Engaging caregivers in the management and treatment of early childhood developmental challenges is a critical component of effective intervention.1 Family-centered care helps to promote positive outcomes with early intervention (across developmental domains), and there’s increasing evidence that parent-training programs can be effective in promoting skill generalization and targeting core impairments in toddlers with autism.2
Furthermore, a 2014 randomized controlled trial revealed that individual Early Social Interaction (ESI) with home coaching using the SCERTS (Social Communication, Emotional Regulation, and Transactional Support) curriculum was associated with improvement of a range of child outcomes, compared with group ESI. The authors commented on the importance of individualized parent coaching in natural environments as a way to improve social components of communication and receptive language for toddlers with autism.3
For many parents and at-home caregivers, however, engaging in home-based and parent-delivered interventions can be overwhelming and anxiety-provoking, as well as complicated by other barriers (competing responsibilities, cultural beliefs, and so on). Additionally, these interventions can themselves be a source of stress for some families.
Dr. Jeremiah Dickerson
Case
Jake is a 3-year-old boy with a history of global developmental delays, who presents with particular struggles: relating his expressive communication, ability to engage peers in an age-appropriate manner, and capacity to self-regulate when frustrated. He and his family participated in an comprehensive autism diagnostic assessment. In reviewing the history and presentation, considerable challenges in the two core symptom domains that characterize an autism spectrum disorder were noted. A diagnosis of autism was provided, and treatment recommendations were discussed. “What can I do at home to help Jake learn?” his mother asked, noting that, with one-on-one attention, he does seem to demonstrate increased responsiveness, less use of echolalic language, and improved eye contact.
Discussion
To complement the autism services that Jake would likely qualify for through an Early Education program, in-home interaction and play to ensure skill development was discussed at length with his mother, who readily acknowledged her own care-giving struggles that, in part, are informed by her own mental health troubles.
We openly explored Jake’s mother’s perceived challenges in engaging with her son at home and developed initial recommendations for interaction that didn’t risk overwhelming her. We impressed upon Jake’s mother that, regardless of a child’s developmental profile, toddlers use play to learn and she can be Jake’s “favorite toy.” After all, “play is really the work of childhood,” as Fred Rogers said.
With all children, back-and-forth interactions serve as the foundation for future development. Using scaffolding techniques, parent support is a primary driver of “how children develop cognitive, language, social-emotional, and higher-level thinking skills.”4 In particular, the quality of parental interaction can influence language development, and, when considering children with autism, there are several recommendations for what parents can do to help build social, play, and communication skills.5 The Hanen Program is a great resource for providers and parents to learn more about parent engagement in early learning, the power of building communication through everyday experiences and attention to responsiveness, and the use of a child’s strengths to help make family interactions more meaningful and enjoyable. Additionally, the 2012 book “An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn” by Sally Rogers, PhD, et al. is an easy-to-read text for parents and caregivers for learning effective and practical strategies for engaging their child with autism.
With Jake and his mother, our team offered the following in-home recommendations:
- Try to keep interaction fun. Be enthusiastic when encouraging Jake’s attempts to communicate.
- Teach Jake song-gesture games. Encourage him to produce routine, predictable gestures to keep the song going (in imitation of mom). Using songs with vowel emphasis is encouraged (for example: Farmer in the Dell with “E I E I OOOOO”).
- Encourage Jake to produce responsive gestures in play and daily routines not involving songs, such as open arms to receive a ball, reaching to mom when about to be tickled, or having his arms up to have his shirt taken off.
- Capitalize on Jake’s natural desires and personal preferences. Activate a wind-up toy, let it deactivate, and then hand it to Jake.
- Initiate a familiar social game with Jake until he expresses pleasure. Then stop the game and wait for him to initiate continuance.
- Adapt the environment so that Jake will need to frequently request objects of assistance to make choices (place favorite toys in clear containers which may be difficult to open so that he must request help).
Clinical pearl
The United States Department of Education recognizes the importance of family engagement in a child’s early years. Their 2015 policy statement notes that “families are their children’s first and most important teachers, advocates, and nurturers. As such, strong family engagement is central – not supplemental – to the success of early childhood systems and programs that promote children’s healthy development, learning, and wellness.”
By recognizing this principle, primary care providers are in a position to talk with parents about how much youth learn through play and regular interaction. This especially holds true for children with autism. Developing in-home strategies to facilitate active engagement, even strategies that may not be a formal component of a home-based intervention program, are instrumental in fostering positive family- and child-based outcomes and wellness.
Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at pdnews@frontlinemedcom.com.
References
1. Annu Rev Clin Psychol. 2010;6:447-68.
2. J Autism Dev Disord. 2010 Sep;40(9):1045-56.
3. Pediatrics. 2014 Dec;134(6):1084-93.