Parent-mediated interventions in young children with autism are well established as an evidence-based guideline. Proper measurement tools of parent support behaviors are critical to assessing effectiveness of interventions of parent-mediated support of child social outcomes. It was initially suspected that progress-monitoring measures of both parent support and child social/behavioral outcomes would be infrequently used in the published literature, which systematic review confirmed. Furthermore, direct observation of parent-child interactions using the IPCI-2 tool confirmed that this particular measure is efficient, validated, easily learned, and potentially invaluable in quantifying parent support behaviors and child social behaviors in children with ASD.
As exhibited in our systematic review, there is no current standard practice regarding parent and child monitoring in the field of ASD. Although parent-mediation was theorized as the mechanism for promoting child social outcomes in all of the studies included in the systematic review, only 25.9% (n=7) used a measure of both parent and child behavior to assess directly observed behavior during parent-child interaction. Of concern, measures that were used to assess both parent and child behavior based on direct observation of parent-child interaction tended to fall into one of two categories. Some were very narrow in focus. For example, two studies focused primarily on shared parent-child positive affect such as smiling, laughing, and elevated playful tone (Brian et al, 2017; Vernon et al., 2012) which warranted reliance on supplementary, separate parent measures to account for additional support behaviors (as cited in Brian et al, 2017). The others involved complex coding schemes, and high levels of training, which are not consistent with recommendations for routine measurement in early intervention (Greenwood, Carta, & McConnell, 2011).
Direct observation of a sample of toddlers with ASD and their caregivers using the IPCI- 2 progress-monitoring measure yielded easily quantifiable and interpretable parent support behavior and child social behavior outcomes with high reliability between two independent coders (92.5%) and significant associations between observed parent behavior and child social communication (Baggett et al., 2011; Schertz et al., 2017). Descriptive analysis of IPCI caregiver and child behaviors were similar for mothers and fathers. Although mothers engaged in higher levels of Maintaining and Extending and Acceptance and Warmth behavior as compared to fathers, this should be interpreted with caution given that this difference was due to five dyads that were univariate outliers.
Correlational analysis supported the study hypothesis that IPCI caregiver facilitator variables would positively correlate with child engagement behavior. Interestingly, caregiver maintains and extends, a behavior built upon following a child’s lead, was significantly
associated with positive social feedback. This finding suggests that children, whose caregivers provide high level support in maintaining their children’s interest, have patterns of higher affective engagement with their parents. Analysis of variance and post-hoc comparison tests provided support for the second hypothesis that mean levels of child engagement behavior would differ significantly among levels of overall caregiver facilitator behaviors. Children whose caregivers engaged in higher levels of support (low versus medium versus high), engaged in significantly higher levels of overall engagement behaviors, as well as composite child follow through and positive social feedback behaviors, with large effects. This particular difference was interesting given that child follow through and child positive social feedback require social engagement, whereas sustained engagement – the child variable excluded from this composite – does not require social engagement behavior to be exhibited.
Contributions to Current Research
This study provided the first systematic review of the early parent-mediated intervention literature. The results from this review supported recommendations from several other studies addressing the need for measures of parent-child interaction that are sensitive to the key proximal indicators of positive parent support behavior and child outcomes to further the understanding of how various intervention components effect change (Brown & Woods, 2016; Oono &
McConachie, 2013). It also highlighted the lack of practical, general progress monitors in use in the current early intervention literature. However, this study fills this gap by showing how the IPCI-2 can be used by lay practitioners working to measure progress in toddler social
communication through parent-mediated intervention. This measure may be used by community interventionists to examine several areas of inquiry including information about whether
coaching strategies are working as intended to increase levels of parent-responsivity as well as general mediating effects of parent behavior on child outcomes. This study showed that variations in levels of parent support (low, medium, high) predict levels of total child
engagement behaviors as well as composite child follow through and positive social feedback. Parent-child interaction progress measures like the IPCI can be used to inform coaches about behaviors that parents are using more or less actively. This data-based information can be used to help coaches make decisions about when to modify coaching to provide more targeted support to parents.
Study Limitations and Implications for Future Research
This study was limited to descriptive analysis of video data of caregiver-child interaction. Future efforts should focus on evaluating the effects of intervention on change in caregiver-child interactions. Future research may also benefit from further investigation that expounds on the
results of this study. One example would be to include variables in analysis that may impact parent facilitator scores such as child autism diagnostic scores, parent stress indices, income- levels, and native-language in order to explore how these variables may describe variations in parent support, as indicated by the IPCI, before the start of the intervention. This may be used to guide decisions about coaching strategies and intensity of intervention in response to specific associations with low facilitator scores before intervention begins. Another, example, would be to consider outliers as a focus of inquiry as they may provide valuable information in regard to causes of variation within specific caregiver-child dyads. These cases may warrant follow-up work to explore as a phenomenon of interest. Furthermore, research should also investigate the use of the IPCI to measure specific changes in caregiver-child interaction at several times points pre- and post-intervention within randomized samples of toddlers with ASD. Future community interventions should ensure parent responsive behaviors are appropriately measured as
recommended by using a parent-child interaction measure, such as the IPCI-2, that can be administered in short routine assessments to evaluate the progress of interventions and make quick decisions regarding treatment (Division for Early Childhood, 2014; Greenwood, Carta, & McConnell, 2011; Odom et al., 2016). Finally, if early ASD intervention studies exhibited more uniformity through use of a validated and reliable parent-child interaction measures, research would benefit from the ability to more accurately synthesize results from parent support within parent-mediated interventions.
Conclusion
Evaluating parent support behavior within the parent-child relationship in early intervention is critical because evidence shows responsive and sensitive caregiving leads to improved joint attention and social communication outcomes in toddlers with ASD. Evidence is
increasing that delivering parent-mediated early intervention through the meaningful and embedded parent-child relationship in natural environments gives children with ASD context to learn joint attention skills and improve other key social communication skills (Siller & Sigman, 2008; Green et al., 2017). Moreover, it is important that these outcomes are measured frequently in early intervention in order to maximize treatment efficiency. Through systematic review of the literature, this study highlighted the lack of practical examples of observation measures that can be used in the community setting. Results from a direct observation of parent-child interaction using the IPCI-2 monitoring tool demonstrated the feasibility of an observation measure with high reliability and utility to capture targeted constructs key to promoting social communication in toddlers with ASD.
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