Area of Investigation

The goals of the study were to test whether participation in the More Than Words Program: 

1. enhanced parental responsivity to their toddler’s actions, focus of attention and communication; and 
2. increased communication in toddlers with symptoms consistent with ASD in comparison with a “business as usual” control group

Research Design and Subjects

This randomized controlled trial was conducted at three project sites (cities in the south, southeast, and northeast United States), and families were recruited from specialty clinics, early intervention programs, pediatric and neurology practices, and the online Interactive Autism Network. 

The study measured children’s communication and parents’ responsivity at three points in time:

Time 1: Prior to randomization

Time 2: Five months post-enrolment in the More Than Words Program (at the end of the intervention period)

Time 3: Nine months post-enrolment in the More Than Words Program (four months after the end of the intervention period)

Subjects: 62 children (51 boys and 11 girls) with a median age of 20.25 months who met criteria for autism spectrum disorders, and their parents. 

Intervention group: 32 children who met criteria for autism spectrum disorders and their parents.

Control group: 30 children who met criteria for autism spectrum disorders and their parents.

Intervention

Over a 12 week period, parents attended the More Than Words Program, which included:

• 8 group sessions for parents
• three home visits (for parent and child) to monitor their progress and provide individualized coaching using videotaping and feedback  

Results

Increase in parent responsiveness

Parental responsivity was analyzed at Time 1, 2 and 3. Nonverbal responsivity was coded when a parent assisted the child during play, imitated the child’s actions with a similar object, expanded on the child’s play or responded to a request from the child. Verbal responsivity was coded when a parent commented on the child’s current focus of attention, or verbally expanded on the child’s communication without being directive.

Parental responsivity was evaluated by measuring statistical significance and effect size. It has been argued that effect sizes provide more meaningful information than statistical significance (Cohen, 1994) since they reflect real world outcomes and allow one to conclude whether “an observed difference is not only statistically significant but also important or meaningful ... ” (University of Michigan School of Natural Resources and Environment, 2012).

While the main effect of the More Than Words Program on parental responsivity did not reach conventional levels of statistical significance, effect sizes were in the medium to large range at both Time 2 and Time 3. This means that there was a significant difference in the level of responsiveness between the experimental and control groups after the program ended and four months later. The study’s authors commented that the magnitude of the effect sizes of the More Than Words Program on parent responsivity was consistent with findings in the McConachie et al (2005) study on More Than Words (see page 4) as well as with other studies on parent-mediated intervention (Green, Charman, McConachie, Aldred, Slonims, Howlin, Le Couteur, Leadbitter, Hudry, Byford, Barrett, Temple, Macdonald & Pickles, 2010). Given that More Than Words is a parent-implemented intervention, increases in parental responsivity and maintenance of these behaviours is critical since child change is dependent on parents’ applying and maintaining application of responsive strategies (Carter et al., 2011).

Child Outcomes

Significant treatment effect for children with low object interest

There was a significant difference between experimental and control groups for children who played with a limited number of toys. Children who played with fewer than three toys at Time 1 showed gains in the following four areas:

• initiating joint attention
• initiating behavioral requests
• weighted intentional communication (scoring involved weighting communication according to whether it was nonverbal, single symbol or multiple symbol, with more advanced levels of communication being weighted higher)
• parent-reported gains in nonverbal communication

These gains were maintained for a four month period post intervention. It is significant that the children generalized the communication skills learned during interactions with their parents, who provided support as needed, to a new context with an unknown experimenter, who presented new toys and did not provide any support.

The fact that these children’s gains were moderated by their initial toy play is important since toy play is a frequent context for parent-child interaction in responsivity-based treatments, and much of the child’s learning can take place within object-oriented joint action routines (Carter et al., 2011).

It is also important to note that children with greater interest in objects (who played with at least six toys at the time of randomization) did not show the same kind of progress, resulting in changes being made to the More Than Words Program to accommodate their more advanced play skills.