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Copyright © 2021 Faculty of Health Science UKM. All right reserved Artikel Asli/Original Article
The Use of Facilitative Interaction Strategies by Parents of Autism Spectrum Disorder Children
Penggunaan Strategi Fasilitatif Semasa Interaksi oleh Ibu Bapa Kanak-kanak dengan Kecelaruan Spektrum Autisme
NOR SHAFIKAH AZNOR & SUSHEEL JOGINDER SINGH
ABSTRACT
Children with Autism Spectrum Disorder (ASD) often demonstrate communication deficits. Parents, who are children’s most important communication partners, may struggle to communicate with their children with ASD and often attend speech and language therapy to learn some facilitative interaction styles that they can use with their children with ASD. The aim of this study was to explore and compare the facilitative interaction styles used by parents of children with ASD who have and have not received speech and language therapy. Thirteen children with ASD and their parents participated in this study. Seven dyads did not receive speech and language therapy and 6 dyads received speech and language therapy. A 10-to-15-minute play interaction was video-taped for each dyad and parents’ facilitative interaction styles were coded. Findings revealed that parents from both groups used the facilitative interaction styles with their children. Generally, parents who had received speech and language therapy previously demonstrated more facilitative interaction styles as they showed higher total mean scores than parents of children who had not received therapy. The use of facilitative interaction strategies by parents will allow children with ASD to communicate more effectively and thus various methods must be employed to provide parents with information about these strategies.
Keywords: Autism spectrum disorder, speech-language pathologist, parent-child interaction, communication strategies
ABSTRAK
Kanak-kanak dengan autism seringkali mempunyai masalah komunikasi. Ibu bapa yang merupakan rakan komunikasi utama kanak-kanak kadang-kadang mengalami kesukaran berkomunikasi dengan kanak-kanak dengan autism dan ada di antara mereka menghadiri terapi pertuturan dan bahasa bagi mempelajari strategi fasilitatif yang boleh digunakan semasa berinteraksi dengan anak mereka.Tujuan kajian ini adalah untuk meneroka strategi komunikasi fasilitatif yang digunakan oleh ibu bapa yang telah dan belum menghadiri terapi pertuturan dan bahasa semasa berinteraksi dengan anak mereka.Tiga belas kanak-kanak dengan autism dan ibu bapa mereka terlibat dalam kajian ini. Tujuh pasangan tidah pernah menerima terapi pertuturan dan bahasa manaka enam pasangan lagi pernah menerima terapi pertuturan dan bahasa. Sesi iteraksi selama 10-15 minit dirakam untuk setiap pasagan dan strategi komunikasi fasilitatif yang dipamerkan oleh ibu bapa dikenalpasti.
Dpatan kajian menujukkan bahawa ibu bapa dari kedua-dua kumpulan menggunakan strategi fasilitatif semasa berkomunikasi dengan anak mereka. Walaubagaimanapun, ibu bapa yang anaknya pernak menghadiri terapi pertuturan dan bahasa menggunakan lebih banyak strategi fasilitatif semasa berkomunikasi daripada ibu bapa yang anaknya tidak pernah menghadiri terapi pertuturan dan bahasa. Penggunaaan strategi komunikasi fasilitatif oleh ibu bapa membantu kanak-kanak dengan autism berkomuniaski dengan lebih efektif dan oleh itu, pelbagai kaedah patut digunakan untuk membekalkan ibu bapa dengan informasi tentang strategi-strategi ini.
Kata kunci: Autism, patologis pertuturan-bahasa, interaksi ibu bapa dengan anak, strategi komunikasi
INTRODUCTION
Autism Spectrum Disorder (ASD) is a developmental disability characterized by deficits in communication, social skills, and the presence of restricted, repetitive patterns of behavior, interests,
or activities which persist throughout the lifetime (American Psychiatric Association 2013; Baio et al. 2018). In the United States, there has been an increase prevalence of ASD from 1.1% to 2.5%, over the periods of 2009–2011 and 2015–2017 (Zablotsky et al. 2019).
Parents are children’s most important communication partners. However, parents often face difficulties interacting with their child with ASD given that communication deficit is one of the main characteristics of many children with ASD.
As such, they tend to be more directive, controlling, or commanding during play interaction (Freeman & Kasari 2013). Parent-child interaction has become an essential part in the intervention as a number of the core symptoms of ASD are specifically impacted by parental behaviors, and many efficacious treatment options for children with ASD rely on altering parental behaviors (Zlomke et al. 2019).
There are several interventions available that focus on teaching positive interaction style to adults, such as Social Communication, Emotional Regulation, Transactional Support (SCERTS) (Prizant et al. 2006), and the Hanen Program (Weitzman 2013). Both programs are aimed at helping children with ASD become competent communicators by encouraging their parents to create communication opportunities for them. The use of facilitative interaction strategies by communication partners promotes language development in children with ASD. For instance, a study by McDuffie and Yoder (2010) on children with ASD found that parents verbal responsiveness towards child’s focus of attention and verbal communication acts aided the process of the child’s early vocabulary acquisition. Similar findings were found in Patterson et al. (2014) study that reported parents’ responsiveness predicted total time in child-initiated joint engagement (time spend engaged together in a task).
Apart from that, Eason, White, and Newsom (1982) reported that parental praise for appropriate play resulted in decreased self-stimulatory behaviours and increased independent, appropriate play in children with ASD. Furthermore, parental directiveness (e.g., asking questions) has been found to be predictive of receptive language gains (Haebig, McDuffie & Weismer 2013). All these interaction styles that are associate with positive child outcomes are facilitative interaction strategies (e.g., labelling, commenting) .
Little is known about how Malaysian parents interact with their child with ASD. A study conducted in Malaysia by Sokmum, Joginder Singh and Vandort (2017) investigated the effectiveness of Hanen More Than Words Program by exploring the parent interaction style as well as children’s performance in language and social skills following parental involvement in the Hanen parental training program. They found that children showed an increase in vocabulary, communication, and social skills following parental participation in the 8 week program (once a week, 2 hours each time).
However, not many parents have the opportunity to join the Hanen More Than Words Program and
instead might rely on their speech-language pathologists (SLPs) to guide them learn facilitative interaction strategies. At the same time, there is a shortage of SLPs in Malaysia. This leads to many families of children with ASD to wait longer for an appointment with the SLP whereby the parents will be able to learn facilitative interaction strategies (Chu et al. 2018). According to Joginder Singh, Iacono and Gray (2011), many SLPs in Malaysia focus on teaching positive interactive styles to parents of children with language difficulties however, no study has been conducted to document the strategies used by the parents. Therefore, the aim of this study was to explore the facilitative interaction styles demonstrated by the Malaysian parents and to compare the facilitative interaction styles used by parents of children with ASD who have and have not received speech and language therapy.
MATERIALS AND METHODS
This was an observational, cross-sectional study that took place in Kuala Lumpur, Malaysia. Ethics approval was obtained from the National University of Malaysia (UKM) Human Research Ethics Committee, JEP-2019-771.
PARTICIPANTS
The study involved children with ASD and their parents. The selection criteria for the children with ASD includes: (a) aged 3-8 years, (b) diagnosed with ASD, and (c) have no hearing and vision problems. The children recruited were those who had received speech-language therapy and those who had not received any speech-language therapy.
A parent that often played with the child (as reported by the parent) was also recruited for the study. Participants were recruited from the university speech-language therapy clinic in Kuala Lumpur Malaysia. Twenty-two families of children with ASD who met the inclusion criteria were approached, and thirteen families agreed to participate, and consent was obtained.
They were divided into dyads who have received speech and language therapy – (returning group) (n=6) and dyads who have not received speech and language therapy (first timers group) (n=7). The children in the returning group were aged 4 years to 6 years (mean = 5.00, SD = 0.89) while children in the first timers’ group were aged 4 years to 7 years (mean = 5.14, SD = 1.07). Of the 13 families, 9 parents were employed;
4 were from the first timers group (57.14%) and 5 were from the returning group (83.33%) whereas 4 parents were not-employed; 3 were from the first timers group (42.86%) and 1 was from the
returning group (16.67%). Other characteristics of the subjects are presented in Table 1.
TABLE 1 Demographic information of the children and parents
First timers n (%)
Returning n (%) Child’s Gender
Male Female Child’s mode of communication Verbal Non-verbal Parents’ education level
SPM Diploma Degree PhD
5(71%) 2 (19%)
4 (57%) 3 (43%)
1 (14.29%) 2 (28.57%) 3 (42.86%) 1 (14.29%)
6 (100%) 0(0%)
4 (67%) 2 (33%)
1 (16.67%) 1 (16.67%) 4 (66.67%) 0 (0%)
PROCEDURE
The play sessions took place at the university clinic. Prior to dyadic play interaction observation, parents completed a demographic information form. Following that, parents were asked to play and interact with their children as they normally would at home and were provided with a standard set of toys in a box, which they could use which included: a doll, kitchen set, blocks, grooming toys, toy telephones, cars, trucks, books with thick
pages, ball, push button toys, musical toys, a shape sorter, pieces of paper with thick crayons, and stacking rings (Joginder Singh et al. 2015). The play interaction was videotaped for 10 to 15 minutes, depending on how long the parents continued to play with the child, using closed- circuit television (CCTV) at the university clinic or a tripod-mounted video recorder.
DATA PREPARATION AND CODING
All video recordings were transcribed using the procedure outlined by Joginder Singh et al. (2015) and then coded for parents use of facilitative interaction strategies. Transcription was done for each verbal behaviour produced by the communication partner and non-verbal or verbal behaviour produced by the child. The coding system was piloted and finalized based on two parent-child dyads. Table 2 presents the definitions of the final facilitative interaction styles coded during the dyadic play interaction observations for the study after the pilot study. The facilitative interaction styles coded in this study were as follows: praise, follow-in comment, expansion, repetition, command, labeling, time delay, and modeling and requesting for imitation. Each style was coded using a form prepared by the authors.
Coding was done for an 8-minute footage sample by taking into consideration the period when the child appeared to be producing the most communicative behaviors (Joginder Singh et al.
2015). During coding, coder paused the video tape, rewound, and/or consulted the coding scheme as necessary to ensure greater accuracy in coding.
TABLE 2 Parent behavior definitions
Code Code Description Example
Praise Parent gives a behavior-specific or non-specific statement of approval on child’s behavior.
Behavior specific: “Good job! You put it down.”
Non-specific: “Clever!”, “Good boy!”, “Yeay”,
“Yes”
Label Parent say the name of object presented either in single word or embeds in connected speech.
“Look, mummy has a book! Let’s read the book! (as parent present the book)
“Car. Blue Car” (as child plays with a blue car) Follow-in
comment
Parent describes what the child was looking at or playing with, without conveying the expectation that the child does something different or respond verbally to the parent.
Child feeds baby.
Parent: “Baby is hungry!”
Child watches parent cut a toy fruit.
Parent: “Mummy is cutting.”
Expansion Parent responds verbally to child’s acts of spoken communication by adding semantic or grammatical information to the child’s previous utterance.
Child: “Ball”
Parent: “Yellow ball”
Child: “Up”
Parent: “Car is going up”
Repetition Parent repeats all or part of the child’s previous utterance.
Child: “Zebra”
Parent: “Zebra”
Child: “Go up”
Parent: “Up”
Command Parent requests the child to change some aspect of their play during object-focused engagement or redirects the child away from current focus of
“Brush the doll’s hair” (as child play with comb and doll)
“Look at this kitty” (as child plays with the car)
attention
Time Delay Parent allows a certain amount of time to pass before providing a prompt or cue.
Parent provides a brief pause after a specific behavior accompanied with a positive look or facial expression to indicate that a response is expected
Model and Request for Imitation
Parent demonstrate what they would like the child to do or say by demonstrating words, phrases, or gestures about objects and activities the child is interested in and then providing
opportunity/specifically requesting the child to imitate.
Pretend kitchen Parent: “I’m hungry”
Child: (doesn’t respond)
Parent: Takes a food item, pretends to eat it and gives it back to the child while saying “I’m hungry” (to encourage the child to give the food to the parent.)
Parent: “I’m going to make a parking garage”
(parent builds the parking garage and knocks it down), then
Parent: “You try now”
Reliability was computed by having an independent coder code 25 % of the video samples that were randomly selected (n=3). This rater was a speech sciences student who had experience working with children with ASD and conducting parent-child interaction observation. Inter-rater reliability was calculated using percentage agreement for each interaction styles by using the formula: number of agreements (the number agreements + disagreements) 100. Reliability for the parental interaction style codes used in this study were: praise = 94%, label = 85%, follow-in comment = 75%, expansion = 90%, repetition = 90%, command = 71%, time delay =81%, model &
request imitation = 69%.
RESULTS
Quantitative analysis was done to address the research questions. The facilitative interaction styles demonstrated by the parents are described first, followed by comparisons across groups.
The mean number of facilitative interaction strategies used by parents in both groups is
presented in Table 3. Findings revealed that parents from both groups used the facilitative strategies during play interaction with the child. The three most frequently demonstrated interaction styles by parents of first timers group were labels (mean = 7.43, SD = 1.43), commands (mean = 6.71, SD = 1.66) and models and request for imitation (mean = 3.57, SD =1.09).The three most frequently demonstrated interaction styles by parents of returning group were commands (mean =8.33, SD
= 1.28), labels (mean = 6.50, SD = 1.48) and follow-in comments (mean = 4.83, SD = 0.60).
Overall, parents from the first timers group had a total mean score of 29.14 whereas parents from the returning group had a total mean score of 34.00 for facilitative interaction styles demonstrated.
While parents from both groups displayed all the eight interaction styles, the total mean scores were generally higher for parents from the returning group. Out of the eight facilitative interaction strategies, parents from the returning group obtained a lower mean score in only three facilitative styles which were labeling (mean = 6.50), expansion (mean =1.17), and repetition (mean = 3.33) compared to the first timers group.
TABLE 3 Facilitative interaction styles demonstrated by parents from the first timers and returning groups
Variables First timers (n=7)
M (SD)
Returning (n=6) M (SD) Praise
Label
Follow-in Comment Expansion
Repetition Command Time Delay
Model & Request Imitation
Total Facilitative Interaction Styles Score
1.29 (0.71) 7.43 (1.43) 3.29 (0.87) 2.00 (1.22) 3.57 (0.90) 6.71 (1.66) 1.29 (0.68) 3.57 (1.09) 29.14 (2.14)
4.00 (1.18) 6.50 (1.48) 4.83 (0.60) 1.17 (0.60) 3.33 (1.73) 8.33 (1.28) 1.50 (0.67) 4.33 (1.12) 34.00 (5.59) M= mean; n=number; SD= standard deviation
DISCUSSION
The current study was design to explore and compare the facilitative interaction styles used by parents of children with ASD who have and have not received speech and language therapy previously. It must be noted that all findings discussed here are based on descriptive data as the sample size was small.
Parents in the first timer group demonstrated fewer facilitative interaction strategies compared to parents in the returning group. This may be because this group of parents experienced a lack of exposure on the facilitative strategies that they can used. As mentioned by Chu et al. (2018), parental understanding and knowledge about the deficits and how to interact with their child depends on how it was explained to them by professionals.
However, it was encouraging to see parents from the first timers group did use some facilitative interaction stratgies, albeit less often, as it suggest that they were creating a conducive communicative environment for their children. These parents could have learnt the these strategies from other professionals, books, or even support groups (Chu et al., 2018).
Similarities were found in both parent groups in that they used commands and labeling most frequently during the play interaction. This is in line with the previous studies whereby the interaction style of parents and their children with ASD is often described as directive, and are highly likely to give many commands (Crowell, Keluskar
& Gorecki 2019). Both groups were also often observed to use labelling as parents often belief that labeling teaches their child new vocabulary and thus they need to constantly label everything.
McDuffie, Yoder, and Stone (2006) reported that labelling is positive communication strategy in that the presence of verbal labels during a referential task increases a child’s attention to a novel object (for children with ASD).
Findings revealed that time delay and praise were the facilitative interaction styles least often used by parents from the first timers group and expansion and time delay were some of the facilitative strategies used least often by parents in the returning group. Both groups seldom used time delay because they were often keen to get their child with communication difficulties to respond and thus kept prompting the child. This suggest that although parents in the returning group might have learnt time delay, they continued to be anxious about their child’s communication and thus struggled with time delay.
Of the eight facilitative interaction strategies, parents in the returning groups used six strategies more frequently that parents in the first timers’
group. Again, this finding suggests that parents
whose child had received speech-language previously probably had been introduced to and trained to use facilitative interaction strategies with their children. Often parent-child interaction is a focus of speech-language intervention as literature has highlighted that parental training resulted in positive outcome in children with communication difficulties (Sokmum et al., 2017). Joginder Singh et al. (2011) reported that Malaysian SLPs often provided training to parents on how to interact with their children who have communication deficits.
Although findings revealed higher mean scores in the facilitative styles demonstrated by the returning group, there was no big difference in the scores between both groups. This might be explained by the fact that findings involved individual differences. According to Hudry et al.
(2013), understanding individual differences in parent-child dyads presents an important step in appreciating how and why some parent–child dyads come to adopt more optimal interaction styles, while for others, parent interaction is more asynchronous and less facilitative.
In addition, the child’s language abilities may also influence the findings of this study. There have been some research indicating an association between children’s verbal abilities and the capacity to engage with their parent (Doussard-Roosevelt et al. 2003). Parents were less synchronous during interaction with their non-verbal child compared to verbal child with ASD (Doussard-Roosevelt et al.
2003).
Apart from that, parent’s generalization of the facilitative interaction styles taught in therapy might be a contributing factor to the findings of no big difference in the mean scores between both groups. It cannot be ascertained from this study whether parents in the returning group were able to generalize strategies that they had learnt previously.
CONCLUSION
To date, there has been no research on how Malaysian parents interact with their children with ASD. With the evolution of parental roles in children’s therapy, family-based interventions will benefit from a better understanding on the nature parent-child interaction as evident from the present study. Generally, parents whose children have received speech and language therapy demonstrated more facilitative interaction styles than the first timer parents. They shared a similarity in the two most frequently used interaction styles indicating that these might be common interaction styles used by families regardless of whether not their child attends speech-language therapy, as parents might already be aware that these strategies
encourage their child to communicate. However, findings from this study need to be interpreted with caution due to the small sample size. The findings of this study calls for larger scale studies exploring the interaction style of parents and their children with ASD, whereby the children’s responsiveness to their parents interaction style should also be explored. The findings of this study also provide Malaysian SLPs with some information about facilitative strategies that are least often used by parents so that SLPs can continue to support parents in using these strategies.
ACKNOWLEDGEMENT
Thanks are extended to all parents and children who participated in the study.
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Nor Shafikah Aznor Susheel Joginder Singh
Center for Rehabilitation and Special Needs Studies Faculty of Health Sciences
Universiti Kebangsaan Malaysia Jalan Raja Muda Abdul Aziz
50300 Wilayah Persekutuan Kuala Lumpur Malaysia
Corresponding author:
E-mail: [email protected] Tel: 03-92895009
Fax: 03-26986039
Received: 6 August 2021 Revised: 1 September 2021
Accepted for publication: 24 September 2021
