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Relationship Focused Early Intervention with Children with
Pervasive Developmental Disorders and Other Disabilities: A Comparative Study
Gerald Mahoney, Ph.D.
Frida Perales, M.Ed.
Case Western Reserve University
Mandel School of Applied Social Sciences
10900 Euclid Avenue
Cleveland, Ohio 44106
Key Words: Early Intervention, Pervasive Developmental Disorders; Relationship Focused
(In Press) Journal of Developmental and Behavioral Pediatrics
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This study compares the effects of Relationship Focused Early Intervention on
toddlers and preschool aged children who were classified as having either Pervasive
Developmental Disorders (PDD) (N= 20) or Developmental Disabilities (DD) (N=30). The
intervention was conducted over a one year time period through weekly individual parent-
child sessions. It focused on helping parents use Responsive Teaching strategies to
encourage their children to acquire and use pivotal developmental behaviors that
addressed their individualized developmental needs. Pre- post- comparisons indicated
significant increases in parents’ responsiveness and children’s pivotal behavior. Both
groups of children made significant improvements in their cognitive, communication and
socio-emotional functioning. However, children with PDD made statistically greater
improvements on the developmental measures than children with DD. On several
developmental measures, children’s improvements were related to increases in both their
parents’ responsiveness and their own pivotal behavior.
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Relationship Focused Early Intervention with Children with Pervasive Developmental
Disorders and Other Disabilities: A Comparative Study
Relationship focused (RF) early intervention addresses the social emotional and
developmental needs of young children by encouraging parents to use strategies that are
designed to help them interact more responsively with their children. There is increasing
evidence that RF interventions are effective at promoting the cognitive and communication
functioning of young children with a variety of developmental risks or disabilities. More
than 15 published studies indicate that parents can be encouraged to engage in
responsive interactions with their children through the use of interactive strategies such a
“take one turn and wait”, “follow the child's lead” or “imitate your child”(1,2,3). In addition,
RF interventions that are implemented for six months or longer often result in significant
improvements in children's development.
Several have proposed that RF intervention could be an effective treatment for
children with Pervasive Developmental Disorders (PDD) (4,5,6,7). Enthusiasm for this
approach is related to at least two factors. First, research conducted with a range of
parents and children over the past 30 years indicates a moderate relationship between
maternal responsiveness and many of the developmental features that are problematic for
children with PDD, including cognition (8), language (9,10) and socio-emotional behavior
(11). Second, recent reports indicate that the same features of parental interaction that
affect the development of typically developing children and children with DD also influence
the development of children with PDD. Siller and Sigmund (12) reported data on 25
children with PDD which indicated that early measures of maternal responsiveness
predicted these children's language development during the preschool-aged period and
up through late adolescence.
Despite the promise of RF intervention, there is insufficient empirical evidence to
recommend this approach for children with PDD. To date, only one investigation of RF
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intervention has been published with this group of children. Greenspan and Wieder (13)
reported a chart study of 200 children. Comparisons of pre- post- data as well as
anecdotal reports suggested that several children made remarkable improvements in
developmental functioning and reduced many of their atypical behaviors. However, the
procedures of this study precluded definitive conclusions. In addition to lacking a control
group, there was inadequate documentation of the intervention, no record of how parents
and families followed through with intervention, and outcomes were assessed by informal
In this study we compare the effects of RF intervention for a one year time period
on the developmental and social-emotional functioning of two developmentally matched
groups: children with PDD and children with other types of Developmental Disabilities
(DD). The design of this study enables us to both replicate previous findings that RF
intervention is effective at promoting the developmental functioning of young children with
disabilities (DD), and to determine whether comparable effects can be accomplished with
children with PDD. The comparison of these two groups allows us to examine a prevailing
assumption of contemporary early intervention practice that children with PDD require
more highly structured and intensive developmental intervention than children with other
disabilities (14). Dawson and Osterling (4) maintain that children with PDD require
structured intervention methods because of their severe information processing deficits,
yet there is little empirical support for this assumption particularly for children less than
five years of age.
The RF intervention used in this investigation is Responsive Teaching (RT) (15).
RT is a newly developed, manualized curriculum that incorporates the instructional
strategies and intervention methods of two previous curricula which had been reported to
be effective with children with DD: the Transactional Intervention Program (16) and the
ECO model (17). RT differs from previous RF interventions insofar as it is based upon a
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logic model (See Figure 1) which asserts that the effects of responsive interaction
strategies on children’s development are mediated by the impact they have on children’s
“pivotal developmental behaviors” (18) (i.e., attention, persistence, interest, initiation,
cooperation, joint attention and affect). Consequently, the RT curriculum is organized
around 19 pivotal intervention objectives, which are behaviors that: (a) have been
described as core processes for cognitive, communication and socio emotional
development and (b) have been reported to be influenced by maternal
<Insert Figure 1 Here>
In this study, the effects of RF intervention are analyzed in relationship to the logic
model of RT. That is, this analysis will examine the relationships between RT intervention,
parental responsiveness, children’s pivotal developmental behavior, and children’s
developmental and socio-emotional outcomes. This procedure minimizes the likelihood
that observed intervention effects can be attributed to extraneous factors such as subject
selection bias, maturation, or children’s history of alternative treatments (20).
Subjects. Subjects included 50 mother-child dyads in which each of the children
had either PDD or other developmental delays (DD). Age ranges were 12 to 54 months,
with 85% of the children less than 36 months of age when they enrolled.
Table 1 presents the demographics of the subjects. The average age of the
mothers was 32.6 years and most were Caucasian (89.1%) and married (92.7%). Mothers
had 14.8 years of education, and almost one-half were working (47.3%). The children
were approximately two years old at the start of the study (26.4 months) and almost two-
thirds (62%) were boys. The only significant demographic difference between the two
groups was that children were significantly older in the PDD group (M=32.4 months) than
in the DD group (M=23.3 months).
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Children in the PDD group had been diagnosed by their physicians with autism
(n=10), autism with mental retardation (n=3) or Pervasive Developmental Disorders (PDD)
(n=7). In addition, these children’s scores on our developmental and social-emotional
measures indicated they met the DSM IV criteria for PDD at entry into this study. As
indicated on Table 1, each of the children had substantial delays in cognitive, symbolic
and communication functioning, and also had severe problems in social interaction and
self regulation as indicated by their scores on both the Temperament and Atypical
Behavior Scale (TABS)(21) and Infant Toddler Social Emotional Assessment (ITSEA)(22)
(See Table 1).
The overall scores for children in the PDD group on the TABS were 3 SD below
the mean, which met the criteria for Regulatory Disorder (21). Research indicates that
severe regulatory problems accompanied by deficits in communication and cognitive
development are highly predictive of a later diagnosis of autism (23). A retrospective study
of 65 parents of children with diagnosed autism reported that 86% of their children met the
TABS criteria of Regulatory Disorder when they were 1 year old (24).
<Insert Table 1here>
Each of the children with DD had significant delays in cognitive and/or
communication development (See table 1). Only 3 of the children in this group had
diagnosed medical conditions (cerebral palsy (n =1); Down syndrome (n=1); and
neurofibromatosis (n=1). The remainder of the children were identified by their parents as
having speech and language problems (n=14) or developmental delays (n=13).
As indicated on Table 1, although children with DD were younger than children
with PDD, the two groups had equivalent developmental age scores for the four domains
measured by the Transdisciplinary Play Based Assessment (TPBA) (25). Group
differences in children’s socio-emotional functioning as measured by the TABS were
significant. Children with PDD had significantly more problems in detachment (p=.000),
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under-reactivity (p=.001), and dysregulation (p=.004) than children with DD.
Procedures. Children received RT during weekly one hour parent-child sessions
that were conducted either at a center-based facility or in parents’ homes by one of six
early intervention specialists. Subjects participated in this study for approximately one
year (M= 11.3 months; SD=2.1). While subjects were scheduled for one session each
week, they received an average of 32.6 (SD=12.9) sessions. At the completion of
intervention, parents reported spending an average of 15.1(SD=2.4) hours each week
carrying out intervention activities with their children at home.
Data Collection. Child and family assessment data were collected at the beginning
and end of intervention. Three instruments were used to assess children’s development
The TPBA (25) is a play-based assessment for children up to six years of age.
This instrument meets the developmental assessment criteria recommended by Zero to
Three (26). It is especially useful for children who are under-represented in the normative
samples of standardized tests, such as children with DD and PDD. It provides these
children opportunities to engage in play activities in a manner that is compatible with their
behavioral style and developmental level.
Each of the play and social behaviors children produced during the observation
were transcribed from videotape recordings and coded according to their developmental
age level as reported in the Developmental Rainbow (27). Developmental Ages (DA)
were computed for two cognitive domains, Object Use and Symbolic Behavior, and two
language domains, Expressive and Receptive Language. DA’s were estimated by
independent raters based upon the highest age level of developmental behaviors children
consistently produced (i.e. more than ten times) during the observation for each of the
four developmental domains. Inter-rater reliability was calculated on 20 percent of the
observations. A t-test indicated no significant differences between the DA ratings for the
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two observers (t = 0.84; p>.05); and a Pearson correlation indicated their ratings were
highly correlated (r= .92; p<.001).
The Developmental Rainbow (27) s a child development profile that is designed to
be used to guide developmental observations and play based assessments of children
from birth through five years of age. This observational tool includes a detailed listing of
the skills and behaviors young children are likely to manifest across five developmental
domains: cognition, communication, social emotional functioning, motor development and
self help skills. Items included in this profile were compiled from several standardized
developmental assessment instruments and preschool curricula and organized according
to developmental age ranges.
The Infant Toddler Social and Emotional Assessment (ITSEA) (22) is a parent
respondent instrument that assesses the socioemotional behavior of children up to three
years developmental age. The scale measures four components of social emotional
functioning including internalizing (e.g., depression-withdrawal), externalizing (e.g.,
aggression, activity), regulatory problems (sleep and eating difficulties) and social
competencies (e.g., empathy).
The Temperament and Atypical Behavior Scale (TABS) (21) is a standardized
instrument for assessing problem behavior of children between one and six years of age.
It is a parent respondent instrument with 55 items that assess four factors: detached;
hyper-sensitive/active; under-reactive; and dysregulated. The TABS has been described
as a sensitive tool for the early diagnosis of Autism (28). A study reported by the
developers of the TABS showed that young children diagnosed with Autism meet the
Regulatory Disorder criteria on the TABS (29).
Pivotal Behavior. Children and their parents were videotape recorded while
playing together for seven-minutes with a set of developmentally appropriate toys.
Parents were instructed to play with their children as they typically do. The Child Behavior
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Rating Scale (CBRS) (30) was used to rate these observations to assess children’s
pivotal behavior. The CBRS has seven items that characterize children's engagement:
Persistence, Attention, Involvement/Interest, Initiation, Cooperation, Joint Attention and
Affect. Trained observers rated each of the items on a five-point Likert scale, ranging from
“1= very low to 5= very high”, after watching the videotaped observations.
Interactive Style. Parents’ style of interacting was assessed with the Maternal
Behavior Rating Scale (MBRS) (31) from the videotapes of parent-child play described
above. The MBRS is a twelve item scale that assesses four dimensions of interactive
style: responsiveness, affect, achievement orientation and directiveness. Research
indicates that the MBRS assesses parenting characteristics associated with children's
developmental growth; and that it is sensitive to changes in interaction promoted through
parent mediated interventions (32, 33).
Coding and Reliability of Parent-Child Observation. Observations of mother-child
play were coded by raters who had received at least 40 hours of training on each scale
and who had attained at least 80% agreement within one point on a five-point Likert scale.
To minimize rater bias, observations were randomly sorted so that pre- and post-
observations for each subject would not be coded consecutively, and pre- and post-
observations would be counter-balanced.
A second rater coded a random selection of 30% of all observations to assess
reliability. For the MBRS, interrater reliability using the Spearman correlation was r= 0.73;
p<.000. Raters attained 60% exact agreement and 99% agreement within one scale
point. Cohen’s Kappa was .43, p< .000. For the CBRS, interrater reliability using the
Spearman correlation was r = 0.77; p<.000. Raters attained 56% exact agreement and
100 % agreement within one scale point. Cohen’s Kappa was .48, p< .000. The level of
reliability attained for these two scales is consistent the levels of reliability reported for
previous studies in which these scales were used (33).
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Effects of RT on Parents’ Interaction and Children’s Pivotal Behavior. Results from
the MBRS are presented in Table 2. A repeated measure MANOVA indicated significant
intervention changes in mothers’ style of interaction. Univariate analyses indicated
significant increases in Responsiveness and Affect. While the Intervention x Group
interaction was not significant, univariate analyses showed significant interactions for two
MBRS subscales. Mothers of children with PDD made greater increases in
Responsiveness and Affect than mothers of children with DD.
<Insert Table 2 here>
Each of the behaviors measured by the CBRS increased during intervention (See
Table 2). A MANOVA indicated significant effects for Intervention and Intervention x
Treatment. Univariate analyses indicated significant intervention effects on all seven
CBRS items. Children with PDD made greater improvements on all items than children
RT Effects on Children’s Development and Socio-Emotional Functioning. Pre-
post- developmental age scores are reported on Table 3. To assess intervention effects
on children’s cognitive and language development we first compared the level of
developmental functioning children attained at post-intervention with the level of
development they were expected to attain based upon assessments of their
developmental functioning at pre-intervention. Expected Developmental Ages were
calculated using the formula [DA1 + (DA1/Chronological Age1 x Months of Intervention)].
A repeated measures MANOVA indicated that the effects of Intervention and Intervention
x Group were both significant at p<.01. Univariate analyses indicated that Developmental
Age scores at post intervention were significantly greater than Expected Developmental
Ages for all four developmental domains. Children with PDD made significantly greater
improvements than children with DD in object relations and receptive language.