Literature Review: PROMPT Therapy

1. Literature Review: PROMPT Therapy Craig Domanski PS 572--Teaching Language and Social Skills to Children with Autism Caldwell College

2. Overview • Article summary • Search terms and parameters • Critique • Guidelines for evidence-based practice • References

3. Journal article summary • Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT Interventions • Rogers, S., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006)

4. Introduction • Children with autism have significant deficits in speech and language production • Language proficiency as an indicator for predicting outcomes • Many interventions focus on language acquisition

5. Two approaches have been used historically: • “Discrete trial teaching” • “Didactic, adult-directed instruction delivered from a pre-set curriculum often taught in massed trials” (Rogers et al., 2006) • After initial discrete trials, more complex language skills are taught through associative learning • Motivation is provided through external rewards

6. Naturalistic teaching methods (I.e., natural language teaching, incidental teaching, or pivotal response training) • “Child-initiated behavior in a natural interactive context” (Rogers et al., 2006) • Incorporates modeling, shaping, and “natural” reinforcers

7. Differences between DTT and naturalistic approaches • Adult-directed v. child-directed • Individualization of each learning opportunity • Type of reinforcement • Role of child as initiator • Degree of generalization promotion

8. Both are behavioral approaches • Language impairment for children with autism is a developmental disorder • Developmental interventions (Prizant) focus on: • Social engagement • Imitation skills • Means-ends concepts • Understanding language

9. The Denver Model • A developmental approach to language acquisition • Specific developmental curriculum • Individualized • Based on discrete trials, naturalistic teaching methods, and dyadic exchanges • Teaching based on attention to both teaching techniques and interpersonal relationships (Rogers et al., 2006) • Can be implemented in inclusive classrooms, individual therapies, or 1:1

10. The Denver Model (cont.) • Only 1 aspect of model implemented in current study (the communication curriculum) • Frequency: 1x/week, 50-min. session; daily home review by parents • Why?: typical of area programs • Description of session: naturalistic social-affective teaching interactions (“sensory social routines”) alternated with didactic instruction

11. Structure of sessions: • Highly motivating social games and activities • Naturalistic teaching • High frequency of social interactions • Imitation of actions (objects, body parts, oral-facial movements, speech sounds) • Massed trials and naturalistic teaching • Receptive understanding (simple instructions) • Naturalistic teaching • Object associations • Matching (objects-pictures, pictures-objects) • Verbal approximations • Naturalistic teaching • Modeling, shaping, and reinforcement • Put in a notebook with goals and objectives, lesson plans, and data

12. PROMPT Therapy • PROMPT = Prompts for Restructuring Oral Muscular Phonetic Targets • Based on neuromotor principles of speech production (Chumpelik (Hayden), 1984) • Use of touch can: • “Develop, rebalance, or re-establish speech motor control” • “Provide a foundation for integrating sensory modalities in developing concepts and expressive language” • “Enhance social-emotional interaction and trust between clinician and client” (Rogers et al., 2006)

13. Elements of PROMPT • “Use of tactile-kinesthetic information as a critical modality for recognizing, developing, re-balancing, and integrating cognitive, linguistic, and motor behavior” • “Determining a Communication Focus or an aspect of development in which to embed and focus communication intervention” • “Developing goals and embedding objectives that embody the Communication Focus whil working on motor/language, cognitive, and social function”

14. Elements of PROMPT (cont.) • “Analyzing the global and speech motor sub-systems to determine three priority areas that need immediate development or rebalancing and create an initial, functional lexicon (core vocabulary)” • “Deciding on the purpose of prompting and what types of prompts should be used to support and develop motor control for speech and language and/or interaction and cognitive development” • Concrete understanding of how chosen goals and objectives will directly affect motor resourcing and, therefore, materials, activity choices”

15. Elements of PROMPT (cont.) • “Insuring that a high degree of motor-sound practice (using prompts for accuracy of production) and generalization of these into novel syllables and words within naturalistic activities are used within each session” • “The inclusion of reciprocal interaction or choice-making, in all activities, in almost every turn.” • “Presentation of the same or similar activities over time to provide a structure in which increased motor-language complexity and cognitive learning of events and sequences may be practiced.” (Rogers et al., 2006)

16. PROMPT in use • Initially, use play-based activities, wait for child to initiate, and require a sound production • Then, use vocal modeling and manual manipulation (of jaw, lips, or other speech mechanisms) while child vocalizes • Fade tactile prompts to visual prompts (of hands moving)

17. Similarities Developmentally-based Focus on shared attention and social interactions Use naturalistic teaching methods Match activities to developmental levels Initially, adult-structured Differences Organization of evaluation data How goals and objectives are chosen Organization of motor systems towards tasks Use of imitation v. tactual-kinesthetic prompts How tasks are taught How programs are modified The Denver Model v. PROMPT

18. Present study • Purpose • Develop the methods and tests of both models for developing speech in non-verbal pre-schoolers with autism • Gather empirical support for both approaches • See if typical frequency of speech sessions with daily parent review would be sufficient in producing speech

19. Participants • 10 children (aged 20-65 months) • Recruited through clinic specializing in treatment of ASD & parent-groups • Criteria for participation: • Diagnosis of autism • Spontaneous functional use of less than 5 words per day • From parent reports and clinical observations • Developmental quotient of >30 • No co-morbid conditions • NOTE: All participants received varying levels of outside therapies

20. Setting • 2-room suite w/ one-way mirror • University of Colorado Autism and Developmental Disabilities Research Laboratory • All sessions videotaped

21. Design • ABA design (replicated 9 times) • Pre- and post-treatment tests • Diagnostic, developmental, and speech-language assessments • 10-min. speech samples in baseline, treatment, and maintenance phases

22. Procedure • Pre-treatment assessments • Autism Diagnostic Observation Scale (ADOS) • Social Communication Questionnaire (SCQ) • Mullen Scales of Early Learning • Vineland Adaptive Behavior Scales • MacArthur Communicative Development Inventory (CDI) • Previous intervention history (through parent interview) • Type of treatment, staff:student ratio, hours in therapy • Background information

23. Baseline • Baseline speech probes (x3) • 15-min. • Examiner put out a new toy every 5 min. and encouraged child to play with it • Play partner instructed not to initiate any activities • Made statements regarding child’s play • Examiner asked for 1 request and 1 episode of joint attention • Scored # of words and # of phrases emitted

24. Treatment • Children randomly assigned to Denver Model or PROMPT • Received 1 hr./ week therapy (12 weeks) • Denver Model: parents present during session • Taught to implement one new skill in each of 4 areas and had them practice • Asked to implement procedures for 45 min. per day

25. PROMPT • Parents observed sessions via video • Parents asked to practice new words or approximations • Not required to manually prompt any responses • Asked to implement procedures for 30 min. per day • Family decided how to incorporate practice into daily routines

26. Procedure (cont.) • Speech samples • Each session was videotaped; a 10-min. sample was randomly selected from each session • Data collection • # of novel words or approximations • # of novel phrases • Function of communication (I.e., joint attention, social interaction) • Spontaneous v. prompted • Summarized in graphs at end of the study

27. Post-treatment • 3 weeks after completion • Same assessments as in pre-treatments • Three month follow-up • Used to score child’s functional use of speech • Identical to speech probes in baseline

28. Treatment integrity • 2 independent speech therapists trained up to fidelity on both interventions • Likert scales developed for both • Developers of scales viewed videotapes regularly, visited quarterly, and supervised (by phone) monthly • Scored at 85% or better for 25% of sessions

29. Results

33. Results (cont.) • 8 of 10 participants engaged in functional use of at least 5 novel words • Generalization probes showed less use • Reasons? • Not enough sessions (12) • Sessions not targeted for generalization and maintenance • Generalization sessions looked at too many novel features • Children “not spontaneous enough”

34. Results (cont.) • Overall gains • Significant gains = score of 2 or 3 on ADOS in pre-treatment, score of 0 on post-treatment • Significant gains observed in both interventions • Denver Model: more in imitation skills • PROMPT: more in functional play skills • Generalization • 9 of 10 participants used novel words at home after treatment • Based on parent report

35. Most gains • One child in each group demonstrated very high levels of increases in target behaviors • Regular use of over 50 words per session • Increases in joint attention • Both exhibited milder forms of autism symptoms • “These children may well have acquired functional speech without these treatments.” (Rogers et al., 2006) • NOTE: 2 participants did not acquire any new words

36. Discussion • Purpose was preliminary tests of interventions • Experimenters urge more research • More replication and extensions • 8 participants generated some new speech, 4 generated novel phrases, 2 used phrases in generalized manners (novel statements in novel settings) • Positive parent feedback

37. Limitations • Children already in a developmental period where language is observed to accelerate • Gains observed were still considered limited compared to typical children • Better gains observed for participants with higher levels of parent involvement • Parents provided extra practice opportunities than what was specified • Implementation monitored by parent report

38. Limitations (cont.) • Direct comparison of 2 interventions was impossible • Too many similarities • Participants differed from one another (age, mental ages, expressive language capabilities) • Many components to each treatment • Limited generalization and maintenance data • Children were receiving outside therapies concurrently • No IOA

39. Future research • Obtain similar participants • Control for effects of treatment • Component analysis of each treatment • Control for more extraneous variables • I.e., outside therapies

40. Search parameters • JABA • PsycINFO • Google • First, attempted “PROMPT Therapy” • 0 in JABA; mixed results in PsycINFO, 8060 on Google • Link for www.promptinstitute.com • Tab for research; provides a research summary • No articles mentioned were peer-reviewed • Out of 6 articles mentioned… • 2 unpublished research, 2 conference proceedings, 2 manuals authored by Hayden • Other links to “research” were all presentations given by Hayden or colleagues • 1 study available (Rogers et al.)

41. PROMPT: Introduction to Technique: A Manual (2006) • References section • Chumpelik--3 articles (2 unpublished, 1 theoretical) • Hayden--11 articles (0 research studies) • Guides, manuals, assessments, etc.

42. Rogers et al. study (Hayden co-authors) • References section • Looked at all research containing PROMPT • 5 references (all Chumpelik or Hayden) • All unpublished, theoretical, or conference proceedings • Google search for entire titles of all possible research studies • None available

43. ASAT online • “Research Summary: One small study indicates that an oral-motor therapy, PROMPT, may be efficacious in establishing early language skills in nonverbal children with autism (Rogers et al., 2006). There have been no other peer-reviewed scientific studies on Oral-Motor Training or Therapy for individuals with autism spectrum disorders.” (2008) • “Recommendations: Researchers may wish to conduct studies with strong scientific designs to evaluate Oral-Motor Therapies. Professionals should present Oral-Motor Therapies as under-researched and encourage families who are considering these interventions to evaluate them carefully.” (2008)

44. Does PROMPT have enough evidence to support its use? • Gina Green’s “gold standards” for evidence based practice… • At least 3 between group designs demonstrating efficacy…NO • At least 3 single case designs demonstrating efficacy…NO • At least 3 investigators needed for corroboration…NO • Documentation of: • How participants were obtained…YES • Continuous measurement of DV…NO • Calibrated data collection…NO • Inter-observer agreement…NO • Procedural integrity…YES (25% of sessions) • Operationally defined baseline condition…YES • Treatment effects…NO

45. Conclusions?

46. References • Rogers, S., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Autism and Developmental Disorders, 36, 1007-1024. • Hayden, D. (2006). PROMPT: Introduction to Technique: A Manual. Santa Fe, NM: The Prompt Institute. • Association for Science in Autism Treatment (2008). Retrieved June 11, 2008, from http://www.asatonline.org/resources/treatments/oral.htm • The Prompt Institute (2008). Retrieved June 11, 2008 from http://www.promptinstitute.com • Green, G. (2008). Evaluating Evidence about Treatments for Autism. Presentation for Applied Behavior Analysis International Conference, San Diego, CA.