Targeting Joint Engagement in Toddlers with ASD: What Predicts Sustained Engagement at Study Follow-up?

Background:

Parent-mediated interventions for toddlers with autism spectrum disorder (ASD) can improve core social communication deficits such as joint engagement, and these improvements are maintained over time (Green et al., 2010; Kasari et al., 2015). Toddlers with ASD may receive intensive therapist-mediated behavioral intervention (BI), however, these approaches may not prioritize targeting specific core deficits of autism, like joint attention (Kasari et al., 2008). Given that toddlers often receive both parent-mediated intervention and BI concurrently, it is unclear whether one approach can better predict toddler outcomes of joint engagement after a research study is terminated.

Objectives:

The present study aimed to assess whether parent mediated intervention fidelity (JASPER) or behavioral intervention hours (treatment as usual) was more predictive of increased joint engagement in a group of young children with ASD at the study’s 6-month follow up.

Methods:

The present study included 86 toddlers (range 22 – 36 months) with ASD and their primary caregiver. These dyads participated in an intervention trial comparing the effects of a parent-mediated JASPER intervention and a parent education counterpart on social communication outcomes. The primary outcome was time spent in joint engagement at the 6-month follow up coded from an unstructured parent child play interaction. Upon exiting study, toddlers returned to receiving behavioral intervention hours as usual. A multiple linear regression was calculated to predict child’s time joint engaged with the parent based on parent implementation fidelity and hours of behavioral intervention. This analysis controlled for autism severity (as measured by ADOS Clinical Severity Scores), IQ (Mullen developmental quotient), and time spent in the joint engagement state at exit. Insignificant predictors were excluded from presented analyses.

Results:

Parents’ implementation fidelity uniquely predicted toddler’s time spent in joint engagement. Parents’ successful adherence to JASPER principles significantly predicted their toddlers’ increased time jointly engaged (t(61)=3.62, p<.005), while toddlers’ total hours of behavioral intervention during the follow-up period did not (t(61)=-0.59, p = .56). Additionally, ADOS severity and Mullen developmental quotient scores were not significant predictors of joint engagement outcomes. Toddlers’ time spent jointly engaged at exit predicted time spent jointly engaged at follow up (t(61)=3.56, p<.005), indicating maintenance of joint engagement outcomes across a 6-month span.

Conclusions:

Parent’s use of JASPER strategies emerged as a significant predictor of toddler joint engagement at follow-up above and beyond the effect of hours of behavioral intervention received during the follow-up period. This suggests that merely more hours accrued across numerous community based behavioral interventions do not translate to better joint engagement. Parents’ implementation fidelity strongly predicted toddler’s time spent in joint engagement states, further supporting the benefit of brief, specific, parent-mediated interventions. The further use of targeted parent-mediated interventions has implications to greatly reduce time and money otherwise spent on other BI resources. These findings may have practical implications for clinicians who seek to recommend interventions that successfully predict gains in the skills most impacted by ASD. Future research should investigate feasibility and effects of other parent-mediated interventions targeting core deficits of autism.