Optimizing Outcomes through Sequencing Parent-Mediated Interventions for Young Children with Autism

项目总结 尽管在自闭症谱系障碍(ASD)儿童的早期识别和干预方面取得了进展， 患有自闭症的儿童的长期结果仍然是可变的。高达40%的自闭症儿童是 在9岁时只会说最少的话，75%的自闭症成人有持续的社交交流(SC) 困难。此外，多达70%的自闭症儿童同时被诊断为破坏性的 行为(DB)障碍。父母在智力障碍的发展和预防中起着重要的作用 对数据库的干预。因此，拟议研究的首要目标是：(A)确定如何最好地 顺序二父母干预：SC干预(项目影响，改善父母为 沟通教师)和DB干预(家长对破坏性行为的培训)和(B)检查 干预结果的主持人和调解人。虽然存在有效性和可行性的证据，但 这些干预单独进行，这是一种自适应干预方法，考虑并优化了两者 干预措施尚未得到评估。这种类型的适应性干预方法可能特别需要 由于教父母使用多个药物的成本、负担和复杂性，导致家长介入干预 干预策略。确定考虑家长主持人的最佳干预顺序和 父母使用干预策略，我们提出了一项序贯、多重分配、随机试验(SMART) 我们将最初随机分配184名患有自闭症的18至36个月大的儿童 接受SC或DB干预。在分别进行为期12周的手动干预之后(第一次- 阶段干预；SC或DB)，干预者将衡量父母对干预策略的使用。在… 至此，所有家长在开始第二阶段干预前将被重新随机抽取。第二阶段 干预决定旨在响应父母实施第一阶段干预 战略。也就是说，高保真(高)实施第一阶段干预策略的父母 实施者)将被重新随机化，以更低的频率接受相同的干预(减少)或 接受另一种干预(切换)。正在实施第一阶段干预策略的家长 低保真度(低实施者)将被重新随机化，以接受相同的干预 家长的指导方法，如建模和体内指导或视频反馈(增强)或接受 另一种干预(切换)。干预24周后(第一阶段12周，第二阶段12周 阶段)，我们将评估儿童SC技能、儿童DB和家庭生活在日常活动中的参与。我们还将 在干预期间持续测量亲子关节参与度，以检查关节接触的程度 参与度对干预结果起中介作用。这项拟议的研究意义重大，因为如果干预 因为一个域(SC或DB)对另一个域有影响，干预序列系统地包括 这两种干预措施可能会对这两个领域产生更大的影响。

PROJECT SUMMARY Despite advances in early identification of and intervention for children with autism spectrum disorders (ASD), the long-term outcomes for children with ASD remain variable. As many as 40% of children with ASD are minimally verbal at 9 years of age, and 75% of adults with ASD have persistent social communication (SC) difficulties. Furthermore, as many as 70% of children with ASD have a co-occurring diagnosis of disruptive behavior (DB) disorder. Parents play an important role in SC development and in the prevention of and intervention for DB. As such, the overarching goal of the proposed study is to: (a) determine how best to sequence two parent-mediated interventions: an SC intervention (Project ImPACT, Improving Parents as Communication Teachers) and a DB intervention (Parent Training for Disruptive Behavior) and (b) examine moderators and mediators of intervention outcomes. While evidence of efficacy and feasibility exist for both of these interventions individually, an adaptive intervention approach that considers and optimizes both interventions has not been evaluated. This type of adaptive intervention approach may be particularly needed in parent-mediated interventions due to the cost, burden, and complexity of teaching parents to use multiple intervention strategies. To determine the optimal intervention sequence that considers parent moderators and parent use of intervention strategies, we propose a sequential, multiple assignment, randomized trial (SMART) design in which we will initially randomly assign 184 children with ASD, between 18 and 36 months of age, to receive either the SC or DB intervention. Following each respective manualized, 12-week intervention (first- stage intervention; SC or DB), the interventionist will measure the parents' use of intervention strategies. At this point, all parents will be re-randomized before starting the second-stage intervention. Second-stage intervention decisions are designed to be responsive to parents' implementation of the first-stage intervention strategies. That is, parents who are implementing the first-stage intervention strategies with high fidelity (high implementers) will be re-randomized to receive the same intervention at a lower frequency (Reduce) or to receive the other intervention (Switch). Parents who are implementing the first-stage intervention strategies with low fidelity (low implementers) will be re-randomized to receive the same intervention with an additional parent instructional method, such as modeling and in-vivo coaching or video feedback (Augment) or to receive the other intervention (Switch). After 24 weeks of intervention (12 weeks for first stage, 12 weeks for second stage), we will assess child SC skills, child DB, and family life participation in everyday activities. We will also measure parent-child joint engagement continually during intervention to examine the extent to which joint engagement mediates intervention outcomes. The proposed research is significant because if an intervention for one domain (SC or DB) has an impact on the other, an intervention sequence that systematically includes both interventions may have an even greater impact on both domains.