RESEARCH
The progress of 28 children was tracked through the first two stages of the R&R program. Children were able to develop effective use of eye contact, point following, and gaze following skills in an average of just under 6 months. Importantly, all of the 28 children showed progress through the two stages, with 94% reaching the end of Stage 2 within 12 months of therapy. 
Socialization, communication, and daily living skills of 5 randomly selected children in the R&R program were investigated after a period of therapy (ranging from 11 to 26 months). All of the children had learned new skills in all three areas. Acceleration in the area of communication and socialization was seen in 4/5 of the children, indicating that they were not simply progressing, but were improving relative to their peers.
This study, conducted by a graduate student from the University of British Columbia, investigated social referencing, language and play skills in a two and a half year old boy before and after 15 weeks of therapy. Dramatic increases in joint attention, functional communication, and play skills were noted.

R&R Autism Intervention Research


Introduction

The past two decades of research in the field of developmental psychology have led to significant advances in our understanding of typical child development, and have provided important insights on the core deficits in autism spectrum disorder (ASD). Reference and Regulate has been developed to provide an innovative approach to autism intervention based on the most current understanding of typical development, and deficits in ASD.  A key finding of recent research in the area of typical child development has been the identification of the pivotal role of social referencing skills in the development of language, play, and emotional regulation ( Bloom, 2000 ;  Morales, Mundy, Crowson et al, 2005 ;  Mundy, Sigman, & Kasari, 1993 ;  Rollins & Snow, 1998 ;  Rutherford, Young, Hepburn & Rogers, 2007 ).  Indeed, social referencing and joint attention have been called "the foundation for all further communication and cultural learning" ( Carpenter et al,1998 ).  Importantly, these social referencing skills have also been identified in a large number of studies as a core deficit in ASD ( Baron-Cohen et al, 1996 ;  Charman, 2003 ). Despite these numerous and well-replicated research findings, rarely, if ever, do the conventional approaches to the treatment of autism address the development of social referencing as a primary goal in a structured, developmentally sound manner ( Kasari, 2006 ). R&R bridges the gap between research and practice by providing a systematic, step-by-step approach to the development of social referencing for children with ASD.  While R&R is based on a strong foundation of research, outcome studies are necessary to determine whether the program is truly effective in remediating the deficits in children with ASD, and improving their quality of life. To this end, we have initiated several projects designed to document children's progress and test the effectiveness of R&R. In addition to company-based research initiatives, we are also undertaking projects in partnership with the academic community with the goal of developing a rigorous, ongoing program of research.  In the following update we outline some of the highlights of our three pilot projects. 
Achievement of Joint Attention in R&R
The first two stages of the R&R program target early joint attention skills including visual referencing, point and gaze following.

- In Stage 1, children learn to look at an adult in order to achieve their wants and needs.
- In Stage 2, children learn to follow an adult's point and eye gaze to an object of interest.

To investigate the progression of children through these stages, data was gathered from the clinical records of 28 preschool aged children. Children of all levels of ability were included in the sample. Analysis of the data revealed that children quickly and consistently mastered the early stages of the R&R program.

- All of the children in this sample were able to acquire the ability to use eye contact instrumentally within one year of therapy. This is a critical finding as treatments for children with autism are often successful only for a portion of children.
- In an average of just 1.5 months, children were consistently able to use eye contact with an adult to request a want or need, when they did this only fleetingly, or not at all, before intervention
- With 6 months of intervention, 90% of children were able to meet mastery criteria for Stage 1, indicating that they would look at an adult for 5 seconds or longer in anticipation of obtaining a desired activity. On average, children took just 3 months to reach this level.
- Sixty percent of children passed Stage 2 (able to follow an adult's gaze to a distant object in the presence of distracters) after only 6 months of therapy.

Figure 1: Mastery of Stage 1 and 2 skills in the first year of therapy. 
 
Adaptive Behaviour after R&R: Retrospective Case Studies
To provide pilot data on generalized outcomes of treatment in the R&R program, we compared pre- and post-treatment performance on the Vineland Adaptive Behaviour Scales (VABS) for five children. These children were randomly selected from the sample used in the case review project described above. Baseline scores on communication, socialization, and daily living domains were obtained from children's original diagnostic reports. All of the children were over age 3 at the start of treatment, and 4/5 had been diagnosed with moderate-to-severe language delays. The period of time spent in intervention varied across children, from 11-26 months. All received between 6-10 hours of intervention per week.

At the time of testing, one child remained non-verbal while all of the others performed within the normal range on a standardized test of language (Preschool Language Scale-4). All of the children showed progress through increases in their raw scores in each of the VABS domains (Communication, Socialization, and Daily Living skills). Acceleration was also seen in many areas for the verbal children; that is, the children's performance relative to their peers improved over the course of treatment. Particular strengths were seen in the areas of Communication and Socialization. The figure below illustrates the acceleration of the 4 verbal participants in the domain of socialization.   These pilot data suggest that children participating in the R&R curriculum are improving their overall functioning, and in particular, demonstrate increases in socialization, traditionally the most challenging area for children with ASD.

- All of the verbal children were reported to use words to express happiness and concern for others, and the nonverbal child used actions to do so.
- All of the children, including the non-verbal participant, demonstrated friendship seeking behaviour and interest in other children.
- All of the children enjoyed a range of different types of play including pretend play, with the verbal children engaging in complex pretend play or "make believe".

Figure 2: Pre- to Post-Treatment changes in socialization standard scores for verbal participants (Scores >=85 are "Average", 70-85 are "Moderately Low", <70 are "Low"). 
 
Social Referencing, Language, and Play: Case study of a child with ASD
This case study, conducted by a speech language pathology graduate student from the University of British Columbia (Akiko Hara), examined social referencing, language and play behaviours in a child ("David") at the onset of treatment at age 2;6, and over the course of the initial 15 weeks of treatment. As our first partnership study, this is the first investigation of R&R that has been carried out by an independent third party. We consider this to be an important step forward in the development of a high quality research program.

Several measures were used in this case study including observational data from play sessions with the experimenter (A. Hara) and the child's mother: the Peabody Picture Vocabulary Test (PPVT-III), and the MacArthur Communicative Development Inventory (CDI). Testing was carried out at three points: onset of treatment (T0), after 10 weeks of treatment (T1), and after 15 weeks of treatment (T2).  Rapid change was observed in the child's performance on measures of joint attention, language, and play, lending support for the clinical observation that progress through the R&R curriculum is associated with generalized improvements in children's functioning.

Social Referencing: Dramatic increases were observed in joint attention behaviours in both experimenter-child and mother-child dyads.  For example, episodes of eye contact increased from approximately 1 time in 15 minutes to 75 times in fifteen minutes.

Language: Receptive vocabulary on the PPVT improved over one standard deviation, from a low score of 81 to an average score of 99 in just 10 weeks. Non-communicative utterances decreased from 45% of the initial language sample to just 9.9% of the final language sample.

Play: After 15 weeks of therapy, increases in turn-taking, cooperation, and emergent pretend play were observed.


Figure 3: Episodes of dyadic and triadic eye contact in a 15 minute play-session with David and his mother.

Summary

The three pilot projects described briefly here have provided early confirmation of our clinical observations that children in the R&R program are acquiring the social referencing skills targeted in therapy, and that they are additionally making significant gains in language, play, and behaviour.

- Early joint social referencing skills can be taught relatively quickly, with core skills such as visual referencing and point and gaze following almost always mastered within the first year of therapy.
- Case study data suggest that many children participating in the R&R program make particularly large gains in the areas of communication and socialization, traditionally the weakest areas for children with ASD and the most difficult to treat.
- Third party data supports the evidence provided by clinical data, showing that changes in joint attention, language, and play can be observed within the first 15 weeks of therapy.

We are encouraged by the positive findings emerging from our research program. We believe that the increasing consensus on the importance of social referencing skills in ASD is vital to the future of children with ASD, and are constantly working to improve the R&R program to reflect new knowledge from development and intervention research.


Current Projects


Projects currently underway include:
Understanding of Other's Perspectives: A clinical data review investigating the progress of R&R participants in "Stage 3: Recognizing, Responding, and Adapting to Other's Perspectives".

Communicative use of language after treatment with R&R: Using Language Communicatively: Using the Canadian-developed Language Use Inventory (LUI: www.languageuseinventory.ca ), we are investigating changes in children's functional use of language in the first months of therapy. The LUI has recently been identified as a recommended instrument for measuring progress in the use of spoken language.


R&R Research Opportunities

We are actively seeking research partners to join us in our work to test the effectiveness of R&R, and to improve the understanding of the role of social referencing in ASD. Our program offers exceptional possibilities for several reasons:

- Active collaboration and support from Dr. Kate Chase, our director of research, who has recently been recommended by the UBC School of Audiology and Speech Science for appointment as a Clinical Assistant Professor at the University of British Columbia.
- A specific, defined curriculum with regular data collection that is developmentally sound and play-based.
- Highly trained and closely supervised intervention staff.
- A large pool of potential participants, with over 50 clients on our current caseload.
- A strong network of community partnerships with child development centres, health units, private speech-language pathologists and occupational therapists, and the early childhood education community.
- Collaboration with a program gaining provincial and national recognition, including invited lectures and workshops in school boards, hospitals, health units, child development centres, provincial professional associations, and in 2010, at the conference of the Canadian Association of Speech-Language Pathologists.

There are many possibilities for future research projects, including single and multiple subject case studies, cross-sectional comparison studies, and randomized control trials. We welcome interested partners and are delighted to work with graduate and post-doctoral students at all levels. 

Please direct all enquires to info@randrforautism.com





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