Coaching Parents of Young Children with Autism in ...

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provides long-distance training and coaching via the Internet to parents of young children with autism spectrum disorders (ASD). The i-PiCS program.
Coaching Parents of Young Children with Autism in Rural Areas Using Internet-Based Technologies: A Pilot Program Hedda Meadan Lori E. Meyer Melinda R. Snodgrass James W. Halle University of Illinois at Urbana-Champaign

Abstract The purpose of this paper is to describe a pilot program (i.e., Internet-Based Parent-Implemented Communication Strategies [i-PiCSJ program) that provides long-distance training and coaching via the Internet to parents of young children with autism spectrum disorders (ASD). The i-PiCS program is designed to teach parents how to use evidence-based teaching strategies to improve the social communication skills of their children with ASD. We describe components of a parent-training program that capitalizes on evidence-based strategies and highlights the potential for delivering this program via the Internet. Potential barriers, benefits, and implications for practice and research are discussed.

Keywords: Communication strategies, autism spectrum disorder, parent training, Internet delivery Autism refers to a wide spectrum of complex developmental disorders that typically appear during the first 3 years of life. It is estimated that 1 in 50 U.S. children has autism based on parent report of school age children; this is a significant increase from the previous 2003 estimate of 1 in 150 children (Center for Disease Control and Prevention [CDC], 2013). The American Psychiatric Association (APA; 2013) recently released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) that includes several changes related to the autism diagnosis: (a) the name of the category was changed from Pervasive Developmental Disorder (PDD) to Autism Spectrum Disorder (ASD); (b) three of the previously separate subcategories under PDD have been eliminated and are now included under the broader ASD diagnosis (i.e.. Asperger syndrome. Pervasive Developmental Disorder-Not Otherwise Specified [PDD-NOS], childhood disintegrative disorder), and Rett Syndrome was eliminated from the DSM-V since the gene that causes it has been identified; (c) the three previous domains of autism symptoms (i.e., social impairment, language-communication impairment, and repetitive/restricted behaviors) have been distilled into two domains (i.e., social communication impairment and restricted interests/repetitive behaviors); and (d) a new category. Social Communication Disorder (SCD), was added to the DSM-V to allow for a diagnosis of disability in social communication skills when there is an absence of repetitive behavior (Autism Speaks, 2013). Due to national trends indicating an increase in the number of children identified with ASD, there is an obvious need to design research-based inter-

ventions to support the development of individuals with ASD. Boyd, Odom, Humphreys, and Sam (2010) emphasized that families need to have access to research-based interventions as part of a responsive service delivery system for young children with ASD. Researchers have reported that parents can learn new strategies and implement them effectively with their children (McConachie &L Diggle, 2007; Meadan, Ostrosky, Zaghlawan, & Yu, 2009; Roberts & Kaiser, 2011). Parent-implemented interventions for young children with disabilities have been found to be effective in etihancing children's communication repertoires and skills in other behavioral domains (e.g.. Kaiser, Hancock, &. Nietfeld, 2000; Mobayed, Collins, Strangis, Schuster, & Hemmeter, 2000; Schultz, Schmidt, &. Stichter, 2011). The purpose of this paper is to describe a pilot program (i.e., Internet-based ParentImplemented Communication Strategies [i-PiCS]) that provides long-distance training and coaching via the Internet to parents of young children with ASD. This program is responsive to current needs and current knowledge related to early intervention (El) for children with ASD.

Early Intervention Services for Young Children with ASD High-quality El programs are characterized by services that are developmentally appropriate, evidence-based, and delivered in the child's natural environment (Bruder, 2010). In addition, the Individualized Eamily Service Plan (IFSP)

Authors' Note Address all correspondence to Hedda Meadan ([email protected]).

Rural Special Education Quarterly -f Volume 32, No. 3—pages 3-10 >• ® 2013 American Council on Rural Special Education Reprints and Permission: Copyright Clearance Center at 978-750-8400 or www.copyright.com

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that is developed in coordination with El service providers should include goals that are family-centered and based on the child and family's strengths. These characteristics of El programs are mandated by law and/or are recommended practices in the field (Bruder, 2010; IDEA, 2004; Sandall, McLean, &. Smith, 2005). Moreover, it is critical for all young children, including young children diagnosed with ASD, to receive high-quality El services in order to promote positive, long-term developmental outcomes (Schertz, 2010). Early intervention services for young children with ASD often consist of multiple approaches based on behavioral and developmental theories, and often these approaches are combined. Researchers have identified an array of evidencebased practices that are effective for children with ASD (Odom, Collet-Klinenberg, Rogers, & Hatton, 2010). Although much of the research has focused on older children with ASD rather than infants and toddlers, several evidencebased practices are believed to be promising for younger children with ASD (Boyd et al, 2010). Notably, many of these evidence-based interventions have been combined and used in what are known as comprehensive treatment models (CTMs), and several CTMs have been found to be appropriate and effective for infants and toddlers with ASD (Odom, Boyd, Hall, & Hume, 2010). Woods and Saffo (2011) summarized the necessary elements of interventions designed for children with ASD (ages birth through 8) based on the National Research Council's 2001 recommendations. The characteristics of effective interventions include: (a) entry into intervention programs as soon as ASD is suspected; (b) active engagement in intensive instruction for a minimum of five hours per day, five days a week; (c) use of repeated, planned teaching opportunities that are structured over brief periods of time; (d) sufficient individualized adult attention on a daily basis; (e) inclusion of a family component, including parent training; (f) mechanisms for ongoing assessment with corresponding adjustments in programming; and (g) priority for instruction on: (1) functional, spontaneous communication, (2) social instruction across settings, (3) play skills with a focus on peer interactions, and (4) new skill maintenance assessment and positive behavior support to address problem behaviors (p.

277). Despite the availability of evidence-based practices and a clear delineation of necessary intervention elements for delivering El services to young children with ASD, challenges still remain for the El field (Bruder, 2010).

Challenges for Early Intervention Service Providers in Rural Areas Numerous challenges may affect the delivery of highquality El services to young children with ASD and other children and families who qualify for El and live in rural areas. First, as the number of children in need of El services increases, there continues to be a shortage of El service providers, and this shortage is particularly acute in rural areas (Cason, Behl, &. Ringwalt, 2012; Hebbeler, Spiker, &. Kahn, 2012). Second, this shortage in personnel is often com-

pounded by the extensive travel time that may be required to reach children who live in rural areas, with some El providers traveling up to 2 Vi hrs one-way in order to provide services to a single child in his/her home setting (Olsen, Fiechtl, & Rule, 2012). As a result, in some rural areas, services are only available in a clinic or hospital (Kasprzak et al., 2012). When EI providers deliver services outside of a child's home, the burden of traveling, regardless of distance, is unduly shifted to families. Third, children living in rural areas are more likely to be living in poverty than children in urban areas, as the poverty rate in rural areas is 25% higher than in urban areas (Cason, 2009; Hallam, Rous, Grove, & LoBianco, 2009). Hallam et al. (2009) found that families living in rural counties with high poverty rates had access to significantly fewer types of El services and that these services were delivered less often and for a shorter duration during each session. They also found that, when El services were available, families living in poverty without access to health insurance often struggled to pay for therapy (Hallam et al., 2009). Given these challenges, there is a clear need for new, innovative El service-delivery options for young children and their families living in rural areas. Innovations focused on the Internet and other related technologies could be a promising new direction.

Intemet'based Interventions in El Internet-based interventions offer one potential solution to some of the challenges associated with rural El service delivery. Access to the Internet for service delivery has increased over the last few years. In fact, a major component of the American Recovery and Reinvestment Act (2009) focused on increasing access to high-speed Internet in communities throughout the United States by providing financial support to enhance the country's infrastructure for broadband technology (The Recovery Board, 2009). As of June 2012, 98% of Americans had access to Internet download speeds of at least 3 megabits per second (Mbps), and 78.5% of Americans had access to broadband speed of 25 Mbps, the speed considered basic and sufficient for video-conferencing (U.S. Department of Commerce, 2013). With widespread, appropriate infrastructure, Internet-based interventions would not only be more accessible, but also more costefficient and flexible in comparison to traditional servicedelivery options (Baggett et al., 2010). In recent years, professional development activities delivered over distance using Internet technologies has been proven effective in both education and health fields (e.g., Baggett et al., 2010; Moore, Fazzino, Garnet, Cutter, & Barry, 2011; Pickering &. Walsh, 2011). Opportunities for distance learning are a great vehicle to increase service providers' knowledge and skills regarding the use of evidencebased strategies; however, professional development activities for service providers alone may not sufficiently ensure that children with ASD will have access to effective interventions (Wainer &. Ingersoll, 2013). With this in mind, parent involvement always has been an important component of El; as we know, parents are not only able to learn new intervention strategies, but also learn how to implement them effectively (Roberts & Kaiser, 2011). Therefore, Internet technologies could be used to teach parents how to effectively

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implement evidence-based strategies with their children with ASD. Currently there is limited information about the application of long-distance coaching models for parents of children with ASD (Vismara, Young, Stahmer, Griffith, & Rogers, 2009). Due to this gap in the literature, we are currently conducting a pilot study to examine the effectiveness of an Internet-based parent training and coaching program delivered to families of young children with ASD.

The Parent'Implemented Communication Strategies (PiCS) Program Deficits in social-communication are one of the core features of ASD; individuals with ASD exhibit delays, deficits, or atypical characteristics in the frequency, type, and quality of social interaction and social relationships with other individuals (CDC, 2013; APA, 2013). Because socialcommunicative competence acquired at an early age is critical for later life adjustment, for acceptance by others, and for quality of life, receiving El services is important. Many investigators (e.g.. Kaiser &. Roberts, 2011; Yoder & Warren, 1999) have addressed social-communication deficits through early communication intervention. These researchers have reported that teaching parents to use strategies that support their children's language development is an important component of effective and enduring early communication intervention (Roberts & Kaiser, 2011). With support from the U.S. Department of Education, Institute of Education Sciences (IES), Meadan, Angelí, Stoner, and Daczewitz (in press) developed the ParentImplemented Communication Strategies (PiCS) program to improve the social-communication skills of young children with ASD and other developmental disabilities (DD) who have limited expressive language. The PiCS research project focused on the development of family-specific, parentimplemented teaching strategies to enhance the child's social communication skills. By emphasizing family-specific interventions that caregivers can implement in their home, the PiCS project taught parents naturalistic and visual teaching strategies that could be generalized across the numerous naturalistic communication opportunities they encountered with their child. The PiCS program included many of the best practices in early intervention including (a) teaching in the child's natural environment (e.g., homes), (b) using research-based teaching strategies to promote social-communication behavior (e.g., milieu teaching strategies), and (c) collaborating with parents in developing and implementing intervention. For years, researchers have documented the effectiveness of naturalistic teaching strategies in promoting and enhancing communication skills (e.g., Halle, 1982; Hart, 1985; Hart &. Risley, 1975; Kaiser & Roberts, 2011). Milieu language teaching that includes modeling, mand-model, time delay, and incidental teaching is a naturalistic teaching program with prodigious empirical support (Hart, 1985; Kaiser & Roberts, 2011). Armed with these strategies, parents can capitalize on children's interest in any object, activity, or situation by using the strategies to teach communication during naturally occurring, spontaneous opportunities. This approach to addressing social-communication holds promise not only for enhancing the communication skills of young Rural Special Education Quarterly

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children with disabilities and limited expressive language, but also for increasing parents' capacity to support their child's communication skills, thereby improving their quality of life and that of their family members (Meadan, Stoner, & Angelí, 2013). Meadan et al. (in press) have developed training materials for the PiCS program and piloted the intervention with families with young children with disabilities and very limited expressive language. They have trained and coached parents in their homes to implement four evidence-based naturalistic teaching strategies (i.e., environmental arrangement, modeling, mand-model, and time delay) and three visual strategies (i.e., visual schedules, visual rule reminders, and visual task analyses). After training, in collaboration with the PiCS coaches, parents developed social-communication goals based on their children's home routines (e.g., meal time, free play). They then coached parents 2 or 3 times each week until they reached an established criterion for using each strategy (Stoner, Meadan, & Angelí, in press). They collected data on both parent and child behavior during naturally occurring parent-child interactions. In addition, they asked parents to evaluate their own implementation of the naturalistic and visual teaching strategies. The data resulting from piloting the PiCS program are promising: parents learned the new strategies and implemented them with integrity. In addition, parents reported that their children's socialcommunication skills improved (e.g., their communication acts were clearer and resulted in positive changes in entire families' interactions with the target children; Meadan et al., 2013; Stoner, Meadan, Angelí, &. Daczewitz, 2012).

Internet-based Parent-Implemented Communication Strategies (i-PiCS) Program To address the need for El services of families living in rural and remote areas, we modified the in-person PiCS program to be delivered via Internet technologies (i.e., the iPiCS program). The Internet permits direct communication, including two-way audio and visual input, between the researchers or service providers and parents. The i-PiCS program includes five phases (see Figure 1) that are described in more detail below.

Pre'intervention Evaluation In the first phase of the i-PiCS program, a speech and language pathologist (SLP) visits the family home to conduct, in person, the Preschool Language Scale—5'^" edition (PLS-5; Zimmerman, Steiner &. Pond, 2012) to evaluate the child's social-communication skills prior to the intervention. (The pre- and post-intervention visits with the SLP are the only inperson contact the parent encounters.) In addition, parents are asked to complete two assessments, the MacArthur Bates Communicative Development Inventory (MCDI; Fenson et al., 2007) and the Ages & Stages: Social Emotional Questionnaire (A&.S:SEQ; Squires & Bricker, 2009).

Technology Training In the second phase of the program, the first longdistance meeting between the parent and the i-PiCS team member(s) is held. This meeting may be conducted via the

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Figure 1. An overview of the i-PiCS Program

Pre-lntervention Evaluation

Technology Training

Naturalistic Teaching Strategies Training

Naturalistic Teaching Strategies Coaching

Environmental Arrangement Strategy

Post-Intervention Evaluation

telephone or via video-conferencing technology (e.g., Skype^*^), based on the parent's preference. In this meeting, the parent is taught to use the technologies that are used in the i-PiCS program, including (a) Box, a secure online file sharing service; (b) iCal®, an Apple calendar application; (c) iPad®, an Apple tablet computer; and (d) Skype^*^, software for video-conferencing. See Table 1 for a description of the technology and how each is used in the i-PiCS program. In addition to the verbal description of how to use each technology tool, the parents receive, via U.S. mail, a manual with written procedures for using the technology and a DVD with video clips demonstrating how to use each technology (e.g., how to connect the iPad® to the Internet, how to upload videos to Box.com®).

Naturalistic Teaching Strategies Training In the third phase of the i-PiCS program, i-PiCS team members instruct the parent in the four naturalistic teaching strategies: (a) environmental arrangement, (b) modeling, (c) mand-model, and (d) time delay. Environmental arrangement requires the parent to arrange the environment in a

way that will increase the likelihood that the child will communicate (e.g., parent places a preferred book in sight but out of the child's reach). Modeling occurs when the parent produces a word, sign, or gesture and expects the child to imitate the production (e.g., parent looks at the child and says/signs "book"). When using mand-model, the parent issues a verbal prompt in the form of a question (e.g., "What do you want?"), a choice (e.g., "Do you want the book or the car?"), or a mand (e.g., "Sign 'book'") in addition to the model. Time delay is achieved when the parent pauses to give the child an opportunity to initiate communication within an established routine (e.g., child finishes his milk, and the parent holds up the container and looks expectantly at the child for 5 s, waiting for a request for "more"). To prepare for the naturalistic-strategy instruction, the team members share the training materials with the parent on Box.com®. Then, during the instructional session that is conducted via Skype^M^ the team members and parents: (a) discuss information about the social-communication intervention; (b) review handouts, flowcharts, and examples for each of the four teaching strategies; (c) watch with the parent.

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by sharing the screen, video clip examples of a parent practicing each of the target strategies with a young child with a disability; (d) collaborate to develop an action plan of how the parent will apply the strategies in everyday family routines; and (e) address any parent questions and concerns.

Naturalistic Teaching Strategies Coaching In the fourth phase, following training, an i-PiCS team member coaches the parent via Skype^'^ on using environmental arrangement in conjunction with each of the three remaining strategies separately until the parent has reached an established performance criterion. After criterion is met for modeling with environmental arrangement, the pair transition to coaching on mand-model with environmental ar-

rangement and, after reaching criterion, they transition to using time delay with environmental arrangement. The coaching protocol is based on the coaching characteristics outlined by Rush and Shelden (2011); Friedman, Woods, and Salisbury (2012); and Stoner et al. (in press). In the coaching protocol, the parent and coach have pre- and post-observation vidéoconférence meetings via Skype^^. Following the pre-observation meeting, the parent places the iPad® on a tripod to allow the coach to observe the parent interacting with his/her child via Skype^*^, and the coach records the interaction using the Camtasia® software (see Table 1 for description of Camtasia®). Immediately after the observation, the parent and coach have a post-observation meeting in which the coach asks the parent to reflect on his/her implementation

Table 1. Technologies Used in i-PiCS Program Box.com©

Secure, online file sharing service (i.e., "cloud")

Shared documents, video, and data 1. within the research team 2. with parents 3. allow parents to record and upload video of their interactions with their child

Camtasia®

Screen video capture software

Recorded the audio and video of SkypeTM sessions with families Edited and annotated videos of the parent and child interacting and used to provide feedback to parent

iCal®

Apple calendar application

Created and used a shared calendar with each family Set alerts for events to remind families to turn in self-reports, prepare for training and coaching sessions, etc.

i Pad®

Apple tablet computer

Gave to each participating family for the duration of the study to allow them to 1. record videos of their interactions with their chiid 2. view and edit study documents 3. SkypeTM with research team members

SkypeTM

Software for videoconferencing, voice messaging, and instant text messaging

Video-conferenced with parents to 1. introduce research team members and conduct preliminary interviews 2. conduct training on naturalistic teaching strategies 3. conduct pre- and post-observation coaching conferences with parents 4. observe parents interacting with their child.

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of the teaching strategies and then provides feedback on the parent's implementation of the targeted teaching strategies. In some coaching sessions, the coach and parent watch a video clip of a previous parent-child interaction using the screen-sharing feature of Skype^^^^ so that both the parent and coach are watching the video simultaneously and can comment as they watch. The parent and coach then discuss the quality of the parent's implementation of the naturalistic teaching strategy and discuss any needed changes.

In addition, the i-PiCS program has the potential to close the gap between research and practice by translating researchbased findings into curricula and procedures that parents can implement in their homes. It also may facilitate the transition from a clinic-expert service delivery model, in which an expert conducts the intervention with the child in a structured setting, to a natural-environment-parent model in which a parent implements the intervention with the child in daily routines.

Post-intervention Evaluation

Although there are many potential benefits that could accrue with implementation of the i-PiCS program, there are some potential barriers to using an Internet-based program to train and coach parents of children with ASD. First, in a survey of the current use of telehealth or teleintervention for El services delivered using distance technologies, coordinators for IDEA Part C services across 26 states and 1 jurisdiction identified concerns about (a) security and privacy, (b) quality of services, (c) reimbursement and billing, and (d) technology infrastructure, such as the availability of broadband/high-speed Internet connection (Cason et al., 2012). Respondents also expressed concern about the "lack of evidence to support the effectiveness of a telehealth service delivery model within IDEA Part C programming" (p. 42). We believe that the pilot i-PiCS program will contribute to the growing body of evidence to support the use of long-distance service delivery (Vismara, McCormick, Young, Nadhan, &. Monlux, 2013) and that it addresses some of the concerns identified in the survey above (e.g., security and privacy, technology infrastructure). Each year, access to Internet and broadband services has increased in both rural and urban areas in the U.S., and programs currently are being implemented to provide faster Internet to areas that historically have gone without such service (e.g., Google Fiber; U.S. Department of Commerce, 2013). Despite these promising developments, there is a disparity in the speed of the broadband services available, with urban residents having more access to faster Internet speeds. In addition, the socio-economic status of some families living in rural areas might prevent families from purchasing available broadband connections, causing another barrier to the implementation of this program. The viability of programs, like i-PiCS, that depend on Internet-based technologies will be limited to those people with access to the broadband speeds necessary to support videoconferencing applications and the other technologies necessary to confer potential benefits offered by the programs. Another potential barrier of using Internet technology to deliver El services is the possible impact on the degree of rapport that can be established with the family. Building rapport (i.e., harmonious interaction between two people in which each person's feelings and ideas are understood and communicated well) with families is an essential component of family-centered services in El (Pletcher & Younggren, 2011); however, attempting to build rapport in a long-distance Internet relationship can be challenging. The technology adopted for long-distance training and coaching may interfere with building rapport (Murphy &. Rodriquez-Manzanares, 2012). For example, a poor connection over Skype^^ may cause the coach or parent to miss critical

Potential Barriers for the i-PiCS Program

In the post-intervention phase, the SLP visits the family home again to evaluate the child's social-communication skills. The same assessments administered in the preintervention evaluation, with both the parent and the chiild, are repeated in the post-intervention evaluation.

Program Evaluation We currently are working with a few families to evaluate the effectiveness of the i-PiCS program. The research design and data-analysis procedures employed are derived from single-case, or within-subject, experimental research methodology (Kazdin, 2011). Recent publications and reports emphasize the importance and strengths of single-case research as an experimental methodology (e.g., Horner et al., 2005; Kratochwill et al., 2010). We are employing a multiplebaseline design across strategies within each family. In this design, intervention effects are demonstrated by observing changes in parents' implementation of each specific teaching strategy when, and only when, that strategy is introduced to the parent. If changes in parent implementation of each strategy occur only when the strategy is taught (and not before), this pattern of data renders threats to internal validity (e.g., history, maturation, testing, regression) implausible. Therefore, we are using this experimental design to examine the effect of the long-distance i-PiCS intervention on changes in the quality and frequency of parents' implementation of the naturalistic teaching strategies when we introduce training and coaching. We also are examining the effect that changes in parents' use of the strategies have on their children's communicative behavior. To date, we have gathered data on three families. Preliminarily, the data indicate that the parents felt comfortable with the use of the Internet technologies and learned how to implement the strategies, correctly, with their children.

Discussion Potential Benefits of the i-PiCS Program Although we still need to analyze the data from the pilot study that is currently in progress, we believe that the i-PiCS program has the potential to increase access to evidence-based practices for many children with ASD and their families who live in remote and rural areas. Furthermore, because the program focuses on teaching parents to use evidence-based strategies to promote their children's social-communication behavior, the i-PiCS program may increase parents' knowledge and capacity to support their children's communication skill development. This, in turn, may enhance communication skills of children with ASD as their parents deliver ongoing, frequent, evidence-based interventions in their everyday settings.

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information. Parents and coaches using long-distance technologies also may find it more difficult to discern nuances of conversation, such as sarcasm and humor (Murphy & Rodriquez-Manzanares). Notwithstanding the potential challenges that providing services via long distances can introduce to building rapport, we have identified and intentionally addressed some indicators of rapport (e.g., personal or non-task related information is solicited, such as inquiring about other family members; support, guidance, and feedback of a personal nature are provided) in our interactions to date with participating parents during the experience we have had with the i-PiCS program. We hope to explore this component more systematically in future studies.

In summary, the purpose of this paper was to describe a pilot program (i-PiCS) that provides long-distance training and coaching via the Internet to parents of young children with ASD. Although we still need to evaluate its feasibility and effectiveness with a large number of families, the i-PiCS program and other long-distance interventions have the potential to address many of the barriers to providing high-quality El services to families in rural areas. By increasing access to evidence-based practices for children with ASD and their families who live in rural areas and, thereby, promoting the social-communication skills of their young children with ASD, we hope that the i-PiCS program will add to the growing body of research in support of long-distance El services and to parent-implemented interventions.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of Kaiser, A. R, Hancock, T. B., &. Nietfeld, ]. R (2000). The effects of parentmental disorders (5tii ed. text rev.). Washington, DC: Author. implemented enhanced milieu teaching on the social communication of children who have autism [Special Issue]. Journal of Early Education and Development, 4, 423American Recovery and Reinvestment Act (ARRA) of 2009, Pub. L. No. 111446. doi:10.1207/sl5566935eedll04_4 5, 123 Stat. 115(2009). Kaiser, A. P. & Roberts, M. Y. &. (2011). Advances in early communication Autism Speaks (2013). DSMV. Retrieved from http;//www.autismspea](s.org/ and language intervention. Journal o/Earlj intervention, 33, 298-309. what-autism/dsm-5 Kasprzak, C , Hurth, ]., Rooney, R., Goode, S. E., Danaher, J. C , Whaley, K. Baggett, K. M., Davis, B., Feil, E., Sheeber, L., Landry, S., Carta, J., & Leve, C. T., . . . Cate, D. (2012). States' accountability and progress in serving young chil(2010). Technologies for expanding the reach of evidence-based interventions: Predren with disabilities. Topics in Early Childhood Special Education, 32, 151-163. doi: liminary results for promoting social-emotional development in early childhood. 10.1177/0271121411408119

Topics in Early CkiUhood Special Education, 29, 226-238.

Boyd, B. A., Odom, S. L., Humphreys, B. P., & Sam, A. M. (2010). Infants and toddlers with autism spectrum disorder: Early identification and early intervention. Journal of Early Intervention, 32, 75-98.

Bruder, M. B. (2010). Early childhood intervention: A promise to children and families for their future. Exceptioruxi Children, 16, 339-355. Cason, J. (2009). A pilot telerehabilitation program: Delivering early intervention services to rural families. International Journal of Telerehahilitation, I, 29-38.

Kazdin, A. E. (2011). Single