Engaging Autism: Implications for Successful School Adaptation

1. Engaging Autism: Implications for Successful School Adaptation Connie Kasari, PhD University of California, Los Angeles AIR-B --Autism Intervention Research Network for Behavioral Health

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. EXAMPLE 1Comparative Efficacy Study: Focus on Core Deficits Joint Attention Initiations:  Point to share, Show  Symbolic Play  JASPER Model

13. 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

14. 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

15. 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

16. 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

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

18. Targeted JASPER Intervention with Teachers as the Mediators (pilot with 16 teachers) Lawton & Kasari, in press, JCCP

19. Joint Attention Intervention:Replication with 58 children and teacher mediated (Kaale, Smith, Sponheim, 2011)

20. 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

21. 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

22. Peer Related School Intervention StudyPeer Intervention Study in Schools Child Assisted Approach Peer Mediated Approach Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2011, JCPP

23. 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)

24. 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)

25. 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)

26. 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

27. 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

28. 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…..

29. Example 3: Involving School Staff Using transitions to facilitate peer interactions, language and behavior regulation And particularly to work in the playground setting

30. 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

31. 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

32. 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