Combining Single Case Design and Group Experimental Design Research

1. Combining Single Case Design and Group Experimental Design Research Ann P. Kaiser, PhD Vanderbilt University IES SCD June 2019

2. Today’s Talk • Overview of research on Enhanced Milieu Teaching (EMT) • Illustrate how single case and group experimental designs have been used to build an evidence base for a specific intervention • Discuss the advantages and limitations • Guidelines for developing research program drawing on both single case and group design methods • Part 1 now and Part 2 on Friday IES SCD June 2019

3. Background: Young Children with Language Impairment • Language development is one of the strongest predictors of children’s long term academic and social outcomes • Primary language impairment with no other developmental disorders • Young children with typical cognitive development but significant delays in receptive and expressive language at age 2 are at-risk for later social and academic development. • The risk for persistent language impairment increases when children live in low resourced homes and communities • Secondary language impairment associated with other developmental disorders • Young children with intellectual disabilities, Down syndrome, autism spectrum disorders, cleft lip and/or palate • Significant persistent deficits in vocabulary, syntax and social language use that impact overall development, social engagement, behavior and academic performance IES SCD June 2019

4. Enhanced Milieu Teaching IES SCD June 2019

5. IES SCD June 2019

6. Enhanced Milieu Teaching • Program of research • Funded by a ranges of agencies NICHD program project on children with intellectual disabilities; IES Goal 3 projects, Autism Speaks, OSERS model demonstration project, HRSA, John Merck Foundation, NIDCD U01 clinical trial • Broad population of children ID, DS, ASD, language delayed, children at-risk due to poverty, children with CLP, children with language delays across Spanish and English, in US and South Africa • Multiple methods Group experimental, RCT, single case designs, descriptive group analyses • Goals: • Improving generalized communication outcomes for children • Understanding the conditions in which communication and language are learned IES SCD June 2019

7. EMT Principles and Strategies • Promote adult-child communication in interactions • Notice and respond • Follow the child’s lead • Increase child engagement with objects and activities Child preferred activities Join the child in play and activity Teach play and participation • Expand the social basis of communicative interactions • Arrange environment to increase engagement • Teach joint attention strategies • Balance turns (mirror and map) • Increase person engagement • Teach child communication target forms to advance language • Respond • Model • Expand • Prompt IES SCD June 2019

8. Evidence For Child Outcomes • Increases child use of language targets • Vocabulary (Kaiser et al, l993*; Scherer & Kaiser, 2010*; Roberts & Kaiser, 2012; Kaiser & Roberts, 2013; Roberts & Kaiser, 2015; Kaiser, Scherer, Frey & Roberts, 2017) • Early syntactic forms (Kaiser & Hester, 1994*) • Moderately complex syntax (Warren & Kaiser, l986*) • Increases child frequency of communication (Warren et al., l994*; Kaiser et al, l993*; Kasari et al., 2016; Curtis, et al.,2017) • Generalization across settings, people, and language concepts (Warren & Bambara, l989; Goldstein & Mousetis, l989; Kaiser & Roberts, 2013) • Maintenance of newly learned targets (Warren & Kaiser, l986; Kaiser & Roberts, 2012; Roberts et al., 2013*) • More effective than drill-practice methods (Yoder, Kaiser, & Alpert, l991*; Kaiser, Yoder, et al., 1996*) * SCD studies IES SCD June 2019

9. Training communication partners as interventionists is an essential component of EMT Partner/Interventionist Key Skills Environmental Arrangement Notice and Respond Balance Turns Model/ Expand Target Talk Time Delay Milieu Prompting Sequence Mode: Signs, SGD, Speech • Therapists • Parents • Siblings • Teachers and assistants IES SCD June 2019

10. A Cascading Intervention Model How to Teach Interventionists? What to Teach Interventionists? • Partner/Interventionists: • Parents • Teachers • SLPs • Therapists • Siblings IES SCD June 2019

11. Maximizing Intervention Effects Teach-Model-Coach-Review Training (Parent Intervention) Interventionist Training • Based on 6 adult learning strategies (Dunst & Trivette, 2009). • Simultaneous use of different methods has the largest effect (d=1.25). Interventionist Use of Strategies Child Language IES SCD June 2019

12. Evidence for Training Parents • Parents learn a range of strategies to criterion levels. • Environmental arrangement (Alpert & Kaiser, 1992*; Hemmeter & Kaiser 1990*) • Responsive interaction strategies (Hancock & Kaiser, 2002*; Kaiser et al., 1996*, Kaiser & Roberts, 2012; 2015) • Modeling language targets (Hancock & Kaiser, 2002*; Roberts & Kaiser, 2015) • Prompting target production using MT techniques (Kaiser, Hancock & Nietfeld*, 2001; Roberts et al, 2015; Wright & Kaiser, 2013*) • Parents generalize these strategies to home interactions with their children (Hancock & Kaiser, 2002; Kaiser & Roberts, 2012; Roberts et al, 2015*Wright & Kaiser, 2013*; Peredo, et al., 2017*). • Parents maintain their newly-learned skills over 6-18 months (Kaiser, et al 2001*; Kaiser & Roberts, 2012;Roberts & Kaiser, 2015; Hampton et al.,2018). IES SCD June 2019

13. EMT Modifications to Child Characteristics IES SCD June 2019

14. Modifications of EMT • JASPER + EMT [J-EMT] • Teaches joint attention, symbolic play, regulation • JASPER + EMT + AAC [J-EMT+ SGD ; Words + Signs] • Teaches joint attention, symbolic play, regulation • Includes speech generating device or signs for input and output • Phonological Emphasis + EMT [PE-EMT] • Models speech targets • Recasts for speech • EMT en Espanol • + Discrete trial training [Rescue protocol] • - Reduce prompt complexity, number of prompts [Simplify] • + Increase Dosage [Dosage] • + Support Partners to use mode and EMT [Partner] IES SCD June 2019

15. Phenotypic Specific Modifications IES SCD June 2019

16. IES SCD June 2019

17. Using Single Case Designs • Foundations • Primary demonstrations of components of EMT • Demonstration of new combinations • Training Interventionists • Demonstrating parent training, sibling training, teacher training • Developing Teach-Model-Coach-Review • Training parent trainers • Examining generalization and maintenance • By intervention agents • By children • Differentiating intervention • Child population demonstrations • Adding mode: sign, SGD • Adding components: JASPER (Kasari et al 2006), positive behavior supports, direct instruction • Modifications for intervention context: Spanish speaking, siblings, classroom IES SCD June 2019

18. Single Case Design Studies IES SCD June 2019

19. Single Case Design Studies: Measurement IES SCD June 2019

20. Measurement Development Based on SCD • Observational measures of EMT components • Definitions, reliability standards and protocols, observer training protocols, • Specified to population’s baseline communication, target skills, mode, language • Fidelity of implementation criteria for primary EMT • Precise: percent responsiveness, percent talk at target level, number and percentage correct use of prompts • Global: Rating on Modified NDBI Checklist • Parent-training- • Teacher training – checklist based • Used for therapist implementation fidelity and parent implementation fidelity • Child proximal targets • # of social communicative utterances (word, gesture, sign,AAC) • # of different words or unique multiword targets • # of uses of specific target sentence types • % responsiveness to obligatory and nonobligatory partner communication • Secondary target measures • Use of AAC, problem behavior, generalization, maintenance, general linguistic development IES SCD June 2019

21. Preparation for RCTs • Estimating relationship between proximal gains and global or distal gains • Therapist-implemented produces more rapid gains in proximal targets for children with ID, DS and language impairment • Parent- implemented produces slightly more rapid gains and better global gains for children with ASD ( See Kaiser & Roberts, 2013) • Amount of gain in intervention (Words Observed) needed for 1 point gain on a standardized assessment varies by population • Development of fidelity measures and standards • Estimating dosage of intervention • Dosage for training partners • Acquisition of EMT at criterion • Mastery of EMT sufficient for generalization and maintenance: training across routines • Child dosage to demonstrate global gains varies by population • Could we have done this better with statistical ES estimates from the literature? IES SCD June 2019

22. Blending SCD and RCTToddlers with Receptive/Expressive Language Delays • Single case MBL with 4 families (Roberts et al, 2012) • Dosage based on proximal outcomes (NDW) • Tested Teach-Model-Coach-Review training protocol • Developed training modules for parents • Estimated power for distal outcomes • RCT Treatment vs Control (Roberts & Kaiser, 2013; 2014) • Longitudinal follow-up (Hampton et al, 2017; Hadley, Kaiser & Roberts, 2018) • Examined relation of parent fidelity to outcomes • Examined mediation of behavior and language outcomes (Curtis et al; 2018) • Examined predictors of response to treatment • RCT multisite clinical trial (Kaiser, Roberts & Hadley, in progress) • Revised and extended intervention to cover vocabulary, syntax, decontextualized language • Completely manualized treatment IES SCD June 2019

23. Blending SCD and RCTEMT en Espanol • Planning: acceptability, feasibility, adaptions • Reviewed data from Spanish speaking families in our previous studies • Interviewed families, providers- validated adapted EMT and TMCR procedures • SCD MBL teaching parents EMT en Espanol with generalization, social validity, maintenance ( Peredo, Zeyala & Kaiser, 2018) • Demonstration of TCMR on parent use of EMT • Made further adaptations of EMT and TMCR • Small RCT powered for parent outcomes (Peredo & Kaiser, under review) • Modest child outcomes • Revised intervention to include more therapist intervention, longer period of intervention, shared book reading • RCTpowered for child outcomes (IES Goal 3 Kaiser & Peredo, 2019) • SCD MBL teaching parents shared book reading strategies ( Lopez, Kaiser, & Peredo, in progress) IES SCD June 2019

24. Group Experimental Studies • Parent vs Therapist (ID)+ SCD embedded • Parent + Therapist ( Toddlers) • Minimally verbal ASD w/AAC • Minimally verbal ASD DT VS JEMT • Minimally verbal ASD DT+JEMT • ASD Toddlers JEMT • Cleft Lip+/-Palate EMT+PE • DS Preschoolers w/AAC • Spanish-Speaking Parents IES SCD June 2019

25. Strengths of SCD • Developing intervention • Demonstrating package interventions • Testing individual components of interventions • Developing implementation fidelity measures and criterion standards • Examine dosage in relation to proximal outcomes • Flexible design could allow modification of treatment, adjustment of dosage • Thorough examination of generalization and maintenance • Examine individual differences in response to treatment on proximal primary and secondary measures IES SCD June 2019

26. Limitations • Focus in on proximal, malleable outcomes: construct validity and relation to global measures may be a limitation • The nature of the intervention is influenced by the design of treatment delivery • Continuous monitoring • Feedback for performance, fidelity • Some behaviors limit the types of flexible SCD that can be used • May not be clear what characteristics of individuals are related to differences in responding • Challenges in estimating effects; Not how ES estimates for proximal outcomes translate from SCD to RCT • Measures used in RCTs are usually not the same proximal measures in context of intervention • Replications would be useful to increase confidence at each step of development, but rarely conducted IES SCD June 2019

27. Suggested Guidelines • Determine your long term goal(s) for your research • Theory of change • Indigenous implementers • Naturalistic context • Analyze what you need to know, have and measure • Participant characteristics • Treatment protocols, training materials, • Fidelity protocols • Measures of dependent variables • Dosage, intensity • Determine what questions can be asked using SCD • Determine the optimal, strongest contemporary design SCD for the question • Determine if designing the SCD for statistical analysis is possible • Determine what SCD replications are needed • Pilot global measures that will be used in RCT IES SCD June 2019

28. Thanks for your time and attention! More information about EMT research can be found at : • http://vkc.mc.vanderbilt.edu/kidtalk Complete List of Published Work : • MyBibliography:http://www.ncbi.nlm.nih.gov/sites/myncbi/1busdkbkcgaQ6/bibliography/41295281/public/?sort=date&direction=ascending Email me: • Ann.Kaiser@Vanderbilt.edu IES SCD June 2019