UCLA CART Symposium: Advances in Autism 2016

1. Early interventions for autism
spectrum disorder: Active
ingredients and deployment to the
community
Connie Kasari. PhD
Autism Intervention Research
Network for Behavioral Health

2. 1
Introduction
No single
treatment
ba
Research to
practice gap
Summary
3c
Deployment
Sustainability
3 issues

3. Our local intervention landscape

4. LAUSD…
Hispanic
Other
Black
White
Hispanic
White
Black
Other
2nd largest school
district; 14,000 students
with ASD
District as a whole is…..
75% Hispanic;
80% free & reduced lunch;
9% White
Students with ASD

5. Disparities are real…..
Public schools should be place
without disparities in services

6. 3 Issues to consider……

7. There is a HUGE research to
practice GAP
1

8. Most children with ASD have
never been in a research study
AND MOST INTERVENTIONS have never been
tested in any controlled study;
The ‘evidence-base’ does not reflect most
children in the community (Weisz, 2004)

9. Proliferation of programs

10. What is the evidence-base for
early interventions?

11. We can improve cognitive outcomes (DQ) in
young children with comprehensive, many hour
per week interventions
DTT- preschoolers
30 hrs/wk vs. <10
40
50
60
70
80
90
100
Baseline 2 years
16 pts
1 pt
ESDM-toddlers
25 hrs/wk vs. fewer hrs
40
50
60
70
80
90
100
Baseline 1 year 2 years
19 pts
5 pts
Smith, Groen & Wynn, AJMR, 2000 Dawson et al, Pediatrics, 2010
DQ
points
n=28 n=48

12. Reproducibility of findings
Problem in science
Original studies—small samples
Often do not replicate
Science, 2015
Confidence in findings?

13. Replications
DTT original Smith et al, 2000 n=28 p<.05
Replication Sallows & Graupner, 2005 n=24 NS
ESDM original Dawson et al 2010 n=48 p<.05
Replication Rogers et al 2014 n=98 NS

14. Similar outcomes in brief parent mediated
interventions?
Focused Playtime
Intervention
40
50
60
70
80
90
100
Baseline 1 year
18 pts
14 pts
SCERTS
40
50
60
70
80
90
100
Baseline 9 months
6 pts
2 pts
Kasari, Siller et al, Infant Behavior &
Development, 2014
DQ
points
Wetherby et al, Pediatrics, 2014
Intervention phase
Intervention
phase

15. What do we make of these
findings…..
Outcome measures
Active ingredients

16. Primary outcome has been
IQ
Cannot rule out dose of
intervention
Year of study matters—
”the counterfactual”
But many factors can influence IQ

17. While IQ is likely important;
it is not a core deficit of
ASD

18. What are the active ingredients
of early interventions?
Dose
Agent of change (BCBA therapist, parent, other?)
Teaching approach
Content ---what is focused on
Others…..

19. What are the active ingredients
of early interventions?
Dose
Agent of change (BCBA therapist, parent, other?)
Teaching approach
Content ---what is focused on
Others…..

20. What are the active ingredients
of early interventions?
Dose
Agent of change (BCBA therapist, parent, other?)
Teaching approach
Content ---what is focused on
Others…..

21. Content focusing on core
impairments
Social Communication
Restricted, repetitive behaviors
To large extent, independent of IQ

22. Engagement Communicative
gestures & language
Play
Early Core Deficits
Social Communication

23. Why focus on early core deficits?

24. Language by age 5-6 best social outcomes
(Lord, 2000; Rutter, 1978)
Joint attention predicts to language
(Kasari et al,2008; Kasari et al, 2012; Mundy et al., 1986; Mundy, Sigman, & Kasari,
1990)
Play skills associated with cognitive abilities
(Kasari et al, 2012)

25. Evidence suggests that
approach matters for
improvements in joint attention,
play, engagement
Spontaneous, child initiations

26. Differences in approach to teaching play
ABA-traditional
DTT teaching symbolic play
NDBI
JASPER

27. Joint Attention, Symbolic Play,
Engagement, & Regulation
JASPER

28. Naturalistic
Developmental
Behavioral
Intervention
(Workgroup, 2014)
NDBI Targeted
Modular Short-term
Addressing Core Deficits

29. Engagement
Play
Joint
attention
Language
JASPER is a layered intervention

30. Highly replicable findings
(therapists, teachers, parents)
 Joint engagement
 Play skills
 Joint Attention
Example NDBI---JASPER
(Joint Attention, Symbolic Play, Engagement
& Regulation)

31. Evidence

32. Information Sharing Hands on Coaching

33. (Kasari, Gulsrud, Paparella, Hellemann, Berry,
JCCP, 2015)
RCT—Comparative Efficacy
N=86
0
50
100
150
200
250
300
350
400
Entry Exit Follow up
JASPER
Parent
Education
Parent Mediated Interventions
Seconds
Child initiated joint engagement

34. (Kasari, Gulsrud, Paparella, Hellemann, Berry,
JCCP, 2015
Parent Mediated Interventions
86 children (2-3 year
olds)
Comparison 2
interventions
20 sessions over 10
weeks
6 month follow up
JASPER group
 Joint engagement
 Play diversity
 Play level
Group comparison
 Parenting stress

35. (Kasari, Lawton, Shih, Barker et al, Pediatrics,
2014
200
220
240
260
280
300
320
340
360
380
400
Entry Exit Follow up
JASPE
Group
Education
RCT-Comparative Efficacy
N=112
Parent Mediated Interventions

36. (Kasari, Lawton et al, Pediatrics, 2014
Parent Mediated Interventions
112 children (2-5 year
olds)
Comparison 2
interventions
24 sessions over 12
weeks
3 month follow up
JASPER group
 Joint engagement
 Symbolic play
 Initiating JA

37. Good evidence of improving core
deficits using JASPER
(NDBI interventions)
Ingersoll, 2011, JADD RCT—improvement in JA initiations from training
imitation
Wetherby et al, 2014, Pediatrics---improvement of collapsed requesting, joint
attention category

38. A single treatment is
not effective for all!
2

39. Minimally verbal make least progress
Difference between preverbal—young children and minimally
verbal –older children
Concern is for the children who remain nonverbal at age 5---
entering kindergarten (about 30% of all children)
Best social and adaptive outcomes are often found for children
who are verbal by school age
Children who are nonverbal (minimally verbal) at school age are
UNDERSERVED, UNDER-STUDIED

40. Characterizing Cognition in Nonverbal
Children with ASD (CCNIA) Intervention
61 children aged 5 to 8 years
Minimally verbal (fewer than 20
functional words)
Had already received 2 years of
intensive early intervention
ALL received JASPER plus a
spoken language intervention
(EMT)
HALF randomized to also receive
Speech Generating Device (iPad)
Kasari et al, JAACAP, 2014

41. Slide courtesy of Danny Almirall May 16, 2014

42. Minimally verbal and meaningful
outcomes
Socially communicative utterances

43. Novel words and comments
Kasari, Kaiser, Goods, Neitfeld, Mathy, Landa, Murphy, Almirall, JAACAP, 2014

44. Minimally verbal
School aged: No words in
beginning; needs access to
communication
Preverbal child: preschool aged
Day 1
Day 2
Day 12

45. Deployment can be limited
Sustainability poor
3

46. Deployment Models
Train the trainer models; deploying
to paraeducators who are doing
both assessment and intervention
NYTD
LAPD
Fitting the intervention
into existing structure with
support
Ya-Chih Chang, PhD
Stephanie Shire, PhD
Chang, Shire, Shih, Kasari, 2016, JADD

47. JASPER findings similar to lab when
conducted in school: Better joint engagement
with others
0
5
10
15
20
25
30
35
40
45
50
JASPER Wait
Entry
Exit
Percentageof
time

48. Nonverbal gestures (high level
joint attention)
0
5
10
15
20
25
30
35
40
JASPER Wait
Entry
Exit
Percentageofchildrenusingpoints,shows,gives

49. Change in Language
0
10
20
30
40
50
60
70
JASPER Wait list
ENTRY
EXIt
%ofchildrenusinglanguage

50. Materials for teachers—Preschool
deployment study (LA and NY)

51. Interventions are complicated
Their success depends on context, individual
differences including age, abilities of child, and
willingness of adults
More than one intervention can work. Children often
need sequences of interventions…..
We need to work harder to make interventions “work”
in community so they sustain over time.
Conclusions

52. Appreciation to families and children who participate in studies
Funding sources
• NICHD, NINDS, NIMH, HRSA, Autism Speaks, Merck Fund
Lab…..research assistants, graduate students, post-docs
Amy Dominguez, Caitlin McCracken, Andy Schlink, Maria Pizzano, Kiana Krolick,
Marina Mladenovic, Marcella Mattos, Nichole Tu, Alyssa Tan, Broghan Hedges,
Marta Wirga, Devyn Tharnstrom, Jamie Crisostomo, Hilary Gould, Jonathan
Panganiban, KC Berry, Alison Holbrook, Chrissy Kang, Belinda Williams, Jill
Locke, Mark Kretzmann,
Michelle Dean, Ya-Chih
Chang
Colleagues-UCLA—
Amanda Gulsrud,PhD,
Stephanie Shire, PhD,
Shafali Jeste, MD
Acknowledgements

53. airbnetwork.org
kasarilab.org