JSLHR
Research Article
Triadic Gaze Intervention for Young Children With Physical Disabilities Lesley B. Olswang,a Patricia Dowden,a Julie Feuerstein,a Kathryn Greenslade,a Gay Lloyd Pinder,b and Kandace Flemingc
Purpose: This randomized controlled study investigated whether a supplemental treatment designed to teach triadic gaze (TG) as a signal of coordinated joint attention would yield a significantly greater increase in TG in the experimental versus control group. Method: Eighteen 10- to 24-month-old children with severe motor impairments were randomly assigned to an experimental (n = 9) or control group (n = 9). For approximately 29 sessions over 17 weeks, experimental participants received TG treatment twice weekly with a speech-language pathologist in addition to standard practice. Control participants received only standard practice from birth-to-three therapists. Coders who were masked to group assignment coded TG productions with an unfamiliar speech-language pathologist at baseline, every 3 weeks during the experimental phase, and at the final measurement session.
Results: TG increased across groups from baseline to final measurement, with the experimental group showing slightly greater change. Performance trends were examined using experimental phase moving averages. Comparisons revealed significant differences between groups at 2 time points (at 12 weeks, r = .30, a medium effect, and at the end of the phase, r = .50, a large effect). Conclusion: The results suggest the promise of a short-term, focused treatment to teach TG as a behavioral manifestation of coordinated joint attention to children with severe physical disabilities.
Y
Bryan, 1989; Woods & Wetherby, 2003). Although the need for treatment may appear obvious, the challenges in working with this population are substantial because of the severity and heterogeneity of their impairments. The purpose of this research was to examine the efficacy of a treatment designed to teach children with physical disabilities to use gaze behaviors as signals of intentional communication.
oung children with severe physical disabilities are at high risk for delayed development of early signals of communication. Complicated developmental profiles can profoundly disrupt production of conventional gaze, gestures, and vocalizations in the context of social interactions. This in turn interrupts critical teaching and learning opportunities during the first months of life (Halle, Brady, & Drasgow, 2004; Iacono, Carter, & Hook, 1998; Olswang, Pinder, & Hanson, 2006; Paparella & Kasari, 2004; Pinder & Olswang, 1995; Pinder, Olswang, & Coggins, 1993). Early intervention for this population is crucial to teach behaviors that facilitate social engagement and joint attention (Arens, Cress, & Marvin, 2005; Goossens’ & Crain, 1987; Paparella & Kasari, 2004; Pinder et al., 1993; Pinder & Olswang, 1995; Reinhartsen, 2000; Wetherby, Yonclas, &
Key Words: early intervention, communication, severe disabilities
Children With Physical Disabilities
Correspondence to Lesley B. Olswang: [email protected] Editor: Rhea Paul Associate Editor: Stephanie Stokes
Young children with severe physical disabilities (e.g., cerebral palsy, congenital conditions, genetic syndromes) constitute a diverse clinical group who can be affected by impairments across sensory, motor, cognitive, and social domains. These children often exhibit unstable health, with accompanying seizure disorders and feeding difficulties threatening survival. Such problems can result in day-to-day performance variability that impairs interactions and greatly affects overall development (Dowden & Cook, 2012). Some children demonstrate poor head and trunk control, which limits their use of gestures, gaze, vocalizations, and even facial expressions unless supportive positioning is provided. When these behaviors are absent, children with
Received March 11, 2013 Revision received August 12, 2013 Accepted March 10, 2014 DOI: 10.1044/2014_JSLHR-L-13-0058
Disclosure: The authors have declared that no competing interests existed at the time of publication.
a
University of Washington, Seattle Children’s Therapy Center of Kent, Kent, WA c University of Kansas, Lawrence b
1740
Journal of Speech, Language, and Hearing Research • Vol. 57 • 1740–1753 • October 2014 • A American Speech-Language-Hearing Association
physical disabilities may begin to produce idiosyncratic signals in an attempt to engage caregivers (Sigafoos & Mirenda, 2002). Some children may have concomitant sensory impairments, including hearing and vision deficits, or hyper/ hyposensitivity to auditory, visual, and/or tactile stimulation. Last, additional challenges may arise from cognitive delays (e.g., knowledge of objects, object relations such as means/ end), which are difficult to assess in this population but can further interfere with the development of early communication skills. Such deficits are particularly problematic because, during the first months of life, children typically produce gaze, gestural, and vocal behaviors to share attention with caregivers about objects, events, and emotions. A critical milestone that occurs around 9 months of age involves the child learning to shift his or her gaze back and forth between an adult and an object or event of interest, a behavior termed triadic gaze (TG; Bakeman & Adamson, 1984; Bates, Camaioni, & Volterra, 1975; Trevarthen & Hubley, 1978). TG is a critical achievement, demonstrating the child’s ability to use coordinated joint attention (CJA). Several research groups have argued that the appearance of TG to coordinate attention between objects and persons marks the transition from preintentional to intentional communication, which is associated with significant neurological change and is highly predictive of later language development (Beuker, Rommelse, Donders, & Buitelaar, 2013; McCathren & Warren, 1996; Mundy & Newell, 2007; Mundy, Sigman, & Kasari, 1990). Thus, as a signal of CJA, TG reflects the child’s growing ability to monitor, relate, and integrate the behavior of self and others (Mundy & Acra, 2006), which supports the development of contingent communication between child and caregiver (Dunst, Trivette, Raab, & Masiello, 2008). Because children with severe physical disabilities have difficulty producing conventional behaviors that are recognized by others, they are less able to participate successfully in natural communication interactions. As a result, these children are at extreme risk for delays in language acquisition (Arens et al., 2005; Halle et al., 2004; Iacono et al., 1998; Paparella & Kasari, 2004; Pinder et al., 1993; Pinder & Olswang, 1995; Reinhartsen, 2000).
Early Intervention Although the need to target communication in early intervention for children with physical disabilities seems apparent, research has revealed the paucity of such focus in practice (Cress, 2004; Pennington, Goldbart, & Marshall, 2005). Since the passage of Part C of the Individuals with Disabilities Education Act in 1997 (Individuals with Disabilities Education Act of 2004, Pub. L. 108-446), early intervention has been characterized by transdisciplinary, caregiver-directed treatment. Services typically are delivered under a primary service provider model, in which one professional consults with the caregiver on child goals, based on family-identified priorities (American Speech-LanguageHearing Association, 2013; Hanft, Rush, & Sheldon, 2004). Although communication can be included as an important
part of early intervention (Warren et al., 2008; Yoder & Warren, 2002), motor-related needs frequently dominate services for children with physical disabilities. The challenge is to develop effective and efficient service delivery models to meet child and family needs while maximizing outcomes across developmental domains. Unfortunately, this approach sometimes ends up prioritizing developmentally appropriate behaviors in a few easily identifiable domains (e.g., mobility, feeding) over other critical milestones such as intentional communication. Efforts to document the efficacy of interventions for teaching intentional communication to this population of young children have been limited (Pennington et al., 2005). However, preliminary research has demonstrated the value of focused, short-term, speech-language pathologist–delivered intervention specifically for this purpose (Pinder et al., 1993; Pinder & Olswang, 1995). The treatment included providing communication opportunities, waiting for the child’s response, recognizing the child’s attempt, and guiding or shaping performance toward TG. Findings showed that children can learn to use TG to request the continuation of a discontinued action and to make a choice between desired objects under structured, familiar conditions after twice weekly treatment for 12–16 weeks. Furthermore, the research documented that children with motor impairments can progress from gazing at an object or an adult (dyadic gaze) to shifting their gaze between an object and adult (TG) with SLP shaping and reinforcement. The heterogeneity of the population was reflected in differences in success among participants; some children rapidly increased TG productions, whereas others learned more slowly, requiring practice with earlier developing behaviors. This research program also documented two changes that coincided with the introduction of participation in TG treatment: (a) an increase in the variety of object play and (b) improvement in caregiver reports of child exploration and interaction with toys (Olswang & Pinder, 1995). Another study suggested the value of teaching this same protocol to caregivers of three children with physical disabilities (Olswang et al., 2006). After six sessions, caregivers demonstrated the ability to provide opportunities for communication and recognize gaze attempts, although they were minimally able to shape TG. In contrast to previous results, these children’s TG productions increased only slightly during the study period, perhaps indicating the importance of shaping. All of this research has shown the promise of a treatment designed to teach gaze behaviors associated with CJA. The research has helped define critical elements of the treatment protocol for maximizing outcomes, namely intense, short-term treatment provided by an SLP who is eliciting, shaping, and reinforcing TG productions. Further exploration of this treatment will have important implications for designing more efficacious services for young children who are at risk for long-term therapeutic needs.
Research Focus The purpose of this research was to examine the value of this treatment for teaching TG as a manifestation of CJA
Olswang et al.: Triadic Gaze Intervention for Children
1741
to young children with severe physical disabilities as a supplement to their ongoing early intervention services (hereafter referred to as standard practice). The four unique aspects of the current research included the following: (a) randomized assignment of children to either an experimental group receiving TG + standard practice or a control group receiving only standard practice, (b) multiple SLPs trained to provide the TG treatment, (c) different SLPs masked to group assignment conducting measurement sessions, and (d) numerous coders also masked to group assignment. We used both between-group and individual time series analyses to answer the following four research questions: 1.
Will young children (ages 10–24 months) with physical disabilities produce TG as a signal of CJA to a greater degree with TG treatment than a control group without that treatment at the final measurement session?
2.
Will the two groups of children demonstrate differences in change in TG production from baseline to final measurement session?
3.
Will trends in level of TG production differ over time for individuals within each group?
4.
Will the level of TG production differ between groups at 12 weeks into the experimental phase and at the end of the experimental phase?
Method General Procedure This research had a randomized, controlled design, in which children with severe physical disabilities between 10 and 24 months of age were randomly assigned to one of two groups: (a) an experimental treatment group (n = 9) or (b) a control group (n = 9). All participants were considered good candidates for learning TG as a conventional and reliable communication signal (see the Recruitment and enrollment section for detailed characteristics). Children were referred by birth-to-three centers in the Seattle area and recruited with the approval of the University of Washington’s institutional review board and parental consent. In accordance with institutional review board requirements, caregivers were informed at the time of consent that participation in this research would not affect their current birth-to-three services in any way. Children in the experimental group received direct treatment for TG delivered by a research SLP in addition to standard practice (treatment provided by their birth-to-three center service providers). Children in the control group received only standard practice sessions. Children in both groups were observed in a play activity with an examiner approximately every 3 weeks to monitor TG learning.
Participants Recruitment and enrollment. Forty-six children were recruited from seven birth-to-three centers in the Seattle,
WA, area (see Figure 1 for a CONSORT flow diagram following Schultz, Altman, & Moher, 2010). Twenty-two children qualified for enrollment based on the following six criteria: (a) age between 10 and 24 months at time of consent; (b) severe motor delay as measured by a score of ≥ 2 SD below the mean on either the Fine Motor or Gross Motor Subscales of the Bayley Scales of Infant and Toddler Development, Third Edition (BSID–3; Bayley, 2006); (c) adequate vision measured by passing five of the first seven items on the Visual Reception Subtest from the Mullen Scales of Early Learning (MSEL; Mullen, 1995); (d) adequate hearing judged by passing four of the first six items on the Receptive Language Subtest of the MSEL, coupled with behavioral observation consistent with functional hearing; (e) interest in toys and people, as revealed through change in muscle tone, facial expression, vocalization, and/or direction of gaze; and (f ) demonstrating >80% dyadic gaze (sustained gaze to adult or object),
Research Article
Triadic Gaze Intervention for Young Children With Physical Disabilities Lesley B. Olswang,a Patricia Dowden,a Julie Feuerstein,a Kathryn Greenslade,a Gay Lloyd Pinder,b and Kandace Flemingc
Purpose: This randomized controlled study investigated whether a supplemental treatment designed to teach triadic gaze (TG) as a signal of coordinated joint attention would yield a significantly greater increase in TG in the experimental versus control group. Method: Eighteen 10- to 24-month-old children with severe motor impairments were randomly assigned to an experimental (n = 9) or control group (n = 9). For approximately 29 sessions over 17 weeks, experimental participants received TG treatment twice weekly with a speech-language pathologist in addition to standard practice. Control participants received only standard practice from birth-to-three therapists. Coders who were masked to group assignment coded TG productions with an unfamiliar speech-language pathologist at baseline, every 3 weeks during the experimental phase, and at the final measurement session.
Results: TG increased across groups from baseline to final measurement, with the experimental group showing slightly greater change. Performance trends were examined using experimental phase moving averages. Comparisons revealed significant differences between groups at 2 time points (at 12 weeks, r = .30, a medium effect, and at the end of the phase, r = .50, a large effect). Conclusion: The results suggest the promise of a short-term, focused treatment to teach TG as a behavioral manifestation of coordinated joint attention to children with severe physical disabilities.
Y
Bryan, 1989; Woods & Wetherby, 2003). Although the need for treatment may appear obvious, the challenges in working with this population are substantial because of the severity and heterogeneity of their impairments. The purpose of this research was to examine the efficacy of a treatment designed to teach children with physical disabilities to use gaze behaviors as signals of intentional communication.
oung children with severe physical disabilities are at high risk for delayed development of early signals of communication. Complicated developmental profiles can profoundly disrupt production of conventional gaze, gestures, and vocalizations in the context of social interactions. This in turn interrupts critical teaching and learning opportunities during the first months of life (Halle, Brady, & Drasgow, 2004; Iacono, Carter, & Hook, 1998; Olswang, Pinder, & Hanson, 2006; Paparella & Kasari, 2004; Pinder & Olswang, 1995; Pinder, Olswang, & Coggins, 1993). Early intervention for this population is crucial to teach behaviors that facilitate social engagement and joint attention (Arens, Cress, & Marvin, 2005; Goossens’ & Crain, 1987; Paparella & Kasari, 2004; Pinder et al., 1993; Pinder & Olswang, 1995; Reinhartsen, 2000; Wetherby, Yonclas, &
Key Words: early intervention, communication, severe disabilities
Children With Physical Disabilities
Correspondence to Lesley B. Olswang: [email protected] Editor: Rhea Paul Associate Editor: Stephanie Stokes
Young children with severe physical disabilities (e.g., cerebral palsy, congenital conditions, genetic syndromes) constitute a diverse clinical group who can be affected by impairments across sensory, motor, cognitive, and social domains. These children often exhibit unstable health, with accompanying seizure disorders and feeding difficulties threatening survival. Such problems can result in day-to-day performance variability that impairs interactions and greatly affects overall development (Dowden & Cook, 2012). Some children demonstrate poor head and trunk control, which limits their use of gestures, gaze, vocalizations, and even facial expressions unless supportive positioning is provided. When these behaviors are absent, children with
Received March 11, 2013 Revision received August 12, 2013 Accepted March 10, 2014 DOI: 10.1044/2014_JSLHR-L-13-0058
Disclosure: The authors have declared that no competing interests existed at the time of publication.
a
University of Washington, Seattle Children’s Therapy Center of Kent, Kent, WA c University of Kansas, Lawrence b
1740
Journal of Speech, Language, and Hearing Research • Vol. 57 • 1740–1753 • October 2014 • A American Speech-Language-Hearing Association
physical disabilities may begin to produce idiosyncratic signals in an attempt to engage caregivers (Sigafoos & Mirenda, 2002). Some children may have concomitant sensory impairments, including hearing and vision deficits, or hyper/ hyposensitivity to auditory, visual, and/or tactile stimulation. Last, additional challenges may arise from cognitive delays (e.g., knowledge of objects, object relations such as means/ end), which are difficult to assess in this population but can further interfere with the development of early communication skills. Such deficits are particularly problematic because, during the first months of life, children typically produce gaze, gestural, and vocal behaviors to share attention with caregivers about objects, events, and emotions. A critical milestone that occurs around 9 months of age involves the child learning to shift his or her gaze back and forth between an adult and an object or event of interest, a behavior termed triadic gaze (TG; Bakeman & Adamson, 1984; Bates, Camaioni, & Volterra, 1975; Trevarthen & Hubley, 1978). TG is a critical achievement, demonstrating the child’s ability to use coordinated joint attention (CJA). Several research groups have argued that the appearance of TG to coordinate attention between objects and persons marks the transition from preintentional to intentional communication, which is associated with significant neurological change and is highly predictive of later language development (Beuker, Rommelse, Donders, & Buitelaar, 2013; McCathren & Warren, 1996; Mundy & Newell, 2007; Mundy, Sigman, & Kasari, 1990). Thus, as a signal of CJA, TG reflects the child’s growing ability to monitor, relate, and integrate the behavior of self and others (Mundy & Acra, 2006), which supports the development of contingent communication between child and caregiver (Dunst, Trivette, Raab, & Masiello, 2008). Because children with severe physical disabilities have difficulty producing conventional behaviors that are recognized by others, they are less able to participate successfully in natural communication interactions. As a result, these children are at extreme risk for delays in language acquisition (Arens et al., 2005; Halle et al., 2004; Iacono et al., 1998; Paparella & Kasari, 2004; Pinder et al., 1993; Pinder & Olswang, 1995; Reinhartsen, 2000).
Early Intervention Although the need to target communication in early intervention for children with physical disabilities seems apparent, research has revealed the paucity of such focus in practice (Cress, 2004; Pennington, Goldbart, & Marshall, 2005). Since the passage of Part C of the Individuals with Disabilities Education Act in 1997 (Individuals with Disabilities Education Act of 2004, Pub. L. 108-446), early intervention has been characterized by transdisciplinary, caregiver-directed treatment. Services typically are delivered under a primary service provider model, in which one professional consults with the caregiver on child goals, based on family-identified priorities (American Speech-LanguageHearing Association, 2013; Hanft, Rush, & Sheldon, 2004). Although communication can be included as an important
part of early intervention (Warren et al., 2008; Yoder & Warren, 2002), motor-related needs frequently dominate services for children with physical disabilities. The challenge is to develop effective and efficient service delivery models to meet child and family needs while maximizing outcomes across developmental domains. Unfortunately, this approach sometimes ends up prioritizing developmentally appropriate behaviors in a few easily identifiable domains (e.g., mobility, feeding) over other critical milestones such as intentional communication. Efforts to document the efficacy of interventions for teaching intentional communication to this population of young children have been limited (Pennington et al., 2005). However, preliminary research has demonstrated the value of focused, short-term, speech-language pathologist–delivered intervention specifically for this purpose (Pinder et al., 1993; Pinder & Olswang, 1995). The treatment included providing communication opportunities, waiting for the child’s response, recognizing the child’s attempt, and guiding or shaping performance toward TG. Findings showed that children can learn to use TG to request the continuation of a discontinued action and to make a choice between desired objects under structured, familiar conditions after twice weekly treatment for 12–16 weeks. Furthermore, the research documented that children with motor impairments can progress from gazing at an object or an adult (dyadic gaze) to shifting their gaze between an object and adult (TG) with SLP shaping and reinforcement. The heterogeneity of the population was reflected in differences in success among participants; some children rapidly increased TG productions, whereas others learned more slowly, requiring practice with earlier developing behaviors. This research program also documented two changes that coincided with the introduction of participation in TG treatment: (a) an increase in the variety of object play and (b) improvement in caregiver reports of child exploration and interaction with toys (Olswang & Pinder, 1995). Another study suggested the value of teaching this same protocol to caregivers of three children with physical disabilities (Olswang et al., 2006). After six sessions, caregivers demonstrated the ability to provide opportunities for communication and recognize gaze attempts, although they were minimally able to shape TG. In contrast to previous results, these children’s TG productions increased only slightly during the study period, perhaps indicating the importance of shaping. All of this research has shown the promise of a treatment designed to teach gaze behaviors associated with CJA. The research has helped define critical elements of the treatment protocol for maximizing outcomes, namely intense, short-term treatment provided by an SLP who is eliciting, shaping, and reinforcing TG productions. Further exploration of this treatment will have important implications for designing more efficacious services for young children who are at risk for long-term therapeutic needs.
Research Focus The purpose of this research was to examine the value of this treatment for teaching TG as a manifestation of CJA
Olswang et al.: Triadic Gaze Intervention for Children
1741
to young children with severe physical disabilities as a supplement to their ongoing early intervention services (hereafter referred to as standard practice). The four unique aspects of the current research included the following: (a) randomized assignment of children to either an experimental group receiving TG + standard practice or a control group receiving only standard practice, (b) multiple SLPs trained to provide the TG treatment, (c) different SLPs masked to group assignment conducting measurement sessions, and (d) numerous coders also masked to group assignment. We used both between-group and individual time series analyses to answer the following four research questions: 1.
Will young children (ages 10–24 months) with physical disabilities produce TG as a signal of CJA to a greater degree with TG treatment than a control group without that treatment at the final measurement session?
2.
Will the two groups of children demonstrate differences in change in TG production from baseline to final measurement session?
3.
Will trends in level of TG production differ over time for individuals within each group?
4.
Will the level of TG production differ between groups at 12 weeks into the experimental phase and at the end of the experimental phase?
Method General Procedure This research had a randomized, controlled design, in which children with severe physical disabilities between 10 and 24 months of age were randomly assigned to one of two groups: (a) an experimental treatment group (n = 9) or (b) a control group (n = 9). All participants were considered good candidates for learning TG as a conventional and reliable communication signal (see the Recruitment and enrollment section for detailed characteristics). Children were referred by birth-to-three centers in the Seattle area and recruited with the approval of the University of Washington’s institutional review board and parental consent. In accordance with institutional review board requirements, caregivers were informed at the time of consent that participation in this research would not affect their current birth-to-three services in any way. Children in the experimental group received direct treatment for TG delivered by a research SLP in addition to standard practice (treatment provided by their birth-to-three center service providers). Children in the control group received only standard practice sessions. Children in both groups were observed in a play activity with an examiner approximately every 3 weeks to monitor TG learning.
Participants Recruitment and enrollment. Forty-six children were recruited from seven birth-to-three centers in the Seattle,
WA, area (see Figure 1 for a CONSORT flow diagram following Schultz, Altman, & Moher, 2010). Twenty-two children qualified for enrollment based on the following six criteria: (a) age between 10 and 24 months at time of consent; (b) severe motor delay as measured by a score of ≥ 2 SD below the mean on either the Fine Motor or Gross Motor Subscales of the Bayley Scales of Infant and Toddler Development, Third Edition (BSID–3; Bayley, 2006); (c) adequate vision measured by passing five of the first seven items on the Visual Reception Subtest from the Mullen Scales of Early Learning (MSEL; Mullen, 1995); (d) adequate hearing judged by passing four of the first six items on the Receptive Language Subtest of the MSEL, coupled with behavioral observation consistent with functional hearing; (e) interest in toys and people, as revealed through change in muscle tone, facial expression, vocalization, and/or direction of gaze; and (f ) demonstrating >80% dyadic gaze (sustained gaze to adult or object),
