story of what will happen the following morning and
reiterate the rest of the plan.
Evaluate the Plan

The coach needs to help the parents find ways to assess the effectiveness of the
solution(s), since memory alone is such a faulty tool. Generating a very simple data
system that parents can carry out, and having them practice it with the coach, is a
necessary part of the behavior change plan. Parents need to stop the intervention
if the data indicate that it is not effective, and the coach needs to remain involved
so that ineffective strategies do not continue and parents do not become discour-
aged and abandon their efforts before the plan gets fixed and leads to progress.
The coach and parents meet 2 weeks after the plan’s implementation to review
how their daughter has responded so far. The parents see positive changes in their
daughter’s development as a result of the plan. They describe her avid participation:
helping to tell the story of what will happen the following day and using her watch
during the day. She is able to cope and say goodbye to her parents without serious
upset, and she welcomes them home with excitement so they might engage in her
choice of activity. The parents feel confident that the plan is working. They do not
foresee making any changes to the plan at this time and want to continue with the
established strategies. They would also like to consider whether similar strategies
may help their daughter cope with other difficult transitions, such as when she needs
to go someplace new or her parents take a different route of travel to a familiar place.
The coach and parents decide to finalize that new plan at the next session.
Conclusion
Coaching parents to help their young children with ASD is exhilarating, intense,
demanding work. This chapter described a wide range of physical, cognitive,
emotional, and social tools to help coaches maintain their motivation for doing
this important work for the long haul. We also outlined how parents might apply
the tool of effective problem-solving methods with regard to their child. Finally,
coaches need tools to replenish themselves so that the ongoing stress of caring
for others who are in such need of care does not lead to distancing, devaluing,
pessimism, and other defensive reactions to the pain that families experience and
helping professionals feel.
Chapter 5
Assessment, Goal Setting,

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

services for their child with ASD for many hours per week as their first inter-
vention. Other families find that their first intervention will involve a few hours
per week (or less) with an early interventionist. This low-intensity intervention
approach has two sets of practices behind it: (1) the typical outpatient therapy
59
delivered by allied health professionals, speech and language coaches, psycholo-

gists, occupational and physical therapists, and others, and (2) the publicly funded
from birth to age 3 service delivery model resulting from Public Law 99-457, built
on a model of parent and family guidance and support, discussed in Chapter 2.
The science that led to the passage of this law involved either parent-implemented
interventions for young children with developmental disorders or an intensive pro-
fessional delivery model (with both approaches using parent teaching and coach-
ing; see Ramey & Ramey, 1998, for a review of this literature). For young children
with or at risk for ASD, the only evidence of the effects of low-intensity services
comes from parent-implemented interventions, a literature that is fairly new and
not typically familiar to parents (Landa, 2018).
Some families first meet their coach as part of their enrollment with a public
intervention service agency. These families may receive a phone call or text to
schedule a home visit with a coach who has been assigned to them. The fam-
ily may or may not have met this person previously, and this may be their very
first experience with an interventionist. Other families may be actively seeking
out a coach, contacting professionals based on others’ recommendations or their
own research, requesting an initial appointment, interviewing coaches, observing
them work with their child, and deciding with which coach they want to work.
In this scenario, parents actively choose their coach and might also pay them in
a fee-for-service model. Regardless of the route taken, parents most likely expect a
traditional hierarchical relationship with this professional, a relationship in which
the professional will instruct the parents and take responsibility for the inter-
vention. Thus, in this initial contact, the parents’ expectations and the coach’s
expectations are at odds, and the coach needs to let the parents know what work-
ing together will mean. The first meeting between a family and a coach provides
a crucial opportunity for inspiring active parents and a supporting professional.
Parents typically begin the intervention process after receiving a diagnosis of
ASD or ASD risk for their child. According to parents, the period before and dur-
ing a diagnosis is one of the most stressful and emotional time for them (Bonis &
Sawin, 2016). Emotions may become more complex as parents search for services
and adequate professional support and attempt to manage the many appointments
and communications with providers (Neely-Barnes, O’Hare, Powers, & Swick,
2012).
The first contact with an interventionist is an intense experience for the fam-
ily. Although the parents have requested treatment, they may still be grappling
with their child’s diagnosis and all that the process of putting in place a treatment
program entails. There likely has been a prolonged period of worry that precedes
the diagnostic evaluation and motivates it, including the waiting period for their
child to receive a diagnostic evaluation, the evaluation and feedback process itself,
the financial impact of missed days of work, and concern about how each person
in the immediate and extended families might react to the presence of autism in
Assessment, Goal Setting, and Treatment Planning 61
the family. Parents may have unanswered questions; they may have been given
information that was not helpful or did not reconcile with what the family believes
is true for their child. Such experiences raise doubts about professional helpfulness
and expertise.
Moving into treatment is a life-changing transition for families: a transition
from life as lived to life into the new and unpredictable world of autism and devel-
opmental disabilities. It can be isolating, confusing, and overwhelming as the fam-
ily learns about and navigates many different treatment options that might help
their child. There are many questions, many feelings, many ups and downs, and
many changes and new demands on a young family. It is a period of sadness, worry,
grief, and anxiety about what lies ahead for the child’s development and future.
The family’s coach becomes part of their support system in this new world.
Professionals sought out by the family after diagnosis hear about what has
occurred from the family’s perspective and can support the family at the start by
being ready to listen and to be present and accepting during a very emotional
time. Sometimes the professional who will assume the coaching role was also part
of the diagnostic process and may have previously provided feedback to the parents
about the evaluation results and diagnosis. The parents already know this person
in one role, but the diagnostic process and its relationships often vary greatly from
the coaching process and its relationships. This shift from the authority figure that
assessment entails to a coach and partner needs to occur so that a positive working
partnership and alliance between coach and parents can be forged. In situations
where it is clear that the evaluator will become the parents’ coach, the transi-
tion might go more smoothly if the evaluator uses a family-centered approach
and builds a partnership-of-experts relationship with the family during the assess-
ment process. Having the parents demonstrate their child’s skills and preferences
in play interactions during the assessment; explicitly voicing the shared-expertise
roles; using a reciprocal style of engagement with parents; giving parents the lead;
acknowledging in many ways that the parents know their child best by active
listening, showing them respect, and incorporating the parents’ perspective and
knowledge into the evaluation process and report—these are all methods for initi-
ating a type of relationship that will aid the transition to coaching.
Getting to Know Each Other

For some families, an intervention agency will select their coach. For other fami-
lies, the family will take responsibility for choosing that person. Regardless of how
the parent and the coach first come together, the coach needs to begin to fos-
ter this new partnering relationship by stepping away from an authority role and
handing the parents the “floor,” while listening and gathering knowledge of their
values and priorities, their aspirations for their child, their fears and their hopes
for what lies ahead. It will help greatly if both parents or other primary caregivers
are present at this first meeting. Important information is being shared on both
sides and important decisions are being made, and those who will be partnering to
raise the child need each other’s support. The coach also needs to meet the people
directly involved in the child’s everyday life and begin to build relationships with
the family.
In this very first contact, the coach needs to obtain several kinds of informa-
tion in order to know how to proceed:
1. The coach needs to hear from the parents about what they are seeking,
what they are most worried about, in what areas they most want to see
change in their child, which other professionals they have already seen and
what they have been told, and what the biggest day-to-day challenges are.
2. The coach needs to learn something about how the adult family members’
relationships are being affected, who the main players are in the child’s
life, the child’s day-to-day care schedule, and the nature of family activities
within and outside of the home.
3. The coach needs to see the child in action; know what the child likes to
do; comprehend what the child understands about people, objects, and
communication; learn how the child communicates wants and desires;
and observe how the child responds socially.
4. The coach needs to see the parents and their child interacting together.
How do they play together with toys? Without toys? How do they negoti-
ate feeding? How do they respond to each other’s cues? What emotions are
apparent and shared by each in their interactions?
While the coach needs to gather this information in his or her first contact
with the parents and their child in order to understand what the family is seeking,
the parents also need to learn what the coach is offering:
Possible Questions the Coach Might Ask

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

1. The family needs to hear about the parent-

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

The process of establishing the child’s short-term goals together is the parents’
next experience of the active parent–coach partnership. For this, the coach typi-
cally needs some information about the child’s current skill levels and behavior
patterns. In our own P-ESDM practice, this is achieved as part of the ESDM Cur-
riculum assessment process and our “P-ESDM Infant–Toddler Curriculum Check-
list” (provided in Appendix B). Regardless of what type of assessment approach
a coach uses, the assessment and goal-setting process occurs within a reciprocal
relationship between coach and parents. The coach demonstrates that parent–
child interactions and parental knowledge form the foundation of the intervention
by including the parents as partners in this assessment process; using an everyday
activity framework to work through the assessment; having parents play with their
child on the floor in various ways that illuminate the skills the coach needs to
assess; asking the parents questions about what they observe at home; having
them demonstrate eating, reading, and other routines as carried out there. This
working together to capture the child’s current abilities in many areas illustrates to
the family how the parent–coach partnership will work in the weeks and months
to come.
The treatment assessment may be completed during an office or home visit.
If the assessment occurs at home, the family’s own materials can be used, but the
coach needs to ensure that the needed materials will be available regardless of
location. This activity takes at least 1.5 hours, with the child and parents allowed
ample time for set-up, adult–child interactions, parent–coach interactions, anno-
tation and scoring, discussion, and clean-up. If additional time is needed, it can
be given during the next contact in the transition to treatment. However, unlike
standardized assessment, this kind of curricular assessment is focused on identi-
fying the next steps of learning—the child’s proximal zones of development in
various domains, and this zone is marked by the transition from successes to fail-
ures in developmental sequences. This does not require that every single item be
administered. Videotaping the assessment is not necessary, but for someone new
to coaching, doing so will be very helpful for self-assessing the quality of parent–
coach interactions and checking scoring later on. Showing this same video at the
end of parent coaching can be a thrilling experience for parents as it will docu-
ment all that has been accomplished via coaching.
The Environment
Because of the intervention’s focus on everyday activities, it helps if the assessment
space has home-like characteristics so that interactions within various play and
care activities can occur in a variety of places, as they do at home: on the floor, at
a child-sized table, on the couch or the coffee table, in a high chair, atop cushions
on the floor. The coach sets up various activities for the parents and child, and
supports transitions between the various activities needed to probe assessment
items.
The Assessment Process

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

A comfortable, reflective closing of the assessment session will help set up the
next coaching session. Assessments often increase parents’ anxiety about their
child’s future. Participating so directly in the assessment can leave parents feeling
very exposed, observed, and evaluated. The coach can help allay parental worry
by inviting parents to share with the coach what they saw and experienced, and
for the coach to share and reflect on his or her own personal experiences as well.
Parents need to hear from the coach about their child’s strengths and potential to
learn; about the parents’ demonstrated understanding and skills with their child;
and observations of the child’s enjoyment, security, and comfort with his or her
parents. The coach’s ability to reflect and share his or her experiences, attention to
expressed emotions of the child and parent, and strength-based orientation deliv-
ers a powerful message to parents about how their efforts will be understood and
how their child will be seen. It also sets up the reciprocal observe–reflect–share–
plan pattern that will emerge throughout each session they spend together. The
message of unconditional positive regard for parents and child helps ease parental
worry about the treatment that is to come, both for themselves and for their child.
The session should also end on time; that delivers an important message.
Reserve the last few minutes of the session for scheduling the first coaching treat-
ment session with the parents, provide any preparatory reading or viewing mate-
rials, and tell parents what the focus of the next session will be—reviewing and
finalizing the short-term (12-week) learning objectives and treatment plan, and
beginning to focus on specific interactive techniques. It is often helpful to let
parents know that coaching sessions will be similar to the assessment session.
There will be several periods of parent–child interaction during which the coach
supports the parents as they work with their child, followed by a short break in
which the coach and parents discuss what just happened, and then a chance to
talk more generally. Finally, the assessment session ends as the coach says goodbye
to the parents and child before they depart.
Collaborating on Short-Term Goals

At some point in the first contact or assessment session, the coach and parents
need to discuss what short-term goals the parents have for their child—their most
pressing needs. In stimulating this discussion, it helps to pick a milestone approxi-
mately 3 months into the future (the child’s birthday, a major holiday, the begin-
ning or end of a season) and ask parents
to imagine desired changes between now
and then.
This idea of short-term changes
building toward a long-term goal helps
parents look ahead positively, rather than
feeling discouraged by the enormity of
the task that lies ahead. It’s also a time to
talk about the fact that children develop
different skills at different rates and that
some skills will develop more quickly than others. A third possibly useful concept
is that the acquisition of various skills may occur in spurts interspersed with peri-
ods during which a child develops certain skills more slowly. This is often observed
when a brand-new skill is being introduced. The first steps in a new objective fre-
quently take much longer to acquire than its later steps; it’s as if the first steps build
the base, and the later steps refine or differentiate the ability further.
Some parents may know right away what they want to see their child learn
to do. They may come to the first session with a list of behaviors or expectations
already written down or mentally prepared to share. When parents share their
goals and the coach writes them down verbatim without offering changes, sugges-
tions, or modifications, it delivers the message that parents have authority: Their
knowledge and priorities matter. Given that more than 80% of parents of children
with ASD already feel “stressed beyond their personal limits” (Bitsika & Sharpley,
2009, p. 540), it is important that parents feel acknowledged and supported in their
ideas about what should be addressed in treatment, rather than feeling discounted
or mistaken. Other parents may be unsure of what skills or goals are appropriate to
expect from their child and need help from the coach to get started. A parent and
his or her partner may be in conflict about which needs to address, and a coach
who listens, learns, and understands the differing viewpoints being expressed can
help the family find common ground. Sometimes the parents’ goal is a long-term
rather than short-term goal, in which case the coach helps the parents think about
what earlier accomplishments will lead to that longer-term goal, with parents then
identifying a more achievable short-term goal.
Coaches should also offer ideas for goals that have arisen from their discus-
sions with the parents or assessment of the child. On occasion coaches have heard
parents describe particular behaviors, activities, or events in their child’s daily life
that present difficulties, and the coach can raise these using the parents’ own
words to suggest possible goals. If the parents want to address goals that concern
needs that the coach has not yet been able to observe, the coach will have to
gain some insight into these needs, perhaps through a video, or visit to a specific
environment where the problem occurs, in order to develop goals and interven-
tion strategies. Sometimes the parent and coach can use role playing to enact a
scenario to develop goals and strategies for new learning. The time spent in col-
laboration around goal setting clearly illustrates the interpersonal process that lies
ahead for families in this coaching relationship.
Writing Objectives and Learning Steps

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

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

cleaning up afterward, in 5 minutes of play in two separate art activities per
week.”
Learning Steps
• Step 1: “Watches and stays in the activity for 5 minutes when I show her
actions to do with the materials on paper.”
• Step 2: “When I model one action and hand her materials, she will mark on
the paper with some help, three times.”
• Step 3: “When I hand her the materials, she will make a mark that I then
copy, and we will take three to four back-and-forth turns.”
• Step 4: “She will help me remove some markers from the container and
then spontaneously pick up one and mark on the paper with it, and we take
three back-and-forth turns.”
• Step 5: “She will help me remove some materials from the container and
then spontaneously pick up one and mark on the paper with it, and we will
take three back-and-forth turns, and then she will help me put away the
materials in the container.”
• Step 6: “When I put the container on the table, she will remove several
markers independently, mark independently, takes several turns with me,
and then when I say it is time to finish and give her the container, she will
initiate putting away some materials.”
The last example below reflects a family goal: for the child to participate with
the family at dinner time. This goal is appropriate for a child who is very moti-
vated to eat but whose main difficulty is wanting to get down from his or her chair
and wander the house with food. The steps list the strategies the parents will use
to teach new behaviors and expectations to the child.
Objective
“When told that it is dinner time, my child will come on his own, get in his
chair, and stay in his chair eating his food until he says, ‘All done’ five nights
this week.”
Learning Steps
• Step 1: “Walks to the table, seats himself, eats preferred foods (may choose),
and leaves his seat when he wishes.”
• Step 2: “Walks to the table, seats himself, eats several bites of preferred
foods, says, ‘All done’ when asked, and hands over plate and cup with help
when asked, before he gets down.”
• Step 3: “Comes to table on his own when called, seats himself, stays seated
while he eats several bites of dinner food, says, ‘All done’ when asked or on
his own, and hands over plate and cup when asked before he gets down.”
• Step 4: “Comes to table when called, seats himself and stays seated while
eating some of the family meal, says, ‘All done’ when asked or on his own,
hands over plate and cup with gestural cue and gets down from his chair.”
• Step 5: “Comes to the table when called, seats self and stays seated while
eating, says, “All done’ and hands over cup or plate to parent spontaneously,
and gets down.”
The objectives reflect the family’s priorities, which they stated when first asked
about their goals for the next 12 weeks, and reiterated when the coach offered
draft objectives for the family to consider. Even though the objectives are family-
chosen, challenges may emerge during their implementation that may require
the alteration, elimination, or addition of other objectives during the treatment
period. Coaches follow family leads here and adapt and update the objectives and
steps as needed so that the written treatment plan always defines family priorities
and actual practice.
Creating and Implementing a Transdisciplinary Treatment Plan

In P-ESDM, the coach creates a treatment plan that addresses all areas of an indi-
vidual child’s short-term learning needs. While some groups do this by having
team members from each discipline write objectives, such a piecemeal approach
can result in duplications, contradictions, and omissions. We have found it most
efficient and effective to have the person who is the coach write all the objectives.
Other team members who have interacted with the child in his or her evalua-
tion or have the child’s quarterly treatment data available to them, and have seen
samples of the child in treatment, live or on a videotape, review and edit objectives
and steps that fall under that person’s disciplinary expertise. This process helps all
team members develop a common way of writing objectives and steps. Standards
that evolve from the group can be codified by the team to define a transdisci-
plinary team standard for writing the individual treatment plan. Using criterion-
based assessment tools that cover all the developmental domains for young chil-
dren in quarterly treatment progress assessments facilitate this transdisciplinary
process greatly, since the tool covers all domains and the coach develops familiar-
ity with the progression of skills across developmental domains.
Once the plan is in place, the coach needs to know the teaching content
and process behind each objective and step in order to best coach the parents.
Partnering different disciplines together, such as the speech and language pathol-
ogist and the physical therapist, in an intervention session will allow each per-
son to help the other learn how to elicit the skill and assess child performance
via coaching, demonstration, and discussion. This kind of process allows for one
team member to coach the parents in all the treatment objectives. Furthermore,
listing all the objectives on a common data sheet makes it far more likely that
most, if not all, will be addressed during one session. In a coaching model, this is
critical in order for the parents to recognize that all the objectives are important
and can be practiced daily in various activities across the day, without taking
hours of time. This is what we aim for in parent coaching: that the parents will
address all their child’s needs in his or her daily activities. The team members
share disciplinary expertise across the team so that everyone develops a generalist
knowledge of children’s intervention needs and can pass on this transdisciplinary
knowledge to parents.
Coordinating Treatment Plans When There Are Multiple Coaches

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

when parents have first asked for help with their child. We have discussed how
to demonstrate the parent–coach partnership through the process of identifying
parents’ goals, the strengths and needs of both the family and child, evolving into
a family-friendly treatment plan of goals, steps, actions, and outcomes for learning
based on everyday activities and learning opportunities, including all the people
who are a part of the family context and potential sources for learning oppor-
tunities. Throughout, we have also discussed the strengths of this approach to
low-intensity intervention, as well as the challenges that can arise in developing
family skills and routines that incorporate goals, activities, and practices, while
additionally incorporating family values, cultural beliefs, and priorities. Finally,
we discussed the coordination of the parent-implemented intervention plan with
other interventions that may be in place for the child and family. Family, home,
and community contexts are far richer in learning opportunities for young chil-
dren with ASD than are specialized settings. The parent–coach relationship can
provide parents with the knowledge and skills to capitalize on these rich learning
opportunities in everyday activities for their young child with ASD. Supporting
parents in this way promotes parental confidence, positive expectations, and a
sense of self-efficacy and empowerment, all of which promote the parents’ mental
health, family relationships, and optimal outcomes for the child.
Chapter 6
Parent Coaching Sessions
What exactly are we trying to create in a parent coaching session? What does it
look like? What does it feel like? How does the coach manage it so that the overall
experience feels satisfying and “whole,” rather than busy and scattered? What can
we do to create an experience in which parents leave feeling better than when
they walked in the door: better about themselves and better about their child,
clear and confident about what they want to accomplish over the week, feeling
like something important happened in the session? This chapter will focus on the
temporal and physical organization, learning content, and interpersonal processes
that occur in each coaching hour. And, it all begins in the first treatment session.
This session moves the focus of sessions from parent–child interactions to parent–
child learning. It transitions the work from planning to doing, sets parents’ expec-
tations for what is to come, and deepens the developing relationship between the
coach and family.
The First Coaching Session
The first coaching session represents a transition from what has occurred in past
visits to this new way of working together that defines parent-implemented inter-
ventions. There are two main topics addressed in this session. It begins by gaining
closure on the past session and its focus on gathering the data needed to create
an intervention plan. It starts off, as all sessions will, with a brief greeting period
and time to share any residual content from the last session (briefly! There will be
ample discussion time at the end for anything that requires processing). The greet-
ing transitions into the daily activities via a planning moment in which the coach
reminds the parents of the two main activities that will happen today: (1) getting
agreement and closure on the intervention plan, and (2) moving into parent–child
73
intervention work on the plan by doing an activity together. The session will end
with discussion time as needed and then a goodbye time to transition parents and
the child out the door.
The greeting time in this session offers a challenge that will exist in every
other session—managing the child while the parents and coach talk. The coach
needs to make materials available for the child that will occupy him or her with
as little adult attention as possible. Some children will happily sit on a parent’s lap
or become engaged with objects that will keep them occupied. If both parents are
present and the child needs some tending, one might manage the child if needed
so the other can engage fully with the coach. If only the parent and coach are
present, then in this and every other session and reflection–discussion activity, we
have found it most helpful for the coach to settle and manage the child so that the
parent can become fully engaged in the thought and discussion taking place. This
can be part of the planning at the start of the session.
Once everyone is seated, any residual issues from the last session have been
shared, and the coach has described the two-part plan for the day, the coach pro-
vides each parent with a copy of the intervention plan—the objectives, written in
family-friendly style (examples occur later in the chapter). The coach introduces
the objectives by reminding the parents that these derive from their previous dis-
cussions as well as any goals the coach may have discussed during the evaluation
session. The coach then summarizes each objective in terms of its essence, as the
parents read along, and confirms that this is a high priority for them. Once the
review is completed and any questions are discussed and resolved, the coach typi-
cally tells the parents that he or she will be tracking their child’s progress on each
objective at every session and is always happy to share such information, and that
the parents should expect to see signs of progress on these goals at home.
The topic then shifts to how everyone will work together on these objec-
tives in the coaching sessions, beginning today. The coach typically describes how
the session will go—a few minutes to greet and chat, a warm-up activity to help
the child transition into action, a plan for the parents’ topic of the day, several
chances for parents to practice as the coach supports their learning and the child’s
learning, and then time to discuss any open topics before the session ends. The
coach next introduces the parents to the materials that they will be using. This
may include a manual for the parents, a notebook the coach has put together for
them, or other general materials for the parents’ regular use. (The refrigerator list
provided in Appendix A.5, subtitled “Stepping into the Spotlight,” is always a pos-
sible kickoff point for the activity of the day.)
Now it’s time to get into the first activity/coaching experience! In a brief
description (10 minutes maximum!), the coach reviews the main points of the
topic for the parents, using the handout as a visual. (See Chapter 7 for pointers
on how to introduce this, and many other topics, if you need some additional
supports.) The coach talks about the techniques the parents can use to increase
Parent Coaching Sessions 75
their child’s performance on the skill, and the coach may suggest or inquire about
what techniques will be the focus today. Any suggestions from the coach should
be based on previous observations of parent–child play—techniques that could
use some shoring up. The parent chooses a material for this first play activity (or
uses materials the child is very engaged with already) and begins to join the child
in play. The coach sits near the parent, generally in a kind of triangular configu-
ration and equidistant from the child and parent and clearly outside of their play
space, but close enough to be able to hand an object to the parent if needed.
During this first coaching opportunity, the coach may restate the targeted
technique as the activity begins. The coach’s two jobs are (1) to support the par-
ent’s use of the new skill and (2) to not interrupt the ongoing interaction between
the parent and child. In this 3- to 5-minute (maximum) play activity, the coach
watches, comments when the parent uses the techniques that have previously
been discussed (“right in front,” “you’re in his spotlight”), and offers any other brief
prompts or supports as needed via gesture and brief comments, provided that these
do not interrupt the ongoing interaction of child and parent, so the coach assures
that the activity goes as planned. The coach finds the right time to close out the
activity, so the opportunity exists for the parent and coach to reflect on what just
occurred. Each share reflections on the established parental goals for the activity
and actual events, with the coach being sure to link the parent’s planned actions
and their effect on the child’s desired behaviors, and show how this addresses one
of the objectives for the child. If there is time for another activity, it occurs in
the same way—based on the reflection–evaluation discussion that just occurred,
using different materials but practicing the same goal for the parent, followed by
reflection–evaluation. The coach’s primary goal is parental mastery of the skill.
The coach then moves the session to closure, moving each member of the
group back to his or her seat if needed, tending to the child as needed, providing
some time for parents to process this transition into active coaching sessions and
any questions or comments in the final minutes. All agree on the time and place
for the next session, the coach provides copies of any materials relevant to the ses-
sion to the parents, advises parents on what they might bring to the next session
(notebook, questions, parent manual, beverage and snack for the child, etc.), and
says goodbye to the parents and child, introducing a brief routine for the child fol-
lowed by departure.
Subsequent Coaching Sessions
The structure we are sharing is based on the writings of Hanft and colleagues
(2004); it involves cycles of planning, observation, coaching, reflection, and evalu-
ation. It includes the session structure and also the process contained in each
activity block. The coaching process involves not only parent and child learning
but also the opportunity to support parents through a process of self-discovery:

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

• Greeting: Joining together, greeting, and transitioning into work
• Progress: Listening to parent progress reports and their goals for the session
• Warm-up activity: Observing parent interaction skills during this first activity
• Reflecting/evaluating: Sharing reflections of parent and child actions together

to help parents understand and evaluate the effectiveness of the strategies they
used; deciding on goals and strategies for next activity coaching
• Coaching Activity 1: Parents practice skills learned; coach supports their learning
goals through on-the-spot coaching
• Reflecting/evaluating: Asking questions and actively listening as parents evaluate

the effectiveness of the strategies used; deciding on goals for the next activity
• Coaching Activity 2: Parents practice skills learned; coach supports their learning
goals through on-the-spot coaching
• Reflecting/evaluating: Sharing and listening to the progress made toward the

parents’ desired outcomes and the next steps toward improvement; developing
a plan for the week using the target skills or concepts with a focus on practicing
using a variety of environments, materials, and activity types
• Discussion of parked topics (if any)
• Closing: Transitioning out of the session with goodbyes to all

know and use and what new learning is needed; the coach also considers what
additional support, resources, or examples may extend progress or improve under-
standing of a topic, and how aligned the new information is with techniques the
parents have learned and previously applied. Throughout each activity period, the
coach creates balance in the interaction, with the parents and coach functioning
as respectful partners participating equally in the discussion and activities that
occur.
The activity structure provides organization for the ongoing observation–
planning– practice–reflection–
evaluation cycle that supports parent and child
learning. We prepare and use the “Coach’s Session Planning Sheet” in Appendix
A.2 during all our sessions with families. It breaks down the session activities with
a recommended time span for each activity based on a 90-minute session (coaches
adjust as needed for shorter sessions). There are spaces to take notes on what has
been observed and discussed with parents. We strongly recommend that coaches
use a form like this that records the content, timing, and notation needed to struc-
ture their preparation, execution, and reflection surrounding each session.
Coaching Session Routines
This first session is a microcosm of all the remaining sessions, setting up the rou-
tines for the coach, parents, and child that will occur throughout the coaching
intervention. Having walked through this experience, it’s time to step behind the
curtain to look at the actual scripts, props, and tools that will make this process
successful for all, measurable via the child’s progress, parents’ skill development,
and parental satisfaction with the experience and the coaching relationship.
Coach Preparation
Successful sessions flow from the coach’s preparation: knowing the parental skills
covered in the last session, the child’s current performance goals, coaching skills
the coach is keeping in mind, and topics from the previous session that need to
be reexamined in the coming session. This is too much to keep in mind during a
session, and codifying this information in a session plan (see Appendix A.2 for a
model) is a critical preparatory step. Additional session materials the coach needs
to keep on hand (or on a clipboard—Sally’s preferred way of organizing materials!)
include the written session plan, child data sheet, parent tool for fidelity assess-
ment, child objectives, parent manual, parent handouts on the new topic and
techniques to be covered and on past topics and techniques (in case more work is
needed on them), any parent checklists, or other materials on the topics relevant
at the moment (both handwritten and from a website), and a coaching fidelity
tool for the coach to review after the session.
Greeting and Check-In

The session begins with greetings all around and a transition into the session envi-
ronment, where parents and coach are seated together and the child settles into
an independent activity while the adults converse. Keep it brief! The goal of this
period is to join together and quickly seat the parents and coach while occupying
the child if necessary so that work can begin. There will be an initial social chat
or greeting, asking how all are doing, as the group transitions to work. The seating
area can be anywhere that the parents and coach may sit near each other and over-
see the child. Joining in involves greeting the parents (first) and child (second). If
the child is occupied, it is helpful not to interrupt, so planning can move forward
with the parents. Sitting in the same place each session, either in the family’s home
or at the center, helps the process of getting started. The initial chat allows for tran-
sition from social greetings to the work at hand. The coach’s action of sitting down
and picking up pen and clipboard signal readiness to begin. Once the parents and
coach are seated and child is occupied, “the greeting activity” is finished.
Either the parents or coach then shift the topic to what the parents have
focused on with the child since the last visit, based on the goals that were estab-
lished then. The coach may need to initiate this shift by recalling the plan in place
when they all said goodbye at the last session, and how that plan has evolved during
the interval. Reviewing these goals activates each parent’s memory and mindset for
the work that is to come. If the parents have planned to keep track of data, this is
the time to ask for and review it, after a genuine thank-you for, and acknowledg-
ment of, the effort required to keep data! This early attention to data actively dem-
onstrates the importance of the information and the effort required to record it.
The coach listens carefully to gather information that will help define the
focus for this session. Parents may share excitement at the success they experi-
enced, or concern, frustration, or uncertainty when asked about their progress
since the last session. They may provide reasons for why they could not follow
through.
Robert’s father Michael tells the coach he feels confident using the toy trains with his
son to imitate his actions. Michael comments that Robert’s distress and tendency to
leave activities have reduced dramatically as a result of the imitation strategy. But it
feels like he is not teaching him anything new by just imitating him, and he wants to
know what other ways he can play with Robert besides imitating every action and
still keep the play going. The coach remarks on the importance of this question and
notes that they will return to it during the session.
Andreas’s mother Maria shares her feelings of failure with her son, who held onto
the toy cars instead of imitating the play actions she demonstrated. The coach asks
that they do this activity together in this session so that the coach can have a better
sense of how to help her.
In both of these examples, the coach listens and follows up on the needs,
questions, or experiences (implied or overtly stated) that the parent has shared by
making these a priority to address in the session.
Potential Problems
It is often the case that a parent will bring up a problem or concern unrelated to
parent coaching topics in these first moments, or at other times during the session.
These need to be responded to—we are here to help—but we also need to main-
tain the goal of the sessions: parents’ acquisition of the concepts and skills needed
to problem-solve and support their child’s progress. In these situations, the coach
learns of the concern, agrees to its importance, and suggests that it be returned
to in the discussion time that will occur later in the session. Jot down the topic in
your session planning sheet so it isn’t forgotten, but “park it” for now, so attention
is solidly focused on parent–child learning.
The Warm-Up Activity: Initial Observation

We have found it very helpful to transition out of talking into parent–child action
by asking the parents to help the child get ready for the session, or show the coach
what they worked on at home over the past week. “Would you help Aisha warm
up for our session?” “Can you show me how your work went during the week?” Or
in your own words, invite the parents to show you how they practiced last week’s
concepts with their child, or how a problem they describe arose.
This brief warm-up activity involves a parent- or child-chosen activity that
provides the coach with a snapshot of the current situation—an opportunity to
evaluate what the parent or child has mastered thus far. This is a time to observe
the interaction very closely, through the lens of the parent fidelity rating tool
(which should now be in the coach’s hands). In this activity only, the coach does
not coach the parent or interrupt what is happening until the end of the activity.
The coach stays physically separate from the dyad, attending to the fidelity sheet,
not making eye contact with either partner. This period of uncoached parent–
child interaction provides a picture of the parents’ current knowledge and skills,
while giving the coach an opportunity to assess the progress of parent and child
and to consider challenges or difficulties that need additional coaching.
The coach watches until he or she has completed the observation—3 minutes
is usually ample time. With any luck, there is a natural (positive) moment for the
activity to end, but the coach can also suggest an ending and help as needed to
end the activity. Alternatively, the coach may suggest that the parent break from
the activity, leaving the child to play. As the parent transitions out of the activity,
the coach makes sure the child is somehow occupied so that the two adults can
talk. A transition phrase from the coach, something like “That’s a helpful picture
for me. Let’s allow her to play while we discuss it,” helps move everyone from the
activity to a couch or chair, or at least turn to each other and move away from the
child, thus marking the transition and providing nonverbal communication to the
child that the adults are not available right now and to begin the next activity:
reflection and planning.
Potential Problems
1. The play activity goes on too long, or one activity morphs into another
and another. The activity has to be short to save time for coaching. The coach can
suggest, “Let’s allow her to continue playing while we talk about it.”
2. The first activity is very brief, and the dyad quickly moves from one activ-
ity to the next without stopping. The coach only needs to see 2–3 minutes of an
activity once it starts, so again the coach needs to interrupt and end the activity.
3. The parent begins to engage the coach instead of the child in the activity
with questions, comments, and the like. A good response is “We’ll talk after you
are done.” Sitting apart from the dyad, turning your body away, and focusing on
your clipboard, the child, or the materials helps lessen the likelihood of this kind
of parental behavior.
4. The coach is tempted to interact with the child in response to the child’s
initiations or through a sincere desire to help the child. Sitting apart helps curb
this behavior as well. Focusing on an assessment of parental skills helps the coach
remain quiet, separate from the interactions during this activity. Not making eye
contact with the child helps considerably!
5. The child continues to seek interaction with the parent and interrupt the
initial adult discussion. In our practice it is the coach’s responsibility to occupy the
child so that the parent can fully attend to the learning tasks at hand. The goal
is for the child to be quietly focused on some activity, seated if possible, so that
parents and coach can think, talk, and plan.
Reflection and Session Goal Setting

This is the next activity and the end point of the discussion to establish the paren-
tal learning goals for the interactions to come. Once the child is occupied and
the parent and coach are back in interaction, the coach begins a reflective discus-
sion with the parent, as he or she will after every parent–child interaction. While
in other reflective periods, the coach may sometimes initiate a reflection, in the
warm-up activity reflection, we ask about the parent’s response to that activity.
The more open-ended the coach’s question can be, the more the parent will be
able to share. A question like “How did that go for you?” or “Did that go as you
expected?” can elicit helpful information about what the parent’s goal was and
how it was, or was not, met. We have found it very helpful to listen deeply, with-
out interruptions, without questions, and without reassurances or praise, until the
parent has finished talking. If the parent provides a closed answer (e.g., “It went
fine”), the coach can ask for more information: “Tell me more” or “Tell me what
you were thinking about” or “Tell me about [restate the parent’s original goal].”
This is not a two-way discussion, but rather a chance for the coach to hear how
the parent is conceptualizing the interactions and interpreting his or her child’s
behavior.
With that information and the information from the observation, the coach
and parent now need to establish a session goal, and there are three choices: (1) to
continue on the topic that was previously reviewed, (2) to move to a new topic, or
(3) to use the next activity to further refine the previous topic’s skills and to then
use the last activity(ies) to begin a new topic. The parent will have his or her own
thoughts about whether to move on or whether to continue, and the coach will
also have data to bring to this decision. If the goal is to continue with the same
topic, then the coach needs to be certain of the skills to be mastered during the
course of this session, and that needs to be verbalized and agreed to so all adults
have the same goal in mind.
Karla, who is very focused on helping her daughter Sofia learn to speak, begins a
warm-up activity with a puzzle. The coach watches Karla hold out and name each
puzzle piece for Sofia to repeat. Sometimes Sofia responds, and other times she does
not but tries to take the piece from the mother. Even when Sofia responds, Karla
holds onto the piece and asks Sofia another question to answer (e.g., “Do you
want to put it in?” or “Where does it go?”). Sofia finally gets up from the table to
leave, and Karla quickly gives her pieces to encourage her to return to the activity.
She takes the pieces and the puzzle to a different location to play alone. The coach
suggests that they let her play while they reflect on the activity. Karla agrees, and
the coach asks how the activity went for her. Karla responds that the exchange is
typical and expresses frustration that Sofia will not cooperate by naming the pieces.
She says that Sofia is just stubborn and wants to do everything by herself, and she
doesn’t know what to do when Sofia tries to take the pieces out of her hand.
This provides an excellent point for the coach to shift to the parent coaching
topic for the session, based on Karla’s learning need. The coach affirms that Karla’s
concerns are an important topic for the day—how to play with puzzles and other
activities in ways that encourage child communication. Inwardly, the coach plans
to focus on the skills involved in following a child’s leads, taking turns, and elabo-
rating from the child’s theme.
If it is time to begin a new topic with the parent, the coach can use parent
fidelity data to decide what the most useful next topic would be. We typically make
sure that the parent has a core skill set: gaining his or her child’s attention, follow-
ing the child’s leads, using the skills of narration, imitating the child, commenting,
“admiring” to respond without directing, taking turns, and using theme and varia-
tions in play (the four-step joint activity routine in ESDM terminology), before we
move to skills that actively address the child learning their treatment objectives
(social communication, gesture, language, child imitation, constructive and pre-
tend play, joint attention, etc.). The core skill set develops the kind of interactions
that allow the parent to create many learning opportunities for his or her child—
interactions that are marked by the child’s attention to the adult, the child’s moti-
vation to continue the activity, the active reciprocal engagement of both child and
adult, adult responsivity and sensitivity to the child, and a flow of activities includ-
ing initiations and endings that are marked by continuous engagement.
If the plan is to continue with the current parent topic instead of a new one,
then the coach and parent identify the key skills to be focused on (based on what
the coach learned from watching the warm-up activity), the coach helps the
parent plan the next activity, which typically uses different materials and differ-
ent activity theme (as suggested in the parent handout “Activity Categories” in
Appendix A.4: books, constructive play with a toy, meals, sensory social routines,
pretend play) and helps the parent transition into the next parent–child activity.
If the plan is to move on to a new topic, then the learning targets of that topic
need to be introduced.
Here is the most didactic aspect of the whole session. The coach introduces
the topic—what it is—why it is important for all children, why it is especially
important for children with ASD, and the specific behaviors (refrigerator list!)
that the parent will target, giving examples from parent–child activities already
observed for this family. In Chapter 7, we provide ideas for ways to describe a
variety of topics that are taught in NDBI, and these follow each of the chapters
in our ESDM parent manual (Rogers, Dawson, & Vismara, 2012). The coach dis-
cusses the main points of the topic using the core strategies (refrigerator list) as a
visual aid for both the coach and parents. It’s a careful balancing act: to present
enough information for parents to understand but not get waded down in detail or
too much talk. Parents need opportunities to comment on, give feedback on, and
share their understanding of new information. Does this seem important to them?
Does it raise concerns for them? What challenges do they anticipate, or have they
already encountered? Once the coach and parent(s) have agreed on the parent
learning goals for the session, the transition to a coaching activity occurs.
Note 1: If more than one parent is actively involved, then each parent may
have a different focus of learning, and each parent may do one of the remaining
activities.
Note 2: There is a lot to cover in this first reflection–planning period and the
coach has to keep it brief, because the key learning will occur in the parent–child
interaction, not in talking about it. Hitting the high points is all that is needed in
order to move to the parent–child interaction. The coach and parent discussion
should not take longer than 10 minutes before the next practice activity occurs.
At the end of this activity, the coach transitions everyone into the next parent–
child interaction, now clearly focused on coaching the parents on a specific set of
techniques to support new parental learning and positive responses in the child.
Potential Problems
The biggest problem that can occur in this and all reflection periods is the need
for child management. This is the child’s break. If possible, provide a toy or object
that will occupy the child for 5 minutes without need of adult supervision. If there
is another adult in the room, it will be very helpful if that person could silently
occupy the child. If this is not possible, then we have found it beneficial for the
coach to manage the child, so the parent can focus on reflection. Those who are
managing the child need to be careful not to teach or interact with the child
(which will distract the parent and therapist and prevent the child break that is
intended), but rather to support the child’s independent play while looking at and
listening to the parent.
Another problem occurs when the parent and coach have differing opinions
about the next parent skill to address. Sometimes a parent may be ready to move
on to a new topic, whereas the coach believes that more practice of previously
taught content would help better prepare the parent for the skills he or she wants
to address. The coach acknowledges the parent’s desire or preference and explains
how the recommended topic will support the parent’s movement toward that goal.
Example phrasing from the coach might be something like this:
“You and I both want your child to use more words. However, speech and
language are built on children’s ability to communicate using gestures, facial
expressions, and actions, as well as making sounds and words. She’s not using
many gestures yet, and I’m thinking that spending this week on strengthening
those would help her get to speech more quickly. We could focus next week on
building more sounds. How does that plan sound?”
With this kind of explanation, the coach has provided the parents with
important information about language development, reiterated their common
goal, voiced their priorities for speech, and put a plan in place, demonstrating
careful listening, deference to their choices, and a working partnership.
Coaching Activity
In all the parent–child coaching activities, the process is the same. As the parent
moves toward developing an activity with the child, the coach moves with the
dyad, near the parent and ready to coach through actions or comments. Avoid
sitting between the child and parent, who should be facing each other. The coach
needs to communicate with the parent, to support, prompt, and reinforce the par-
ent, whose skill development is the target of the coach’s efforts. The parent begins
to interact with the child, trying out the new strategies. This is an opportunity for
the coach to quickly record the child’s progress data on the child data sheet before
focusing on coaching the parent.
The goal of coaching is to help the parent achieve the targeted skills discussed
in the plan so that he or she experiences how it feels to use the technique success-
fully and how it helps the child learn. However, in order to succeed, coaching
during an ongoing activity needs to occur in a way that does not interrupt the flow
of the parent–child activity or take the parent’s mind off the interaction. This
means that coaching during the activity has to be brief and directive. Examples are
handing a different toy to the parent (one that will work better); pointing to a
child behavior or an object that needs attention; naming successful targeted tech-
niques that are being demonstrated; directing a head nod, comment, and/or smile
to the parent after a successful action; verbally modeling what the parent could be
saying, or providing a brief instruction: “Stop him.” “Get attention.” “Wait, offer
it.” “Prompt him.” “Hold onto that toy.” “Praise her.” “Well done; that’s it, bravo.”
No questions or comments to elicit parent responses are made at this point. They
are reserved for the reflection and evaluation
phase.
This parent–child activity continues for
3–4 minutes, until a logical ending or transi-
tion point into the next reflection–evaluation
activity, with its accompanying engagement
of the child, change in position, and prepara-
tion for parent–coach dialogue.
For Darius, who was working on following his son Jayden’s lead by imitating before
introducing new ideas, and doing so only when it’s his own turn: During coaching
about four-step joint activities, the coach watches Darius in play and makes quick
affirmations or comments about Darius and Jayden in action together: “You’re
following his trains around the track.” “Show him how you can set your animal on
top of the train to ride around the track.” “He just looked at you when you made
that engine sound.”
For a mother, Asami, who wanted to work on child communication during the
topic on nonverbal communication: As her son Hiro points to the hole for a puzzle
piece of a fish and Asami names it, the coach prompts, “Hand him the fish to put
in.” The coach reminds Asami to bring more words into the interaction: “Say what
you’re doing right now,” and Asami responds with “in” or points and says “here”
as she places the piece in the puzzle. The coach points out Hiro’s attention to his
mother’s gestures. Hiro points to an empty place in the puzzle, and Asami starts to
respond without speaking. The coach says, “Name it. Then give it to him.” As the
interaction proceeds, Asami begins to add words to both her actions and her child’s.
In both examples, the coach continues to support the parent’s learning within
the parent–child interaction with brief, focused verbal or gestural comments or
directions to assure a successful experience.
The Reflection–Evaluation–Planning Cycle

A brief opportunity for shared reflection follows each activity so that the parent
has time to process what just occurred and consolidate his or her learning by dis-
cussing it, shown in Figure 6.1. A particular theme in the reflection–evaluation–
planning dialogue is the relationship between parents’ actions and strategies and
their child’s behavior in response. The coach can facilitate a reflective process by
using open-ended and nondirective questions or by a reflection to enable the par-
ent to consider some aspect of the interaction.
Open-ended questions may begin with what, when, where, who, and how.
Questions may start with the reflection and become more focused as the conver-
sation evolves—for example, “It seemed like your child became much more verbal
Observation
Check-in
and warm-up
Continuation
mastery Joint planning
Closing with
Topic
an action plan
Reflection Practice
Evaluation Feedback
Figure 6.1. The coaching process: Actions and interactions.

after [some event] occurred. I wonder why?” “Your child got so interested in that
activity. How did you do it?” “How did that activity compare to the goal you set?”
“Based on what you just shared, how would you do this next time?” “Why” ques-
tions should be used cautiously to avoid a feeling of blame, although it may be
possible to ask sensitively worded “why” questions without the parents feeling they
have done something incorrectly—for example, “Why do you think she does not
like the activity?”
When the parent shares a reflection, the coach may restate or summarize the
associated content, knowledge, or feelings to demonstrate active listening. This
allows the coach to confirm or clarify his or her understanding and also gather
further information if necessary—for example, “You feel comfortable using this
strategy in toy play with your child but not in other routines that don’t involve
toys. Hmm, I wonder what other types of activities we should try next. What do
you think?” “I hear your concern about how other people react to her tantrums.
What does it mean in terms of taking her out in public?” “You seem disappointed
that your child did not follow through in the way you expected. What stood in
the way?”
The coach also needs to share a brief reflection about the interaction—
thoughts you are pondering, feelings that arose, expectations that you had that
were or were not met; statements (not questions) that begin with reflective phrases
like “I noticed,” “I wondered,” “I was thinking about,” “It occurred to me while
I watched”—focusing on the relationship between parent behavior and child
response, or the parent’s goals for the interaction. Coach reflections can illumi-
nate additional aspects of the interaction related to the goals of the interaction.
Given the partnering relationships, coaches should sometimes reflect first so that
the parent does not always have to lead this activity, and so that it does not seem
rote. Try to balance who leads off reflecting across activities, so the parent is not
always in the “hot seat,” right after leading an activity.
The coach has to be comfortable with moments of silence that may occur
when it is the parents’ turn to speak. It takes time to think and organize thoughts.
Some thoughts or feelings may be uncomfortable for the parents to explore; taking
time to process feelings may ease communication. A coach who always jumps in to
fill the silence out of good intentions to help a family, or out of his or her own dis-
comfort with silence, may inadvertently take away parents’ opportunity to process,
reflect, or figure things out. Parents may feel rushed to say something or incapable
of giving the “right” answer to appease the coach. It may harm rather than help
the process of creating a safe and trusting coaching relationship. Coaches need
to learn to be quiet after a question or statement is made, and not follow up with
additional questions or suggestions. Quiet waiting from the coach demonstrates
acceptance and respect toward the parents. It emphasizes how important the par-
ents’ input is to the process and ongoing work.
From the reflection emerges a summary from the coach or parent that
evaluates the status of the parent’s goal and a plan for the goal in the next activ-
ity. The plan is typically either: (1) a further improvement to be made in the
targeted parent skill in the same type of activity, or (2) generalizing the skill to
a different type of activity. If the previous activity involved toys, then the next
activity might be a sensory social activity, or a caretaking activity, or a book or
art activity. The “Activity Categories” cartoon in Appendix A.4 provides a frame-
work for generalization. In each coaching session, it helps a parent’s generalization
to vary the activity types and to practice all of them over the course of a few
sessions. If the reflection follows the final coaching activity of the session, then
the plan involves parental interactions with the child in their daily home activi-
ties until the next session, which also involves some generalization. Although all
of this sounds lengthy, the entire reflection–evaluation planning activity is only
5–10 minutes maximum and requires careful time management on the part of the
coach. The following illustrations of this process are helpful in conceptualizing
such a dialogue.
Let’s return to our two coaching vignettes to illustrate the coach’s use of
reflective questions and active listening. We pick up first with the coaching con-
versation with the father of a 2-year-old son whose goal is to imitate and follow his
child’s interests in play before introducing other play ideas to the activity. While
the child continues playing with trains, the coach invites the father to self-reflect
on what happened compared to the goals he identified at the start of the activity.
Coach: You went into the activity with two goals. You wanted it to be fun
for Liam, but you also wanted to try to follow his lead. How did that go
for you?
Kyle: I realized that I can’t just start off with how I want to play with the
trains. Otherwise, he cries and grabs for the trains, and then it becomes
really hard to try to play with him at all.
Coach: That didn’t happen today.
Kyle: Yeah. I didn’t try to control or take all of the trains right from the
beginning. I think he was expecting me to do that again, which is why he
fussed at first when I sat down on the floor with him. But I let him take
the whole bag of trains so he could start off the activity and get into it.
And when he couldn’t open the bag, I waited for him to look at me or to
say something. When he didn’t do this, I asked if he wanted help, and he
gave me the bag and looked at me to open it. I was thrilled! I let him take
the trains he likes the most, and then I just closed up the bag and set it in
front of him. When he was ready to take out tracks from the bag, he gave
it to me right away and said, “Open.”
Coach: You gave him the lead, and he kept coming back to you. Seems like
he wanted to include you in the play.
Kyle: Yeah, I always thought he just wanted to play with them alone, and he
could have, but he didn’t. He kept bringing me back in.
Coach: One thing that stood out to me was how you worked in choices again
and again.
Kyle: I asked him if he wanted straight or curved tracks. I think I also gave
him choices of which color train he wanted next and which order to con-
nect the trains on the track.
Coach: He had so many choices, and he was also OK with you making some
choices.
Kyle: I slowed myself down this time, compared to before when I tried to
control everything and show him right away how to play with the trains.
I paid more attention to what Liam likes about trains, and I copied him
and these actions until I could tell that he liked it. Then I did something
I wanted to do with them, like crash them!
Coach: [Evaluative comment] It was like the more leads you gave him, the
more Liam pays attention to you and wants you to keep going, and he can
then handle you taking a turn to show him something new and different.
Kyle: Yeah, that was really something! I never thought he wanted to play
with me, and I never thought he would try to copy me!
Coach: [Moving to the plan] So the next activity you have, what will you be
focusing on?
Kyle: That I could try to teach him something new in the activity, but only
after he has a chance to get started, And it must still relate to something
he likes to do or wants to do. Like last time that we talked, about adding
one thing at time, instead of lots of ideas at once.
Coach: We have time for one more activity. Want to give this a try with a
different set of materials, maybe books or art?
Kyle: Sure, that’s a good idea. But books seem too hard. I’ll do some drawing
with him, following his leads and imitating him, and just add something
different once in a while, only one new thing at a time.
In this reflection, Kyle recognizes and names several strategies to become a

part of Liam’s play. He comments on the fun he and Liam experience together in
the activity, compared to his past attempts to control the trains. He is proud that
he could demonstrate a new play concept to his son and that Liam liked the idea
and wanted to continue repeating it in the same activity. The coach and Kyle
discuss the skills he used to navigate new play ideas with his son and the different
learning opportunities that resulted. Kyle expresses his confidence with some but
not all of the strategies to extend Liam’s play. He opts for more practice in how to
add new play actions and scenarios to activities. The coach and father decide to
pursue this topic for the remainder of the session and to finalize a plan for Kyle to
continue working toward his goal at their next session.
In our second coaching vignette, Deborah wants her daughter Leah to speak
more words during activities. She has tried to teach her how to ask for items or
materials, but generally finds that Leah leaves the interaction or waits until Debo-
rah leaves before doing the activity herself. Deborah identified and practiced new
strategies to approach communication with Leah, and now the coach wants Debo-
rah’s reflections from the last coaching activity.
Coach: Let’s allow Leah to play for a few minutes while we revisit the puzzle
activity. We talked about other ways to practice communication besides
holding onto the materials at the start of the activity. What did you try,
and how did it go?
Deborah: It was very different than what I expected or had done in the past.
Coach: Can you tell me more about that?
Mother: Before I would take all of the pieces and make her ask me for each
one. It was stressful and not fun for either of us. She cared more about the
pieces than playing with me, and I felt like unless I had the pieces, then
I didn’t know how to make myself important to her. Plus once she had all
of the pieces, I never knew how to get them back without taking them, at
which point she always gets up and walks away.
Coach: How did this activity compare to what you have described?
Deborah: It was easier. I focused my attention and ideas on how I could play
with her or play in the activity instead of worrying about the pieces. It
didn’t occur to me until we talked about it today that naming what I do
in my turns would help her speak. I was really surprised when she said
“fish” after I did. Leah is actually listening and learning from me and from
what I say.
Coach: We heard her say several words from watching what you did. She said
“in” or “there” when she wanted to put in the puzzle piece. There was also
a social purpose to her communication.
Deborah: What do you mean?
Coach: There were a few times when she said, “fish” after you put in the
piece, but it had a different goal and feel to it than wanting to get the
item from you. She said it with a tone of excitement and a smile. It’s like
Leah is watching you and interested in what you’re doing, and saying
“fish” in this context is a way of connecting with you, as if to say, “Hey,
that’s a fish. I know that that’s called ‘fish’!” She’s commenting.
Deborah: I didn’t think about it that way, but I see the difference.
Coach: There were other types of communication you showed her besides
spoken words. I saw her watch you demonstrate these and then try them
herself.
Deborah: Oh yeah, you mean when she pointed to where the pieces go or to
the pictures on the board after I did it?
Coach: Yes. What was she communicating to you in those moments?
Deborah: Sometimes it seemed like she was asking for another piece, but
other times it goes back to what you were just talking about. Where she
was excited about the picture she saw on the board, and she wanted to
share that excitement and show me the picture.
Coach: She wanted to see if you saw what she saw.
Deborah: What would I do if she didn’t respond right away to what I say or
show her?
Coach: Well, let’s think about that. There were times where she didn’t say
“fish” or point to something in the activity. What did you do in those
situations?
Deborah: That’s true. I said the word or showed her the action again.
Coach: She might need to hear the word or see you do something a few
times, especially when it is a new word or action. What else could you do
if she didn’t naturally respond after you repeated the word or action?
Deborah : I can’t help her say the word, but I could help her do the action, or
I could see if there is a gesture or a sign I might add to the word that will
make it easier for her to tell me what she wants or is thinking. She could
point to where my piece goes or hand me the next piece she wants me to
put in, or she might like if I made a fish face or sang “Slippery Fish” after
we put in all the pieces.
Coach: You know a lot of strategies to help her communicate. Your ideas
about her attention to gestures and playful body movements can support
language when words may not come as easily. Should we practice this
again?
Deborah: Yes, and maybe with a different activity like when I have to change
her clothes. She doesn’t like for me to do it, but she tolerates it more when
I sing songs. Maybe we could practice communication instead of me sing-
ing a whole song.
Coach: Let’s do that next.
The coach assists the mother in her reflection on the activity and the next
steps to take to continue supporting her daughter’s communication. The coach
begins by asking Deborah to reflect on her use of other strategies to elicit com-
munication from Leah and encourages the mother to elaborate with more infor-
mation so the coach can better understand Deborah’s perspective. The coach
acknowledges Deborah’s progress and provides further examples of her mastery of
these skills. The conversation also includes open-ended questions from the coach
to aid Deborah in imagining additional strategies to support Leah’s communica-
tion. The coach and Deborah decide to stay with the topic of communication so
that she can practice supporting Leah’s communicative gestures and words within
the context of a less preferred routine.
In both coaching examples, the coach encourages the parent to explore his
or her knowledge, skills, and experience related to the coaching topic, and to con-
sider adjustments or next steps as necessary in the session plan. Also evident in
both examples is the coach’s responses to the parent’s self-reflections in ways that
support, affirm, elaborate, and provide insight. The coach’s feedback first follows
the parent’s reflection to assure an accurate understanding of his or her thoughts,
ideas, and needs. The coach waits for a while before providing recommendations.
Even when the coach knows other strategies the parents could use, the coach
holds back and encourages them to generate their own solutions, adding examples
from the coach’s observations to support their ideas.
When the coach gives recommendations, ideas, or feedback, it is clear, con-
cise, and relevant to the activities that occurred. It describes specific examples
of parent–child behavior so that the parents can relate the content back to their
actions and those of their children and know exactly what the coach means. Lastly,
there is no critical or negative tone to the coach’s words. The coach does not point
out any overlooked or incorrect actions. The conversations between each parent
and coach build a relationship of trust, respect, and open communication. In both
coaching examples, the sessions continue with further practice to build parental
understanding and confidence in the targeted skill or topic. The box on the next
page summarizes the key features of this reflective/evaluative process. The coach
will continue to use observation, reflection, feedback, and practice at the end
of the session to summarize and plan next steps (before the next session) and to
review with the parents the effectiveness of the coaching process.
The evaluation section following the last coaching activity needs to lead to
a plan for the week, rather than for the next activity. The discussion often sum-
marizes the skills practiced across the session and cements parents’ understanding
before they go home to continue working toward their goals. It needs to focus on
generalizing skills to other activities at home. In this planning process, the parent
needs to visualize using the target skill or concept across many activities during
the day and the week (what is meant when we say “generalization”). Appendix
A.4, the “Activity Categories” chart, is an excellent visual aid for this discussion,
as is Appendix A.3, “Parent Daily Practice Chart.” The coach might take notes for
Supporting Parent Reflection

• Coach solicits the parent’s reflection with an open question (or leads off with own
reflection).
• Coach restates the parent’s comments for accurate understanding.
• Coach shares reflection that emphasizes the effects of targeted parental acts on
child learning/behavior.
• The two discuss the activity to evaluate parental mastery/need for practice.
• Coach encourages parental problem solving when mastery has not yet been
achieved.
• Coach’s tone is thoughtful and accepting, not cheerleading, not critical.
the parent as he or she discusses plans for these different activities, perhaps on the
daily chart. Any record keeping that the parents are going to do (e.g., sleep diary,
food dairy, word list) should also be discussed at this juncture.
This is also a good point at which to discuss the child’s progress, with the
coach sharing data that have been gathered during the activity periods, pointing
out areas of gain in skill, but also discussing any skills that are not improving. Here
is the place to help the parent plan to target a specific child skill during the next
week, making sure the parent knows how to elicit the skill, how to foster increased
child mastery, and in what daily activities this skill can be practiced. Setting a spe-
cific goal for the child’s skill development that will be assessed at the next session
and writing it down for the parents and coach (on the session planning sheet!)
demonstrate the importance of child learning. The coach may offer to email or
text the parent to check on skill progress, or ask the parent to text or email about
it at specific times between now and the next session. Establishing both a specific
target for the parent and a clear follow-up plan between sessions typically supports
parental efforts and also assures that any problems in home teaching are revealed
and addressed rapidly, so neither parent nor child experiences failure. If the skill
is too difficult to teach at home at this stage in the coaching, then that can be
prioritized as the first topic to be discussed at the next session. The coach can
end the final reflection–evaluation–planning conversation by asking if something
particularly helpful or not helpful took place in the session. This gives parents the
opportunity to directly provide feedback about their experience with the coach.
Spending time to review the whole session helps the coach and parents gauge
the progress that they and the child are making. It also provides an opportunity
for parent feedback on the usefulness and impact of the coaching relationship and
session. The coach needs to know the parents’ true perspective on how helpful
they find the session, what else they might need to facilitate their learning, and
what changes could be made to improve the coaching process and relationship.
Parent feedback assists the coach’s self-evaluation of coaching skills and what
styles, techniques, communication, and interactions are the best fit for these par-
ents.
Potential Problem
It is very common for coaches to assume the role of parent cheerleader following
each activity, and sometimes during activities as well, with the goal of reinforc-
ing parent efforts and adding to parental motivation. Following the guidance of
Hanft et al. (2004), we have worked very hard to embrace a different style of
coaching. Praise connotes evaluation and authority. While children often need
this kind of feedback because they are not yet able to self-evaluate, adult learners
evaluate themselves. Parents need self-evaluation skills for all the hours that they
will spend with their child without the coach. The process of reflection shared
between parent and coach fosters the self-reflective process that the parent needs
in order to work independently of the coach. It is modeled from the process that
therapists use to evaluate their own treatment, session by session, and it is the pro-
cess that skilled adults use routinely to self-monitor and improve their work. Thus,
we inhibit, as much as we can, the desire to praise the parent after activities so
that parents can learn to evaluate the activities themselves, and thereby make cor-
rections and identify success independently. This learning occurs through reflec-
tive activities, through active listening to parental reflections, through sharing
personal reflections about observed parent and child goals, acts, and emotions,
through attention to the effect of parent behavior on child behavior, and through
reminders of topics and skills already mastered.
Discussion Time
This is the time period for returning to any topics parents identified earlier as
needing attention, or for asking if other topics exist that they want to discuss at
today’s session. If there are none, then the session can continue through one more
round of activity and reflections until closing. If topics do arise, given the brief
time period (10 minutes), there will likely be no opportunity to discuss more than
one problem (so the parents need to prioritize topics in advance), or to solve any
large problems, but time is available to put a plan of action in place that will allow
the coach and parents to develop an approach to the problem during the next
visit. A child’s behavior problem may need to be described so that frequency data
can be gathered at home. Then it can be prioritized in the next session’s discus-
sion period, to consider the ABCs involved in the behavior, to consider follow-up
with other adults in the family network about the problem, or to discuss a referral
or consultation, either outside the treatment group or with a member of the treat-
ment team with more expertise in this particular area than the coach has. An
important part of the parent learning process is to go through the steps together
of gathering the information needed and of identifying the tasks that have to be
completed to lead to a behavior plan and behavior change—skills that will help
parents to problem-solve independently in the future. At the end of the discussion,
any plans or topics that must be carried over to the next session should be written
down in the coach’s notes and targeted for the next session. If a check-in is needed
concerning a new skill or problem before the next scheduled session, that should
be planned for as well, as this phase transitions into the closing.
Closing
The session closing is the transition into departure. It is a time to briefly confirm
and record the action plans that have been set for the parents and coach, to con-
firm the date and time for the next scheduled session, and to say your goodbyes
to the parents and child in a quick separation at the door. It is easy to get caught
up in continued discussion during this phase, and the coach has to be intentional
about the closure that has been established and the need to “park” any continuing
topics until the next session. The coach’s bodily communications: standing up,
gathering materials, moving to closure with the child—these are the actions that
move the closing through to its conclusion.
Coach’s Reflection and Note

After the door is closed and you are either in the treatment room alone or in
your car, take 5 minutes to gather your thoughts. Finish your notes on the child’s
progress; jot down needs and topics for the next session, action plans, successes, or
concerns; or complete a data sheet or two. Keeping a new session planning sheet
on your clipboard and using it during this moment of review will help you essen-
tially plan some content for next session as you sort through your own thoughts. A
review of the coaching fidelity checklist and rating tool (Appendix A.9 or A.10)
will help your reflection on your coaching characteristics and session manage-
ment, perhaps giving you new points to add to your planning for the next session.
Focus for a moment on the emotions generated during the session. This aids your
own reflection–evaluation–planning process before these thoughts dissolve in the
press of the next client and another session. It also provides content for reflective
peer supervision and for seeking additional help if coaching problems are creating
discouragement, self-doubt, parent- or self-blaming, anger, or hopelessness.
Unfinished Business
Thus far, we’ve been advancing the basic principles and practices that have allowed
us to support the parents of young children with ASD as they embed intervention
practices in everyday activities at home. Our research studies have demonstrated
that parents have learned to do this with a high level of fidelity to the core prac-
tices. The approach already described has consistently demonstrated parents’ abil-
ity to learn those practices, transfer them to a home environment, and maintain
them even when weekly sessions have ended.
However, there is more to deal with in parent coaching than parent learning.
Three additional topics will be the focus of the rest of this chapter. These are all
aspects of coaching that occur “down the line,” after the first months of coaching
have passed, and they all focus on how to assure that children are receiving what
they need from the parent-implemented intervention. The first of these topics is
how to add the focus on child progress and child objectives to the coaching ses-
sions without losing sight of the adult behavior within child-focused interactions.
The second topic has to do with ways of addressing difficulties in the coaching
relationship with parents, and the third topic concerns termination of the coach-
ing relationship.
Addressing Child Objectives within Coaching Sessions

Thus far, we have focused exclusively on supporting parents’ learning of inter-
active skills that will support their children’s learning. However, children with
autism have core difficulties that interfere with their ability to learn from other
people. Their difficulties with social communication, joint attention, imitation,
and pretend play, their reduced motivation for social interaction, and their engage-
ment in repetitive and restrictive behaviors and interests present major challenges
for parents in everyday situations. We see the results of their learning problems
when we assess their skills in order to develop learning objectives for them.
One difference between P-ESDM and some other parent-implemented inter-
ventions is our belief that for most children, their learning needs will have to
be directly addressed in a parent-implemented intervention to stimulate progress
in all areas. After all, this is the purpose of the intervention, to help children
progress! How does the coach help this happen? It happens bit by bit, as par-
ents become skilled in their new learning, beginning with the child data that the
coach keeps for each session.
Each week, the coach takes data on the child’s progress on the objectives
that were developed at the start of the intervention. In order to track progress,
the coach has to observe activities that will support child objectives. While some
objectives, like language, imitation, or social engagement, can be addressed in any
type of activity, other activities, like pretend play, self-care skills, and fine motor
skills, require specific materials, actions, and themes for their practice. To monitor
progress in these areas, the coach must see parents carry out the targeted activities
in session. Thus, the data-keeping process itself starts to shape activities, so atten-
tion is focused on child objectives. For activities that are not parent go-to’s (pre-
tend play is often one of these), this requires that the coach ask the parents to do
the activity with the props and actions that will elicit the targeted child behavior.
This is an important didactic moment for parents, and they will likely need coach-
ing support in order to learn how to conduct this activity in a way that addresses
their child’s learning needs. Because this is a new activity focused on child learn-
ing rather than new parent techniques, the best place for it is as the last activity of
the day. The coach supports the parents through the activity and points out what
the child’s current skill level is and what the target skill is. Here is a natural point
to ask the parents if they can practice this activity at home over the coming week
and, when they agree, to then come back to it in the next session’s discussion time
in order to help them develop a plan for mastering the activity. The data-taking
process itself has directly brought the targets of child learning into coaching. This
is why we emphasize data keeping throughout the session.
A second process fostered by data helps to shift attention to child learning
targets, and this occurs when the coach begins to summarize the progress he or
she has observed. We expect that children will show progress within a few weeks
on many of their social, communication, and play objectives as the parents learn
techniques that better support their attention, involvement, communication, and
imitation, which now occur inside all activities. Sharing their child’s progress on
specific objectives is very reinforcing to parents’ efforts, and it is a natural point
of celebration. This can happen after any parent–child activity in the coach’s part
of the reflection–evaluation–planning cycle. Showing parents the data sheets and
the progress made further strengthens their efforts. However, it also draws the
coach’s attention to what is not progressing, and the coach may begin to share this
in the discussion time, as part of planning for the next week’s home activities or
the next week’s session. Some skills involve a small refinement, like responding at
first instruction. For parents who always gesture with instructions or always repeat
the instruction several times, the child has not had the chance to demonstrate the
skill. The coach may raise this issue and then ask the parent to be aware of such
behaviors, to try and give an instruction once and then move to a prompt. The
coach might even role-play this with the parent to be sure it is understood. That
might be the parent’s “homework” for the week. Please see the materials provided
in Appendix C for examples of simple self-monitoring tools that parents can use at
home to focus their attention on the new skills that they themselves are learning.
It often happens that it is in the reflection time after the session ends that
the coach becomes aware the child is not progressing on one or another target, in
which case the need to support child learning on that skill can be prioritized in
the planning activity at the start of the next session as one of its goals. Including
a child learning target as part of a session plan often leads the coach to want to
demonstrate “how to do it” to the parents and to then have them imitate what the
coach has done. We personally do not use this approach for several reasons. We
prefer to discuss the skill with the parent, get the parent and child interacting in
an activity, and then point out an opportunity as it arises and coach the parent as
needed to support the child’s target skill. In this way, the parent has the personal
experience of helping his or her child learn something new, and this progress
has come out of the child–parent activity that they have evolved and their own
interactive style. We don’t model the skill because we want the parent to have the
experience firsthand and to do it in his or her own way.*
As the intervention moves along and the parents gain more and more skills,
this attention to child progress continues—moving the initial focus on parent
learning to a shared focus on parent learning and child learning. As parents begin
to demonstrate mastery of the skills they are learning, the sessions become more
and more focused on child learning. The warm-up always begins our sessions so
that fidelity data can show us any areas that need parental review, covered typi-
cally in the first activity, and then the remaining activities may be focused on
child learning targets within the parent–child activity, with parents using the
skills they have learned.
Our data have shown that parents, on average, master the techniques we
have been helping them learn after eight sessions. At that point, the coach’s focus
is on maintaining the parents’ skills while focusing on the child’s progress, and
each activity is focused on child learning. The coach continues to take data on
parent fidelity and child progress, but the coach and parent may shift into a co-
intervention approach in which they alternate activities as partners in the inter-
vention delivery, each focused on child learning, each attending to child progress
and intervention skills, each working to embed this style of interaction into more
and more of the child’s everyday routines within the family.
Difficulties in the Coaching Relationship

The philosophy and approaches that we have discussed thus contribute might-
ily to building a positive working relationship that builds both the parents’ and
child’s skills and ends with high levels of parental satisfaction. Our data show
this! However, difficulties arise in every relationship of every type, and sometimes
these are not fleeting. Long before the parents end the relationship by moving
on to another provider, or by asking to end the coaching relationship and have
the interventionist provide direct intervention instead, warning signs emerge.
*Do we ever model? Yes, occasionally, most often to problem-solve a skill that parents are having difficulty
supporting. In that situation, we imitate the parent’s approach and try to figure out a solution, and then
reverse roles so the parent has a chance to perform the skill with our support. We might also model if a parent
explicitly asks us to, so they can see the skill from the “sidelines.” This is rare but not off-limits!
Cancelled appointments, no shows, reports of no time to practice, desires to talk

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

Parent coaching is often a short-term activity, filling the space for services prior to
the time that children are old enough to be eligible for public school services at
age 3. The ending of an intervention relationship is an ongoing part of an inter-
ventionist’s life, and the relationship may end in various ways. It may be that the
coach and the family have previously decided on a set number of sessions, which
was communicated from the onset of service. This is likely to happen in research
studies, for example. Alternatively, sessions may end when the coach and parents
mutually agree that the coaching process has met its goals, and parents feel able to
use knowledge from the intervention, to self-assess, and to self-correct without the
coach being present. Funding may end, or parents may begin another intervention
that requires the time they allocated for parent coaching.
Endings can also result in negative experiences for both the coach and par-
ents. Coaches may believe that there is much unfinished business, or that relatively
little was accomplished, resulting in feelings of failure, of “imposter syndrome,” or
of anger toward systems that created the termination or families that appeared to
do so little between sessions. They also may feel a great deal of guilt, knowing that
the child received so little of the intervention that was very much needed, or sad-
ness over the lost and unrecoverable time for child learning.
Parents may also end the coaching relationship with negative feelings about
the whole experience, believing that it was a waste of time, or that the interven-
tionist “left” them unprepared and alone, or that no one will ever be able to do
what this interventionist did for them.
There are steps the coach can take before the coaching relationship ends
to prepare everyone for the ending in a way that leads to positive closure, and
this involves ongoing attention to the gains that the parents are making in help-
ing their child learn and the gains in the child’s progress. The goal of increasing
parental independence, problem solving, and decision making described through-
out these chapters prepares the parents for the time ahead, after this coaching
intervention ends. The final sessions should involve increased parental focus on
child progress. The increased use of self-monitoring tools and data tools that allow
parents to assess gains and needs themselves, and an increased focus on parents’
problem-solving skills and the application of their new learning to decision mak-
ing become critical, as the coach shifts from a leadership and coaching role to
work on the sidelines, to function more as a sounding board for parents than as
an initiator of content. Session content shifts to maintain the new learning that
has occurred, continuing to build the child’s skills within home routines using
objectives and steps and data systems—ranging from very simple to more complex
according to the parents’ preferences. Given the amount of child progress that has
occurred during the coaching sessions, the coach may offer to provide another set
of child objectives for the parents to work from. This would be most helpful if the
next intervention will not involve help for parents at home.
Four weeks before the end-date for coaching, session planning can shift to the
parents’ requests for choosing the topic of the day based on what they will need
after sessions end, and such planning and doing can continue in each of the final
sessions. Discussions of resources for additional parent coaching when the fam-
ily needs it help reassure them that help will be available in the future. In some
coaching relationships, the session schedule can purposely start to thin out, going
from every week to every 2 weeks, to prepare parents. Some coaches may continue
to make a monthly visit for a few months after the final session to support parental
independence. If it is not possible for the coach to reinstate these periodic follow-
up sessions, is there another colleague functioning in a coaching role or some
other resource that might be able to assist? Exploring these options with parents
provides some reassurance of help along the way. If follow-up sessions are planned,
we have found it helpful to maintain the same familiar activity structure of the
coaching process, with decisions about next steps being made during the discus-
sion time.
The final session is often a bittersweet experience, looking back and looking
ahead. Using the same session structure, it is often the time to have each person in
the room do a final activity with the child, for the pleasure of observing the child’s
progress and for the pleasure of rewarding adult–child interactions. The discussion
time is a moment to relish what has been accomplished and the amount of learn-
ing that has occurred. Parents and coach will each share how they have grown
from the experience and how they have seen the child grow. Parents might bring
a small gift, the coach may do an art activity with the child and ask to keep the
result as a remembrance, or parents might ask for a picture of the coach and child
posing together. These kinds of acts help parents realize that the coach will not
forget them or the relationship that was forged in the room.
Conclusion
This chapter has walked coaches through a typical coaching session, piece by
piece, to provide a template for a session that provides a considerable amount
of time for parent–child interactions and coaching, while also allowing for the
more general person-to-person, family-focused support that interventionists want
to give and that parents of newly diagnosed young children very much need. We
also addressed issues that come up after the working relationship and rhythm of
the sessions have been established, and parent learning has been the topic of the
sessions for enough weeks that children and parents are both demonstrating new
learning in the sessions. These have included increasing attention to child learn-
ing, evolving into cotreatment sessions as parents master the intervention skills,
and dealing with termination. We have also addressed ways to confront challenges
that signal the potential failure of the coaching relationship, all of which need to
include some ongoing support from others, given how painful an experience this
is for coaches. Coaching relationships in early intervention birth to age 3 services
are by definition short-term relationships, and termination of the coaching rela-
tionship is a bittersweet experience—a time to celebrate all that has been accom-
plished and a time to acknowledge the feelings of loss that come with the end of
fruitful partnerships unified around children’s needs.
Chapter 7
Guides for Introducing

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

to Child Learning
Rationale: Why Gaining Children’s Visual Attention
Is So Important for Learning
What to Share with Parents: Watching what others do—their actions, gestures,
facial expressions—and listening to the language tied to these behaviors are how
102
Introducing Intervention Topics and Strategies to Caregivers 103
young children learn about the world, people, and objects around them. Babies and
toddlers rely on this exposure to develop skills and language and to support their
milestones. In fact, their brains are wired to watch, listen, and respond to people
because those interactions are as biologically necessary as other wired responses
like crying when hungry, tired, or scared.
For Coaches: Highlight the developmental importance of young children’s atten-

tion to other people, not just their environment, for learning from what they see.
Justification: Why This Is Such an Important Issue

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

observed in children’s interactions with parents or in stories shared by the parents
to highlight why more attention to others equals more opportunities to learn and
strengthen their development.
Five Steps for Increasing Children’s Attention to Interacting Adults

What to Share with Parents: Name and describe the step(s) that parents are to
learn today. Help the parents select activities to practice those strategies with their
children, and plan and problem-solve how to continue their practice of specific
child goals they established until the next coaching session.
For Coaches: Keep in mind what parent–child skills are already in use by parents.
Also keep in mind how many steps need more practice to cover in a given session
without overwhelming or confusing parents.
Step 1: Identify the Spotlight of the Child’s Attention

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

What to Share with Parents: Children’s learning from interactions cannot go
any further without paying attention to people’s voices, faces, and actions within
those activities. We want to make children’s attention to people as easy as possible.
This requires finding the positions that put people in children’s spotlight, meaning
children will look at adults—their eyes and facial expressions, where they look,
the movements their mouths make when they speak, the actions that they take
with toys or objects—and finding positions or activities that support children’s
bodies and arousal needs. Do children need to sit in a beanbag chair for better
support for their back and feet when looking at a book with their parents? What
about letting a child lean against a table if sitting for longer periods is difficult? Is
lying on the ground an option when playing social games or singing songs? What
about physical games to wake up a passive, quiet child or sensory activities to calm
a child with higher energy? Let’s brainstorm for ideas to increase your child’s atten-
tion to you.
For Coaches: Reference the activity ideas for this step to help the parents decide
which positioning ideas to try with their child. Consider what you observed from
the child in Step 1 to help parents brainstorm on positioning ideas. Resist the
temptation to share your ideas first.
Step 3: Eliminate the Competition

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

What to Share with Parents: Paying attention to how children with ASD respond
to proximity or the physical closeness of another person helps to gauge their social
comfort zone for interactions and learning. Leaning away or taking steps back
from an adult who moves closer suggests a child is uncomfortable with close space.
Looking at an adult, watching actions happen in an activity, or maybe even raised
corners of the mouth to suggest a smile suggest that a child is at ease with the adult
and the adult’s space. We want to read children’s cues, particularly their nonverbal
reactions—their body language, facial expressions, movements—to understand
their level of comfort and to make adjustments when necessary. What signals have
you seen from your child in activities today or previously that suggest comfort-
able social zones? What about uncomfortable social zones? How could we respond
going forward to try to change that experience?
For Coaches: Offer activity ideas for this step to help parents share examples of
comfortable and uncomfortable reactions from their child and how to respond to
them. Consider sharing observations in the form of questions or statements from
earlier activities done with the child to support parents’ reflection.
• “How would you describe your child’s comfort level during the song?”
• “How did your child respond when you moved in closer to sing the song?”
• “Where else could your body be in relation to hers?”
Step 5: Join in by Following Your Child’s Lead

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

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

reward system.
6. Being a very frequent source of fun and pleasure increases your child’s attention
to you at all times. As your child learns the cues that you use to begin an activ-
ity, he or she learns more about your communication. (Rogers & Dawson, 2010,
p. 92)
These six points can always be turned into a handout to share with parents.
Why Not Having Fun Together Is a Problem

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

in Parent–Child Interactions
Step 1: Find the Rhythm of SSRs
What to Share with Parents: There are two golden rules that separate SSRs from
other types of activities. Unlike toy play or other activities involving materials, (1)
parents and children engage face-to-face in SSRs to highlight the social attention
and engagement we want to prioritize and attach to the fun inside the games, and
(2) SSRs call for reciprocity or equal actions between parents and children. Nei-
ther is always the leader nor always the follower. Instead, parents and children take
turns leading and following one another. They communicate with words, gesture,
facial expressions, and movements or actions to keep the game going. Although
parents often have to start the game to show their child how to participate, parents
are quick to support a child’s lead when he or she pauses a game midaction or a
song midverse, and to wait or encourage their child to gesture, say a word, look at
them, or move his or her body to resume another round of the game. As rounds
continue, the child becomes an expert in how to participate and in how to cue
parents with words, gestures, actions, facial expressions, or other signs to continue
the fun. There is a clear rhythm and balance to SSRs. It is an exchange between
two partners. Parent starts, parent pauses, child cues, parent continues, parent
pauses, child cues, parent continues, and so on. Talk with parents about what
kinds of SSRs their child likes to do or might enjoy trying, and how they can start
to practice back-and-forth rhythm.
For Coaches: Reference the activity ideas and tips for this step to help generate
SSRs and strategies that parents can practice with their child. Remember that
parents may need to repeat an SSR two to three times before pausing to wait for or
help their child cue to continue the game. When parents need to cue their child
to respond, coach them through least-to-more prompting strategies—start to do
the action or say the word and pause, add emphasis or exaggeration to the action
or word, look at the child excitedly and expectantly, model or show the cue again
to encourage the child’s imitation, or physically guide the child through the cue,
mindful not to overdo the physical support and upset or rob him or her of the
motor imprint necessary to learn how to independently do the cue the next time.
Coach and support parents in a few SSRs with the back-and-forth rhythm and
cues in place.
• “What sensory social routine do you want to try?”

• “Let’s talk through the start, pause, cue, and continue rhythm or pattern so
we have a plan on how to support your child through the routine.”
Step 2: Build a Repertoire and Refine the Routines

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

couraged if they take to some games right away, whereas others are not fan favor-
ites. Some children need more than one go with a game to take part in the fun
and to then want to participate themselves. Unless children clearly protest, repeat
the routine or try it again another time.
2. Parents can add variations, or new ideas, to familiar songs or games, such
as new movements, sound effects, or other people (“If You’re Happy and You Know
It, Jump Up and Down,” pretending to be each animal while “Old McDonald” is
sung, or cousins joining in “Ring-Around-the-Rosy”).
3. Parents can add props, or objects and materials, to new or existing SSRs.
Props are positioned between children and parents’ face-to-face interactions and
generally managed by parents to maintain children’s attention on them. We want
to avoid children taking and walking off with the props. Choosing props that
children enjoy parents using or that require parents’ help to start and continue
the game may prevent the objects from taking over the interaction and instead
draw children’s attention to parents’ faces, bodies, and actions to see, understand,
and respond to their cues for communication and interaction. With props, parents
carry out the back-and-forth rhythm of SSRs the same way they do without props.
Parent starts prop, parent pauses prop, child cues, parent continues prop, parent
pauses prop, child cues, parent continues prop, and so on. Anything done several
times can start to lose its appeal. Also true is that every activity or routine natu-
rally comes to an end.
Parents’ practice and success with SSRs rest not just on a repertoire of
choices, but also on when and how to end and move from one game to the next.
Changes in children’s body language, attention, or excitement may signal the end
is approaching. Other times, parents may be ready to end or need to stop before
children are. Trial-and-error is definitely permitted here. When it is time to be “all
done,” prepare your child with a warning that the end is approaching, say when
you are finished, and then start the next activity (whether it is another SSR, an
activity with toys, or some other kind of activity) to help your child see the transi-
tion taking place and how to follow you into the next interaction.
Let’s discuss what other routines with or without props come to mind.
For Coaches: Reference the activity ideas and tips for this step to help parents
practice new SSRs with and without pros and add variations to familiar SSRs.
Remember that parents may need to repeat a new SSR two to three times before
pausing to wait for or help their child cue to continue the game. When parents
need to cue their child to respond, coach them through least-to-more prompting
strategies—start to do the action or say the word and pause, add emphasis or exag-
geration to the action or word, look at the child excitedly and expectantly, model
or show the cue again to encourage the child’s imitation, or physically guide the
child through the cue, mindful not to overdo the physical support and upset or
rob him or her of the motor imprint necessary to learn how to independently do
the cue the next time. Coach and support parents with each of the three options
to expand SSRs to find a back-and-forth rhythm and cues in place before moving
onto Step 3. This way we hold onto smiles for both parents and children.
• “What variation or prop with a sensory social routine would you like to try?
Let’s talk through the start, pause, cue, and continue rhythm or pattern,
so we have a plan on how to support your child through the new routine.”
• “How did the transition go with your child? What should we keep the same,
and what do we want to try differently?”
Step 3: Optimize Your Child’s Energy Level for Learning

What to Share with Parents: Children, like adults, are in the best state to learn
when they are attentive, alert, and engaged, not when they are distracted, anxious,
agitated, overly excited, or tired. This last step seeks to help children find and hold
onto their best energy or arousal level for finding activities to be fun, as well as
interacting with and learning from others. We will continue with our practice of
SSRs alternated with other activities as we watch children for signs of engagement
and enjoyment versus overexcitement, fatigue, boredom, or other behaviors that
may put a stop to our games and decide how to try and regain optimal states for
learning. Sometimes this may be turning down the “dial” or intensity of the game
to head off signs of overarousal—not listening or responding, running around,
yelling, screaming, hitting, or exhibiting other concerning behaviors. Other times
parents may need to turn up the dial or intensity of the game to energize an
underaroused child—sluggish, bored, unresponsive, uninterested, or displaying
other passive behaviors.
think ahead to the behaviors that help versus hurt their child attend, partici-
pate, and learn within a familiar or new SSR, followed by adjustments they might
need to make and recognizing when to do them during SSRs in response to the
child’s attention, motivation, and arousal levels. Reflect with parents after each
SSR on the adjustments made during a routine and how the child responded to
these changes. It is important for the parent to see and understand the connection
between his or her actions and their effect on the child’s behavior in order to know
whether to take them again or try something else.
• “How would you describe your child’s attention and energy in the sensory
social routine?”
• “How did your child’s attention and energy shift in response to your
change(s) in the sensory social routine?”
• “What do you want to keep the same in that routine and what do you want
to change?”
Topic III: Why Back-and-Forth Interactions (Turn Taking)

Are So Important for Learning
What to Share with Parents: Here, we focus on an interaction where the child
and parent are jointly involved from start to finish, participating in an entire
activity together. We call this a “joint activity,” and it can be used for any moment
of interaction with children—from play with or without toys to looking at books,
meals and snacks, diapering, dressing, bathtime, getting ready for bed, and other
caretaking routines or exchanges that happen between young children and their
families. The reason joint activities are important for young children’s develop-
ment goes back again to the multitude of natural learning opportunities and skills
ready to be unleashed inside these specific interactions. Children get to practice
and learn concepts like patience and tolerance in the form of taking and waiting
for turns with another person, sharing materials or toys, flexibility when seeing
how someone else does something, problem solving through personal differences,
and negotiation and conflict resolution. Unlike activities where parents initiate
more of what unfolds, following their children’s interests and actions to ease into
activities, joint activities aim to approach parent and child as equal (or more equal
than before) play partners to find a better balance in their style of interaction. No
one is the boss, and no one is the follower. Instead, the two partners take turns
leading and following. One leads, and the other follows. Then the follower leads,
and the leader now follows. Back-and-forth exchanges like this happen across
selecting activities to do together, adding new play ideas to make activities last
longer, sharing materials, and taking turns with toys, along with our actions, facial
expressions, and words or sounds.
For Coaches: Feel free to invite families to share examples of joint activities
already in effect with their child or to acknowledge if none have been developed;
then reflect on what joint activities they envision trying with their child.
Help parents answer this question if doing so assists their planning:
• “What joint activities happen now or that you see as important activities to
introduce to your child’s development or family life?”
Why Not Taking Turns in Parent–Child Interactions Is a Problem

What to Share with Parents: It’s important for children with ASD to see and
respond to their parents’ turns or other communication signals so that they can
build essential skills like play, imitation, sharing, alternating attention between
people and objects, problem solving, flexibility, and so much more. We worry that
without these and other skills, children with autism will continue to play mostly
alone and become more removed over time, rather than draw parents or other
children and play partners into their activities for engagement, enjoyment, and
continued learning. The risk of these missed social learning moments in early
childhood is as great to children’s brain development, during which their brain
cell networks are particularly ready to absorb and process social and language
information, as it is to their behavior. We want to turn up the volume of parents’
eyes, faces, bodies, and voices through joint activities to help children expect, see,
and respond to these communicative messages and initiate on their own, without
losing out on the fun of social interactions. We will next talk about and practice
how to carry out joint activities.
For Coaches: Parent–child communication includes the eyes, face, body, and
voice, which means that messages are sent and received through any and all of
these channels. Consider giving examples of the different communicative signals
that parents have shared and their child already does, or skills that parents would
like their child to develop within joint activities to help parents start thinking
about how to do activities together so they can be used as learning opportunities
to practice such goals. If parents do not volunteer this information, invite them to
reflect and share examples.
• “What learning moments so far stand out to you when you practice or think
about joint activities with your child?”
• “What parts of your communication [remember, think eyes, face, body, and
voice] could we turn up for your child to take more notice?”
• “What parts of your child’s communication with their eyes, face, and body
do we need to turn up to support (or help him or her find) his or her voice?”
• “What concerns or worries do you have about trying joint activities?”
Techniques for Building Turn Taking and Theme and Variation

in Play
Step 1: Understand the Four-Part Framework of Joint Activities
for Taking Turns
What to Share with Parents: There are four parts that make up joint activities,
and each part contributes learning opportunities and social values to the back-
and-forth interactions we want to create between parents and children with ASD.
Think of joint activities as conversations that parents and children have together
whereby their turns to play a game, sing a song, look at a book, eat a snack, get
dressed for the day, and many more moments that happen throughout the day
involve a set of turns to carry out the desired actions. The focus of joint activities
is to share, or to take turns, doing those actions instead of parents performing all
the actions for children or children performing all the actions by themselves. The
framework involves four steps:
1. Parent or child choose a song or game to start and repeat it two to three
times to create momentum for the child to find fun in the activity and
want to keep it going. This is called the “set-up.”
2. The other partner joins in to do the same activity so that each is watching,
imitating, taking turns, or somehow going back-and-forth with the other
to continue the same activity. This is called the “theme.”
3. At some point, doing the same thing becomes boring or unintentionally
invites less desirable behaviors to develop, making the activity more dif-
ficult to stop. The parent reads the child’s body language to gauge when to
add some changes to the activity. The parent and child continue to watch,
imitate, take turns, or somehow go back-and-forth together to continue the
same activity a little differently from the way it started. This is called the
“variation” or “elaboration.”
4. At some point, the activity naturally comes to a conclusion. The parent
is ready to end the activity or it needs to end. The child communicates to
the parent his or her desire to end the activity. The parent reads the child’s
body language suggesting that it is time to end the activity. Whichever way
it happens, one partner communicates that it is time to end the activity

and the other partner acknowledges the message. Toys or items if used are
put away.
The set-up, theme, variation, and closing continue in the next activity and the
activity after that, and so forth.
For Coaches: We want parents to understand the framework in order to contem-

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

the Joint Activity
What to Share with Parents: The set-up of how the joint activity starts between
parents and children establishes the tone for the rest of the interaction to unfold
and continue. The set-up begins with how parents “hook” their children’s atten-
tion and interest to watch, approach, and join the activity, and the options below
present a few different scenarios of how parents and children might do this.
Whichever way the set-up happens, good body positioning supports good com-
munication, so children can see their parents’ eyes, facial expressions, gestures,
body movements, and hear the words spoken to understand the theme and how to
participate themselves.
• Option 1: Parents choose the toy or SSR that they know from past expe-
rience their children like or a new activity (whether it is toy-based or an SSR)
they think their children might like. They start the activity by demonstrating
the theme of the language and actions of the activity they want the children to
understand and imitate.
FORM 7.1
Joint Activity Template
Activity Set-Up Theme Variation Closing
Who chooses the What action does What other ideas When is it time to
activity? the parent and or changes can end the activity?
child do together? the parent and
How does the How will the
child add to the
activity start? activity end?
activity?
What is the next
activity?
Play-Doh Place Play-Doh bin on Imitate child’s Add googly eyes and Hold out bin for
table. action with my own pipe cleaners to make child to put away one
Play-Doh. insects out of Play- or more items.
Offer two closed Doh.
containers for child Offer “Hokey Pokey”
to choose between. Use rolling pin and or “We’re Going on a
cookie cutters to Treasure Hunt” song
Hold out hand for
make shapes out of next.
child to give selected
Play-Doh.
container for you to
open.
From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J.
Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright © 2021 The Guilford Press. Permission to photocopy
this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details).
Purchasers can download enlarged versions of this material (see the box at the end of the table of contents).
116
A mother knows her daughter likes water, but she has not tried water play with
her daughter apart from bathtime. The mother takes a spray bottle of water to
try a new SSR with her. The mother kneels in front of her daughter to set up
good body positioning where they are face-to-face and then shows the bottle to
her daughter. The mother holds out the water bottle for her daughter to touch
the bottle and then sprays her own hand with water to show her daughter the
water inside the bottle and to see how she is reacting to the game. The daughter
looks at the bottle, and the mother sprays her hand again and then wipes some
of the water on her daughter’s hand so that she can feel the water, too. As the
mother is not yet sure whether her daughter likes this game, letting her feel the
water gives the mother a chance to better read her reaction. The daughter puts
her hand with the water to her mouth to taste it. The mother sprays her hand
again and then holds out her hand for her daughter to touch the water. A theme
is emerging to this routine.
• Option 2: Parents offer a choice of activities to their children and demon-

strate the theme they want them to understand and imitate.
A child looks at the puzzle, not the book, when her father offers a choice between
the two. The father interprets her look at the puzzle as her communicating that
she wants to do that activity and sets it on the floor for them to do together. He
picks up a piece to place in the puzzle, but his daughter does not see his action.
She is looking elsewhere at the floor. He tries again, but his daughter misses
that turn, too. The father sets couch cushions on the floor where his daughter’s
attention seems to be and places the puzzle on top of the cushions so the activity
will be closer to her eye level. This time when he picks up a piece, his daughter
sees him put it in the puzzle. Then he hands her a piece to take and do the same.
Father and daughter are now better connected to continue the theme together.
• Option 3: Children choose the toy and set the theme for the activity.
A child picks up a car and rolls it back and forth. His mother picks up another
car to repeat the same action.
• Option 4: Parents or children choose the toy or SSR and participate together
in the physical set-up of the activity before starting the theme. For activities with
toys, parents and children can take materials to wherever the activity will occur,
open containers, and set out the materials together. For SSRs that involve props,
parents and children can do the same steps.
A mother carries a Ziploc bag of trains, while her son carries a bag of tracks to
the table. Once at the table, the mother helps her son make choices on how to
set up the trains—which bag should they open first, which track or train should
they take out from the bag, who should take out the track or train, where does
the track or train go, and so forth until the activity is set up. Now driving trains
over the tracks can start as the theme to this activity.
Each option and scenario show how parents and children are partners from
the start of a joint activity. One partner chooses the toy or routine and shows
the actions involved in the activity for the other to take turns and do the same.
Sometimes with new activities, parents have to take a little more of the lead to
repeat actions or encourage and help their children to participate until the activ-
ity and actions involved become more familiar to the children, so they can more
easily understand them and experience the fun. At some point, parents, children,
or both partners in the activity will lose interest in the theme, or the children
become so experienced with the theme that parents will need to add other play
ideas to keep the theme and fun going for more interactive learning to happen.
This is the variation that we will practice in a later step. When children start to
lose interest or parents run out of ideas to add to an activity, it’s time to clean up
and end the activity altogether.
For Coaches: Parents do not have to practice all four options to set up an activ-
ity with children. Instead help parents choose toys, objects, or SSRs that will be
helpful in establishing the set-up and theme of play with their children. Consider
choosing activities that you and parents may have “sketched out” in a Joint Activ-
ity Template (Form 7.1) if that would support the parents’ practice. The following
goals of this step are important to reach with parents:
1. Parents have discovered activities with or without toys that embrace good
body positioning with their children.
2. Parents can follow or demonstrate play ideas that support their children’s
interests, imitate their actions, and take turns with children as the basis for
developing themes.
3. Parents are conscious of the four parts to joint activities even if those parts
are not yet reflected in their activities.
• “How will you and your child set up the joint activity?”
• “What is the theme of the joint activity?”
Step 3: Set the Theme

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

interactions with their children.
• “What is the theme of the joint activity?”

• “How do you and your child take turns with the theme?”
• “How did your child respond to the theme?”
• “How would you describe your child’s attention span and participation in
the theme?”
Step 4: Elaborate the Joint Activity and Add Variations

What to Share with Parents: With the theme, parents or children pick an idea
and repeat the actions to play or interact together. At some point, though, that
idea can start to become stale for parents, children, or both. It is only natural
to do an action for so long before wanting to stop and do something else. This
is where variations come into the picture. Parents or children add other ideas
to the activity to keep the interaction, the fun, and the learning going strong.
Variations—make-believe, role play, using objects in other ways, and adding new
steps to familiar routines—bring creativity to interactions. For children with ASD,
variations help expand their imagination and flexibility to contribute or partake
in ideas different than what they are accustomed to. There are three ways to vary
themes: add new materials to the activity, add or change the actions within the
activity, or add more steps to the actions happening in the activity. We return to
the earlier scenario to show how variations were added to the activity.
Scenario 1: Once the mother and daughter have turn taking down to spraying
water on each other’s hands, the mother adds other actions to vary the game. She
names and touches her daughter’s “toes” to spray water on them and then does
the same thing on her own “toes.” That action makes her daughter laugh, so the
mother says “toes” again before spraying both of their feet. At the next opportunity,
the mother gives her daughter a choice: to either have her “toes” or “hand” sprayed.
When her daughter looks at her foot, the mother says “water” and then “toes”
when spraying them. The mother offers a few more choices between hands and
toes before adding another body part to spray. This time, she names and touches
her own “head” and sprays a mist of water above it. She then touches her daugh-
ter’s head and asks, “Head?” to see if she wants water sprayed on it. When her
daughter touches her own head, the mother says “head” and sprays water over her
daughter’s head. Now the mother and daughter have three body parts to choose
from when next spraying. The mother has also thought of other variations to try
another time: (1) asking who will spray from the bottle, (2) adding objects to spray
with water (e.g., plastic animals or cars), or (3) moving the activity elsewhere to
named locations or objects to spray with water (e.g., cups on the table or flowers
in the yard). Lots of variations will bring more fun and learning opportunities to
this game.
For Coaches: Reference the activity ideas for this step to help parents vary activi-
ties. Remember that parents should also pay attention to their children’s actions for
ideas of how activities could vary. A troubleshooting tip here (when variations do
not stick) is to be sure that the theme is really well established first so that children
understand the play concept and find it to be fun. Other issues could be whether
parents follow children’s interests or actions enough times before changing their
focus, or have the children’s attention in the first place before varying activities.
If variations are just too difficult for children to do (no matter how long parents
follow children or try to make the variations fun and enticing), parents can help
children copy their variation, praise them, and then let them go back to the theme
and join them for a few more times in it before trying the variation again.
Just as with themes, parents may also want to practice variations within care-
taking and family routines that happen daily, such as diaper changing, bathtime,
dressing, and meals, and if not in coaching sessions then in action planning with
you, encourage them to try on their own and to share updates at the next session.
Use the Joint Activity Template format outlined in Step 1 if that helps parents’
planning.
Parents may need reminders to name these new materials, actions, or steps
added to activities. Just as in the last step, their attention may be more focused on
their direct actions, as well as their children’s actions, to add variations than to
name or label everything that happens during activities. You can coach parents
to first develop some variations before bringing up this point or gradually support
them to add language to their variations as their success and confidence grow.
• “How can you vary or expand the joint activity? How will you take turns
in the variation?”
• “What other materials, actions, or steps can you add to the theme?”
• “How will [or did] you decide it is [or was] time to vary the activity?”
• “How did your child respond to the variation?”
• “What ideas could [or did] your child offer for variation?”
• “How would you describe your child’s attention and participation in the
variation?”
Step 5: Close One Joint Activity and Transition to the Next

What to Share with Parents: It is time to end the joint activity when children
lose interest, parents lose interest, or parents cannot think of anything else to do
and the play has become repetitive or stale. When this happens, someone makes
the move to signal it is time to end the activity. Children may say, “All done,” or
start to put away the materials themselves to communicate they are done. Parents
follow children’s lead to participate in the clean-up. Other times, parents have
the opportunity to teach these skills to their children. Parents can ask them, “All
done?” or “Should we stop?” and hold out containers to see if the children will
put away the materials, parents can start to put away materials to show children
how to do the same, or parents can set up the next activity, guiding their children
through a change of activities. Any of these actions signal that both parents and
children acknowledge the end of the activity, that together they put away the toys
or materials used in the activity, and that together they transition to something
else. This is the closing, and it marks the final part of joint activities. Let’s see how
the mother and daughter in the earlier scenario closed their joint activity together.
Scenario 1: The mother and daughter continue to take turns picking body parts to
spray with water. Besides hands, toes, and heads, they now add the tummy, eyes,
and arms to their routine. When the mother notices that her daughter does not
seem as eager to take her turn or to pick where to spray the water, she asks, “All
done?” and holds the bottle over the kitchen counter to gesture that she will place
the bottle there if the game was finished. The daughter looks at her mother but does
not reach for the bottle, so the mother interprets her eye contact as confirmation
that she does not want the game to continue. The mother repeats, “All done,” this
time as a statement, not a question, and places the bottle on the counter to signal
the game is finished. The mother then picks up and holds out her daughter’s cup,
asking, “Juice?” to see if she is thirsty. The daughter reaches for her cup to signal
she is thirsty, so the mother helps her daughter into a seat at the kitchen table and
then gives her some juice to drink. The mother also pours herself some water and
sits down next to her daughter at the table. Now they have another joint activity
to do together.
For Coaches: Reference the activity ideas for this step to help parents close and
transition to other activities. One of the activity ideas involves how parents decide
whether to do an SSR or toy/object activity in their transition from one joint
activity to the next. We share thoughts about how to discuss this question in the
next step as a wrap-up to the whole chapter. You can wait until the next step to
bring up that topic, or share it now in this step with parents—whichever makes
sense to you based on whatever information the parents have shared and what you
have observed in their practice activities with their children.
Consider revisiting previously practiced activities to help parents decide how
to now add the closing and any transitions. Parents may also want to practice or
talk about closings and transitions for activities other than play, such as caretaking
and family routines. Adding closings and transitions to the Joint Activity Tem-
plate columns may assist parents who are visual learners in deciding how to do
those and other activities from start to finish with their children.
• “What is the theme of the joint activity? How will you take turns with the
theme?”
• “How can you and your child end and transition to the next joint activity
together?”
• “How did you decide it was time to end the activity?”
• “What cues could [or did] your child give you to indicate he or she was done
with the activity? How will [or did] you respond?”
• “How did your child respond to the closing and transition?”
• “What will you keep the same about that closing and transition? What will
you change or do differently the next time?”
Step 6: Create Joint Activities during Other Daily Routines to Foster

Multiple Areas of Development
What to Share with Parents: All kinds of moments in families’ lives have a joint
activity structure. Diapering has an initiation (a parent bringing his or her child
to a changing table or laying the child on the floor and getting out the wipes,
ointment, a clean diaper, and maybe a change of clean clothes); a theme (chang-
ing into a clean diaper and possibly new clothes!); one or more variations (sing-
ing songs, playing footsie games, or adding objects like stuffed animals, dolls, or
action figures to tickle, sing to, or entertain the child in some way during the rou-
tine); and a closing (a parent holding out hands to lift up the child or to help the
child pull him- or herself up). Meals, baths, brushing teeth and hair, books, doing
chores, getting dressed or ready to leave the house, and many more care routines
that happen every day can be turned into joint activities for new ways to carry
out these interactions with children. Particularly when it is difficult to find the
time to sit down and play with children, daily routines give plenty of practice for
interaction and learning. Knowing the four parts to a joint activity, parents now
have a “script” to think through, to transform any interaction into something they
can do together with their children. Every encounter or exchange with parents
and other family members or caregivers can now be filled with more learning. It is
intervention all day long. Adults and children are also likely to find more fun in
this approach because children’s smiles will be found within such interactions, and
who can resist happy, excited children?
In the last step, we talked about how to decide what type of activity to pur-
sue in the transition. Up until this point, the options have been joint activities
with toys/objects or SSRs, but now we have a third option: care routines. We
recommend rotating across all three to keep joint activity routines fresh, differ-
ent, and sensitive to children’s arousal and motivation for learning. Imagine that
a parent and child have enjoyed a fun game of jumping off the couch into pil-
lows. A mother and her daughter set up the pillows and take turns crashing into
them. Mom gradually adds the actions of first rolling herself and then her child
across the pillows and later squishing each other with the pillows. But then Mom
observes that her child’s energy has gone too high, and she is running around the
room and not paying attention to her mother’s efforts to get her back into the
game. Mom realizes it is time to end this game and to transition to something else
that will calm her daughter and quiet her body. At the same time, the child is too
overaroused to transition to a still activity like looking at a book. Some movement
needs to be involved, but with a purpose. Mom tells her daughter that she needs
to give more water to the family dog Cooper, and she brings over an empty cup
to build in extra steps to do this chore. Together, mother and child walk to the
kitchen sink to fill up the plastic cup and to pour water in Cooper’s bowls, both
inside the house and in the backyard. Next, the mother says, “Let’s show Cooper
the water,” and they put on his leash to walk him over to the bowl in the house to
see if he’s thirsty. He is not but that’s OK. His leash is now on, so Mom says, “Let’s
take Cooper for a walk around the block and then he will be thirsty.” Mom brings
a few treats in her pocket as a variation (to introduce during the walk), so her
daughter can give them to Cooper. Soon the child is focused, settled, and engaged
in a completely different joint activity from the last one.
We consider families’ daily interactions to fall into six types of activities:
1. Toy or other object play

2. Social play (SSRs)
3. Meals (snacks included)
4. Caregiving (bathing, dressing, changing, bedtime, etc.)
5. Books
6. Household chores
Let’s think about how to start turning these interactions into joint activities for
your family.
For Coaches: Reference the activity ideas for this step to help parents choose and
develop daily routines into joint activities. Coaching with parents and children
may occur in this step to practice a routine not yet turned into a joint activity.
But, the focus of this step is action planning through collaborative discussion to
help parents identify the activities and routines in their day that would benefit
from the joint activity framework. Which activities lack more structure or involve
more challenging behavior? Which activities happen lots of times in the day, thus
offering more opportunities for learning to take place? Which activities involve
siblings or caretakers who would add to and gain from the joint interaction? Par-
ents may choose joint activities across all six types to practice right away or only
one or two types. Support parents with however many they choose. You can always
revisit the six types later once the parents have had some success with their initial
choices. Also make sure to discuss how to decide the type of activity parents and
children transition to next if not covered in the last step.
• “What is the theme of the joint activity? How will you take turns with the
theme?”
• “How can you and your child end and transition to the next joint activity
together?”
Topic IV: Why Nonverbal Communication

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

children already have may help parents see that communication is, in fact, already
happening and understand the rationale behind why we want to continue to
strengthen and support spoken words through talking bodies.
• “What body language does your child use now to communicate with you?”
• “What body language do you use to communicate with your child?”
• “What other talking body moments can we create between you and your
child?”
Why Is Lack of Nonverbal Communication a Problem

for Young Children?
What to Share with Parents: When children communicate, they are in charge
of their own voice. When children do not communicate or do so under limited
conditions, they lose that ability to effectively say what they want or do not want,
to share their thoughts and feelings, and to connect and engage with others. What
also occurs is the tendency to take up that communication for children—to antic-
ipate what they want or react to their distress, and to take care of those needs
and do the things that we know they want or do not want. A fidget, a whine,
an action on someone or something—these behaviors mean something, but as a
reaction to what children want or feel, not a communication directed to or shared
with another person. And when we respond to children by doing the thing that
they want us to, then we send the message to them to keep using these less help-
ful behaviors instead of clearer and more meaningful communication. We want
to break this well-intentioned but limitless habit of acting for children and instead
teach them how to use their first communication system, their talking bodies. We
lay out five steps for teaching children and parents how to send and receive com-
munication through their talking bodies. This way, we create a two-way system
for communication to go back-and-forth between two people: child and parent or
another play partner.
For Coaches: Invite the parents to set goals with their talking bodies for them-
selves and their children. Consider referencing activities or moments within inter-
actions to help parents generate ideas if they are unsure of how to proceed.
• “What talking bodies have you noticed so far in your child?”

• “What talking bodies have you noticed so far in yourself?”
• “What [other] talking body opportunities might be available in [name a spe-
cific joint activity like ‘shapes’ or a joint activity category like ‘toy play’]?”
• “What parts of your communication [remember, think eyes, face, body, and
voice] could we turn up for your child to take more notice of?”
• “What parts to your child’s communication with eyes, face, and body do
we need to turn up to support [or help him or her find] his or her voice?”
• “What concerns or worries do you have about working on your and/or your
child’s talking bodies?”
Step 1: Do Less, So Your Child Does More
What to Share with Parents: Doing less means that parents still anticipate their
children’s needs but help them use gestures, eye contact, expressions, and sounds
to say what they want, to make choices, to refuse things they don’t want, and to
share thoughts and feelings. This step is how to encourage children to communi-
cate their needs and wants instead of you giving free access to everything. Refer to
the six activity types below. What each activity type has in common is the joint
activity framework: the set-up, theme, variation, and closing. How can we help
children do more within each of these parts of the joint activity?
1. Toy or other object play

2. SSRs
3. Meals
4. Caregiving (bathing, dressing, changing, bedtime, etc.)
5. Books
6. Household chores
For Coaches: Reference the activity ideas for this step to help parents think about
how children can do more within joint activities. Use the template in Form 7.2,
“Activities That Encourage Nonverbal Communication,” to fill out with parents
and plan activities that will encourage children’s nonverbal communication. You
will see from the template that parents list different activities, followed by the
materials and/or actions that children like about those activities; how parents can
join children in their likes; the requests that children can make with their bodies
to access those materials or actions; and the body language that parents wait for
their children to use before they respond with the materials or actions the children
want. This method plans out the opportunities that parents create around chil-
dren’s likes and wants for them to communicate with their bodies—gaze, gestures,
voice. You don’t have to fill out all five columns with the parents in this step if that
seems like too much information to give to them at once, but rather concentrate
on the column on how children can use their bodies to request the materials or
actions they like about the activity.
FORM 7.2
Activities That Encourage
Nonverbal Communication
The body
My child can language I
My child request with his am waiting
Activity likes to: I can join by: or her body by: to respond to is:
Diapering Get out of a Holding out my arms to pick R eaching or pointing to Looking at me.
dirty diaper. up my child and take them to the item or toy they Making a sound or
Be done with the changing table. want to hold while I saying a word.
the routine. Handing toys that my child change them.
R eaching out arms.
likes to hold or play with while Handing me a clean
being changed. diaper to put on them. Walking or taking a
step toward me to
Holding out my arms to Lifting arms to be be picked up.
pick up my child from the picked up.
changing table. Giving me the diaper.
Meal/Snack Eat Showing a drink with small R eaching or pointing to Looking at me.
Drink amounts of liquid in the cup. the item they want. Looking at me and
Asking my child which cup to Giving me or holding laughing/smiling at
drink from. out their cup, bowl, or what I do.
Asking my child if they want food for more drink Looking at me and
more to drink. and food. what I offer them.
Handing small portions of Looking from me to Making a sound or
food at a time. one of the two items saying a word.
I have (or vice versa)
Offering utensils for my child to say, “I want that Giving me items for
to use. one.” more help, or when
Asking my child if they want done.
Looking from me to
the food in a plate or bowl. the cup, bowl, or plate Pushing away or
Asking my child if they want (or vice versa) to say, giving back items
more food. “Put the drink/food they don’t want.
Helping my child open drink/ there.” Nodding or shaking
food containers for more of Giving me containers their head.
the item(s) they want. for my help to open.
Asking my child to hand me Giving me their cup
their cup, bowl, or plate for or food to have some,
more of the item(s) they too.
want. Watching me when I
Asking my child to give me a drink or eat and talk
drink or bite. about what’s happening
Drinking from my own cup or make silly sounds.
or eating from my own bowl/ Giving me their cup,
plate to make comments and bowl, or plate when
add silly sounds. done. (continued)
128
FORM 7.2. Activities That Encourage Nonverbal Communication (p. 2 of 2)
My child can The body language

My child request with his I am waiting
Activity likes to: I can join by: or her body by: to respond to is:
129
• “How might your child become more involved in [name the set-up, theme,
variation, or closing]?”
• “What choices can you offer your child in [name the set-up, theme, varia-
tion, or closing]?”
• “What opportunities can you create for your child to need help in [name
the set-up, theme, variation, or closing]?”
• “How can your child refuse items or actions in [name the set-up, theme,
variation, or closing]?”
• “How can your child comment about items or actions in [name the set-up,
theme, variation, or closing]?”
• “What materials can you and your child trade or share in [name the set-up,
theme, variation, or closing]?”
Step 2: Wait a Little

What to Share with Parents: One way for parents to do less is by waiting for chil-
dren to cue them with their talking bodies for what they want, instead of knowing
what they want and giving it to them right away. Items and activities may have to
be arranged differently so that children cannot access them without their parents.
Otherwise, why ask for something that children already have? Look for children’s
eye contact, a gesture like an outstretched hand or a movement like taking a step
forward, a vocalization, or some sound to say they want a particular item or activ-
ity. When parents see that talking body signal, they should then quickly give their
children what they are requesting, with a simple communication naming what
the children wanted. Respond to any talking body message children give, even if
it is just one behavior, such as eye contact or a gesture, because children need to
see the actions that will result from their behavior to understand they can com-
municate in this way.
think about how to wait for their children’s talking body cues. Also available is
the Activities That Encourage Nonverbal Communication Template used with
parents in the last step, where the body language that parents are waiting for
their children to use to make requests can now be added (or highlighted if already
included in the prior step). When parents need assistance on how to identify and
create these moments, start with the opportunities in activities for children to
request items/toys or actions, and how parents can rearrange or hold off on turn-
ing over those items or doing those actions until their children cue them. Keep in
mind that sometimes children may not understand what their parents are waiting
for them to do. All children see is that they do not get the usual item or action
and they may become frustrated and upset. To instruct and guide their children,
parents can model the talking body behavior to use—holding up an item near
their face to support the children’s eye contact with them or extending and nam-
ing the toy to see whether the children will reach for it. Go back over activity ideas
that you and the parents developed using the Joint Activity Template to find those
moments where parents can wait or pause activities for children’s talking bodies.
• “How can you wait for your child to ask for items or actions in the activity?”
• “What talking body communication could or did your child demonstrate to
ask for items or actions in the activity?”
• “What you can do to help your child understand what you are waiting for
him or her to do?”
Step 3: Create Lots of Practice Opportunities

What to Share with Parents: Children need lots of practice to learn anything
new. Here, we want parents to create many opportunities in the routines and
activities already happening with children to show them how to use their bodies
to communicate. Finding ways to hold back a little to help children communicate
what they want does not mean ignoring their needs. Parents are best at knowing
what their children need a lot of times, frequently before the children even do. We
want parents to continue to tap into that knowledge of what they know their chil-
dren need to show them how to use eye contact, sounds, reaches, directed smiles,
and other simple, nonverbal body gestures to communicate those needs. The idea
here is to create communication “temptations.”
think about how to create practice opportunities within existing routines/activi-
ties and potentially new interactions. Parents could offer items or actions they
think their children will not like to help them politely refuse or decline those
options. Parents could create opportunities for children to need their help to open
or activate objects, to add silly sounds to games, to carry out favorite songs or other
SSRs. Children can set up the materials for the activity, choose items or actions,
ask for more, ask for help when they cannot open or make something work, give
or trade materials, politely reject things they do not want, follow and share ideas
for elaboration, and put away materials when the activity is done. Parents can try
this with one part of the joint activity framework, such as the theme to increase
children’s participation, and then as they feel more confident, add the other parts,
like the set-up, variation, and closing, to have their children do more.
Also important at some point to cover with parents before advancing to the
next step is which communicative gestures parents should first teach their chil-
dren. There are three main points to hold onto as you work with parents on this
section: (1) Choose gestures that relate to the children’s requests for people and
items/activities (we will address joint attention gestures for parents in Topic VII of
this chapter); (2) choose gestures with lots of practice opportunities available to
the children and parents or other caretakers; and (3) choose gestures that make
sense for children their age.
Later in this chapter, we will delve into how parents can teach and ask chil-
dren for more elaborate communication, such as pointing instead of reaching for
what they want; gesturing and making eye contact or combining other behaviors
at the same time; and expanding simple, nonverbal communications into spo-
ken words and across different communicative functions, like refusing or sharing
items. For now, though, the goal is to help parents create as many moments as pos-
sible for children to use nonverbal communications such as eye contact, sounds,
reaches, directed smiles, and other body gestures.
• “What communication temptations can you practice daily with your child?”
• “What talking bodies will your child use to communicate with you?”
• “What will be your response if your child does not use a talking body?”
Step 4: Hang In There! Persist!

What to Share with Parents: Whenever parents try something new or different,
all children naturally need a minute (or two) to understand what is happening,
whether they like or dislike it, and what is being asked or expected of them in the
interaction. Children with ASD need the same benefit, especially if parents have
changed the way an activity or a routine previously occurred. But, they also need
their parents to do three things to help them make it through new routines: (1)
Keep new routines easy for children to understand and do with parents, (2) make
practice opportunities easy (meaning straightforward and clear) so children can
communicate and get what they want, and (3) persist with repeating the routines
and the learning that occur within the interactions because, like anything else,
practice makes perfect!
For Coaches: Reference the activity ideas for this step to help parents create new
routines that are approachable for their children, easy for them to communicate
within. Refer back to the Activity Categories Template you may have completed
with the parents to find out how they would describe the ease of use for children to
understand and communicate in those practiced activities. Troubleshoot with par-
ents when children fuss or resist during activities on how to make the interactions
and/or talking body communications simpler for children to demonstrate, more
directly related to what the children want, or on how the parents might embed
more practice during the day, depending on what they describe. Remember that
children’s agendas have to be supported and the new routine must be just as timely,
effective, and easy in terms of talking bodies communication as whatever parents
did before this concept was introduced; otherwise, the road to communication
will take a lot longer and involve a lot more struggle.
• “What talking bodies communication can your child easily produce? If

you’re not sure, then let’s start with what items/materials or actions your
child will want included in the activity, and what communications make
sense to teach him or her to ask for them.”
• “How can you help your child complete the communication necessary to
tell you what he or she wants in the activity?”
• “Describe how you handed over the objects or actions your child wanted in
the activity?”
• “How can you continue your practice of this activity and the talking bodies
communication within it until our next session?”
Step 5: Position Yourself “Face-to-Face and Close Enough to Touch”

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

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

What to Share with Parents: Parents want to add simple gestures and the speech
that goes with those actions to routines to grab children’s attention to do the same.
Simple gestures are any hand or body movement that is relatively easy for children
to imitate and that makes sense to do in the activities, such as reaches, points,
gives, pushes away, picks up, or puts in objects/toys. For activities without objects
or materials, like SSRs, add actions that can be a part of song verses, sound effects,
or the physical actions happening in the game (e.g., claps, hops, peekaboo, tickle
motion with fingers, animal motions). Parents model or demonstrate the gestures
first in their turns and then encourage their children to do the same. Sometimes
parents may need to repeat or show gestures more than once or make other adjust-
ments to their body positioning or to the pace of the activity (e.g., speeding up or
slowing down) to make sure that children hear and see their spoken words and
gestures. Help children follow through with the gesture and be sure they reach
the goal they wanted to achieve and there is lots of celebration (e.g., the parent
helps her child clap his hands and sings the next verse of “If You’re Happy and You
Know It, Clap Your Hands,” or the child touches a picture in her book and her
parent makes a silly animal sound). Gestures can also be made during setting and
cleaning up activities, caretaking routines, and chores whenever parents show or
ask children to pick up, give, and put away items. A child’s gesturing shows his or
her understanding and response to others’ language. All parent–child routines can
include gestures for communication to occur.
For Coaches: Reference the activity ideas for this step to help parents add ges-
tures to their routines. Sometimes an easier opportunity for parents is getting their
children to help in the routine, using the materials and actions they want them
to, or completing a less preferred activity more quickly, like diapering or brushing
teeth. Guide parents through how to name, or label, the materials and actions that
relate to what their children want and then how to involve the children in practic-
ing those gestures to get their needs met. We also want parents and children to
practice gestures not only with toys but also with books, SSRs without props, and
daily caretaking routines. Keep a coaching eye out for the possible adjustments
mentioned above that parents may need to make to their actions or activities to
support children’s understanding and abilities to carry out gestures.
• “What gestures can you model and teach your child to do in this activity?”
• “How can you help your child follow through with the gesture when he or
she needs to?”
Step 2: Add Predictable Steps

What to Share with Parents: Repeating routines where parents do the same steps
and sequences as in play and certain tasks helps children understand the actions
and expectations involved so that they can participate with greater ease and inde-
pendence. This does not mean that routines always stay the same. We still want
to add variations or change up the ways in which activities unfold to teach a wider
number of skills, as well as flexibility and creativity, to children. But carrying out
activities or games in predictable steps a few times in a row teaches children to
anticipate what’s coming next so that when parents pause at one of the steps and
use an exaggerated gesture to cue children that something should happen, they
can respond with their talking bodies—eyes, voice, gestures. The more steps that
parents build into routines, the more opportunities there are to teach different
skills to children, so they can see the skills in practice and do them on their own.
For Coaches: Reference the activity ideas and the examples for this step to help
parents add predictable steps to their routines and to encourage their children to
respond. Remember that the joint activity framework parents already know and
should be using from the previous topic is the same structure parents use here. If
parents need a reminder, go back to that topic with them to review the four parts.
If helpful, share the example below: how to add predictable steps to highlight
a typical activity that parents do every day with their children. Notice there are at
least 17 possible communicative steps in this one interaction. See the talking body
examples given previously that parents could use throughout any of the six differ-
ent activity types (i.e., play with a toy or other object, SSRs, meals, caregiving,
books, and chores). How many could parents create within other daily routines
like bathing and eating, or play activities that can become quite elaborative?
Louise has built a predictable routine around dressing for her 24-month-old son
Henry. She has worked earlier with Henry on how to participate in dressing—pulling
shirts over his head, putting his arms through the sleeves, sitting down to put his legs
through his underwear and pants or shorts, and standing up to pull them up over
his waist. Now she wants to add steps for Henry to open his dresser’s drawers and
choose between clothing items to wear.
Set-up: Step 1: Louise brings Henry into his room and kneels down in front of
him to touch the onesie he wears for sleeping, and says, “Take off” as she unzips it.
Step 2: Louise looks expectantly at Henry who looks elsewhere around the room.
Louise tugs the onesie a little bit off Henry’s shoulder and waits again for him to
respond. Her cue works, and Henry removes his arms from the onesie as Louise
says, “Arms out.” Step 3: Louise waits to see if Henry continues to undress from
the onesie. When he does not, she pulls a little on the bottom of the onesie, and
that gesture reminds Henry to wiggle and pull the onesie down his legs. Step 4:
Louise expects Henry to next sit on the floor and pull off the onesie from his feet,
but instead he surprises her with his own variation when he tries to do it standing
up and holding onto her shoulder. She tells him “off legs,” and he repeats the phrase,
lifting up his legs for her to help him.
Theme: Now it is time to get dressed. Step 5: Louise points to Henry’s dresser
and says, “Open drawer.” When Henry does not respond, she exaggerates the
action of trying to pull open the drawer and says, “Help me.” Henry finds this
funny and helps her open the drawer. Step 6: Louise takes out two shirts—one
blue and the other green, holds one in each hand, and asks Henry, “Which shirt?”
Henry reaches for the green shirt. Step 7: Louise touches Henry’s head and says,
“Put shirt on.” As Henry brings the shirt to his head, Louise scrunches the shirt to
make it easier for him to find the hole and to pull it over his head himself. Step 8:
Then Louise waits to see if Henry automatically puts his arms through the holes.
Henry does for one arm and then gets distracted with a piece of fuzz he collects on
his finger. Step 9: Louise holds out her hand and says, “I’ll help. Give me,” for
Henry to let go of the fuzz. Step 10: She adjusts the shirt slightly to make the hole
easier for Henry to find (for his arm that needs to go through it) and to remind him
of what to do next, and Henry responds. Louise and Henry repeat the steps to pick
out and put on a pair of pants (Steps 11 and 12) and socks (Steps 13 and 14).
Variation: Steps 15 and 16: Louise touches the onesie that Henry took off
and tells him to “pick up” and “put [it] in” the laundry basket that she holds out.
Closing: Step 17: Dressing is done! Louise points to Henry’s door and asks,
“Ready to go?” Henry lifts his hand in the direction of the door and Louise responds,
“Yeah, let’s go!”
Step 3: Provide Needed Help

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

Tool—for Everyone!
What to Share with Parents: Imitation is a built-in learning tool. Children natu-
rally copy what they see their parents do. They copy the actions and gestures their
parents make. They copy the sounds and words their parents say. Children do this
because their brains, like adult brains, are naturally wired to resonate with other
people’s actions, through the brain’s “mirror neuron system.” Brain cells called
mirror neurons activate both when we act and also when we see others carrying
out actions. The cells react to the behavior of the other person as though the
observer was acting. Mirror neurons are what make it possible for children and
adults to imitate a behavior immediately after someone else does it, or to hold onto
that information even without practicing the behavior right away and to imitate
it later on. Children’s natural capacity for imitation means that any play partner
(adult, sibling, grandparent, teacher, day care provider) can pass on endless skills
to observe, remember, and put into action:
1. How to interact socially with others through facial expressions, body lan-
guage, proximity, staying on topic, listening/speaking, and other social
rules for conversation
2. How to empathize and feel the same emotion that another feels
3. How to string together sounds that turn into the spoken words we hear
others say and to understand the meaning of those words through the
actions that follow
4. How to convey emotion in those words through the gestures, actions, pos-
tures, and other nonverbal cues that we add to our speech
5. How things work, from objects to games and routines, when we carry out
actions we see others doing
6. How we share a connection or identify with someone when we copy what
that person does because we have that moment or experience in common
Imitation is a powerful learning tool to teach so many different behaviors to chil-

dren.
For Coaches: You can ask parents to share what this information means to them
or cite examples of imitation that you have seen children learn from their parents’
actions and language to encourage their reflection on this topic. Even though this
is the first mention here of imitation of parents, every child has imitated some-
thing his or her parent has done in earlier sessions.
You can ask these optional coaching questions of parents:
• “What have you seen your child learn through imitation?”

• “What are several examples where your child has imitated what you have
said or done?”
Why Is Not Imitating Very Much a Problem for Young Children?

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

What to Share with Parents: When parents imitate children’s sounds, three
events occur: (1) Children begin to notice their own vocalizations, (2) children
hear more sounds and parents’ words that usually accompany those sounds, and
(3) children have more opportunity to make sounds and vocalizations. We want
these three things to happen because children need a large vocabulary of sounds
to learn how to turn on their voice (i.e., that sounds happen intentionally, not by
chance); to learn how to make specific sounds to express that they want something
(e.g., “ba” for ball, or “ah” for up); and to become more proficient through practice
at turning those sounds into spoken words. Even when parents are not sure what
sound children make or what it means, imitate it to communicate to your children
that you have heard them and that their vocalization matters. When parents do
this, they say, “I heard you” to their children and give meaning and importance
to the sound. Parents physically position themselves so the children can see their
faces and imitate whatever vowel (e.g., “oh,” “ah,” “eee”), consonant sound (e.g.,
“geh,” “da,” “wa”), or other sound effects come forth, except for crying, screams, or
whines that children make when playing with their voices. Then parents wait to
see whether their children will make the sound again. If they do, parents repeat
the sound and pause again for children to take their turn within this back-and-
forth game. If children do not repeat the sound, parents make the sound and wait
again, trying to entice them into the game.
For Coaches: Reference the activity ideas and parent–child example provided ear-
lier to help parents and children imitate each other’s sounds and words. Go back
to activities where parents have had this success beforehand but may not have
realized what they did to accomplish this step.
You can ask these optional coaching questions to help parents plan how to
use this step:
• “What sounds does your child make?”

• “What songs, finger games, or other language activities does your child like,
and what key word or phrase can you highlight in these activities for your
child to imitate?”
• “What modifications might need to happen in these activities [when chil-
dren do not readily imitate parents]?”
Step 2: Imitate Actions on Objects

What to Share with Parents: Children notice when parents imitate their actions
with objects. They like that parents copy what they do. They listen to their parents
name the objects and actions as they happen. They add more words to their grow-
ing vocabulary. They develop a sense of reciprocity, or this social coordination of
“you” and “I” going back-and-forth to do something together. This back-and-forth
helps children with ASD pay attention to not only the objects that parents hold
but also more importantly what parents do with them in order for their children
to learn new skills and build their repertoire of play ideas through the actions that
parents show them.
How do parents start? Go back to building the theme of a joint activity routine.
Parents copy children’s actions with their own object and label what’s happening.
When children hit a drum, parents hit the drum with their stick and say “bang,”
or when children scribble on paper with their marker, parents do the same and
say “color.” When children stop their action, parents stop, too, and look expec-
tantly to cue their children to resume. For children who do not readily continue
an action on their own, parents can say the action word (e.g., “bang,” “color”) or
briefly start the action (e.g., tap the drum once or make a mark on the paper) to
encourage children’s return to the activity. Parents continue their start-and-stop
motions timed to children’s actions until they see eye contact, smiles, or other
body language indicative of children’s awareness of the back-and-forth rhythm of
the theme.
For Coaches: The example above is a brief explanation of the teaching sequences
presented earlier for how to use matching or multiple-piece toys to practice imi-
tation during play activities and with objects beyond playtime (e.g., mealtimes,
bathtime, household chores). Keep in mind that parents’ pace to imitate their
children’s actions will likely change based on the children’s level of interest
and arousal during activities. Sometimes parents may need to speed up their
actions and other times slow down their actions. There is a lot of information
and strategies packed in this and the previous step. Don’t hesitate to take more
than one coaching session to help develop different interactive games for teach-
ing c hildren to imitate sounds and actions with objects before moving onto the
next step.
use this step:
• “What matching or multiple-piece objects or toys can you use with your
child?”
• “What actions does your child like to do with the object that you can imi-
tate?”
• “What other actions do you think your child would like to see you do with
the object?”
• “How can you encourage your child to continue the imitation?”
• “What opportunities during the day do you have to imitate your child?”
Step 3: Imitate Hand Gestures and Body/Facial Movements

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

• Introducing new actions or materials to routines that add more flexibility,
learning potential, and fun to interactions
• Pausing routines midverse or in action for children to cue with talking body
communication that interactions should continue
Now is the time to teach children how to imitate and associate their parents’
gestures, body movements, and physical actions with the words that are part of a
song or game. Parents use the theme of a joint activity routine (just like they did in
Steps 1 and 2) to start the song or game and show children how to do the gesture
or movement. A mother sings, “You put your foot in. You put your foot out. You
put your foot in and shake it all about . . . ” to the “Hokey Pokey,” or in another
joint activity routine she says “blow” and puffs her cheeks to blow a raspberry on
her daughter’s tummy. In the next round of the song or game, parents pause right
before the gesture or movement and look expectantly at their children to cue them
to do the gesture or movement now. Sometimes children need a stronger hint to
understand that parents are waiting for them to do something. This is when par-
ents can prompt, or give extra help, to teach children what they want them to do.
Parents speed up or slow down the pace (depending on which helps children pay
closer attention to the motion) to exaggerate and repeat the gesture or movement,
encouraging their children to try the motion. Going back to our examples, the
mother starts the verse, “You put your foot in . . . ” and lifts up her foot, holding
it in the air, or puffs up her cheek and puts her lips together to start the raspberry
motion while encouraging her daughter: “Haley, do too.” If extra help is needed,
parents guide their child’s body through the action, careful to not overdo it with
too much physical assistance lest the child not develop the skill on his or her own.
The mother could touch or gently lift up her daughter’s foot before quickly letting
it go, prompting her daughter to finish the motion herself. The mother encourages
her daughter to move her foot by herself in the next round, even if not perfect or
complete, because an objective is to celebrate any act that children try to imitate.
Since children cannot be physically guided to imitate facial movements like blow-
ing raspberries, the mother may add other sound effects or dramatic motions to
encourage her daughter to imitate the raspberry. The mother slowly and loudly
takes in air to puff up her cheeks and makes funny noises as she pretends to blow
a raspberry on her daughter before pausing in the next round, with her cheeks
puffed out, to encourage her child’s imitation.
For Coaches: The examples above offer a brief explanation of the teaching
sequences along with parent–child examples and activity ideas referenced in
this step to help parents teach their children to imitate the gestures and move-
ments within SSRs. Keep in mind the helpful tip about prompting: for parents
to give the least amount of help possible for children to imitate their gesture or
movement, and to give less and less help over time so that children learn how
to make the motion without help. Coach parents through these strategies within
SSRs before turning to the activity ideas of different gestures, movements, and
sounds that parents can add to other daily routines, like diaper changing, dress-
ing, or mealtimes.
use this step:
• “What sensory social routines does your child like to do with you?”
• “How does your child signal you with talking body communication to con-
tinue sensory social routines?”
• “What gesture or body movement can you add to each sensory social rou-
tine? When will you pause to cue your child to imitate it?”
• “What facial expressions, sound effects, dramatic motions, or other exag-
gerations can you add to the routine to encourage your child to imitate
your gesture or body movement?”
• “How can you guide your child to imitate the gesture or body movement
when extra help is needed?”
• “To what other activities besides sensory social routines can you add ges-
tures or body movements for your child to imitate?”
Step 4: Imitate and Expand on Actions

What to Share with Parents: Parents changing up activities keep interactions
fun, less repetitious, and full of imitative turn-taking opportunities to show chil-
dren how to use different materials and actions in a variety of ways. When children
have more than one way to engage with toys and social games, this expands how
they see and think about objects and actions. Also, whenever children imitate
something new, their ability to imitate only grows stronger and subsequent actions,
gestures, or facial/body movements only become easier and quicker to imitate.
The other good news here is that parents already know how to expand on
their actions by adding variations to joint activity routines practiced earlier! Let’s
revisit.
1. Parents start with a theme to teach children to imitate a specific sound,

action with objects, hand gesture, or a facial/body movement. Parents label and
repeat this action a few times to capture children’s attention and to build up the
fun behind that action. Remember that we want children to find fun in the action
to make them more likely to want to imitate it.
2. Once the activity is fun to children, parents can now teach them to imi-
tate their actions. In the next round of the theme, parents pause midaction or
midverse and look expectantly at children to imitate their action. Parents recog-
nize any effort from children to do the imitation, even if not perfect, and then
resume the theme. Remember, we want children to find the action relatively easy
to do since it is a new skill; otherwise, they may be less likely to imitate the action
again. If children do not readily imitate the action, then parents may need to
speed it up or slow it down or add gestures or facial expressions (if not a part of
the action already) to encourage children to try the imitation. Parents physically
guiding children through a motion is used only when the other prompts do not
elicit imitation.
3. When children imitate the action with ease and consistency, parents
replace the theme with a variation (also called an elaboration) to the activity. Par-
ents follow the same teaching sequence to show, label, and help children that is
needed for them to imitate a different sound, action with an object, hand gesture,
or facial/body movement. Parents continue to teach one new action at a time to
expand the children’s imitation skills. Parents celebrate any and all efforts that
children make with imitation, especially with regard to behaviors that are more
difficult for children to initially imitate. As children develop different actions, par-
ents ask them to choose which to do next (e.g., “Clap hands or stomp feet?” “Roll
dough or poke dough?” “Woof, woof or meow, meow?”). This lets children take
turns leading activities and have a voice in the actions they would like to pursue
with their parents.
For Coaches: Reference the activity ideas to help parents develop variations to the
games they play with their children. Variations can be simple. Think about what
materials, actions, or sequences parents can add to change up activities, one action
at a time, and that children will find fun in and want to imitate. In addition, chil-
dren may need extra reinforcement, or access, to desired materials/actions before
parents’ next expectation to imitate another action. Help parents continue to read
children’s talking bodies to know when to stick with the same action or switch to
a new one. Remember the steps below to coach parents’ teaching sequence with
regard to imitation:
1. Parents show, label, and repeat an interesting action that children will find
fun to imitate.
2. Parents pause and wait for children to imitate the action. Parents cheer if
children do.
3. Or, parents exaggerate the action and encourage children to imitate the
action with cheers if they do.
4. Or, parents physically guide children to start the motion or to do the entire
action only if the extra help is necessary. Be sure that parents fade this
prompt as soon as possible.
use this step:
• “What theme(s) and action(s) does your child like to imitate in this activ-
ity?”
• “What other action(s) do you think your child will like and imitate in this
activity?”
• “How will you prompt your child to imitate the new action(s)?”
• “How will you fade your prompt(s) for your child to imitate the new action(s)
by him- or herself?”
Step 5: Put Imitation Games into the Joint Activity Frame
What to Share with Parents: Let’s revisit the four parts of a joint activity routine:
set-up, theme, variation, and closing/transition to see how different examples of
imitation games fit into this framework.
Using Double Sets or Multiple-Piece Objects and Toys
1. Set-up. Parents position themselves and their objects in front of the chil-
dren in order to be seen and heard.
2. Theme. Parents copy children’s actions with their own object and label
what’s happening. Parents continue their start-and-stop motions timed to chil-
dren’s actions until they see eye contact, smiles, or other body language indicative
of children’s awareness of the back-and-forth rhythm of the theme.
3. Variation. Once a theme develops, parents show a different action with
their object for children to imitate. Parents stick to showing (and teaching) one
action at a time. The different action could be something that parents have seen
their children do previously with objects (e.g., tap on the xylophone or draw circles
on the paper) or something new that parents think children will like (e.g., tap on
household objects, tickle each other with a stick, draw animals, or place stickers
on paper and color over them). Parents label the new action and repeat it a few
times before pausing and waiting expectantly for the children to copy their action.
When children copy new actions, parents celebrate and join in to complete the
actions, too. When children do not readily copy the new action, parents encour-
age them to try it again, and may need to change up the tempo or motion or add
gestures, expressions, or sound effects as enticements to increase the children’s
motivation to want to imitate the action. Parents and children go back-and-forth
with the new action just like they did with the theme, or they can return to the
prior theme if children find the new action harder or less interesting to do. Parents
can always try another action to see whether children like that one better than the
last. Children can also make choices between actions that parents ask (e.g., “Drum
or pan?” or “Circle or star?”) to maintain high interest in the activity.
4. Closing/transition. When new actions run their course and there are no
other actions to think of or try, parents prepare children for the end of an activ-
ity. Remember that activities took time to start and build with children, so it only
makes sense that activities take time to end, especially when children are not yet
ready for the fun to stop. Parents can try several strategies to support children
through closings and transitions. They can gradually put away objects to make
fewer available to children. They can give warnings of how much time or turns
are left before the game ends. They can tell children that they want to be done
with the activity and start putting away some of their objects when double sets are
used. They can set up and talk with excitement about the next activity. All these
steps attempt to explain and ease children’s anxiety with the change and to focus
children’s attention on what is coming next, not what is coming to an end. Parents
can also use clean-up routines to teach children to imitate actions when they label
and put back objects in containers or on shelves. Matching can be taught, too,
when parents show children how objects of the same color (e.g., red pegs in one
bag and blue pegs in another), same size (e.g., small blocks in one container and
large blocks in another), or same appearance (e.g., markers in one box and crayons
in another) can be put away together.
Using SSRs
1. Set-up. Parents pick a movement or gesture that relates to a favorite song or
game their children like and is relatively easy to imitate.
2. Theme. Parents start the song or game to show children how to do the
gesture or movement.
3. Variation. Parents teach one gesture or movement at a time before using
the same prompts to teach other gestures or movements. When Haley learns how
to lift up and extend her foot in front of her body her clothing to the “Hokey
Pokey” song, the mother shows her how to jump, listening to “Put her whole body
in and her whole body out” in the next verse.
4. Closing/transition. When parents or children tire of the gestures or facial/
body movements and there are no other actions to think of or try, parents pre-
pare children to end the song or game. Parents give warnings of how much time
or turns are left before the song or game ends. They can tell their children that
they want to be done with the activity and to put away their props if used in the
song or game. They can set up and talk with excitement about the next activity to
highlight to children what is coming next, as opposed to what is ending. Again,
parents’ language and actions help children understand and move ahead.
For Coaches: Coach parents through the set-up, theme, variation, and clos-
ing/transition for any joint activity routine practiced thus far with imitation, to
establish the full framework with children. Refer to the Joint Activity Template
(Form 7.1) to help parents plan how imitation can be included within other child
care routines, besides with toys, object play, or SSRs. The rest of the coaching
chapters in this book rest on parent–child abilities to become play partners and to
imitate one another’s actions. Stay with this chapter and revisit earlier chapters,
if necessary, to help parents and children develop the steps. The more imitative
games that you can help parents develop with children, the higher the number
of learning opportunities the parents will create to strengthen not just their chil-
dren’s imitation skills, but also their attention, play, communication, thinking,
and engagement skills.
use this step:
• “What can your child imitate you doing during set-up?”

• “How can you and your child imitate each other in the theme?”
• “What other sounds, gestures, or facial and body movements can you and
your child imitate?”
• “When is it time to end the activity? How can you prepare your child for
the transition?”
• “What can your child imitate you doing during clean-up?”
Topic VI: Understanding the ABCs

of Children’s Behavior
What to Share with Parents: Whenever a new behavior develops or an old one
changes, learning takes place. This holds true for children as much as it does for
parents or adults. Whether a person wants to eat healthier and exercise more
often, or a parent wants her child to look at her and speak words more often, both
examples require change on the part of the person to learn something new or
to do something different in terms of his or her behavior. Earlier sections of this
chapter have asked parents and children to do something different—to change
something about their behavior—in order to create fun-filled joint interactions for
children to learn new skills. For parents, the expectation has been to adopt new
strategies in how they approach, engage, and interact with children to capture
their attention and motivation for learning to occur. For children, the expectation
has been to develop or expand skills for interaction, communication, and play
with their parents. In this topic, we give a name to the mechanics of learning that
parents and children have been using: the ABCs of learning, or, more formally,
applied behavior analysis (ABA), which refers to the science of how learning hap-
pens for people to change or develop new behavior. A common misperception is
that ABA is one specific intervention approach. In fact, ABA is an entire knowl-
edge base of how to understand, teach, and change behavior in people—adults
and children alike! This topic goes over the important “rules” of how to increase
parental awareness of:
• Their own behavior

• The meaning and purpose behind children’s behaviors (the Bs)
• The events or actions that lead to children’s behavior (the As, antecedents)
• The events or actions that follow children’s behavior and determine
whether they are more or less likely to repeat that behavior again (the Cs,
consequences)
Once parents have mastered these concepts, additional teaching tools become
available to encourage the development of positive behaviors in children and to
show children new ways of behaving that are more age-appropriate or functional
to their development. Parents maximize their ability to help children learn and to
benefit the most from the interactions that parents provide.
For Coaches: You can ask parents to share what they understand or know thus
far about ABA to encourage their reflection on this topic. Even though this may
be the first mention of ABA to parents, the previous topics have taught parents:
(1) to complete some action that cues a behavior in their child (antecedents) and
(2) to respond to that behavior in some way either encouraging or discouraging it
from happening again (consequences). Bring up at least one example (if parents
do not) to help parents see the connection between their behavior and their chil-
dren’s.
• “What new behavior have you taught your child to do?”

• “How did you teach your child to use the new behavior?”
• “How did you respond when your child used the new behavior?”
Step 1: Pay Attention to What Your Child Does—B Is for Behavior
What to Share with Parents: All behavior has a reason why it happens. This
means that children (and adults) take actions or say the things they do to achieve
a goal for that behavior. Behavior serves a purpose or function. Even unusual,
infrequent, or random behavior has an underlying reason why children (or adults)
do it. The first two rules to know about children’s behavior are the following:
1. Observe what children do with their behavior, not what they seem to
“know.” Children with autism have difficulty communicating and relating their
feelings or emotions to others, as well as understanding them. Instead, parents
can rely on what children do routinely with their actions to figure out what they
understand and know how to do when it comes to a skill, routine, or learning
moment asked of them. When we focus on what children with ASD actually do,
not what we think they can do or how they respond if made to do something, we
gain a clear picture of their vulnerabilities and the skills that they would benefit
from learning.
2. We already said that all behavior happens for a reason, but let’s define what
those possible reasons are. Children (and adults) do what they do to: (1) get some-
thing they like or want or (2) avoid something they do not like or want. These pat-
terns hold true over time, meaning that when a behavior results in something that
people like, they are more than likely to repeat it. Similarly, when a behavior results
in getting out of or avoiding something that people do not like, they are also more
likely to do it again. Sometimes more than one reason or goal might be behind
why the same behavior happens, such as a child screaming out of excitement when
bubbles are blown or out of frustration when a favorite toy is taken away.
Let’s talk about how these two rules apply to your child’s behavior.
For Coaches: Reference the activity idea and tips to help parents observe their
children’s behavior and consider the goals or functions behind what they say and
do. A plan for how parents can continue their observation of, and reflection on,
the children’s behavior and function(s) at home should be developed before your
session ends. Consider discussing examples of behavior that serve more than one
purpose or function if applicable to what parents describe about their children.
Consider encouraging parents to observe and define children’s behavior across
more than one type of interactive activity (i.e., toy play, SSR, meals/snacks, care-
taking, books, chores) to broaden their understanding. Begin to use the ABC
Action Plan Template (see Form 7.3) to help parents learn to describe behaviors
and all other aspects of ABC chains.
use this step:
• “What behavior have you observed your child using?” [Have parents include
at least one positive example if undesirable behavior is initially described.]
• “What does your child want to accomplish with that behavior?” [Have par-
ents include at least one positive example if undesirable behavior is ini-
tially described.]
• “How would you describe your comfort level, differentiating between an
observable behavior from your child versus how your child feels?”
FORM 7.3
ABC Action Plan Template
What positive
What What are What behaviors consequences
is the the learning are expected from How will I teach the follow my child’s
activity? opportunities? the child? behaviors to my child? behaviors?
Meals My child will To come to the table C all her name, show food She eats and
sit at the table and sit in her booster or drink item that she likes, drinks plus my
when she wants chair when told. push out her chair, and tap cheers!
to eat and To look at me and it for her walk over and She eats and
drink. reach or make a sit in it. drinks plus my
My child will sound for what she Be face-to-face and name cheers!
tell me what she wants when I name and hold out food and She eats and
wants to eat and show food and drink items. drinks plus my
and drink. drink items. To give her a napkin for her cheers!
My child will use To wipe her face with to take and, while watching She eats and
a napkin to wipe a napkin when told. me wipe my face, for her drinks plus my
her face. To stay in her chair to do the same on her face cheers!
My child will while eating and while I say, “Wipe face.”
She does not have
stay seated to drinking. To watch for signs of her to eat or drink
eat and drink. To look at me and being restless, meaning she’s anymore.
My child will tell gesture, make a ready to get out of her
chair, and to ask her, “All She leaves the table,
me she’s all done vocal sound, or hand and we do another
with her food me her cup or bowl done?”
activity.
and drink. indicating that she’s To hold out my hand and
My child will done with her food say, “Give me,” with the
give me her and drink. option to put the cup, bowl,
cup, bowl, and To give me her cup, or napkin in my hand if she
napkin. bowl, and napkin doesn’t pick them up herself.
when told.
150
Step 2: Choose the Reward—C Is for Consequence

What to Share with Parents: We have already said that all behavior happens
for a reason: to get something, or to avoid or stop something. Whether or not a
behavior achieves its goal to get something or avoid/stop something is called the
“consequence.” Consequences matter and are important for parents to understand
because how people or the environment respond to behavior basically decides
whether someone does that behavior again or not. Let’s go over the rules for how
consequences work.
Rule 1: Behavior that achieves its goal is likely to happen again. Conse-
quences are actions or events that follow behavior, and when those actions or
events help behavior achieve its goal, the technical name is “reinforcement.”
• A parent who picks up her daughter (the consequence) after her child lifts
up her arms (the behavior) teaches the child that lifting up her arms is how
to get Mommy to pick her up when she wants to be carried (reinforcement).
• A parent who starts a game of hide-and-seek (the consequence) after his
child asks for another round of the game (the behavior) teaches the child
that saying those words are how to continue doing something fun with
Daddy (reinforcement).
• A child repeatedly flicking the light switch on and off (the behavior)
because he enjoys the visual stimulation (the consequence) also means that
the behavior is likely to continue, assuming nothing is done about it (rein-
forcement).
Rule 2: Behavior that achieves its goal to get something is likely to happen
again, as will behavior that achieves its goal to avoid/stop something. There are
two types of reinforcement: positive and negative. Both respond to behavior to
help someone achieve a goal. The difference lies in the type of goal that is met as a
result of that consequence or reinforcement. Consequences that help behavior get
something are called “positive reinforcement.” Consequences that help behavior
avoid/stop something are called “negative reinforcement.”
• A parent who gives a toy (the consequence) in response to his son looking
at him and reaching for the toy (the behavior) because the child wants the
toy (the goal or purpose for the behavior) teaches the child that his use of eye
contact and gesture are why he was given the toy and increase the likeli-
hood that the child will engage in both behaviors the next time he wants
something (positive reinforcement).
Parent has toy → child looks at parent and reaches for toy → parent gives
toy to child → child learns to look and reach to ask for an item
• A parent who shows her child how to hand her a toy (Behavior 1) instead of
crying (Behavior 2) because the child cannot make it work and needs help
(the goal for the behavior), followed by the parent fixing the toy and giving
it back to her child (the consequence), stops the child’s crying and teaches
him or her that handing over an item, not crying about it, is how to ask for
help (negative reinforcement).
Child cannot fix toy and cries → parent shows child how to hand her
the toy for help → child stops crying → parent fixes and gives toy back
to child → child learns to give item to ask for help
• A parent who gives food or drinks (the consequence) while her child walks
around the room while eating and drinking (the behavior) whenever the
child is hungry or thirsty (the goal for her behavior) teaches the child that
walking around a room, not sitting for meals, is OK and increases the likeli-
hood the behavior will continue as is (positive reinforcement).
Child shows signs of hunger or thirst → parent gives food or drink

to child → child walks around the room while eating or drinking →
child learns this routine is OK at mealtime
Rule 3: Positive and negative reinforcement can change or teach new

behavior. Learning new behavior depends on what type of consequence follows
the action. The more opportunities that children have to use a behavior—whether
it is a prosocial behavior like looking and reaching to communicate they want
something, an unhelpful behavior like crying when upset because something does
not work, or demonstrating no behavior and being given an item for doing noth-
ing at all), the stronger those behavior become.
• When parents give something (like a toy or their attention) to a behavior

they want their child to keep using, the consequence they deliver, positive
reinforcement, tells their child, “Yes! Do that behavior again.”
• When parents give something (like a toy or their attention) to a behavior
they do not want their child to keep using, the consequence they deliver,
positive reinforcement, tells their child, “Yes! Do that behavior again,” even
though parents, in fact, do not want their child to continue it.
• When parents give something (in this case, a different behavior) to avoid or
stop a behavior they want their child to use, the consequence they deliver,
negative reinforcement, tells their child, “Use this behavior instead of that
one to get your goal met.”
• When parents give something (like a toy or their attention) to avoid or
stop a behavior they do not want their child to use, the consequence they
deliver, negative reinforcement, tells their child, “Yes! Do that behavior

again,” even though parents, in fact, do not want their child to continue it.
Rule 4: Behaviors that are not reinforced will decrease over time or not
happen at all. A behavior that cannot achieve its goal has less reason to happen.
The longer a behavior goes without achieving its goal, the weaker that behav-
ior becomes until it does not occur at all. There are two types of consequences
that can make this happen. A behavior that goes without positive reinforcement
is called “extinction.” When used carefully and correctly, extinction can teach
children to stop using less desirable behavior. But when used incorrectly or unin-
tentionally, extinction can also teach children to stop using positive, prosocial
behavior.
• The parent who decides to no longer give food or drink to her child while
she walks around a room teaches the child that her behavior will no longer
get her the food or drink that she wants. The child still needs to be taught
what behavior to do to eat or drink instead of walking around the room.
Don’t worry! That step comes in the next section.
• The parent who does not give toys or items when a child makes eye con-
tact while reaching for an item teaches the child that his behavior will no
longer get him what he wants. In this case of extinction, we risk stopping a
communicative behavior that we actually want to promote and strengthen.
A behavior that is followed by something unpleasant or unwanted to make

that behavior less likely to happen again is a negative consequence and called
“punishment.” Time-outs are one example of punishment, as are taking away a
reward, stopping a favorite activity, or grounding a child when misbehavior hap-
pens.
There is a lot to understand and think about when it comes to the actions
and events that follow children’s behavior. But there’s good news here. First are the
wide range of consequences at parents’ hands to teach children new behavior and
to change existing ones. Second are the thousands of opportunities that already
exist within parents’ interactions and routines with children. The wheel does not
have to be re-created. Third are coaching sessions to help parents observe chil-
dren’s behavior and decide how to respond, and, in fact, that’s what will happen
next. By observing children’s behavior and the type of consequence that currently
follows, parents can determine the goal or reason behind the children’s behavior,
whether the existing consequence helps the behavior meet or not meet its goal,
and whether that pattern of behavior → consequence (or B → C) should be kept
or replaced with another behavior and/or consequence chain. The last bit of, and
the most important, good news here is that with these powerful tools, parents help
children grow to their upmost potential!
For Coaches: This information is detailed and will take anyone time to under-
stand. Devote the necessary coaching time and session(s) to talk through the
step’s activity ideas, parent–child scenarios, and templates to help parents observe
and define the functions and relationships between children’s behavior and the
consequences that follow. Although not discussed with parents in the examples
above, keep in mind when consequences brought up or observed by parents may
relate to the environment (e.g., the buzzing of fluorescent lights), to actions other
than the parents’ (e.g., another person flushing the toilet or the elevator door
opening as parent and child walk past it), as well as from children’s own responses
(e.g., a child running around the room or sticking his hands in his ears because of
the sensation produced by an action). The same rules for consequences apply, but
parents may need guidance on how to identify the consequence that should fol-
low. Overall, it is better not to advance to the next step until parents can generally
identify: (1) whether the consequence that follows children’s behavior increases
or decreases its occurrence, (2) how to support positive behavior–consequence
chains with learning opportunities throughout play and routines, and (3) how to
change undesirable behavior–consequence chains to encourage development and
growth.
use this step:
• “What desirable behavior have you observed your child using, and what
does your child want to accomplish with that behavior?”
• “What undesirable behavior have you observed your child using, and what
• “What consequence(s) follow your child’s desirable behavior?”
• “What consequence(s) follow your child’s undesirable behavior?”
• “What consequence(s) are important to keep giving your child? What
consequence(s) would you like to change?”
Step 3: Identify What Came First, Right before the Behavior

Occurred—A Is for Antecedent
What to Share with Parents: Step 1 of this chapter explained that behavior occurs
to gain, or to avoid or stop, something. Step 2 explained that the consequences
that follow behavior matter in terms of whether the behavior happens again or
not. When consequences support behavior to meet its goal (i.e., to gain or avoid/
stop something), behavior strengthens and is likely to occur again. When con-
sequences do not support behavior to meet its goal (i.e., behavior wanted to gain
something or avoid/stop an experience and that didn’t happen), behavior weakens
and is less likely to occur again. The last part to understanding and teaching or
changing behavior focuses on the events right before behavior happens to cue or
trigger its taking place. This is called the “antecedent,” or “stimulus.” Let’s review
the rules for antecedents.
Rule 1: Behavior occurs in response to antecedents. Remember, we said

behavior happens to get or to avoid/stop something. That something is the ante-
cedent. It can be something observable that the child sees and wants, such as
a toy or piece of candy. It can be something observable that the child sees and
does not want or wants to stop, such as medicine, broccoli, or brushing his or
her teeth. Antecedents can be brought on by children’s other senses than sight,
including sounds, tastes, smells, and touch. A child hears a vacuum running and
starts to cry. A child smells cookies baking and comes into the kitchen. A child
feels a tag on the back of a shirt and wants to take off the shirt. Or, antecedents
can be something children feel, like hunger, thirst, sleepiness, fear, and happiness.
A child reaches for the drink that Mom shows her because she is thirsty. A child
hides behind Dad’s legs when a dog and its owner pass them on the sidewalk. A
child may be hard to console because she did not sleep through the night. Lastly,
antecedents can be events or situations that cue children to respond with certain
behavior. Children see a park and want to run toward it. A set of elevator doors
open and children walk in to go for a ride. Parents need to focus just as much
attention on antecedents as they do consequences to understand the whole pic-
ture on what leads up to cueing behavior and what follows once behavior occurs
to strengthen or weaken its ability to happen again.
Rule 2: Antecedents can be nonverbal cues, verbal instructions, or events

that trigger behavior to occur. In the last step, we touched on the different ante-
cedents that children can see, hear, taste, touch, smell, feel, or experience to
cause specific behavior to happen. But parents also have antecedents through
their words and actions to teach, change, or encourage children’s behavior. Think
back to every chapter before this one; each has shown parents how to say or do
something to cue the behavior they want to see in their children. Parents have
a wide range of antecedents: their language, gestures, facial expressions, sound
effects, play, turn taking, and other actions to carry out games and routines with
children. The examples below remind parents of different antecedents highlighted
in previous chapters and the teaching that is already in effect with children. Now
just give a technical name to parents’ actions and language that helps children
learn.
• A parent shows how to perform a new fun-filled action with his toy (the
antecedent), so his child will imitate him (the behavior).
• A parent points to where a toy piece has fallen (the antecedent) to help the
child find the piece and pick it up (the behavior).
• A parent holds out a book in each hand and asks his child which book she
would like to read (the antecedent), prompting her to look at him and point
or say which one (the behavior).
Rule 3: Use antecedents that other children use. When parents are unsure
of what antecedent to use to cue their children’s behavior, they should think about
what events cue this behavior for other children the same age. If parents cannot
figure out what other children respond to, they could observe other children using
the behavior to see what antecedents caused it to happen, ask friends or family
members what their children respond to, or ask teachers or other caretakers what
they see children doing. Using antecedents similar to what other children and
adults use means children with ASD will have a greater chance of understanding
cues that many different people use and strengthening their use of that behavior
when done with multiple people. This is why we encourage parents’ use of lan-
guage, gestures, expressions, body language, and other antecedents that happen in
everyday situations and routines; they make it so much easier for children to learn
antecedent–behavior–consequence patterns that others will also use. Children
learn what they need to approach, engage with, and respond to many people, not
just their immediate family, and in many situations, not just the “teaching” ones.
For Coaches: Now we ask parents to see the relationship and function between
the antecedents that precede and cue children’s behaviors. Just as in the last step,
devote the necessary coaching time and session(s) to talk through this step’s activ-
ity ideas and parent–child scenarios on antecedents and behaviors. Guide parents
to list the positive, or functional, relationships between the antecedents and child
behaviors they want to maintain, as well as child behaviors that might benefit
from other antecedents. We strongly encourage staying with this step until parents
show confidence in thinking through antecedents and behaviors patterns, which
is different than expecting parents to feel 100% confident in knowing how to
change or teach new behaviors. Parents will struggle with the remaining steps if
they cannot “see” the antecedents that cue children’s behavior in many situations
(and the consequences that follow and will strengthen or weaken it).
use this step:
• “What antecedent(s) happen before your child’s desirable behavior?”
• “What antecedent(s) happen before your child’s undesirable behavior?”
• “What behavior from your child is important to strengthen? What behavior
from your child is important to change or teach him or her to do?”
Step 4: Put Together the ABCs of Learning

What to Share with Parents: Now that parents know the ABC rules of learning,
they can decide on the behaviors they want their children to keep using, the new
behaviors they want to teach them, and the behaviors they want to change.
Rule 1: Keep the ABCs for behavior you want to happen. Parents know
what behavior they want their children to use. When parents see that behav-
ior in the children, think about the antecedents that cued it to happen and the
consequences that followed to support or discourage it from happening again.
When parents know the ABCs, they have the power to help children practice that
behavior again and again until it becomes an automatic action. Let’s go through
an ABC example to demonstrate parents’ teaching power.
• A child no longer wants to color (the antecedent) and walks away from the
activity (the behavior) to take out other toys (the consequence). Her mother
brings over the crayons and box (the antecedent), so the child will put them
away (the behavior) before taking out other toys (the consequence). When
the child does not respond (the behavior), the mother puts a few crayons in
the box and says, “crayons in,” and “help me” as she hands crayons for the
child to return to the box (the antecedent). The child puts the crayons in
the box (the behavior), and the mother helps take out other toys the child
wants (the consequence).
Rule 2: Know the ABCs for unwanted behaviors. Parents know what
behavior they want their children to not have. When children use behavior that
parents do not want, parents should first think about the current antecedents
and consequences that support or trigger the behavior to happen. Before parents
change or teach new behavior, parents need to understand why children do the
behavior in the first place and what events before and after its occurrence will give
the behavior reason to re-occur.
• A child hits his sister (the behavior) when she walks up to his train table
(the antecedent) because the child thinks she will take his trains (the goal
for the child’s behavior). The parent tells him “no” and picks up his sister
to comfort her while the child continues to play with his trains (the conse-
quence). Even though the parent is clear that hitting is not allowed, the child’s
play with trains continues uninterrupted and he does not learn how to ask for
help or tell his sister not to touch his trains the next time he thinks she will take
his trains.
Rule 3: Change the ABCs for behavior you want to change. Once par-
ents understand why children do a certain behavior and what antecedents and
consequences support that behavior to happen, parents can change the pattern.
Now parents can think about other behavior they want their children to use in
place of less desirable or challenging behavior and the new antecedents and con-
sequences they need to provide in order to teach children to use more appropriate
behavior and reinforce (i.e., strengthen) it. Let’s return to our last example to show
new antecedent–behavior–consequences patterns.
• The next time that Mom sees her daughter approaching her brother at his
train table (the former antecedent), the mother intervenes before her son
is able to hit his sister and asks him what he can give his sister to play with
from the train table (the new antecedent). The son replies, “Nothing!” (the
old behavior). The mother tries again: “The trains are yours. Can she put
animals on the table or cars on the table?” (the new antecedent). The son
yells again, “No! I don’t want to!” (the old behavior) The mother repeats
her message, “The trains are yours. The trains are Sammy’s. Sissy gets ani-
mals or cars?” and holds up one of each to her son (the new antecedent).
He points toward the animals in his mother’s hand and says, “That” (the
new behavior). The mother places the toy animals on the table within his
reach and tells him, “Give animals to your sister when you do not want her
to touch your trains. Let’s do together” (the new antecedent). After the boy
gives an animal to his sister, his mother gives him a big hug and tells him
how proud she is of him. He also sees that his sister takes the animal to the
floor instead of touching his trains and that makes him happy (the new
consequence). The mother knows she still needs to help her son understand
and use the new antecedent, behavior, and consequence pattern but she
now thinks they are on the right track!
Rule 4: Behavior takes time to develop and it takes time to undo. Behaviors
generally do not develop overnight. While children might say or do something
that parents have not heard or seen before, it’s the behavior that achieves its goal
over time that becomes a habit and part of children’s repertoire. This means that
when children engage in behavior that parents do not like and want to change,
parents should intervene to change the ABC before the behavior becomes more
difficult to undo and teach an alternative in its place.
Rule 5: New behavior has to be relatively easy and make sense to use.
Children use behavior to achieve a goal (remember, to get or to avoid or stop
something). The easier and more obvious new behavior is for children to use and
to achieve goals, the smoother the learning process goes for both children and
parents. This rule doesn’t hold true forever. But for children learning a lot of rules
at once on how to increase attention, interaction, communication, play, and other
skills, this rule helps them see the relationship between the new behavior that
parents want them to use and the familiar consequence children want to follow
their action. New behavior that is within children’s developmental grasp, that
leads to the goal achievement children want or do not want, or that helps them
cope through upset when something cannot go their way is the most effective way
to teach and change behavior.
For Coaches: Now we ask parents to “connect all the dots” on the relationship and
function between children’s behavior and the antecedents and consequences that
surround their action. Refer to the exercises that you and parents went through
in Steps 1–3 to help parents see the ABC sequences that underlie children’s cur-
rent repertoire of desirable and undesirable behaviors. Help parents start with
child behaviors and goals followed by consequences and then antecedents. (Hint:
The “recency effect” in cognitive psychology says that people have an easier time
recalling what happens last in a sequence, rather than what happens first.) Make
sure parents include positive, or desirable, ABC sequences if the only ones they list
focus on what they wish their children did not do. Once parents finish their list,
guide them through a reflection on which ABC sequences they want to maintain,
change, or add for new learning opportunities. The next step relies on parental
understanding of ABC sequences to increase children’s learning for new skills and
to allow existing behavior to flourish. The time and energy required for parents to
develop this knowledge will not be wasted.
use this step:
• “What antecedent(s) and consequence(s) happen before and after your
child’s desirable behavior?” [You can ask this as a two-part question if that
makes it easier for parents to think about and answer.]
child’s undesirable behavior?” [Again, you can ask this as a two-part ques-
tion if that makes it easier for parents to think about and answer.]
• “What behavior from your child is important to strengthen?” What behav-
ior from your child is important to change or teach him or her to do?”
Step 5: Use the ABCs to Increase Your Child’s Learning Opportunities

and Teach Your Child New Skills or Behaviors
What to Share with Parents: Every moment with children is a potential learning
opportunity. This statement can seem overwhelming, but that’s not our intention.
Rather, it is to show how much parents can mobilize ABC sequences within exist-
ing interactions to help children learn. And to make the most of these opportuni-
ties, parents have to remember the following rules.
Rule 1: Remember children’s goals. Know what children want or do not

want. It does not mean parents give into children’s every whim. But, parents need
to understand what children are trying to achieve with desirable and undesirable
behavior before they can respond appropriately.
Rule 2: Respond with antecedents and consequences for the behavior par-
ents want to see in children. Parents provide the nonverbal language, verbal
communication, or situational cues that will lead to the behavior they want to see
in their children. Parents respond with the goal that children want when they use
desirable behavior.
Rule 3: Be aware of distractions. Parents cannot control or remove all dis-
tractions to children, especially when out in public places. Parents need to be
aware of distractions that can be potential reinforcers for children, as in something
they want or do not want, and have an ABC or two ready to help them navigate
their way through that challenge. If it’s something children want, such as food,
toys, or attention, what behavior can parents teach their children to ask for the
item or person? If it’s something children do not want, such as unpleasant sounds,
texture, or something that scares them, what behavior can parents teach their
children to communicate or resolve the issue? If it’s something children want or do
not want but parents cannot grant their request, are there alternatives parents can
offer to redirect their children’s attention to, and interest in, what they do have
and to help them cope with the upset?
Rule 4: Teach (or aim for) more mature behavior in children. Parents ask-
ing themselves how children communicate what they want and do not want lets
them reflect on the complexity of behavior observed in children. If their children’s
behaviors are increasing and improving in frequency, clarity, and sophistication,
then ABC sequences are serving their purpose to aid the children’s development.
If children’s behaviors happen with ease, parents could add other ABC sequences
to expand those behaviors across other skills, activities, people, or places. If chil-
dren’s behaviors do not improve or start to and then stop, parents need to revisit
and change ABC sequences so their children do not fall behind further in develop-
ment. Besides observing or speaking with friends, family members, or teachers to
see what other children the same age do, parents can go online to trusted institu-
tions like the Centers for Disease and Control and Prevention and Autism Speaks
to reference their checklists of the skills and developmental milestones children
normally achieve by certain ages. Developmental pediatricians and psychologists
can also share their knowledge about typical (and atypical) child behavior.
Rule 5: Follow through on ABCs. When children do not respond the first,
second, or even third time with behaviors parents want them to use, it can feel
frustrating to parents, but, in fact, this is a real opportunity to help children
achieve an “ah-ha” moment. Think back to when something didn’t make sense
and then suddenly something clicked, and it did make sense. What a powerful
experience that was! We want children to have that same awakening. To help
children get there, parents need ABCs. First are antecedents to cue children’s
behaviors. Whether that’s parents showing, saying, or doing something or children
feeling something, antecedents are available but not yet given to children until the
behavior happens. Parents hold back with antecedents until children communi-
cate or complete one of the behaviors on the parents’ list that relate to the ante-
cedent. When children use the behavior, parents deliver consequences or what
children want or don’t want to happen, so they achieve their goal as a result of the
behavior. When children do not respond or resort to unwanted behaviors like a
tantrum, parents help children to respond or use behavior that is appropriate. If it
is a word that parents want children to say, parents model the word or add entice-
ment like gestures or actions if that helps to increase their children’s motivation
or gives them alternative communications (think “talking bodies”) to respond. If
it is gestures or actions that parents want children to do, parents can also repeat
and slow down to help children see and process behaviors or speed up to motivate
children to act. When extra help is needed, parents can physically guide children
through behaviors they are trying to teach. After children act, parents deliver con-
sequences. A full ABC sequence (antecedents cue behaviors parents want chil-
dren to use to receive desired consequences) is the secret to learning. Now parents
and children can both experience “ah-ha’s”!
For Coaches: Using the exercises that you and parents have been conducting,
now address the last step in the ABC sequences that reinforce children’s current
repertoire of desirable and undesirable behaviors. Help parents identify the rein-
forcers that met children’s goals (i.e., parents gave something the children wanted
or removed/stopped something they didn’t want) and what behaviors children did
(whether verbal or nonverbal) to communicate their goal. These are the learning
opportunities parents provided to children in those situations. If parents recall
that their children offered no behavior but reinforcers happened anyway, those
represent missed learning opportunities for parents to recognize and reconsider.
Help parents continue this activity to: (1) reinforce their continued effort of
learning opportunities perhaps across other behaviors, play materials or activities,
items, caretaking routines, play partners, or locations; and (2) become more aware
of potential missed opportunities to help children respond before consequences
result.
You can ask these optional coaching questions to help parents plan how to use
this step (all questions but the last two are repeats from the previous step):
child’s desirable behavior?” [You can ask this as a two-part question if that
makes it easier for parents to think about and answer.]
child’s undesirable behavior?” [Again, you can ask this as a two-part ques-
tion if that makes it easier for parents to think about and answer.]
• “What behavior from your child is important to strengthen? What behavior
from your child is important to change or teach him or her to do?”
• “What other learning opportunities are available during the day to
strengthen behavior you want your child to keep using?”
• “How can we turn missed moments into learning opportunities for your
child?”
Step 6: Change Unwanted Behavior

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

Strengthens behavior and likely to happen again
Antecedent → Behavior → Consequence (child does not achieve goal) =
Decreases behavior and less likely to happen again
Now let’s consider when children use unwanted behaviors and the ABC
sequences (1) maintain the challenging pattern or (2) change the pattern to teach
more desirable behaviors.
This ABC sequence maintains children’s unwanted behavior:
Antecedent → Unwanted behavior → Consequence (child achieves goal)

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

achieve goal) = Decreases behavior and less likely to happen again →
Antecedent → Replacement behavior → Consequence (child achieves
goal) = Strengthens wanted behavior and likely to happen again
Here’s how parents teach replacement behaviors to children:
1. Identify ABC sequences and children’s goals for unwanted behaviors that
occur often and disrupt interaction and learning.
2. Think about what children could do differently to achieve their goals.
These become replacement behaviors for children to learn how to use instead of
unwanted behaviors to achieve their goals. Remember in Step 4 that we said the
easier and more efficient new behaviors are for children to use, the more often
they will do so and the stronger those behaviors become. The same rule applies
with replacement behaviors: to be easy for children to use, or easy for parents to
help children use, and quickly result in the same rewards children intended with
unwanted behaviors. Replacement behaviors that are hard for children to use,
even with parents’ help, or that take too long to achieve desired outcomes, or are
only used some but not all of the time are not likely to work and unwanted behav-
iors will continue.
3. Write out new ABC sequences to show how replacement behaviors will be
taught to children. Start with “B” or replacement behaviors, then “C” or conse-
quences of desired outcomes that the children will receive for their use of replace-
ment behaviors, and “A” or antecedents that cue and teach the children to use
replacement behaviors.
4. Practice! New behaviors only grow in strength from practice. And practice
helps troubleshoot, refining and improving ABC sequences for maximal learning
and behavior development to happen. Tiptoeing around situations or demands to
lessen the likelihood of unwanted behaviors does not do children and families any
good. Children continue with lesser behaviors that over time only become stron-
ger and potentially more problematic. Parents continue with struggles. Siblings or
other family members get caught in the middle. No one learns or benefits.
5. A word of caution. The ABCs intend to help parents think about behav-
iors in order to promote and strengthen desirable behaviors in children. But, the
ABCs cannot erase all unwanted behaviors from happening. Children feel dis-
appointment, frustration, fatigue, fear, anger, sadness, pain, or other upset and
sometimes need to cry or scream to release those emotions. If unwanted behaviors

persist or intensify and parents are concerned, please consult a pediatrician or
family doctor to make sure health-related problems are not involved. If children’s
health is not an issue, then parents can also discuss these ABC concepts with
early intervention coaches or other professionals who have training in behavior
management.
For Coaches: Help parents do 1–4 above, using at least one of their examples of
an ABC sequence that supports an unwanted behavior. Make sure that unwanted
behaviors parents choose can be sufficiently addressed with replacement behaviors
in your scope of practice; otherwise, referrals should be made to appropriate pro-
fessionals. This step also includes a case example of unwanted behaviors addressed
with ABC sequences to share with parents if that improves their understanding
of these concepts. We want parents to know much more about why children do
behaviors parents want them to keep using and why children do behaviors par-
ents want them to stop using. With this knowledge and ABC tools, parents can
support children’s desirable behaviors and replace unwanted behaviors with more
functional alternatives. Equally important, parents will need these ABC tools to
teach the social communication behaviors addressed in the remaining chapters.
You can ask the following optional coaching questions to help parents plan
how to use this step (all questions but the last two are repeats from the previous
step).
• “What desirable behaviors do you see your child using? When do they hap-
pen? How do you make them happen?”
• “What undesirable behavior do you want your child to stop doing or to do
less often? What is your child’s goal for using that undesirable behavior?
What antecedent and consequence support that undesirable behavior to
happen?”
• “What replacement behavior is relatively easy for your child to learn and
will still result in your child’s goal? What antecedent and consequence will
support your child to use the replacement behavior? When will you use
this new ABC sequence?”
• “What could stand in your way of using the new ABC sequence to main-
tain the replacement behavior with your child?”
Topic VII: Why It Is So Important That Children

Learn to Share Interests and Attention with Others
(Joint Attention)
What to Share with Parents: Hopefully, by now it is no surprise that children’s
attention to parents and others is important! In fact, not much can happen during
interactions or be taught without children paying attention to us. This is why pre-
vious chapters focus on how parents encourage and support children’s attention
to their faces, bodies, voice, and actions. This teaches children the power of two
people (the parent or another adult and the child) doing things together. Children
watch parents’ actions, listen to their language, try actions themselves, take turns,
express and observe emotions, and communicate intentions. Through these dif-
ferent behaviors, parents and children share experiences that unlock the learning
potential to gain new information and skills.
Now we teach children how to share their attention between themselves, par-
ents, and objects or events that happen. Like a triangle, this three-way interaction
called “triadic or joint attention” teaches children how to shift their gaze and use
gestures and language to share information, emotion, or meaning about some-
thing that interests them and to respond to those things that interest others. Joint
attention supports a lot of learning and communication development both during
infancy when these skills start to develop and later when language, social, and
cognitive abilities grow as children age. We want to build joint attention skills and
the related social, communication, cognition, and language learning that derive
from these shared experiences.
For Coaches: Share examples with parents on what joint attention looks like with
children to start a reflection. Have parents tried these or similar experiences with
children? Have you observed any joint attention behaviors in children? Or if not
yet, what dyadic behaviors have parents seen or have you seen in children to focus
attention on objects or people? Children need to learn these dyadic behaviors and
to participate in joint attention, so we want to make sure parents see their value,
too.
• “How do you and your child share moments?”

• “How does your child let you know when something excites him or her?”
• “How does your child respond when you share something with him or her?”
Why Is It a Problem?
What to Share with Parents: Without joint attention, children with ASD are
less likely to share their excitement and thoughts about objects or events with
parents and other important people in their lives. Also less likely to happen is
children’s ability to read another person’s cues and understand their excitement
and thoughts about objects or events that interest them. Children with ASD lose
out on opportunities to develop the desire to seek out the attention and praise
from others over something fun and enjoyable, and to talk about what happens
and relate to the other person’s feelings or emotions about the experience when
joint attention is limited. But joint attention and the multiple skills that are on
display during these special moments do not have to be different for children with
ASD. We will describe and practice steps for parents to help children with ASD
understand and use joint attention and benefit from the same social, language,
and critical thinking opportunities that happen during these exchanges. We start
with strategies that parents have already used to strengthen children’s ability to
shift eye contact or gaze between a person and an object or event:
• Parents position themselves and objects in front of children for all activities
to draw children’s attention to their faces and eyes.
• Parents develop joint activities across the six different activity types (i.e.,
toy play, SSRs, books, meals, caretaking routines, and household chores) to
do together with children.
• Parents pause activities midaction to cue children to use their talking bod-
ies of eye contact, gestures, actions, facial expressions, sounds, or words to
communicate needs.
Once parents increase their children’s skills, parents and children are ready
for the three steps we cover next to develop joint attention skills.
For Coaches: Include any example where children have responded to interac-
tive strategies listed above to shift their gaze to communicate or to perhaps share
excitement about an object or event with parents. Maybe it was parents pointing
to or holding up a toy and then their children looking from parents to the object
and back again. Or, perhaps the children made a sound out of excitement and
smiled during an SSR with parents. If children have yet to shift their gaze or ges-
ture for shared enjoyment (but have done one or both to request something), then
help parents see children’s current skills as a stepping stone to now being ready to
understand and use joint attention to share. If children are not yet shifting their
gaze or gesturing to request, stay with previous chapters to troubleshoot with par-
ents.
You can ask these optional coaching questions of parents if not covered
already:
• “How do you and your child share moments?”

• “How does your child let you know when something excites him or her?”
• “How does your child respond when you share something with him or her?”
Step 1: Teach Your Child to Give You Objects

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

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

What to Share with Parents: With this step, parents teach children how to draw
someone’s attention to objects of interest to share the experience. We want chil-
dren to hold things in front of parents (or others) and to gradually make eye
contact and comments that will draw parents’ attention to look at the object.
Showing out of interest is a very important skill in children’s development because
the action gets people to label and talk about the objects for children to listen to
the words, connect those words to their meaning, and build their vocabulary. As
children learn to show objects and watch others do it, too, they also learn to enjoy
the social attention and praise that naturally comes with the action. That positive
consequence increases children’s desire, or motivation, to want to share things
with others.
Parents start by holding out objects children like or may find interesting and
by commenting to draw children’s attention to them. Be sure to name objects in
comments (e.g., “Look at the X,” or “X”) and again when children look at them
(e.g., “It’s an X!”). Parents can do this many times each day during play when it is
their turn with an object and they can show what it’s called, how it works, or new
actions that can be done with the object before returning it to the child. Parents
can also show objects that are part of usual routines for children to look at before
receiving what they want. Parents can say and hold out a “cup,” “spoon,” or other
items during mealtimes for children to look at before receiving each object to
drink or eat with. With any opportunity, parents show and name the objects for
children to look at and when they do, parents rename the objects and hand them
over quickly to their children.
Children receiving objects after they look at them is the positive consequence
or reward that motivates them to want to look at objects the next time and each
time thereafter parents practice the skill. When children are quick to look at an
object that parents name and hold out, they are now ready to be taught how to
also look at parents before receiving the object. Parents do all the set-up steps the
same to cue children to look at the object—they name the object enthusiastically
and hold it out for children to see, but they do not hand over the object until
the children look from the object to them. To help children get the hint to do
this, parents can talk about the object, add gestures or sounds that relate to the
object, and move it closer to their face to draw children’s attention to their eyes.
Parents, however, should avoid touching or moving a child’s face to make him or
her look at them; otherwise, we risk upsetting children with an invasive action
they do not enjoy and it will, in fact, make them less likely to want to look at
people. Any quick or subtle look that children give to parents counts and parents
respond quickly and enthusiastically when giving the object to the children. Chil-
dren receiving the object and with their parents’ cheers is what’s key to making
them do the behavior.
Once children consistently look at parents’ objects, parents can begin to teach
children how to show the objects themselves. The gesture is similar to how par-
ents taught children to give them objects. When children have an object, parents
position themselves in front of their children and the object to say, “Show me X”
(make sure to name the object), while parents hold out their hands as if they were
asking the children to give them the object. Parents should emphasize the word
show when they say it because that’s the antecedent to cue children what you are
asking them to do and it has a different meaning than the word give previously
taught to children. Children should be able to reach out with the object since
the gesture was part of the focus in the last step. But if a child does not, parents
repeat the request and touch the child’s wrist or even elbow to help him or her
move the object up and outward. When children show either on their own or
with parents’ help, parents do not take the object but instead admire it and respond
enthusiastically (e.g., “Wow! You have a X,” “That’s a cool X!” “I see X!”). Parents
can also touch, not take away, children’s objects that merit admiration and com-
ments about them.
After children routinely hold up objects in response to parents’ request, par-
ents can stop offering their hands to see if the children will respond to their words
alone. When children do, parents respond the same way as before—admire the
object, make comments, and not take the object from children’s hands. If children
do not respond, parents offer their hand partway but not all the way, as a partial
cue to remind children of the right gesture to make. Parents offer their hand less
and less as they continue this practice with the children until they respond right
away to parents’ words. Children’s eye contact from objects to parents may need
to be taught as an additional step, just as when parents had to show objects to
children. Parents teach children to look at them only after children respond with
ease and consistency to showing objects upon request by their parents. When this
happens, parents ask children to show an object, but hold off naming or comment-
ing about it until their children look at them. If children do not look, parents can
ask them again to show the object, can say their name, or can add a gesture or
sound to “lure” children’s attention to their face, but must hold back enthusiastic
comments until eye contact has occurred. As soon as children look, even if very
quickly or briefly, parents respond with admiration and comments.
For Coaches: We want children to respond to parents showing objects and with
eye contact before parents teach children how to show them objects. This step
may take more than one coaching session depending on parent–child progress.
Refer to the activity ideas and tips for each gesture to help parents think of the
objects they use with their children and that they can show to one another dur-
ing play, caregiving routines, or other types of activity. Coach parents to use the
“look” and “show me” instructions but as parent–child showing skills strengthen,
see if parents can use other words to cue children to look at their objects (“Come
see!” “I have an X!”) and to show their objects to parents (“Let me see!” “You have
an X!”). We want children to shift their gaze between objects and parents, but we
may need to help parents manage their expectations if children are not able to do
this every single time. We want to be careful that children do not lose or lessen
their motivation to want to show objects to parents if and when eye contact is not
paired with the gesture. If this starts to happen and the suggestions above on how
parents draw children’s attentions to their faces do not work, then another tip is for
parents to respond with some but not as much enthusiasm to children’s look at the
objects and to reserve the big response for when children do look at them during
some point in the exchange. We are applying differential reinforcement in how
“big” parents go in their praise and attention to children—some praise and atten-
tion when children look at objects upon request, but more praise and attention
when children shift their gaze from objects to parents. Lastly, make sure parents
continue their use of “give me” throughout activities so that children do not forget
how to use that skill.
use this step:
• “What objects can you show to your child?”

• “How will you teach your child to look at what you show him or her?”
• “What happens after your child looks at what you show him or her?”
• “How can you support your child’s eye contact with you when you show an
object?”
• “What objects can your child show you?”
• “How will you teach your child to show you an object?”
• “What happens after your child shows you an object?”
• “How can you support your child’s eye contact when he or she shows you
an object?”
• “During what other daytime activities can you and your child show each
other objects?”
Step 3: Teach Your Child How to Point to Objects

to Share Experiences
What to Share with Parents: Pointing is just as important as giving and show-
ing for parents and children to comment about, and share interest in, objects and
events they see. Children typically learn to point after giving and showing, and
that’s why we teach it once children know how to do the other two gestures. And
just like giving and showing, it’s easiest for parents to teach children to first follow
and understand their points and then to point themselves.
Parents use their finger to point, or tap, and draw children’s attention to
objects nearby that they may want or are looking at. The gesture is easy to under-
stand. As parents point, they say the name of the object. When children follow
parents’ point to look at the object, parents name the object again to affirm that
the children found it and help them achieve their goal. If children do not look,
parents may need to reposition themselves, the object, and/or their children and
point again, or point to something closer that’s within the children’s line of sight.
Keep pointing while children pick up the object to help them see the relationship
between the point and the object itself.
A lot of opportunities exist within play and other daily routines to help chil-
dren practice pointing to objects. Parents can point to and name the next toy
for children to take out and where to place it. Parents can point to a toy before
activating it or initiating the action children will enjoy. Parents can point to and
name the juice inside a container before pouring more of it into the children’s
cups; they can do the same with another item of food children want to eat before
giving it to them. Parents can point to the next clothing item they want a child
to put on and where the child can place her dirty clothes. In these and other
moments, parents first wait for children to look at the named item or help them
look, and then respond with an action.
Children need a few skills before they are ready to learn how to point by them-
selves. First is what we just described—following parents’ pointing to objects—
and second is reaching with their hand consistently toward objects to indicate
what they want and making their choices known without having to touch the
objects. To begin to teach pointing, parents hold the object that children want
slightly away to stimulate the child to reach for that item. When the child does,
parents quickly mold the child’s hand into a point while giving the instruction
(e.g., “Point to X”) and help the child touch the tip of his or her index, or first,
finger to touch the object wanted. Then parents immediately name and give the
object to the child (e.g., “Here’s X”).
Teaching children how to point is easier for parents if they hold the object
for children to touch in their less dominant hand and use their dominant hand to
help children form their point. Or, parents can rest the object on a table, floor, or
somewhere in front of children’s sight, so both of their hands will be free to help
the children. Just as with the giving and showing gestures, parents teach children
to point first without expecting eye contact. Children can start off by extending
their index finger with or without their other fingers folded to touch the named
object. With time and practice, children will learn to close their other fingers to
make a point. Once children point easily and consistently to request an item, par-
ents can begin to wait for children to look at them after they point before giving
up the object. Parents’ positioning themselves in front of children makes it easier
for children to look at them; they can also call a child’s name, move the object
closer to his or her face, or add a gesture or sound to encourage the child’s eye
contact.
The good news is the number of opportunities throughout play and other
routines for children and parents to practice pointing to objects up close (called
“proximal points”) or to objects at a distance (called “distal points”) to communi-
cate requests or to show and comment about them. Children can point to make a
choice between two objects either close-up or far away. All of these are opportuni-
ties to let children practice pointing and showing to express different meanings
(e.g., “I want,” “Give me that,” “Hey!,” “Look at that,” “What’s this?,” “I see it,” or
“Show me this”), all of which adds words to their vocabulary.
For Coaches: This step comes with a lot of activity ideas to help parents teach
children how to follow and form a point. We strongly encourage guiding parents
through this information in stages, as outlined in the step. Start with parents
teaching children to follow their points to objects up close and then far away,
before parents teach children to point to request objects and to show or comment.
With each stage, parents should let children point first without eye contact to
make the gesture easier to learn before expecting them to point with eye contact.
Just as happens with the other two gestures of giving and showing, children may
need time and practice to master pointing and to shift their gaze between objects
and parents. And like before, we want to be careful that children’s motivation
to show objects to parents is not lost or lessened if and when their gesture is not
perfect or eye contact is not paired with the gesture. If this starts to happen and
the suggestions above on how parents draw children’s attentions to their faces do
not work, go back to the coaching tip of differential reinforcement for parents to
respond with some but not as much enthusiasm to children’s look at the objects
and to reserve the big response for when children do look at them before or after
pointing. Lastly, parents and children should be able to incorporate all three ges-
tures—giving, showing, and pointing—in back-and-forth exchanges before mov-
ing on.
use this step:
• “What objects can you point to for your child to take, pick up, or place?”
• “What activities besides toy play can you point to, to show objects to your
child?”
• “How will you teach your child to follow your point and look at the object?”
• “What happens after your child follows your point and looks at the object?”
• “How can you support your child’s eye contact with you when you point to
an object?”
• “What objects can your child point to and request?”
• “How will you teach your child to point to and ask for or show an object?”
• “What happens after your child points to an object?”
• “How can you support your child’s eye contact when he or she points to an
object?”
• “During what other daytime activities can you and your child point to show
each other objects?”
Topic VIII: Developing Flexible,

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

• “What toys are his or her most favorite? Least favorite?”
• “What play actions does your child see others do?”
Why Is Play a Problem in Autism?

What to Share with Parents: When children play alone or their actions are
repetitive, simple, or limited in interests, they do not experience the same amount
of learning as their peers: to watch others, to imitate what they see others do, to
think of and try new ways of doing things, to practice and strengthen new skills,
to share and cooperate, and to learn language. Over time, repetitive, simple,
or restricted toy play remains just that for children with ASD and significantly
reduces their chances to experience new learning opportunities for language,
socialization, creativity, tolerance, and flexibility. Children with ASD need play
skills with others and with toys so they get the same benefits to their develop-
ment as other children their age do. This is why we encourage the type of inter-
action that parents have practiced with children to build attention, motivation,
thinking, language, socialization, imitation, and communication. Now we turn
to constructive toy play under this topic and then pretend play (also called “sym-
bolic play”) in the next—so children with ASD learn to play and have fun with
lots of different materials in lots of different ways with lots of different people.
Both types of play are easier to teach children when they can watch and imitate
parents’ play actions with toys or objects. Think about how any new idea parents
show children requires that children watch what happens and copy the same
action, too. If children struggle to imitate others’ actions with toys or objects, it is
not a waste of time to go back to the activities and strategies on imitation before
focusing on the strategies explained in this chapter. In fact, parents strengthening
their children’s imitation skills will help them develop more mature and varied
play.
For Coaches: Ask parents for their feedback on how children’s toy play has
improved, what’s helped to make that change possible, and what play skills with
toys would children benefit from learning next. Parents need to know how to use
imitation as their main tool for teaching play skills, as explained in the next sec-
tion. Pull any part of the imitation strategies into your coaching if parents and
children need the practice to carry out the next section.
• “How has your child’s play with toys improved?” [Ask for positive examples if
none are mentioned and share at least one example if the parent is unsure.]
• “What strategies so far have helped to improve your child’s play with toys?”
[Ask specifically about imitation teaching strategies if not mentioned by
parents.]
• “What about your child’s play with toys still concerns you?”
What Parents Can Do to Increase Variety, Flexibility, and Learning

Opportunities in Parent–Child Toy Play
What to Share with Parents: Parents teach play skills to children just like they
taught children to imitate actions with toys or objects using the four-part joint
activity framework. Here’s a refresher:
1. Set-up. Parents choose toys or objects that children like and want to play
with, and set up the activity to support children’s attention to themselves as well as
the materials. Parents copy children’s actions with the materials to begin the play.
2. Theme. Most toys or objects have at least one main action in terms of how
parents and children play with them. Balls are thrown, markers color paper, pots
and pans are banged with a spoon. Parents and children use toys or objects in ways
that other children would naturally play with them and take turns to find a fun
action as the main theme they can do together. They only need that one action to
create the theme for play. Sometimes the theme will come from parents watching
and copying children’s actions, assuming those actions relate to how the toy or
object should be used. Other times parents may demonstrate a play theme with the
toy or object they think their children will like and want to do. Although themes
can and should develop from parents following children’s play interests, we focus
the teaching sequence below on how parents set up fun-filled play themes to build
children’s skill set with toys.
• Parents and children are seated or standing face-to-face when the toys or
objects come out and are put between them.
• Parents take a few pieces (not all) and show their children how to do some-
thing they think the children will like and find fun. They use simple words
to name the toys or objects and actions involved. Parents may need to work
quickly when showing children how something works and with sound
effects or dramatic actions added if that captures children’s attention and
interest to join in right away. If toys or objects do not have multiple pieces,
parents and children have one of each (e.g., each has a ball, marker, or
spoon to bang the pot) or take turns with the sole toy or object. Parents and
children take turns doing the theme, with the parents taking faster or fewer
turns in the beginning if that helps children see and experience the fun of
the theme and want to join in.
• Parents read children’s talking bodies (i.e., face, body language, voice) for
how interested children are in the theme. Are children looking at the toy
or object as parents show the action? Do they reach for the toy or object?
Do their eyes widen out of curiosity? If children show these or other signs of
interest, parents give the toy, object, or piece to them and see if they copy
what the parents did. When children imitate, parents cheer, take another
turn, and hand the toy, object, or piece back to the children to use again.
When children seem disinterested or do not imitate the theme, parents
repeat the action with something extra added to entice them to participate.
Parents can exaggerate the effect of the toy or object, use sound effects or
gestures with the toy or object, slow down or speed up the motion of the toy
or object, or apply other ideas they think of that might encourage the chil-
dren to try the theme. When those strategies do not work, parents physi-
cally guide children through the action to complete the theme, followed by
cheers and another toy, object, or piece for more back-and-forth turns.
• Sometimes children do not like, or take right away to, a particular theme no
matter how much cheerleading and help parents provide. Parents should try
a few times to encourage or help children complete the theme, but parents
should also be careful not to force an idea onto children when their talking
bodies remain unchanged or unconvinced of the fun. Most toys or objects
have more than one action that parents can show as another theme. Balls
can be rolled, not just thrown. Markers can draw lines or dots, not just
scribbles on paper. Parents take turns to show another play theme, encour-
age or help children to imitate the action, label the objects and actions
involved, and cheer and enjoy children’s efforts to learn.
• We encourage parents to build themes and children’s play skills with vari-
ous types of toys, some of which children may not be playing with yet:
{ Books
{ Art materials
{ Ball play
{ Puzzles, shape sorters, color sorters, pegboards
{ Building toys (blocks, Legos) and nesting toys
{ Stringing and lacing
{ Musical toys
{ Outdoor toy play (sand, water)
{ Bath play
3. Variation. Only when children understand, like, and participate in the
theme are they ready for parents to show them more than one thing they can do
with a toy or object to expand their play skills. Variation teaches children play
flexibility and complexity on how to use toys or objects and actions in different,
fun ways. Variation exposes children to more language learning and skill build-
ing through the new toys or objects and actions that are added to play. Variation
encourages children to pay attention and play longer, to think about the new
things happening, and to use the skills to participate. Variation adds lots of benefit
to children’s development, not just fun. There are three ways variation (along with
play flexibility, play complexity, and language learning) can happen.
• Parents add other toys or objects to do the same play actions that started the
theme. For example, for a theme of tossing balls into a bucket, parents and
children can toss in other items, like beanbags, stuffed animals, or other-
sized or colored balls.
• Parents add other actions with the same toys or objects that started the
theme. For example, for a theme of tossing balls into a bucket, parents and
children can do other actions with the balls, like rolling, catching, bounc-
ing, kicking, or running them up and down arms, legs, backs, or even tum-
mies to tickle one another. For a theme of using markers to scribble on
paper, parents and children can draw other things on the paper, like shapes,
numbers, letters, or animals.
• Parents add other steps or phases (whether that involves new materials and
actions) for children to complete the theme. For example, for a theme of
throwing balls, parents and children can set up bowling pins to knock down
and then restack them to repeat the action.
• Whether parents add other play materials, actions, or steps to the theme,
parents follow the same teaching sequence to build variation as they did
to build the theme. Parents show the new play material, action, or step one
idea at a time (e.g., Mom rolls the ball up and down her child’s legs) instead
of multiple ideas back-to-back (e.g., Mom rolls the ball up and down her
child’s legs, bounces the ball, sticks the ball inside her child’s shirt to tickle
her tummy, adds a beanbag and throws it onto the child’s lap, rolls the ball
across the table for her child to catch) for children to imitate. When chil-
dren imitate and any attempt counts, parents make a big fuss (in a good
way) to celebrate their achievement. When children do not readily imitate
on their own, parents repeat their turns to encourage and entice children to
do the same or help children to imitate that action. Children should imitate
the variation at least once to plant a memory for the next time they come
back to the activity with their parents. And parents should try the variation
again even if the play idea is not a huge hit right off the bat with children.
Sometimes children need more time and practice to like an idea, so parents
should not just give up if something is not an immediate hit. In fact, repeti-
tion is key to all children learning new concepts. When parents demonstrate
something more than once, children get to see and think about how that
new idea works and whether they like the idea well enough to want to do
it themselves. And when children are able to repeat actions, their practice
builds and strengthens the skill into an automatic behavior that becomes
a part of their routine and repertoire. They no longer need Mom or Dad’s
encouragement or help because they know how to do it by themselves! Par-
ents and children take turns to continue each variation that children like,
and at any point they can return to the initial theme of the activity.
4. Closing/transition. Parents watch for children’s interest, or their own, start-
ing to wane—remember talking bodies—and prepare children when the end of an
activity is approaching. Even with an alert, children may still need a little time to
ease out of a fun activity. Parents can start to put away toys or objects, prompting
their children to join them, or they can offer choices to children of which activi-
ties to do next, encouraging them to clean up before moving on.
For Coaches: In this section, there are a lot of activity ideas, helpful tips, and
overall coaching materials to go through with parents for increasing the number
of typical toddler–preschooler cause-and-effect toys and the complexity of play

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

What to Share with Parents: Children need to be able to play alone construc-
tively with their toys. Parents cannot always be with children to engage them in
activities. Parents have to consider the needs of other children if there are siblings,
their spouse or partner, and themselves besides meeting the daily responsibilities
of work, the household, and whatever else life throws at them. There is nothing
wrong with parents taking time throughout the day for other people or to do
other things while children play appropriately by themselves. It is also important
in development that children know how to come up with functional play ideas
and actions on their own, without needing parents to always guide them. And
there ought to be different play options available for how children can occupy
themselves with toys or objects and strengthen their play skills and independence
than only watching videos or television shows that do not encourage any of the
above. A practical goal for parents to work toward with children is 10–15 minutes
of independent play once children (1) can easily and frequently imitate actions
that parents do (2) during set-ups, themes, variations, and closing/transitions (3)
across a number of play routines with different toys. When children have these
three skills down, they are ready for parents to teach them how to choose a toy or
object, set it up, and play without parents taking any turns to play or model how
to do something. This establishes a different role for parents, but parents take this
approach deliberately because now the focus is on children’s spontaneous, inde-
pendent (not joint) play. There are five steps parents follow to do this.
For Coaches: Make sure that children can imitate variations whether they are
other actions, toys or objects, and sequences of actions shown with toys or objects
and without parents’ physical help. Parent repetition or encouragement to do
the modeled action is OK, but we want children to develop the motivation and
understanding to complete the action themselves. If it is unclear to you whether
the children are at this stage, ask their parents to do the activities with them
and to then share with you examples of when they saw them happening without
incident.
use this step:
• “What themes and variations does your child readily imitate without any
help?”
• “I would love to see what that activity looks like. Would you share that with
me now?” [You can ask this as a follow-up to the last question.]
• “Would you show me what that looks like with your child?” [You can ask
this as a follow-up to the first question.]
• “How does your child currently keep him- or herself busy when you need to
do other things?”
Step 1: Organize for Independence

What to Share with Parents: How children’s toys are organized is important to
how the teaching process begins. Too many toys out at once can make it harder
for children to choose and focus on any one toy at a time, and instead lead to
randomly picking up and dumping toys or trying a toy once or twice before going
onto the next one. We want a few selected toys, no more than six, available for
children to choose from at a time. We recommend cause-and-effect toys that
children like and that include a number of different actions children can do by
themselves, like puzzles, shape sorters, building blocks, Play-Doh or other sen-
sory materials like water play, drawing, painting, or pegs and a pegboard. Parents
should also consider activities that other children this age play or look online for
ideas, and follow the teaching sequences in the last section to show children how
to do these new activities before offering them as an independent play choice.
Parents should avoid toys that are electronic, that need someone’s help to operate,
or that could turn into repetitive play because the goal is to promote children’s
independent, constructive play skills. The selection of toys should also change
every few days or weekly depending on children’s level of interest to keep playing
with the toys and to strengthen and expand children’s play skills over many toys
and many actions.
Once parents have made their selection, organize the toy pieces in contain-
ers, bins, shelves, or baskets that children can carry and see and get to on their
own. We recommend a low shelf with the containers (or whatever parents choose
to hold the toys) arranged side by side, as opposed to stacked or arranged on the
floor. Children will need to walk over to the area to look at their options, make
a choice, pick up the toy, and take it in one trip to wherever they will begin their
play. So where the toys are located and how they are organized are important to
children’s ability to complete this step. If toys are difficult to identify or pieces fall
out of a too small container or require multiple trips to carry, these or other set-
backs could discourage the child’s focus and motivation to want to play with that
toy. Let’s make the set-up and what we want children to be able to do as easy and
clear as possible to help them succeed.
For Coaches: If parent ideas seem too mature for children or not geared at inde-
pendent play, is it possible for parents to scale back the play by one age level or
change the focus of the play, so children will be able to participate and still like
the activity (e.g., a child puts the pegs wherever she would like on the pegboard
instead of by color)? Starting with play ideas that children can do by themselves
can sometimes establish the attention span and interest needed so that parents
can teach other concepts leading to children doing more actions by themselves
(e.g., how to connect the pegs to build a tower or a rocket ship that blasts off).
Children can also learn to do more for themselves during the setup and cleanup
to start and end activities (e.g., to open and take off the lid to play with pegs or to
pick up the box and put away in the closet).
use this step:
• “What toys do you think your child would like to play with, and can he or
she do the play actions without help?”
• “How can you organize and set out those toys to make choosing and the
set-up relatively easy for your child?”
• “What can we troubleshoot to make sure this plan works for your child?”
Step 2: Ease Out of the Play Partner Role

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

about what they are doing and to want to continue to play constructively and
independently with toys or objects.
Children who stop their play or notice when parents physically move back
from the activity may need that extra encouragement or enthusiasm from parents
to continue their turn. Parents can narrate or talk about what their children will
need to do when it’s their turn (e.g., “There’s a circle and a triangle. Which one
do you want?” “Make another snake”) to try to motivate them to resume their
interest in the activity. Parents can also move materials closer to children’s reach
or start their turn and have children finish it as an effort to shift children’s atten-
tion on what to play with next, instead of their parents attempting to pull back
again from the activity. Parents give children a few minutes at a time to play by
themselves before commenting on their actions. Even if children only do some-
thing once in an activity and then want to stop, they still did it! When parents
notice children’s play skills slowing down, parents can comment on other varia-
tions that children could try, for instance, adding other objects, actions, or steps
to their play. Try not to take turns to show the ideas to children, but instead offer
ideas or ask the children for their own so you stay to the side of the interaction
not in it.
As children practice, parents pay attention to and even jot down how long
children are able to play by themselves and how many times, if any, they need help
to stay on track. Over time, parents want children to be able to play by themselves
for 10 to 15 minutes and for the number of times children need help to decrease
as their play skills and interest grow. For now, we want children to engage in con-
structive theme and variation phases with toys or objects by themselves for a few
minutes at a time.
For Coaches: Coach parents through this teaching sequence in a few activities
so that they learn how to shift from an active play partner who takes turns with
children to a commentator on the side who supports children’s play. For now, focus
mostly on parents’ ability to decrease their support during the theme and variation
with toys or objects since the next step covers the set-up and closing/transition
phases.
use this step:
• “What toys do you think your child would like to play with? And can he or
• “What play actions and body language do you want your child to show
before you start to pull back or turn your body away from the activity?”
• “If your child notices what you do, how can you encourage your child to
continue?”
Step 3: Decrease Support for the Set-Up

and Closing/Transition Phases
What to Share with Parents: Once children can do the last step, they are ready
to carry out the set-up and closing/transitions of activities by themselves to add
more independence to their play. Let’s look at how parents do this within the joint
activity framework.
1. Set-up. Parents have children walk over to where the toys are organized to
choose what they want to play with and to take that item to the table, floor, or
other play space and get started. Parents position themselves next to children, but
not right in front of them and not too close, so that gradually parents can move
behind children as their focus turns more and more to their play. When children
need help, parents should respond, but it is important to let them do as much of
the action as possible by themselves to build their independence at problem solv-
ing, not only playing. Parents start by telling children what to do (e.g., “take off
the lid”) followed by gesturing when saying isn’t enough (e.g., touching, mimicking
how to open, or pointing to the lid) before physically starting the motion for chil-
dren to finish (e.g., opening the lid from one corner instead of all four) or moving
children’s bodies from behind or the side to learn how to do the action from their
perspective (e.g., placing one hand to hold onto the box and the other hand on the
lid to pull it off). Helping children from behind or beside their bodies, rather than
in front of them, teaches children how to carry out actions on their own. This is
the one time where parents are not face-to-face with children when we want them
to maneuver the mechanics of an action by themselves, rather than participate in
an activity and share the experience together.
2. Theme. Parents follow Step 2: Wait for children to begin their play and
comment occasionally after every few minutes of children’s independent play on
the actions that would keep them feeling encouraged and motivated. When chil-
dren stop in their play, make suggestions or take very brief turns to keep the chil-
dren going.
3. Variation. Parents follow Step 2: Offer ideas for children to try with other
toys, actions, or steps added to their play. Comment occasionally after every few
minutes of children’s independent play to acknowledge what they’re doing. When
children need help, instruct them: offer, demonstrate, give, or point out what to do.
A last resort is to initiate the motion yourself or help children from behind their
bodies to finish the action. Do not take turns. Continue to observe and comment.
4. Closing/transition. When play ideas have run their course and children
seem done with a toy (or tell you so), parents should encourage them to put the
toy or pieces back into their container and to return it to the shelf or spot where
other containers of toys are stored. If children need help, parents should help as
commentators or from the sidelines, remaining less directly involved in the actual
clean-up, such as pointing to or moving pieces closer to children’s reach, holding
the container for children to put away pieces, or turning clean-up into a game of
how fast children can do it by themselves. If children do not put the toy container
back in the right spot, parents can point to it, or walk the children along with the
container over to the storage area. They can also help the children from behind
or the side to carry the container to the right spot and set it down. Then children
get to pick the next toy to play with and practice the same sequence over again.
For Coaches: Parents should practice the entire joint activity framework to
decrease their support and role in children’s independent play.
use this step (the first three questions are repeated from Step 2 in case they apply
to parent–child practice with this step):
• “What toys do you think your child would like to play with, and can he or
• “What play actions and body language do you want your child to exhibit
before you start to pull back or turn your body away from the activity?”
• “If your child notices you pulling back, how can you encourage your child
to continue the activity?”
• “What signals is your child sending to suggest he or she is ready to end the
activity?”
• “How can you encourage your child to clean up without your help or help
from the side?”
Step 4: Change Toys Frequently

What to Share with Parents: Not all at once, parents change one or two of
the toy choices, including children’s favorites, often enough and before children
tire of their choices to widen children’s exposure to different toys, play ideas, and
skills. For some children, the rotation might occur every other day, whereas other
children may need more time to get the hang of how to play with something on
their own or want to keep playing with it a little longer before switches are made.
Toys that are new or less interesting choices can be included in the mix only after
children and parents have played with them together (i.e., taking turns within the
usual joint activity framework) and children understand how to play with them
and have some motivation to do so.
For Coaches: Although we want frequent toy rotation to benefit children’s play,
parent input on how often they can actually make it happen, and stay consistent,
is important to know. If parents cannot complete this task at least weekly, ask
them to share what stands in their way and try to problem-solve with them. Also
important for families to know is this: Do not go out and buy new toys as the only
way for children to get more toy experience and play skills. You can go back to the
lists that parents made earlier in this chapter for increasing children’s variety and
flexibility across different toys. Or, you can help parents make another list of new
toys or objects children might like to play with on their own once they know how
to use materials with parents.
use this step:
• “What toys can you rotate across time for your child to play with by him-
self? Which toys does your child like to play with, and can he do the play
actions without help? Which toys might your child like to play with on his
own or after you show him how to do it?”
• “How many toys should be available for your child to choose at a time? And
how much time should elapse before you rotate in the next one or two
toys?”
• “Which starter toys from the list do you want your child to choose?”
• “What can we troubleshoot to make sure this plan works for your child?”
Step 5: Move Farther Away from Your Child

What to Share with Parents: Parents gradually move farther away and make
themselves less available as children’s play increases with a toy or object. Parents
can look at something else from their seat, maybe a book or their phone if not
distracting to children, or get up to do something in another room with periodic
checks and positive comments about their children’s independent play. When
children cannot get something to work or their play stalls or stops, parents give
the children a little time to problem-solve on their own before jumping in to help
or offer an idea. Keep in mind that children’s play may not be as creative or elabo-
rate as when they play with parents, but the goal here is children’s independence
to do constructive, solitary play, not necessarily re-creating every skill parents have
taught them in previous chapters. As children’s independence improves and they
can complete the entire independent play routine from set-up to clean-up and any
transitions on their own, parents can add an electronic toy (one at a time) to the
children’s choices to see what happens. If children tend to only play with that toy,
or while playing with it, their play goes from functional to repetitive, parents can
stop including electronic toys as an option. That rule should apply to any toy (elec-
tronic or not) when children “get stuck” and cannot move away from it. Repetitive
play limits children’s learning opportunities to try new things. That’s why parents
rotate different toys for children to choose from and increase their play repertoire
and flexibility, as well as limit boredom.
For Coaches: Observe and, as needed, coach parents to move farther away and
make themselves less available while children play by themselves. Ask parents
before they practice this step how they want to occupy themselves while children
play independently. Parents could put unused items away, step outside the room
to do something, talk with you about how to continue their practice of this step,
or jot down ideas to share later in the session with you. Parents should select
whichever option they believe will be less distracting or anxiety-provoking to their
children, and keep an eye out for how the children respond when their attention
and in some cases bodies are elsewhere than in the same room. If parents decide
to leave the room and the session is in your clinic (as opposed to their home),
parents should tell children where they are going and that they will be back in a
minute so as not to alarm the children in a setting that is not their home. Parents
can decide if children need that same warning when they leave a room in their
own home. When parents move away from children’s play or out of the room, we
recommend that parents time how long children can play by themselves before
asking for help, expressing their desire to be done, or demonstrating a behavior
(positive or negative) to get their parents’ attention. Doing so gives parents a sense
of how long they may have to accomplish something else before children are likely
to want their attention. Parents can then return to the room where the children
are, or if the parents haven’t left, they can share positive comments about the
children’s play. This way, parents give children their attention for the thing we
want them to do—to learn how to play on their own—and not for something
else, like asking for help or an escape from boredom. Ask parents what other ques-
tions they might have to put, and to keep, this plan in action. Briefly, parents can
practice this (and frankly any skill from this book) either when siblings are doing
their own thing (e.g., napping, attending school, or spending time with another
parent or caregiver), or they can teach children and siblings how to carry out
an independent play routine together. When children don’t readily add to their
own play, parents need to make sure children are interested in the toys or objects
they have. Children need to like what they have to want to do things with them.
If children’s interest is real, then parents can verbalize ideas for children to try
with other materials, actions, or sequences in their play, or parents can take brief
turns modeling new ideas while their children are watching. Parents repeat quick
turns or introduce other strategies if children need more enticement to participate
before physically helping children do the action.
use this step:
• “What cues or signs do you want to see in your child before you start to
move away from an activity?”
• “What other help besides physical assistance can you offer when your child
needs help?”
• “How does your child interact with the toy or object?” [Ask this question
when you want to see if children are even interested in an activity, or par-
ents share that the children have not added new actions to it.]
• “In what other ways besides physical help can you demonstrate new actions
for your child to do with the toy or object?”
• “What can we troubleshoot to help you encourage and support your child
to do the independent play routine on his or her own?”
Topic IX: Why Pretend Play Is So Important

for Young Children’s Learning
What to Share with Parents: The play skills practiced in the last topic taught
children to think about and create constructive play ideas and actions with toys.
A puzzle piece goes into the puzzle board, a ball is thrown or kicked, a block is
stacked. Now we introduce pretend play (also called “symbolic play”) to expand
children’s thinking abilities and play ideas from their imagination, instead of
focusing only on concrete actions with physical materials. An animal puzzle piece
can “walk” and make its animal sound before going into the puzzle board, a ball
can have a happy face (or other face) drawn on it and come to life to “talk” to chil-
dren, or a block can be “food” that children pretend to eat. We add to children’s
play skills with more spontaneity, creativity, and flexibility, and in doing so, the
creative thinking associated with pretend play is deeply rooted in language and
other aspects of thought important to children’s development.
What to Share with Parents: Young children expand their knowledge about the
social world when they play make-believe (expressing what they see, think, and
feel) and share those experiences with others. Pretend play opens up children’s
mental world of imagination beyond the physical world, developing endless play
ideas and using those play skills to join in and further such play with other chil-
dren. Pretend play carries meaningful themes about people and their lives that
we want children with ASD to also experience. We follow the next set of steps so
children will receive the exposure, practice, and guidance they need to develop
such skills.
For Coaches: Ask parents to describe children’s pretend play or revisit that con-
versation, if asked in the section “Why Pretend Play Is So Important,” for a sense
of children’s capabilities thus far versus needs that could become potential learn-
ing goals. Pretend play should be introduced after children are able to play with
many different toys, combine objects in play, and carry out different actions with
individual toys or objects. Children should also know how to imitate and engage
in joint attention when playing with others before advancing to pretend play.
Explain to parents how these skills will build more imaginative make-believe play,
particularly if children would benefit from more time and practice before moving
forward with this section. If parents mention examples of children’s creative or
make-believe play, ask them what’s helped to make that development possible. We
also list a question below about themes families experience that they may want
to act out in pretend play with their children once you transition to the coaching
steps with them.
You can ask these optional coaching questions of parents (the first question is
repeated from the earlier section “Why Pretend Play Is So Important”):
• “How does your child imagine or pretend during play?”

• “What strategies so far have helped your child show more flexibility or cre-
ativity in his or her play?”
• “We talked about how children can act out themes from real life and actions
they see others doing. What themes from your family’s daily life might your
child like to make-believe and re-create in play?”
What Parents Can Do to Increase Their Child’s Symbolic Play Skills

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

they were alive and could move, talk, or take turns in play themselves (e.g.,
a lion putting in a puzzle piece or a doll eating a goldfish cracker).
2. Symbolic substitution. Involves using objects as if they were something else
(e.g., pretending that a block is a cell phone and putting it to our ear to
talk, or a spoon is an airplane and flying it around the room).
3. Symbolic combinations. Involves doing several different pretend-play actions
to create an event or theme (e.g., pretending to give a bath to a stuffed ani-
mal involves six different pretend-play actions: using a bowl as a bathtub,
filling up the bowl with pretend water, putting the animal in the bowl,
using a sponge to pretend wash the animal, pouring pretend water from a
cup over the animal, and drying off the animal with a towel).
For Coaches: Be aware that pretend-play skills and sequences may take consid-
erable time for some children to develop. Toddlers typically develop these skills
beginning at 12 months old and continue their advancement in abilities to 36

months old and beyond. Help parents manage their expectations, if needed, to
think of pretend-play skills as a long-term activity that may take a year or two to
complete, but that can still be started and practiced immediately. Start to gather
parents’ ideas on how to facilitate play or other routines (think: meals, bathtime,
reading books, household chores, diapering, getting dressed, or other caretaking
routines) to practice the three different types of pretend-play skills.
• “What play ideas could you try with any of these types of pretend play?”
• “How could dolls, stuffed animals, or other objects take turns in your child’s
favorite games or other routines?”
• “What toys or objects could you pretend are something else to show your
child how they work in play?”
• “What events or themes could you act out in steps to show your child how
to do?”
Step 1: Teach Conventional, or Functional, Play Skills
What to Share with Parents: Make-believe begins for children when they use
toys or objects based on how other people use them. A child pretends to feed
himself with a spoon, picks up a tissue and pretends to sneeze into it, or puts on
Mom’s necklace. Conventional, or functional, play is defined by the social mean-
ing of other people’s actions that children watch and copy themselves, instead of
sticking with only the physical attributes or cause-and-effect properties of a toy
or object. It is an important step in children’s play development because children
watch other people to learn how to do these pretend actions. Conventional play
is social learning—attending to what other people are doing and imitating what
they do. Parents teach children to develop conventional play skills through the
usual four steps of a joint activity routine. Let’s go through a play example with a
hairbrush (or comb).
1. Set-up. The parent brings out the object, or it could be a choice between
items (e.g., a hairbrush or comb) for the child to choose which to use in play. If
the parent offers a choice, he or she goes with whichever item the child chooses or
seems to like. The parent can keep the item not selected nearby to use later with
the child, but not in a way that interferes with the theme developing with the
chosen item.
2. Theme. The parent takes a turn to name and do the conventional or social
action with the item. The item can be shared with the child, or the parent and
child can each have the same item to use on him- or herself. Using the hairbrush,
the parent says, “Brush hair” while brushing her hair. After the parent takes her
turn, the parent hands over the hairbrush (if shared) or encourages the child to do
the same action. If the child does not readily imitate, the parent repeats her turn
with exaggeration or enthusiasm, or helps the child start the brushing motion to
finish him- or herself. The parent and child continue their turns with the theme.
3. Variation. Once the child does the theme readily and without the parent’s
help, other play ideas involving the item can be added to the interaction. The par-
ent and child can switch roles—the parent brushes the child’s hair and encourages
or helps the child brush the parent’s hair, or dolls or stuffed animals can have their
hair brushed, too. The parent uses her own name and the child’s to mark turns
with the items and actions that make up the play (e.g., “Mom’s hair,” “Claire’s
hair,” “Mom’s turn,” “Claire’s turn,” “Brush Dolly”).
4. Closing/transition. When the parent and child are out of play ideas or inter-
est fades (for either play partner), parent and child acknowledge they are done and
put away the materials to decide what activity to do next.
Parents can introduce conventional objects and actions during other routines
besides play that they do with their children. They can brush their teeth with their
own toothbrush and encourage or help children do the same with their brush. If
children do not take right away to a conventional action that parents demonstrate,
parents can still take their turn to expose children to the idea of brushing one’s
teeth. Parents can also shift to other social objects or actions involved in the rou-
tine to see if those ideas initially hold more interest for children. If children do not
show much interest in parents feeding themselves with their fork, would children
like feeding parents, a doll, or a stuffed animal from their fork? The goal is to stay
creative and persist with play ideas, so children will become more interested in
what parents show them with materials. Adding social moments to these everyday
interactions helps children learn more about what people do and the words that
go with the objects and actions in life’s daily routines.
For Coaches: See the activity ideas and parent–child scenarios for this step to
help parents adapt joint activity routines and teach conventional play skills to
children. Coach parents through these steps in play and in at least one other rou-
tine (e.g., meals/snacks, getting dressed, books) that’s possible to do in a session.
This will give parents some ideas of how to use real objects to teach children this
first step of symbolic play. If you think parents are ready for such a suggestion,
you can also start to discuss the speech and language techniques explained in the
next topic, because the kinds of play parents do in this chapter will help children
make progress in their speech as well. Either way, parents should continue to
read or just practice this chapter with you to build pretend-play skills with their
children.
use this step:
• “What real-life activities or routines can you use when playing with your
child?”
• “What actions with the materials can you show your child within these
activities?”
• “How can dolls or stuffed animals be used in these activities?”
• “How can you teach your child to imitate these actions if he or she needs
help?”
• “What other routines that happen often can you do with your child [e.g.,
meals, bath, dressing, changing, outdoor play, books, social sensory rou-
tines, household chores, self-care activities, errands]?”
Step 2: Animate Dolls and Animals

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

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

What to Share with Parents: As parents and children pretend-play actions with
different materials and figures across different routines, children’s play skills to
pretend and imagine grow stronger. Children develop more initiative and ideas to
play make-believe with props and a doll or stuffed animal, and they instruct par-
ents who to be and what to do and say in their roles. We want children with ASD
to also move from watching and imitating parents’ play suggestions to coming up
with their own play ideas for parents to now follow. Parents support this transi-
tion from imitation to spontaneous pretend play when they set up the props or
materials in some kind of orderly way for children to see and choose which items
they want to use. Materials related to a specific theme, for instance, giving a doll a
pretend bath, could be laid out on a table or the floor (e.g., the doll, a plastic bath-
tub or bowl large enough for the doll to fit inside, a cup, a sponge or washcloth,
pretend soap, a towel), or materials for more than one theme, such as giving the
doll a pretend bath or pretend haircut, could be organized in separate boxes or bins
for children to choose from. Then parents wait and look expectantly at children
to choose a theme if a choice is offered and what play actions they will do first,
instead of the parents leading off with their own play ideas for children to imitate.
When children initiate a spontaneous play action (e.g., put the doll in the bowl
for a bath or pick up a hairbrush), parents might first comment on it (e.g., “The
doll is in the bathtub” or “Brush”) and then follow their children’s idea. Parents
can imitate the same action if there is more than one of the same object to use,
such as picking up a second brush, or parents can help to support the children’s
play idea, such as holding the bowl steady or adjusting the doll to stay upright. If
children do not lead off with a spontaneous play idea, parents can offer a choice
between themes if more than one play idea is suggested (e.g., “Does Dolly want a
bath or haircut?”), or point to or hold out two materials for a theme (e.g., “Bathtub
or Dolly?”)—and see if the children then begin an action, rather than parents
starting an action or giving a specific play idea for children to carry out. When
children need more help beyond a choice to get started, parents want to give as
little direct help as possible to encourage children’s independence and spontaneity
with their play. Parents could make statements or ask questions out loud to hint at
ideas (e.g., “I see a washcloth, soap, and a cup,” or “Hmm, where does Dolly sit for
a bath?”), followed by more direct suggestions (e.g., “Dolly goes in the bathtub,” or
“Dolly is dirty. Let’s wash her”) before taking turns or physically helping children
do the play action. This sequence of providing gradual bits of help when children
do not immediately respond and pausing after each opportunity for children to
enact the desired behavior is called a “least-to-most prompting hierarchy.” Parents
have been using least-to-more prompting all along when they first wait to see what
children can do on their own before using their voice or gestures to cue children
what to do or physically helping children complete the action. When children
do respond or initiate a play idea, parents comment and imitate the action with
enthusiasm and glee so that children get the most enjoyment out of the learning
opportunity and interaction to want to come up with more of their own play ideas.
This teaching sequence is the key to increasing children’s spontaneous play:
• Provide familiar, interesting materials in a visually organized way and with-

out other distractions to motivate children and help them think about play
ideas to do.
• Wait for children to offer their play ideas first, or give the least amount of
help for them to come up with play ideas.
• Comment and copy what children do with enthusiasm and enjoyment.
• New play ideas can gradually be added to complement what children do or
come up with, or to help children return to a theme when their play inter-
ests or actions become repetitive or “stuck.”
For Coaches: Coach parents to stay with this step until: (1) children initiate play
ideas at least during the activity if not selecting materials or the theme to lead off
the activity; and (2) when parents help children come up with or carry out play
ideas, they do so without physical prompts. Don’t forget to reflect on parent–child
communication skills if you and parents are working on those strategies in addi-
tion to this topic.
use this step:
• “What objects and props can your child choose for pretend play with fig-
ures?”
• “How will you set out the materials to help your child think of ideas and
start to play?”
• “How can you encourage your child’s spontaneous play actions with figures
or characters?” [Help parents think about least-to-more teaching strate-
gies to suggest play ideas when children do not immediately come up with
them. The next question is another way to ask parents about this.]
• “What teaching strategies can help your child create spontaneous play
actions with figures when he or she is not sure what to do?”
• “How can you respond to reinforce your child’s play actions [spontaneous
or imitative]?”
• “What do you need in order for you and your child to act out different play
scenarios or routines with props and figures?”
Step 4: Teach Symbolic Substitutions

What to Share with Parents: The next type of pretend play to teach children is
make-believe with objects. Children do this when they pretend that an object is
something else, like looking through a paper tower roll as if it were a telescope or
singing and making silly sounds through it as if it were a microphone, or they pre-
tend and act out actions with invisible objects, such as holding their hand as if they
had a bottle to feed a baby doll. Treating objects as other things or making them
up “out of thin air” are huge milestones in children’s development. These skills
show that children’s imagination can guide their actions and thoughts beyond the
world of objects or their physical attributes and cause-and-effect properties. Play
becomes more abstract and less rule bound, which are important characteristics
for children with ASD to understand and know how to do when it comes to the
play of their age-mates and being able to participate, contribute, and keep up as
capable play partners. We start with teaching children how to pretend that objects
represent other real objects during play, before teaching children to pretend-play
with invisible objects.
Parents use the same joint activity format used to teach all the other play
skills.
Helping Children Learn about Ambiguous Objects

1. Set-up. Parents use props or materials that children are familiar with from
other pretend-play activities and include a few ambiguous objects or materials that
are neutral or without a strong identity of their own to children and could serve as
good substitutes to represent something else (e.g., a napkin becomes a parachute
for the action hero to hold when it jumps off the table, a block becomes a rolling
rock that crashes into a toy car, or a marker rubber-band-bound to each foot of the
doll now lets her ski or skate across the floor). Parents select ambiguous objects
that represent realistic objects based on some key physical feature, such as size,
color, or material. Parents want to find one or two ambiguous objects to substitute
for two key objects in each of their play themes with children with figures (dolls,
stuffed animals, action heroes, etc.), and props related to each play theme are also
included. When parents have arranged all the materials, children can pick out
familiar objects and choose the theme for parents to follow, or parents can suggest
a theme that their children might like, particularly when they need a little help
to get started.
2. Theme. Parents hold off on using ambiguous objects right away and instead
use real objects (or wait for the children to use real objects) to start the pretend-
play theme on each other and the doll, stuffed animal, or other figure. When chil-
dren do not respond right away, parents continue with the least-to-most prompting
hierarchy to encourage children to come up with their own play ideas, or to do an
action before offering hints, suggestions, or stepping in as the last-resort physical
help to complete an action.
3. Variation. After parents and children have played out a theme with real
objects, parents now introduce ambiguous objects, one at a time, to represent real
objects used in the theme (e.g., a fork becomes a hairbrush to brush hair, or flat
circles of Play-Doh become cookies for everyone to pretend-eat). Parents take a few
turns to model and label the actions with ambiguous objects and to name ambig-
uous objects as the real objects (e.g., “Look, here’s my hairbrush! Brush Dolly’s
hair” or “Monkey is making a chocolate cookie. Now he’s going to eat it”). Hand
over the materials to the children and encourage them to do the same actions
with ambiguous objects. When children do, repeat those actions with ambiguous
objects to join children in the fun and reinforce their learning. Gradually show
how the other ambiguous object(s) can be included in the play theme with the
same least-to-most prompting sequence, to help children understand and partici-
pate with independence. When children use ambiguous objects with excitement
and ease, include real objects alongside the substitutions (e.g., an actual hairbrush
and a fork, or real or plastic cookies and Play-Doh) to do play actions with both
types of objects.
4. Closing/transition. When interest or play ideas start to wane, help children
participate in an organized closing/transition: Clean up and put away materials
and move on to another activity.
Helping Children Learn about “Invisible” (Pantomimed) Objects

Note: Make sure that children spontaneously use a number of ambiguous
objects to represent real objects during play before starting these steps. The more
that children really understand the concept that one object can substitute for
another, the easier this concept of how to gesture or pantomime as if they are
using an actual object will become for them.
1. Set-up. Just like with the set-up for ambiguous objects, leave out one or two
key objects that will become the invisible objects to pretend to have in the play
theme (e.g., leaving out the hairbrush for one play theme or cookies for another
play theme).
2. Theme. Play out the familiar and enjoyable theme using the props and
doll, stuffed animal, or figure that parents have arranged in the set-up. When it’s
time to use the missing object, parents pretend to have it in their hands and do
the associated motion or action while describing what they’re doing (e.g., parent
runs her hand down the doll’s hair while saying, “Brush doll’s hair,” or parent holds
out her hand to the monkey and says, “Here’s a cookie. Eat it, Monkey”). Parents
repeat the action a few times and encourage or help children to do the same. After
parents and children have gone back-and-forth a few times acting out with the
invisible object, parents offer the real object and let the children use it on one of
the figures, while parents do the invisible action without the object on the other
figure.
3. Variation. Parents wait until children can act out an invisible object with
gestures before they repeat the process with another main object left out of a favor-
ite play theme. They use the same language and actions to show how to represent
the real object with gestures or movements for children to imitate. Go slowly from
one routine to the next and use real objects intermixed with invisible ones when-
ever children seem confused or do not catch on right away.
4. Closing/transition. As usual, when interest or play ideas wane, help chil-
dren participate in an organized closing/transition: Clean up and put away materi-
als and move on to another activity.
For Coaches: See the activity ideas and tips to help parents and children learn
how to play with symbolic substitutes. Talk through with parents the fact that
this phase of pretend play takes a long time for all young children to develop. In
fact, it is important not to rush this process because all the different play themes,
scenes, and props that parents and children use together only help children learn
more and more about real life, how to participate, and become a part of life events
through their ideas, language, and actions. The more that parents understand how
this process works, hopefully the less stressed or worried they will feel about the
amount of time children naturally take to develop these skills. Instead, parents
can focus on the fun aspects of play, which will build up their children’s knowledge
of how to pretend with ambiguous and invisible objects and learn more about the
social world through their imagination and play interactions with others. But if at
any point, these pretend-play skills do not become clearer to children, then coach
the parents to go back to carrying out pretend-play actions using real objects with
dolls or figures in their play themes for children to imitate. This should improve
their consistency and understanding before trying again with ambiguous or invis-
ible objects.
this step. When children are ready to learn about invisible objects, you can ask the
same questions with “ambiguous objects” substituted for “invisible objects.”
• “What ambiguous/invisible objects could you use in play with your child?”
• “How will you first set up and use real objects on figures to develop the play
theme before using ambiguous/invisible objects?”
• “How will you show your child to use ambiguous/invisible objects as real
objects on figures?” [Help parents think about least-to-more teaching strat-
egies to suggest play ideas when children do not immediately come up with
them. The next question is another way to ask parents about this.]
• “What teaching strategies can help your child use ambiguous/invisible
objects as real objects with figures when he or she is not sure what to do?”
• “How can you respond to reinforce your child’s pretend-play actions with
ambiguous/invisible objects?”
• “What do you need in order for you and your child to carry out play actions
with different ambiguous/invisible objects?”
Step 5: Develop Symbolic Combinations

What to Share with Parents: The last type of pretend play involves teaching
children to combine pretend-play actions to act out an entire scene (not just a few
related actions) from some real-life routine or event. The scene could be some-
thing that children participate in daily, like waking up and all the different actions
that make up this routine (e.g., go to the potty, wash hands, brush teeth, take off
pajamas, choose clothes, get dressed, and walk to the kitchen for breakfast). Or,
the scene to act out could be outings or errands that children do with parents or
as a whole family, such as grocery shopping, mailing a package at the post office,
driving through a car wash, playing at the park, or other events that children
commonly observe and experience. Whatever the activity, each involves a number
of actions that children can pretend to do with parents and figures, so their play
becomes richer and more elaborate. To make this step easier for children to learn,
they should be able to play out, without difficulty, several different themes where
they can imitate and spontaneously come up with different pretend actions with
objects to use on parents, figures, and themselves, even if replacing real objects
with ambiguous or invisible objects to complete the same pretend action is still
an emerging skill. Let’s go through the four-part joint activity framework to teach
children to combine and act out pretend-play actions from real-life scenes.
1. Set-up. Parents arrange props or objects for a few different themes that
represent familiar routines or events so children can choose which to do (e.g., hav-
ing a picnic, acting out the story “The Three Little Pigs,” or going to the doctor’s
office) and which figures will participate as characters in the scene. To get started
with the theme, parents involve children in setting out and naming props and
figures.
2. Theme. Parents wait for children to begin a pretend act with an object
and/or figure, or encourage children with questions, statements, or hints to help
them get started with the chosen theme (e.g., “What do we want to eat on our
picnic?,” “I see lots of food to put in the picnic basket,” “Bear needs help”). Parents
continue to let children take the lead to build and carry out the theme, encourag-
ing and helping when needed. When children imitate or spontaneously produce
pretend actions, parents’ comments and actions mirror children’s play.
3. Variation. Once children start to act out the theme, parents add actions
that support or relate to the real-life event or routine. They narrate and show the
action, one idea at a time, in their turns (e.g., “The grass is wet. I want to sit on
the blanket to eat our food. Help me set down the blanket” or “We need forks and
napkins to eat our food”) and encourage or help children do the same, either with
their own set of materials or by sharing items. Parents continue to demonstrate
actions and prompt children through imitation.
4. Closing/transition. When children’s interest or play slows down or starts
to feel repetitive, or nothing else can be added to the scene, it is time to end the
activity and for children to put items away in their bin or box. If children still want
to continue playing, parents can indicate the other themes children could do next
or let children continue practice with independent play as long as their actions are
not repetitive.
Parents can follow the joint activity steps to play out any kind of scene from
daily routines (e.g., making a sandwich, bathing, brushing teeth, getting ready for
bed), family events, or the children’s favorite books, television shows, or movies.
The more that children do this kind of play, the more they understand about
real-life experiences. In fact, parents may find that daily routines that are difficult
for children to do or not their most favorite may become easier or even fun as
children learn and practice the steps and narration in play. Acting out real-life
events can also prepare children for new experiences that might otherwise seem
difficult or scary. When parents help children pretend their way through the steps
of going to the doctor or the dentist’s office, getting a haircut, going to another
child’s birthday party, or using a noisy piece of equipment like a blender to make a
smoothie, parents create a “script” for what children can expect in a new experi-
ence and what skills and behaviors to use inside its sequence of events. Parents can
use this strategy called “priming” to familiarize children through any life experi-
ence whether it’s new or repeated, to improve children’s understanding and ability
to participate and to ease frustration or anxiety when a particular event causes
more upset. Through this supportive exposure, children will come to know the
whole script for each of these experiences, from beginning to end, and will be able
to participate in acting them out with parents or other family members included
in the play.
For Coaches: When parents would like ideas about what to act out with their
children, you and the parents can create a list of real-life experiences and routines
their children have experienced many times. For upcoming activities that a child
will experience for the first time (a visit to the dentist, family picnic, birthday
party, etc.), playing out the experience with dolls, with animals, and/or with each
other helps the child understand and cope with a new or stressful experience.
Once parents and children have some familiarity with a script, siblings or other
family members can play a role in the scene, too.
use this step:
• “What real-life events, routines, or familiar stories could you and your child
act out?” [Guide parents to first pick ideas that children will find enjoy-
able before trying other events that may be more difficult or stressful for
children to do.]
• “What objects or props and figures do you need for you and your child to
re-create the event?”
• “How will you set up the needed items to encourage your child to start the
play?”
• “How will you help your child combine pretend-play actions in a sequence?”
[Help parents think about least-to-more teaching strategies to suggest play
ideas when children do not immediately come up with them. The next
question is another way to ask parents about this.]
• “What teaching strategies can help your child understand and carry out
‘scripts’ from a real-life event?” [Ideas include visits to a location to see
what actions happen there, making storybooks or taking pictures with
smartphones or tablets to build scripts, creating puppet shows to act out
events.]
• “How can you respond to reinforce your child’s participation?”
• “What do you need in order for you and your child to act out new or more
stressful real-life events?”
Topic X: Helping Young Children Develop Speech

What to Share with Parents: Parents may wonder why parent coaching sessions
wait so long to discuss children’s ability to speak. It’s because everything in the
earlier topics is actually also building the foundations for speech development:
attention, vocalization, imitation, play, sending messages to others via nonver-
bal gestures, and joint attention. When children have all these skills, learning to
speak—expressive language—and understand speech—receptive language—are
much easier. This topic aims to help parents support children to use and under-
stand speech through the active social interaction strategies already in use with
people and their facial expressions, gestures, and body language.
For Coaches: Ask parents for their perspective about children’s current abilities
with these prerequisites, especially if any seem to be in question from your obser-
vations. You can also ask parents about children’s status with expressive and recep-
tive language to hear how they view their children’s communication compared to
your observations.
• “How would you describe your child’s skills with these milestones?”
• “How does your child use words to express him- or herself?”
• “What types of communication [e.g., requests, comments, affirmation, pro-
tests, asking for help, greetings] are easier and more difficult for your child
to use?”
• “How would you describe your child’s understanding of what you and others
say to him or her?”
• “What types of communication [e.g., requests, comments, affirmation, pro-
tests, asking for help, greetings] are easier and more difficult for your child
to understand?”
• “How would you describe your child’s communication [both use and under-
standing] with other people [e.g., family members or someone he or she
meets for the first time]?”
What to Share with Parents: By now, parents likely see a pattern of why behaviors
affected by ASD are problematic for young children and their development. When
children’s social attention to others is lessened or decreased, so is their ability to
initiate, engage, and connect with others, and fewer social interactions with others
means fewer opportunities for children to listen, learn, and respond to language.
Everything parents have practiced has focused on strategies to decrease the amount
of time children with ASD spend unengaged with others, or on behaviors that iso-
late them and make it harder for others to approach and play with them. That’s why
parents strive to interact face-to-face with children and with toys, objects, props,
or just themselves to develop meaningful, shared experiences instead of resorting
to electronic toys, devices, computer games, or items where children’s attention
gets “stuck.” That’s also why parents label and talk about what they see and do
with children and what children see and do with them. Because the key, and this
remains true for any skill that we want to teach children, is that children learn from
their interactions with people. Now given the demands of life for parents and families,
we also know that filling all the hours in a child’s waking day is just not possible or
always healthy. Parents deserve a break from parenting, too. But, the reason that
we talk about practicing the strategies during play activities, caretaking, or other
routines that families usually do with young children is to take advantage of the
moments when parents and children are naturally together. So, let’s discuss the
next set of strategies to continue working on children’s ability to use and under-
stand language! We discuss expressive language (the ability to use language) first
followed by receptive language (the ability to understand language).
For Coaches: Help parents see the connection among behaviors affected by ASD,
such as attention, social, or communication, and subsequent opportunities for
social interaction and learning for children with ASD. You can ask how parents
relate to this information, which routines are doable with children versus those to
work toward, and what changes (hopefully positive) they have seen so far in their
children’s abilities to interact and learn more often from meaningful social activi-
ties with others throughout the day. Check in with parents as well for how they
fare with all of this change. For parents who may struggle to put the strategies into
effect with children, are there other resources your practice or organization can
offer to them?
• “How do you relate to this information?”

• “What does this information mean to you and your family?”
• “How do you now see your child’s social attention to others [e.g., interest,
initiative, responsivity, engagement], compared to when we first started
sessions?”
• “How has your child’s social attention changed? What’s helped?”
• “What changes have you observed in yourself [e.g., parents’ behaviors, hab-
its, routines, lifestyle] in doing all of this to help your child learn? How do
you manage?”
What Parents Can Do to Build Their Child’s Expressive Speech

and Language
What to Share with Parents: We dive into strategies to help children turn on
their voice by making sounds such as an animal, a car, a train, or other playful
noises that they do back-and-forth during interactions with parents. Developing

these skills paves the way to build speech.
For Coaches: Parents can share examples of playful or other vocal sounds their
children make.
• “What sounds is your child prone to make?”

• “What activities encourage your child to make sounds?”
Step 1: Build Up Your Child’s Vocabulary of Sounds

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

• “What activities encourage your child to make sounds?”
• “How can you respond to your child’s sounds to encourage him or her to
repeat them?”
Step 2: Develop Vocal Games with Your Child’s Sounds

What to Share with Parents: Once parents and children vocalize back-and-forth
from sounds that children make, parents can start the vocal games themselves.
Parents start off face-to-face with children—in a highchair for a meal, at the
changing table, on their laps, facing adults, leaning up against a table, on the
bed, on the floor, or in other positions—to support good attention. Parents look
at children, make a sound they know children can, and wait expectantly for chil-
dren to repeat back that sound. When children do, parents answer back with the
same sound to carry out a conversation. When children make a sound but not the
same one the parents did, parents can repeat the original sound (not the different
sound the children made) to acknowledge children’s effort with a vocal response
and to also give more exposure for children to try out the new sound. It’s also OK
when children do not respond with any vocal sound. Sometimes children need to
hear (or see) something more than once, and they are still listening and thinking
about the sound each time parents make it. Parents persist and can change their
tone, pitch, or speed, use songs or props, like toy microphones or an empty paper
towel roll, to add emphasis to their sounds, as well as try mouth movement games,
like patting children’s mouths or running their fingers over children’s lips, to see
whether that may encourage a vocal response from children. Parents continue to
practice these vocal games as both a leader (being first to make the various sounds
that they have heard children do) and as a follower (imitating sounds when chil-
dren make them first). Parents and children practicing both of these roles, as a
speaker making sounds first and as a listener responding to others’ sounds, teaches
children how to start, answer, and sustain conversations. And that’s a big step
toward speech!
For Coaches: See the helpful tips and parent–child story for how parents can
practice this step. As mentioned in the last step, some parents like to keep a list
of sounds children make to track their development and progression. If parents
started this list in the last step, ask them to share it with you to help decide which
sounds parents can start practicing with children. As practice progresses, parents
can add new sounds to their list and even check off the sounds that children
repeat after their parents first make them. Seeing the list grow and differentiating
between sounds that children produce first and repeat when parents make them
first may be very encouraging to families.
• “Let’s start with sounds that the child already makes. Which could you try
and within what activities to encourage your child to answer you [or repeat
them] back?”
• “How might you respond to your child’s sounds to encourage him or her to
repeat them again?”
• “What strategies that we’ve discussed might encourage your child to respond
to your sound when he or she does not readily do so?”
Step 3: Increase Opportunities for Listening and Responding

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

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

Language Development
What to Share with Parents: How parents talk to children influences children’s
language development. That’s why coaching strategies encourage parents to talk
frequently to children when they are face-to-face, using simple language about
what they and the children do, see, and experience with objects and actions that
make up their activities. Parents who use speech mostly to give instructions or
corrections to children limit opportunities for their language learning, whereas
parents who talk to children throughout the day during both play and nonplay
activities help them develop larger vocabularies. The easiest way for parents to
talk a lot to children is when they follow children’s focus of attention to describe
the children’s own actions and objects. Parents may recall this strategy from ear-
lier coaching on how to capture children’s attention and interest by talking about
what they like and do. But, parents putting words to what children look at, play
with, touch, or use also helps children connect parents’ words to the objects and
actions children are attending to and thinking about. This is how children learn
the meaning of words and encourages them to say those words, too. Parents can
think of a simple vocabulary of the words they want their children to learn and
then use those words frequently for children to get enough exposure and prac-
tice to learn them. Remember, everything needs a name—the objects and actions
that children encounter; the SSRs children like to do; the food, drinks, toys, and
people children want. Parents may want to focus on colors, counting, the names
of shapes, or letters for children who are beginning language learners. Those con-
cepts will come later as children learn the names of objects and actions, and their
vocabularies grow and lay the foundation for them to learn these higher-thinking
concepts. For now, beginning language learners need to learn the names of objects
and actions they experience to develop a base. Another consideration is how com-
plex parents’ language should be when speaking to children. In general, parents’
language ought to be just a little more complex than their children’s. This way,
parents’ language is clear and to the point (to help children learn the meaning
of words) but also descriptive (to help children’s vocabulary grow). For children
who are not yet talking or just beginning to use words, parents want to keep
their language really brief, using one- or two-word phrases that capture children’s
actions and objects. For children speaking in two- to three-word phrases, parents’
language can increase to four to five words.
For Coaches: Consider listing language examples that parents can use with chil-
dren based on the children’s language level. See the language phrases, helpful tips,
and parent–child story for ideas to accomplish this with parents. If parents started
a list of children’s sounds from earlier steps, adapt or add to that list the words that
parents can say that relate to those sounds and the objects and actions of children.
Parents may also need practice and feedback to avoid speaking in more words
than their children’s language level permits and/or to focus on physical or cogni-
tive attributes instead of the names of objects and actions. A list, chart, or some
visual template to assist parents with recognizing children’s vocal growth from
this and earlier steps may help them resist this temptation and stick with the
one-word-up rule: parents add one more word to their own speech than their chil-
dren typically use. Feel free to also use and explain that term if it helps parents
remember what to do and how to use it.
Ideally, we want parents to be able to help their children make or show prog-
ress in these three areas before moving onto the next step: (1) to turn on their
voices, (2) to develop more sounds or words, and (3) to make sounds or words
back-and-forth with parents and others in vocal play that supports the framework
for conversations to happen.
• “Let’s figure out your child’s language level to know how many words we
should use to speak to him or her. What sounds or words does your child
say regularly?” [Ask about vocal and consonant sounds for children not yet
saying words so that you have the full picture of the children’s vocal devel-
opment and only count words that children say spontaneously to gauge the
one-word-up rule.]
• “What can you talk to your child about as you and he or she do activities
together?” [Encourage parents to include nonplay activities for more diver-
sified practice with children. The question below is another way to ask par-
ents whose language examples or ideas may exceed the one-word-up rule.]
• “What objects and actions can you name in the activities that you do with
your child?” [Encourage parents to include nonplay activities for more
diversified practice with children.]
Step 5: Add Sounds to Gestures

What to Share with Parents: For children who can turn on their voice to make
sounds or words in back-and-forth “conversations” with parents and others, the
next step is adding gestures to their sounds or words. Parents do this when they
build up children’s talking bodies to communicate—through eye contact, gestures,
facial expressions, and body language. Now it’s time to put sounds to those ges-
tures. Just like other skills taught to children, parents model, or show, children how
to put sounds, words, or even wordlike sounds (we call this “word approximations”
and they count, too) to gestures. There are three steps for parents to follow:
1. Parents choose a gesture and a sound, word, or word approximation that

their child uses frequently and model the two together. For children who make
sounds (as opposed to words or approximations), parents can see whether any cur-
rent sounds resemble words to select, like “ah” for that, cat,” or ball, or “da” for dad
or down (it could also work for that). For the child who says words or approxima-
tions, parents follow the one-word-up rule to pair simple words with gestures.
A child knows how to reach or point to make a choice or to show his mother
what he wants. The mother decides that either gesture will work since the child
reaches and points fairly equally. Next the mother thinks about which vocaliza-
tion her child already uses that can be paired with a reach or point when she
shows him how to do both. Currently, her son only makes sounds, not yet words
or approximations. The mother looks over her list of sounds for the child and
sees that “ah” is one he says often, so she decides to pair that sound with the
word that when her son reaches or points to something he wants. The next time
her son reaches for an object that his mother holds, she asks him, “That? You
want that?” and pauses for him to say “ah,” that, or another sound that is his
attempt to say the word. When her child does not respond, the mother tries one
more time with “Do you want that?” and enunciates the word that to bring
more attention to the word for her son. The child looks at her and reaches for
the object without a sound. Rather than discourage her son from the talking body
communication he does use—his eye contact and a reach—to tell her what he
wants, she gives him the object while saying, “That. You wanted that.” While
the mother would have liked her son to say a sound or even the word, she knows
that she will have many more opportunities to model and practice the skill each
time the child reaches or points for something he wants. And, the mother wants
her son to continue feeling encouraged and capable of making requests to her
whether it’s through his voice, eyes, gestures, or other body language. When her
son does learn to add the sound or word to his reach or point, the mother also
knows it will be important to quickly give him what he has asked for so that he
makes the connection: that his vocalization and gesture led to him receiving
what he wanted.
2. Parents add sounds or simple words to children’s gestures or actions. We
mentioned this idea beforehand when parents make animal, transportation-
related, or other playful sounds that relate to the toys, social games, books, or
songs they do with their children. Other examples include: parents saying “no,
no” when children push away something they don’t want; “uh oh” when children
accidentally drop something; “boom” when children tap or hit objects and toys;
“boo” when children uncover their parents’ faces during a game of peekaboo; “hi”
or “bye” depending on the context when children wave; and “wow” when children
give, hold up, or point to something of interest. Parents follow the suggestions just
laid about above to select a sound or simple word to pair with their children’s ges-
ture, and then model the sound or word and gesture to try to get their children to
imitate it. When children do, parents can demonstrate the sound or word and ges-
ture to keep the interaction going. When children do not imitate, parents encour-
age children to imitate their sound or word with a gesture, or recognize children’s
other talking body communication to “speak” and look for the next interactive
opportunity to try the combination again. Let’s go back to the mother and son in
the last example to see how they’re doing with this step.
The child loves when he runs out from behind the couch and into his mother’s
arms, and she squeezes and tickles him. The mother thinks about what sound
or word she can say when he runs out, and before she does the actions he likes.
She was going to choose “boo” but wants to keep that sound for peekaboo, so
comes up instead with another sound or word for this game so that her son prac-
tices with more than one sound or word. In looking over the child’s sound and
word list, she sees that he says “ha” and decides the sound is doable for him to
imitate. The child runs out from behind the couch, and the mother says “ha” as
she scoops him up in her arms. The child laughs and squeals with delight, and
they continue like this for a few more rounds, with him listening for the sounds
or words his mother says that are tied to the fun actions he loves for her to do.
On the fourth go, the mother changes her positioning; she is no longer seated,
but now kneeling on the floor so the child cannot immediately run into her lap.
This time the mother says “ha” with outstretched arms but waits for the child to
imitate her before taking him in her arms. The child doesn’t respond, so she says
it again, “ha,” and waits. He continues to look at her and makes a slight sound,
though not quite a “ha,” as he wiggles his body. But, the mother recognizes the
child’s attempt to say the sound and scoops him up while saying “ha” to reinforce
his effort to try to imitate her. Mom and child continue to play the game with
more “ha’s” coming from the child.
3. This step is for children who respond to parents with gestures and sounds,
but not yet words. When children make a sound and gesture, parents add the
real word as they hand over the object or do the action children are requesting.
Remember that words need to be simple—think single words that are nouns or
verbs—and ideally they contain some sounds the children can already make and
imitate in games or routines with parents. We return to the mother and son in the
example below.
During bathtime, the child points to each bath toy he wants from the mother and
says “dah.” The mother responds with her usual “That?” and now she names
each bath toy as she hands it over to the child, “Duck, whale, fish.” The mother
is careful to clearly articulate the first consonant of each word for her son to hear
the “dah” in duck, the “wah” in whale, and the “f” in fish. Since this is the first
time the child is hearing his mother name his bath toys, the mother focuses on
that task for the moment, instead of worrying if her son will try to imitate these
new words. She still takes turns with the bath toys so that she can hold them up
one at a time to name the word for her son to hear, and before and after he says
“dah” and points to ask for each one. She expects that he will start to say some
of the words after they have done this new routine several more times, and she
will make sure that she has his full attention when she speaks the words to help
him understand what it is she now wants him to say.
For Coaches: Parents and children should keep a number of vocal imitation
games going and with at least a variety of sounds that children can imitate to
support their ability to say words before moving onto the next section, on building
children’s receptive language skills. Coach parents to accept any sound match that
children make and support parents to remain patient with their children’s vocal
journeys. It can be a long road from a vowel or consonant-vowel sound to the full
word, but this is the way that all children learn to speak. Children learn to say
what they can, and with practice and time, their abilities to move and position
their mouths, to hear the sound differences and say something more precisely, as
well as the development of their speech muscles to physically produce and form
sounds, all help them come closer to saying the real word. And, that’s very encour-
aging when children with ASD have all the abilities to follow the same route!
use this step:
• “How can you talk to your child in play and nonplay activities?”
• “What language level should you use to speak to your child? Remember, we
want to use just a word or two more than what your child says on his or
her own.”
• “How can you position yourself for easy contact with your child while nar-
rating what you and your child do together in activities?”
• “How can you still participate in activities with your child so he or she hears
your language for what you do, not just what he or she does?”
• “What simple sounds can you add to your child’s gestures?” [Help parents
select sounds they know their children can imitate.]
• “How can you encourage your child to imitate your sounds?”
• “When your child imitates or says sounds with gestures, what simple words
can you say in response?” [Help parents use the one-word-up rule with
nouns and verbs.]
• “How can you encourage your child to imitate your words?”
What Parents Can Do to Help Their Child Understand Speech

What to Share with Parents: A big part of the language difficulty for children
with ASD is understanding the words that people around them use. Some chil-
dren might seem to understand more than they actually do by compensating for
their lack of language with other skills or abilities, like looking around a room or
zeroing their attention in on a particular object or cue to make good guesses about
what will happen next and based on their past experiences (e.g., parents getting
out children’s shoes and socks or taking out their car keys are cues for children to
understand they’re about to leave the house, instead of parents saying, “Let’s go to
the store,” or “It’s time to get in the car”). Other times children with ASD seem
to ignore everything all together, speech and cues alike. Parents could be practic-
ing all the language strategies covered in the book—adding labels to objects and
actions to children’s activities, using sounds and simple words, and providing lots
of language models—and yet their children still seem not to “hear” their words.
In these cases, children with ASD may not fully understand the importance of
listening when people speak or of following through with a response or action to
people’s words. But, parents can still teach their children to listen and to respond,
and there are two pieces of good news here. The first is that the steps given ear-
lier in this chapter build children’s expressive language skills and using those
techniques also develops children’s receptive language skills, or their ability to
listen, understand, and respond to what people say. And the more that parents
practice such techniques, the more they help children understand the importance
of speech—that children need to listen and attend to what is said, and that a
response is expected when someone speaks to them—and develop both sets of
skills. The second lies with the next set of steps that focus precisely on children’s
understanding and responding to others’ speech.
For Coaches: Parents may want to talk about how this information resonates with
their understanding of ASD and/or experiences with children. Keep in mind the
option to invite parents’ stories if doing so may deepen their understanding of
what’s happening in ASD and/or with their child.
• “What comes to mind as we talk about what happens in ASD?”

• “What questions do you have about what happens in ASD?”
• “What concerns or worries do you have about this topic?”
Step 1: Expect a Response, Then Get It

What to Share with Parents: People may not always know what to do or how
to respond when children with ASD seem to ignore their language. This can be
worrisome for two reasons. Over time, people may stop expecting that child to
respond. And, a child who isn’t expected to respond won’t learn the importance
of speech. Thus, people’s expectations and follow-through that children respond
to their language are crucial. What’s involved in making that happen goes back to
strategies parents are already using with children. First is the need to get children’s
attention (think: positioning relative to your children’s, removing or managing
distractions, including children’s likes or interests if applicable in the situation),
followed by a simple instruction and brief wait for their response. If children do
not respond, then parents quickly prompt children to do so, followed by a posi-
tive consequence related to what children were asked to do. The turn-taking rou-
tines parents have been practicing are great examples of these moments already
happening with children. Parents use their turns to teach something they want
children to do (e.g., to turn over a toy or watch and try a new play idea). Parents
initially wait for children to try to take that action themselves, or help children
complete the request with least-to-most prompting before following through with
the outcome children wanted (e.g., a parent fixes or creates fun with a toy that a
child gave him, a child wants to keep building on a new play idea or to go back
to the prior theme). Parents state gentle and easy but frequent requests, ideas,
or instructions, and follow-through teaches children the meaning of their words
through children’s attention and responsiveness to adult speech.
For Coaches: Guide parents to consider the types of requests or instructions they
can add to existing play and other routines, as well the least-to-most prompts they
may need to help children respond to their language. This step is an exception
where parents may need to resort to physical, rather than verbal and gestural,
prompts when the situation calls for a faster follow-through with children. But like
any skill taught with physical prompts, parents need to fade them as soon as pos-
sible to support children’s independence with requests or instructions.
use this step:
• “What request or instruction can you add to this activity?”

• “How can you support your child to follow through with the request or
instruction?” [Another way to ask this question comes next.]
• “What strategies that we’ve discussed can help your child respond to your
request or instruction?”
• “What do you think would happen if you held back from using a physical
prompt this time with your child?”
• “What other requests or instructions could you ask or give your child to do
at home?”
Step 2: Remember the Natural Reinforcers of Your Child’s Speech,

and Be Sure to Use Them for Responding to Speech
What to Share with Parents: When parents pick reinforcers that work with chil-
dren’s own goals and motivations for doing what was asked of them, children are
more likely to respond and do the same thing again. When no reinforcer follows
or one that does not matter much to children, they are less likely to respond and
do the same thing again. This concept goes back to the ABCs, which say learning
happens only when behaviors are followed by reinforcers or positive experiences
like a favorite object, action, or activity. So, we revisit the ABCs where parents
give children a request or instruction (the antecedent), wait or prompt children to
respond if not on their own (the behavior), and follow through with a reinforcer
that children find motivating and that, whenever possible, relates to the children’s
behavior (the consequence). Here are some examples.
The parent says,
• “Sit down,” and the child sits to start a fun-filled play activity.
• “Open,” and the child takes off the lid of a container to eat some cereal.
• “Come here,” and the child walks over to be picked up.
• “Give me my glasses,” and the child hands them over for her dad to put on
his face.
• “Show me your tummy,” and the child touches his stomach for his mom to
tickle him there.
What if it’s difficult, though, to think of a reinforcer that relates to what

parents want children to do or that children find motivating? When parents find
that trying to work new skills into children’s interests or likes does not work, this is
where the “first/then” rule (also called the “Premack principle”) may help children
learn to tolerate and cooperate with the request or instruction. With it, parents
think about something rewarding that can follow children’s completion of the
request or instruction, and then follow through for children to go through the
experience. Let’s look at some examples.
A parent says,
• “First socks and shoes, then outside.”

• “First wash hands, then juice.”
• “First clean up, then bubbles.”
For Coaches: Coach parents to think about the request or instruction they want
children to comply with and what natural reinforcer—or if not intrinsic, then
something preferred—that can follow children’s cooperation with the request
or instruction. If the question comes up of why should we have to reinforce, or
“reward,” children for doing what’s asked of them, parents may see a conflict with
this principle compared to their parenting, cultural, religious, or other personal
beliefs. Or, parents may not think their children need the same amount or level of
reinforcement to follow requests or instructions given all the learning they have
accomplished. Whatever the issue may be, it is important to ask questions and
listen to parents’ perspectives, as well as to find common ground with the reasons
parents share since this is how children learn and how adults operate, too (e.g., we
go to work to make a living, we plan to have dessert that night, we finish a term
paper and treat ourselves to a pedicure!). We all live by and with incentives, and
doing so does not usually make our actions any less sincere or less valuable.
Once parents have formulated some requests or instructions and reinforcers,
just as in the last step, they use least-to-most prompts to help children respond to
their language and may need to resort sooner to physical rather than verbal and
gestural prompts when the situation calls for a faster follow-through with chil-
dren. Parents ideally practice this within the context of play and nonplay activities
before moving on to the next step.
this step (all questions but the two asking parents to think about reinforcement
are repeated from the last step):
• “What request or instruction can your child do in this activity?”

• “What reinforcer will motivate your child to meet the request or instruc-
tion?”
• “What is something preferred that can follow your child completing this
less preferred request or instruction?”
• “What other requests or instructions could you ask your child to do at
home?”
Step 3: Instruct Less and Follow Through More

What to Share with Parents: Parents following through to help children respond
to their instructions, questions, ideas, comments, or other language opportunities
teaches children that words have meaning. And, this carries responsibilities for
parents: to be ready for the consequences of what they say and when they say it, to
assure that children follow through with the expectation. When parents are in a
rush or children are having a difficult moment or there are other interferences in
the background, parents might hold off or be very selective in what they ask their
children to do. For example, instructions can focus on the actions that parents
know children can do or are capable of learning how to do—sitting, standing,
giving an item, showing where it goes, coming over when called, looking at what
someone else wants to show them, putting something on, taking something off, or
putting an item down or in or on top of something. Parents give the request and
wait for children’s response; if none, they then walk children through how to meet
the request, fading their supports as quickly as possible for children to become
capable of completing the action by themselves. Fewer instructions, but with more
follow-through and not the other way around, are what will help children under-
stand parents’ and others’ speech.
For Coaches: Use Form 7.4, “Action Plan Template for Parent Follow-Through,”
with parents to select the play activities or other routines and the requests or
other receptive language learning opportunities that children can do within these
interactions. Parents also select the different responses children do to meet their
FORM 7.4
Action Plan Template for Parent Follow-Through
Activity/ Parent
routine Parent request Child response Reinforcer follow-through
Mr. Potato —Give me the nose. The child does the The child participates The parent models
Head —Put on the hat. requested action (e.g., in the parent’s the request, repeats
—Where are his glasses? give, put on, pick turn (e.g., touch or the request, gestures
—I have an earring. up, point to, or look point to where the (e.g., lifts a hand to
It goes on her ear. at the named piece) piece goes or put in cue the child giving
and receives the the piece for the the piece or shrugs
reinforcement. parent), receives shoulders upward for
the next piece the child to look for
to continue the the piece), moves the
activity, or chooses piece closer or puts
what to do next in it in the child’s hand
the activity. to cue the child
to do the action,
or physically guides
the child to do the
action.
Mealtime —Take out the mat and The child does the The child receives The parent initiates
put it on the table.* requested action the preferred food each request and
—Open the drawer and (e.g., take out, open, or drink. provides a prompt if
take out a napkin. choose, give, or look needed. Prompts are
—Do you want a fork at what the parent graduated to provide
or spoon? does) and receives only as much support
—Where does your cup the reinforcement. for the child’s
go? requested action
—Open the container of as needed for the
fruit. child to respond as
—Do you want goldfish requested. The adult
in your bowl or on your provides no more
plate? than two repetitions
—Hand your sister a of the request
napkin, please. before moving into
—I want a bite, too. a gestural, partial
—Look! I am going physical, or full
to take a big bite of physical prompt.
carrot.
—Put your napkin in
the trash.
—Take your cup to the
counter.
—Put your bowl in the
sink.
—Help me wipe the table.
(continued)
*Instruction examples listed as back-to-back steps can always be separated into two requests for children to do.
215
FORM 7.4. Action Plan Template for Parent Follow-Through (p. 2 of 2)
Activity/ Parent
routine Parent request Child response Reinforcer follow-through
216
expectations, the reinforcement that children receive for their responses, and the
follow-through to conduct when children do not respond on their own. When
follow-through is necessary, the strategies listed in the template’s last column
reflect least-to-most prompting as reminders of how parents can ensure a response
from children, while still promoting their independence to do as much of the
behavior by themselves. The first two rows of the template are examples intended
to help inspire ideas, but we encourage parents to select the requests and amount
to ask of children for more (not less) follow-through.
this step (some of the questions below are repeated from the last step):
• “What play activity or other routine can you give instructions for your child
to do?” [Ask the next question once parents select an activity or routine.]
• “What request or instruction can your child do in this activity?”
• “What reinforcer will motivate your child to meet the request or instruction?”
• “What is something preferred that can follow your child doing this less
preferred request or instruction?”
• “What other requests or instructions could you ask your child to do at
home?”
Step 4: Teach Your Child to Understand Brand-New Words

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

1. Parents will select a play or nonplay activity and instructions for children
to do that fit within the scope of the activity.
2. Parents will figure out reinforcers or positive consequences that children
care about and that relate to children’s behaviors (when possible).
3. Parents give children the instructions and wait for them to respond or help
them follow the instructions if no response ensues.
4. Parents give reinforcers for children following instructions.
For Coaches: Parents might like to use the “Action Plan Template for Parent
Follow-Through” to include other requests for children to do and some instruc-
tions may consist of two steps (e.g., “Pick up the toy and put it there,” or “Throw
the napkin in the garbage and put your bowl in the sink”). For skills with lots of
steps, with the parents, list the steps and prompts besides verbal instructions they
can use to show children how to do the skills.
Before parents’ last sessions with you, discussion should take place and a plan
established for how they will continue to monitor their own learning and their
children’s based on the strategies and skills you have helped them to develop.
use this step:
• “What other requests or instructions can your child do in this activity?”

• “What back-to-back instructions could your child do in this activity, like
pick something up and put it somewhere or bring it to you?”
• “What other skills would you like your child to know how to do?” [Ask the
next question once the parent selects a skill.]
• “What are the steps for your child to learn how to do that skill?”
• “Is the first or last step easier to show your child how to do?”
• “What prompts besides verbal instruction can you use to show your child
how to do that step?”
• “What signs from your child tell you that he or she is learning how to do
that step by him- or herself and you can fade your prompt(s)?”
Closing
In closing, this chapter has been more “technical” than any of the other chapters
in this book, and we have written it this way in response to many requests for help
that we receive from coaches in the field and from those taking our coaching work-
shops. Many experienced coaches will already have established ways of describing
the various techniques they teach parents. However, we are holding in mind those
interventionists working in public early intervention programs and those who are
working as generalists and want to transfer their skills and knowledge to par-
ents so that parents can integrate their interventions into a child’s everyday life.
Changing from direct delivery to a parent coaching-focused intervention requires
a great deal of change in the interventionist’s moment-to-moment actions within
an intervention session, and this chapter is written to provide interventionists
with topics and dialogue prompts that we have found to be quite helpful in trans-
ferring the reasons behind the intervention practices to parents. We assume that
interventionists using this content will fit this material into their own personal
styles of interaction and communication, as well as the learning styles and interac-
tion styles that they have developed with each of the families they treat.
We also recognize that these topics are focused on addressing the develop-
ment of play, social communication, and interaction in young children with or at
risk for ASD, and thus represent only a limited number of developmental domains
that are affected in most of these children. However, these are the developmental
domains most disrupted and delayed in early ASD, and these are the skills that
are most predictive of better outcomes down the line. Focusing on these areas does
not preclude including any additional targets in the coaching intervention that an
individual child needs, but these areas are core components for all the NDBIs for
early autism and are therefore essential to address.
Chapter 8
Variations in Coaching Practices
Thus far, we have been describing a scenario where the coach establishes a con-
structive, effective coaching relationship with families through which both par-
ents and children progress well toward their goals. However, this typical scenario
does not describe the day-to-day and week-to-week variations that arise in ongoing
work with children with ASD, their families, or the life of the interventionist. As
readers know, themes and variations, moving forward and stalling out, reward
and frustration, elation and disappointment—all are part and parcel of this type
of work. It is common to have to quickly redo a carefully thought-out coaching
session plan in the moment because of what has been observed or shared by the
family. Thus, the coach often has to let go of what he or she considered a great
intervention idea because the family rejects it outright (“It’s OK with me if he
sleeps in our bed with us forever!”).
The following chapter describes some of the variations in our coaching
practices in P-ESDM that we have experienced over the years. We want to give
newer coaches ways to circle around, detour from, substitute, or accept obstacles to
steady progress. We’ll consider innovative coaching approaches to increase access
to intervention services and problem solving amidst challenging situations and
diverse family needs. We will also explore coaching parents who vary considerably
in their motivation, skills, abilities, and capacity to engage in intervention, and
the coach’s need for cultural humility and ease with the learner role in the face of
unfamiliar customs and beliefs.
Significant variation in approach does not imply the inability to affect desired
change. These examples describe coaching decisions to meet specific family and
child needs while continuing efficacious intervention methods and a constructive
learning environment. In so doing, we illustrate in more depth some of the nec-
essary tools in each coach’s tool kit. We begin with the stories of three different
families.
220
Variations in Coaching Practices 221
Variations in Family Stories

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

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

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

Allie was a stay-at-home mother of two young children, a 1-year-old boy and a
3-year-old girl Ava, and the wife of a busy and successful businessman. She already
had her hands full, managing her home and all the family’s needs, including sup-
porting her husband at required social events. Her daughter had been diagnosed
with ASD approximately 1 year ago. At the time of Ava’s diagnosis, Allie stayed
up late at night to research, locate, and start intervention for Ava. Once services
began, she enrolled her toddler in a full-day nursery school program and added
all of Ava’s intervention needs to her daily schedule. Her husband supported
her efforts but could not share either the physical or emotional burdens, given
his demanding job and his own grief and anxiety. The two decided not to share
Ava’s diagnosis with anyone just yet. Ava’s weekly interventions included inten-
sive ABA intervention in the home, speech and occupational therapy sessions
at a clinic, and a supported play group with two other children. Then there were
the neurological and genetic exams to rule out epilepsy or other complications
and routine pediatric visits to monitor Ava’s overall developmental growth and
milestones. Ava’s team leader, the supervisor of her ABA team, observed Allie’s
competence and commitment to Ava’s needs and complimented her frequently on
her ability to support Ava, attributing the child’s rapid progress to Allie’s dedica-
tion and efforts. A comment that the team leader made frequently was “I wish all
my parents could do what you do for their children.” Allie was, in fact, exhausted
and felt very alone, but she thought all that mattered was Ava and getting her the
help that she needed.
Following a year of intervention, Ava’s gains in language, attention, social
engagement, play, and self-care had moved her standard scores into the normal
range in all areas, and her behavior had improved markedly. Her intervention
team altered her intervention plan so she would now participate in an inclusive
ABA preschool center program where all of her intervention needs were met at
the center. Allie’s toddler had grown to love preschool and was thriving there, but
the mother found herself at home, isolated and alone. None of the services that
had been established or the hard work that Allie had done addressed any of her
own emotions or personal needs in caring for her daughter. Allie felt a myriad of
emotions—grief, fear, anger, blame, sadness, and loneliness. She had more and
more trouble functioning during her day at home and found herself tearful, irri-
table, and tired all the time. She thought daily about what would happen to Ava as
she became older and she noted each gain and each symptom, balancing her hope
of a cure with her panic about a lifelong disability. Would Ava’s peers continue to
accept her, or would they pull away or ostracize her? Would Ava fall in love? How
would she support herself, and who would take care of her once Allie and her
husband were gone? Would this responsibility fall to Ava’s younger brother, and
would he grow to resent Ava? What if somehow Ava became hurt by someone she
trusted? Would she know to tell someone or would the abuse continue? These fears
plagued Allie, as did her knowledge that one day she would not be there to protect
and care for Ava. She worried about her marriage and her inability to share any of
these feelings with her husband. The gulf was widening, and she felt abandoned
and alone. Both these parents needed help with their individual situations and a
lifeline back to each other.
In the IEP review meeting held at the center, the psychologist, speech pathol-
ogist, and team leader—a behavior analyst—met with Allie in a small, comfort-
able, carpeted room, sitting around a coffee table, to discuss Ava’s new treatment.
The team leader began, “Now that we get to see Ava all day, we have a pretty good
sense of how she is doing here, but we don’t have such a good sense of how things
are going at home now. How are things at home now?” Allie sat silently, looking
down, and started to cry. The team members felt her sadness, offered her a tissue
box, and waited. Allie began to share: her loneliness, her fears, the emptiness of
her daily life. When she paused, her team leader said empathically, “Things are
so hard for you right now. I’m so sorry. Do you have someone you talk to about all
this?” And then Allie revealed the estrangement between the couple, the depres-
sion, the silence. “It sounds like Ava’s needs have taken quite a toll on your family.
I wonder if it would be helpful for us to meet together with you and your husband.
We have not seen him in a long time, and it was an oversight on our part to not
communicate with him directly. Would that be helpful, or if not, is there another
way we can help? The experience of diagnosis and beginning intervention can be
such a painful one for families, but things can get better.”
Allie felt so supported by this dialogue—the careful listening, the reflection,
the emotional support, the optimism conveyed in that last sentence. She thought
a minute and decided that this idea would be a good next step, and said so. The
team leader asked her whom she wanted in attendance, and Allie indicated that
she thought it would be important to have the whole team there, to answer all
her husband’s questions. After the meeting, the team reflected on their lack of
inclusion of the father in meeting invitations. He had been so active in their
initial meeting. They had handed over to Allie their own responsibility for com-
municating with both parents. They discussed how to approach the next meeting,
the need to provide support for Allie, the signs of depression and anxiety they
had seen and heard, the need for support for the couple. They decided that the
clinical psychologist on the team should be actively involved in the next meeting
given her skill set. They thought about Allie’s social isolation and wondered if
parent-to-parent contact might be helpful. There was a very active mother among
their families, with family roles similar to Allie’s, who had started a parent support
group. Mental health services including family counseling also seemed important
interventions to raise.
At their next peer supervision meeting, the team leader brought up the sub-
ject of Allie again, feeling very guilty that she had been in that home every 2
weeks for the entire year and had not tuned into any of these issues. She asked her
team for help in reviewing her own work, and how she might have done things
differently to try to avoid the current situation from developing again.
What are your thoughts on this as a reader? This may be a helpful topic for
your own team to discuss. What ideas that have been brought forward in this
coaching book apply to the situation with Allie?
The coach decided, with her team’s support, not to wait until the team meet-
ing, but to raise the topic of the parent support group at her next coaching session
with Allie, who was open to the idea and said she would consider it. The coach
asked if she would like a phone call from the group leader, and Allie hesitantly
agreed. The leader called her the next day and initiated a warm, comfortable con-
versation about the difficult situation they both now found themselves in, and
how much it might help her to have other parents to talk to. She invited Allie to
the next group coffee, later in the week. Allie agreed, although she was not sure
how much she wanted to share in front of a group of people whom she did not
know. At the same time, she appreciated the warmth and understanding commu-
nicated in that first phone call, and hoped that she might experience some of that
connection in the group.
Allie was grateful that she did not have to say much at her first meeting. The
leader introduced her to the five women and one man in the room and shared a
little about their group and the ground rules they had developed: the expectation
of “acts of kindness” from each other, the agreements about confidentiality, about
listening without interrupting, about not giving advice unless it was specifically
requested, about the importance of “I” statements rather than cross-talk. As the
members shared stories, thoughts, and experiences from their week, a lot of what
was said resonated with Allie. Some group members expressed the pain and fear
that Allie first felt when Ava was diagnosed. Others were exploring various inter-
vention options. Some had been in the trenches for a few years and were thinking
ahead to the future and what it might hold. All were sharing their lives in deeply
personal ways—with humor, pain, loss, anger, and for some, acceptance, about
their lives in ASD. The father in the group touched on the strain that his child’s
needs placed on his marriage. He shared his feelings about his own struggles with
how to take care of his son, whereas he saw his wife’s very natural instincts with
their son. She understood what their son wanted when he took one of them by
the hand, leading his mother or father to what he wanted, and how instead she
taught him to touch or point to the item or thing he wanted, or how to lift up his
arms and look at her to pick him up and attempt to say the word of the food that
he was looking for when he stood in the pantry staring up at the shelves. As the
son’s father, this group member felt that he should also know how to anticipate
and read his son’s needs, how to provide for him, and keep him healthy and safe.
Instead, he regarded himself as a failure as a father and husband, and his shame
had gradually alienated him from his wife and left him unsure of how to approach
her and explain these feelings. Allie took some comfort in listening to everyone
share. She did not have to hide her feelings or pretend that everything was fine at
home. Although she did not talk much in this session, when the group took turns
speaking at closing, she thanked them and said it meant a lot to her to be there,
and that she would return for the next meeting.
While driving home, Allie wondered whether her husband ever felt the way
that the father in the group had described. Allie thought about how she handled
everything related to Ava’s intervention since she and Phil first became concerned
about Ava not talking. From researching services to handling all appointments
and sessions and learning how to use interactive techniques with Ava, Allie self-
admittedly did not involve Phil. He was already busy with work and even more
since Ava’s treatment. Allie realized how left out Phil might feel about Ava’s learn-
ing and development. She did not want Phil to feel unfit as a father to Ava and
was glad about the team’s efforts to directly involve him. She also thought that
Phil might get something out of attending the next support group meeting and
planned to approach him with that very idea.
Meanwhile, the coach sent out email messages to both Allie and Phil inviting
them to a team meeting to review Ava’s last 12 weeks of progress and to consider
goals for the coming year, since Ava was beginning her second year of treatment.
She asked them to suggest days and times over the next 2 weeks when they might
be available for a 2-hour meeting. Phil checked his schedule, found a window of
time, and emailed the possibility to Allie, who then sent an email to the team,
copying her husband, to set up the meeting. They arrived in separate cars to the
meeting, which was again held in the comfortable space, with hot coffee, water,
and cups available at the doorway. The coach greeted each and introduced them
to the other group members.
The meeting started exactly as the previous meeting had begun. In response
to the question about how Ava was doing at home, directed to the couple, Allie
looked at Phil and waited. He began, stating apologetically that his work was so
demanding that he had little time at home, often leaving early and arriving late
at night. He commented on how much he enjoyed seeing Ava’s steady progress on
the weekends when he was not traveling, and expressed his appreciation to the
team for their efforts. He also looked right at Allie and expressed his appreciation
to her for all she was doing for Ava and for their family and home. As the group
listened, he became reflective. “After she was diagnosed, the world turned pretty
black for me, and it was all I could do to get to the office and do my job. I felt kind
of numb, and alone, and far away from everything.” Allie put her hand on his, and
he held it. “Now I see her chatting, watching movies, running around in her little
pool in the yard, and she seems like a different child, like any other child, and it
gives me hope. I see her curiosity, her humor, her personality. She makes me feel
more alive.”
Allie squeezed his hand and they looked at each other. “I want to do more to
help Allie. I don’t want you to have to do this all alone.” Allie wiped away some
tears, and the nearest team member passed over a tissue box. The team psycholo-
gist spoke up: “We are happy to help you both continue to help her. That’s our job.
Shall we talk about some things that you see she still needs help with? How can
we all help her learn those skills this year, with us working with her at school and
you at home?” Both parents nodded, and the conversation moved to goals for the
coming year.
As plans for learning were made that involved home and family activities,
the coach made a point of looking at both parents and directing questions about
home learning to both. Allie answered first, describing what she could do in her
time with Ava. The coach thanked her and then purposely looked at Phil, who
had ideas of his own for his weekend time with Ava. When Allie asked him if that
would really work out for him, he said, “I don’t feel like I know my own daughter
very well, or my son either, for that matter. I want to feel like their dad. You know
how to do so much with them. I want that, too.” In the pause that followed, the
psychologist commented how difficult the year after diagnosis and treatment was
for so many families, how deeply it affected mothers and fathers alike—the sad-
ness, the worry, and how hard it could be on each parent and on the couple and
family. People and families adjust, and find their ways forward, but they need help
in the process, from each other, from other family members and friends, and from
other professionals, including therapists and counselors. She added, “Knowing
what kind of help you need to be the kind of parent you want to be with Allie is
the biggest step toward achieving it, and our job is to help you find those supports.
I’m so pleased that we could all meet together, and I apologize to you, Mr. Warner,
for not including you in all our prior emails and communications. That was an
error on our part, and we will not make that mistake again. We’ve covered a lot
today, and our time is almost up. I imagine you will need some time at home to
process all that we discussed today. Shall we meet again in a few weeks to check in
and see how your home goals are going, and if there are other supports you have
identified that we can help you find?” Phil answered, “I like that plan, and I’ll need
some real concrete help with my own goals for my time with Ava, something writ-
ten, something specific.” The coach immediately volunteered to build that plan
with him at her next parent coaching session and asked him to set a date and time
to work on that task.
Take some time to reflect on this team meeting and discuss it with your own
team. Are there other points you would have raised in this meeting? Are there
interventions in it that you and your team members disagree with? Have you ever
been in meetings like this? What would you find useful in your own practice in
terms of how this team managed this session?
The progress review meeting occurred a month later, with the psychologist
and coach in the family’s home. The difference in the mood of both parents was
clear. Both parents reported enthusiastically on progress with Ava with their own
activities, and when the psychologist asked about whether they were finding it
helpful to discuss their activities together, their descriptions of their problem-
solving dialogues made it clear that the lines of communication had opened up.
Allie also described the ideas and help that she and Phil were getting from the
parent group (Phil attended when he could), and she reflected on how differently
she felt now than a few months earlier, how much less alone, how much more
optimistic. Phil’s nonverbals mirrored her statement.
Think about the variations in typical intervention practice that were brought
into play for this family. Are these variations that you have used before? Are there
families in your own practice that resonated with you as you read Allie and Phil’s
story?
Akio and Kumi Sato

Akio and Kumi Sato and Kumi’s parents moved from Japan to the United States
when their son Kaito, 2 years, 3 months old, was diagnosed with ASD. They did
so to participate in a research study that would offer a 2-year home-based intensive
intervention program to Kaito delivered by a well-trained team in their home at
no cost to the family. In addition, the team worked directly with the parents and
grandparents to coach and support them in how to use the intervention tech-
niques within their daily activities and family routines with Kaito. Within the
first few weeks of intervention, the Satos noticed subtle but significant differences
in Kaito. He appeared more curious in what his family did and would walk over
to take a closer look, something he never did before intervention started. He sat
longer to do certain activities with his family, such as looking at a picture book or
putting pegs into a pegboard. He also smiled and laughed with others in activities
he loved, such as his sister tickling and chasing him or his grandmother twisting
water from a washcloth over his head during bathtime. These developments made
his family ecstatic and hopeful for his prognosis to continue learning new skills.
There was just one problem. His parents did not feel competent or confident
in their ability to help Kaito learn. While the intervention team held regular
meetings with the parents and the team leader had parent coaching visits with
them every 2 weeks, the Satos did not understand everything said. Conversational
English was not easy for them, and the rapid speech and amount of information
provided during their team meetings required great concentration and attention
on their part. They could not process the information fast enough to answer ques-
tions being asked of them. During parent coaching sessions at home, the coach
included all the adults, which required that the parents act as translators between
grandparents and coach. The coach worked hard to use the kind of parent-
centered dialogues we have described here: open-ended questions, parental choice,
and shared control of the goal and session planning processes. However, this was
a different scenario than what the Satos were accustomed to with professionals in
Japan. They expected that professionals would tell them what to do, and they were
uncomfortable answering questions about their goals, their ideas, or their personal
experiences or feelings. They were shy and embarrassed about their English skills.
The grandparents found the process incomprehensible and questioned the exper-
tise of the coach because why else would the coach ask for their ideas and input?
The parents felt caught between the grandparents and the gratitude and pleasure
they experienced as they watched the teamwork with Kaito. The parents did not
want to work with Kaito in front of their coach and were not comfortable in their
parent coaching sessions, and neither was their coach, who began to dread these
sessions and found herself looking for reasons to cancel them.
Take a few minutes to put yourself in the coach’s place. What might you be
feeling about yourself, and about the Satos? What ideas would you have for vary-
ing your coaching practices? What steps would you take to increase parental com-
fort and involvement, and ease tension with the grandparents? What steps would
you take to deal with your own feelings?
The coach decided to ask for a reflective supervision session with her team.
In this session, she first described the scenario, and her own feelings of frustra-
tion, inadequacy, failure, and powerlessness to help the family use the intervention
techniques in everyday activities with them at home. She described her sense of
hopelessness as she watched the grandparents feed him, cater to his every whim.
“They undo everything we have done as soon as we walk out of the house! It feels
like a waste of time and money, and I don’t know what to do. I’m not the right per-
son for this family,” she shared tearfully. The team members listened carefully, and
when she was finished, they began to ask open-ended follow-up questions. How
did she wish the sessions would go? How would she change them if she could? How
did she think the parents wished the sessions would go? How would they change
them if they could?
As the dialogue continued, helpful ideas bubbled up. One group member
shared what she had learned about cultural differences in working with Asian
families and colleagues in a previous job. She discussed the preference for some
families to be in a learner role, especially early in the intervention. She also dis-
cussed working with families in which the culture itself expects less independence
from young children than does American culture. Another considered the chal-
lenges of being in the interpreter role and wondered about other ways to support
the grandparents’ needs and interests. A third asked the coach what would she
like to do if she was to start again with a clean canvas. The speech and language
therapist observed the language-based communication challenges embedded in
every contact and wondered what effects those could be having for everyone.
Stop here and consider other open-ended questions and reflections that you
would offer in this session.
The coach left the meeting with several ideas that she discussed at her next
meeting with her supervisor. One involved an inservice session for the team from
the local Asian-Pacific Mental Health Center to increase their cultural awareness
of typical professional–family relations in Japan. This occurred, with considerable
discussion about the meaning of having a son with a significant disability and
cultural processes related to grief and treatment. The center agreed to continue
to support the team, and also suggested a translator from their team who might
be of help. A second idea involved a meeting with the parents at the center with
a translator present as well as the supervisor and team member with experience
with Asian families. The purpose of the meeting was threefold: (1) to discuss how
the parents most wanted to use the parent coaching meetings, (2) to discuss the
cultural differences between life in Japan and life in the United States as it related
to working with therapists as well as topics of child language learning and child
independence, and (3) to consider how best to help with communication with the
grandparents about Kaito’s needs and interventions.
The meeting occurred with the translator, a therapist from the Asian-Pacific
Mental Health Center. In it, the parents were far more talkative and open than
they had been previously. They expressed their gratitude to the coach and team
members about their care for Kaito and the family, and their amazement at his
rapid progress. They shared their astonishment at hearing him begin to say words
in both languages, and their pride in his rapid response to toilet training, which
had been a priority for them. In response to questions about what they most
wanted during their coaching sessions, they answered that it was difficult to listen
and respond with the grandparents present. When the coach asked whether the
parents might like to meet at the center with the coach and Kaito, they enthu-
siastically agreed, and said that what they most wanted Kaito to learn was how
the coach would help him play at home, go on walks to the park, and behave well
within a Japanese-language church service they wanted to attend. They thought
this last goal in particular would matter very much to the grandparents and help
them come on board with Kaito’s interventions. They expressed gratitude for
the written and video materials the coach had provided, since written English
was easier for them to absorb than conversational English alone. They were very
pleased that he could eat with a fork and spoon, even though it was not something
that they expected, and they shared their pride in the compliments they received
at church family dinners about his eating skills and behavior at the table. They
wanted to learn how to help him manage as well in other settings so that they
would not be embarrassed by him. They also wanted to understand how Ameri-
can families explained their children’s autism to others and how they managed
grandparents who denied any problems. The translator’s mental health expertise
and cultural expertise were of tremendous help in this meeting, and she offered to
continue to be a part of team meetings in the future.
Several changes in intervention delivery resulted from this meeting. The
coach and family began to meet at the center, and the coach comfortably took
on a more educational orientation in her sessions with the parents. She went with
them to a playground with Kaito, and also to a church service and the lunch that
followed to learn about expectations and activities for toddlers. She developed a
plan for Kaito in the next coaching session, writing out on a dry erase board the
goals that the parents wanted Kaito to do in each of these settings, followed by
the steps of how to help him learn each goal. The father then recorded this on
his phone, and they went to the playground at the center to try out Steps 1 and
2. The father recorded the coach’s actions and then asked his wife to record him
as he tried the same activity on the swing, with the coach’s help. He then asked
his wife to try as well, as he recorded. Kaito responded well with both parents—
requesting “go” for pushes (Step 2) and “down” (Step 1) when he wanted to get
down to push the swing himself. The parents were very excited that he enjoyed
this and chatted about the swing at the park that evening. Similar activities took
place around church activities, with the coach modeling and writing out each
intervention program for the parents, with the parents recording each activity.
They later told the coach that they used the videos to cue themselves and also
shared them with the grandparents. They also began to bring videos of Kaito to
the coaching sessions, both to show how well he was doing and also to ask for help
when activities broke down. For church activities, the coach developed a plan of
how to increase his participation and made sure the intensive intervention team
taught him the core skills in sessions, which she then practiced with the parents
in coaching sessions. When the parents asked the coach if she would come to
church with them the first time to show them how to support him, she did (all
recorded by the father). As the parents became more and more comfortable with
the new approach and more confident about Kaito’s learning and their own ability
to teach him, they continued to bring videos and questions about problems that
occurred, and by the next quarterly review, they were ready to set goals for coach-
ing for the next quarter. Akio also became more comfortable sharing observations
and reactions during sessions, though Kumi held back, until one day she brought
Kaito alone, and surprised the coach with how much she wanted to talk about her
son. At the next quarterly team meeting, the team members and translator lis-
tened with rapt attention as Akio explained (in English) how he and his wife had
answered questions about Kaito that came up at a church lunch once Kaito began
to attend the toddler group, and how much support the minister provided to them.
He exclaimed in wonderment about his ability to use the term “autism,” and the
supportive reactions of the other parents, many of whom knew about autism. He
had provided links to a Japanese website about autism for some families who asked
about it. His wife commented on how much Kaito had learned, that there was no
reason for shame, that she thought he would do great things in his life.
This family experience highlights cultural variations that may deviate from
typical coaching practices used with Western families. How do your coaching prac-
tices recognize and respond to potential cultural stigmas associated with autism
and mental health needs? Are there other coaching resources you would need to
help a family like the Satos?
The rest of this chapter discusses in more detail the adaptations used in the
above examples as well as coaching parents in a group format.
Coaching Adaptations
Mental Health and Counseling Services
The process of observing child difficulties, referral, diagnosis, and beginning inter-
vention raises deep and painful emotions for most parents. The grief and mourning
after a child autism diagnosis have been well described in the clinical literature.
The interpersonal processes that we have described in this text can provide con-
siderable support for families and many opportunities to discuss these issues with
a caring, listening coach. However, many parents need mental health services
along the way. Recognizing the signs and symptoms of mental health difficulties
is a critical skill within an early intervention team. Identify this skill set within
your team; make sure that team members are aware of the signs and symptoms of
such needs, and discuss how and when to bring these issues to the fore. This will
help all team members listen better for such signs and bring their concerns to peer
supervision so that the mental health difficulties of family members do not con-
tinue to worsen over time, as did Allie’s.
Coaching techniques that we have discussed in this text can help to provide
needed support and a two-way communication line that will help parents share
their ongoing experiences, both positive and negative. These include checking in
every week on how things are going, making time for parents to raise any topic
in the coaching session, deep and careful listening, the use of the reflection pro-
cess, and avoiding the cheerleader role with its general praise, compliments, and
unmitigated enthusiasm.
Dealing with Conflicts

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

Cultural differences involve far more than language, race, and ethnicity. They
involve religious practices, community norms, social class and socioeconomic
status, regional and local practices, and parenting philosophies and practices,
among many other factors. These are transmitted to parents throughout their
lives through their relationships with important others—family of origin, friends,
classmates, church contacts, work colleagues, recreational groups, and community
contacts, among many others.
All of the families described here demonstrated specific sociocultural aspects
of the challenges they were facing, aspects that were not part of their coach’s
lives. Careful listening, peer supervision, consultation and learning from outside
the group, thinking outside of the box, and a cultural framework were needed to
help each of these families. Every family is part of one or more specific subcul-
tures. Coaches need to be careful not to assume that physical similarities with
their clients imply shared cultural understanding, or vice versa. Learn to ask many
questions over time to understand the family’s practices, philosophies, challenges,
preferences, fears, and hopes regarding parenting and raising their autistic child.
Telehealth Coaching
The rise of the Internet has paved the way for telehealth as an alternative approach
to coaching families with ASD (Hall & Bierman, 2015; Hall, Culler, & Frank-
Webb, 2016). Telehealth (also used interchangeably with the term “telemedicine”)
is medical information exchanged from one site to another using electronic com-
munications, such as two-way video, email, smartphones, tablets, and other wire-
less tools, to improve a person’s health status (American Telemedicine Associa-
tion, 2014). Our own research has examined various technology platforms starting
initially with DVDs and websites for parents to access written and video content
to video conferencing, where parents can see, hear, and communicate in real time
with a coach from their homes. Through these applications, families throughout
the United States and in other countries have practiced, reflected, and evalu-
ated their learning and their children’s progress with the P-ESDM (www.helpisin-
yourhands.org; Vismara, McCormick, Monlux, Nadhan, & Young, 2016; Vismara,
McCormick, Shields, & Hessl, 2019; Vismara, McCormick, Young, Nadhan, &
Monlux, 2013; Vismara, Young, & Rogers, 2012). More and more clinical settings
now have the potential for delivering telehealth services to families. Both research
evidence and clinical experiences have reassured us about the ability of this
modality to deliver high-quality parent coaching to families who need this service.
However, each professional discipline has specific ethics and practices regarding
Internet delivery of treatment, protection of confidential information, licensing,
billing, record keeping, and other aspects of clinical care. Individual professionals
who wish to use telehealth services need to consider their malpractice insurance,
professional ethics, agency policies, and the security of Web-based communica-
tion before they begin to provide this service. However, we are confident that
telehealth services will become more and more widely available, breaking down
access barriers for many families and professionals alike, and resulting in more ser-
vice delivery and more economical delivery in the years to come. There are many
online courses for those wanting to understand more about the legal and practical
use of telehealth within their professions.
Coaching Parents in Groups
Parent group coaching is increasing in use among families with ASD (Baker-Eric-
zén, Stahmer, & Burns, 2007; Gengoux et al., 2015; Hardan et al., 2015; Minjarez,
Williams, Mercier, & Hardan, 2011). The synergistic experience of being part of a
group and able to connect, support, and learn from each other while learning and
practicing how to foster child learning is an important benefit of this experience.
Comfort and insight may come from watching other families at work with their
children as well as listening to other parents’ stories and experiences that have
impacted their lives. Parents may develop new resources and connections through
these exchanges for working with their children and for connecting with other
parents, which help them feel less alone and more adjusted psychologically and
emotionally (Minjarez et al., 2011).
In our own initial efforts to figure out how to coach parent groups in P-ESDM,
the focus remains on helping parents form and reach their goals through the use of
planning, action, personal reflection, evaluation, and other adult education prin-
ciples (Trivette, Dunst, Hamby, & O’Herin, 2009). We also use the family-centered
approach described in Part C of the IDEA. In group coaching, parents meet with
the coach as a group without their children to identify goals that will serve as learn-
ing foci in sessions. They then practice with their children at home and in 15-min-
ute one-on-one sessions with the coach, followed by a chance to reflect–evaluate–
plan in terms of the impact that intervention has on their parenting actions, their
child’s behavior, and their daily life. The coach (and the group) listen, support, and
process without imposing beliefs, values, or priorities onto parents. Resources and
tools are provided just as they are in individual coaching, and coaching remains
focused on the contextual, relationship, and behavioral variables important to par-
ent–child–family dynamics, interactions, and learning (Vismara & Rogers, 2018).
Coaching in all these formats involves preparation before and after each ses-
sion to assure that it starts and ends on time, follows an agenda or plan, and
addresses the actions and topics of the families. We use the same coaching session
plan that we use in one-to-one coaching, although in group delivery, not all of the
coaching activities outlined may be possible without children present in sessions
(see Form 8.1). (We offer alternatives below.) Table 8.1 lists the similarities and
differences in preparation between coaching individual families and groups.
With groups, the first session may begin with the coach posing discussion ques-
tions for parents to answer together as an ice-breaker to get to know each other and
to find out common interests or needs for formulating connections. In addition,
the coach and group may want to set ground rules with regard to their commu-
nication and behavior toward one another, for example, no interrupting, keep all
that is shared confidential and limited to the people in the room, no telling each
other what to do or criticizing what a parent has done. Moreover, emotions and
stress may be high when talking about personal and difficult experiences. The
group needs to be a safe conversation space that helps parents share, discuss, and
resolve their differences of opinion in constructive ways so that it is always a place
of support and encouragement for its members and members remain committed to
one another’s success. Research tells us that parents who feel safe enough to openly
communicate and describe their experiences in detail are more likely to benefit
from coaching and engage in intervention practices important to children’s devel-
opment, compared to those who feel less able to do so (Hutman, Siller, & Sigman,
2009; Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2012; Siller, Hutman, & Sig-
man, 2013). Table 8.2 lists the similarities and differences between the first session
for coaching individual families and for groups.
Planning and Observation

In group work, the initial check-in and planning set the stage for actions that will
follow. In group coaching, each parent briefly describes what was practiced since
Table 8.1. Group Coaching Preparation

Similarities to individual coaching Differences from individual coaching
• Planning sheet outlines intervention • Not all activities on planning sheet may be
topics and coaching activities to cover possible with groups.
in sessions.
• Planning sheet may address more than one
• The coach is organized, prepared, topic or need with groups.
and ready to start and end sessions on
• The meeting room is of adequate size and has
time.
visual or other coaching aids to accommodate
• The coach summarizes information learning.
and parent, child, and coaching data
• Intervention toys and child care volunteers
after each session.
are available if children are included.
FORM 8.1
First Group Session Plan
Coach: Client: Session Date:
Topic/Goals from Last Session:
Check-in (updates/needs/tentative session plan)
Observation (reflection/evaluation/session plan)
Topic (strategies/goals)
Coaching Activity 1 (reflection/evaluation)
Coaching Activity 2 (reflection/evaluation)
Closing (action plan/questions/needs)
237
Table 8.2. Plan for the First Session

Similarities to individual coaching Differences from individual coaching
• Explains the structure, organization, and • “Ground rules” are recommended to go
coach versus family roles involved with over positive communication practices
sessions. with groups.
• Positive communication practices are • Group confidentiality is discussed and
modeled by coach to promote a safe, practiced.
accepting environment.
• Volunteers arranged if children participate
• Goal setting follows parent priorities and in group sessions.
defines the intervention content and
• Test the Internet and audiovisual
behaviors taught in sessions.
connection in rooms selected for video
• Goals and teaching steps follow an ABC conferencing.
learning contingency in parent-friendly
• Find common ground in group goals to
language.
build peer connections and social support.
the last session. The coach and other members celebrate achievements, no matter
how small. Challenges are asked about or acknowledged but not problem-solved
until the coach observes the parent and child in action.
In group sessions where children are present, parents work with their child in
a brief activity in front of the group, discussing the goal and providing some reflec-
tion afterward to share with the group. If children are not present, parents may
opt to share video, or at least goal-tracking sheets, of their practice at home. The
coach takes parent fidelity and child performance data to track progress and to
guide the reflective conversation that will take place next with parents. Data are
not talked about as numbers or scores necessarily with parents, but rather as par-
ent–child behaviors that relate to the learning strategies and goals parents strive
to change. Constructing data into meaningful actions and constructive feedback
parents can follow and feel good about doing is how the coach supports their
learning. Below are two statements from a coach talking about data. What differ-
ences do you notice between the two statements? Which approach would resonate
if you were the parent in the session?
Coaching Statement 1
“I noticed the different ways you pulled Henry’s attention to you. When Henry
looked past you, you followed his eyes to the musical instruments and moved
them right in front of you. You gave him a moment to look at the instruments
and named each one for him to notice. When his attention lingered on the
drum, you picked it up and held it out for him to take. He looked at you while
doing so. I saw other looks Henry gave you when you sang, ‘The Ants Go
Marching’ and banged your drum. Henry’s attention seemed to lessen from
you as other tools he could use to hit the drum were added to the activity.
What could we try differently next time to introduce these new and creative
ideas without Henry losing sight of you?”
Coaching Statement 2
“I scored a ‘3’ for how you pulled Henry’s attention to you. This score means
you had Henry’s attention on you some of the time but not all the time. The
actions where you enticed Henry to look at you was following his interest to
the instruments and moving them in front of you, as well as singing a favorite
song while drumming. I also saw Henry’s attention slipping from you as more
materials were added to the activity. What could we try differently next time
to hold onto Henry’s attention and get your score to a ‘4’ or ‘5’?”
Topic of the Day and Coaching

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

Similarities to individual P-ESDM Differences from individual P-ESDM
• Defined by the topic and goals and • Multiple learning tools and coaching
supported with coaching. modalities to accommodate unique
and different learning styles and when
• Coaching in the moment is concise,
children cannot participate in sessions.
positive, and improves parent–child skills.
• Group input to other parents’ action
• Accomplishments (no matter the size)
plans.
recognized.
• Increased attention to parents’ body
• At least two different coaching activities
language and nonverbal signs of
practiced per session.
discomfort or dissatisfaction.
• Reflection and evaluation follow after
• Unobstructed view of parent–child
each coaching activity.
interactions for telehealth coaching.
• Results in a plan of how information will
• Parent–child videos as a substitute for live
be practiced, by whom, where, when, and
coaching if children cannot participate in
measured.
groups.
outlines the similarities and differences of coaching action for individual families
and groups.
Reflection and Evaluation

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

Similarities to regular P-ESDM Differences from regular P-ESDM
• Share insight about practice and progress • Time management is central for everyone
to make coaching decisions and before in the group to share.
new content is introduced.
• Group contributions are important to
• Goal tracking sheets, questions, bonding through success and struggles.
or statements may help with time
• Anticipate how to use content at home if
management or recall.
children do not participate in groups.
Table 8.5. Evaluation Phase

Similarities to regular P-ESDM Differences from regular P-ESDM
• Assess progress toward desired outcomes after • Invite group praise and support.
each practice.
• Parents need to feel encouraged and
• Different options for goal tracking. comfortable to ask for help when in
groups or online.
• Adults decide which evaluation methods work
best. • Different evaluation methods may be
used simultaneously with groups.
• Informs coaching decisions and action plans.
• Any and all progress are acknowledged.
• Problems are addressed within a defined time
frame set by coach and learner.
practice with families. Parent coaching and the adapted coaching modalities
described in this chapter are not intended to substitute for intensive early inter-
vention. We do not have data that compare the efficacy of each. However, data
do demonstrate that parent-implemented ASD-specific interventions help families
and children when compared to generic interventions, or no interventions. Par-
ents are first and foremost their child’s parents, not their therapists. We use parent
coaching to equip parents with tools to help their interaction and communication
with their child and to help their child learn how to grow and learn in everyday
life at home. We believe in the importance of parent coaching even when children
are receiving intensive early intervention from a skilled team, and all of our studies
and clinical practices have used parent coaching to support parents’ involvement,
knowledge, advocacy, and confidence in themselves and their children.
The parents in the examples that started this chapter each faced a specific
set of challenges, but they also had multiple commonalities: their love for and
commitment to their children, their desire to teach their children and be involved
in their care, and the insight and wisdom about their child’s abilities and needs
parents hold. It is our role as coaches to be flexible and adapt to parents even when
this means setting aside our own expectations, values, and preconceptions of how
the intervention should unfold. Through this process of communicating, accept-
ing, and adapting, trust builds between the parent and coach and forms a solid
foundation for the coaching process and for parent and child learning and growth.
Chapter 9
Looking to the Future

Challenges and Opportunities
In this chapter, we suggest several directions for future research on different

aspects of parent coaching and discuss the broader impact of parent-implemented
intervention. These research directions include: (1) understanding how parent-
delivered early interventions can be adapted for children with ASD who have
co-occurring psychiatric or medical conditions; (2) developing and implementing
strategies for use with children and families in low-resource communities within
the United States and globally; and (3) creating and evaluating parent-delivered
intervention for infants at risk for ASD.
Children with ASD Who Have Co-Occurring Conditions:

Treating the Whole Child
Practitioners who serve as therapists or parent coaches for families with children
with ASD have long recognized that ASD is not one condition, but rather rep-
resents a heterogeneous group of neurodevelopmental disorders characterized by
difficulties in social interaction and engagement and the presence of restricted
and repetitive behaviors. The fact that a core tenet of any ASD early intervention
program is that it must be individualized reflects awareness of the tremendous
heterogeneity found among children with ASD. Therapists help families establish
individualized goals based on the unique needs and characteristics of each child
and family. The specific strategies and sequence of activities also are specifically
tailored for each child and family. The core principle is that treatment for ASD
is not “one size fits all,” but rather a highly personalized endeavor. This is a tenet
of all empirically validated early intervention programs (Schreibman et al., 2015).
There is increasing recognition that ASD also overlaps with several psychiatric
242
Looking to the Future 243
and medical conditions that need to be treated in their own right. This has led
to a call for early intervention approaches that address more than one condition.
Psychiatric Conditions
Two of the most prevalent psychiatric comorbidities are anxiety and attention-
deficit/hyperactivity disorder (ADHD); 40–60% of children with ASD meet diag-
nostic criteria for one or both of these disorders (Leyfer et al., 2006; Turygin,
Matson, & Tureck, 2013), as illustrated in Figure 9.1. Research has shown that
having both ASD and another condition, such as ADHD and/or anxiety, affects a
child’s outcome (Magnusdottir, Saemundsen, Einarsson, Magnusson, & Njardvik,
2016; Sikora, Vora, Coury, & Rosenberg, 2012; Sprenger et al., 2013). Such chil-
dren tend to have more severe deficits in social interaction and language, higher
levels of sensory sensitivities, and more challenging behaviors, such as tantrums
and aggression. In addition to these differences in behavior, having ASD in com-
bination with ADHD and/or anxiety also affects a child’s physical well-being. The
presence of these co-occurring diagnoses has been linked to increased gastroin-
testinal problems and difficulties with sleep (Johnson, Gliga, Jones, & Charman,
2015; Singh & Zimmerman, 2015). The presence of a co-occurring diagnosis, such
as ADHD, is one of several family and child factors found to be associated with
disparities in access to diagnostic assessments and early intervention. Other fac-
tors that lead to a delay in diagnosis include ethnic or racial minority background
and lower parental education and socioeconomic status. One study found that
children who received an initial diagnosis of ADHD before being diagnosed with
ASD were nearly 30 times more likely to receive their ASD diagnosis after age 6
(Miodovnik, Harstad, Sideridis, & Huntington, 2015).
Autism
ADHD Anxiety
Figure 9.1. Conditions that can co-occur with ASD. Forty to 60% of children with ASD
also meet diagnostic criteria for ADHD and/or anxiety.
In addition, the presence of both co-occurring anxiety and ADHD symp-

toms has been found to interfere with the ability to fully benefit from behavioral
interventions (Antshel et al., 2011). This is one reason why current research is
examining how early intervention approaches, including parent-delivered inter-
ventions, should be adapted to better fit the needs of children with ASD who
have a co-occurring psychiatric condition. While this research is ongoing, there
are a number of things that a parent coach can do to increase the likelihood that
early intervention will be successful. First, become familiar with the symptoms of
co-occurring psychiatric conditions that commonly affect young children with
ASD. Although the symptoms likely begin during infancy, these conditions are
detectable as early as 3 years of age. Symptoms of ADHD include inattention
(e.g., trouble holding attention on tasks or play activities, failure to complete a
task, easily distracted) and hyperactivity/impulsivity (e.g., fidgets, squirms, leaves
seat frequently, runs about and climbs on things, trouble waiting). Children with
ADHD (and infants who are later diagnosed with it) tend to be more irritable and
fussier (Sullivan et al., 2015).
Interestingly, these problems are ones that are common for a young child with
ASD, especially if they are just beginning a treatment program. Many children
with ASD initially are unable to sustain their attention to a play routine and
wander around the room or climb on furniture. Some children become fussy and
irritable when they sense that some demands will be made of them. However, as
the intervention proceeds, we expect to see that the child is increasingly able
to focus his or her attention on a play activity when it is engaging and develop-
mentally appropriate and start to readily approach the parent with an interest in
playing together rather than running around the room. We also know from expe-
rience that children differ in terms of how quickly they are able to “learn to learn,”
meaning that they become attuned to the play activities and engage in them for
developmentally appropriate periods of time. When a child is on the extreme end
of this continuum and is making very little progress despite the sustained efforts of
both the parent coach and parent, it is time to consider whether the child might
have ADHD.
Similarly, children younger than age 3 are less likely to be diagnosed with
an anxiety disorder, although the symptoms can begin to appear much earlier.
Common symptoms of an anxiety disorder in a young child include frequent cry-
ing; extreme fears (e.g., of certain sounds or objects); reluctance to separate from
the parent; extreme distress reactions when novel objects are introduced; frequent
meltdowns and tantrums, especially in novel situations; avoidance of certain
activities; refusal to speak; and specific phobias (e.g., of restrooms or dogs). Stud-
ies have shown that children with ASD who have higher levels of sensory over-
responsivities are more likely to have an anxiety disorder (Mazurek et al., 2013).
Specific phobias are especially common among children with ASD and might be
related to negative sensory experiences (e.g., fear of the toilet after hearing loud
flushing) and difficulties shifting their attention away from the negative experi-
ence.
If symptoms are affecting the child’s ability to make progress from a parent-
mediated intervention or the parent mentions that anxiety or ADHD-like symp-
toms are interfering with family life, a referral to an appropriate specialist is war-
ranted. Early intervention with young children with ASD and their families should
always be conducted within the context of an interdisciplinary team. This means
that either the parent coach is in a setting where other disciplines are part of the
clinical care team or the parent coach is aware of the appropriate referrals for spe-
cialists, as needed. Consultation with a psychologist, psychiatrist, and sometimes
a primary care pediatrician can be helpful.
Regardless of the ultimate diagnosis of a co-occurring condition, it will be
important to adapt the intervention to consider the impact of the co-occurring
condition. Fortunately, best practices for treating ADHD and anxiety in young
children involve the application of principles of applied behavior analysis, which
is already part of P-ESDM. The strategies that focus on the principles of ABA
(antecedent–behavior–consequence) will be especially relevant as you consider
how to guide the child’s behavior to enhance social engagement and learning.
Behavioral principles that you are already familiar with, such as slowly introduc-
ing novel activities (called “graded exposure”), encouraging the parent to reinforce
approximations to the longer-term behavioral objective, and reinforcing increas-
ingly long periods of appropriate engagement in activities, will go a long way in
Symptoms of ADHD and Anxiety

in Young Children
ADHD Anxiety
• Trouble holding attention to play • Crying often

activities • Having extreme fears
• Failure to complete a task • Reluctance to separate from parent
• Easily distracted • Extreme distress reactions to novel
• Fidgets and squirms objects
• Leaves seat frequently • Frequent meltdowns and tantrums
• Runs about and climbs on things • Avoidance of certain activities
• Trouble waiting • Refusal to speak
• Irritable and fussy • Specific fears (e.g., of restrooms or
dogs)
• Fears related to sensory sensitivities
helping the child and parent. Ideally, the parent coach and a professional who is
trained in the behavioral treatment of ADHD and/or anxiety will meet together
with the parent to develop ways in which the parent coaching session can be
adapted and to identify shared goals and strategies. This is not unlike how the
parent coach might work collaboratively with the speech language therapist and
occupational therapist who are working with the child and parent.
Medical Conditions
A wide range of medical conditions frequently co-occur with ASD and can have
an impact on the child’s ability to benefit from early intervention. Two very com-
mon medical conditions include sleep and gastrointestinal problems (Holingue,
Newill, Lee, Pasricha, & Daniele Fallin, 2018; Mannion & Leader, 2014). Interest-
ingly, these are more common in children who have ADHD and/or anxiety.
Sleep problems are common in many young children. About half of parents
of typically developing children report that the child has trouble sleeping. How-
ever, sleep problems are even more common in children with ASD. The majority
of children with ASD have problems falling asleep. This increased rate of sleep
problems in children with ASD has been shown to have a biological basis and is
related to differences in genes that regulate sleep–wake cycles. Research over the
past decade has demonstrated the importance of sleep for brain health. Sleep is
important for memory consolidation, stress reduction, and the ability to sustain
attention. Sleep appears to be especially important for the developing brain and
the retention of new skills and self-regulation. Clearly, these are key areas affecting
the lives of all people, but can especially impact a young child with ASD who is
engaged in an early intervention program.
At the beginning of the intervention program when you are getting to know
a child and his or her family, it’s a good idea to ask parents about the child’s sleep
patterns. The most common problems in children with ASD include trouble fall-
ing asleep, sleepwalking, nightmares, and frequent nighttime awakenings requir-
ing parental intervention. The parent coach should explain that the presence of
sleep problems could affect how much the child benefits from early intervention
and that there are now behavioral and medical treatments (e.g., melatonin and
other medications) helpful for addressing sleep problems in most children with
ASD. Simple behavioral interventions to promote good sleep hygiene include
establishing a regular nighttime routine, limiting use of electronic media before
bedtime, and using extinction to reduce bedtime demands. A referral to the child’s
primary care pediatrician is warranted to address persistent sleep issues.
What kinds of behaviors might lead you to suspect that the child is not get-
ting adequate sleep? Children with sleep difficulties tend to have more difficulty
sustaining their attention during play, are irritable, have more frequent tantrums,
and have more difficulty retaining new skills.
Signs of Inadequate Sleep in Children

• Difficulty sustaining attention during play
• Irritability, fussiness
• Tantrums
• Difficult retaining new skills
• Daytime sleepiness
Research has found that children with ASD have gastrointestinal problems
more frequently than other children. The most common problems are constipa-
tion, diarrhea, and abdominal pain. Studies have also shown that children with
gastrointestinal problems are more likely to have trouble sleeping and exhibit more
frequent irritability, tantrums, and aggression. Because of language delays and poor
body awareness, some children with ASD are unlikely to tell their parent that their
tummy is hurting. Instead, parents and the parent coach will need to look for signs
that the child might have gastrointestinal distress. Signs of gastrointestinal dis-
comfort can include whining, moaning, screaming, sobbing “for no reason at all,”
grimacing, wincing, pushing on the abdomen, rotating the torso or trunk in a dis-
torted way, agitation, self-injurious behavior, sleep disturbance, and irritability. If
the parent coach or parent notices these behaviors, especially if they have an abrupt
onset, it is important to have the child evaluated by a physician. A referral to the
child’s primary care pediatrician is appropriate. The child’s pediatrician might rec-
ommend that the child be evaluated by a pediatric gastroenterologist. Specific rec-
ommendations for treating gastrointestinal problems in children with ASD have
Signs of Gastrointestinal Distress in Children

• Whining, moaning
• Screaming, sobbing “for no reason at all”
• Grimacing, wincing
• Pushing on the abdomen
• Rotating the torso or trunk in a distorted way
• Agitation, irritability, fussiness
• Self-injurious behavior
been developed and published (Furuta et al., 2012). Treating gastrointestinal dis-
tress will help the child benefit from parent-mediated interventions.
Although this section has focused on
the most common psychiatric and medical
conditions that co-occur with ASD, many
other conditions also can be present and
affect a child’s and family’s ability to engage
successfully in a parent-mediated interven-
tion. Examples of other common conditions
include eating and feeding problems, aller-
gies, nutritional deficiencies, sensory deficits
such as hearing and vision problems, specific genetic conditions (e.g., fragile X
syndrome) that have unique effects on the child’s strengths and abilities, and epi-
lepsy, among others. The parent coach should be familiar with these conditions
and have a plan for interdisciplinary collaboration to ensure that the child can
optimally benefit from early intervention.
Children and Families in Low-Resource Communities
Participating in parent-mediated ESDM typically assumes that parents will have

the resources to travel frequently to see the parent coach; take regular time away
from work or other daily activities to be part of parent coaching sessions; have
access to materials such as toys, Play-Doh, dolls, and so on; and live in a home
that is not so noisy, unsafe, crowded, or busy that it would be extremely difficult
to have sustained periods of quality time focused on parent–child interaction (e.g.,
regular meal- and bathtimes). The majority of families worldwide live in condi-
tions that make it difficult to meet most of these assumptions we often bring to
the therapy session. It’s essential that the parent coach understand the home and
family context in which the child and parent live and take these into account
when discussing expectations for the parent and child. How often will they come
for therapy? Who will be involved? When will therapy techniques be practiced
at home? A major barrier for many families is living outside urban areas, making
it difficult to travel to see a parent coach on a regular basis. Advances in tech-
nology have made it possible to deliver parent-mediated interventions remotely
using telehealth methods (discussed in Chapter 7). Such methods can include
the use of smartphone apps, DVDs, videoconferencing, and Web-based content
to deliver the treatment remotely. Recently, a systematic review of nine studies
that used telehealth to deliver a parent-mediated intervention was published,
which included one study of P-ESDM led by Laurie Vismara (Parsons, Cordier,
Vaz, & Lee, 2017). In all, this review included 197 parents from the United States,
Canada, and Australia. The review concluded that telehealth approaches were
beneficial for improving parents’ knowledge and children’s social behavior and
communication skills. Although still in its early stage, this line of research is very
promising in offering hope for reaching more families who cannot engage in face-
to-face interaction with a parent coach due to their geographic location.
Over the past several years, there also has been increasing interest in address-
ing the tremendous treatment gap that exists in meeting the needs of young
children with ASD in low- and middle-income countries compared to wealthy
Western countries. Indeed, the vast majority of children with ASD live in lower-
income countries and have no access to any treatment before school age. Even
after school age, the majority of these children cannot access specialized services
for their ASD. This means that the majority of children with ASD will continue
to have significant levels of disability including behavioral, communication and
cognitive disabilities, placing a tremendous strain on their families. It is clear that
this challenge cannot simply be addressed by training more professionals. More
than 5 million children with ASD, ages 2–9 years, live in India alone (Arora et al.,
2018). One approach currently being evaluated is training nonspecialist commu-
nity health workers to become parent coaches for parent-mediated interventions,
referred to as “task-shifting.” This approach has been successful in addressing the
needs of populations with other challenges, such as depression, HIV-AIDS, and
schizophrenia. This is a significant undertaking that requires substantial adapta-
tion of current evidence-based parent-mediated interventions to make them fea-
sible and culturally appropriate for low-resource settings. The process involves: (1)
conducting focus groups and qualitative interviews with both parents and commu-
nity workers to better understand the cultural context, attitudes, values, resources,
and constraints, and (2) adaptation of the treatment manual to be more culturally
relevant, appropriate for nonspecialists, and feasible. For example, parents may
be encouraged to use water, sticks, leaves, and other common materials rather
than toys during play routines. Lauren Franz, a child psychiatrist, has been work-
ing in Africa over the past several years to improve access to early intervention
for young children with ASD (Franz et al., 2018). Noting the potential benefit
of P-ESDM for families in Africa, she has been adapting the intervention to be
culturally appropriate and feasible within sub-Saharan Africa. She started out by
systematically studying whether the use of joint activity routines, including play
routines in which P-ESDM is embedded, are applicable in low-resource, cultur-
ally diverse environments in South Africa. She worked closely with parents and
other caregivers to understand whether joint activity routines would be feasible
in the multicultural, multilingual South African context. She found that, in fact,
parents in South Africa readily described many joint activity routines that they
commonly use in their daily routines, suggesting that P-ESDM is a promising early
intervention approach in this low-resource country (Ramseur et al., 2019). Franz
is currently conducting a trial assessing the benefits of P-ESDM when delivered
by community workers for improving outcomes for young children with ASD and
their families in South Africa. Franz’s work is one example of the exciting progress
that offers hope for families in regions across the globe where access to trained pro-
fessionals is limited or nonexistent. Recent studies have provided evidence of the
positive benefits of parent-delivered interventions for children with ASD in other
regions of the world. One study involved the use of nonspecialized health work-
ers in Goa, India, and Rawalpindi, Pakistan, and showed that adapting and task
shifting an intervention initially used in a high-income context were feasible and
resulted in positive outcomes for improving parent–child interaction (Rahman et
al., 2016). This work is inspiring and suggests that parent-delivered interventions
are likely to be a key element in addressing the treatment gap that exists for the
large majority of young children with ASD and their families.
Parent-Implemented Interventions
for Infants at Risk for ASD
Studies of infants at genetic risk for autism, such as infant siblings of children with
ASD, and home videotapes of infants later diagnosed with ASD have shed light on
the earliest symptoms of ASD (Osterling & Dawson, 1994; Ozonoff et al., 2010).
Whereas about a quarter of children with ASD develop normally and then lose
skills during the second or third year of life, most children with ASD begin show-
ing signs of ASD during the second half of the first year of life. Among the earliest
symptoms are poor eye contact; reduced communicative babbling; failure to orient
when their name is called; lack of use of gestures, especially pointing; and differ-
ences in temperament (overly fussy or quiet and passive). We have learned a lot
about the early symptoms of ASD in infants by prospectively following cohorts of
infants who have an older sibling with ASD since it is known that approximately
one in five of these infants will develop ASD (Ozonoff et al., 2011). Such studies
have shown, for example, that infants who later develop ASD are paying attention
to the world in different ways beginning by 2–6 months of age (Jones & Klin, 2013).
As we have become better at detecting ASD symptoms in infants, researchers
have been developing interventions that can promote social and communication
development in an infant at risk for ASD. Parent-implemented interventions are
particularly well suited for infants. Although the research is just beginning, three
proof-of-concept studies have been conducted that provide initial support for the
efficacy of early interventions with infants at risk for ASD. The first study was
conducted by Rogers and colleagues at University of California Davis (Rogers et
al., 2014). Fourteen infants between 7 and 15 months of age who were exhibiting
early behavioral symptoms of ASD took part in the study. Symptoms included
lack of communicative babbling, being fixated on objects, repetitive behaviors,
lack of gaze coordination between the parent and objects, and showing little inter-
est in interacting with people. Seven of the 14 infants were provided with 12
weekly parent coaching sessions. The remaining seven infants, who had declined
intervention, comprised the comparison group. The intervention was an infant
version of ESDM, in which parents were coached to use interactive strategies that
promoted social engagement and communication. At 18–36 months, the treated
infants showed fewer autism symptoms than infants who were not provided with
intervention (although they still showed some signs of ASD). Infants whose par-
ents received coaching also had higher language scores on the Mullen Scales that
were similar to those of typical infants, whereas the group that was not treated had
significantly delayed language abilities.
The second study was conducted by Green and colleagues in the United
Kingdom (Green et al., 2015). This was a randomized controlled trial of fifty-four
7- to 10-month-old infants who had an older sibling with ASD, half of whom
received parent coaching in a parent-implemented intervention. Infants whose
parents received coaching showed fewer ASD symptoms at the end of the inter-
vention. Three years later, children in the parent-delivered intervention group had
milder autism symptoms and, during parent–child interaction, were more attentive
and more likely to initiate interactions (Green et al., 2017). No effects of the inter-
vention on overall developmental or language level were found at age 3.
The third study was conducted by Dawson and colleagues (Jones, Dawson,
Kelly, Estes, & Webb, 2017). At 6 months of age, 36 high-risk infant siblings were
administered a task that assessed the infant’s ability to recall faces (a skill area
that has been shown to be deficient in children with ASD). Brain activity was
assessed by recording electroencephalography (EEG) while the infants watched
videos of dynamic social and nonsocial stimuli, and an event-related potential
(ERP) task that assessed their brain responses to faces and objects. At 9 months,
infants were randomly assigned to receive no intervention or a parent-delivered
intervention focused on promoting infant social engagement and communication.
When infants were assessed at 12 and 18 months of age, treated infants were better
at recalling faces and showed more normalized patterns of brain activity to social
stimuli. These early studies are promising. Research with larger samples is needed
to replicate these findings, understand the key elements that are responsible for
effective treatment, and indicate for whom infant intervention is most effective.
Looking Ahead
In the research and evolving practices on intervention for early autism, it has
become clear that parent-implemented interventions supported through parent
coaching have much to offer children and families and are an appropriate starting
point for toddlers in the 12- to 30-month age range (Rogers et al., 2014). Look-
ing ahead, the following recommendations will help improve our confidence and
refine our approaches in working with very young children with ASD:
1. We need more evidence for the developmental impact of parent-implemented

intervention, including understanding factors related to variation in developmental
outcomes. Additional longitudinal data are needed that examine whether parent-
implemented interventions based on parent coaching can have similar effects on
children’s developmental quotients (i.e., IQ) and symptoms to those found for inten-
sive, therapist-delivered interventions (Dawson et al., 2010; Lovaas, 1987). The
work by Wetherby et al. (2014) suggests the potential power of parent-implemented
interventions for improving developmental outcomes, but additional research sup-
port is needed. There are reasonable arguments against considering improvements
in language learning and overall developmental rates as the most important crite-
ria for measuring whether an intervention is effective. However, we have few viable
alternative outcome measures. Most measures, including those assessing adaptive
behavior, are not independent of IQ gains. An outcome that focuses solely on ASD
symptoms does not address the fact that longitudinal studies suggest that IQ and
language learning, rather than ASD symptoms, are most predictive of long-term
outcomes (although none of these is independent of the others).
There are both humanistic and disability-centered arguments that would
argue against taking an outcomes orientation for an intervention in favor of a sup-
ported inclusion orientation, but these arguments and alternatives fit better when
discussing adults with disabilities than discussing young children. It is the typical
“role” for young children to be learners and to learn to communicate, play, and
contribute to their families in ways defined by family values, culture, and commu-
nity. Thus, outcomes for young children’s development typically assume increased
development of communication, social interaction, play, family participation, and
independence skills. Applying these same expectations to children with disabili-
ties is not a focus based on their disabilities or deficits, but rather one based on
their social roles as children, a focus that is important to many families.
2. We need to master interdisciplinary practice. Interdisciplinary, collabora-
tive models of early intervention are considered best practice. However, in truth,
clinical practices are much more likely to be multidisciplinary than interdisciplin-
ary. Families are often seeing many specialists who are addressing different needs
of their child, but too often these specialists are not working closely together to
develop a coherent, comprehensive intervention plan. Specialization continues
largely due to health billing and reimbursement practices that reward disciplinary
rather than interdisciplinary care. Treating the whole child by addressing family,
contextual, medical, and behavioral (social, emotional, language, cognitive) needs
will result in the best outcomes for children.
Birth to 3 early intervention programs that do not rely on health reimburse-
ment funding are, in theory, well positioned to practice interdisciplinary care,
given their requisite staffing patterns. However, interdisciplinary practice takes
time to learn, and it requires that teams practice intervention plans that are
created and implemented together in order to share roles, knowledge, and skills
and foster interdisciplinary collaboration across the group. This kind of inter-
interdisciplinary transmission works when a group of parents, their young chil-
dren, and their interdisciplinary team are all together at one place and time.
However, while home visiting has become the main method of delivery of early
intervention due, in part, to the requirements of delivery in the least restrictive
environments and in typical environments. Home visits are not a viable setting for
interdisciplinary teamwork due to staffing costs. In the future, increased focus on
innovative ways of facilitating interdisciplinary approaches will be important for
achieving best outcomes for children.
3. We need to transition from expert models toward family-centered models of
assessment and coaching intervention. Unlike delivery of early intervention for chil-
dren with other types of developmental difficulties and their families, early inter-
vention service delivery for ASD often relies on a professionally driven model of
intervention for children and families (see Dunst & Trivette, 2009a, 2009b), for
helpful descriptions of core differences in the models. A coaching relationship is
consonant with family-centered supports. It is a service model that uses family-
centered practices from the very first contact with the family, through the initial
contacts, assessment, feedback, and planning. Family-centered care has already
established the groundwork for coaching relationships between parents and pro-
viders. More importantly, family-centered practices result in greater benefit for
families and for children than expert-based models (see Dunst & Trivette, 2009b,
for a review of multiple studies and meta-analyses).
For those who are still in their professional training programs or plan to work
in pediatric settings, family-centered care and parent coaching practices need to
become part of the curriculum in the medical and allied health and early educa-
tion fields. For those professionals already working in early intervention, inservice
training workshops and credentialing packages in coaching and family-centered
care need to become far more accessible and affordable.
4. We need to understand and define characteristics of helping relationships when
parents implement the intervention. In parent-implemented studies that use a coach-
ing model, both children and parents are recipients of the coaching intervention,
while both coaches and parents are implementers of the intervention. How should
these relationships look? Early intervention researchers have provided detailed
descriptions of types of adult–child interactions that help children progress as cap-
tured in various fidelity of treatment measures. However, fidelity of implementa-
tion measures for interventionists, considered a necessity in child-focused treat-
ment studies, are just as necessary in parent-implemented intervention studies.
What are the actions and behaviors that coaches need to provide to be the most
effective at supporting parents to implement interventions? How do we measure
those skills? Such tools are needed for training, for research, and for personal
practice. There are existing tools in the literature for parent coaching, but they
come from the general disability literature that may not include autism. We don’t
know whether existing tools are as helpful for parents of young children with
autism as they are for parents of children with other disabilities. Parents of young
children with autism have been found to experience higher levels of stress as com-
pared to parents of children with typical development or other developmental
disabilities (Hayes & Watson, 2013; Sanders & Morgan, 1997). It will be helpful
to determine whether the coaching and family-centered models (as opposed to an
expert model) that have been developed for children with other developmental
disabilities are helpful for families who have children with ASD.
Conclusion
In this book, we have shared our knowledge and experience regarding coaching
parents to help their children with ASD communicate, learn, and connect with
them and other family members. We need to support and empower parents. This is
best accomplished by moving away from the role of expert to a more family-centered
model with families as experts. Research in developmental science and early detec-
tion has had a substantial impact on our current models for parent-focused inter-
ventions, as has research on understanding how adults learn. The latter informs
our strategies for working with parents, including how to best promote their abil-
ity to adapt their own behavior through learning, practice, habit formation, and
replacement of earlier behaviors. Research on adult learning has provided strong
support for the therapist adopting the role of coach, rather than expert or trainer.
We have described the natural course of parent-focused intervention, which
typically involves a phase focused on parent learning, followed by a second phase
focused on achieving the child’s learning goals. As intervention inevitably involves
challenges and setbacks, we have described strategies for how to make adjustments
to the treatment plan and flexibly adapt to the unique needs of each family. Just as
each child with ASD has unique strengths and challenges, each parent brings his
or her own unique history, resources, expectations, cultural and family attitudes
and values, and personal characteristics to the treatment sessions. An individual-
ized approach to intervention is fostered by the flexibility and respect that coaches
bring to their work with families.
We have learned much about how to promote development and learning in
young children with ASD and their families. Providing much more access to pres-
ent knowledge for the world’s families and children will go a long way to improv-
ing the outcomes and meaningful participation in all aspects of community life
as these children grow up—a challenge to all interventionists with these tools.
Learning how to identify children as early as possible and provide feasible, acces-
sible interventions at lower cost and with meaningful outcomes remains a chal-
lenge for ASD researchers and practitioners worldwide.
Appendix A
Handouts and Checklists Used Routinely

in Parent Coaching Sessions
As you have already experienced in Chapters 4, 5, and 6, we use many simple paper and
pencil tools to organize ourselves, prepare for sessions, take notes through sessions, track
time, record data, rate our own skills, and manage the coaching sessions. Using these
tools allows the coach to maintain fidelity to the model, conduct a considerable amount
of teaching, keep data on all participants in the session, and still allow for the family-
centered, reflective characteristics that are essential aspects of the ESDM. We have seen
that the most experienced and skilled coaches are those that lean the most heavily on
these tools; thus, we consider them essential for maintaining the quality and impact of
this model.
Contents
Appendix A.1: Coach’s Clipboard List 257

Appendix A.2: Coach’s Session Planning Sheet 258
Appendix A.3: Parent Daily Practice Chart 259
Appendix A.4: Activity Categories 261
Appendix A.5: Refrigerator List 262
Appendix A.6: Parent–ESDM Fidelity Coding Sheet 263
Appendix A.7: Parent Skills Checklist 264
Appendix A.8: Parent Self-Monitoring Checklist 267
Appendix A.9: Coach’s Fidelity of Implementation Brief Checklist 269
Appendix A.10: ESDM Coaching Fidelity Rating Tool 271
Appendix A.11: Stages of Change and Possible Coaching Techniques 279
255
APPENDIX A.1
Coach’s Clipboard List
1. Coach’s Session Planning Sheet
2. Post-it Notes
3. Child Data Sheet
4. Parent Fidelity of Implementation Data Sheet
5. Child Objectives
6. Activity Categories Cartoon
7. Refrigerator List
8. Parent Daily Practice Chart
9. Coaching Fidelity of Implementation Brief Checklist
10. Coaching Fidelity of Implementation Data Sheet
257
APPENDIX A.2
Coach’s Session Planning Sheet
Therapist: Date: Child:
Session No.:
Parent coaching topics covered in previous session:
Discussion points from last session to return to:
Time Activity Notes

Greetings:
0–5 min. • Initial chat
• Gather data and thank parent for it
Progress report:
• Main focus last week?
5–10 min.
• How did your work with [child] go?
• What do you want to accomplish today?
Activity 1: Warm-up
10–15 min. • Show me how your work on went.
Take parent fidelity data here.
Reflection and discussion
15–20 min. • How was that for you?
Note use of already taught topics.
Discussion of readiness for new topic, or continued
20–30 min.
work with current topic (self-paced learning)
Activity 2: Coaching—different activity type
30–35 min.
Take child data here.
35–40 min. Reflection, evaluation, planning
Activity 3: Coaching—different activity type

40–45 min. • Parent practice of new skills
Take child data here.
45–50 min. Reflection, evaluation, planning for week
50–60 min. Open discussion time or final activity
60–65 min. Review of plans for parents and child at home
Transition to departure, packing up, and goodbyes

65–75 min.
all around
Notes:
258
APPENDIX A.3
Parent Daily Practice Chart
Joint object Sensory social Caregiving Chores
activities routines Dressing, diaper Meals and Book Mail, laundry,
Learning Social games—no changing, snacks sharing caring for
toys, dolls, toys: peekaboo, bathing, washing Preparation, eating, Books, pets, watering plants,
bubbles, balloons, rough/tumble, songs, hands, hair, brushing and clean-up, photo albums, dishwasher, wipe up,
Parent focus for week noisemakers, balls rhymes, tickle; outdoor play teeth, bedtime wash-up pictures on iPad car washing
1.
2.
3.
259
4.
5.
6.
Today’s date: Key: + Tried this today in this routine and it went well.
– Tried this today in this routine but it didn’t go well.
My plan for today: × Didn’t get a chance to work on this in this routine today.
(continued)
From Coaching Parents of Young Children with Autism: Promoting Connection, Communication, and Learning by Sally J. Rogers, Laurie A. Vismara, and Geraldine Dawson. Copyright ©
2021 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can
download enlarged versions of this material (see the box at the end of the table of contents).
APPENDIX A.3. Parent Daily Practice Chart (p. 2 of 2)
Parent Notes from Today

What stood out about my time with my child today:
I felt competent about these successes:
260
What I needed more help with:
My plan for tomorrow:

APPENDIX A.4
Activity Categories
Bathing Books
Dressing/diapering Household tasks
Meals Outdoor activities
Sensory/social routines Toy play
261
APPENDIX A.5
Refrigerator List
Stepping into the Spotlight

Goal: To increase your child’s attention to you.
Steps:
• Identify your child’s attentional spotlight.
• Find your position in that spotlight, face to face and close enough to touch!
• Eliminate the competition for your child’s attention.
• Find your child’s comfort zone and stay inside it.
• Follow your child’s lead: Use active listening, narrating, helping, and imitating.
From An Early Start for Your Child with Autism by Sally J. Rogers, Geraldine Dawson, & Laurie A. Vismara. Copyright
© 2012 The Guilford Press. Reprinted in Coaching Parents of Young Children with Autism: Promoting Connection, Com-
munication, and Learning (Guilford Press, 2021). Permission to photocopy this material is granted to purchasers of this
book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of
this material (see the box at the end of the table of contents).
262
APPENDIX A.6
Parent–ESDM Fidelity Coding Sheet
Coach: Parent and date:
Child and session:
Item Activity 1 Activity 2 Activity 3

a. Management of child
attention
b. ABC format
c. Instructional techniques
d. Modulating child affect/

arousal
e. Management of
unwanted behavior
f. Use of turn taking/
dyadic engagement
g. Child motivation is
optimized
h. Adult use of positive
affect
i. Adult sensitivity and
responsivity
j. Multiple varied
communicative
functions
k. Adult language
l. Joint activity and

elaboration
m. Transition between
activities
Comment columns
for note taking
Scoring rules: View the entire activity before scoring. Read the full definition of each rating
before assigning score. Give a single numerical score. Note reasons for score in boxes. See
Rogers and Dawson (2010) for definitions.
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APPENDIX A.7
Parent Skills Checklist
Name: Rater:
Activity
Skill
1 2 3
Stepping into the Spotlight: Capturing the Child’s Attention

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

Follows rather than redirects the child’s interest. If needed, offers good activities
for the child to choose.
Watches the child’s actions, admires, and narrates what the child is doing or
looking at.
Joins in by imitating the child’s goals, including sounds.
Helps the child by making it easier for child to reach goals, by repeating the
activity, by handing over desired objects, etc.
Using Sensory Social Routines to Increase the Child’s Pleasure and Social
Engagement and Optimize the Child’s Arousal
Uses sensory social routines (SSRs).
Pauses to elicit child active communications to continue SSRs.
Uses SSRs to create/improve/sustain optimal child arousal state for learning.

Note. Use a plus sign (+) to indicate that the skill is used in most opportunities, +/– to indicate that the skill is used
in roughly half of opportunities, minus sign (–) to indicate that the skill is used in few or no opportunities within the
joint activity. If there were no opportunities to use it, code N/O.
(continued)
264
APPENDIX A.7. Parent Skills Checklist (page 2 of 3)
Activity
Skill
1 2 3
It Takes Two to Tango: Building Back-and-Forth Joint Activity
Routines to Increase Engagement and Learning Opportunities
Uses toys or objects appropriate for the child’s age, and for the child’s interest.
Chooses objects that support turn taking and varied play.
Uses four-step joint activity routine in both SSRs and object routines.
Takes balanced turns with the child to create a theme.
Length of adult turns is well fitted to the child’s attention.

Recognizes when the child is losing interest or is over- or understimulated or if
play is becoming too repetitive.
Has the child help clean up some or all of the activity. Uses various strategies as
needed to help child transition.
Talking Bodies: Helping the Child Learn to Use Body Language
Creates many skillful gestural communication learning opportunities for the child.
Recognizes subtle body language efforts/attempts for communication.
Elicits and makes consequences for the child’s gestures appropriately.
Waits for the child to communicate.
Persists and helps so the child successfully communicates.
Scaffolds the child to use body to communicate in many situations.
Do What I Do! Helping the Child Learn by Imitating

Imitates and extends the child’s sounds when they occur.
Uses double sets of toys or multiple objects for imitation.
Frequently imitates the child’s actions with objects.
Embeds at least one gesture or body movement to imitate in each SSR.
Adds facial expression and sound effects to SSRs and daily routines.
Follows the one-word-up rule for the child to imitate speech across target
activities.
Pauses and waits for the child to imitate the action before helping the child do so.
Prompts child appropriately to imitate action.

Provides repetitions and expansions on imitation that are appropriate for the
child’s needs.
(continued)
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APPENDIX A.7. Parent Skills Checklist (page 3 of 3)
Activity
Skill
1 2 3
Uses the Basic Learning Principles for Helping the Child Engage,
Communicate, and Learn New Skills
Understands the goals, antecedents, and consequences underlying wanted and
unwanted behaviors in target activities.
Consistently uses As and Cs skillfully to build adaptive skills following both
wanted and unwanted behaviors.
Creates multiple high-quality ABC learning opportunities throughout most target
activities.
The Joint Attention Triangle:
Sharing Interests in Objects and Activities with Others
Provides multiple learning opportunities for joint attention: Help, give, show, point
gestures.
Skillfully uses language, gesture, and ABC teaching to develop or maintain joint
attention gesture skills.
Skillfully teaches pointing skills to attend to, place, choose, and pick up toys, food
items, pictures in books, others.
Skillfully supports the child to coordinate gaze and gesture in joint attention
activities.
Teaches the Child to Play Flexibly and Independently
Skillfully teaches new actions on objects via joint activity themes, expansions, and
imitation skills in all target activities.
Developing Speech/Language: Supporting the Child to Use
and Understand Speech through Active Social Engagement
Imitates and expands child’s vocalizations appropriately.
Carries out back-and-forth vocal routines with the child, using pause-and-wait
strategies effectively to support the child’s turn.
Uses lots of sound effects, single words, song routines, and “baby games” that
combine action and simple words or sounds with the child.
Skillfully elicits and consequates the child’s word productions to support speech/
language development.
Supports the child to use speech/language for multiple pragmatic functions.
Consistently helps the child follow through with instructions.
Uses appropriate language levels in language learning activities.
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APPENDIX A.8
Parent Self-Monitoring Checklist
Parent: Date: Activity:
a. My child showed consistent interest in the activity and in 1 2 3

me throughout the activity. Not often Sometimes Mostly true
Next time I will:
b. My child’s attention was not distracted or if it was, I tried 1 2 3

my best to manage distractions and focus my child on Not often Sometimes Mostly true
me and the activity.
Next time I will:
c. My child and I had frequent eye contact and face-to-face 1 2 3

interaction during the activity. Not often Sometimes Mostly true
Next time I will:
d. My child and I had fun. We both smiled frequently and 1 2 3

enjoyed ourselves. Not often Sometimes Mostly true
Next time I will:
e. I followed my child’s attention in the activity rather than 1 2 3

only trying to direct my child’s attention from one thing Not often Sometimes Mostly true
to another.
Next time I will:
f. In our activity there was lots of turn taking between me 1 2 3

and my child, either in actions or social exchanges. Not often Sometimes Mostly true
Next time I will:
g. My turns involved a mix of commenting, imitating, 1 2 3

showing, and elaborating on my child’s activities. Not often Sometimes Mostly true
Next time I will:
h. In our activity I provided many opportunities for my child 1 2 3

to communicate with eyes, body, sounds. Not often Sometimes Mostly true
Next time I will:
(continued)
267
APPENDIX A.8. Parent Self-Monitoring Checklist (page 2 of 2)
i. I consistently imitated my child’s sounds or expanded 1 2 3

them into words with the same sounds. Not often Sometimes Mostly true
Next time I will:
j. I consistently responded to my child’s looks, smiles, 1 2 3

sounds, and actions by naming things and actions. Not often Sometimes Mostly true
Next time I will:
k. I narrated my child’s activities and added sound effects. 1 2 3

Not often Sometimes Mostly true
Next time I will:
l. Our joint activity had all four parts: set-up, theme, 1 2 3

variation, and closing. Not often Sometimes Mostly true
Next time I will:
m. I followed my child into play by helping, joining in, and 1 2 3

imitating his or her actions. Not often Sometimes Mostly true
Next time I will:
n. When my child’s attention shifted, I followed the shift 1 2 3

with appropriate language and action. Not often Sometimes Mostly true
Next time I will:
o. I showed my child play actions that my child could do 1 2 3

either independently or with just a little help. Not often Sometimes Mostly true
Next time I will:
p. I showed my child a new play action two to three times 1 2 3

and then waited for him or her to imitate, giving help if Not often Sometimes Mostly true
needed to imitate.
Next time I will:
q. If my child got stuck on an action or toy, I found a way 1 2 3

to engage him or her in a new activity. Not often Sometimes Mostly true
Next time I will:
268
APPENDIX A.9
Coach’s Fidelity of Implementation
Brief Checklist
+/– Set-up Notes
Greets parent and child
Parent reports some events of week
Parent identifies focus with child for last week
Parent identifies what is going well and not so

well reflectively
Parent identifies any problems with child or
concerns or other points for discussion
Therapist demonstrates active listening
strategies during this period
Any data are gathered and commented on
Avoids lengthy discussions during this period
There is a smooth flow into warm-up activity
+/– Warm-up and session planning Notes

Parent–child play proceeds without
interruptions
Activity illustrates parent topic from past
week
Parent shares evaluative or reflective
comments about the activity
Therapist comments on parental techniques
in action and parental focus
Goal of and plan for the rest of the session
emerge from the joint discussion
Smooth transition into the first learning–
coaching activity
(continued)
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APPENDIX A.9. Coach’s Fidelity of Implementation Brief Checklist (page 2 of 2)
Activity
+/– Coaching activities 1 2 3
Preparation occurs via review of points, tools, or concepts as
needed for activity
Parent conducts activity with sufficient coaching to achieve goal
Coaching acts help parent not interrupt ongoing interactions

between dyad
Both parent and coach share reflection/evaluation/planning after
activity
Coach manages child to allow parent time to think without
interrupting parent
Coach’s comments are helpful to parent and lead to action
planning
Exchange is comfortable, not stilted, and constructive rather than
judgmental
Goal and plan for next activity emerge
Repeated activities represent different home routines
Activity
+/– Closing 1 2 3
Balanced discussion occurs
Generalization to other activities is discussed
Open topics from opening are discussed
Enough time has been allowed for an organized closing
Goodbyes occur
Plans for next session have been made: place, time
There is a smooth transition out the door
270
APPENDIX A.10
ESDM Coaching Fidelity Rating Tool
A. Greeting and checking in: The coach greets parent(s) and child. The parent(s) should
provide a snapshot of the week and identify their focus with child for the past week, usually
set at the previous session. The therapist gathers any data that parent(s) completed since
previous session. The parent(s) may raise other questions or concerns, which the therapist
acknowledges. This is a brief period that sets a base for quickly moving into action.
1. There is no invitation or opportunity for parent(s) to share their experiences since the
last session. The coach either begins to interact with the child directly or begins the
next topic, or asks the parent(s) to initiate a child interaction immediately.
2. The coach asks the parent(s) to summarize progress and challenges from the past ses-
sion; however, the parental opportunity is not realized due to coaching problems. The
coach may interrupt the parent(s) and take over the lead, or may begin the topic of
the day without review, or child management needs may become the focus without an
opportunity later to return to the topic of sharing and review.
3. The parent(s) may share progress and challenges from the past session. However, the
therapist disregards one or more important elements: (a) reviewing parent(s) home
data, (b) active listening without taking over the lead, (c) acknowledging the parent(s)
efforts, (d) transitioning smoothly into parent(s)–child interaction; (e) finding a way to
organize the parent(s) comments into the session’s activities.
4. The parent(s) may share progress and challenges since the past session. The therapist
shows interests, listens actively, follows up as needed, and acknowledges their efforts over
the week and on the data sheets that are collected. This opening transitions smoothly
into parent–child activity.
B. “Warm-up” parent–child joint activity: This phase allows the coach to observe and eval-
uate parent(s)–child progress based upon what was discussed and practiced in the last ses-
sion. (1) The focus of the interaction emerges from the parent(s) sharing of the week’s activ-
ities and theme; (2) an uninterrupted parent–child activity occurs that allows parent(s) and
child to move into action and allows the coach to gauge progress; (3) after the activity, the
coach invites the parent(s) to reflect on the activity, to evaluate the extent to which the
parent(s) goals were realized; (4) the coach then comments constructively in a way that
reinforces parental use of learned techniques; and (5) there is a smooth transition into the
next phase.
1. There is no warm-up parent(s)–child activity either because the coach does not set it up,
or interrupts the parent(s) and child before an activity fully develops.
2. A warm-up activity begins, but no theme has been developed prior to the activity. In
addition, several other parts are missing. The coach may provide general praise or criti-
cism. Or, there is no feedback from coach to the parent(s). Or, the coach begins a long
period of coaching, forgetting that this is a “warm-up.” The coach does not transition
quickly into the theme for the day.
(continued)
271
APPENDIX A.10. ESDM Coaching Fidelity Rating Tool (page 2 of 8)
3. There is a warm-up activity and it has a theme. The coach may make an interrupting
comment or two during the interaction but the parent(s) will complete the activity
without being derailed. The coach provides feedback, but does not elicit parental feed-
back soon enough in the conversation and/or puts the parent(s) “on the spot” when
asking for feedback. The activity moves into the next phase fairly smoothly.
4. The warm-up activity occurs in response to the previous session’s theme. All five parts
are present. The coach allows the activity to occur without interruption, or with only
the most minor comments that do not interrupt the play. The coach invites the parent(s)
to provide some evaluation of the activity; the coach provides constructive comments
concerning parent(s) behavior and child response afterward and there is a smooth tran-
sition to the next activity.
C. Introduction of the topic of the day: This phase sets the main topic for the session and
mentions the sequence of events that will happen in the session (if this has not occurred
earlier). The coach (1) defines the topic from the manual: its goal, main parenting strate-
gies, and effects on child behavior adjusted well for time; (2) ties the topic to parent(s)
goals for the child; (3) ties the new topic into previous observations or discussions with
the parent(s); (4) applies multimodal strategies (print materials, verbal explanation, visual
demonstration) that best fit the parent(s) learning needs; (5) solicits parent(s) input to
assess understanding; and (6) demonstrates sensitivity to parent(s) cultural and child-
rearing beliefs.
1. There is no theme identified for the session. Interactions occur with the child and
parent(s) without a previously stated plan.
2. The coach begins to identify the topic, but does not complete the main points of the
topic. No other critical parts are addressed. No plan emerges for how this information
will actually unfold during the session. Parent goals are not discussed or if so, do not
relate to the topic and/or child goals. There is no discussion or not enough time set aside
to check in with the parent(s) at the end of the session. This score can also be used
when the topic is introduced but the main points are “lost” in a sea of talk.
3. The topic is presented. However, one or two of the critical parts are missing: (a) ties the
topic to parent(s) goals for the child; (b) ties the new topic into previous observations
or discussions with the parent(s); (c) lays out the sequence of events that will happen
in the session (if this has not occurred earlier); (d) uses appropriate multimodal strate-
gies for this family including language level and open-ended questions; (e) sensitivity
to parental values and practices; or (f) time is not used well when explaining topic (too
much or too little information).
4. The topic is clearly identified and a plan for the session is laid out. These are tied
into parent goals for the child, and into previous observations or discussions with the
parent(s). Parent buy-in is sought and gained. The presentation uses multimodal features
and adequate talking time well fitted to this family’s learning style and needs. Assess
understanding with open-ended questions. Parent values and priorities are addressed.
D–E. Coaching on the week’s topic: (Note: You will code this twice—once for each activity.)
This phase focuses on the coach’s skills to support parent attention and success at using the
topic skill. Coaching does not interfere with ongoing activity, improves parent(s) practice as
272
activity continues or from one activity to the next, and occurs across at least two activities
during the session. By the end of the coaching, the parent(s) can state the main strategies
and child goals to practice before the next session. Coaching strategies involve (1) tying
the key teaching strategies to parent actions and child behavior and goals; (2) provision of
enough support for the parent(s) to successfully carry out the new skill and achieve the child
target; (3) invitation for parent(s) to reflect on experience and evaluate key interactions using
open-ended questions and active listening; (4) another practice interaction using a different
activity, with enough support for success; and (5) coaching practices (e.g., active listening,
providing feedback, direct modeling) fit parent learning styles, understanding level, values.
1. Parent coaching does not occur. Coach is in an authority position, doing the skill, dem-
onstrating it without role shift, or “telling” parent(s) how to do it rather than supporting
parent(s) to do it.
2. Coaching occurs but is unsuccessful at supporting parent(s) to use the target skill inde-
pendently by the end of the activity. Coach has not successfully used coaching tech-
niques (e.g., prompt fading, shaping, differential reinforcement, multimodal approaches,
or other teaching strategies) that would support parent learning style and skill acquisi-
tion. Or, parent(s) may be too anxious or distressed to continue due to too much criti-
cism, evaluation, or directions.
3. Coaching occurs and provides enough support for parent(s) to partially perform target
skill in the activity. However, parent(s) may not be independently using the skill and
coaching lacks one or more elements: (a) Attention to the parent learning preference,
understanding level, or child targets are missed; (b) the coach is too directive, provides
feedback without eliciting parent reflection and evaluation; or may be too quiet, miss-
ing moments to encourage more practice; (c) generalization to another activity does not
occur; or (d) information does not relate back to parent actions and/or child behavior
and goals.
4. Coaching occurs and is successful at supporting parent use of target skill and elicita-
tion of child skill. Coach adjusts techniques according to parent learning styles, under-
standing level, child goals, and increasing success. Strategies tie parent actions to child
behavior and goals with practice across at least two activities. Parent(s) showed use of
reflection and evaluation to build skills. Parent(s) can tie practice to child goals across
different activities or settings at home.
F. Closing: In the last 10 minutes or so of the session, the coach and parent(s) carry out a bal-
anced discussion in which the coach: (1) makes time for any topics the parent(s) brought up
for discussion earlier and addresses them; (2) elicits parent understanding of the topic, the
parent and child skills involved; (3) supports parent(s) to consider use of the techniques in
multiple activities and contexts of daily life; (4) invites parent reflection and evaluation of
the utility of the session activities; (5) reviews the next meeting time; and (5) says goodbye
to both parent(s) and child in a smooth transition out of the door. Parent(s) and child leave
on a positive note.
1. There is no organized closing. Time runs out and the family leaves without a clear
review, or there is no clear ending and conversation is still occurring all the way out the
door and into the hall. There is no clear goodbye.
273
2. There is a closing but it is missing most of the above elements. Open topics are not
addressed, generalization is not addressed, the discussion is not balanced, and reflection,
evaluation, and planning for next session or goodbyes are missing.
3. A closing occurs, a plan is made for next time, and goodbyes are said. Parent(s) and
coach have a balanced discussion. However, open topics are not addressed, and/or the
session topic is not reviewed and generalized.
4. The closing addresses topics still open, generalization across daily activities, and ends
the session smoothly. Conversation has been balanced, reflection and evaluation have
occurred, details of next session addressed, clear goodbyes to all, and smooth transition
out the door.
Coaching characteristics: Across the whole session, to what extent was the coach . . .
G. Collaborative: The coach works with the parent(s) as a partner to reach common goals
rather than deciding on the goal for the parent(s) to achieve or leaving all responsibility to
the parent(s). It’s about the balance in the relationship.
1. The coach is not a collaborative partner in the process. The coach may be in an author-
ity position, not acknowledging parent knowledge and abilities, not seeking parent input,
reflection, evaluation, telling the parent(s) what to do. Or, the coach is in an onlooker
role, giving all control to the parent(s) rather than sharing responsibility, knowledge,
understanding, and skills with the parent(s).
2. The coach attempts to collaborate with the parent(s) to identify common goals and top-
ics but misses openings and opportunities to draw out parent knowledge and expertise,
taking more of an authority role than a collaborative one. Or, the coach listens and sup-
ports without expanding upon a topic, comment, or question, thereby not sharing their
own knowledge with the parent(s).
3. The coach joins the parent(s) in common goals and acknowledges parent knowledge
and abilities. However, there is not an easy flow of shared observations, reflections,
evaluation, and ideas across the session. The collaborative roles do not seem well worked
out yet, or moments of conflict or withdrawal occur.
4. The coach collaborates with the parent(s) to establish and reach common goals. Each
shares expertise with the other, and conveys recognition and respect for the other’s
knowledge and abilities. The coach asks questions, listens, and summarizes parent
responses to identify goals, topics, and concerns. Parent(s) may also ask questions, lis-
ten, and reflect. The collaboration seems well worked out and comfortable for all.
H. Reflective: Throughout the session the coach reflects on (1) what she has observed, (2) the
relationship between the learning goals and observed actions, (3) effects of parent behavior
on child behavior, and (4) emotional expressions that are occurring. These reflections pro-
ceed and lead to evaluations, ideas, and suggestions so that the coach’s line of thinking is
transparent to the parent(s). The coach invites parallel reflections from the parent(s), and
supports the parent(s) to use reflection to lead to evaluation and action plan. These reflec-
tions focus on child goals, emotions, motivations, and communications, and the relations
among context, parent behavior, and child behavior.
1. The coach does not assume a reflective stance during the session. Instead, the coach
274
may invoke specific rules to evaluate and lead to action. Or, the coach may consistently
ask parent(s) for reflection or feedback rather than offering it herself.
2. The coach provides one or two reflective comments during the session, but these do not
lead transparently to ideas for actions so parent(s) cannot benefit from the line of thought
involved. The coach invites parental reflection occasionally but then offers the action
plan rather than assisting parent(s) to form one through the reflection/evaluation process.
3. The coach reflects on several of the areas and draws out some parental reflection as well.
Some of the coach’s reflections lead to action plans, but this is not consistent, or trans-
parent, to the parent(s). The coach attempts to support parent(s) to move from reflec-
tion to evaluation and action, but these are only partly successful. If topics of reflection
do not end up with action plans, code here.
4. The coach reflects on most of the five areas, provides transparent lines of thought from
reflection to action, and supports parent reflections and evaluative processes. There are
enough relevant examples elicited from the session and from opportunities at home to
enhance parent knowledge and practice on the targeted topics before the next session.
Reflection/evaluation leads to action plans.
I. Nonjudgmental: The coach uses descriptive rather than evaluative or judgmental language
to point out relations between parent actions and child behavior.
1. The coach’s feedback across the session is generally judgmental and evaluative and does
not address parent action and child response. The coach may praise the parent(s) in
language that is vague or not tied to either specific parent actions or child behaviors
(“that was great,” “good job,” “how fun,” “your child did so well”). Or, the coach’s tone
and word choice appear harsh or critical of the parent(s) and/or child.
2. The coach’s feedback across the session uses evaluative, judgmental language that
addresses either parent actions or child behavior but not the links between them (“I like
how you did X,” “That was great how your child responded with X,” “You didn’t follow
through”).
3. The coach’s feedback across the session mixes descriptive and evaluative language and
frequently addresses links between parent actions and child behavior.
4. The coach’s feedback across the session is predominantly descriptive rather than evalu-
ative and it consistently highlights relations between parent actions and child behavior
(“I noticed that when you did X, your child typically responded with Y,” “It seemed like
whenever X happened, Y followed”); with enough examples to support parent under-
standing and practice before the next session.
J. Conversational and reciprocal: The interactions between the coach and therapist are
balanced. The tone is conversational rather than didactic. The therapist listens well and
responds to parent topics. The tone is friendly, warm, encouraging, and optimistic and
maximizes child and parent enjoyment and success.
1. The coach dominates the interaction, leaving little time for parent input by talking at
rather than with the parent(s). Or, the parent(s) may dominate the interaction and the
coach does not exert appropriate strategies to become an active partner, with parental
comments and questions left unanswered.
275
2. The coach makes some efforts to establish reciprocal exchanges, but is not generally suc-
cessful and the balance is more often off than on between the partners. However, the
coach’s efforts are clear, in use of questions to the parent(s), moments of active listening,
and offering reflections.
3. The tone of the interaction is more often reciprocal than not, but the balance and
reciprocity are not consistent. There are clear occurrences when it lapses and one or
the other partner takes control without the coach re-righting the balance. This could
involve times in which the coach failed to follow up on a comment or question in
which the parent(s) sought a response, or times in which the coach passes the lead to
the parent(s), and then takes it back in the silence before the parent response. Or, the
coach shifted back to a didactic, authoritative tone when explaining new information
to the parent(s) without shifting to the parent(s) to restate, reflect, question, or com-
ment. Multiple interruptions and lack of topic maintenance are other examples of coach
gaffes.
4. The coach interacts with the parent(s) as partner(s), sensitive to the timing of conversa-
tion, staying on topic, and sharing control. The coach does not interrupt the parent(s)
unless it is with permission and in the service of the communicative exchange (e.g.,
re-righting digression, asking for clarification, answering a question that was asked but
lost, restatement to check understanding). Turns are balanced, and partners command
a fairly equal amount of “floor time.”
K. Ethical conduct: The coach demonstrates appropriate professional behavior and does not
talk about other patients or own children, criticizing other therapists or approaches, too
much self-disclosure, discouraging comments, jokes, crossing of professional boundaries,
making a request for therapist benefit, coercing child or family.
1. The therapist violates ethical boundaries as described above.
2. There is no violation of ethics. However, the boundaries are not clear, as demonstrated
by sharing of personal details, making a request for therapist benefit, using something in
the home without permission, making inappropriately friendly comments to parent(s)
or child, and so forth.
3. There is no violation of ethics and no crossing of boundaries. However, the therapist
demonstrates an instance of over-familiarity or other behavior that in retrospect gives
one pause (initiating affectionate behavior like kissing the child, hugging the parent[s],
commenting on the house décor, etc.).
4. The coach maintains appropriate professional behavior and ethical conduct throughout
the session. Any self-disclosure serves the purpose of supporting parent learning or par-
ent experience.
L. Organization and management of session: Data, materials and furniture, readiness, child
is occupied, physical space is well organized, session follows protocol, space and structure fit
family and child well, transitions smooth.
1. The session appears quite disorganized, both temporally and physically. There does not
seem to be a temporal plan in place. The family and child do not seem to know what to
expect. Needed materials are not available, or the materials are not organized in ways
that facilitate the child and family.
276
2. One aspect of the session appears disorganized, either the timing or the physical set-up.
Or, child is not adequately occupied and so consistently derails topics.
3. There is a temporal structure in place, and there is a physical organization in place at
the start of the session. However, the organization of one of these falters at some point
during the session in ways that adversely affect the work going on for the child, family,
or therapist.
4. The session is well organized, both temporally and physically. The session’s activities
flow according to the plan, or, if plan is derailed by child need, a new organization is
developed and essential parts are not lost. The session ends on time, the room is well set
up for the child and family, and materials and activities are managed so that the child
and family are well organized by the therapist’s management of the setting and session.
M. Managing parental implementation difficulties: Parent implementation difficulties often

reveal themselves in (1) lack of follow-through in interventions requested by the parent(s)
(e.g., homework, sleep, eating); (2) habitual lateness, cancellation, or no show; (3) a great
deal of discussion and explanations that interfere with time spent working with child; (4)
many excuses for child behavior (e.g., being tired, ill); and (5) philosophies of parenting
that are fundamentally contrary to the intervention (not wanting to reward child for appro-
priate behavior).
1. There is a clear conflict or negative exchange that arises related to an issue during the
session. It is not successfully addressed or managed and the issue pervades the rest of the
session, impairing the working alliance needed for the session to achieve its goals.
2. There is a clear conflict or negative tone that arises during the session. There is some
effort by the therapist to address the difficulty, and there is some effort at repair, but
some negative or uncomfortable effects continue afterward in the session.
3. There is a clear conflict or negative tone that arises during the session. The therapist
works to address it and there is a repair of the breach and the shared work starts up
again and allows for the session to achieve its goals. However, the underlying issue is not
explored and addressed as such so that a full resolution is accomplished.
4. There is no conflict in the session. Or, in an exchange in which there is a conflict
between therapist and parent(s), in the following interactions the therapist demon-
strates awareness of underlying issues, invites parent(s) to share viewpoint and listens
and acknowledges their views, finds a point of convergence that results in a resolution of
the conflict and a new solution that all can embrace, and this process strengthens the
parent–coach alliance and refocuses all on child intervention needs.
277
Early Start Denver Model Coaching Fidelity Coding Sheet

Therapist: Rater and date:
Child and episode:
Item Code Comments
a. Greeting and check-in
b. Warm-up activity
c. Introduction of the topic
d. Coaching on the topic:

Activity 1
e. Coaching: Activity 2
f. Closing
g. Collaborative
h. Reflective
i. Nonjudgmental
j. Conversational and
reciprocal
k. Ethical conduct
l. Organization and
management
m. Managing conflict and

implementation difficulties
Comment columns
for note taking
278
APPENDIX A.11
Stages of Change and Possible
Coaching Techniques
Therapist
documentation
Phase Activity column
Pre- Stage 1. Moving toward change: Listening and
contemplation reflecting, motivational interviewing, cognitive, and
experiential techniques primary
Key question #4 I don’t really need to be doing this; my child will be fine.
Behavioral 1. Parent has not initiated contact but has been referred
characteristics by someone else.
2. Parent does not acknowledge child’s diagnosis or
difficulties and/or rejects the proposed treatment
approach.
3. Parent is reluctant to discuss child issues with others.
4. Most often seen in the non-referring parent, key family
members, or parent who referred based on urgings of
others.
Therapeutic goal Parent moves toward acknowledgment of child difficulties
or needs and openness for treatment to occur.
Session Delay enrollment. Provide information about study and
activities answer parent questions. Provide project materials.
Describe what would be involved. Perhaps show a
parent–child video, session example, or pre–post video
of parent–child interactions. A target activity handout to
provide a sense of how this would go.
Some helpful 1. What motivated you to come in today?
questions 2. What are you looking for, for your child?
3. What can I do to help?
4. How are you feeling about being here?
5. Try to categorize the parent’s state:
a. Reluctant—expresses reservations (e.g., “Am
I going to be able to learn this model?” “The
intervention seems too difficult to use every day.”
“I don’t have the time to do this.”)
b. Rebellious—challenges, questions, or expresses
hostility (e.g., “I don’t think your information
is accurate.” “Does intervention really make
a difference to my child’s outcome.” “I don’t
appreciate being here.”)
(continued)
From Table of Motivational Stages of Change and Related Therapist Activities by Sally J. Rogers and Laurie A. Vismara.
Copyright © 2012 Sally J. Rogers and Laurie A. Vismara. Reprinted in Coaching Parents of Young Children with Autism:
Promoting Connection, Communication, and Learning (Guilford Press, 2021). Permission to photocopy this material is
granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can
download enlarged versions of this material (see the box at the end of the table of contents).
279
APPENDIX A.11. Stages of Change and Possible Coaching Techniques (page 2 of 8)
Therapist
documentation
Some helpful c. Resigned—statements about self or others that are
questions pessimistic, defeatist, hopeless, or negative in tone
(continued) (e.g., “I’m not good at playing with my child.” “My
child doesn’t like being around me.” “There are no
activities my child enjoys doing with others.”)
d. Rationalizing—explaining away the problems.
e. Ambivalence—giving mixed messages, both
verbal and nonverbal, about desire for change and
desire to pursue treatment, not paying attention or
responding to therapist, changing the direction of
the conversation that the therapist is pursuing
Key therapeutic 1. Human relationship (HR)
techniques 2. Providing requested information
3. Active, reflective listening: open-ended questions,
reflective statements, restatement
4. Developing discrepancy, rolling with resistance,
increasing change talk
Contemplation Stage 1. Moving toward change: Listening and

reflecting, motivational interviewing, cognitive, and
experiential techniques primary
Key question #5 I’m not sure if this will help my child but I am open to
learning more.
Behavioral 1. Parent acknowledges that child has difficulties.
characteristics 2. Is considering doing something about child difficulties
but is not yet ready or sure about what route to take.
3. Ambivalence is high. Pros and cons are equal.
Therapeutic goal Parent develops the motivation to begin to prepare for
action. There is movement toward a commitment to act,
demonstrated either by enrolling in project or by deciding
to get services elsewhere. The therapist has helped “tip
the balance toward change” (DiClemente & Velasquez,
2002, p. 208).
Session Family meeting is scheduled to (1) review information
activities about proposed treatment approach, study consent,
home procedures; (2) answer parent questions; (3)
establish the family’s social support network; and (4)
address barriers for implementation. Child evaluation also
happens in this stage.
280
Therapist
documentation
Some helpful 1. What kind of information do you need to begin?
questions 2. What are your areas of concern about starting
intervention?
3. What have you learned about the effects of early
intervention on young children with ASD? (If no
response:) What information would you like on the
effects of early intervention on young children with
ASD?
4. How do you think your life would be different if you
and your child were doing this intervention?
5. What would you like to see your child learn after a
year of intervention?
6. Would it be helpful to know how some other parents
and children have responded to this intervention?
7. What do you see as the pros and cons of getting
started in this intervention? (Make a table.) How
might things change for you/your family/your child?
8. Have you ever tried to change one of your own
patterns or behaviors before? How did it go?
Key therapeutic 1. HR
techniques 2. Joint planning process to identify parent goals for self
and child
Preparation Stage 2. Ready for change: Behavior change processes

are quite important
Key question #1 I am not really doing much at home yet but I want to and
I’m working up to it.
Behavioral Has enrolled in project. Is ready for and committed to
characteristics taking action in the near future.
Therapeutic goal Help parent to formulate goals for child and develop goals
and a plan of action for self. Child plan is developed in
this phase.
Session Home visit: Meet at parent home to prepare for
activities sessions—set up learning spaces, select toy/learning
materials, introduce website, review their availability and
schedule sessions.
281
Therapist
documentation
Session Clinic visit: Observe parent implementation of materials
activities from prior week; work together on parent and child
(continued) learning goals.
Some helpful 1. On a scale of 1–5, how motivated are you to get
questions started?
2. What would need to happen in order to move from X
to Y (lower to higher rating, if score is 3 or lower)?
3. What do you hope your child can learn in the next 3
months?
4. Which of these six parent–child activities do you
think might be good learning formats for your child?
Which not? Which do you enjoy the most?
5. What are your favorite ways to help yourself
remember things and keep track of information?
6. How do you like to approach each day? As a blank
slate or a to-do list?
7. How do you like to learn about something new?
8. Have you worked with any teachers or coaches in
the last few years that were really great? What made
them great?
9. Have you worked with any teachers or coaches in
the last few years that were pretty bad? What made
it bad?
10. What other resources may you or your family need
to feel prepared to help your child?
Key therapeutic 1. HR
techniques 2. Active, reflective listening: open-ended questions,
3. Home checklists
4. Environmental evaluations for parent to become aware
of people and things at home
5. Visual aids, multimodal treatment materials
6. Visit schedule may drop to once per week if parent
prefers
282
Therapist
documentation
Action Stage 2. Ready for change: Coaching for behavior
change processes is quite important
Key question #2 I’m working on things daily: I feel “full steam ahead”
about this.
Behavioral Active parental behavior change is occurring seen in
characteristics parent use of techniques and materials. Parent is actively
involved in changing their parenting patterns. Parent is
using materials and plan.
Therapeutic goal Help parental behavioral change plans be successful and
reflected in data on parent behavior and child behavior
change and learning. Teach parent each P-ESDM skill to
mastery as quickly as possible. Order can be flexible—
based on parent desires and skills, child needs, and
parent fidelity data. Goal: parent at fidelity on P-ESDM
skills and providing self-monitoring data and child home
data weekly. This is a difficult period for parent.
Session Two visits per week, one at home; following basic session
activities schedule. Monitor parent learning via fidelity scores and
parent home videos, parent self-monitoring data and
child change.
Some helpful 1. How did things go this week?
questions 2. What parts of the plan were you most focused on?
3. What was most helpful this week? How did it help?
4. What problems came up that you didn’t expect? How
did you deal with them?
5. May I see your data sheets?
6. What do you most want to focus on today?
Main therapeutic 1. HR
techniques 2. Differential reinforcement of other behaviors
3. Self-monitoring
4. Problem-solving strategies
5. Reinforcers (emotional and tangible)
6. Attention to discriminative stimulus (antecedents)
7. Begin new skill as soon as parent has mastered last
skill. If parent is already at fidelity on a skill, review it
and move on.
283
Therapist
documentation
Maintenance Stage 2. Ready for change: Coaching for behavior
change processes quite important
Key question #6 I work on things daily and it feels like a more natural
part of my parenting routines now.
Behavioral Parent is using tools routinely and provides weekly
characteristics self-monitoring data and child home data. Verbalizes
ESDM principles spontaneously and uses them to solve
problems independently. Demonstrates comfort with
many techniques. Is maintaining fidelity.
Therapeutic goal Help parent sustain changes, maintain motivation, and
resist relapse. Help parent find reinforcers in new ways of
behaving and in child growth.
Some helpful 1. What motivates you now? Where are your rewards?
questions 2. What problems came up this week? How did you
address them?
3. How did things go this week?
4. What parts of the plan were you most focused on?
5. What are you finding most helpful? Least helpful at
this stage?
6. What problems came up that you didn’t expect? How
did you deal with them?
7. May I see your data sheets?
8. How do you want to use our time today?
Therapeutic 1. HR
techniques 2. Self-monitoring
3. Problem-solving strategies
4. Reinforcement (emotional and tangible)
5. Attention to discriminative stimulus
6. Support self-efficacy
Lapse and Stage 1. Moving toward change: Motivational

repair interviewing, cognitive, and experiential techniques
primary
Key question #3 I’m kind of in a slump; I feel like my motivation to work
on things at home is slipping. OR I’m kind of in a slump
but I’m able to keep working on things at home/I’m
working on things at home but I feel in a slump.
284
Therapist
documentation
Behavioral Parent demonstrates a lapse in adherence to behavior
characteristics plan. Describes loss of motivation or lacking resources to
address personal needs (stress, depression, loneliness).
Expresses doubts about own ability or child ability to
grow. Lack of daily data or drop in frequency of practice
or cancels sessions. May explain via child illness,
tiredness, visitors, etc. without use of problem-solving
efforts. Fidelity score may have dropped below criterion
or other activities have lessened (reporting progress,
using website, emailing updates, trying new experiences
with child).
Therapeutic goal Assess current stage in addition to lapse. Recycle
through stages. Shift to motivational interviewing
strategies for increasing motivating for behavior
change. Try to move to commitment for action and into
preparation stage for how to resume. Try to end with
parent having worked out some action plan for current
week and a method for you to help monitor this. Goal is
for the following session to be in action stage.
Session Resume twice weekly visits, focus on discussion with
activities parent to determine current stage and to work on
increasing motivation for change and change talk. Unlike
the action and maintenance phases, there may be more
talk than action during this stage.
Some helpful 1. Listen and reflect back on the parents’ feelings.
questions 2. What do you think is going on? With yourself? With
your child?
3. What do you want to do?
4. What is the best way for us to use our time today?
5. What needs to change or be in place?
Therapeutic 1. Return to twice weekly visits if these have dropped
techniques off.
2. Develop a monitoring plan with parent for contacts
during the coming week.
3. HR
285
Human relationship
fidelity—all stages Score of 1 Score of 2 Score of 3
Reflective listening 1. Therapist presents 2. Therapist presents 3. Listens attentively
roadblocks involving roadblocks involving without interrupting
directing, interrupting, agreeing, praising, and restates with
warning, disagreeing. reassuring, changing simple or complex
the subject without restatements to
permission, giving test understanding.
unasked for advice, Questions are fewer
too many questions, than statements.
close-ended questions,
or trying to persuade.
Affirmations 1. Does not make any 2. Makes compliments 3. Observes client
positive statements rather than observing strengths at least once
about client. strengths. during the session.
Summaries 1. Does not 2. Occasionally 3. Provides helpful
summarize at the summarizes but lacks brief summaries at
end of discussions appropriate frequency, key points in session
to organize what has brevity, or helpfulness to collect, link, or
gone on, to mark in the summaries. transition.
and organize topics,
mark transitions, or
link different topics
together.
Empathic 1. Therapist denies 2. Therapist does not 3. Therapist draws
acceptance of client feelings or mark client feelings out feelings and
client’s feelings and perspective or and perspective, either perspectives if not
perspective suggests that they are by not drawing out or offered, and restates
other than what they by not restating when with appropriate affect
are. they are spoken. when they are offered.
Respect for client’s 1. Therapist tells 2. Therapist listens 3. Therapist elicits
autonomy, self- client what to do and to client but does not and respects client
efficacy, and how to do it. mark client discussion choices and goals,
decision-making of wishes, goals, or including no change
ability choices. (Rosengren, 2009).
Collaborative 1. The two seem to 2. The two are talking 3. The two are
relationship be working against but not much is working as partners
each other (wrestling), happening (standing). (dancing; Rosengren,
or one is passive and Therapist may be 2009). Interactions
the other active (out underactive. are balanced.
of sync). Therapist Therapist resists
is more active than righting reflex.
client.
Evocation 1. Draws solutions 2. Therapist listens 3. Therapist draws
and ideas and to whatever parent out client’s views on
motivation from client. shares but does not change (Rosengren,
Therapist directs and bring it to change talk. 2009).
argues for change.
286
Appendix B
P-ESDM Infant–Toddler
Curriculum Checklist
Sally J. Rogers, Geraldine Dawson, Laurie Vismara,
Meagan Talbott, Cynthia Zierhut, Jamie Winter, Carolyn McCormick,
Marie Rocha, and Emily Holly1
Child name or ID: Curriculum date:

Child birthday and age: Assessor:
Parent(s) interviewed:
Others interviewed:
Instructions: Use the checklist to define the child’s most mature skills, those skills that
are currently emerging, and those skills that are currently not in the child’s repertoire, in
each domain. Consult the Infant–Toddler Curriculum Item Descriptions for more detailed
descriptions of each item and administration practices. Bolded items are scored from the
Parent Report. No more than 10% of nonbolded items should be scored solely from Parent
Report.
(continued)
1The Infant–Toddler Version of the Curriculum Checklist used in the PATH and C-ESDM projects was adapted for
the TEDI project. Items added in this revision are noted with an asterisk. The work on this instrument was partially
supported by Grant No. 8089 from Autism Speaks and Grant No. NIH R21HD1003372 from the National Institutes
of Health.
287
APPENDIX B. P-ESDM Infant–Toddler Curriculum Checklist (page 2 of 13)
Use the following codes for behavior in each of these columns:

Observed, Parent Report, and Other/Teacher Report:
+ or P (pass) for consistent performance at appropriate times
+/– or P/F (pass/fail) for inconsistent performance
F (fail) when the behavior is difficult to elicit
For the CODE column, use the following:

A (acquired)—child clearly demonstrates skill and parent reports skill is used
consistently.
P (partial or prompted)—child is only able to demonstrate skill inconsistently or with
additional prompting and parent/other reports the same, or child demonstrates some,
but not all, of the steps of the skill.
N—child is unable or unwilling to demonstrate the skill and parent/other reports
difficulty.
X—no opportunity, or not appropriate for this child.
To rate each child, either start at the beginning of each section or establish the basal for each
section. The basal is established when the child receives ratings of “A” in the CODE column
for four items in a row for each section. Continue to rate each item sequentially in each
section until the child reaches the ceiling of four “N” ratings in a row for that section, or you
reach the last item in the section. It is important that the examiner feel confident about the
basal and ceiling levels, so the examiner may choose to complete more items to establish the
basal and ceiling levels for each section. Curriculum checklist items may also be scored from
the parent’s interactions with the child, both during the curriculum administration and the PCI
measure. For infants, parents should be heavily involved.
The Infant–Toddler Curriculum Checklist can be used to target teaching areas for each
domain. The target area for teaching in each domain is the point where item ratings move
from “A” to “N.”
288
Receptive Communication: Understanding Early Gestures

1 When adult puts arms out to gesture Self-explanatory
“pick up” child leans in and/or puts
arms up.
2 Comes in response to “hands out” Crawls, walks, or otherwise moves within arm’s reach of
gesture for come here. adult; may be accompanied by the adult saying, “come
here.”
3 Responds with anticipation to 3+ Examples include: smiling or beginning to laugh as parent

different gestures associated with holds up hands to tickle, kicking feet as parent starts
familiar sensory social routines. “bicycle, bicycle” game with child.
4 Puts indicated object in adult’s Responds to adult gesture by placing or attempting to place
outstretched hand with or without the object in hand. Adult may use other hand to point to
verbal instruction (e.g., “give me”). open palm.
5 Places objects where you point with Responds to adult point to open container during clean-up
or without verbal instruction (e.g., “put routine by dropping/placing item in container, or places
in”). object in other desired location as indicated by adult’s point.
6 Follows 5+ different instructions (e.g., Responds to adult’s gestural cue by performing action.
“give me,” “sit down,” “look,” and
“come here”) with gestures.
Receptive Communication: Understanding Speech

1* Responds to loud sounds. Orients to loud sounds.
2 Looks to playful sounds. Demonstrates awareness of sound by turning eyes and head
and looking at person.
3 Looks to partner when name is called Turns eyes and head toward partner’s body when child is
when unoccupied. not engaged in another activity.
4 Looks to or reaches to 2–3 familiar Self-explanatory

items when named (e.g., “blankie,”
“ball”).
5 Looks to partner when name is called Turns eyes and head toward partner’s body when child is
when occupied. focused on something else or engaged in another activity
(i.e., playing with a toy).
6 Stops actions momentarily in response Stops an ongoing activity when told “No, stop”, or
to inhibitory words “stop/no.” demonstrates awareness by pausing temporarily, turning
eyes and head toward adult, or showing distress (e.g.,
crying).
7 Follows 5+ different verbal instructions Completes instruction by performing action without adult
(e.g., “give me,” “sit down,” and “come gestures or physical guidance. Adult may repeat instructions
here”) without gestures. a second time without gesture cue.
8 Looks to/goes to 1–2 very familiar Turns eyes and head toward named person who is in
people when named. the same room or moves within arm’s reach when asked
“Where’s Mommy?” or “Go to Daddy?,” etc.
9 Responds to verbal instruction to give/ Self-explanatory

point/show for 8–10 specific objects in
natural play, dressing, eating routines
(e.g., baby, chair, car, block, bear).
289
Receptive Communication: Understanding Speech (continued)

10 Identifies 3 named pictures in book Responds to “Where is . . . ?” or “Show me . . . ?” by
by visually attending or touching when looking at, touching, or pointing to the picture.
asked, “Where’s the ” or told,
“Show me .”
11 Looks to/touches/points to photos of If the named person/pet is present, child clearly looks
3–4 important people when named. at the person or pet when named (may also point). If
pictures, child looks at, touches, or points to picture when
named.
12 Demonstrates understanding of 4–5 Child responds to verbal instructions involving verbs (e.g.,
action verbs by making those actions shakes maraca, bangs sticks, hugs baby, pokes Play-Doh,
with and without objects (e.g., shake, stands up, claps hands). Child has to follow both types—
throw, go, dance, jump, clap). body actions and actions on objects.
13 Attends and joins with interest for Stays with adult, pays full attention, and participates in a
5–10 minutes as adult reads familiar story the adult is reading. Examples include: alternating
book with simple sentences. eye contact between book pages and adult, pointing to
pictures in book, turning book pages, vocalizing the names
of pictures in book.
14 Follows novel one-step commands Completes instruction by looking at adult and performing
involving familiar objects/actions. action without adult gestures or physical guidance. Adult
may repeat instructions a second time without gesture cue.
15 Identifies 5+ different actions in Vocalizes and/or gestures (e.g., points) in response to

pictures and books. adult’s questions. Examples are “Where’s baby sleeping?”
or “Do you see the dog running?” Response need not be
accompanied by eye contact.
16 Follows 2+ different, 2–3 part routine Child sequences 2–3 actions together on an object in
instructions given in familiar situational response to verbal instruction.
routines (e.g., “Get your shoes and
bring them to me”).
17 Understands 3+ different prepositions Demonstrates understanding of prepositions by following

describing spatial relationships verbal instructions using objects.
involving objects (e.g., in, on, under).
Expressive Communication: Communicative Gestures

1 Requests objects and social games Reaches toward desired object in adult’s hands to indicate
by reaching or body movements (e.g., request or uses motor prompt to initiate to or continue
holds leg out for pat-a-feet). social games. Gesture need not be accompanied by eye
contact or vocalizations/words. Does not include reaching
just to grab.
2 Returns affection gestures (e.g., hug, Child spontaneously and consistently hugs back familiar
kiss, high five) to familiar others? adults with arms and body; kisses back with pucker on
cheek or lips.
3 Responds correctly to a choice of 2 by Adult holds up and names two objects, one in each hand
reaching to preferred item. but out of reach of child. Child reaches toward desired
object. Does not need to be accompanied by eye contact or
vocalizations/words. Does not include reaching just to grab.
4 Indicates “no” by pushing away or Other conventional gestures (e.g., shaking head, sign “all
giving back. done”) or words (“no”) are acceptable. Gestures need not
be accompanied by eye contact or vocalizations/words.
290
Expressive Communication: Communicative Gestures (continued)

5 Gives an object to ask for help. Indicates help by placing object in adult’s hand, offering
object to adult, verbalizing, or looking to adult. Gesture need
not be accompanied by eye contact or vocalizations/words.
6 Combines eye contact with gesture Spontaneously turns head and eyes to adult and makes eye
(e.g., reaching, grabbing, signing “all contact for 1–2 seconds to request object.
done”) for request, help, or protest.
7 Returns waves for greetings and Child responds to greetings with both words and gestures,
departures (i.e., hi and bye). without prompting.
8 Uses proximal point to request. Points to object within 6–12 inches with first or index
finger (not open hand) to indicate request. Object may be in
adult’s hand or in reach of the child.
9 Uses distal point to request. Uses first or index finger (not open hand) to point toward
desired object, 3 feet or more away from child.
10 Spontaneously shakes head “no” to Self-explanatory
decline.
11 Spontaneously nods head “yes” to Self-explanatory
assent.
12 Use target signs or gestures with Child combines specific gestures and vocalizations or word
vocalization to express (request, all approximations to communicate all four of these functions.
done, share, help, and protest).
Expressive Communication: Vocal/Verbal Communication
1* Produces vowel sounds. Excludes crying or vegetative sounds.
2* Makes sounds to show joy and Different sounds for each emotion.
displeasure.
3* Makes vocalizations with varying Vocalizations vary in pitch, not flat.
intonation.
4* Vocalizes back-and-forth with adult for Vocalizes (vowel only) with eye contact for at least 2
at least 2 rounds (vowel). rounds. Vocalization can be initiated by either partner.
5 Produces 2–3 different consonants. Vocalizations occur with or without adult verbal models.
Vocal play counts.
6* Vocalizes back-and-forth with adult for Babbles (with CV combination) with eye contact for at least
at least 2 rounds (CV). 2 rounds. Vocalization can be initiated by either partner.
7 Vocalizes to communicate. Vocalizes in conjunction with eye contact and/or gesture
(e.g., reaching) to request desired item or object.
8 Makes eye contact to obtain a desired Turns head and eyes to adult and makes eye contact for
object when adult blocks access/ 1–2 seconds with or without a gesture (e.g., reaching,
withholds desired object. grabbing) to request object. Eye contact and gesture need
not be accompanied by vocalizations and words.
9 Says name of one important person Either prompted or spontaneous.
(e.g., “Mama”).
10 Vocalizes with eye contact to request. Turns head and eyes to adult and makes eye contact while
vocalizing to request desired item. Vocalization may be an
approximation (e.g., “aah” for ball or “ooh” for go).
11 Produces 4–6 different consonants. Vocalizations occur with or without adult verbal models.
Vocal play counts.
291
Expressive Communication: Vocal/Verbal Communication (continued)

12 Imitates self-initiated CVs 3 rounds Child vocalizes a consonant-vowel sound, adult imitates it,
with adult in context. and child vocalizes the sound again.
13 Imitates adult-initiated familiar CVs Adult vocalizes a consonant-vowel sound and child imitates
1–2 rounds. it.
14 Vocalizes with identical CVCV Vocalization need not be accompanied by eye contact or
sequences (e.g., “ba-ba,” “di-di”; gesture.
reduplicative babbling).
15 Vocalizes with differing CVCV Self-explanatory
sequences (e.g., “ba-da,” “di-da”;
variegated babbling).
16 Imitates 5+ different sound effects or Self-explanatory
animal sounds in play (e.g., “zoom”
and “woof woof”).
17 Imitates 5+ different CV word Produces 5 or more words or approximations within familiar
approximations in a play activity (e.g., routines. They can be spontaneous or spontaneously
“ba” for “ball,” “ca” for “car”). imitated but not prompted; must occur within the same
joint activity.
18 Names 3+ different objects important Imitated or spontaneous
to child (e.g., “bottle,” “blankie,”
“doggy”).
19 Produces 3+ different word Imitated or spontaneous
approximations in a single joint activity
(e.g., “uh” for “up,” “ca” for “car,” and
“zooo” for “zoom”).
20 Spontaneously requests 5+ different Self-explanatory
objects that are in sight.
21 Spontaneously requests 3+ different Self-explanatory
actions (e.g., “up,” “down,” “go”).
22 Spontaneously uses 20 different Self-explanatory
words in a week.
23 Spontaneously labels 5+ different Self-explanatory
objects and 5+ different pictures to
comment (not request).
24 Says the names of 3 important people Child uses names to label people in pictures, mirror, and
in photos and in person (including real life. Can be in response to question, “Who is that?”
self).
25 Combines verbalization, wave, and Self-explanatory
eye contact to initiate and respond to
greetings/departures.
26 Says “no” to protest. Says “no” when offered food or object.
27 Says “yes” to affirm. Says “yes” when offered food or object.
28 Spontaneously uses 50 different Self-explanatory
words in a week.
29 Combines several two-word phrases Verbalization must include eye contact. Articulation need
spontaneously (e.g., “more cookie,” not be perfect.
“mama shoes,” “go door”).
292
Expressive Communication: Vocal/Verbal Communication (continued)

30 Asks several questions with Questions may be one-word utterances with rising
appropriate intonation (e.g., “go?” “all intonation. Verbalization must include eye contact.
done?” “what’s that?”).
31 Produces 2–3 word combinations for Verbalizations must include eye contact. Examples: “want
a variety of communicative functions more juice,” “bye, Sally,” “help me open,” or “no ball.”
(i.e., gaining attention, requesting, Articulation need not be perfect.
greeting, protesting).
32 Produces 2+ word utterances to Verbalizations must include eye contact and are not related
comment to another person (e.g., “see to requests for objects or actions. Articulation need not be
cow,” “airplane go fast,” or “doggie”). perfect.
33 Labels actions words in pictures and Verbalizations need not be accompanied by eye contact.
books (e.g., “eating” or “bird flying”). Articulation need not be perfect.
34 Names 1–2 colors. Verbalizations need not be accompanied by eye contact.

Adult may ask, “What color is the car?” but child must
initiate answer. Approximation may be accepted.
35 Responds to “who, what, where” Must answer one of each type of question for mastery.
questions. Verbalization need not be accompanied by eye contact.
Adult may ask a second time.
36 Asks simple “yes, no” questions with Verbalization must include eye contact. Questions may be
rising intonation. one-word utterance with rising intonation. Examples include
“Cookie?” or “Go bye-bye?”
37 Answers simple information questions Verbalizations must include eye contact.

(name, age, etc.).
Joint Attention
1 Makes eye contact 2–3 times with an Activities can be with or without objects.
adult during an activity.
2 Smiles 2–3 times during an activity Activities can be with or without objects.
with adult.
3 Looks at objects and pictures that you Follows adult touch with gaze or by touching object or
touch during play. picture.
4 Looks at shown item (“Name, look”). Turns eyes and head in direction of object held by adult.
5 Looks at pictures or objects that you Child looks at picture or object when adult points within a
proximally point to without touching. few inches of a picture or an object.
6 Follows distal point to object across Responds to distal point by looking at, approaching, and/or
the room. picking up the toy.
7 Shifts gaze from object to person when Self-explanatory

requesting object or help.
8 Gives and takes objects with This involves a spontaneous give or take. If it is a take, the
coordinated eye contact. adult should not offer the object. The gaze communicates a
“request.”
9 When holding an object, responds to Self-explanatory

“show me ” by extending
object to adult.
293
Joint Attention (continued)

10 Shows objects spontaneously. This involves routine acts of showing—positioning the toy
toward the adult’s face, looking to the adult, and waiting for
a comment. Pass if this is seen 3 times within the session.
11 Points to objects, pictures, and people This involves routine acts—at least 4 within the session.
to comment (or for naming). Child must point to target and look to adult and wait for
comment. Point may be proximal or distal.
12 Gets adult attention (eye contact) using Self-explanatory
gesture (e.g., wave, show, turn face,
pat, show object, tap) or name.
13 Shares smiles with adult when This involves clear gaze shifts from object to adult eyes and
alternating gaze during an activity. back to object to share pleasure. Should be seen several
times in a 10-minute period.
14 Initiates joint attention by shifting gaze This involves clear gaze shifts from object to adult eyes and
from object to adult to comment on back to object. Can also include vocalization and/or gesture
object or share experience. (e.g., point, touch, or reach). Pass if this is seen a few times
in a half hour of play.
Social Skills: Dyadic Engagement
1* Recognizes familiar faces vs. stranger. Change in affect or engagement observed when child
focuses gaze on familiar vs. unfamiliar adult, may be parent
report item.
2* Likes to look at self in mirror. Change in affect observed when child focuses gaze on self
in mirror, may try to pat or swipe at image. Take care to
distinguish from interest in the mirror itself.
3* Responds to others’ emotions. Shows some social contagion or recognition—responds to
smiles with smiles, anger with sadness or fear, etc.
4* Wary or fearful of strangers. Shows distinction between familiar and unfamiliar adults.
May reach to parent, turn away from stranger, etc.
5* Has favorite toys. Parent report item.
6* Plays peekaboo. Looks for parent when hidden, some indication (through
gaze or actions) that interest is more than in materials
(blanket).
7* Enjoys and engages socially in 2–3 Parent report item.
sensory social games.
8 Accepts brief social activities and Child shows no avoidance, withdrawal, or negative affect.
touch.
9 Maintains engagement in sensory Shows interest in sensory social routine by approaching,
social routines for 2 minutes. observing, or actively participating, and requesting
continuation of the routine through eye contact, gestures
(e.g., reaching, imitating adult’s movement), or vocalizations
for 3 different sensory social routines.
10 Enjoys and engages socially in 5–10 Participates in any action behavior (reaching, imitate,
different sensory social games. vocalize) in a game. Eye contact and smiles alone are
not enough. Examples include rhymes/songs (“Itsy-Bitsy
Spider,” “If You’re Happy and You Know It”), games
(“Ring-Around-the-Rosy,” “Patty-Cake”), bubbles,
balloons, books, airplane.
294
Social Skills: Dyadic Engagement (continued)

11 Engages consistently in 4-part dyadic Consistently participates throughout 4-part dyadic
joint activity routines with adult (with activities including the set-up, co-construction of a theme,
smooth transitions). elaboration, and closing.
12 Verbally requests or physically initiates Child spontaneously initiates and cues social gazes through
familiar social games. body movements, gestures, or vocal patterns (e.g., adult’s
name or an action word) that are specific to a familiar social
game.
13 Chases another, hides and searches for Eye contact and smiles alone are not enough. Examples are
others in hide and seek, and/or dances “Hide and Seek,” “Ring-Around-the-Rosy,” playing ball, and
in circle games. chase (reciprocal).
Imitation
1* Copies (or attempts) sounds or Action occurs immediately following example. May be
gestures. prompted or spontaneous. Does not have to be exact
but should share some aspect of the model. Example:
Vocalization may share intonation but not exact consonant.
2* Imitates 1 action on object. Partial credit for partial imitation or attempts.
3 Watches adult in parallel play. Shows interest in activity by observing adult play acts and
continues the play schema being imitated.
4 Imitates 2–3 different single actions on Imitates actions on object within 5 seconds of adult’s
objects. model. Examples include banging two objects together,
placing an object in its container, or rolling an object.
5 Imitates 5+ different single actions on Imitates actions on object within 5 seconds of adult’s
objects. model. Examples include banging two objects together,
placing an object in its container, or rolling an object.
6 Imitates 3+ multiple-step actions on Imitates a sequence of 3 or more related actions on one
one object. toy (e.g., taking off the shape-sorter cover, taking out the
shapes, putting the lid on, and putting the shapes through).
7 Imitates 3 different visible body Imitates actions that child can see him- or herself make
movements inside songs/game (e.g., clapping, stomping feet).
routines.
8 Imitates 3 different invisible body Imitates 3 different actions that child cannot see him- or
movements inside songs/game herself make (e.g., hands on head, ears, or patting cheeks).
routines.
9 Imitates 3+ different oral facial Imitates oral-facial movement within 5 seconds of adult’s
movements inside songs/game model (e.g., wiggling tongue, blowing raspberries, making
routines. “kissy lips,” or puffing cheeks).
10 Imitates 2–3 novel actions in Approximates novel actions during new song or game after
unfamiliar songs/game routines. adult models.
11 Imitates 2-step movement sequences Child spontaneously imitates 2 or more actions in a row
in songs/game routines. within a single song without any prompting or waiting.
Cognition
1* Watches objects as they move. Focuses gaze on objects 1–3 feet away, gaze may be brief,
and tracking may not be smooth across the midline.
2* Coordinates gaze and reaching. Uses hands and eyes together, like seeing a toy and
reaching for it.
295
Cognition (continued)
3* Tracks objects side to side. Fixates gaze on object and follows it as it is moved through
the midline in the majority of opportunities.
4* Looks at things nearby. Visually explores the environment by fixing gaze on multiple
objects/people. Movement of head/eyes without fixating on
objects does not count.
5* Brings objects to mouth. Self-explanatory
6* Tries to get objects out of reach. Child attempts to grasp objects nearby. They do not
necessarily have to be successful, but should indicate active
interest in the objects in their environment. Reflexively
grasping objects placed in their hand does not count.
7* Passes things from one hand to Without dropping

another.
8* Explores objects using 2–3 actions. Interacts with objects in more than one motor pattern—
banging, shaking, mouthing, waving, dropping, spinning.
9* Watches the path of something as it Self-explanatory

falls.
10* Looks for hidden objects. After seeing object hidden by adult, pulls back blanket or
washcloth to get to hidden object.
11 Acts according to the differential Interacts with toys that match the characteristic of the toy.
qualities of 5 different objects (e.g.,
shakes a maraca, stacks blocks).
12 Takes objects in and out of containers. Release of objects into and grasping and pulling of objects
out of container.
13 Matches 3 sets of identical objects. One set of objects is 1 matched pair. May be in response to
adult verbal (e.g., “Put here”) or physical cue (e.g., hand-
over-hand) for first few trials, but child needs to complete
matching/sorting independently. Examples include:
matching/sorting trains and tracks, crayons and paper, or
sticks and circles in separate containers.
14 Matches 3 sets of identical pictures. One set of objects is 1 matched pair. May be in response to
matching/sorting independently. Puzzles do not count.
15 Matches 3 sets of objects to pictures. One set of objects is 1 matched pair. May be in response to
matching/sorting independently.
16 Matches 3 objects by color. One set of objects is 1 matched pair. May be in response
to adult verbal (e.g., “Put here”) or physical cue (e.g.,
hand-over-hand) for first few trials, but child needs to
complete matching/sorting independently. Examples include
matching/sorting red versus blue blocks, orange versus
green pegs, or yellow versus purple balls into separate
containers.
17 Matches 3 objects by shape. One set of objects is 1 matched pair. Self-explanatory
296
Cognition (continued)
18 Matches 3 objects by size. One set of objects is 1 matched pair. Example: During
clean-up, when adult puts little bear in one container and
big bear in another, child correctly sorts 5 or more bears
(big and little) in corresponding containers.
19 Sorts similar objects into like groups by Child matches and sorts non-identical objects by identity
3 categories (e.g., cars, horses, balls). (e.g., cars, horses, balls, socks, shoes, cups).
20 Sorts related common objects into 3 Self-explanatory

categories by function (e.g., eating,
clothing, toys).
21 Recognizes objects are missing and Child recognizes when 1 object out of a set is missing and
looks for or asks for them (e.g., doll asks for it or searches for it (e.g., a missing puzzle piece, a
missing shoe, puzzle missing piece). missing shoe, a missing cup).
22 Matches objects across 2 features Child matches/sorts 5 objects by color and shape, or shape
(e.g., size and color, shape and color). and size, etc.
23 Matches objects by quantity (1–3). Child matches objects in quantity groups for 5 trials
involving the quantities 1 to 3 (e.g., domino pieces, animal
crackers on a plate).
Play
1 Acts on 3–5 single objects using Interacts with toys all in the same way (e.g., shakes every
undifferentiated schema. toy, bangs every toy, mouths every toy).
2 Holds 1 object in each hand and acts Holds 1 object in each hand and interacts with both toys in
on them using the same schema. the same way (e.g., holds 1 block in each hand and mouths
each 1, or holds a block in 1 hand and a ring in the other
and shakes both blocks at the same time).
3 Brings 2 objects together in play (e.g., Connects 2 toys by physically bringing them together or
bangs blocks together). by using 1 object to act on the other (e.g., bangs 2 blocks
together, uses a drumstick to bang a drum).
4 Makes repetitive actions that cause Makes an action on an object, observes the result, and then
interesting results. makes the action again (e.g., pushes button on cause-and-
effect toys, squeezes squeaky toy, shakes rain stick).
5 Orients materials appropriately (e.g., Self-explanatory

turns car or cup right side up).
6 Pushes car or train with model. Intentionally pushes the car so it moves forward and/or
backward so that all 4 wheels stay on the table/floor.
7 Plays independently with 3+ different May be in response to adult cue to start routine but places
toys requiring 3 repetitions of the same 3 or more pieces independently (e.g., places rings on a ring
action. stacker, takes nesting cups in/out, stacks blocks, or places
pegs in holes).
8 Completes 3+ piece puzzle with May be in response to adult cue to start routine but places
wooden handles. 3 or more pieces independently.
9 Completes 2+ different actions with Play involves independent completion of the object/activity
2–3 multistep toys. but may be in response to adult cue to start routine. Pass
with 2–3 toys. Examples include placing blocks in a block
sorter, opening top, and dumping blocks out; putting balls in
a ball maze, hitting the ball with the hammer.
297
Play (continued)
10 Completes 2+ different actions with Play is developmentally appropriate (i.e., not restricted
5–10 more multistep toys. or repetitive), relates to the object/activity, and involves
two-step actions on objects (e.g., placing blocks in a block
sorter, opening top, and dumping blocks out; putting balls
in a ball maze, hitting the ball with the hammer). May be in
response to adult cue to start routine.
11 Shows conventional actions with Actions are socially conventional and direct toward self.
objects on self with a model. Examples include: places phone to ear, brushes hair with
hairbrush/comb, puts spoon/fork to mouth, wipes nose with
a tissue, cup to lip, put beads on.
12 Shows conventional actions with Actions are socially conventional and directed toward
objects on others with a model. others. Examples include: feeds other with spoon, combs
adult’s hair.
13 Shows conventional actions Self-explanatory
spontaneously with objects on self and
others.
14 Combines related objects in play (e.g., Child demonstrates awareness of functional relations of
fork on plate, spoon in dish). multiple sets of objects in his or her play and in clean-up.
15 Acts on figures or dolls with props Requires spontaneous action; do not pass for imitation only.
(e.g., feeds teddy bear with spoon).
16 Demonstrates a trial-and-error Pass if child routinely demonstrates trial-and-error problem
approach to problem solving with solving in object play.
constructive toys; schemas are flexible,
not repetitive.
17 Constructive play involves sequencing Construct 3 or more schemas. Multiple objects may be
complex schemas with multiple trucks on road, blocks make building, beads make necklace.
coordinated objects (e.g., trucks on
a road, blocks make building, beads
make a necklace).
18 Links 3 or more related actions in a Examples are building track, pushing train, and crashing
play sequence. train or taking out Play-Doh, using shape cutter, taking out
shape.
19 Physically places figures in appropriate Places figures in appropriate context during play. Examples
context (e.g., miniatures on furniture/ include: seats figure in chair or puts figure in car.
vehicles).
20 Arranges props for the theme. Arranges 2 or more props in 3 or more different play
schemas. Examples are seeking out a plate and fork to feed
baby, putting hat on self and other to play dress-up.
21 Animates agents with actions (e.g., Self-explanatory
moves stuffed dog as if dog is running
after a ball).
22 Uses several placeholder objects as Pretends that objects are something other than what they
props (e.g., pretends a block is a cell actually are.
phone).
23 Spontaneously combines 3+ related Examples: gives a baby doll a bottle and then covers it with
behaviors in pretend play. a blanket; pours water in pot, stirs food, and pours food in
bowl; puts on firefighter hat, drives fire engine truck, and
puts out fire.
298
Play (continued)
24 Directs partner in play. Provides 3 or more relevant instructions directed to partner
to carry out some aspect of play theme across 2 or more
play activities.
25 Plays out several life events (e.g., Plays out 3 or more life events, each containing at least 3
birthday, McDonald’s, the doctor) embedded activities, interacting with partner through verbal
including the use of verbal scripts. scripts and object actions.
26 Plays out several story themes in play. Plays out 3 or more story themes with partner using
multiple actions and scripts as described in the item above.
Examples: Little Red Riding Hood, The Three Little Pigs,
and Three Billy Goats Gruff.
27 Takes on a character’s role and plays States role (e.g., “I’m the Mommy”) and plays out a life
it out. scene with verbal script, activities, and gestures appropriate
to role with three or more exchanges to partner.
28 Follows another’s lead in play. Follows partner’s play directives verbally or nonverbally, 5
or more times by imitating partner’s acts or responding to
partner’s instructions.
299
Appendix C
Parent-Friendly Data-Tracking Tools
Appendix C contains a few simple templates that we have created for parents to use for
self-evaluation of their progress. In each of the data tools we have provided, parents only
need to mark a check, “X,” or plus sign next to the goal(s) they practiced successfully, a
minus sign when their efforts were not successful, or NP (“not practiced”) for goals they
did not practice. We keep the templates easy to use and focus on what parents deem
important to track so that they feel ownership of the forms’ contents.
We learned an important lesson from parents who began to track data at home,
either their own or their child’s. We learned to ask about data sheets at the very begin-
ning of the session, to look at any data sheets as soon as parents provided them, and to
comment on them, in order to convey the importance of data and to show our respect
for the effort required to record this information at home. We learned that if we did not
ask for the data and remark on it, there would be no data the next session. So, ask to see
the data!
Contents
Appendix C.1: Simple Tally System 303

Appendix C.2: Days of the Week Tracking Chart 304
Appendix C.3: Activities Data Tracker 305
Appendix C.4: Goals and Activities Bar Chart 306
301
APPENDIX C.1
Simple Tally System
Here, we offer a tally system to track how often a parent practices each goal. The Xs in
each box indicate how frequently a goal has been practiced at the end of the day, week,
or whatever amount of time the parent chooses, with the total number of times practiced
summarized entered below each goal.
My child watches My child makes or My child copies My child takes

me try new play copies my sounds gestures that I three or more turns
ideas without during play or show him how to do when I follow his
leaving the caretaking routines. in songs. ideas and encourage
interaction. him to continue
play with a toy,
songs, or other
games with me.
XXXX XXXXXXXX X XXXXXXXXXX
Total Times Total Times Total Times Total Times

Practiced: 4 Practiced: 8 Practiced: 1 Practiced: 10
303
APPENDIX C.2
Days of the Week Tracking Chart
These two examples track goals or steps by days of the week. Parents can check off boxes
in the top table or make tallies in the bottom table once a goal or step has been achieved.
If a goal or step is attempted but not successful, a minus sign or a similar symbol to indi-
cate lack of success should be marked. If a step was not practiced, then the parent needs
to document that with “NP” or similar notation. This is important because documenting
lack of success or lack of practice provides extremely important data to the coach, who
can determine if there is a problem with the step or with the way it is being practiced.
Additionally, using an NP code creates a little motivation to practice a skill the next day
and it alerts the coach to the possible need for motivational strategies. Sums or totals can
be added to the table, as shown in the second example, if helpful to the parents in order
to track how often each goal or step has been reached throughout the week and at the
end of each day.
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Goal/Step
Goal/Step
Goal/Step
Goal/Step
Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total
Goal/Step 16
Goal/Step 15
Goal/Step 38
Goal/Step 19
Total 12 15 9 11 0 8 12
304
APPENDIX C.3
Activities Data Tracker
Here’s another type of table to track how often goals or steps are achieved across activi-
ties that families typically perform with their young children. The range of activities can
always be decided by the family members, as can the type of goals chosen; parents can
also add totals in the last column and row to summarize progress across activity type.
Other variables could also be included in addition to, or in place of, the activities prac-
ticed, such as the intervention strategies used to achieve goals.
Sensory
Social
Toy Play Routines Meals Books Bathtime Diapering Dressing Outdoor
Goal/Step 2 2 4 1 2 5
Goal/Step 1 3 3 1 3 4
Goal/Step 4 5 1 8 7 6 7
Goal/Step 1 4 6 8
305
APPENDIX C.4
Goals and Activities Bar Chart
The coach may also consider a template like the one shown below that summarizes par-
ents’ evaluation data across sessions. We find that parents appreciate seeing progress over
time charted as it validates their hard work and achievements. Laurie typically does this at
the midpoint and in the 10th out of 12 sessions with families, although the frequency can
be adjusted based on how many sessions are offered to families. The chart also illustrates
how often four goals were practiced inside the three routines of play, meals, and bathtime
(alternatively, teaching steps could be recorded instead of goals). A similar chart could be
devised with the ESDM Curriculum Checklist to show the number of skills achieved per
domain from one quarter to the next.
16
14
12
10
0
Goal 1 Goal 2 Goal 3 Goal 4
Play Meals Bath time
306
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Index
Note. f or t following a page number indicates a figure or table.
ABC Action Plan Template, 149 Applied behavior analysis (ABA)

ABCs of behavior and learning ABC sequences of behavior intervention topic
ABC sequences of behavior intervention topic and, 147–164
and, 147–164 early intervention and, 14
helping young children develop speech knowledge base needed by coaches and, 25–26
intervention topic and, 212–214 overview, 9, 10, 11
Acceptance, 32–33, 48–49 Asking for objects, 164–173
Acquisition skills, 178–179 Assessment
Action Plan Template for Parent Follow-Through family-centered model of intervention and, 18
form, 214–217, 218 overview, 63–66
Action stage of change, 51–52. See also Stages of parents’ role in, 13
change P-ESDM Infant–Toddler Curriculum Checklist,
Activities Categories handout, 44, 91–92, 132–133, 63–64, 287–299
261 short-term goals and, 66–67
Activities Data Tracker, 305 Attachment relationship, 14–16. See also
Activities That Encourage Nonverbal Relationships
Communication form, 127, 128–129, 130–131 Attending to others, 164–173
Activity plan, 44. See also Topics for coaching Attention, joint, 164–173, 293–294
sessions Attention of child, 102–107
Activity/coaching experience of the coaching Attention-deficit/hyperactivity disorder (ADHD),
session. See also Coaching session routines; 243–246, 243f
Parent coaching sessions; Topics for coaching
sessions Behavior, 147–164. See also ABCs of behavior and
in a group format, 239–240, 239t learning
overview, 74–75, 76, 83–85 Blame, 38
Stages of Change and Possible Coaching Body language. See also Gestures; Nonverbal
Techniques checklist, 279–286 communication
Adaptations to coaching, 233–240, 236t, 238t, 239t, imitation as a learning tool intervention topic
240t, 241t. See also Parent coaching and, 141–143
Adult learning principles, 29–30, 37–40. See also nonverbal communication (body language)
Learning intervention topic and, 125–138
Animate play, 188. See also Play; Pretend play; Toys sharing interests and attention with others (joint
Antecedents that lead to a behavior, 147–164. See attention) intervention topic and, 164–173
also ABCs of behavior and learning Boundaries, 53–54
Anxiety and anxiety disorders, 48–49, 243–246 Broader autism phenotype, 15–16
316
Index 317
Caregiver coaching. See Parent coaching coaching activity and, 83–85

Caregiver-implemented intervention. See Parent- coach’s reflection and notes, 94
implemented early intervention approaches discussion time, 93–94
Centering practices, 48–49 greetings and check-ins, 78–79
Changing behavior in a group format, 236–239, 236t, 238t, 239t,
ABC sequences of behavior intervention topic 240t, 241t
and, 162–164 overview, 77, 85f, 100–101
stages of change and, 50–52, 51f, 279–286 reflection and session goal setting, 80–83
Stages of Change and Possible Coaching reflection–evaluation–planning cycle and,
Techniques checklist, 279–286 85–93, 85f
Check-in period of coaching sessions. See Coaching warm-up activities, 79–80
session routines; Greeting period of sessions Coaching time of sessions, 74–75. See also Coaching
Check-ins in between coaching sessions, 94 session routines; Parent coaching sessions
Checklists. See Handouts/forms/checklists Coach’s Clipboard List, 41, 257
Cleaning-up after an activity, 183–184, 185. See also Coach’s Fidelity of Implementation Brief Checklist,
Ending activities 94, 269–270
Clipboard as a coach’s tool, 41, 257 Coach’s Session Planning Sheet, 77, 258
Clock as a coach’s tool, 43 Coach’s tools
Closing period of coaching sessions, 74, 75, 76, 94. clipboard and pencil, 41
See also Coaching session routines; Ending clock, 43
activities; Parent coaching sessions Coach’s Clipboard List, 257
Coaches. See also Coaching relationship; Parent Coach’s Session Planning Sheet, 41–43
coaching data checklists, 45–46
assessment and, 65–66 emotional thermometer, 47
boundaries and, 53–54 mindfulness as, 48–49
coach preparation, 77 other tools to consider, 48–54, 51f
coordinating treatment plans when there are overview, 41, 57–58
multiple coaches, 71 parent manual as, 44
emotional thermometer and, 47 problem solving, 54–57
first contact with parents and children and, reflective mirror (supervision) as, 48
61–63 Refrigerator List, 45, 262
humility and, 53 wide-angle perspective as, 47
knowledge base needed by, 24–30 Collaboration
overview, 40 coordinating treatment plans when there are
relationship between coach and parent and, 30–34 multiple coaches, 71
role of, 2–3, 6–8, 7t, 93 dealing with conflicts and, 233–234
support for, 34–37 first contact with parents and children and,
wide-angle perspective and, 47 61–63
Coaching. See Parent coaching knowledge base needed by coaches and, 37
Coaching fidelity checklist. See Coach’s Fidelity of relationship between coach and parent and, 31
Implementation Brief Checklist short-term goals and, 66–67
Coaching fidelity rating tool. See ESDM Coaching Comfort zone of children, 105–106
Fidelity Rating Tool Communication. See also Language
Coaching relationship. See also Coaches; Parent back-and-forth interactions (turn taking)
coaching; Relationships intervention topic and, 112–125
assessment and, 64 gaining children’s attention intervention topic
boundaries and, 53–54 and, 102–107
difficulties within, 97–99 helping young children develop speech
ending the coaching relationship, 99–100 intervention topic and, 200–218
establishing and building, 61–63 language interventions and, 16–17
overview, 5–6, 59, 72, 101 nonverbal communication (body language)
parental motivation and, 38–39 intervention topic and, 125–138
relationship between coach and parent and, P-ESDM Infant–Toddler Curriculum Checklist,
30–34 63–64, 287–299
supporting a coaching approach and, 34 relationship between coach and parent and, 33
Coaching session routines. See also Parent coaching sharing interests and attention with others (joint
sessions; Topics for coaching sessions attention) intervention topic and, 164–173
closing, 94 Community, 13, 248–250
coach preparation, 77 Competencies, 20–21
318 Index
Conflicts, dealing with, 233–234 Early Start Denver Model Coaching Fidelity
Consequences of behavior, 147–164. See also ABCs Coding Sheet, 278
of behavior and learning; Reinforcement ESDM Coaching Fidelity Rating Tool, 271–277
Constructive toy play, 173–187. See also Play knowledge base needed by coaches and, 26
Contemplation stage of change, 51–52. See also motivational interviewing (MI) and, 50–52, 51f
Stages of change overview, 3–4, 3f, 13–14
Conventional play, 189–190. See also Play writing objectives and learning steps, 67
Co-occurring conditions, 242–248, 243f Education for All Handicapped Children Act
Copying. See Imitation (Public Law 94-142), 18, 21
Core skill set, 82. See also Topics for coaching sessions Elaborations, 143–147
Counseling services, 233 Emotions
Creative play, 173–187. See also Play emotional thermometer tool, 47
Culturally informed practices, 234, 248–250 ending the coaching relationship and, 99–100
mindfulness and, 48–49
Data checklists, 45–46. See also Handouts/forms/ negative emotions, 35–36, 99–100
checklists positive emotions, 99–100
Days of the Week Tracking Chart, 304 supporting coaches and, 35–36
Developmental processes Empowerment, 20–21, 38–39
ABC sequences of behavior intervention topic Ending activities
and, 160 back-and-forth interactions (turn taking)
future research needs regarding, 252 intervention topic and, 121–124
helping young children develop speech flexible creative object play intervention topic
intervention topic and, 200–218 and, 177, 183–184
infants at risk for ASD and, 250–251 imitation as a learning tool intervention topic
knowledge base needed by coaches and, 37 and, 146
language interventions and, 16–17 ESDM Coaching Fidelity Rating Tool, 94, 271–277
P-ESDM Infant–Toddler Curriculum Checklist, Ethical standards, 53–54
63–64, 287–299 Evaluation stage of problem-solving, 57
pretend play intervention topic and, 188–189 Evidence-based practices, 24–25
short-term goals and, 66 Expand on actions, 143–147
Diagnosis Expertise, 24–30
beginning coaching following, 59–61 Exposure to sounds, 204–205
co-occurring conditions and, 242–248, 243f Expressive language. See also Language
feelings and reactions to, 1 helping young children develop speech
parents’ role in, 13 intervention topic and, 200, 201–210
process of, 61 overview, 201
Discussion time of sessions, 74, 76, 93–94. See also P-ESDM Infant–Toddler Curriculum Checklist,
Coaching session routines; Parent coaching 290–293
sessions; Reflection/evaluation during Eye contact and gaze, 166, 169–173
coaching sessions
Distractions, 105, 160 Facial movements
imitation as a learning tool intervention topic
Early intervention. See also Parent coaching; and, 141–143
Parent-implemented early intervention sharing interests and attention with others (joint
approaches attention) intervention topic and, 166
clinician-driven, 1–2 Families, 29–30
coaching and, 4–8, 7t Family, Infant and Preschool Program (FIPP), 20
future research needs regarding, 252–254 Family-centered model. See also Interventions;
language interventions and, 16–17 Parent-implemented early intervention
overview, 22t, 254 approaches
parent–child relationship and, 14–16 emergence of, 3–4, 3f
research regarding, 9 future research needs regarding, 252–254
Early Start Denver Model Coaching Fidelity interdisciplinary teams and, 18–19
Coding Sheet, 278 overview, 2–3, 20–21, 22t
Early Start Denver Model (ESDM). See also parent coaching and, 19–21
Parent-Implemented Early Start Denver Model parent group coaching and, 235–240, 236t, 238t,
(P-ESDM) 239t, 240t, 241t
assessment and, 63–64 shifting to parent coaching and, 28–29
data checklists and, 45–46 Feedback, 32–33
Index 319
Fidelity measures. See also Handouts/forms/ reviewing in first coaching session, 74

checklists session routines and, 80–83
Coach’s Fidelity of Implementation Brief short-term goals and, 66–67
Checklist, 94, 269–270 writing objectives and learning steps, 67–70
Early Start Denver Model Coaching Fidelity Goals and Activities Bar Chart, 306
Coding Sheet, 278 Goodbye time of sessions. See Closing period of
ESDM Coaching Fidelity Rating Tool, 94, coaching sessions
271–277 Greeting period of sessions, 73, 74, 76, 78–79.
Fidelity of Implementation (FOI) data sheet, See also Coaching session routines; Parent
45–46 coaching sessions
knowledge base needed by coaches and, 26–28 Group parent coaching, 235–240, 236t, 238t, 239t,
overview, 45–46 240t, 241t
parent fidelity data, 45, 81
Parent–ESDM Fidelity Coding Sheet, 263 Hand gestures. See Gestures
Fidelity of implementation (FOI) Handouts/forms/checklists. See also Refrigerator
knowledge base needed by coaches and, 26–28 lists
supporting a coaching approach and, 34 ABC Action Plan Template, 149, 150
First Group Session Plan form, 236, 237 Action Plan Template for Parent Follow-
Flexibility, 54 Through, 214–217, 218
Follow through Activities Categories handout, 44, 91–92,
ABC sequences of behavior intervention topic 132–133, 261
and, 161 Activities Data Tracker, 305
helping young children develop speech Activities That Encourage Nonverbal
intervention topic and, 214–217 Communication form, 127, 128–129, 130–131
Forms. See Handouts/forms/checklists Coach’s Clipboard List, 257
Fun. See also Play Coach’s Fidelity of Implementation Brief
flexible creative object play intervention topic Checklist, 269–270
and, 173–187 coach’s reflection and notes, 94
fun in parent–child interactions intervention Coach’s Session Planning Sheet, 77, 258
topic and, 107–112 data checklists, 45–46
Future directions and research, 242–248, 243f, Days of the Week Tracking Chart, 304
252–254 Early Start Denver Model Coaching Fidelity
Coding Sheet, 278
G eneralist approach, 13–14 First Group Session Plan form, 236, 237
Generating ideas stage of problem-solving, 55 Goals and Activities Bar Chart, 306
Genetic factors, 15–16 Joint Activity Template, 115, 116, 118, 119, 121,
Gestures. See also Body language 122–123
helping young children develop speech overview, 44, 74–75
intervention topic and, 207–210 Parent Daily Practice Chart, 43, 91–92, 259–260
imitation as a learning tool intervention topic parent manual and, 44
and, 141–143 Parent Self-Monitoring Checklist, 45, 267–268
nonverbal communication (body language) Parent Skills Checklist, 264–266
intervention topic and, 125–138 Parent–ESDM Fidelity Coding Sheet, 263
P-ESDM Infant–Toddler Curriculum Checklist, P-ESDM Infant–Toddler Curriculum Checklist,
289, 290–291 63–64, 287–299
sharing interests and attention with others (joint Refrigerator List, 44, 45, 262
attention) intervention topic and, 164–173 Simple Tally System, 303
Goals Stages of Change and Possible Coaching
addressing within coaching sessions, 95–97 Techniques checklist, 279–286
assessment and, 63–66 Health concerns, 246–248
coaching and, 4–5 Help, asking for, 136–138
Coach’s Session Planning Sheet and, 41–43 Help Is in Your Hands website, 26, 39–40, 44
ending the coaching relationship and, 99–100 Home practice plan, 41–42
flexible creative object play intervention topic Humility, 53
and, 178–179
parental motivation and, 37–40, 49–52, 51f Imagination
problem solving and, 54–55 flexible creative object play intervention topic
reflection–evaluation–planning cycle and, and, 173–187
85–93, 85f pretend play intervention topic and, 187–199
320 Index
Imitation generalist model and, 12–14

flexible creative object play intervention topic shifting from to parent coaching, 28–29
and, 173–187 “Invisible” objects in play, 195–197. See also Play;
gaining children’s attention intervention topic Pretend play
and, 106
imitation as a learning tool intervention topic
and, 138–147
Joint activities
back-and-forth interactions (turn taking)
P-ESDM Infant–Toddler Curriculum Checklist, intervention topic and, 112–125
295 imitation as a learning tool intervention topic
Implementation stage of problem-solving, 56–57 and, 140–141, 142–147
Incidental teaching, 25 Joint Activity Template, 115, 116, 118, 119, 121,
Independence and independent play, 13, 179–187. 122–123
See also Play Joint attention, 164–173, 293–294
Individualized education plans (IEPs), 26
Individualized family service plans (IFSPs), 25–26
Individualizing interventions, 39–40 Knowledge base needed by coaches, 24–30
Individuals with Disabilities Education Act (IDEA),
18, 21 Language. See also Communication
Infant–adult interactions, 17. See also Parent–child back-and-forth interactions (turn taking)
interactions intervention topic and, 118
Infants at risk for ASD, 250–251 flexible creative object play intervention topic
Interactions with others. See also Parent–child and, 173–187
interactions helping young children develop speech
back-and-forth interactions (turn taking) intervention topic and, 200–218
intervention topic and, 112–125 language interventions and, 16–17
flexible creative object play intervention topic P-ESDM Infant–Toddler Curriculum Checklist,
and, 173–187 63–64, 287–299
gaining children’s attention intervention topic pretend play intervention topic and, 187–199
and, 102–107 sharing interests and attention with others (joint
helping young children develop speech attention) intervention topic and, 164–173
intervention topic and, 200–218 Laughter, 54
sharing interests and attention with others Learning. See also Adult learning principles
(joint attention) intervention topic and, ABC sequences of behavior intervention topic
164–173 and, 147–164
Interdisciplinary models, 252–253 assessment and, 63–66
Interdisciplinary teams child objectives and, 95–97
generalist model and, 12–14 data checklists and, 45–46
knowledge base needed by coaches and, 37 developing learning steps, 67–70
motivational interviewing (MI) and, 50–52 early intervention and, 14
overview, 13–14, 18–19 flexible creative object play intervention topic
reflective supervision and, 48 and, 173–187
Interests, sharing with others, 164–173 fun in parent–child interactions intervention
Internet-based coaching, 234–235 topic and, 107–112
Interpersonal support, 36 gaining children’s attention intervention topic
Interventionists. See also Coaches and, 102–107
generalist model and, 13 helping young children develop speech
knowledge base needed by coaches and, 24–30 intervention topic and, 200–218
overview, 1–2 imitation as a learning tool intervention topic
role of, 2–3, 6–8, 7t and, 138–147
supporting a coaching approach and, 34–37 incorporating adult learning principles into
Interventions. See also Activity/coaching coaching, 29–30
experience of the coaching session; Early interventions that support learning styles, 13
intervention; Family-centered model; language interventions and, 16–17
Parent coaching; Parent-implemented early opportunities for, 4–5, 8
intervention approaches; Topics for coaching parental motivation and, 37–40, 49–52, 51f
sessions pretend play intervention topic and, 187–199
clinician-driven, 1–2 sharing interests and attention with others (joint
co-occurring conditions and, 242–248, 243f attention) intervention topic and, 164–173
Index 321
supporting a coaching approach and, 34–35 data from, 45, 75

writing objectives and learning steps, 67–70 parent group coaching and, 236–239, 238t
Limited resource availability to children and One-on-one therapy model, 18–19
families, 248–250 Operant learning model, 16–14
Listening, 50, 106–107, 204–205. See also
Communication Pantomimed objects in play, 195–197. See also Play;
Lists, refrigerator. See Refrigerator Lists Pretend play
Looking at objects, 166, 169–173 Paper as a coach’s tool, 43–44
Low-resource communities, 248–250 Parent coaching. See also Coaches; Coaching
relationship; Coaching session routines; Parent
Maintenance skills, 178–179 coaching sessions; Topics for coaching sessions
Maintenance stage of change, 51–52. See also Stages adaptations to, 233–235
of change assessment and, 63–66
Make-believe play. See Play; Pretend play beginning the process of, 59–61
Medical conditions, 246–248 with children and families in low-resource
Medical model, 18 communities, 248–250
Mental health services, 233, 243–246, 243f co-occurring conditions and, 242–248, 243f
Mindfulness, 48–49 coordinating treatment plans when there are
Motivation multiple coaches, 71
parental motivation and, 37–40, 49–52, 51f family-centered care and, 19–21
Stages of Change and Possible Coaching first contact with parents and children and,
Techniques checklist, 279–286 61–63
Motivational interviewing (MI), 50–52, 51f future of, 252–254
Multidisciplinary models, 252–253 in a group format, 235–240, 236t, 238t, 239t,
240t, 241t
Naturalistic approaches, 25–28. See also for infants at risk for ASD, 250–251
Naturalistic developmental–behavioral early motivational interviewing (MI) and, 50–52, 51f
intervention model (NDBI) overview, 4–8, 7t, 10–11, 22t, 23–24, 40, 57–58,
Naturalistic developmental–behavioral early 59–61, 72, 220, 240–241, 254
intervention model (NDBI). See also Topics for parental motivation and, 37–40, 49–52, 51f
coaching sessions process of, 85, 85f
data checklists and, 45 relationship between coach and parent and,
fidelity of implementation (FOI) tool and, 26 30–34
knowledge base needed by coaches and, 25–28 session plan and, 41–42
overview, 9, 11, 254 shifting to, 28–29
supporting a coaching approach and, 34–37 short-term goals and, 66–67
variations in family stories, 221–233 Stages of Change and Possible Coaching
Needs, individual, 13, 20–21 Techniques checklist, 279–286
Negative emotions and reactions, 35–36, 99–100. supporting interventions based on, 34–37
See also Emotions transdisciplinary treatment plan and, 70–71
Negative reinforcement, 151–152. See also variations in family stories, 221–233
Consequences of behavior; Reinforcement writing objectives and learning steps, 67–70
Nonjudgmental stance, 32–33 Parent coaching sessions. See also Activity/
Nonverbal communication. See also Body language; coaching experience of the coaching session;
Gestures Coaching session routines; Parent coaching;
helping young children develop speech Session plan
intervention topic and, 200–218 addressing child objectives within, 95–97
nonverbal communication (body language) assessment and, 65–66
intervention topic and, 125–138 difficulties within the coaching relationship and,
97–99
Object play, 173–187. See also Play ending the coaching relationship, 99–100
Objects, attention to, 164–173. See also Joint attention first session, 73–75
Observation–planning–practice–reflection– overview, 73, 100–101
evaluation cycle, 77 preparing for, 77
Observations structure for, 75–77
ABC sequences of behavior intervention topic Parent Daily Practice Chart, 43, 91–92, 259–260
and, 148–149 Parent fidelity of implementation tools. See Fidelity
coaching session routines and, 79–80 measures
322 Index
Parent manual, 44. See also Handouts/forms/ Plan for sessions. See Coach’s Session Planning
checklists; Refrigerator lists Sheet
Parent Self-Monitoring Checklist, 45, 267–268 Plan–act–reflect–evaluate process, 32, 42, 47
Parent Skills Checklist, 264–266 Planning moment of sessions, 73–74, 80–83, 85–93,
Parent training models, 19–20 85f. See also Coaching session routines; Parent
Parent–child interactions. See also Infant–adult coaching sessions
interactions; Interactions with others; Parent– Planning stage of problem-solving, 56
child relationship Play
back-and-forth interactions (turn taking) back-and-forth interactions (turn taking)
intervention topic and, 112–125 intervention topic and, 112–125
fun in parent–child interactions intervention flexible creative object play intervention topic
topic and, 107–112 and, 173–187
helping young children develop speech fun in parent–child interactions intervention
intervention topic and, 205–207 topic and, 107–112
overview, 15–16 imitation as a learning tool intervention topic
planning the activity/coaching experience of the and, 138
coaching session based on, 75 P-ESDM Infant–Toddler Curriculum Checklist,
sharing interests and attention with others (joint 297–299
attention) intervention topic and, 164–173 pretend play intervention topic and, 187–199
Parent–child relationship, 14–16. See also Pointing to objects, 170–173. See also Gestures
Relationships Positive emotions and reactions, 99–100. See also
Parent–coach relationship. See Coaching Emotions
relationship Positive reinforcement, 151–152. See also
Parent–ESDM Fidelity Coding Sheet, 263 Consequences of behavior; Reinforcement
Parent-implemented early intervention approaches. Practice-based coaching (PBC) framework, 3–4, 3f
See also Early intervention; Family-centered Praise
model; Interventions; Parent-Implemented parental motivation and, 38
Early Start Denver Model (P-ESDM) relationship between coach and parent and,
coaching within, 4–8, 7t 32–33
for infants at risk for ASD, 250–251 sharing interests and attention with others (joint
overview, 12–14, 22t attention) intervention topic and, 170
research regarding, 9 Precontemplation stage of change, 51–52. See also
Parent-Implemented Early Start Denver Model Stages of change
(P-ESDM). See also Early Start Denver Model Preferences, 13
(ESDM) Premack principle, 213
assessment and, 63–64 Preparation stage of change, 51–52. See also Stages
group format for, 235–240, 236t, 238t, 239t, 240t, of change
241t Pretend play, 187–199. See also Play
overview, 9, 11, 220 Proactive stance, 21
parent coaching and, 20 Problem definition stage of problem-solving, 54–57
P-ESDM Infant–Toddler Curriculum Checklist, Problem solving, 54–57
63–64, 287–299 Progress monitoring, 45–46, 95–97
transdisciplinary treatment plan and, 70 Proximal points, 172. See also Pointing to objects
Parents Proximal zones of development, 64
communication with, 20–21 Psychiatric conditions, 243–246, 243f
incorporating adult learning principles into Punishment, 153
coaching, 29–30
motivation and, 37–40, 49–52, 51f Receptive language. See also Language;
overview, 15–16 Understanding speech
relationship between coach and parent and, 30–34 helping young children develop speech
Patience, 112–125 intervention topic and, 200, 210–218
Peer support overview, 201
motivational interviewing (MI) and, 50–52 P-ESDM Infant–Toddler Curriculum Checklist,
reflective supervision and, 48 289–290
supporting coaches and, 36 Reflection
Pencil as a coach’s tool, 41 reflective supervision and, 48
P-ESDM Infant–Toddler Curriculum Checklist, relationship between coach and parent and,
63–64, 287–299 31–32, 33
Index 323
Reflection/evaluation during coaching sessions. Sessions. See Coaching session routines; Parent
See also Coaching session routines; Discussion coaching sessions
time of sessions; Parent coaching sessions Shared decision-making, 20–21
in a group format, 240, 240t, 241t Sharing skills, 164–173. See also Turn taking
overview, 76 Short-term goals, 66–67. See also Goals
reflection and session goal setting and, 80–83 Showing objects to others, 164–173
reflection–evaluation–planning cycle and, Simple Tally System, 303
85–93, 85f Social play. See also Play
Reflection–evaluation–planning cycle, 85–93, 85f fun in parent–child interactions intervention
Reflective mirror (supervision), 48. See also topic and, 107–112
Supervision pretend play intervention topic and, 191
Refrigerator Lists, 44, 45, 262. See also Checklists; Solitary play. See Independence and independent
Parent manual play
Reinforcement. See also Consequences of behavior Sounds. See also Vocalizations
ABC sequences of behavior intervention topic helping young children develop speech
and, 151–154 intervention topic and, 201–210
helping young children develop speech imitation as a learning tool intervention topic
intervention topic and, 212–214 and, 139–140
parental motivation and, 37–38 P-ESDM Infant–Toddler Curriculum Checklist,
sharing interests and attention with others (joint 291–293
attention) intervention topic and, 170 responding to sounds made by others, 204–205
Relapse and repair stage of change, 51–52. See also Speech. See also Vocalizations
Stages of change helping young children develop speech
Relationships. See also Coaching relationship intervention topic and, 200–218
back-and-forth interactions (turn taking) language interventions and, 16–17
intervention topic and, 112–125 nonverbal communication (body language)
parent–child relationship, 14–16 intervention topic and, 125–126
relationship between coach and parent and, P-ESDM Infant–Toddler Curriculum Checklist,
30–34 289–290
sharing interests and attention with others (joint Spontaneous play, 192–194. See also Play
attention) intervention topic and, 164–173 Stages of change
Resources available to children and families, motivational interviewing (MI) and, 50–52, 51f
248–250 Stages of Change and Possible Coaching
Responding to sounds made by others, 204–205 Techniques checklist, 279–286
Routines for sessions. See Coaching session routines Stimulus. See Antecedents that lead to a behavior
Strengths, 13, 21
S elf-care, 47 Summary “refrigerator” lists. See Refrigerator Lists
Self-efficacy, 20–21 Supervision. See also Reflective mirror (supervision)
Self-monitoring, 96–97, 99–100 motivational interviewing (MI) and, 50–52
Sensory social routines (SSRs) reflective supervision, 48
back-and-forth interactions (turn taking) supporting coaches and, 36
intervention topic and, 115–125 Support, 34–37, 233–234
fun in parent–child interactions intervention Symbolic combinations, 188, 197–199. See also Play;
topic and, 108–112 Pretend play
imitation as a learning tool intervention topic Symbolic play. See Play; Pretend play
and, 142–147 Symbolic substitution, 188, 194–197. See also Play;
Session plan. See also Coaching session routines; Pretend play
Parent coaching sessions; Topics for coaching
sessions Tablet of paper, 43–44
overview, 41–43 Talking to children, 205–207
parent group coaching and, 236–239, 238t Teams, interdisciplinary. See Interdisciplinary teams
preparing for coaching sessions and, 77 Techniques to teach during coaching sessions. See
reflection–evaluation–planning cycle and, Topics for coaching sessions
85–93, 85f Technology, telehealth and, 234–235
Stages of Change and Possible Coaching Telehealth coaching, 234–235
Techniques checklist, 279–286 Termination, 99–100
using a clock as a tool and, 43 Therapist, 6–8, 7t. See also Coaches
Session routines. See Coaching session routines Therapist–child intervention sessions, 28–29
324 Index
Three-way interactions, 165. See also Joint attention Treatment plan. See also Topics for coaching
Time-outs, 153 sessions
Tolerance, 112–125 assessment and, 65–66
Tools, coach’s. See Coach’s tools coordinating when there are multiple coaches, 71
Topics for coaching sessions. See also Activity/ reviewing in first coaching session, 74
coaching experience of the coaching session; short-term goals and, 66–67
Coaching session routines; Core skill set; transdisciplinary treatment plan and, 70–71
Session plan writing objectives and learning steps, 67–70
ABC sequences of behavior, 147–164 Triadic attention, 165. See also Joint attention
back-and-forth interactions (turn taking), Triggers of behavior. See Antecedents that lead to
112–125 a behavior
flexible creative object play, 173–187 Turn taking
fun in parent–child interactions, 107–112 back-and-forth interactions (turn taking)
gaining children’s attention, 102–107 intervention topic and, 112–125
in a group format, 239–240, 239t helping young children develop speech
helping young children develop speech, 200–218 intervention topic and, 211–212
imitation as a learning tool, 138–147 sharing skills and, 164–173
nonverbal communication (body language),
125–138 Understanding speech, 200, 210–218. See also
overview, 82–83, 102, 218–219 Receptive language
pretend play, 187–199 Unwanted behavior, 162–164. See also Changing
sharing interests and attention with others (joint behavior; Topics for coaching sessions
attention), 164–173
Stages of Change and Possible Coaching Variations to activities
Techniques checklist, 279–286 constructive toy play and, 176–177
Toys. See also Play flexible creative object play intervention topic
flexible creative object play intervention topic and, 184–185
and, 173–187 imitation as a learning tool intervention topic
pretend play intervention topic and, 187–199 and, 143–147
Training Vocal games, 203–204, 209–210
knowledge base needed by coaches and, 27–28 Vocalizations. See also Sounds; Speech
motivational interviewing (MI) and, 50–52 helping young children develop speech
Transdisciplinary approach intervention topic and, 200–218
motivational interviewing (MI) and, 50–52 imitation as a learning tool intervention topic
transdisciplinary treatment plan and, 70–71 and, 139–140
Transitions P-ESDM Infant–Toddler Curriculum Checklist,
back-and-forth interactions (turn taking) 291–293
intervention topic and, 121–124 sharing interests and attention with others (joint
flexible creative object play intervention topic attention) intervention topic and, 166
and, 177, 183–184
imitation as a learning tool intervention topic Warm-up activities in coaching sessions, 76,
and, 146 79–80. See also Coaching session routines;
Treatment and Education of Autistic and Related Parent coaching sessions
Communication-Handicapped Children Week, plan for, 43–44
(TEACCH), 12–14, 19–20 Wide-angle perspective, 47

Sally J. Rogers, Laurie A. Vismara, Geraldine Dawson - Coaching Parents of Young Children With Autism - Promoting Connection, Communication, and Learning-The Guilford Press (2021)

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Sally J. Rogers, Laurie A. Vismara, Geraldine Dawson - Coaching Parents of Young Children With Autism - Promoting Connection, Communication, and Learning-The Guilford Press (2021)

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Coaching Parents of Young Children with Autism

Early Start Denver Model for Young Children with Autism:

Early Start Denver Model Curriculum Checklist

Human Behavior, Learning, and the Developing Brain:

Human Behavior, Learning, and the Developing Brain:

Imitation and the Social Mind: Autism and Typical Development

FOR GENERAL READERS

A Parent’s Guide to High-­Functioning Autism Spectrum Disorder:

What Science Tells Us about Autism Spectrum Disorder:

THE GUILFORD PRESS

All rights reserved

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED DUPLICATION LICENSE

The publisher grants to individual purchasers of this book nonassignable permission to

Library of Congress Cataloging-in-­Publication Data is available from the publisher.

ISBN 978-1-4625-4571-1 (paperback) — ISBN 978-1-4625-4572-8 (hardcover)

Chapter 1 Helping Parents Help Their Young Children with Autism: 1

Chapter 2 Key Practices in Coaching Parents 12

Chapter 3 Becoming a Coach: Knowledge, Characteristics, 23

Sally J. Rogers, PhD, is Distinguished Professor Emeritus of Psychiatry and

Geraldine Dawson, PhD, is the William Cleland Distinguished Professor of Psy-

Chapter 4 The Coach’s Tools 41

Clipboard and Pencil, 41

Chapter 5 Assessment, Goal Setting, and Treatment Planning 59

From Diagnosis to Treatment Planning, 59

Chapter 6 Parent Coaching Sessions 73

The First Coaching Session, 73

Chapter 7 Guides for Introducing Intervention Topics and Strategies 102

Topic VII: Why It Is So Important That Children Learn to Share

Chapter 8 Variations in Coaching Practices 220

Variations in Family Stories, 221

Chapter 9 Looking to the Future: Challenges and Opportunities 242

Children with ASD Who Have Co-­Occurring Conditions:

Appendix A Handouts and Checklists Used Routinely in Parent 255

Appendix B P-ESDM Infant–Toddler Curriculum Checklist 287

Appendix C Parent-Friendly Data-Tracking Tools 301

Appendix C.1: Simple Tally System, 303

Helping Parents Help Their Young

Why Has This Model Emerged?

Defining Coaching within Parent-­Implemented

Unique Aspects of the Coaching Relationship

ultimately promote self-discovery. Goal accomplishment is the result of the efforts

Table 1.1.Role Differences: Coach versus Interventionist

Where Do These Ideas Come From?

Who Are We Writing For?

What Lies Ahead?

enhance practitioners’ motivation and skills to support parents to embed interven-

Key Practices in Coaching

The current emphasis on parent-­implemented interventions for early ASD is fueled

The Generalist Model Developed by TEACCH

Key Practice: Attending to the Positive Parent–Child

were eventually proven wrong. Beginning with the landmark contributions of

Key Practice: Building Language Interventions Based

Key Practice: Interdisciplinary Teams

to the downward extension of what some consider a “best practices” model of

Key Practice: Parent Coaching

Coaching approaches can be found within sports, business, education, humanistic

1. Relationships are egalitarian and collaborative, rather than authoritarian.

hands-on therapy practices. Deeply informed by research in infant–­toddler devel-

In a system-­centered model, care processes are structured to facilitate the function

Dunst and Trivette (2009a) proposed a framework for help-­giving relationships

A Parent’s Guide to High-Functioning Autism Spectrum Disorder:

Library of Congress Cataloging-in-Publication Data is available from the publisher.

Children with ASD Who Have Co-Occurring Conditions:

Defining Coaching within Parent-Implemented

The current emphasis on parent-implemented interventions for early ASD is fueled

hands-on therapy practices. Deeply informed by research in infant–toddler devel-

In a system-centered model, care processes are structured to facilitate the function

Dunst and Trivette (2009a) proposed a framework for help-giving relationships

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

1. The family needs to hear about the parent-

Below are some examples of “parent-friendly” objectives and learning steps.

but also the opportunity to support parents through a process of self-discovery: