A randomized controlled trial of Hanen's ‘More Than Words’ in toddlers with early autism symptoms

May combine two claims.

In this RCT of toddlers with early autism symptoms, the HMTW intervention had no main effect on parental responsivity or on children's communication.

“There were no main effects of the HMTW intervention on either parental responsivity or children’s communication.”

May combine two claims.

HMTW assignment was associated with residualized gains in parental responsivity from Time 1 to Time 2 (Glass's Δ = .71) and from Time 1 to Time 3 (Glass's Δ = .50).

“However, the effects on residualized gains in parental responsivity from Time 1 to both Times 2 and 3 yielded noteworthy effect sizes (Glass’s Δ = .71, .50 respectively).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The mean rating on the group leader experience questionnaire was 3.46 out of 4.

“Consumer satisfaction was extremely high, with mean ratings of 5.48 (out of 6) on the group experience questionnaire and 3.46 (out of 4) on the group leader experience questionnaire.”

The quote only partly states this claim.

Across treatment groups, children showed a large increase in weighted frequency of intentional communication from Time 1 to Time 3 (d = .77, p < .05).

“Overall, children’s increases in communication from Time 1 to Time 3 were moderate (IJA d = .43, IBR d = .55), large (weighted frequency of intentional communication, d = .77), and very large (PIA-CV nonverbal communication d = 1.15), ps < .05.”

The quote only partly states this claim.

Across treatment groups, children showed a very large increase in PIA-CV nonverbal communication from Time 1 to Time 3 (d = 1.15, p < .05).

“Overall, children’s increases in communication from Time 1 to Time 3 were moderate (IJA d = .43, IBR d = .55), large (weighted frequency of intentional communication, d = .77), and very large (PIA-CV nonverbal communication d = 1.15), ps < .05.”

May combine two claims.

Although no main effects of treatment were observed on child outcomes, exploratory analyses revealed several significant conditional effects.

“Although no main effects of treatment were observed on child outcomes in the current study, exploratory analyses revealed several significant conditional effects.”

The quote only partly states this claim.

Across treatment groups, children showed a moderate increase in initiating behavioral requests from Time 1 to Time 3 (d = .55, p < .05).

“Overall, children’s increases in communication from Time 1 to Time 3 were moderate (IJA d = .43, IBR d = .55), large (weighted frequency of intentional communication, d = .77), and very large (PIA-CV nonverbal communication d = 1.15), ps < .05.”

The quote only partly states this claim.

Across treatment groups, children showed a moderate increase in initiating joint attention from Time 1 to Time 3 (d = .43, p < .05).

“Overall, children’s increases in communication from Time 1 to Time 3 were moderate (IJA d = .43, IBR d = .55), large (weighted frequency of intentional communication, d = .77), and very large (PIA-CV nonverbal communication d = 1.15), ps < .05.”

The quote only partly states this claim.

Across treatment groups, parents showed a moderate decrease in responsivity from Time 2 to Time 3 (d = −.44, t(38) = −2.4; p = .02).

“and showed moderate decreases in responsivity during the follow-up period (from Time 2 to Time 3) d = −.44, t(38) = −2.4; p = .02.”

May combine two claims.

For initiating joint attention, initiating behavioral requests, and PCFP weighted frequency of intentional communication, both higher and lower regions of significance were interpretable.

“In predicting residualized gains in IJA, IBR and PCFP weighted frequency of intentional communication, both higher and lower regions of significance were interpretable.”

May combine two claims.

In the current study, there were no main effects of treatment on child outcomes immediately after treatment or 5 months after treatment.

“In the current study, there were no main effects of treatment on child outcomes immediately after the parent-implemented treatment or 5 months after treatment.”

May combine two claims.

Although the authors expected joint attention to moderate the effects of HMTW on child outcomes, none of the interactions were statistically significant.

“Although we had expected joint attention to moderate the effects of the HMTW intervention on child outcomes, none of the interactions were statistically significant.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Parents rated the HMTW intervention and group leaders extremely favorably.

“Although the mean fidelity of treatment implementation was high with respect to measured HMTW content and interventionist quality, and parents rated the HMTW intervention and group leaders extremely favorably, the size of the parent groups was not commensurate with Hanen recommendations.”

May combine two claims.

Communicative and social deficits are core to ASD and are among the first symptoms observed.

“Communicative and social deficits are not only core to ASD, but are among the first symptoms observed (Zwaigenbaum et al., 2009).”

• cites Zwaigenbaum et al., 2009Not checked yet

  Not checked in the free run.

May combine two claims.

Very few intervention studies have focused on the toddler period; the Early Start Denver Model (ESDM) is a notable exception with positive efficacy findings.

“To date, however, very few intervention studies have focused on the toddler period, with positive findings for the efficacy of the Early Start Denver Model (ESDM) providing a notable exception (Dawson et al., 2010; Vismara & Rogers, 2008).”

• cites Dawson et al., 2010Not checked yet

  Not checked in the free run.

• cites Vismara & Rogers, 2008Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

There is consensus that parents should be involved in interventions designed for infants and toddlers with ASD.

“In contrast to interventions for preschool-aged and older children with ASD, there is consensus that parents should be involved in interventions designed for infants and toddlers (Meadan, Ostrosky, Zaghlawan, & Yu, 2009; Zwaigenbaum et al., 2009).”

• cites Meadan, Ostrosky, Zaghlawan, & Yu, 2009Not checked yet

  Not checked in the free run.

• cites Zwaigenbaum et al., 2009Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Green et al. noted that the positive effects of treatment observed were limited to the parent-child dyad and did not appear to generalize to interactions with other adults.

“Green et al. noted, however, that the positive effects of treatment observed were (thus far) limited to the parent–child dyad, and did not appear to generalize to interactions with other adults.”

• cites Green et al.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The weighted frequency of intentional communication is more sensitive to change over time than the unweighted variable, and growth in the weighted variable (but not the unweighted variable) predicts later social impairment in younger siblings of children with ASD.

“Previous research has indicated that the weighted variable is more sensitive to change over time than the unweighted variable and that growth in the weighted variable (but not the unweighted variable) was predictive of later social impairment in younger siblings of children with ASD (Yoder, Stone, Walden, & Malesa, 2009).”

• cites Yoder, Stone, Walden, & Malesa, 2009Not checked yet

  Not checked in the free run.

May combine two claims.

The ICCs on proportion of codable intervals with a parental response were .46 at Time 1, .84 at Time 2, and .75 at Time 3.

“The ICCs on proportion of codable intervals with a parental response were .46 at Time 1, .84 at Time 2, and .75 at Time 3.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The original PIA demonstrated strong psychometric properties for children between 20 months and 5 years, 11 months.

“The original PIA (Stone & Hogan, 1993) demonstrated strong psychometric properties for children between 20 months and 5 years, 11 months.”

• cites Stone & Hogan, 1993Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The number of participants with valid outcome data differs across measures, influencing power.

“Owing to child non-compliance, technical problems, and human error, the number of participants with valid outcome data differs across the measures, influencing power (see Table 2).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The conditional effects were exploratory in nature.

“These conditional effects were exploratory in nature.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The ICCs for weighted triadic communication were .95, .97, and .99 for Times 1, 2, and 3, respectively.

“The ICCs for weighted triadic communication were based on blind, independent codings of a random selection of approximately 20% of the sessions at each time period and were .95, .97, and .99 for Times 1, 2, and 3, respectively.”

Classified as probably not a substantial claim.

Coding for all videotaped procedures was completed by coders who were blind to treatment group.

“Coding for all videotaped procedures was completed by coders who were blind to treatment group using software that enables computer control of digital recordings (ProcoderDV; Tapp & Walden, 1993).”

Probably not a substantial claim: may not pass S3 (load-bearing).

It is possible that the current sample's limited joint attention skills, which were sampled only in the ESCS, constrained this potential moderator's variability.

“Thus, it is possible that the current sample’s limited joint attention skills, which were sampled only in the ESCS, constrained this potential moderator’s variability.”

May combine two claims.

Children who entered the study with more limited object interest appear to have benefited, while children with greater object interest showed attenuated growth.

“That is, children who entered the study with more limited object interest appear to have benefited, while children with greater object interest showed attenuated growth.”

Classified as probably not a substantial claim.

All participants with pre-treatment data and data from at least one follow-up period were included in analyses, irrespective of HMTW treatment attendance.

“All participants with pre-treatment data and data from at least one of the follow-up periods were included in analyses, irrespective of HMTW treatment attendance.”

May combine two claims.

These conditional effects indicated that the HMTW intervention was facilitative of communication for some children, but attenuated growth in communication for others.

“These effects indicated that the HMTW intervention was facilitative of communication for some children, but attenuated growth in communication for others.”

May combine two claims.

No statistically significant main effects of site or site-by-treatment interactions were observed for any of the outcome variables (all ps > .20).

“No statistically significant main effects of site or siteby-treatment interactions were observed for any of the outcome variables (all ps > .20).”

May combine two claims.

The prior HMTW case series reported a range of positive outcomes for children, and the quasi-experimental study reported positive gains in observed parenting behaviors and parents' reports of the number of words children used.

“The case series reported a range of positive outcomes for children and the quasi-experimental study reported positive gains in observed parenting behaviors and parents’ reports of the number of words children used.”

• cites Girolametto, Sussman, & Weitzman, 2007Not checked yet

  Not checked in the free run.

• cites McConachie, Randle, Hammal, & Le Couteur, 2005Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Interobserver reliability was estimated through blind, independent codings of a random selection of approximately 20% of sessions at each time period.

“Interobserver reliability was estimated through blind, independent codings of a random selection of approximately 20% of the sessions at each time period.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Interobserver reliability for differentiated play at Time 1 was ICC = .87.

“Interobserver reliability was estimated through blind, independent codings of a random selection of approximately 20% of the sessions at Time 1 (ICC = .87).”

May combine two claims.

There were no differences between the HMTW and 'business as usual' control groups on sociodemographic characteristics or on any Time 1 measures of the experimental or clinical child variables (all ps > .10).

“There were no differences between the HMTW and ‘business as usual’ groups on sociodemographic characteristics or on any Time 1 measures of the experimental or clinical child variables (all ps > .10) (see Table 2).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The treatment that facilitated linguistic communication for children with low object interest also effectively taught object play skills; the contrasting treatment did not teach object play (McDuffie, Lieberman, & Yoder, in press).

“The treatment that facilitated linguistic communication for children with low object interest also effectively taught object play skills; the contrasting treatment did not teach object play (McDuffie, Lieberman, & Yoder, in press).”

• cites McDuffie, Lieberman, & Yoder, in pressNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Families were randomized within each site using software with a random number generator to assign children to the HMTW intervention or control group.

“Families were randomized within each site using software that utilized a random number generator to assign children to the intervention or control group.”

May combine two claims.

Green et al. (2010) found no main effects of a parent-mediated communication-focused treatment on autism severity, clinical language measures, or teacher ratings of adaptive communication.

“A second recent study also assessed a parent-mediated communication-focused treatment in preschool-aged children with autism (Green et al., 2010), and found no main effects of the treatment on autism severity, clinical language measures, or teacher ratings of adaptive communication.”

• cites Green et al., 2010Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Green et al. found a medium effect size of the intervention on observed child social communication and on parent-reported child communication.

“There was, however, a medium effect size of the intervention on observed child social communication, similar to the behaviors coded in the current study as well as on parent-reported child communication.”

• cites Green et al., 2010Not checked yet

  Not checked in the free run.

May combine two claims.

In previous work in which initiating joint attention did moderate the effect of treatment on outcome (Yoder & Stone, 2006a), initiating joint attention was assessed across two contexts and the children were somewhat older.

“In previous work in which IJA did moderate the effect of treatment on outcome (Yoder & Stone, 2006a), IJA was assessed across two contexts and the children were somewhat older.”

• cites Yoder & Stone, 2006aNot checked yet

  Not checked in the free run.

May combine two claims.

The intra-class correlation coefficients for number of IJA and IBR were .93 and .68 at Time 1, .95 and .96 at Time 2, and .95 and .99 at Time 3.

“The intra-class correlation coefficients (ICCs) for number of IJA and IBR were .93 and .68 at Time 1, .95 and .96 at Time 2, and .95 and .99 at Time 3, respectively.”

May combine two claims.

Across sites, HMTW was implemented with 88% (SD = 4.7) of intended elements present in group sessions and 89.9% (SD = 7.9) of intended elements in individual sessions.

“Across sites, HMTW was implemented with 88% (SD = 4.7) of intended elements present in the group sessions and 89.9% (SD = 7.9) of intended elements in the individual sessions.”

May combine two claims.

Object interest is important to responsivity-based treatments because teaching episodes tend to occur in object-oriented joint action routines and because providing access to objects contingent on child communication is frequently used as a functional reward.

“Object interest is important to responsivity-based treatments because teaching episodes tend to occur in object-oriented joint action routines and because providing access to objects contingent on child communication is frequently used as a functional reward.”

May combine two claims.

The presence of moderate to large effect sizes for the parental responsivity outcome and the child outcome moderation effects meet or exceed the usual benchmark of .50 for determining clinically meaningful effects.

“The metric that supports the clinical significance of these findings is the presence of moderate to large effect sizes for the parental responsivity outcome and the child outcome moderation effects, which meet or exceed the usual benchmark of .50 for determining clinically meaningful effects (Hill, Bloom, Black, & Lipsey, 2008; Wolf, 1986).”

• cites Hill, Bloom, Black, & Lipsey, 2008Not checked yet

  Not checked in the free run.

• cites Wolf, 1986Not checked yet

  Not checked in the free run.

May combine two claims.

Analyses documented pre-treatment equivalence on measures of child, family and non-project interventions, along with a lack of differential attrition across groups, raising confidence in internal validity.

“Finally, analyses documenting pre-treatment equivalence on measures of child, family and non-project interventions, along with a lack of differential attrition across the HMTW intervention and ‘business as usual’ control groups, raise confidence in the internal validity of the study.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Due to the extent of missing data, a full intent to treat design with imputation was not pursued.

“In addition, although overall study attrition was low and there was no evidence of differential attrition across the treatment and control groups, statistical power was constrained for several outcome measures due to child non-compliance, technical problems, and experimenter error; due to the extent of missing data a full intent to treat design with imputation was not pursued.”

Classified as probably not a substantial claim. May combine two claims.

The use of an experimental design and 'partial' intent to treat analyses are strengths of this study.

“The use of an experimental design and ‘partial’ intent to treat analyses are strengths of this study.”

May combine two claims.

Some children showed clear gains in communication that were associated with being randomized to the intervention while others showed attenuation in communication growth.

“However, some children showed clear gains in communication that were associated with being randomized to the intervention while others showed attenuation in communication growth.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Children with ASD who have limited object interest may be particularly well suited to the HMTW approach.

“Children with ASD who have limited object interest may be particularly well suited to the HMTW approach, which emphasizes teaching parents to show their child what is interesting about toys and to prompt, wait for, and respond to requests.”

May combine two claims.

Parental sensitivity training resulted in attenuated growth on parental sensitivity and attenuated reduction on child aggression in certain subgroups in a study by Stolk et al. (2008).

“For example, parental sensitivity training (a part of which is responsivity training) resulted in attenuated growth on parental sensitivity and attenuated reduction on child aggression in certain subgroups of participants in a study by Stolk et al. (2008).”

• cites Stolk et al. (2008)Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The non-commensurate parent group size may have compromised the potential learning opportunities and social supports that emerge in group sessions with a larger number of parent participants.

“This circumstance may have compromised the potential learning opportunities and social supports that emerge in group sessions with a larger number of parent participants.”

May combine two claims.

Although nonsignificant effects can occur due to low within-site sample size, the findings of this randomized controlled trial are compatible with the hypothesis that the current findings are generalizable to a relatively broad range of settings in the United States.

“Although nonsignificant effects can occur due to low within-site sample size, the findings of this randomized controlled trial of the HMTW intervention are compatible with the hypothesis that the current findings are generalizable to a relatively broad range of settings in the United States.”

Classified as probably not a substantial claim.

An additional methodological strength is the multi-method assessment of child communication that was employed.

“An additional methodological strength is the multi-method assessment of child communication that was employed.”

May combine two claims.

The majority of assessors and all observational coding of children's behavior were blind to treatment condition.

“Further, the majority of assessors and all observational coding of children’s behavior were blind to treatment condition.”

Classified as probably not a substantial claim. May combine two claims.

This study measured communication during parent-child interactions, examiner-child interactions, and via parental report.

“This study measured communication during parent–child interactions, examiner–child interactions, and via parental report.”

Classified as probably not a substantial claim. May combine two claims.

The lack of overall treatment effects on child outcomes may be due to the relatively low intensity of the HMTW intervention, or to non-optimal implementation due to smaller than recommended group size.

“The lack of overall treatment effects on child outcomes may be due to the relatively low intensity of the HMTW intervention, or to the non-optimal implementation due to smaller than recommended group size.”

• AssumptionRests on an assumption: The HMTW intervention is relatively low intensity.