Blended Developmental ‐Behavioral Intervention for Toddlers at Risk for Autism: The Southern California BRIDGE Collaborative

Josh Feder, MD
Director of Training,

Southern California BRIDGE Collaborative

Disclosures 2103

• • • • •

Clinical SymPlay, ICDL Grad School, Early Years COC and BRIDGE Circlestretch, CAPTN, Cherry Crisp FTE = 2.5 (cloned)

Overview (pecha kucha)
• 20 slides at 20 sec each = 6:40 & discussion • The Problem • Settling on an Intervention • ImPACT as a Blended Model • Warming it Up to Create BRIDGE • Outcomes: progress and challenges

The Problem – Circa 2007
• • • •
K. Searcy to A. Stahmer

Growing numbers of people with ASDs Diminishing resources Need to catch cases earlier Diverse views on best intervention: strict behavioral, PRT, Developmental (DIR) • Little research on intervention in toddlers • Community Based Participatory Research: collaborative, shared decision making that supports Evidence Based Practice.

Settling on an Intervention:
2008 - 2010, ‘pre-funding’ Concrete problem solving – Process oriented evolution

• Diverse group: researchers, clinicians (MH, SL, OT, Ed), parents, funders (SDRC,Harbor RC, Kaiser ); most from the behavioral world, some from the smaller developmental world (M. Burgeson, M. Culligan, HOPE Infant, L. Jenkinson J. Feder, et. al.) • Meeting monthly – with FOOD! – gradual coalescing trust – deciding on a name and logo • Reviewed multiple programs for: parent-focus, evidence in ASD, developmental breadth, crossdisciplinary breadth

Settling on an Intervention
2010 – 2012 grant (250k) Concrete problem solving – Process oriented evolution

• 3 picked for community presentation: P.L.A.Y. Project, Enhanced Milieu Training, and Project ImPACT • Focus groups from community • Mediated final decision-making & process of acceptance: • Picked Project ImPACT with plan to enhance and modify

A Blended Program: ImPACT Components
Direct Teaching Prompting Reinforcement Interactive Techniques Playful obstruction Balanced turns

Communicative temptations
Follow your child's lead Imitate your child Animation Modeling & expanding language

Warming It Up to Create BRIDGE
ImPACT Goals: • Social engagement – measurable joint attention • Communication – measurable number of words • Social imitation - measurable events • Play – measuarable play skills Warming it Up to make BRIDGE: • Bring Empathy to Engagement • Communication beyond ‘language’ & # of words • Affective nuance beyond ‘animation’ • Caring about Individual Differences • Holding each other in a Parallel Reflective Process

Piloting the Intervention –
Feasibility StudyParticipants & Measures

Participants

• 13 children (with 12 moms and one dad) , 7 to 21 months, at-risk for ASD, 85% Male, 77% Caucasian
• Mullen Scales of Early Learning, Early Learning Composite: M = 89.9; SD = 20.9; Range = 67-119

• Measures • Child: MacArthur/Bates Communicative Development Inventory – Communication and Symbolic Behavior Scales •Parent: Fidelity of implementation of the intervention strategies » Intervention content knowledge quiz » Treatment Satisfaction.

Procedures
Context: 4 clinics, multidisciplinary, training days, setting reflective precess Recruitment: referred by local agencies or the Regional Center. Consent, intake assessments assigned to provider based on funding / geographic location. Intervention: • 1.5 hour sessions, twice per week for 12 weeks (approx. 29 hours total). • Parents received manual and learned 1-2 strategies per week. • Sessions: reviewing strategies, modeling techniques with child, coaching parent with child •Homework: times to practice, questions on success and difficulty • Missed sessions were rescheduled. Assessments: The research team conducted assessments before and after intervention.

BRIDGE Outcomes:
• Training: feels too compressed; examples aren’t for toddler ( ImPACT for older kids ) • Clinicians: floortimers do floortime, behaviorally oriented people often focused on specific goals (‘ball!’) • Parents: good fidelity, master 70 -80% of strategies, • Parents like it, but not the HW • Kids: McArthur-Bates improve Saying 30 more words, understanding 85 more words, using 15 more gestures; • Kids: % Prelinguistic dropped from 40 to 30%, Early 1 Word rose from 15 to 45 %, Late 1 Word fell from 30% to 0; Multiword rose from 15 to 35% • Researchers: got talks, posters, and papers out of it

BRIDGE Outcomes: Progress
• Clinical: expanding to other clinics and regions • Research: continued Community Based Participatory Research (CBPR), 2013 grant: 500 k for studying training process • Training: writing treatment manual, expanding training, conference presentations • Continued reflective parallel process at many system levels supports commitment and sustainability.

BRIDGE Challenges
Recruitment: Finding families For many clinicians: • Embracing engagement • Utilizing reflective process • Giving control over to parents • Helping clinicians and parents learn to wait • Helping clinicians and parents to be empathic For some clinicians: • Accepting formal goals for sessions • Taking data For Parents: need to retool manual for younger children and better respect for principles of adult learning (change homework)

Rewriting Parent Manuals: Can Pictures help?

Rewriting Clinician Manual: e.g. ‘what not to say’ clinician- parent cartoons (‘I can’t meet at 5, I have to take my daughter to violin lessons’)

The Future
• • • • • More meetings – more food! More training and more clinics More research - and more publications! More families helped, we hope And gradual shifting toward a culture of true evidence based practice

Evidence Based Practice
Where clinicians look at all relevant research and use their clinical judgment and experience to offer families choices for treatment that fit their own culture and values in a process of true informed consent

Ideas For Discussion
• What are your experiences with working with people who have diversity in training? • Do we agree that both open-ended and structured approaches can be legitimate and appropriate ways to intervene? • Do you accept the idea that families should be the ones to decide what they want for treatment? What if what they want is something that you feel is not a good fit for them? If so, how do we ensure that this is not due to our own biases?