The Autism Society Event and Education Recordings Archive

The P.L.A.Y. Project model trains parents to work with young children with ASD. Sponsored by the NIMH, we have conducted the first controlled clinical trial of a DIR / Floortime play-based approach. Families were enrolled at four Easter Seals’ community sites comparing The P.L.A.Y. Project versus standard community intervention. Michigan State University guided research design and data analysis. The authors will present The P.L.A.Y. Project model, the research design and the outcomes compared between the groups. The development of replicable, cost-effective intensive interventions for the treatment of young children with autism spectrum disorders (ASD) is a priority for both the health and education systems in this country and internationally. Additionally, there is a national shortage of personnel trained in these approaches even as the number of children identified with ASD is increasing. The National Academy of Sciences report (2001) emphasizes intensive (25 hours/week, 1:1 or 1:2 teacher: pupil ratios), engaging and comprehensive interventions that start early (18 months to 5 years of age). The high prevalence of children with ASD coupled with the need for intensive intervention means that very substantial resources are required to effectively address autism. Given that most states do not typically provide broad support for intensive interventions, the unmet national need is enormous.

The Play and Language for Autistic Youngsters (P.L.A.Y.) Project, a parent coaching model, is an innovative solution addressing this national need. The P.L.A.Y. Project is play-based, matched to the child’s developmental level, individualized to follow the child’s lead and interests, focused on building relationships, time intensive (two hours per day) and integrated with school and other therapies. Based on the theoretical DIR-framework of Stanley Greenspan MD, we have developed The P.L.A.Y. Project to help young children develop language and social skills.  The DIR model focuses on social reciprocity, affect and functional/pragmatic communication.  Preliminary clinical evidence shows that this parent-training model is effective. Early dissemination of the model into community agencies, schools and hospitals has also been successfully accomplished, leading to establishment of an alliance with a major national partner – Easter Seals.  Each year, Easter Seals serves more than 1 million individuals with disabilities and their families.  Currently, they have approximately 60 programs providing care to children and adults with autism in 33 states.  

The PLAY Project Model: Program Description. Over the last six years, The P.L.A.Y. Project, under the medical direction of Richard Solomon MD, has established itself as a multifaceted statewide autism training and early intervention program  (See: www.playproject.org ).

The model focuses on parents as the child’s first and most important play partners.  Parents are coached, using a structured skill-based mode, to play in a way that helps the child progress through a series of functional developmental levels.  By embedding interventions into naturally occurring interaction and learning opportunities, parents become the primary interventionists, and the child is then able to receive the recommended intensity of services.  The ability of parents to provide this level of intervention is supported in the literature. The P.L.A.Y. Project is financially affordable and empowers families as they experience success.

This intensive play-based intervention focuses on contingent reciprocal interactions versus drill-based approaches and The P.L.A.Y. Project represents a genuine alternative to ABA-type behavioral therapies. While there is a growing body of literature in social – pragmatic models, this study is the first controlled trial of a DIR-based program.

Methods.  We are reporting here on the results of a controlled trial of The P.L.A.Y. Project versus standard community interventions.  This study has been sponsored by the National Institute of Mental Health (NIMH), and is being conducted in collaboration with Easter Seals and Michigan State University (MSU).  The study has been conducted at four Easter Seals community sites – two sites trained in The P.L.A.Y. Project model and two sites offering standard community intervention only , for example, pre-school, some OT and some speech & language therapy. Ten children and their parents were enrolled at each site.  Thus 20 children received standard intervention plus The P.L.A.Y. Project intervention and 20 children received the standard intervention only. MSU has participated in the study for research design and data analysis. The IRB Human Studies Committee at MSU approved the study and informed consent process. Of the 40 families who were enrolled, 38 completed the study.

Staff at each site was trained in the procedures of the study. Families were recruited from the community for their participation in the study. Children were excluded from the study if they had received an “intensive intervention” during the prior 12 month period. The ASD diagnosis was confirmed using the ADOS (Autism Diagnostic Observation Scale) instrument. One child was removed from the study due to failure to confirm the ASD diagnosis by ADOS. Additional efforts were made to recruit racial and ethnic minorities into the trial.
Once enrolled both children and parents were pre-assessed with multiple instruments. Children were evaluated for developmental level, speech & language, social skills and sensory profile including:
·       Mullen Scales of Early Learning,
·       Vineland II Adaptive Behavior Scales,
·       REEL-3, and
·       Sensory Profile (Winnie Dunn)
A baseline video captured parent – child interaction prior to intervention and these films have been evaluated using the FEAS - Functional and Emotional Assessment Scale,
Parents were pre-assessed for vocabulary level, as well as levels of stress and depression including:
·       PSI - Parent Stress Index,
·       CES-D Depression Scale, and
·       PPVT-4 Peabody Picture Vocabulary Test.

A family intake form gathered data on demographics. An autism services inventory captured the types of ASD services being received by the child.

Following the pre-assessment families participated in The P.L.A.Y. Project Home Consultation program for 5 to 7 months at 2 Easter Seals sites intervention sites. Trained home consultants made 5 home visits, about once each month per family. Home consultants used The P.L.A.Y. Project Skill Sequence to train the parents in how to more playfully, and more effectively interact with their child. The Skill Sequence provides structure to the play. A videotape taken at each visit was later analyzed by the home consultant and the results reported to the parents to give further feedback on activities and techniques recommended for the next month. Parents were encouraged to play with their child about 2 hours each day, usually provided in multiple 15-20 minute sessions.  A log was kept by each family to track the hours actually spent. These P.L.A.Y. families received in addition the standard community intervention available to them.

At 2 Easter Seals sites not trained in The P.L.A.Y. Project model, children received the standard intervention offered in their community. Typically this consisted of attending half days of pre-school, one hour of OT per week and one hour of speech & language therapy per week. An autism service log captured the types and levels of services received.
Following the intervention phase both groups of children and parents were post-assessed with multiple instruments (see listing above). Children were again evaluated for developmental level, speech & language, social skills and sensory profile. A video captured parent – child interaction following the intervention phase.  Parents were assessed for levels of stress.  Parents in The P.L.A.Y. Project group completed a satisfaction survey to report their experience in working with this model.

All data obtained at the sites were de-identified and each form was coded so results remain anonymous. MSU entered the coded data and analyzed the results and compared the groups. Two independent raters trained in the FEAS measure analyzed each pre- and post-videotape focusing on a study of parent sensitivity to child cues and detailed review of child’s developmental level. Videos were coded and mixed so the independent raters were not able to determine which films were captured before or after intervention.

Results. This presentation will report the outcomes of this study for children’s developmental level, speech & language, social skills and sensory profile and compare the findings for the two groups. We will report on the level of stress experienced by parents and conclude how The P.L.A.Y. Project intervention modified stress levels. We will show the number of hours that parents spent on delivering The P.L.A.Y. Project intervention and report on the importance of these hours of intensive intervention. The presentation will also report on the level of satisfaction of parents with The P.L.A.Y. Project intervention.  (Note: as of the date of submission of this abstract, the study is just being completed and results are currently being analyzed.)

Discussion. Easter Seals’ approach has been to apply The P.L.A.Y. Project methods to empower parents to effectively participate in intervention with their child.  Where previously there was isolation and grief, this program has additional benefits of bringing parents and children together in engaging and playful relationships.  While families learn to unlock their child’s potential, Easter Seals and The P.L.A.Y. Project are also educating entire communities to care effectively and compassionately for these families. This presentation describes this model for young children with autism spectrum disorders as implemented in communities served by Easter Seals affiliates.

This study is significant since it is the first controlled trial of a DIR-based intervention.  The intervention needs of children with autism are unique. Unlike children with cognitive impairments, children with autism have serious social impairments, are difficult to engage and thus require a specialized intervention approach. Children with autism have been shown repeatedly to respond dramatically to intensive early intervention. They have a latent capacity to improve their functional development that depends on starting early and working intensively. We need intervention programs that address these unique needs and are delivered in ways that are both effective and economically feasible. The P.L.A.Y. Project may be one such program.

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