RESEARCH ARTICLE

The Social ABCs Caregiver-Mediated Intervention for Toddlers With

Autism Spectrum Disorder: Feasibility, Acceptability, and Evidence
of Promise From a Multisite Study
Jessica A. Brian, Isabel M. Smith, Lonnie Zwaigenbaum, Wendy Roberts, and Susan E. Bryson

The Social ABCs is a parent-mediated intervention for toddlers with suspected or confirmed autism spectrum disorder
(ASD). We undertook a multi-site pilot study to evaluate feasibility and acceptability, and to identify trends in child and
parent behavior to inform future research using a larger sample and a rigorous research design. The program involved
12 weeks of parent coaching, followed by 12 weeks’ implementation, and 3-month follow-up assessment for 20 parent-
toddler dyads (age range: 12–32 months). Parents successfully learned the techniques and rated the intervention as
highly acceptable. Paired samples t-tests revealed significant gains in children’s functional communication (responsivity,
initiations), and language gains (age-equivalents on standardized measures) commensurate with typical developmental
rates. Significant increases in shared smiling and social orienting also emerged, but were attenuated at follow-up.
Parents’ fidelity was positively associated with child responsivity. Training parents as mediators is a feasible and highly
acceptable approach that provides a potentially cost-effective opportunity for intensive intervention at a very young age
at the first signs of ASD risk. Child and parent gains in several key variables demonstrate the promise of this interven-
tion. Autism Res 2016, 9: 899–912. V C 2015 The Authors Autism Research published by Wiley Periodicals, Inc. on

behalf of International Society for Autism Research

Keywords: autism spectrum disorder; toddlers; high-risk; early intervention; parent-mediated; caregiver-mediated;
pivotal response treatment; communication; smiling

As prevalence estimates increase and early identification manifestations of ASD and the developmental needs of
efforts improve, the need for feasible, cost-effective infants and toddlers. Evidence continues to support the
interventions for infants and toddlers with autism spec- efficacy of interventions based on applied behavior ana-
trum disorder (ASD) has become critical. ASD is a neu- lytic (ABA) principles, typically with intensive therapist-
rodevelopmental disorder characterized by impaired delivered programming. Despite compelling evidence of
social-communication and restricted repetitive interests efficacy, resource requirements may limit uptake in
and patterns of behavior [American Psychiatric Associa- many regions and thus the need remains for less
tion, 2013], with recent prevalence estimates >1% [i.e., resource-intensive interventions. This is particularly rel-
1/68; Centers for Disease Control and Prevention, evant when policy makers may be willing to provide
2014]. The past decade has yielded substantial advances resources for directed intervention in the face of risk for
in earlier detection, often within the first two years of ASD (e.g., familial risk, emerging “red flags”), rather
life, particularly in high-risk samples [e.g., younger sib- than waiting for confirmed diagnoses.
lings of children with ASD; see Jones, Gliga, Bedford, The most prominent comprehensive intervention
Charman, & Johnson, 2014, for a review]. Converging models in use and under investigation for toddlers with
evidence on the nature and timing of the emergence of ASD favor a naturalistic approach that is both behavior-
ASD has informed the development of novel interven- ally and developmentally informed (i.e., “Naturalistic,
tion approaches that are sensitive to both the earliest Developmental, Behavioral Interventions;” NDBIs;

From the Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada (J.B.);
Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada (J.B., W.R.); Departments of Pediatrics and Psychology & Neuroscience,
Dalhousie University, Halifax, Nova Scotia, Canada (I.M.S., S.B.); Autism Research Centre, IWK Health Centre, Halifax, Nova Scotia, Canada (I.M.S.,
S.B.); Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada (L.Z.); Autism Research Centre, Glenrose Rehabilitation Hospital,
Edmonton, Alberta, Canada (L.Z.); Autism Research Unit, The Hospital for Sick Children, Toronto, Ontario, Canada (J.B., W.R.); Integrated Services
for Autism and Neurodevelopmental Disorders, Toronto, Ontario, Canada (W.R.).
Received July 06, 2015; accepted for publication October 29, 2015
Address for Correspondence and reprints: Jessica Brian, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital 150 Kilgour
Road. Toronto, ON, M4G 1R8, Canada. E-mail: jbrian@hollandbloorview.ca
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and dis-
tribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Published online 21 December 2015 in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/aur.1582
C 2015 The Authors Autism Research published by Wiley Periodicals, Inc. on behalf of International Society for Autism Research
V

INSAR Autism Research 9: 899–912, 2016 899

Schreibman et al., 2015), and a recent emphasis has been 2005]. In standard PRT programs, parents participate in
placed on adapting programs specifically for use with 25 hr of one-to-one training, although preliminary evi-
infants and toddlers. Pivotal Response Treatment [PRT; dence demonstrates the effectiveness of even briefer
Koegel & Koegel, 2006], an established naturalistic ABA- training models [Koegel & Koegel, 2006; Coolican,
based intervention, stands out as particularly appealing Smith, & Bryson, 2010; Minjarez, Williams, Mercier, &
for this younger age group, given its emphasis on natu- Hardan, 2011].
rally occurring, child-focused, play-based interactions. Parent-mediated interventions for infants and tod-
The strategies and principles that form the basis of PRT dlers with ASD have gained traction over the past sev-
have been applied to a variety of service delivery models, eral years, with mixed, but promising results [Beaudoin,
with evidence of improved child responding, generaliza- Sebire & Couture, 2014]. An initial evaluation of a
tion, and increased positive affect [Mohammadzaheri, parent-mediated adaptation of ESDM [Vismara,
Koegel, Rezaee, & Rafiee, 2014; Ventola et al., 2014], as Colombi, & Rogers, 2009] demonstrated early promise.
well as collateral effects on nontargeted skills [Koegel, However, an RCT of a 12-week parent-mediated ESDM
Carter, & Koegel, 2003; Smith et al., 2010; Smith, Flana- program, for toddlers aged 14–24 months, yielded less
gan, Garon, & Bryson 2015; Koegel, Singh, Koegel, Hol- positive findings [Rogers et al., 2012]. Specifically, the
lingsworth, & Bradshaw, 2014], and increased self- ESDM-parent group demonstrated no advantage over a
initiated (vs. prompt-dependent) behavior [e.g., Koegel & “treatment as usual” community intervention group in
Koegel, 2006]. Evidence of efficacy comes from relatively terms of parent skill acquisition or child outcomes.
comprehensive programs [e.g., Smith et al., 2010] and More recently, a pilot study evaluating Infant Start, a
briefer models [e.g., 3–4 months in duration; Mohammad- parent-delivered adaptation of ESDM for younger
zaheri et al., 2014; Ventola et al., 2014]. PRT techniques infants, has reported reduced ASD-related symptoms in
have shown promise when applied to infants and toddlers seven symptomatic infants (aged 7–15 months) follow-
using lower-intensity approaches to directly target the ing intervention [Rogers et al., 2014]. These findings
core social impairments in ASD [e.g., Koegel, Vernon, & demonstrate the potential impact of parent-mediated
Koegel, 2009; Steiner, Genoux, Klin, & Chawarska, 2013; intervention even for very young babies with emerging
Koegel et al., 2014]. ASD, but further evidence is needed. Of particular rele-
Strong evidence to support the efficacy of interven- vance is whether very early intervention can success-
tion in toddlers with ASD has come from the early start fully target core ASD impairments such as social
Denver model [ESDM; Dawson, Rogers, Munson, & engagement and shared positive affect [e.g., Landa, Hol-
Smith, 2010], an intensive (20 hr/week), comprehen- man, O’Neill, & Stuart, 2011].
sive, ABA-based intervention specifically adapted for use Several recent RCTs have examined the effectiveness
with toddlers. ESDM incorporates a developmentally of different parent-mediated NDBIs for toddlers with
sequenced curriculum into a play-based model, inte- confirmed ASD [Kasari et al., 2010; Carter et al., 2011;
grated with PRT techniques. A randomized control trial Schertz, Odom, Baggett, & Sideris, 2013; Wetherby
(RCT) yielded significant improvements in IQ, adaptive et al., 2014], or for those at risk for ASD, either based
behavior, and autistic symptoms following two years of on measured risk markers obtained from population
this intervention in 18- to 30-month olds with ASD screening [Baranek et al., 2015] or sibling status alone
[Dawson et al., 2010]. Findings highlight the potential [Green et al., 2015]. These studies have provided evi-
for significant developmental gains in toddlers with dence of improvements in various indices of social
ASD, but the resource-intensity of such programs may development [i.e., response to joint attention, joint
limit widespread community uptake. In the infant and engagement, focusing on faces, attentiveness to parent;
toddler age group, a potentially feasible and cost- Kasari et al., 2010; Schertz et al., 2013; Green et al.,
effective approach is to train parents to provide the 2015; Wetherby et al., 2014], gains in parenting respon-
intervention. Primary caregivers can be trained in the siveness [Carter et al., 2011; Baranek et al., 2015; Green
use of development-enhancing strategies that can be et al., 2015], and improvements in child communica-
applied at a high intensity throughout the child’s typi- tion abilities [Carter et al., 2011; moderated by object
cal daily routines [Kasari, Gulsrud, Wong, Kwon, & interest at baseline; Wetherby et al., 2014] and particu-
Locke, 2010]. As with many evidence-based interven- larly in receptive language [Baranek et al., 2015;
tions for ASD, parent training is an integral component Wetherby et al., 2014].
of PRT [Koegel & Koegel, 2006]. A solid body of evi- Thus, evidence is converging to support the efficacy of
dence supports the feasibility and effectiveness of par- NDBIs adapted for use with infants and toddlers, and
ent training as part of a comprehensive preschool parent-mediated models hold promise. To date, parent-
program, with evidence of positive changes in child mediated models with varying intensities (i.e., from 16
behavior, parental affect, and parent-child interactions to 96 visits/family, ranging from 4 to 12 months in dura-
[e.g., Koegel, Bimbela, & Schreibman, 1996; Openden, tion) have demonstrated efficacy in improving child

900 Brian et al./Social ABCs in multisite study INSAR

Table 1. Toddler and Parent Characteristics at Baseline is a manualized intervention that primarily targets two
Mean (SD) toddler age in months 22.05 (5.12) early developmental domains argued to play a central
Range: 12–32 and reciprocal role in the emergence of ASD: early func-
Toddler age group (frequency) <18 months: 2 tional verbal communication and positive affect sharing
18–23 months: 9 [see Brian et al., 2015]. By focusing on these two core
24–30 months: 8
>30 months: 1
domains, we aim to strike a balance between promoting
Toddler sex (n Males: n Females) 14:6 meaningful developmental progress while maximizing
Site (n Toronto: n Halifax) 11:9 feasibility and portability of the intervention. We focus
Ethnicity Caucasian: 15 on functional (verbal) communication as this is among
East Indian: 3
the defining deficits in ASD. Moreover, language devel-
Asian: 2
Highest level of maternal High school: 2 opment has been identified by parents as a key area of
education (n 5 17) Partial university: 2 concern [Coonrod & Stone, 2004], particularly in the first
Completed college or 2 years of life, and language ability is a strong predictor
university: 12 of later outcomes. Our focus on positive affect sharing
Graduate school: 1
AOSI Total scores (n 5 2) 13, 8 was motivated by its important role in the development
Mean (SD) ADOS-2 comparison metric 5.89 (2.59) of reciprocal relationships with caregivers during
Mean (SD) ADOS-2 Social Affect (SA) 10.50 (4.76) infancy, combined with evidence of deficits or even
score (n 5 18) declining trajectories beginning in the first year of life in
Mean (SD) ADOS-2 Restricted/Repetitive 4.83 (1.95)
high-risk infants later diagnosed with ASD [e.g., Zwaigen-
Behavior (RRB) score (n 5 18)
Mean (SD) ADOS-2 Total Score (SA 1 RRB) 15.33 (6.00) baum et al., 2005; Bryson et al., 2007; Ozonoff et al.,
(n 5 18) 2010; Landa, Gross, Stuart, & Faherty, 2013]. Also, smil-
Mean (SD) Mullen Scales of Early 85.61 (25.88) ing together with a primary caregiver very early in life is
Learning-Early Learning Composite Range: 49–139 thought to lay the groundwork for the development of
Standard Score (n 5 18)
emotional connectedness (or intersubjectivity) involved
Note. ADOS-2 comparison metric and domain scores were derived from in understanding others, which is impaired in ASD [Hob-
ADOS (WPS edition; Lord et al., 1999). Total score diagnostic cut-offs
for ADOS module 1 (no words) are: ASD 5 11, Autism 5 16; Module 1 son & Meyer, 2005; Gallese, 2006; Mundy, Gwaltney &
(some words): ASD 5 8, Autism 5 12; Module 2 (under 5 years): Henderson, 2010; Brian et al., 2015]. Moreover, learning
ASD 5 7, Autism 5 10. is facilitated by positive emotion [e.g., Hohenberger,
2011], suggesting that positive affect sharing may play a
facilitating role in the development of other skills (e.g.,
social orienting/attention, play, and receptive language, functional communication), and may thus be a pivotal
and for supporting parenting responsiveness. However, element of intervention.
positive trials are not universal [e.g., see Rogers et al., Our objective was to evaluate feasibility and accept-
2012] and relatively less success has been demonstrated ability of the Social ABCs and to explore the promise of
in terms of improving expressive communication skills this intervention by examining change, post-training
and emotional responsivity, arguably core features of and at 3-month follow-up, in child functional vocal
ASD, and thus key intervention targets in this age group communication and shared positive affect, and the pos-
[Brian, Bryson, & Zwaigenbaum, 2015]. sible collateral effects on child social orienting. We also
In response to the growing need for evidence-based, examined the relationship between fidelity of imple-
feasible, and sustainable interventions for toddlers with mentation and child gains. These findings will inform
emerging ASD, we developed the Social ABCs. This is a future research using a larger sample in a controlled
caregiver-mediated, ABA-based intervention, with adap- clinical trial.
tations to address the developmental needs of infants
and toddlers (e.g., strategies to promote emotion regula-
Methods
tion in infants). Sensitive to these developmental needs, Participants
together with an appreciation of the natural social
context of infants and toddlers, and the need for cost- Table 1 outlines the key participant characteristics. The
effective models, the Social ABCs involves training a pri- primary caregivers of 20 toddlers with suspected or con-
mary caregiver in the home. The Social ABCs [described firmed ASD were enrolled (mean age of toddlers at
in Siller et al., 2014] is a live parent-coaching model that intake: 22 months; range: 12–32 months) at one of two
incorporates the principles and procedures of both par- Canadian sites: IWK/Dalhousie in Nova Scotia (NS; n 5 9)
ent responsiveness training [Landry, Smith & Swank, and SickKids/University of Toronto in Ontario (n 5 11).
2006] and ABA, as represented by PRT [Koegel, et al., Nine cases (3 from NS) were from our large, multisite lon-
1999], with modifications for infants and toddlers. This gitudinal “Infant Siblings Study” [ISS; Zwaigenbaum

INSAR Brian et al./Social ABCs in multisite study 901

et al., 2005], and the remaining 11 (6 from NS) were com- Challenges, and Taking Care of Yourself), and took
munity referrals, seven of whom also had an older sibling place for the first 20–30 min of each home visit; result-
with ASD. Participants were eligible by virtue of elevated ing in approximately 13 coaching hours per family.
scores on our key assessment measures (see below), com- Although designed as a 6-month intervention, actual
bined with clinician concern regarding ASD. All were duration varied slightly due to illnesses and competing
born at 36–42 weeks gestation, weighing >2500 g; none demands, for a mean duration of 8.7 months
had identifiable neurological or genetic disorders, or (SD 5 1.79). Specific dosage of the intervention (to tod-
severe sensory or motor impairments. At entry, 9 had dlers) was not measured, because the objective is to
confirmed ASD diagnoses (3 from NS) and 11 (6 from NS) learn techniques that can be integrated into the fam-
had suspected ASD or significant ASD-related concerns ily’s daily routines (vs. a set number of hours per day
(with elevated scores on our ASD symptom measures). set aside for “intervention”).
Diagnoses were all informed by the Autism Diagnostic
Observation Schedule [ADOS; Lord, Rutter, DiLavore, &
Standardized assessments. Standardized assess-
Risi, 1999], Autism Diagnostic Interview-Revised [ADI-R;
ments were conducted at two time-points: (1) Intake
Lord, Rutter, & LeCouteur, 1994], and clinical impression
(Mean 5 0.85 month [SD 5 1.27] prior to collection of
of diagnosticians with extensive ASD experience. At exit,
baseline video data), and (2) Follow-up (Mean 5 8.7
18 cases (9 from NS) had confirmed ASD; none of the con-
months [SD 5 1.87] after intake), following active train-
firmed cases at intake lost their diagnosis. See Table 1 for
ing plus three months of parent implementation with-
details about parents’ ethnicity and educational
out coaching. Assessments were conducted using
attainment.
standardized administration and scoring procedures, by
Procedure trained clinical-research staff with research-level reli-
ability on relevant measures. All evaluations at one site,
Intervention. Participants received our Social ABCs
and 50% at the other site were conducted by examiners
parent training by one of four trained parent coaches
who were not involved in the intervention in any way
who were initially trained by PRT-reliable trainers, and
and were blind to intervention status. Cross-site differ-
authors SB and JB. All parent coaches achieved fidelity
ences in children’s performance on standardized meas-
in implementation of and parent coaching in our inter-
ures were examined statistically to ensure that there
vention model. Parent coaches attended a week-long
was no systematic bias at the site with only 50% inde-
training workshop that included working directly with
pendent examiners.
toddlers with red flags for ASD or related developmental
concerns, followed by one-on-one work with at least
three families to practice the intervention strategies. Video data collection and coding. Continuous 10-
Direct work was video-recorded and reviewed by trained minute video clips of parent-child interactions were
senior staff. Fidelity of implementation was measured taken at three key times: Baseline (BL), post-training
for coaches in the same way as for parents (described (PT), and follow-up (F-up), with three clips collected at
below). Parent coaching skills were modeled and prac- each (on different days) to obtain representative behav-
ticed during a pre-pilot phase, with regular video review ior samples. Parents were instructed to play with their
from the team (including SB and JB) until parent coach- children as usual, but were told that we wanted to see
ing fidelity was achieved. The intervention included 12 how they communicate. For each time point, two clips
weeks of in-home didactic training sessions combined were selected by a blinded coder based on visibility and
with in vivo parent coaching with a focus on positive maximal codable time recorded; mean scores were cal-
reinforcement of accurate use of intervention techni- culated for each behavior per time point. These data
ques (8 weeks of “Active Training”, followed by 4 weeks were subjected to the analyses outlined below. All
of “Consultation and Refresher”). This was followed by coaching was withheld during data acquisition. For
12 weeks of parent implementation with no additional each video-coded variable, 20% of video segments were
help from trainers. Each home visit was 1 to 1.5 hours coded by a second rater, also blind to study phase, for
in length, tapering from 3 visits in week 1, to 2 visits in inter-rater reliability.
week 2, and then once weekly through to week 8.
Measures and Coding Scheme
Weeks 9 and 11 included telephone or email contact as
needed, with refresher and consultation sessions in Standardized measures. Standardized assessments
weeks 10 and 12. Didactic sessions were based on our were conducted at intake and follow-up using well-
manual’s eight modules (The ABCs of Learning, established measures for this age group, as follows:
Enhancing Communication, Sharing Positive Emotion, The Autism Observation Scale for Infants [AOSI;
Motivation and Arousal, Play and The Social ABCs, Bryson, Zwaigenbaum, McDermott, Rombough, &
Daily Care-giving Activities, Managing Behavioral Brian, 2008] is a 15–20 minute semistructured direct

902 Brian et al./Social ABCs in multisite study INSAR

Table 2. Coding Definitions for Video-Coded Language Variables
Language opportunities Number of language opportunities provided by the parent, including direct prompt (i.e., a verbal
model), indirect prompt (i.e., “ready, set. . .”), or time delay (parent holds up the object of
interest and waits expectantly for a vocal response). Reported as rate/minute.
Responsivity Proportion of appropriate child vocal responses, following a parental prompt (reported as %; see
Inappropriate Responses for exclusionary examples).
Inappropriate responses Proportion of child nonfunctional, noncommunicative, echolalic, out of context, inappropriate,
undirected, or disruptive responses to parent prompts.
Initiations Number of child-initiated functional, appropriate vocalizations (rate/min).
Functional vocal utterances (FVU) Composite measure of the overall number of functional/meaningful, task-directed, and purposeful
vocalizations with appropriate volume and directedness to person or activity (including both
initiations and appropriate vocal responses). Reported as rate/minute.

observational measure, with good psychometric proper- time point, in three domains: Communication, Shared
ties, that identifies early behavioral markers of ASD in Positive Affect, and Social Orienting/Engagement [see
infants/toddlers aged 6–18 months. We used a total Coolican et al., 2010, for detailed operational defini-
score cut-off of 7 to identify risk based on evidence of tions]. Communication indices were: (1) Language
good positive (0.75) and negative predictive value Opportunities provided by caregiver, and four child
(0.98–0.99) in earlier work [see Bryson & Zwaigenbaum, behaviors; (2) Responsivity; (3) Inappropriate
2014] for infants in this age group. The AOSI was con- Responses; (4) Initiations; and (5) Functional Vocal
ducted by research-reliable staff to capture ASD symp- Utterances (FVU); see Table 2. All videos were coded for
toms at baseline only for participants in the appropriate 10 min, except one 9-min, 46-sec clip at F-up. To
age range. account for this slight variability, frequencies are
The ADOS [WPS edition; Lord et al., 1999] is a stand- reported as behaviors/min (i.e., rate). Shared Positive
ardized, semistructured direct observational measure of Affect involved partial interval coding, with each 10-sec
communication, social interaction, play, and behavior, segment coded for presence or absence of: (1) Child
with excellent inter-rater reliability and high stability smiling at caregiver; (2) Child smiling at toy/activity;
when used beyond age 2 years [Lord & Schopler, 1989]. (3) Caregiver smiling at child; and (4) Caregiver smiling
Module 1 was mainly used, except for one participant at toy/activity (very rare so not analyzed); (5) Child and
at intake and three at follow-up who were assessed Parent smiling together (i.e., with smiles directed at
using Module 2 (all conducted by research-reliable one another). Social Orienting/Engagement, defined as
administrators with supervision by a registered psychol- the child looking toward the caregiver, also used partial
ogist). To compare scores within and across modules, interval coding (10-sec intervals, presence/absence).
scores were converted to revised algorithms and the
comparison metric was used [ADOS-2; Lord et al., 2012.
Although primarily used to identify ASD symptoms at Fidelity of implementation. Following Koegel and
intake, the ADOS also served as a possible indicator of Koegel [2006], parent fidelity was coded from video,
change at follow-up. using continuous interval coding (ten 1-min intervals).
The Mullen Scales of Early Learning [MSEL; Mullen, Each interval was coded as correct or incorrect/not used
1995] is a standardized direct assessment of five devel- for each of ten PRT antecedent techniques or responses
opmental domains for ages 0–68 months: Gross Motor, to child vocal behavior: child choice, child attending
Fine Motor, Visual Reception, Receptive Language and (to person or activity/object), shared control, clear
Expressive Language. The Early Learning Composite opportunity, pace, recast, contingent reinforcement,
(ELC) is a standard score (mean 5 100, SD 5 15) repre- natural reinforcement, reinforcement of attempts, and
senting an overall measure of cognitive ability. Domain positive emotion [see Koegel & Koegel, 2006, for
scores are represented as T-scores (mean 5 50, SD 5 10), descriptions of these PRT strategies]. The fidelity of
and age equivalents (AE) are derived from raw scores. implementation score was the average percentage of
The MSEL has good-to-adequate psychometric proper- intervals, across all ten strategies, during which parents
ties. Given our focus on language outcomes, we used demonstrated appropriate use of the techniques.
the MSEL Receptive and Expressive Language domain
scores as outcome measures.
Parent satisfaction. As a partial index of social
validity of this program, we developed a 7-item ques-
Video-coded variables. Our primary outcomes of tionnaire to assess the acceptability of the intervention,
interest were the video-coded variables. Videos were framed in terms of “helpfulness.” Questions were rated
coded, by a coder blind to study objectives and study on a 5-point Likert scale (1: “not at all helpful” to 5:

INSAR Brian et al./Social ABCs in multisite study 903

 Effect Sizes (ES) were calculated using Cohen’s d. To
examine associations among variables and changes
on video-coded variables (i.e., 8 variables across
2 time-points), as well as possible baseline characteris-
tics that predicted change, critical P was adjusted
more stringently using family-wise error correction
(0.05/16 5 0.0031).

Results
Participant Characteristics and Performance Across Study
Sites

Table 1 presents information on participant characteristics

and performance on ADOS/AOSI and MSEL at intake.
Fisher’s exact tests revealed no significant associations
between study site and sex, ethnicity, maternal education,
or referral source (P’s > 0.32). No between-site differences
were found for mean age, ADOS comparison metric, or
MSEL T-scores or Age Equivalents at intake (all P’s > 0.13)
or follow-up (all P’s > 0.18), or for video-coded variables
at BL (P’s > 0.28), PT (P’s > 0.42), or F-up (P’s > 0.18).
Language and Communication
Standardized measures. Significant gains were
observed in age-equivalent scores on both Receptive
and Expressive Language domains of the MSEL, both
with large effect sizes (see Table 3). An average gain of
6–8 months’ equivalent emerged between assessments.
Standard scores did not differ across time for Receptive,
P 5 1.0, or Expressive Language, P 5 0.28, nor did the
ADOS comparison metric.
Video-coded variables. Intraclass correlations for
language indices ranged from 0.940 to 0.964 (mean-
5 0.955). Statistically significant gains emerged across
time-span 1, that were maintained at follow-up (time-
span 3), for: Responsivity, Initiations, FVU, and
caregiver-provided Language Opportunities (see Fig. 1),
all P’s < 0.002, with medium-to-large effect sizes (ES,
range: 0.72 to 1.26; see Table 4). Changes over time-
Figure 1. Children’s communication gains on video-coded span 2 were all non-significant (P’s > 0.25), demonstrat-
measures of (a) functional vocal utterances (b) responsivity, ing maintenance of gains, but no further increases, after
and (c) initiations. the intensive training period.
Shared Positive Affect (Smiling) and Social Orienting
“extremely helpful”). Because we designed this ques-
tionnaire part-way through the study, it was only Smiling. Inter-rater agreement was high for smiling
offered to the last 11 participants. (mean agreement 5 87%; range: 65–95%). In time-span
1, a trend emerged toward gains in Child Smiling to
Analyses their caregiver (ES 5 0.47) but this was nonsignificant
with corrected alpha; and a significant decrease
Changes across time-points were examined via paired emerged in the rate of child smiling to a toy/object/
samples t-tests. For video-coded behaviors, we separately activity (ES 5 0.63). A nonsignificant trend toward
compared BL vs. PT (time-span 1), PT vs. F-up (time-span increased Parent Smiling to their child also emerged
2), and BL vs. F-up (time-span 3), with family-wise during this time-span (ES 5 0.43; see Table 4). Shared
correction for multiple comparisons (0.05/3 5 0.0167). Smiling increased significantly during this period

904 Brian et al./Social ABCs in multisite study INSAR

Table 3. Performance on Standardized Measures of Language and Social Communication at Baseline and Follow-up
Measure Intake/Baseline Follow-Up P value (Effect Size)

MSEL–RL: mean age equivalent, months (SD) 18.07 (8.78) 24.67 (10.20) 0.003 (0.93)
MSEL–EL: mean age equivalent, months (SD) 17.94 (9.10) 25.50 (11.51) <0.001 (1.22)
MSEL–RL: mean T-score (SD) 40.59 (17.39) 40.59 (15.24) 1.0 (0.00)
MSEL–EL: mean T-score (SD) 41.11 (18.25) 43.78 (16.82) .28 (.26)
ADOS-2 comparison metric Mean (SD) 6.18 (2.35) 6.12 (1.61) 0.90 (0.03)

Notes. MSEL: Mullen Scales of Early Learning; RL: Receptive Language domain; EL: Expressive Language domain; ADOS-2 comparison metric calcu-
lated from ADOS-2 algorithm scores for Social Affect and RRB (Lord et al., 2012).

and nonlanguage behaviors, as well as between early

(i.e., time-span 1) and later (time-span 3) changes. We
did this by exploring correlations among change in
eight variables across these two time-spans (with cor-
rected P 5 0.05/16 5 0.0031): Initiations, Responsivity,
Language Opportunities, FVU, Child Smiling, Parent
Smiling, Shared Smiling, and Social Orienting. Signifi-
cant associations emerged between several communica-
tion indices (see Table 5) and between Parent and Child
Smiling (see Table 6). A moderate association emerged
between change in child Social Orienting and change
in Parent Smiling across time-span 3 (r 5 0.59;
P 5 0.007). With the stringent error correction, none of
the smiling change data were significantly correlated
with changes in communication indices. However,
trends indicated possible associations between gains in
Child Smiling (time-span 1) and increased Initiations,
FVU, Language Opportunities, as well as improved T-
scores on the MSEL EL domain, P’s range 5 0.010–0.037
(see Table 7).

Baseline language functioning. To explore the role

of baseline language level in treatment response, chil-
dren were divided into “Low” (n 5 8) and “High”
(n 5 11) language groups based on baseline MSEL lan-
Figure 2. Gains in video-coded indices of (a) social orienting guage T-scores (i.e., RL or EL T-score <30 vs. 30; 2
and (b) shared smiling. standard deviations from the standardization mean).
Univariate ANOVA revealed two trends that failed to
(ES 5 0.61), but was attenuated at F-up (no longer differ- reach significance with the adjusted critical P: specifi-
ent from BL, but with a modest ES 5 0.38; see Fig. 2). cally, the subgroup with low language scores at baseline
made somewhat greater gains in MSEL RL T-score,
F(1,13) 5 6.16, P 5 0.028; and in Social Orienting (BL vs.
Social orienting. Inter-rater agreement was also strong F-Up), F(1,17) 5 4.79, P 5 .043 than the high language
for this variable (mean 5 85% agreement; range: 68–97%). group.
Statistically significant increases in child orienting toward
caregiver emerged in time-span 1, with a medium effect
Referral source. Given that our sample consisted of
size (ES 5 0.64), but this gain was attenuated at F-up, and both community referrals and participants identified
no longer different from BL but with a modest effect size through our ISS, we explored potential group differen-
nonetheless (ES 5 0.33; see Table 4 and Fig. 2). ces on this basis. At baseline, no significant differences
Associations Among Variables emerged, all P’s > 0.31. However, significant differences
emerged over time-span 3, favouring ISS participants
To explore possible mediators of treatment response, over community referrals, for both increased rate of Ini-
we examined associations between changes in language tiations (mean change 5 1.99, SD 5 1.28 vs. 0.24,

INSAR Brian et al./Social ABCs in multisite study 905

Table 4. Performance on Video-Coded Indices of Language, Affect, and Social Orienting at Baseline, Post-Training, and
Follow-Up
P Value BL vs. PT P Value BL vs. F-up
Variable Mean (SD) Baseline (BL) Post-Training (PT) Follow-Up (F-up) (Effect Size) (Effect Size)

Responsivity (%) 56.80 (0.24) 80.90 (0.24) 81.15 (0.22) <0.001* (1.26) <0.001* (1.57)
Initiations (rate/min) 1.41 (1.28) 2.53 (1.75) 2.44 (1.88) 0.003* (0.77) 0.002* (0.78)
Functional vocal utter- 4.26 (3.29) 7.27 (3.58) 7.10 (3.36) 0.001* (0.93) <0.001* (1.16)
ances (rate/min)
Language opportunities 6.34 (3.16) 8.36 (3.14) 8.21 (2.99) 0.005* (0.72) 0.001* (0.88)
(rate/min)
Child smiling to care- 24.70 (17.08) 32.85 (19.01) 30.05 (14.43) .048 (0.47) 0.21 (0.29)
giver (% intervals)
Child smiling to object/ 11.74 (7.41) 7.10 (6.48) 8.00 (4.99) 0.013 (0.63) 0.06 (0.46)
activity (% intervals)
Caregiver smiling 44.10 (16.43) 50.65 (19.56) 46.65 (18.64) 0.068 (0.43) 0.42 (0.18)
(% intervals)
Shared smiling 15.70(11.09) 22.65 (14.33) 20.90 (11.38) 0.013* (0.61) 0.11 (0.38)
(% intervals)
Social orienting 27.00 (14.04) 36.55 (16.61) 34.45 (18.21) 0.009* (0.64) 0.16 (0.33)
(% intervals)

* Indicates statistically significant difference with corrected P 5 0.05/3 5 0.0167.

Table 5. Significant Pearson Correlations (r; P values) among Change Scores for Language Variables
Initiations FVU FVU Language Opportunities Language Opportunities
(Time-span 3) (Time-span 1) (Time-span 3) (Time-span 1) (Time-span 3)

Initiations Pearson r 0.762 0.703 0.766 0.649 0.696

(Time-span 1) (P) (<0.001) (0.001) (<0.001) (0.002) (0.001)
Initiations Pearson r – 0.377 0.746 0.313 0.703
(Time-span 3) (P) (0.101) (<0.001) (0.179) (0.001)
FVU Pearson r – – 0.758 0.944 0.660
(Time-span 1) (P) (<0.001) (<0.001) (0.002)
FVU Pearson r – – – 0.701 0.935
(Time-span 3) (P) (0.001) (<0.001)
Language opportunities Pearson r – – – – 0.711
(Time-span 1) (P) (<0.001)

Note. FVU, Functional vocal utterances; Time-span 1: (Baseline vs. Post-training); Time-span 3: (Baseline vs. Follow-up).

Table 6. Significant Pearson Correlations (r; P values) amongst Change Scores for Smiling Variables
Child smile (Time-span 3) Parent smile (Time-span 1) Parent smile (Time-span 3)

Child smile Pearson r 0.600 0.626 0.464

(Time-span 1) (P) (0.005) (0.003) (0.039)
Child smile Pearson r – 0.506 0.688
(Time-span 3) (P) (0.023) (0.001)
Parent smile Pearson r – – 0.708
(Time-span 1) (P) (<0.001)

SD 5 0.57) and FVU (mean change 5 4.62, SD 5 2.25 vs. SD 5 11.15), and was maintained at F-up (80.20%,
1.40, SD 5 1.49), both P’s 5 0.001. SD 5 9.69); t’s 5 210.47 and 211.95, respectively, both
P’s < 0.001. At baseline, none of the caregivers reached
Feasibility and Acceptability
75% fidelity; at PT, 18/20 had attained this level, and
Parent fidelity of implementation. Inter-rater reli- 16 retained this level at F-up. Fidelity of implementa-
ability for parent fidelity was very strong (mean 5 90%; tion at PT was significantly associated with change in
range: 81–100%). Parent fidelity increased significantly children’s Responsivity from BL to F-up, r 5 0.58,
from BL (Mean 5 52.55%, SD 5 10.94) to PT (84.30%, P 5 0.007.

906 Brian et al./Social ABCs in multisite study INSAR

Table 7. Nonsignificant Trends (Pearson r, P values) Suggesting Possible Associations between Gains in Child Smiling and
Gains in Language Behaviors
Initiations Initiations FVU Language opportunities MSEL EL T-score
(Time-span 1) (Time-span 3) (Time-span 3) (Time-span 3) (intake vs. follow-up)

Child smile Pearson r 0.559 0.553 0.560 0.514 0.524

(Time-span 1) (P) (0.010) (0.011) (0.010) (0.021) (0.027)

Note. FVU, Functional vocal utterances; Time-span 1: (Baseline vs. Post-training); Time-span 3: (Baseline vs. Follow-up); MSEL: Mullen Scales of
Early Learning; EL: Expressive Language.

Parent satisfaction. The intervention received risk babies with ASD outcomes. Similarly, one-third of
extremely positive satisfaction ratings from parents the high-risk infant siblings with ASD outcomes in our
(n 5 11; mean 5 29.82, SD 5 2.82 out of a possible 35). larger sample were characterized by declining develop-
No differences were found across site or referral source. mental trajectories of standard scores, and 20% by
actual raw score loss or plateau on the MSEL [Brian
et al., 2014]. Given these findings, the current sample
Discussion
would arguably not be expected to demonstrate age-
appropriate developmental gains in language function-
This study demonstrates the feasibility and acceptability
ing, across the time-span examined, in the absence of
of our novel parent-mediated Social ABCs intervention
intervention.
for infants/toddlers with ASD, and provides evidence of
We observed significant gains in shared smiling and
promise of this intervention’s efficacy. Strengths
trends toward increased parent smiling to their chil-
include the use of a manualized program, measurement
dren, and children smiling to their parents, accompa-
of fidelity, the use of blinded coders and assessment of
nied by decreased child smiling at toys/objects,
inter-rater reliability, the enrollment of a relatively
indicating a selective increase in smiling to people.
young group with confirmed or suspected ASD, and the Moreover, increased smiling by one social partner was
inclusion of outcome variables that are associated with associated with increased smiling in the other, suggest-
core ASD features. Our most informative indices of ing a reciprocal relationship. Evidence of the natural
change were obtained from video-coding of parent- history of infants later diagnosed with ASD points to a
child interactions. Significant gains emerged in child- declining pattern of social smiling beginning between
ren’s communication on several proximal video-coded 12 and 18 months of age [Ozonoff et al., 2010; Landa
measures, including responsivity to adult prompts, rate et al., 2013]. Our findings of gains, rather than loss, fur-
of initiations, and functional vocal utterances, which ther support the potential efficacy of our intervention.
were maintained three months following parent train- A collateral post-training increase in children’s social
ing. Post-training gains in responsivity and total func- orienting was also observed, and this was moderately
tional vocal utterances were characterized by strong associated with parental smiling. Evidence suggests that
effect sizes, and gains in self-initiated language were changes in social orienting may be among the earliest
medium-to-large. Using age-equivalent scores, we also manifestations of ASD, with evidence of declining tra-
observed gains on standardized measures of receptive jectories beginning as early as 6 months of age [Ozonoff
and expressive language commensurate with typical et al., 2010] in the absence of intervention. Our
developmental rates. Failure to observe gains in stand- reported medium-sized gains in social orienting stand
ard scores suggests that our participants did not achieve out compared with findings from a similar age group,
a rate of gain greater than that expected for typical also over a 12-week period, regardless of intervention
development, but neither did they lose standing rela- [effect sizes of 20.02 and 0.06 for treatment and com-
tive to their age peers. These findings stand in contrast munity control groups, respectively; Rogers et al.,
to previous reports describing the natural histories of 2012], albeit using a different measure of social orient-
high-risk infants in this age range when followed longi- ing. Although it has been postulated that reduced social
tudinally, in the absence of intervention. For example, orienting may be secondary to more basic attentional
declining developmental trajectories have been deficits [see Brian et al., 2015, for an overview], a failure
described (based on Mullen T-scores) in a sizable pro- to orient selectively to social stimuli (i.e., faces and the
portion of high-risk babies from 6 to 36 months [Landa, affective expressions they hold) may result in fewer
Gross, Stuart, & Bauman, 2012], and specifically in opportunities to learn from faces and make sense of
those with ASD outcomes. Landa et al. [2013] also the information they can provide. Increased social
reported declining raw language scores (which would orienting affords the opportunity for increased affect
necessitate declining standard scores) in 48% of high- sharing, and both are known to enhance learning

INSAR Brian et al./Social ABCs in multisite study 907

[Kasari, Sigman, Mundy, & Yirmiya, 1990; Messinger, is that the families enrolled in the ISS may be a some-
Fogel, & Dickson, 2001; Hohenberger, 2011]. Moreover, what unique group in ways not captured by our data
our findings suggest a reciprocal relation between child (e.g., motivation/resources to enrol in research well
orienting and parent smiling, which highlights the impor- before detection of developmental concerns).
tant interaction between child and caregiver, discussed Although not statistically significant, a trend was
in more detail below. observed toward greater improvement in receptive lan-
Unfortunately, increases in both shared smiling and guage and social orienting for participants with lower
social orienting were not consistently maintained at baseline language functioning. This may be explained,
follow-up, revealing the possible vulnerability of these in part, by “ceiling” effects for the high language group
gains once coaching ended. In reviewing our interven- (borne out by initial receptive language T-scores within
tion strategies, it became clear that we placed greater average limits). Not to be overlooked, however, is that
emphasis on language development (vs. affect sharing the subgroup with lower baseline language gained
and social orienting) in our formal teaching strategies, almost a full standard deviation. Although not statisti-
and these skills were maintained once coaching ended. cally significant, this meets Jacobson and Truax’s [1991]
Social orienting and smiling increased initially but were definition of clinically significant change (i.e., scores
perhaps less well-established during the training phase, moving from below, to within, two standard deviations
rendering gains in these behaviors more vulnerable to of the population mean). This subgroup also made
extinction. However, we note that a consistent pattern somewhat greater gains in social orienting, almost dou-
has emerged for all video-coded indices wherein the bling their baseline rate. These preliminary findings
greatest rate of gain appears to occur during the coach- raise the possibility of an association between improved
ing phase, with leveling out during implementation. It social orienting and improved receptive language, an
remains possible that, with a larger sample, the appa- interpretation that underscores the importance of social
rent non-significant gains for some variables across orienting as a potentially pivotal intervention target for
Time-Span 3 would become significant. Moreover, these this age group. Because these patterns are only non-
data may point to the need to enhance the coaching significant trends, we will further consider these appa-
phase in some way to ensure retention of gains once rent differences in future work with larger samples.
coaching ceases. As we refine our model, considerations
include whether we need to place a greater emphasis
on shared affect and perhaps target social orienting Parent gains and associated child gains. Parents
more directly. Alternatively, it remains an empirical provided significantly more language opportunities
question whether infants may have reached a natural after training, and showed modest, but nonsignificant
“ceiling” in the rate of these behaviors, in which case, a increases in smiling at their children. Perhaps more
postcoaching plateau would be an acceptable outcome. importantly, however, some intriguing associations
We also identified a positive association between between caregiver smiling and several important child-
child-initiated vocalizations and adult-provided lan- related indices emerged. First, changes in parent smiling
guage opportunities. Although we cannot determine were associated with changes in child smiling, which
causality, this may suggest the importance of establish- was not directly targeted in our intervention, thus sup-
ing the contextually appropriate use of language in the porting our premise that changes in parent behavior
development of functional, self-initiated language. We may result in changes in child behavior, even if not tar-
were encouraged that increased adult prompting did geted directly. The potential to increase positive affect
not result in prompt-dependency in our program, in our participants is encouraging in light of evidence
which has been a perennial challenge in more highly of declining positive affect sharing in high-risk infants
structured ABA-based models [e.g., Smith, 2001], and with ASD between 12 and 24 months of age [Ozonoff
may have been mitigated by our use of naturalistic, et al., 2010; Landa et al., 2013], reduced smiling in
motivation-based, PRT procedures [cf. Koegel & Koegel, high-risk infants with ASD more generally [Filliter et al.,
2006]. 2015], and the important role positive affect plays in
Although preliminary, we observed differential learning. Further, a moderate association emerged
response to treatment based on referral source (ISS vs. between gains in parent smiling and increased child ori-
community). Specifically, we observed an advantage for enting to the parent. It is of great interest to us that
children referred through our longitudinal study of there may be a relation between child orienting and par-
high-risk infant siblings relative to community referrals, ent smiling, regardless of the direction. Questions to
despite virtually identical fidelity in the two parent explore further are whether parents smile more because
groups, both post-training and at follow-up. This find- their children are looking at them more (thus appearing
ing is preliminary due to small subgroups, but warrants more engaged in the interaction), or if the parents’
further examination in larger samples. One possibility smiling (directly targeted in our intervention) may have

908 Brian et al./Social ABCs in multisite study INSAR

led to increased child orienting (i.e., children may find measure strengthens the argument that the interven-
it more reinforcing to look at a smiling face). These tion contributed to the observed gains. Although fidel-
smiling data highlight the importance of targeting shar- ity remained high throughout the implementation
ing of positive affect, which may have a collateral phase, it may be surprising that this was not associated
impact on other important conditions for learning with continued gains in social smiling and orienting.
(e.g., attending to a social partner). The attainment of One possibility, yet to be explored, is that our partici-
any new skill (e.g., communication) will be facilitated pants (and their caregivers) may have reached ceiling
by enhanced positive affect and increased engagement levels in smiling and orienting so there was no more
[e.g., see Fossum, Williams, & Smith, 2015, wherein room to increase. Alternatively, this may also be
higher rates of baseline positive affect predicted better explained by our relatively greater emphasis on the
communication outcomes for preschoolers with ASD in communication target during parent coaching (recall
a comprehensive early intervention program]. that many of the communication gains did maintain
Parents achieved a high degree of fidelity in imple- post-training). Our measure of parent satisfaction is also
menting the Social ABCs strategies following training. limited by the fact that only half the sample completed
Indeed, the vast majority of parents (90%) achieved at it. The relatively well-educated and primarily Caucasian
least 75% fidelity, a benchmark recommended by sample may also limit the generalizability to other
Stahmer and Gist [2001], and fidelity was associated socio-cultural groups. Finally, our relatively small sam-
with gains in children’s responsivity to adult prompts ple may have been under-powered to detect small sub-
over the entire treatment period, providing support for group differences, though this remains one of the
the claim that our intervention procedures had an largest studies of parent-mediated intervention for tod-
impact on the primary child outcome measure. dlers with emerging ASD. We observed trends that indi-
In addition to positive parent satisfaction ratings, cated possible subgroup differences in response to the
unsolicited feedback from parents revealed very positive intervention, which need to be explored systematically
responses to the intervention. One parent beautifully in future studies.
captured the essence of the program in the following
statement: “The focus on sharing positive emotions
Conclusions and Future Directions
reminded me that play is fun. Because I want to play
with my child now, I am spending so much more time Our findings reveal gains in several language and com-
interacting. . . I feel like these interactions have had so munication indices, shared positive affect, and social
much to do with his language burst.” orienting for toddlers with confirmed or suspected ASD,
over a relatively short time, with parents as mediators.
Limitations Parents attained a high degree of fidelity relatively
quickly and rated the intervention as highly acceptable.
Our findings demonstrate that the Social ABCs is a feasi- Training parents as mediators presents an opportunity
ble model for parents to learn and deliver, and that for the integration of intervention into daily activities,
parents find it enjoyable. We recognize that our lack of allowing for intensive very early intervention that is
a control group precludes definitive conclusions about developmentally sensitive, feasible, and cost-effective.
the impact of this intervention. However, three key Bolstered by our preliminary evidence of promise, next
findings provide evidence of promise regarding the effi- steps include a RCT to establish efficacy (currently
cacy of our program: First, and perhaps most compel- underway), translation to community settings (e.g.,
ling, is that for every video-coded variable that front-line childcare or infant development specialists),
demonstrated change, this occurred during the interven- as well as efforts to evaluate systematically any partici-
tion coaching phase, and plateaued once the coaching pant or family characteristics that predict differential
ceased. This suggests that the coaching was responsible responses to treatment. Finally, we are highly moti-
for the observed gains, but this will need to be tested in vated to explore the cost-effectiveness of this model
a more rigorous design. Moreover, given the docu- compared with more intensive, comprehensive inter-
mented delays in our participants at intake, together ventions for toddlers with ASD.
with previous reports revealing developmental decline
Acknowledgments
in a substantial proportion of high-risk babies and those
with ASD outcomes in particular, the likelihood of This research was funded by Autism Speaks as part of
achieving age-appropriate gains in language simply the Toddler Treatment Network (AS-TTN). At the time
from maturation (as a group) was low. Finally, the sig- of the study, Dr. Bryson was supported by the Joan and
nificant correlation between fidelity of implementation Jack Craig Chair in Autism Research. Dr. Smith is cur-
and gains in our primary (communication) outcome rently supported by the Joan and Jack Craig Chair in

INSAR Brian et al./Social ABCs in multisite study 909

Autism Research. Dr. Zwaigenbaum is supported by the Network, 11 sites, United States, 2010. Morbidity and Mor-
Stollery Children’s Hospital Foundation Chair in tality Weekly Report, Surveillance Summary, 63(2), 1–20.
Autism Research and by an Alberta Innovates-Health Coolican, J., Smith, I.M., & Bryson, S. (2010). Brief parent
training in pivotal response treatment for preschoolers with
Solutions Health Scholar Award. The authors wish to
autism. Journal of Child Psychology and Psychiatry, 51(12),
thank the families for their hard work and dedication
1321–1330.
and for welcoming us into their homes. We are very Coonrod, E.E., & Stone, W.L. (2004). Early concerns of parents
grateful for our exceptional parent coaches, Terry of children with autistic and nonautistic disorders. Infants
McCormick, Erin Dowds, and Stacey MacWilliam. We & Young Children, 17(3), 258–268.
also wish to thank Daniel Openden for engaging us in Dawson, G., Rogers, S., Munson, J., & Smith, M. (2010).
thoughtful discussions about coaching positive affect. Randomized, controlled trial of an intervention for tod-
Finally, we thank our video coders, Julie Longard, Sarah dlers with autism: Early Start Denver Model. Pediatrics,
Dhooge, Heather Hiscock, and Jessica Soley, as well as 125, e17–23.
Kate Bernardi for her assistance with assessments and Filliter, J.H., Longard, J.C.P., Lawrence, M.A., Zwaigenbaum,
L., Brian, J., Garon, N., & Bryson, S.E. (2015). Positive affect
data management.
in infant siblings of children diagnosed with autism spec-
trum disorder. Journal of Abnormal Child Psychology,
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