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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

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slide1

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
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
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 ingredients1
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
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
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
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
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
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
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
general theme engagement as critical intervention target
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 1 comparative efficacy study focus on core deficits
EXAMPLE 1Comparative Efficacy Study: Focus on Core Deficits

Joint Attention

Initiations:

 Point to share,

Show 

Symbolic Play 

JASPER Model

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

Cohen’s d = .59 - .71 15-17 months in 12 months

Kasari, Freeman & Paparella, 2006, JCPP

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

what we learned
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
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

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

Lawton & Kasari, in press, JCCP

slide19
Joint Attention Intervention:Replication with 58 children and teacher mediated (Kaale, Smith, Sponheim, 2011)
what we learned1
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
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 study peer intervention study in schools
Peer Related School Intervention StudyPeer Intervention Study in Schools

Child Assisted Approach

Peer Mediated Approach

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

summary of ucla peer study
Summary of UCLA Peer Study

6 WEEK TREATMENT (12 SESSIONS)

12 WEEK FOLLOW UP

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

  • PEER Mediated Interventions > CHILD Assisted Interventions
  • Primary Outcome
    • Social Network Salience (d=.79)
primary outcome social network salience ms smith rm 15 t1

PRIMARY OUTCOME Social Network SalienceMs. Smith Rm. 15 T1

Charlotte (8)

Elijah (6)

4.5

Larry (5)

7.5

Cory (7)

Adam (3)

Leah (7)

Olivia (9)

8

Alicia (4)

Ella (7)

Leah (4)

5.5

Nora (2)

Sam (4)

Tomas (4)

Miguel (4)

2

5

Giovanni (6)

Magnolia (3)

Nola (1)

Alejandro (4)

Lucas (2)

Isolate: Nicholas (3), Nolan (4)

summary of ucla peer study1
Summary of UCLA Peer Study

6 WEEK TREATMENT (12 SESSIONS)

12 WEEK FOLLOW UP

  • 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)
other findings
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
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
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
Example 3: Involving School Staff

Using transitions to facilitate peer interactions, language and behavior regulation

And particularly to work in the playground setting

what we still don t know but are attempting to find out
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
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
Acknowledgements

Collaborators

Gail Fox Adams

Ya-Chih Chang

Lauren Elder

Amy Fuller

Kelly Stickles Goods

Amanda Gulsrud

Nancy Huynh

Eric Ishijima

Mark Kretzmann

Kelley Krueger

Jill Locke

Charlotte Mucchetti

Stephanie Patterson

  • Funding
  • Autism Speaks
  • NIH
  • HRSA; Autism Intervention Network for Behavioral Health—AIR-B
  • Private donors