Engaging Autism: Implications for Successful School Adaptation

Connie Kasari, PhD

University of California, Los Angeles

AIR-B --Autism Intervention Research Network for

Behavioral Health

Today’s Talk

1. Active ingredients of interventions Factors that matter—why the intervention

works Research chipping away at these issues

2. Focus on core deficits DSM V---still the same core deficits—social

and communication 3. Intervention studies that are based in

school settings

Active Ingredients

Approach ABA most common Many types and interpretations

Dose Intensity (hours per week for how long?) Density?

Agent of Change—parent, teacher, therapist, etc

Content Context

Active Ingredients

Approach ABA most common Many types and interpretations

Dose Intensity (hours per week for how long?) Density?

Agent of Change—parent, teacher, therapist, etc

Content Context

CONTEXT—Why Schools?

Kids spend the most part of the day in school Limited evidence that school programs utilize

evidence based practices Schools often use eclectic approaches

Eclectic is good---when informed not random Often random; driven by outside forces; convenient;

untested For mainstreamed children, interventions may be

absent Parents spend a lot of time driving children to

therapies outside of school Often for attention they are not getting in school

Critical need to bring general education into the conversation

Conducting research in schools

Not easy…… Schools have additional layers of

complexity State mandated curricula District or building level procedures Multiple interruptions and pressures that

are not in any manual Suspicion about researchers, and research

in general

Evidence based interventions in schools

Important to remember (Weisz, 2004)

Vast majority of children have never been tested in any outcome study

Of the many treatments available, only a fraction have ever been tested in research

Although particular programs have their disciples, most therapists/teachers do not adhere to any one treatment but create their own based on previous training, supervision and experiences.

Researchers have their own tradition of moving interventions into schools

Efficacy research In the lab studies---highly controlled with

specific types of children Partial effectiveness

Researchers in natural setting (home or school) Effectiveness research

School staff who implement research under close supervision

Deployment Community partnered research methods

Issues we need to consider to bring interventions to scale in schools……

Need dismantling studies Figure out the active ingredients—what is important to

an intervention (Comprehensive interventions necessary, but not all aspects

are important)

An active ingredient can lead to a module---teachers more likely to add a module than completely change practices (e.g. Chorpita, 2004; Weisz et al, 2011)

Partial effectiveness research from the beginning to determine active ingredients Reduces time from lab to school

Examples from our work—Focusing on Core Deficits

Lab based efficacy studies Joint attention and play in preschool children

Partial Effectiveness Studies Studies conducted in schools by research staff

Peer interaction studies Effectiveness studies

Teach staff to deliver Teacher/paraprofessional mediated studies

Community Partnered research—the future

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General Theme: Engagement as Critical Intervention Target

Issues around engagement consistent across age….. What are behavioral signs of engagement?

Shared attention and affect Joint attention Social play with others Conversation

EXAMPLE 1Comparative Efficacy Study: Focus on Core Deficits

Joint AttentionInitiations: Point to share,

Show

Symbolic Play JASPER Model

JASPER model

All children were in same preschool program ABA based, 30 hours per week Hospital based school program 58, 3-4-year-old children

Randomly assigned children to 1 of 3 conditions Joint attention, Symbolic play, Control Short term (6 weeks), every day intervention Expert therapists (children seen outside of class)

Goal to improve core social communication skills and predict to language a year later

Changes obtained in joint attention, play and language outcome one year later

Kasari, Freeman & Paparella, 2006, JCPPKasari, Paparella, Freeman, & Jahromi, 2008, JCCP

What We Learned

Treatment protocols evolve as you learn more about how they work……

Learn about active ingredients, potential mechanisms for why the intervention works…..

Also learn what might not work….. Clinical significance

Effectiveness Trial in Preschools

Much adaptation may be necessary to bring treatment to real world contexts

Challenges are the classroom environment Some teachers do not work directly with children If they do, sustaining focus in the midst of distractions Collecting data, not a preferred task

Two examples in preschool environment UCLA study; Norway trial

Teaching Teachers

Teaching teachers 1:1 to deliver intervention 1:1 with child during the day…….

Targeted JASPER Intervention with Teachers as the Mediators (pilot with 16 teachers)

Lawton & Kasari, in press, JCCP

Joint Attention Intervention:Replication with 58 children and teacher mediated (Kaale, Smith,

Sponheim, 2011)

What We Learned

Buy in critical Important to teach teachers what ‘change

processes’ they needed to effect; not just techniques or materials used

Important so they can apply to the next child who may be quite different from the first

Also important to establish where the same strategies can benefit all children

Example 2: Partial Effectiveness Trial of Peer Interventions in Mainstream Schools Partial Effectiveness ---testing the

intervention in the context with real world participants from the beginning

School based comparative efficacy study 60 HFA first to fifth graders (30 different

schools in Los Angeles) Testing common interventions—peer

mediated and child assisted

Peer Related School Intervention StudyPeer Intervention Study in Schools

Peer Mediated ApproachChild Assisted Approach

Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2011, JCPP

Summary of UCLA Peer Study

CHILD(1:1)

PEER(3 peers)

NO Treatment

CHILD+PEER

• PEER Mediated Interventions > CHILD Assisted Interventions

• Primary Outcome• Social Network

Salience (d=.79)

6 WEEK TREATMENT (12 SESSIONS)

12 WEEK FOLLOW UP

Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2011, JCPP

Alejandro (4)

Giovanni (6)

Lucas (2)

Leah (7)

Nora (2)

Olivia (9)

Alicia (4)

Adam (3)

Elijah (6)

Charlotte (8)

Cory (7)Larry (5)

Leah (4)Ella (7)

Sam (4)

Miguel (4)

Tomas (4)

Magnolia (3) Nola (1)

Isolate: Nicholas (3), Nolan (4)

4.5

5.5

2

7.5

5

8

Summary of UCLA Peer Study

CHILD(1:1)

PEER(3 peers)

NO Treatment

CHILD+PEER

• Other Findings favoring Peer Mediated Interventions:

• Number of Received Friend Nominations (d=74)

• Less isolated on playground (growth curves over tx)

• Improved rating of social skills (by Teachers) (d=.44)

6 WEEK TREATMENT (12 SESSIONS)

12 WEEK FOLLOW UP

Other Findings

What about children who are doing well (socially connected)? 20% of children had a reciprocal friendship These same children had higher social network status They were NOT any more engaged on the playground?

Playground a difficult environment—requires specific intervention

1:1 assistant as solution in school setting In this study, children with a 1:1 were less engaged

Deployment Focused Model

Idea would be to bring treatment research into practice settings early (not the last phase)

Consider sequential process in the setting, from the beginning 1. treatment that can work in everyday

practice 2. assess treatment outcome in practice 3. examine moderators and mediators in

context

Considerations in bringing interventions into practice settings

Practitioner concerns about relevance of EBT To their situations Their children Their families

Alliance and buy in critical….. Researchers must understand the

context (the particular schools) in which they work…..

Example 3: Involving School Staff

Using transitions to facilitate peer interactions, language and behavior regulationAnd particularly to work in the playground setting

What We Still Don’t Know but are Attempting to Find Out

Expansion to populations we know less about…..

Low income, underserved families Minimally verbal

Treatment experienced ‘tx resistant’ children Observations of minimally verbal 5 to 8 year olds

in class….41% of time unengaged; 18% jointly engaged; more time on break than academically engaged

Need for effective school based interventions that academically and socially challenge children

Conclusions---Next steps

Natural time course of treatments from research to practice (too long!)

Schools are where children with ASD spend the most time and this is where interventions should take place

Researchers need to collaborate with school staff to move the needle forward in bringing evidence based interventions to scale

We need to measure child outcomes of school interventions—what works, what doesn’t

Next steps are to deploy interventions into the community that can be sustained

Acknowledgements

CollaboratorsGail Fox AdamsYa-Chih ChangLauren ElderAmy FullerKelly Stickles GoodsAmanda GulsrudNancy HuynhEric IshijimaMark KretzmannKelley KruegerJill LockeCharlotte MucchettiStephanie Patterson

• Funding• Autism Speaks• NIH• HRSA; Autism Intervention

Network for Behavioral Health—AIR-B

• Private donors