Browsing by Author "Franz, Lauren"

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    Barriers and Facilitators to Implementing a Caregiver-Coaching Early ASD Intervention in South Africa
    (2019) Makombe, Chipo Belindah Theodorah; Shabalala, Nokuthula; Franz, Lauren
    Sub-Saharan Africa (SSA) has a scarcity of research on autism spectrum disorder (ASD) and available early interventions, as most of what is known about the disorder is from highincome countries. Early detection and intervention methods were found to have positive effects on developmental delays and to alleviate symptom severity in children with ASD or at risk of it. There is a need for scalable interventions in low-resource settings, which are characterised by a lack of highly-trained specialists, infrastructure and funding. This study explored the barriers and facilitators to implementing and sustaining a caregiver-coaching ASD early intervention, informed by the principles of the Early Start Denver Model (ESDM), adapted for South Africa and for delivery by non-specialists. The study also identified some changes that could be made to improve intervention adoption and sustainability. Nine multilevel stakeholders involved in the implementation of the caregiver-coaching intervention were purposively sampled, individual in-depth interviews were conducted, transcribed verbatim and thematically analysed. Major implementation facilitators included: ECD worker baseline ASD knowledge and experience; skills gained from the training received and coaching; clear in-session caregiver-coaching structure; value of strong team relationships; clear video illustration of intervention concepts; and the mastery and generalisation of skills by the ECD workers, ECD supervisors and caregivers. Implementation barriers included: the complexity of the intervention and coaching concepts; misalignment of ECD teacher training with the caregiver-coaching approach; logistical challenges; and mismatch of the video content with the South African context. Facilitators to sustain the intervention included: child outcomes; caregiver ‘buy-in;’ and competence; and the need for ongoing live supervision. Barriers to sustaining the intervention included: structural issues of poverty, transportation and unemployment. Positive child and caregiver outcomes could be offset by larger contextual and system-level issues such as poverty and the need for ongoing support, supervision and local coaching materials in South African languages. The results will inform tailoring of the intervention training and supervision approach for a larger pilot study.
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    Bringing Parent–Child Interaction Therapy to South Africa: Barriers and Facilitators and Overall Feasibility—First Steps to Implementation
    (2022-04-07) Dawson-Squibb, John-Joe; Davids, Eugene Lee; Chase, Rhea; Puffer, Eve; Rasmussen, Justin D M; Franz, Lauren; de Vries, Petrus J
    There is a large assessment and treatment gap in child and adolescent mental health services, prominently so in low- and middle-income countries, where 90% of the world’s children live. There is an urgent need to find evidence-based interventions that can be implemented successfully in these low-resource contexts. This pre-pilot study aimed to explore the barriers and facilitators to implementation as well as overall feasibility of Parent–Child Interaction Therapy (PCIT) in South Africa. A reflective and consensus building workshop was used to gather South African PCIT therapist (N = 4) perspectives on barriers, facilitators, and next steps to implementation in that country. Caregiver participants (N = 7) receiving the intervention in South Africa for the first time were also recruited to gather information on overall feasibility. Facilitators for implementation, including its strong evidence base, manualisation, and training model were described. Barriers relating to sustainability and scalability were highlighted. Largely positive views on acceptability from caregiver participants also indicated the promise of PCIT as an intervention in South Africa. Pilot data on the efficacy of the treatment for participating families are a next step. These initial results are positive, though research on how implementation factors contribute to the longer-term successful dissemination of PCIT in complex, heterogeneous low-resource settings is required.
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    Describing caregiver-child outcomes and caregiver perceptions of non-specialist caregiver coaching for autistic children in South Africa
    (2023) Dawood, Zahra Ismail; Harty, Michal; Franz, Lauren
    Background: There is limited access to caregiver coaching using naturalistic developmental behavioural interventions (NDBI). Caregiver use of NDBI strategies can support growth in a child's joint attention skills and engagement, which in turn may promote child language acquisition. Caregiver's access to coaching may be increased using a cascaded task-sharing approach where coaching is delivered by non- specialists. When interventions are adapted to new contexts, implementation outcomes such as acceptability, appropriateness and feasibility need to be tracked alongside behavioural changes. In this proof of principle study, carried out in Cape Town, South Africa, caregiver-child behavioural outcomes and caregiver perceptions of the strategies that were taught in a task-sharing coaching intervention delivered by non-specialists are described. First, the Joint Engagement Rating Inventory (JERI) was used to assess changes in child behaviours, caregiver behaviours, and dyadic engagement in 10 caregivers and their children, in response to 12, 1-hour NDBI- informed caregiver coaching sessions. Then 10 another set of caregivers were interviewed to understand their outcomes and perceptions of the acceptability, appropriateness, and feasibility of the caregiver coaching strategies. Methods: 20 caregiver-child dyads (caregiver: ≥18 years old; child: DSM-5 diagnosis of autism spectrum disorder, 18-72 months, African or Coloured (mixed race)) received 12, 1-hour NDBI-informed coaching sessions. While delivery modality differed due to COVID-related restrictions (10 received in-person coaching and 10 received telehealth coaching), the coaching session content remained the same. The JERI was used to capture child joint engagement and social communication skills, caregiver ability to support and extend their child's abilities, and fluency of the dyadic interaction for 10 caregiver-child dyads. Summary statistics (median and interquartile range) were presented graphically for each participant (in-person coaching group). An additional 10 caregivers, in the telehealth coaching group, completed qualitative interviews to elicit perceptions of coaching strategies. Interviews were audio-recorded, transcribed verbatim and analysed using directed content analysis focusing on the acceptability, appropriateness, and feasibility of the coaching strategies. Results: There was a general increase in JERI caregiver items. The median for caregiver strategies including scaffolding and following in on child's focus increased from pre-intervention (Mdn=5) to post-intervention (Mdn=6). In addition, an increase was also seen in caregiver language facilitation and communicative temptations, pre- (Mdn=4) and post-intervention (Mdn=5). Children spent a similar amount of time in object (Mdn=2) and joint engagement (Mdn=6) states pre- and post- intervention. Children's responsiveness to their caregivers pre- and post-intervention was similar (Mdn=4.5) however, an increase in attention to caregiver was noted pre- (Mdn=3.5) and post-intervention (Mdn=4). The greatest increase was seen in child expressive language pre- (Mdn=2) and post-intervention (Mdn=4.5). In the qualitative interviews, caregivers reported that the strategies they learnt were acceptable and met their approval. They reported that the intervention was appropriate, as the strategies worked for them and helped to improve their child's social interaction, communication skills and behaviour. Lastly, caregivers reported that the strategies taught to them were feasible, and with sufficient time to practice the strategies, they became easier to incorporate into their daily routine. Caregivers also stated that due to the intervention they gained a greater understanding of their child, they noticed an increase in their own confidence, and indicated they were motivated to continue to use session strategies after the intervention was complete. Conclusion: The JERI can be used to detect changes in caregiver and child behaviours, as well as dyadic interaction following the NDBI coaching intervention in a low-resource South African context. Caregivers reported that the cascaded task- sharing NDBI approach was acceptable, appropriate, and feasible and they were able to integrate the strategies into their daily routines. Although further research is needed, these findings indicate that NDBI can be implemented in a low-resource South African context by caregivers after being coached by non-specialists.
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    Towards naturalistic developmental behavioural interventions for autism in Africa: nature and context of caregiver-child interactions in low-resource South African environments
    (2022) Ndlovu, Minkateko; de Vries, Petrus J; Franz, Lauren; Viljoen, Marisa
    Naturalistic developmental behavioural interventions (NDBI) are a group of evidence-based early interventions for autism spectrum disorders (ASD). Caregivers can be trained to deliver NDBI strategies during interactions with their young child with ASD. However, NDBI research predominantly comes from high-income countries, and the evidence base for NDBI in low/middle-income countries (LMICs) and across cultures is lacking. To understand the ‘fit' of an NDBI approach in LMICs, it is crucial to understand and be able to measure the nature of interactions between caregivers and their children with ASD and the context wherein caregiver-child interactions occur. This study sought a) to evaluate the utility of a specific measure of caregiver-child dyadic interactions and b) to examine daily routines in which caregiver-child interactions occurred in low-resource South African contexts. Methodology Children with ASD (between 18-72 months old) and their ≥18-year-old caregivers were recruited under a larger project. Interactions of 21 caregiver-child dyads were video-recorded using a standardised parent-child interaction (PCI) protocol with two 6-minute-long free-play sessions (Part I: child explored the room and available toys while the caregiver remained seated; Part II: caregiver interacted with their child as they would at home). Two research-reliable raters rated the videos using 16 items from the Joint Engagement Rating Inventory (JERI), a 7-point Likert scale behavioural coding system. Reliability and descriptive analyses were conducted. Structured interviews were conducted with ten caregivers using the Parent Survey of Home and Family Experiences (PSHFE) to explore the context of daily routines. Descriptive analyses were performed. Results For caregiver-child interactions, observer agreement for 12 of 16 items was reasonable, with weighted kappas (within 1 scale point) of 0.66-1, an estimated accuracy of 88-99%, and percentage agreements of 75-100% for all items. Ratings for items across Parts I and II of the JERI showed variability without any ceiling effects. Six items showed floor effects. Most caregiver item ratings were at the mid-point of the 7-point Likert scale. In Part II, children used more expressive language and paid more attention to their caregivers. On the PSHFE, most children participated daily in various child routines, play and early literacy activities with mothers as main partners. Most children never participated in spiritual and community activities, typically due to the child's age, safety and other reasons not specified in interview response categories. Conclusion Reliability, floor/ceiling, behavioural and Part I vs Part II profiles suggested that the JERI, used for the first time in a South African context, has potential utility both to describe caregiver-child interactions and be used as an intervention outcome measure in LMICs. The PSHFE results provided contextual data of common daily activities into which NDBI strategies could be embedded to support child generalisation of skills in South Africa.