Youth Insearch Leadership
The full Promising Practice Profile is available for download in PDF format (518 KB)
Project title
ProAQtive Early Intervention Program
Project practice
Multi-disciplinary early childhood education and family support program provided as an early intervention strategy for preschool children with autism spectrum disorders and their family.
Project undertaken by
Autism Queensland Inc.
Start date
February 2005
Focal areas
- Healthy young families
- Supporting families and parents
- Early learning and care
- Creating Child friendly communities
- Families and children's services working effectively together
Program
Invest to Grow (ItG)
Issue
The program was developed in response to an identified gap in services to address the needs of families of young children with autism spectrum disorders following diagnosis and prior to their enrolment in educational facilities.
Their support needs included:
- child-focused issues related to Autism Spectrum Disorder (ASD) symptoms (e.g., communication, social and behavioural issues; delays in the development of self-care skills; and difficulties being included in regular child-care and educational settings).
- family coping issues (e.g., a need for accurate information about their child's condition; ASD-specific strategies; and assistance to manage grief, stress and anxiety).
Program context
Autism Queensland provides a broad range of services to individuals with autism spectrum disorder (ASD) and their families including education and therapy programs, regional and metropolitan outreach services, respite services, supported accommodation, and training for both families and professionals.
The ProAQtive Program is an autism-specific early-intervention program for children aged 3½ to 4½ years that aims to enable the children to achieve better educational and social outcomes.
The ProAQtive program offers:
- a 2-day per week program from 9.30 am to 2.45 pm in a special education environment offering activities including social skill and functional behaviours development, and outdoor play;
- one-on-one specialist assistance for each child including:
- 1 hour speech therapy per week;
- 1 hour physiotherapy per week; and
- 1 hour occupational therapy per week;
- a minimum of one home visit per term is used to assess the home learning environment and make recommendations about supports;
- two parent contact days per term where parents consult the three therapists and teacher and/or observe the program;
- visits to the child's other education placements (e.g., preschool, special education developmental unit or child care facility);
- individualised referrals to the Social Worker and Family Support team on an as needs basis; and
- an Individualised Education Plan (IEP) developed and reviewed throughout the year.
The ProAQtive Program is offered at two locations: North Brisbane (Brighton) and South Brisbane (Sunnybank).
The total staffing arrangement for the 2-day program includes:
- two teachers (one based at Brighton and one at Sunnybank);
- four teachers aides (two at both site);
- floating therapists (physiotherapist, speech therapist, occupational therapist) moving between sites; and
- program manager who coordinates the program and undertakes the initial assessments and collection of data throughout the program.
To subsidise the program cost shortfall, the program is offered on a user-pays basis with parents paying $75 per week for the 40-week school term.
Program objectives
The program aims to improve the quality of life outcomes of the children including:
- improved social and communication skills;
- increased independence in self-care including toileting, hygiene management (tooth brushing, face washing, bathing), dressing and independence at mealtimes; and
- improved readiness for other educational and child-care settings (e.g., through increased on-task behaviour, compliance with adult directives and decreased challenging behaviours).
The program also aims to achieve outcomes for families including:
- a better understanding of ASD and ASD-specific strategies, particular as they relate to their child;
- improved capacity to manage grief, stress and anxiety; and
- opportunities for community-based activities and social networking.
Practice description
The following key elements have influenced the model development and are seen as the key ingredients of its success.
An eclectic approach
As the population of children with ASD represents a wide spectrum of abilities and impairments, a narrowly focused practice model or an overly prescriptive approach is neither appropriate nor effective (Jordan & Jones, 1999; Kasari, 2002; Prizant & Rubin, 1999; Wolery & Garfinkle, 2002).
A multi-disciplinary approach drawing on strategies and techniques from a broad range of practices was used including:
- using alternative communication methods through developing picture exchange skills based on Picture Exchange Communication System (Bondy & Frost, 2001);
- focusing on early development and maintenance of communication skills;
- using visual schedules to promote environmental predictability and reduce uncertainty, anxiety and distress;
- concentrating speech therapy on the acquisition of fundamental "social attention" and listening skills; and
- addressing the range of sensory information processing and motor skills issues that are also frequently associated with ASD through cccupational therapy and physiotherapy services (Dawson & Osterling, 1997).
An individualised approach
Due to the heterogeneous nature of ASD, each child presents unique learning styles, behaviours, intellectual challenges and level of interests in the environment (Dunlap & Fox, 1999). An individualised intervention approach for both the child and the family unit is therefore required (Fox et al., 1997; Iovannone, et al., 2003). Examples of how such an approach is operationalised in service delivery are detailed below.
Group size
Small group size with a 2:1 child/adult ratio enables staff to work intensively with each child.
Needs assessment
Prior to commencing the program, staff members arrange an appointment at the family's home or at Autism Queensland to conduct the Needs Assessment. This Needs Assessment consists of gathering any relevant reports relating to the child's development and collecting information about the child and family covering the following areas: activities of daily living and self care; neuro-cognitive skills; communication and socialisation skills; fine and gross motor skills; challenging behaviour; parental stress and information regarding the family's emotional wellbeing. The purpose of this Needs Assessment is to establish:
- a clear picture of the child's individual skills, preferences, dislikes and individual learning styles;
- the parents' main concerns for their child; and
- the impact on the family unit.
Individual Education Plans
Individual Education Plans (IEP) are prepared for each child in consultation with the child's parents, group teacher, psychologist, therapists and input from relevant early childhood placement staff. They are formal documents required by the Department of Education, Training and the Arts.
IEP Goals:
- are developed and prioritised according to the identified needs of each child on the basis of initial assessment and observation;
- are addressed as part of the program and allow staff working with the child to focus on specific areas of need identified in the IEP (a collaborative approach is taken in encouraging goal attainment and generalisation of these skills to other settings);
- generally relate to domains such as communication, social functioning, independent living skills, adaptive behaviour, sensory sensitivity issues and pre-academic skills development; and
- are developed during the first term of placement and reviewed six months later with modifications as goals are attained.
Progress reports
Two progress reports are prepared for each child throughout the course of the year-long placement providing a review of progress and a regularly updated summary of individual strengths and weaknesses demonstrated while attending the placement.
Exit report
An exit report is also provided at the conclusion of placement providing recommendations for future placement. These reports provide specific suggestions for strategies that have been effective for the individual child during the course of placement in attaining and maintaining goals.
Transition plans
Each child's program incorporates a transition plan to assist with the integration of each child into his or her future educational placement setting. This is done in collaboration with the parents and staff from the future placement setting.
A functional approach
Functional skills relate to those behaviours that are purposeful, useful and impact on an individual's environment, quality of life and independence (Dawson & Osterling, 1997; Jordan & Jones, 1999).
Children with ASD often have difficulty acquiring these skills. A lack of functional skills may result in the exclusion of children with ASD from mainstream educational and childcare settings.
Useful behaviours developed in the program include:
- Toileting is an important functional self-care activity, in that it greatly enhances the capacity of the child to be included in mainstream settings. The development of toileting skills is encouraged through development of a structured daily routine, an instructional DVD and visual supports.
- Self-care skills such as hygiene management (tooth brushing, face washing, bathing), dressing and independence at mealtimes. These skills are taught as a scheduled group activity with 1:1 guided assistance (including hand-over-hand) as required until the child becomes accustomed to the behaviour. Songs and stories with visual supports are used to cultivate interest in the activity and parents are taught to encourage these behaviours in the home with a graduated reduction in assistance thus developing greater independence.
- Functional communication skills such as requesting, making choices and seeking assistance. These skills taught explicitly during the speech therapy sessions and integrated throughout the program.
- Functional social skills such as turn taking, waiting and greetings. These skills are taught explicitly during scheduled speech therapy sessions and throughout the day's structured teaching activities. Individualised opportunities for learning occur through 1:1 interactions with the teacher, aides and therapists. Children's learning is further facilitated through participation in group activities and structured games. Skills are generalised to different activities, staff and environments.
Positive behavioural support
Positive behaviour support is a systematic approach that aims to reduce challenging behaviours and to teach positive behaviours as an alternative (Donnellan et al., 1998; Singer et al., 1999).
Staff are encouraged to:
- Undertake functional analysis of children's challenging behaviour (i.e., ask the question "Why is this behaviour occurring? What purpose does it serve? Does it represent a communicative intent?"). The psychologist often supports staff in the identification of possible triggers for challenging behaviour and analysis of the function of observed behaviours.
- Plan approaches to behaviour management rather than reacting to behaviours once they have occurred. A proactive approach to behaviour management is emphasised in this program. Teaching staff and parents are assisted in the development of specific behaviour management plans and taught to implement these interventions appropriately by the psychologist.
- Teach positive behaviours as an alternative to challenging behaviours (Koegel et al., 1996; Keen & Knox, 2004). Explicit information is given to children (on an individualised basis depending on the target behaviour) using picture-based cues (and limited verbal cues) as a means of teaching the child what they need to be doing in order to access reinforcement. Further teaching assistance is provided through modeling and "showing" the child what to do in order to access reinforcement. Frequent practice followed by reinforcement is used to fortify these learning experiences.
Autism specific teaching and learning environment
A highly supportive and structured teaching environment ensures that each child is given individual attention and assistance within the group context and that opportunities for skills practice and learning are maximised while the stressors associated with physical layout and activities are reduced.
Features of the classroom environment include:
- predictability of routine;
- minimal "clutter" in a room;
- smooth processes for transitioning from one activity to another; and
- reduction of overwhelming and extraneous sensory input in order to avoid sensory overload.
Careful analysis of the teaching environment is required to ensure these features are addressed. The use of visual schedules and some individual task breakdowns are used to increase environmental predictability. Children's belongings and the tools they will be requiring for any given activity are kept to a minimum and provided in separate storage containers for each individual. Colour/symbol coding on storage containers is also used, depending on the child, to assist with the identification of his/her personal belongings and equipment. Temporal and visual preparation is used to reduce anxiety associated with transitioning from one activity to another or from one location to another. For example, pictures of the gym and the Occupational Therapist are shown to the children prior to walking to leaving the classroom. The time given to this transition process is dependent on the needs of the individual children in the class and is based on the judgement of staff working with the group.
A family-centred approach
The literature suggests that the most successful programs are those that are family centred (McDonald et al., 1999; Keen & Knox, 2004).
The characteristics of family-centred programs are outlined below.
- Focus on family involvement and participation in programming. Parents are required to attend and observe the classroom activities at least once each term. These Parent Contact sessions aim to provide parents and caregivers with the opportunity to observe and learn from watching teaching staff and therapists. Discussion of techniques seen during the class encouraged after the session is complete. Parents are also required to attend and contribute information as part of the Individual Education Plan (IEP) process. This is seen as an essential part of individual program planning and goal identification for each child and parents are encouraged to identify priority goal areas for their child.
- Improve the parent's behavioural management knowledge and skills. Parents are encouraged to utilise services provided by the Autism Queensland psychologist who assists with the development and implementation of individualised behaviour support programs. Parents are trained to understand the principles and practices of behaviour management in order that they become more independent in the use of these strategies in the home environment (Gividia-Payne, 1995; Keen & Knox, 2004).
- Support parent help-seeking behaviour. Family-centred programs reinforce the capacity of parents to advocate on their own behalf by supporting them in making contact with appropriate resources such as other health professionals and educational programs.
- Improve parents' confidence. The program targets parents' confidence in utilising specific strategies for challenging behaviours and reinforce the consistency of their behavioural management approach. This is achieved through 1:1 discussions with teaching staff, therapists and the psychologist. Home visits are offered in order that observations can be made and feedback can be provided to parents regarding the application of these techniques in the home environment. Communication books are used on a daily basis to enhance the conveyance of information from home to Autism Queensland (and any other educational setting) regarding the child. Positive experiences, difficulties and concerns are relayed using this method.
- Provide opportunities for inclusion of children in community based activities. The program includes regular community outings (e.g., to local shopping centres and local library) aimed at teaching children to regulate their behaviour and respond in a socially appropriate manner in community contexts.
The program offers family members:
- access to specialised counselling by psychologist and social worker where required;
- regular parent information and training sessions for both parents;
- networking with other parents and the opportunity to develop additional social and support networks (e.g., parents are provided with social work services and given the opportunity to attend scheduled weekends away with other parents that are supported and facilitated by the social worker);
- regular sibling groups occur throughout the year aimed at providing other family members with support, information and the opportunity to share their experiences with other siblings and counsellors; and
- community-based activities - parents are encouraged to attend community based outings, to learn how to manage their child's behaviour in community contexts.
Research base
The literature provides supportive evidence for the following key components of the program, which are outlined as follows:
The use of visual supports
Quill (1995, 1997) has been a strong advocate for the use of visually cued instruction with children with ASD. She attributes the relative strengths of individuals with ASD in processing visually-cued instruction to the fact that static visual information can be perused and processed slowly, while information presented orally is rapid, sequential and transient and therefore more difficult for individuals with ASD to process.
A wide variety of visually cued instruction techniques have been recommended for children with ASD. These include visual displays of skill sequences to support the learning of daily living skills, graphic supports to enhance social communication and graphic reminders of behavioural rules. Dettmer et al. (2000) found that visual supports were effective in assisting two boys with autism to make the transition from one activity to another in school and home settings. Bryan and Gast (2000) found that picture activity schedules were effective in teaching children with ASD to independently engage in on-task and on-schedule in the classroom.
Picture Exchange Communication System (PECS)
The PECS system was developed by Bondy and Frost (2001) to teach spontaneous social-communication skills to non-verbal children with ASD by means of visual symbols or pictures.
Physical prompts are used to teach the child to pick up and exchange a symbol/picture for a desired object. The prompts are faded out over time. Once the child is using symbols to gain a desired item, training moves on to picture discrimination, vocabulary extension and the construction of sentences.
Yoder and Stone (2006) compared the effect of the PECS system with another communication intervention called Responsive Education and Pre-linguistic Milieu Teaching (RPMT) on the spoken communication of 36 preschoolers with ASD. They found that PECS was more successful than RPMT in increasing the number of non-imitative spoken communication acts and the number of different non-imitative words, although the RPMT program was more effective if the children began the program with very low levels of object exploration (Yoder & Stone, 2006).
Carr and Felce (2007) investigated the impact of the PECS system on the communication of 24 children with autism aged between 3 and 7 years in comparison to 17 children with autism in a non-intervention control group. The communicative initiations and dyadic interactions between the children and teachers increased significantly in the PECS group but not in the control group.
Howlin et al. (2007) investigated the impact of providing expert training and consultation in the use of PECS to teachers of 84 elementary school age non-verbal children with ASD in specialist school settings. Classes were randomly assigned to three groups: (a) intermediate treatment group that received PECS training immediately after assessment; (b) delayed treatment group that received PECS training 2 terms after baseline assessment; (c) no treatment group that received no PECS training. In the groups receiving PECS training/consultation, there were significant increases in the rate of communicative initiations and rate of PECS use in the classroom. However, for the "immediate treatment" group, follow-up suggested that the positive effects were not maintained once classroom consultations ceased. The authors conclude that PECS has potential value for non-speaking children with autism, but that the lack of maintenance of the treatment effects suggests that ongoing intervention is likely to be required (Howlin et al., 2007).
Autism-specific teaching and learning environment
The features that are common to various autism-specific teaching and learning approaches include:
- highly predictable and structured routines with smooth processes for transitioning from one activity to another; and
- minimisation of extraneous sensory input in order to avoid sensory overload.
Olley and Reeve (1997) described features such as the use of structure, clearly defined physical spaces and highly predictable and transparent schedules as the "conventional wisdom" common to many published and unpublished educational programs for children with ASD.
The widely-used educational program, TEACCH (Treatment and Education of Autistic and Related Communications Handicapped Children), recommends features of classroom organisation and management that are likely to enhance the salience of educational input, while minimising extraneous input (Schopler et al., 1995). The school day is structured with a high level of predictability and routine. The classroom is divided into clearly separate areas for different tasks.
Connor (1999) also advocates educational strategies which are characterised by structure, salient educational input and minimal extraneous input for students with ASD. These include focusing the child's attention before any communication by using his or her name or a pre-arranged signal, giving clear simple instructions one at a time, the removal of distracters, and the provision of an individual work area for tasks that demand a high level of concentration (Connor, 1999).
Positive Behaviour Support
The process of Positive Behaviour Support entails five essential steps (Buschbacher & Fox, 2003). Firstly, the goals are set by a collaborative team including the family, teacher, therapists and other related service personnel. Secondly, there is a process of comprehensive functional assessment, which includes gathering information about the environment in which the behaviour occurs, the antecedents that trigger the behaviour and the consequences of the behaviour. This is followed by the development of a hypothesis about the relationship between the child's behaviour, the environment, and the communication function served by the behaviour. The team then develops a comprehensive support plan, which includes long-term supports (strategies to assist the child's overall health, development and social/communication skills) and prevention strategies (manipulation of the environmental antecedents and attention to cues that appear to be working for the child). Most importantly, social and communication skills are taught to replace the challenging behaviour. The final step in the process is to implement the support plan with outcome monitoring, measurement and refinement of the plan as needed.
Positive Behaviour Support Programs have been found to be effective in reducing the challenging behaviours of children with disabilities. Carr et al. (1999) found that two thirds of studies reviewed described problem behaviours as being reduced by 80% or more, while a review of six studies by Horner et al. (2000) found that the average percentage of challenging behaviour reduction was 94.6%.
Education and skills training for parents
There is some evidence to suggest that education and skills training programs for parents of young children with autism may be beneficial in terms of parental mental health and adjustment.
Tonge et al. (2006) studied the impact on parental mental health of a parent education and behaviour management intervention as compared to a parent education and counselling program. Both programs resulted in significant and progressive improvement in overall mental health at follow up. The parent education and behaviour management program was more effective in reducing anxiety, insomnia, and somatic symptoms and family dysfunction than the parent and counselling program.
Salt et al. (2002) also found that a Scottish early intervention program resulted in a non-significant reduction of parental stress, while the parental stress of a no-treatment comparison group increased.
Outcomes
The main outcomes for the children who participated in the program included:
- improved communication skills;
- increased social interaction;
- decreased dysfunctional stereotypical behaviours; and
- increased independence in self-care skills such as toileting, hygiene management (tooth brushing, face washing, bathing), dressing, eating and drinking skills.
The main outcomes for the parents who participated in the program included:
- opportunities to network with other parents of children with ASD;
- increased understanding of their child's development; and
- satisfaction that they and their child benefited from the program.
Evidence of outcomes
The program initially ran from February 2005 to December 2005 and was independently evaluated by an external consultant, Dr. Pamela Spall and Associates.
Where standardised assessments were used, the Reliable Change Index (Jacobson et al., 1984) was used to determine whether the changes were clinically meaningful. The Reliable Change Index represents the number of scale points needed on a psychometric measure to determine if a change in a person's score from pre- to post-intervention is due to real change or chance variation (Jacobson et al., 1984). The Reliable Change Index is calculated using the Standard Error of Measurement to estimate the range of chance variation. In this instance, Reliable Change Indices were calculated at p <.05 level of significance (less than 5% chance that the change was due to chance). Reliable Change Indices were used for the Gilliam Autism Rating Scale (Gilliam, 1995), the Communication and Symbolic Behaviour Scale (Wetherby & Prizant, 1993) and the Parenting Stress Index: Short Form (Abidin, 1990).
The evaluation did not use an experimental design as at the time there was a lack of availability of a control group due to limited numbers of children on the waiting list. It is therefore not possible to ascertain to what extent the outcomes were influenced by other factors such as developmental maturation, involvement in other programs (such as the Education Queensland programs), the home learning environment or the intensity of parental involvement. Another limitation was the small sample size (12 children), which limits the capacity to generalise the results to the broader population of children with ASD. However, the following results listed below give some indication of the changes that occurred in both the children and their parents during the course of the year.
Child outcomes
- Communication skills and social interaction skills were evaluated before and after the program using the Gilliam Autism Rating Scale (Gilliam, 1995) and the Communication and Symbolic Behaviour Scale (Wetherby & Prizant, 1993). A third of children (36%) showed a clinically significant change in the communication domain and 42% showed a clinically significant change in the socialisation domain.
- Stereotypical behaviours were measured before and after the program using theGilliam Autism Rating Scale (Gilliam, 1995). 42% of children showed a clinically significant change.
- Self-care skills were measured before and after the program using the Adaptive Behaviour Questionnaire(Littman, 2005), a questionnaire specifically designed for this project. The extent of improvement is expressed in terms of 1, 2 or 3-4 point improvement on a 5 point rating scale ("1" indicating that the child was able to perform the task 100% of the time and "5" indicating that the child could never performed the task). For example, 2 points improvement indicates improvement from rating 4 to rating 2. The percentage of children who demonstrated some improvement in their ability to perform self-care tasks varied across each task. For example 73% of children showed between 3-4 points improvement on using a spoon; 58% showed a 3-4 point improvement on recognising the need to urinate; 33% showed a 3-4 point improvement on attempts to wipe nose. The task area where no improvement was highest was recognition of need to defecate (50%).
Parent outcomes
The Parenting Stress Index-Short Form (PSI-SF) (Abidin, 1990) was used to determine the impact of the program on parental stress. Four domain scores were derived from the PSI-SF Total Stress, Parental Distress, Parent Child Dysfunctional Interaction and Difficult Child. Nine of the mothers and seven of the fathers returned this questionnaire. Five out of nine mothers demonstrated clinically significant change of measures of total stress including parental distress. Five out of seven fathers demonstrated a clinically significant change on the domain of parent-child dysfunctional interactions and three out of seven on total stress.
The Parent Satisfaction Survey(a series of questions devised specifically for this project) was administered through telephone interviews after completion of the ProAQtive program. Ten of the 12 mothers were available to be interviewed. Overall, the satisfaction level of the parents interviewed was high at Sunnybank and Brighton. A number of key points are summarised as follows:
- 100% of parents identified that they met other parents and got new ideas for things to do with their child;
- 90% of parents identified that they got advice to solve problems and help in understanding their child's development;
- 80% of parents reported that they got on well with staff;
- 80% reported that their child received enough individual attention;
- 90% of parents reported that they received regular information about their child in the program;
- 90% of parents indicated that they, their child and their family benefited from the service;
- all parents reported that their children "enjoyed" (60%) or "somewhat enjoyed" (40%) participating in the program;
- 70% of parents indicated that their child was able to access a range of specialist services (e.g., physiotherapist, speech therapist etc); and
- 70% of parents were able to implement what they had learned at home.
The areas where parents were "very satisfied" and "satisfied" were where they were helped in:
- improving their child's development (60% - very satisfied and 40% - satisfied);
- parenting your child (40% - very satisfied and 50% - satisfied); and
- improving your child's behaviour (40% - very satisfied and 50% - satisfied).
Some areas of dissatisfaction were as follows:
- 70% of parents said that they did not get help in getting referrals to other services that might help their child or family;
- 100% of parents identified transport as a problem - they all drove to and from the programs; and
- staffing changes were identified as a problem by Brighton.
Policy analysis
The innovative ProAQtive Program has been designed using the best available evidence of multidisciplinary strategies that provide effective intervention for young children with a range of autism spectrum disorders.
The formal independent evaluation has demonstrated that during the program period the children made significant improvements across the range of social, educational and behavioural domains that were the focus of intervention. Autism Qld acknowledges that without comparison data from a control group, the specific contributions of the program to the improved outcomes of the children cannot be determined. Despite this limitation, it does appear that the program can demonstrate some particularly positive parental perceptions and experiences. The family-focused nature of the program design and the attention to individualised planning and delivery are seen as critical elements of success that are readily replicable. With sufficient resource support and training, the other cited key elements are also replicable.
The program continues to be run and has been provided at two additional service sites with a user pay policy enabling the gap in program expenses to be covered.
Project evaluations
Independent external program evaluation conducted by Dr Pamela Spall and Associates.
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Contact
Sarah Littmann
Psychologist
Autism Queensland Inc
437 Hellawell Road
Sunnybank Hills QLD 4109
Phone: 07 3273 0066
Fax: 07 3273 8306
Email: sarahl@autismqld.com.au
Website
More information
More information on the Promising Practice Profiles can be found on the Communities and Families Clearinghouse Australia website.