Effects of A Triadic Parent-Implemented Home-Based Communication Intervention For Toddlers

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research-article2015
JEIXXX10.1177/1053815115589350Journal of Early InterventionBrown and Woods
Article
Journal of Early Intervention
2015, Vol. 37(1) 44–68
Effects of a Triadic Parent- © 2015 SAGE Publications
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DOI: 10.1177/1053815115589350
Communication Intervention for jei.sagepub.com
Toddlers
Jennifer A. Brown1 and Juliann J. Woods2
Abstract
A series of three multiple-baseline single-case studies with replication across nine parent–child
dyads was used to evaluate the effects of a parent-implemented communication intervention on
parent and child communication for toddlers with Down syndrome, autism spectrum disorder,
and developmental delays. Interventionists coached parents to implement communication
strategies and supports in family-identified routines over 24 intervention sessions. Parents
demonstrated increased responsive and modeling strategy use, and children exhibited higher
rates of targeted communication forms from baseline to intervention phases. For eight of the nine
dyads, the gains increased across the intervention phase, and effects were carried over into the
maintenance phase. The results support the use of triadic parent-implemented communication
interventions that can be implemented in the early intervention system. Clinical and research
implications of teaching parents of toddlers with various etiologies to use responsive and
modeling strategies through a collaborative family-guided coaching process are discussed.
Keywords
early intervention, communication, collaborative consultation, coaching, family-centered, natural
environment
Introduction
The importance of expanding the evidence base for early communication interventions is under-
scored by the prevalence of communication impairments in children with various etiologies and
the predictive relationship between communication skills and later academic and social perfor-
mance (Hebbeler et al., 2007; Johnson, Beitchman, & Brownlie, 2010). Because of the integral
role communication has in young children’s participation in everyday activities, recommended
practices for infants and toddlers with communication delays include incorporating intervention
within natural activities through collaboration with parents (American Speech-Language-Hearing
Association [ASHA], 2008; Early Intervention Program for Infants and Toddlers With Disabilities,
2011; National Research Council [NRC], 2001; Sandall, Hemmeter, Smith, & McLean, 2005;
1University of Georgia, Athens, GA, USA

2Florida State University, Tallahassee, FL, USA
Corresponding Author:
Jennifer A. Brown, Department of Communication Sciences and Special Education, University of Georgia, 536
Aderhold Hall, Athens, GA 30602, USA.
Email: jbrown8@uga.edu
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Brown and Woods 45
Wilcox & Woods, 2011). Although the importance of translational research is widely recognized
(Durlak, 2013; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Institute of Education
Sciences, 2013; Justice, 2008; National Institute on Deafness and Other Communication
Disorders, 2012), to date, early communication intervention research has been limited in its
direct translation to implementation in community settings in which children regularly receive
services. Therefore, early communication interventions should be examined not only in terms of
child outcomes but also in relationship to the process and context used to teach parents (Schertz,
Baker, Hurwitz, & Benner, 2011; Trivette, Dunst, & Hamby, 2010; Woods & Brown, 2011).
Parent-Implemented Interventions
Several intervention studies and systematic reviews have shown that parents can effectively use
communication strategies and supports with positive effects on their children’s communication
outcomes (e.g., Boyd, Odom, Humphreys, & Sam, 2010; Girolametto, Weitzman, & Clements-
Baartman, 1998; Jackson, 2009; Kaiser & Roberts, 2013; Kashinath, Woods, & Goldstein, 2006;
Law, Garrett, & Nye, 2004; Roberts & Kaiser, 2012; Wetherby & Woods, 2006). The interven-
tions examined in these studies were based on the established framework that parents have an
instrumental role in their children’s language development (Hart & Risley, 1995; Landry, Smith,
& Swank, 2006) by teaching parents to use specific communication interaction and support
strategies.
Roberts and Kaiser (2011) conducted a meta-analysis of 18 parent-implemented communica-
tion intervention studies. The children in the studies ranged from 15 to 77 months and were with
primary language impairments (11 studies) and secondary language impairments (7 studies),
including autism spectrum disorder (ASD), Down syndrome (DS), and developmental delays
(DD). Children receiving parent-implemented interventions had positive, significant effects for
expressive language when compared with nontreatment groups, particularly for expressive lan-
guage form, g = 0.82, p < .01. When parent-implemented and therapist-implemented interven-
tions were compared, child languages outcomes were similar or slightly higher for children
receiving parent-implemented interventions. Intervention strategies common across effective
studies included (a) responsiveness to child communication, (b) expanding child communication,
(c) enhancing the type of language input, and (d) balancing parent and child communication to
establish reciprocal supportive communication exchanges.
In three recent randomized control trials, researchers examined parent-implemented interven-
tions for toddlers and young preschool-age children. Roberts and Kaiser (2012) compared lan-
guage outcomes of children between 24 and 42 months with primary language impairments in a
combined clinic and home Enhanced Milieu Teaching (EMT) intervention program. Rogers et al.
(2012) examined the effects of a clinic-based parent-implemented version of the Early Start
Denver Model (P-ESDM) for toddlers at-risk of ASD. Carter et al. (2011) studied parent respon-
sivity and child communication of toddlers with red flags for ASD following participation in
Hanen’s More Than Words (HMTW; Sussman, 1999) combined group and individual parent
training intervention. The children in the comparison groups received “business as usual” sup-
ports; many of the children and families in the P-ESDM and HMTW studies participated in vari-
ous community-based interventions, whereas 92% of the children in the EMT study did not
receive any language intervention. Interestingly, only the EMT study demonstrated significant
main effect differences between intervention and control groups. Without carefully defining or
controlling the intervention that the control groups in the P-ESDM and HMTW studies received,
the results are difficult to interpret beyond stating that each of the examined interventions was
similarly effective as other interventions that children and families may be typically receiving. In
addition to location variations of the respective parent-implemented intervention (e.g., home or
clinic), the researchers in each of these three studies used different processes to teach the parents

46 Journal of Early Intervention 37(1)
to implement intervention strategies. This highlights the issue that although parent-implemented
intervention studies share the common focus of teaching parents to implement specific strategies,
the intervention and process in which parents are taught vary substantially.
When examining limitations of parent-implemented intervention studies of toddlers, two
additional considerations related to the Individuals With Disabilities Education Act (IDEA) Part
C service delivery can be noted—the parent’s role and the service location. Part C stipulates that
early intervention services and supports are designed to build the families’ capacity to support
their children’s development and are to be provided in their natural environments, including both
physical locations (i.e., setting) and the family’s routines and activities (i.e., context; IDEA,
2004; National Early Childhood Technical Assistance Center [NECTAC], 2008). Family capac-
ity-building underscores an important distinction among the broad category of parent-imple-
mented interventions. Although the terms training and coaching are often used interchangeably
or in a nonspecific manner, there are important differences between the two approaches.
Specifically, training parents to implement intervention in predetermined intervention contexts is
different than collaborating with parents as decision makers in the process of coaching them to
embed intervention in their everyday routines. Parent training often entails the interventionist to
provide information, model strategies while the parent watches, and provide specific instructions
to the parents on what and how to use strategies within play activities (e.g., Fey et al., 2006;
Girolametto et al., 1998). However, family-guided parent coaching includes parents as integral
decision makers and collaborators in how, where, and when the intervention is implemented
(Kashinath et al., 2006; Wetherby & Woods, 2006; Woods, Kashinath, & Goldstein, 2004).
Interventions using a parent coaching approach focus on the triadic interaction of the interven-
tionist supporting the bidirectional parent–child interactions and communication (Salisbury &
Cushing, 2013; Woods, Wilcox, Friedman, & Murch, 2011).
KidTalk–TaCTICS Project (KTTP)

KTTP is an approach to parent-implemented intervention designed to explore and demonstrate
implementation of evidence-based communication intervention within the framework of com-
munity-based systems. KTTP is a model demonstration project that represents a merger of two
communication interventions, EMT and Family-Guided Routines-Based Intervention (FGRBI).
This blended intervention was designed to provide a systematic approach to both the content
being taught to the parents (i.e., the intervention itself) and the process in which the parents were
taught to use the intervention. Specifically, parents learned to use communication intervention
strategies embedded in their everyday activities through a family-guided coaching process.
The central tenets of EMT include arranging the environment to promote communication,
responding contingently to a child’s communication, imitating the child’s actions, giving the
child specific and targeted language input, and using a prompting procedure to elicit specific
child targets (Hancock & Kaiser, 2002; Hester, Kaiser, Alpert, & Whiteman, 1996; Roberts &
Kaiser, 2012). FGRBI focuses on the use of responsive communication strategies within family-
identified and preferred everyday routines and activities to promote functional communication
(Kashinath et al., 2006; Woods, 2005; Woods et al., 2004). FGRBI builds on the natural sequence
and rhythm of everyday home and classroom routines to offer the child frequent opportunities to
communicate and to generalize new skills throughout the day in the child’s everyday learning
environments.
Although both EMT and FGRBI studies have yielded positive parent and child outcomes, they
have not previously been studied as a merged intervention approach. This combination is
designed to address several previous limitations and extend findings. The focused number and
sequence of intervention strategies as part of a manualized intervention increases systematization
from earlier FGRBI studies. The use of a family-guided triadic coaching approach within varied

Brown and Woods 47
everyday routines extends the specified parent training in clinic play settings frequently used in
EMT studies. Studying the effects on toddlers across different communication patterns decreases
the average age of participants and increases diversity of child diagnoses.
The purpose of this study was to examine the effect of the triadic parent-implemented interven-
tion on parents’ use of embedded intervention strategies and on children’s targeted communication
outcomes. The current investigation proposed to answer the following research questions:
Research Question 1: Does participation in KTTP with a triadic parent coaching model
increase the parents’ use of language intervention strategies?
Research Question 2: Does participation in KTTP with parents implementing intervention
strategies increase children’s use of targeted language outcomes?
Method
A series of three single-case nonconcurrent multiple-baseline studies with replication across
child–parent dyads was used to evaluate the effects of a family-guided communication interven-
tion for toddlers with DS, ASD, and DD in terms of two dependent variables: (a) parents’ imple-
mentation of intervention strategies and (b) children’s targeted communication outcomes. This
scale-up study was part of a larger KTTP model demonstration and research study.
Participants
Nine children and their families from the larger project participated in the current study.
Inclusionary criteria for the parent–child dyads were as follows: (a) Children met eligibility crite-
ria for local Part C services with communication needs, (b) children were under 36 months of age
at start of participation, (c) parents reported communication as their primary concern for their
child, and (d) parents expressed an interest in participating in parent-implemented intervention
and provided informed consent for at least one primary parent and child to participate in study
activities. None of the children were enrolled in language intervention with a Part C speech-lan-
guage pathologist (SLP) outside this study during the course of the intervention. Two children
received physical therapy, and two children received occupational therapy. Parents reported that
all services outside KTTP were provider-delivered and child-focused rather than collaborative
parent-implemented interventions. Child participants are referred to by pseudonyms to protect
their anonymity. Demographic information for child and parent participants is included in Table 1.
Child participants. The children ranged in age from 12 to 28 months at the start of the study. Children
met eligibility for Part C services based on established conditions (e.g., DS) or DD (e.g., communi-
cation delay). Specifically, Kailee, Charlotte, and Emerson had DS. Peter, Mila, and Wyatt had social
communication delays and were given a confirmatory diagnosis of ASD from trained diagnosticians
independent of the current study. The ASD assessment process was completed through the FIRST
WORDS® Project (http://med.fsu.edu/index.cfm?page=autismInstitute.firstwordsStaff) and
included a variety of naturalistic, semistructured, and structured assessments, including the Autism
Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore, & Risi, 1999). Mae, Abigail, and
Oliver presented with DDs with low communication rates. Mae had a neurological medical condi-
tion, Abigail had social communication needs including limited reciprocal interactions with low
rates of communicative initiations, and Oliver was identified with challenging behaviors.
The children’s expressive communication levels were categorized into benchmarks of prever-
bal, first words, word combinations, and sentences by criteria based on defined ranges of phonol-
ogy, vocabulary, grammar, and pragmatics (Tager-Flusberg et al., 2009). The children’s
assessment scores at entry in the study are presented in Table 1 to further describe their

48
Table 1. Child and Family Characteristics and Initial Child Assessment Data.
Study 1 Study 2 Study 3
Kailee Charlotte Emerson Peter Mila Wyatt Mae Abigail Oliver

Child’s age in months 21 12 20 28 23 26 27 24 25
Gender F F F M F M F F M
Race/ethnicity White White White African Hispanic White White White White
Home language(s) English English English Luganda, English, English English English English
English Spanish
Parent
Education level Graduate Graduate 4-year 4-year 4-year 2-year HS diploma Graduate degree 4-year
degree degree degree degree degree degree degree
Work status Part-time Stay-at- Stay-at- Stay-at- Stay-at- Full-time Stay-at-home Part-time Full-time
home home home home
MSEL
NVDQ 92.86 70.83 91.07 91.07 87.68 79.49 79.63 110.42 121.15
VDQ 78.57 79.17 75.00 75.00 73.91 57.69 70.37 95.83 103.85
PLS-4
AC 75 71 68 94 84 71 75 91 91
EC 73 77 79 85 89 71 73 97 87
TLS 71 71 71 89 85 77 71 94 88
MCDI

Words produced 4 0 16 258 148 50 84 375 83
Communication level benchmark Preverbal Preverbal Preverbal First words First words First words First words First words/Word First
combination Words
IGDI-ECI weighted total 3.00 (9.7) 0.83 (3.3) 3.33 (9.0) 5.50 (14.6) 3.83 (11.1) 3.83 (13.2) 12.80a (13.9) 2.5 (11.8) 9.50a (12.5)
communication
Note. HS = high school; MSEL = Mullen Scales of Early Learning; NVDQ = Nonverbal Developmental Quotient; VDQ = Verbal Developmental Quotient; PLS-4 = Preschool Language
Scale, 4th ed.; AC = auditory comprehension; EC = expressive communication; TLS = Total Language Score; MCDI = MacArthur–Bates Communication Development Inventory;
words produced = number of reported expressive words; IGDI-ECI = Infant Growth and Development Indicator–Early Communication; weighted expressive communication rate per
minute (vocalizations and gestures = 1, single words = 2, multiple words = 3), mean normed rates are displayed in parenthesis.
aWithin one standard deviation of the mean IGDI rate.
Brown and Woods 49
development. Despite Peter, Mila, Abigail, and Oliver’s standardized language test scores within
one standard deviation from the mean, their parents’ primary concern was social communication.
In addition, eight of the children presented with communication rates below the normative mean
rates on the Infant Growth and Development Indicator–Early Communication Indicator (IGDI-
ECI), which is described below.
Parent participants. The primary parents participating in this study were all biological or adopted
mothers; however, several of the fathers participated in a portion of the sessions in tandem with
the mothers. Only the data for the mother are presented because in each dyad, the mother was the
primary participant. The parents ranged in age from 24 to 45. Maternal education level and work
status for each participant are detailed in Table 1.
Interventionists. Four certified SLPs with early intervention experience, including the first author,
served as the interventionists. Their years of experience ranged from 1 to 10 years; three of the
interventionists had master’s degrees, and one had a PhD. Each interventionist was trained by
observing live and video-recorded intervention sessions, implementing intervention sessions,
comparing self-completed fidelity checklists with trainer-completed fidelity checklists, and par-
ticipating in reflection and problem-solving discussions. Before participating in the study, inter-
ventionists met fidelity standards of a minimum of three intervention sessions at 80% or higher
as measured on the Intervention Treatment Fidelity Form (see Appendix A).
Settings
All assessment and intervention activities were conducted in the families’ homes. The interven-
tionist met with the family for approximately 60 to 75 min once a week for 24 sessions during the
intervention phase. The identified primary parent, child, and interventionist were present for each
intervention session. Other family members, including the father, siblings, and grandparents,
were often present as well. A research assistant accompanied the interventionist to video record
the sessions. Intervention sessions were scheduled at a time convenient for the family, including
morning, afternoon, and evening sessions. The family identified the routines to embed interven-
tion strategies based on their typical activities, preferences, and priorities. Each family identified
a minimum of three different routines across at least two routine categories (i.e., play, early lit-
eracy, caregiving, chores) for each of the intervention strategies. Strategies were taught and prac-
ticed in those routines in the specific location of the house in which the family typically
participated in them. Each family’s materials and objects that were typical for the routines were
used; the interventionist did not bring any additional materials.
Design
We used three nonconcurrent multiple-baseline single-case studies with replication across par-
ent–child dyads. As a demonstration study, the single-case design provided an opportunity to
explore components of the parent-implemented intervention at a molecular level. A minimum of
five data points in the baseline phase and nine data points in the intervention phases as well as
replication across three phases for each participant add to the experimental effect (Horner et al.,
2005; Kratochwill et al., 2010).
Data Collection
Baseline, intervention, and maintenance sessions were video recorded for the purposes of the
larger project. The number of baseline sessions varied between 5 and 10 sessions for

each participant. Nine intervention sessions were analyzed for each child. The length of session
segments was designed to be long enough to capture different routines and to be representative
of the triadic interaction, while being brief enough to measure the behaviors efficiently. For our
study, 10-min continuous samples from the intervention sessions were identified based on the
following procedure. First, a 10-min sample was randomly selected from each baseline session.
Second, 1 intervention session from every 4 sessions was randomly selected (i.e., 1 from the fol-
lowing groups of sessions: 1-4, 5-8, 9-12, 13-16, 17-20, 21-24) to represent the course of the
intervention. Third, to reach a total of 9 intervention sessions, 3 additional sessions were selected
through a simple random sampling process from the entire set of 24. A random 10-min sample
was identified from each of the selected intervention sessions. Last, maintenance samples were
collected for each dyad at two time points—1 month post intervention and 3 months post inter-
vention. If the 10-min samples in any phase did not have adequate video quality to code the
dependent variables (e.g., child and/or parent were not in view of camera; audio levels were too
low), another random time selection from the same date was made.
Measures
Initial measures. The following standardized measures were administered to characterize each child’s
development at the start of the study: Mullen Scales of Early Learning (MSEL; Mullen, 1995), a
standardized norm-referenced measure of cognitive functioning for children birth to 68 months;
Preschool Language Scale–Fourth Edition (PLS-4; Zimmerman, Steiner, & Pond, 2002), a standard-
ized norm-referenced measure of auditory comprehension and expressive communication for chil-
dren birth to 6 years, 11 months; and MacArthur Communication Development Index (MCDI;
Fenson et al., 1993), a standardized norm-referenced parent-report measure of communication skills
in children 8 to 30 months. All three initial measures had adequate reliability and validity indexes for
the measured skills. In addition to the scores derived from each of the measures, MSEL developmen-
tal quotients (DQ) were calculated to describe nonverbal and verbal abilities. Age equivalent scores
were divided by the child’s age and multiplied by 100 to obtain the quotients. Fine motor and visual
reception age equivalents were averaged for nonverbal DQ (NDQ), and receptive and expressive age
equivalents were averaged for verbal DQ (VDQ). Assessment results are displayed in Table 1.
Ongoing measure. The IGDI-ECI was administered at five time points (baseline; Sessions 8, 16,
and 24; 3-month follow-up) as a consistent normative progress-monitoring measure of child
communication. The IGDI-ECI captures children’s expressive communication in a brief semis-
tructured play exchange with a trained reliable administrator. It is intended to be a sensitive
measure of children’s expressive communication growth over time with scores compared with a
normative sample of 1,653 infants/toddlers (Greenwood, Walker, & Buzhardt, 2010; Luze et al.,
2001). The IGDI-ECI has strong levels of inter-rater and alternate forms of reliability as well as
adequate criterion validity measured by strong relationships to other child communication mea-
sures. Child communication is coded in terms of expressive elements of gestures, vocalizations,
single words, and multiple words. IGDI-ECI scoring produces frequencies of each communica-
tive behavior and weighted Total Communication Scores based on the complexity of expressive
communication. Communication rates are compared with normative communication rates based
on the child’s age in months. Comparing the participants’ communication rates with rates within
one standard deviation from the normative sample mean provides a systematic way to assess
expressive communication rates. IGDI-ECI rates of total communication at the beginning of the
study are presented in Table 1, and results across the five time points are presented in Table 2.
Observational coding systems. Video segments were coded for parent-implemented interven-
tion strategies and child communication independently in The Observer XT 10 software by

Brown and Woods 51
Table 2. IGDI-ECI Rates of Weighted Total Communication: Measured Rates Compared With
Normed Rates Over Time.
Child Baseline Session 8 Session 16 Session 24 Maintenance

Kailee 3.00 (9.7) 4.50 (11.1) 5.00 (12.5) 8.67a (13.9) 10.50a (15.3)
Charlotte 0.83 (3.3) 1.33 (4.7) 3.33 (6.1) 3.67 (7.6) 8.17a (9)
Emerson 3.33 (9.0) 6.50a (10.4) 7.50a (11.8) 7.50 (13.2) 7.67 (14.6)
Peter 5.50 (14.6) 4.00 (16.0) 10.50a (17.4) 10.83 (18.8) 13.50 (20.2)
Mila 3.83 (11.1) 12.67b (12.5) 16.00b (13.9) 28.00b (15.3) 28.66b (10.4)
Wyatt 3.83 (13.2) 4.50 (14.6) 10.50a (16) 12.33a (17.4) 16.50a (18.8)
Mae 12.80a (13.9) 15.00b (13.2) 17.50b (14.6) 20.50b (16) 22.50b (17.4)
Abigail 2.50 (11.8) 10.83a (15.3) 17.33b (16.7) 23.50a (15) 21.17b (18.1)
Oliver 9.50a (12.5) 11.50a (13.9) 13.33b (15.3) 14.00a (18.1) 19.33b (16.7)
Note. IGDI-ECI Total Communication weighted rate per minute of expressive communication. Mean normed rates
are displayed in parenthesis. Weighting is applied as vocalizations and gestures = 1; single words = 2; multiple words =
3. IGDI-ECI = Infant Growth and Development Indicator–Early Communication.
aWithin one standard deviation below the mean.
bMet or exceeded mean rate based on IGDI normative data.
Noldus Information Technology (2010), which allowed for measurement of the frequency,
duration, and co-occurrence of operationally defined behaviors. Undergraduate research
assistants and the first author served as primary coders. Each research assistant coder was
trained in one of the two coding systems through a systematic process of reading and dis-
cussing the definitions, observing exemplars and nonexemplars for each definition, and cod-
ing alongside a trained coder, to independently coding sessions. Coders were required to
meet the criterion agreement level of Cohen’s kappa values of .60 or greater on a minimum
of 10 training intervention videos before coding sessions for the current study (range = .69-
.86). Kappa levels above .60 are generally considered to indicate good agreement and are a
recommended reliability index in single-case research (Horner et al., 2005). To minimize
drift from the coding definitions, biweekly coding meetings were held to discuss the defini-
tions and display examples.
Parent-implemented intervention strategies. Parents’ use of communication intervention strategies

was coded as start–stop behaviors. As displayed in Table 3, strategies were grouped into catego-
ries of responsive interactions (e.g., contingent imitation, mirroring and mapping, and verbal
expansions), modeling (e.g., providing a model at the child’s target level), and prompting/milieu
teaching (e.g., expectant pause, open-ended question, choice question, direct prompt preceded by
one of the other prompting strategies). The grouping of strategies for analysis was congruent with
the sequence of intervention strategies taught to the parents.
Child communication. The child’s communication acts were coded according to modified defini-
tions of the IGDI-ECI communication procedure and definitions (Luze et al., 2001) in start–stop
nonexclusive behaviors. These definitions were used to align with the IGDI-ECI as a project-
specific measure. To clearly identify the child’s target communication use, single words were
separated into two behaviors: single signed words and single verbal words. Likewise, multiple
words were separated into multiple signed words and multiple verbal words. Each child’s com-
munication was coded for gestures, vocalizations, single signed words, single verbal words, mul-
tiple signed words, and multiple verbal words; however, intervention decisions and, therefore,
data analysis were based on each child’s target communication level.

Table 3. Overview of Measured Communication Intervention Strategies Taught to Parents.
Intervention strategy
category Specific strategy components Examples
Responsive interactions Contingent imitation: Parent’s Child says “bottle” and the parent
verbal and/or nonverbal says “bottle” OR the child points
imitative response to the child’s and the parent follows with a
communication act point
Mirroring and Mapping: Mirroring Child raises his or her arms and the
(imitating) the child’s actions parent does the same and says
and mapping a word or phrase “up”
to the action Child says “ball” and the parent says
Expansions: Parent repeats/ “bounce ball” OR child points to a
responds to the child’s cookie out of reach and says “uh”
utterance/gesture/sign by and the parent says “cookie”
adding a word or modeling
an expanded form of
communication based on the
child’s utterance
Modeling Parent provides a model of the Parent says “shoe” while putting on
child’s communication target. the child’s shoes when the child
Model is directly related to hasn’t made a communication
the immediate context, is at attempt
the child’s target level, and is
followed by a parent verbal
pause.
Prompting/milieu teaching Expectant pause: Waiting with Parent waits for approximately 3-5
Prompts are used only when an expectation of a child’s s, asks “What do you want?” asks
child is making a clear response—expectation is “Do you want brush or soap?”
request at level lower than indicated by positioning of uses direct “say” prompt by saying
targeted communication body and/or materials and/ “say soap.”
or facial expression and/ Note: Parent may use one or more
or waiting before next prompting strategy in a prompting
communication act in familiar sequence, but the sequence
routine or script must increase in support. Direct
Open-ended question: A question prompt should be used only
that can have more than one after a lower support prompt
answer; yes/no questions was attempted. When the
or “test” questions are not child responds with target, the
considered open-ended prompting sequence is completed.
questions
Choice question: Verbally or
nonverbally giving a choice
between activities, materials,
actions; having several
materials available without a
specific reference (verbally or
nonverbally) to the options
is not considered a choice
question
Direct prompt: Directly requesting
the child to produce a
communication act

Brown and Woods 53
Procedure
Prebaseline. KTTP project staff met with interested families, explained the project, and obtained
informed consent from the parents. A focused conversation was completed to gather information
about the family’s priorities and concerns and their typical routines and activities.
Baseline. The number of baseline sessions was staggered with sessions ranging from five to nine.
The interventionist video recorded the parent and child participating in play, caregiving, early
literacy, and family chore/errand routines for a minimum of five sessions. Parents were instructed
to interact with their child as they normally would in each routine. There was no attempt to influ-
ence the parent’s behaviors. During the baseline period, the initial assessment measures were
completed (see Table 1).
Intervention. The triadic intervention was conducted entirely in the families’ homes and/or commu-
nity locations where the families typically visited (e.g., neighborhood park, library, grocery store). A
minimum of three different family-identified routines across at least two routine categories (play,
caregiving, early literacy, family chores/errands) served as the context for each intervention session.
At the beginning of the session, parents identified which specific routines, targets, and strategies to
use based on their perceived importance for child participation and frequency of occurrence to ensure
sufficiency of opportunities to practice. Collaborative problem solving occurred to expand and/or
refine strategy use or to identify new routines or strategies to try. The interventionist followed a
coaching protocol consisting of setting the stage, observation, opportunities for practice, and prob-
lem solving within each routine and across the session to build the parents’ capacity to embed strate-
gies with contextual fit to their priorities and interaction styles in their preferred routines.
The manualized intervention sequence began with establishing routines and then progressed
based on parent and child performance to embedding environmental arrangement, responsive
interactions, modeling, and prompting/milieu teaching strategies into established routines (see
http://kttp.cci.fsu.edu for more information on the intervention model). Intervention session pro-
cedures are outlined in the fidelity measurement form (see Appendix A), and an overview of the
measured intervention strategies is provided in Table 3. The introduction of new intervention
strategies was individualized for each family based on data collected during the previous inter-
vention session and parents’ preferences. Strategies within responsive interaction and modeling
categories (e.g., contingent imitation and providing a model of communication target) were
taught simultaneously. The specific strategies were determined based on conversations with the
parent about contextual fit and appropriateness to maintain integrity of their routines. Prompting/
milieu teaching strategies were taught to parents only to increase complexity of child requests;
therefore, their frequency of use was directly related to the child’s current level of requesting
below their target communication form. Interventionists intentionally provided information on
the rationale behind potential intervention strategies to expand parents’ implementation beyond
the routines practiced during the session. Session plans and between-visit plans were developed
collaboratively with the parents as a component of the coaching process. Interventionists used a
mixture of information sharing, observation, joint interaction, conversation, direct teaching/dem-
onstration, caregiver practice with feedback, guided practice with feedback, and problem-solv-
ing/reflection coaching strategies to teach the parents within a triadic coaching model. The
theoretical framework, definitions, and process of the caregiver coaching approach used in this
study are described in Friedman, Woods, and Salisbury (2012) and in Woods et al. (2011).
Maintenance. The interventionist video recorded the child and parent participating in a variety of
routines 1 month and 3 months after the 24 intervention sessions were completed as a mainte-
nance measure of the parent’s strategy use and child communication.

Reliability
A minimum of 20% of the sessions for each coding system were independently coded ensuring
ongoing reliability. Inter-observer reliability measures were calculated using Cohen’s kappa to
account for chance based on the observed frequency of behavior occurrence and nonoccurrence
(Kazdin, 2011). Reliability means were calculated with The Observer XT software for each
measured variable; results ranged from .74 to .86, all above the level of good agreement.
Fidelity
Monitoring and measuring how an intervention is being implemented are important for evaluat-
ing its outcomes (Kaderavek & Justice, 2010; Marturana, Friedman, Brown, & Woods, 2011).
Fidelity was measured for the implementation of intervention (i.e., the interventionist’s adher-
ence to the model) and treatment enactment (i.e., parents’ participation and use of targeted inter-
vention components). Fidelity measurement forms are included in Appendices A and B. The
project team reviewed video-recorded intervention sessions on an ongoing basis and completed
fidelity checklists for 30% of complete sessions. A second research assistant independently coded
50% of the sessions to ensure measurement reliability.
Social Validity
Parents completed written questionnaires following the intervention phase to characterize the inter-
vention’s utility, acceptability, and feasibility. Specifically, they responded to 10 Likert-type 5-point
scale questions and 3 open-ended questions about the coaching process, time involved, use of strat-
egies, supporting their child’s communication, and whether they would recommend the interven-
tion to other families. Example Likert-type scale items (with response anchors of 1 = no; 3 =
sometimes; 5 = yes) included “I feel more effective in supporting my child’s language and com-
munication”; “the time requirement involved was reasonable for me and my family”; “my coach
(interventionist) presented information clearly”; and “I use the KTTP strategies at home with my
child.” Open-ended questions included “What do you think was the most useful aspect?” “What do
you think was the least helpful aspect?” and “What could we do to make KTTP better?”
Data Analysis
Frequency counts for each measured variable were obtained through the coding software The
Observer XT. The functional relationship between the intervention and dependent variables of
parent-implemented strategies and child communication was analyzed through visual inspection
and descriptive statistics of graphed data (Kazdin, 2011). The level, trend, and variability of data
across phases for each participant provided the context for analysis (Kratochwill et al., 2010).
Levels were measured with means of each phase. Immediacy of intervention effect was measured
with means of the first three intervention sessions, and effect of sustained intervention was mea-
sured with means of the last three intervention sessions. Visual analysis of the slope of the best
fitting line provided information on the data trends. Variability was measured with visual inspec-
tion of the deviation from the slope.
Two nonoverlap indices were used to support and quantify visual analysis: (a) percentage of
all nonoverlapping data (PAND; Parker, Hagan-Burke, & Vannest, 2007) and (b) nonoverlap of
all pairs (NAP; Parker & Vannest, 2009). Despite a lack of agreement over a particular effect size
estimator for single-case designs, their use may be appropriate as a rough measure of the magni-
tude of effect of the intervention (Campbell & Herzinger, 2010; Kratochwill et al., 2010; Parker,
Vannest, & Davis, 2011). The validity of statistical analysis of single-case data is strengthened

Brown and Woods 55
when more than one index is used as a tool for examining phase change (Parker et al., 2011).
Nonoverlap indices are parametric procedures that do not rely on independence assumptions;
therefore, they align with the dependent nature within-participants data. PAND provides the per-
centage of data that remains after eliminating data points that are overlapping from baseline to
intervention phases, with values greater than 50% indicating associations above chance. NAP
extends the comparison of nonoverlap by providing a percentage of all individual pairwise com-
parisons across baseline to intervention phases. In addition, NAP provides a p significance value
(Parker & Vannest, 2009). NAP calculations were made with the single-case research NAP online
calculator software (Vannest, Parker, & Gonen, 2011).
Results
The purpose of this study was to examine the functional relationship between the KTTP interven-
tion and (a) parents’ use of communication intervention strategies, and (b) children’s use of com-
munication targets for children eligible for Part C services. Results for each parent–child dyad
across the three multiple-baseline studies are provided in Figures 1, 2, and 3. It is important to
note that the axes differ across the figures because methodologically, each multiple-baseline
study was conducted independently. Phase means are presented in Table 4. Statistical analysis
PAND and NAP results are presented in Table 5. IGDI-ECI communication rates across five time
points are presented in Table 3.
Parent Communication Intervention Strategy Use

Parents’ intervention strategy acquisition and implementation were specifically measured for (a)
responsive strategies (e.g., contingent imitation, mirroring and mapping, verbal expansions); (b)
modeling strategies (e.g., language models at the child’s target level); and (c) prompting/milieu
teaching (e.g., expectant pause, open-ended question, choice question, and direct prompt pre-
ceded by one of the other prompting strategies). In alignment with the intervention approach’s
focus on responsivity and modeling as foundational and primary strategies, parents increased
their implementation of those strategies at a higher rate than prompting/milieu teaching strate-
gies. Based on that emphasis and the variable frequency of opportunities for appropriate use of
prompting/milieu teaching strategies matched to child requests, the analysis was focused on
responsive and modeling strategies.
As shown in Figures 1, 2, and 3, all nine mothers demonstrated increases in responsive and
modeling strategies following relatively low baseline frequencies. Kailee, Peter, Mila, Wyatt,
Abigail, and Oliver’s mothers sustained similar or higher levels into the maintenance phase.
There was a slight decrease in strategy use in the maintenance sessions for Charlotte, Emerson,
and Mae’s mothers, but they each demonstrated maintenance averages above their baseline aver-
ages. Peter, Mila, Wyatt, and Abigail’s mothers demonstrated the largest possible PAND associa-
tion, 100% nonoverlapping data, in their level change from baseline to intervention. The NAP
results were congruent with PAND results, demonstrating significant phase changes of respon-
sive and modeling strategies. Mae’s mother had the most variability among participants after a
steep initial increase. She was the only parent to use fewer intervention strategies at the end of
the intervention than at the beginning.
Child Target Communication Use

Communication targets were selected based on each child’s communication level during the
baseline phase. Throughout the intervention, the child’s second communication target was
emphasized more as the child’s communication performance progressed. Both communication

Figure 1. Study 1, children with DS: Frequency of parent communication strategy use and targeted
child communication acts in 10-min samples across baseline, intervention, and maintenance phases.
Note. Kailee’s communication targets: 1 = single verbal words, 2 = multiple verbal words; Charlotte and Emerson’s
communication targets: 1 = single signed words, 2 = single verbal words. DS = Down syndrome.
targets were measured throughout the study. The second communication target was at a more
sophisticated level than the first target. Developmentally, it would be expected for the first com-
munication target’s slope to increase at a decreased rate as the second target increased (Luze
et al., 2001). Communication rate increases in session samples were supported by the results of
IGDI-ECI total communication phase changes (presented in Table 2).
As shown in Figures 1, 2, and 3, all nine children increased at least one of their targeted
communication levels with differing amounts of variability from the baseline to intervention

Brown and Woods 57
Figure 2. Study 2, children with ASD: Frequency of parent communication strategy use and targeted
Note. Peter, Mila, and Wyatt’s communication targets: 1 = single verbal words, 2 = multiple verbal words. ASD =
autism spectrum disorder.
phase and maintained at least the second target’s level into the maintenance phase. Kailee,
Charlotte, Emerson, and Wyatt presented with stable low communication baselines with mean
frequencies of one or fewer communication targets per sample. There were minimal immedi-
ate increases for these four children followed by upward trends as the intervention progressed.
Kailee and Wyatt’s use of both communication targets significantly increased. Kailee contin-
ued the increase of her first target (single verbal words) and maintained the level of her sec-
ond target (multiple verbal words) into the maintenance phase. Wyatt’s second target (multiple
verbal words) increased with a large slope into the maintenance phase. Charlotte and Emerson

Figure 3. Study 3, children with DD: Frequency of parent communication strategy use and targeted
Note. Mae, Abigail, and Oliver’s communication targets: 1 = single verbal words, 2 = multiple verbal words. DD =
developmental delays.
demonstrated significant increases of their first target (signed single words) and a slight
increase of their second target (single verbal words) in the end of the intervention into the
maintenance phase. Peter started with a relatively high level of his first target (single verbal
words) during the baseline phase, and that frequency decreased slightly as his second target
production (multiple verbal words) increased with a significant steady upward trend. Similar
to Peter, Mila and Oliver demonstrated an upward trend of their second targets (multiple ver-
bal words) as their production of first targets (single verbal words) decreased. Abigail’s first
target production of single verbal words maintained a nonsignificant steady level without an

Brown and Woods 59
Table 4. Mean Frequencies Across Phases.
First three Intervention Last three Maintenance

Baseline phase intervention points phase intervention points phase
Parent intervention strategies
Study 1
Kailee 8.6 47 70.33 109 116
Charlotte 15.67 23 49.44 88 76.5
Emerson 24.29 27.33 48.99 63 49
Study 2
Peter 12.2 30.33 33.11 37.5 40
Mila 20.86 33.33 43.89 53.33 76
Wyatt 9.88 30 38.44 48.33 65
Study 3
Mae 25 64.33 53.56 40.67 40
Abigail 20 44 48.78 57.67 79
Oliver 14.63 29.33 30.33 30.67 40
Communication Target 1
Study 1
Kailee 0.4 2 23 35 50
Charlotte 0 0.67 7.11 13 23.5
Emerson 0.43 1.33 6 10.33 10
Study 2
Peter 13.2 9.33 9.56 10.5 13.5
Mila 10.57 39.33 23.44 14.66 24
Wyatt 1 3.33 13.67 21.33 10
Study 3
Mae 17.8 51 38 29.33 13.5
Abigail 15.67 15 14.78 20 18.5
Oliver 4.38 8 8.89 11.33 13.5
Communication Target 2
Study 1
Kailee 0 0 4.11 9.33 8
Charlotte 0 0.33 2.33 6.33 11.5
Emerson 1 1.33 2.22 4 5
Study 2
Peter 4.6 9 17.33 23.25 24.5
Mila 3.14 9 23.44 31.67 45
Wyatt 0 0.67 2.33 5 38.5
Study 3
Mae 13 17.33 32.56 39.33 29.5
Abigail 12 16.33 30 47.67 69
Oliver 0.5 6 18.89 26 24.5
increasing slope or level; whereas, her second target (multiple verbal words) frequency
increased with a significant upward trend with some variability along the slope. In a similar
pattern to her mother’s strategy use, Mae’s target communication frequencies had the most
variability among participants in all three studies. Despite this variability, Mae’s intervention
mean frequencies for both targets were higher than baseline means, and nonoverlap indices
indicated increased levels.

Table 5. Statistical Nonoverlap Analysis of Single Case Results for Parent Intervention Strategies and
Child Communication Targets.
PAND: Percentage of All Nonoverlapping Data

Responsive and modeling
% 93a 87a 88a 100a 100a 100a 93a 100a 94a
Scaled 0.857 0.733 0.75 1.00 1.00 1.00 0.857 1.00 0.882
Prompting/milieu
% 71b 93a 100a 71b 63c 47 64c 67b 71b
Scaled 0.43 0.867 1.00 0.428 0.25 -0.058 0.286 0.333 0.412
Target 1
% 85a 93a 88a 36 81a 88a 79a 47 65c
Scaled 0.714 0.867 0.75 -0.286 0.625 0.764 0.571 -0.067 0.294
Target 2
% 79a 73b 69%b 86a 94a 82a 93a 73%b 100a
Scaled 0.571 0.467 0.375 0.714 0.875 0.647 0.857 0.467 1.00
NAP: Nonoverlap of All Pairs

Responsive and modeling
NAP 0.93* 0.94** 0.81* 1.00*** 0.98** 1.00*** .95** 1.00*** .99**
p value .012 .005 .039 <.001 .002 <.001 .008 <.001 <.001
Prompting/milieu
NAP 0.84* 0.92** 1.00*** 0.78 0.51 0.67 0.79 0.80 0.79
p value .038 .008 <.001 .096 .959 .248 .092 .059 .052
Target 1
NAP 0.90* 0.94* 0.91** 0.18 .88* 0.81* 0.86* 0.45 0.83*
p value .016 .005 .007 .053 .011 .034 .033 .768 .024
Target 2
NAP 0.83* 0.79 0.71 0.92* 0.91** 0.83* 0.91* 0.82* 1.00**
p value .045 .077 .169 .011 .007 .021 .014 .045 <.001
Note. PAND scaled values can be compared with phi coefficients, ranging from 0 = no association to 1.0 = complete
dependence.
a.50 = large association.
b.30 = medium association.
c.10 = small association.
*p < .05. **p < .01. ***p < .001.
Fidelity
Fidelity was measured to ensure interventionists were implementing the intervention model as it
was planned and parents were participating and implementing the strategies as intended.
Interventionists’ implementation fidelity averaged 95.4% (range = 83%-100%) across the inter-
vention phase. There were no apparent patterns in fidelity items missed for interventionists.
Parents’ fidelity was measured with a mean of 94.9% (range = 71%-100%). Parents did not miss
more than two of the applicable items for any given session, and no parent consistently missed
the same item across sessions. Reliability of independently double scored sessions for fidelity
yielded 93% agreement.

Brown and Woods 61
Social Validity
Parents rated all items on the Parent Satisfaction Survey with a 4 or 5 (5 = yes, very satisfied, or
all the time, depending on the specific question). Parents considered themselves to be effective
in supporting their children’s communication and reported that their children were communicat-
ing at higher rates because of the intervention. They also reported that the time commitment was
reasonable, that they continue to use the strategies in daily routines and activities, and that they
would recommend the KTTP intervention to other families.
Discussion
These findings contribute to early communication intervention in four primary areas. First, the
results extend support for parent-implemented communication intervention for toddlers. Second,
the transactional relationship between parents’ increased use of responsive and modeling inter-
vention strategies and children’s increased targeted communication rates align with previous
research on parent responsiveness. Third, intervention that is congruent with recommended and
mandated practices of building parents’ capacity to support children’s development in family-
identified everyday activities and routines can yield positive parent and child outcomes. Last, it
is important to examine intervention approaches that are designed to meet the communication
needs of children with various primary and secondary communication disorders. These factors
are important for translation of research to practice for toddlers and their families receiving
community-based early intervention services.
Parent Implementation and Child Communication

Visual inspection of the parent’s intervention strategy use alongside her child’s target communi-
cation provides information about the relationship between each member of the dyad. Kailee,
Mila, Wyatt, and Abigail had steep upward trends in targeted communication rates, and their
parents demonstrated similar trends in implementation of responsive and modeling strategies.
Charlotte and Emerson presented with communication rate slopes that increased later in the inter-
vention process just as both of their parents increased their responsive and modeling strategy use
as the intervention progressed. Peter and Oliver, as well as both of their parents, had slight
increases in levels with variable upward trends for targeted communication rates and responsive
and modeling strategies. Mae demonstrated the most variable pattern of child communication
and, interestingly, that pattern aligned with her mother’s variable use of intervention strategies.
These congruent patterns support the functional relationship between parent and child communi-
cation (Hart & Risley, 1995; Landry et al., 2006).
Parents’ increase in responsive and modeling strategies congruent with their children’s
increase in targeted communication further supports the evidence for these strategies (e.g.,
Landry et al., 2006; McDuffie & Yoder, 2010; Siller & Sigman, 2008; Warren, Brady, Sterling,
Fleming, & Marquis, 2010). Specifically, parents’ continued use of strategies in everyday rou-
tines following completion of the intervention phase suggests that not only are these strategies
effective but are also attainable and functional for parents to maintain, which supports the notion
of family capacity-building in natural environments (Dunst & Trivette, 2009; IDEA, 2004).
Context of Coaching in Family-Guided Routines

Despite an increasing number of studies in which home environments were one of the contexts
(e.g., Roberts & Kaiser, 2012) or home routines were planned (e.g., Rogers et al., 2012), few
parent-implemented interventions were conducted using family prioritized routines in their home.
This study adds evidence that not only can parents learn to use intervention strategies, but they can

also do so in the context of their preferred routines as collaborators and decision makers in the
intervention process (Dunst, Bruder, Trivette, & Hamby, 2006; Wetherby & Woods, 2006; Woods
et al., 2004). Families identified the routines in which to embed intervention strategies, and the
integrity of each family’s routines was maintained. This family-guided coaching approach aligns
with adult learning principles of increased autonomy and ownership by focusing on enhancing
parents’ competence and confidence within activities in which the parents selected, actively
planned, and implemented (Bransford, Brown, & Cocking, 2000; Dunst & Trivette, 2009; Woods
& Brown, 2011). Additional research is needed to examine the best approach for parents who do
not respond, especially when they exhibit mental health and/or physical concerns.
Intervention Across Disorder Types

Although the small sample size of each study limits comparisons across etiologies, it is noteworthy
that parents and children with DS, ASD, and DD made gains from participating in this intervention
approach. Early intervention providers typically serve children with various primary and secondary
language impairments (Hebbeler et al., 2007), so finding effective practices that are not disability
specific may make the use of evidence-based practices more feasible. Specifically, understanding
intervention strategies that can be tailored to each child’s developmental level and communication
needs follows a descriptive developmental approach to intervention as opposed to a disability spe-
cific model (Paul & Norbury, 2011). This is especially pertinent to early intervention service deliv-
ery because a specific disability diagnosis is not needed for eligibility. Therefore, a provider might
be hesitant to use intervention approaches that are designed for a specific disability if the child has
not been identified with that diagnosis. It is also interesting that two of three children with DS
increased their use of single signed words at a faster rate than single verbal words, further support-
ing augmenting verbal communication to provide an effective and meaningful communication
mode for children as early as possible (e.g., Wright, Kaiser, Reikowsky, & Roberts, 2013).
Strengths and Limitations

Experimental control was enhanced and internal validity threats were decreased by providing
sufficient data points in the baseline and intervention phases, replicating phases within and across
participants, and studying three replications of multiple-baseline studies (Horner et al., 2005;
Kazdin, 2011; Kratochwill et al., 2010; Kratochwill & Levin, 2010). In addition, two nonoverlap
indices were used to support the visual inspection of data. The intervention phase length was
designed to be long enough for parents to learn to implement the strategies based on previous
studies of EMT that indicated parents’ implemented strategies with fidelity after 24 sessions and
for the strategies to have an effect on child communication without being too long, in which the
threat of maturation would be significant (Kazdin, 2011). The threat of testing was minimized
substantially by using video-recorded natural routines in typical intervention sessions.
External validity in single-case designs is established through effect and phase replication
across settings, participants, and researchers (Kratochwill et al., 2010). This series of studies dem-
onstrated replication across participants in family-guided routines. Examining this study along
with other family-guided routines in intervention studies (Kashinath et al., 2006; Woods et al.,
2004) provides an initial basis for the generalizability of using family-guided routines as the con-
text for communication intervention. Our results extend those of previous studies by demonstrat-
ing feasibility with younger children, using a limited number of specified intervention strategies
as a part of a manualized intervention, implementation with a defined family-guided coaching
approach, and increased rigor through various implementation and fidelity measures.
Although the results demonstrate support for family-guided communication interventions for tod-
dlers with various etiologies receiving Part C services, it is necessary to interpret the results in light
of the study’s limitations. Sampling and generalizability limitations are particularly relevant. Random

Brown and Woods 63
selection increased validity; however, there is limited empirical guidance for selecting the specific
number of intervention sessions and durations of samples. Therefore, it is possible that the selected
samples were not fully representative of the intervention. Internal validity could have been strength-
ened, with subsequent stronger basis for making effect claims, if measurement for each participant
was implemented concurrently. Changes in child communication could have been enhanced by fac-
tors outside the intervention, including maturation and experiences beyond the intervention.
Substantial threats to external validity are inherent to single-case designs until they have been suffi-
ciently replicated. Although components of this series of studies provide replication support to both
FGRBI and EMT, the specific results should not be generalized beyond the participating dyads.
Although the children presented with diverse communication profiles and diagnoses, two of the
children’s VDQs were within the average range, and only one child’s VDQ was more than two stan-
dard deviations below the mean. Therefore, the extension to children with more severe impairments
is limited. Functional relationships were demonstrated across dyads in the three studies; however,
single-case design was not sufficient to make comparisons of the intervention effect between etiolo-
gies. More so, it is important to be clear that because this study did not compare interventions, the
results do not suggest that this parent-implemented intervention yields greater results than other
parent-implemented interventions or is better than other intervention approaches.
In addition to internal and external validity threats, it is also important to recognize that rates
of broad communication forms were measured as child outcomes. Increasing communication
rate and form are useful outcomes, but they are limited in scope. Relevant components of com-
munication content and use were targeted in tandem with communication form and rate. For
consistent measurement and to align with the larger project’s use of IGDIs, content and use tar-
gets were not used as study measures.
Implications
This study yielded several implications for practice and future research by contributing to the evi-
dence base for delivering high-quality communication services for toddlers and their families
within the Part C early intervention system. Careful integration of EMT strategies with FGRBI and
a systematic coaching approach shows promise for communication intervention for infants and tod-
dlers within Part C. Specifically, coaching parents to implement systematic intervention strategies
within a variety of everyday routines was associated with increased communication rates and
expanded communication forms. The functional relationships exhibited across participants with
DS, ASD, and DD add support for this intervention for children with various etiologies and offer an
approach that may be useful for many children served on Part C caseloads. These findings illustrate
how intervention can be provided in natural environments—location (i.e., home and community),
context (i.e., family-identified routines and activities), people (family members, other caregivers),
and materials (family’s materials already used in routines)—by supporting caregivers to use inter-
vention strategies through a collaborative coaching approach to affect children’s communication
outcomes. That change in both parent and child behavior was achieved in the home environment
using everyday toys and materials lends support to a manualized approach with some flexibility and
that includes the parent participating in the decision-making process.
Additional research studying intervention approaches that can be implemented in Part C
services is important so SLPs and other early intervention providers can make evidence-based
decisions on the interventions they provide. Further examination is needed to align high-qual-
ity coaching practices, intervention strategies, and relevant child outcomes with the context in
which services are delivered. Research that integrates these components supports the needs of
toddlers with communication impairments and their families as well as the field’s implementa-
tion of evidence-based practice. It will also be important to examine whether implementation
fidelity can be maintained by providers using a manualized approach across a range of child
communication levels, disorder types, and family preferred routines and activities.

Appendix A
Intervention Fidelity Measurement Form
Appendix B
Treatment Enactment Fidelity Measurement Form

Brown and Woods 65
Authors’ Note
The opinions expressed are not those of the funding agencies, and no official endorsement should be
inferred.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-
cation of this article: Partial support for this research was provided by grants from the U.S. Department of
Education, Office of Special Education Programs—Kidtalk–Tactics Model Demonstration Center on Early
Childhood Language Intervention (H326M070004) and Project LIFE: Leadership in Family-Centered Early
Intervention Personnel Preparation Grant (H325D070023).
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Effects of A Triadic Parent-Implemented Home-Based Communication Intervention For Toddlers

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589350

Jennifer A. Brown1 and Juliann J. Woods2

1University of Georgia, Athens, GA, USA

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KidTalk–TaCTICS Project (KTTP)

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Study 1 Study 2 Study 3

Kailee Charlotte Emerson Peter Mila Wyatt Mae Abigail Oliver

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Child Baseline Session 8 Session 16 Session 24 Maintenance

Parent-implemented intervention strategies. Parents’ use of communication intervention strategies

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Table 3. Overview of Measured Communication Intervention Strategies Taught to Parents.

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Parent Communication Intervention Strategy Use

Child Target Communication Use

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Table 4. Mean Frequencies Across Phases.

First three Intervention Last three Maintenance

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PAND: Percentage of All Nonoverlapping Data

NAP: Nonoverlap of All Pairs

Kailee Charlotte Emerson Peter Mila Wyatt Mae Abigail Oliver

*p < .05. **p < .01. ***p < .001.

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Parent Implementation and Child Communication

Context of Coaching in Family-Guided Routines

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Intervention Across Disorder Types

Strengths and Limitations

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Declaration of Conflicting Interests

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p < .05. p < .01. p < .001.