Systematic review: emotion dysregulation and challenging behavior interventions for children and adolescents on the autism spectrum with graded key evidence-based strategy recommendations.

Challenging behavior, such as aggression, is highly prevalent in children and adolescents on the autism spectrum and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behavior measures, while few included emotion dysregulation measures. This review highlights the importance of teaching emotion regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

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.

Programmatic Costs of Project ImPACT for Children with Autism: A Time-Driven Activity Based Costing Study.

Programmatic cost assessment of clinical interventions can inform future dissemination and implementation efforts. We conducted a randomized trial of Project ImPACT (Improving Parents As Communication Teachers) in which community early intervention (EI) providers coached caregivers in techniques to improve young children's social communication skills. We estimated implementation and intervention costs while demonstrating an application of Time-Driven Activity-Based Costing (TDABC). We defined Project ImPACT implementation and intervention as processes that can be broken down successively into a set of procedures. We created process maps for both implementation and intervention delivery. We determined resource use and costs, per unit procedure in the first year of the program, from a payer perspective. We estimated total implementation cost per clinician and per site, intervention cost per child, and provided estimates of total hours spent and associated costs for implementation strategies, intervention activities and their detailed procedures. Total implementation cost was $43,509 per clinic and $14,503 per clinician. Clinician time (60%) and coach time (12%) were the most expensive personnel resources. Implementation coordination and monitoring (47%), ongoing consultation (26%) and clinician training (19%) comprised most of the implementation cost, followed by fidelity assessment (7%), and stakeholder engagement (1%). Per-child intervention costs were $2619 and $9650, respectively, at a dose of one hour per week and four hours per week Project ImPACT. Clinician and clinic leader time accounted for 98% of per child intervention costs. Highest cost intervention activity was ImPACT delivery to parents (89%) followed by assessment for child's ImPACT eligibility (10%). The findings can be used to inform funding and policy decision-making to enhance early intervention options for young children with autism. Uncompensated time costs of clinicians are large which raises practical and ethical concerns and should be considered in planning of implementation initiatives. In program budgeting, decisionmakers should anticipate resource needs for coordination and monitoring activities. TDABC may encourage researchers to assess costs more systematically, relying on process mapping and gathering prospective data on resource use and costs concurrently with their collection of other trial data.

Clinician Intentions to use the Components of Parent Coaching Within Community Early Intervention Systems.

PURPOSE: Parent coaching is a complex, psychosocial intervention with multiple core components. Clinicians' use of these core components may be influenced by distinct factors; no research has examined whether clinician perceptions of parent coaching vary across core coaching components. This study aimed to examine the extent to which clinicians working with families of young autistic children in publicly funded early intervention intend to use core parent coaching components, and to examine how closely psychological factors relate to providers' intentions to use each component. METHODS: Using the Theory of Planned Behavior as a framework, this study compared the strength of clinicians' intentions across five core parent coaching components: collaboration with parents, delivering the intervention within daily routines, demonstrating the intervention, providing in-vivo feedback, and reflection and problem solving. We examined the associations between intentions and psychological determinants of intentions (i.e., attitudes, norms, and self-efficacy) for each component. RESULTS: Clinicians' average intentions varied by core component, with strongest intentions for demonstrating the intervention strategy for a parent. The associations between intentions and psychological determinants also varied by core component. Attitudes, injunctive norms, and self-efficacy, but not descriptive norms, significantly related to clinicians' intentions to use collaboration and daily routines, whereas attitudes and descriptive norms, but not injunctive norms and self-efficacy, significantly related to clinicians' intentions to use feedback and reflection and problem solving. CONCLUSION: These results suggest that implementation strategies should be tailored to the specific intervention component to be most efficient and effective. The results also provide examples of potentially malleable factors that implementation strategies can strategically target.

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.

Heart rate increase predicts challenging behavior episodes in preschoolers with autism.

Identifying triggers for challenging behavior is difficult in some children with autism because of their limited communication abilities. Physiological indicators of stress may provide important insights. This study examined whether heart rate (HR) predicts challenging behavior in children with autism. While wearing an electrocardiograph monitor, 41 children with autism aged 2- to 4-years participated in tasks designed to induce low-level stress (e.g. waiting for a snack). Coders identified 106 time periods during which challenging behaviors occurred and also coded 106 randomly selected time samples that did not include challenging behaviors. Thirteen (32%) participants exhibited challenging behaviors and were included in the study. Baseline-corrected HR was computed for each behavior/time sample. On average, children with autism showed a 22 ± 16% HR increase from baseline 58 ± 22 seconds before the onset of a challenging behavior episode. Peak HR change had moderate predictive utility (area under the curve = .72, p < .001). The increase in HR before challenging behaviors was similar for children of different characteristics (age, autism severity, expressive language ability, overall developmental ability). Results highlight the promise of using physiological stress to predict challenging behavior in preschoolers with autism; although, they need to be replicated in larger samples. Given recent advances in wearable biosensing, it may be useful to incorporate HR monitoring in autism intervention. Lay summary In children with autism, changes in heart rate (HR) may help us predict when challenging behavior is about to occur - but this hypothesis has not been well studied. In this study, HR increase moderately predicted challenging behavior in preschoolers with autism. Given recent advances in wearable sensors, it may be useful to incorporate HR monitoring in autism intervention.

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.

Boon or Burden: The Effect of Implementing Evidence-Based Practices on Teachers' Emotional Exhaustion.

This study examined the association between (1) beginning-of-the-year emotional exhaustion and use of three evidence-based practices (EBP) for children with autism spectrum disorder; and (2) use of these EBP and end-of-year emotional exhaustion among 46 kindergarden to 2nd grade autism support teachers participating in a randomized trial. Emotional exhaustion was measured at the end and beginning of the school year using a subscale of the Maslach Burnout Inventory. Fidelity was measured using monthly observations, coded by research assistants trained to reliability. Correlations were used to examine unadjusted associations and ordinary least squares regression was used to examine associations adjusted for beginning-of-year burnout, years teaching, and average change in student cognitive functioning. Emotional exhaustion at the beginning of the year was not associated with EBP use. Greater fidelity to each EBP was associated with lower end-of-year emotional exhaustion (coefficients ranging from - .34 to - 1.13, all p's < .05). Results indicate that helping teachers implement EBP with greater fidelity may help reduce burnout, a substantial challenge in the field.

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.

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.

A multi-constituent qualitative examination of facilitators and barriers to caregiver coaching for autistic children in publicly funded early intervention.

LAY ABSTRACT: Caregiver coaching is an evidence-based practice for young autistic children, but it is not widely used in community-based early intervention services. Previous research has explored why caregiver coaching is not widespread in early intervention, but only from the perspective of early intervention providers. Caregivers, providers, and administrators are all involved in the decision of whether to use caregiver coaching in early intervention. Therefore, it is important to include all perspectives in research regarding this practice. In this study we interviewed 20 caregivers of autistic children, 36 early intervention providers, and 6 administrators from early intervention agencies and asked questions about their perspectives regarding the use of caregiver coaching in early intervention. We did this to figure out what factors help and hinder the use of caregiver coaching in this setting and to see how caregivers, providers, and administrators agreed or disagreed on these factors. All participants agreed that caregivers' attitudes and expectations can influence whether caregiver coaching is used. In addition, all participants agreed that when caregivers and providers collaborate and have a strong working relationship, it can facilitate the use of caregiver coaching in early intervention. Other factors, such as caregiver stress and provider flexibility were also discussed. Based on these findings, we suggest strategies that can be used to possibly increase the use of caregiver coaching in early intervention for autistic children and their families.

Beyond the Task List: A Proposed Integration of Naturalistic Developmental Behavioral Interventions to BCBA Training.

Naturalistic developmental behavioral intervention (NDBI) is firmly rooted in both the science of ABA as well as developmental science. Research indicates that many practicing board certified behavior analysts (BCBAs) are unfamiliar with NDBI models and do not implement these approaches when working with young autistic children (Hampton and Sandbank Autism, 26(4), 875-888, 2022). In this article we align NDBI to the seven dimensions of ABA, describe their compatibility with the ABA service system, and urge community agencies and insurance funders to support NDBI use. Finally, we provide a roadmap for BCBAs who provide behavior analytic intervention to young autistic children and for Verified Course Sequence faculty to effectively align the 6th edition BCBA Test Content Outline with the principles and application of NDBI.

Toward deeper understanding and wide-scale implementation of naturalistic developmental behavioral interventions.

LAY ABSTRACT: Naturalistic Developmental Behavioral Interventions (NDBIs) are a group of early interventions that use a variety of strategies from applied behavioral and developmental sciences. Although Naturalistic Developmental Behavioral Interventions have been demonstrated effective, Naturalistic Developmental Behavioral Interventions are not implemented on a wide scale within early intervention programs for children on the autism spectrum. Potential reasons likely stem from differing theoretical orientations of developmental and behavioral sciences and practitioners' lack training, knowledge, and support for implementing Naturalistic Developmental Behavioral Interventions. In support of efforts to promote wide-scale implementation of Naturalistic Developmental Behavioral Interventions, we (1) clarify their common features, (2) discuss possible misconceptions, and (3) offer reasons why Naturalistic Developmental Behavioral Interventions should be widely implemented. We also provide recommendations to the autism service community, intervention developers, and researchers.

Systematic Review: Emotion Dysregulation and Challenging Behavior Interventions for Children andAdolescents with Autism with Graded Key Evidence-Based Strategy Recommendations.

Challenging behavior, such as aggression, is highly prevalent in children and adolescents with autism and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single-case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behaviors measures while few included emotion dysregulation measures. This review highlights the importance of teaching emotion-regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously-designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Who gets coached? A qualitative inquiry into community clinicians' decisions to use caregiver coaching.

LAY ABSTRACT: Providers' beliefs about an intervention's fit with a family can affect whether or not they use that intervention with a family. The factors that affect providers' decisions to use evidence-based practices for young autistic children have not been studied. These factors may play a role in the major differences we see in the quality of and access to early intervention services in the community. We looked at differences in providers' use of caregiver coaching, an evidence-based practice, with families from minority or vulnerable backgrounds, and the possible reasons for those differences. We did this to figure out what factors affect providers' use of caregiver coaching. We interviewed 36 early intervention providers from early intervention agencies in two different parts of the United States. Providers pointed out things like what they thought about a family's circumstances that affected their beliefs about how well coaching fits with minority and vulnerable families. Our findings bring attention to these beliefs that likely make accessing evidence-based practices for minority and vulnerable families harder and lessen the quality of care for these families of young autistic children. These findings highlight the need to come up with and use strategies to improve both access to and the quality of evidence-based practices for young autistic children from minority and vulnerable groups.

Feasibility of delivering parent-implemented NDBI interventions in low-resource regions: a pilot randomized controlled study.

BACKGROUND: This implementation feasibility study was conducted to determine whether an evidence-based parent-implemented distance-learning intervention model for young children at high likelihood of having ASD could be implemented at fidelity by Part C community providers and by parents in low-resource communities. METHODS: The study used a community-academic partnership model to adapt an evidence-based intervention tested in the current pilot trial involving randomization by agency in four states and enrollment of 35 coaches and 34 parent-family dyads. After baseline data were gathered, providers in the experimental group received 12-15 h of training while control providers received six webinars on early development. Providers delivered 6 months of intervention with children-families, concluding with data collection. Regression analyses were used to model outcomes of the coach behaviors, the parent fidelity ratings, and child outcomes. RESULTS: A block design model-building approach was used to test the null model followed by the inclusion of group as a predictor, and finally the inclusion of the planned covariates. Model fit was examined using changes in R2 and F-statistic. As hypothesized, results demonstrated significant gains in (1) experimental provider fidelity of coaching implementation compared to the control group; and (2) experimental parent fidelity of implementation compared to the control group. There were no significant differences between groups on child developmental scores. CONCLUSIONS: Even though the experimental parent group averaged less than 30 min of intervention weekly with providers in the 6 months, both providers and parents demonstrated statistically significant gains on the fidelity of implementation scores with moderate effect sizes compared to control groups. Since child changes in parent-mediated models are dependent upon the parents' ability to deliver the intervention, and since parent delivery is dependent upon providers who are coaching the parents, these results demonstrated that two of these three links of the chain were positively affected by the experimental implementation model. However, a lack of significant differences in child group gains suggests that further work is needed on this model. Factors to consider include the amount of contact with the provider, the amount of practice children experience, the amount of contact both providers and parents spend on training materials, and motivational strategies for parents, among others. TRIAL REGISTRATION: Registry of Efficacy and Effectiveness Studies: #4360, registered 1xx, October, 2020 - Retrospectively registered, https://sreereg.icpsr.umich.edu/sreereg/.

Metrics to evaluate implementation scientists in the USA: what matters most?

BACKGROUND: Implementation science has grown rapidly as a discipline over the past two decades. An examination of how publication patterns and other scholarly activities of implementation scientists are weighted in the tenure and promotion process is needed given the unique and applied focus of the field. METHODS: We surveyed implementation scientists (mostly from the USA) to understand their perspectives on the following matters: (1) factors weighted in tenure and promotion for implementation scientists, (2) how important these factors are for success as an implementation scientist, (3) how impact is defined for implementation scientists, (4) top journals in implementation science, and (5) how these journals are perceived with regard to their prestige. We calculated univariate descriptive statistics for all quantitative data, and we used Wilcoxon signed-rank tests to compare the participants' ratings of various factors. We analyzed open-ended qualitative responses using content analysis. RESULTS: One hundred thirty-two implementation scientists completed the survey (response rate = 28.9%). Four factors were rated as more important for tenure and promotion decisions: number of publications, quality of publication outlets, success in obtaining external funding, and record of excellence in teaching. Six factors were rated as more important for overall success as an implementation scientist: presentations at professional meetings, involvement in professional service, impact of the implementation scientist's scholarship on the local community and/or state, impact of the implementation scientist's scholarship on the research community, the number and quality of the implementation scientist's community partnerships, and the implementation scientist's ability to disseminate their work to non-research audiences. Participants most frequently defined and described impact as changing practice and/or policy. This expert cohort identified Implementation Science as the top journal in the field. CONCLUSIONS: Overall, there was a significant mismatch between the factors experts identified as being important to academic success (e.g., tenure and promotion) and the factors needed to be a successful implementation scientist. Findings have important implications for capacity building, although they are largely reflective of the promotion and tenure process in the USA.

Examining US Public Early Intervention for Toddlers With Autism: Characterizing Services and Readiness for Evidence-Based Practice Implementation.

As the rates of Autism Spectrum Disorder (ASD) increase and early screening efforts intensify, more toddlers with high likelihood of ASD are entering the United States' (US') publicly funded early intervention system. Early intervention service delivery for toddlers with ASD varies greatly based on state resources and regulations. Research recommends beginning ASD-specific evidence-based practices (EBP), especially caregiver-implemented intervention, as early as possible to facilitate the development of social-communication skills and general learning. Translating EBP into practice has been challenging, especially in low-resourced areas. The main goal of this study was to obtain a more comprehensive understanding of public early intervention system structure, service delivery practices, and factors influencing EBP use for children with ASD in the US. Participants (N = 133) included 8 early intervention state coordinators in 7 states, 29 agency administrators in those states, 57 early intervention providers from those agencies, and 39 caregivers of children with ASD receiving services from those providers. Online surveys gathered stakeholder and caregiver perspectives on early intervention services as well as organizational factors related to EBP implementation climate and culture. Stakeholders identified key intervention needs for young children with ASD. In general, both agency administrators and direct providers reported feeling somewhat effective or very effective in addressing most needs of children with ASD. They reported the most difficulty addressing eating, sleeping, family stress, and stereotyped behaviors. Data indicate that children from families with higher income received significantly higher service intensity. While administrators and providers reported high rates of high-quality caregiver coaching (>60%), caregivers reported low rates (23%). Direct providers with more favorable attitudes toward EBP had greater EBP use. In turn, provider attitudes toward EBP were significantly associated with implementation leadership and culture at their agency. Results suggest that publicly funded early intervention programs in the US require additional resources and training for providers and leaders to support improved implementation climate and attitudes toward ASD EBPs. Results also suggest that more state system support is needed to increase use of ASD-specific EBP use, including high-quality caregiver coaching, to better serve toddlers with ASD. Recommendations for implementation strategies are addressed.

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.

Does implementing a new intervention disrupt use of existing evidence-based autism interventions?

LAY ABSTRACT: Interventions for children with autism spectrum disorder are complex and often are not implemented successfully within schools. When new practices are introduced in schools, they often are layered on top of existing practices, with little attention paid to how introducing new practices affects the use of existing practices. This study evaluated how introducing a computer-assisted intervention, called TeachTown:Basics, affected the use of other evidence-based practices in autism support classrooms. We compared how often teachers reported using a set of evidence-based practices in classrooms that either had access to TeachTown:Basics or did not have the program. We found that teachers who had access to the computer-assisted intervention reported using the other evidence-based practices less often as the school year progressed. Teachers also reported that they liked the computer-assisted intervention, found it easy to use, and that it helped overcome challenges to implementing other evidence-based practices. This is important because the computer-assisted intervention did not improve child outcomes in a previous study and indicates that teachers may use interventions that are appealing and easier to implement, even when they do not have evidence to support their effectiveness. These findings support the idea of interventions' complexity and how well the intervention fits within the classroom affect how teachers use it and highlight the need to develop school-based interventions that both appeal to the practitioner and improve child outcomes.