Extended Abstract
Introduction
Autism is a type of neurodevelopmental disorder characterized by significant deficits in communication and social skills, along with the presence of restricted and repetitive behaviors. Communication deficits are among the most prominent and persistent features in individuals with autism. Most of these individuals show a lack of inclination toward establishing communication with others from childhood, and even if they desire to communicate, they often do not experience successful interactions due to impairments in their communication skills. This issue significantly impacts their own and their families’ mental health, social development, quality of life. Autism spectrum disorder is classified into three levels, and within each level, the severity of symptoms can vary among individuals. Based on the level of the disorder, the required level of support for these individuals is determined as follows: Level 1 requires support, Level 2 requires substantial support, and Level 3 requires very substantial support from those around them.
Early diagnosis underscores the necessity of initiating rehabilitation interventions promptly for these children. If children with autism receive intensive early interventions over a longer duration, they achieve greater improvements compared to treatments as usual.
Correspondingly, numerous research findings emphasize the necessity of parental training and direct involvement in the early interventions for children with autism.
The Parent-Implemented Early Start Denver Model (P-ESDM) interventions, derived from the Early Start Denver Model (ESDM), are designed for children with autism under 60 months of age. It is an evidence-based model that utilizes developmental, relational, and applied behavior analysis approaches in its techniques, presenting these techniques within the framework of everyday routines and play-based activities that can be implemented by parents.
Research has reported the effectiveness of the P-ESDM interventions in the development of received language, social skills and imitation, socio-communicative development, cognition, fine and gross movements, communication skill development, and language development in children with autism. This study was conducted to determine the effect of the P-ESDM interventions on improving communication skills and reducing the severity of symptoms in children with autism.
Methods
This experimental case report with an A-B design was conducted on 4 children (3 boys and 1 girl) under the age of 60 months diagnosed with autism. The intervention training was provided in individual weekly sessions lasting one hour, totaling 12 weeks for each family. Following an introductory session, the start date for the individual sessions was determined for each family. In the individual sessions, the researcher first provided explanations regarding the session’s objectives, the rationale behind these objectives, and the steps to achieve them. Subsequently, the training was implemented practically for the child. Throughout the week and on a daily basis, mothers sent videos of their interactions with their child, documenting the implementation of the received training. The children’s assessment was conducted in 7 stages using assessment scales provided to their mothers. These stages comprised 2 baseline assessments, 3 assessments during the intervention, and 2 follow-up assessments. The instrument utilized was the Autism Treatment Evaluation Checklist (ATEC). The Gilliam Autism Rating Scale-Second Edition (GARS-2) was employed to determine autism severity.
The content of the interventions was adapted based on the 2009 publication by the creators of the P-ESDM, aiming at instructing early intervention techniques to the parents of children with autism. These techniques were delivered to parents through individual one-hour training sessions over a period of 12 weeks. Initially, raw data for each subject were recorded in each of the baseline, intervention, and follow-up phases. Subsequently, descriptive statistical indices, including comparisons of means, and indices for between-condition and within-condition analyses, such as trend changes, data stability, and an examination of the percentage of overlapping data (POD) and the percentage of non-overlapping data (PND), were calculated and analyzed for communication skills and autism severity.
Case Presentation
Subject 1: The first subject was a 34-month-old boy, the only child in his family, who had received a diagnosis of Level 2 autism from a psychiatrist 4 months prior to the intervention. The child communicated using unintelligible words and occasionally exhibited echolalia, which was only comprehensible to his mother. Due to aggression, the child was prescribed risperidone. The child presented with restless sleep, weak pointing skills, and moderate eye contact. As a result of the mother’s efforts and persistence in encouraging independence in personal tasks, the child could perform personal affairs, such as eating, independently. In the within-condition analysis and according to the mean index, the mean communication scores for Subject 1 decreased from 26 at baseline to 20, and both level and trend indices were descending. Regarding autism severity, in terms of the mean index, the subject’s score decreased from 105 at baseline to a mean of 80.6, and both level and trend indices were descending after the intervention. The intervention was 100% reliable in reducing communication challenges and the severity of autism symptoms.
Subject 2: The second subject was a 36-month-old girl, the second child in her family, who had received a diagnosis of Level 2 autism from a psychiatrist 4 months prior to the intervention. She communicated using single words and occasional two-word phrases. She exhibited significant echolalia, along with relatively appropriate pointing skills and moderate eye contact. She displayed an interest in interacting with others but demonstrated difficulties in establishing peer relationships. Additionally, due to the use of a sedative medication, she had adequate sleep patterns. In the within-condition analysis and according to the mean index, her mean scores decreased from 23 at baseline to 14, and both level and trend indices were descending. Regarding autism severity, in terms of the mean index, the subject’s score decreased from 94 at baseline to 85.6, and both level and trend indices were descending after the intervention. The intervention was 100% reliable in reducing communication challenges and the severity of autism symptoms.
Subject 3: The third subject was a 42-month-old boy, the third child in his family, who had received an autism diagnosis from a psychiatrist 3 months prior to the intervention. He exhibited limited pointing skills and eye contact and communicated using only a few words, without forming sentences. His sleep patterns were adequate. He displayed passivity in interactions with others but was domineering and aggressive toward his parents and siblings. In the within-condition analysis and according to the mean index, his mean scores decreased from 25 at baseline to 22.6, and both level and trend indices were descending. Regarding autism severity, in terms of the mean index, the subject’s score decreased from 102 at baseline to 96, and both level and trend indices were descending after the intervention. The intervention was 100% reliable in reducing communication challenges and the severity of autism symptoms.
Subject 4: The fourth subject was a 48-month-old boy, an only child and adopted, who had received a Level 2 autism diagnosis for eight months. He exhibited weak pointing skills and relatively appropriate eye contact. He communicated through single words and two-word phrases. He had adequate sleep patterns. Moreover, he displayed a positive relationship with his step mother but presented as stubborn and aggressive in his interactions with his step father. In the within-condition analysis and according to the mean index, his mean communication scores decreased from 24.5 at baseline to 21, and both level and trend indices were descending. Regarding autism severity, in terms of the mean index, the subject’s score decreased from 89 to 96, and both level and trend indices were descending after the intervention. The intervention was 100% reliable in reducing communication challenges and the severity of autism symptoms.
Conclusion
Based on the findings of this study, a significant difference was observed between the pre-intervention and post-intervention scores regarding communication challenges and the severity of autism symptoms across all four participating children with autism. Additionally, follow-up assessments indicated a consistent improvement trend in the the subjects, suggesting the sustained and enduring effect of the P-ESDM interventions.
Ethical Statement
The current study was approved by the Ethics Committee of Islamic Azad University, Ahvaz Branch (IR.IAU.AHVAZ.REC.1399.111).
Funding
This article has been extracted from Fahimeh Sajedifar’s Ph.D dissertation in Psychology and Education of Exceptional Children at the Faculty of Psychology, Islamic Azad University, Ahvaz Branch.
Conflicts of Interest
No conflicts of interest.
Acknowledgement
We would like to thank the esteemed parents, particularly the mothers, who participated in the study, for their cooperation and efforts.
Key Message: Parental training using the P-ESDM interventions can significantly reduce communication challenges and the severity of symptoms in children with autism, leading to improvements in their communicative skills.