Building Capacity to Support Students with Autism Spectrum Disorder: A

1. Building Capacity to Support Students with Autism Spectrum Disorder: A Modular Approach to Intervention Rose Iovannone, Ph.D., BCBA-D iovannone@usf.edu University of South Florida Rose iovannone, ph.d., bcba- iovannone@usf..edu The contents of this training were developed under grant R324A150032 from the US Department of Education

2. Acknowledgements • Pis • Tristram Smith, University of Rochester • Cynthia Anderson, May Institue • MAAPS Coordinators and Coaches • USF-Krystal McFee, Elizabeth Cassell • UR-Samantha Hocheimer, Brenna Cavanaugh, • May—Ryan Martin, Whitney Kleinert, Meghan Silva, Brittany Juban • Qualitative Researcher • Sharon Hodges, USF

3. In Memory of Tristram Smith 1961-2018 Haggerty-Friedman Endowed Professor of Developmental Behavioral Pediatric (DBP) Research, University of Rochester Medical Center Treasured collaborator, mentor, and friend “He could say in 30 words what would take the rest of us a lifetime. He may have been unassuming, but when he spoke, everyone would listen.” – Susan Hyman, DBP Division Chief

4. Objectives • Participants will: • Identify the challenges of implementing evidence-based practices for students with ASD • Describe the features of the MAAPS modular approach and discuss how the model addresses the challenges • Describe the practice-based coaching process provided to teachers in implementing MAAPS interventions • Discuss how implementation of MAAPS can improve the performance of students with ASD.

5. Preview • Introduction to school-based intervention for students with ASD • Introduction to MAAPS Model • Research support • Case Example

6. Who is here? • Teachers • Administrators • Behavior Analysts • School Psychologists • Other educators • Students • University faculty/staff • Family

7. Intro to Autism spectrum disorders (ASD) • Dramatically increased prevalence • 2000-2012 prevalence increase from 1/150 to 1/68 (CDC, 2012) • 1998-2010, number of school aged children receiving ASD services increased from 54,064 to 370,011 • Children with ASD • Core deficits • Social/communication • Restricted, repetitive behaviors • Co-occurring • Cognitive • Challenging Behaviors

8. Challenges with Evidence-based practices in schools • Evidence-based interventions for children with ASD exist but are not consistently implemented in school settings (Kasari & Smith, 2013). • Barriers: • External validity of current research base • Environmental context • School staff expertise and training • Heterogeneity of ASD presentation • Competition with fad-interventions, misinformation, etc.

9. Modular interventions • Students with Autism Accessing General Education (MAAPS; Anderson, Smith, & Iovannone, 2018) provides individualized interventions grounded in behavior analysis. • Comprehensive interventions vs. social validity • Modular approach (Weisz et al., 2012) enables educators to choose evidence- based components that match the need of a given child.

10. Students with Autism access general education (MAAPS) • Research Development Grant • Institute of Education Sciences (IES), National Center for Special Education Research (NCSER) • Purpose • Develop comprehensive intervention for students with ASD • Effective • Socially Valid • Promise of effectiveness

11. MAAPS Development •Year 1 • Develop materials • Focus groups for feedback • Refine model •Year 2 • Feasibility test •Year 3 • Evaluate effectiveness

12. What is MAAPS? • Comprehensive modular approach to intervention • Framework for school teams to: • Assess student needs & select interventions • Design and implement evidence-based interventions • Active coaching to support educators • Data-based decision-making • Iterative process

13. MAAPS Modules

14. MAAPS Modules • Modules Include: • Outlines for Coaches • Vignettes • Sample intervention materials, data sheets • Implementation guides for educators

15. OVERVIEW OF THE MAAPS PROCESS

16. MAAPS Process Formation of Student-Focused Teams Module Selection & Goal Setting Module Development & Training Module Implementation & Active Coaching Data-Based Decision Making

17. MAAPS Process Step 1: Form a student-focused team • Core Team: • MAAPS Coach • Teacher/Educator (primary implementer) • Caregivers • Extended Team: • Specialists (SLP, OT, BCBA, School Psychologist, etc.) • Paraprofessionals/assistants • Administrators

20. Step 2: Assessment—MAAPS guiding questions • Semi-structured Interview • 0-3 scale • 0 = less urgency; 3 = high urgency • Purpose-identify specific modules to address student concerns • Two parts • Interview • Action plan • Questions with 2 or 3 responses indicate modules for consideration

21. MAAPS Process Step 2: module selection and goal setting

24. MAAPS Process Step 3: Development & Training • MAAPS Coach and the teacher review and customize • A Module Implementation Guide (MIG) created • Coach and teacher practice the intervention and plan for implementation.

26. Step 4: Implementation • Teacher implements MIG • Collect data on outcomes • Teacher Reflection Form • Active Coaching - Feedback

27. MAAPS Process Step 4: Module Implementation & active coaching

31. Coaching and feedback

32. MAAPS Process Step 5: team meetings & Data-Based Decision- making • Core & Extended teams reconvene each month to: • Review student progress • Troubleshoot challenges with the intervention • Set new goals and select new modules

33. MAAPS RESEARCH SUPPORT

34. Research • Three studies • Year 1 – Focus Group • Year 2 – Feasibility Study • Year 3 – Pilot (underpowered randomized controlled trial)

35. Model development & Refinement Review & Feedback • Research Question: What expansions and refinements are needed to MAAPS for the development of a manualized modular intervention for students with ASD? • Six national experts and six providers reviewed materials and provided feedback (mean Likert-type scale ratings, range 0-3) • Evidence-based = 2.40 • Relevant to educators = 2.67 • Likely to increase opportunities for inclusion = 2.56

36. Model development & Refinement Focus Groups • Focus groups conducted across three sites: • 14 focus groups (teachers, parents/caregivers, administrators) • 20 administrators • 33 teachers • 18 parents • 3 administrator interviews (in one site) • Focus group questions stimulated discourse about implementation of evidence-based practice for students with ASD in schools.

37. Focus group findings • Balancing immediate resource needs with long-term needs for capacity building to support students with ASD • Lack of resources (training, staff, funding) • Lack of educator skills to implement EBPs • Need for modular approach to adjust to contextually diverse environments Iovannone et al., (in revision)

38. Year 2 feasibility study participants & Setting • 15 students across sites • 2 female • 13 male • Mean Age = 9.45 • Race-11 White; 2 Black; 1 More than one; 1 Other • Ethnicity-Not Hispanic = 12; Hispanic = 3 • 18 teachers across sites • 15 female • 2 male • 1 not reported • Mean Age = 39 • Race-16 White; 1 Black; 1 More than one (American Indian and Pacific Islander) • Ethnicity-14 Not Hispanic; 4 Unknown

39. Year 2 Results Student Outcomes • Goal Attainment Scaling (GAS)/Teacher-Nominated Target Problems (TNTB): • 11/14 students rated “much improved” or “very much improved” on at least one of three behaviors • 8/14 rated as “much” or “very much improved” on all 3 target behaviors

40. Year 2 Results Teacher Outcomes • Usage Rating Profile (URP); 6 point Likert Scale • Acceptability M = 5.22 • Usability M = 5.61 • Feasibility M = 5.47 • Coaching Quality M = 3.84 (4 point Likert Scale) • Teacher implementation fidelity • Across 51 observations, adherence mean = 93%; quality mean = 99%

41. Lessons Learned from feasibility study • Despite initial feasibility and acceptability, changes were necessary: • Coach’s Outlines for modules were simplified • Changes to modules: additions, combinations, omissions, etc. • Reduction of team meetings

42. Year 3 pilot study • Underpowered randomized controlled trial • Compared MAAPS group with enhanced services as usual group (14 students in each group for 28 total) • Primary dependent variable • Developmental Disabilities modification of the Children’s Global Assessment Scale (DD-CGAS) • Data collected by masked evaluator (to condition) • Three time measurements (baseline, mid, exit)

43. Year 3 pilot study student outcomes

44. Year 3 fidelity

45. CASE EXAMPLE 1

46. Forming the Student-Focused Team

47. Getting to Know the Student Age: 10 at time of intervention Family: Mother, father Strengths: inquisitive, kind to others School: self-contained autism classroom Grade: 5th Diagnosis: Autism Spectrum Disorder • • Marley • • • •

48. Assessment—MAAPS Guiding Questions Part 1: Interview • Team identified 3 areas: Content Areas of MAAPS:

49. Assessment—MAAPS Guiding Questions Part 1: Interview • Team identified 3 areas: Part 2: Action Plan • Team prioritized implementation of selected modules 1. Engagement 2. Visual Cues 3. Conversation

50. Restricted or Repetitive Behaviors, Interests, or Activities Module Guiding Questions Priority “The next four questions focus on the student’s interests.” Increasing Variability Does the student play or interact with objects or activities in a restricted way? PROBES:  Does the student seem to enjoy repeating movements with objects, lining objects up, or completing activities in the same order each day?  Does the student vary his/her play or activities from day to day or does he/she seem to always go back to the same thing?  Does the student seem to seek out these objects or activities, even during instructional time? Low High 0 1 2 3 Engagement If the student has an intense interest, could that interest be incorporated into teaching? PROBES:  Is the student’s interest something that he/she could work for?  Could pictures or other materials related to the interest be used in teaching materials? Low High 0 1 2 3 Rituals Does the student engage in a series of behaviors in a set way, almost as if compelled to do so? PROBES:  How does the student show rigidity or ritualistic behavior? Does it happen at other times?  Do you ever notice the student doing things in a specific way or number of times?  How easily can you distract the student if he/she is in the middle of a ritual? Low High 0 1 2 3