Parent training boosts language in nonverbal children with autism

Children with autism who speak few or no words improve in their verbal abilities after their parents learn to engage them in conversation during play, according to a pilot study¹.

The parents learn strategies such as following their child’s focus and engaging the child with words and toys. These strategies are part of an established behavioral therapy for autism called JASPER, which is known to improve social skills and communication when implemented by trained therapists.

The new work is part of an ongoing trend of coaching parents to provide autism therapies. This approach has the advantage of incorporating the treatments into the child’s daily life. Few studies have explored the effectiveness of this approach, however. The new study’s findings begin to fill that gap.

“Parents really took to the intervention,” says lead investigator Connie Kasari, professor of human development and psychology at the University of California, Los Angeles. “They really could master the strategies to the same extent as therapists.”

The findings also show that parents do not need to use these strategies perfectly: Those who implement at least 75 percent of the techniques see improvements in their children.

“That’s an important message,” says Helen Tager-Flusberg, director of the Center for Autism Research Excellence at Boston University, who was not involved in the study. “Because if you say to parents, ‘You’ve got to be as good as the therapist,’ they’re going to throw their hands up.”

Therapists-in-training:

Kasari and her colleagues studied 22 boys with autism, aged 5 to 8 years, who spoke fewer than 20 words at the start of the study. These ‘minimally verbal’ children were part of a larger study, published in 2014, in which children with autism received JASPER for six months².

The children’s parents watched as therapists delivered the therapy for the first three months. The therapists then coached the parents to deliver the treatment for another three months.

For instance, parents learned to playfully hold a toy out of a child’s reach or to use a toy in an unexpected way to encourage the child to communicate. They were also coached to repeat any words a child attempted to use during play.

Each month, the researchers recorded 10-minute videos of the parents playing with their children using a standard set of toys. They tallied how many times each child spoke spontaneously during these sessions. They also categorized each utterance into two types: ‘requests,’ such as a plea for help using a toy, and ‘comments,’ such as verbally calling a parent’s attention to a toy or shared experience.

“Comments are kind of that top-level skill that we’re looking for, that we usually see with the least frequency and with the least spontaneity” in minimally verbal children with autism, says Stephanie Shire, assistant professor of special education and clinical sciences at the University of Oregon in Eugene.

The researchers found that the children made an average of four utterances of either type during a session at the start of the study. By the end of the study, that number had grown to more than 12. The findings appeared 8 January in the Journal of Autism and Developmental Disorders.

The children also showed an increase in the number of comments: They made only about one comment per session at the start of the study, but more than five by the end.

Parental performance:

The researchers rated how frequently and accurately the parents performed JASPER strategies at the end of the study. They scored each parent based on a checklist of 53 items.

On average, the parents mastered 70 percent of the strategies. What’s more, their scores tracked with their children’s gains: As a group, the 10 children whose parents who scored 75 percent or above showed a significant increase in the number of comments.

“This gives us a better understanding of what level parents need to be implementing a practice to see significant change,” says Aubyn Stahmer, professor of psychiatry and behavioral sciences at the University of California, Davis MIND Institute, who was not involved in the study. “There isn’t a lot of data for how well is good enough, and this study really helps us figure that out.”

To try to understand why some children improved more than others, the researchers compared the strategies mastered by parents who scored above and below 75 percent. They found that the high-scoring parents were most proficient in establishing and expanding play routines and in setting up opportunities for their children to communicate during play.

“Knowing what areas certain parents are having a hard time with is really important, because it tells us as clinicians where we maybe need to spend more time focusing on the intervention,” says Vanessa Hus Bal, assistant professor of psychiatry at the University of California, San Francisco, who was not involved in the study.

Shire says a next step is to explore whether certain aspects of the therapy are particularly important for improving a child’s social communication skills.

The researchers are also refining how they measure changes in a child’s communication abilities. For example, they have determined that a tool called the Communication Complexity Scale is a valid and reliable measure of communication ability in minimally verbal children with autism³.