Concordance between a U.S. Educational Autism Classification and the Autism Diagnostic Observation Schedule.

States in the United States differ in how they determine special education eligibility for autism services. Few states include an autism-specific diagnostic tool in their evaluation. In research, the Autism Diagnostic Observation Schedule (ADOS for first edition, ADOS-2 for second edition) is considered the gold-standard autism assessment. The purpose of this study was to estimate the proportion of children with an educational classification of autism who exceed the ADOS/ADOS-2 threshold for autism spectrum (concordance rate). Data were drawn from 4 school-based studies across 2 sites (Philadelphia, Pennsylvania, and San Diego, California). Participants comprised 627 children (2-12 years of age; 83% male) with an autism educational classification. Analyses included (a) calculating the concordance rate between educational and ADOS/ADOS-2 classifications and (b) estimating the associations between concordance and child's cognitive ability, study site, and ADOS/ADOS-2 administration year using logistic regression. More San Diego participants (97.5%, all assessed with the ADOS-2) met ADOS/ADOS-2 classification than did Philadelphia participants assessed with the ADOS-2 (92.2%) or ADOS (82.9%). Children assessed more recently were assessed with the ADOS-2; this group was more likely to meet ADOS/ADOS-2 classification than the group assessed longer ago with the ADOS. Children with higher IQ were less likely to meet ADOS/ADOS-2 classification. Most children with an educational classification of autism meet ADOS/ADOS-2 criteria, but results differ by site and by ADOS version and/or recency of assessment. Educational classification may be a reasonable but imperfect measure to include children in community-based trials.

Self-Regulation is Bi-Directionally Associated with Cognitive Development in Children with Autism.

Children with autism are at high risk for self-regulation difficulties because of language delays and emotion-regulation difficulties. In typically-developing children, language development helps promote self-regulation, and in turn, cognitive development. Little research has examined the association between self-regulation and cognitive-skill development in children with autism. Children with autism (5-8 years), who were minimally-verbal (n=38) or typically-verbal (n=46) participated in a structured cognitive assessment and were observed for self-regulation difficulties during the cognitive assessment at the beginning and end of an academic year. Results showed that children with autism who were minimally- compared to typically-verbal had more self-regulation difficulties. Increase in self-regulation difficulties predicted less cognitive-skill gains, regardless of verbal ability, and cognitive skill gains also predicted changes in self-regulation difficulties. Interventions targeting self-regulation may be appropriate for all children with autism and should be adapted for minimally-verbal children.

Community-academic partnerships in implementation research.

Community-academic partnerships(CAPs) are a critical component of implementing and sustaining evidence-based practices (EBPs) in community settings; however, the approaches used and mechanisms of change within CAPs have not been rigorously studied. The first step to advancing the science of CAP is to operationally define and contextualize the approaches used in CAP as part of the implementation process. Our research group has gleaned valuable lessons about the best ways to develop, support, and nurture community partnerships within the context of implementation. In this article, we share these lessons learned and relate them to implementation strategies that are most relevant to community-partnered implementation endeavors. The implementation strategies most relevant to CAPs are as follows: (a) building a coalition, (b) conducting local consensus discussions, (c) identifying barriers and facilitators to implementation, (d) facilitating interactive problem solving, (e) using an advisory board or workgroup, (f) tailoring strategies, (g) promoting adaptability, and (h) auditing and providing feedback. We offer suggestions for future research to systematically evaluate these strategies, with an eye toward advancing the science of CAP and implementation science and the goal of guiding future research and improving the implementation of EBPs in community settings.

Randomized Trial of a Computer-Assisted Intervention for Children With Autism in Schools.

OBJECTIVE: Computer-assisted interventions (CAIs) are popular for educating children with autism, but their effectiveness is not well established. This study evaluated the effectiveness of 1 CAI designed to improve children's language, cognitive, and academic skills, TeachTown: Basics, in a large urban school district. METHOD: Teachers (n = 59) in autism support classrooms and their consented students in kindergarten through second grade (n = 154) were randomized to TeachTown: Basics or waitlist control. Child outcome was measured at baseline and after 1 academic year using the Bracken Basic Concepts Scale-Receptive and Expressive versions and the Differential Ability Scales, Second Edition (DAS-II). Random effects regression models that included clustering of time within students and students within classrooms were used to test whether the change over time in each outcome differed between groups. RESULTS: There were no statistically significant differences in outcomes for children who received TeachTown: Basics or treatment as usual. Increased time spent using TeachTown: Basics was associated with worse receptive language outcomes for children in the experimental group after 1 academic year. However, there was no association between minutes spent using TeachTown and changes in expressive language or DAS-II score. CONCLUSION: Despite growing enthusiasm for CAIs in autism treatment, the present findings indicate that CAI might not be effective at improving language and cognitive outcomes for children with autism spectrum disorder. The decision to implement CAIs in schools should be carefully balanced against the evidence for effectiveness of these programs. Schools might be better served by investing in treatment strategies with established evidence. CLINICAL TRIAL REGISTRATION INFORMATION: RCT of TeachTown in Autism Support Classrooms: Innovation and Exnovation; https://clinicaltrials.gov/; NCT02695693.

Do Student Characteristics Affect Teachers' Decisions to Use 1:1 Instruction?

One-to-one instruction is a critical component of evidence-based instruction for students with autism spectrum disorder, but is not used as often as recommended. Student characteristics may affect teachers' decisions to select a treatment and/or implement it. This study examined the associations between students' clinical and demographic characteristics and teachers' reported use of discrete trial training (DTT) and pivotal response training (PRT). Children's higher sensory symptoms, lower social approach, lower verbal skills and higher self-regulation difficulties were associated with more frequent 1:1 DTT and PRT. Results suggest that teachers give more frequent 1:1 instruction to children with more observable impairments, do not match children to type of 1:1 intervention, and may inadvertently neglect other students for whom individualized intervention may still be beneficial.

The Utility of Measuring Intentions to Use Best Practices: A Longitudinal Study Among Teachers Supporting Students With Autism.

BACKGROUND: School-based interventions can result in profound social, behavioral, and academic improvement for students with autism, but teachers rarely implement them. It is important to understand why this occurs and use this information to increase the use of evidence-based practices. Toward this goal, 2 proof-of-construct studies demonstrate the theoretical and methodological advantages of measuring behavioral intentions to use specific practices. METHODS: Two observational studies enrolled public school teachers who work with students with autism. The studies measure the strength of teachers' intentions to use each of 4 different evidence-based practices, assess variability in intentions, and test whether intentions predict future teacher behavior. RESULTS: In adjusted analyses, intentions to use a specific evidence-based practice were strongly associated with subsequent use (adjusted odds ratio = 5.2). The proportion of teachers who reported strong intentions varied from a low of 33% to a high of 66%, depending on the practice. CONCLUSIONS: The findings illustrate that the strength of intentions, which varies depending on the specific practice, can predict implementation. More generally, the studies demonstrate how measures of intention can aid efforts to identify implementation barriers. The approach taken can be applied to study implementation of any practices designed to improve student health.

Parent and Teacher Concordance on the Social Responsiveness Scale for Children with Autism.

There are inconsistent findings regarding parent and teacher agreement on behavioral ratings of their children with autism. One possible reason for this inconsistency is that studies have not taken autism severity into account. This study examined parent and teacher concordance of social behavior based on symptom severity for children with autism. Participants were 123 parent-teacher dyads who completed the Social Responsiveness Scale. Symptom severity was assessed using the Autism Diagnostic Observation Schedule (ADOS). Results indicated that parent and teacher ratings were statistically significantly correlated at the beginning and end of the academic year, but only for severely affected children. Teacher report of social deficits was correlated with symptom severity as measured by the ADOS; parent report was not. These findings have implications for improving assessment procedures and parent-teacher collaboration.

Study protocol: implementation of a computer-assisted intervention for autism in schools: a hybrid type II cluster randomized effectiveness-implementation trial.

BACKGROUND: The number of children diagnosed with autism has rapidly outpaced the capacities of many public school systems to serve them, especially under-resourced, urban school districts. The intensive nature of evidence-based autism interventions, which rely heavily on one-to-one delivery, has caused schools to turn to computer-assisted interventions (CAI). There is little evidence regarding the feasibility, effectiveness, and implementation of CAI in public schools. While CAI has the potential to increase instructional time for students with autism, it may also result in unintended consequences such as reduction in the amount of interpersonal (as opposed to computerized) instruction students receive. The purpose of this study is to test the effectiveness of one such CAI-TeachTown-its implementation, and its effects on teachers' use of other evidence-based practices. METHODS: This study protocol describes a type II hybrid cluster randomized effectiveness-implementation trial. We will train and coach 70 teachers in autism support classrooms in one large school district in the use of evidence-based practices for students with autism. Half of the teachers then will be randomly selected to receive training and access to TeachTown: Basics, a CAI for students with autism, for the students in their classrooms. The study examines: (1) the effectiveness of TeachTown for students with autism; (2) the extent to which teachers implement TeachTown the way it was designed (i.e., fidelity); and (3) whether its uptake increases or reduces the use of other evidence-based practices. DISCUSSION: This study will examine the implementation of new technology for children with ASD in public schools and will be the first to measure the effectiveness of CAI. As importantly, the study will investigate whether adding a new technology on top of existing practices increases or decreases their use. This study presents a unique method to studying both the implementation and exnovation of evidence-based practices for children with autism in school settings. TRIAL REGISTRATION: NCT02695693 . Retrospectively registered on July 8, 2016.

Training Teachers to use Evidence-Based Practices for Autism: Examining Procedural Implementation fidelity.

The purpose of this study was to examine the extent to which public school teachers implemented evidence-based interventions for students with autism in the way these practices were designed. Evidence-based practices for students with autism are rarely incorporated into community settings, and little is known about the quality of implementation. An indicator of intervention quality is procedural implementation fidelity (the degree to which a treatment is implemented as prescribed). Procedural fidelity likely affects student outcomes. This project examined procedural implementation fidelity of three evidence-based practices used in a randomized trial of a comprehensive program for students with autism in partnership with a large, urban school district. Results indicate that teachers in public school special education classrooms can learn to implement evidence-based strategies; however they require extensive training, coaching, and time to reach and maintain moderate procedural implementation fidelity. Procedural fidelity over time, and across intervention strategies is examined.

Services for children with autism spectrum disorder in three, large urban school districts: Perspectives of parents and educators.

This study used qualitative methods to evaluate the perceptions of parents, educators, and school administrators in three large, urban school districts (Los Angeles, Philadelphia, and Rochester) regarding services for children with autism spectrum disorder within the context of limited district resources. Facilitators followed a standard discussion guide that contained open-ended questions regarding participants' views on strengths and limitations of existing services and contextual factors that would facilitate or inhibit the process of introducing new interventions. Three primary themes were identified: (1) tension between participant groups (teachers and paraprofessionals, staff and administration, teachers and parents, special education and general education teachers), (2) necessity of autism spectrum disorder-specific and behavioral training for school personnel, and (3) desire for a school culture of accepting difference. These themes highlight the importance of developing trainings that are feasible to deliver on a large scale, that focus on practical interventions, and that enhance communication and relationships of school personnel with one another and with families.

The role of treatment fidelity on outcomes during a randomized field trial of an autism intervention.

This randomized field trial comparing Strategies for Teaching based on Autism Research and Structured Teaching enrolled educators in 33 kindergarten-through-second-grade autism support classrooms and 119 students, aged 5-8 years in the School District of Philadelphia. Students were assessed at the beginning and end of the academic year using the Differential Ability Scales. Program fidelity was measured through video coding and use of a checklist. Outcomes were assessed using linear regression with random effects for classroom and student. Average fidelity was 57% in Strategies for Teaching based on Autism Research classrooms and 48% in Structured Teaching classrooms. There was a 9.2-point (standard deviation = 9.6) increase in Differential Ability Scales score over the 8-month study period, but no main effect of program. There was a significant interaction between fidelity and group. In classrooms with either low or high program fidelity, students in Strategies for Teaching based on Autism Research experienced a greater gain in Differential Ability Scales score than students in Structured Teaching (11.2 vs. 5.5 points and 11.3 vs. 8.9 points, respectively). In classrooms with moderate fidelity, students in Structured Teaching experienced a greater gain than students in Strategies for Teaching based on Autism Research (10.1 vs. 4.4 points). The results suggest significant variability in implementation of evidence-based practices, even with supports, and also suggest the need to address challenging issues related to implementation measurement in community settings.

Implementation challenges in translating pivotal response training into community settings.

Implementing evidence-based practices (EBPs) for children with autism is challenging for teachers because these practices are often complex, requiring significant training and resources that are not available in most school settings. This brief investigation was designed to identify areas of strength and difficulty for teachers implementing one such EBP, pivotal response training (PRT). Observational data were gathered from 41 teachers participating in two separate investigations involving PRT. Despite differences in training procedures, teachers demonstrated similarities in areas of strength (clear opportunities/instruction and child choice) and difficulty (turn taking and multiple cues). These findings suggest next steps toward systematic adaptation of PRT for classroom use. The research may serve as a model for the process of adapting EBPs for practice settings.