Study Examines the Power of Play for Children Showing Early Signs of Autism

“Bop-bop-bop.”

A mom shakes a maraca to the beat as her toddler looks on. “Now, you do it!” she says.

This simple game can help young children at risk for autism develop imitation skills, a key building block of social communication.

“Imitation is a core behavior for learning all sorts of things,” said Brooke Ingersoll, a professor of clinical science at MSU. “We use imitation to learn new skills. We also use imitation as a way of socially connecting with others. So, it’s a very important developmental skill that many children with early signs of autism have difficulty acquiring.”

Ingersoll and a team of researchers, working closely with early intervention providers and parents/caregivers, hope to help boost children’s social communication skills by increasing access to evidence-based strategies.

As part of a multisite study, Ingersoll and a team of researchers representing three other states are examining the effectiveness of training early intervention providers in a method called “reciprocal imitation teaching,” or RIT. Providers then coach parents and caregivers on how to use these simple but effective play-based activities.

“One of the best ways of improving outcomes for young children showing early signs of autism is to intervene early with autism-specialized interventions—interventions that specifically target social development,” Ingersoll said.

“What’s nice about RIT is that it’s easy for providers to learn to use and it’s easy for them to teach (to) parents. And it addresses a core, important social communication behavior.”

The study is funded by National Institute of Mental Health grants totaling $12 million, of which MSU’s share is $3.2 million. Ingersoll, who directs MSU’s Autism Lab, is the lead investigator for the MSU site.

Partnering with Early On

Autism spectrum disorder affects 1 in 59 children in the U.S.

The trial is one of the first to study the efficacy of early intervention strategies for autism within the Part C system, a federal, community-based program that serves children ages 0-3 with disabilities or developmental delays.

In Michigan, the program is called Early On and is offered in each of the state’s 83 counties. Providers visit families for about one hour a week on average, and their caseloads include children with a wide range of disabilities. The simplicity of RIT makes it well-suited for this system because it is easy for both providers and families to learn and implement, Ingersoll said.

“We have providers who have been asking us for this,” she said. “Our interventions are actually developed in the context of communities and evaluated that way. We’re constantly getting feedback from caregivers and providers.”

Before training began, Ingersoll consulted with providers, inviting them to small focus groups to help design the materials so that it would mesh well with the Part C infrastructure.

During the training, the research team had monthly consultations with providers to discuss any issues or questions. Ingersoll and her team also seek feedback on what works and what doesn’t and adjust the training accordingly.

How It Works

The MSU team has recruited 40 Early On providers representing 65 sites in Ingham, Kalamazoo, Kent, Oakland, and Ottawa counties. The “RIT now” group receives training and shares that with participating families; the “RIT later” control group provides typical early intervention services but receives training at the end of the trial. All participating families receive a full evaluation of their child for autism spectrum disorder, which can help them qualify for school and community services.

Providers and parents in the “RIT now” group receive a lesson guide that introduces the intervention. The parent/caregiver is taught to take turns imitating their child’s play and then asking their child to imitate their play in a back-and-forth social game.

These activities are examples of “naturalistic developmental behavioral interventions,” Ingersoll said. “By targeting imitation/social engagement in this very naturalistic way, it provides kind of a ‘boost’ so that children are better able to learn from their environment and their interactions with other important people in their lives.”

Once providers complete the training, they provide coaching to parents during home visits. Parents and caregivers are asked to practice the activities with their child 20 minutes per day.

Ingersoll and her team assess the children at intake, at 4 months, and at 9 months. Typically a parent or caregiver might be asked to bring their child to a research lab for the assessments. However, because the trial began during the COVID-19 pandemic, the team provided each family with a bag full of toys, a blanket, a camera, portable Wi-Fi, and an iPad.

Even after pandemic restrictions were lifted, the assessments remained virtual, which has allowed the team to evaluate children in their homes and made participation easier for families. The team provides live tech support to the family as they record play sessions that are scored by the researchers.

“I think we get a better sample of the child’s behavior because we actually see them with their parent in their home where they’re comfortable,” Ingersoll said. “It really allows for us to be able to assess families without placing an additional burden on them to come to a center.”

Promising Early Results

Early On providers have welcomed the project. Jenniver Sova supervises home visitors as an early childhood administrator for special education of the Kalamazoo Regional Educational Service Agency (KRESA). She has worked with Ingersoll in the past and embraced the opportunity to participate in the current study.

“I’m a big fan of [Ingersoll’s] work with autism and with parent coaching,” Sova said. “She is very realistic about what will work in a natural setting and is not too clinical, especially as we look at training caregivers and families.”

Eight KRESA providers have participated in the study. Noting that “we have a high incidence of autism in the area,” Sova said providers and families alike have embraced RIT.

“Parents walked away feeling very optimistic because [their children’s] social engagement did increase.” Providers have benefited as well. “It’s just adding to their toolbox of things that will help, especially with children with autism,” she said.

Jennifer Darawi, the Early On team coordinator with Hazel Park Schools, does weekly home visits with children with developmental delays or disabilities and coordinates team meetings with colleagues.

Like Sova, she and her team work with a number of children with autistic characteristics. “I wanted more tools to support their social communication to help them make developmental progress,” Darawi said. She has incorporated RIT and her families have embraced it as well.

“[Participating in the study] helped me to develop my caregiver coaching practices. I am better at co-planning with the families and modeling and explaining these strategies I am using so that parents can understand what I am doing and why,” she said.

Darawi reports that she has seen promising results. “The children became more engaged, and their parents/caregivers learned how to play in a way that their children enjoyed,” she said.

Beyond the Lab

For Ingersoll, working with study participants like Sova and Darawi has been rewarding. “Seeing them really embrace the process of research with the idea that they are contributing to helping improve community services—I really enjoy that,” she said.

A desire to improve community services is what drew Ingersoll to the field of autism research. As an undergraduate student, she answered an ad in the school newspaper seeking an in-home behavioral therapist for a child with autism. Dissatisfied with limited options available through the school system, the family had built their own team.

“I learned an incredible amount,” Ingersoll recalled. “Being able to see up close their experience got me really interested in trying to improve services in general so that families wouldn’t have to develop their own program.”

After graduation, she worked in an inclusive preschool classroom at the Emory Autism Center in Atlanta. Those formative experiences influenced her to extend her research into the community.

“We’re always developing more appropriate methods,” she said. “We want to make sure that we’re not just keeping them within university programs, but we’re making them available broadly in the community.”

The current study exemplifies that dynamic.

“Interventionists are in the community, the parents are the ones doing the intervention, and even the assessments are being done in ways that parents can use to help them understand their child’s development better,” she said.

“We’ve been able to maintain the integrity that you need to be able to draw conclusions while still moving it completely into the community,” she added. “I feel like the results we’re going to get from this are going to be so much more powerful than the results we would get from a more traditional lab-based study.”