1228592

research-article2024
FOAXXX10.1177/10883576241228592Focus on Autism and Other Developmental DisabilitiesHamodat et al.

Article
Focus on Autism and Other

Effects of Brief Parent Coaching on the

Developmental Disabilities
2024, Vol. 39(2) 96­–105
© Hammill Institute on Disabilities 2024
Communication Skills of Preschoolers Article reuse guidelines:
With Autism Spectrum Disorder and sagepub.com/journals-permissions
DOI: 10.1177/10883576241228592
https://doi.org/10.1177/10883576241228592

Limited Verbal Ability focus.sagepub.com

Teba Hamodat, BSc1 , Helen Flanagan, PhD1,2, Dorothy Chitty, PhD3,

and Isabel M. Smith, PhD1,2,4

Abstract
The publicly funded early intervention program for preschoolers with autism spectrum disorder (ASD) in Nova Scotia,
Canada, uses the pivotal response treatment (PRT) model. Parents are coached in use of PRT strategies during their
children’s first week of treatment. We explored whether parents of older preschoolers with limited verbal ability learned
to implement PRT strategies with fidelity after brief coaching and whether PRT strategy use was associated with gains in
children’s communication skills. We coded precoaching and postcoaching parent–child play episodes of 39 children (4.4–
5.5 years) with limited verbal skills for parents’ PRT fidelity and children’s correct responding to language opportunities and
frequency of initiations. Parents’ use of PRT strategies significantly improved, as did children’s responsiveness to parent-
provided language opportunities. This study provides evidence for the utility of brief parent coaching in PRT for older
preschoolers with ASD whose verbal skills are limited.

Keywords
autism spectrum disorder, limited verbal ability, pivotal response treatment, parent coaching

Given that children diagnosed with autism spectrum disor- underscore the efficacy of these interventions (Sandbank
der (ASD) vary considerably in their cognitive and lan- et al., 2020; Simpson, 2005).
guage abilities, it is important to understand which One NDBI widely used with children with ASD is pivotal
interventions, in which contexts, provide optimal results for response treatment (PRT; Koegel & Koegel, 2006). The PRT
children with varying profiles of baseline abilities (Vivanti model targets pivotal aspects of learning, such as motivation
et al., 2018). One group that is receiving increasing atten- and initiations, and collateral gains occur in domains such as
tion in autism research is children with minimal verbal abil- communication. The model focuses on increasing the child’s
ities—those who use few functional words, “significantly overall motivation to develop their communication and social
fewer than expected levels relative to age” (Koegel et al., skills by ensuring that the adult is following the child’s choice
2020a). Approximately 25% to 30% of school-age children in activities, using natural reinforcers, and reinforcing the
with ASD are nonverbal or minimally verbal (Tager- child’s “good enough” attempts to engage in the appropriate
Flusberg & Kasari, 2013), and agreement is lacking regard- behavior. Results of randomized controlled studies compar-
ing the most effective treatment for these children (for ing PRT with general psychoeducation (Hardan et al., 2015),
review, see Brignell et al., 2018).
Evidence-based interventions for ASD include naturalis-
tic developmental behavioral interventions (NDBIs) in 1
Department of Psychology & Neuroscience, Dalhousie University,
which the primary target is often communication. These Halifax, Nova Scotia, Canada
2
IWK Health Centre Halifax, Nova Scotia, Canada
interventions rely on engaging the child in naturally occur- 3
IWK Health Centre – EIBI, Halifax, NS , Canada
ring activities in which they show interest and rewarding 4
Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia,
their communication and social behavior. The child’s every- Canada
day routines are used to incorporate increasingly complex Corresponding Author:
learning experiences so that behavior generalizes to new Isabel M. Smith, IWK Health Centre, 4th Floor Link, P.O. Box 9700,
contexts. Systematic reviews and meta-analyses have high- Halifax, Nova Scotia, Canada B3K 6R8.
lighted the promise of NDBIs and the rigor of studies that Email: [email protected]
Hamodat et al. 97

a delayed-treatment group (Gengoux et al., 2019), or dis- strategies following brief parent coaching (Lane et al.,
crete-trial behavioral therapy (Mohammadzaheri et al., 2014) 2016). Our goal was to extend these findings using a larger
favor PRT, evidencing increased functional utterances from sample of older preschoolers with limited verbal abilities,
preintervention to postintervention. for whom the benefits of verbal interventions are inade-
Research underscores the importance of involving par- quately understood (Koegel et al., 2020b).
ents in the delivery of ASD interventions (Prata et al., 2018). Characterization of children’s verbal ability is inconsis-
Teaching parents skills that are used in clinician-led inter- tent in the literature. Descriptions of children’s communica-
ventions facilitates application of skills from the clinician to tion skills vary, ranging from ability to imitate syllables to
the parent, and in parallel, from the center to the home phrase speech. In addition, diverse language assessment
(Bearss et al., 2015; Bryson et al., 2007). Parents’ involve- measures have been used. These variables complicate com-
ment in intervention for their children with ASD positively parability between studies and the identification of appro-
influences parent–child interactions and children’s under- priate treatment options (Koegel et al., 2020a). The term
standing of language (Oono et al., 2013). Many studies “limited verbal ability” has been a helpful addition to the
have shown that parents learn to implement PRT adequately literature. Children who have limited verbal abilities have
(Duifhuis et al., 2017; Gengoux, 2019; Hardan, 2015; significant delays compared to their peers of the same age;
Minjarez et al., 2011), and that their ability to implement this category may include older preschoolers using single
PRT strategies has positive effects on their children’s com- words or short-word combinations (see Koegel et al.
munication gains (Minjarez et al., 2011). (2020a) for differentiation between minimally verbal and
In the Canadian province of Nova Scotia (NS), the pub- limited verbal categorizations).
licly funded early intervention program for children with Most intervention studies for minimally verbal children
ASD under the age of 6 years provides up to 1 year of clini- with ASD have explored the impact of augmentative and
cian-delivered PRT (Bryson et al., 2007). Critically, clini- alternative communication interventions, which include
cians coach parents to implement PRT in their child’s first aided systems such as picture books, symbols, or speech-
week of the program, learning to provide language opportu- generating devices (Brignell et al., 2018; Koegel et al.,
nities and use natural reinforcement for verbal utterances, 2020a). To our knowledge, only one study has investigated
thereby targeting communication skills. One goal is that the impact of a PRT program specifically for minimally ver-
parents will provide developmentally appropriate language bal children. Schreibman and Stahmer (2014) conducted a
opportunities, typically one or two clear words that the randomized controlled trial comparing intensive parent-
child can repeat in context. A related goal is for parents to and clinician-delivered PRT with a commonly used aug-
reduce the number of developmentally inappropriate ques- mentative and alternative approach, the picture exchange
tions posed to their children, for example, multiword ques- communication system (Bondy & Frost, 1994), in which
tions to which their children cannot yet respond. Parents are children are taught to use pictures to communicate. In their
coached to use PRT strategies at home, during (and beyond) study, minimally verbal 2- to 4-year-olds (defined as those
the 1-year clinician-delivered program, which is most often with nine or fewer intelligible words) made similar gains in
implemented in a typical preschool or daycare setting (see expressive and receptive language after 23 weeks of inten-
Smith et al., 2015, for a description of the program). sive intervention using either PRT or the Picture Exchange
In most studies exploring the impact of parent coaching Communication System. This study provides evidence that
in PRT, parents are coached over weeks, ranging from 8 to intensive parent- and clinician-delivered PRT may be effec-
25 hours of direct parent coaching in an individual or group tive for minimally verbal children with ASD; however, the
format (Verschuur et al., 2014). Coolican et al. (2010) used authors did not explore the specific impact of the parent
a single-case experimental design to explore the impact of coaching intervention component.
brief coaching for parents of children who were waiting to In a systematic review, Koegel et al. (2020b) found that
start the NS PRT-based program. Children were between 2 few studies that have explored verbal communication inter-
and 5 years of age and their baseline language levels varied ventions for minimally verbal children with ASD have
from one-word approximations to short phrases. With just 6 looked at the impact of parent education or coaching com-
hours of coaching, all eight parents improved from pre- ponents. Moreover, details have been lacking regarding
coaching to postcoaching in their ability to implement PRT fidelity of parents’ implementation of these interventions.
strategies accurately, with five parents reaching a criterion To our knowledge, no study has investigated the impact of
level of fidelity (i.e., 75% accuracy). Furthermore, all chil- brief parent coaching in PRT on the communication gains
dren’s use of functional verbal utterances increased signifi- of preschoolers with ASD whose verbal abilities are very
cantly. Coolican and colleagues’ study provides empirical limited. Shire et al. (2018) examined the ability of parents
evidence for the effectiveness of brief parent coaching in of older (school-age) minimally verbal children with ASD
PRT. Similar findings have been reported regarding the to implement an adapted NDBI and the associated gains in
positive impact on parents’ learning of naturalistic their children’s communication. Children of parents whose
98 Focus on Autism and Other Developmental Disabilities 39(2)

postintervention implementation fidelity was at least 70% leaders, notably author D.C., and families were provided
(achieved by 11 of 22 parents) showed significant increases information about the contributions of the research team to
in spontaneous commenting (either spoken or using an aug- the on-going development of the early intervention program.
mentative device) during intervention, whereas no signifi- To be eligible for the government-funded service, children
cant gains were found for children whose parents did not must be younger than 6 years of age and have a confirmed or
meet the fidelity criterion. Parents in that study were provisional diagnosis of ASD from a specialist psychologist
coached in an intervention combining two NDBIs: Joint or developmental pediatrician (see Smith et al., 2019).
Attention Symbolic Play Engagement and Regulation As part of the intervention program, clinicians routinely
(Kasari et al., 2010) and enhanced milieu teaching gather videos of parent–child play episodes before and after
(Hemmeter & Kaiser, 1994), with half of the parents addi- initial parent coaching. Videos from families that had pro-
tionally trained in the use of a speech-generating device. vided written research consent (n = 284) were screened by
The combined intervention shares some features with PRT, author T.H. for study eligibility. Videos fulfilled these inclu-
such as modeling and prompting to promote communica- sion criteria: (a) video-recorded episodes available pre-
tion, but differences include the Kasari et al. (2010) study’s coaching and postcoaching, (b) parent–child play episodes
explicit focus on increasing joint attention behavior and no less than 10 minutes at each time point, (c) same care-
imitating children’s language and functional play actions. giver in parent–child play episodes at each time point, and
Furthermore, parents’ receipt of 8 hours of active parent (d) child’s maximum utterance in pre-parent-coaching
coaching took place over 3 months in conjunction with video no more than a two-word combination (with routin-
weekly workshops and passive coaching (clinician delivers ized units such as “I want” and “thank you” considered one-
intervention while verbally highlighting information to the word utterances; see Biller & Johnson, 2019). Given our
parent), and this coaching component was not examined in study’s focus on older preschoolers with limited language,
isolation (Shire et al., 2015). Despite this distributed coach- we excluded children with phrase speech or greater verbal
ing and enhanced opportunities for practice, only half of abilities. (Our sample included some children who would
these parents of older children reached 70% fidelity in inter- meet minimally verbal criteria; see Koegel et al., 2020a for
vention implementation. Further research is necessary to differentiation between minimally verbal and limited verbal
better understand the effectiveness of parent coaching with categorizations). Videos were also excluded if nonverbal
parents of preschoolers whose verbal abilities are limited. communication methods (i.e., picture exchange communi-
Our aim in this study was to investigate the effects of cation system or gestural communication) were used in the
brief parent coaching in PRT on the communication skills precoaching recording. Furthermore, we excluded record-
of older preschoolers with ASD with limited verbal abili- ings for which poor video or audio quality precluded accu-
ties—those with significant expressive delays for their rate behavioral coding such that parents’ use of PRT
chronological age. Our research questions were as follows: strategies or child communication within the parent–child
interaction could not be adequately assessed. The target
Research Question 1: After 8 hours of parent coaching sample size was 40, based on an alpha level of .05, power of
in PRT, do preschoolers with limited verbal ability .80, and a medium effect size (d = 0.46 for child initiations;
show increased initiations and responsivity to parent- cf. Hardan et al., 2015).
presented language opportunities? Of 284 videos screened, 142 were of children with stron-
Research Question 2: After brief parent coaching, are ger verbal abilities, 66 were missing one time point, 24 were
parents of preschoolers with limited verbal ability less than 10 minutes, one did not include the same caregiver
able to implement PRT strategies with fidelity? precoaching and postcoaching, and one included a staff
Research Question 3: Are parents’ levels of implemen- member. Three videos were excluded because of poor audio
tation of PRT strategies associated with their chil- quality, seven for use of nonverbal communication methods,
dren’s communication skills after coaching? and one for parent coaching not completed. Videos of 39
children (sex assigned at birth: 34 male, 5 female) and their
caregivers (hereafter, “parents”; 27 mothers, 10 fathers, one
Method grandfather, and one aunt) met eligibility criteria. Children
were between 4.4 and 5.5 years of age (M = 4.8, SD = 0.19)
Participants and were nonverbal (38%), used single words (21%) or used
This study was carried out within the context of a larger no more than two-word combinations (41%).
project designed to examine children’s preintervention Parents who consented to full participation in research
behavioral characteristics and their association with out- (consent A, which included direct contact with the research
comes in the Nova Scotia program, approved by the IWK team and completion of research measures not discussed here)
Health Research Ethics Board (#1020646). The project were provided with a demographics form that gathered infor-
was developed collaboratively with intervention program mation regarding race/ethnicity and socioeconomic status.
Hamodat et al. 99

Parents who consented to partial research participation (con- reinforcement. A strength-based, least-to-most prompting
sent B, limited to anonymous sharing of information gathered approach was used to enhance parental self-efficacy and
by the clinical service) shared videos of parent–child play epi- encourage new learning and independent problem-solving.
sodes but did not complete other research measures. Only At the end of Day 4, a postcoaching video was recorded.
three families from our study’s sample provided full research After this coaching period, children continued in the 1-year
consent (consent A); therefore, demographic information is intervention program, which included therapist-provided
not reported here. However, during the study period 89% of PRT and positive behavior support (Carr et al., 2002). Some
families who were offered the early intervention program par- children with sustained low responsivity to PRT were sup-
ticipated and 94% of those enrolled consented to research par- ported to transition to the Picture Exchange Communication
ticipation, so we expect our subsample is similar as that System (Bondy & Frost, 1994). Parents received follow-up
described by Smith et al. (2019). coaching throughout the program and were encouraged to
use learned strategies across daily routines (see Bryson
et al. (2007) and Smith et al. (2015) for other program
Intervention
details).
The program’s primary target areas included communica-
tion and social/play skills. Treatment goals for some chil-
Outcome Measures
dren included self-care skills (e.g., toileting) and reducing
challenging behavior. Owing to a waitlist structure that Fidelity of PRT Implementation. We coded video-recordings
required offering treatment to the oldest preschoolers first, of pre–post parent–child play episodes for PRT strategies
all children in this cohort began intervention at age 4 or 5. based on a protocol adapted from Koegel and Koegel (2006;
The program was designed to be 12 months, but 10 children available upon request). We used 2-minute interval coding
in our sample transitioned to school earlier (minimum par- (i.e., five 2-minute intervals per 10-minute video). First, we
ticipation was 6 months). At the beginning of the program, coded parents’ ability to provide at least two developmen-
clinicians coached parents in PRT for 2 hours per day for 4 tally appropriate language opportunities per interval. Lan-
consecutive days. On Day 1, clinicians recorded precoach- guage opportunities that met criteria as developmentally
ing videos while parents were asked to play/interact with appropriate included brief model prompts (e.g., holding up
their child as they typically would while trying to elicit a block and saying “block,” cueing the child to repeat),
communication. Clinicians then provided parents with choice questions (e.g., “red or blue block?”), time delays
didactic information, including a handout, on the pivotal (e.g., holding the block in anticipation of the child saying
area of motivation and strategies involved in PRT. “block”), or leading prompts (e.g., “ready, set, . . .”). Criti-
Importantly, clinicians tailored strategies to each child’s cally, the parent had to have shared control of the object
developmental level (e.g., model prompts were encouraged and/or activity for the language opportunity to be scored as
for children with little speech). In vivo feedback regarding acceptable. Shared control requires that the parent pause the
parents’ PRT use started on Day 1 and continued throughout activity, either by holding back/impeding the child’s access
parent coaching. The early intervention program has devel- to an object (e.g., holding a block out of reach), or pausing
oped a structured training model for parent coaching. Before a physical activity (e.g., waiting to provide tickles). Second,
coaching independently, all coaches must have been coach- we assessed whether parents attained the child’s attention
ing with fidelity (>80% for all criteria) across two families prior to providing language opportunities (child needed to
(see Appendix). be attending to the object and/or activity when most lan-
Clinicians taught parents the Antecedent-Behavior- guage opportunities in the interval were presented). Third,
Consequence (ABC) model of behavior and encouraged we observed whether parents provided reinforcement con-
parents to use this framework to create language opportuni- tingent on the child’s appropriate verbal response following
ties for their children. Pivotal response treatment motiva- most language opportunities in an interval. To meet criteria,
tional strategies were emphasized within this model: parents had to either provide natural reinforcers following
clinicians taught parents the antecedent strategies to follow the child’s correct/good attempts or withhold natural rein-
the child’s lead, obtain shared control of a reinforcer, obtain forcers for inadequate responses. Last, we coded parents’
the child’s attention then provide a clear language opportu- ability to follow the child’s lead (i.e., allowing the child to
nity; and consequence strategies to provide immediate, choose toys/activities in which they were interested and
natural reinforcement of the target behavior. Clinicians using these as the basis for language opportunities). Parents
gave parents the rationales for strategies and specific posi- who provided at least two developmentally appropriate lan-
tive feedback regarding their use of these strategies. guage opportunities with shared control, appropriate atten-
Corrective feedback/prompting focused on one strategy tion, contingency, and who followed their children’s lead in
until the skill was demonstrated starting with following four of the five 2-minute intervals (i.e., 80%) met fidelity
child lead and moving through to the last skill of immediate criteria for PRT implementation. These criteria are used in
100 Focus on Autism and Other Developmental Disabilities 39(2)

training clinical teams in this program and have been previ- together coded 20% of the videos (n = 16). The videos for
ously used in measuring parents’ implementation fidelity in double coding were stratified by child language level (no
PRT (Gengoux et al., 2019; Hardan et al., 2015) and other words, single words, two-word phrases) then selected by
NDBIs (Abouzeid et al., 2020). Precoaching and postcoach- using an online random number generator (Randomizer.
ing overall fidelity composite scores were created by aver- org). We used the AC1-statistic (Gwet, 2002) to calculate
aging scores for PRT strategies: attention, lead, contingency, reliability for interval coding (i.e., attention, contingency,
and two language opportunities per interval. following lead, and two language opportunities per inter-
val), given its relative stability irrespective of prevalence of
Frequency of Language Opportunities. We counted the num- ratings, compared to Cohen’s kappa (Wongpakaran et al.,
ber of developmentally appropriate language opportunities 2013). Intraclass correlation coefficients using two-way
provided by parents throughout each 10-minute video. random-effects models (Koo & Li, 2016) were used to
examine reliability of other constructs (frequency of devel-
Questions Posed. We recorded counts of developmentally opmentally appropriate language opportunities and ques-
inappropriate questions parents posed to their children tions posed, child initiations, and correct responding).
within precoaching and postcoaching parent–child play epi- Interobserver reliability was calculated for each reliability
sodes. For children at this early language level, only simple coder separately.
choice questions (e.g., “ball or cup?”) were counted as Intraclass correlations between the primary coder and
appropriate; all others were considered too complex (e.g., coders 1 and 2, respectively, were: .85 and .98 for initia-
what would you like to play?). tions; .97 and .98 for question count; .92 and .99 for lan-
guage opportunity count; and .83 and 1.00 for percentage
Initiations. We counted children’s spontaneous utterances correct responding, indicating good to excellent reliability
(including word attempts and vocal exclamations of excite- (Koo & Li, 2016). Overall, interval coding reliability
ment or protest). Initiations needed to be socially directed ranged from moderate to excellent. AC1-statistics for the
(to the parent), which may have included shifts in gaze primary coder and coders 1 and 2 were .62 and .85 for
toward the parent, direct eye contact, or coordinated vocal- attention; .73 and 1.00 for contingency, and .78 and .91 for
izations (see Maljaars et al., 2011, for a similar language opportunities, respectively. The AC1-statistic
conceptualization). could not be computed for “lead” for either reliability
coder as codes were the same in every interval (i.e., no
Correct Responding. We calculated percentages of children’s variability in coding). However, percentage agreements
correct responding to parent-provided language opportunities. for each coder with the primary coder (author T.H.) were
high (93% and 100%).
Statistical Analyses
Results
We conducted statistical analyses using R software (R Core
Team, 2013). We examined change in aspects of parents’ On average, four and a half days elapsed between the pre-
fidelity of PRT implementation from precoaching to post- coaching and postcoaching videos (SD = 2.38, Mdn = 3)
coaching using paired-samples t-tests. To examine the with a range of 2 to 13 days due to family circumstances
effects of parents’ use of PRT strategies on their children’s affecting service delivery. The number of days between pre-
communication gains during training, we first conducted coaching and postcoaching was not significantly associated
paired-samples t-tests to examine whether children’s fre- with parents’ PRT fidelity after training (r = −.12, p = .41).
quencies of initiations and percentages of correct respond- Details regarding parents’ fidelity of PRT implementation
ing increased from precoaching to postcoaching. Then, are in Table 1. Parents’ mean overall fidelity scores signifi-
Pearson correlations were conducted to examine whether cantly increased from 33% to 73% during training. Parents
these proximal child outcomes were associated with par- showed significant increases with large effect sizes in their
ents’ PRT implementation quality (change in fidelity scores ability to provide a minimum of two language opportunities
during coaching) and frequency (increased frequency of per interval with appropriate attention and contingency,
parent-provided language opportunities). from precoaching to postcoaching. Parents were success-
fully following their children’s lead in activities before
coaching and continued using this skill at postcoaching.
Interobserver Reliability Before training began, parents were providing their children,
We calculated interobserver reliability for all play-episode- on average, with four language opportunities in a 10-minute
based coding. Author T.H. coded all pre- and post-parent- span. This significantly increased after coaching, such that
coaching videos. Two other coders, one of whom was blind parents gave an average of 16 language opportunities.
to whether videos were precoaching or postcoaching, Furthermore, parents significantly reduced the number of
Hamodat et al. 101

Table 1. Descriptive Statistics and Paired-Samples t Test Results for Fidelity of Parent Implementation of PRT Strategies (% of
Intervals), Overall Composite Scores, and Questions Posed Precoaching and Postcoaching.

Paired-samples t test

Variable Precoaching M (SD) Postcoaching M (SD) t df p da

Attending (%) 15.38 (26.54) 58.97 (31.10) 7.48 38 <.001 1.20
Following lead (%) 88.72 (22.85) 93.85 (17.86) 1.22 38 .230 0.20
Contingency (%) 11.28 (21.91) 62.56 (31.52) 9.79 38 <.001 1.57
Two LOs (%) 18.97 (29.72) 75.39 (28.46) 9.12 38 <.001 1.46
Composite score 33.59 (20.78) 72.69 (21.82) 9.17 38 <.001 1.47
Number of LOs 4.18 (6.46) 15.69 (10.29) 8.03 38 <.001 1.29
Number of inappropriate questions 37.85 (22.10) 15.92 (15.50) −6.78 38 <.001 1.08

Note. PRT = pivotal response treatment; LO = language opportunity.

a
Cohen’s d effect size.

Table 2. Means, Standard Deviations, and Paired-Samples t Test Results for Child Outcomes.

Paired-samples t test

Primary child outcomes Precoaching M (SD) Postcoaching M (SD) t df p d

Initiations 11.39 (10.59) 11.51 (7.71) 0.06 38 .95 0.01
% Correct responding 36.05 (42.67) 70.13 (32.07) 5.13 38 <.001 0.82
a
Cohen’s d effect size.

Table 3. Pearson Correlations Between Parent Variables and postcoaching as well as fidelity score increases were signifi-
Changes in Children’s Communication Outcomes. cantly associated with increases in children’s initiations dur-
Change in child Post-coaching increase Post-coaching increase ing coaching (see Table 3).
outcomes fidelity composite in frequency of LOs
Initiations .36* .36* Discussion
% Correct .60** .21
responding In this study, we aimed to evaluate the impact of brief par-
ent coaching in PRT for children with limited verbal abili-
Note. LO = language opportunity. ties. Fifty-nine percent of our sample of 4- to 5½-year olds
*p < .05. **p < .001.
used no or only single words and others used no more than
two-word combinations prior to intervention.
inappropriate questions they posed their children during Our results corroborate previous findings of parents’
training, from a mean of 38 to a mean of 16. When each PRT ability to learn and use PRT strategies with fidelity
strategy was explored in isolation, 44% (n = 17) parents met (Gengoux et al., 2019; Hardan et al., 2015; Minjarez et al.,
fidelity for attention, 46% (n = 18) for contingency, 67% (n 2011) and provides further evidence that even brief parent
= 26) for two language opportunities, and 90% (n = 35) for coaching in PRT leads to meaningful gains (Coolican et al.,
following lead. Overall, 31% (n = 12) of parents met the 2010). With 8 hours of coaching, parents improved their
PRT implementation fidelity criterion for all four PRT strat- ability to provide their children with language opportunities
egies after coaching (minimum of 80% for attention, lead, with appropriate attention and contingency. Parents in this
contingency, and language opportunities). sample were appropriately following their children’s leads
Children correctly responded to language opportunities before the training week. This is likely because parents of
that their parents provided at a higher rate at end of training children with ASD in Nova Scotia are routinely taught this
(see Table 2), and this was significantly associated with par- skill by speech-language pathologists prior to entering the
ents’ fidelity score increases (see Table 3). No significant PRT program. A key finding was that parents significantly
improvements were observed for children’s frequency of increased the number of developmentally appropriate
initiations (see Table 2); however, increased frequency of language opportunities they provided to enhance their
parents’ language opportunities from precoaching to children’s communication (from 4 to 16 per episode, on
102 Focus on Autism and Other Developmental Disabilities 39(2)

average). We saw a parallel decrease in developmentally Stahmer (2014) sample consisted of 2- to 4-year olds with
inappropriate questions (i.e., questions to which these chil- delayed speech (no more than nine words) and as such,
dren could not be expected to respond; from 38 to 16 per communication gains may have been more likely for those
episode, on average). younger children than our 4- to 5-year olds with substantial
Approximately one-third of parents (n = 12) met PRT expressive language delays.
implementation fidelity after training. After only four This study’s limitations include that, given the necessity
coaching sessions, these parents attained a similar level of to screen more than 250 precoaching video-recordings for
skill to that required of beginner early interventionists. A participants’ eligibility, author T.H. was not blind to pre–
smaller proportion of parents met full criteria for fidelity post video categorization, which may have influenced cod-
than in the study by Coolican et al. (2010) [five of eight]. ing of parents’ implementation fidelity. In addition, we lack
However, we used a higher fidelity criterion (80% vs 75%) family demographic information including ethnicity, house-
and included only older children with limited verbal abili- hold income, and parent education, which we were able to
ties, who may be more challenging to teach. For example, it gather only for a few families who completed other compo-
may be more challenging to be contingent on vocalizations/ nents of the larger study. Parent coaching is a prerequisite to
verbalizations in children who vocalize less frequently, and start clinician-delivered intervention for this public pro-
the children therefore have fewer occasions from which to gram; the high uptake of early intervention participation by
learn. Our findings are comparable to those of Shire et al. families suggests that our subsample represents families
(2018), who found that less than half (10 out of 22) of enrolled. In addition, parent participation was supported in
the parents of minimally verbal school-age children who many ways, primarily by the naturalistic context in which
received 8 hours of active coaching in another NDBI inter- PRT was delivered, but also by providing letters when
vention over 3 months met their 75% fidelity criterion. requested that describe parents’ involvement in coaching
Thus, our findings add to a small body of research that sug- for use with their employers. Last, although quantitative
gests that many parents of children with limited verbal data regarding parents’ satisfaction with the program was
skills can be coached to fidelity in a short period, while oth- sought as part of the larger study, none of the parents in our
ers may make meaningful gains without meeting full fidel- sample completed this questionnaire. Earlier studies of this
ity criteria. program support its social validity (D’Entremont et al.,
In our study, children demonstrated significant increases 2021).
with a large effect size in correctly responding to language Our results underscore the importance of parents’
opportunities provided by their parents during training. This involvement in treatment for all children, including for
increase was associated with parents’ improved implemen- children with limited verbal abilities. This group often
tation of PRT strategies. These gains are particularly prom- requires high levels of support, and studies are needed to
ising as these children’s spoken language skills were understand the impacts of coaching these parents (Koegel
considerably delayed relative to typical developmental et al., 2020b). Parent coaching programs are empowering
expectations. This suggests that parents’ provision of devel- and provide the necessary psychoeducation and skills
opmentally appropriate language opportunities, followed training so that parents can better understand their child’s
by natural reinforcement, helped these children to show diagnosis, manage developmental expectations (Karst &
important short-term gains. If sustained, such changes have Van Hecke, 2012) and importantly, incorporate therapy
the potential to change children’s communication develop- into their children’s natural environments and routines.
ment trajectories. Generalization of skills can occur by providing many and
We did not find significant increases in spontaneous ini- varied opportunities for the child to learn (Karst & Van
tiations by children during training. This is not surprising Hecke, 2012; Prata et al., 2018). This study demonstrates
considering both these children’s verbal abilities and the that even brief parent coaching programs can have impor-
short study period. However, the significant association tant positive effects.
between increases in parents’ language opportunities and This study adds to a body of research supporting the
fidelity scores with increases in children’s initiations is importance and effectiveness of parent coaching in NDBI
encouraging. Studies with longer follow-up periods have strategies. The Nova Scotia early intervention model for
documented gains in spontaneous communication in chil- preschoolers with ASD consistently incorporates individu-
dren characterized as minimally verbal (e.g., Schreibman & alized parent coaching as a first step in a comprehensive
Stahmer, 2014; Shire et al., 2018). Differences between our intervention program. Our team’s research has highlighted
methods and (Shire, Shih and Kasari, 2018) treatment links between the use of this model and higher parent satis-
approach, duration of treatment, or the operationalization of faction (D’Entremont et al., 2021). This study demonstrated
“minimally verbal” for their participants (i.e., fewer than 20 impacts of this training component on children’s outcomes,
spontaneous words in the 5- to 8-year age range) may have even in older preschoolers whose limited verbal skills cre-
contributed to different findings. The Schreibman and ate challenges for treatment.
Hamodat et al. 103

Appendix +
 (plus): The person being observed utilized this
Pivotal Response Treatment (PRT) training principle
Train-the-Trainer Fidelity − (minus): The training principle was not observed
Child Name: ___________ Trainee: ______________ NA (not applicable): The training principle did not
Trainer: _______________ Date: ____________ apply to the interval being observed.
4. Fidelity scoring is based on the performance of the
trainer.
Prompting 5. Intervals for which the trainer provides no feedback
(suggestive are scored as—(minus) in all categories. The person
Focus on Clear Focus on feedback –move being observed must actively seek opportunities to
2-Minute priority Specific and positive to more directive
interval issues feedback concise implementation when required) provide feedback.
6. The person being observed must score 80% (4 out of
0–2 5) in each category to meet fidelity.
2–4
4–6
6–8 Acknowledgments
8–10
The authors thank Dr. Loriann Williams and Brittany Fitzgerald
%
for their help in adapting the coding scheme and in coding
videos.

1. Timely Provision of feedback to Trainee (during or

immediately after ABC as much has possible) Declaration of Conflicting Interests
Comment The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
2. Prompt-implement-reinforce article: D.C. is the Clinical Leader of the NS early intervention
Comment: program for preschoolers with ASD. Other authors have no poten-
tial conflicts of interest to disclose.
3. Provide rationale
Comment: Funding
This work was supported by a CIHR Operating Grant (MOP
4. Global feedback 142293), as well as the CIHR Canadian Graduate Scholarship,
Comment: Nova Scotia Graduate Scholarship, and the Research Nova Scotia
Scholars Award to the first author, and the Joan & Jack Craig
5. Supportive of Trainee Initiated Interactions with Chair in Autism Research to the last author.
Child
Comment: ORCID iD
Teba Hamodat https://orcid.org/0000-0001-6148-916X
6. Pace feedback to Trainee
Comment
References
7. Positive Affect and Appropriate Proximity Abouzeid, N., Rivard, M., Mello, C., Mestari, Z., Boulé, M.,
Comment: & Guay, C. (2020). Parent coaching intervention program
based on the Early Start Denver Model for children with
autism spectrum disorder: Feasibility and acceptability study.
Additional Global Fidelity Training Research in Developmental Disabilities, 105, 103747. https://
Criteria doi.org/10.1016/j.ridd.2020.103747
INSTRUCTIONS Bearss, K., Burrell, T. L., Stewart, L., & Scahill, L. (2015). Parent
training in autism spectrum disorder: What’s in a name?
Clinical Child and Family Psychology Review, 18(2), 170–
1. Score fidelity in five 2-minute intervals. After each 182. https://doi.org/10.1007/s10567-015-0183-9
2-minute interval, score each of the five training Biller, M. F., & Johnson, C. J. (2019). Social–cognitive and
principles. speech sound production abilities of minimally verbal chil-
2. Scoring should be based on the gestalt of the inter- dren with autism spectrum disorders. American Journal of
val (i.e., the overall impression). Speech-Language Pathology, 28(2), 377–393. https://doi.
3. Score each category as: org/10.1044/2018_AJSLP-18-0008
104 Focus on Autism and Other Developmental Disabilities 39(2)

Bondy, A. S., & Frost, L. A. (1994). The picture exchange com- Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J.
munication system. Focus on Autistic Behavior, 9(3), 1–19. (2010). Randomized controlled caregiver mediated joint
https://doi.org/10.1177/108835769400900301 engagement intervention for toddlers with autism. Journal
Brignell, A., Chenausky, K. V., Song, H., Zhu, J., Suo, C., & of Autism and Developmental Disorders, 40(9), 1045–1056.
Morgan, A. T. (2018). Communication interventions for https://doi.org/10.1007/s10803-010-0955-5
autism spectrum disorder in minimally verbal children. Koegel, L. K., Bryan, K. M., Su, P. L., Vaidya, M., & Camarata,
Cochrane Database of Systematic Reviews, 11, CD012324. S. (2020a). Definitions of nonverbal and minimally ver-
https://doi.org/10.1002/14651858.CD012324.pub2 bal in research for autism: A systematic review of the lit-
Bryson, S. E., Koegel, L. K., Koegel, R. L., Openden, D., Smith, erature. Journal of Autism and Developmental Disorders,
I. M., & Nefdt, N. (2007). Large scale dissemination and 50(8), 2957–2972. https://doi.org/10.1007/s10803-020-
community implementation of pivotal response treatment: 04402-w
Program description and preliminary data. Research and Koegel, L. K., Bryan, K. M., Su, P. L., Vaidya, M., & Camarata,
Practice for Persons with Severe Disabilities, 32(2), 142– S. (2020b). Parent education in studies with nonverbal and
153. https://doi.org/10.2511/rpsd.32.2.142 minimally verbal participants with autism spectrum disorder:
Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. A systematic review. American Journal of Speech-Language
P., Sailor, W., Anderson, J. L., Albin, R. W., Koegel, L. K., Pathology, 29(2), 890–902. https://doi.org/10.1044/2019_
& Fox, L. (2002). Positive behavior support: Evolution of an AJSLP-19-00007
applied science. Journal of Positive Behavior Interventions, Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treat-
4(1), 4–16. https://doi.org/10.1177/109830070200400102 ments for autism: Communication, social, & academic devel-
Coolican, J., Smith, I. M., & Bryson, S. E. (2010). Brief parent opment. Paul H Brookes.
training in pivotal response treatment for preschoolers with Koo, T. K., & Li, M. Y. (2016). A guideline of selecting and
autism: Parent training in PRT. Journal of Child Psychology reporting intraclass correlation coefficients for reliability
and Psychiatry, 51(12), 1321–1330. https://doi.org/10.1111/ research. Journal of Chiropractic Medicine, 15(2), 155–163.
j.1469-7610.2010.02326.x https://doi.org/10.1016/j.jcm.2016.02.012
D’Entremont, B., Flanagan, H. E., Ungar, W. J., Waddell, C., Lane, J. D., Ledford, J. R., Shepley, C., Mataras, T. K., Ayres,
Garon, N., den Otter, J., Leger, N., Vezina, F., & Smith, I. M. K. M., & Davis, A. B. (2016). A brief coaching inter-
(2021). Comparing the impact of differing preschool autism vention for teaching naturalistic strategies to parents.
interventions on parents in two Canadian provinces. Journal Journal of Early Intervention, 38(3), 135–150. https://doi.
of Autism and Developmental Disorders, 52(11), 5018–5032. org/10.1177/1053815116663178
https://doi.org/10.1007/s10803-021-05349-2 Maljaars, J., Noens, I., Jansen, R., Scholte, E., & van Berckelaer-
Duifhuis, E. A., Den Boer, J. C., Doornbos, A., Buitelaar, J. K., Onnes, I. (2011). Intentional communication in nonverbal
Oosterling, I. J., & Klip, H. (2017). The effect of pivotal and verbal low-functioning children with autism. Journal
response treatment in children with autism spectrum disor- of Communication Disorders, 44(6), 601–614. https://doi.
ders: A non-randomized study with a blinded outcome mea- org/10.1016/j.jcomdis.2011.07.004
sure. Journal of Autism and Developmental Disorders, 47(2), Minjarez, M. B., Williams, S. E., Mercier, E. M., & Hardan, A. Y.
231–242. https://doi.org/10.1007/s10803-016-2916-0 (2011). Pivotal Response group treatment program for parents
Gengoux, G. W., Abrams, D. A., Schuck, R., Millan, M. E., Libove, of children with autism. Journal of Autism and Developmental
R., Ardel, C. M., Phillips, J. M., Fox, M., Frazier, T. W., & Disorders, 41(1), 92–101. https://doi.org/10.1007/s10803-
Hardan, A. Y. (2019). A pivotal response treatment package for 010-1027-6
children with autism spectrum disorder: An RCT. Pediatrics, Mohammadzaheri, F., Koegel, L. K., Rezaee, M., & Rafiee, S. M.
144(3), e20190178. https://doi.org/10.1542/peds.2019-0178 (2014). A randomized clinical trial comparison between piv-
Gwet, K. (2002). Kappa statistic is not satisfactory for assessing otal response treatment (PRT) and structured applied behavior
the extent of agreement between raters. Statistical Methods analysis (ABA) intervention for children with autism. Journal
for Inter-Rater Reliability Assessment, 1(6), 1–6. of Autism and Developmental Disorders, 44(11), 2769–2777.
Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., https://doi.org/10.1007/s10803-014-2137-3
Ardel, C. M., Phillips, J., Frazier, T. W., & Minjarez, M. B. Oono, I. P., Honey, E. J., & McConachie, H. (2013). Parent-
(2015). A randomized controlled trial of Pivotal Response mediated early intervention for young children with autism
Treatment Group for parents of children with autism. Journal spectrum disorders (ASD). Evidence-Based Child Health:
of Child Psychology and Psychiatry, 56(8), 884–892. https:// A Cochrane Review Journal, 8(6), 2380–2479. https://doi.
doi.org/10.1111/jcpp.12354 org/10.1002/ebch.1952
Hemmeter, M. L., & Kaiser, A. P. (1994). Enhanced Milieu teach- Prata, J., Lawson, W., & Coelho, R. (2018). Parent training for
ing: Effects of parent-implemented language intervention. parents of children on the autism spectrum: A review. Health,
Journal of Early Intervention, 18(3), 269–289. https://doi. 5(3), 1–8. https://doi.org/10.21035/ijcnmh.2018.5.3
org/10.1177/105381519401800303 R Core Team. (2013). R: A language and environment for sta-
Karst, J. S., & Van Hecke, A. V. (2012). Parent and family tistical computing. R Foundation for Statistical Computing.
impact of autism spectrum disorders: A review and proposed https://www.r-project.org/
model for intervention evaluation. Clinical Child and Family Sandbank, M., Bottema-Beutel, K., Crowley, S., Cassidy, M.,
Psychology Review, 15(3), 247–277. https://doi.org/10.1007/ Dunham, K., Feldman, J. I., Crank, J., Albarran, S. A., Raj,
s10567-012-0119-6 S., Mahbub, P., & Woynaroski, T. G. (2020). Project AIM:
Hamodat et al. 105

Autism intervention meta-analysis for studies of young and Developmental Disorders, 45(6), 1858–1872. https://doi.
children. Psychological Bulletin, 146(1), 1–29. https://doi. org/10.1007/s10803-014-2345-x
org/10.1037/bul0000215 Smith, I. M., Flanagan, H. E., Ungar, W. J., D’Entremont, B.,
Schreibman, L., & Stahmer, A. C. (2014). A randomized trial Garon, N., den Otter, J., Waddell, C., Bryson, S. E., Tsiplova,
comparison of the effects of verbal and pictorial naturalis- K., Léger, N., Vezina, F., & Murray, P. (2019). Comparing
tic communication strategies on spoken language for young the 1-year impact of preschool autism intervention programs
children with autism. Journal of Autism and Developmental in two Canadian provinces. Autism Research, 12(4), 667–681.
Disorders, 44(5), 1244–1251. https://doi.org/10.1007/s10803- https://doi-org.ezproxy.library.dal.ca/10.1002/aur.2072.
013-1972-y Tager-Flusberg, H., & Kasari, C. (2013). Minimally verbal school-
Shire, S. Y., Goods, K., Shih, W., Distefano, C., Kaiser, A., aged children with autism spectrum disorder: The neglected
Wright, C., Mathy, P., Landa, R., & Kasari, C. (2015). end of the spectrum. Autism Research, 6(6), 468–478. https://
Parents’ adoption of social communication intervention doi.org/10.1002/aur.1334
strategies: Families including children with autism spectrum Verschuur, R., Didden, R., Lang, R., Sigafoos, J., & Huskens, B.
disorder who are minimally verbal. Journal of Autism and (2014). Pivotal response treatment for children with autism
Developmental Disorders, 45(6), 1712–1724. https://doi. spectrum disorders: A systematic review. Review Journal of
org/10.1007/s10803-014-2329-x Autism and Developmental Disorders, 1(1), 34–61. https://
Shire, S. Y., Shih, W., & Kasari, C. (2018). Brief report: Caregiver doi.org/10.1007/s40489-013-0008-z
strategy implementation—Advancing spoken communication Vivanti, G., Kasari, C., Green, J., Mandell, D., Maye, M., &
in children who are minimally verbal. Journal of Autism and Hudry, K. (2018). Implementing and evaluating early inter-
Developmental Disorders, 48(4), 1228–1234. https://doi. vention for children with autism: Where are the gaps and what
org/10.1007/s10803-017-3454-0 should we do? Autism Research, 11(1), 16–23. https://doi.
Simpson, R. L. (2005). Evidence-based practices and students org/10.1002/aur.1900
with autism spectrum disorders. Focus on Autism and Other Wongpakaran, N., Wongpakaran, T., Wedding, D., & Gwet,
Developmental Disabilities, 20(3), 140–149. https://doi.org/1 K. L. (2013). A comparison of Cohen’s Kappa and Gwet’s
0.1177/10883576050200030201 AC1 when calculating inter-rater reliability coefficients: A
Smith, I. M., Flanagan, H. E., Garon, N., & Bryson, S. E. study conducted with personality disorder samples. BMC
(2015). Effectiveness of community-based early interven- Medical Research Methodology, 13(1), 1–7. https://doi.
tion based on pivotal response treatment. Journal of Autism org/10.1186/1471-2288-13-61