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
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1. Active ingredients of interventions
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2. Focus on core deficits
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Factors that matter—why the intervention works
Research chipping away at these issues
DSM V---still the same core deficits—social and
communication
3. Intervention studies that are based in school
settings
Active Ingredients
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Approach
 ABA most common
 Many types and interpretations
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Dose
 Intensity (hours per week for how long?)
 Density?
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Agent of Change—parent, teacher, therapist, etc
Content
Context
Active Ingredients
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Approach
 ABA most common
 Many types and interpretations
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Dose
 Intensity (hours per week for how long?)
 Density?
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Agent of Change—parent, teacher, therapist, etc
Content
Context
CONTEXT—Why Schools?
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Kids spend the most part of the day in school
Limited evidence that school programs utilize
evidence based practices
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Schools often use eclectic approaches
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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
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Often for attention they are not getting in school
Critical need to bring general education into the
conversation
Conducting research in schools
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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
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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
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Efficacy research
 In the lab studies---highly controlled with specific
types of children
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Partial effectiveness
 Researchers in natural setting (home or school)
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Effectiveness research
 School staff who implement research under close
supervision
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Deployment
 Community partnered research methods
Issues we need to consider to bring
interventions to scale in schools……
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Need dismantling studies
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Figure out the active ingredients—what is important to an
intervention
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(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)
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Partial effectiveness research from the beginning to
determine active ingredients
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Reduces time from lab to school
Examples from our work—Focusing on Core
Deficits
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Lab based efficacy studies
Joint attention and play in preschool children
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Partial Effectiveness Studies
Studies conducted in schools by research staff
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Effectiveness studies
Teach staff to deliver
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Peer interaction studies
Teacher/paraprofessional mediated studies
Community Partnered research—the future
General Theme: Engagement as Critical
Intervention Target
11
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Issues around engagement consistent across age…..
What are behavioral signs of engagement?
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Shared attention and affect
Joint attention
Social play with others
Conversation
EXAMPLE 1
Comparative Efficacy Study: Focus on Core Deficits
Joint Attention
Initiations:
 Point to share,
Show 
Symbolic Play 
JASPER
Model
JASPER model
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All children were in same preschool program
 ABA based, 30 hours per week
 Hospital based school program
 58, 3-4-year-old children
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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)
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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
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
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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…..
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Clinical significance
Effectiveness Trial in Preschools
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Much adaptation may be necessary to bring treatment to
real world contexts
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Challenges are the classroom environment
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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
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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
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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
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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
Child Assisted Approach
Peer Mediated Approach
Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2011, JCPP
Summary of UCLA Peer Study
CHILD
(1:1)
PEER
(3 peers)
NO Treatment CHILD+PEER
6 WEEK TREATMENT
(12 SESSIONS)
12 WEEK FOLLOW UP
Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2011, JCPP
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PEER Mediated
Interventions > CHILD
Assisted Interventions
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Primary Outcome
• Social Network Salience
(d=.79)
Charlotte (8)
4.5
Elijah (6)
Cory (7)
Adam (3)
Leah (7)
8
Ella (7)
7.5
Larry (5)
Olivia (9)
Alicia (4)
Leah (4)
5.5
Nora (2)
Sam (4)
Tomas (4)
Miguel (4)
2
Magnolia (3)
Nola (1)
Alejandro (4)
Isolate: Nicholas (3), Nolan (4)
5
Giovanni (6)
Lucas (2)
Summary of UCLA Peer Study
CHILD
(1:1)
PEER
(3 peers)
NO Treatment CHILD+PEER
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Other Findings favoring Peer
Mediated Interventions:
•
•
6 WEEK TREATMENT
(12 SESSIONS)
•
12 WEEK FOLLOW UP
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
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What about children who are doing well (socially
connected)?
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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
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In this study, children with a 1:1 were less engaged
Deployment Focused Model
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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
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Practitioner concerns about relevance of EBT
 To their situations
 Their children
 Their families
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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 regulation
And particularly to work in the playground setting
What We Still Don’t Know but are Attempting
to Find Out
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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
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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
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
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Funding
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Autism Speaks
•
NIH
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HRSA; Autism Intervention
Network for Behavioral Health—
AIR-B
Private donors