Engaging Autism: Considerations for underserved, under-represented and under-resourced  

Connie  Kasari,  PhD  

University  of  California,  Los  Angeles  

AIR-B --Autism Intervention Research Network for

Behavioral Health

ASF Science and Sandwiches

December 6, 2012

UCLA Kasari Lab Intervention Studies

  Targeted  Interventions   Core  deficits  (beyond  dose  and  approach)  

  Underserved,  under-­‐represented    Infants,  toddlers   Minimally  verbal   School  aged,  included  in  general  education   Under-­‐resourced  

  Community  based   Schools  are  where  all  children  can  be  found  

Engagement  as  Critical  Intervention  Target  

  Young  children:  focus  on  joint  attention,  play,  engagement  with  parents  (the  core  de?icits)  

  Look  to  behavioral  signs  of  engagement    Shared  attention  and  affect    Joint  attention    Social  play  with  others    Conversation  

Targeted  Intervention  Approach  to  Address  Problems  of  Engagement  

  To  affect  engagement,  intervention  needs  to  be  targeted,  dense  and  long  term  

  The  targets  of  intervention  change  with  development,  and  with  amount  of  impairment  in  individual  children  

  Debate  in  the  field  as  to  how  much  direct  teaching  versus  naturalistic  methods  should  be  used  

JASPER    Joint  Attention,  Symbolic  Play,  Engagement,  Regulation  

Joint Attention Initiations:

-Point to share

-Show #

-Symbolic Play

Change  in  proximal  outcomes:  Joint  attention  and  play  

Joint Attention Initiations

Play Level

Why  are  these  targets  important?    They  predict  to  distal  language  outcomes  

Follow  up  1  year  later:  JA  and  SP  groups  better  language  

Follow  up  for  Low  Language  Group:  JA  group  best  outcomes  

Kasari, Paparella, Freeman & Jahromi , 2008, JCCP

Pay  off  from  early  focus  on  joint  attention/joint  engagement  

  Follow  up  of  children  in  original  study,  5  years  later    40  out  of  the  58  children    32  became  verbal  and  8  minimally  verbal    Predicting  Expressive  Language:  

  Treatment  group    CA    IJA    Play  Level    Expressive  Language    DQ    Gender  

Pay  off  from  early  focus  on  joint  attention/joint  engagement  

  Follow  up  of  children  in  original  study,  5  years  later    40  out  of  the  58  children    32  became  verbal  and  8  minimally  verbal    Predicting  Expressive  Language:  

  Treatment  group  

  CA  

  Initiates  joint  attention  

  Play  Level  

  Expressive  Language  

  DQ    Gender  

9

Kasari, Gulsrud, Freeman, Paparella, Hellemann, 2012, JAACAP

What  did  we  learn  from  this  study?  

  Active  ingredient  to  early  intervention  is  a  focus  on  early  developing  core  de?icits    Joint  attention    Play  

  Results  suggest  the  mechanism  is  likely  engagement  as  JA  and  SP  interventions  led  to  similar  outcome  

  Suggestion  that  APPROACH  also  matters-­‐-­‐-­‐the  fusion  of  developmental  and  behavioral  approaches  

JASPER

Difference  between  preverbal  and  nonverbal  children  

  Most  young  children  are  preverbal…..we  can  get  them  to  talk  

  Concern  is  for  the  children  who  remain  nonverbal  at  age  5-­‐-­‐-­‐entering  kindergarten  (about  30%  of  all  children)  

  Best  social  and  adaptive  outcomes  are  often  found  for  children  who  are  verbal  by  school  age  

  Children  who  are  nonverbal  (minimally  verbal)  at  school  age  are  UNDERSERVED,  UNDER-­‐STUDIED  

Access  to  Communication  Important  JASPER-­‐EMT  studies  

Boy 5 ½ years; No words or sounds

School  aged  Studies:  What  is  the  Issue?  

  For children with ASD:   More issues about social inclusion/acceptance than academic

support for some children   Others---issues about intervention in general—minimally

verbal, low verbal, learning   Level of support needed (or if it is needed)

  1:1 assistant?   Concerns mostly about feeling connected, belonging for

ASD   Intervention for ASD---or for those around ASD?

UCLA  School  aged  Studies:  Children  have  different  views  about  friends,  relationships  

  Important to ask children

  Gives you window into their world

  Provides clues as to what is needed for intervention, and if intervention is needed

Information  gained  from  asking  

  How  connected  child  is  to  other  children  in  the  class   How  popular  (salient)  the  peer  group  is  

  If  children  they  nominate  as  best  friends  nominate  them  back  (reciprocity)  

  How  many  children  they  nominate  as  friends      How  many  children  nominate  them  as  a  friend  

Alejandro (4)

Gerry (6)

Lonnie (2)

Len (7)

Nancy (2)

Olive (9)

Alex (4)

Adam (3)

Erick (6) Charlotte (8)

Cori (7) Luke (5)

Leah (4) Ellen (7)

Stan (4)

Miguel (4)

Thomas (4)

Maggie (3) Nora (1)

Isolate: Nick (3), Noel (4)

4.5

5.5

2

7.5

5

8

Connection to Social Groups at School—few children with ASD are isolated!

Chamberlain, Kasari, Rotheram-Fuller, 2007, JADD; Kasari et al, 2011, JADD; Rotheram-Fuller et al, 2010, JCPP

Second, Third Graders (n=17 ASD; matched TYP)

  First  to  Fifth  Graders  (n=60  ASD;  matched  TYP  

Friends and Reciprocity

Nearly all children can identify a friend and/or best friend

Over 90% of children with ASD can identify a friend during elementary ages, but this drops to less than 50% for adults

Reciprocity is limited …… 20 to 34% of children with ASD have a reciprocal friendship depending on study

60% for typical children

What  about  children  who  are  doing  well  (socially  connected)?  

  20%  of  children  had  a  reciprocal  friendship  (best  or  top  3)  

  These  same  children  had  higher  social  network  status  

  Were  they  also  more  engaged  on  the  playground?  

  NO…..playground  may  be  just  too  difficult  an  environment  

UCLA  study  on  peer  intervention  study  in  the  schools  

Modular,  individualized  approach  

  Child  Assisted    Observed  child  on  

playground,  obtained  teacher  reports,  peer  networks,  self  reports  

  Determine  top  3  problems  for  child  engaging  with  peers  

  Worked  on  1  at  at  time  

  Peer  Mediated    3  peers  willing  from  the  

class    Had  peers  identify  some  

children  who  had  difficulty  on  playground  

  Had  peers  generate  ideas  to  help  engage  all  children  on  the  playground  

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, 2012, JCPP

Social Network Centrality Second Grade - T1

Isolates: A1, C3, E5***

B2 (3)

F6 (1)

L12 (3)

P16 (6)

S18 (6)

D4 (1)

H8 (7)

J10 (7)

O15 (4)

R17 (5)

G7 (1) I9 (7)

N14 (6)

K11 (1)

M13 (1)

6.5

6

6 3

2

7

Second Grade –T2 A1 (2)

E5 (3)***

B2 (1)

F6 (2)

P16 (7) R18 (6)

C3 (2)

D4 (6)

H8 (8)

J10 (8)

O15 (5) Q17 (6) G7 (3)

I9 (3) N14 (3)

K11 (1)

L12 (4)

M13 (2)

2.5

6.5 6.5

1.5

5

8 3

2.5

Second Grade -T3

Isolates: L12, M13, N14, S19

A1 (3)

G7 (6)

H8 (3)

J10 (3)

K11 (5) T20 (10)

E5 (3)

C3 (4) I9 (9)

Q17 (5)

F6 (1) D4 (2)

R18 (5)

O15 (1)

P16 (1)

1

7 7

3.5

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  

  Effect  of  the  1:1  assistant    About  half  of  the  children  had  a  1:1  assistant  

  They  were  the  least  engaged  on  the  playground  (with  peers  or  with  the  aide)  

  Need  to  think  about  how  to  train  aides  better    Just  completed  para-­‐educator  intervention  on  the  playground    Can  change  adult  behavior  and  improve  child  engagement  

What  Needs  to  Happen  to  deploy  evidence  based  interventions  into  schools  

  Researchers  need  to  conduct  research  in  school  settings;  effectiveness  research  from  beginning  not  last  step  

  Distillation  and  matching  approaches  to  intervention    Isolating  active  ingredients  of  intervention  

  Matching  to  needs  of  child  in  context  

  New  approaches:    Researchers  and  school  staff  need  to  work  together….community  partnered  research  (balance  of  power)    NEW:    partnered  research  with  LAUSD  for  low  resourced  schools  

  Testing  playground  intervention  

  Functional  routines  in  special  education  classrooms  

Next  Steps/New  Studies  

  Determine  active  ingredients  of  intervention    Importance  of  building  adaptive  strategies  (a  potential  sequence  of  

interventions  for  particular  children…new  ACE  network  project  as  example)  

  Deploying  interventions  into  the  community  that  can  be  sustained    Preschools  

  Teaching  teachers  to  engage  children  in  ways  to  increase  social  and  communication  skills  

  Elementary  schools    Playground  intervention  

  Functional  routines  in  special  education  classrooms  

Acknowledgements  Funding!    NIH,  HRSA,  Autism  Speaks,  Private  donors  

Current  Gail  Fox  Adams  Kathleen  Berry  Ya-­‐Chih  Chang,  PhD  Michelle  Dean  Amy  Fuller  Lizzy  Fuller  Jordan  Gibson  Hilary  Gould  Kelly  Stickles  Goods,  PhD  Amanda  Gulsrud,  Phd  Alison  Holbrook  Nancy  Huynh,  PhD  Eric  Ishijima,  PhD  Dahlia  Kabab  Mark  Kretzmann,  PhD  Kelley  Krueger  

Jason  Lee  Caity  McCracken  Charlotte  Mucchetti  Chris  Osborn  Jonathan  Panganaban  Stephanie  Patterson  Wendy  Shih  Shawna  Ueyama  

•  Community  Sonia  Dickson-­‐Bracks,  MBUSD  Carolyn  Gelfand,  LAUSD