In an Imperfect World: Barriers and Facilitators to Educators' Evidence-Based Practice Use for Elementary-Aged Autistic Students in Inclusive Settings.

Educators' use of evidence-based practices (EBP) provides positive outcomes for autistic students in multiple areas of learning (e.g., peer interactions and academic skills) and may promote access and participation in general educational settings. However, many teachers report limited use of EBPs for their autistic students, with inconsistent fidelity. This study sought to understand barriers and facilitators educators identify to implementing EBPs with autistic students in general education classrooms. To understand educators' perspectives and experiences, we conducted a qualitative study with 81 educators who serve elementary-aged autistic students in one state. In response to interview questions based on the Consolidated Framework for Implementation Research framework, educators reported on multiple factors, including the general education environment, access to resources, training in EBPs, and professional collaboration. Implications for practice, training, and research are discussed. Specifically, we address educators' need for increased training and the availability of educator resources.

Applying a User-Centered Design Framework to Develop a Remote Research Assessment Protocol for a Randomized Clinical Trial for Toddlers with Early Autism Characteristics.

COVID-19 required many research teams to shift from in-person to remote assessments, which posed both procedural and theoretical challenges. While research has explored the utility of remote assessments for autism diagnosis from the perspective of families and clinicians, less is known about their application in clinical trials. This paper describes the development of a remote research assessment protocol for a randomized clinical trial focusing on the implementation of reciprocal imitation teaching (RIT) with toddlers in Part C early intervention. This project spans two phases. For Phase 1, our team developed and documented a series of steps utilizing user-centered design (UCD) strategies (e.g., recruiting potential users, creating a prototype, engaging in iterative development) for the purpose of redesigning an assessment protocol for a remote environment. For Phase 2, we examined preliminary outcomes of the redesign process. Primary end users (assessors) rated post-redesign usability and acceptability, while acceptability was examined using attrition data from secondary end users (family participants). Preliminary fidelity of implementation was also examined. The iterative redesign process allowed the research team to refine aspects of the assessment that ultimately led to promising preliminary ratings of usability, acceptability, and feasibility, as well as high fidelity. Preliminary data suggest that the redesigned assessment appears to be an acceptable, feasible, and usable tool for autism clinical trial research and that assessors can use it with fidelity. Further research is needed to examine the reliability and validity of the assessment, as well as implementation characteristics on a larger scale.

"On an island by myself": implications for the inclusion of autistic students in self-contained classrooms in public elementary schools.

Introduction: Autistic students have limited access to inclusive classes and activities in their schools. Principals and special education teachers who directly teach and administer programs for autistic elementary students can offer critical insight into factors, such as educators' attitudes, that may impact inclusive opportunities in schools. These attitudes may serve as barriers to or facilitators of promoting an inclusive school setting. Methods: Semi-structured interviews with 26 elementary school principals and 26 special education teachers explored their experiences implementing evidence-based practices for autistic students (pivotal response training, discrete trial training, and visual schedules) in 26 self-contained classrooms in the United States. Autism-specific culture and inclusion emerged as a theme, which was analyzed for this paper. Results: An inductive approach to thematic analysis revealed principals' and special education teachers' perspectives regarding the "autism-specific culture" in the school, including attitudes towards and inclusion of autistic students in self-contained classrooms in the broader school environment. Analysis of text related to "autism-specific culture" detailed aspects of inclusion, factors (i.e., barriers and facilitators) affecting inclusion, principals' and special education teachers' attitudes towards autistic students placed in self-contained classrooms, attitudes of other school staff towards teachers in self-contained classrooms, and recommendations to support an inclusive school environment for autistic students. Discussion: Results suggest that valuing "equal" access to classes and activities for autistic students in self-contained classrooms may not be sufficient for promoting an inclusive school environment, Educators may benefit from targeted strategies to facilitate inclusion. Strategies range from supporting educators' attitudes and knowledge of autism to shifting physical aspects of the school environment (e.g., location of classrooms). Additional implications for supporting the true inclusion (i.e., inclusion that goes beyond physical inclusion) involves of autistic students in self-contained classrooms schools are discussed.

Concordance of multiple informant assessment of school-based social skills intervention and association with child outcomes: Results from a randomized trial.

Background: Fidelity, or the degree to which an intervention is implemented as designed, is essential for effective implementation. There has been a growing emphasis on assessing fidelity of evidence-based practices for autistic children in schools. Fidelity measurement should be multidimensional and focus on core intervention components and assess their link with program outcomes. This study evaluated the relation between intervention fidelity ratings from multiple sources, tested the relation between fidelity ratings and child outcomes, and determined the relations between core intervention components and child outcomes in a study of an evidence-based psychosocial intervention designed to promote inclusion of autistic children at school, Remaking Recess. Method: This study extends from a larger randomized controlled trial examining the effect of implementation support on Remaking Recess fidelity and child outcomes. Schools were randomized to receive the intervention or the intervention plus implementation support. Observers, intervention coaches, and school personnel completed fidelity measures to rate completion and quality of intervention delivery. A measure of peer engagement served as the child outcome. Pearson correlation coefficients were calculated to determine concordance between raters. Two sets of hierarchical linear models were conducted using fidelity indices as predictors of peer engagement. Results: Coach- and self-rated completion and quality scores, observer- and self-rated quality scores, and observer- and coach-rated quality fidelity scores were significantly correlated. Higher observer-rated completion and quality fidelity scores were predictors of higher peer engagement scores. No single intervention component emerged as a significant predictor of peer engagement. Conclusions: This study demonstrates the importance of using a multidimensional approach for measuring fidelity, testing the link between fidelity and child outcomes, and examining how core intervention components may be associated with child outcomes. Future research should clarify how to improve multi-informant reports to provide "good enough" ratings of fidelity that provide meaningful information about outcomes in community settings. Plain Language Summary: Fidelity is defined as how closely an intervention is administered in the way the creators intended. Fidelity is important because it allows researchers to determine what exactly is leading to changes. In recent years, there has been an interest in examining fidelity of interventions for autistic children who receive services in school. This study looked at the relationship between fidelity ratings from multiple individuals, the relationship between fidelity and child outcomes, and the relationship between individual intervention component and child changes in a study of Remaking Recess, an intervention for autistic children at school. Schools were randomly selected to receive the intervention only or the intervention plus implementation support from the research team. Observers, intervention coaches, and individuals delivering the intervention themselves completed fidelity measures. Child engagement with peers was measured before and after the intervention. Several measures of self-, coach-, and observer-report fidelity were associated with each other. Higher observer-reported fidelity was associated with higher child peer engagement scores. No single intervention step was linked to child peer engagement and both treatment groups had similar outcomes in terms of fidelity. This study shows the importance of having multiple raters assess different parts of intervention fidelity, looking at the link between fidelity and child outcomes, and seeing how individual intervention steps may be related to outcomes. Future research should aim to find out which types of fidelity ratings are "good enough" to lead to positive changes following treatment so that those aspects can be used and targeted in the future.

The implementation of the screening tool for autism in toddlers in Part C early intervention programs: An 18-month follow-up.

LAY ABSTRACT: The early detection of autism spectrum disorder can lead to access to autism spectrum disorder-specific services that have been shown to have a large impact on a child's overall development. Although a stable diagnosis of autism spectrum disorder can be made by age 2 years, most children are not diagnosed until much later. To address this issue, this study examined the effectiveness of training Part C Early Intervention providers to use an interactive autism spectrum disorder screening tool, the Screening Tool for Autism in Toddlers. Sixty-nine providers attended a 1-day training workshop on the use of the Screening Tool for Autism in Toddlers. After the workshop, providers reported increased knowledge about recognizing the early signs of autism spectrum disorder, and about 45% of the providers reported using the Screening Tool for Autism in Toddlers with families in their caseloads 18 months after the training. These results suggest that the Screening Tool for Autism in Toddlers is feasible for use within Early Intervention settings. In addition, they suggest that specific providers might serve as a screening "point-person," rather than expecting the Screening Tool for Autism in Toddlers to be used by all providers. Future research should aim to identify specific characteristics of agencies or providers that might be best suited for using the Screening Tool for Autism in Toddlers.

Caregiver Attributions of Toddlers' Behaviors: A Comparison Between Groups of Children with Differing Developmental Concerns.

Little is known about the attributional patterns of caregivers of autistic children, particularly in relation to caregivers of children with other developmental or behavioral disorders. This study examined differences in caregiver attributions of child behavior between three groups: toddlers with (1) Autism spectrum disorder (ASD) or ASD concerns; (2) Other developmental concerns; and (3) No concerns. Qualitative descriptions of actual child behaviors were coded using a three-stage content analysis. Regression analyses were utilized to determine if group membership predicted types of positive and challenging behaviors caregivers endorsed, as well as their attributions of these behaviors. Caregivers of children with ASD or ASD concerns endorsed similar types of behaviors, but rated their child's positive behaviors as less characteristic of their child and more a function of the particular situation, less stable or permanent, and less controllable as compared to caregivers of toddlers with other developmental or no concerns. Additionally, they rated their child's challenging behaviors as more stable or permanent and less controllable as compared to caregivers of toddlers with other developmental concerns or no concerns. These findings suggest that caregivers of children with ASD and ASD related concerns may be vulnerable to a negative attributional pattern, which can have important implications for child and family functioning and overall quality of life.

Clinical Characteristics of Youth with Autism or Developmental Disability during Inpatient Psychiatric Admission.

Children with autism spectrum disorder and developmental disabilities (ASD/DD) often experience severe co-occurring psychological and behavioral challenges, which can warrant inpatient psychiatric care. However, very little is known about the characteristics and clinical care of children with ASD/DD within the context of inpatient psychiatric settings. In this paper, we describe factors unique to inpatients with ASD or DD, by drawing on electronic health records from over 2300 children and adolescents ages 4-17 years admitted to a pediatric psychiatric inpatient unit over a 3-year period. Patients with ASD/DD accounted for approximately 16% of inpatients and 21% of admissions, were younger, more likely to be readmitted, more likely to be male, and more likely to have Medicaid insurance, as compared to patients without ASD/DD. Clinically, those with ASD/DD more frequently had externalizing concerns documented in their records, in contrast to more frequent internalizing concerns among other patients. Within the ASD/DD group, we identified effects of patient age, sex, and race/ethnicity on multiple dimensions of clinical care, including length of stay, use of physical restraint, and patterns of medication use. Results suggest the need for psychiatric screening tools that are appropriate for ASD/DD populations, and intentional integration of anti-racist practices into inpatient care, particularly with regard to use of physical restraint among youth.

Iterative redesign of a caregiver-mediated intervention for use in educational settings.

LAY ABSTRACT: Teachers often report concerns about behavior challenges in their students with autism spectrum disorder (ASD) in the school setting. Furthermore, teachers often report that they do not have adequate training in how to manage these challenging behaviors effectively. The RUBI program is an intervention initially developed for parents of children with ASD and co-occurring challenging behavior in clinic settings. The present project used school staff input to systematically redesign RUBI to be used with educators in schools. School staff gave input at multiple stages of development to ensure the adapted intervention was appropriate to use in a school setting. Responses were coded and analyzed to identify strengths and weaknesses of the RUBI manual in schools and adaptations were made accordingly. Scores of how appropriate, possible, likable, and usable RUBI would be in schools rose after the intervention was redesigned. The redesigned RUBIES manual may give school staff the tools they need to manage disruptive behaviors. In addition, collaborating with providers over multiple stages to redesign established interventions for new contexts may be a promising way to help bring research tools to practice in the future.

Neurodiversity and Autism Intervention: Reconciling Perspectives Through a Naturalistic Developmental Behavioral Intervention Framework.

Proponents of autism intervention and those of the neurodiversity movement often appear at odds, the former advocating for intensive treatments and the latter arguing that autism must be accepted as a form of diversity. The history of behavioral intervention has understandably outraged many in the Autistic community, though many still value supports focused on quality of life. This commentary argues that Naturalistic Developmental Behavioral Interventions (NDBIs) hold promise for bridging the gap between early intervention and the neurodiversity movement. However, we recognize NDBIs have much room to grow and suggest multiple strategies for improvement. We believe these updates are not only feasible for clinicians and researchers to implement but will ultimately lead to improved quality of life for Autistic individuals.

A Pilot Randomized Clinical Trial of an Enhanced Pivotal Response Treatment Approach for Young Children with Autism: The PRISM Model.

The symptoms of autism spectrum disorder are conceptualized to alter the quality of parent-children interactions, exposure to social learning exchanges, and ultimately the course of child development. There is evidence that modifying the procedures of Pivotal Response Treatment (PRT) to explicitly target social motivation enhances child engagement and parent-child synchrony in moment-by-moment exchanges. However, it is unclear if these within session improvements ultimately yield favorable developmental outcomes over time. The current investigation presents feasibility, utility, and preliminary efficacy data of a pilot randomized clinical trial (RCT) of a Pivotal Response Intervention for Social Motivation (PRISM) model. Data on participant factors, treatment protocol acceptability, and outcome variance and effect size are highly favorable and support the pursuit of a future, large scale RCT.

Language Differences at 12 Months in Infants Who Develop Autism Spectrum Disorder.

Little is known about early language development in infants who later develop autism spectrum disorder (ASD). We analyzed prospective data from 346 infants, some of whom were at high risk for developing ASD, to determine if language differences could be detected at 12 months of age in the infants who later were diagnosed with ASD. Analyses revealed lower receptive and expressive language scores in infants who later were diagnosed with ASD. Controlling for overall ability to understand and produce single words, a Rasch analysis indicated that infants who later developed ASD had a higher degree of statistically unexpected word understanding and production. At 12 months of age, quantitative and qualitative language patterns distinguished infants who later developed ASD from those who did not.