Play and Language for Autistic Youngsters

The P.L.A.Y. Project ModelCommunity Based Autism Training and Early Intervention

www.playproject.org

Richard Solomon M.D.Medical Director

The Ann Arbor Center

for Developmental & Behavioral Pediatrics

Background: Prevalence

• Prior to 1990s: 4-5 per 10,000 for autism

• Current estimates: 2-6 per 1,000 children for autism spectrum

• Brick NJ: 4 per 1,000-AD; 6.7 per 1,000-ASD

• 2003 California study: Doubling in last 4 years

• 1 in 150. CDC 2007.

• Four times more common in boys. 1 in 88

Number of Children with Autism Served Under IDEA, Part B, 1991-92 to 1998-99,

6-21 years

0

10,000

20,000

30,000

40,000

50,000

60,000

91-92(n=27)

92-93(n=49)

93-94(n=51)

94-95(n=52)

95-96(n=52)

96-97(N=52)

97-98(n=52)

98-99(n=52)

School Years

Number of Children

Source: U.S. Department of Education, Office of Special Education Programs, Data Analysis System (DANS)

Figure 1. Increase in the Number of Autism Cases in Michigan Schools 1983-2000

0.0

200.0

400.0

600.0

800.0

1000.0

1200.0

1400.0

1600.0

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

Percent Increase From 1982

Total Disabled

With Autism

Background: Intervention

• National Research Council (2001)• Begin early: 18 month-5 years• 25 hours/week• 1:1 or 1:2• Engaging• Strategic Direction• Comprehensive programs address ASD

PLAY Workshop

Developmental Course of Autism

6 yrs old

Developmental

Age

2

FDL 1

34

5

6Cognitive Impairment

Typical Development

Autism: Natural Course

Autism: Intensive Intervention

6 yrs oldAge

Background Intensive Interventions

• Behavioral Approaches• EIBI/Discrete Trial--Lovaas/UCLA Young Autism Program

• Verbal Behavioral--Sundberg/Carbone

• Pivotal Response Therapy--Koegel & Koegel

• Developmental Approaches• D.I.R--Greenspan & Weider

• Responsive Teaching--Mahoney

• McConachie--Hanen

• The P.L.A.Y. Project--Solomon

• The Denver Model--Rogers

Background: Interventions

Core Deficits

EIBI PLAY

Language

Delays

Teach skills in Small steps &

Reinforce

Affect connects language to events.

Social

Deficits

Adult directed

Reward and shape social overtures

Child led

Contingent reciprocal intrx

Repetitive

Behaviors

ABCs of ABA to reduce prob. beh.

Use behavior to understand child

Background: The Need

• Pennsylvania Experience• Cost for professional intervention:

$40-60,000 per child per year• Effective, efficient interventions needed• Community-based, family centered

approaches are efficient.• Few well done studies on parent training

approaches

PLAY Project:Vision

“The vision of the PLAY Project is to be a community based/regional autism training and early intervention center dedicated to empowering parents and professionals to implement intensive, developmental interventions for young children with autism

in the most effective and efficient way.”

The PLAY Project: Mission

• Promote MD early identification and early intervention. See journal--Pediatrics (2007)

• Educate community re: National Research Council recommendations

• Use community based approaches to promulgate developmental, individual differences and relationship based interventions (DIR)

• Support families in a parent-professional partnership

• Evaluate effectiveness of program

PLAY Workshop

D.I.R.® Model/Floortime (Greenspan)

• Developmental, Individual differences and Relationship-based

• One-on-one intensive engagement

• Child centered - meet’em where they’re at

• DIR is the theory, ‘Floortime’ the practice

• 15-25 hour/week beside school

• 6 Functional developmental levels

PLAY Workshop

Greenspan/DIR Model

6 Functional Developmental Levels• Self regulation and shared attention (FDL 1)

• Engagement (FDL 2)

• Two-way Communication (FDL 3)

• Complex two-way Communication (FDL 4)

• Shared Meanings & Symbolic Play (FDL 5)

• Emotional Thinking (FDL 6)

PLAY Project

Community Development I

• Collaboration/Coalition Building• MAAP • Referring physicians (Neurology, Psychiatry, DBP)• School Districts/State Dept of Education• Autism Societies• Child Welfare Programs• Community Mental Health Children’s Services• Parent support groups• Early On Systems Coordinator

P.L.A.Y. Project & Programs (2006)(Play and Language for Autistic Youngsters)

PLAY Project

Regional Training Center

Office Consultation

Home Consultation

Training Program

MAP Parent Support

Prog. Eval & Research

•Office Visit at AACDBP

•Diagnosis

•Referrals to SLP, OT & Home Consult..

•Monthly half day visits

•Train parents in DIR model;

•Video feedback training (FEAS)

•Community-based trainings

•Introductory & intermediate

•Training Center

•Parent Support

•Parent/Prof Partnership

•Advocacy and Resources

•Prog Eval of

Home Consult Program and Comm. Train.

•NIMH trial planned

PLAY Project

Ann Arbor Center Home Consultants • 25 Families/consultant/yr = 1 FTE• Average 20 feedback sessions per year

– 10 Home Visits (roughly monthly)– 10 Video Reviews

• 260 visits per consultant year • 6 half day sessions per week• 1 hour service radius• Half day for supervision• Home Consultant Training

• Intensive initial training• Weekly supervision • ICDL Training Summer Institute

The PLAY Project

Home Consultant: Visit Design• Monthly half day/3 hour visits• Review of PLAY Project Manual/Training• Model PLAY Techniques by Consultants• Observe and Coach PLAY Partners (Parents)• Video Feedback at the visit• Visit Report Form (Curriculum) after the visit• Reflective Supervision• Use ‘PLAY Skill Sequence’

PLAY Skill Sequence: Summary

2.Assess Child’s unique: CZ Activities, SP & FDL

1. List Principles & Strategies Based on Comfort Zone (CZ) Sensory Profile (SP) and Functional Developmental Level (FDL)

3. Define Daily&Weekly Curriculum/Activities

5. Create Menu Of Specific Techniques

4. Follow Child’s Cues, Lead & Intent to Increase Circles

6. Video Tape/Critically Review Interactions and Progress

7. Refine Curriculum, Methods & Techniques

PLAY Project

Home Consultant: Intake

• Assessments • Family Intake Form • Childhood Autism Rating Scale (CARS) • Greenspan Social-Emotional Growth Chart• Functional Emotional Assessment Scale (FEAS)• REEL-3 (Language)• Satisfaction Surveys (3 months/1 year)• FDL Progress Charts

Functional Developmental Level Progress Chart: Child's Name: AAC-06-103

Home Consultant: Ann Arbor Center

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 [04/04/05] 2 V ideo

[05/09/05]

3 [06/09/05] 4 V ideo

[07/15/05]

5 [08/11/05] 6 V ideo

[09/15/05]

7 [10/11/05] 8 [12/15/05] 9 [02/08/06] Date Date Reference

Monthly Visit

Percent Attainment

FDL1

FDL 2

FDL 3

FDL 4

FDL 5

FDL 6

Solid engagement

Working at lower levels

Upper symbolic levels filling in

© Copyright - 2006 Richard Solomn MD

Functio nal Develo pmental Level Pro g res s Chart: Child's Name: AAC-06-102

Ho me Co ns ultant: Ann Arbo r Center

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 [04/12/05] 2 [05/12/05] 3 [06/06/05] 4 [07/22/05] 5 [08/25/05] 6 [10/07/05] 7 [11/08/05] 8 [12/12/05] 9 [02/08/06] 10 [Date] Date R eference

Monthly Visit

Percent Attainment

FDL1FDL 2FDL 3FDL 4FDL 5FDL 6

Holes in lower levels

Lower levels filling in

Upper symbolic levels appearing

P.L.A.Y. Project & Programs (2006)(Play and Language for Autistic Youngsters)

PLAY Project

Regional Training Center

Office Consultation

Home Consultation

Training Program

MAP Parent Support

Prog. Eval & Research

•Office Visit at AACDBP

•Diagnosis

•Referrals to SLP, OT & Home Consult..

•Monthly half day visits

•Train parents in DIR model;

•Video feedback training (FEAS)

•Community-based trainings

•Introductory & intermediate

•Training Center

•Parent Support

•Parent/Prof Partnership

•Advocacy and Resources

•Prog Eval of

Home Consult Program and Comm. Train.

•NIMH trial planned

P.L.A.Y. Project & Programs(Play and Language for Autistic Youngsters)

PLAY Project

Regional Training Center

Office Consultation

Home Consultation

Training Center

MAP Parent Support

Prog. Eval & Research

Community based trainings

School based Trainings

Agency Trainings

DVD Workshop Internet/Virtual Resources

PLAY Project

Community Trainings

• Annual Conference

• PLAY Project Workshops• Level 1: Introduction to PLAY/DIR• Level 2: Intermediate PLAY/DIR• Level 3: Family Support/Watch & Learn

• DVD Digital Video Workshop• Skill Sequence• Dozens of Examples of Parents Playing

PLAY Project

School & PLAY

• Parents training plus training of pre/school staff guarantees ‘intensity’ (15 hrs/week, 1:1)

• Cost effective, naturalistic, integrated into classroom • PPHC trains selected teachers, staff and/or

paraprofessionals as PLAY Partners• Continuity between home and school=generalization• DIR Framework informs all interactions• IEP Goals: Attention, engagement, initiation:• “1000 circles a day” & much less prompting.

PLAY Project

Agencies Trained• PLAY Projects in 25 States • Strong Easter Seals Affiliation• Various Agencies

• Private Rehab Centers, • Education: Birth-3, Special Ed Pre-Schools, Schools, • Hospitals and Health Centers• Community Mental Health Centers

• 150 PLAY Home Consultants trained• 1000 children per year provided services• 15 Sites in Michigan

The PLAY Project

Training Process I

• Intensive training weekend – 4 days• DIR Model, functional developmental

levels• Home visit process• PLAY Skill Sequence• Taking videos, analyzing videos• Preparing reports for families• Administrative matters

The PLAY Project

Training Process II

• Home Consultant trainee builds caseload

• Trainee ready to begin home visits following intensive training

• Recommend caseload of 6-25 children with ASD

• Videos obtained at home visits

The PLAY Project

Training Process III• Supervision, Certification, Licensing & Cost

• Portion of home visit videos sent to Supervisors

• Supervisors provide trainee with constructive feedback by audiotape

• 20 videos sent over 12-18 month period• Certification expected on completion of

Supervision process• Agency licensed annually $750 (not 1st year)• Cost: $4500-5500 depending on number• Designed to be self-sustaining

The P.L.A.Y. Project: Michigan

Age 3-5Lo

Med

High

Traverse City

Grand Rapids

Midland

Troy

DownriverAnn Arbor

South Bend, IN Toledo, OH

Flint

West UP

Saginaw / Bay City14 PLAY

Projects serving the state Lansing

Whitmore LakeW. Detroit

Marquette (07)

PLAY Project

Internet: Relate Now• Secure virtual community for families with a

child with autism• Parents select team for child• Videos can be uploaded and reviewed from a

distance.• Videos archived as examples• Expert blogs and articles• Specifically designed for PLAY Project • Long distance case studies and webinars• $30 monthly subscription pays for service

P.L.A.Y. Project & Programs (2006)(Play and Language for Autistic Youngsters)

PLAY Project

Regional Training Center

Office Consultation

Home Consultation

Training Program

MAP Parent Support

Prog. Eval & Research

•Office Visit at AACDBP

•Diagnosis

•Referrals to SLP, OT & Home Consult..

•Monthly half day visits

•Train parents in DIR model;

•Video feedback training (FEAS)

•Community-based trainings

•Introductory & intermediate

•Training Center

•Parent Support

•Parent/Prof Partnership

•Advocacy and Resources

•Prog Eval of

Home Consult Program and Comm. Train.

•NIMH trial planned

Pilot study of a parent training program for young children with autism: The P.L.A.Y. Project Home Consultation

Solomon, R. J. Necheles, C. Ferch, and D. Bruckman.

Autism 11, no. 3 (2007) 205-224

The PLAY Project

Program Evaluation: Sample• 68 subjects were analyzed

• 74 children were recruited in 14 months• 6 families withdrew

• Sample Characteristics• Average age 3.7 (SE = 0.2) (Range 2-6)• Average age at dx 35.3 months• 71.6 % (20/68) of mothers and 71.2% (20/67) of

fathers had college degree or better • Severity of autism (see chart)

The PLAY Project

Program Evaluation: Home Consultation

Measures:

• Functional Emotional Assessment Scale (FEAS)

• Valid/reliable, norm referenced video rating scale• Rates parent sensitivity to child• Rates child functional developmental level

• Clinical rating of progress

FEAS

THE CHILD AND THE CAREGIVER ARE ASSESSED IN SIX DIFFERENT AREAS- These are based on the Developmental Levels of Emotional Functioning

(Greenspan and Wieder)

PLAY Workshop

Greenspan/DIR Model

• 6 Functional Developmental Levels• Self regulation and Shared Attention (FDL 1)

• Engagement (FDL 2)

• Two-way Communication (FDL 3)

• Complex two-way Communication (FDL 4)

• Shared Meanings & Symbolic Play (FDL 5)

• Emotional Thinking (FDL 6)

FEAS ASSESSMENT METHOD

• The child and caregiver are evaluated on play capacities during symbolic and sensory (tactile and movement) play over a fifteen minute period.

• Five minutes with symbolic, five minutes with tactile and five minutes with movement toys.

Scores on each individual item range from:

• 0 Behavior not seen at all or observed briefly.

• 1 Behavior present some of the time or observed several times.

• 2 Behavior is consistently present or observed many times.

Examples of Caregiver Questions for Regulation:

• Shows sustained interest in the child, focuses on child’s signals (gestures, vocalizations), keeping the child involved.

• Is sensitive and responsive to child’s need for touch by stroking or touching child in a pleasurable way and /or encourages child to explore textured toys.

Examples of Child’s Questions for Regulation:

• Is interested and attentive to play with toys• Is comfortable touching textured toys and in being

touched by caregiver• Reactivity

– Underreactiveity: Appears sluggish or withdrawn

– Overreactivitry: Appears aroused by toys and environment

Examples of Caregiver Questions for Purposeful Communication:

• Allows the child to decide on the play topic, to initiate play and explore toys in ways that the child seeks or needs.

• Responds to the child’s wishes, intentions and actions in a contingent way, building on how the child wishes to play.

Examples of Child’s Questions for Purposeful Communication:

• Opens Circles - Initiates intentional actions with objects while also engaged in interactions with the caregiver.

• Closes Circles – Responds to caregivers cues in a contingent manner.

The PLAY Project

Program Evaluation• Pre/Post Measures

• Clinical (home consultant) ratings– Estimates of children’s FDL at baseline and 1 yr

• Fidelity (hrs/week of P.L.A.Y. Project methods– High (> 15), Medium (10-14), Low (< 10)

– Parent report (logs ineffective)

• Other hours of other interventions• Client satisfaction surveys at 3 mo and 1 year

The PLAY Project

Program Evaluation• Statistical Analysis and Scoring

• Inter-rater reliability: Paired t-test (two tailed)• FEAS Total Scores: Paired t-test (two tailed)

– Subscale scores for 6 possible functional developmental levels were totaled.

– Total scores were compared before and after intervention.

• FEAS Scaled Scores: Paired t-test (two tailed)– Subscale scores were used to establish functional

developmental level using strict criteria.

The PLAY Project

Program Evaluation: Results• FEAS

– Inter-rater Reliability:• When the raters scored each child on the FEAS the

difference in scores were not significantly different (p > 0.05 paired t-test). This finding occurred in both the before and after intervention scores.

• When the raters scored each parent on the FEAS the difference in scores were not significantly different (p > 0.05 paired t-test). This finding occurred in both the before and after intervention scores.

• Kappa scores for inter-rater reliability were good to very good.

The PLAY Project

Program Evaluation• Statistical Analysis and Scoring (cont)

• Home Consultants Clinical Ratings: Paired t-test (two tailed).

– Scores based on clinical estimate of FDL (Greenspan)

– 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6

• Autism Severity: Medical evaluation (1-5) – Autistic disorder-severe, moderate, mild

– PDD NOS

– Aspergers

• Fidelity: High >15 hrs/wk, Med 10-14, Low < 10• Satisfaction surveys: VS, S, SS, NS

The PLAY Project

Sample: Autism Severity

0

5

10

15

20

25

Severe 10Moderate 23Mild 18PDD NOS 14Aspergers 3

The PLAY Project

Program Evaluation: Sample

• Other Programs and Interventions• 12 Children < 3 yrs old in Early On received

approximately 2 hour/wk of intervention• 56 Children > 3 yrs old in special education

preschool which provides 4-5 half days/2.5 hours per day.

• None of the children received other intensive interventions (e.g. ABA)

The PLAY Project

Program Evaluation: Results

• FEAS: Parent Outcomes• There was no change in parent FEAS scores before

and after PLAY implementation (p = 0.63)

• FEAS: Child Outcomes• There was a highly statistically significant change

in the FEAS total scores AND scaled scores before and after PLAY implementation (p< 0.0001)

The PLAY Project

Results: FEAS Total Score

0

10

20

30

40

50

60

70

80

90

Before After

CaregiverChild Total

**

* p= 0.63 ** p< 0.0001

*

The PLAY Project

Program Evaluation: Results• Satisfaction

• 74% completed surveys• 70% were very satisfied• 10% satisfied

• Clinical Outcomes• Based on FEAS scaled scores 45.5% of children

made good to very good progress after intervention.• Based on Home Consultant Clinical Scores

– 52% of children made very good progress i.e. > 1.5 FDL

– 14% of children made good progress i.e. 1 FDL

The PLAY Project

Results: Child Scaled FEAS

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Before After

FEAS ScaledHC Clinical

* p< 0.0001

* *

The PLAY Project

Results: Fidelity

0

2

4

6

8

10

12

14

16

18

High Low

G/VGFairNo Change

p= 0.09

The PLAY Project

Discussion• First report of a parent training program evaluation

based on DIR theory.

• PLAY Project Home Consulting Program operationalized DIR theory:

• Extensive training manual• ‘Skill Sequence’• Structured home visiting• Video feedback

The PLAY Project

Discussion• Limitations

• Pilot study without controls

• More in depth, repeated and objective measures needed

• Daily logs unreliable

• Parents were educated; families intact; only one parent working in many families.

• Generalization to other environments not measured

The PLAY Project

Conclusions• Parents appear to have skills early on. • Between half and two-thirds of the children made

good to very good clinical improvement.

• More hours of intervention resulted in improved outcomes.

• More rigorous study is needed

• PPHC model shows promise as a cost effective intervention for young children with autism

The PLAY Project

Future: NIMH/SBIR Research

• Phase I study piloted controlled study of PLAY Project versus community standard intervention at 4 Easter Seals sites over 5 month period (2006-07)– Study complete. Pilot successful.

• Planned Phase II NIMH, an RCT, will compare 100 children in PLAY vs. 100 children in community standard intervention at 20 sites over 2 year period. Application due in December, 2008.

• Study sites partner: Easter Seals.• Research design partner: Michigan State University

P.L.A.Y. Project & Programs (2006)(Play and Language for Autistic Youngsters)

PLAY Project

Regional Training Center

Office Consultation

Home Consultation

Training Program

MAP Parent Support

Prog. Eval & Research

•Office Visit at AACDBP

•Diagnosis

•Referrals to SLP, OT & Home Consult..

•Monthly half day visits

•Train parents in DIR model;

•Video feedback training (FEAS)

•Community-based trainings

•Introductory & intermediate

•Training Center

•Parent Support

•Parent/Prof Partnership

•Advocacy and Resources

•Prog Eval of

Home Consult Program and Comm. Train.

•NIMH trial planned