Parent Responsiveness to Children at Risk of ASD
Marisa claps as her toddler, Stela, fits a star into the shape sorter. “Star!” Marisa says. Marisa offers her daughter another shape, but Stela shakes her head and pats the music player.
“Ah!” Stela says, glancing at her mother.
“Music?” Marisa asks. Stela grins at her, giggling. “Okay!” Marisa says. “Here’s the music!” She turns on a collection of children’s songs, singing as Stela dances to the music.
This interaction provides several examples of parent responsiveness. Parents demonstrate “responsiveness” when they: (1) recognize their child’s current focus of attention and (2) quickly respond to that interest in a positive and meaningful way, such as by playing with or talking about the child’s interest. Other qualities of “responsiveness” include being affectionate and animated, offering praise and encouragement, sharing control of the interaction, taking conversational or play turns, and interacting within or slightly above the child’s current developmental level. When parents use these behaviors that take into account their child’s interests, communicative signals, affective state, and/or developmental level, they promote their child’s further development in domains such as communication, social skills, and cognition (Landry et al. 2001). Because parent responsiveness fosters social interaction and communication, this topic is important to consider in the context of children with or at-risk for autism spectrum disorder (ASD), who demonstrate deficits in social-communication. Based on the growing research in this area, this chapter will discuss the following topics: (1) the historical context of parent responsiveness, (2) current understandings of parent responsiveness to children at-risk for ASD, (3) ASD interventions targeting parent responsiveness, and (4) future directions.
Recognizing ASD as a biological condition is critical when discussing parent responsiveness. Historically, professionals blamed parents for causing autism, viewing the disorder as relationship-based, rather than biologically based. Decades of research now contradict this belief, indicating that ASD is caused by brain differences, rather than any way that parents interact with their child, but the harm to families has been deep and long-lasting. A brief review of this history is warranted to clarify how views of parent responsiveness in ASD have changed over time.
Parent-child relationships in the context of autism were first described by Dr. Kanner in 1943, who stated that the parents of these children were not “warmhearted.” The idea of “cold” parenting took root in popular culture, leading to the harmful concept of “refrigerator mothers” – or the idea that children develop autism because of their mothers’ frigid personalities. The “refrigerator mother” movement caused extreme harm to families, leading to parents being separated from their children, stigmatization, and feelings of guilt (Feinstein 2011). In the 1960s and 1970s, parents and researchers questioned the validity of blaming autism on parent-child relationships and made discoveries that pointed toward biological causes of autism, ushering in the concept of an “autism spectrum disorder” (Feinstein 2011). In 2011, researchers discovered that infant siblings of children with ASD had an approximately 1:5 chance of developing ASD, as compared to 1:68 children in the general population, providing further evidence for the genetic nature of ASD (Ozonoff et al. 2011). Researchers also found that parenting styles in families with ASD are not inherently different than other families (Siller and Sigman 2002; Watson 1998). Meanwhile, advances in technology allowed for research into biomarkers of ASD, generating further findings that ASD involves neurological disruptions (e.g., Hazlett et al. 2017).
Although our understanding of what causes ASD is still unfolding, one point is clear: ASD is not caused by “cold” parenting. When considering parent responsiveness to children at-risk for ASD, then, it is critical to make the distinction between: (1) blaming parents for not acting “warm enough,” an idea that is outdated and detrimental; versus (2) recognizing that parents are responding to their children in typical ways, but that the child’s disorder impedes the process of a fluid social interaction. Interventions targeting “parent responsiveness” are not meant to “remedy” parent behaviors, but rather to provide strategies to help parents overcome the social difficulties created by their child’s ASD.
With this history in mind, this next section will detail what is currently known about parent responsiveness to children at-risk for ASD. The Transactional Model of Development posits that children’s characteristics influence how parents act and, in turn, these parent behaviors influence children’s development (Sameroff 2009). Using this model in the context of children at-risk for ASD, it is important to consider: (1) how early characteristics of ASD influence parent responsiveness and conversely (2) how parent responses to children at-risk for ASD impact child development.
Impact of ASD Characteristics on Parent Responsiveness
Children are primarily identified as “at-risk” for ASD for two reasons: (1) the child has been flagged as “at-risk” during a developmental screening and/or (2) the child has an older sibling diagnosed with ASD, which increases the probability developing ASD. Research with each “at-risk” group provides insight into how children at-risk for ASD could influence parent responsiveness by demonstrating symptoms in one or both ASD diagnostic categories: (a) social interaction and communication impairments and/or (b) restricted and repetitive patterns of behaviors and interests.
Social interaction and communication. Social-communication impairments have been the most widely studied, in terms of their influence on parent-child interactions. Among typically developing children, strong communicators elicit more parent responses (Abraham et al. 2013). Communication behaviors among children at-risk for ASD similarly impact parent responses − the main difference, compared to typically developing infants, is how well children communicate. Infants at-risk for ASD tend to develop poorer communication skills than low-risk infants, producing fewer consonant-vowel combinations (Garrido et al. 2017b) and demonstrating less sophisticated gestures. By 18 months, infants at-risk for ASD use one-eighth as many “pointing and showing” gestures as low-risk infants (Leezenbaum et al. 2014). “Pointing and showing” gestures are considered sophisticated forms of communication, because these gestures are later-developing and bring other people into a shared interaction (Paul and Norbury 2012). Because vocalizations and gestures both impact how parents respond, each will be described below.
Looking at vocalizations, an infant’s use of consonant-vowel combinations is important for eliciting responses. Parents of 9-month-old infants tend to respond more when their baby combines consonants and vowels (e.g., “bah-bah”), as opposed to only using vowels (e.g., “ah-ah”). This pattern is the same across low-risk and high-risk infants (Talbott et al. 2015); however, infants at-risk for ASD tend to produce fewer consonant-vowel combinations than typically developing infants (Garrido et al. 2017b) and use fewer directed vocalizations in a social back-and-forth manner (Garrido et al. 2017b; Swanson et al. 2017). Thus, infants at-risk for ASD may evoke less feedback from their caregivers because their vocalizations are often: (a) less sophisticated (i.e., vowels-only) and (b) not directed to others.
In addition to vocalizations, using more sophisticated gestures also encourages parents to respond more frequently. One way of responding to gestures is by “translating” the gesture − or putting the gesture’s meaning into words (e.g., saying “up” when infants raise their hands). When 13-month-olds have no family history of ASD, parents translate “giving and requesting” gestures (early developing) less frequently, instead providing more translations for “pointing and showing” gestures (later developing). However, parents of “high-risk” siblings translate “giving and requesting” gestures more frequently than parents of low-risk infants, while also providing translations for other gestures. It may be that having an older child with ASD prompts parents to be more attuned to and/or more concerned about their younger child’s communication, making them more likely to translate all forms of gestures, rather than selectively responding to more advanced gestures (Leezenbaum et al. 2014).
Another factor influencing parent responses is the child’s ability to walk while gesturing. When typically developing 13-month-olds move while gesturing, mothers tend to direct the child’s actions (e.g., “Throw the ball!”); however, if the child gestures while remaining stationary, mothers vary between offering affirmations, descriptions, directives, or no verbal response. Overall, mothers tend to provide: (a) more verbal responses to children who are walkers and (b) no verbal responses to crawlers (Karasik et al. 2014). Currently, it is unknown how the motor abilities of infants at-risk for ASD impact parent responsiveness; however, research examining motor skills sheds some light on this issue. When compared to low-risk infants, high-risk infants demonstrate poorer fine and gross motor skills from 12 to 36 months of age (Garrido et al. 2017a); furthermore, higher gross and fine motor skills are associated with better interpersonal skills among 2- to 17-year-old children with ASD (Mody et al. 2017), suggesting a possible link between the ability to walk and the development of social-communication. Because of these motor and social interaction deficits, it seems possible that infants at-risk for ASD would demonstrate difficulty gesturing while walking, reducing opportunities for parents to respond.
Thus far, we have discussed how the ability to produce communication impacts parent behaviors. Similarly, the ability to understand communication influences how frequently parents respond. Among typically developing infants and toddlers, parents talk about the child’s interest more frequently if the child demonstrates greater receptive language; unsurprisingly, this pattern holds true for toddlers and preschoolers with ASD (Watson 1998). Young children with or at-risk for ASD vary in their language skills, but often demonstrate two patterns: (1) lower expressive and receptive language than expected (Garrido et al. 2017a; Paul and Norbury 2012) and (2) relatively weaker receptive than expressive language, suggesting that the foundations of comprehension supporting expressive language are less robust among young children with ASD (Paul and Norbury 2012).
Restricted and repetitive patterns of behavior. In addition to social-communication, infants at-risk for ASD elicit different parent responses based on symptoms in the category of “restricted and repetitive patterns of behavior.” This category has not received much attention in parent-responsiveness literature; however, available research suggests that the following behaviors could change parent-child interactions: unusual sensory patterns, activity levels, object play, and stereotyped behaviors.
One study has examined how patterns of sensory reactivity in 1-year-olds at-risk for ASD influences parent responsiveness (Kinard et al. 2017). In this study, infants were identified as “at-risk” for ASD based on a community screening, rather than family history, and elicited different types of behavior from parents, depending on their communication and sensory profiles. When children communicated less and were more hypo-reactive (i.e., exhibited diminished or delayed response to sensory stimuli), parents tended to respond by talking less and using more physical play actions. Conversely, when children communicated more and demonstrated less hypo-reactivity, parents responded with fewer physical play actions, but more talking. Both the children’s patterns of sensory reactivity and communication accounted for unique variance in parent responsiveness. The authors speculate that parents of toddlers with hypo-reactivity have learned that talking to their child fails to get his/her attention, and so rely on physical play responses to engage the child (Kinard et al. 2017). Infants at high familial risk for ASD often demonstrate hypo-reactivity (Van Etten et al. 2017); thus, this sensory pattern has the potential to be influential among families with infants at-risk for ASD.
Kinard and colleagues (2017) also found that a combination of hyper-reactivity (i.e., overreaction or painful response to sensory stimuli) and communication skills influenced how parents responded to their children; however, the findings varied, depending on whether communication and hyper-reactivity were measured via parent report or clinician observation, making it unclear how to interpret the results. Hyper-reactivity in non-ASD populations could provide insight into how this sensory pattern impacts parent behaviors. When infants (not identified as at-risk for ASD) show tactile hyper-reactivity, mothers tend to respond more with talking than physical touch and communicate from a farther distance than if their infant has no sensory difficulties (DeGangi et al. 1997). Parents of infants with sensory processing disorders also seem to have a harder time matching their responses to their infants’ behaviors (DeGangi et al. 1997).
In addition to sensory patterns, children with or at-risk ASD may demonstrate additional behaviors that make the parent-child interaction difficult, such as low activity levels (Wan et al. 2012), high activity levels (Meek et al. 2012; Watson 1998), wandering without engaging (Watson 1998), over-focusing on one toy (Watson 1998), less functional object play (e.g., spinning objects, visual examination) (Kaur et al. 2015), or producing large amounts of undirected vocalizations, which may function as an early repetitive or stereotyped interest (Swanson et al. 2017). Parents of children with ASD respond as frequently to their child as parents of typically developing children; however, parents of children with or at-risk for ASD also tend to manage their child’s behavior more frequently (Meek et al. 2012; Wan et al. 2012; Watson 1998). The use of behavior management might be an attempt to stimulate, focus, or expand the children’s play repertoires (Watson 1998). In the case of younger siblings, it may also be that parents have developed a directive style based on interactions with their older child with ASD, which they now use with their infant; or they may be experiencing stress from parenting an older child with ASD that influences how much their direct their infant’s behaviors (Wan et al. 2012). The relationship between parental directive actions and children’s restricted and repetitive behaviors needs to be examined in future research.
Impact of Parent Responsiveness on Children At-Risk for ASD
With an understanding of how a child’s ASD characteristics could influence parent responses, this section will discuss how, in turn, parent responsiveness could impact children at-risk for or with ASD. The role of parent responsiveness on child outcomes can be viewed in three ways: (1) intensity level and consistency over time, (2) type of response and how well the response “matches” the child’s current needs, and (3) parent responses in the context of parent-implemented interventions. Each of these aspects will be discussed below, in terms of how they contribute to child outcomes.
Intensity and consistency of parent response. The intensity and consistency of parent responses is crucial for achieving optimal child outcomes. Parents who are highly responsive spend much of their interactions: (1) observing their child to determine his/her interests or communication attempts and (2) quickly responding to the child’s actions in a way that is supportive, affectionate, meaningful, and appropriate to the child’s current interests and abilities. Parents who are consistently responsive will maintain these high levels of responsivity from infancy through childhood. When parents demonstrate a combination of high-intensity and consistent responsiveness, their children are likely to develop stronger cognition, communication, and social skills than if parents provide low or inconsistent levels of responding (Landry et al. 2001). Children can still benefit from periods of high-responsiveness if parents are inconsistent in maintaining these levels (e.g., highly responsive during infancy, but minimally responsive during preschool years); however, such inconsistent responsiveness is not as effective as consistent responsiveness in supporting children’s long-term cognitive, linguistic, and social gains (Landry et al. 2001). Inconsistent patterns of responding could occur for many reasons, such as (a) beliefs about what children need as infants versus as preschoolers (Landry et al. 2001) and/or (b) characteristics of the child that make it increasingly difficult to respond, as described earlier in this chapter.
Type and developmental “match” of parent response. In addition to intensity and consistency, children achieve different outcomes depending on: (a) the type of parent response and (b) how well this response matches the child’s current needs. Parent responses are often divided into two categories: (1) physical actions and (2) verbal feedback. Physical actions are defined as play actions or other physical movements parents use in response to the child’s focus of attention (e.g., imitating actions, demonstrating new actions, helping the child, pointing to or showing objects, or providing encouragement or affection in a physical way). Verbal feedback is defined as talking in response to the child’s current focus of attention (e.g., verbally imitating, expanding, labeling, translating gestures, describing, affirming, and directing or prompting).
When defining verbal responses, a distinction should be made between “nondirective,” “directive,” and “re-directive/intrusive” verbal behaviors. Nondirective verbal feedback involves commenting on a child’s interest without directing his/her actions (e.g., “That’s a cow”). In contrast, directive verbal feedback is responsive to the child’s interest, but requires that the child change his/her behavior (e.g., “Put the cow in the barn”). Redirections or “intrusive” comments are not considered directive feedback, because they are unresponsive to any aspect of the child’s attention (e.g., “We’re done with the cow, let’s read a book”) (Siller and Sigman 2002). Directive feedback is beneficial for both children with typical development and ASD, as long as parents are responding to the child’s focus of attention (Masur et al. 2005; McDuffie and Yoder 2010); thus, both directive and nondirective feedback will be included in this discussion.
Children seem primed to benefit from a variety of verbal and physical responses that are well matched to their current needs. Around 9- to 10- months-old, infants make gains in motor skills and intentional communication that allow them to crawl and explore their environment, manipulate objects in more advanced ways, and initiate social games (Kaur et al. 2015; Paul and Norbury 2012; Wan et al. 2012). For example, infants at low-risk for ASD begin purposefully dropping objects around this age to explore sound-effects and initiate social games with their parents (Kaur et al. 2015). Infants often imitate their first words sooner when parents describe these exploring behaviors (Tamis-LeMonda et al. 2001). In contrast, infants at-risk for ASD demonstrate less activity, movement, and object manipulation at this age (Wan et al. 2012) and are less likely to drop objects to initiate social games (Kaur et al. 2015). As detailed earlier, parents of infants at-risk for ASD tend to redirect their children more frequently, possibly due to the lack of functional play and presence of stereotyped or repetitive behaviors that make it challenging to respond. The impact of these directive behaviors is unclear; however, research with typically developing infants indicates that responsive directive behaviors are associated with positive language outcomes, but intrusive directive behaviors are associated with smaller vocabulary growth (Masur et al. 2005).
In addition to motor and object exploration, 9- to 10-month-olds are making advances in their vocalizations, babbling with consonant-vowel combinations to engage in back-and-forth social interactions (Paul and Norbury 2012). When parents respond to vocalizations at this age, infants seem ready to learn vocabulary, saying their first words sooner when parents provide: nondirective verbal feedback (e.g., describing, affirming), directive verbal feedback (e.g., prompting play), and demonstrations of play actions. Directive feedback (e.g., prompting play and demonstrating play actions) also helps children acquire more vocabulary and combine words at earlier ages (Tamis-LeMonda et al. 2001). When compared with low-risk infants, infants at-risk for ASD produce more vowel-only vocalizations, less social babbling, and fewer conversational turns (Garrido et al. 2017b; Swanson et al. 2017), possibly eliciting fewer or different parent responses (Talbott et al. 2015). More research is needed to explore how this dynamic impacts later child outcomes; however, infants at-risk for ASD may be missing verbal and/or physical feedback that could be beneficial for later vocabulary development.
Between 10 and 12 months, infants advance from babbling to word attempts (Paul and Norbury 2012). Responses that support early word imitation become important for later language outcomes. At 10 months, children’s language seems most supported when parents respond with physical actions, as opposed to verbal responses. When parents physically respond in a way that matches the child’s interests, engages them in an interaction, and is meant to help the child learn, infants tend to have larger expressive vocabularies at 13 months of age (Masur et al. 2005). In contrast, infants have lower expressive vocabularies at 13 months if their parents were very talkative at 10 months (Masur et al. 2005). Shorter utterances and more physical play actions may better match children’s current abilities than “streams” of talking, which could be hard for 10-month-olds to process (Masur et al. 2005).
Around their first birthday, infants reach new milestones in communication, motor skills, and play, allowing them to benefit from parent feedback in more complex ways. In terms of verbal communication, 1-year-olds say their first nonimitated words, which are formed with consonant-vowel shapes and can be used in conjunction with pointing to comment on objects (e.g., saying “ba”/ball while pointing to a ball) (Paul and Norbury 2012). Whereas physical responses seem most influential at 10 months, verbal responses become most powerful at this new stage, scaffolding 1-year-olds’ attempts at word production. Types of verbal responses that seem most beneficial include: (a) verbal imitation, which helps children build their vocabulary; (b) verbal imitations, expansions, and play prompts, which help children combine words sooner; and (c) asking questions, which (along with verbal imitations and expansions) help children learn to talk about the past (Masur et al. 2005; Tamis-LeMonda et al. 2001). When compared to parents of low-risk infants, parents of infants at-risk for ASD make smaller increases in how much they respond to their infant’s vocalizations over 13–18 months of age (Leezenbaum et al. 2014), possibly because of the nonsocial and unsophisticated nature of their child’s vocalizations (Garrido et al. 2017b). More research is needed to examine how reduced verbal feedback at 1 year of age could impact child language outcomes; however, these limited parent responses could have negative implications, given the power of verbal input at this age.
As more sophisticated gestures emerge around the end of the first year, parents are prompted to “translate” the gesture’s meaning into words (Leezenbaum et al. 2014). In turn, these translations help children develop more vocabulary, such as (a) more nouns by 17 months when parents translate “commenting” gestures with object-labels and (b) more verbs by 17 months when parents translate “requesting” gestures with action words (Olson and Masur 2015). Similar patterns have been found for infants at-risk for ASD. Both infants at low- and high-risk for ASD produce more words at 18 months when their parents translate “pointing and showing” gestures at 13 months (Leezenbaum et al. 2014).
As typically developing toddlers approach their second birthdays, they experience a language burst, producing 50 to 100 words by 18 months, combining words, and needing less contextual support to understand language (Paul and Norbury 2012). Children seem able to process more complex verbal feedback at these older ages, developing a larger subsequent vocabulary when parents provide verbal descriptions and expansions (e.g., Child: “Shoe”; Parent: “Mama’s shoe”), as opposed to simply imitating the child’s vocalization (Masur et al. 2005). Responding with physical actions also helps children develop larger vocabularies (Masur et al. 2005). When children with ASD attempt to communicate, parents respond with nondirective and directive verbal responses, both of which help children increase their vocabulary (McDuffie and Yoder 2010). Similar to typically developing children, expanding the communication attempt of a child with ASD, as opposed to simply imitating, seems to have a greater impact on vocabulary outcomes 6 months later (McDuffie and Yoder 2010). This verbal feedback appears most beneficial when parents adjust the complexity of their verbal input to the child’s current language. When toddlers with ASD are minimally verbal, nondirective verbal feedback is associated with language gains; however, these same benefits are not seen for verbally fluent toddlers with ASD (Haebig et al. 2013). It may be that simplistic verbal input that supports language in minimally verbal toddlers with ASD is not sufficiently complex to scaffold the language of toddlers with ASD with more advanced language skills (Haebig et al. 2013).
Along with communication, toddlers are expanding their play repertoire and ability to pay attention, so that, by 18 months, they are playing simple pretend games and following 1-step commands with minimal contextual support (Paul and Norbury 2012). Parents who respond to their child’s focus during play, as opposed to redirecting the child, continue facilitate their child’s language-learning during the toddler stage (Masur et al. 2005). Although redirections negatively impact vocabulary development, parents who direct their child’s attention seem to be providing examples of how to initiate an interaction, making it more likely that their child will also initiate joint engagement (Meek et al. 2012). In contrast to the play skills and attention levels of typically developing toddlers, toddlers at-risk for ASD continue to mouth objects at 15 months, may only be beginning to use objects with functional ways, and demonstrate limited social attention (Kaur et al. 2015). As long as parents respond to their child’s focus of attention, both directive and nondirective verbal responses to children with ASD have been associated with greater short- and long-term increases in social-communication and language (Haebig et al. 2013; McDuffie and Yoder 2010; Siller and Sigman 2002, 2008). Similar to typically developing populations, when parents model how to point to or show a toy, children with ASD tend to initiate joint attention more frequently (Meek et al. 2012; Siller and Sigman 2002).
Thus, for both low-risk infants and infants with or at-risk for ASD, children achieve positive language outcomes when their parents respond to the child’s focus of attention, adapting these responses over time to match the child’s current developmental needs. It is encouraging that responsive parenting helps children with ASD make long-term gains in social and language skills; however, it is also critical to note the challenges that parents face when trying to establish responsive parent-child interactions. To address these needs, researchers have developed parent-implemented interventions for infants and toddlers with or at-risk for ASD, designed to achieve two main outcomes: (1) enhance parent responsiveness through interventionist coaching and (2) improve child outcomes through parent use of responsive strategies. A brief review of parent responsiveness interventions is provided below.
Examples of parent-implemented interventions incorporating parent responsiveness strategies
Examples of interventions
Examples of child goals
Examples of parent strategies
Preschool Autism Communication Trial (PACT) intervention
Shared attention; initiating communication; communicating for a variety of reasons; pragmatics
Match parent language to child’s level; interpret child’s behavior as intentional communication; follow child’s lead; provide verbal imitations and expansions; motivate child to communicate with “teasers” or “sabotage”
Green et al. (2010)
Enhanced Milieu Teaching
Word combinations; requesting
Provide verbal imitations and expansions; follow child’s lead; match parent language to child’s targeted level; balance turn-taking with child; provide milieu prompts (e.g., modeling, time delay); give positive feedback
(Kaiser et al. 2000)
Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) intervention
Joint engagement; initiating and responding to joint attention; functional play; symbolic play
Follow child’s lead; imitate child’s actions; describe child’s actions; provide imitations and expansions; give corrective feedback; arrange environment to facilitate engagement (e.g., face-to-face with eye contact)
(Kasari et al. 2010)
Joint Attention Mediated Learning (JAML) intervention
Focusing on faces; turn-taking; responding to joint attention; initiating joint attention
Play face-to-face games with vocalization; imitate child gestures; interpret child’s behavior as meaningful communication; join child’s repetitive play; follow child’s lead; pause for child response; play teasing games; create animation, excitement, and suspense; offer “surprises”
Schertz and Odom (2007)
Responsive Teaching (RT)
Cognition; communication; social-emotional functioning
Match responses to child’s developmental level, interest, and behavioral style (e.g., follow child’s lead); create reciprocal interactions (e.g., play face-to-face games without toys); share control (e.g., wait silently for a more mature response); provide contingent feedback (e.g., respond to unintentional behaviors as if meaningful conversation); demonstrate positive affect (e.g., respond to child in playful ways)
Mahoney and MacDonald (2007)
Adapted Responsive Teaching (ART)
Social-communication; sensory-regulatory behaviors
Incorporates similar strategies as RT intervention, but uses strategies to target social-communication and sensory-regulatory behaviors
Watson et al. (2017)
Summary and Future Directions
Parent responsiveness is critical for helping children with or at-risk for ASD develop social, communication, and cognitive skills. From a transactional framework, early symptoms of ASD impact how parents respond to their child; in turn, these responses influence child outcomes. Children with better communication skills elicit more responses from parents; however, children at-risk for ASD commonly exhibit deficits in social, communication, and motor skills that may limit how parents respond. Restricted and repetitive patterns of behavior also make parent-child interactions more challenging for parents. Despite these challenges, parents help their children develop important skills when they: (a) frequently respond to their child’s focus of attention, (b) limit how much they redirect their child’s attention, (c) maintain these high levels of responsiveness across infancy and childhood, (d) provide a variety of verbal and physical responses that align with the child’s skill level, and (e) adapt these responses over time to meet the child’s changing needs. Based on the benefits of parent responsiveness, parent-implemented interventions for children with or at-risk for ASD have been developed to: (a) help parents overcome challenges in parent-child interactions and (b) improve child outcomes through enhanced parent responsiveness. Researchers are continuing to study these interventions, so that programs can be tailored to families’ needs.
Although parent-implemented interventions have a strong evidence base, researchers are continuing to examine the effectiveness of these interventions for infants and toddlers at-risk for ASD. Interventions have achieved varied outcomes for children, based on initial characteristics of the child and/or family (Oono et al. 2013). Because of these varying outcomes, the field is moving toward an ideal of “tailored” intervention approaches, where programs can be matched to families based on their initial characteristics. For future research, it will be beneficial to examine initial child and family characteristics in at-risk populations and the extent to which these characteristics predict treatment outcomes in a variety of parent-implemented intervention programs.
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