The Home TEACCHing Program for Toddlers with Autism
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- Welterlin, A., Turner-Brown, L.M., Harris, S. et al. J Autism Dev Disord (2012) 42: 1827. doi:10.1007/s10803-011-1419-2
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The study evaluated the efficacy a parent training intervention for children with autism based on the TEACCH model. Twenty families were randomly assigned to the treatment or waitlist group. All families were compared at pre- and post-treatment on formal dependent measures. Direct measures of behavior were compared across six matched pairs using a multiple baseline probe design. The results of the multiple baseline design showed robust support for improvement in child and parent behavior. Due to the sample size and short time frame, results of a repeated measures analysis of variance did not reach significance.
KeywordsAutismEarly interventionTEACCHHome-based intervention
Children with autism exhibit three main clusters of symptoms: qualitative impairment in social interaction, impairment in communication, and narrow and stereotyped patterns of behavior and interests (APA 2000). By definition, these features must develop before 3 years of age. There is no known “cure” for autism spectrum disorders (ASDs), however, a growing number of interventions exist that increase functioning and quality of life for these individuals (Dawson et al. 2010; Smith et al. 2000), with some evidence that intervention begun at very early ages showing particular promise (McGee et al. 1999; Dawson et al. 2010). Unfortunately, only a small body of research exists on the efficacy of comprehensive intervention programs, and many of the studies that do exist have not used conventional standards of research design and methodology (Odom et al. 2010; Gresham et al. 1999). This lack of research leaves families at risk of placing their children in programs that may not be beneficial, as some research has begun to demonstrate that different child characteristics are associated with different responses to intervention (Carter et al. 2011; Yoder and Stone 2006). The present study evaluated the efficacy of a comprehensive home-based early intervention program for young children with autism based on the TEACCH methodology and uses a novel research design that meets many of the current research standards.
Treatment of autistic and related communication handicapped children (Division TEACCH), has emphasized professionals working together with parents since its inception (Schopler 1994). A substantial body of research demonstrates that parent training programs provide a number of benefits for both children with autism and their families (Kasari et al. 2010; Aldred et al. 2011; Schertz and Odom 2007; Diggle et al. 2003), though results have not always demonstrated strong positive effects for all children (Carter et al. 2011; Green et al. 2010). One potential benefit is decreased parent stress. A large body of research indicates that stress levels among parents of children with autism are elevated compared to parents of typically developing children and those with other clinical conditions (e.g. Sanders and Morgan 1997; Sivberg 2002; Weiss 2002). It is well recognized that stress can lead to a number of deleterious effects on the well-being of individuals experiencing stress, and it can have negative effects on those who interact or depend on the individual. Robbins et al. (1991), for example, found a significant negative correlation between maternal stress level and child developmental progress. Parent training programs that result in reducing parent stress, therefore, are clearly warranted.
Division TEACCH has nine regional centers located across North Carolina, and serves children and adults of all ages who have or are suspected of having autism. The aim of Division TEACCH is to use general characteristics of learning in autism plus highly individualized approaches to help individuals with autism both learn skills and use visual, organizational, and structured adaptations to their environment to function as independently and effectively as possible in society (Schopler 1994). Structured teaching, the methodological framework of TEACCH, is a series of cognitive, developmental, educational and behavioral strategies that involve using assessments to create highly individualized curricula, visual work systems and teaching tasks, and positive routines that are based on the unique learning styles of children with autism (Mesibov et al. 1994).
A main focus of the TEACCH programs is to teach parents how to assess and implement individualized supports for their children. The “Home TEACCHing Program” is an outreach model designed to serve the early intervention needs of 2- to 3-year-old children with autism and their families. The program runs for 12, 90-min sessions in which a clinician provides hands on training to parents on the “structured teaching” methodology of TEACCH. Over the course of the program, parents begin to take on an increasingly active role in teaching their children, while under the supervision of the clinician, so that upon completion of the program, parents are able to conduct sessions independently. Sessions cover a range of topics from structuring the home to teaching pre-academic skills, communication, and self care.
The body of literature supporting the efficacy of TEACCH methods and programs is growing; however, many programs still lack empirical support (Panerai et al. 2002). To date, no studies have examined the efficacy of the TEACCH early intervention programs, and only a few studies have examined TEACCH parent training programs in general (Marcus et al. 1978; Short 1984; Ozonoff and Cathcart 1998a, b).
One study by Ozonoff and Cathcart (1998a, b) examined the effectiveness of a TEACCH home based intervention with 11 children with autism by comparing them to a matched no-treatment control group. Parents were instructed on how to teach cognitive, academic, and pre-vocational skills to their preschool children. Measures on the Psychoeducational Profile-Revised (PEP-R; Schopler et al. 1990) were collected before treatment and after a 4 month period on both groups of children who were matched according to age and pretest PEP-R scores, time to follow-up, and severity of autism. The results indicated that the experimental group demonstrated significantly more improvement than the control group on the imitation, fine motor, and cognitive subtests of the PEP-R as well as on the total subtest score. The use of a control group was a considerable strength in the study, however, participants were not randomly assigned to groups, and those who administered measures of the dependent variable were not blind to group assignment. Furthermore, treatment fidelity measures were missing, and no measures were taken of parent behavior.
Research on comprehensive early intervention methods for individuals with ASDs as a whole is limited compared to other child mental health or behavioral issues due to methodological challenges in autism research (Lord et al. 2005). According to a NIMH supported working group charged with developing guidelines for designing research studies of interventions for individuals with ASDs, no single research design can deal with all methodological challenges (Smith et al. 2007). Although conducting RCTs continues to be a priority given its robust design, other research designs and statistical methods are also regarded as important to innovate (Lord et al. 2005). Single subject designs, for example, have advantages including close monitoring of treatment effects and the need for less time and resources compared to group studies. The limitations of single subject designs include the small number of participants, difficulty generalizing results to larger populations, measuring overall outcomes, and some subjectivity in the interpretation of the results.
The current study aimed to examine the efficacy of the Home TEACCHing program using a dual approach to assessment that combines the advantages of single subject design and those of a group design. We hypothesized that the Home TEACCHing program would lead to changes in both parents and children relative to a waitlist condition. Specifically, we hypothesized that parents would learn to implement structured teaching with their child and that stress would decrease. For children, we hypothesized that there would be positive effects on observed child behavior during sessions and on developmental outcome measures in comparison to a waitlist control group. This is the first study of the TEACCH program to (1) examine programming exclusively for children 3 years of age and younger, (2) utilize a waitlist control group with random assignment, (3) include systematic measurement of treatment fidelity and a treatment manual that allows for reliable training and replication (Kasari 2002), and (4) ensure that assessors and video coders were blind to group assignment. It is also the first study to use a combination single case design and group design as a method of assessing an early intervention treatment in individuals with ASDs.
Participants and Setting
Twenty 2–3 year old children with autism and their parents participated. Families were paired based on chronological and mental age (e.g., within 6 months for each) and then randomly assigned to the treatment (Home TEACCHing Program; HTP) or waitlist (WL) group. Families in the WL group were told that they would receive treatment after the 12 week wait period. Six families (e.g., three pairs) completed the multiple baseline single-subject design phase of this study. The other 14 completed baseline and post-intervention assessments only. Children were recruited from the Chapel Hill and Raleigh TEACCH Centers in central North Carolina. Inclusion criteria included a chronological age of less than 42 months and a clinical diagnosis of autism.
Single Subject Design
Data were collected monthly by videotaping parent/child teaching sessions in the home. Videotaped sessions for both the treatment and waitlist groups consisted of videotaping parents setting up a teaching area and conducting 5 min of direct teaching. Videotapes were collected prior to the first (pre-treatment) treatment session and approximately after the fourth, eighth and twelfth (post-treatment) treatment sessions for the treatment group. Videotapes for the waitlist group were collected at the same intervals as the treatment group while in the waitlist and again at the same intervals during their treatment phase.
During videotaping, the HTP and WL parents were provided with a rug, a shelf, small table, small chair, large 2 × 3 × 2 ft. basket, and a home teaching kit. The home teaching kit was comprised of a 5–7 self-contained tasks designed to teach children with autism a variety of fine motor, cognitive, play, problem-solving, and communication skills. A research assistant directed the parent to complete a 5-min work session using a standardized instruction. The research assistant then began videotaping, stepped away from the parent/child dyad, and provided minimal interaction during the videotaping. Materials were removed after videotaping, though the treatment families had access to their own set of materials during their participation in the program.
Operational definitions of parent and child behaviors
Work session set up: defined as the placement of the following items/objects in the proper arrangement according to the following criteria before the child is transitioned to the work area:
1. Auditory distractions and visual distractions are minimized
2. Work table: table set up in location with no other movable items/objects within 3 ft
3. Chair placement: facing one side of the table
4. Chair placement: pulled out 1–2 ft away from the table’s edge for easy access to child
5. Shelving: located no more than 6 inches from the table
6. Shelving: located catty corner left of the chair, lengthwise along the table
7. Shelving: edge of shelf is located within child’s reach
8. Finished basket: located catty corner right of the chair (across from shelves)
9. Finished basket: edge of basket is touching edge of table
10. Task arrangement: tasks are placed on the shelf side-by-side
11. Task arrangement: tasks are not stacked
12. Task arrangement: at least 1 task is located within the child’s reach on the shelf
13. Task arrangement: 1 task located in front of the child, on table, within 3 in. of reach
14. Rug is placed to define the play area within 3–6 ft from work table
15. Toy basket: located on rug or within 1 ft of rug
16. Toy basket: all toys are stored in the basket
Effective Prompt: any instance of the parent providing a clear verbal, visual, gestural, or model instruction to the child that results in compliance with instruction within 3 s of prompt. An effective prompt is limited to approximately 3 consecutive prompts and includes prompts for orienting or attending behavior (e.g. Are you ready?). Does not count if the child does not change behavior due to prompt. (e.g., parent says “come here” when child is already moving in his/her direction)
Ineffective Prompt: any physical prompt (taking a child’s body part to engage in an instruction) or any verbal, visual, gesture or model guidance provided to the child that does not result in compliance by the child within 3 s of prompt or any instruction that is repeated consecutively more than approximately 3 times
Child Independent functioning: defined as one or more of the following actions:
the child initiates or reaches for tasks on the shelf without prompting (without prompting excludes when helped due to inability to reach task due to size, though initiation must be unprompted)
the child places tasks on the work table or on the floor in front of his/her body without prompting
the child completes tasks for more than 3 s without prompting
the child pushes/throws tasks toward or places them in the finished basket without prompting
Two coding systems were used. First, the percentage of 10-sec intervals that the parent and child were engaged in targeted behaviors was calculated using a partial-interval coding system. Parent behavior variables included (a) total effective prompts, and (b) total ineffective prompts. The child behavior variable was independent functioning. Second, a point by point coding system was used to track a third parent behavior: parent set-up behavior. It was used to calculate the percentage of individual components present from a checklist of 16 items indicating correct placement of furniture and teaching activities. Brief operational definitions are provided in Table 1. Additional information about the behavior codes can be obtained from the first author.
A research assistant also collected treatment integrity data to ensure that the treatment protocol was being followed. The clinician was unaware of when the fidelity checks were being conducted. Treatment fidelity checks were scored as the number of applicable steps correctly performed. Additional information about the behavior codes and treatment fidelity checks can be obtained from the first author.
A multiple baseline probe design across HTP and WL family pairs was used. Baseline videotaping of each family within the pair began simultaneously, and the treatment was introduced sequentially to evaluate its effects on child and parent behavior. It was hypothesized that parent’s ability to successfully set up the teaching environment and activities and parent prompting would improve in response to treatment, and that child independent functioning would increase.
Interobserver Agreement and Treatment Integrity
Two independent observers collected data during 35.8% of sessions. Reliability ranged from an average of 84.9–99.0% across all target behaviors. Treatment integrity data were collected by a research assistant who used a procedural checklist of treatment steps to assess correct implementation by a clinician who was unaware of being observed and not part of the research team. Data showed the treatment was implemented with a range of 87.5–100.0% accuracy.
The group study was a randomized pre-post treatment design. Child outcome was measured using the Mullen Scales of Early Learning (MSEL; Mullen 1995) and Scales of Independent Behavior-Revised (SIB-R; Bruininks et al. 1996). Both scales have demonstrated good reliability and validity. The Parenting Stress Index-3rd edition (PSI; Abidin 1995) was used to assess parent stress. Assessments were performed either in the home or in the clinic. During the post-assessments, the number of hours children spent in non-project interventions such as speech and occupational therapy were collected via interview from 50% of parents to allow comparison between groups regarding uptake of community services.
Once initial baseline assessments were completed, families were randomly assigned to either the HTP or the WL condition. Those assigned to the HTP group began meeting with a clinician 1.5 h a week for 12 sessions. Each treatment session consisted of several 5–10 min teaching times in which parents were trained to work with their child. These teaching times consisted of the clinicians teaching specific cognitive, fine motor, and language skills to the child while modeling appropriate prompting behavior to the parents, and how to set up the teaching environment. As children began learning the activities, the clinician systematically faded their prompts until the children were completing tasks independently. Parents were also provided with 30 min of education about autism and intervention strategies. At the end of each session, parents were assigned written homework and asked to apply new skills learned between treatment sessions. After the 8th treatment session, parents took an active role in teaching time, with the clinician providing coaching and feedback on teaching procedures and on how they set up the teaching environment. A standardized treatment manual was used with each family; however, individualization was also built into the program. For example, the presentation, difficulty, and layout of tasks were based on assessment of the child’s skills and learning style. After waitlist families were assessed on post-treatment measures, they had the opportunity to participate in the program. Additional information about the treatment can be obtained from the first author.
Single Subject Results
Single subject design participant demographic characteristics
Demographic characteristics for group comparison
Home TEACCHing (n = 10)
Waitlist (n = 10)
Age in months
Gender (% male)
Ethnicity (% Caucasian)
Maternal education (% some college or more)
Mean (s.d) hours in occupational therapy
Mean (s.d) hours in speech therapy
Effect sizes for HTP and WL
Baseline to post-test
Mullen developmental quotient
PSI total stress
SIB social interaction
SIB language comprehension
SIB language expression
Mullen developmental quotient
PSI total stress
SIB social interaction
SIB language comprehension
SIB language expression
Parent stress, as measured by the PSI, decreased slightly between pre- and post-test for participants in the HTP, but increased slightly for parents in the WL group. Group differences were not statistically significant.
The current results support the feasibility of this home based program using structured teaching methods. Results suggested that participation in the HTP led to improvement in children’s independent work skills and parents’ ability to structure the environment for learning and effectively prompt their children during teaching sessions. While this study was underpowered, within-group effect sizes for improvements in child developmental and adaptive skills, and decreases in parent stress were encouraging and suggest future study is warranted. The combined approach of a detailed multiple baseline study and randomized group design makes this a unique study of a comprehensive early autism intervention program.
These preliminary results, if replicated, could carry important implications. First of all, with regard to improvement in children’s independent work skills, the structured teaching methodology focuses on teaching children to engage in positive work routines as independently as possible (Mesibov et al. 2005). Work routines consist of a behavior chain of taking, completing, and putting away activities in a left to right sequence. Once this behavior chain is learned, it can be generalized to a wide variety of activities and settings, which can facilitate broad learning and independence. Learning this behavior chain also avoids over-reliance on adult prompts for on-task behavior.
Secondly, the results showed that parents could learn to use physical structure of the environment as an antecedent intervention. The structured teaching approach promotes using physical structure, including the use of furniture and boundaries and organization of materials, to provide visual cues that are thought to increase on-task behavior, reduce behavior challenges, and increase independence (Mesibov and Shea 2011). Future studies could manipulate aspects of physical structure used in the home program to examine both the influence of different aspects of physical structure and the presence versus absence of physical structure on child behavior.
Third of all, the results suggested that the treatment program increased effective prompting behavior in parents. Providing effective prompts is a pivotal skill needed for parents to ensure responding and learning from their children. Effective prompting also results in conservation of time and resources. Parents were taught to rely on visual prompts versus verbal prompts which is in line with the goals of the TEACCH program. Given that many individuals with autism tend to be visual learners (Quill 1997), an emphasis is placed on relying on visual prompts and cues, or at least supplementing verbal prompts and cues with visual ones (Mesibov et al. 2005) to match children with autism’s learning style and to decrease prompt dependence thereby increasing independence. Less use of ineffective prompts is important as it may contribute to decreased behavioral challenges in children.
Within-group effect sizes for the HTP group were medium to large for developmental and adaptive skills as well as for parent stress. However, results revealed no statistically significant differences between the HTP and WL groups. The effect sizes were encouraging for a 12-week parent-mediated program, and suggest that future study with a larger sample size could be important. Results also suggest that a longer, or more intensive, intervention may be better suited for examination of change in global developmental skills. Decreased parent stress during the initial months after a child is diagnosed with ASD could be quite important given the high stress often seen in these parents during the preschool years (Estes et al. 2009).
There were several limitations in the current study. Only one baseline probe was collected for treatment families. An extended baseline of at least three probes to show baseline stability would have allowed for stronger conclusions to be made about treatment effects, however, the shortened baseline period used in the study was necessary to avoid delaying access to treatment. Also, the overall limited number of probes that were collected during treatment sessions is a limitation, and may have masked the strength of treatment effects. Finally, we only collected information on the other interventions for 50% of participants, which could make it challenging to interpret the group-level analyses as it is possible that the WL group sought more intensive services while on the waiting list, however, we did not see a significant difference in number of hours of outside intervention between groups for half of the participants and believe this trend to be true for all participants.
In summary, the current study represents an initial piloting of a home based intervention based on the TEACCH model. The target behaviors analyzed in the current study reflect some of the core concepts of the structured teaching methodology. Future studies may want to directly examine the effects of the strategies on other pivotal behaviors such as nonverbal communication skills, imitation, and joint attention, as these skills enable children to access further learning from their environment and are vital goals of early intervention programs (Rogers and Vismara 2008). Also, future students may want to consider testing this program when conducted over a longer period of time. Finally, future research could break apart components of the home program to demonstrate which aspects of the program are responsible for change, and whether increased or decreased intensity would make a difference in both child and parent outcomes.
We wish to thank the participating families and the team that made this program and research possible including Ron Faulkner, Susan Boswell, Lindsey Schumacher, Devon Hartford, Johanna Lima, Mandy Benson, and Nadette Welterlin-Hugg. Their contributions were invaluable to the completion of this project. Part of this project was the doctoral dissertation of the first author. Dr. Welterlin was supported, in part, by the Harris Fellowship Award and the 2007 Graduate Research Grants Program Award. Dr. Turner-Brown was supported by Division TEACCH, by the National Institutes of Child Health and Human Development T32-HD40127 and P30 HD03110, and by grant R40 MC 22648 through the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program