Parent Coaching in Early Intervention for Autism Spectrum Disorder: A Brief Report.

Coaching caregivers of young children on the autism spectrum is a critical component of parent-mediated interventions. Little information is available about how providers implement parent coaching for children on the autism spectrum in publicly funded early intervention systems. This study evaluated providers' use of parent coaching in an early intervention system. Twenty-five early intervention sessions were coded for fidelity to established caregiver coaching techniques. We found low use of coaching techniques overall, with significant variability in use of coaching across providers. When providers did coach caregivers, they used only a few coaching strategies (e.g., collaboration and in-vivo feedback). Results indicate that targeted training and implementation strategies focused on individual coaching components, instead of coaching more broadly, may be needed to improve the use of individual coaching strategies. A focus on strengthening the use of collaboration and in-vivo feedback may be key to improving coaching fidelity overall.

Pre-treatment clinical and gene expression patterns predict developmental change in early intervention in autism.

Early detection and intervention are believed to be key to facilitating better outcomes in children with autism, yet the impact of age at treatment start on the outcome is poorly understood. While clinical traits such as language ability have been shown to predict treatment outcome, whether or not and how information at the genomic level can predict treatment outcome is unknown. Leveraging a cohort of toddlers with autism who all received the same standardized intervention at a very young age and provided a blood sample, here we find that very early treatment engagement (i.e., <24 months) leads to greater gains while controlling for time in treatment. Pre-treatment clinical behavioral measures predict 21% of the variance in the rate of skill growth during early intervention. Pre-treatment blood leukocyte gene expression patterns also predict the rate of skill growth, accounting for 13% of the variance in treatment slopes. Results indicated that 295 genes can be prioritized as driving this effect. These treatment-relevant genes highly interact at the protein level, are enriched for differentially histone acetylated genes in autism postmortem cortical tissue, and are normatively highly expressed in a variety of subcortical and cortical areas important for social communication and language development. This work suggests that pre-treatment biological and clinical behavioral characteristics are important for predicting developmental change in the context of early intervention and that individualized pre-treatment biology related to histone acetylation may be key.

Using Novel Implementation Tools for Evidence-based Intervention Delivery (UNITED) across public service systems for three evidence-based autism interventions in under-resourced communities: study protocol.

BACKGROUND: There are a growing number of evidence-based interventions (EBIs) for autistic individuals, but few are successfully implemented with fidelity in under-resourced communities and with families from traditionally disenfranchised groups. Implementation science offers tools to increase EBI use in communities, but most implementation strategies are designed specific to a single EBI. It is not feasible to develop a new implementation strategy each time a new EBI is introduced in the community. Therefore, to test the effectiveness and generalizability of implementation strategies we are developing and testing a multifaceted implementation strategy with three EBIs concurrently. The goal of this protocol paper is to describe the randomized field trial of an implementation strategy for use across autism EBIs, diverse settings and participants, with the goal of increasing rapid uptake of effective practices to reach our most vulnerable children. METHODS: We developed a multifaceted implementation strategy called Using Novel Implementation Tools for Evidence-based intervention Delivery (UNITED) to facilitate the implementation and sustainment of three EBIs in under-resourced settings. We will compare fidelity to, and effectiveness of, each intervention [Mind the Gap (MTG), Remaking Recess (RR), Self-Determined Learning Model of Instruction (SDLMI)] with and without UNITED in a randomized field trial. Randomization will be stratified using a minimization allocation method. We will train community practitioners using remote delivery of modules specific to the intervention, and active coaching via Zoom for at least 6 sessions and up to 12 as dictated by each EBI. Our primary outcome is fidelity to each EBI, and our secondary outcome is at the child or family level (family empowerment for MTG, child peer social engagement for RR, and adolescent self-determination for SDLMI, respectively). We will measure progress through the implementation phases using the Stages of Implementation Completion and cost-effectiveness of UNITED. DISCUSSION: The results of this study will provide rigorous data on the effectiveness and generalizability of one relatively light-touch implementation strategy in increasing use of autism EBIs and associated outcomes in diverse under resourced public service settings for underrepresented autistic youth. TRIAL REGISTRATION: Mind the Gap: Clinicaltrials.gov Identifier:  NCT04972825 (Date registered July 22, 2021); Remaking Recess: Clinicaltrials.gov Identifier:  NCT04972838 (Date registered July 22, 2021); Self-Determined Learning Model of Instruction: Clinicaltrials.gov Identifier:  NCT04972851 (Date registered July 22, 2021).

Implementation-as-Usual in Community-Based Organizations Providing Specialized Services to Individuals with Autism Spectrum Disorder: A Mixed Methods Study.

Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental disorder. ASD community-based organizations (ASD-CBOs) underutilize or inconsistently utilize evidence-based practices (ASD-EBPs) despite numerous available EBPs to treat ASD. Nonetheless, ASD-CBOs implement changes to practices regularly. Understanding ASD-CBO's implementation-as-usual (IAU) processes may assist to develop strategies to facilitate ASD-EBP adoption, implementation and sustainment. A convergent mixed methods (quan + QUAL) design was utilized. Twenty ASD-CBO agency leaders (ALs) and 26 direct providers (DPs), from 21 ASD-CBOs, completed the Autism Model of Implementation Survey Battery, including demographic and agency IAU process questions. Surveys were analyzed through descriptive and content analyses. A subset of 10 ALs provided qualitative interview data that were analyzed using coding, consensus and comparison methods to allow for a more comprehensive understanding of the IAU process within their ASD-CBOs. Quantitative analyses and qualitative coding were merged utilizing a joint display and compared. Results suggest that the IAU process follows some phases identified in the Exploration, Preparation, Implementation, Sustainment (EPIS) framework but were conducted in an informal manner-lacking specificity, structure and consistency across and within ASD-CBOs. Moreover, data suggest adding a specific adoption decision phase to the framework. Nonetheless, most ALs felt previous implementation efforts were successful. IAU processes were explored to determine whether the implementation process may be an area for intervention to increase ASD-EBP utilization in ASD-CBOs. Developing a systematized implementation process may facilitate broader utilization of high quality ASD-EBPs within usual care settings, and ultimately improve the quality of life for individuals with ASD and their families.

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.

Effectiveness of community-based early intervention for children with autism spectrum disorder: a meta-analysis.

BACKGROUND: Research trials of early intervention (EI) programs for children with autism spectrum disorder (ASD) generally demonstrate medium-to-large gains, on average, compared with "treatment as usual," in different developmental domains. Almost all children with ASD receive their treatment through community-based services, however, and studies suggest that evidence-based interventions rarely make their way into community practice. Understanding the effectiveness of community-based EI and factors associated with these effects is the first step in developing strategies for wide-scale implementation of effective EI. METHODS: Studies of community-based EI for children with ASD were identified through a systematic search. Changes in cognitive, communication, social, and adaptive functioning from pre-treatment to post-treatment were assessed using standardized mean gain scores. Effect sizes were estimated using random effects models. Moderators of interest included type of community EI program, year of publication, intervention duration, and sample selection. Moderator effects were assessed using analysis of variance of mixed-effects models and meta-regression analyses. RESULTS: Forty-six groups from 33 studies met inclusion criteria (1,713 participants, mean age 37.4 months, 81.1% male). There were small but statistically significant gains in each of the four domains. Hedges's g ranged from 0.21 for adaptive behavior to 0.32 for communication outcomes, after removing outliers and correcting for publication bias. EI programs associated with universities and hospitals were superior, on average, to other community EI programs for cognitive and adaptive behavior outcomes. Intervention duration was negatively associated with effect sizes for communication and adaptive behavior outcomes. CONCLUSIONS: These results indicate that there remains a large gap between outcomes observed in community settings and those reported in efficacy trials.

Rethinking the idea of late autism spectrum disorder onset.

A common theory of autism spectrum disorder (ASD) symptom onset includes toddlers who do not display symptoms until well after age 2, which are termed late-onset ASD cases. Objectives were to analyze differences in clinical phenotype between toddlers identified as ASD at initial evaluations (early diagnosed) versus those initially considered nonspectrum, then later identified as ASD (late diagnosed). Two hundred seventy-three toddlers recruited from the general population based on a failed developmental screening form or parent or physician concerns were followed longitudinally from 12 months and identified as early- and late-diagnosed cases of ASD, language delayed, or typically developing. Toddlers completed common standardized assessments and experimental eye-tracking and observational measures every 9-12 months until age 3. Longitudinal performance on standardized assessments and experimental tests from initial evaluations were compared. Delay in social communication skills was seen in both ASD groups at early-age initial assessment, including increased preference for nonsocial stimuli, increased stereotypic play, reduced exploration, and use of gestures. On standardized psychometric assessments, early-diagnosed toddlers showed more impairment initially while late-diagnosed toddlers showed a slowing in language acquisition. Similar social communication impairments were present at very early ages in both early-detected ASD and so-called late-onset ASD. Data indicate ASD is present whether detected or not by current methods, and development of more sensitive tools is needed.

Integrating a Parent-Implemented Blend of Developmental and Behavioral Intervention Strategies into Speech-Language Treatment for Toddlers at Risk for Autism Spectrum Disorder.

Naturalistic developmental behavioral interventions include an explicit focus on coaching parents to use therapy techniques in daily routines and are considered best practice for young children with autism. Unfortunately, these approaches are not widely used in community settings, possibly due to the clinical expertise and training required. This article presents the work of the Bond, Regulate, Interact, Develop, Guide, Engage (BRIDGE Collaborative), a multidisciplinary group of service providers (including speech-language pathologists), parents, funding agency representatives, and researchers dedicated to improving the lives of young children with autism spectrum disorder and their families. The group selected and adapted a parent coaching naturalistic developmental behavioral intervention specifically for use with toddlers and their families for community implementation. Lessons learned from the implementation process include the importance of therapist background knowledge, the complexity of working with parents of young children, and needed supports for those working closely with parents, including specific engagement strategies and the incorporation of reflective practice.

Community-Academic Partnerships: A Systematic Review of the State of the Literature and Recommendations for Future Research.

POLICY POINTS: Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research, to provide firsthand knowledge and insight. Based on our systematic review of major literature databases, we recommend using a single term, community-academic partnership (CAP), and a conceptual definition to unite multiple research disciplines and strengthen the field. Interpersonal and operational factors that facilitate or hinder the collaborative process have been consistently identified, including "trust among partners" and "respect among partners" (facilitating interpersonal factors) and "excessive time commitment" (hindering operational factor). Once CAP processes and characteristics are better understood, the effectiveness of collaborative partner involvement can be tested. CONTEXT: Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research. Community stakeholders can provide firsthand knowledge and insight, thereby increasing research relevance and feasibility. Despite the greater emphasis and use of community-academic partnerships (CAP) across multiple disciplines, definitions of partnerships and methodologies vary greatly, and no systematic reviews consolidating this literature have been published. The purpose of this article, then, is to facilitate the continued growth of this field by examining the characteristics of CAPs and the current state of the science, identifying the facilitating and hindering influences on the collaborative process, and developing a common term and conceptual definition for use across disciplines. METHODS: Our systematic search of 6 major literature databases generated 1,332 unique articles, 50 of which met our criteria for inclusion and provided data on 54 unique CAPs. We then analyzed studies to describe CAP characteristics and to identify the terms and methods used, as well as the common influences on the CAP process and distal outcomes. FINDINGS: CAP research spans disciplines, involves a variety of community stakeholders, and focuses on a large range of study topics. CAP research articles, however, rarely report characteristics such as membership numbers or duration. Most studies involved case studies using qualitative methods to collect data on the collaborative process. Although various terms were used to describe collaborative partnerships, few studies provided conceptual definitions. Twenty-three facilitating and hindering factors influencing the CAP collaboration process emerged from the literature. Outcomes from the CAPs most often included developing or refining tangible products. CONCLUSIONS: Based on our systematic review, we recommend using a single term, community-academic partnership, as well as a conceptual definition to unite multiple research disciplines. In addition, CAP characteristics and methods should be reported more systematically to advance the field (eg, to develop CAP evaluation tools). We have identified the most common influences that facilitate and hinder CAPs, which in turn should guide their development and sustainment.

All Together Now: Measuring Staff Cohesion in Special Education Classrooms.

This study sought to validate a new measure, the Classroom Cohesion Survey (CCS), designed to examine the relationship between teachers and classroom assistants in autism support classrooms. Teachers, classroom assistants, and external observers showed good inter-rater agreement on the CCS and good internal consistency for all scales. Simple factor structures were found for both teacher- and classroom assistant-rated scales, with one-factor solutions for both scales. Paired t tests revealed that on average, classroom assistants rated classroom cohesion stronger than teachers. The CCS may be an effective tool for measuring cohesion between classroom staff and may have an important impact on various clinical and implementation outcomes in school settings.

The Role of Implementation Climate in Moderating Educator Use of Evidence-Based Practices and Outcomes for Autistic Students.

Ensuring effective use of evidence-based practice (EBP) for autism in schools is imperative due to the significantly increasing number of autistic students receiving school services each year. High-quality EBP use has proven challenging in schools. Research indicates implementation climate, or how EBP are supported, rewarded, and valued, and EBP resources are related to successful implementation. However, limited understanding of system-level contextual factors that impact EBP implementation for school-based providers makes development of appropriate implementation supports challenging. Understanding these factors is crucial for selecting and tailoring implementation strategies to support EBP scale up. In this observational study, California school-based providers (n = 1084) completed surveys related to implementation climate, leadership, autism experience and EBP implementation (use, competence, knowledge). Student outcomes included state level academic and behavioral indicators. Using an implementation science framework (Aarons et al., in Administration and Policy in Mental Health and Mental Health Services Research 38:4-23, 2011) and multilevel modeling, we examined the relationship between EBP Implementation and student outcomes and the moderation effects of provider and district level factors. Higher implementation climate predicted better EBP implementation outcomes, and proved more impactful when provider hands-on autism experience was low. Greater EBP resources predicted a higher percentage of students who met math standards only when district poverty level was high. Our findings suggested moderating effects on EBP implementation from both provider and system level factors. Implementation climate and resources may be especially key in addressing equity issues related to high poverty schools in which teachers often have less autism experience.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention.

BACKGROUND: Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching. METHODS: We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors. RESULTS: The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching. CONCLUSION: Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.

Role of Primary Care Clinician Concern During Screening for Early Identification of Autism.

OBJECTIVE: The aim of this study was to evaluate the added value of primary care clinician (PCC)-indicated concern during primary care universal standardized screening in early identification of autism. METHODS: Toddlers were screened for autism during primary care checkups (n = 7,039, aged 14.24-22.43 months) in 2 studies. Parents completed the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up. For each participant, PCCs indicated whether they had autism concerns (optional in 1 study-before or after viewing screening results, required before viewing screen results in the other). Children at high likelihood for autism from screen result and/or PCC concern (n = 615) were invited for a diagnostic evaluation; 283 children attended the evaluation. RESULTS: Rates of PCC-indicated autism concerns were similar whether PCCs were required or encouraged to indicate concerns. High likelihood of autism indication on both screen and PCC concern resulted in the highest positive predictive value for autism and positive predictive value for any developmental disorder, as well as the highest evaluation attendance, with no significant difference between the positive screen-only and PCC concern-only groups. Although the frequency of PCC-indicated autism concern did not differ significantly based on the child's cognitive level, PCCs were more likely to identify children with more obvious autism characteristics compared with more subtle autism characteristics as having autism. CONCLUSION: The findings support the recommendation of the American Academy of Pediatrics that both screening and surveillance for autism be incorporated into well-child visits. High likelihood of autism on either screen or PCC concern should trigger a referral for an evaluation.

Building Better Bridges: Outcomes of a Community-Partnered New School Transition Intervention for Students on the Autism Spectrum.

New school transitions can be challenging for students on the autism spectrum. No published, evidence-based interventions exist to support families and teachers of students transitioning to elementary and secondary school during this critical period. Using Community Partnered Participatory Research, we developed Building Better Bridges (BBB), a caregiver coaching intervention that includes training on effective school communication, educational rights, advocacy, and child preparation strategies. We compared BBB (n = 83) to a module/resources-only comparison (n = 87) in a four-site randomized controlled trial in racially and ethnically diverse, under-resourced communities. In our intent-to-treat analysis, caregivers and teachers in BBB rated students' transitions to the new classroom as more positive, relative to the comparison group. Results suggest this low-cost intervention can improve the transition process for families and students at high risk of poor transitions.

Diagnosis of autism spectrum disorders in 2-year-olds: a study of community practice.

BACKGROUND: Longitudinal research studies have demonstrated that experienced clinicians using standardized assessment measures can make a reliable diagnosis of autism spectrum disorders (ASDs) in children under age 3. Limited data are available regarding the sensitivity and specificity of these measures in community settings. The aims of this study were to determine how well a standardized diagnostic observational measure (Autism Diagnostic Observation Schedule - ADOS) functions alone, and with a brief parent measure within a community setting when administered by community clinicians. METHODS: Clinical records for 138 children between the ages of 24 and 36 months of age who were evaluated for possible ASD or social/language concerns at a hospital-based developmental evaluation clinic were examined. Evaluations were conducted by community-based clinical psychologists. Classification results obtained from standardized diagnostic measures were compared with case reviewer diagnosis, by reviewers blind to scores on diagnostic measures, using The Records-based Methodology for ASD Case Definition that was developed by the Metropolitan Atlanta Developmental Disabilities Surveillance Program. RESULTS: When compared with case review diagnosis, the ADOS demonstrated strong sensitivity and specificity for both Autism versus Not Autism and ASD versus Nonspectrum (NS) diagnoses in this young sample. The Social Communication Questionnaire (SCQ), using the lower cutoff of ≥12, had adequate sensitivity when differentiating Autism from Not Autism, but weak sensitivity when differentiating ASD from NS, missing about 80% of the children with pervasive developmental disorder - not otherwise specified. Using either the Modified Checklist for Autism in Toddlers or the SCQ in combination with the ADOS did not result in improved specificity over the ADOS alone and led to a drop in sensitivity when differentiating ASD from NS disorders. CONCLUSIONS: These results demonstrate that following best practice guidelines, the ADOS can be successfully incorporated into clinical practice with relatively good sensitivity and specificity, and worked well with a referred sample of 2-year-olds. A parent questionnaire did not lead to any improvement in diagnostic classification above the ADOS used in isolation.

Overcoming tensions between family-centered care and fidelity within Early Intervention implementation research.

LAY ABSTRACT: Early Intervention systems provide therapeutic services to families of young children birth to 3 years with developmental delays and are considered a natural access point to services for young children and their families. Research studies in the autism field have been interested in training providers to deliver evidence-based practices in Early Intervention systems to increase access to services for young children with an increased likelihood of being autistic. However, research has often overlooked that Early Intervention systems prioritize family-centered care, an approach to working with families that honors and respects their values and choices and that provides supports to strengthen family functioning. This commentary points out that family-centered care deserves greater attention in research being done in Early Intervention systems. We describe how family-centered care may shape how interventions are delivered, and discuss directions for future research to evaluate the impact of family-centered care alongside intervention delivery.

Implementation readiness for evidence-based autism practices in school systems.

Background: The increase in the number of autistic children being identified has led to increased demand on public schools to provide high-quality services. Effectively scaling up evidence-based practice (EBP) use for autistic students is challenging, given the complicated organization of special education. Teachers have significant challenges implementing autism EBP with fidelity. Factors such as implementation leadership and climate and attitudes toward EBP are linked to successful EBP use and may vary at different levels of the education system. Examining mechanisms of successful implementation is a critical step to support scale-up. Method: In this observational study, conducted from September 2018 to March 2020, California school personnel (n = 2273) at multiple levels of the system completed surveys related to implementation climate, leadership, and attitudes toward EBP. Data were collected throughout California at the Special Education Local Plan Areas, County Office of Education, and district and school levels from educators and administrators working in public schools supporting autistic students. Multi-level modeling was conducted to characterize implementation readiness. Results: Overall, implementation climate and leadership scores are low across levels with regional levels rated more positively than districts or schools. Attitudes toward EBP were moderate, with those working in schools having the poorest ratings and specialists/trainers and related service providers (e.g., speech-language pathologists) having the highest ratings. Conclusions: Outcomes provide a unique opportunity to compare implementation factors across organizational levels with a large, statewide sample. These data provide guidance for developing implementation interventions at multiple levels of the education system to increase readiness for effective scale-up of autism EBP in schools. Personnel and leaders at different organizational levels may need differentiated training targeting improved implementation climate and leadership. Personnel within districts and schools may experience a particular benefit from leadership support for EBP implementation.

The increase in the number of autistic children being identified in schools is increasing. To address this, schools are trying to do a better job of using high-quality practices based on research. However, teachers have had difficulty using research-based strategies for autistic students the way the manuals indicate they should be used. This might be due to the complexity of the strategies or limited support from special education leadership and infrastructure. Research shows that leaders can be very important in helping teachers use effective strategies. Over 2200 school personnel in California, including administrators, professional development providers, teachers, and paraprofessionals completed surveys asking about how their leaders, schools, districts, and regions supported the use of research practices for autistic students. Overall, limited support is provided in special education, with regional agencies providing more support than districts or schools. These data suggest that school and district leaders need training in how to support educators in using autism-specific strategies.

Does Treatment Fidelity of the Early Start Denver Model Impact Skill Acquisition in Young Children with Autism?

There is increasing evidence supporting the effectiveness of the Early Start Denver Model (ESDM) for children on the autism spectrum. However, substantial variability in response to the ESDM has been reported across participants. We examined the plausible yet untested hypothesis that variations in the fidelity level of therapists delivering the intervention contribute to variability in children's response to the ESDM. Videotaped sessions (n = 40) of toddlers on the autism spectrum who received the ESDM from trained therapists were coded to obtain measures of therapist fidelity and children's learning in response to the therapists' instruction. Variations in overall fidelity, along with variations in most items included in the ESDM fidelity checklist, contributed to the children's learning response during the sessions.

A Waitlist Randomized Implementation Trial of Classroom Pivotal Response Teaching for Students With Autism.

Classroom Pivotal Response Teaching (CPRT) is a community-partnered adaptation of a naturalistic developmental behavioral intervention identified as an evidence-based practice for autistic children. The current study evaluated student outcomes in a randomized, wait-list controlled implementation trial across classrooms. Participants included teachers (n = 126) and students with autism (n = 308). Teachers participated in 12 hours of didactic, interactive training and additional in-classroom coaching. Generalized Estimating Equations accounted for clustering. Adjusted models evaluated the relative effects of training group, CPRT fidelity, and classroom quality on student outcomes. Results indicate higher CPRT fidelity was associated with greater increases in student learning. Having received CPRT training predicted increased student engagement and greater decreases in reported approach/withdrawal problems. These differences may be linked to the theoretical foundations of CPRT of increasing student motivation and engagement and collaborative adaptation to increase feasibility in schools. Overall, results suggest CPRT may be a beneficial approach for supporting autistic students.

Initial diagnostic impressions of trainees during autism evaluations: High specificity but low sensitivity.

Reducing the age of first autism diagnosis facilitates access to critical early intervention services. A current "waitlist crisis" for autism diagnostic evaluation thus demands that we consider novel use of available clinical resources. Previous work has found that expert autism clinicians can identify autism in young children with high specificity after only a brief observation; rapid identification by non-experts remains untested. In the current study, 252 children ages 12-53 months presented for a comprehensive autism diagnostic evaluation. We found that junior clinicians in training to become autism specialists (n = 29) accurately determined whether or not a young child would be diagnosed with autism in the first five minutes of the clinic visit in 75% of cases. Specificity of brief observations was high (0.92), suggesting that brief observations may be an effective tool for triaging young children toward autism-specific interventions. In contrast, the lower negative predictive value (0.71) of brief observations, suggest that they should not be used to rule out autism. When trainees expressed more confidence in their initial impression, their impression was more likely to match the final diagnosis. These findings add to a body of literature showing that clinical observations of suspected autism should be taken seriously, but lack of clinician concern should not be used to rule out autism or overrule other indicators of likely autism, such as parent concern or a positive screening result.