Pilot Evaluation of the Social ABCs Parent-Mediated Intervention for Autistic Toddlers in Israel
Phase: NA
Conditions: Autism, Autism Spectrum Disorder (ASD)
Sponsor: Hebrew University of Jerusalem

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Testing ‘The Social ABC’s’ Parent-Mediated Intervention for Toddlers with 
Autism Spectrum Disorder  
 
PI: Gal Meiri PhD, Psychiatry Department, Soroka Medical Center. Be’er Sheva.  E-mail: 
galme@clalit.org.il 
Co PIs:  
Tanya Nitzan, PhD student, Psychology Department, Ben Gurion University of the Negev. Be’er Sheva; 
E-mail: tanya.nitzan@gmail.com  
Ilan Dinstein, PhD, Psychology Department, Ben Gurion University of the Negev. Be’er Sheva; E-mail: 
dinshi@bgu.ac.il 
Judah Koller, PsyD, Seymour Fox School of Education, Hebrew University of Jerusalem. E-mail: 
judah.koller@mail.huji.ac.il  
 
Background 
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impaired 
social communication and restricted repetitive interests and patterns of behavior. ASD is considered a 
highly heterogeneous disorder. This heterogeneity is reflected in the child’s characteristics, including 
clinical variability in the severity of autism symptoms, (DSM-5; American Psychiatric Association, 
2013). Substantial individual differences are also apparent in treatment outcomes (Howlin, Iliana, & 
Tony, 2009). Current clinical recommendations are that children receive at least 25 weekly hours of 
targeted, intensive, early intervention in order to achieve optimal outcome (National Research Council, 
2001; Zwaigenbaum et al., 2009). Unfortunately, most children with ASD in Israel and throughout the 
world do not receive such treatment due to limitations in time, financial resources, and insurance 
coverage (Symon, 2001). Increased waiting times for services due to the growing number of children 
being diagnosed with ASD further contributes to difficulties in accessing services (Nevill, Lecavalier, 
& Stratis, 2016).  
Recent studies have suggested that intervention may be performed by parents after training in 
specific techniques that can be utilized in the home environment (Nevill et al., 2016). Providing parents 
with the skills to effectively cope with their child’s developmental delays can also increase the parents’ 
sense of competence, reduce stress, and improve family cohesion (Koegel, Symon, & Kern Koegel, 
2002). This motivates the development of models for parent-mediated interventions that can reduce 
ASD symptoms (Nevill et al., 2016), particularly in low resource or isolated communities where other 
alternatives are less viable (Divan et al., 2015). Accordingly, there has been rapid growth in research 
examining the effectiveness of parent-mediated interventions in the past 15 years (Guralnick, 
Hammond, Neville, & Connor, 2008; Nevill et al., 2016). 

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The Social ABCs is one such parent-mediated intervention program, which has been shown to 
be feasible, cost-effective and sustainable. A cross-site RCT study revealed that even a relatively brief 
parent-mediated intervention using this technique yielded improvement in several social 
communication domains (Brian, Smith, Zwaigenbaum, & Bryson, 2017). The program primarily targets 
two early areas of difficulty in ASD: early functional verbal communication and positive affect 
sharing (Brian, Smith, Zwaigenbaum, Roberts, & Bryson, 2016). Functional (verbal) communication 
is considered to be one of the defining deficits in ASD. Moreover, language development has been 
identified by parents as a key area of concern (Coonrod & Stone, 2004), particularly in the first two 
years of life, and language ability is a strong predictor of later outcomes in children with ASD (Brian et 
al., 2016). Positive facial affect (i.e., smiling) is thought to have innate hedonic value that serves to 
motivate the development of very early social-communication skills such as eye gaze and reciprocal 
social smiling, which are often impaired in ASD (Brian, Bryson, & Zwaigenbaum, 2015). Moreover, 
learning is facilitated by positive emotion, suggesting that positive affect sharing may play a facilitating 
role in the development of other skills (e.g., functional communication), and may thus be a pivotal 
element of ASD intervention (Brian et al., 2016).  
 
Aim  
The present study will evaluate the effectiveness of a short parent-mediated intervention (The 
Social ABCs program) on children’s behavior and several parent measures. Participants will be 12-36-
month-old children with ASD. Several measures of behavior and ASD symptoms will be collected once 
before and twice after the intervention to allow measurement of short and long term outcome. The study 
will also explore whether individual child (e.g., gender, age, autism severity, language ability) or parent 
characteristics (e.g., education level, income) have an impact on treatment success. 
 
Research Design 
Up to 100 children 12-40 months old with ASD will be recruited for this study by Prof. Meiri and Co-
Investigators at the Pre-School Psychiatry Unit as well as by Dr. Analya Michaelovski at the Child 
Development Center at Soroka University Medical Center (SUMC). All data collection and research 
procedures will be performed at the National Autism Research Center of Israel (NARCI), located in the 
Psychiatry Building at SUMC. Participating families in the current research will be selected from those 
already recruited to the large longitudinal ASD study carried out by NARCI, which has already been 
approved (SOR-14-0222).  
Inclusion criteria: Children with the following inclusion criteria will be recruited to the study: 

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§ Those who meet ASD criteria according the DSM-V, as evaluated both by a psychologist and by 
one of the following professions: child psychiatrist, developmental physician or child neurologist. 
§ Diagnosis was completed before the child turned 36 months old. 
§ History of full pregnancy, born at 36-42 weeks gestation age with a birth weight >2500 gram. 
§ Absence of identifiable neurological, genetic, or severe sensory or motor conditions. 
§ Primary language at home is Hebrew. 
§ Parents are willing to come to SUMC for training. 
Recruitment: Identified families will be contacted by Tanya Nitzan, a current PhD student in the 
Psychology department at BGU (mentored by Drs. Meiri, Dinstein, and Koller), and a Speech Language 
Pathologist with over 5 years of expertise in treating children with ASD. Tanya will call the parents and 
explain the intervention program so that they can decide whether to participate in the research. Note 
that our existing Helsinki approval (SOR-14-0222) allows us to re-contact the families and offer them 
an opportunity to participate in additional research. Additionally, we will recruit more participants 
through social media (e.g., Facebook) and distribute pamphlets in special education kindergarten's. 
Baseline assessment: Recruited families will be asked to complete a combination of questionnaires and 
participate in standardized behavioral assessments before the beginning of the intervention. 
1. Consent form for the study. 
2. Questionnaires: 
§ Intake questionnaire containing general socio-demographic questions and family history. 
§ Parenting Stress Index – Short Form (PSI-Short; Abidin, 1995). This questionnaire quantifies 
the amount of stress that is associated with parenthood activities. 
§ Parental Self-Efficacy Scale (Hastings & Brown, 2002). This questionnaire quantifies the 
parent’s view of their parenting capabilities. 
§ Family Accommodation Scale (FAS-RRB). Measurement of how accommodating parents are 
towards challenging behaviors of their children. 
§ Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP). Parent 
report regarding the child’s abilities. 
§ Adaptive Behavior Assessment System 2 (ABAS-2). Parent report regarding the abilities of the 
child in daily activities and independence. 
3. Standardized assessments:  
§ Autism Diagnostic Observation Schedule (ADOS-2). In this semi-structured assessment, a 
clinician interacts with the child using predefined games and tasks and scores the severity of 
ASD symptoms including social difficulties and repetitive behaviors. 

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§ Developmental assessment: Mullen Scales of Early Learning. This is a developmentally 
integrated assessment that quantifies language, motor, and perceptual abilities, measures 
cognitive ability and motor development quickly and reliably.  
§ Language assessment: Preschool Language Scales, Fourth Edition (PLS™-4). This is an 
interactive assessment of developmental language skills. 
The intervention 
6-week intervention program:  The families will receive Social ABCs coaching from Tanya Nitzan, 
Tamar Matz Vaisman, or Tamar David, who have successfully completed training in administering this 
intervention program with the developers of the program in Canada. All three therapists have extensive 
background in autism care and research. Parent training using the Social ABCs (see Group Social ABCS 
Protocol on NIH website: REB # 17-745) will be conducted either at NARCI or online (i.e., 
communicating with the parents at home using the zoom software). All intervention meetings will be 
recorded with audio and video for further research purposes.  
Training will last six weeks and include group sessions where the strategies of the Social ABCs 
manual modules (‘didactics’) will be explained as well as individual sessions with the parents and child 
to practice the strategies and discuss each particular family’s needs. The 6-week program includes 
multiple 1.5-hr appointment according to the following schedule: weeks 1-3: 3 visits per week, weeks 
4-5: 2 visits per week, week 6: 1 visit. The appointments will include didactic group sessions based on 
the manual, followed by parent-child practice with live coaching. See Appendix A for a detailed 
schedule of these visits.  
Training modules are as follows: 
Week 1: Module 1: The ABCs of Learning –this module covers the basics of the three-part chain of 
antecedent-behavior-consequence within the context of child vocal communication. 
§ Week 2: Module 2 & 3. 
o Module 2: Enhancing Communication, which further elaborates on the integration of the 
ABCs into the context of fostering child communication development 
o Module 3: Sharing Positive Emotion, which highlights the importance of, and strategies for, 
developing positive connections between parent and child. 
§ Week 3: Module 4: Motivation and Arousal –this module teaches parents to identify and foster child 
motivation, and helps parents optimize their child’s arousal levels to enhance learning and social 
connection. 
§ Week 4: Module 5 & 6. 
o Module 5: Play and The Social ABCs provides information on integrating the strategies into 
developmentally appropriate and meaningful play routines 

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o Module 6: Daily Caregiving Activities provides instruction on how to use the Social ABCs 
in everyday caregiving contexts. 
§ Week 5: Module 7:  Managing Challenging Behavior 
Week 6: Module 8: Taking Care of Yourself 
Outcome Assessment: 
1. Questionnaires: questionnaires and parent reports will be administered at 2 time-points: at the 
beginning of the intervention and 12 weeks after. These will include the same questionnaires 
described in the baseline assessment (see above) in addition to: 
§ Social ABCs Satisfaction Questionnaire (unpublished): developed specifically to evaluate 
parents’ experiences in Social ABCs training. To be completed at post-intervention only. 
2. Standardized assessments: the same behavioral assessments described in the baseline assessment 
will be administered 12 weeks after the beginning of the intervention. 
 
Data analysis: 
We will examine correlations across initial and outcome behavioral measures including the 
ADOS-2 severity score, developmental assessment, pre-school language scale and other questionnaires 
described above. We will also calculate differences in scores before/after intervention to determine 
change over time. Statistical significance of differences across study time-points will be assessed using 
multi-variance two-way mixed-design (M)ANOVAs and t-tests for continuous variables and χ2 tests for 
categorical variables. 
 
Risk and comfort 
There is no risk associated with participating in this research. However, some parents may find 
it difficult to attend the intensive schedule at SUMC. The intervention will also require parents to change 
their behavior and to continue applying the principles of the intervention at home. As with any change 
in a parent’s behavior, this will require self-discipline and persistence. Successful completion of the 
intervention is likely to have beneficial impact on children’s functional verbal communication and 
positive affect sharing.  
 
Summary 
Despite the need for a feasible intervention for children with ASD diagnosis, and the long 
waiting lists to treatment, there is currently very little structured research regarding the efficacy of short-

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term behavioral interventions, particularly in Israel. The research will expand our understanding 
regarding the individual and family factors that might predict the success of the treatment.     
 

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Appendix A: Schedule of Visits for Social ABCs Group Participants 
Week 
G/I? 
Visit Topic 
Visit Length  
Activities 
Data Collection 
 
 
 
 
 
 
Baseline 
I 
Study Consent + 
Intro Module 
1.5 hour 
• Consent 
• Intro Module 
• Questionnaires 
 
 
 
 
•  
• PLS-4 (baseline) 
• ADOS-2 (baseline) 
• Mullen (baseline) 
 
 
 
 
 
 
Week 1 
  
G 
Module 1 
1.5 hour 
• Module 1 Didactic 
• Video examples 
 
I 
Module 1  
1 hour 
• 15-min tips  
• Live coaching 
 
I 
Module 1  
1 hour 
• 15-min tips  
• Live coaching 
 
 
 
 
 
 
 
Week 2  
 
G 
Module 2 & 3 
1.5 hour 
• Module 2 & 3 Didactic 
• Video examples 
 
I 
Module 2 
1 hour 
• 15-min tips  
• Live coaching 
 
I 
Module 3 
1 hour 
• 15-min tips  
• Live coaching 
 
 
 
 
 
 
 
Week 3 
G 
Modules 4 
1.5 hour 
• Module 4, 5, & 6 Didactic 
• Video examples 
 
I 
Module 4 
1 hour 
• 15-min tips  
• Live coaching 
• 15-min video 
• Live coding 
I 
Module 4 
1 hour 
• 15-min tips  
• Live coaching 
 
 
 
 
 
 
 
Week 4  
G 
Module 5 & 6 
1.5 hour 
• Module 7 Didactic 
• Video examples 
 
I 
Module 5 & 6 
1 hour 
• 15-min tips  
• Live coaching 
 
 
 
 
 
 
 
Week 5  
G 
Module 7 
1.5 hour 
• Module 8 Didactic 
• Video examples 
 
I 
Module 7 
1 hour 
• 15-min tips  
• Live coaching 
 
 
 
 
 
 
 
Week 6 
I 
Module 8 
Future Goals 
1 hour 
• 15-min tips  
• Live coaching 
• 15-min video 
• Live coding 
• Questionnaires  
 
 G=Group Sessions, I=Individual Sessions 
 
 

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