1 Evaluation of an Early Start Denver Model-Based
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1 EVALUATION OF AN EARLY START DENVER MODEL-BASED INTERVENTION FOR YOUNG CHILDREN WITH AUTISM IN AN INCLUSIVE PRESCHOOL SETTING BY JESSICA TUPOU A thesis Submitted to the Victoria University of Wellington In fulfilment of the requirements for the degree of Doctor of Philosophy Victoria University of Wellington 2020 2 ABSTRACT Autism spectrum disorder (ASD) is a neurodevelopmental disorder defined by difficulties in social communication and the presence of restricted or repetitive behaviours or interests. There is evidence to suggest that early intervention (EI) can lead to improved outcomes for children with ASD. Inclusive preschool-based delivery of EI appears to satisfy current legal and best-practice recommendations around the delivery of EI for young children with ASD. It may also offer several potential benefits including cost-effectiveness, efficiency and opportunities for children with ASD to learn from their peers. The Early Start Denver Model (ESDM) is a promising naturalistic behavioural developmental intervention for young children with ASD aged between 12 and 60 months. The ESDM can be delivered to children in a group-based format and several studies have demonstrated its effectiveness when delivered for 15 to 25 hours per week in designated ESDM preschools with low child–teacher ratios. However, the preschools involved in these studies may not be representative of the typical preschool setting for many communities. Thus, more research is needed to determine the effectiveness of this intervention when delivered under conditions that more closely reflect the typical real-world preschool setting. In the present thesis, two studies with multiple probe across participants designs, each involving three preschool children with ASD, examined the feasibility and effectiveness of the use of the ESDM in an inclusive preschool setting. Specifically, Study 1 evaluated the effectiveness of a modified version of ESDM therapy delivered by a certified therapist and Study 2 evaluated (a) the effectiveness of a brief ESDM coaching programme, and (b) the effectiveness of a modified version of ESDM therapy delivered by preschool teachers. For both studies, the intervention was delivered in regular community preschools and no major changes were made to the typical preschool environments or routines. Effectiveness was assessed by measuring improvements in child active participation, vocal/verbal communication and imitation, and, for Study 2, teachers’ fidelity of implementation of ESDM techniques. Teachers’ perceptions of the acceptability and effectiveness of the intervention were also assessed via a questionnaire and in-depth interviews. In Study 1, an outside certified therapist delivered 3 hours per week of ESDM to three children with ASD over an 8- to 10-week period. Participants showed improvement in active participation, imitation and either intentional vocalisations or spontaneous functional utterances. These results were generally maintained at follow-up. For Study 2, a brief coaching programme was used to train three preschool teachers to use the ESDM with a child with ASD who attended the inclusive preschools where they worked. Teachers improved in 3 their use of the ESDM strategies and children demonstrated improved levels of active participation but results for child imitation and communication were mixed. Teachers also found the intervention to be acceptable and effective. Together, the results from these studies provide preliminary support for the feasibility and effectiveness of the ESDM when delivered in real-world inclusive preschool settings. More research is needed to determine the most effective approach to delivering EI for ASD in an inclusive preschool setting. It may also be valuable to evaluate the extent to which gains made by children and teachers during intervention generalise to other people and/or settings. 4 ACKNOWLEDGEMENTS My sincere thanks to the children, families and teachers who participated in this research. It was a privilege to work with each and every one of you and this project would not have been possible without you. I would also like to thank my primary supervisor, Professor Jeff Sigafoos, for his sage advice and guidance throughout this project. Thank you also to Dr. Larah van der Meer for getting me started on the ESDM journey and providing support and guidance during the early stages of my PhD. An extra special thanks goes to Dr. Hannah Waddington, I am so appreciative of your knowledge and ability to solve any research problem that is thrown your way! Your unwavering enthusiasm and positivity were an invaluable support, particularly during the more difficult parts of this PhD journey. I am also thankful for the advice and support that I received from my teammates at the Victoria University Autism Clinic, especially Trisha Toreka Lealiifano-Mariota, Lauren van Noorden, Sally Curtis, Willow Sainsbury, Carla Watkin and Eleanor Wilson. Thank you also to Hannah McCaleb, Lauren van Noorden and Carla Watkin for your assistance with interobserver agreement and procedural integrity. To my past and present office buddies (Kristen Finlayson, Ann Pairman and Sola Freeman), thanks for the long chats and wise advice that you provided along the way. Finally, a special thanks to my family for your love and support throughout this process. Thank you to my husband Amanaki for supporting me in every way possible. I could not have done this without you! Thank you also to my children Micah, Maximus, Carter and Grace for understanding and stepping in to help when I’ve been busy with research or writing. Thank you also to my mum for picking kids up from school, bringing dinner and patiently listening to all of my PhD talk! 5 PUBLICATIONS ARISING FROM THIS THESIS Tupou, J., van der Meer, L., Waddington, H., & Sigafoos, J. (2019). Preschool interventions for children with autism spectrum disorder: A review of effectiveness studies. Review Journal of Autism and Developmental Disorders, 6, 81-402. doi:10.1007/s40489-019- 00170-1 Tupou, J., Waddington, H., van der Meer, L., & Sigafoos, J. (2020). Effects of a low intensity Early Start Denver model-based intervention delivered in an inclusive preschool setting. International Journal of Developmental Disabilities. doi:10.1080/20473869.2019.1707434 Tupou, J., Waddington, H., & Sigafoos, J. (in press). Evaluation of a brief teacher coaching program for delivering an early intervention program to preschoolers with autism spectrum disorder. Infants and Young Children. 6 DECLARATION BY THE AUTHOR This thesis is composed of original work conducted by me in fulfilment of a PhD under the supervision of Professor Jeff Sigafoos and Dr.s Larah van der Meer and Hannah Waddington from the School of Education at Victoria University of Wellington. No part of this thesis has been previously submitted for any other degree or diploma. Work by other authors has been referenced in the text and others’ contributions have been clearly stated. The studies included in this thesis received ethical clearance from the New Zealand National Health and Disability Ethics Committee (Reference Number 18/CEN/29/AM01, see Appendix A). My primary supervisor, Professor Jeff Sigafoos, provided input into the design, analysis and interpretation of results and editing of all chapters in this thesis. Dr. Larah van der Meer provided input into the design, analysis of data, and editing for the literature review and Study 1. Finally, Dr. Hannah Waddington, provided input into the design of Studies 1 and 2, as well as assistance with data analysis, interpretation of results and editing for all chapters. Aside from this input, the studies presented in this thesis were designed and conducted by me. This thesis includes three original papers published in peer reviewed journals, these are presented in Chapters 2, 4 and 5. All changes made to the original published versions of these papers have been clearly detailed at the beginning of each chapter. My contribution to each co-authored paper is outlined at the front of each publication. I have included the publication agreements for each article in Appendix B as evidence of the publishers’ permission to include the articles in this thesis. 7 TABLE OF CONTENTS ABSTRACT ......................................................................................................................... 2 ACKNOWLEDGEMENTS .................................................................................................. 4 PUBLICATIONS ARISING FROM THIS THESIS .............................................................. 5 DECLARATION BY THE AUTHOR .................................................................................. 6 LIST OF FIGURES ............................................................................................................ 12 LIST OF TABLES .............................................................................................................. 13 PREFACE........................................................................................................................... 14 CHAPTER 1 ....................................................................................................................... 15 INTRODUCTION .............................................................................................................. 15 Autism Spectrum Disorder........................................................................................................... 15 Definition and Description ......................................................................................................