title: Joint attention and symbolic play in young children with autism: a randomized controlled intervention study. Tutorial: The Practical Application of Longitudinal Structural Equation Mediation Models in Clinical Trials Randomized Controlled Caregiver Mediated Joint Engagement Intervention for Toddlers with Autism Challenges in Evaluating Psychosocial Interventions for Autistic Spectrum Disorders PLAY Project Home Consultation Intervention Program for Young Children With Autism Spectrum Disorders: A Randomized Controlled Trial ‘Everyday Memory’ Impairments in Autism Spectrum Disorders Intact Prototype Formation but Impaired Generalization in Autism. Parent-mediated communication-focused treatment in children with autism (PACT): a randomised controlled trial Caregiver-Mediated Intervention for Low-Resourced Preschoolers With Autism: An RCT Isolating active ingredients in a parent-mediated social communication intervention for toddlers with autism spectrum disorder. Parent-assisted transfer of children's social skills training: effects on children with and without attention-deficit hyperactivity disorder. Treatment mechanism in the MRC preschool autism communication trial: implications for study design and parent-focussed therapy for children. Preschool Deployment of Evidence-Based Social Communication Intervention: JASPER in the Classroom A new social communication intervention for children with autism: pilot randomised controlled treatment study suggesting effectiveness. Measurement error, time lag, unmeasured confounding: Considerations for longitudinal estimation of the effect of a mediator in randomised clinical trials A randomized controlled trial of preschool-based joint attention intervention for children with autism. Incorporating a Peer-Mediated Approach Into Speech-Generating Device Intervention: Effects on Communication of Preschoolers With Autism Spectrum Disorder. Outcomes of children receiving Group-Early Start Denver Model in an inclusive versus autism-specific setting: A pilot randomized controlled trial Measuring child social communication across contexts: Similarities and differences across play and snack routines A play and joint attention intervention for teachers of young children with autism: A randomized controlled pilot study Video-feedback Intervention to promote Positive Parenting adapted to Autism (VIPP-AUTI): A randomized controlled trial Randomized comparative efficacy study of parent-mediated interventions for toddlers with autism.
abstract: BACKGROUND Delays and deficits in joint attention and symbolic play constitute two important developmental problems in young children with autism . These areas of deficit have been well studied in autism but have rarely been the focus of treatment efforts ( see Kasari , Freeman , & Paparella , 2001 ) . In this study , we examine the efficacy of targeted interventions of joint attention and symbolic play . METHODS Participants were 58 children with autism aged 3 and 4 years ( 46 boys ) . Children were r and omized to a joint attention intervention , a symbolic play intervention , or control group . Interventions were conducted 30 minutes daily for 5 - 6 weeks . Both structured assessment s of joint attention and play skills and mother-child interactions were collected pre and post intervention by independent assessors . RESULTS Results indicate that both intervention groups improved significantly over the control group on certain behaviors . Children in the joint attention intervention initiated significantly more showing and responsiveness to joint attention on the structured joint attention assessment and more child-initiated joint attention in the mother-child interaction . The children in the play group showed more diverse types of symbolic play in interaction with their mothers and higher play levels on both the play assessment and in interaction with their mothers . CONCLUSIONS This r and omized controlled trial provides promising data on the specificity and generalizability of joint attention and play interventions for young children with autism . Future studies need to examine the long-term effects of these early interventions on children 's development Abstract The study of mediation of treatment effects , or how treatments work , is important to underst and ing and improving psychological and behavioral treatments , but applications often focus on mediators and outcomes measured at a single time point . Such cross-sectional analyses do not respect the implied temporal ordering that mediation suggests . Clinical trials of treatments often provide repeated measures of outcomes and , increasingly , of mediators as well . Repeated measurements allow the application of various types of longitudinal structural equation mediation models . These provide flexibility in modeling , including the ability to incorporate some types of measurement error and unmeasured confounding that can strengthen the robustness of findings . The usual approach is to identify the most theoretically plausible model and apply that model . In the absence of clear theory , we put forward the option of fitting a few theoretically plausible models , providing a type of sensitivity analysis for the mediation hypothesis . In this tutorial , we outline how to fit several longitudinal mediation models , including  simplex , latent growth  and  latent change models  . This will allow readers to learn about one type of model that is of interest , or about several alternative models , so that they can take this sensitivity approach . We use the Pacing , Grade d Activity , and Cognitive Behavioral Therapy :  A R and omized Evaluation ( PACE ) trial of rehabilitative treatments for chronic fatigue syndrome ( IS RCT N 54285094 ) as a motivating example and describe how to fit and interpret various longitudinal mediation models using simulated data similar to those in the PACE trial . The simulated data set and Mplus code and output are provided This study aim ed to determine if a joint attention intervention would result in greater joint engagement between caregivers and toddlers with autism . The intervention consisted of  24 caregiver-mediated sessions  with follow-up 1 year later . Compared to caregivers and toddlers r and omized to the waitlist control group the immediate treatment ( IT ) group made significant improvements in targeted areas of joint engagement . The IT group demonstrated significant improvements with medium to large effect sizes in their responsiveness to joint attention and their diversity of functional play acts after the intervention with maintenance of these skills 1 year post-intervention . These are among the first r and omized controlled data to suggest that short-term parent-mediated  interventions can have important effects on core impairments in toddlers with autism . Clinical Trials # : NCT00065910 In 2002 , the National Institutes of Health sponsored a meeting concerning method ological challenges of research in psychosocial interventions in Autism Spectrum Disorders . This paper provides a summary of the presentations and the discussion s that occurred during this meeting . Recommendations to federal and private agencies included the need for r and omized clinical trials of comprehensive interventions for autism as the highest , but not the sole priority . Ongoing working groups were proposed to address psychosocial interventions with a focus on relevant statistics , st and ardized documentation and methods of diagnosis , development of outcome measures , establishment of st and ards in research ; and the need for innovative treatment design s , including application of design s from other research areas to the study of interventions in ASD Objective : To evaluate the effectiveness of the Play and Language for Autistic Youngsters ( PLAY ) Project Home Consultation model , in combination with usual community services ( CS ) , to improve parent-child interaction , child development , and autism symptomatology in young children with autism spectrum disorders ( ASDs ) compared with CS only . Methods : Children ( N = 128 ) with autism or PDD-NOS ( DSM-4 criteria ) aged 2 years 8 months to 5 years 11 months and recruited from 5 disability agencies in 4 US states were r and omized in two 1-year cohorts . Using videotape and written feedback within a developmental framework , PLAY consultants coached caregivers monthly for 12 months to improve caregiver-child interaction . CS included speech/ language and occupational therapy and public education services . Primary outcomes included change in parent-child interactions , language and development , and autism-related diagnostic category/symptoms . Secondary outcomes included parent stress and depression and home consultant fidelity . Data were collected pre- and post-intervention . Results : Using intent-to-treat analysis ( ITT ) , large treatment effects were evident for parent and child interactional behaviors on the Maternal and Child Behavior Rating Scales . Child language and developmental quotient did not differ over time by group , although functional development improved significantly . PLAY children improved in diagnostic categories on the Autism Diagnostic Observation Schedule ( ADOS ) . PLAY caregivers ' stress did not increase , and depressive symptomatology decreased . Home consultants administered the intervention with fidelity . Conclusions : PLAY intervention demonstrated substantial changes in parent-child interaction without increasing parents ' stress/depression . ADOS findings must be interpreted cautiously because results do not align with clinical experience . PLAY offers communities a relatively inexpensive effective intervention for children with ASD and their parents Abstract ‘ Everyday memory ’ is conceptualised as memory within the context of day-to-day life and , despite its functional relevance , has been little studied in individuals with autism spectrum disorders ( ASDs ) . In the first study of its kind , 94 adolescents with an ASD and 55 without an ASD completed measures of everyday memory  from the Rivermead Behavioural Memory Test ( RBMT ) and a st and ard word recall task ( Children ’s Auditory Verbal Learning Test-2 : CAVLT-2 ) . The ASD group showed significant impairments on the RBMT  , including in prospect i ve memory , alongside impaired performance on the CAVLT-2 . Social and communication ability was significantly associated with prospect i ve remembering in an everyday memory context but not with the CAVLT-2 . The complex nature of everyday memory and its relevance to ASD is discussed Cognitive processing in autism has been characterized by a difficulty with the abstract ion of information across multiple stimuli or situations and subsequent generalization to new stimuli or situations . This apparent difficulty leads to the suggestion that prototype formation , a process of creating a mental summary representation of multiple experienced stimuli that go together in a category , may be impaired in autism . Adults with high functioning autism and a typically developing comparison group matched on age and IQ completed a r and om dot pattern categorization task .  Participants with autism demonstrated intact prototype formation in all four ways it was operationally defined , and this performance was not significantly different from that of control participants . However , participants with autism  categorized dot patterns that were more highly distorted from the category prototypes less accurately than did control participants . These findings suggest , at least within the constraints of the r and om dot pattern task , that although prototype formation may not be impaired in autism , difficulties may exist with the generalization of what has been learned about a category to novel stimuli , particularly as they become less similar to the category 's prototype Summary Background Results of small trials suggest that early interventions for social communication are effective for the treatment of autism in children . We therefore investigated the efficacy of such an intervention in a larger trial . Methods Children with core autism ( aged 2 years to 4 years and 11 months ) were r and omly assigned in a one-to-one ratio to a parent-mediated communication-focused ( Preschool Autism Communication Trial [ PACT ] ) intervention or treatment as usual at three specialist centres in the UK . Those assigned to PACT were also given treatment as usual . R and omisation was by use of minimisation of probability in the marginal distribution of treatment centre , age ( ≤42 months or > 42 months ) , and autism severity ( Autism Diagnostic Observation Schedule-Generic [ ADOS-G ] algorithm score 12–17 or 18–24 ) . Primary outcome was severity of autism symptoms ( a total score of social communication algorithm items from ADOS-G , higher score indicating greater severity ) at 13 months . Complementary secondary outcomes were measures of parent-child interaction , child language , and adaptive functioning in school . Analysis was by intention to treat . This study is registered as an International St and ard R and omised Controlled Trial , number IS RCT N58133827 . Results 152 children were recruited . 77 were assigned to PACT ( London [ n=26 ] , Manchester [ n=26 ] , and Newcastle [ n=25 ] ) ; and 75 to treatment as usual ( London [ n=26 ] , Manchester [ n=26 ] , and Newcastle [ n=23 ] ) . At the 13-month endpoint , the severity of symptoms was reduced by 3·9 points ( SD 4·7 ) on the ADOS-G algorithm in the group assigned to PACT , and 2·9 ( 3·9 ) in the group assigned to treatment as usual , representing a between-group effect size of −0·24 ( 95 % CI −0·59 to 0·11 ) , after adjustment for centre , sex , socioeconomic status , age , and verbal and non-verbal abilities . Treatment effect was positive for parental synchronous response to child ( 1·22 , 0·85 to 1·59 ) , child initiations with parent ( 0·41 , 0·08 to 0·74 ) , and for parent-child shared attention ( 0·33 , −0·02 to 0·68 ) . Effects on directly assessed language and adaptive functioning in school were small . Interpretation On the basis of our findings , we can not recommend the addition of the PACT intervention to treatment as usual for the reduction of autism symptoms ; however , a clear benefit was noted for parent-child dyadic social communication . Funding UK Medical Research Council , and UK Department for Children , Schools and Families OBJECTIVES : To compare 2 short-term , community caregiver training interventions for preschool-aged children with Autism Spectrum Disorder who had low re sources . Low re source was defined by the US Department of Housing and Urban Development low-income index or 1 “ indicator , ” ( eg , Medicaid eligibility ) . Child outcomes focused on joint engagement , joint attention , and play . METHODS : Participants included 112 families of a child who had Autism Spectrum Disorder who met criteria for being low-re source d and who were r and omly assigned to 1 of 2 3-month interventions , group caregiver education or individualized caregiver-mediated intervention ( CMM ) .  Children were assessed for social communication skills pre- and post-treatment , and followed up at 3 months . RESULTS : All children improved in joint engagement and initiating joint attention , with significantly greater improvement by the CMM group . Outcomes on play skills were mixed , with improvement of symbolic play for the CMM group and no change in functional play skills . Joint engagement maintained over time for the CMM group , and initiating joint attention maintained for both groups over time . CONCLUSIONS : This study is among the first r and omized trials comparing 2 active interventions with a large sample of low-re source d families . Results suggest improvements in core autism deficits of joint engagement , joint attention , and symbolic play with relatively brief , caregiver-mediated interventions , but additional support is necessary to maintain and generalize these gains over time BACKGROUND Behavioral interventions are commonplace in the treatment of autism spectrum disorders , yet relatively little is known about how and why these interventions work . This study tests the relationship between isolated core components of a packaged social communication intervention and the primary outcome , joint engagement , to better underst and how the intervention is affecting change in individuals . METHODS A total of 86 toddlers and their parents were enrolled in the study and r and omized to one of two treatments , the joint attention , symbolic play , engagement , and regulation ( JASPER ) parent-mediated intervention or a psychoeducational intervention . Measures regarding the parent 's use of intervention strategies were collected before and after the 10-week intervention . Additional measures of child and parent joint engagement were also collected . RESULTS A significant effect of treatment was found for all four of the core strategies of the intervention , favoring a larger increase in the JASPER condition . A hierarchical linear regression revealed several individual predictors of joint engagement , including parent-rated buy-in , interventionist-rated parent involvement , and parental use of strategies . To complement the hierarchical analysis , we also tested the potential mediating effect the strategies may have on the relationship between treatment and joint engagement . Results showed that the strategy of mirrored pacing mediated the relationship between treatment and joint engagement in the positive direction . CONCLUSIONS These results strongly suggest that the mirrored pacing strategy is an active ingredient of the JASPER treatment OBJECTIVE Previous research has demonstrated that peer rejection is a significant part of the clinical presentation of many children with attention-deficit hyperactivity disorder ( ADHD ) . Outcome studies of treatment interventions have typically failed to show generalization of treatment gains to the home and classroom . This has been especially true for children who have comorbid oppositional defiant disorder ( ODD ) . The present study was intended to demonstrate generalization of an outpatient social skills training program when parents were trained in skills relevant to their child 's social adjustment . METHOD Thirty-five children with ADHD and 14 children without ADHD were given  12 sessions of treatment ( treatment group ) . Outcome was compared with 12 children with ADHD and 12 children without ADHD who were on a waitlist for treatment ( waitlist group ) .  Nineteen children with ODD were in the treatment group and five in the waitlist . Stimulant medication was prescribed for all children with ADHD . RESULTS Subjects with ADHD showed improvement comparable with that of subjects without ADHD on all teacher- and parent-reported measures of peer adjustment and social skills , except teacher-reported withdrawal . Children with ODD had outcome comparable with that of children without ODD . Effect sized ranged from 0.93 to 1.34 indicating that the average treatment group subject was better off than 83.4 % of waitlist subjects on outcome measures . CONCLUSIONS The present results suggest that children with ADHD are best heiped by a combination of social skills training for themselves , collateral training for their parents and stimulant medication BACKGROUND The PACT r and omised-controlled trial evaluated a parent-mediated communication-focused treatment  for children with autism , intended to reduce symptom severity as measured by a modified Autism Diagnostic Observation Schedule-Generic ( ADOS-G ) algorithm score . The therapy targeted parental behaviour , with no direct interaction between therapist and child . While nonsignificant group differences were found on ADOS-G score , significant group differences were found for both parent and child intermediate outcomes . This study aim ed to better underst and the mechanism by which the PACT treatment influenced changes in child behaviour though the targeted parent behaviour . METHODS Mediation analysis was used to assess the direct and indirect effects of treatment via  parent behaviour on child behaviour and via child behaviour on ADOS-G score . Alternative mediation was explored to study whether the treatment effect acted as hypothesised or via another plausible pathway . Mediation models typically assume no unobserved confounding between mediator and outcome and no measurement error in the mediator . We show how to better exploit the information often available within a trial to begin to address these issues , examining scope for instrumental variable and measurement error models . RESULTS Estimates of mediation changed substantially when account was taken of the confounder effects of the baseline value of the mediator and of measurement error . Our best estimates that accounted for both suggested that the treatment effect on the ADOS-G score was very substantially mediated by parent synchrony and child initiations . CONCLUSIONS The results highlighted the value of repeated measurement of mediators during trials . The theoretical model underlying the PACT treatment was supported . However , the substantial fall-off in treatment effect highlighted both the need for additional data and for additional target behaviours for therapy Few research -developed early intervention models have been deployed to and tested in real world preschool programs . In this study , teaching staff implemented a social communication modularized intervention , JASPER , in their daily program . Sixty-six preschool children with autism in twelve classrooms ( 12 teachers ) were r and omized to receive immediate JASPER training ( IT ) or were waitlisted ( WL ) for 3 months with a 1-month follow up . Measures of core deficits ( initiations of joint engagement , joint attention gestures and language , play skills ) and st and ardized cognitive measures were improved for IT over WL children . IT teachers achieved and maintained high fidelity .  Teachers can implement evidence -based interventions with significant improvements in core deficits of their children with ASD BACKGROUND Psychosocial treatments are the mainstay of management of autism in the UK but there is a notable lack of a systematic evidence base for their effectiveness . R and omised controlled trial ( RCT ) studies in this area have been rare but are essential because of the developmental heterogeneity of the disorder . We aim ed to test a new theoretically based social communication intervention targeting parental communication in a r and omised design against routine care alone . METHODS The intervention was given in addition to existing care and involved regular monthly therapist contact for 6 months with a further 6 months of 2-monthly consolidation sessions . It aim ed to educate parents and train them in adapted communication tailored to their child 's individual competencies . Twenty-eight children with autism were r and omised between this treatment and routine care alone , stratified for age and baseline severity . Outcome was measured at 12 months from commencement of intervention , using st and ardised instruments . RESULTS All cases studied met full Autism Diagnostic Interview ( ADI ) criteria for classical autism . Treatment and controls had similar routine care during the study period and there were no study dropouts after treatment had started . The active treatment group showed significant improvement compared with controls on the primary outcome measure -- Autism Diagnostic Observation Schedule ( ADOS ) total score , particularly in reciprocal social interaction-- and on secondary measures of expressive language , communicative initiation and parent-child interaction . Suggestive but non-significant results were found in Vinel and Adaptive Behaviour Scales ( Communication Sub-domain ) and ADOS stereotyped and restricted behaviour domain . CONCLUSIONS A R and omised Treatment Trial design of this kind in classical autism is feasible and acceptable to patients . This pilot study suggests significant additional treatment benefits following a targeted ( but relatively non-intensive ) dyadic social communication treatment , when compared with routine care . The study needs replication on larger and independent sample s. It should encourage further RCT design s in this area Clinical trials are expensive and time-consuming and so should also be used to study how treatments work , allowing for the evaluation of theoretical treatment models and refinement and improvement of treatments . These treatment processes can be studied using mediation analysis . R and omised treatment makes some of the assumptions of mediation models plausible , but the mediator– outcome relationship could remain subject to bias . In addition , mediation is assumed to be a temporally ordered longitudinal process , but estimation in most mediation studies to date has been cross-sectional and unable to explore this assumption . This study used  longitudinal structural equation modelling of mediator and outcome measurements from the PACE trial of rehabilitative treatments for chronic fatigue syndrome ( IS RCT N 54285094 ) to address these issues . In particular , autoregressive and simplex models were used to study measurement error in the mediator , different time lags in the mediator– outcome relationship , unmeasured confounding of the mediator and outcome , and the assumption of a constant mediator– outcome relationship over time . Results showed that allowing for measurement error and unmeasured confounding were important . Contemporaneous rather than lagged mediator– outcome effects were more consistent with the data , possibly due to the wide spacing of measurements . Assuming a constant mediator– outcome relationship over time increased precision BACKGROUND Deficits in joint attention ( JA ) and joint engagement ( JE ) represent a core problem in young children with autism as these affect language and social development . Studies of parent-mediated and specialist-mediated JA-intervention suggest that such intervention may be effective . However , there is little knowledge about the success of the intervention when done in preschools . AIM Assess the effects of a preschool-based JA-intervention . METHODS 61 children ( 48 males ) with autistic disorder ( 29 - 60 months ) were r and omized to either 8 weeks of JA-intervention  , in addition to their preschool programs  ( n = 34 ) , or to preschool programs only  ( n = 27 ) . The intervention was done by preschool teachers with weekly supervision by trained counselors from Child and Adolescent Mental Health Clinics ( CAMHC ) . Changes in JA and JE were measured by blinded independent testers using Early Social Communication Scale ( ESCS ) and video taped preschool teacher-child and mother-child play at baseline and post-intervention . CLINICAL TRIALS REGISTRATION Clinical trials.gov : NCT00378157 . RESULTS Intention-to-treat analysis showed significant difference between the intervention and the control group , with the intervention group yielding more JA initiation during interaction with the preschool teachers . The effect generalized to significantly longer duration of JE with the mothers . CONCLUSIONS This is the first r and omized study to show positive and generalized effects of preschool-based JA-intervention Purpose This study examined the effects of incorporating a peer-mediated approach into a speech-generating device ( SGD ) intervention on communication of 45 nonverbal and minimally verbal preschoolers with autism spectrum disorder ( ASD ) and 95 peers without disabilities . The SGD was an iPad 2 ( Apple ) with voice output app . Method Effects were evaluated using a multivariate r and omized control trial design with repeated measures for 4 cohorts across baseline , intervention , generalization , and maintenance phases . Children were r and omly assigned to an experimental treatment that trained peers on use of the SGD or a business-as-usual comparison condition with untrained peers .  Communication outcomes were measured for both children with ASD and peers . Results Children receiving the treatment demonstrated significant increases in rates of communication and more balanced responses and initiations ( a measure of reciprocity ) than children in the comparison group . They were able to generalize improvements and maintain communication gains . Treatment fidelity was high for school staff and peer implementation . Conclusions Results support positive effects on communication of teaching young children with ASD and peers without disabilities to use the same SGD system in typical preschool activities . SGD interventions that utilize peer-mediated approaches may improve core deficits in communication and reciprocity and allow for greater classroom social participation and interactions with peers A major topic of debate is whether children with autism spectrum disorder should be educated in inclusive or specialized setting s. We examined the feasibility and preliminary effectiveness of delivering the Group-Early Start Denver Model to children with autism spectrum disorder in inclusive versus specialized classrooms . We r and omly assigned 44 preschoolers with autism spectrum disorder to receive the Group-Early Start Denver Model  across one school calendar year in classrooms that included only children with autism spectrum disorder or mostly children who were typically developing .  Blind-rated indicators of teaching quality showed similar results across setting s , which were above the local benchmark . Children showed improvements across blinded proximal measures of spontaneous vocalization , social interaction , and imitation and across distal measures of verbal cognition , adaptive behavior , and autism symptoms irrespective of intervention setting . Mothers of participants experienced a reduction in stress irrespective of child intervention setting . Across both setting s , age at intervention start was negatively associated with gains in verbal cognition . Delivery of Group-Early Start Denver Model in an inclusive setting appeared to be feasible , with no significant differences in teaching quality and child improvements when the program was implemented in inclusive versus specialized classrooms Improving measurement of outcomes in r and omized controlled trials of early interventions for autism spectrum disorder ( ASD ) has been identified as a priority in the field . In addition , the importance of measurement across context s has been indicated by research ers and community stakeholders alike [ Lord et al. , ; McConachie et al. , ; Schreibman et al. , ] . The Brief Observation of Social Communication Change ( BOSCC ; Grzadzinski et al. , ) , an observational rating scheme of brief play interactions , was developed to address a need for measures that are reliable , sensitive to change , and valid for use in research setting s. The goal of this study was to examine the feasibility and utility of applying the BOSCC to a new context : a home snack routine . Results suggest that rating the BOSCC on home snack routines is feasible and psychometrically sound , and captures change in child social communication behaviors . However , the utility of the BOSCC for measuring restricted and repetitive behaviors ( RRBs ) is less clear . Nonetheless , differences in RRBs across play and snack lend support for the cl aim that measurement across context s is essential . Application of the BOSCC across context s may allow research ers to obtain a more accurate estimate of intervention response and help capture context ‐specific changes in social communication . It may also provide a method for research ers to evaluate the effect of context on child social communication more broadly . Autism Res 2019 , 12 : 636–644 . © 2019 International Society for Autism Research , Wiley Periodicals , The aim of this study was to pilot test a classroom-based intervention focused on facilitating play and joint attention for young children with autism in self-contained special education classrooms . Thirty-three children with autism between the ages of 3 and 6 years participated in the study with their classroom teachers ( n = 14 ) . The 14 preschool special education teachers were r and omly assigned to one of three groups : ( 1 ) symbolic play then joint attention intervention , ( 2 ) joint attention then symbolic intervention , and ( 3 ) wait-list control period then further r and omized to either group 1 or group 2 . In the intervention , teachers participated in eight weekly individualized 1-h sessions with a research er that emphasized embedding strategies targeting symbolic play and joint attention into their everyday classroom routines and activities . The main child outcome variables of interest were collected through direct classroom observations . Findings indicate that teachers can implement an intervention to significantly improve joint engagement of young children with autism in their classrooms . Furthermore , multilevel analyses showed significant increases in joint attention and symbolic play skills . Thus , these pilot data emphasize the need for further research and implementation of classroom-based interventions targeting play and joint attention skills for young children with autism In a r and omized controlled trial , we evaluated the early intervention program Video-feedback Intervention to promote Positive Parenting adapted to Autism ( VIPP-AUTI ) with 78 primary caregivers and their child ( 16–61 months ) with Autism Spectrum Disorder .  VIPP-AUTI is a brief attachment-based intervention program , focusing on improving parent – child interaction and reducing the child ’s individual Autism Spectrum Disorder – related symptomatology in five home visits . VIPP-AUTI , as compared with usual care , demonstrated efficacy in reducing parental intrusiveness . Moreover , parents who received VIPP-AUTI showed increased feelings of self-efficacy in child rearing . No significant group differences were found on other aspects of parent – child interaction or on child play behavior . At 3-months follow-up , intervention effects were found on child-initiated joint attention skills , not mediated by intervention effects on parenting . Implementation of VIPP-AUTI in clinical practice is facilitated by the use of a detailed manual and a relatively brief training of interveners OBJECTIVE This study compared effects of two parent-mediated interventions on joint engagement outcomes as augmentations of an early intervention program for toddlers with autism spectrum disorder ( ASD ) . METHOD Participants included 86 toddlers ( range 22 - 36 months ) with ASD and their primary caregiver . Caregiver-child dyads were r and omized to receive 10 weeks of h and s-on parent training in a naturalistic , developmental behavioral intervention ( joint attention , symbolic play , engagement and regulation-JASPER ) or a parent-only psychoeducational intervention ( PEI ) . Dose was controlled in terms of research er-parent contact and early intervention services received by the child . RESULTS Results yielded significant effects of the JASPER intervention on the primary outcome of joint engagement . The treatment effect was large ( Cohen 's f² = .69 ) and maintained over the 6-month follow-up . JASPER effects were also found on secondary outcomes of play diversity , highest play level achieved , and generalization to the child 's classroom for child-initiated joint engagement . The PEI intervention was found to be effective in reducing parenting stress associated with child characteristics . All secondary effects were generally small to moderate . CONCLUSIONS These data highlight the benefit of a brief , targeted , parent-mediated intervention on child outcomes . Future studies may consider the combination of JASPER and PEI treatments for optimal parent and child outcomes . Trial registry no. NCT00999778
target: The findings did not support the widely reported generalisation ' difficulties ' associated with autism .
background: Research ers have generally considered autistic individuals to have difficulties generalising learned skills across novel context s. Successful generalisation is necessary for an intervention to have benefits in everyday life beyond the original learning environment .
  We conducted a systematic review of r and omised controlled trials of early social communication interventions for children with autism in order to explore generalisation and its measurement .