934558

research-article2020
AUT0010.1177/1362361320934558AutismHampton et al.

Original Article

Autism

Multi-component communication 2020, Vol. 24(8) 2104­–2116

© The Author(s) 2020
Article reuse guidelines:
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DOI: 10.1177/1362361320934558
https://doi.org/10.1177/1362361320934558

A randomized controlled trial journals.sagepub.com/home/aut

Lauren H Hampton1 , Ann P Kaiser2 and Elizabeth A Fuller2

Abstract
The objective of this study is to evaluate the effectiveness of a multi-component communication intervention on social
communication for young children with autism. As many as half of children with autism are not yet talking by age
3, and up to a third of children with autism will remain minimally verbal past age 5. Spoken language outcomes are
greatest when parents and clinicians are delivering language interventions to children with autism as compared to
parents or clinicians alone. This study incorporates caregiver training, Discrete Trial Teaching, and JASP + EMT + SGD.
A total of 68 children between ages 3 and 5 with autism, and their caregivers, participated in this study. Children were
randomly assigned to the treatment or control group. Children in the treatment group received 36 sessions of the
multi-component intervention in the clinic and at home. Children in both groups received a speech-generating device
and the caregivers received an individualized training on how to program the speech-generating device. All participants
were evaluated prior to intervention, immediately following intervention, and 4 months following intervention. Children
in the intervention group demonstrated significantly greater joint attention than those in the control group immediately
following intervention. Children in the intervention group, additionally, demonstrated greater social communication
with their caregivers 4 months following intervention. This brief, multi-component intervention may be effective for
improving social communication in young children with autism who are at risk for remaining minimally verbal. Future
research is needed to understand for whom and under what conditions this intervention is most effective.

Lay abstract
This study reports the results of a randomized trial for preverbal preschoolers with autism that demonstrates the effects
of multiple intervention strategies including caregiver training. About 50% of children with autism are not talking by age
3 and up to 30% of children with autism will remain minimally verbal past age 5. Interventions delivered by clinicians
and caregivers have the greatest effects on spoken language and may reduce the rate of those who remain minimally
verbal. Sixty-eight children ages 3–5 with autism and their caregivers participated in this randomized trial comparing the
communication intervention to a comparison group. A brief, multi-component, communication intervention (including
a speech-generating device) for children with autism that addresses core deficits may be effective in improving joint
attention skills immediately following intervention and social communication skills 4 months following intervention.
Future research is needed to understand for whom and under what conditions this intervention is most effective.

Keywords
autism spectrum disorders, communication and language, minimally verbal, parent training, preschool, speech-
generating device

Children with autism under the age of 8 demonstrate better 1

University of Texas at Austin, USA
spoken language outcomes and social communication out- 2
Vanderbilt University, USA
comes after having early interventions that include both
Corresponding author:
direct treatment from a clinician and caregiver-imple- Lauren H Hampton, University of Texas at Austin, 1912 Speedway,
mented components (Fuller & Kaiser, 2019; Hampton & Stop D5300, Austin, TX 78712, USA.
Kaiser, 2016). At 33 months, about half of children with Email: [email protected]
Hampton et al. 2105

autism do not yet have meaningful speech (Eaves & Ho, due to poor imitation skills, low receptive language, or
2004). Although many of these children go on to develop unfamiliarity with an SGD (Carpenter et al., 2002;
phrase speech, and thus would be classified as preverbal at Charman et al., 2003; Dawson et al., 2004; Mundy et al.,
this age, a third of children with autism remain persistently 1987; Stone & Yoder, 2001; Toth et al., 2006; Weismer
minimally verbal at age 5 despite early intervention (Tager- et al., 2010; Yoder & Stone, 2006). Given that DTT has
Flusberg & Kasari, 2013). Interventions that target spoken been found effective for improving these critical precur-
language during this transitional stage (ages 3–4) may be sors to language in preverbal children with autism (Lovaas,
critical in reducing the percentage of children who remain 1987; Paul et al., 2013; Reichow & Wolery, 2009; Smith,
minimally verbal at age 5 and beyond. 2001), including direct instruction on precursor skills with
Two evidence-based early interventions that include a naturalistic intervention approach could result in better
clinician-implemented components, and often include par- outcomes (Kasari et al., 2006), especially for this popula-
ent-implemented components, have demonstrated tion with severe delays in developing spoken language.
improvements in social communication and language for This randomized clinical trial examined the effects of a
minimally verbal and preverbal children with autism: multi-component communication intervention composed
Discrete Trial Teaching (DTT; C. Smith et al., 2004; T. of (1) JASP + EMT + SGD, (2) DTT, and (3) caregiver
Smith, 2001) and JASP + EMT, an intervention that incor- training for preschoolers with autism between preverbal
porates components from the Joint Attention, Structured and first words of language development. The following
Play, Engagement, and Regulation (JASPER; Kasari et al., research questions were addressed: (1) Does a short-term
2006) intervention and Enhanced Milieu Teaching (EMT; multi-component communication intervention improve
Kaiser & Hampton, 2017). DTT provides children with social communication for preverbal children with autism?
massed systematic instructional trials in a structured con- (2) Do outcomes maintain 4 months following interven-
text to teach a variety of skills related to communication tion? (3) Does caregiver training improve caregivers’ use
and development. JASP + EMT is a play-based interven- of language facilitation strategies?
tion that includes responsiveness, play and language mod-
eling, play and language expansions, modeling and
encouraging joint attention, and eliciting new communica- Methods
tion through time delays and prompting episodes (see
Trial design
Supplemental Material 1). JASP + EMT is a type of
Naturalistic Developmental Behavioral Intervention, This project was a randomized controlled trial
which has been shown to result in the generalized use of (R40MC27707) of a communication intervention for
language and communication skills, fewer behavior prob- young children with autism with preverbal or first word
lems, more spontaneous initiations of communication language development (Tager-Flusberg et al., 2009).
(Sandbank et al., 2020; Schreibman et al., 2015), and Participants were recruited in Nashville, TN from early
greater spoken language when verbal input is paired with a intervention programs, preschools, and outpatient clinics
speech-generating device (SGD; Kasari et al., 2014). between January 2014 and July 2017. The trial was
Although interventions using alternative and aug- approved by Vanderbilt University’s Institutional Review
mented communication systems are common components Board (#141453) and all caregivers provided informed
of communication interventions for children with autism, consent.
a recent systematic review identified a gap in the research
when using these communication systems beyond simple
Participants
requests (Logan et al., 2017). In addition, some studies
that do teach broader communication functions with an The child inclusion criteria were as follows: (1) chrono-
SGD notably do not report the maintenance of social com- logical age between 36 and 60 months; (2) confirmed
munication skills achieved in the study. autism diagnosis on the Autism Diagnostic Observation
JASP + EMT + SGD (JASP + EMT with SGD modeling) Schedule—Second Edition, Module 1 (ADOS-2; Lord
has been shown to result in improvements in spoken lan- et al., 2012); (3) a visual reception score greater than
guage for older children with autism (ages 5–8) who were 18 months (Mullen, 1997); (4) fewer than 20 different
minimally verbal (Kasari et al., 2014). Despite overall spontaneous words during a 20-min language sample
improvements for the group receiving this intervention, (consistent with previous studies; Kasari et al., 2014); (5)
about 25% of participants did not make progress during no indicated secondary diagnosis; and (6) the primary
the first 12 weeks of treatment, suggesting that additional caregiver spoke mostly in English at home to the child.
forms of instruction might be needed for some children to Eighty-four children were screened (Figure 1). Children’s
benefit. participation in outside services was not specified for
Some children with autism may benefit less than others inclusion in the study, but was monitored at all time-
from naturalistic interventions such as JASP + EMT + SGD points. The participating children received outside
2106 Autism 24(8)

Enrollment

Assessed over the phone (n = 172)

 Not meeting inclusion criteria

(n = 36)
 Excluded (not including - English not primary (n = 4)
rescreens) - Location, too far (n = 12)
(n =11) - Age (n = 12)
- LS too high (n = 8) Assessed for eligibility (n = 84) - Exceeds language (n=6)
- Cognitive too low (n = 2) - Secondary diagnosis (n = 2)
- ADOS score too low (n = 1)  Other reasons (e.g., not enough
time to fulfill study requirements)
(n = 8)
 (Passive) Refusal (n = 33)

Randomized (n = 73)

Allocation

Allocated to intervention (n = 37) Allocated to community group (n = 36)

 Dropped prior to completion of screening  Dropped prior to completion of screening
(n=3) (n=2)

Analysis

Analyzed in the intervention group (n = 34) Analyzed in community group

 Completed pretest data (n=34)  Complete pretest data (n=34)
 Completed posttest data (n=32)  Complete posttest data (n=29)
 Completed follow-up data (n=32)  Complete follow-up data: (n=26)
 Dropped:  Dropped:
- Scheduling issues (n= 1) - Scheduling issues (n = 5)
- Distance (n = 1) - Child reaction to assessment (n = 1)
- Moved (n = 1)
- Critical family situation (n = 1)

Figure 1. CONSORT diagram.

services ranging from 0 to 38 h per week. Children in informed of their randomization assignment, and hence
both groups received speech/language and behavioral they were not included in the data analysis due to failure
services, and no significant differences in hours per week to complete sufficient pre-intervention assessments for
of intervention were observed between groups (Table 1). analysis. Seven participants (two in the intervention
Sixty-eight children and their caregivers were rand- group and five in the comparison group) withdrew from
omized to treatment (34) or comparison (34) and included the study prior to post-intervention assessment; three
in the analysis (Figure 1). Five children were originally additional participants from the comparison group with-
randomized but dropped from participation prior to being drew prior to the follow-up. These 10 participants were
Hampton et al. 2107

Table 1. Child characteristics.

Control: n = 34 Intervention: n = 34 p value

Mean (SD; range) Mean (SD; range)
%Male 79 76 0.770
%White, non-Hispanic 52 64 0.324
Age at entry (months) 43 (6; 36–55) 43 (5; 36–57) 0.854
Mullen visual reception T score 27 (4; 21–40) 26 (3; 21–33) 0.705
ADOS-2—total score 30 (5; 10–28) 21 (5; 9–33) 0.213
ADOS-2—calibrated severity score 7.4 (1.7; 5–10) 8.0 (1.7; 4–10) 0.146
Caregiver education level (%)
High school degree or less 12 8 0.689
Some college 9 26 0.056
College degree 54 47 0.460
Graduate or professional 24 17 0.359
%Low income 18 18 1.000
Outside services (hours per week)
Speech/language services 1 (1; 0–5) 0.8 (1; 0–6) 0.344
Behavioral services 1 (3; 0–12) 2 (4; 0–13) 0.179
Total services 5 (8; 0–25) 7 (8; 0–38) 0.324

SD: standard deviation; ADOS-2: Autism Diagnostic Observation Schedule—Second Edition.

Cognitive scores were measured from the visual reception subscale of Mullen Scales of Early Learning (Mullen, 1997), and autism severity was
measured from ADOS-2, Module 1 (Lord et al., 2012). Low income was defined as a household income falling below 200% of the income-to-needs
ratio specified by the Federal Poverty Line during the year of entry into the study. p values were calculated using t tests for continuous variables and
chi-square tests for categorical variables. There were no significant differences between groups on any baseline variables.

included in the analysis. Caregivers were mothers locations. After every 3–4 trials, the grid size increased
(n = 57), fathers (n = 8), and grandmothers (n = 3). until the child was presented with a 5 × 5 grid. Based on the
child’s performance, the project staff recommended the
grid size in which the child was able to find the ball in the
Randomization majority of configurations. If the child was unsuccessful in
Following initial screening, the participants were rand- “chasing the ball” across three teaching trials, the 2 × 2 lay-
omized to the intervention or the comparison group using out was recommended for initial programming.
the REDcap randomization tool (Harris et al., 2009); all The Proloquo2Go™ app was used under a custom set-
research personnel were blind to the allocation process. ting. This was selected to ensure systematic individualiza-
tion across participants. In the most common configuration
(5 × 5), each participant was given a core set of words
SGD along the bottom row. These words could be applied to
Participants in both the intervention and comparison most settings (e.g. “all done,” “more,” “stop,” or “help”).
groups received an iPad with the Proloquo2Go™ app The caregiver and therapist selected these words together.
(AssistiveWare®, 2010) to use throughout the 8-month Activity-specific pages were created for at least five com-
study participation period. A project staff member pro- mon family routines with types of vocabulary presented
vided caregivers with training (45 min) on programming, from left to right to encourage early word combinations:
how to use the device for communication, and setting up pronouns, verbs, adjectives, and nouns. These basic con-
activity pages for the child in daily routines. Caregivers figurations were adjusted for different grid sizes as appro-
were encouraged to use the device across daily activities, priate. Example pages are available in Supplemental
model language on the device, and include the device in Material 2.
other therapies/services.
During the initial assessment, the participants completed
Comparison group
a short task, “chase the ball,” to identify the best grid size
for displaying communication symbols on the SGD. The Participants assigned to the comparison group were
task for the child was to touch the ball in the display pre- referred to community-based services for children with
sented on the grid. The grid started in a 2 × 2 layout dis- autism. Parents in the comparison group were not instructed
playing four basic line drawings of common objects on the use of the JASP + EMT or DTT procedures, or how
including the red ball. After each trial, the ball changed to specifically integrate the SGD into play interactions
2108 Autism 24(8)

intervention period)
(distributed across SGD programming and basic implementation*
Workshop

4 total sessions Workshop 1: Responsive interaction

(1-1 with caregiver; Workshop 2: Language strategies
45-60 mins each)
Workshop 3: Prompting

Joint attention
DTT
Receptive language
(0-20 minutes:
(2x/week; 40-60 minutes)

adapted to child skill Imitation

level )
SGD proficiency
Clinic

Teach the caregiver (5 minutes) 1-2 strategies to practice

Interventionist models full intervention with SGD in play

(10-25 minutes); decreasing with caregiver mastery
JASP+EMT+SGD
40 minutes total Coached caregiver implementation focused on 1-2 strategies in play
(5-20 minutes); increasing with caregiver mastery

Review the practice with the caregiver (5 minutes)

(1x/week; 75-90 minutes)

Teach the caregiver (5 minutes) 1-2 strategies relevant to the selected routines
Interventionist models the routine briefly focusing on the focused strategies
Home

JASP+EMT+SGD (2-5 minutes each routine)

in 3 caregiver Coached caregiver implementation during the selected routines
selected home
routines (5-10 minutes each routine)
(30 minutes total)
Review with the caregiver and plan for future practice (5 minutes)
*also delivered to comparison group

Figure 2. Multicomponent communication intervention components.

JASP + EMT + SGD: Joint Attention, Structured Play, Engagement and Regulation plus Enhanced Milieu Teaching plus a speech-generating device.
DTT: Discrete Trial Teaching.

with their children. Check-ins occurred every 8 weeks to to individual parent and child performance such that the
update the SGD software. Participants were offered oppor- caregiver practice time was increased in proportion to
tunities to access the experimental intervention following their skill fluency, parent workshops were introduced as
the completion of follow-up testing (this intervention was the caregiver mastered communication support strate-
not available in the community setting). gies, and child DTT was decreased as the child mastered
key foundational skills. Therapists were master’s level
clinicians who had previously met fidelity criteria for all
Intervention group of the individual components of the intervention. The
The children and caregivers assigned to the intervention same therapist implemented all intervention components
received three intervention sessions (two clinic and one for a given family.
home) per week for 36 sessions (45–60 min per session)
within a 4-month period and three total caregiver inter- DTT. Each clinic-based session (24 sessions) included up to
vention workshops. The multi-component adaptive inter- 20 min of therapist-implemented DTT (Eikeseth et al.,
vention included (1) therapist-implemented DTT with the 2002). This focused DTT instruction was designed to pre-
child to teach foundational skills, including the use of the teach the key skills that would also be modeled and used the
SGD in the clinic only; (2) therapist-implemented JASP + EMT + SGD portion of the session, similar to pre-
JASP + EMT + SGD during play and routines with the vious applications of the JASPER intervention (Kasari
child in the clinic and at home; and (3) caregiver training et al., 2006). Based on their performance during DTT base-
to implement JASP + EMT + SGD in the clinic and at line assessments (Supplemental Material 3), the child par-
home (Figure 2). Overall, the intervention was adaptive ticipants received instructions on (1) joint attention,
Hampton et al. 2109

(2) imitation, (3) receptive language, and (4) matching and for the child’s skill level and interests, and opportunities
basic requesting skills using the SGD. Instruction in each for the caregiver to ask questions.
program lasted 5 min per session. The four programs used During each intervention session with the child and the
direct instruction to teach skills foundational to learning caregiver, the TMCR framework was used (Kaiser et al.,
social communication that could potentially maximize ben- 2016; Roberts et al., 2014). The therapist began each ses-
efits of the JASP + EMT + SGD intervention and provided sion by reviewing two specific JASP + EMT + SGD strat-
children with targeted practice in skill areas in which they egies. The therapist then modeled these strategies with the
demonstrated specific deficits. When a child demonstrated child. The therapist verbally highlighted her use of the
criterion levels of performance for all skills in an individual strategies at least twice for each strategy. The caregiver
program (80% correct over two consecutive sessions), that then practiced the strategies with the child and received
program was dropped from the intervention sessions, result- coaching from the therapist (e.g. the therapist made sug-
ing in a 5-min reduction in overall session length. gestions for engagement and play and handed the parent
play materials, praised the caregiver’s use of specific strat-
JASP + EMT + SGD. The primary component of the inter- egies, prompted the caregiver to use a strategy, and pro-
vention was a naturalistic communication intervention: vided limited corrective feedback). The therapist ended the
JASP + EMT + SGD implemented by therapists and car- session by reviewing and linking the caregiver’s use of
egivers described by Kasari et al. (2014). Each child specific JASP + EMT + SGD strategies to the child’s play
received 30 min of play-based JASP + EMT + SGD dur- and communication.
ing each session (home and clinic). Play and language tar- The amount of time the caregiver practiced the inter-
gets were selected based on initial assessments. Throughout vention strategies with the child systematically increased
the intervention, the therapist and the caregiver used the across the 36 sessions, from 5 min at the beginning of treat-
SGD to model communication and to provide the child ment to 20 min at the end. The combined time for thera-
with a nonverbal response mode. pist-plus-caregiver implementation of JASP + EMT + SGD
in each session was 30 min; thus, the amount of therapist-
Caregiver training. The strategies used in the JASP + provided direct intervention to the child decreased from 25
EMT + SGD intervention were introduced to the caregiver to 10 min across the 36 sessions.
during three didactic workshops; workshops occurred Each home session (12 total sessions) included play
before the first intervention session, between sessions 12 with toys and two additional home routines, selected by
and 18, and between sessions 24 and 30. Workshops were the family, in which the caregiver practiced the use of
individual sessions with the therapist and the caregiver JASP + EMT + SGD strategies. Typical routines selected
held in addition to the regularly scheduled sessions. The by the caregiver included mealtime, hand washing, out-
timing of workshops was based on the individual caregiv- door play, bath time, dressing, and book reading. Each rou-
er’s mastery of the intervention strategies, consistent with tine lasted 5–20 min; caregiver training followed the
procedures in prior studies using the Teach-Model-Coach- TMCR framework described above. Typically, the thera-
Review (TMCR) approach (Hampton et al., 2017; Kaiser pist modeled the routine the first one or two times the rou-
et al., 2016; Roberts et al., 2014; Roberts & Kaiser, 2012, tine was implemented; thereafter, the caregiver practiced
2015). Workshops included a rationale for each strategy, the routine and the therapist provided coaching and feed-
video examples of the therapist or caregiver using the strat- back to support the caregiver. Over the 12 home sessions,
egy with the child, role-playing, discussion of adaptations the family was encouraged to select different routines such

Table 2. JASP + EMT + SGD strategies and the corresponding workshops when strategies were taught to caregivers.

Workshop Strategies (goal criteria) Definitions

1 Matched turns (80% correct) Percentage of adult utterances in response to a child’s utterance or
action
1 Target-level language (50% of utterances) Percentage of adult utterances using a child’s predetermined MLU
2 Expansions (40% of opportunities) Percentage of child utterances to which the adult imitates and adds a
word
3 Time delays (80% correct implementation) Percentage of nonverbal prompting sequences that were used correctly
3 Milieu prompting (80% correct Percentage of verbal prompting sequences that were used correctly
implementation)

JASP + EMT + SGD: Joint Attention, Structured Play, Engagement and Regulation plus Enhanced Milieu Teaching plus a speech-generating device;
MLU: mean length of utterance.
Values are presented as the percent of opportunities in which the caregiver used each strategy. The therapist used all strategies during all sessions,
but coached caregivers in strategies specific to the workshop for each phase. The strategies above describe the verbal strategies measured in
the language transcripts. Caregivers were also taught engagement and play strategies including environmental arrangement, play levels and play
expansions, and using joint attention and gesture. Criteria levels indicate goal-use of strategies.
2110 Autism 24(8)

that by the end of the intervention at least six different car- strategies was measured during the 10-min CCX at each
egiving routines were practiced. major assessment point. Caregiver utterances were tran-
scribed and coded for the use of JASP + EMT + SGD
strategies as defined in Table 2.
Fidelity
Fidelity of intervention was measured from video record- Early Social Communication Scales. The total number of ini-
ings for 17% (210) intervention sessions. Four clinic and tiations of joint attention was measured during the Early
two home sessions for each family were randomly selected Social Communication Scales (ESCS), administered by a
from their 36 intervention sessions. Fidelity assessments novel assessor (Mundy et al., 2003). The ESCS is a com-
were completed for all components of the intervention mon and valid observational measure of early social com-
(JASP + EMT + SGD, Kasari et al., 2014; DTT, Eikeseth munication behaviors in children with autism who are
et al., 2002; and caregiver training, Roberts et al., 2014) preverbal or minimally verbal (Trembath et al., 2019).
using a checklist (see Supplemental Material 1) and
reviewed on a continuous basis. Overall fidelity for thera- Preschool Language Scales. Global language was measured
pist implementation of the JASP + EMT + SGD compo- using the expressive and receptive language subscales of
nent was 89.45% (standard deviation (SD) = 4.27), for the the Preschool Language Scales, Fifth Edition (PLS-5;
DTT component it was 96.62% (SD = 9.93), and for the Zimmerman et al., 2011). The PLS is a valid measure of
caregiver training component it was 86.31% (SD = 9.49). language ability in children with autism (Volden et al.,
2011) that provides a standard score and age equivalent
scores. Raw scores were used in this study due to floor
Measures
effects for the standard and age equivalent scores for the
All assessments were completed by an assessor blind to preverbal participants.
group assignment in a small clinic room in a different loca-
tion than the intervention. Following the screening assess- Demographic questionnaire. Demographic information
ment, the full battery of initial assessments was about the children and their families including socioeco-
administered over 2 days within a 2-week period. Post- nomic status (SES) and child participation in therapies in
intervention assessments were completed approximately the community was obtained via survey from caregivers at
4 months after the pre-intervention and follow-up assess- each assessment point.
ments were completed 4 months after the post-intervention
assessment. Fidelity of assessment administration was ADOS-2. At baseline, the child participants were evalu-
measured for 20% of the nonstandardized assessments and ated for symptoms of autism severity on ADOS-2 (Lord
averaged 95.28% (range: 80%–100%) across measures. et al., 2012). ADOS-2 is the gold standard diagnostic
assessment for autism. All participants were adminis-
Naturalistic language sample. Naturalistic language sample tered the first module, based on entry-level language
(NLS) was a 20-min interaction between the child and an levels. ADOS-2 yields a total score and a 10-point cali-
assessor using six novel toy sets. The NLS provided a general- brated scale that allows for comparison across partici-
ized measure of social communication by observing children in pants and over time (Gotham et al., 2009). The raw
a novel context with novel materials and with an adult who did total score was used as a covariate in all outcome anal-
not use JASP+ EMT + SGD strategies. The video-recorded yses to control for overall autism severity among
NLS was transcribed and coded for social communicative participants.
utterances (SCU), by coders blind to random assignment, using
the Systematic Analysis of Language Transcripts (SALT) soft- Mullen Scales of Early Learning. Participants were
ware (Miller & Chapman, 2008). Each SCU was defined as assessed for cognitive ability at baseline based on the
spoken, SGD, or gestural requests and comments that included Early Learning Composite of the Mullen Scales of
a secondary indicator (pointing, showing, giving, eye contact) Early Learning (Mullen, 1997). The visual reception
that confirmed the social intention of the utterance. subscale is commonly used as a proxy for a nonverbal
intelligence quotient and this standardized score was
Caregiver–child interaction. Similar to the NLS, a 10-min used to characterize participants at baseline (Bishop
caregiver–child interaction (CCX) including a different et al., 2011).
standard set of novel toys, was video-recorded, tran-
scribed, and coded for SCU. Similar to the NLS, coders Caregiver satisfaction. Caregivers in the intervention group
were blind to random assignment. The CCX provided a completed a brief survey (20 items) at posttest asking to
proximal measure of social communication by observing rate their satisfaction with the intervention strategies,
the caregiver and child in a novel setting with novel mate- effectiveness, and coaching procedures. Each item asked
rials. The caregiver use of the JASP + EMT + SGD caregivers to rate the intervention on a scale from 1 to 5,
Hampton et al. 2111

with higher scores indicating higher satisfaction with the Model building. A model building approach was used to test
intervention provided. the model fit of four possible covariates (age, autism sever-
ity, nonverbal intelligence quotient (IQ), and pre-interven-
tion scores of the dependent variable), identified a priori.
Coding and inter-observer agreement
Covariates were entered in the order listed. Among the
All variables were coded by trained coders blind to the four dependent variables of interest, inclusion of autism
participants’ group assignment. Inter-observer agreement severity and pre-intervention scores resulted in an
(IOA) for the observational assessments was completed by improved model fit as measured by a significant change in
having a second independent coder score the video- the F statistic. Autism severity and pre-intervention score
recorded measures for at least 20% of the assessments dis- of the dependent variable were maintained in all of the
tributed across timepoints (pre, post, follow-up), subsequent models as covariates. The model fit was evalu-
participants, and groups. IOA was calculated as the total ated using an F statistic of the model fit of the original
agreements divided by the sum of agreements and disa- (nonimputed) data. Each model had a statistically signifi-
greements. IOA for SCU-CCX was 89.21% (range: cant F statistic (p < 0.05) indicating that the included pre-
73.00%–100%). IOA for SCU-NLS was 91.00% (range: dictors significantly improved the model fit, with the
71.10%–100%). Intraclass correlation coefficients (ICCs) exception of caregiver use of expansions at follow-up
were calculated for the ESCS as suggested by the coding (p = 0.06), caregiver use of time delays at posttest (p = 0.21)
manual (Mundy et al., 2003), which were consistent with and follow-up (p = 0.052), and caregiver use of milieu
the published literature (joint attention: ICC = 0.903; confi- prompts and follow-up (p = 0.13). However, given that the
dence interval (CI): 0.83–0.94). models approached significance, the pretest variable was
maintained in each model for consistency across models.
Statistical analyses
Results
Prior to beginning the analyses, scores for each variable
were examined for outliers and nonnormal distributions. Means and standard deviations of all observed covariates,
Outlying scores were verified for accuracy. All child vari- pre-intervention variables, and outcome variables are sum-
ables were transformed to adjust for normality. Variables marized in Table 3. Independent-samples t tests (for con-
that did not have a skew between –1 and 1 and a kurtosis tinuous variables) and chi-square tests (for categorical
between –2 and 2 were transformed using square roots variables) indicated no significant between-group differ-
prior to imputation so that all variables fell within this ences at baseline for any included variables (Table 1).
acceptable range of normality (George & Mallery, 2010).
All proposed baseline covariates were examined using a
Post-intervention
correlation matrix. None of the proposed covariates
(autism severity, pre-intervention scores, see below) had a To test the hypothesis that the intervention improved lan-
correlation greater that r = –0.532, thus mitigating the con- guage and communication outcomes, separate linear
cern of collinearity, given that standards indicating values regression analyses were completed for the four dependent
that exceed a correlation of 0.90 are a concern for multi- child communication variables of interest at the post-inter-
collinearity (Hair et al., 2016, p. 196). vention and follow-up timepoints, controlling for autism
Multiple imputation of missing data was used to com- severity and pre-intervention scores. There was a signifi-
plete the proposed intent-to-treat analysis using SPSS cant effect of group assignment on joint attention at post-
(IBM Corp., 2017). Data for all participants who com- intervention (p = 0.031). On average, group assignment
pleted the screening assessments (Mullen, ADOS-2, and predicted increases in SCU-CCX (p = 0.076), SCU-NLS
NLS) were analyzed regardless of whether they completed (p = 0.612), and PLS–Expressive/Receptive raw scores
intervention sessions, post-intervention, or follow-up (p = 0.056 and p = 0.150, respectively), but these increases
assessments. The five participants who were randomized were not significant. It is important to note that SGD utter-
but dropped prior to completing baseline assessments were ances averaged less than one occurrence in each NLS or
the only participants excluded from imputation due to CCX; changes in SCU were primarily improvements in
incomplete Mullen scores. Fully conditional specification spoken language. All results are shown in Table 3.
using an iterative Markov chain Monte Carlo method with
50 iterations was used. The comparison and intervention
Follow-up
groups were imputed separately. Given the range of miss-
ing data for each variable of interest (0%–21%), 20 impu- At the follow-up, group assignment did not significantly
tations were created as recommended (Graham et al., predict a between-group difference on joint attention
2007). All child-level analyses were completed on each of (p = 0.515). There was a significant difference between
the 20 imputed data sets; inferences were based on the groups in SCU-CCX (p = 0.049) but no significant
pooled results using Rubin’s (2004) rules. between-group differences on SCU-NLS (p = 0.460) or
 2112

Table 3. Observed means and standard deviations of communication outcomes and regression outcomes at posttest and follow-up.

Mean (SD) Pretest Posttest Follow-up

Control Intervention Control Intervention β (SE) p value Control Intervention β (SE) p value
Child communication outcomes
SCU (CCX) 7 (10) 6 (9) 9 (11) 11 (13) 0.63† (0.36) 0.076 8 (10) 11 (13) 0.84* (0.43) 0.049
Joint attention 3.3 (4.1) 4.5 (5.5) 4.1 (5.5) 5.6 (4.0) 0.61* (0.28) 0.031 5.0 (3.9) 6.0 (5.0) 0.17 (0.26) 0.515
SCU (NLS) 12 (14) 12 (14) 22 (27) 22 (23) 0.27 (0.43) 0.612 25 (22) 27 (26) 0.23 (0.51) 0.460
PLS–Expressive 23 (5) 22 (5) 25 (5) 25 (5) 1.43† (0.74) 0.056 27 (5) 26 (6) –0.35 (0.86) 0.679
PLS–Receptive 23 (5) 23 (6) 25 (6) 26 (7) 1.41 (0.98) 0.150 28 (7) 26 (8) –1.25 (1.23) 0.311
Parent strategy outcomes
Percent correct
Matched turns 26% (14) 24% (16) 30% (12) 41% (18) 0.12** (0.04) 0.003 31% (16) 38% (17) 0.08 (0.05) 0.137
Target-level language 10% (6) 10% (6) 7% (4) 28% (16) 0.21*** (0.03) <0.001 8% (6) 16% (11) 0.08** (0.03) 0.003
Expansions 6% (17) 10% (22) 4% (5) 18% (18) 0.14*** (0.04) <0.001 4% (4) 13% (19) 0.09* (0.04) 0.025
Number of correct episodes
Time delays 0.03 (0.17) 0 (0) 0 (0) 0.31 (0.93) 0.27† (0.16) 0.094 0 (0) 0.45 (1.04) 0.42* (0.19) 0.025
Milieu prompting 0.26 (0.93) 0.12 (0.41) 0.29 (0.84) 1.47 (2.18) 1.27** (0.41) 0.002 0.45 (1.29) 0.96 (1.43) 0.51 (0.34) 0.13

SD: standard deviation; SE: standard error; SCU: social communicative utterances. CCX: caregiver–child interaction. NLS: naturalistic language sample. PLS: Preschool Language Scales, Fifth Edition (raw
scores; Zimmerman et al., 2011); ASD: autism spectrum disorder.
All models are controlled for ASD severity and pretest score. Means and SDs reported are observed outcomes for ease of interpretability. Group differences are results from the imputed analysis.
†
p < 0.1; *p < 0.05; **p < 0.01; ***p < 0.001.
Autism 24(8)
Hampton et al. 2113

PLS–Expressive or Receptive (p = 0.679 and p = 0.311, in the intervention group used five more utterances in a
respectively) at follow-up (Table 3). 10-min sample from pretest to follow-up, nearly doubling
their rate of communication, which is a considerable
increase for a population characterized by their low rate of
Caregiver outcomes communication. However, the majority of participants in
Caregivers trained in the intervention group at post-inter- both groups remained at a first-words or preverbal classifi-
vention used significantly more target-level language cation (fewer than 20 different words used spontaneously
(p < 0.001), matched turns (p = 0.004), expansions in a 20-min language sample) at follow-up (64% of the
(p < 0.001), and correct prompting strategies (p = 0.003). intervention group and 73% of the control group; Tager-
At follow-up, trained caregivers used significantly more Flusberg et al., 2009). Caregivers implemented and main-
target-level language, expansions, and time delay strate- tained key JASP + EMT + SGD intervention strategies at
gies (p < 0.05; Table 2). At post-intervention, caregivers follow-up which likely contributed to the observed
in the intervention group rated their satisfaction with the improvements in child SCU-CCX at follow-up.
intervention high with an average rating of 4.76/5.0
(SD = 0.43). Strengths
This randomized controlled trial of a multi-component
Discussion communication intervention is the first to examine the
effects of combining direct teaching and naturalistic inter-
Main findings vention strategies with the use of an SGD for preverbal or
Children assigned to intervention demonstrated significant early verbal preschool children with autism. For this popu-
improvements in initiated joint attention immediately fol- lation at high risk for remaining minimally verbal, a sig-
lowing this short-term multi-component communication nificant improvement in early communication skills is a
intervention compared to the comparison group. This promising indicator that language trajectories might be
improvement in joint attention represents a moderate to improved with a longer application of this multi-compo-
small effect size (d = 0.312) and is consistent with previous nent intervention. Although previous trials have identified
research reporting effects of early intervention on social effective intervention strategies for improving core autism
communication outcomes (Fuller & Kaiser, 2019). symptoms (Kasari et al., 2006; Schertz et al., 2013), this
Although these effects were no longer significant at fol- study is the first to identify core improvements in the sub-
low-up, the differences at follow-up represent a small set of children with autism at the greatest risk for develop-
effect size (d = 0.223) which is also similar to previous ing fluent speech. These findings are consistent with
results for this population. Positive, but nonsignificant, previous evidence that the inclusion of an SGD in early
results were observed for all other communication meas- intervention does not inhibit the development of spoken
ures, and importantly posttest differences on the PLS language (Kasari et al., 2014; Schlosser & Wendt, 2008).
expressive subscale were significant at the 0.1 level. In Increases in SCU in both groups were predominantly spo-
addition, caregivers learned most intervention strategies ken communication, with communication using the SGD
and retained most of these strategies at follow-up includ- accounting for an average of less than one utterance per
ing target-level talk, language expansions, and time delay observation.
strategies. At follow-up, caregiver matched-turn respon- This study also represents a feasible and acceptable
siveness declined slightly from intervention levels and implementation of a multi-component intervention that
correct episodes of milieu prompting decreased markedly requires three sessions of parent training per week.
from intervention levels, suggesting that booster training Although the total dosage in this study was low (36 ses-
sessions may be required to maintain high levels of respon- sions), the dosage of three sessions of parent training per
siveness and precise use of prompting procedures as indi- week was relatively high compared to other studies
vidual children’s language and communication changes (Heidlage et al., 2020; Roberts et al., 2019). Overall, par-
over time. ents rated the intervention as highly acceptable.
The relative difference in joint attention did not main-
tain at the 4-month follow-up. However, children in the
Limitations
intervention group used significantly more SCU during the
CCX at follow-up, indicating that the intervention group The results of this study should be considered in light of
maintained some aspects of improved proximal social specific limitations. First, the relatively small sample size
communication after the intervention. Although this dif- and attrition may have impacted the ability to detect sig-
ference was small (d = 0.259), the improvement was nificant differences between groups (Lipsey, 1990;
observed primarily in spoken language (rather than SGD McClelland, 2000). Second, although the quantity of out-
use) in this early verbal population. On average, children side services was recorded in hours per week and did not
2114 Autism 24(8)

differ between groups, the quality and/or components of Acknowledgements

these services were not measured and may have contrib- Thank you to Mark Lipsey and Tiffany Woynaroski who contrib-
uted to the outcomes for all children in both groups. uted their expertise to the analyses of the results.
Finally, this study implemented the individual components
of the combined treatment at lower doses than previous Declaration of conflicting interests
studies for both the DTT component (Reichow et al., 2012) The author(s) declared no potential conflicts of interest with
and the clinician implementation of JASP-EMT + SGD respect to the research, authorship, and/or publication of this
(Kasari et al., 2014), which may have impacted the effec- article.
tiveness of the overall model. For example, in the original
study of JASPER, children received 30 min per day of cli- Funding
nician-implemented JASPER and DTT to teach precursor
The author(s) disclosed receipt of the following financial support
skills in addition to a 6 h/day early intensive intervention for the research, authorship, and/or publication of this article: All
program, for 6 weeks, a more frequent therapist-imple- phases of this study were supported through the Health Resources
mented dosage than this study; however, the immediate and Services Administration Grant (No. 5R40MC27707) and the
post-intervention effects of the two interventions for joint US Department of Education Grant (No. H325D070075).
attention were similar. In addition, although results of the
follow-up study of the effects of the JASPER with DTT Trial registration
intervention indicated long-term effects on spoken lan- This trial was registered with ClinicalTrials.org (No.
guage for a broad range of children with autism (Kasari NCT02291172).
et al., 2008), these effects have yet to be replicated in a
sample of minimally verbal children with autism. Future ORCID iDs
research should consider study designs that allow for the
Lauren H Hampton https://orcid.org/0000-0002-4137-9307
analysis of the relative contributions of individual compo-
nents of the intervention and individualization of dosage of Elizabeth A Fuller https://orcid.org/0000-0001-5296-5056
these components based on participant skills and response
to intervention (Chow & Hampton, 2019). Supplemental material
Although the results of this study were modest, the par- Supplemental material for this article is available online.
ticipants in this study represented the severe range of the
autism spectrum and were at high risk for remaining mini-
mally verbal. Autism severity in this sample, as rated on References
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