All children, with no severe acute or chronic diseases, need meet the diagnostic criteria for ASD or GDD of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition(DSM-5) and clinical judgment by physician with complete related diagnostic test scale results before the training, aging from 18 to 72 months without systematic trainings. The caregivers should sign the informed consent of the course and video recording, uploading at least two videos at two key time-points: Baseline(BL) and Post-training (PT; within six months), presenting the interaction about home routines or play routines, with about 10 minutes every video.
Participants and Ethical Considerations
33 children and their caregivers, who participated CMI course in the Department of Child Health Care of our hospital from September 2018 to June 2019, met the inclusion criteria and were enrolled, with 30 boys and 3 girls. The age ranged from 22 to 69 months and the mean age was 39.61±13.12 months. The Institutional Research Ethics Boards approved the study and caregivers gave informed consent to participate. 31 children confirmed as ASD and 2 GDD. Caregivers filled in information when participating CMI. Table 1 showed the family characteristics including residence, main caregiver, family structure, parental education and annual household income.
CMI is based on the theory of Applied Behavior Analysis(ABA), mainly for children aged 2-6 years with NDDs and their caregivers who haven’t trained before systematically. CMI consisted of ten 90-minute sessions, 2 weeks a teaching cycle, and it was carried out by qualified trainers of our department who were trained and supervised by the master trainer of PST through the standard training videos. Parent-theory teaching and parent-child interaction proceed simultaneously. One caregiver attended to parent-theory teaching alone, including: (1) introduction of CMI and encouraging children to participant; (2) appropriate home routines and play routines; (3) learning the way of communication and prompting interaction; (4) prompting communication and developing language; (5) regulating child’s emotions; (6) teaching alternatives to challenging behavior; (7) teaching children new skills; (8) self-care and adjustment of caregivers; (9)/(10) practices and comments. At the same time, another caregiver with the child participated group courses divided into music, games, snacks and exercise modules. At the end of the 2-week course, caregivers were encouraged to try their best to apply the theory and intervention skills in the daily life, including home routines and play routines, in order to prompt the ability of cognition, motion, social adaptability and behavior. This study collected the based demographic information, video data and diagnostic sales at two key time‐points at least: Baseline(BL); Post-training (PT; within 6 months).
Video-Coded Scheme and Assessment Measures
The collected videos before and after the intervention were coded as the primary outcome variables. The caregivers were encouraged to record 10-minute videos of caregiver-child interaction about home routines or play routines, to evaluate whether and what the caregivers demonstrated appropriate use of techniques including: (1) environmental sets (i.e., the caregiver sets up the environment and moves to be face to face to promote engagement in play or home routines); (2) offering choices (i.e., the caregivers offers choices for the activity, follows the child’s appropriate choices and interests and comments on the child’s focus of attention and actions); (3) building and sustaining routines; (4) pauses (i.e., the caregivers pauses and allows space for the child to communicate); (5) responding (i.e., the caregivers notices the child’s communication and responds promptly by expanding it by imitation, expansion and modelling of words and gestures); (6) matching (i.e., the caregiver provides communication models that match the child’s communication goals, including gestures and spoken language); (7) requesting (i.e., the caregiver sets up the environment to create opportunities for communication to request); (8) sharing (i.e., the caregiver sets up the environment to create opportunities for communication to share); (9)supporting and regulating (i.e., the caregiver supports the child’s engagement and regulation throughout the interaction.); (10) different degrees of assistance (i.e., the caregiver promotes child’s learning of new skills by using instructional strategies into developmentally appropriate small steps and teaching one step at a time, constructing and applying visual supports as needed, giving lowest level of help needed for the child to be successful, and fading the level of help in a timely way); (11) challenging behaviors (i.e., if challenging behavior occurs, the adult responds by demonstrating use of the appropriate strategies to reduce the behavior and support the child’s regulation based on the function of the behavior). Based on those 11 strategies, the question(Q) 1 to 10 of Adult/Child Interaction Fidelity Rating(A/CIFR) is matched with the strategy from (1) to (10) above, and strategy (11) is set as an additional question marked “*”. Five degrees every question, they are: 0-The skill/strategy is not demonstrated or inappropriately applied when opportunities are present; 1-The strategy is used somewhat appropriately at times; 2-Implementation of the strategy is mixed- about 50% of the time the strategy is correct; 3-Appropriate and accurate implementation of the strategy occurs up to 80% of the time; 4-Strategies are applied appropriately in 80-100% of opportunities.
In the preliminary stage, the writer watched the reference videos of CMI and learned the corresponding scoring rubrics of A/CIFR scored by experts. Then, the writer and another author trained by experts evaluated 12 videos of 4 children with NDDs (total time: 137′58″) synchronously, and the consistency test was 99.24%.
Baby-junior high school students ability of social life scale (S-M)(8, 9), based on S-M Social Life Ability Examination established by Japanese Institute of Psychological Adaptation, was revised by professors of Beijing Medical University and Chinese Psychological Society, mainly for Chinese children with mental retardation aged 0-14 years. S-M evaluated six parts of ability, including self-help, locomotion, occupation, communication, socialization and self-direction, as important as Gesell Developmental Scales(GDS) for diagnosis of GDD.
Gesell Developmental Scales(GDS)(10) was compiled by A Gesell, an American psychologist, and revised twice in 1941 and 1980 respectively. It focused on five areas of ability, which were gross motor, fine motor, language, adaptability and individual-social behavior, mainly for children with GDD aged from 4 weeks to 6 years. The result of GDS showed developmental quotient(DQ) instead of intelligence quotient(IQ). It’s used widely in China not only as the golden standard for the diagnosis of GDD but also as an auxiliary tool for the diagnosis of ASD. A study(11) showed that the results of GDS indicated developmental backwardness and imbalance in ASD children that the DQ scores in fine motor ability, adaptability, language and individual-social behavior are lower especially in the latter two functions compared with that of gross motor.
Wechsler Preschool and Primary Scale of Intelligence (WPPSI)(12) was one of the three continuous intelligent scales created by Wechsler, a famous American medical psychologist, mainly for children with mental retardation aged 4-6.5 years. WPPSI gave consideration to the ability of both language and operation, which could reflect the intelligence level of preschool and primary children.
Autism Diagnostic Observation Schedule(ADOS) (13)was the golden standard for diagnosis of ASD, identifying ASD symptoms of communication, interaction, game/imagination, stereotyped behaviors and limited interests. According to the verbal expression level and age, the assessor should choose one of the four modules appropriately.
We first compared the results of A/CIFR between BL and PT to evaluate whether caregivers’ skills of family intervention improved and whether the longer daily family-intervention period was, the more significant the promotion was. Secondly, by making comparison of assessment scales including S-M, GDS, WPPSI and ADOS between BL and PT, whether children’s abilities and symptoms improved through family intervention. What’s more, we analyzed whether the caregivers’ promotion of intervention skills would be influenced by demographic, including the main caregiver, family structure and household income. We used SPSS 22.0 to manage data. Data also allowed for positive and negative values and were normally distributed (skew (< |2|); kurtosis (< |3.5|). Nonparametric test (Mann–Whitney U test or Wilcoxon signed-rank test) was used for comparisons between BL and PT for data of scales mentioned above. Spearman Correlation was used to analyze the influence factors on caregivers’ skill promotion. P <0 .05 was considered statistically significant.